mood swings
A Man with an Angry Brain
Over the past 30 years, I’ve spent nearly 25,000 hours counseling angry men, and until about two years ago, my enthusiasm was beginning to wane. If you’ve worked with angry male clients, you can understand why. These men are generally highly reluctant clients, who are often in your office only because they’ve gotten “the ultimatum” from their wives or girlfriends or bosses or sometimes court judges: “Get therapy for your anger or get out / you’re fired / you’ll go to jail.” Many, considered by everyone who knows them to have an “anger problem,” arrive in your office convinced that they don’t have an anger problem: the real problem is their stupid coworkers, annoying girlfriends, demanding spouses, spoiled kids, or unfair probation officers. However, they arrive at your office with a shotgun at their backs, so to speak, and know they have no choice. They hate the entire situation because it makes them feel powerless.
No wonder they feel powerless: they’re being coerced to lay down their anger, the only weapon they’ve ever had against feelings of powerlessness. They often trace their reliance upon anger to a childhood history of danger, trauma, shaming, and pain. Anger is the emotion they can trust, the one that might keep danger at bay. As they grew up, they continued to use anger to make people they regard as dangerous back away. By the time you see them, they regard just about every person in their lives as “dangerous,” including loved ones. These men have become habitually angry. I liken their condition to the default option on a computer: their anger goes on automatically unless they consciously turn it off.
Of course, it isn’t easy to turn off the default option when the way to do so is hidden deep within the machine’s (our brain’s) control panel. Furthermore, men for whom anger is a default emotional response to life’s vicissitudes are often relatively untrained in experiencing and communicating other emotions. For example, one of my clients “went off”–screaming and threatening bodily harm against his father’s doctors–when his father died, to the point the police had to be summoned, because he couldn’t handle his grief. Anger was the only emotion he could call upon in time of need. Not surprisingly, when these men come to therapy, whether as individuals or in couples or groups, they’re frequently defensive, argumentative, passive-aggressive, protective of their right to be angry, and doubtful about my competence to understand or help them in any way.
It’d be misleading to say that my most difficult clients are unmotivated. More accurately, they’re antimotivated, committed to undermining any behavioral programs or specific anger management tactics I offer. Meaningful change takes many repetitions: “Practice, practice, practice” is a hallmark of anger-management training. For example, taking the time to put a problem into perspective (“On a 1-10 point scale, Joe, how important is it for your teenage daughter to get home every night by 8 p.m.?”) works well, but only if the client is motivated enough to practice putting things into proper perspective perhaps as often as several times a day. It stands to reason that trying to argue such men out of their commitment to anger is pointless. I long ago realized I couldn’t beat them in face-to-face combat; they’re better at in-your-face challenges and making contemptuous remarks than I’ll ever be. I needed a tool that allowed me to sidestep their oppositionality and create a therapeutic alliance.
At a deeper level, chronically angry people have become lifelong victims of what’s sometimes called negative neuroplasticity. They’ve unintentionally trained their brains so well, through countless repetitions of undesired behavior (at least, undesired by the rest of the world), that they’re primed to think, feel, and say things that increase their own anger. For example, Joe may well think that if his daughter gets home after 8 p.m. it means she’s probably having sex with some male punk. That kind of thought pattern is automatic.
So now we have two major concerns. First, some of my clients enter treatment antimotivated. Second, their brains have been programmed to react automatically with anger and hostility to a wide variety of situations. What kind of therapeutic intervention can address these issues?
Focusing on the Brain to Increase Motivation
About six years ago, I stumbled across the answer when I attended a session about the brain at the Networker Symposium in Washington, D.C. The controversial brain researcher Daniel Amen was just beginning his lecture when he mentioned in passing that he’d been browsing through the books on anger in the sales area. “None of them said anything about the brain,” he noted somewhat dismissively. Now many of those anger books he was trashing were my books, so at first I was defensive. But by the end of the talk, I realized he was right, at least about the books I’d authored. I hadn’t mentioned anything about brain processes for a simple reason: I didn’t know anything about them. That led me to immerse myself in the subject of the brain, and as I did so, my enthusiasm for working with angry clients increased exponentially.
