C is for Cognitive Behaviour Therapy (CBT)

Cognition is so important in terms of mental health. It is the whole basis of cognitive behaviour therapy (CBT). The belief in CBT is that your life experiences consist of five components; environment (past and present), thoughts, moods, behaviours and physical reactions. These components are all interconnected and a change in one can influence the others. Although adjustments in all five areas are probably needed to improve mental health, CBT puts the emphasis on your thoughts. Thinking patterns are thought to be most important when trying to make lasting positive changes in your life. A change in thought patterns from the usual negative to more positive and constructive can cause similar changes in the other components.

Of course, it isn’t as easy as it sounds. Your negative thoughts are automatic. You have to actively identify them and then use a strategy to combat them. I like to use logic. What are the facts? What information do I have to support my thoughts? What is the proof? I use previous experiences too. What has happened in similar situation? How did I cope? What have I learned that will help me this time? You have to work at it before it becomes natural. CBT has really helped me manage anxiety and perfectionism.

Then, there is depression. My issue is self-loathing. I hate the way I look, I’m not successful, I am inadequate. These are my thoughts. I know they are negative and I know I need to combat them. There is nothing wrong with the way I look. I get compliments, no one calls me ugly. I am successful. I am a Ph.D. candidate, that can’t be a failure. I am adequate. I am a good person, I work hard, I try to lead a balanced life. That is adequate. I have re-framed my negative thoughts into more positive ones. I realize my self-loathing is irrational and there are no flaws in my logic, so why do I feel worse?

The whole thing creates a conflict in my head. I know my thoughts are irrational, but logic is not enough to change the way I feel. It seems like I am lying to myself. Not only that, but I am a failure because I can’t get CBT to work for me. I gave up on therapy for a while because of this. Only after doing my own research and talking to the mental health community online did I figure out there were other forms of therapy I hadn’t tried. I guess CBT is either the front line in terms of talk therapy or it was for my specific case. All the clinicians I worked with wanted to go in that direction.

Here is a list of some of the other options.

• Psychoanalysis – This was developed by everyone’s favourite psychologist, Freud (note the sarcasm here) and is where the whole lying on the couch thing came from. It is intense, several sessions a week are required. It focuses on bring unconscious thoughts and behaviours to the surface.
• Interpersonal Therapy (IPT) – This one examines the relationships in your life. There is a focus on communication and may involve role playing with the therapist.
• Dialectical Behaviour Therapy (DBT) – This is centered around the discussion of opposing views and work on how to balance the two extremes. There are usually individual and group sessions. This form of therapy is often recommended for Borderline Personality Disorder.
• Mindfulness-based Therapy – It is focused on talking and mediation. Its purpose is to reduce stress and prevent a relapse in depression
• Eye Movement Desensitization and Reprocessing (EMDR) – This method stimulates the brain through eye movements intending to make distressing memories less intense.
• Life Coaching – The focus is on hopes and ambitions. It uses empowering and motivational methods to reach goals and make changes in life.
• Arts-based Therapies – Involves expression through various art forms, visual arts being the most common. The aim is to help you release emotions and understand yourself better.
• Bibliotherapy – The use of self-help books.
• Acceptance and Commitment Therapy (ACT) – Uses acceptance and mindfulness strategies to increase psychological flexibility.
• Hypnotherapy – Uses hypnosis to modify behaviour, emotional content and attitude.
• Somatic Psychology – Focuses on the link between mind and body. It teaches you to become more aware of the physical body and how the mind interacts with it.
• Humanistic Therapy – The focus is on the person as a whole. It explores your relationship with different parts of yourself (emotions, behaviours, mind, body, etc.).
• Existential Therapy – It is a holistic therapy that considers depression the result of how you make sense of yourself and the world around you.
• Compassion Focused Therapy (CFT) – This is usually recommended for those that have high levels of shame and self-criticism. It has Buddhist and evolutionary elements.

My psychiatrist recommended I try DBT next. I was supposed to start in January. In the mean time I have been art journaling and I have a couple self-help books on ACT and mindfulness.

