Monthly Archives: April 2015

Cognitive Pearl #069 Iyar 11, 5775 20 April, 15

What You Say 






A bit of a digression.

As I write these post I’m on my way to Meron, the location of the grave of Rabbi Shimon Bar Yochai (you can read about him here). Hoping to skip the crowds next week (it’ll be Lag BaOmer which you can read about here), I decided to make my pilgrimage a week early. While this isn’t the place for a discussion of the mystical dimensions of this pilgrimage (and visits to the burial sites of other saints and sages) it is an opportunity to touch on culture and cognition.

Culture is universal. Wherever you find two humans you’ll find culture. Manifestations of culture are nearly infinite. My pilgrimage to the grave of a culturally designated saint is not unique; people the world over visit similar sites. And there are many other kinds of cultural pilgrimages too: cinco de mayo in Spain and Saint Patrick’s Day in Ireland come to mind. Sporting events are also cultural pilgrimages. As are festivals and annual gatherings.

So the question we need to ask is what is all of this culture about? Why do humans have his need to abandon all sense and sensibility, their jobs, their families, and the opprobrium of their normal lives and go nuts?

For me the answer begins with something I heard from Dan Siegal, a developmental psychiatrist, in an interview a few years back on Shrink Rap Radio (an excellent resource which you can find out more about here). Siegal was speaking about the mind as a process (as opposed to a thing) which regulates the flow of information within the organism and with other organisms. At one point he said something that still makes my ears ring:

Yes, I study the way energy and information flow is shared in relationships across generations. That’s what culture is!

The implications of that idea is that culture is what one generation tells another. Culture teaches ideas (we call that indoctrination) that are central to the continuation of that culture. So while pilgrimages to holy sites of every ilk fulfill our needs for belonging, entertainment, and so much more, they are primarily about absorbing the ideals of those who came before us.

And as cognitive therapists who assert that the ideas that we hold are what makes us or break us, our clients’ culture is enormously relevant.

Cognitive Pearl #068 Iyar 10, 5775 29 April, 15

one kind word













In a previous post, I suggested that the breadth of cognitive treatment depends on the severity and chronicity of the disorder. In other words, the worse the disorder and the longer it’s influence on functioning the ‘more’ treatment required. 

That seems straightforward, right?

It is but it needs to be broken down so that we understand three dimensions: 

What is meant by severity.

What is meant by chronic.

What is the difference between ‘more cognitive therapy’ and ‘less cognitive therapy’. In other words, we want to understand how cognitive therapy alleviates the conditions that it aims to treat. 

Let’s start with severity. As a convenient place let’s consider the global assessment of functioning of the DSM (you can see it here). The authors of the DSM direct us to consider the occupational, social, and psychological impact of the disorder in determining severity. This seems to be an eminently practical method (until one considers the ideological underpinnings of this approach but that’s for another time).

As a cognitive therapist however I find social functioning to be the most relevant for the simple reason that one’s ability to be part of a social fabric is a far more important indicator of health than occupational and psychological abilities. As I’ve stated in previous posts, psychological health and illness is far more influenced by our social connectedness than the neurotransmitters floating around our brains or the autonomous ideas held in our heads.

From this point of view, my work with clients is oriented towards this social connectedness above all else. From my experience, when people are more connected to others who positively influence their activities, ideas, and feelings they easily shed the dysfunctions of illness. And when their social connectedness is so sparse that they are allowed to ‘marinate’ in their own darkness they just get worse and worse. 


To be continued. 



Cognitive Pearl #067 Iyar 9, 5775 April 28, 15

Seth Godin Draw A Map










In the world of psychotherapy, everything is up for debate. When we speak of chronic disease or disease severity there are a million and one opinions.

Take chronicity for example: we tend to think of chronic illness as an affliction that doesn’t go away. A minor cold has a beginning point and an end point. Schizophrenia on the other end doesn’t seem to have either; the DSM speaks of the prodromal phase, a descent into illness that is almost only identifiable retrospectively.