How can learning about the brain–particularly the angry brain and how it got that way–possibly influence clients who have a hard time taking in therapy or sticking with anger-management techniques? Aren’t concepts drawn from brain research simply too abstruse, too abstract, and apparently unrelated to daily life to make much difference to them? In fact, what I’ve found is just the reverse: these men are fascinated by information about how anger develops in the brain and why it’s so hard to control, and they consider it far more relevant to their lives than many standard therapy concepts. Getting to understand a bit of what happens “inside their heads” when they get angry resonates deeply with them. In one way, they can cling to their defensiveness and denial systems, since they certainly can’t be accused of deliberately messing up their minds. Sidestepping their defensiveness and emphasizing their opportunity to do something right that will retrain their brains gives them a positive direction and a possible source for well-earned personal pride. Furthermore, hearing me explain how, by regular, committed behavioral practice of various anger-management techniques, they can literally change their own brain circuits, stimulates both hope that they can change and desire to begin. For the first time in their lives, they feel they might be capable of literally using their own brains tochange their brains. It is a real revelation to many angry men.
My own enthusiasm for brain science and my belief in angry men’s inherent capacity to reorganize their own neural circuitry are probably another key to revving up their motivation to try. My “brain talk” to them isn’t just a lecture about applied neurophysiology, but in truth a kind of triggering mechanism arousing their own curiosity and interest. Clearly, my enthusiasm evokes–in their brains–a mirroring enthusiasm for this process. It may well be that my sheer enthusiasm for this endeavor, my joy and excitement about the brain, triggers left-hemisphere mirror neuronal activity that bypasses right-hemisphere negativity and cynicism.
Devron Johnson is a 40-year-old male who’s been divorced for 10 years, partly because of his anger problems. An intelligent but not highly educated man, he works as a heating and cooling technician. He has two adolescent sons, with whom he barely converses and seldom visits. He’s now in a new relationship with Sheila, a 36-year-old mother of three younger children who live with them. Although Devron has never been physically violent with the children, he often frightens them with his angry outbursts.
This man grew up in a tough part of Detroit, where survival was the name of the game. His parents separated and reconnected several times during his childhood. The family atmosphere was markedly hostile–full of negativity, accusations, and occasional violence. Devron said he hated his father because he was never there for him, not even when he became a star athlete on his high school’s baseball team.
Devron sought therapy because Sheila had threatened to end their relationship unless he became much nicer to her kids. He added that he was also in trouble at work because “I gave the finger to my boss once too often.”
Here’s how Devron described his anger: “Man, I had a bad attitude in school. I beat people up if they looked at me wrong. But I gave that up. I don’t hit nobody anymore. But Sheila says I still have a bad attitude. She says I look for problems with her kids. Then I blow because I have a really short fuse. And I have a hard time letting go of my anger, too. Once I get pissed at someone, they stay my enemy forever.” Still, Devron does want to change. He loves Sheila and even grudgingly admits he likes her children. He doesn’t want to lose them. However, he doubts whether I, or anybody else, can help him. A few years ago, he attended an anger-management program for about 10 weeks, but says, “I didn’t get nothing useful from it.”
Like many angry clients, Devron came to counseling under duress–the “get help, or get out” final call. This isn’t a formula for success, since such clients often arrive for counseling thinking that they’ll more or less passively go through the motions to get the wife/boss/law off their backs, and then they’ll be free to revert to previous behavior. By contrast, Devron was directly skeptical and dismissive–derisive, in fact. Instead of pretending to buy the package, he openly challenged me to prove I had something new to offer. It’s uncomfortable to be sneered at by your client, but I’ve learned to recognize an open challenge as a positive indicator for success. Devron’s disdain was a sign of energy that might be used in counseling, if I could develop an alliance with him.
