The Made It Clinic has recently moved to a new office location, and we got a chance to experience the joys – and fears – of fitting out an office for the first time. As any writer or painter will tell you, the blank page or canvas can be intimidating – so many options, so many choices, so much pressure, where to even start? Or worse yet, no ideas at all to fill all that space.
And anyone who has done any DIY will tell you the problem is just the same, if not worse, for a blank wall, and a blank room. And we had two floors of empty, echoing space to turn into something useful.
Now, the fear of the blank page, or wall, can be powerful. Making something new is challenging, and with challenge often comes trepidation. Being challenged pushes us out of our comfort zones. Some people enjoy exploring that new part of their reality, but for others it is more difficult. But there’s no reason it has to be debilitating.
Here’s a couple of quick tips I use for dealing with the pressure. First of all, breathe. Good advice at almost all times, but especially when you are dealing with strong emotions. A deep breath gives you a moment to settle, calm, and refocus on the situation.
Second of all, breathe again. Let the breath flow around the feeling and make space for it within you. No feeling is bigger than you are; you can always make space for it.
Third, breathe again, again. This time, focus on what’s important to you, on why you want to build that office/paint that wall/write that book. Connecting with your values and taking actions towards them can make the challenge feel that much more meaningful, and surmountable.
And finally, just start! Even one word, one dot of paint, or one chair dragged in from another room can make that blank page/canvas/wall suddenly not blank anymore. Now, it’s not about the blank space in front of you – it’s about improving what’s already there.
It can be a long road, at times, conquering the blank space. But, as we can attest now that we’ve settled into our new space, the journey is often worth it.
Best of luck with your next blank wall, and the masterpiece that will come from it.
-Daniel, Practice Manager
IS CBT a POS?
This is a hot topic for me, because it's a trap I fall into - criticising and rejecting something when I don't understand it.
Here are some lines I found in a book about therapy, and I think they would be quite agreeable to most psychologists:
"The therapist should take the stance that any feelings the (person) has may appropriately be discussed during the session. That is, all feelings are acceptable."
"(The aspiring therapist) must be, first, a good psychotherapist. He must possess necessary characteristics such as the capacity to respond to the patient in the atmosphere of a human relationship - with concern, acceptance, and sympathy."
"It is important to keep in mind that the techniques detailed in this book are intended to be applied in a tactful, therapeutic, and human manner by a fallible person - the therapist."
I've been hearing lots of trainees say "I use ACT because I don't like CBT". I think part of why they feel free to say this to me is because I am a giant ACT/CBS nerd and will sprout out about it at the slightest encouragement (also I like to think I am an approachable supervisor...). When I ask them why, they usually say that CBT is clunky and impersonal.
And I'll be the first to admit that I also thought this when I was a provisional psychologist. "I want to be an ACT therapist," I chirped. This probably mortified my supervisor at the time, though she was a very tactful woman, and simply said, "I think you should attend some CBT training to help you meet your competencies."
Those quotes above? They are from Cognitive Therapy of Depression, written by Beck and co in 1979.
I don't think there is a problem with CBT as an approach in itself. I think it has an image problem. Over time, for whatever reason, maybe an over-adherence to technique without an understanding of the therapy's tenets, theory and history, has led to CBT getting a bad rep. Also, supervisors (myself included) must give off the vibe that it is ok to reject an approach offhandedly.
In ten-twenty years time, ACT will probably have the same image problem. "I can't believe that they told people to just defuse from their thoughts! Like, thoughts are nothing?!" "ACT is so clunky!" ACT is not the answer to CBT. CBT is not the problem. CBT is worth learning and using as a tool to support our clients.
Helpful and Helpless Worries
One way I explain rumination is through the frame of ‘helpful’ and ‘helpless’ worries.
A helpful worry is a thought that helps us solve a problem. It draws our attention to things that we can deal with. It is a call to action. Completing the action improves our situation.
A helpless worry is a thought that makes action harder. It causes paralysis or worse, it can lead us to act in ways that do not improve our situation.
The sound of helpful and helpless is different for everyone. You will know if a thought is right for you based on what it makes you do – does it lead to actions that enrich your life? Or is your world growing smaller because of it?
Before dismissing helpless worries, it might be worthwhile to consider the value behind them. After all, we wouldn’t feel worried unless the issue was somehow important to us.
For example, for me, the helpless worry of ‘something might happen to my daughter when she is not with me,’ arises because of the protective and nurturing instinct I have towards my daughter. The thought is a helpless one for me because it makes me freeze in fear for a moment and leads me to contemplate actions that do not improve my daughter’s situation (e.g. keeping her by my side forever and ever so I am never worried about her safety). Instead of worrying helplessly, or responding to the distress in the worry, I may acknowledge the value – ‘I care about my daughter. My daughter will grow if I can facilitate new experiences for her’.
