This is the second in a series of articles on emotional intelligence for personal growth. The first part is here.

Mindfulness is a non-judgmental, present-centered awareness in which each thought, feeling, or sensation that arises is acknowledged and accepted as it is. It is a skill that is learned by committed practice. The object is to focus one's attention on thoughts, feelings and events in the present moment while remaining curious, open, and accepting whatever occurs.

The idea is to take on the role of an observer of your own mind. Notice everything that happens without holding onto anything, having a "Teflon Mind". An important part of observing is putting words to the experience. The effect of naming the experience effectively separates you from it. Thoughts are just thoughts, feelings just feelings, all transient experiences that are not necessarily a part of or define who we are.

True mindfulness involves immersing yourself in your experiences so that you actually forget yourself. The idea here is to stop the conversation you have with yourself, or as Eastern traditions put it, letting go of ego. This internal dialogue, while an important skill in the right circumstances, can become a major distraction. Imagine yourself walking through a beautiful park muttering to yourself. Would you remember what you saw in the park? You'd probably remember more about what you were muttering to yourself!

One way to do this is to focus on what is at hand. "See the job, do the job." The idea is NOT to always stay busy, ut to invest all of yourself in everything you do. "Smell the roses." Another thing to watch while doing things judging if this should have happened or whether it's fair, just, or right or wrong. It IS, the only value in questioning why is avoiding a problem in the future. Anything more than that is a waste time and emotional energy. See what you are doing, but don't evaluate it. Focus on the facts without evaluating it. Count on your intuitive self to react appropriately, changing the harmful situation or changing your harmful reaction to the situation.

Another distraction to your experiences is multi-tasking. Doing more than one thing at a time spreads your skills thin so that your product becomes sub-optimal, perhaps even mediocre. If you multi-task regularly, you actually train yourself to be easily distracted. There is some research that suggests that this subtle distraction training contributes significantly to attention deficits that impair your concentration. Research also suggests that training persons with Attention Deficit Disorder with mindfulness techniques can be an effective treatment!

The idea is to keep your mind's eye on the objectives until the task is done having faith that you will do the best job your can and react appropriately should something go wrong. Think about it, if you are preoccupied with what might go wrong while doing something, will your focus be on the job or the fear of what might happen? If you are distracted by fear, how good a job can you do?

Most of us, when not structured and focused on a task at hand, are thinking about past and future events. We either review previous experiences looking for new learnings we might have missed or planning our reactions to anticipated events. We focus on the moment only when there is something immediately presenting that requires a response. Our focus is often divided between what is happening in the moment and the thoughts on which we are focused.

For those of us that have more than our share of regrets and/or worries, being focused on the past or the future becomes a nearly full time job! This is not good. Without your full participation in the moment you are in, you are distracted, your reactions are primed with the emotions of the worry or regret. That means your judgment and decision making ability is impaired by emotionally distorted judgments! Have you ever been startled by someone while preoccupied with regrets or worries? Did you react with an emotion not meant for the other person? Most people have had that experience. It is likely we have all experienced spilling our internal emotion on an unintended other. And if that person was paying attention, he or she probably noticed your emotion and wondered if you were upset with them!

Few of us have the ability to be focused on the moment at will. It is a skill that takes a lot practice and a commitment to follow through. The eventual reward is an incredible feeling of peacefulness, acceptance, and centeredness combined with heightened concentration. You see, a mind uncluttered by regrets or worries has only the moment to focus on. Self-consciousness dissolves into the experience of the moment. Instead our focus is on our senses, our perceptions, punctuated by the thoughts and feelings flowing through our minds. The ultimate state of mindfulness is what is called flow.

Flow is the state in which the person is fully immersed in what he or she is doing with a feeling of energized focus, full involvement, and an expectation of success. Flow could be conceived of as being completely focused and motivated in a single-minded immersion. Emotions and thoughts are synchronized in the service of performing and learning. In flow, the emotions are not just contained and channeled, but positive, energized, and aligned with the task at hand. While in flow, we feel a clear sense of direction, confidence, intense concentration, and personal control. We feel a natural and continuous intrinsic reward. Time seems altered, slowed or moving quickly. Feedback for one's actions and focused redirection come easily and painlessly so that action and awareness seem to merge.

One does not have to reach the ultimate form of mindfulness to benefit. With each strengthening of the skill comes with incredible benefits in quality of life. There are many tools available to us that will help us learn. Check out the resources here.

Continued here.

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I caught this article at Psychcentral.com, Positive Thoughts Make Things Worse for Poor Self-Esteem . It struck me as a counter-intuitive finding for a research study. I've been helping clients build self-esteem for over 30 years and while positive thoughts is not a short road to better self-esteem, it certainly does work over the long run. I'd estimate that at least six months is required to make significant progress with self-esteem from solely refocusing on the positive, and some people require much more time. Several things jumped at me as I read the article. First of all, Dr. Grohol quoted an article from the The Economist of all places. Both articles stated the research was published in this month's Psychology Research and authored by Wood et al (2009). A review of the past three months of that journal produced no article.

So I went to the old reliable, I googled the lead author, Joanne Wood. I came up with several mentions of her at academic institutions and emailed the author for a reprint. I also found another review of the same article by Ed Yong writer for the Science Blog Not Exactly Rocket Science dated May 15th.

The next day, the article arrived in my email with a short note from the author saying it hadn't been published yet! Apparently, there have been some pre-publication prints floating about likely for publicity purposes. This is one of my pet peeves. Articles submitted to peer reviewed journals are intended to inform the academic community and allow scholarly review and comment. The object of repeated review is to ensure the research is sound and is appropriately interpreted. When it appears first in lay publications, the writers who are not scientists often inadvertently distort the interpretation of the research, as I've noted before. That really didn't happen this time. Both the Psychcentral.com and The Economist got the research mostly right. But Ed Yong did a much better job of explaining the fine points.

This time, it's the researchers that make a subtle but major error in an assumption involving an interpretation of a key measurement. Its subtle because it's endemic in our culture. It seems like everyone assumes that negative feelings are harmful. In this case, Wood et al (2009) found that their subjects who had low self-esteem, immediately reported a lower mood and self-esteem after telling themselves sixteen times they are a "lovable person." Interestingly, persons with high self-esteem report only slight, non-significant improvement in self-esteem.

I decided to do an anecdotal demonstration of the "intervention" for my own understanding. After saying to my self 16 times "I am a loveable person", I felt annoyed, a little silly, embarrassed, and was reminded of quite a few traits which make me not always so lovable. But I can't imagine how this would have any long term effect on my self-esteem either way.

An even bigger problem is one that I talked about before and called it Dust Bowl Empiricism. Researchers are so enamored with their professional activities, they demonstrate their preference for inductive research. Wood et al. reviewed all the relevant research on their topic quite satisfactorily, but then failed to do a sufficient review of related theory. In previous post, I quoted Michael Schermer, a columnist with Scientific American, who eloquently asserted that the really valuable research, the kind of research that can fairly readily be used to educate the public, "higher-order works of science that synthesize and coalesce primary sources into a unifying whole toward the purpose of testing a general theory or answering a grand question." To be fair, few researchers venture into grand theory, perhaps because of the dearth of recent reviews, and perhaps because of the few notable exceptions have been eviscerated by their colleagues for their efforts. Sigmund Freud comes to mind. I have sometimes wondered if psychology's love-hate relationship with Freud resulted in an over-emphasis on induction and de-emphasis of deduction and construct validity.

Wood et al. appears to be testing a specific intervention using Cognitive Behavior Therapy (CBT). CBT purports to change feelings by changing thoughts.

While I prefer more psychodynamic conceptualizations, lets approach this issue of negative feelings from cognitive-behavioral point of view for purposes of demonstrating how relevent theory would aide in the interpretation of research. There is conceivable explanation of low self-esteem and associated negative emotion in the concept of "conditioned emotional response" or CER. A person may learn they are not valuable or important by, for example, an invalidating experience. That invalidating experience is remembered in at least two ways, by the facts of the event and by the associated emotions. According to current understanding of neurophysiology, memories of facts and emotions are kept in different part of the brain, presumably by different methods of storage with different processes of recall. The hippocampus and medial temporal lobe are involved in verbalized memories. Emotional memories involve the amygdala.

Sufficient invalidating experiences may lead to low self-esteem. Whenever a sufferer of low self-esteem remembers an invalidating experience or experiences a new one, she is likely to remember the event and feel the emotion associated with the experience.

In the Wood et al. experiment, the lowered mood and self-esteem are experienced after a validating experience. The subject feels the emotions associated with the original invalidating experience of invalidation perhaps because the positive self-talk controdicts the perception of the subject. Wood et al. makes that point. However, what she misses is that the subject is under going extinction of the conditioned emotional response. The subject is experiencing the emotion without the triggering invalidating experience. According to the theory of Classical Conditioning, repeated exposures to the emotion without the associated invalidation will eventually weaken the conditioning. Perhaps this process is complicated by the fact that the alternative experience, validation, is a close opposite to the conditioning stimulus, triggering a strong emotional response.

In my experience, this triggering of a strong negative emotional response associated with past destructive learning without the presence of the negative stimulus actually quickens the de-conditioning. What this experience amounts to is an abreaction, an emotional re-experiencing of the past event in a supportive and nurturing environment.

One point of the research is well taken. A person with an abysmal self-esteem reading a self-help book will find herself ruminating about how wrong it is that she could be so lovable. Such a person, supported only by herself, is not receiving the necessary nurturing due to her low self-esteem. She is likely re-conditioning the CER with more invalidating self-talk.

The reviews of this article did a fair job of presenting the study. However, there is risk in presenting research to a lay audience. The well written review by Yong had unintended consequences. The comments below the article contained some anquished and angry responses:

As a person with very low self-esteem who has been encouraged to think positively and love myself throughout my life, I can only thank Joanne Wood for publishing this study. Packaged one-size-fits-all programs promoting the personal pep talk only serve to make those people already in touch with their mediocre side more acutely aware of their non-value within society.