“Actually, Devron, I do have something to offer you that you probably haven’t run into before,” I told him, “I can help you change your brain.” I proceeded to explain with the enthusiasm and energy I usually feel when talking about the brain that he was actually capable of making fundamental, long-term changes in the way he thinks. “Devron, all it takes is commitment and persistence. I know you’re capable of both of those things because you’ve told me how much you love Sheila and the kids–that’s commitment–and how you’ve stuck it out with them when it would have been easier to walk away–that’s persistence.” I emphasized to him that he’d developed lifelong habits of anger that had become deeply rooted in his brain. But I assured him that he and he alone could make changes in those habits if he so desired. However, I cautioned him that real brain change doesn’t come easy. I said he’d need to make a strong commitment to practice new behavior for at least several months, so he could build, improve, and expand new circuitry inside his brain while reducing the power of his negative brain circuits. I briefly mentioned such concepts as neuroplasticity and myleinization, but only as a tactical move, to assure him that I did, in fact, know what I was talking about. I told him I didn’t just believe this brain stuff might work, I was absolutely convinced because I’ve seen many other angry people change their brains in just this way, and because I myself had changed my brain to become much more optimistic and generous.
As I spoke, I watched Devron’s “show me” expression change to hope and wonder. “You mean I can really change the way I think?” he asked. It turned out that Devron’s oppositionality obscured a deep sense of pessimism and hopelessness. He’d believed that change was impossible, in effect dooming him to a lifelong anger career. But now, maybe because of my own sense of conviction, he began to see possibilities. We talked a little more before the hour ended, and I asked him to think about how much he wanted to change his brain and in which ways. I also asked him what positive goals he wanted to pursue–for example, what other emotions he might be willing to experience if his brain wasn’t dominated by anger. A positive goal is important with all clients, of course, but especially with angry clients, who often mistakenly set only the negative goal of being less angry. I explained to Devron that only setting a negative goal like quitting being angry was like deciding that a car that currently could only go in reverse would be just fine if you could get it to stay in neutral. The idea is to move forward in life, to get that car moving ahead. Of course this same idea applies to only quitting drinking (instead of leading a sober lifestyle) or stopping being critical (instead of giving praise).
Finally, I cautioned Devron again that real brain change doesn’t come easy. I told him he’d need to make a strong commitment to practice new behavior for at least several months so he could build, improve, and expand new circuitry inside his brain while reducing the power of his negative brain circuits. I then sent him home with two pages of examples of possible brain change plans he could implement. One example was converting criticism and pessimism to praise and optimism. Another was to convert resentment into forgiveness. A third was to look for the good in people (and himself) instead of the bad.
When Devron returned a week later, he said he’d thought a lot about changing his brain and his life. He’d discussed it with Sheila, who’d told him she’d stick around for a while if she saw him really working to change his behavior. Now he was eager to make a six-month commitment to brain change. I then gave him some handouts I’ve created to help him name his brain-change plan. A person with a good brain plan has given it a name that means something at an emotional level, includes specific initial behaviors to maximize the opportunity for immediate success, and at least speculates about longer-term improvements and additions, and how achieving these changes might affect him or her. I also gave Devron the chapter on neuroplastic change from my book to reinforce the idea that changing his brain was realistic, if and only if he’d make a strong commitment to it.
Devron returned the next week in a quandary. He told me that he and Sheila had had a big disagreement about what his brain-change plan should include. She wanted him to be nicer to her children. Devron told me that he wanted to be nicer to them, but that his first concern was quitting thinking so pessimistically about the world. “If I can’t quit thinking that everyone is out to screw me over, I don’t think my changes will last,” he said. I thought Devron had hit upon a clear understanding of how he needed to change at an existential level. Brain-change plans aren’t simple behavioral alterations: they really change your brain, and in doing so, ultimately affect your connections with yourself, those you love, and the universe. So I affirmed Devron’s insight. However, I did point out that his goal and Sheila’s weren’t contradictory. Being nicer to the kids could well become one way that he altered his mindset of hostility and suspiciousness. After all, deeply held beliefs don’t change completely on their own. Devron needed to try out new behavior and receive positive rewards for doing so in order to give his brain the opportunity to be transformed.
