Tag Archives: cognitive therapy

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 #083 Sivan 10, 5775 May 28, 15

greatest fear

 

 

 

 

 

 

 

 

Over the years the New York Times, a newspaper celebrated by intelligentsia the world over, has introduced a surprisingly intelligent discussion about mental health and psychotherapy. So it was fascinating to read of a case vignette in which poetry was a central prop in the dynamic between healer and client. You can read the article here.

To be sure, the management of the case was problematic. The comments, when you look past the snideness and the rage so common to comment sections, raise some very valid questions. While there is no doubt that the client’s poetry and the discussions that revolved around it played a major role in this case, it’s seems that the central axis here was the client’s wounded narcissism and the therapist’s valiant and impotent efforts to ‘domesticate it’.

What this write up triggered for me was a reflection on the integration of artistic expression into treatment. I am not by any means an art therapist. However I’ve long believed that one enormous value of artistic expression is that it allows us to become rulers and gods of the crazy universes that we inhabit. For one beautiful expressive moment we ‘own’ whatever threatens to destroy us or we hold the reins of an otherwise fleeting mysterious dream. Whether it’s our own creations or the visions and words of others, we are no longer unwanted visitors in this world; we are the kings and queens. 

And what could be better than that?

 

Cognitive Pearl #080 Sivan 2, 5775 May 20, 15

q

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. 

Cognitive Pearl #078 Iyar 25, 5775 May 14, 15

Its not the circumstances

 Reflecting on the common physical causes for insomnia which I encounter with my clients, they all share one common root: disregard for connection between mind and body. It seems that we all live without regard to the body which so cares for us.

So for instance, the amount of artificial light which we fill our living spaces can have cumulative devastating impact on our health (this was brought home to me by some frightening data about breast cancer and light pollution which you can read about here). Yet as much as we read about how important it is to ease the body towards sleep by decreasing exposure to light, we keep the lights on and use our phones, computers, and tablets to stimulate ourselves late into the night. 

I mention this disconnection here because for most of our clients, insomnia is another manifestation of their negative relationship with their bodies. While deeply delving into this relationship is not always required, it’s important to at least raise the issue. 

Cognitive Pearl #075 Iyar 22, 5775 May 11, 15

jealousy

 

 

 

 

 

 

 

 

In the world of cognitive therapy, upgrading is fundamental. With that in mind, (hopefully!) with today’s post, you’ll notice improvements which will make the content even more exciting and useful. Let me know what you think!

Today’s Tachlis Takeaway: many sleep problems can be helped with the methods of cognitive therapy.

When we think of sleep, we may often think of a necessary evil which we must ‘put up with’. Just look at the coffee section of my local supermarket: there’s a solid eight meters of valuable shelf space devoted to a bitter beverage whose most important redeeming quality is that it can keep us awake. Looking back on my forty year love affair with coffee, I’ve got some serious doubts that I would have been able to start and complete even one degree without the steady drip of stimulants into my veins.

Sleep however gets a bum rap. It’s quite telling that the Bible tells us that Adam was asleep when he was matched up with Eve. Marriage, the most important event in a human’s life; and here a central protagonist was out cold. But it’s not just the Bible that tells us something about sleep; modern science continues to inform us of the many, many blessings of sleep.  Or, r’l, the terrible ills that can befall the human mind and body when we don’t sleep enough.

Where we psychotherapists come in is that many of the barriers to the blessings of restful sleep respond to the skills which we offer. In the coming posts we’ll consider some of cognitive therapy techniques which can help our clients (and ourselves) to sleep and to heal. 

 

Cognitive Pearl #074 Iyar 18, 5775 May 7, 15

Lag BoOmer BonFire

 

 

The dizzying smoke of a million bonfires lingers in the air of Jerusalem. For some Lag BaOmer was a magical evening; for others it was a night of noise, irritation, closed windows, and coughing.

Isn’t that a fitting epitaph for Rabbi Shimon Bar Yochai (you can read more about him and Lag BaOmer here)? An all eclipsing hero to some; a dangerous and tiresome rebel to others.

