September 10th: Worldwide Suicide Prevention Day.

Today is World Suicide Prevention Day.

In Canada, suicide is the leading cause of non-natural deaths.

The stigma of mental illness, and the many barriers to getting help, mean that people often don't get the help that they need and deserve.

It's our job to make it easier for people to come forward and find the resources that they need. Spread the word, do your part to reduce stigma, and support those who require help.

More info here: link.

Here To Help BC: link.

The Vancouver Crisis Centre: link.

And a powerful video from the Movember Foundation Canada (link):

Many people go without the help they want and need.

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Over the years, there's been a lot of discussion and debate about funding for psychotherapy. Currently, psychologists in Canada are not covered by government-funded health care plans.

While some extended health care plans do provide coverage, it's usually limited. Also, many people do not have access to those sorts of plans. This leaves a lot of people paying out of pocket. For many, it's worth it as their quality of life after treatment will be much, much better.

A recent study, described in the link, shows that in BC, way too many people struggling with depression go without the care that they want and need (both medication and psychotherapy).

Some quotes from the CBC:

"The study's authors found that, of all British Columbians diagnosed with depression, only 53 per cent received the minimum baseline of treatment."
"They found that only 47 per cent of those prescribed antidepressants received them for 12 weeks, and only 13 per cent received four therapy sessions.
Puyat said the actual number of depressed people receiving inadequate care is likely much higher than the study found, since the study only considered patients who sought treatment, and many people do not."

You can read the rest of the article here: link.

Why negative emotions are important.

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We all experience negative emotions and on a pretty regular basis. For some people, they're persistent and too intense. This can be an awful and unmanageable place to be. Often times, people will try various ways to achieve some sort of relief or to escape their negative emotions, but these strategies usually backfire or make things worse.

I've worked with clients who initially believe that therapy success means no longer feeling negative emotions. And you can understand why - they've been suffering and want it to end. But that's not the goal, as negative emotions serve an important function for us. Also, we're stuck with them. *Caveat: this isn't to say that negative emotions can't become more manageable and less debilitating for those who suffer.*

Negative emotions (and positive emotions, too) tell us important things about what's going on. Anger tells us that something unfair or unjust is happening. Sadness tells us that we're experiencing loss. Anxiety means that there is threat that needs to be addressed. Shame indicates that we've acted in a way that contradicts our values. Emotions motivate us to act, which is a good thing.

This piece delves into negative emotions and why we need to embrace them. It's a helpful read.

From Scientific America:

Negative Emotions Are Key to Well-Being
Feeling sad, mad, critical or otherwise awful? Surprise: negative emotions are essential for mental health
By Tori Rodriguez
A client sits before me, seeking help untangling his relationship problems. As a psychotherapist, I strive to be warm, nonjudgmental and encouraging. I am a bit unsettled, then, when in the midst of describing his painful experiences, he says, “I'm sorry for being so negative.”
A crucial goal of therapy is to learn to acknowledge and express a full range of emotions, and here was a client apologizing for doing just that. In my psychotherapy practice, many of my clients struggle with highly distressing emotions, such as extreme anger, or with suicidal thoughts. In recent years I have noticed an increase in the number of people who also feel guilty or ashamed about what they perceive to be negativity. Such reactions undoubtedly stem from our culture's overriding bias toward positive thinking. Although positive emotions are worth cultivating, problems arise when people start believing they must be upbeat all the time.

Read the rest here: link.

Doing things on your own can be pleasurable, too.

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Social connections are clearly crucial for the vast majority of people. There's a huge pile of research demonstrating that social isolation has an immense negative impact on well-being. Social connections help buffer us against all sorts of negative experiences and make it easier to cope. They also provide value and meaning to us.

People with depression and anxiety (among other things), tend to have reduced social connections. Isolation contributes to, and results from, anxiety and depression. It's a vicious circle of feeling shitty and avoiding social contact.

But what about spending time alone for those who aren't badly depressed or anxious?

Being able to be content alone appears to be important to us, too. Strong discomfort with being alone can be a red flag.

This short piece on being alone reviews an interesting set of studies which demonstrate that many people are comfortable doing things on their own but choose not to. It's related to a fear of being judged (i.e., what a loser), and the prediction that doing things alone will be less enjoyable. Neither, it turns out, are true.

