Tuesday, July 7, 2009

Anger Management

In his blog Exquisite Corpse, writer and NPR commentator Andrei Codrescu this week offered his views on the dangers of anger management. He writes, "Anger is such a great feeling. I would hate to see it lost to management."

The poet and novelist goes on to list some historical horrors, such as slavery and child labor, that would still be common in this country were it not for anger. He also alludes to circumstances and people that would evoke outrage in practically anyone.

I realize that all of this is offered in the sublime, ironic style that Codrescu so deftly employs. It requires no rebuttal. In fact, his points are some of the same points that I would make to anyone seeking help due to anger issues: Anger can be justified. Anger can be useful. It is a basic emotion and therefore helps define us as human beings.

The point that I would add, coming from a CBT perspective, is that anger management is about staying focused on your goals. Say you're in a hurry to get to an important meeting, when you're stopped by a police officer for speeding. Now you're really running late, and that makes you angry. Your goal is to get through the interaction as soon as possible so you can be on your way. If you allow your anger to influence your behavior, perhaps getting mouthy with the cop, then you'll likely be kissing your goal goodbye. If, on the other hand, you're able to use techniques to temper your anger's intensity, you're more likely to move things along.

In other words, managing anger doesn't give others a free pass. It rather gives you a leg up.

Sunday, June 21, 2009

Major-League Anxiety

Some people spend much energy keeping their symptoms of mental illness private. If they work hard enough at covering things up, the average person might be able to get by without too many people noticing that anything is wrong. When you're a major-league baseball player, that's not going to happen.

For more than a month, St. Louis Cardinals' infielder Khalil Greene has had a very public battle with social anxiety disorder. He reportedly has experienced increased self-consciousness during games, resulting in verbal and physical outbursts. The problems also didn't help his level of play. On May 31 a St. Louis Post-Dispatch article quoted Greene as saying:
"It's so strong. It's a very intense feeling and it's very unpleasant. It's not life threatening. I'm not putting myself at risk. But at the same time those responses are there automatically. I really have to concentrate to slow down, focus and stay in the game."
As a result of his problems, Greene was placed on the disabled list May 28, and later began a "rehab assignment" in the minor leagues. He returned to the Cardinals last week.

Whatever Greene has been doing to address his disorder has not been reported, but if quality of play is any measure, his treatment is working. Over the weekend Greene hit a home run in each of the three games he played in Kansas City, helping put the Cardinals back in first place. Even more encouraging, two of his homers came after he'd fallen behind in the count by two strikes. Further, Post-Dispatch columnist Bernie Miklasz reported Greene played "fine defense" at third base, having been moved from his position at shortstop.

The quickness of all of this calls for caution. Relapse both large and small is the norm for people dealing with any mental illness. Let's hope that Greene is learning effective techniques that he can call upon during times of stress, which must be constant during the long baseball season. If CBT is part of his treatment, then he is learning how to be his own therapist--something any professional athlete (not to mention those of us who are not so rich and famous) could appreciate.

Whether or not Khalil Greene can keep up his comeback is yet to be seen. Support from Cardinals fans can only help. Having grown up in St. Louis, I proudly count myself among them.

Go Khalil, and go Cards!

Sunday, May 31, 2009

CBT podcast

The hour-long radio program on CBT that aired May 6 is now available for listening as a podcast. Host Jeff Frey, MD and I discuss topics such as how CBT works, automatic thoughts, mindfulness, medication vs. talk therapy, and similarities and differences between various types of mental health professionals (licensed clinical social workers, psychologists and psychiatrists). The show is called Your Health Matters, and it airs every Wednesday, 6-7 p.m. Central on KOPN 89.5 fm in Columbia, MO.

Monday, May 18, 2009

Mindfulness and options

Mindfulness has found its way into the work of many cognitive-behavioral therapists, and for good reason. Any practice that has the potential to increase awareness, improve focus and reduce harmful judging deserves our consideration.