...and...

And when I feel unloved by one person even i feel like no one at all loves me or values me. How can I value myself when i feel like that. and after going thru a marriage where my ex always devalued me and everything i did if he did not approve of it. being abusive, verbally, mentally, emotionally, and physically... and even tho i have come a long way past this experience, it haunts me and i feel lower then dirt. no positive self talk makes me feel better, only makes me feel worse, cuz i figure if i don't actually believe what i am saying or thinking how can it possibly be true?

Unfortunately, some people with very low self-esteem have been reinforced in their belief that positive thinking can't help. Self-help is best read by the worried well. People with long standing issues with low self-esteem need psychotherapy. Both the authors, Wood et al., and reviewer, Yong, stated this clearly, the other two articles did not. Even so, this knowledge proved harmful to a few. I certainly do not fault the authors for this problem. Yong especially did a great job. One can't ensure everyone reads the entire article or even correctly understands it.

I believe we as professionals who write about mental health have a duty to be as clear and thorough as possible in an attempt to avoid confusion and inadvertant harm. But knowledge is powerful. Sometimes, knowledge mishandled can lead to worsening of symptoms that hopefully brings those in need to help.

Reference: Wood, J., Perunovic, W. Elaine, & Lee, J. (2009). Positive Self-Statements: Power for Some, Peril for Others Psychological Science DOI: 10.1111/j.1467-9280.2009.02370.x

Update 7/15/09: Joanne V. Wood, PhD responds to all the media hype about her research.

Recently, I exchanged messages with Michele Rosenthal, author of the blog, Parasites of the Mind. She asked me a very good question, one that is so much a part of my everyday work, a good long contemplation was needed just to tease out a good answer.

Speaking of inspiring, how do you inspire a client to believe in what he/she is doing? It's so difficult to believe in anything when PTSD has settled its big black cloud on your head.

Any general rules of the game for (self) empowering belief?

Another therapist, Mary Redoutey, joined our discussion and attempted to answer this question. She took the conventional route.

All therapy in essence is self empowered therapy.... The therapist is the partner in the process. I can sit in the chair in my office, can make suggestions, can teach, can do anything as much as I want... and nothing different will happen unless of course the client is present, listens somewhat attentively, suspends negativity long enough to experience a shift in feeling state and/or thoughts or actions.... And the work in the session does not transfer into the client's life unless the client chooses to make the necessary changes.

Essentially, Mary says that therapists don't change people, people can only change themselves. I have commented on a release for a new book that made this point as well. While it is true that what a client brings to therapy may account for much of the effectiveness of therapy, I don't think this is the core of Michelle's question. As I understand her question, she wants to know what the therapist brings to the therapy room.

My first attempt at replying was rooted in my daily routine. I'm always helping people understand how their past experience impinges on their current symptoms.

Consider what happens between mother and child. A child develops their self-concept initially based on how they are treated by their mother. In therapy, the therapist communicates his belief in the client. And if the connection already exists, a seed is planted. But as an adult, only the client can nurture the seed to germination and growth. The therapist can only teach them how.

Generally, when I take this tact, which is common with the childhood trauma survivors I see, I am helping them see the importance of exploring their childhood history and their relationships with their caregivers as a way to understand the origins of their symptoms. This is a much more specific answer that still only partly answers Michelle's question.

I think Michelle wants to know what is the therapists role in motivating a client in each and every step through therapy. In other words, what is the client getting from paid expert advice they can't get from a book? From Michelle's point of view, perceptions of her options are clouded by the rollercoaster existence that accompanies PTSD.

There has been extensive research on this topic. Most recently, much of this research has taken on a ideological fervor endorsing Cognitive Behavior Therapy (CBT). I've written often about my opinion CBT. Suffice it to say, CBT may be the core methodology in helping a client manage their thoughts and building treatment plans, but there is much more to behavior change than changing thoughts. One of CBT's central assumptions is patently false. Not all feelings are produced by or changable by thoughts. Much of our earliest learning occurs before thoughts begin to play a major role in our learning around the age of 8.

Patterson (1989) identified common specific factors recognized by virtually all schools of psychotherapy. He included therapist acceptance, permissiveness, warmth, respect, nonjudgmentalism, honesty, genuineness, and empathy or empathic understanding. Three of these, warmth, empathy, and genuineness have considerable research backing. In a previous article, Patterson (1984) points out:

There are few things in the field of psychology for which the evidence is so strong. The evidence for the necessity, if not the sufficiency, of the therapist conditions of accurate empathy, respect, or warmth, and therapeutic genuineness in incontrovertible.... The fact that specific change occurs in a therapeutic relationship without the addition of so-called specific techniques, such as interpretation, suggestion, instruction, etc., is also evidence of the sufficiency of the relationship by itself.

More recent research has found the competence of the therapist is critical. Verhofstadt et al. 2008, in their article about the value of emotional similarity and empathic accuracy in support giving with couples. They cite:

...mounting evidence that unskilled support can be ineffective or even harmful to the support recipient.... In summary, whereas matching the partner's emotion during a support-seeking interaction may provide a sufficient basis for understanding the partner's current affective state(s) and responding with appropriate emotional support and consolation, understanding the partner's specific thoughts and feelings during a support-seeking interaction may provide a sufficient basis for understanding what kind(s) of help the partner desires and how to provide such help in an acceptable way.

Successful therapists must be able to adapt to their clients' emotional uniqueness and to accurately perceive their thoughts and feelings to provide appropriate support in an acceptable way. Perhaps even more important, therapists must be perceptive and adaptive enough to understand the clients complaint that brought them to therapy and the nature of their quandary beyond the clients' own understanding, or the underlying problems. And having discovered what must be done, therapists must be able to provide the clients insight into their dilemma, provide a rationale for a course of action, and persuade their clients to make changes they are unlikely to find easy or achieve without significant discomfort. Initially, clients are often unable to understand the significance of their problems or nature and potential benefit of the required changes. If they did they wouldn't need therapy!

There is only one experience that I find cuts through virtually any dark cloud, and that is the touch of human empathy. When people who are overwhelmed by pain suddenly find someone who seems to understand how they feel, they no longer feel alone and abandoned by the world. A skilled therapist can provide more than the usual kind of empathy. After years of exploring the human condition, the therapist reaches within the client's experience that at least begins to provide some meaning to explain and place in context her experience.

Preston and de Waal (2002) describes the nature of human interaction as involving an exchange of complementary emotional and thought messages. These shared representations allow people to adjust their responses based on the communicated states of others suited to relieve each others' distress. (Cited in Gruhn et al., 2008)

Grillion et al. (2008) describe the emotional exchange between client and therapist and the unique skills required of the therapist.

When the context becomes safe enough for the client to lower his or her defenses, the alteration of regulatory structures becomes possible. The therapist's own self-regulatory movements reveal his or her inner states to the client. Much like the "good enough mother", the therapist's efforts to regulate his or her own inner states show the client that he or she is in contact with the client. Personal therapy for therapists helps to extend the range of experience that they can draw upon in their work with clients (Schore, 2006, cited in Grillion et al. (2008). According to Amini et al. (1996) the most effective interventions are based on the therapist's awareness of his or her own physical, emotional, and ideational responses to the client's veiled messages.

Accordingly, when the therapist has increasingly expanded self-integration and awareness in regard to his or her state of mind with respect to attachment, then he or she has a larger capacity for assisting clients to achieve integration and awareness. This understanding derives from the primary attachment relationship within the developmental psychobiological perspective in which parents who have secure or "earned" secure states of mind with respect to attachment function in certain ways (including attunement and sensitivity) with their infants that result in attachment security in their children. Therefore, from an attachment point of view, the more secure the therapist is, the greater the likelihood is that he or she can assist clients with achieving greater security (Beebe, 1998, cited in Grillion et al. (2008). Therapist self-awareness broadens "clinical intuition", which is referred to as the art of psychotherapy (Bugental, 1987; Schore, 2006; cited in Grillion et al. (2008).

Thus the relationship of between therapist and client is perhaps the second most important aspect therapy, right behind client characteristics and motivation. So it is critically important that the client has a good relationship with the therapist. Clients must be willing to shop around to make sure there is a good match. Cooper (2008, quoted in Croft, 2008) makes research based recommendations for finding the right therapist.

Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. Ask yourself whether you like your therapist and feel respected by them - the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process.

References

Croft, Alison. (2008, October 17). Clients, Not Practitioners, Make Therapy Work. Press release by the British Association For Counselling & Psychotherapy on a new book Cooper, Mick (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. In Medical News Today. Retrieved May 1, 2009, from http://www.medicalnewstoday.com/articles/125815.php.

Grillon, C., Pine, D., Lissek, S., Rabin, S., & Vythilingam, M. (2009). Increased Anxiety During Anticipation of Unpredictable Aversive Stimuli in Posttraumatic Stress Disorder but not in Generalized Anxiety Disorder Biological Psychiatry DOI: 10.1016/j.biopsych.2008.12.028

Grühn, D., Rebucal, K., Diehl, M., Lumley, M., & Labouvie-Vief, G. (2008). Empathy across the adult lifespan: Longitudinal and experience-sampling findings. Emotion, 8 (6), 753-765 DOI: 10.1037/a0014123

Patterson, C. H. (1984). Empathy Warmth And Genuiness In Psychotherapy: A Review Of Reviews. Psychotherapy, 21, 431-438

Patterson, C. H. (1986). Foundations For A Systematic Eclectic Psychotherapy. Psychotherapy, 29, 427-435

Verhofstadt, L., Buysse, A., Ickes, W., Davis, M., & Devoldre, I. (2008). Support provision in marriage: The role of emotional similarity and empathic accuracy. Emotion, 8 (6), 792-802 DOI: 10.1037/a0013976

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Since I heard of all the excitement in the therapy literature about forgiveness therapy, I've been a skeptic. I've worked with a lot of people who have experienced unforgivable abuse. Often they are tortured by their feelings of anger, resentment, helplessness, violation, and shame for allowing themselves to be a victim. They also feel guilt about their anger with the perpetrator so much so they feel morally obligated to forgive the perpetrator. When they do, they seem to feel no personal relief from forgiveness except for less anger and guilt and a better relationship with the perpetrator. But they seem no closer to recovery than before.