From the Atlantic:

The Unexpected Pleasure of Doing Things Alone
People avoid going out by themselves because they think they'll appear antisocial, but it turns out they'll end up having a lot more fun than they expected.
By Joe Pinsker
Two years ago, a Dutch creative agency opened a concept restaurant in Amsterdam that would be, in the words of its founder, “the perfect place to dine in pleasant solitude.” The restaurant is called Eenmaal—this name has been translated into English as “dinner for one”—and was launched in an attempt to start dissolving the stigma attached to going out alone. Apparently picking up on the same cultural drift, a new fast-casual restaurant in Washington, D.C., has tiered, bench-like seating with individual trays, an arrangement that caters to solo diners.
As antisocial as those ideas may sound, it’s surprising that the world hasn’t seen more of them. Today, more than a quarter of American households are home to just one person—a figure that has tripled since 1970. Also, the median age at which Americans get married has recently reached a record high. Given these demographic shifts, one would think that by now, going out to the movies or to dinner alone wouldn’t be the radical acts they still are.

Read the rest here: link.

Learning to be resilient.

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Life has a tendency to mess with the program, from bad hair days all the way through to extreme types of trauma.

A growing body of research shows that when confronted with adversity, how people think about the adversity, and themselves in relation to the adversity, can have a striking effect on their ability to cope and overcome. In other words, what makes us more or less resilient is how we think.

Not everybody is born resilient this way, but there’s now good evidence that resilience can be cultivated and learned. Sounds good, right?

From the New Yorker:

How People Learn to Become Resilient
By Maria Konnikova
Norman Garmezy, a developmental psychologist and clinician at the University of Minnesota, met thousands of children in his four decades of research. But one boy in particular stuck with him. He was nine years old, with an alcoholic mother and an absent father. Each day, he would arrive at school with the exact same sandwich: two slices of bread with nothing in between. At home, there was no other food available, and no one to make any. Even so, Garmezy would later recall, the boy wanted to make sure that “no one would feel pity for him and no one would know the ineptitude of his mother.” Each day, without fail, he would walk in with a smile on his face and a “bread sandwich” tucked into his bag.
The boy with the bread sandwich was part of a special group of children. He belonged to a cohort of kids—the first of many—whom Garmezy would go on to identify as succeeding, even excelling, despite incredibly difficult circumstances. These were the children who exhibited a trait Garmezy would later identify as “resilience.” (He is widely credited with being the first to study the concept in an experimental setting.) Over many years, Garmezy would visit schools across the country, focussing on those in economically depressed areas, and follow a standard protocol. He would set up meetings with the principal, along with a school social worker or nurse, and pose the same question: Were there any children whose backgrounds had initially raised red flags—kids who seemed likely to become problem kids—who had instead become, surprisingly, a source of pride? “What I was saying was, ‘Can you identify stressed children who are making it here in your school?’ “ Garmezy said, in a 1999 interview. “There would be a long pause after my inquiry before the answer came. If I had said, ‘Do you have kids in this school who seem to be troubled?,’ there wouldn’t have been a moment’s delay. But to be asked about children who were adaptive and good citizens in the school and making it even though they had come out of very disturbed backgrounds—that was a new sort of inquiry. That’s the way we began.”

Read the rest here: link.

Feeling overwhelmed or stuck? This one tool might be what you need.

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Sometimes when feeling stuck or overwhelmed with negative emotions, it’s really difficult to act in a way that is most effective or helpful. Often, our behaviour is dictated by a strong instinct to escape or reduce those negative emotions (e.g., anxiety, fear, shame, anger, guilt, etc.). But, in trying to feel better in the short-term, we may act in ways that are not the best for us in the long-term. We might even make things worse.

Say, for example, that you’re struggling in a relationship – it might be a friendship, an intimate relationship, or a relationship at work. Perhaps there’s an ongoing conflict and anger, or you’re having difficulties setting boundaries, saying no, or asking for what you want. Maybe you’re really anxious. You may be tempted to distance yourself from that person, or avoid having the conversations that you need to have to improve things. In distancing or avoiding, you’re trading short-term relief from, or avoidance of, negative emotions for long-term stress. The problem and the way that you feel are likely to get worse.