And it never goes away.

Or so it seems.

In Israel and in the United States, those with schizophrenia are considered as disabled for life by Bituach Leumi and the Social Security Administration. However more and more reports of full recovery are emerging. Furthermore, as technology rapidly reshapes society, the definition of disability itself has become a moving target. New occupational opportunities have allowed many formerly disabled people to enter the workplace.

This says nothing of the ideological underpinning of occupational limitation as disability. As a Jew, scarred by the obscenity of Arbeit Macht Frei (‘Labor Makes Freedom’, the sign greeting the Jews and other undesirables as they entered the Nazi death camps) the connection between productivity and human worth is frightening.

This riff however does nothing to clarify the issue I raised in my previous post: how does the cognitive therapist determine the depth of treatment. And that dear reader is where I’ll pick up next. 

Cognitive Pearl #066 Iyar 8, 5775 April 27, 15

The words You Speak Become The House You Live In

Most of us think of cognitive therapy as a way of understanding and relieving depression, anxiety, and whatever else we use it for by focusing on the thoughts that underlie the disorders.

That is all true.

Yet, for me at least, cognitive therapy is about approaching the processing system that is the human mind. Whether it’s depression, joy, psychosis, impulsivity, concentration, love, pain, and all the rest, (and there’s a whole lot more!) the mind takes in information, processes it, and then uses those processes to guide how it navigates its existence. Cognitive therapy seeks to alter cognitive processes by illuminating them and by upgrading them.

The end result is a better life. 

While some mistakenly claim that cognitive therapy is superficial, it isn’t at all. It’s just that we cognitive therapists have found that not every single cognitive process needs to be illuminated and upgraded to make things better. Generally speaking, chronicity and severity are the best guides to how much we need on the table. 

More on that in the next post. 


Cognitive Pearl #065 Iyar 7, 5775 April 26, 15

File this one under Pygmalion effect or a really questionable use of projective identification.

Our clients, and for that matter everybody else, are social creatures. That means that we are as influenced by the social context as we are by our inner drives and longings. In fact, since the vast majority of our knowledge is second hand (we would not even know our name or gender without someone telling us) it can be argued that social influence is an even greater factor in our inner lives than our intrapsychic activities. What all of this means is that our joy, our aspirations, and even our physical and cognitive being are shaped by the people around us.

Here’s why I bring this up: my clients, like yours, are members of social environments. All have parents (duh), all live in the company of others (I assume that none of us are working with people located on the moon), and all are trying to make personal changes in the midst of social pressures.

Each of us is are part of that social pressure cooker.

So when we see the unruly Godliness in our clients they see it too. And if Heaven forbid we see them as trapped by circumstances (including our diagnoses!) they trapped in our projections. 

I don’t know about you, but I love to see people fly. 

Yom HaZicharon & Rav Lichtenstein ע׳ה

A reflection at the nexus of Yom HaZicharon and the death of Rabbi Dr. Aharon Lichtenstein. 

The human response to suffering is to break down. We fall apart. We crumble to pieces. Witness the reaction of Iyov to the news that his world had been destroyed:

And Iyov got up and tore his coat and he plucked the hair of his head and he fell upon the ground (Iyov 1:20).

But more than breaking our person, suffering blows up the ideas that we had of the world. Like an exploded balloon, our comfort in the world is blown apart. Witness the descent of Iyov into the madness of grief and confusion. It makes us crazy, this suffering. Nothing makes sense. How could it?

And then we try to find a new normal. For some, it becomes easier to see the pieces as separate, detached from each other. We choose sides. We hurry into identities and ideologies and then pull them tight around ourselves. ‘At least we know what we are’, we tell ourselves. The world becomes smaller and predictable. Or so we hope. 