I work with persons with depression and anxiety, as well as long standing serious problems with relationships (personality disorder) due to growing up in a chaotic environment. So it is conceivable that forgiveness therapy may have been designed for a healthier population. Seeking to try to better understand this dilemma, I attended a great conference recently taught by Mary Hayes Grieco and colleagues on forgiveness therapy. From the conference flyer:

This day-long course is intended to introduce the counseling professional to a model of wholistic psychological health and an effective method for accomplishing forgiveness that is one of the most useful tools for therapy available today.

You will:

• review current research linking forgiveness with stress reduction


• learn the Psychosynthesis Model of psychological health and wholeness


• learn The Eight Steps of forgiving another and the steps of self forgiveness


• understand how forgiveness brings healing into a family system


• learn how forgiveness brings integration and closure to trauma survivors


• develop strategies for applying the eight steps of forgiveness in a clinical practice

The course material reflects the connection between spirituality and emotional healing but the content is inclusive and non-denominational. We will discuss how to incorporate these concepts appropriately in a secular setting.

It was a small class of 17. Mary and her three assistants seemed to thrive in a small group setting. The atmosphere was most comfortable for listening and it allowed Mary to shine with her skill of personal connection. I got a sense of her therapeutic leadership skills, her gentle and humorous style, and her amazing ability to instill hope with her gentle encouragement. Her eyes positively sparkle with warmth, confidence and belief in her method. She succeeds as well as anyone I've seen providing a secular foundation for spirituality even though her foundations are clearly religious.

She defines forgiveness functionally, rather than semantically. To forgive is to release an expectation that is causing one to suffer, to cancel a debt of demands and expectations that one is holding on to, and to dissolve an attachment that blocks one's flow of love and energy. This is not the moralistic obligatory forgiveness that seems to have locked many of my clients in place.

The core of her method follows:

The Eight Steps of Forgiveness of Another

1. State your will to make a change in attitude
2. Express your emotions about what happened
3. Cancel the expectation(s) you are holding in your mind
   • Shift expectation to positive preference
   • Acknowledge reality
   • Re-state your will to move on; open up to getting your needs met in a different way
   • Release the expectation with words and inner letting go
4. Open up to the Universe to receive exactly what you need
5. Sort out the boundaries: give them responsibility for their actions and take yours; visualize your personal space like a sphere of light around you
6. Send unconditional love to the person
7. See the good in them or in the situation
8. See the good

Notice the physical change and take time to gently integrate it.

Other authors have a bit more elaborate definition of forgiveness. Enright and Fitzgibbons (2000, p. 29), in their book Helping Clients Forgive, defines forgiveness as, after validating the person had been unfairly treated, a person chooses to forgive by willfully abandoning resentment (to which they have a right) and endeavor to respond to the wrongdoer based on the moral principal of beneficence (providing aid without thought of reciprocity or restitution), which may include compassion, unconditional worth (because he is human), generosity (in receiving more than what he deserves), and moral love (concern and respect to which the wrongdoer, by nature of the hurtful act or acts, has no right).

They also define what forgiveness is not: pardon, legal mercy, leniency, condoning, excusing, reconciliation, conciliation, justification, forgetting, restitution, forgiveness for self only. It is not the same as incomplete synonyms of letting time heal, abandoning resentment, possessing positive feelings, saying "i forgive you", making a decision to forgive. They also note confusing similar concepts. Forgiveness is not a quick fix for most. Acceptance and moving on doesn't involve how one feels about the offender. Nor is it in any way cloaked revenge.

Clearly, the forgiveness I had in mind is not what is described here. I had in mind the moralistic obligation to "turn the other cheek", something I've never understood. Mary confidently asserts in her brochure:

Recent research on the relationship of forgiveness to health and happiness demonstrates empirically what religions and philosophers have suggested throughout history: that forgiveness is necessary in order to find peace from life's hurts, losses and disappointments. The ability to move on is critical to completing the emotional healing process.

I think at this point I agree with everything but the use of the word "necessary". The literature review in the presentation gives a compelling argument for the value of forgiveness. But I don't believe I've seen a proof that it is necessary. What the method does contain seems to be a bit broader concept of change. Franz Alexander et al. (1946) defined "the corrective emotional experience:

In all forms of etiological psychotherapy, the basic therapeutic principle is the same: to re-expose the patient, under more favorable circumstances, to emotional situations which he could not handle in the past. The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.

In my clinical experience, there are two major obstacles to the effectiveness of forgiveness. Reed and Enright (2006) describes them well:

Women who have experienced spousal emotional abuse present at least two unique challenges for recovery. First, learned helplessness (Sackett & Saunders, 1999) develops as a pattern of self-blame in response to the criticism and ridicule by the abusive spouse and often remains well beyond the end of the abusive relationship (Dutton & Painter, 1993). "If only I had done this to please him" quickly deteriorates in the ongoing, unpredictable stress of the abusive relationship to "I am trying to prevent this, but nothing is working" and remains in a residual "Maybe I am worthless and none of my decisions are valid." Therefore, any treatment for these women should demonstrate outcomes in practical decision making and moral decision making....

Second, Seagull and Seagull (1991) described an obstacle to recovery for emotionally abused women labeled accusatory suffering, which entails maintaining resentment and victim status. The assumption in accusatory suffering is that healing the wounds of the abuse will somehow let the perpetrator off the hook. At a deeper level, accusatory suffering may be seen as a defense against the fear that the woman is somehow responsible for her own victimization, a fear that is often inculcated by the victimizer (Sackett & Saunders, 1999). Seagull and Seagull (1991) argued that although accusatory suffering (resentment and victim status) may function as a temporary strategy to help the woman adapt to the extreme experience of spousal emotional abuse, it seriously hinders substantial post-relationship, post-crisis recovery. Therefore, any treatment for these women should demonstrate a change in victim status.

Each of these two obstacles represent major challenges to clients from highly traumatic and abusive environments. The risk of attempting forgiveness prematurely potentially could lock in place both a sense of helplessness and personal responsibility. In that case, forgiveness removes the resentment and improves the broken relationship, it leaves in place the client's vulnerability to recurrence. Reed and Enright (2006) continues:

The FT client is encouraged to tell her own unique story of the abuse experience, with the purpose of working through this story to a healthy resolution that includes forgiveness. During the forgiveness process, the client does the hard work of uncovering anger and shame, grieving the undeserved pain from the abuse, and reframing the former partner (personal history, fallibility, and culpability, yet inherent human worth), with the purpose of relinquishing debilitating resentment.

Key here is the clients' ability to uncover and own their anger and, in particular, the underlying shame. The anger and resentment serves to both motivate the client to face her fears and change their circumstances, while protecting her sense of self from her underlying feeling of responsibility for having allowed the abuse and her own aggressive impulses to avenge their mistreatment. If the resentment is released prematurely, before the shame has been recognized and resolved, the client may be left will little emotional energy to move beyond self-loathing. From Greenberg and Pascual-Leone (2006):

maladaptive shame can be transformed into self-acceptance by accessing anger at violation, self-soothing, compassion, and pride. Thus, the action tendency to shrink into the ground in shame or to flee in fear is transformed by the tendency to thrust forward as part of newly accessed anger at violation or pride at accomplishment. This sequentially ordered pattern is what actually creates confidence.

Thus the negative emotion actually combines with natural positive emotions to trigger a transformation.

Consider this clinical description of a woman with possible borderline personality from Bridges (2006) who failed to respond with an emotional transformation.

Her general tone is one of blame, complaint, and resentment toward her husband for being away and enjoying himself while she is left to deal with the dog's illness. Yet, at no point does she mention that she is angry or even irritated. Her inability to put her anger into words and its relationship to her later waking with a "pain in the neck" almost cries out for interpretation. When she does mention her feelings, it is in regard to the puzzling, perhaps existential statement of feeling "nervous about living a lie." When the therapist makes an explicit attempt to inquire about her feelings related to the recent incident when she had started crying, she responds not by referring to her emotions but by instead focusing on legal details. The overall impression is one of the patient's skipping over the surface of her emotional life via her pressured, externally focused speech as a stone skips over the surface of water.

To summarize, this patient with a "venting" style displayed a pattern characterized by (1) high initial heart rate (HR) with little variability that gradually decreased from beginning to end of session; (2) rapid, incessant speech involving low-intensity expression of negative emotions, primarily complaint, resentment, and externalized blame of others; (3) very low levels of emotional processing (e.g., EXP < 2) characterized by an external focus on frustrating others and events with few references to their personal relevance or meaning or her immediate in-session experience; and (4) self-reports of experiencing intense negative emotions during sessions that were incongruent with her observable emotional behavior. One of the most surprising and interesting findings was that, on a purely physiological level, venting works! This patient showed an average decrease in heart rate from the beginning to end of each session of at least 18 beats per minute (bpm) for 9 of 12 sessions. If one were using progressive relaxation or desensitization and focusing only on decreased arousal as a measure, treatment would appear to be going very well indeed. Although this is obviously not the case, at least for this patient the opportunity to go to a session each week and "get out feelings" while experiencing a very real sense of physiological relief appeared to be very reinforcing in the short term but resulted in little if any long-term change.

So it's not as simple as venting one's anger about mistreatment, but venting reinforces the self-righteous anger by providing temporary emotional relief. To make a long lasting change, it is necessary to ferret out all underlying feelings as well. Resentment often defensively covers shame. The positive aspects of anger can be a strong motivator to transform shame into behavior change. Until this emotional transformation is complete, forgiveness is premature. It's most important to note, that adaptive negative emotions are at the core of movement in transformational therapy. Here anger serves as the energy to transform the shame into pride and confidence. The "debilitating resentment" Reed and Enright (2006) speaks of is not the core of being stuck. It's the shame of an often irrational sense of personal responsibility for ones own trauma and about aggressive impulses for revenge that is covered by the resentment and prevents recovery. Thus forgiveness of the other is not the primary ingredient, but forgiveness of one's self comes first.