So what might help?

The Three Magic Questions

The Three Magic Questions is a tool that many clients find really effective when stuck, overwhelmed with negative emotion, or wanting to avoid. It has its roots in Acceptance and Commitment Therapy, which focuses heavily on goals and values.

Goals are typically things that people would like to improve, do differently, or achieve. Values can be personal, such as honesty, persistence, courage, loyalty, strength, and compassion. Values can also be things that a person values, like contributing, relationships, achieving, being at peace, good sex, intimacy, etc.

In my practice, goals and values contextualize the work that clients do – it helps keep them focused on what they want and what matters, rather than focusing exclusively on the things that have caused them distress and suffering.

How the tool works.

When you find yourself:

  • acting in ways that are messing up your life or relationships
  • wishing that things could be different but not knowing how to get there
  • overwhelmed by emotions that paralyze you, or cause you to act in way that makes things worse and not better
  • having difficulty making choices that are helpful rather than harmful
  • avoiding things you’d like to do because of fear and anxiety
  • stuck in a rut
  • (feel free to add to the list!)

Ask yourself the following three questions:

  1. What can I do now to make things better in the long-term?
  2. How can I act to get me closer to meeting my goals?
  3. How do I act in a way that best aligns with my values, and what I value?

For this to be effective, the key is to make sure you answer all three questions. It requires that you know your goals and values, which is something that people often fail to clarify. So do that first before you address the problem or difficult situation. Keep them in focus. Then work through the questions.

Usually this helps tell you what avenue you should take. Having said that, occasionally things do not work out. And that’s ok. It’s better to act in a way that’s more effective, which can sometimes be risky, than to stay stuck. And if things do blow up in your face, you’ll almost certainly survive and build resilience.

What does this look like in practice?

Here are two examples, one non-sexual, the other sexual:

Example 1

Say you’re someone who struggles with social anxiety. You’d love to have more friends, as they’re important to you, and a social life would be nice. But your anxiety is stopping you from going out and spending time with people. It sucks.

A friend texts you and invites you to a social get-together with some people you know. Immediately, your anxiety kicks in. What if you say something stupid? What if you have nothing to say at all? What if they think you’re weird or too quiet? What if they don’t like you?

The instinct is to turn down the invitation, or if you do go, to get really drunk to cope. Both options are not particularly helpful in the long-term.

To get unstuck, you would first want to identify your goals and values. Your goal is to meet people and have a better social life. You clearly value friendships and having a social life, despite your anxiety. With those goals and values in mind, the best thing to do is to accept the invitation, despite the anxiety.

And with anxiety, we know that the most effective way to reduce it in the long-term is to do the things that cause the anxiety. Over time, these repeated experiences (i.e., exposure) help us recognize that what we fear most is not likely to happen, and even if it does, we’ll probably be able to cope. As such, anxiety goes down and confidence goes up.

Example 2

You have a lot of anxiety about sex. It could be about your lack of experience, sexual performance, ability to orgasm, the way you look, ability to communicate, or the desires that you have. Your worries are getting in the way of your sex life. You find that you’re not pursuing sexual experiences that you could be having, and wish you were having. It’s just way too vulnerable and scary.

Your partner, or a potential partner, starts flirting with you. It’s clear where things are heading. Immediately you feel your anxiety kick in. What might happen if you have sex? What if you’re no good? What if you get judged or criticized? What if you disappoint this person? What if you get shamed, or feel ashamed?

As your anxiety builds, all you can think of is ways to avoid having sex. You feel the urge to say or do something to make it clear that you’re not interested. For you, this is a repeated pattern and you’re feeling frustrated, disappointed, and ashamed.

But then you remember your goals and what you value. You want to have a healthy and satisfying sex life. You value sexual experiences and recognize that as a sexual person, sex is a crucial part of your life and intimate relationships. Despite sex being scary, you want it. You also remember that you’ve had great past experiences. You trust that you can again. And you know that avoiding is only making things worse. So you take the plunge. It will be one more experience that gets you closer to what it is that you want. It’s still really scary, but the anticipation is always worse than the doing.