Someone practicing mindfulness is noticing their inner experiences (thoughts, feelings, urges and body sensations, for example), without necessarily acting upon them. The practice is designed to enrich whatever one chooses to focus upon, by allowing them to fully participate.

In my last post I wrote about how black-and-white thinking occurs when someone is limited in their ability to see good options for themselves. In her book, Mindfulness, Ellen J. Langer describes how the practice of mindfulness can serve as an antidote to this type of thinking. She writes:

A model of mindful receptivity is the inertial navigation system in modern aircraft. This device is constantly receiving new information, constantly letting the pilot know where the plane is at any particular moment. We have a similar mechanism operating within us as we walk or balance ourselves in other ways. Our minds, however, have a tendency to block out small, inconsistent signals (p. 67).

The inconsistent signals Langer mentions can be any bit of information or alternative point of view that we don't normally consider. Many times, we limit our own options by the way we think, which means only considering the options that come to us readily. Being mindfully aware of all information available allows us to see possibilities that we'd either dismissed or never considered. As Langer points out, the results can be liberating.

Tuesday, May 12, 2009

Thinking in black and white

An important part of any therapy is helping people make sense of things. As a therapist, if I can help someone figure out what’s really driving their emotions and behaviors, then there’s a chance they can do something about it.

One of the ways that CBT makes sense of things is by helping people identify the thoughts behind their moods. Once you pinpoint the thoughts, then you can start to examine them for accuracy.

I’ve found that many of my clients benefit from a list of thought categories that drive moods. These lists have various names—cognitive distortions, irrational beliefs, thinking errors—none of which I particularly like because of their pejorative nature. They’re simply ways of thinking that everyone engages in from time to time. The important thing is to recognize when your thoughts fit into one of the categories.

In this post, I’d like to look at one of the most common thought categories: black-and-white thinking (a.k.a. all-or-nothing thinking or dichotomous thinking). This happens when you see yourself as having very limited options in a situation, and none of them is good. Further, the options often represent opposite extremes (hence the “all-or-nothing”).

Some examples:

“I’m either a complete success or a total failure.”
“I can either stay in my job forever or quit right now.”
“If I don’t bottle up my anger, then I explode.”

When feelings are running high, it’s easy to lose sight of your options. Depression and anger can narrow your view even further. The CBT way of addressing these kinds of thoughts is to challenge them by asking, “Are these really the only options?” “Is there some middle ground or alternative that I haven’t considered?” Often it’s helpful to see your options as a continuum, with extremes at either end. This can help highlight the possibility that other choices exist somewhere in between.

Tuesday, May 5, 2009

CBT on the air!

For an hour of radio discussion about CBT, tune in or log on to KOPN 89.5 FM in Columbia, MO, Wednesday, May 6, 6:00-7:00 p.m. Central. I’m scheduled to be the guest on Your Health Matters, a weekly call-in program hosted by Jeff Frey, MD. I’m looking forward to answering all sorts of questions about CBT. The on-air phone number is (573) 443-TALK.

Saturday, May 2, 2009

Awareness and automatic thoughts

One of the often-cited benefits of CBT is that it can work quickly. Some people achieve their goals in just a few sessions; for others, the process can take a year or more. Some of the people who report rapid progress tell me it's because they feel more aware--aware of their own thoughts, feelings or even just the "issue" that brought them to therapy.

There are many paths to awareness: meditation, yoga, reading and group therapy are but a few. In CBT, people often start to increase their awareness by noticing their thoughts, or more specifically, their automatic thoughts.

Psychiatrist Aaron Beck coined the term automatic thoughts after noticing something interesting. His patients' moods, such as sadness or nervousness, didn't always match the thoughts that they were expressing to him. He discovered that people often have two streams of thought going at any given time--thoughts they are fully conscious of, and others that happen "automatically," without any real acknowledgement or reflection. People notice the moods that happen as a result of these automatic thoughts, but they don't stop to articulate or question the thoughts themselves.

