Dr. B's Blog

Churchill and the Stigma of Depression

This article is an interesting follow-up to the previous entry I made. I think that the author does an effective job teasing apart what works and for whom:

In the case of depression, the core stigma is that depression is a weakness, a moral failing. That depressed people are soft, weak, pitiable. This attitude is specific to depression – not even bipolar disorder is seen in the same way, let alone the other diagnoses. They have their own stigmas. Depression’s is weakness.

Now this is why Churchill is a good counterexample. Not just because he’s famous or ‘great’, but because he was famously tough. He faced down Hitler. He was blood, sweat and tears. In the most famous photos of him (and they are famous, out of all his photos, because they correspond to the mental image) he is almost unsmiling – but never despairing. Just resolute.

I think the key here is the notion of Churchill being a counterexample and not just an example of someone with mental health difficulties being successful. It's the notion of opposite action in, ahem, action. By that, I mean that we have someone dealing with the syndrome of depression. Withdrawal, isolation, self-doubt are all part of this syndrome. What we see in someone like Churchill is that he's working to act opposite to those action urges. 

Perhaps what makes a good role model is to highlight someone doing behaviors that are specifically opposite to the action urges we're trying to deal with. Again, some research is needed here, but two articles to start the conversation.

BBC: Do famous role models help or hinder?

Apparently, last week was mental health awareness week in the UK. I didn't realize it at the time I bookmarked this article

Churchill might tell me something about the art of statecraft, or Fry about the pressures of fame and the joy of words, but someone closer to home, with a life more like mine and challenges more like mine, will tell me far more about a life with mental health difficulty and how best to live it.

I always wonder what one "should" do with respect to role models in mental health and I think it probably comes down to individual characteristics about what makes most sense in treatment. I'm sure there's a research study or two about this issue so I'll see if I can track one down and post about it in the near future.

Please see this post for a follow-up.

TED Talk: All it takes is 10 mindful minutes

Most people assume that meditation is all about stopping thoughts, getting rid of emotions, somehow controlling the mind. But actually it's … about stepping back, seeing the thought clearly, witnessing it coming and going.

 (Andy Puddicombe)

He talks about meditation, but I believe that what he highlights applies equally well to mindfulness. While one might quibble with his emphasis on "doing nothing", the message is clear and relevant.

"You are getting sleepy... Very sleepy...."

Among the patients I've worked with over the years, sleep difficulty is easily the most common secondary complaint to their presenting problems. And it's often one that's neglected or forgotten about amongst the many other issues going on. Many clients are on sleep medication and have found some relief from them, but I came across this book which claims that:

A number of studies have shown that drugs like Ambien and Lunesta offer no significant improvement in the quality of sleep that a person gets. They give only a tiny bit more in the quantity department, too. In one study financed by the National Institutes of Health, patients taking popular prescription sleeping pills fell asleep just twelve minutes faster than those given a sugar pill, and slept for a grand total of only eleven minutes longer throughout the night.

I'm not a psychiatrist so I don't know about the science of the meds. But if it works only because you think it should, what's really wrong with that?

Modulating interpersonal intensity

In group last week (Dec. 6, 2012), we were wrapping up our discussion of the Interpersonal Effectiveness module. I left the group with the idea that there's a lot to be said about modulating intensity rather than being over-the-top assertive all the time. I have always felt that it's best to be only as assertive as you need to be - both from an effectiveness standpoint and a self-respect one. (Needless to say that the third of our 3 Interpersonal Effectiveness goals, relationship, will be best served by lower intensity.)

I recently ran across a very brief article about the effectiveness of being less assertive for New York cabbies. The nugget from this article (and I'd heard this before): cabbies got paid more by hinting at higher tips than demanding them.

Joshua Gross estimates, that this simple nudge has increased the income of taxi drivers by $144 million per year. Had the drivers demanded this increase via an increase in rates it probably never would have happened.

If it works in New York, it can work anywhere.

