Mindfulness and the Superbowl

During last night's Super Bowl broadcast, one of the commentators made a reference to mindfulness and acceptance! Did you catch it?

Ok, ok, he didn't use quite those words, but he was talking about those concepts. It was during the 34 minute game delay caused by a power-outage that shut down the lights in half of the stadium. The delay occurred early in the second half, when the Ravens had a sizable lead and quite a bit of momentum. As it became clear that the delay would be lengthy, questions were raised about how the teams and players would manage it: Would they be able to stay warmed up? Would the Ravens lose their momentum? Would the 49ers be able to capitalize on the delay to change their game plan? Which team would it benefit/hurt more?

A commentator was asked what he thought the coaches would be saying to their players. His response was that both teams needed to stay focused on the present moment. The Ravens needed to avoid jumping ahead to imagine themselves winning, and the 49ers needed to not get caught up in what they wished they could change about the plays that had already occurred. They needed to do what was needed in the current moment.

Mindfulness, of course, is at its heart an awareness of the present moment. While mindfulness meditation involves quiet observation of our internal experiences (thoughts, feelings, sensations), mindfulness can be applied to more active pursuits. One mindfulness exercise is to "do one thing" in the moment: if you're washing dishes, be fully present in the experience of washing dishes. If you're playing football, be fully present in the current play. Not the last play. Not the next play. Just this one - be here now.

Another element of mindfulness is nonjudgment: observing whatever is present in the moment without judging it. This is where acceptance comes in. This was also another aspect of the commentator's advice to the teams in the midst of the game delay. If they got frustrated or angry or impatient as a result of the delay, that could throw them off their game. Their heads wouldn't be in it anymore, and their emotions could get in the way of executing important plays. Instead, they needed to accept it without judgment: "it is what it is."

How well any of the players last night achieved a state of mindfulness and/or acceptance is something only they could say. The Ravens did in fact lose their momentum, and the 49ers almost eked out a win in the end...almost. The 49ers, like the rest of us, can only adopt that non-present-moment refrain: "Next year!"

Over the "Cliff" - the Power of Language

The latest word out of Washington is that the Congress will not agree on any kind of legislation by tonight's deadline that would avert the spending cuts and tax increases set to take effect tomorrow. There are any number of things I could write about this situation - perhaps about the importance of compromise, the implications for social services, or the class inequality which will mean the poor shoulder a heavier burden. All of these issues are important. However, from a psychological perspective, what has stood out to me throughout conversations on this topic is how the language we use to talk about it influences its emotional impact.

Notice in my first sentence that I referenced "spending cuts and tax increases," rather than the more common phrases that are being used to describe the situation. In contrast, media and politicians speak of the "financial crisis" as "the fiscal cliff." Words like "crisis" and "cliff" imply threat and danger. These words are chosen to incite anxiety among the public, and therefore to further stir up an already tense political climate.

Post-modern schools of practice such as Narrative Therapy, and Acceptance and Commitment Therapy are based on the premise that our perceptions of "reality" are based on language rather than fact. They build on Social Constructionism's stance that all "truths" are constructed through social processes. What all this means is that we use language to construct reality, and the reality we end up with is more a function of the language we choose than "facts."

In therapy, we work with clients to alter their perceptions of reality by changing the way they think about things. We may call it reframing, or cognitive restructuring, or reauthoring, or interpretation, but the desired result is that people will find more flexible and less negative ways of making meaning out of their experiences.

The same process might apply to the so-called fiscal cliff. Because talk of "going over the cliff" calls up a vivid image of...well, falling off a cliff...the natural response is to want to dig in our heels and cling to something for safety. That reaction does not inspire balanced and flexible ways of thinking about our economy!

Unfortunately, "tax increases" and "spending cuts" have also become layered with socially-constructed meaning. These seemingly-neutral descriptions have become rallying cries for partisan politics - the words elicit a negative, defensive response from conservatives and liberals, respectively. Unfortunately, this effect of language has paralyzed our entire political system, preventing any of our politicians from taking a balanced, flexible approach - an important ingredient in any meaningful compromise.

I don't have an answer or solution here. It is more of an observation, and an encouragement to be aware of the impact of language - the language you choose, and the language you hear - and consider whether that language is the only, or most helpful, way of thinking and speaking.

Not Judging the Judgments

I was talking with a group about mindfulness and acceptance today - as in the Acceptance part of Acceptance and Commitment Therapy, which teaches people to accept rather than resist unwanted thoughts and feelings. Mindfulness, the skill of observing one's thoughts, feelings, sensations, and other aspects of internal experience without "buying into" them (seeing them as Facts) or acting on them.

