Author Archives: Josh Mark

About Josh Mark

Always looking in between the lines to find the inner truths and beauty, I feel blessed to live in a time of such wonderful promise. My story begin in Stamford, Connecticut and has taken me around the world to Jerusalem.

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. 

Cognitive Pearl #084 Sivan 13, 5775 May 31, 15 Poetry & Cognition

IMG_1419

 

 

 

My previous post touched on the integration of poetry and artistic expression into our work as healers, teachers, and professionals of every stripe. Of course it is absolute hubris to think that art needs some sort of ‘scientific validation’ or in the lexicon of contemporary Orthodox Judaism, a ‘teudat kashrut’; humanity has soared out of its most horrible depths on the wings of poetry and art well before a bunch of psychological hotshots started poking around with brain scans and computers.

As a yeshiva bochur however poetry has a unique place beyond other artistic forms. In spite of the often maligning characterizations of the yeshiva bochur, what outsiders often don’t appreciate about us is our love of precision. Whether we’re arguing over who bears responsibility for a wayward ox or the correct amount of cayenne pepper in a cholent, we will go to the mat to get to the truth. We want our ideas, to be clean, concise, and free of dross.

So it shouldn’t surprise anyone that poetry’s exacting demands of beat, rhythm, meter, rhyme and structure should mean so much to this yeshiva bochur. The ethereal ideas of great poetry brings me into communion with what really truly is; nothing less and nothing more. In the poem lies the essential truth, a truth so miniaturized, rarified, and refined that it can take me by the hand and schlep me with my big American ego into its beauty.

With that in mind, I share one of my favorite poems about how we can heal each other. It’s written by Hafez, a Persian mystic, who appeared to have appreciated the terrible loneliness that still challenges us to this day. 

With That Moon Language

Admit something: 

Everyone you see, you say to them,

“Love me.”

Of course you do not do this out loud;

Otherwise,

Someone would call the cops.

Still though, think about this,

This great pull in us

To connect.

Why not become the one

Who lives with a full moon in each eye

That is always saying,

 With that sweet moon language,

What every other eye in this world

Is dying to

Hear.

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 #082 Sivan 4, 5775 May 22, 15

IMG_1421-2

With Shavuot upon us, two ideas have been rolling around my head, ideas that I think are super important in our work as healers and teachers.

The first  idea is about trying new things, making mistakes, and then picking up the pieces to make an even more beautiful masterpiece. The Torah is shockingly candid about mistakes. While the purveyors of super-hero fiction (and many so-called Gedolim biographies) would like us to believe that heroes are flawless, the Torah gives us permission to embrace the reality of our imperfect-perfect existence and to dance with it. Even Hashem, with all of His abilities, could not stop us from messing up just 40 days after the greatest moment in human history. We made a Golden Calf, an epic mess which we’re still cleaning up to this day.

Oops.

Yet Hashem didn’t throw in the towel. He gave us and Him another chance to make it work. And it did. Just look at how far we’ve come.

The second idea is a bit more ‘cognitivy’. In my spare time I’ve been reading a lot about non-symbolic cognition. Think of how a dog might view the meat counter in a supermarket. He sees (or smells) the meat but little else. Unless there’s a predator present, everything but the meat is invisible to him because it has no symbolic value. At least to a dog. Among our species, non-symbolic cognition is a hallmark of clinical depression; the severely depressed individual looks at a world of grey, flatness, and lacking any symbolic contours. While we see energy, beauty, and opportunity he sees blankness.

What’s this got to do with Shavuot? Well we’re told that Hashem forced the Torah on us through brute coercion. The Midrash uses the phrase, ‘He held a the mountain like a barrel over them’.

This first iteration didn’t work out as planned; we relapsed into our idolatrous roots. The reason that I think we failed is that we were unable to see what we were being given; it was invisible to us. The glory of the Mitzvot had no symbolic gravitas to us.

Yet.

We were still thinking in ‘Egyptian’, with its pyramidical distributions of power, and soul crushing ideology of meaningless dispensable cogs in someone else’s dreams. Hashem’s idea of unbounded spirit, unchained from the gravity of materialism seemed ridiculously invisible. To paraphrase the words of Eric Fromm, we tried to escape from our own freedom.

