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

Seven Elements of Good Mental Health: 1. Temet Nosce – The Prospering Soul

Life shouldn’t just be about avoiding poor health, but also enjoying good health. Our psychological health is no different.

Before we take a look at poor mental health, let’s look at some of the ways that people can enjoy good mental health and wellbeing. This next series of posts will discuss seven elements that are Biblically and scientifically recognised as important to people living richer and more fulfilling lives.

These aren’t the only ways that a person can find fulfilment, nor are they sure-fire ways of preventing all mental health problems either. They’re not seven steps to enlightenment or happiness either.   But applying these principles can improve psychosocial wellbeing, and encourage good mental health.

1. Temet nosce – “Know thyself”

Generally speaking, there are two ways that a person can live their lives, as a boat or as a buoy – those who set out to find life or to let life find them.

Some people are quite content to be buoys – to stay in the same place and let the social currents and tides bring different elements to them. They’re more passive in their approach, content to just accept that life will just come and go as it will.

Then there are those who don’t want to stay in the one place, but want to chart their own course, discover what life is for themselves. Whose to say what’s best for each individual person? We all have our own choices to make.

For those people who are boats, who want to set their course and discover life, it helps a lot in the journey to know where you’re going.

This may seem obvious enough. In fact, it seems too obvious – we often think we know where we’re going when in reality, we haven’t a clue where we really want to go or how to get there.

For starters, it helps to know where you want to go. Some of us are gifted with an amazing confidence, self-assurance and motivation, and have the ten year plan all mapped out, but those people are the minority. It’s fine if we don’t know where exactly we want to go, but what would help every since person is to at least know the direction you wish to sail in, which are our values.

The word ‘values’ can mean different things to different people, but in the Acceptance and Commitment framework, values refer to “Leading principles that can guide us and motivate us as we move through life”, “Our heart’s deepest desires: how we want to be, what we want to stand for and how we want to relate to the world around us.” [1] Values help define us, and living by our values is an ongoing process that never really reaches an end. Living according to your values is like sailing due west. No matter how far you travel, there is always further west you can go. While travelling west, there will be stops a long the way, stop-overs along our direction of travel like islands or reefs. These are like our goals in life.

The difference between goals and values is important. You could set yourself a whole list of different goals, and achieve every one of them, but not necessarily find meaning or fulfilment in their accomplishment if they’re all against the underlying values that you have. So goals are empty and unfulfilling if they aren’t undergirded by your deeper values.

How can you understand your values? There are a couple of ways. Ask yourself: “What do I find myself really passionate about? What things irk me? If I could do anything I wanted, and money was no object, what would I do?” Is there a recurrent theme running through your answers? I have always found myself irritated by mass-marketing, and more recently by disingenuous social media memes and unscientific health messages. The theme – ‘truth’. I know, it sounds a bit trite, like some second-rate comic book hero, but I’ve mulled over this a lot, and for me, ‘truth’ is one of my deepest values.

There are other ways to discover what your values are. Some people have suggested writing your own eulogy (the speech someone gives about you at your funeral). It sounds a bit morbid, and it’s only a figurative exercise, but it tends to sharply clarify what you want your life to be like. What do you want your legacy to be? Think about the things that you want to be known for at the end of your life, and see if there is a word that best describes those desires.

If that’s a bit too confronting, there are some on-line tools that can also give you an idea. There is only so much a long list of questions can discover about you, but results of the survey can provide a starting point for further thought. There is a couple of free resources that may be helpful (though you will have to register):
* https://www.authentichappiness.sas.upenn.edu – and click on the drop-down menu in the “Questionnaires” section, and select “Brief strengths test”
* http://www.viacharacter.org/Survey/Account/Register

One final note on the buoys and the boats – whether you’re a buoy or a boat, you’re still going to encounter large waves, strong currents, and wild storms, as well as peaceful weather. As a buoy, those adverse conditions will simply find you where you are. You can’t escape from them. You’re also going to experience those same large waves, strong currents and wild storms as a boat. The difference is that buoys have no choice but to ride out the adverse conditions. Boats, on the other hand, can use the power of the difficult circumstances to power them to their destinations if they can harness them correctly. Boats can’t outrun bad weather all the time. Adversity is inevitable. Happiness, contentment, enlightenment, or whatever you’re seeking, isn’t found in avoiding or controlling our adverse circumstances, but about learning how to follow our values in the midst of the calm weather or the wild.

As Christians, one of our primary values is our love for God and our desire to follow Jesus. Scripture teaches that each of us has our own unique path to follow. Ephesians 2:10, “For we are God’s workmanship, created in Christ Jesus to do good works, which God prepared in advance for us to do.” ‘Workmanship’ in the Greek is ‘poiema’ from which we get our English word ‘poem’. We are not a meaningless jumble of letters that makes no sense. We are a beautifully crafted blend of rhythm, harmony and meaning. You are a sonnet from the mouth of God. I believe that our individual purpose stems from our common purpose and values, like leaves are dependant on the branches, trunk and roots of the tree. I heard a brilliant summary of the purpose of the Christian life, which was simply “To know Christ, and to make Christ known.” I believe that it’s from this common value, shared by all Christians, that our direction in life stems from.

In knowing our values, we can know ourselves, and engage in life in it’s fullness.

References

[1]        Harris R. The happiness trap : how to stop struggling and start living. Boston: Trumpeter, 2008.

Looking backward, moving forwards

I used to think that with each new year, I was getting wiser.