Both of these examples have to do with anxiety, as anxiety is the most common thing I see in my practice. But, the tool works for other negative emotions and experiences too. Once you get a handle of it in one context, it is easily transferred to different difficult situations. Try it out!

Understanding anxiety: The basics.

What is anxiety and why do we experience it?

We all experience anxiety from time to time. Anxiety is an emotional response to real or perceived threat. It's a sibling of worry, nervousness, stress, and fear. Anxiety is a normal emotion, and is often helpful despite it being unpleasant to experience.

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Way back in our past, we evolved to experience anxiety as it kept us physically safe. If we noticed a bush that was rustling, our brains and bodies would react almost instantaneously, putting us into a state of fight or flight. This is the anxiety response. Anxiety would prepare us to fight for our lives or run away in case the rustling was a saber-toothed tiger. If it turned out that the rustling was caused by something non-threatening, like a bird or rodent, then no big deal. Better to be prepared (i.e., anxious) just in case. On the other hand, if we didn't experience anxiety, and there really was a saber-toother tiger in the bushes, we'd likely get eaten because we weren’t ready to fight or flee. Put another way, anxiety is like an alarm system, and better that the alarm system is overly sensitive than not respond when a threat is real.

While anxiety keeps up physically safe, it also keeps us safe psychologically/emotionally. We tend to become most anxious about things that are important to us. It often signals that there's a threatening problem for us to solve.

Some examples of how anxiety can be helpful:

  • If we weren't a little anxious when standing at the edge of a cliff, we might not be aware of what we're doing and accidentally fall off.
  • If we didn't get a little anxious about the tasks that we need to complete for work or school, we might never get around to doing them or might never focus our efforts on doing them well.
  • If we didn't get a little anxious about problems in our relationships, we might become complacent or check out.

Anxiety is both a psychological experience and a physiological experience. Emotionally, we feel on edge and may have worrisome or fearful thoughts. Physically, anxiety manifests as a racing heart, quick breathing, sweaty palms, a sick feeling in the stomach, and a sense of being under pressure.

When does anxiety become a problem?

Some people are wired to be more anxious from birth, while others seem to become increasingly anxious over time or in response to things going on in their lives.

For some people, anxiety is frequent and intense. At its worst, it's characterized by racing, uncontrollable, and overwhelming thoughts. If it gets bad enough, some peoples' anxiety may even start interfering with their lives in significant ways. It's a terrible place to be and comes at a huge cost to mental and physical health, and quality of life. 

Anxiety can become crippling if it starts to chew up all a person's mental resources, and can cause mood to plunge. It crowds out all positive emotions and thoughts, and gets in the way of living a good life.

Imagine being in a state of persistent fear and feeling that you have no control? That's what it's like to be really anxious.

What are the components of unmanageable anxiety?

Anxiety is a response to real or perceived threat when there is uncertainty or ambiguity. It is future focused  (i.e., what if ______?), but often drags us back to our past failures and times when we've been hurt physically or psychologically. It may cause us to ruminate about our prior experiences and obsess about our futures.

There are three main components to anxiety that when all present, make it particularly bad:

  1. The belief that something catastrophic is going to happen. Not just a little catastrophic, but the absolute worst possible outcome.
  2. Over prediction of the likelihood that catastrophe is going to happen (i.e., it's going to happen for sure).
  3. Under prediction of one's ability to cope should something catastrophic happen.

So, in the face of uncertainty, if you believe that something really terrible is going to happen and you won't be able to cope, then you're likely to experience significant anxiety.

Here are some examples:

  • Michael has anxiety about flying (phobia). Even though he's flown before and knows that accidents are extremely rare, he's sure that the next plane he flies in will crash. When that happens, there's nothing he will be able to do - he will die.
  • Angela has anxiety around people (social anxiety). Even though she's been able to have friends and relationships in the past, she's certain that if she socializes with people, she'll say something stupid and people will judge her. It will be humiliating and will confirm her belief that she's a loser. Nobody will want to spend time with her, so she won't have any friends.
  • Sam has anxiety about his sexual performance. He is sure that he will not be able to get an erection when he has sex and his partners will be disappointed. He'll see himself as a failure and nobody will want to be with him. Sam will never have the sex life that he wants.
  • Sharon is anxious about her body. She feels like she's sexually unattractive. She's afraid that her sex partners will find her repulsive and will reject her. Nobody will want to have sex with her or date her, and she'll be alone forever.