Another way to look at helpless worries is to look for the call-to-action in them. For example, for many people, the worry of ‘I will never find my life partner in this hectic world of online dating’ arises because of a want for a relationship. So the call-to-action is to find a way to meet someone.
By looking at the value and the call-to-action behind a helpless worry, we can turn it into something helpful.
learning a new skill
Ever learnt a new language? Trained to run a marathon? If you were to tally up all the time you spent on the pursuit, how many hours did it take to become proficient?
Going to therapy is learning a new way to be with your thoughts and feelings. It’s a skill, just like using chopsticks or learning to read. Just like the other skills, learning it requires time, awareness and attention.
Time is finite. We all eventually run out of it. To achieve anything, we need to allocate time to it. I often request that my clients attend therapy regularly to begin with, usually weekly or fortnightly. The reason is because this is the time someone tends to be most motivated to do the work it takes to change. During this time of motivation, I try to socialise us into spending time on the task. I will also set activities or readings to be done between sessions. This is a strategy to find time outside of the therapy context to continue developing our skills.
Thoughts, feelings, and behaviours are so close to our ‘selves’ in proximity that they are often invisible. We think so much that we cease to see our thoughts. We learn to dismiss many body signals like hunger, tiredness, sadness, and boredom. We become so automatic in our daily tasks that they require little effort at all. These skills are important, however, when there is a mismatch of skills application to task (e.g. dismissing hunger when we really should be eating), then awareness is required to take us off autopilot. Therapy is a great place to build awareness of the processes that drive our thoughts, feelings, and behaviours. If I scanned my body, do I notice that I am still annoyed hours after something has happened? When did I start to learn that I should keep my opinions to myself? Am I really more efficient when I multitask? Once we are aware, then we can explore and change.
Just spending time on something doesn’t guarantee that we will achieve what we set out to achieve, because all time spent is not equal. Attention is the ability to focus on what we’re doing. The more attention we can dedicate to a task, the better we are able to engage in it. Learning a new skill requires attention. Therapy is the place that helps us focus our attention on what we are doing.
There is one more aspect that helps when learning a new skill, and that is teaching it to others. When we explain the process to a novice, we are consolidating it in our own minds. Sometimes my clients may notice that I say ‘Can you explain that a bit more?’ or ‘Can you explain that in a different way?’ Just by hearing ourselves speak about something we usually take for granted helps us make sense of it for ourselves.
Fly on the Wall - Day 2
What a heavy Day 2 with Dr Warburton on the impact of screen media on the youth of today. I remember stumbling out of the conference room during the lunch break and staring out at the river for a bit, trying to understand what I had just heard.
There are a number of take-home messages about screen media. For me, the most important message is that media and platforms such as video games and social media are formulated to be behaviourally addictive and we should take care when using them. This is hard for me to hear as I come from family and social group who really embrace the culture of video games. Two years ago, when I went down to Melbourne for an industry conference, my husband went to PAX, a gaming convention created by my two favourite gaming industry commentators. I am very resistant to post anything critical about video games, but it would be unprofessional to ignore the part of the population who are engaged in problematic use of screens to the extent that their health wellbeing is affected.
If you’re always on your smartphone, that behaviour didn’t happen by accident. Children and adolescents are particularly susceptible as their pre-frontal cortex is still developing. This part of the brain helps them regulate emotions and make decisions, and is developed depending on how we are taught by our environment. Tasks that help us strengthen the prefrontal cortex include attention training tasks (like mindfulness), inhibition tasks (like not eating that second marshmallow), social communication (like deep conversations with our loves ones), and many more. The best place to do this is in the physical world which we inhabit, involving all our senses.
If a young person spends 6 hours in front of a screen for recreational purposes (this is the ‘average’ amount for adolescents today), the content they are accessing will impact how their brain develops. Prolonged early exposure to violence changes how a brain activates. These changes are reflected in the connection of our brain cells. This is not to say that we need to eradicate media from a young person’s life. These days, that would greatly impact their social functioning (‘everyone else is doing it’). The abstract of a chapter Dr Warburton wrote summarises it perfectly:
“Multi-billion-dollar industries such as advertising, Hollywood, television, educational media and training simulators all work on the basic premise that screen-based activities can change the way people think, feel and behave. Research shows that this is also the case for violent video games, which are linked to increased aggression, desensitisation to violence, hostile thoughts and feelings, and decreases in prosocial behaviour and empathy. The secret to managing video game play is aspiring to a healthy media diet: moderation in amount, preferential exposure to helpful content, and taking the age of the child into account.” – From Nurturing Young Minds in a Digital Age.