I’d like to offer a side comment here. We often expect our angry clients to act as if they were living in a safe world, a world in which people are pleasant, trustworthy, loving, and consistent. This false belief on our part sets clients up to fail. Devron’s siblings, for instance, regularly engaged in felonious behaviors, such as drug dealing and robbery, and expected him to join them as he often had in the past. He told me during therapy that he’d begun declining these invitations. When I asked him if he’d practiced being assertive with them, he laughed. “I guess if telling my brother to go to hell when he attacked me for not going along with some scam he was into, then yes, I was very assertive.” The result of his new “good” behavior was that his family ostracized him for several months. Fortunately though, Sheila and her children were dependably in his corner, so that Devron could practice new, prosocial behavior around them without being criticized or ridiculed.
Devron named his plan “Learning to Trust.” I was tempted to add “and take in love,” but Devron would have labeled that phrase unmanly. When I asked him how he planned to begin this plan, he suggested he could go to his father to see if he could learn to trust the man he most distrusted in the world. Needless to say, this was a palpably rotten idea: in all likelihood, his father would once again have demonstrated his complete untrustworthiness, potentially undermining everything Devron was trying to do. I talked him out of it with some difficulty by pointing out that he was betting his whole stake on one roll of the dice. “Besides, it’s a bad bet,” I said. “You’d be better off investing in a smaller stake, like letting yourself trust Sheila more.” That reminded him of his real priorities.
He decided to open up emotionally a little more to both his family and a few trusted coworkers. For example, he told some of his history to two of his coworkers, the ones he felt most comfortable with, and they responded positively with their own self-disclosures. Then he took a bigger chance by admitting to Sheila that he had cheated on his first wife. Much to his shock, she told him she’d known about it for a long time–his ex-wife had thoughtfully given Sheila that information when she’d begun dating Devron–but she’d chosen not to mention it and trust that he’d be faithful to her.
Shiela’s disclosure and assertion of trust brought him to tears. At that very moment, his brain-change plan spontaneously expanded to include being trustworthy to others. Since Devron had a long history of lying by omission (“Oh, I must have forgotten to tell you that”) this expansion was quite significant. It had proved harder for him than the initial goal because he’d had to retrain himself not to leave out some of the truth “so nobody could pin me down.” He kept expanding from his core commitment to develop trust. He realized along the way that he’d been mean to Sheila’s children because he didn’t want to get close to them and then lose them. But Sheila came through by rewarding his obvious changes with reassurance that she’d stay with him.
I regularly review a client’s brain-change plan with him or her, rather than just assume it’s working fine. It’s important to challenge clients quickly if they’re letting their plan drift.
The final addition to Devron’s plan was learning how to be more empathetic. Devron acknowledged that empathy was strange territory for him: “Frankly, I never gave a damn what anybody else felt.” But now that he felt safer, he could do what safe people do: care about and take a real interest in others. Like many angry people, he has some difficulty being empathic. Empathy partly depends on automatic attunement processes usually learned in infancy through parent–infant synchronic movement. He experienced few such experiences as a child. We talked together about this deficit, a deficit he was determined to challenge. He immediately made a real effort to put himself in the shoes of others. It’s just that he had trouble first taking off his own shoes. For instance, he told his 12-year-old daughter, Amy, who was being teased by classmates, that he knew exactly how she felt, even though he’d been the bully, not the victim, when he’d been in school. But here again, the principles of neuroplasticity apply. Devron realized he’d misunderstood the situation when his daughter got mad at his reply. He then consciously took the time to listen better. Gradually, this behavior was becoming faster, smoother, and more automatic.
