But I’m normally a rational person …

She shifted uncomfortably in her seat, her uneasy hands fidgeting together, her eyes flitting around as she tried to focus on the wall across from her, unable to find a target for her empty gaze.

“But … I’m normally a rational person,” she said, finally putting words to the thought that had been evading her for half a minute.

She was a woman in her mid thirties, with a comfortable job, a family and a mortgage in the suburbs.  We were halfway through a standard GP consult, and we had already discussed and resolved something trivial before she finally plucked up the courage to change tack and reveal the hidden agenda she’d hoped to discuss all along.

“I’m anxious all the time.  I try so hard, but I can’t seem to stop thinking about all the things that could go wrong.”

I empathised.  I’ve been there too – I’ve lived through times when my anxiety disorder was so debilitating that I wouldn’t call someone on the phone for fear of dialling the wrong number.  Or when I was so depressed that I couldn’t see anything positive for the future, when nearly every thought I had was saturated with moribund darkness.

I was anxious as a teenager, but I was depressed as an adult.  I’d been through medical school and I had attained by GP fellowship when my depression took hold.  During the four years or so that I spent with the black dog, I was constantly haunted by the same narrative that now haunted my patient … “I’m a rational person, why am I thinking like this?”

The fact I had fellowship level medical training intensified my mental self-flagellation, “I know all about depression.  I understand CBT.  I know I’m ruminating on catastrophic thoughts.  So why can’t I stop them?  If only I could think more positively, I’d be so much better.”

I found myself in a self-defeating spiral, often called the struggle switch, where I thought I knew how to climb out of my psychological mire, but all I achieved in trying to climb out was to sink further in, making me feel more defeated, even more of a failure.  It was a very difficult time which I thought would never end.

Eventually it lifted, like a heavy fog thinning in the morning sunlight, but it certainly wasn’t the result of anything clever I did.  So why did my rational brain keep filling my mind with irrational thoughts?

The answer lay in a paradigm shift away from the long held beliefs that we were taught at medical school and in our general practice training.  We’ve been lead to believe for so many years that our thoughts were the key driver of our behaviour, but it turns out that it’s actually the other way around, our behaviour is but one of a number of key driver of our thoughts.

The foundation of CBT is the notion that challenging maladaptive thoughts helps to empower behavioural change.  Except that research suggests that cognitive therapy specifically targeting problem thoughts offers no extra improvement over behavioural therapy alone.

Herbert and Forman confirm this when they point out that, “proponents of behavioral activation point to the results of component control studies of CT, in which behavioral activation or exposure alone is compared to behavioral activation (or exposure) plus cognitive restructuring. The majority of these studies have failed to demonstrate incremental effects of cognitive restructuring strategies.” [1]

This fact has been further confirmed by a number of meta-analyses [2] and by a large randomised controlled trial comparing behavioural therapy and cognitive therapy side by side with medication for depression [3].

So therapies aimed at fixing thinking works equally as well as therapies aimed only at promoting therapeutic action.  However, when thinking therapies are added to behaviour therapies, they add no extra benefit over and above the behaviour therapies alone [2].  This suggests that action is the driver of the therapeutic effects of psychological therapy.  If thinking were the driving force of psychological change, the addition of cognitive therapy to behaviour therapy should have an incremental effect.

That cognitive therapy works equally well as behavioural therapy may be related to their fundamental similarities. Dobson et al explains, “Behavioural Activation is implemented in a manner that is intended to both teach coping skills and to reduce future risk. The same is true for Cognitive Therapy, which adds an emphasis on cognitive change, but otherwise takes a similar skills-training approach.” [3]  In other words, cognitive behavioural therapy is just behavioural therapy with bling.

Herbert and Forman summarise it nicely, “The ideas that thoughts and beliefs lead directly to feelings and behavior, and that to change one’s maladaptive behavior and subjective sense of well-being one must first change one’s cognitions, are central themes of Western folk psychology.  We encourage friends to ‘look on the bright side’ of difficult situations in order to improve their distress. We seek to cultivate ‘positive attitudes’ in our children in the belief that this will lead to better academic or athletic performance. Traditional cognitively-oriented models of CBT (e.g., CT, stress inoculation training, and rational emotive behavior therapy) build on these culturally sanctioned ideas by describing causal effects of cognitions on affect and behavior, and by interventions targeting distorted, dysfunctional, or otherwise maladaptive cognitions.” [1]

I understand this is going to ruffle some feathers, and not everyone is going to be keen to dispense with CBT just yet, but I hope this gets us thinking about thinking at the very least.