Did you know there were so many different types of talk therapy? Do you have experience with any of these therapies? What do you think is the best approach? Is medication the more important element?

B is for Biological Basis

Mental health problems are frustrating because it is hard to classify them as having a biological or psychological basis. I know there has to be some psychological component, mental illnesses are diagnosed based on behaviour after all. I am hoping for some solid research showing depression and other mental health issues have a biological basis though. If the cause is in my biology, there isn’t much I could have done to have prevented it. It is not in my control. I am not to blame. A psychological basis would imply that my behaviour is the problem. I am responsible for my behaviour and so I am to blame, or so society dictates. Calling depression a brain malfunction would minimize the shame I feel when I have to explain myself. I don’t want people to feel sorry for me, but I don’t want them to always wonder why I don’t just snap out of it either.

There is support for both the biological and psychological sides. Since mental processes are carried out by the brain, all disorders of mental function are biological. Just like the lungs are the organs for breathing, the brain is the organ for the mind. Where else could mental illness be if not the brain? Not so long ago, we didn’t know that much about how the lungs worked. All doctors could do for respiratory disease were observe physiological presentation and listen to patient complaints. Today, there are all sorts of tests to measure lung function. The same principles apply to the brain, we just don’t know enough about it yet.

On the flip side, some go to extremes, arguing that everything from mental illness, to criminality and sexual orientation are seen less as a matter of choice than a genetic destiny. Mental health problems could be the result of normal personality traits coming together in such a way to make functioning in today’s world difficult. One scientist compared the brain to a computer and mental processing to the software. There can be a bug in the software that prevents things from running smoothly, but the hardware is still fine.

What do you think? Do mental illnesses fall into one of two distinct categories (psychological vs. biological), or do they exist on a continuum having different percentages of biological and psychological contributions?

Recent research posed similar questions to clinicians (psychiatrists, psychologists and social workers) to determine their beliefs on the causes of mental illness. I would like to know what my psychiatrist thinks. After all, his beliefs would probably have an effect on my therapy and may determine whether or not he prescribes medication and which medication it would be. The study showed that clinicians tend to look at mental health problems across a spectrum of biological to psychological rather than categorical. They believe disorders with a larger biological component would respond best to medication, while those with a larger psychological component would respond better to therapy.

They didn’t show all 445 identified mental illnesses on this spectrum, but they did show 9 familiar ones. I looked up my primary diagnosis, depression, on the graph and it was right smack in the middle. Clinicians viewed depression as having biological and psychological contributions that were almost even. Darn. Other diagnoses like bipolar and bulimia were more clear cut in clinician minds, showing larger biological and psychological components respectively.

It turns out the biological basis I was hoping would explain my depression is a double-edged sword. Although the average person would probably be more compassionate about a brain malfunction, clinicians would be less so. This study showed clinicians felt more compassion towards those with mental health problems thought to be caused by psychological factors. Researchers thought perhaps the emphasis on biology was dehumanizing, causing the patient to be viewed as more of a biological mechanism than a person.

Regardless of the beliefs of clinicians or those of society in general, I think we can all agree, the more we understand about all components of mental illness, the better.

Resources: Ahn, Proctor and Flanagan, 2009

When CBT Fails

I like cognitive behaviour therapy (CBT). It makes sense. It helps a lot with my anxiety and perfectionist tendencies. The idea is to change false automatic thoughts (cognitive distortions) and make them more realistic, constructive and positive. My favourite method of combating cognitive distortions is looking at reality. What are the facts? What information sustains my conclusion? What is the proof? For example, during the fall, I had my comprehensive exams for my Ph.D. I had to defend my research proposal among other things. I was being really hard on myself and feeling miserable. I was thinking that I was never going to be able to think of all the angles, the experts would find holes in my proposal and think I’m an idiot. The cognitive distortion here is mind reading. I’m assuming I know what the others are thinking and thus being hard on myself and making myself anxious. In reality, I can’t really know what they are thinking. The purpose of these exams is to solve any major problems in my theory before I get started. No one person can think of everything, that’s why there are four different experts coming to evaluate my idea. They probably wont think I’m an idiot either, I’m a student, my purpose is to learn. Besides, I can’t be the worst Ph.D. candidate there ever was. Here, I relied on logic to talk myself down from a situation that I was making myself sick over.

