Monthly Archives: June 2015

Cognitive Pearl #093 Time Distortion & Misery

We rise by lifting others

Like you, I spend my life in the company of people complaining of great difficulties with anxiety and despair. Certainly, each has their own individual story. In fact beyond the commonality of the piercing, acute intensity of their misery they have nothing in common.

Except for one this one weird thing:

They all feel out of sync with the passage of time.

My anxious clients feel as though they are forever behind; ‘it’s too late!’ they complain as they contemplate impending catastrophes. My depressed clients, anchored with concrete to injuries and indignities of the past, relate to time as a loop, sweeping them around and around through more of the same old same old.

The anxious and depressed are not the only ones who struggle with time. The last quarter century spent in the company of addicts has taught me how they too feel upended by time. Urges feel like they will last forever like some incredibly prolonged tooth extraction. Or sometimes their addiction will generate a glowing time cocoon in which they feel as though all is well, as though it will last forever. And then those suffering from psychoses have their own difficulties with time: they are often out of sync with the flow of time, having great difficulty calculating how long tasks take or coordinating appointments with others.

What all of this means to me as a cognitive therapist is, like dysfunctional thinking patterns, diet and health, and social and family background, I must also consider the relationship with time as part of my work with clients. In the coming post, I’ll discuss why our relationship with time is so important. I’ll also share some of the ways that I’ve tried (not always successfully) to alter my clients’ relationship with time.

For the interested, two Biblical passages stand out in reflecting the connection between time distortion in human suffering. The first, a heart rendering verse in Deuteronomy 28:67:

In the morning you shall say, Would it were evening! and in the evening you shall say, Would it were morning! for the fear of your heart with which you shall fear, and for the sight of your eyes which you shall see.

The second, Genesis 8:22 tells us how the cessation of the seasonal passage of time was part of the destruction of the world in the time of Noah:

While the earth remains, seed time and harvest, and cold and heat, and summer and winter, and day and night shall not cease.

Cognitive Pearl #092 A Man Amongst His Peers & Looking Beyond The Prism Of Illness


Tshirt Mishlay












In order to help our clients get out of the social loop of ‘special needs’ we decided to focus on their own self-stigmitziation. From our perspective, our clients had been socialized into roles where they and others saw them as needing special treatment and accommodation. It seemed that almost every dimension of their lives was viewed as directly connected to their illness, as opposed to less ‘red-flagged’ dimensions such as social naiveté or ignorance. They ‘learned’ that everything was illness related and that unless addressed by medication, there was nothing to be done. 

For instance, we were told that Bob, 43, and diagnosed with schizophrenia since aged 21, often failed to complete assigned tasks in one of the Old Navy warehouses. This bothered him because he missed out on the camaraderie and friendly competition in this very supportive environment. Yet he had made an uncomfortable peace with it because he reasoned that his medications were getting in the way. 

Our occupational therapist however saw things differently. She saw that the problem was that Bob had failed to develop a system to sort and prioritize and then economize his energies. Without her having to go to the warehouse, she helped Bob develop a better way. No medication needed; just someone who was willing to look outside the narrow prism of illness. The result: a man amongst his peers. 

Cognitive Pearls #091 Listening, Healing, And Really Helping

white flowers on chizkiyahu hamelech











Having observed how differently our clients behaved outside, in a non-clinical environment we resolved to consider how we, as well intentioned therapists, were failing them. Instead of helping them deal with the real challenges that they faced, we, unwittingly, compelled them to comply with a helpless, pathologized role.

So we went back to the drawing board. That always begins with questions: What did these clients really need? What could we, in our roles as psychiatrists and social workers, do to meet those needs?

We began to listen much more closely to what the clients had to say. By ‘say’ we kept in mind that verbal communication could not be the only bridge to understanding. We needed to listen deeply, looking for subtle nuances and clues, abandoning our preconceived notions. When possible, we turned to people in their living and work environment to help us understand our clients’ needs, We spoke with parents and siblings. We spoke with supervisors at the stores where they worked.

A great deal of information emerged. We learned, for instance, that these young people wanted to have relationships that were deeper than the ‘special needs’ label that earned them politeness but little else. We learned that their families, as loving and supportive as they were, kept them in boxes intended to keep them safe but unable to explore, improvise, and find some mastery and joy in the rich world that they lived in.

So what did we do?

Stay tuned!

