Category Archives: Cognitive Therapy

Why is sexual abuse like murder?

We commonly speak of sexual abuse as murder.

Some perhaps go even further: they say that sexual abuse is WORSE than murder.

That’s because in the case of physical murder the victim, now dead, no longer suffers the ignominy of the crime committed against them.

In the case of sexual abuse, the victim goes on living but with all of the psychological and social damage hobbling them.

The parallel of murder and sexual abuse is drawn from the Bible.

In the discussion of sexual violence in Deuteronomy 22 we find these verses:

25 But if a man finds the betrothed girl in the field, and the man overpowers her and lies with her, then only the man who lay with her shall die.
26 Whereas to the girl, you shall do nothing the girl did not commit a sin deserving of death, for just as a man rises up against his fellow and murders him, so is this case.
27 Because he found her in the field. The betrothed girl had cried out, but there was no one to save her.

This parallel is compelling.

Speaking for myself, it makes me wonder about life and what it means to be alive.

And by extension it makes me think about what is destroyed when a woman or man is sexually violated.

Look at it like this:

If you were to ask anyone what is it to be alive they would probably say that it means to have a heart beat, to show signs of physical life.

In all honesty, I wouldn’t say that they are wrong.

But the Bible is placing in murder and sexual violation in one category.

Pretty shocking, no?

It would seem that the commonality between the two is that there is denial of self determination.

To be robbed of agency is to die.

It would seem then that to be alive is to be able freely determine where one wishes to go and what one wishes to do.

To be able to chart the direction of one’s life.

Having worked with victims of sexual abuse over the past thirty years this kind of murder is real.

These victims are caught in a web of shame, powerlessness, fear, and confusion that denies them the ability to live joyfully and powerfully in their own lives.

Their hearts may still beat out a normal sinus rhythm but their spirits, like a corpse, are dead and buried.

But that is what makes their resurrection so much more amazing and miraculous.

Davening With Fire 003 Wild Within The Rules

Rock Bottom

 

The rules of prayer cover hundreds of chapters in the Shulchan Aruch, the most embraced code of Jewish law. It seems strange though that prayer should be so highly regulated and regimented. After all, prayer is all about heart felt expression, something that would be at odds with rules and structure.

Before apologizing and advocating for those rules however, I do want to recommend that by all means pray.

Whatever method suits you.

With the rules.

Without the rules.

Pray wherever you are.

Dressed.

Not dressed.

In a bar (or worse).

In a synagogue.

In jail.

In a meeting.

How Ever.

Whatever.

Wherever.

To whomever.

For whatever.

Just pray. 

We can worry about the details later.

Cognitive Pearl #098 Suicide & Hope

Einstein It's A Miracle

 

 

 

 

 

 

 

 

 

 

 

A client asked me if I was worried that he might commit suicide.

Wow. That’s a question that I don’t get asked everyday. As loaded as the question was however I felt it was important to give the answer. Not ‘an’ answer.

The answer.

‘Actually, I am a bit worried that you might suicide but I’m more worried that you’ll miss an opportunity which lays before you.’

Now it was his turn to be caught off-guard.

So I explained that as I saw it, he was dealing with some terrifying issues. These were issues (relating to family obligations) that he was finally taking on in a manner that offered the best chance of his coming out the other side. The size of the prize makes the journey fraught with danger, suicide being a small risk compared with the bigger risk of bailing out of the process. In the meantime we would continue to work the process and in the vernacular of my youth, let the chips fall where they may.

Content with my explanation he left a few minutes later when our session was over. The after-image as he left: determination and confidence.

Suicidality has fascinated me since entering the profession. It’s struck me that overall, all of the holy trinity of professions (psychiatry, social work, and psychology) seem to be quite confused by the whole topic. Whether it’s predicting suicidality or what to do to prevent it, professional consensus remains elusive. Societal expectation that somehow we soothsayers of the human mind should ‘know’ who kills himself and who doesn’t even more ironic.

For me however suicidality goes to the heart of my approach to cognitive therapy. And that’s the topic I’ll be fleshing out in the coming posts.

Cognitive Pearl #096 Time & Mother Earth

Don't Look At The Jug

 

 

 

 

 

 

 

 

In my previous post, I introduced two ways to help reorient clients to the present moment. Here’s one more:

3. Strengthening their executive functions. Our minds are complex chaotic systems within systems. Yet, somehow our minds sustain us physically, emotionally, and so forth. This is all due to the blessing of our executive functions. You can read more about them here. Anxiety, depression, psychosis, as well as psychosis and many other states (including bereavement) levy a heavy price on these functions. Here are some of the things that I do with my clients to strengthen them, 

Get them writing. Shopping lists, budgets, schedules, reminders, sudoko games, and journaling help organize frenzied minds. Whether it’s with paper and pencil or using an app on a phone, the physical act of writing grounds and organizes. Grounding reduces cognitive stress so they can more easily focus on the challenges and opportunities of the moment. 

Get them physical. Anxiety, depression, psychosis, you name it, are states that remind me of a scene in the movie 2001: A Space Odyssey when one of the astronauts has been severed from the tether that connects him with the space ship. We see him horribly and helplessly floating away. My clients always relate to that image. My answer is to get them reconnected with Earth. They do this through bathing, cooking, cleaning, walking, peeling potatoes, dancing in their living rooms, or tossing a ball from hand to hand. Anything that gets them out of their ‘lost in space’ mind set and back to Earth will help them reorient to the now. 

Use Prostheses. Without getting into the spiritual and psychological downsides of smart phones, tablets, and all the rest, technology can really help our clients. Calendar apps, To Do List, apps, Journaling apps, and even Cognitive Therapy apps (here’s a good one). And let’s not forget how the convenience of music, lectures, and guided imagery meditation in the palm of the hand. This technology is no different than the prosthetic arms and legs and eyes that we use to the limited live again. And living brings people back to the now. 

To be continued!

Shabbat Shalom!

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 #080 Sivan 2, 5775 May 20, 15

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As a cognitive therapist, helping relieve insomnia requires getting into the thoughts and beliefs that otherwise make sleep impossible. Mind and body are connected; what the mind thinks it ‘translates’ into physical reactions. The body is a captive eavesdropper on the thoughts, worries, regrets, and impulses that criss-cross the mind.

An example:

Last week a client made an important decision which would have great influence on her future. Without going into the details if this decision fell in between ‘what-to-order-for-dessert’ (trivial) and ‘who-to-marry’ (super not trivial), this particular decision would fall closer to the who to marry direction. Not surprisingly she complained of sleep difficulties. In this specific case, she was able to fall asleep literally when her head hit the pillow but awakened two hours later and then not be able to fall asleep again.

It didn’t take a rocket scientist or advanced, experienced cognitive therapist to understand why this was: her mind, after a two hour nap, began percolating with activity. The body, ever ready to help out, heard the mind, and threw some coals on the fire. By coals on the fire, I mean acetylcholine, the neurotransmitter of physical activity. It also stopped dumping adenosine, the neurotransmitter of sleepiness, into the blood stream. The result was a body ready to go and buy a dress (oops! I’ve said too much already!). 

What we did about however was pretty cool. More on that later.