Is forgiveness of the offender necessary? That I think depends more on the value system of the client. I believe an emotional transformation from maladaptive anger and shame to angry determination to make changes through self-encouragement and self-nurturance is the primary driver of recovery from trauma. Many of my clients seem to readily make the transformation from resentment to angry determination. Forgiveness, if it comes at all, comes as a consequence of the primary change, effortlessly, later on, as if part of a unforced natural process. Others feel an obligation to forgive and do so as a part of recovery. Unfortunately, too many go through a forgiveness process before they have made an emotional transformation. I find myself trying to encourage them to back track to their anger, which they thought they got over, so they can finally forgive themselves.

To be sure I'm pleased to have another important tool in the therapeutic tool box. However, given the acutity of the population I work with in a short term intensive program, there is probably little utility for full blown group forgiveness therapy. But at the very least I will be much more comfortable with a clients request that they wish to learn to forgive their victimizer.

References

Alexander, F. et al. (1946). Psychoanalytic Therapy: Principles and Application. New York: Ronald Press. Retrieved April 19, 2009, from http://www.psychomedia.it/pm/modther/probpsiter/alexan-2.htm.

Bridges, M. (2006). Activating the corrective emotional experience Journal of Clinical Psychology, 62 (5), 551-568 DOI: 10.1002/jclp.20248

Enright, Robert D. and Fitzgibbons, Richard P. (2000). Helping Clients Forgive - An Empirical Guide for Resolving Anger and Restoring Hope Washington DC: American Psychological Association IBSN: 1-55798-689-4

Greenberg, L., & Pascual-Leone, A. (2006). Emotion in psychotherapy: A practice-friendly research review Journal of Clinical Psychology, 62 (5), 611-630 DOI: 10.1002/jclp.20252

Reed, G., & Enright, R. (2006). The effects of forgiveness therapy on depression, anxiety, and posttraumatic stress for women after spousal emotional abuse. Journal of Consulting and Clinical Psychology, 74 (5), 920-929 DOI: 10.1037/0022-006X.74.5.920

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I have been really enjoying my access to a large number of professional journals over the past couple years. Working at a teaching hospital definitely has it's academic perks. I've been particularly gratified to see a growing sophistication in research methods, creative approaches and a maturing view of results.

Until recently, practice based research articles have often taken the form of providing some support for a therapist preferred approach to therapy. I can understand that, for I am too, highly invested in how I do and why I do it. But many if not most therapy based research describes a new fangled therapy with a new name. This sort of research seems to me to be more self-serving and contributing to a ever fracturing of psychological science. There are so many theories and therapy methods with rather limited clear definitions or research support, there is little opportunity for advancing knowledge of what works.

A new book was announced at the Annual Conference of the British Association For Counselling & Psychotherapy. Titled Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly, it is written by Professor Mick Cooper of the University of Strathclyde. The book is a research review focused on common factors successful therapy. "The book, which is the first reader-friendly summary of research findings in the field, also offers advice to people who are considering seeing a therapist, on their choice of practitioner and the best type of therapy available to them." The author concludes that the most important factor is a client who is motivated and actively involved in using therapy to build on his or her strengths. In addition, one of the best indicators of a positive therapeutic outcome is a strong relationship between therapist and client. These two factors are far more important than a therapist's ideology or particular techniques.

This is not news to those inside the field who have been paying attention. When I was in training in the late 70's, warmth, empathy, genuineness and humor were thought of as important therapist attibutes because they contributed to a good working relationship with the client. Then it was widely understood that psychologically minded persons, capable of abstraction, insight, self-reflection, and most importantly, with motivation to follow through on treatment outside of the session were found to be ideal candidates for therapy. Unfortunately, they were those least likely to need therapy!

Research took an ideological turn when Cognitive Behavior Therapy became the most thoroughly researched treatment method. And early claims were that results were consistently better than what they called "placebo". Now it seems, advocates, academia, even insurance companies are on the CBT bandwagon, tauting this one method as the only way to go. Even the British government has invested committed £170 million over three years to expanding the availability of CBT.

The trouble is that 20 years of research had complied an impressively large pile of research papers that document a very little differences in improvement when comparing CBT, every kind of manual defined treatment modality known to man. The author of the book argues:

Many clients will benefit from CBT but there is a danger in putting too much emphasis on the type of therapy that a therapist provides, rather than the therapist's ability to relate to his or her client in caring and understanding ways, and the needs and preferences of individual clients. Rather than moving towards a therapeutic 'monoculture', we need to be able to provide people with a range of therapies and therapists, so that they can choose the one that best suits them and build on their particular strengths.

[..]Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. Ask yourself whether you like your therapist and feel respected by them - the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process.

What a breath of fresh air!

Reading this book review reminded me of a number of articles I read a couple years ago linked to The Institute for the Study of Therapeutic Change (ISTC) founded by Scott Miller, Barry Duncan, and Mark Hubble. Their collaboration "resulted in several books and dozens of articles, and culminated in the APA best selling, The Heart and Soul of Change. As detailed in that book, the things that make therapy work are largely about the client--the true hero of therapeutic change--and the quality of the relationship formed with the therapist, far more important than model or technique."

Michael J. Lambert of Brigham Young University in 2005 published an article in the Journal of Clinical Psychology on common factors in effective psychotherapy. Lambert takes his argument down a creative path. He suggests that the attention placebo includes therapeutic effective common factors.

Placebo is a research concept that is most commonly used in pharmacological research. Basically, if you find a drug that most people find better than a sugar pill, you have a new product! There is a problem when you apply this concept to researching outcomes in psychotherapy. Just what is the therapy version of a sugar pill? A placebo for therapy outcome has been said to include life events, social support, hopeful expectations, and biochemical changes that accompany treatment and enhance immune function and biochemical balances that facilitate recovery. The problem is therapy is all about providing social support and hopeful expectations from the effectiveness of the therapeutic relationship, the so called "attention placebo."

The "social support, hopeful expectations" part of therapy are essentially the "attention" part of the placebo effect. Certainly this part of a placebo effect is an essential part of psychotherapy, not something to be merely separated or controlled from measurement of therapeutic effectiveness. Lambert effectively makes that point:

Placebo controls make less sense when extended to psychotherapy research because the benefits of treatments and placebos depend on psychological mechanisms. Many authors in the 1980s rejected the placebo concept in psychotherapy research because it is not conceptually consistent with testing the efficacy of psychological procedures (e.g., Dush, 1986; Horvath, 1988; Wilkins, 1984). Nevertheless, the search for causes of improved patient functioning within the traditional scientific method has persisted, albeit under a variety of different terms. Rosenthal and Frank (1956) defined a placebo as being theoretically inert. It is inert, however, only from the standpoint of the theory behind the therapy studied. As Critelli and Neumann (1984) have observed, "virtually every currently established psychotherapy would be considered inert, and therefore a placebo, from the viewpoint of other established theories of cure" (p. 33). Consequently, placebos have sometimes been labeled as nonspecific factors (e.g., Oei & Shuttlewood, 1996). This conceptualization raises serious questions about the definition of nonspecific. Once a nonspecific factor is labeled, does it then become a specific factor and fall outside the domain of a placebo effect? For example, if a variable like therapist warmth is operationally defined and measured does it then become a specific factor, but if not measured a nonspecific (i.e., placebo)? (Bowers & Clum, 1988). Others have suggested the term common factors as a replacement for terms like placebo and nonspecific, in recognition that many therapies have ingredients that are not unique but are nonetheless efficacious. Thus, research on placebo effects might be better conceptualized as research on common factors versus the specific effects of a particular and unique technique.

Common factors are those dimensions of the treatment setting (therapist, therapy, client) that are not specific to any particular technique. Research on the broader concept of common factors investigates causal mechanisms such as expectation for improvement, therapist confidence, and a therapeutic relationship that is characterized by trust, warmth, understanding, acceptance, kindness, and human wisdom. But also can be expanded to include some mechanisms that are often regarded as unique to a particular form of treatment such as exposure to anxiety-provoking stimuli, encouragement to participate in other risk-taking behavior (facing rather than avoiding situations that make the patient uncomfortable), and encouraging client efforts at mastery such as practicing and rehearsing behaviors. Such a view of common factors recognizes that while specific theories of psychotherapy may emphasize systematic in vivo or in vitro exposure to frightening situations, or social skills training, nearly all therapies encourage people to review and discuss the things they fear and face rather than avoid such situations. Common factors, no matter how unimportant they may be from the point of view of a particular theory (theoretically inert or trivial) are central to nearly all psychological interventions in practice, if not, theory.

Lambert's review reports one factor that is consistently found to be important to therapeutic effectiveness, the relationship between the therapist and the client. Most notably, outcome may be largely related to early response to treatment, before the core techniques have been implemented by the therapist.

At present, the active mechanism linking early response to long-term outcomes is unknown. Whatever the active ingredients are, they appear to work quickly in many cases. The timing of improvements during psychotherapy has theoretical implications beyond placebo explanations for change. If response to therapy precedes introduction of theoretically important techniques, then it is difficult to attribute central importance to these techniques in the healing process. Early responders to psychotherapy may be more resilient, better prepared, more motivated, and thus more receptive to therapeutic influences of any kind. Early response may also indicate a better fit between client and therapist and reflect the positive effects of the working alliance which often can be detected by the third session of treatment. For example, Krupnick et al. (2000) found that the relationship between the client and his or her therapist was most predictive of outcome. This finding is notable because the authors encountered this result across treatment modalities, including two distinct psychotherapies, as well as antidepressant medication, and placebo conditions.