The good news is that anxiety is the most treatable of all psychological difficulties.

Stay tuned for more on anxiety and ways of addressing it.

Myths about mental illness that need to be trashed.

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Despite great strides in the public's understanding of mental illness, there remain many stereotypes and misconceptions. And often times these stereotypes and misconceptions have a compounding negative impact on people who are already struggling.

Linked below is an excellent article on myths about mental illness, from the perspective of someone who has walked the walk.

The misconceptions that he challenges:

  1. Mental health problems last forever.
  2. Only violent or unstable people have mental health problems.
  3. You can’t handle relationships.
  4. You can just snap out of It
  5. Treatment is a waste of time.

From Lifehacker:

The Misconceptions About Mental Health That We Need To Unlearn
by Eric Ravenscraft
Mental illness isn’t like a sinus infection. You can’t just wait it out or take a pill to make everything go away. Our brains are complex and enigmatic, and mental illness is no different. This leads to a lot of misconceptions that make recovery much harder. Here are a few things you should know, whether you’re a sufferer or not.
Before we talk about misconceptions, it helps to identify just what “mental illness” means. Everyone has stress and difficult emotions from time to time and this is normal. Mental illness, on the other hand, is any condition that makes it difficult to function in daily life. It can affect your relationships, your job, or prevent you from reaching any otherwise attainable goal.
If that sounds like a pretty wide definition, it’s because the human mind is complex. Mental illness can range from anxiety and mood disorders that have a severe and tangible effect on your emotions and motivation, to psychotic disorders like schizophrenia that affect your perceptions or senses with things like delusions or hallucinations. Living with any of these can be debilitating. We rely on our senses, emotions, and perceptions to get us through the day. When any of those fail, it can make life difficult.

Read the rest here: link.

Over-thinking: Obsessing and ruminating.

Obsession and rumination are things that we all do to a certain extent. Obsessions tend to be recurrent worries about the future. Ruminating is about the past, and our real or perceived mistakes and failures.

Obsessions and ruminations are not typically helpful, and when experienced as out of control, can be really upsetting. They are also ineffective in terms of solving problems and feeling better, as they tend to trap us in a cycle of anxiety and powerlessness. Thankfully, therapy can be very effective in helping people who really struggle with obsessions and ruminations.

This video clip from Buzzfeed provides a very irreverent look into the mind of someone who obsesses and ruminates. Any of it sound familiar?


How complaining only holds you back.

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A great piece on the brain science behind complaining (and worry) and how we can re-train our brains to reduce the impact of negativity on our lives. It ties in nicely with cognitive behavioural therapy (restructuring the way that we think) and mindfulness (acceptance, living in the moment, and letting go of the past).

From curiousapes.com:

The Science of Happiness: Why complaining is literally killing you.
by Steven Parton
Sometimes in life, all the experience and knowledge simmering around in that ol’ consciousness of ours combines itself in a way that suddenly causes the cerebral clockwork to click into place, and in this fluid flow of thought we find an epiphany rising to the surface.
One such point for me came in my junior year at University. It changed the way I viewed the world forever as it catapulted me out of the last of my angsty, melancholic youth and onto a path of ever-increasing bliss. Sounds like I’m verging on feeding you some new-agey, mumbo-jumbo, doesn’t it? Well, bear with me, because I assure you the point here is to add some logical evidence to the ol’ cliches, to give you what I would consider my Science of Happiness. 

Read the rest here: link.

The Dude offers some sage advice.

The film The Big Lebowski is full of all sorts of wisdom that is directly relevant to therapy. I was first made aware of this by my mentor Dr. Mahesh Menon, who would occasionally quote The Dude in CBT group therapy at the hospital. If you haven't seen the movie, I recommend that you do. It's not for everybody, but there are tidbits in it that might help make it easier to let distressing thoughts, memories, and feelings go. The Dude just rolls with the punches. Two of my favourites.