Devron’s plan, then, began with developing some basic trust in the world, which led to being trustworthy himself, which morphed into increased empathy and actually caring about others. He quit working with me after approximately nine months. Our last session included Sheila, who affirmed that Devron had become much less angry, more caring, and far more present in their lives. She’d previously doubted his changes would endure, “But he’s only becoming nicer,” she admitted. “I don’t doubt him any longer.” Devron added that he now felt deep inside his soul that he could trust Sheila. He felt safe in a relationship for the first time in his life. “So now I have no reason to be mad all the time.” Of course, he and Sheila still argue from time to time, as do almost all couples. But Devron controls his initial burst of anger far better than before, calms down quicker, and lets go of his anger sooner.
http://www.alternet.org/personal-health/angry-brain-how-help-men-uncontrollable-tempers?paging=off
Read Full Post | Make a Comment ( 1 so far )What is Anger
So what is anger?
Simply put, anger is an emotion. In fact, anger is just an emotion – it is neither right nor wrong to feel it. Unresolved anger can lead to serious physical and mental health problems such as heart disease, stroke, depression and anxiety.
What is the purpose of Anger?
The purpose of anger is to alert us to danger and in doing so produce the flight or fight response. In other words, anger is meant to protect us from harm. All of the physical effects you experience when you are angry are there to tell you that something is wrong. It can motivate us to make positive changes in our community or advocate for others. For example, Martin Luther King was motivated by outrage over racial prejudice (some of which he experienced first hand) to start a civil rights movement in America. With this in mind, you can see that anger, in and of itself, is not negative.
It is, however, a complex emotion. Anger is usually considered a secondary emotion. When we get behind our anger, we discover that there is always a primary emotion such as fear, sadness or frustration at root of it. Understanding the emotions behind the anger is one way of expressing anger appropriately, but we will discuss this later.
Where does anger come from?
Anger is usually caused by some kind of perceived or actual injustice, selfish or thoughtless act, hurtful remark, etc. But this is not where anger comes from. Anger comes from inside of you. It is a natural response to dissatisfaction with your environment.
Read Full Post | Make a Comment ( 1 so far )Angry all the time Advice
Question:
I am in my mid-50s and I am struggling with anger and negativity issues. Menopause has not been easy, and I think I’m mostly through it, yet these overwhelming emotions continue to haunt me. I was on antidepressants for a number of years but I went off two years ago, deciding that I don’t want to go through the rest of my life in a fog. For a while things were OK, but more and more lately I find myself plunged into such negativity, such bitterness, such anger — I don’t want to be this person! It’s like I get pissed off and/or have my feelings hurt over situations where I feel slighted or left out — for example, it seems that every time I turn around, friends are planning a trip to Europe or somewhere I’d love to go but can’t afford, and then I’m envious and resentful. Or I hear about a big gathering of friends to which I wasn’t invited, and I wonder why and my feelings are hurt. Or I feel bitter toward my job and co-workers because it seems everyone is moving forward and I’m stuck and feeling marginalized. I seethe inside over stupid stuff like if someone fails to say hello to me as he rushes past or when someone cuts me off in traffic. I really try to stop myself from being so ridiculous, but I can’t seem to do it. My husband once remarked that everything seems to be an affront to me, that I take everything so personally, and it’s true.
The good thing is that I don’t feel this way all of the time. It’s quite the roller coaster I’m on, though the highs aren’t extreme or manic — I just feel a little better, less negative. But the lows are downright scary at times. I’ve been seeing a therapist since last November, and I felt that I was making breakthroughs and learning about myself a bit (though I can’t say I’ve reached the point where I like myself any better), but we seem to be at a standstill. She keeps promoting meditation, and I do understand that once I make the effort to include it in my life on a regular basis (I’m sporadic at best), it will hopefully make a difference, but I’m starting to feel a little desperate for a more immediate relief from all of this negativity and anger. It wears me out! I feel like I’m distancing people from me, and I can’t blame them. My closest friends have been supportive (yet I haven’t been totally forthcoming about what’s going on with me — they just know I’m going through a really bad time), but I suspect my more casual friends wonder what the hell is wrong with me. I feel like a blob of paranoia, insecurity, and self-doubt, and those feelings all too easily merge into the anger and negativity.