For me, coming to an understanding that my thoughts were just the dashboard and not the engine helped me to pay less attention to them and to focus my healing energies on what was really important, taking values based action rather than just fighting with my stream of thoughts.

And it’s helped me to empathise differently with my patients and reassure them that you can still be a rational person even if your thoughts don’t always seem to follow suit.

References
[1]       Herbert JD, Forman EM. The Evolution of Cognitive Behavior Therapy: The Rise of Psychological Acceptance and Mindfulness. Acceptance and Mindfulness in Cognitive Behavior Therapy: John Wiley & Sons, Inc., 2011;1-25.
[2]       Longmore RJ, Worrell M. Do we need to challenge thoughts in cognitive behavior therapy? Clinical psychology review 2007 Mar;27(2):173-87.
[3]       Dobson KS, Hollon SD, Dimidjian S, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of consulting and clinical psychology 2008 Jun;76(3):468-77.


KINTSUKUROI CHRISTIANS – Available at Koorong, Amazon, iBooks and other good book retailers

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Black is the new black – Mental illness touches more of us than we realise (or want to admit)

I rarely get sick.

I say this while superstitiously touching my wooden desk to try and avoid putting the mockers on myself.  Thankfully, I have a fairly robust immune system and, after years or working in hospital paediatrics and general practice, and having been sneezed at or coughed on multiple times a day, I have been exposed to just about every variation of the cold virus and influenza possible.

Even for those of us with an immune system as solid as a prize bull, we still get sick every now and then.  We all get upper respiratory viruses so commonly that we just consider it a normal part of life.  Most people will take some paracetamol or ibuprofen and keep going.  Some people will go to their GP, and while a most will (… should …) come away some simple reassurance, occasionally some will need a prescription medication for a nastier bacterial infection.  An even smaller percentage will need admission to hospital because of a much more severe infection.

I read an interesting blog this week on Psychology Today by Dr David Rettew.  Its provocative title was, “Is Mental Illness the Rule Rather Than the Exception?”

The blog discussed the study being carried on in Dunedin which has been following a cohort of a thousand people for the last thirty-five years.  This particular study looked for common factors that were shared by those people who had never been affected by a certifiable psychiatric disorder.  What was interesting was that only seventeen percent of the people in that cohort had NOT been affected by a mental illness at some point in that thirty-five-year time frame.

Now for the average Australian, there are some obvious kiwi jokes going begging here (like, I’d be depressed too if I had to live in New Zealand, or how can someone tell if a sheep is really depressed or not, etc. etc.).  All jokes aside, seventeen percent of people not affected … that’s a remarkable figure.  In researching my latest book (soon to be released …) I had come across the figure of fifty percent of people had a lifetime prevalence of any mental illness.  That’s one in every two, and chances are that if you weren’t the person affected, you would know someone who was affected, but the Dunedin figures are even higher.  If you can accurately extrapolate them, four out of every five people will be affected by mental illness at some point in their lives.

The inevitable response from modern psychiatry’s critics is entirely predictable – there will be claims that the DSM5 is simply making diseases out of normal human life experiences, that our humanity is being pathologised and over-medicated for the benefit of big Pharma.

But as Rettew points out in a separate blog post, something may be such a common occurrence as to be considered part of the normal human experience but it can still be a pathology.  The common cold is so common that it’s a normal part of life, but it’s still a disease.

Whether four out of every five people will be affected by mental illness or one out of two, whatever the number, the idea that most of our population will be afflicted with a mental illness at some point in their lives isn’t necessarily a negative thing.  As Rettew also discusses, we don’t arbitrarily change the definitions of physical illnesses to match how many people we think should suffer from them, and neither should we arbitrarily change the diagnostic boundaries of mental illness so less people appear mentally unwell.