We are often taught from a very young age that we should be able to "control" our thoughts and feelings, and our culture suggests that we can avoid or get rid of whatever we don't like. Unfortunately, or perhaps fortunately, neither of these messages is true: we actually can't control our thoughts and feelings (and trying to do so typically causes them to intensify, even if they initially seem "controllable"), and more often than not in life, we can't get rid of things we don't like. In fact, trying to control the uncontrollable may cause more distress than whatever it is we were trying to avoid experiencing.

By deciding to accept (rather than avoid, control, or otherwise fight) an experience (thought, feeling, etc.), we take away this added distress, and free up mental and emotional space for what is truly important to us - our values.

Easier said than done, however! Take, for example, one member of my group. Trying to understand the concept, she said: "So, instead of telling myself I shouldn't have hurt feelings, and not to be so weak, acceptance would be telling myself that everyone is weak sometimes and it's ok?"

Now, she's heading in the right direction by giving herself permission to have hurt feelings. However, she's not quite there yet: she is still judging hurt feelings as "weak."

DBT teaches that mindfulness should (try to) be nonjudgmental of whatever thoughts and feelings we experience. Of course, some of the thoughts rattling around in our heads at any given time are likely to be judgments of one form or another. Mindfulness involves stepping back from judgment by recognizing these thoughts as judgments, without becoming attached to the them as "facts." Acceptance means also accepting that you will have judgments...and treating them like any other thoughts.

As my group member summarized: "So I guess I should not judge the judgments either, huh?" I think she's getting it!

Fear of the Unknown

A theme that has been coming up among my clients this week is fear of the unknown. Specifically, several of them who are "stuck," immobilized by their ambivalence about recovery, have identified the fact that they don't know and can't imagine what recovery might be like as the strongest force pulling them away from recovery efforts.

While everyone may experience different versions of it, I think we all share this kind of fear of the unknown. The whole fortune telling industry banks on this anxiety, and our willingness to spend money to make life more predictable. The thing is, life is inherently unpredictable, and seems to delight in proving that to us.

And here is the other thing: even when we have every reason to expect a positive outcome, we still experience the fear. For example, one of the ways I have tried to assuage my clients' fear of recovery is to remind them of other people's stories of what recovery is like - both the stories of people they may know, and stories that have been published in popular recovery books. However, while such stories may temporarily raise overall sense of hope that recovery might be possible and positive, they don't erase the fear.

The fact that fear continues regardless of efforts to cognitively talk oneself out of it suggests that this kind of anxiety is not cognitive at all. In fact, although I rarely subscribe to Freudian theory, I think he may have been onto something when it comes to anxiety. Freud identifies five types of anxiety, associated with stages of development:

1. The first kind of anxiety which infants experience Freud called automatic anxiety. It is a reaction to stimuli that are perceived as threats beyond the infant's control - things that cannot be escaped or regulated. Ego psychologists have renamed this kind of anxiety annihilation anxiety. They argue that "infants experience these terrifying moments at the level of excruciating organic distress, accompanied by inchoate fears that overwhelm them" (Berzoff et al., p. 81), in large part because they have not yet developed a structure of defense mechanisms to assuage their anxiety.
2. The next form of anxiety that develops, in early childhood, is separation anxiety, or fear of abandonment. It is less intense than annihilation anxiety, but still quite intense, since young children depend upon adults for their very survival.
3. The next level of anxiety involves fear of loss of a caregiver's love and esteem (fear of rejection). It shapes children's behavior by motivating them to adhere to rules and limits set by caregivers.
4. The fourth level of anxiety Freud termed "castration anxiety," but modern theorists have renamed fear of bodily harm, or loss of valued physical or mental capacities. It is understood as "projected fear of retribution for hostile wishes against a parent" (p. 82).
5. Finally, the fifth stage recaps the four earlier stages, this time triggered not by interactions with the caregiver, but by internal interactions between the superego and ego.

While I have some skepticism about the latter two stages, I have observed the first three to be common ongoing concerns for people at various ages and stages of development; therefore, I can easily believe that they might be universal.

I also suspect that they have something to do with our fear of the unknown. My theory is that the unknown becomes a projective test of our deep-seated anxieties. In the absence of evidence or data about the nature of what will come (which is, after all, the definition of the unknown), our psyche runs through its repertoire of worst fears. Thus, when clients are able to explore their fear of the unknown, common themes that come up include abandonment, rejection, loss of capacity, and even annihilation.