Counting myself among the former, Lag BaOmer is a quintessential cognitive therapy holiday. Granted that such a statement seems counter-intuitive; after all, cognitive therapy advocates empiricism (the school of philosophy which holds that only that which can be seen can be truly understood) and Lag Baomer is a celebration of the mystical, of the unseen, of the unknowable mystery of the Universe.

For me however empiricism has it limits just like every body of human knowledge. Everything, perhaps with the exception of death, is subject to the law articulated so poetically by another fantastical character of much more recent vintage, Forrest Gump, ‘it happens’. As much as we strut about with our data, statistics, predictions, and all the other synonyms for human hubris we just don’t know.

Lag BaOmer and its mystical traditions remind me that no matter how clever we get, humanity will never fully know the whole score. As close as we get to figuring it all out, the loving Designer of all stays just beyond our grasp. He sprinkles beauty as a leads us deeper and deeper into the cosmos. 

So what then is the place of cognitive therapy when each of us is immersed in a universe so much out of our control?

There are of course many reasons to do what we can to make our lives better. For me, cognitive therapy has offered one unparalleled gift and for this it is supremely relevant. That is is the pure pleasure of clear thought and the joyous life that results. Once I get all of the traps and tricks of misery-making-embodied-pseudo-thinking out of my head the sky turns blue, the universe opens itself, and I’m swept into the mystery of it all.

So pass me a marshmallow and throw another log on the fire. 

Bar Yochai, the holiest oil has anointed you; you’ve ascended to the loftiest of levels; glory encompasses you. 

Cognitive Pearl #072 Iyar 16, 5775 5 May, 15

A terribly tortured client complained about her feelings. Not a specific feeling. She simply hated the whole idea of feelings; they were inconvenient; bothersome. Not surprisingly, she was suicidally depressed, full of self hatred, and utterly confused by why she was so miserable.

There’s good news. She’s doing great now; cognitive therapy has helped her far more than all of the hospitalizations and medications. She’s come to understand that feelings are wonderful teachers and friends. Instead of repressing them she lives her life joyfully by respecting the wisdom they offer.

Her story comes to mind as I reflect on my trip (told in a previous post) to Meron. Instead of taking our car, I decided on public transportation (it was actually really nice!!). One major difference between going in a private car and public bus is that on a bus there are no bathroom breaks. Otherwise, the driver would be forced to pull over every second; tachlis, a three hour trip would take three days. So instead we must all ‘hold it in’, cutting ourselves from our the messages that our bodies tell us.

The same is true of the family which my client comes from. Many children. Harried parents. A culture which indoctrinates towards sameness and ostracizes difference. In a world like that who has time for feelings? Who has time for inconvenient truths spoken by the heart. ‘Onward!!’, she was told again. Onward towards where? To a place whose entry fee was the cruelest kind of amputation: the person from herself.

Cognitive Pearl #070 Iyar 12, 5775 1 May, 15

We rise by lifting others

 

 

 

In considering the depth of cognitive treatment I take the approach that above all, my efforts must ultimately lead to positive social reintegration. Humans are a social animal; we can do amazing things when we’re attached to others. From a cognitive therapy perspective, social connectedness forms the bridge that allows the transfer of new ideas between people. These are the ideas that save our lives. 

Consider depression. Or schizophrenia. Both share features in common: thought disturbance and  emotional disconnection are the most visible. When most of us think of schizophrenia, delusions and hallucinations come to mind. Or when we think of depression we think of the immobilizing heaviness of self hatred and despair. Yet in both cases, social disconnectness is the most important determinant of outcome. That connectedness provides the leverage to keep the client connected to reflection, reality testing, and the magic of community. 

So tachlis, as a cognitive therapist, my treatment plan and its length, intensity, and depth is designed around getting the client back in touch with others. 

After all, life is with people. 

More on this next week.

Shabbat Shalom!

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. 

Chalilah. 

To be continued.