As I said, I don’t want to be this person. Thanks for listening.
Angry All the Time
Answer:
Dear Angry All the Time,
Have you talked with your therapist about the automatic thoughts that occur right before you feel this anger? Can you bring them to consciousness? Can you say them out loud and/or write them down?
These immediate thoughts are sometimes the key to our subsequent emotions. If we can get to them, we can avoid the negative feelings. That’s what I’ve found.
For instance, when stuck in traffic, I may find myself impatient, gripping the wheel hard, having vengeful thoughts about the other drivers, offering uncharitable words for their hair or the way they jut their chin or their clothes or the state of their cars; all these thoughts swarm in my head, but if I can calm down and go back to the original thought that went through my head, it may be something like, “Fuck! I’ll never get there!” or “I’m going to be late!” or “I’m always late!” or “People don’t know how to drive!”
It is these thoughts that cognitive behavioral therapy teaches us to catch and evaluate for truthfulness and relevance. The idea is that if a statement is neither true nor relevant (or, I suppose, even if it is true, but not relevant), it doesn’t make sense for us to feel badly about it. It doesn’t matter. If we can substitute other words for these automatic thoughts, we can avoid the subsequent feelings. And if we avoid the feelings then we can be happier. We may even come out of a bad depression over time.
We take such thoughts apart and substitute more realistic, appropriate thoughts, like, “I may be late, but if I’m late, my friends will wait for me,” or, “I’ll get there eventually if I just stay in the car and keep inching forward,” or, “People’s driving styles really differ from mine, probably because they were taught differently, or they don’t have as much experience as I do, or they aren’t as skillful as I am. But they’re legally allowed to drive, so I should steer clear of them so they don’t succeed in running into me.”
The book Feeling Good describes how to do this. Ask your therapist if you can get to work on some kind of cognitive therapy.
I’m glad your therapist is suggesting meditation. How are you doing with it? Sometimes it’s hard to make time for something that involves doing so much of nothing. If you were going bowling, that would be one thing. But you’re just going to sit there. What is that? That’s so close to nothing, it’s hard to schedule time in for it.
But it works. You can emerge from 15 or 20 minutes of sitting with a new, fresh outlook. Stuff that made me angry seems just fine now!
Make some time for it. Give yourself a break. You deserve to feel better!
Do antidepressants work?
The following script is from “Treating Depression” which aired on 60 Minutes – Feb. 19, 2012.
The medical community is at war – battling over the scientific research and writings of a psychologist named Irving Kirsch. The fight is about antidepressants, and Kirsch’s questioning of whether they work.
Kirsch’s views are of vital interest to the 17 million Americans who take the drugs, including children as young as six and to the pharmaceutical industry that brings in $11.3 billion a year selling them.
Irving Kirsch is the associate director of the Placebo Studies Program at Harvard Medical School, and he says that his research challenges the very effectiveness of antidepressants.
Irving Kirsch: The difference between the effect of a placebo and the effect of an antidepressant is minimal for most people.
Lesley Stahl: So you’re saying if they took a sugar pill, they’d have the same effect?
Irving Kirsch: They’d have almost as large an effect and whatever difference there would be would be clinically insignificant.
Stahl: But people are getting better taking antidepressants. I know them.
Kirsch: Oh, yes.
Stahl: We all know them.
Kirsch: People get better when they take the drug. But it’s not the chemical ingredients of the drug that are making them better. It’s largely the placebo effect.