This and a number of other research reviews make a persuasive argument that therapeutic technique is relatively unimportant in maximizing a positive outcome. CBT has been found to be minimally more effective than other therapy approaches. I could imagine how manualized treatment that is most common in these research studies may well minimize the early response factors Lambert mentions above. CBT, designed for a manualized approach, may be less susceptible to suppressing early responses and thus has a more consistent record of comparatively more positive outcomes. Since the magnitude of response when comparing outcomes across therapeutic techniques are minimal in most cases, it seems particularly unwise to attribute CBT with the best outcomes, especially since some of the most important factors related to therapeutic outcomes have been systematically controlled out or inadvertently suppressed by the manualized approach.

References:

Michael J. Lambert (2005). Early response in psychotherapy: Further evidence for the importance of common factors rather than "placebo effects" Journal of Clinical Psychology, 61 (7), 855-869 DOI: 10.1002/jclp.20130
Miller, S., & Duncan, B. (n.d.). "What Works" in Therapy? TalkingCure.com. Retrieved December 28, 2008, from http://www.talkingcure.com/reference.asp?id=100.

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Aaron Beck, considered the Father of Cognitive Therapy, is an American psychiatrist and a professor emeritus at the Department of Psychiatry at the University of Pennsylvania. He is President of the Beck Institute for Cognitive Therapy and Research that is directed by his daughter, Judith S. Beck, Ph.D.. He is noted for his research in psychotherapy, psychopathology, suicide, and psychometrics, and the Beck Depression Inventory (BDI), one of the most widely used instruments for measuring depression severity. At age 87, the man is still publishing, building on his pioneering work on the cognitive model of depression. In his latest article published in the American Journal of Psychiatry, he recalls his early work:

Caught up with the contagion of the times, I was prompted to start something on my own. I was particularly intrigued by the paradox of depression. This disorder appeared to violate the time-honored canons of human nature: the self-preservation instinct, the maternal instinct, the sexual instinct, and the pleasure principle. All of these normal human yearnings were dulled or reversed. Even vital biological functions like eating or sleeping were attenuated. The leading causal theory of depression at the time was the notion of inverted hostility. This seemed a reasonable, logical explanation if translated into a need to suffer. The need to punish one's self could account for the loss of pleasure, loss of libido, self-criticism, and suicidal wishes and would be triggered by guilt. I was drawn to conducting clinical research in depression because the field was wide open--and besides, I had a testable hypothesis.

I decided at first to make a foray into the "deepest" level: the dreams of depressed patients. I expected to find signs of more hostility in the dream content of depressed patients than nondepressed patients, but they actually showed less hostility. I did observe, however, that the dreams of depressed patients contained the themes of loss, defeat, rejection, and abandonment, and the dreamer was represented as defective or diseased. At first I assumed the idea that the negative themes in the dream content expressed the need to punish one's self (or "masochism"), but I was soon disabused of this notion. When encouraged to express hostility, my patients became more, not less, depressed. Further, in experiments, they reacted positively to success experiences and positive reinforcement when the "masochism" hypothesis predicted the opposite (summarized in Beck).

Some revealing observations helped to provide the basis for the subsequent cognitive model of depression. I noted that the dream content contained the same themes as the patients' conscious cognitions--their negative self-evaluations, expectancies, and memories--but in an exaggerated, more dramatic form. The depressive cognitions contained errors or distortions in the interpretations (or misinterpretations) of experience. What finally clinched the new model (for me) was our research finding that when the patients reappraised and corrected their misinterpretations, their depression started to lift and--in 10 or 12 sessions--would remit.

We owe a lot to Dr. Beck. His cognitive model of depression still dominates how I and most of my colleagues write treatment plans for persons suffering with depression. Our goal is to inspire and teach our clients to change their negative self-evaluations, correct distorted memories, and create an expectation of success. The only problem is depression is not that simple.

Try as they might, many clients are able to recognize what they need to do, understand how their thoughts about themselves and their world need to change, are able to state those changes, and diligently practice them. But when they really need to be able to master their fate, when ruminative thoughts spiral downward into the depths of depression, their efforts quickly collapse and they succumb.

So is the Cognitive Model of Depression wrong? No, I think it's incomplete. There is the biomedical model of depression involving errant neurotransmitter levels treated by various anti-depressants. That discussion is beyond this article's purpose. I'm more interested in what we as therapists can do differently in the counseling office. Of course we need to be sure a severely depressed client is referred for a medication review. But I want to know how we might better facilitate our clients attempts to master their mood. To this end, I will review my recent reading on the subject of emotion and argue to include emotion in a new Cognitive Theory.

Mindfulness is a very simple concept, but a skill that escapes a lot of people. Simply put, when we are mindful we act as an observer of our minds, our thoughts and feelings, without judging, or holding onto anything. The object is to be completely present in the moment, mostly focused on our senses, our eyes, ears, nose, and skin. Having complete faith in ourselves, we simply accept whatever comes, assuming we have all we need to cope with anything as best we can. Worry and regret becomes a major distraction from being mindful in that it distracts from our attention to what is happening now.

Jon Kabat-Zinn's stuff in the right sidebar provides great training material.

Mindfulness has wide application in treatment of anxiety, depression, mood regulation as well as crisis stabilization. Now it has been found helpful in managing pain.

HealthSkills Weblog

€˜Mindfulness meditation has a quieting effect on me. It gives me a peaceful feeling while doing it and I am able to reduce my back and leg pain by deflecting the pain and by focusing on other parts of my body€™.

It's also interesting that things like activity planning and exercise were not specifically included in the programme, but activity levels increased. As expected, acceptance of their situation increased, as did quality of life measures. Pain intensity reduced and '€˜global'€™ health and mental health [improved].

Shame has been a particular interest for me. It has appeared repeatedly as a major barrier in therapy, especially in those for whom therapy has failed in the past. It takes a lot of courage to re-enter therapy after feeling it was previously insufficient. Fortunately, a person returning to therapy after a less than satisfactory experience is significant motivated to try new ideas.

Agreeing to therapy is a humbling experience in and of itself. The American culture so values individualism, asking for help is often viewed as a sign of weakness, perhaps more likely by those who need help the most. I have previously written about the pervasiveness of shame in many long term issues I've seen in therapy. It's almost as if the person attempts to punish himself into change. But the misery extends well beyond what is helpful in motivating change into a self-imposed purgatory. Eventually, the person becomes so desperate to escape that they engage in self-destructive compulsive and addictive behaviors to temporarily escape the pain. Unfortunately, once the consequences of the escape behaviors becomes apparent, misery returns worse than before. This pattern of habitual and cyclical self-recrimination and escape could explain life long patterns of substance abuse and chronic maladjustment including depression. I've been finding some fascinating research that explores shame in therapy that has motivated some intensive research.

Hook and Andrews (2005) reviewed the literature on shame in therapy. They found that shame has recently been found associated with onset and course in depression, especially in chronic and recurrent depression. Personality traits that evoked shame were "as likely to be consequences or concomitants of depression as they were to be precursors." They speculated that "feeling ashamed of personal qualities and behaviors may lead to a chronic course of the disorder by affecting disclosure of the issues involved, thereby impeding therapeutic progress".

Hook and Andrews (2005) also studied questionnaire data of self-described persons who suffered from depression to "examine relationships between shame, disclosure in therapy, and current symptoms...." Of the study's 85 respondents, 54% withheld significant information from their therapist, 42% withheld information related to depressive symptoms and behaviors. Nearly 3/4 of respondents who withheld information said they did so because of shame. Most intriguing, those who were no longer in therapy who also had not disclosing depressive symptom/behaviors had significantly higher depressive symptoms currently than other participants. The study combined with the article's review of the literature, found that "significant relationships have been established between shame-proneness and non-disclosure of symptoms/behaviors in both therapy groups, and of this type of non-disclosure and current depression symptoms in those no longer in therapy."

This is the kind of research I can bring back to work tomorrow and use. It also appears to be a research approach and topic I may be able to emulate. One point they make in the discussion is that while many authors have spoken against assessing shame directly, "if one does not ask, one does not find out about such experiences". And the information that might be withheld otherwise would likely involve depressive symptoms and related behaviors. This finding replicates a previous study of women with eating disorders, which found a significant association between non-disclosure in therapy and shame that involved eating disorder symptoms. I have tended to teach my clients to expect that they will find that those things they most wish not to share are likely to be need disclosure and work to assure a good outcome in therapy.

Another interesting twist in the discussion was an attempt at explaining why "disclosure of symptoms may be more important for depression recovery than disclosure of other upsetting issues and experiences. One explanation is suggested by evidence from Pennebaker and Beall’s (1986) study that disclosure of feelings confers more benefit on long-term health than disclosure of purely factual information." Does that sound clinically sound or what? Ever had a client not want to share the details of a particularly shameful event? I've had some good success encouraging them to share the feelings about the event and how it affected them later, while leaving out the details.

This article is both inspiring of my interest in research as well as immediately practical in clinical applications. I'm going to be digging through this bibliography next week.

Hook, A., Andrews, B. (2005). The relationship of non-disclosure in therapy to shame and depression. British Journal of Clinical Psychology, 44(3), 425-438. DOI: 10.1348/014466505X34165

BPS RESEARCH DIGEST reviews recent research articles in professional journals. It's a good place to try to keep up with the literature. It has been a pleasant surprise indeed that many psychodynamic principles have recently demonstrated in research. Unconscious motivations, emotion based early learning have repeatedly been demonstrated. Now I was pleased to find the begins of a research demonstration of one of the most important insights into the obstacles for change that emerge in therapy: the labeling effects of diagnosis and the self-destructive nature of shame.

Psychological outcome research tends to follow the same model, matching therapy to diagnosis. The client is again little more than the holder of the diagnosis and the subject of the therapy: their individual decisions and personality are rarely considered (again, except where these are part of the diagnosis or lead to non-compliance).