For guidelines on the age of the child, there’s some good information on RaisingChildren.net.au. In addition, I would like to add that screens are not parents. We need to be companions and supervisors for our children when they are in front of screens.
Interestingly, Dr Warburton gets many death threats from people about his video game research. If people in the video game community are trying to assert that video games do not increase aggression and hostility, this does not seem like a productive activity.
Fly on the Wall - Day 1
It is Day 1 at the 2018 Rural Training and Youth Support Conference and I am learning a lot. The keynote speaker today was Dr Marc Milstein who specialises in communicating scientific papers in practical ways. He spoke about the neuroscience of anger and some of the wider biological and environmental issues. In the afternoon, I attended a talk by Dr Wayne Warburton from Macquarie University on counselling angry and aggressive clients.
It’s always interesting to listen not just to the speakers, but to the questions coming from the audience. This helps me understand the issues that front-line workers are experiencing when working with the youth.
There were three questions that really struck me, and there are no easy answers. It always depends*.
Here are my first impressions:
Is it better to medicate children early for anxiety?
I get this question from worried parents who don’t want their children to feel distressed or fall behind (e.g. miss school). I also see parents at their wit’s end, having tried everything that they can think of. Medication seems like the easy solution, and this is where the danger lies because childhood anxiety is not easy. Children have very little control over their environment. Their attachment relationships, home environment, school environment, and friendships all play a part in how they will develop. As such, intervention for anxiety can not lay solely with changing the child. Medicating a child can mistakenly attribute the ‘problem’ to the child, and children labelled as ‘problem children’ are at risk of poorer outcomes in life. Psychoeducation and family-based or school-based interventions can be effective in assisting a child with anxiety. When I see a child under the age of 13, I will always ask for parent involvement. I find that parent’s regard for their child, and parent willingness to be involved in their child’s therapy, produce the best long-term outcomes.
What is the best treatment for anxiety or depression caused by illness (e.g. an autoimmune disorder)?
In response to this question, there was some discussion about whether therapy would be beneficial at all. Something that psychologists don’t advertise is that many of us are trained in techniques that help us to assist in detecting, clarifying, and problem solving through a client’s reported symptoms. We are experts at helping people experiencing depression or anxiety engage in behaviours that will improve their quality of life. In this way, psychologists can assist in the management of mood in cases of chronic illnesses. Furthermore, with emerging interest in trauma or stress and autoimmune diseases, I would say that therapy still has a part to play.
How would you deal with a student having a meltdown in class?
I can still vividly remember an incident, back when I was a provisional psychologist, where I was confronted by a very angry child. His school reported that he was prone to ‘meltdowns’ and I was fortunate enough to experience one of these firsthand when he picked up a chair and threatened to throw it at me. I can still see this small child with skinny arms lifting this massive chair above his head, pure hatred in his eyes.
At the time, I had no idea what I was seeing. I blurted, “come with me,” and thanked the heavens that he decided to trust me.
Angry kids are like icebergs. The part that rages around destroying the classroom is the part that sticks out of the water. In the moment, it’s important not to take their behaviours as a personal attack, and instead focus on a stance of kind firmness to take charge in a non-threatening way. The real work comes afterwards in adjustments that support a child’s sense of safety and ability to self-regulate. Also, a lot of angry kids are hungry kids, so frequent meal breaks and snacks can help.
It’s getting late now so I will call it a day. I look forward to another day of learning tomorrow.
* N.B. I also asked a question about whether to treat sadness or anger first in adolescent anger management groups. A fellow member of the audience muttered, “you treat the person”, which is always humbling to hear.
Sometimes clients come in with the goal of not feeling anxious anymore. On the surface, this seems perfectly reasonable. Why would anyone want to feel anxious? Or sad, or angry, or hopeless, or in pain? The problem with goals that aim to eradicate internal experience is that:
I’d like to elaborate on Problem 3, because I think this is where the biggest problem lies. We mistakenly assume that as soon as X is gone, we’re going to feel more of Y. For example, if we’re not anxious anymore, we’re going to be happier.
The thinking error here is that distress is the opposite of happiness. In fact, some meaningful life experiences may be distressing no matter what we do. Sometimes, the focus of reducing distress actually gets in the way of living a meaningful life.
A personal example for me is the process that it took to deliver my daughter into this world. The experience was both distressing and joyous (and exhausting, and terrifying… the list goes on). If I was unwilling to experience the discomfort and risk of pregnancy and birth, I would never have had a child, and never experienced the heights of happiness and connection that can come from being a parent.