Irving Kirsch’s specialty has been the study of the placebo effect: the taking of a dummy pill without any medication in it that creates an expectation of healing that is so powerful, symptoms are actually alleviated. This is the placebo response…
Kirsch, who’s been studying placebos for 36 years, says “sugar pills” can work miracles.
Kirsch: Placebos are great for treating a number of disorders: irritable bowel syndrome, repetitive strain injuries, ulcers, Parkinson’s disease. Even traumatic knee pain. In this clinical trial some patients with osteoarthritis underwent knee surgery. While others had their knees merely opened and then sewn right back up.
Kirsch: And here’s what happened. In terms of walking and climbing, the people who got the placebo actually did better–
Stahl: Come on.
Kirsch: –than the people who got the real surgery.
Stahl: No.
Kirsch: And that lasted for a year. At two years after surgery, there was no difference at all between the real surgery and the sham surgery.
Stahl: Is it all in your head or–
Kirsch: Well, it’s not all in your head because the placebos can also affect your body. So if you take a placebo tranquilizer, you’re likely to have a lowering of blood pressure and pulse rate. Placebos can decrease pain. And we know that’s not all in the mind also because we can track that using neuro-imaging in the brain as well.
He says the doctors who prescribe the pills become part of the placebo effect.
Kirsch: A clinician who cares, who takes the time, who listens to you, who asks questions about your condition and pays attention to what you say, that’s the kind of care that can help facilitate a placebo effect.
He says he got into researching the effect of antidepressants by accident.
Kirsch: I was interested in evaluating the size of the placebo effect. I really didn’t even care about the drug effect because everybody, including me, knew it worked. I used to refer patients to get prescriptions. I didn’t change the focus of my work onto looking at the drug effect until I saw the data from our first analysis.
What he saw was that it almost didn’t matter what kind of pill doctors gave patients.
Kirsch: We even looked at drugs that are not considered antidepressants: tranquilizers, barbiturates. And do you know what? They had the same effect as the antidepressants.
Stahl: Come on.
Kirsch: Really.
Kirsch was so surprised by his initial findings, he decided to do a second study – using data not only from the drug companies’ clinical trials that had been published in medical journals.
This time he got data that weren’t published but had been submitted to the FDA, which he got through the Freedom of Information Act.
Kirsch: These are the studies that showed no benefit of the antidepressant over the placebo. What they did is they took the more successful studies, they published most of them. They took their unsuccessful studies and they didn’t publish them.
Stahl: So when you did your study, you put all the trials together?
Kirsch: That’s right.
Stahl: You’re looking at patients who took the real drug and patients who took the placebo.
Kirsch: Yes.
Stahl: Did they get equally better, or did the ones who took the pills get even a little better?
Kirsch: If they were mildly or moderately depressed, you don’t see any real difference at all. The only place where you get a clinically meaningful difference is at these very extreme levels of depression.
Stahl: Now look, psychiatrists say the drug works.
Kirsch: Right.
Stahl: The drug companies and their scientists say the drug works. Maybe you’re wrong.
Kirsch: Maybe. I’d add to that, by the way, patients say the drugs–
Stahl: Patients say the drug works.
Kirsch: And, for the patients and the psychiatrists, it’s clear why they would say the drug works. They take the drug; they get better. Our data show that as well.
Stahl: You’re just saying why they get better.
Kirsch: That’s right. And the reason they get better is not because of the chemicals in the drug. The difference between drug and placebo is very, very small; and in half the studies non-existent.
Kirsch and his studies have triggered a furious counterattack – mainly from psychiatrists, who are lining up to defend the use of antidepressants like Dr. Michael Thase, a professor of psychiatry at the University of Pennsylvania School of Medicine, who has been a consultant to many of the drug companies.
Stahl: Irving Kirsch says that depressants are no better than placebo for the vast majority of people with depression, the vast majority. Do you agree with that?
Michael Thase: No, no. I don’t agree. I think you’re confusing, or he’s confusing, the results of studies versus what goes on in practice.