Contrary to notions of the 'miracle therapy' or 'super-shrink', recent research suggests that the client contributes as much to the chances of a successful outcome in therapy as either the therapist or their technique. In fact, client factors may predict more of the outcome than therapeutic rapport and technique combined.

Anne Hook and Bernice Andrews (2005) surveyed people who had received psychological therapy for depression. Half of the current clients and a third of ex-clients reported withholding some information about their depressive symptoms (e.g. low self worth, suicidal thoughts) and behaviour (e.g. substance abuse, aggression) from their therapist.

The main reason given for withholding information was shame. People who had concealed symptoms were more depressed on completion of therapy than those who had 'revealed all'.

As their previous research had linked a tendency to feel shame to higher levels of depression, this seems a fairly obvious result: shame and related non-disclosure are simply part of the clinical picture of depression.

I like to describe shame as the self-destructive expression of guilt, the natural feeling associated with making a mistake that serves to motivate self-assessment and behavior change. Shame goes much further. A person who feels shame believes that their mistake is another demonstration of how much of a hopeless loser they are. Ultimately it becomes the core of a chronic self-loathing that leads on-going disappointment, discouragement and a sense of being a victim to one's own ineptitude, with no hope of change.

Shame provides the motivation for much long standing self-destructive and self-defeating behavior. If a person feels overwhelming shame after making a mistake, they are unable to examine their personal responsibility closely so as to facilitate behavior change. It's too painful. Instead, they engage in ruminative self-punishment that robs the individual of any remain energy to do the examination or make any changes. Such penance, because it goes well beyond a symbolic act of contrition leads to long standing self-destructive patterns of behavior. Misery extends well beyond what is helpful in motivating change into a self-imposed purgatory.

Eventually, the person becomes so desperate to escape that they engage in compulsive behaviors, what I call "temporary feel goods." These behaviors include drug and alcohol abuse, excessive gambling, or any bad habit, taken in isolation may appear harmless enough, but when it is routinely used to escape self-motivating misery, it creates problems that complicate the picture dramatically. Other behaviors are more obviously self-destructive such as sexual addictions, raging and controlling angry behavior and violence, self-injurious behavior, compulsive spending, or excessive risk taking like speeding. Even seemingly innocuous behavior like day dreaming, fantasizing, or computer game playing can take up tremendous amount of time and energy in interfere with productive functioning. That just leads to more misery, more shame and more escapist self-destructive behavior.

Breaking the pattern is more than just a matter of "cognitive restructuring". A shame-based person may already recognize their self-destructive ways. But some inner compulsion drives this incessant self-punishment. I've found that the source of much of this shame comes from early emotion-based learning, the learning that occurs in early often during school age and pre-school experiences. Another source is abuse and neglect, especially from parents or other caregivers, but can also come from abusive adolescent/adult relationships. Another common source is trauma survivors. There is strong association between the severity of PTSD and shame-based ruminations about the trauma. Feeling somehow responsible for witnessed trauma can be particularly debilitating.

Emotional learning has been conceived by Freud as internal conflict and by behaviorists as "conditioned emotional responses." Such learning is particularly persistent and difficult to change. Making those changes often looks like what has been called "reprogramming" treatment of cult and brainwashing survivors. A repeatedly revisiting of the traumatic event, or intensive prolonged exposure, has been shown to be particularly effective in changing the shame-based patterns associated with PTSD. (Journal of Consulting and Clinical Psychology 2006, Vol. 74, No. 5, 898-907, Journal of Consulting and Clinical Psychology 2007, Vol. 75, No. 3, 409-421). Gut wrenching recollection of childhood and traumatic events allows learning new emotional responses to future eliciting events.

BPS RESEARCH DIGEST

"In other words, our data suggest that effort and hard work offer the most promising route to happiness. In contrast, simply altering one's superficial circumstances (assuming they are already reasonably good) may have little lasting effect on well-being.

Temporary feel goods are just that. The only way to happiness is hard and persistent work on our difficulties.

Tripped over a great post from Just Noticeable Differences on the "Vienna Psychoanalyic Society". Organized by Freud as a support group for his students, it eventually launched the careers of the first dissenters from his orthodox view of psychiatry. In retrospect, Freud got a lot of attention perhaps because of his preoccupation with what many people confused with sex. Yes, sex was included in his concepts if the ID. His definition of sex included sensuality of all kinds. He called certain sensations "sexual" because of the pleasurable sensations the body produced when satisfying these sensuous urges.

I've always thought the Adler was the father of modern psychology, he received none of the recognition. This article makes this point well. A good read.

Mental illness is less understood than most people think. Common sense would have it that good parenting makes all the difference. It's just not that simple. The NY Times has a great series on "Troubled Children" that is well worth the read. The articles include some good background on the nature of mental illness and it's development.

Today six million American children have been diagnosed with a serious mental disorders, a number that has tripled since the early 1990's.

But that doesn't mean that the rates of illness have increased in the past few decades. Rather, it is the decease in stigma of seeking help and that more professionals and parents are willing to attribute problems with children to mental illness. ADHD and Bipolar illness is diagnosed with alarming frequency these days, clearly an indication of misdiagnosis in both the past and the present.

From the NY Times series:

Still, many psychiatrists believe that, although childhood bipolar disorder may be real in families like the Finns, it is being wildly over-diagnosed. One of the largest continuing surveys of mental illness in children, tracking 4,500 children ages 9 to 13, found no cases of full-blown bipolar disorder and only a few children with the mild flights of excessive energy that could be considered nascent bipolar disorder -- a small fraction of the 1 percent or so some psychiatrists say may suffer from the disease.

Moreover, the symptoms diagnosed as bipolar disorder in children often bear little resemblance to those in adults. Instead, the children's moods seem to flip on and off like a stoplight throughout the day, and their upswings often look to some psychiatrists more like extreme agitation than euphoria.

[...]The children in one group, a minority, have mood cycles similar to those of adults with bipolar disorder, complete with grandiose moods, and a high likelihood of having a family history of the illness. Those in the other group have severe problems regulating their moods and little family history, and may have some other psychiatric disorder instead.

[...]Last year in the United States, about 1.6 million children and teenagers -- 280,000 of them under age 10 -- were given at least two psychiatric drugs in combination, according to an analysis performed by Medco Health Solutions at the request of The New York Times. More than 500,000 were prescribed at least three psychiatric drugs. More than 160,000 got at least four medications together, the analysis found.

Many psychiatrists and parents believe that such drug combinations, often referred to as drug cocktails, help. But there is virtually no scientific evidence to justify this multiplication of pills, researchers say. A few studies have shown that a combination of two drugs can be helpful in adult patients, but the evidence in children is scant. And there is no evidence at all -- "zero," "zip," "nil," experts said -- that combining three or more drugs is appropriate or even effective in children or adults.

Diagnosis is very complicated, largely because the whole concept is a rather crude way to explain all the varieties of behavioral disorders into a linear and causal model of mental illness that will facilitate treatment planning. Unfortunately, diagnosis and treatment is more like shaping Jello without a mold.

The human body doesn't work in a linear way. There is no simple way to describe a step-by-step process of disease development and no simply way to ensure an accurate way to prescribe treatment. Instead, the body, while a whole in itself, it is too complex to be thought of as one interacting system. The best we can do is break it up into parts and posit hypotheses about how parts might function. Our model of brain function, mental illness and treatment has fallen behind our knowledge. Worse yet, economics has pushed medicine to embrace a simple solution for a very complex problem. Giving a patient a pill sometimes works. It's so simple and cheap to do, if one pill doesn't work, another pill is offered, sometimes replacing the first, sometimes adding to it.

Frankly the state of our science doesn't really support the first pill, much less the second. There is growing evidence that therapy is as effective as the primary treatment or at least in combination with medications.

Psychotherapy has had it's own problem with linear thinking. There is more research on Cognitive Behavior Therapy, showing it as effective or more so than all other treatments, so the assumption is made that since the practice of CBT is "evidence-based", that it must be the treatment of choice. CBT is a simple straight forward process that can often be encapsulated into a manual. But there is no consistent evidence that CBT is any better than any other treatment. There is a dearth of meaningful comparison studies.

The problem is that mental health treatment is not amenable to meaningful research. Mental illness often has life long process of ebbs and flow where only part of the time is it "clinically" treatable, but it's roots and symptoms are pervasive throughout the lifespan. Studies are necessarily time limited. Treatments are offered most often for no more than six months and then outcomes are measured. Not surprisingly, treatment is demonstrated as disappointingly little more effective than "placebo". A placebo is a an intervention, such as giving the patient some helpful attention, which might reasonably be seen as helpful by a patient but there no reason to believe it should be as effective as the studied treatment. But the placebo is pretty effective itself, much more so than sitting on a waiting list for treatment.

Lets take a fresh look at the model of mental health, illness and behavioral science. Lets simplify the model from the biological realities but not so much as a singular linear model of one sequence of events producing an outcome. Actually, I've found it useful to conceive of the mind as having two main parts. One part is largely made up by the cortex, or the evolutionary most recently developed brain function. It's this part of the brain that is largely responsible for manipulating symbols, interpreting and remembering patterns of perceptions, and self-awareness and self-monitoring.

The cortex overlies a phylogenetically older part of the brain that largely makes up the autonomic nervous system. In this part of the brain, the body functions largely "automatically" with little interaction with the cortex. Here the heart is stimulated to beat, breath is maintained, pain sensors are monitored and automatic behaviors like walking and steering a car is monitored, largely without conscious awareness. Here is also the roots of our emotions, the biochemical and hormonal precursors to the thoughts whose symbolic representations we create to understand our emotions.

The cortex is the thinking part of the brain. The autonomic nervous system is the emotional and functionally analogic part of the brain. That part of us we imagine as "rational" or "logical" largely resides in the cortex. Those parts of us that are instantly compelled to act out of sheer emotion reside in the autonomic brain. Virtually all of our behavior is in fact the result of BOTH parts of the brain. So it is equally inaccurate to call our behaviors as rational manifestations or solely emotionally based. Our behavior is largely the result of both parts of us.