So, where does that leave us - clients and therapists alike? Recognizing these core fears and their developmental basis does not necessarily make the fear go away. And when it comes to fear of the unknown, the only true antidote is to turn the unknown into the known. That means "feeling the fear and doing it anyway" - accepting the experience of fear, exposing oneself to fear without avoidance, and guiding our choices and actions by our values and goals rather than our emotions or worry thoughts (sounds a lot like ACT, right?).

How do you think about the fear of the unknown? How do you respond to clients' fear of the unknown?

FEELING better vs. feeling BETTER

People often come to therapy in order to "feel better" - less depressed, more happy, less anxious, more calm, etc. We might even be able to help people feel better, if the bad feelings are the result of a mental health problem. However, just as many mental health problems seem to be the RESULT of trying to "feel better" by getting rid of the unpleasant emotions that are a normal part of life. Abusing substances, sex, gambling, and one's own body are all in service of numbing the pain. Therefore, recovery has to involve coming to terms with the fact that life can be painful.
In these cases, the goal isn't feeling BETTER - it's FEELING better. In other words, becoming better at feeling.

What does it mean to become better at feeling?

First, it means accepting - even welcoming! - the full range of human emotions. We have them for a reason. They provide us with invaluable information about our environment, they communicate with us and those around us, and allow us to move through life in ways that are both more effective and more satisfying than if we were guided by thoughts alone. (Think about it: satisfaction itself is an emotional response!). In order to reap these benefits from feeling, we have to open ourselves to the full range of emotions. We don't get to be selective. If we try to turn off one emotion (sadness, or fear, or anger, for example), we also sacrifice joy and all of the other pleasant emotions. Numb is numb. (And, really, numbness isn't sustainable: sooner or later all those icky feelings we've been avoiding will explode, implode, or leak at inconvenient times, without our having much control over it).

Once you've accepted that you're stuck with the whole gamut of emotions, it means learning to (1) notice when you are having a feeling, and (2) identify and label those feelings. Emotions are complex. They vary in intensity. They involve physical sensations and cognitive interpretations. You can have several at the same time. You can even have feelings about feelings. It takes practice to sort them all out, especially if you've been in the habit of turning them off. Sometimes it helps to have a list of feeling words available when you first begin trying to observe and describe your emotions.

Finally, it involves having a feeling and doing nothing about it - not acting on it, or trying to change it, just sitting with it, knowing that it will pass when it's ready, because emotions come and go. Ultimately, it means being able to decide when to act on an emotion, and when not to.
Mindfulness is a useful practice to cultivate, to help you become better at feeling, because it creates space to notice feelings of various shapes and sizes, observe how they shift and change, and separate from them enough to take in the information they provide without acting impulsively. Journaling can develop increased emotional awareness, and writing about emotional things has also been shown to lessen distress. Self-soothing is useful to know to help you ride out intense feelings when they come. What other practices help you be better at feelings (rather than necessarily feeling better)?!

Don't Argue With Crocodiles

Many of the problematic behaviors that bring people to treatment - substance abuse, eating disorders, self-injury, avoidance, etc - have evolved as attempts to control unwanted thoughts or feelings. In fact control is among the most popular coping strategies around.

One of the main reasons we try to control our thoughts and feelings is because taking control actually works for us in some situations. Indeed, getting rid of things you don't like in the outside work is often both possible and effective. For example, if you don't like the color of your walls, you can paint them, and if you don't like your job, you can look for a new one. Unfortunately, what works well in the external world just doesn't work well in our internal world of thoughts and feelings.

Have you ever tried not to think about something? For example, if I tell you not to think about pink elephants, what happens? Probably you thought about pink elephants (which you have most likely not thought about the rest of the day or week). Because of the way our brains work, trying not to think about something causes that thought to stay in our heads - after all, you can't recognize whether or not you're thinking about something without...thinking about it! Therefore, trying to control your thoughts tends to increase rather than decrease the thoughts you don't want.

Similarly, you can't talk yourself out of emotions you don't want. Although society often tells us that it's important to control our emotions, it just doesn't work. Have you ever been told "stop crying" or "don't be afraid?" Did you feel differently after hearing those words? Probably not. We can't just turn off our emotions, and even if we manage to suppress them for awhile, the "rebound," and come back even more intensely than before. The reason we can't talk ourselves out of emotions is that emotions are regulated by the oldest part of the brain, that evolved before humans developed language. This part of the brain is pretty similar to the brains of animals like snakes and crocodiles. Have you ever tried to argue with a crocodile?

