Sunday, October 23, 2016

What you need to know about social anxiety and treatment options for your and your family...

I have two jobs: therapy and writing.  I tend not to mix the two, but I do write features for newspapers and magazines that discuss mental health issues.

Last month I went to a seminar run by Michael Eysenck, the psychologist who's noted for his work in the field of anxiety (if you're older, you might remember his dad who was a personality researcher).

As a result of that, I wrote a piece about social anxiety and I found some excellent Malaysian experts to weigh in on treatment options.

You can read Are You Suffering From Anxiety for free here, in The Star...

Friday, October 7, 2016

Visualisation, meditation, and mindfulness in therapy


This is a long one, so grab a cup of coffee, okay?

Most people who see me come out of desperation.  They’re depressed, anxious and stressed.  To complicate matters, many suffer from guilt. They think that it’s “weak” to ask for help or that they’ve somehow brought their troubles onto themselves. 

Let me say right away that I think it’s perfectly sensible to ask for help.  After all, when your car isn’t right, you talk to a mechanic.  If your shoe’s leaking, you talk to a cobbler. So when you’re not yourself, why not ask a therapist for an opinion?  Sensible, right?  Right!

So once we get that out of the way, we start discussing what’s going on. Although it varies from case to case, a typical assessment with me takes about two hours and includes:
·        A suicide inventory
·        A depression inventory
·        A stress inventory
·        A discussion on sleep history
·        A discussion of personal health
·        A discussion of family health
·        A discussion about your attitudes and needs from therapy

At the end of it, I will give you a quick overview of my first impressions.  Then I go off and analyse everything in detail.  I spend a couple of days drawing up a personal plan for you that explains where you are, identifies your goals, and that sets out in detail the steps that have to be taken to get to your goals.

On paper that all sounds okay but in practice it means that between your emailing me to say, “Help!  I need you, NOW!” and actually getting down to getting a plan in place takes time.

Not nice when you’re already stressed!

So when we talk the first time, I often teach a simple relaxation technique called visualisation. It’s designed to help get you started into managing your stress and depression easily and quickly.

What is visualisation?
Visualisation is about forming a mental image. I ask clients to remember a time when they were particularly calm or happy.  We discuss that incidence, and then rebuild the scene, complete with scents, sounds, textures and actions.

They close their eyes, and we talk ourselves into the scene. I usually make a tape and send it to them, so that they can start off listening to it.  Over time, they become practiced and can pull up the image effortlessly when they feel stressed.

Visualisation is not the same as mindfulness or meditation. Visualisation is just about recreating a mental image of a time and place.

Mindfulness is about focusing on the now, opening your sense, and acknowledging and accepting your feelings and thoughts.

Meditation is like mindfulness, but it’s more focussed on a specific goal, like building compassion. Often it comes with prescribed systems of thought.

Mystic mumbojumbo
Now, as I said last time, I’m an evidence-based practitioner so you may be wondering why I’m promoting a technique like visualisation that appears to come straight from the mystic.

I’ve always been interested in how meditation and prayer affect the mind. In fact, I have a certificate in clinical hypnotherapy, something I picked up hoping to discover more about the process. 

Unfortunately the course I took didn’t work out too well.  I was hoping to learn about modern research such as the magnetic resonance imaging (MRI) studies by people like Sara Lazar from Harvard University. Sadly, what we got was mostly gobbledegook and pseudoscience.

You’d think from all the press about how wonderful mindfulness is that there’s some good studies out there validating the claims made every day in articles.  However, that is not the case.

I’m not going to bore you with a laundry list, but here are my three top concerns about current literature on the subject.

1. Too small. Many studies that promote meditation and mindfulness are very small, typically with less than 30 people. This means that meaningful statistical analysis of results is extremely difficult.

2. No control groups. There are too many studies without control groups. In a proper study, half the people would use meditation or mindfulness and the other half not. It’s the best way to rate effectiveness.

3. Bad design. A lot of studies don’t actually study the effects of mindfulness or meditation.

Cognitive Behavioural Therapy (CBT) is a standard technique used for depression management. CBT involves analysing patterns of thoughts and behaviour. The idea is that you have beliefs that influence your thoughts and these prompt action.