The take away is that not only did the Jewish people need to be deprogrammed so that they could fully embrace the Mitzvot, our clients do as well. While we don’t have any mountains to hold over their heads, we can use our creativity, example, and our skillfulness to evoke the dormant human spirit. 

Chag Samayach everyone!

Cognitive Pearl #081 Sivan 2, 5775 May 20, 15

sleeping baby

 In my previous post, I spoke of a client who falling soundly asleep, is awoken by the thoughts making a racket in her mind. She’s unable to fall asleep again because of her stressed out mind and the activating signals which it broadcasts to the body.

In the following session, I suggested that she keep a journal handy. Should this episode occur again, she could use the time to ‘unload’ or ‘download’ her troubles into the journal. What was recorded could then be used for further reflection during the waking hours of the day. Or she could use the awake time to organize her thoughts so that they wouldn’t be running around her head causing all sorts of havoc. Predicting that some of the thoughts would be anxious and distorted in nature, I reviewed the procedures for doing a dysfunctional thought record with her.

Along with prescribing of a journal and a dysfunctional thought record, the client and I discussed ways to prepare her body to return to sleep. In this particular case, chamomile tea and some relaxing music turned the trick. Other clients have found relief in listening to guided imagery, taking a bath with a few drops of lavender oil added, offering a prayer, doing some light housework (I find doing the dishes to be incredibly relaxing at 3am in the morning), or through diaphragmatic breathing. 

In this specific client’s case however there were other comorbid psychological barriers which made the return to regular sleep more difficult. In other words, things were not that simple. The triggering event of the insomnia evoked many of the insecurities which had plagued her previously. Yet, these easy interventions helped restore the balm of sleep, something that helped the client deal with the crushing circumstances of her life. These interventions allowed us to keep the emotional work in the treatment room without spilling into the bedroom. 

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. 

פנינה קוגנוטיבית #079 אייר כ׳ח, תשעה 17/5/15

We dont escape


בעשר שנים אחרונים נשמע בארץ, במיוחד בכנסים מקצועיים, על טיפול דיאלקטי התנהגותי (.D.B.T). אני גם תרמתי לתודעה זה דרך הרצאות שהצגתי במסגרות שונות. אחרי כמעט 20 שנים מאז שהשתתפתי מסלול הכשרה הראשונה שמרשה לינהן ניהלה בחוף המזרח של ארה׳ב עלו לי הרבה מחשבות, רעיונות, שאלות, וביקורות על שיטה זה. לא שאני פוסל אותה; להפך, בעיני ראיתי איך שהוא יכול להושיט יד לחבר’ה שטיפולים שונים כמו טיפול בפרמכיולוגיה וטיפול בשיחות נכשלו לספק מענה ׳מספיק׳. לדעתי, ובמיוחד פה בארץ עם מנטליות שונה ועם רגישויות ופתיחות תרבותית שונה מארה׳ב אנו חייבים לחשוב פעם שנייה ושלישית על איך אנו ממשיגים ומלמדים את המודל ואת הכישורים של .D.B.T. ולכן ראיתי לנכון להתיחס לדיונים אלו בפוסטים הבאים. אשמח לקבל את משובכם.

לצורך חזרה על קצת מהתשתית מהמודל של .D.B.T, אנו מניחים שחוסר כשרונות חשובות גורמות לאי יכולות לקליינטים לתפקד באופן יעיל ממול לאתגרים הנורמטיביים של החיים. בגלל חסורונות אלה, קליינטים מוצאים מענים ׳יקרים׳ והרסניים בפתולוגיות שונות כמו מניפיולציות שונות, התמכריות, פגיעה עצמים כמנגנון הרגעת עצמית, אובדנות ועוד. כישורי .D.B.T משלימים את הפערים ביכולת הקליינט. הכישורים הרבים מחולקים לארבע קטגרויות: 

כישורי יחסים בינאישייםכישורי מנוחת הנפש (Mindfulness)

כישורי הרגעת עצמית (Emotional regulation)

כישורי התמודדות בניסיונות (לחצים)

הנה תרשים עזרה שאני מחלק לקליינטים שלי:

היהלום של כישורי DBT