Unless you want to be eaten, you shouldn't argue with crocodiles. Nor should you argue with your emotions. In spite of cultural messages that it's important to control your emotions, and you'll be better off the more control you have, attempts at control really just make our difficult life situations worse. It's like trying to dig your way out of a hole you've fallen in. You might dig and dig and dig, only to realize that you're even deeper in the hole than you were to begin with. You might then decide to dig harder, only to get the same bad result. To avoid getting any deeper, you have to stop all the digging!

Emotions like sadness, anger, and fear are normal reactions to difficult situations. The only thing we should - or even can - do about them is experience them. In fact, we know that animals like crocodiles can learn from direct experience, and the animal part of our own brains can, too. So take the leap of willingness to experience the thoughts and feelings that you'd rather not have. Observe them, watch them come and go, and learn how both feelings and thoughts pass with time. We may not rid ourselves of pain that way - but avoidance wasn't really ridding us of pain anyway! However, we might be able to live richer, more authentic and satisfying lives - we just have to stop digging and arguing with the crocodiles!

A Psychodynamic Slant on Motivation for Change

When we think about a client's motivation, probably the most common lenses we use are stages of change and motivational interviewing. We think about ambivalence, and how to shift the balance of pros and cons. We think about resistance, and the overall function of the behavior in the person's life. But we may not always think about identity.

However, the role of identity deserves consideration here, as psychodynamic theorists well know. Specifically, motivation to change seems to be closely tied to whether the behavior in question is ego syntonic or ego dystonic. Something that is ego syntonic is seen as an acceptable part of the ego (i.e., one's self-image, or identity), while something that is ego dystonic is seen as unacceptable to or in conflict with one's self-image.

These terms were developed by Freud, in reference to repressed material and ego defenses, but I learned them in the context of diagnosis. Specifically, I was taught that many of the personality disorders are ego-syntonic (which makes sense if they are based on personality structure), and some Axis I disorders can also be experienced as ego-syntonic, including dysthymia and anorexia nervosa. Various forms of addiction may initially be experienced as a choice, and therefore ego-syntonic, and not become ego-dystonic until well after physiological dependence has locked someone into continuing the behavior. In contrast, the majority of Axis I disorders are ego-dystonic; in other words, they are experienced as being at odds with one's identity, almost like a foreign incursion into the self. As a result, people are generally more motivated for treatment and change.

It makes sense, right? If something feels authentic to your self, you don't feel the need or desire to change it - you don't see it as a "problem," but a reality or state of being. However, if it feels like it's interfering with your true self, it's natural to want or need a solution to the problem. (Note, however, that wanting change to happen does not necessarily translate into feeling like one can or should do anything to bring about change - for example, people who are depressed universally want to feel betterm, but often feel unable to make the behavioral changes providers recommend).

Nevertheless, people enter treatment at all levels of motivation (sometimes because they want change, and other times as a result of external pressure to change) - that means that we are likely to encounter, from time to time, clients who experience the "presenting problem" as ego-syntonic. What can we do to raise these clients' awareness of the dissonance between the problem and their selves?

Two possible interventions spring to mind:
1) Externalizing conversations, a la Narrative Therapy - this therapeutic approach frames the problem as something separate from and external to the client, often by objectifying or personifying it. Then, by beginning to see it as something external, clients are helped to recognize the discrepancies between their own feelings, beliefs, goals, and values, and those the problem seems to be pursuing. For example, my clients with eating disorders can come to recognize that while they're trying to achieve perfection, their eating disorder is trying to kill them. These two goals are mutually exclusive; therefore the eating disorder begins to feel ego-dystonic.

2) Values-based action, a la ACT - while this approach does not intentionally externalize the problem, it does seek to elucidate clients' most deeply held values and goals, and encourages clients to identify and pursue goal-directed behavior that is in line with their values, irrespective of "inner experiences" (symptoms, feelings, thoughts, sensations, urges or memories). This in achieved, in part, through mindfulness and acceptance skills.

Are there other approaches you use or think might be effective with clients who experience their presenting problem as ego-syntonic?

How Language Interferes With Learning

We usually think of language as a facilitator of learning. Through language, humans are able to represent things and ideas symbolically in their thoughts, and create novel solutions or responses to something in their environment without any prior exposure to it. We can perform mental operations to develop accurate predictions, and develop complex systems of meaning based solely on language (e.g., philosophy or mathematics. Therefore, it may sound crazy to say that language can actually interfere with learning.