Cognitive Pearl #090 Sivan 27, 5775 June 14, 15 The Broken Coffee Maker & A New Group Model

always smile back at children








As you can imagine, coffee is part of the glue that brings people together. Our clinic’s industrial strength coffee maker was famous for bringing clients in for group and med checks when they might otherwise skip it altogether.

So when something or another broke, my group members came up with their own solution: they marched across the street to the local bodega as they waited for group to get started.

Now, for some  of you a bodega is as familiar as any store in the urban landscape of New York. For those who are not, think of a makolet but with a hispanic, Catholic orientation. You’ll find votive candles next to plantains (a kind of banana)  across the aisle from things that you’d never find in a makolet in Israel (for Kosher reasons). What made this bodega a bit different however was that it was owned and operated by a Pakistani family.

Go figure.

Of course the coffee maker broke for all of us. And social workers also need a steady infusion of coffee to keep us going. Taking a page from our clients’ play book, three of us followed them across the street.

And we were shocked.

Here were our clients, the same people who were nearly incommunicado in group, lively interacting with each other and with the proprietors of the store. It was literally like someone had turned on the electricity! They were alive! Even more strikingly, when they all returned to the clinic for group, they resumed their social withdrawal. 

It was then that the format of the group changed. The results still bring a smile to my face years later. 

Stay tuned!

Cognitive Pearl #089 Sivan 27, 5775 June 12, 15 Old Navy & Miracles Part I

brighter than bright







Complete recovery from schizophrenia is sadly the exception rather than the rule. Whether it’s due to severity of the pathophysiology or a combination of other factors, people suffering from schizophrenia usually become chronically impaired. Their functional abilities decline. Their medications, as wonderful as they are, leave them stuporous and undermine their health. They become ‘locked’ into a state which defines what they can do and what they can’t do.

Miracles still happen, though! When given useful psychotherapy, support, and opportunities, people can enjoy life a bit more. They can become more active in their families and communities. They can find new zest in life, moving from mere, colorless existence to raucous, joyous living.

This was driven home to me many years ago when I coordinated an aftercare group for adults who had been considered to be hopelessly locked into their psychiatric disability. This group was developed in response to a wonderful initiative taken by the Old Navy & Gap clothing stores. The owners of the chain had instituted a policy that all of their stores were required to employ a significant percentage of adults with severe psychiatric illness and disability.

In order to support that initiative the company expanded its mental health insurance coverage and also worked with local plinics to support their workers. My hospital was located in the same area where Old Navy had ten stores; and that’s how our group came to be.

Sitting down together in those first months however was a bit difficult. Members were shy, much like one might expect out of someone diagnosed with paranoid schizophrenia.

Until the coffe maker broke.

To be continued…

Cognitive Pearl #088 Sivan 22, 5775 June 9, 15 Schizophrenia & Stress Management

striped flowers



The first break group, aside from offering wonderful peer support, was designed to strengthen our clients’ abilities to handle excessive stress. We worked with the assumption that excessive stress, for many reasons, makes the symptoms of schizophrenia worse.

When clients were stressed, hallucinations became more intrusive. Paranoia and lack of motivation became more paralyzing. Understandably, the psychiatrists responded by increasing doses of the antipsychotics which helped but also, because of side effects, generated other problems.

By teaching our clients to reduce stress and to master it we found that they did really well. And cognitive therapy was a major part of that. For instance, having clients do a daily dysfunctional thought record on a stressor helped strengthen their ability to monitor their thoughts. It also helped them steer clear of thinking distortions. This allowed them to better master the challenges that they faced and to feel in in control of their lives. 

By coupling basic psychiatric rehabilitation skills (such as assertiveness skills and financial management) with cognitive therapy these two women became stronger and capable of resuming their premorbid lives. To this day they are fully recovered, leading lives in unencumbered by schizophrenia. Did cognitive therapy do the trick? Not by itself. It did however play a valuable supporting role in two beautiful stories of recovery.

Cognitive Pearl #087 Sivan 20, 5775 Schizophrenia, Cognitive Therapy, & Possibilities

All truth Schopenhauer












Over the last 25 years of work with adults suffering from schizophrenia in all of it’s manifestations, I’ve seen some wonderful turn-arounds. By turn-around, I’m speaking of individuals who either made full recoveries or who made unexpected improvements in their functioning.