In some disorders, particularly anxious disorders such as Social Anxiety or Obsessive-Compulsive Disorder, the illness is not so much in the unpleasant internal experience, but the over focus on avoiding or eradicating distress. In these cases, people end up engaging in unworkable, time and energy consuming behaviours. It might start as excuses not to see our friends, or triple checking that the doors are locked. These behaviours exist to provide some short-term relief, but often grow to become unmanageable because, paradoxically, the more we try to avoid distress, the bigger it grows.
Eventually, what starts out as a ‘puddle’ of distress becomes an uncrossable ‘ocean’, and any thought of happiness goes out the window because we are too busy trying to manage the distress.
The solution is easier said than done, which is to learn to accommodate discomfort while working towards worthwhile life endeavours. Valuing, accepting, understanding, reflecting, acknowledging, and compassionately self-caring are alternative ways of interacting with internal experiencing.
Autism Spectrum Disorder is a label for a group of symptoms thought to be of a neurodevelopmental origin. The disorder arises from a combination of neurological (brain) differences, which could be in the anatomy, functioning, or connectivity of the brain. Given the complex interactions of environment and biology starting in utero (in the womb), these differences can arise for a number of combined reasons. Sometimes it’s because genes tell the brain to grow that way. Sometimes it is a result of brain injury. Sometimes it can be in the transmission of information (e.g. modelling of relationships) through early attachment. Whatever the cause, the workings of the brain are altered, producing altered sensory processing. This is expressed (seen) through differences in social interaction, strange sensitivities or tolerances, and inflexible or intense interests and rituals.
There is a bit of back and forth regarding whether autism is a ‘disorder’ or a ‘condition’. This has arisen from research and also the reported experiences of people living with the condition.
The argument for autism as a classification as a disorder rests on the ideas that sensory processing in autism is impaired and impaired processing produces maladaptive (inappropriate) behavioural responses. Maladaptive behaviours require corrective intervention if an individual with autism is to remain functional in everyday society. Additionally, a secondary ‘disorder’ often seen in cases of autism is that while individuals with autism may be able to adapt functional behaviours, this requires the use of additional cognitive (brain) resources to compensate for the way that their brains naturally want to work. This means that they may experience increased fatigue and frustration, leading in the long term to low self-esteem, anxiety, and depression. In other words, if an individual with autism is smart enough, they can adapt to their environment (and sometimes do really well!), but this comes at a personal cost.
This argument is not incompatible with the argument for autism as a condition. The difference in the view points between disorder and condition is that those who classify autism as a condition frame the sensory processing issues as a ‘difference’ rather than a ‘disorder’, and these differences are actually more common than we think. For example, if we dig enough, we’ll find that almost all of our friends and family have their quirks. Without these quirks, we would not have individual strengths or variation, and when it comes to problem solving, we would not be able to draw on the rich perspectives offered by people who see the world in different ways. It is a less stigmatising and more inclusive understanding of neurodevelopmental differences in the context of evolutionary biology. Researchers and advocates that take this stance want to build a more inclusive society that understands and encompasses differences, and where individuals with autism can best use their differences to their advantage.
Intervention for Autism
In either case, intervention in required at both individual and societal levels, involving the participation of family and sometimes friends. Left untreated, severe symptoms of autism leave an individual unable to participate in society, resulting in poor quality of life, poor health and education outcomes, and lower socio-economic status. A good rule when thinking about whether someone with autism requires intervention is to consider the functional impact of their condition. Is it stopping them from learning and developing skills required for social and occupational functioning? Is adapting to the demands of living causing a high level of distress?
The first step to a good treatment plan for individuals with neurodevelopmental issues is to do a thorough assessment, including cognitive assessment. The rationale for this is that neurodevelopmental differences cause differences in functioning. Without a cognitive assessment, we don’t have an idea of what functions differ. Is it a limited working memory capacity? Is a high verbal comprehension masking poor auditory processing? Knowing the strengths and deficits in an individual’s cognitive domains gives us an idea of what they find challenging (‘what sets them off’). However, thorough assessment is rarely done before treatment, usually due to lack of funds or lack of understanding of importance of assessment.
