Saturday, August 29, 2009

Suppressing Does not Work - Part Two of Two - Searching for Something that Does Work

Hello Friends:

There's a post on Psyblog called "Why Thought Suppression is Counter Productive" that follows along similar lines to those I'm addressing in Parts I and II here. So either I'm a really trendy blogger, have come late to the party, or (the worst) I'm a conformist. Egads.

Anyway, they cite some of the same studies (including the famous one with the white polar bear that I changed to chocolate; Wegner et al. 1987). And come to the same obvious conclusions - suppression does not work. Suppressing thoughts is (a) impossible, and (b) makes you think more about what you are suppressing, and (c) makes you feel like a failure for not doing the impossible.

The amount of research suggesting that thought and emotion suppression = bad is pretty overwhelming, and this is just from doing simple searches for the stuff on Google. Like this article in the October 2008 Journal of Aggression, Maltreatment, and Trauma (there is a journal for everything out there) entitled A Preliminary Examination of Thought Suppression, Emotional Regulation, and Coping in a Trama-Exposed Sample. They find that "Thought suppression, emotion suppression, and avoidant coping strategies were positively related to psychopathology." And this one from the Association for Behavioral and Cognitive Therapies published in 2005 entitled Rebound Effects Following Deliberate Thought Suppression: Does PTSD Make a Difference? In this study they found that all groups, regardless of PTSD diagnosis or not, "showed a rebound in trauma-related thoughts following deliberate thought suppression. This rebound was associated with increases in negative affect, anxiety, and distress ...."

On top of the difficulty with trying to avoid thinking about something (again, not at all surprisingly) it is even more difficult to stop thinking about something if it is emotionally charged in some way. Like say those people from the second study above who were trying to suppress thoughts about their car accidents, and subsequently suffered yet more anxiety and distress. This in the end makes it even harder to suppress the thoughts, since they can be associated with additional anxiety from just trying to suppress them. And then iterate until you are seriously messed up. This has direct application for us anxious/depressed folks from the get go, since we have very strong emotional associations with things other people might not. For us, there are huge challenges in trying not to ruminate over thoughts and memories tied to emotions of shame, failure, humiliation, sadness, anger, despair, and fear. Say that three times fast. (Side note - Kinda like Carlin's old skit of the Seven Words You Can't Say on TV. Dated and dirty, but then again most things are.)

So what to do? Well, the result of all this research, and plenty of other stuff as well, is the new focus on the 'third generation' therapies which include the concepts of acceptance and mindfulness. ACT, for example (described nicely in this article from the 2008 edition of Social Work) is a therapy based on accepting what is happening instead of running from it. MBCT (described poorly on the MBCT site, since I'm assuming they'd prefer you bought their book) targets using acceptance and mindfulness to try stop the downward mood spirals that they believe lead to recurrent depression.

These 'accepting' based therapies are not saying "I'm disordered, I accept it, and am stuck with it". Accepting here is more like non-judgmentally admitting and acknowledging. It is the starting point that supposedly lets you stop brooding. There is no longer any 'point' to feeling bad about being depressed, or feeling embarrassed because you have OCDs. In the therapies you hypothetically learn to accept yourself the way you are now, and realistically determine: what really can't change, what can change in the future, and what can actually be changed right now.

This is essentially why I've been checking out Mindfulness, Zen Mediation, and stuff as a new way to try to help myself. I think there is some great stuff in these therapies. And I also think there are some serious problems, but I'll talk about those in detail when I do my book reviews on the subject, especially the MBCT book. Which I actually did buy.

And now, should I go meditate, or watch some Carlin on UTube?

Image is Trinity from Katie Tegtmeyer on Flikr via Creative Commons

Friday, August 28, 2009

Suppressing Does Not Work - Part One of Two - Behavioral Rebound

Hello Friends:

For the next five minutes, you can choose to do one of two things - you can talk about chocolate, OR you can specifically talk about anything BUT chocolate. Five minutes. Go.