If You're Too Busy to Meditate, Read This

Mindfulness practice, sometimes equated with meditation, is a very big part of DBT. It helps us focus and manage our emotions more effectively. It helps us live in the moment without judgement and increases our awareness of our current experience. It helps us stay focused.

Research shows that an ability to resist urges will improve your relationships, increase your dependability, and raise your performance. If you can resist your urges, you can make better, more thoughtful decisions. You can be more intentional about what you say and how you say it. You can think about the outcome of your actions before following through on them.

Mind your emotion

One of the complaints I often hear with respect to blogs is that they feel a lot like opinion and very little like research and data1. A primary objective of this particular blog is to present to you data that supports my assertions. Since I’m not a researcher (and there are many more talented people doing good work) I’m going to review articles for you. It may be that you don’t have access to these articles or you don’t understand them because of all the research-ese that goes into them. No matter the reason, I hope to help.

First up in our ”mindfulness articles” series is “Minding One’s Emotions: Mindfulness Training Alters the Neural Expression of Sadness ” (warning: pdf link). This technical article examines the differences in fMRI data from a control group and a practiced mindfulness trained group in response to induced sadness. As with much rigorous research, the groups were randomly assigned to control or treatment status and data were compared with the same stimuli.

The researchers utilized 3 minute clips of video, alternating in valence between sad and neutral video types and gathered data on participants’ subjective degree of sadness. The data were analyzed using a multivariate procedure designed to test for significant differences between groups and across time points and valence of the video (technically called a 2x2x4 mixed model ANOVA). This type of analysis allows us to draw conclusions about what the actual differences are between these various conditions.

Interestingly, the researchers found no difference between the control and mindfulness-trained groups on level of subjective sadness. That’s right – there was no difference between the participants who were trained in mindfulness and others on how affected they perceived themselves to be by the video clips. They were, however, less physiologically reactive to the stimuli.

Examining the effects of MT, we found that despite similar levels of self-reported dysphoria, the MT group demonstrated less neural reactivity to sadness provocation than the control group.

In other words, their brains reacted differently to the information presented by their “emotional system”. We find some information about what could be occurring in the fMRI data also collected during the study. There appeared to be less activation in the areas of the brain associated with self-referential processing and autobiographical memory. Similarly, the mindfulness trained group exhibit less inhibition in brain areas associated with interoceptive awareness. This difference suggests that they are somehow regulating their emotional response (which, you’ll recall, is similar across both groups) differently/more effectively than untrained participants because they are aware that something is happening to them. In other words, they are mindful of their current emotion.


There appears to be two take-home points from the afore-reviewed article. Our mindfulness-trained participants did not generate self-referential thoughts in response to the video clips. This cognitive distance appeared to allow some separation between the participants and the subject matter. And, secondly, there a marked awareness of the physiological processes occurring during the emotional experience and that process was observed as such – a physiological change.

A plausible mechanism of action for mindfulness effects may include the development of metacognitive skills for detached viewing of emotions, rather than the elaboration of emotional content through cognitive reappraisal.

This suggests a different way forward for dealing with significant negative emotion. Typically, our best efforts at dealing with emotional information is to re-attribute, re-evaluate, re-interpret the events. We work on generating alternative explanations for behavior or shifting “locus of control” to an external object, as well as using perspective taking (e.g., “How would you tell your friend to react to this situation?”). One of the problems with this type of strategy is that we have a tendency to end up in circular arguments with one “side” being more persuasive than the other depending on, guess what? Your mood. And when you’re already depressed, you’ve got a harder time doing this reappraisal work.

By shifting the plane of focus to something other than the cognitive back and forth we typically see, mindfulness can allow a different way to process information. By exiting this necessarily circular argument, we can start to make progress on dealing with emotion as it is: a natural reaction to events. When we start viewing emotions as natural phenomena and not events that need to be challenged or beaten back, we may finally be able to end the fight against reality in which we have been engaged.

If it's raining outside.