We need to accept that, at times, people will be functionally impaired to varying degrees because of mental illness just like people will be functionally impaired by physical illness.  We need to treat mental illness with the same respect as we would physical illness.

In the same way that not all physical illnesses require medication, neither do all mental illnesses.  By and large, most mental illnesses that people suffer from will be short lived and self-limiting, the psychiatric equivalent of having a cold.  Some people will need treatment for their mental illness, but usually this takes the form of structured behavioural therapy like ACT or CBT.  Occasionally, people will need to take a medication and very occasionally, some people will need to be hospitalised because of their mental illness.

For too long, mental illness has been viewed from an extreme perspective – mental illness is uncommon and severe. The nuances of mental illness have been lost or ignored in the white noise of ignorance and sanctimony.  The lack of subtlety and understanding has failed us as a community.  When treated early, mental illness has a much better prognosis, but the stigma, fear and misunderstanding perpetuated by the all-or-nothing approach has left a lot of people without treatment and therefore with worse outcomes overall.

If people were to realise that most of us will be touched by mental illness at some point, then perhaps there would be more understanding and less judgement, something that would lead to less suffering because of mental illness.

That would only be a good thing.

~~~~~

If you think you might be affected by mental illness or if you would like to know more, see your local GP, family physician or psychologist.  On line information can be found at many reputable sites including Beyond Blue – https://www.beyondblue.org.au

The Prospering Soul – Christians and Depression Part 2

For most church-goers, putting the terms “Christian” and “depression” in the same sentence just doesn’t seem natural. In part 1, we looked at what depression is and why depression affects a lot more of the church than the church is aware of.

In this instalment, we’ll look at some general ways to handle depression, and what the Bible says about being depressed.

In the first blog, I explained how I understood depression as the end result of the brains capacity to deal with the demands of life. Too many demands or not enough resources overwhelms the brain and low mood is the end result.

So how do you manage depression? Well, if the system is failing because of increased demand or decreased capacity to cope, then it’s logical to manage depression by decreasing demand and increasing capacity to cope.

We can increase our capacity to cope by increasing our brains capacity to grow new nerve branches, and to make the cells more efficient at doing their job.

Increasing the growth of new nerve cell branches (in science speak – ‘synaptogenesis’) involves increasing the growth factors. BDNF has been proven to be increased by anti-depressant medications [1, 2] and by exercise [3, 4]. There may be some evidence that diet might improve depression in a similar way although the evidence is weak [5], so we should take that with a grain of salt.

The next way of managing depression is to increase the capacity to cope. The way we do that is through psychological therapies. There are several styles of psychological therapies, too many for me to discuss them all here. In the real world, most psychologists use a mix of a number of techniques that they tailor to the needs of their patient. I’m going to quickly outline the two most commonly used therapies.

Cognitive Behavioural Therapy, or CBT for short, is “based on the theory that emotional problems result from distorted attitudes and ways of thinking that can be corrected. The aim is to treat difficulties by problem solving, finding better strategies for coping, and overcoming irrational fears.” [6] Essentially it’s the combination of two different therapies, Cognitive therapy, and Behavioural therapy. Cognitive therapy, as the name suggests, assumes that people have mental health problems because of patterns of irrational thinking. Behavioural therapy is quite broad, but looks to challenge the thinking patterns with action (for example: gradual exposure to something a person is afraid of).

CBT is the most well researched form of psychotherapy, and has a lot of evidence for it’s effectiveness [7]. Though there is good evidence that it’s the behavioural arm that gives it any clout [8, 9]. Trying to change your mental health just by trying to change your thoughts is generally ineffective.