If you are like the people in this 2007 study, by doing either of these things, you will have changed your eating behavior towards chocolate compared to a control group that got to talk about whatever they wanted. If you talked about chocolate (and were male), you wound up eating more of it than the control group. If you suppressed talking about chocolate (and were either male or female) you wound up eating more of it than the control group.

No way to win, here.

The point from my perspective, anyway, is that while you might guess ahead of time that talking a whole bunch about chocolate would make you want some, you'll want chocolate if you specifically don't talk about it, as well. This is a form of behavioral rebound. The idea isn't new - it's classic folk wisdom that when you're told not to do or want something, you want it that much more. But the folk wisdom plays out as true in the research, as well.

The implication for behavior, perhaps especially to sticking to an eating plan, is pretty clear. Any kind of focus on something you don't want to do, either by indulging in it or trying to run from it, could actually make it more likely that you'll do it in the end. I found this out the hard way one year when I gave up chocolate for Lent. Very dumb, since right at the end of Lent someone hands you a big basket of candy that almost always contains a solid 1 lb milk chocolate bunny. The bunny was gone from this Earth in about fifteen minutes. And then I was sick for the next two days. Unlike getting sick from drinking, which can put you off the alcohol in question forever, I didn't give up chocolate afterwards. I gave up Lent.

So getting to the point. Suppression/deprivation probably changes our behavior because it changes our thoughts first. The experiment above directly related to behavior, that is, talking and then eating. But, you don't have to measure how much chocolate was consumed to see the difference, you can go ahead and look directly at your thoughts. Example ... with apologies to
Wegner et al. 1987.

Exercise 1 - For the next three minutes, do not think of chocolate. You can think about anything else but chocolate. Three minutes. Go.

Did you think about chocolate? Much? More than usual?

Exercise 2 - Okay, now you can take the next three minutes and think about whatever you want, chocolate included. Go.

Right. Did chocolate come up again. Much? More than usual?

If you are like most of the population, the first exercise borders on ridiculous. Like the behavioral rebound, there is a sort of thought rebound. It’s impossible to not think of something you’ve been told not to think about. It seems the very act of trying to suppress or avoid the thought makes it more likely to come up. And, as it turns out, it makes it more likely to turn up later (as in the second exercise) than it would have if you hadn’t been forced to ‘avoid’ it earlier. Either way, it seems that trying to avoid thinking about something is a rather good technique for making yourself think about it a lot.

If you are like me, you’ve encountered this fact plenty when trying to ‘fix’ yourself regarding your disorders. For example, my 'bad' thought is "I’m a failure". Saying to myself “stop thinking that” is useless. I have wanted to stop thinking it all my life, and I’ve tried very hard to stop. I still think it all the time. My usual response, when the idea comes up, is either to wallow in the truth of it or try to smush it ruthlessly.

While I could imagine wallowing in it to be counterproductive (even if unstoppable) I also imagined that smushing ruthlessly (on those occasions I manage to do that) to be productive. According to the research, this isn't so. Trying to stomp on and toss out 'bad' thoughts seems to give them just as much life and energy as ruminating or brooding over them.

I would find this discouraging if I hadn't read it in the context of a way to do something other than run towards or run away from thoughts. And I'll post about that in Part II.

But for now I gotta go. I really need some chocolate.

Your Hostess With Neuroses

Image from kspodder on Flikr via Creative Commons

Wednesday, August 19, 2009

Mindfulness and Being Emo

Hello Friends:

Had an exceptionally depressed day today, but in the spirit of my "I'm going to post even if I'm so depressed I'm not funny anymore" resolution, here is my post. And an emo picture to create the right atmosphere.

Today is one of those days when I am convinced I am using up other people's precious oxygen. When I wished I'd never met anyone so I wouldn't have to go through the hell of letting them down. Not meeting their expectations, you know? When you have a day where you can't even get in the shower, you are not going to be meeting anybody's expectations. Certainly 'my' body was expecting a shower. It's SOL.