Put in a nutshell, CBT works like this:

When you come in for therapy you’re like this
Belief: wasps are dangerous,
Thought when you see a wasp: this dangerous beast will sting me,
Behaviour: run away.

With therapy you change this to
Belief: wasps are nature’s most effective guardians, killing off pests,
Thought when you see a wasp: this is a beautiful and useful animal,
Behaviour: say “Awwwwww, cute!” and admire the wasp.

I ought to be shot for reducing CBT in this way, but for our purposes, it’s good enough.  You can read a proper article about how CBT works here

From what I see, many studies investigating the use of meditation and mindfulness use plain old CBT and throw in a bit of meditation. The study then says it’s testing the meditation and mindfulness - ignoring the possibility that it’s good old-fashioned therapy that’s working and the rest is just glam and glitter.

Having said that, there are a few studies that are well designed, and well conducted, that hint at some promising ideas.

One of these is the Harvard study I mentioned earlier.  You can read ithere but basically the study looked at two groups, one that took a Mindfulness-Based Stress Reduction course and one that didn’t.  MRIs showed that the group who took the course ended up boosting grey matter concentration in their hippocampus, an area of the brain that’s associated with emotional control. 

Another good study (read it here) comparing 22 people who practised meditation and 22 people as the control group found similar results.

There are a few more, but really not enough to say there’s rock solid evidence, However, it’s interesting and I’m curious about further work in this area. After all, emotional control is central to managing depression and stress.

Dangers of meditation and mindfulness
You might ask why I don’t just chuck in mindfulness on top of CBT and be done with it. The problem is that other studies have found that meditation and mindfulness can be dangerous and that some practitioners say that it’s often misrepresented or misunderstood.  You can read about that here and here

This makes perfect sense to me. You see, depression and stress tend to cause cognitive biases, a fancy way of saying that it messes with your mind.

People who are depressed and stressed typically focus more on the negative rather than the positive. You’ve seen this yourself: when nine good things happen, someone who is down focuses on the one thing that went wrong.

Another by-product is feeling that you’re somehow secretly a bad person.  Also, many people feel there’s a devil on their shoulder, whispering that everyone hates them.

As you might expect, when you ask someone who’s already feeling bad to focus on the “true inner you” for an hour you’re not going to have them coming back to you and saying, “I’m a wonderful human being and I love all my precious flaws”.  What you’re much more likely to get is a self hating wreck who’s just remembered every mistake they’ve ever made in their lives. Possibly a suicidal wreck.

This effect is well discussed in rumination studies. You can read an overview of that here.

Another concern I have about mindfulness and meditation is that if you’re studying the kind that leads to distancing yourself, you might miss the opportunity for analysing and understanding your emotions and therefore miss the opportunity to manage them better. I haven’t seen good studies on this, but it’s something I worry about.

So what’s the bottom line?
Generally speaking, I see Buddhists and Hindus in Malaysia work rather carefully with this subject. Those who are devout do talk about the different types of systems, and they discuss methods that should be avoided if you’re stressed or depressed. Frankly, I don’t know enough about the ins and outs of it to comment at that level of detail.

While I’m interested in mindfulness and meditation, as I’ve said before, I’m an atheist so the prayer part of certain meditation systems pass me by.  I’m also not a spiritual person.  I tend to be practical. I’m telling you this because you should know my limitations.

So if you’re not yourself, I would err on the side of caution and suggest you avoid any kind of meditation or mindfulness that encourages rumination.

However, I think that a little short visualisation of a pleasant scene or image can’t do any harm. It’s the equivalent of looking at a sunset, or of eating an ice-cream.

Finally, there’s a cross-cultural element at work here. For my clients who come from the Middle East and Asia, visualisation is familiar and comforting. It also comes naturally, so it’s already part of their mental health toolbox.

For me, therapy is about helping people make effective change to reach their goals.  It should be safe and as painless as possible.  However, it’s not always easy to make decisions about approaches. That is why I discuss the pros and cons with clients whom I think will benefit before we get into it. Then I let them decide what they want to do.

What do you think?