Tag Archives: cognitive therapy

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 #097 Returning The Crown: Mastery & Redemption

If I make you breakfast


It’s been so many years yet the wisp of a lyric of a Sheryl Crow song still rings in my mind:

“I’m a stranger in my whole life”

That’s a sentiment that our clients can relate to. Rooted as they are in pain and shame and in the impossibleness of their individual situation they are strangers in their own lives. They are the masters of nothing; the pawns of nearly everything.

It’s hard not to think of this terrible state as we enter into the Nine days prior to Tisha B’Av (you can read about that here). These Nine days sweep us all into the vortex of pain caused when our fears rebelled and ruled over our faith. The terrible report of the spies, the destruction of the Temples in Jerusalem, and all the rest were symptoms of the real problem; we fell to our knees, bowing down to our own abject terror. 

And we’ve been trying to stand up ever since. 

The work of redemption and healing, whether it’s for our clients, ourselves, our nation, or the world, is returning the crown to where it belongs: clear thought. Only clarity of thought and the joyous transcendence which flows from it offers us the possibility of coming home to ourselves. 

Cognitive Pearl #095 The Moment & It’s Loving Embrace

Jerusalem cats tale






In my previous post, I suggested that a function of the sensation of the passage of time is part of our pattern recognition abilities. The sensation of time provides a background standard to organize the contents of our lives. We categorize, prioritize, plan, and respond based on the sensed temporal immediacy.

In our work, ‘sensed’ or ‘felt’ time has great relevance. The anxious, overwhelmed client not only experiences a swarm of threats; all of those threats are bearing down on him NOW. For the anxious there is no reprieve of ‘later’. As one of my clients described it, ‘I’ve gotta do everything right the hell now!!’

Similarly, the depressed client, especially when in a dysphoric mood state, is immobilized by regrets anchored in the temporal space of NOW. While clients may describe events in the past tense, their affect and cognition are temporally centered in the present and in the future. A client described his misery as watching ‘reruns of past failures scheduled for the next hundred years’.

In order to feel better our clients must do things that give them pleasure and mastery. Because of its enormous influence on their abilities to plan and do things, our clients’ temporal orientation is vitally important. The good news is that temporal reorientation in the vast majority of circumstances is accomplished easily. Here’s some of the ways which I’ve noticed and which I’ve developed further:

1. The imposition of temporal order through activity scheduling. The mere establishing of appointments has a reorienting effect. Cognitive therapists have long used activity scheduling to extend our efforts to bring the client back to the unpolluted now.

2. Helping the client establish a renewed sense of time through dialogue. The client centered psychotherapies in general, and cognitive therapy in particular, have always advocated ushering the client into the moment. We do this with dysfunctional thought records and with all of the homework assignments that we prescribe.

Most importantly it is our reassuring insistence which compels both client and therapist into the present. Instead of preoccupation in the past, we focus on present symptoms and ways to feel better now. While I acknowledge that past experiences and future risks are part of our work, I often explain to my clients that the best way to heal their lives and help them blossom, is to be rooted in the loving embrace of the present moment. From that secure position they can go back or forward in time and process anew the traumas of the past and fears of the future. 

To be continued!

Cognitive Pearl #094 Which Side Of The Bathroom Door

If your eyes are open






The motivational speaker, Zig Ziglar, once remarked that the length of a minute depends on which side of the bathroom door one is. His observation graphically illustrates that time is experienced differently depending on circumstances (such as needing to go potty).

Yet what fascinates me is why we need to keep track of time in the first place. Is it not enough that our physiological functions keep track of time for themselves? Beyond the social convenience of keeping track of time (it’s much easier to plan a meeting when we all arrive at the same moment) and the technological requirements for synchronization, why did nature endow us with the sense of time?

To suggest an answer, at least this cognitive therapist’s perspective, let’s consider the most basic of cognitive skills: pattern recognition and it’s correlate, pattern deviation. Pattern recognition requires the ability to discern. This incredibly important cognitive skill requires a reference point against which observed phenomena are monitored.

This capacity is not uniquely human. My dog can track a wayward ball rolled across the floor and grab it. What makes the human capacity for pattern recognition different however is the enormous demands that we put on ourselves and our environment. While Sleepy’s abilities to track that ball are no doubt a manifestation of his predatory skill set, he has no idea of the subtle and myriad differences that I need to live my human life.

And that’s where the sensation of time comes in.

The sensation of the passage of time provides the background information for us to measure so many of the contents of our crazy, complicated lives. Priorities are set according to their time (temporal) immediacy. Our interaction with the world around us is shaped by the duration of events. Time provides the ‘antihero’ to those wonderful moments of transcendence, moments when time falls away like some unneeded clothing. And when human life is disrupted such as by trauma and misery, time becomes both part of the suffering, and as we’ll read about in the next post, part of the healing.

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 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.