Sometimes though, logic isn’t enough, I wish it were.. Something can make all the sense in the world, but when you are depressed it doesn’t matter, logic is not enough to change the way you feel. When I try to apply CBT strategies to depression, it feels empty, like I am lying to myself. I know a lot of my problems come from low self-esteem. Is low self-esteem interchangeable with hating yourself? Right now I really hate myself. I hate myself so much I don’t know how to continue existing. I am overwhelmed with anger towards myself. My skin is crawling with hatred. I can’t bare to look in the mirror or hear my own voice. I hate the things I say and the thoughts I have. I’m too ashamed to go out in public and be seen by strangers, never mind people I actually know.

I know this hatred toward myself is irrational. I am not a bad person, most people say I am kind. I’m not on People magazine’s most beautiful people, but no one calls me ugly, except for myself. I’m not too fat or too thin, I wear the clothes that are right for me. I have friends and people who love me. I have the right number of achievements for someone my age. There is no reason for me to despise myself so, yet I do.

I don’t always hate myself. Sometimes I’m fine and I don’t think about how I feel about myself at all. Other times, this wave of loathing washes over me and all I can do is be angry and/or cry. My logical self knows the way I feel is irrational, so I don’t act on it. I know it will pass and I’ll go back to not thinking about it. I try to use CBT to undo my distorted view of myself, but it feels fake and is not changing the way I feel.Why isn’t the logic enough to make me feel differently?

I don’t know what to do with myself when this happens. I usually try to distract myself somehow. Sometimes it works, sometimes it doesn’t. Eventually, the day ends and I climb in to bed and hope that sleep takes me away from myself.

Do you ever feel this way? What do you do?

W is for Worth

Sometimes I feel worthless. I can’t do anything right, I have no talent, I’m useless. I don’t deserve the air I breathe. For some people, this self-hate is ironed into you. This is how you think and what you tell yourself everyday. No wonder everything seems pointless.

I was feeling like this during one of my appointments with a psychologist. She told me to write two lists. One of all the screw-ups I’ve had and the second of all my accomplishments. She told me to look at the big things and the little things. She said that my list of accomplishments would come out longer. This would make me feel better. So I did my homework. The screw-ups came easily, but I had to really think about the accomplishments. My lists came out dead even! So that exercise back-fired. Oh well, she meant well.

Psych was determined though, so she had another suggestion at my next appointment. She told me to ask at least two people to write down a list of the things they valued about me. I felt stupid asking people to do this, but I did it anyway. You can’t accuse me of not trying here! I asked my mother and my husband to write lists. I gave them a week and went to my next psych appointment with the lists in hand. Psych and I went over the lists together. They listed about 15 things each. Very few of the things they listed had anything to do with how I look or what I’ve accomplished. This is how I usually evaluate myself, on my appearance and accomplishments. Maybe I’m going about this wrong if the people I care about most don’t evaluate me that way? The lists were very similar. Two people said I was kind and generous. I think I’m selfish. It’s kind of hard to argue against what two people think of me. So maybe there’s some truth to it?

I kept the lists. I keep them for emergencies when I start to hate myself again. It’s a good reminder that appearance and career accomplishments aren’t the be all and end all. Anyway, the point is, these lists got me thinking. They not only made me feel better about myself, but they caused me to gain a new perspective on worth.

My cat, Ewok, doesn’t have an income, in fact she costs money. She doesn’t contribute to housework, she gets fluff all over the place. She mostly curls up in a ball and sleeps all day, yet I consider her valuable. Other people have plants that they take care of. They do so because the plant has worth to them. Maybe we expect too much of ourselves. We shouldn’t have to be the best, to make lots of money or have many accomplishments to be important. Sure we would all like to, but we can’t all be number one! Animals and plants don’t do any of these things. Yet, they are given worth just for existing. Shouldn’t we give ourselves the same consideration?

I never really thought about it that way before. It makes a lot of sense to me.

Your worth is a given because you exist.