If it’s raining outside, and you happen to be out there, you’re probably going to get wet. That is, unless you’ve prepared by bringing a raincoat, umbrella, poncho or trash bag. This truism is often the way I frame my discussion of emotion. It’s generally accepted by most people that when it’s raining outside, you’ve got a couple options to avoid getting wet - prepare by bringing the aforementioned gear or don’t go outside. To expect not to get wet without doing either of those things is kind of absurd1. Natural reactions - getting wet - to everyday occurrences - rain - are, umm, natural, and, double ummm, normal.

We don’t expect people not to get wet just by willing themselves to be dry or by believing that if they only thought about things differently, they’d stay dry.

Or that if “normal” people were in the same situation, they’d be dry.

It’s. Just. Not. True.

If someone is able to stay dry in a rain storm, chances are they’ve got a nice big golf umbrella, a good pair of hiking boots and a fancy Gore-tex jacket. You may not have any of those things right now, but you can learn to get them. And, in the meantime, you can work on using what you’ve got, maybe a trash bag or an old newspaper, to keep yourself as dry as possible.

With that tidy metaphor out of the way, let’s get down to the business of learning about emotion. Understanding it so that we know what we’re dealing with. Emotion comes from prompting events. These events can be internal (e.g., thoughts) or external (e.g., a car accident). They can be actual or they can be just perceived. It doesn’t really matter because in dealing with emotions, perception is reality.

A prompting event can lead to an interpretation of that event. These interpretations are deeply personal and are often what people think of when they try to deal with emotions. I don’t know how many times I’ve heard, “If I could just think differently, I wouldn’t feel so bad.” That’s sort of true. And sort of not true at the same time. In other words, just thinking about things differently (or changing your interpretations), is not always going to work to change how you feel2. If it always were so easy, self-help books would be all anyone ever needed for therapy and I’d be out of a job!

A prompting event can also lead to any number of physiological reactions. When you get frightened and get goosebumps? That’s the sort of thing I’m referring to. Flushing face, tension in your shoulders. Additionally, interpretations can also lead to physiological reactions. “Someone’s broken into my house and my life’s in danger” will lead to a racing heart and quickened breathing, for example. These physiological reactions are hard-wired and not something that we can just stop doing3 right away.

We then have what are called, in DBT parlance, “action urges.” These are the things that you are driven to do as a result of the situation/interpretation/physiological reaction. When you’re scared, you run. When you’re angry, you lash out. When you’re ashamed, you hide. Again, these are all considered hard-wired reactions. Think of it from an evolutionary perspective. Back in the day, things that caused fear were often life threatening. It made sense to run when your life was threatened. Right?

So, we have at least 3 sources for the formation of an emotion. There are other potential sources, such as history and vulnerability factors, and we’ll get to those in another post. But, to get back to our metaphor, there are 3 storm fronts that are moving your way and there’s not much you can do to keep them from getting to you. At least right now, all you can do is cope with them4.


Not absurd in the “crazy” way, but just absurd in the strict definitional sense.↩

Read about behaviorism and learning theory to understand why.↩

We can do things like progressive muscle relaxation to deal with these reactions.↩

As we progress through these skills, you’ll be able to control the weather. How cool will that be?↩

GigaOm on mobile health

I'm a little partial to the use of mobile apps to help in mental health but so this article naturally caught my eye:

Over time, people will come to rely more on their phone to keep them healthy than they do on their actual doctor. Rather than going once a year for a check-up and to get a few basic tests done, you will be monitored day in and day out by your phone. This does not mean that doctors will go away, but it does mean that the role of the doctor will be forever altered. It also means that doctors will be empowered with a lot more data on what their patients are up to between visits, which will help them provide better care.

I don't for a minute think that I'm going to be able to replace my doctor (or think that you should replace yours!) but I do firmly believe that these devices will allow us to do more and better tracking of relevant therapy information allow for much more efficient use of therapy time and measures of progress. This, I'm my opinion, is a good thing.

Here's Mihaly Csikszentmihalyi talking about the concept of Flow. Flow is about being in the moment, without judgement. You melt into your experience and all other issues tend to fade away. It'd be a nice way to live your life, don't you think?