Fine, enough of that. I didn't want to write about that. What I'd planned for today was to write some more about 'Mindfulness' (see my last post, Zen and the Art of Sanity Maintenance, if you don't know what I'm talking about.) So in spite of feeling like doo doo, I'm gonna write it. So there.

For example, one of the professional journals I'm reading with some consistency (because it is conveniently available from my psychologist) is Depression and Anxiety. In the in the June 2009 issue there is a paper entitled "Effectiveness of Mindfulness-Based Cognitive Therapy as an Adjuvant to Pharmacotherapy in Patients with Panic Disorder or Generalized Anxiety Disorder" by Kim et al. Yes, I read this for 'fun'. Can't help it. This is what grad school did to me.

As I mentioned, I originally got pointed towards mindfulness when I heard about it as part of a treatment for BPD. That treatment is DBT (Dialectical Behavioral Therapy.) But there are a slew treatments now being implemented for issues across the board including mindfulness-based stress reduction (MBSR), acceptance and commitment therapy (ACT) and mindfulness-based cognitive therapy (MBCT). MBCT is the one that has most recently caught my eye because (as noted here in this 2009 paper), it was originally used to "target cognitive vulnerabilities associated with the repeated relapse and recurrence of major depressive disorder". Something that is being used in both depression and anxiety therapy seems like a direct hit for me.

In the research described in this paper, they actually excluded those with comorbid depression since they just wanted to see how the MBCT did with 'pure anxiety'. They put some of their people through an MBCT program, and some through a basic ADE program (basic education in what anxiety and panic are, how they function biologically, etc.) They made a point of making sure the ADE group did not do any mindfulness related work. Both programs lasted for eight weeks. At the end of that time they used a standard criterion for 'anxiety remission' to see if there was a difference between the groups. Of course, a study is only as good as their criterion for judging differences, but researchers are stuck with using whatever is documented and reasonably reproducible. I won't quibble with their definition of 'remission'.

Anyway, they had 16 people in the MBCT group meet the criterion for remission after eight weeks, and none in the ADE group. Hardly a surprise for the poor ADE people, since I hardly stopped having panic attacks myself just because I learned what they were. But having sixteen people go into 'remission' from a group of say 30 to 40, and after only eight weeks of MBCT, sounds very interesting.

They also happened to check the MBCT group's before and after scores on certain depression indicators. Which sort of makes no sense since they were trying to eliminate that variable. Anyway, their MBCT group showed significantly more improvement on those scales than the ADE group, as well.

So the upshot of the paper, which is consistent with almost all the other research I have read, is that "MBCT reduces anxious and depressive symptoms in patients with PD or GAD by moderating worry and rumination." They also state, which may be a little bit of a reach, that "these results are consistent with previous studies which concluded that meditation can reduce phobic and obsessive-compulsive symptoms."

It sounds a bit too good to be true. Reminds me of all that past broo-ha-ha surrounding anti-depressant medications like Prozac. The magic bullet. Har.

Still, I'm now several weeks into my own Zen meditation class, and it certainly isn't doing me any harm. I haven't been doing anything as structured as a full up MBCT program, so I can hardly expect to note 'results' of my own by now. But I have gone ahead and bought the book "The Mindful Way Through Depression" by Williams et al. so I can take a closer look at MBCT.

I'll report back on that when I've run more experiments on myself. I wonder if anyone will publish that paper?

Your Hostess with Neuroses

Image is "With Messy Hair" by nyki_m on Flikr via Creative Commons

Monday, August 17, 2009

Zen and the Art of Sanity Maintenance

Hello Friends:

I debated about the title, since I don't really feel like I'm maintaining my sanity; that would assume I had the sanity to start with. More like insanity maintenance.

Either way, I've taken up meditation. It's been about six weeks that I've been 'sitting' consistently. No doubt one question that comes to your mind is, 'why?' As in 'why did you start?' and 'why keep doing it?' and 'why on Earth?'.