In reality, I’m probably just getting older … like sun-baked plastic, slowly growing more rigid, cracked and brittle with each passing day. Which is why I no longer blog about subjects like the eleven steps to self-attainment or the seven habits of highly effective nose pickers, or new years resolutions in three easy payments. Call me a grumpy old man, but I’ve been down that road. Hey, if it lights your candle, then I wish you all the best. But to everyone else, if you’re happy to humour a cantankerous old sceptic, I’d like to share my musings on a year that was more morbid than magical.

2014 was quite a year. After suffering from depression for most of the three previous years, I was hoping that 2014 was going to be a year of consolidation. It turned out quite the opposite. I celebrated a birthday milestone with a party that was one of the most amazing experiences of my life, and is still remembered fondly by those who could. That, and I published my second book. In terms of highlights, that was it.

Otherwise, it was a year of adversity. Nearly every one of my family members was in hospital this year at some point. And death came for my wife’s mum, Robin Williams, the cricketer Phillip Hughes, and everyday heroes like Tori Johnson and Katrina Dawson in Sydney’s Lindt Cafe siege. In late October, I nearly lost my wife. Many of my friends suffered untold tragedies too.

I’m not going to sugar-coat it, 2014 was a tough year. In the shower this morning, where I get all of my best thinking done, I was contemplating the year that was, and how I was going to move forward. 2014 had left me emotionally bruised and bleeding, and I will carry some of the scars forever. Though while I may be broken, in many ways, that’s not such a bad thing. Brokenness changes your perspective. I’m more grateful for my family. I can empathise on a deeper level with my patients in their distress. I’ve come to understand the wilderness experience of the soul.

I’ve come to realise that goals without deeper values undergirding them are vacuous and futile.

I have a deeper understanding of the grace of God, who despite my brokenness, misery and existential despair, was holding me up and bringing me through. He was my lifeguard, keeping my head above water, swimming me to shore.

Hmmm, perhaps I’m not as rigid or as brittle as I thought.

In 2015, I won’t be making any silly resolutions trying to better myself, because in being broken, I can finally see what’s truly valuable in my life. I may be limping, but at least I’m finally limping in the right direction.

If you’re broken and limping too, let’s limp together into a new year that is richer and more fulfilling than the last.

My patient, Kev

I meet a lot of people in my job. Some are not particularly memorable, and some I truly wish to forget. But every now and then, I meet a person who’s memorable for all the right reasons. Kev was one of those people.

Once upon a time, Kev was a business man, a corporate manager who started in the postal service in his late teens, but got more experience and moved into the Commonwealth Bank, where he quickly moved through their ranks and became a regional manager. Towards the end of his career, he moved industries to become the CEO of one of the smaller private hospitals in Brisbane in the 1980’s.

After he retired, his wife developed dementia, and he cared for her at home for many years, before he became too weak. They both moved into a nursing home, but his wife succumbed a couple of years later.

When I met Kev in early 2013, he was dying. His heart and his lungs were failing, and he couldn’t walk ten metres without gasping or needing oxygen. He was gaunt and frail, and extremely thin. I was worried that if he fell, he might snap.

But his intellect remained untouched by the disease ravaging the rest of his body. He was quick-witted, jovial, and always polite. He was the consummate professional – always showing respect, and earning it. I could see why he was so good as a businessman. He was a pleasure to be around – so much so that I spent extra time with him every week just chatting, when I should have been finishing off my work.

In the week before he died, the last time I saw him, as I sat in his room listening to some more of his stories, he looked me in the eye and said,

“Don’t sweat the small stuff. You don’t have to do everything. Let people flow in the things they can do. There are more important things in life.”

He smiled as he looked at the photos on his wall of his wife and kids.

I smiled and shook his hand. “I’ll see you later, Kev”, I said. I never did see him again.

I still remember him now, skinny and breathless, but with a big smile on his face and a sparkle in his eyes every time I entered his room. And I remember his advice on living a life driven by values.

New Years Day is a time to start afresh, a celebration of new beginnings, a focal point to take stock and refocus. But if we’ve learnt anything at all from our previous attempts at New Years resolutions, it is that they don’t work. Don’t be mislead by the occasional partial successes. I sometimes hit a golf ball straight, but that still doesn’t mean my golf swing is any good. New Years resolutions are the same – they are fundamentally flawed, in spite of the accidental successes that we sometimes have.

The truth is that etherial statements, or short term goals for self-improvement don’t help us. We don’t need New Years resolutions, we need New Years re-evaluations.

Values are different to goals. A goal is like a destination, where as a value is like a direction. Our individual values are like the direction of the breeze. It’s easier to sail with the breeze of our values than against it.

We often get goals and values confused. Goal orientation means that we move from place to place, sometimes travelling in the same direction as our values, but sometimes against them. When we live according to our values, the goals seem to set themselves as we live according to what we truly believe in, what truly motivates us.

A few things can acts as guides to help us learn what our values are. What are your passions or what makes you mad? Is it justice, or injustice? Is it relationships? Is it children, or family? The environment? What is it that gets your juices flowing?

Another way of understanding your values is to do the eulogy exercise. It’s a little morbid, perhaps. But simply, the eulogy exercise involves writing your own eulogy. What is it that you want others to remember you for? What do you want your epitaph to say?

The eulogy exercise helps us to plan our lives with the end in mind. When you’re on your death bed, will you regret not finishing that report, or will you regret whether you lived according to your values, your deepest desires. Putting your values into perspective makes it much easier to let things go that aren’t truly important. It’s a lesson I’m continually working at too.

May 2014, and the rest of your life, be about the important things. Don’t sweat the small stuff.

I hope you have a happy new year.

Cheers, Kev.