In the last couple of decades, a new wave of psychological therapies has emerged from this idea that Cognitive Behavioural Therapy is just Behavioural Therapy with bling. The most notable is Acceptance and Commitment Therapy, or ACT for short. ACT is different to CBT in that ACT doesn’t rely on the idea of changing thoughts, but on simply accepting them. ACT “is a psychological therapy that teaches mindfulness (‘paying attention in a particular way: on purpose, in the present moment, non-judgementally’) and acceptance (openness, willingness to sustain contact) skills for responding to uncontrollable experiences and thereby increased enactment of personal values.” [10]

According to ACT, you don’t have to change your thoughts, because thoughts aren’t that powerful to begin with – they’re just words. Sometimes they’re true, and sometimes they’re helpful, but if we spent all of our time trying to fight them, we miss out on experiencing the joy in the present moment, and we can lose sight of the values that guide us into our future fulfilment.

The common link between good psychotherapy is that their therapeutic effect comes from improving skills in different areas that the patient lacks. That is, psychological therapies increase the capacity of the patient to cope with things that would have otherwise wouldn’t have handled well and would have caused distress.

The last way to manage depression is to limit the excessive demands that have been placed on the system in the first place, or in other words, reduce the unnecessary stressors. People who are depressed tend to be bad at this, but there are a few basic skills that are common to all stress management techniques that can form the platform of ongoing better skills in this area. The full list will be a blog for another time, but the simplest technique is to breathe!

It’s really simple. Sit in a comfortable position. Take slow, deep breaths, right to the bottom of your lungs and expanding your chest forward through the central “heart” area. Count to five as you breathe in (five seconds, not one to five as quickly as possible) and then count to five as you breathe out. Keep doing this, slowly, deeply and rhythmically, in and out. Pretty simple! This will help to improve the efficiency of your heart and lungs, and reduce your stress levels.

Remember, B.R.E.A.T.H.E. = Breathe Rhythmically Evenly And Through the Heart Everyday.

To recap, there are three main ways to manage depression – increase the brains ability to process the incoming information, increase the capacity to cope, and decrease the amount of stress that our brains have to process.

The fourth way to help manage depression is prayer. There is limited scientific information on the effects of prayer on depression, although a small randomised controlled trial did show that prayer with a prayer counsellor over a period of a number of weeks was more effective than no treatment [11]. But the Bible encourages us, “Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God. And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus.” (Philippians 4:6-7)

And Jesus himself called to those heavy in heart, “Come to me, all you who are weary and burdened, and I will give you rest. Take my yoke upon you and learn from me, for I am gentle and humble in heart, and you will find rest for your souls. For my yoke is easy and my burden is light.” (Matthew 11:28-30)

One final thought. It’s sometimes hard to understand how strong Christians can become depressed in the first place. After all, the Bible says that the fruit of the Spirit is joy (Galatians 5:22). 1 Peter 1:8 seems to suggest that every Christian should be “filled with an inexpressible and glorious joy.”

So when you’re filled with the opposite, it makes you feel like a faithless failure, and Christians without depression assume a similar thing for Christians they know who are suffering from depression. It’s the logical conclusion to draw after all – if the fruit of the Spirit is joy, and you are not filled with joy, then you mustn’t be full of the Spirit.

But when you look through the greatest heroes in the Bible, you see a pattern where at one point or another in their lives, they went through physical and emotional destitution. Sure, their lives had some pretty amazing highs, but they often experienced some amazing lows as well. Moses spent forty years in the wilderness, and when God appeared to him in the burning bush, he argued with God about how weak and timid he was (Exodus 3 and 4).

In 1 Kings 18, Elijah had just seen God rain down fire to supernaturally consume his sacrifice, capture and kill four hundred and fifty prophets of Baal, and watched God break the drought over Israel. At the height of this run of amazing connection to God, Jezebel the evil queen threatened him, and he ran for his life in a panic and asked God to kill him, twice, over the period of a couple of months (1 Kings 19).

Peter had spent three years with Jesus, the Messiah himself, hearing him speak and watching him perform miracle after miracle after miracle. Peter even saw the empty tomb first hand on the very first Easter Sunday, but still, he gave up on life with God and went back to his former occupation, which turned out to be lots of hard work for very little reward (John 21:1-3).