So, given this, its not surprising that there are times we wonder why we behave certain ways, or why we know we need to make a change, but mysteriously find ourselves unable to do so. While our awareness directs most functions of the rational cortex, we have relatively little "rational" control over the autonomic brain.

Traditionally, culture has attempted to explain this as a mind/soul duality. Judeo/Christian tradition posits that the primitive nature of humanity must be overcome by suppression of our autonomic impulses. Freud developed that concept into his scientific systemic model of the id (autonomic), ego (awareness), and superego (conscience). His concepts led to the idea that suppressed impulses caused problems, internal conflicts, that were manifested in dysfunctional behavior.

I think it's much more useful to think of the body as a functional whole that emerged from millions of years of natural section into a amazingly effective organism. I'd rather assume that ALL parts of us are as necessary to survival as any one. On an experiential basis, this requires a leap of faith. Ambivalence is an uncomfortable condition. Our mind is known to do all sorts of convenient fictional explanations of motives and their behavioral manifestations in attempt to maintain an illusion of rationality. One such example is cognitive dissonance.

In order to make use of our incredibly effective brain, we must be aware of as many of it's manifestations as is possible. We must recognize and be able to put into words emotions as complex and varied as our thoughts. We must also accept the fact that our thoughts and emotions OFTEN contradict each other, but in a real and very personal sense, both are right. Both parts of the brain learn their reactions. They also are born with reactions characteristic of the genes they inherit. Environmental insults, such as neuro-toxins and brain trauma can alter both parts of the brain structurally and functionally.

My assumption is that we function best when we make the most of everything we have. Marsha Linehan in developing Dialectical Behavior Therapy, took a similar view. The "Wise Mind" was conceived of as a combination of "Emotion Mind" and "Rational Mind". This all may seem simplistic and convenient thinking, but from a clinical stand point, the concepts work quite well.

Cognitive learning is the most available for change. We think, therefore we do. If we change how we think, we change what we do. However, everyone knows from their last New Year's resolution that it's not that simple for the many behaviors we want to change.

Our culture has developed the concept of "character" to explain how some people can change and others cannot. Character is largely thought to be genetically determined. That makes the non-thinking part of us to be very difficult and unlikely to change. Indeed, that has been the bias of psychiatry for many years. Diagnostically, Personality Disorders are roughly equivalent to the common concept of character. Though, psychological developmental models have demonstrated that nurture has quite a bit of influence over nature, it is still largely assumed personality is unchangeable. Medicare and many other insurance companies won't pay for treatment based on a diagnosis of a Personality Disorder.

But we do know from Behavior Theory that even reflexive behavior like salivating, heart rate and emotions can be learned and unlearned. Personality Disorders are assumed to be so pervasive and embedded in lifestyle and biochemistry to be largely untreatable. However, those of us who have worked a lot with persons with personality disorders know that they can change with knowledge and sustained effort and lifestyle change.

Personality Disorders seem to emerge from unfortunate childhood events, child abuse, neglect, or trauma, especially repeated trauma and chaotic lifestyles in the parents or caregivers. Parents with personality disorders beget children who grow up similarly impaired. While the actual behavioral style and sensitivity to the environment may well be genetically determined, the behavior is largely learned by emotional conditioning.

In Behavior Theory, a strong emotion creates a unique learning sequence. Elicit a strong emotion, with say a loud noise, the person will be strongly motivated to do something. They may jump in a startle response. But the person will also learn approach or avoidance behavior, based on the valence of the emotion, rewarding or punishing. Then, when you pair a neutral environmental stimulus with the intense emotion, eventually, just the neutral stimulus acquires the emotion eliciting effects of the original.

When a child grows up in a chaotic environment, she experiences strong emotions all the time. She is likely to also learn approach and avoidance behaviors in a way that is often random associated with unrelated environmental events. She is said to have learned "superstitious" behavior. Unlearning this behavior is a major challenge. That is because emotional learning is in a way "hardwired" in the autonomic brain. Representations of the environment are paired with an emotional responses outside of her cognitive awareness. She develops persistent bad habits that over time pile up into patterns of dysfunctional behaviors and can become a Personality Disorder.

Treatment of a Personality Disorder must address the behavior, often manifested in a characteristic lifestyle, the thoughts and attitudes of the individual, and the emotional responses that together drive the behavior. The basic paradigm of therapy becomes conditioned emotional responses described above and must be repeated over and over again, with the cooperation of the individual during periods of withering emotions. Not surprisingly, few volunteer for this sort of treatment until things become intolerable. The other problem, is that few clinicians offer this sort of treatment. Despite it's grounding in Behavior Therapy, this is not mainstream CBT. DBT covers some of the same ground, but the experiential notion of making changes in the context of strong emotions seems to be absent.

Traditional psychoanalytic therapy has used "abreaction" for many years. Crisis intervention theory also had a similar concept. But neither of these models claim that the method is effective with long standing chronic psychopathology. Marsha Linehan's DBT is the one of the few treatments that claim to be effective with personality disorders, especially borderline personality disorder. Although Linehan's model continues the tradition of encouraging suppression of excessive emotion by teaching incompatible behaviors, it does encourage patients to be "mindful" of their emotions and to combine them with rational thought for wisdom.

Why aren't more people doing this? There is several reasons. There is little recent theoretical formulations beyond Linehan's that support this approach. Current concepts of crisis intervention emphasize stabilization as the goal. In fact, virtually all the insurance company criteria for termination of mental health treatment call for stabilization of symptoms, rather than permanent behavior change! This is the same reasoning that got psychiatry stuck on handing out pills first.

Medication is often a helpful option. But given the recent highlight on suicidality with anti-depressants, side-effects of all medications, especially anti-psychotics, psychotherapy seems a prudent course to start and use medication adjunctively, rather than the other way around.

The National Health Service in Britain has adopted Cognitive Behavior Therapy (CBT) as the first choice treatment for depression and anxiety. Collective experience is that medication is very expensive and has disappointing results.

The article from Times Online argues that CBT has trouble maintaining results in the long run. However, the issue isn't what therapy works best, it's about what therapy works best for whom. Anti-depressant medications and CBT has the most impressive outcomes, but these measurements seldom look at long-term outcomes.

Anti-depressants in my experience take the edge off of depressive symptoms for most people. CBT offers a good set of skills for clients to learn that enable them to redirect their thoughts and change their feelings on a moment to moment basis. These are critically important skills that everyone can benefit from.

Some depression and anxiety have deeper causes. A history of abuse, neglect, or signficant or repeated trauma can very much complicate the treatment of all mental illness. Recovery from trauma is a long difficult road, as has been demonstrated by the recent studies about war veterans with post-traumatic stress disorder. Cognitive skills training, medication, insight oriented therapy that often involves intensive reworking of emotional memories. Teaching an insightful understanding of emotions and their context and their meaning and how one can cope becomes an important, painful and time consuming part of treatment. While long term psychotherapy may be indicated in a few cases, episodic returns to therapy may be necessary over many years to learn how to cope.

The problem with interpreting research and it's appearance in the news contributes to misunderstanding because treatment of mental illness is about helping individuals. It's hard to draw broad sweeping conclusions about treatment and creating policy that allows for exceptions. Policy can never replace the assessment of the individual clinician.

Times Online

According to the most authoritative sources, at least half those patients receiving CBT for panic disorder had suffered relapse or sought new help after 24 months, which isn’t very cost effective.

Last Monday, at a conference on Practice-Based Commissioning in Manchester, Professor Layard admitted that CBT is appropriate for only about 40 per cent of patients overall. Stunningly, the largest body of evidence into counselling outcomes, the 35,000 cases comprising the CORE Survey, has been totally ignored by NICE and Layard alike. Looking at the figures just for depression, CORE shows there is no significant difference in the long-term success rates for CBT over traditional forms of therapy such as “person-centred” or “psycho-dynamic”: CBT works for 75 per cent of patients; the rest for 76 per cent.

So a summary of the evidence tends to show that alll talking treatments are roughly equal in effectiveness because it is the relationship with the therapist that counts. MORE

On-line education with chat room support for eating disorders, on-line self-help support for depression, on-line treatment for panic disorder, on-line and phone-based help for sexual problems, and phone therapy with miscarriage sufferers have been recently studied as reported in recent journal articles. While this is exciting and concerning at the same time, these studies is only a beginning of a new area of research in providing mental health services.

I'm committed to having some part in this process and hope you will join me in this effort by visiting ePsyQ.com supporting our efforts in whatever way you can. If you can only join Top Health Sites and display our banner on your site that's great! If you want to list your health service and/or spread the word about the FREE listing at ePsyQ.com Health Directory, fabulous! If you can join in the discussion and development of this project, all the better. Hope to see you soon on ePsyQ.com!

Mental health counseling given over the phone may ease some women's depression symptoms after a miscarriage, a small pilot study suggests. The therapy was offered to women with "subsyndromal" depression, which is less severe than major clinical depression but still causes significant symptoms -- such as sleep disturbances, chronic lack of energy, appetite changes and feelings of hopelessness.

Past studies have shown that women who suffer a miscarriage are at risk not only of major depression, but of the considerably more common subsyndromal depression as well.

This latest study, reported in the Journal of Clinical Psychiatry, was a pilot project testing whether phone-based counseling could help women with milder depression following a miscarriage. Such therapy aims to overcome some of the obstacles that keep people from in-person mental health counseling, like lack of time or reluctance to talk face-to-face. Of the 19 women researchers followed, those who received counseling over the phone a handful of times showed a greater decline in depression symptoms. MORE

Thanks for Psych Central for the links.

Cognitive Behavior Therapy (CBT) has become "THE" evidenced-based psychotherapy. The National Association of Cognitive-Behavioral Therapists explains what that means.