The first relates to self-judgment, and rumination about our perceived past failures. These don't have to rule our futures. 

The second relates to negative thoughts. Thoughts are much like opinions - we don't have to buy into them or believe them, especially when they're trying to tear us down.

The Dude abides.

Therapists describe what unique suffering clients believe they endure.

Often times, clients believe that they're the only ones who are experiencing, thinking, or feeling what they do. They feel alone and uniquely broken. This creates a sense of isolation, hopelessness, and despair. But often their experiences are shared and not at all abnormal. Finding this out can be a huge relief.

A recent post on Reddit (if you don't know what Reddit is, click here and here) asked therapists to share what they'd heard from their clients regarding this feeling of being uniquely screwed up. The post blew up. People who have struggled with mental health jumped in to add their perspectives and thoughts. It's rich with insight.

Check it out here: link.

And samples:


Introduction to mindfulness.

Mindfulness can be exceptionally helpful in alleviating the overwhelming nature of negative thoughts, beliefs, memories, emotions, and sensations.

The most crucial element of mindfulness is awareness. It is not about fighting off negative internal experiences; it's about recognizing and accepting them for what they are.

In the coming months, I will write much more about mindfulness. For the time being, this brief clip from Headspace, the most popular mindfulness app, provides a great introduction. Check it out:



Validation: It's Not About The Nail.

Have you ever had that experience when someone (usually your partner or family member) comes to you upset or feeling low, and when you try to help out by advising them how to solve their problem, it only makes things worse? I think we've all been there.

One of the pillars of good psychotherapy is validation. Validation is particularly crucial during the first few sessions working with a new client. While it's true that clients are looking for more effective strategies to solve their problems (i.e., change), often what they need to hear first is that you, the therapist, understands them.

This fall, I've been taking a workshop on Dialectical Behaviour Therapy (DBT) and one of the central dialectics is the balance between validation of the client's current ways of being, and necessary change. The psychologist teaching the workshop used the following video to demonstrate how difficult if can be for therapists to validate their clients' experiences when the  solution to their problems seems obvious. It's a very popular clip (almost 12 million views), and for good reason. Check it out.

"Wicked" intrusive thoughts.

It may come as a surprise to you that people experience hundreds of unintended thoughts, daily. Many of these thoughts are experienced as "intrusive," and up to 20% of them could be described as "bad" (i.e., immoral, evil, etc.). For most people, though, these types of thoughts come and go, and do not persist or negatively affect the individual. For others, however, especially those affected by anxiety, depression, and other mental disorders, these intrusive thoughts can become suffocating and overwhelming.

This piece identifies 5 main categories of "wicked" instrusive thoughts:

  1. Morbid, Creepy Thoughts
  2. Sexually Perverse Thoughts
  3. Prejudiced Thoughts
  4. Schadenfreude
  5. Violent, Murderous Thoughts

From Psychology Today: Wicked Thoughts.

 

Perfectionism and how to manage it.

When people think of perfectionism, the first thing that comes to mind is often work and achievement. Perfectionism can drive people to achieve great things, but it comes at a cost. Rarely is it possible to achieve absolute perfection, and for a perfectionist who sees themselves in a very black and white manner, anything less than perfect is experienced as a failure. And repeatedly feeling like a failure can take a toll; mental health can suffer (among other things).

Perfectionism impacts many domains of life, including relationships and body image, where it can have similar negative effects. This article discusses perfectionism in more detail, and provides some helpful antidotes.

perfectionism.jpg

From the Emotion Machine:

If you want to never be happy or satisfied with your life, one great way to do that is to raise your expectations to an unrealistically high standard that can never possibly be met.
This is the essence of perfectionism. It’s the inability to be happy with something until it is perfect, without any flaws whatsoever. Of course, the problem with this mindset is that perfectionism is often an illusion. 
Life rarely works out exactly the way we want, in any domain – whether it’s relationships, work, or goals. 
And many times being more happy with your life requires that you let go of these expectations and learn to be more content with how things are, rather than how you picture they should be in an “ideal world.”
Many studies are beginning to show the many ways perfectionism can destroy your happiness.

Read the rest here.