There are those however who refuse to give up on the human destiny, to see the universe in all of it’s complexities and heart breaking beauty. Rav Lichtenstein was such a person. A sometimes student of his, I was always impressed by the depth and breadth of his ideas. Not that I always understood them but that’s my bad; not his. He thought nothing of introducing Chaucer or someone else into a lecture on Teshuva (Repentance) on or in a riff on chazaka (ownership). Not because he wished to make a statement but simply because Chaucer said it better. The Lubavitcher Rebbe a’h once said that those who keep their religious books separate from the secular books don’t understand either. Rav Lichtenstein got that; he saw a world as one. 

יהי זכרו ברוך


Cognitive Pearl #064 Iyar 1, 5775 April 20, 15

The Pattern Interrupt Schedule is easily tailored to specific needs. When I work with depressed clients, we will agree that at each interval they will perform some behavior. Changing scenery comes to mind: the client gets up from wherever he is sitting and goes outdoors for some fresh air, takes a bathroom break, chats with a colleague or any other opposite action. For those suffering from anxiety, they can do a few rounds of diaphragmatic breathing, light yoga, journaling, prayer, or any other grounding behavior that suits them. The idea is to punctuate the automaticity and monotony of the inner states of misery. 

Cognitive Pearl #063 Nisan 30, 5775 April 19, 15

Last week, I introduced the rational response form. The ‘idea’ behind it is that the form triggers the client’s critical thinking abilities. With that upgrade in thinking he, with some help from his cognitive therapist, comes up with concrete ways to act on these new ideas. 

This brings me to the pattern interrupt form, a skill sheet intended to punctuate the smothering gravity of depression. The form also has the effect of triggering mental rehearsal for the purpose of developing new habits. 

Some explanation:

The mental experience of depression and any form of suffering is profoundly different from the mental experience of the peak states of joy, bliss, and flow. Without treading into the gory details of unsymbolized thought, time distortion, and all the rest of the dysfunctional inner dimensions of depression, suffice it to say that the experience is an unpleasant monotony of despair, collapsing into itself. This nauseating swirl of chaos needs punctuation; pattern interrupt is one effective way to do just that. By breaking up the client’s day with helpful tasks, he can challenge the hopelessness and chaos of his inner world. 

Cognitive Pearl #062 Nisan 28, 5775 April 17, 15

This may sound a bit off topic but we need to talk about this Schlissel Challa business. It’s a lot more connected to cognitive therapy than meets the eye. (For those who want more information on this custom click here and here.) We rationalists tend to look down on such ‘segulot’, lucky charms, and amulets. This negativity however is so misplaced! In fact, it usually backfires in the worst ways because in its hubris, it fails to recognize that the rational and the scientific all have their limits. Arthur Schopehnauer told us that ‘Every man takes the limits of his own field of vision for the limits of the world’. (Actually it was God who told Job the same thing but Schopenhauer sounds better.) Or as Taleb reminds us again and again, we are easily and dangerously seduced into the falling hook, line, and sinker for the vivid, failing to consider the undetectables. Segulot remind us that as much as we think we’ve figured the world out, there is still so much that we don’t know and can’t know. And that’s great news especially for us joy freaks! It means that we’re surrounded by mystery; it means that life will never be boring. 

That’s it for now. I’ve gotta go stick a key in the challah. 

Shabbat Shalom to all! 

Cognitive Pearl #061 Nisan 27, 5775 April 16, 15

Clients almost universally complain of feeling stuck. They know that change is needed but are frustrated by barriers both known and unknown. The work of cognitive therapy is to reveal those barriers in order to challenge the cognitions, or beliefs, that support them. While much of the foundational work is done during sessions, in order for clients to utilize these understandings, a rational response form can help.

You can see an example of a Rational Response Form here.

In my practice, as we dismantle the thoughts and inner processes or hot thoughts, we list each of them on a form. We then go to work disputing these hot thoughts, writing the disputations down on the form. Then we come up with opposite actions, behaviors intended to neutralize the embodied heaviness of the hot thoughts. The client then goes home with the forms and is sent on ‘mission possibles’ to perform the opposite actions.