The same pattern is also seen in King David, Gideon, and a number of other great leaders through the Bible. The take home message is this: it’s human nature to suffer from disease and dysfunction. Sometimes it’s physical dysfunction. Sometimes it’s emotional dysfunction. It’s not a personal or spiritual failure to have a physical illness. Why should mental illness be treated any different?

As the stories of Moses, Elijah and Peter testify, being a strong Christian doesn’t make you impervious to low mood or emotional fatigue. Hey, we’re all broken in some way, otherwise why would we need God’s strength and salvation! Having depression simply changes your capacity to experience the joy and love of God. Closing your eyes doesn’t stop the light, it just stops you experiencing the light. Being depressed makes it hard to experience God’s love, but it doesn’t stop God’s love.

In the 80’s and 90’s, a popular Christian musician was a man named Carmen. One of his best known songs had these words,

“When problems try to bury you and make it hard to pray, it may seem like Friday night, but Sunday’s on the way!”

It’s really hard when you’re afflicted by the dank darkness of depression. But nothing will separate us from the love of God (Romans 8:35-39), including depression. You may not feel it, but God’s love is there, and Sunday’s on the way.

Remember:

  1. Depression is a common mental health condition that can have prolonged and devastating consequences. Depression is characterised by either a sadness or a lack of joy which are abnormal in their intensity and their duration, but also affects sleep, appetite and motivation. It’s caused by abnormalities in genes which affect the brains ability to grow new nerve cell branches, and which also affect in-built coping mechanisms, so stress is both more likely to occur in people who are more prone to depression, and the stress is then handled poorly, overloading their emotional capacity.
  1. The management of depression is three-pronged: to improve the brains ability to grow new nerve cells through exercise and/or medication, to learn new ways to cope with distress, and to decrease the amount of stress in the first place.
  1. Christians are not immune from depression, and it’s important for Christians to understand that Christians suffering from depression are not weak, or failing in their spiritual walk, or are unloved by God. The love of God is always present, even if they are unable to process it properly. As dark and dismal as depression can become, there is hope. It may seem like Friday night, but Sunday’s on the way.

References

[1]        Duman RS, Li N. A neurotrophic hypothesis of depression: role of synaptogenesis in the actions of NMDA receptor antagonists. Philosophical transactions of the Royal Society of London Series B, Biological sciences 2012 Sep 5;367(1601):2475-84.
[2]        Anderson I. Depression. The Treatment and Management of Depression in Adults (Update). NICE clinical guideline 90.2009. London: The British Psychological Society and The Royal College of Psychiatrists, 2010.
[3]        Karatsoreos IN, McEwen BS. Resilience and vulnerability: a neurobiological perspective. F1000prime reports 2013;5:13.
[4]        Rimer J, Dwan K, Lawlor DA, et al. Exercise for depression. The Cochrane database of systematic reviews 2012;7:CD004366.
[5]        Lai JS, Hiles S, Bisquera A, Hure AJ, McEvoy M, Attia J. A systematic review and meta-analysis of dietary patterns and depression in community-dwelling adults. The American journal of clinical nutrition 2014 Jan;99(1):181-97.
[6]        NowOK. Cognitive Behavioural Therapy. Dictionary of Psychotherapy 2015 [cited; Available from: http://www.dictionary.nowok.co.uk/cognitive-behavioural-therapy-cbt.php
[7]        Ruiz FJ. Acceptance and Commitment Therapy versus Traditional Cognitive Behavioral Therapy: A Systematic Review and Meta-analysis of Current Empirical Evidence. International journal of psychology and psychological therapy 2012;12(3):333-58.
[8]        Longmore RJ, Worrell M. Do we need to challenge thoughts in cognitive behavior therapy? Clinical psychology review 2007 Mar;27(2):173-87.
[9]        Dobson KS, Hollon SD, Dimidjian S, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of consulting and clinical psychology 2008 Jun;76(3):468-77.
[10]      Smout M. Acceptance and commitment therapy – pathways for general practitioners. Aust Fam Physician 2012 Sep;41(9):672-6.
[11]      Boelens PA, Reeves RR, Replogle WH, Koenig HG. A randomized trial of the effect of prayer on depression and anxiety. Int J Psychiatry Med 2009;39(4):377-92.

If you’re suffering from depression or any other mental health difficulties and need help, see your GP or a psychologist, or if you’re in Australia, 24 hour telephone counselling is available through:

Lifeline = 13 11 14 – or – Beyond Blue = 1300 22 4636