Cognitive-behavioral therapy is the most researched psychotherapeutic approach because:

• each cognitive-behavioral approach has specific techniques that can be tested for effectiveness;
• CBT encourages the development of specific goals that are measurable, and, therefore, can be researched;
• cognitive-behavioral therapists (to varying degrees) are interested in the research and research process;
• cognitive-behavioral therapists are not interested in techniques that "feel right" or "seem correct", but techniques that are effective.

If that were all true, then there would be no issue, everyone would start doing CBT. Here is a great post from Anxiety Insights.

It is hailed as a quick fix for depression, schizophrenia, ME - even infertility. Now the government sees it as the answer to Britain's widespread mental health problem. So what is cognitive behavioural therapy? And does it really work?

There is no doubt that CBT has the weight of scientific evidence behind it when compared with other forms of psychotherapy, such as the let-them-talk-freely ideas of Rogerian counseling or psychodynamic therapy, which tend to be much harder to subject to clinical trials because of their more nebulous nature.

But while there are few, if any, mental health specialists prepared to dismiss CBT out of hand, there are a significant number of experts who feel that CBT is being grossly oversold. The primary objection seems to be that it doesn't work for everybody (not even nearly, say some), and that this one-size-fits-all approach may ride roughshod over more traditional forms of therapy which can be just as - if not more -worthwhile in many cases.

Ok, so what is all the controversy? CBT can be considered an ideology of treatment, or it can be seen as a structure within which all therapy functions. In a way, most therapists providing time-limited psychotherapy under standards set by insurance companies are providing CBT under a broad definition. Insurance companies require therapists to help the client set goals in an Individual treatment plan that are measurable. In other words, someone other than the therapist and the client can see the goal has been accomplished. You might ask, "how can I see that I'm feeling better?" Well, you may smile more. You may report you are feeling better, i.e. the symptoms you presented to the therapist when you agreed to therapy have improved.

Ultimately, in my experience, most of the time, both clients and therapists hope that the clients behavior will change. When asking them after the fact, both will agree at least part of what they were working on was changing the thoughts the client had about their situation in hopes that would improve their feelings and behavior.

These two criteria, measurable goals, and a focus on behavior change, describe a broad definition of "CBT" authorized for payment by insurance companies.

The National Association of Cognitive-Behavioral Therapists defines CBT much more narrowly. Let's go through their definition, point by point.

What is Cognitive-Behavioral Therapy? [Also here.]

Cognitive-Behavioral Therapy is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do. Cognitive-behavioral therapist teach that when our brains are healthy, it is our thinking that causes us to feel and act the way we do. Therefore, if we are experiencing unwanted feelings and behaviors, it is important to identify the thinking that is causing the feelings / behaviors and to learn how to replace this thinking with thoughts that lead to more desirable reactions.

There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy.

However, most cognitive-behavioral therapies have the following characteristics: 1. CBT is based on the Cognitive Model of Emotional Response. Cognitive-behavioral therapy is based on the scientific fact that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change.

Well, that sounds reasonable, but a bit contrary to common beliefs. If changing our thoughts change our feelings and behavior, we ought to be able to memorize new beliefs and we're done! Anyone who has tried to make a New Year's resolution or quit cigarettes know that it's just not that simple.

2. CBT is Briefer and Time-Limited. Cognitive-behavioral therapy is considered among the "fastest" in terms of results obtained. The average number of sessions clients receive (across all types of problems) is only 16. Other forms of therapy, like psychoanalysis, can take years. What enables CBT to be briefer is its highly instructional nature and the fact that it makes use of homework assignments.

I know from my stint in Clinical management, that average number of sessions for most therapists in places I worked varied from 5 to 10. Only a few of therapists I worked with would call themselves practitioners of CBT. Sixteen is probably a good number of sessions when a client should expect to have experienced significant improvement. If not, they need to consider seeing another therapist or at least a major change in the treatment plan.

My therapeutic experience suggests that many if not most of the most needy clients don't have the where-with-all to complete a homework assignment without taking the time to educate and redirect motivation for several sessions.

3. A sound therapeutic relationship is necessary for effective therapy, but not the focus. Some forms of therapy assume that the main reason people get better in therapy is because of the positive relationship between the therapist and client. Cognitive-behavioral therapists believe it is important to have a good, trusting relationship, but that is not enough. CBT therapists believe that the clients change when they learn to think differently; therefore, CBT therapists focus on teaching rational self-counseling skills.

Now this assumption seems to match common sense. Of course, one would expect the working relationship with the therapist to be important, but not the primary reason therapy works. The problem is that research suggests it's not that simple. In a previous post I briefly mentioned a concept called the attention placebo. The placebo is essentially the part of the therapeutic situation that is not the treatment being measured. Think about that. Everything about the therapy is intended to be helpful. How can you separated one part from another? Common sense, again, is correct. It's not easy and deceptively complex.

Rehm in the American Psychological Association Journal Prevention & Treatment. 5(1), July 2002, described the attention placebo as life events, social support, hopeful expectations, and biochemical changes that accompany treatment and enhance immune function and biochemical balances that facilitate recovery. Research has generally demonstrated that the attention placebo has a substantial therapeutic effect. In an article written by Michael Lambert in JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 61(7), 855–869 (2005), he states,

Evidence is presented demonstrating that placebo control groups benefit more from psychotherapy than no-treatment control groups but less than patients who receive theory-driven treatments.

In my previous post, my point was slightly different.

While I understand the argument that without a placebo control, one can never hope to measure the effect of treatment attributable to medication alone. However, imagine if a patient picked up his medication from a grumpy, shaming pharmacist, do you think the medication would be as effective? I think not. The placebo effect is as integral a part of treatment as the medication.

All indications are that the relationship with the therapist, whose personality is as unique as you or I, is inseparable from the particular therapy provided. The methods used even in CBT are inseparable from the personality and style of the therapist.

Lets get back to the definition of CBT.

4. CBT is a collaborative effort between the therapist and the client. Cognitive-behavioral therapists seek to learn what their clients want out of life (their goals) and then help their clients achieve those goals. The therapist's role is to listen, teach, and encourage, while the client's roles is to express concerns, learn, and implement that learning.

With the exception of one choice of word, I think most therapists would agree with this statement. Helping a client to work on "what they want out of life" is a sure way to extend therapy from 16 sessions towards the years that psychoanalysis often requires. Lets settle on the phrase in parentheses, "their goals". Items 6, 8, 9 and 10 are essentially non-controversial and enjoy a near universal application in various therapeutic ideologies.

5. CBT is based on stoic philosophy. Cognitive-behavioral therapy does not tell people how they should feel. However, most people seeking therapy do not want to feel they way they do. CBT teaches the benefits of feeling, at worst, calm when confronted with undesirable situations. It also emphasizes the fact that we have our undesirable situations whether we are upset about them or not. If we are upset about our problems, we have two problems -- the problem, and our upset about it. Most sane people want to have the fewest number of problems possible.

Again, the definition seems to fly in the face of common sense, and also contradicts item 4 in the definition. In my experience, people come to therapy feeling miserable. People who are stoic, out of touch with their feelings, may not even have a good idea why they are miserable. Their primary goal is to feel better. A CBT therapist claims to have ready a redefinition of the client's primary goal. Recall item 1 in the definition and my response. Thoughts are suppose to have total control over our feelings and behavior. The fact is that, from a physiological point of view, there are many kinds of thoughts and feelings, only some of which are directly available to us at anyone one moment. Behavior is controlled by a bio-chemical process we are only beginning to understand in a very rudimentary way.

Westen in his article in journal Psychological Bulletin November 1998 Vol. 124, No. 3, 333-371 published by the American Psychological Association, makes a spirited and thorough explication of how unconscious thoughts and feelings affect our behavior every day, with little or no direct access to immediate change as suggested by CBT. I'll only give one example of the research cited in his lengthy literature review.

Shedler, Mayman, and Manis (1993) studied participants in two studies with illusory mental health, who reported themselves to be free of psychological distress and symptomatology but whose descriptions of their early memories (a projective measure) were rated as showing signs of psychological disturbance. Participants underwent a mildly stressful procedure that can be disturbing to someone who is highly defensive (reading aloud, performing a phrase association test, or providing projective stories). Those participants who viewed themselves as healthy but showed unconscious evidence of distress in their early memories were significantly more reactive on a measure of cardiac reactivity related to heart disease than participants who were either low or high on both measures of distress. They also showed more indirect signs of anxiety (such as stammering, sighing, and avoiding the content of the stimulus) while simultaneously declaring themselves to be the least anxious during these tasks.

Goleman in his book Emotional Intelligence (1995, Bantam Books, New York) says:

Unconscious opinions are emotional memories and are stored in the amygdala. The dry facts of the emotional memory are stored in the hippocampus. The amygdala stimulates the adrenal gland to ensure an intense response to the memory. The more intense the stimulation, the stronger the imprint.

During at least the first year or two of life, this is the primary memory function. These early memories become the rough blueprints for future emotional life.

Goleman does a good job of citing the literature supporting his assertion. Clearly our conscious thoughts do not control all feelings and behavior. Nor will changing our conscious thoughts always change our feelings and behavior.

Item seven is the last I will comment on.

7. CBT is structured and directive. Cognitive-behavioral therapists have a specific agenda for each session. Specific techniques / concepts are taught during each session. CBT focuses on helping the client achieve the goals they have set. CBT is directive in that respect. However, CBT therapists do not tell their clients what to do -- rather, they teach their clients how to do.

This item and it's reliance on homework makes it pretty clear that CBT was designed to treat relatively healthy individuals with only a couple problems that need addressing for which the client willingly cooperates with working on one goal at a time. In my experience, most of the clients I've seen have chaotic lives. I can't count on planning an agenda for a session. While I may bring a list of items I'd like to cover, I check in with the client first and usually find our time directed to a new incident in the past week or so.

CBT is clearly not the new "Coca Cola". It does provide a good broad structure to conceive of therapy with measurable goals, stepwise progress and thoughts, feelings and behavior change as preferred outcomes. In that sense, it makes all such therapy "evidence-based."