CBT helps people get into the habit of noticing their automatic thoughts. You can try this the next time you experience a strong emotion, and aren't sure why. Ask yourself, "What was going through my mind when I started to feel this way?" Other questions to try include "What does this situation mean to me?" or "What do I think this says about my life?"

Identifying these thoughts is the first step. In CBT, people also learn how to evaluate their thoughts for accuracy. Of course, some thoughts are 100 percent accurate. But when depression or anxiety is part of the picture, people often focus on the worst or most scary things they can think of. CBT can help broaden the view, helping people see their lives in the most realistic, balanced way possible. They may still feel sadness or worry, but their feelings will be more appropriate to the situation.

And it all starts with awareness.

Monday, April 20, 2009

Anger: The guest that won't leave

Say you’re waiting in your car at a red light. It turns green. You start to go, when another car zips through the intersection, running their red light and nearly taking off your front end. Now you’re angry. How long does it take for you to cool down?

If you take a long time to cool off from anger, you may be doing one of two things: rehearsing or elaborating.

Rehearsing refers to playing out situations in your mind in which you act upon your anger. You tell the person off. You make cutting remarks. You scream. You might even exact revenge in creative ways. None of this actually happens, but it’s all very real inside your head.

What happens to your anger level while you’re imagining these elaborate scenes? Most likely, it’s on the way up. It’s only natural for your anger to intensify, or at least gain staying power, if you’re keeping it around in your thoughts. After all, you’re rehearsing for anger, and we tend to get better at what we rehearse.

Another mental activity that keeps anger around is elaborating. After getting angry at someone you know, have you ever found yourself thinking of every thing you don’t like about that person? Or you might make a mental list of every time they made you mad in the past. The current issue may even be forgotten by the time you’re through. In any case, you’ve just given yourself a lot more reasons to be angry.

Trying to stop rehearsing or elaborating altogether is a lofty goal, but there are ways to cut back. Using ideas from anger management self-help books, working with a therapist, and practicing mindfulness can all make a big difference. Just becoming aware of when you’re engaging in either of these activities can help. And when you’re able to shorten your cool-off time, just think of the extra time and energy you can devote to things that matter more to you than that person who just ran a red light.

Monday, April 13, 2009

From zero to 100 in a heartbeat

The last time you found yourself getting seriously angry, how long did it take? A lot of people say they go from feeling perfectly fine to feeling really angry in about two seconds. Some people even report feeling “blinded” by their anger. They do or say things they later regret.

How is it possible for something so powerful to sneak up on you so quickly? The answer may lie in self-awareness.

Self-awareness is knowing what’s going on in your mind and body at any given moment. When you react to a situation—like that driver who just cut you off on the freeway—changes happen in your body and mind. These are your anger cues. They tell you that unless you do something different quick, you might be headed for trouble.

There are at least four different types of anger cues to look for—body sensations (rapid heartbeat, for example), behaviors (such as slamming objects), emotions (embarrassment, fear, etc.), and thoughts (“Here we go again!”). Everyone’s cues are different. If anger is a problem for you, it’s important to become intimately familiar with your own unique anger cues.

This idea fits well with CBT, which can help people heighten their awareness of their own inner experience. This is often a first step toward managing moods and behaviors. When coupled with mindfulness practice, CBT can be used to foster tolerance of anger cues without necessarily acting on them.

For a lot more information on anger, check out AngerManagementExpert.

Tuesday, April 7, 2009

Finding yourself in a mood

Ever find yourself “in a mood” without knowing how you got there? You might have been feeling just fine only a short time ago. Nothing earth-shattering happened. Yet somehow you’re now feeling stressed, sad or whatever, and you have no idea why.