The second step is to decide on some targeted goals that are going to improve the quality of life and functioning of the individual. Clear and focused goals are important in measuring progress and effectiveness. They can also be used to determine what treatment may work best. For example, if the goal is to improve perspective taking, then a psychologist may be able to assist through a training program that enables the development of increasingly complex deictic relations (way of framing events in relation to self and others). If the goal is to improve the comfort of the individual by accommodation for their sensory differences, an occupational therapist may be able to assist with some sensory-based therapy and adjustments. In any case, improvements can then be systematically measured. If there is no improvement, or if improvement in a specific area does not result in improvement in overall functioning/quality of life, then the treatment plan can be adjusted. Sometimes, as intervention may span across multiple domains, or second opinions may be sought, it falls to the client or their families to keep track of the goals they are working on.
The third step to a good treatment plan is regular review. A review of the treatment plan ever 3 – 6 sessions or so helps therapist and client keep on track with goals and effectiveness. If goals have been achieved, or if they are no longer relevant, a review can provide renewed and focused direction. Behavioural training, which has shown lots of promise in skills training and the treatment of maladaptive behaviours associated with autism, has a great evidence base, but alas is very boring. Progress can feel like a grind. Regular reviews can improve commitment to the process of longer interventions.
Finally, a good treatment plan should involve skills development with a graduated return of responsibilities to an individual with autism and/or their families. The ultimate goal of self-management in the long term minimises reliance (and thus cost for clients!) on the therapists and builds self-esteem.
The best of you
I’ve been at a loss recently in regards to my own behaviour when approaching a painting project in my complex. Correspondence on this issue has taken up much of my down time, and I’ve had this churning, dreaded feeling in my stomach every time I open my personal emails.
While I should know better because of my profession, I am just realising yet again that aspects of a situation can draw out undesirable characteristics in anybody. If an environment is tense and antagonistic, I find myself drawn to respond in kind. Shooting back a terse email is automatic and requires little effort at all when I am angry.
When my brother-in-law visited yesterday, he commented that my approach to life’s challenges seemed very relaxed and open. His words made me think about the life I like to lead and the approach I like to take when solving problems. This led to the realization that I had not been acting this way in terms of the painting project, and it was actually my response in the situation that had led to my despair.
While it is difficult to read disagreeable emails, I realised that my prolonged distress had more to do with my unhappiness in my own behaviour. Somehow, my behaviour had become so incongruent with my values that I hardly recognised myself in these emails. The distress at having to respond to these emails did not come from the problems being insurmountable (I am of the fatally optimistic mindset that no problem is insurmountable), it was because the emails brought out the worst in me.
Now that I know this, I am trying to keep my values in mind when responding to the emails. I want to be open, collaborative, and solution focused. Today when I responded to the string of emails with my values in mind, I found that I could breathe a little easier and my stomach didn’t churn as much. Nothing in the situation has changed, but I am better able to endorse my current behaviour, which makes it easier to sit in my own skin.
Of course, the flip side of this is that some situations in life really are toxic and we might do well to remove ourselves from the situation when we can. I am certainly not going to participate in projects of this sort again in the near future. Life’s too short!
Daniel the practice manager put Issue 2 of the New Philosopher magazine out this month in the clinic’s waiting area. I was flicking through it and came across an interview with John Searle in which he is quoted, “consciousness is a biological property like digestion or photosynthesis.”
I quite like the idea of consciousness as a biological process. Certainly, the brain is an organ. It is a part of the central nervous system, which we can map out in our bodies. The mind is harder to grasp. It is what psychologists call a ‘construct’ – something that we can not measure directly. We can’t put a ruler to it and measure its length. We can’t put it on a scale and measure its weight. The mind and its properties can only be measured indirectly through questions that we propose. It is ever elusive and at times tangled with the divine.
John’s words puts consciousness in the perspective of it’s function. In other words, it makes us think about the purpose of consciousness. If consciousness is another body function, like digestion, what does it contribute to our survival and wellbeing? Digestion helps us convert food into energy and gets rid of waste product. It’s necessary. John proposes (I think) that the function of consciousness has something to do with meaning-making. It helps us make sense of all the stimulus we are bombarded with… sound, lights, heat, pressure, et cetera… it transforms physics and chemistry into a cohesive narrative through which we navigate.
I like this practical view of consciousness. Often, we get too caught up in the ‘sense’ we have made of the world and we forget that sense-making should be in service of a purpose, not the other way around. It would be like eating for the sake of having something to digest, rather than digesting for the sake of continuation of the organism. Digestion isn’t the end goal. Yet, we sometimes fight for the stories our minds have made. We say to ourselves things like, “this shouldn’t have happened to me” or “they would be better off without me”, we treat them as truth, and we don’t stop to wonder for a moment what the function of these thoughts might be. If we can view consciousness as a biological property, we are freed to consider the process of thoughts; are the thoughts I’m having advancing my survival, or am I experiencing the thinking equivalent of indigestion?