And yet, researchers have demonstrated that verbal language can block our ability to learn from experience. Steven Hayes and his colleages, who developed Acceptance & Commitment Therapy (ACT), first did extensive research on the role of language in behavioral functioning. In the 1980's, they conducted studies using a computer game where people earned points based on how quickly or slowly they pushed a button. There was a trick in the game, though: pushing the button quickly earned more points early in the game, but then the rules changed so that pushing the button slowly earned more points. When people were not given any instructions, they developed their strategy based on what was working for them (i.e., based on experience), and were able to adapt quickly to the change in rules. However, when they were given a verbal instruction - to push the button quickly to earn more points - they did not adapt their strategy even when it stopped working (i.e., when the rules changed and pushing the button slowly would earn more points).

This phenomenon has been dubbed "rule-based insensitivity" - in other words, verbal "rules" we develop or are told to help us function effectively can also stop us from registering contradictory information from actual experience. As a result, we may persist in ineffective behavior because our language interferes with our ability to learn from experience. This seems to be especially true for people who tend to be rigid in general - a category that includes many people with various mental health problems.

An important target for treatment, then, for people whose verbal "rules" are interfering with their ability to learn from their experience and adapt to their environment, is to increase people's flexibility. The goal is for verbal rules to be only one of a range of data informing behavior, along with information from our moment-to-moment experiences (observations, sensations, emotions, thoughts), and the results of our interaction with our environments (i.e., noticing whether or not our interactions produce the desired resutls).

Mindfulness is the best way to develop this skill, because it helps people become more aware of their thoughts, feelings, sensations, urges, and memories (all aspects of one's inner experience), as well as the environmental context and response. Once people have this information at their disposal, the task becomes helping them make choices based on all of the information, such that they are moving in the direction of their goals rather than continuing self-defeating patterns.

What do you think about this research? How might it affect how you think about therapy and mental health problems?

Cognitive Defusion

Acceptance and Commitment Therapy (ACT) is one of the so-called "Third Wave" cognitive-behavioral approaches. Unlike previous iterations, which focused on removing or correcting a thought, behavior, or emotional response, third wave approaches integrate mindfulness to increase acceptance of problematic thoughts and emotions while developing adaptive strategies for interacting with the world (DBT is another third wave approach).

One of the ideas from ACT that I find particularly interesting is "cognitive defusion." To understand it, it helps to begin with the opposite: "Cognitive fusion." Basically, cognitive fusion occurs when we see a thought as literal truth, rather than a thought produced by our mind. We're like fish swimming in water without realizing they're under wanter. We become so immersed in our thoughts that we aren't really aware of them being thoughts. Often, that means that our evaluations of events feel as real and unchangeable as the event itself.

Sometimes, perhaps even most of the time, cognitive fusion isn't actually problematic. Our thoughts are helpful, or at least not harmful, and we go about our lives fairly successfully, all while thinking our thoughts are "true." However, sometimes cognitive fusion is both problematic, and harmful. The types of thoughts most likely to cause such problems are evaluation, and self-conceptualization. For example, someone who is fused to the thought "I am a bad student" is likely to act as if he or she is a bad student, and end up with a self-fulfilling prophecy.

If we think about the kind of thoughts that clients bring into therapy, we're likely to find all kinds of examples where taking a thought as fact adds to clients' suffering. Even something as simple as thinking "I am depressed" is problematic if it causes us to identify ourselves with depression. Believing the thought "I can't deal with panic" is likely to make someone desperate to avoid panic - an avoidance that can give rise to agoraphobia.

Since trying not to have these kinds of thoughts paradoxically causes them to happen, we have to instead learn to have the thoughts while also recognizing that they are thoughts rather than facts or literal truths - we have to defuse from the thoughts. Cognitive defusion teaches us to notice the process of thinking, so that we don't get swept up in our thoughts and allow them to define our reality.

Cognitive defusion begins with observing our own inner experiences (mindfulness), and labeling thoughts as thoughts, emotions as emotions, sensations as sensations, memories as memories, and urges to act as urges to act. So, instead of "I am depressed," we would think "I am having the feeling that I'm depressed," and instead of "I can't deal with panic," we would think "I am having the thought that I can't deal with panic." It is also helpful to distinguish thoughts that are descriptive (my desk is wooden) from thoughts that are evaluative (my desk is ugly).

Once we are aware of these inner experiences, there are several strategies to further defuse from them: We can try to objectify them by imagining them as external objects or beings. We can remove the emotional impact of the thought by turning it into just words - for example, by saying the words over and over, or very slowly, or in a funny voice, or as a song. We might imagine the thoughts as a radio broadcast, or internet pop-up ads. The idea is to turn the words of the thought into something you notice, but don't have to believe or disbelieve.

What do you think about this idea of cognitive defusion. What ideas do you have about how to defuse?