My first psychologist introduced me to guided visualization as a tool to deal with anxiety attacks. This is the sort of thing where you imagine yourself someplace safe and pleasant. My favorite is a certain beach on the big island in Hawai'i. The key is to imagine it as fully and completely as possible, using all your senses. The feel of the sun, the sound of the waves, the smell of the sea air, and the taste of the Mai Tai you're drinking. Sometimes it's a Margarita. Or POG with rum. I digress. So you imagine yourself there so fully that in a sense you really are there, and not wherever it is you are having a panic attack. This tool has served well in some situations as a means to distance myself from the panic and anxiety long enough to put my cognitive techniques to work. It also helps in less acute situations, like dealing with crowds.

This is essentially what I thought meditation was. I had also heard about people staring at candles or chanting in order to achieve bliss, but didn't actually see myself doing that kind of thing, and certainly didn't think achieving bliss could be that easy or no one would ever leave home. In a sense, though, these are all in fact meditation. But there is a particular sort of meditation called 'mindfulness' or 'insight' meditation that is quite different in practice and theoretically leads to a different outcome.

I kept seeing 'mindfulness' come up again and again as I've done my research into PTSD (my main problem) and into BPD (which I'm quite certain was what my mother suffered from. Here's an example of the sort of thing I've been reading in the journal 'Advances in Psychiatric Treatment, 2002') I don't have BPD myself, but have now seen 'mindfulness' brought up often in conjunction with treatment for that disorder, and more recently as a treatment for PTSD. It seems that at the present time the major sort of therapy used for BPD sufferers is DBT (Dialectical Behavioral Therapy), as developed by Linehan around 1993. DBT has as one of its aspects a mindfulness or 'Zen' component. It's crazy that that was fifteen years ago and I'm only now really beginning to see how this is a part of my own mental puzzle. But psychology has changed a lot in the last fifteen years, especially looking at PTSD and BPD. And I suppose I've changed a lot, too.

Anyway, I finally got curious enough to pick up a couple of books on mindfulness so I could see if there was something in it I could adapt to work for me. And in a nice co-incidence, my local Yoga Center was just starting a session on 'Foundations of Meditation'. So I signed up for the class, and read a bunch of books.

First of all there is a bunch that can be very confusing. Sort of teasing out what is Buddhist religion from the practice of Buddhist philosophy. There is a whole spectrum and Buddhism is as complicated as Protestantism, what with all the different churches/sects and what they emphasize. And I'm not looking for a new religion, I'm looking for this core of 'mindfulness'. But with help from a few good books (that I'll review in more detail) and from my class, I've found the very basic starting point. This is 'sitting' practice.

It is easy in principle and a real challenge when you try it. The Zen meditation aspect is one where you note as thoughts come into your mind, but then set them aside and come back to counting your breathing, over and over. It's a great way to see just how chattery your mind is. If yours is like mine, then you don't have an internal voice, you have a freaking internal committee that won't shut the hell up. There is a more 'content' oriented sort of meditation that is really more of the 'mindfulness' end of things, where you watch the thoughts come and go, and they themselves are sort of the focus of the meditation. You don't try to hang onto or cling to anything, even if it is a happy thought, and you don't try to run from anything, even if it is painful or guilty feeling. You just let them arise and move on, one after another. Or in my case you watch them pounce all over each other.

So I can't report on the real value of it yet, since it's only been six weeks total. But I will say that this, along with the progress I've had in my Integrated Therapy (the energy work I talked about in previous posts here and here) I'm still seeing things change and move. This is great. I no longer have that feeling I had when I started my medication - that feeling of 'I've tried everything and this is my last chance' and 'if this does not work I've no other recourse'. It seems there were still lots of things I haven't tried, and I'm feeling more encouraged.

If these don't work, I'll bet there are other ideas out there, too.

Your Hostess With Neuroses

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