Next time this happens, try asking yourself, “What went through my mind when I started to feel this way?” If you’re not sure, take your best guess. It’s very likely that if you can identify your thought, then you’ll have a handle on why you’re feeling the way you are.

This idea is key in cognitive-behavioral therapy: What goes through our minds—not what happens in our environment—is mainly responsible for our moods.

It’s possible that something happened to trigger your thought. Maybe it was your spouse’s tone of voice, or the expression on your boss’s face. Whatever the trigger, it was the meaning you attached to it that led to your mood. CBT helps you identify these meanings and examine them, with the goal of gaining better control over your own moods and behaviors.

Friday, April 3, 2009

What's it like to be in CBT?

If you imagine therapy as a place to lie on a couch and talk endlessly about your problems, then you may be surprised by CBT. Mental health pioneers like Aaron Beck and Albert Ellis had something very different in mind when they developed what has come to be known as cognitive-behavioral therapy.

First, CBT is a partnership between client and therapist. They work together throughout therapy to help the client achieve change. The therapist is not an all-knowing guru who imparts wisdom on the client, but more like a collaborator in the process of gathering data. The data is then used to help the client move forward toward their goals.

Second, CBT is an active therapy. The therapist routinely assigns homework to help the client learn more about themselves and to try new behaviors. Homework fits with CBT’s goal of having the client become their own therapist, since the client is practicing CBT on themselves each time they do an assignment. Homework can also be used to gather that all-important data mentioned above.

Third, CBT is solution-focused. Even if someone is depressed and is always thinking negatively, some of their thoughts may be 100 percent accurate. In these cases, the therapist helps the client to learn problem-solving skills. These skills can lead the client toward new behaviors, which in turn might help them to see things differently than they normally would.

Fourth, CBT is time-limited. This means that instead of taking the years required by some types of psychoanalysis, CBT is usually much briefer. The length of therapy is driven by the client’s progress toward specific goals. Eight to twelve sessions is often all it takes to help people achieve the changes they seek.

Finally, CBT is present- and future-oriented. This stands in contrast to a focus on the client’s past or childhood. The past can certainly be considered in CBT, but usually as a way of informing the client’s current way of thinking or acting. The idea is to make changes in the present, with an eye toward future goals.

Wednesday, April 1, 2009

A Definition of CBT

Cognitive-behavioral therapy (CBT) is a way to deal with real-life obstacles and achieve meaningful change. It’s a type of counseling, or therapy, that helps people see the link between their thoughts, beliefs, emotions and actions.

A basic assumption of CBT is that what happens in life is not what causes you to feel strong emotions—such as sadness, anxiety or anger—or to act in ways that go along with those emotions. Rather, it’s your thoughts about what happens that really drive your feelings and behaviors.

For example, say you go out to dinner with a friend you haven’t seen in a while. Everything goes wrong—the service is slow, the food is lousy and the music is too loud. You spend the whole time thinking “This is terrible! I can’t believe how badly it’s turning out.” In fact, you’re so preoccupied with the problems that you miss a lot of what your friend has to say.

Meanwhile, your friend finds it all unfortunate, but chooses to focus on how nice it is to see you again and catch up on your life.

How would you feel? Frustrated? Angry? Upset? Probably very different from how your friend feels. You both just went through the same experience, but the way you perceived it made a big difference.

How does CBT work?
A skilled CBT therapist can help you become more aware of the links between your thoughts, emotions and actions. You might also gain insight into how it’s all driven by your underlying beliefs. These include your rules, attitudes and assumptions about yourself, others and the world. Once you start to define your thoughts and beliefs, you can learn ways to address them to better suit your goals.

Your problems won’t all be solved, but you might gain tools to help you manage your moods and behaviors. The ultimate goal of CBT is for you to become your own therapist.

Thanks for visiting my blog. Please come back from time to time for more notes on CBT, including thoughts on how CBT can apply to depression, anxiety and anger.

In the meantime, here's a good article that highlights some of the main features of CBT.