Let’s consider two of the full recoveries (1). In both cases the clients resumed their previous vocational activity (students) and social functioning. They remained in some form of aftercare and continued to take low maintenance doses of antipsychotic medications; as of this writing they still do. Interestingly and not surprisingly, both were young women in the early twenties. Both experienced a sharp descent into psychosis which lasted about six months; during this time there was increasing paranoia, irritability, depression, and then florid psychosis leading to hospitalization. In one case, there was heavy use of marijuana as a way to self medicate away anxiety; predictably it had  negative effects as well.

That’s the bad news. Now the good news.

Both of these women were fortunate to have parents who they were close with. Both had access to high quality hospitalization, well trained clinicians, and great aftercare. Both had social networks and extended family relationships so that their care didn’t fall only on their parents. Both had vocational arrangements which by law and basic human decency they could return to as they became more and more capable.

In addition to all of these blessings, both of these women participated in a ‘first break’ group, an educational program for young adults going through their first episode of severe psychiatric illness. Along with the manic, the severely depressed, and one soul terribly tortured by obsessions and compulsions, these two women learned skills to reduce stress, increase mastery, and intensify focus.

Cognitive therapy was an integral part of that. 

More on that in my next post!

Shavua tov to all!


(1) Aside from the fact that I met both of these individuals while I worked in various day treatment programs in the United States, all of the details have been obscured.

Cognitive Pearl #086 Sivan June 4, 15

You Know What The Problem Is With The World






In the decades since I began my study of cognitive therapy, its relevance in the treatment of schizophrenia was been excitedly discussed. The idea, for instance, that hallucinations and delusions involved thinking distortions seemed appealing. Or that the absence of motivation, the hallmark of the negative symptoms (for more information read here), could be improved with cognitive therapy techniques seemed plausible.

Unfortunately, all of this early enthusiasm was misplaced. For the most part we’ve found that cognitive therapy has little impact on the symptoms of schizophrenia (for a review of the scientific literature see here). This may be due to the pervasive effect of the disease on the client’s metacognitive ability, or in simpler terms, to think about his thoughts. Or it may be the effect of the brain dysfunction on the client’s interpersonal connectedness which interferes in his ability to benefit from any form of psychotherapy. Lastly, the absence of illness insight, or the lack awareness of disability gets in the way of treatment. After all, if the client doesn’t think that there’s anything amiss there’s no need for treatment.

This is not to say that cognitive therapy has no place in the treatment of the symptoms of schizophrenia. It does. As you will read in coming posts, clients have benefitted greatly from outside the box uses of cognitive therapy techniques (as well as psychodynamic psychotherapy). What we must remember however is that the scientific community is a long way from understanding schizophrenia. In spite of the excitement about new drugs, which really do help, we are still far from understanding how an invisible pathological process can wreak such havoc on the brain.

Stay tuned though: all is not lost. Many people diagnosed with schizophrenia do fully recover. And those who don’t can still live lives of richness and joy. 

Cognitive Pearl #085 Sivan 16, 5775 June 3, 15

The way we talk to our children









Music is life; life is music. I simply cannot conceive of life without the energy and wisdom of music wrapping me in it’s embrace. So whenever there is a chance to reflect on music in my life as a Jew, I can’t pass it up. And this week’s portion gives me such a chance.

We read how God tells Moses to make trumpets (you can read the text here). These trumpets however are not for entertainment; they are to be used as a means for our leadership to communicate with us at moments of great importance: gathering together, going to war,  celebrating victory and at other times as well.

The text instructs us about which notes which should be blown on these trumpets. There were two: the tekiah, or a long monotonous sound and the teruah, a staccato, broken, wavering note. Quite telling are the instructions regarding when these notes are blown: when the people must be summoned to gather together, the bold, brash tekiah  is blown. When they travel out of the encampment they are instructed to blow a teruah.

In short, triumphant exclamation when we gather; broken, wavering note when we travel. 

What can we learn from this?

For me the take away is that life requires a sound track. Coming together and reunions are  jubilant moments; moments when we can toot our horn, knowing full well that nothing compares to coming together. Go great is gathering together that Heaven is nearly helpless against us. 

Yet, when we journey forward, as we surely must, we bear in mind the risks which should fill us with humility: Must we go? Are we really ready? What can we do to make sure that we will once again come together? That is a time for the broken staccato of the teruah.

Because only fools rush forward. 

Have  a day filled with beautiful music.