He says that Kirsch’s statistical analysis overlooks the benefits to individual patients. And while he agrees there’s a substantial placebo effect -Especially for the mildly depressed, using a different methodology, he finds that the drugs help 14 percent of those moderately depressed, and even more for those severely depressed.
Thase: Our own work indicates pretty convincingly that this is a large and meaningful effect for a subset of the patients in these studies.
Stahl: But even by your own numbers more people, maybe twice as many people, are having a placebo effect than are actually being helped by the drug.
Thase: That’s correct.
Stahl: In the moderate range?
Thase: That’s correct.
Stahl: And this isn’t troubling to you?
Thase: I wish our antidepressants were stronger. I hope we have better ones in the future. But that 14 percent advantage over and above the placebo is for a condition that afflicts millions of people, that represents hundreds of thousands of people who are better parents, who are better workers, who are happier and who are less likely to take their life.
Since the introduction of Prozac in the 1980s, prescriptions for these drugs have soared 400 percent - with the drug companies having spent billions over the years advertising them.
Stahl: I don’t know about you, but I’m seeing more women running through daisy fields after looking morose than ever before.
Dr. Walter Brown: Absolutely. There’s a lot of hype out there
Dr. Walter Brown is a clinical professor of psychiatry at Brown University’s Medical School. He has co-authored two studies that largely corroborate Kirsch’s findings.
Brown: The number of antidepressant prescriptions over the last decade has increased and most troublesome, the biggest increase is in the mildly depressed, who are the ones who are least likely to benefit from them.
He says they’re getting virtually no benefit from the chemical in the pill. Like most experts, he says these drugs do work for the severely depressed, but he questions the widely held theory that depression is caused by a deficiency in the brain chemical called serotonin, which most of these pills target.
Brown: The experts in the field now believe that that theory is a gross oversimplification and probably is not correct.
Stahl: And the whole idea of antidepressants is built around this theory?
Brown: Yes, it is.
To approve any drug, the Food and Drug Administration merely requires that companies show their pill is more effective than a placebo in two clinical trials – even if many other drug trials failed.
Brown: The FDA for antidepressants has a fairly low bar. A new drug can be no better than placebo in 10 trials, but if two trials show it to be better, it gets approved.
Stahl: Does that make sense to you?
Brown: That’s not the way I would do it if I were the king. But I’m not.
Dr. Tom Laughren, director of the FDA’s division of psychiatry products, defends the approval process.
Stahl: We’re told you discard the negatives. Is that not right?
Tom Laughren: We consider everything that we have. We look at those trials individually–
Stahl: But how are you knowing that the two positives deserve bigger strength in the decision?
Laughren: Getting that finding of a positive study by chance, if there isn’t really an effect, is very low. I mean, that’s basic statistics and that’s the way clinical trials are interpreted. A separate question is whether or not the effect that you’re seeing is clinically relevant.
Stahl: Okay. Is it clinically relevant?
Laughren: The data that we have shows that the drugs are effective.
Stahl: But what about the degree of effectiveness?
Laughren: I think we all agree that the changes that you see in the short-term trials, the difference between improvement in drug and placebo is rather small.
Stahl: It’s a moderate difference.
Laughren: It’s a small, it’s a modest difference.
It’s so modest – that in Great Britain the National Health Service decided to dramatically revamp the way these drugs are prescribed. It did so after commissioning its own review of clinical trials.
Tim Kendall: We came to the conclusion that for mild to moderate depression, these drugs probably weren’t worth having.
Stahl: At all.
Kendall: Not really.
Dr. Tim Kendall, a practicing psychiatrist and co-director of the commission that did the review says that like Irving Kirsch – they were surprised by what they found in the drug companies’ unpublished data.
Kendall: With the published evidence, it significantly overestimated the effectiveness of these drugs and it underestimated the side effects.
Stahl: The FDA would say that some of these unpublished studies are unpublished because there were flaws in the way the trials were conducted.
Kendall: This is a multibillion dollar industry. I doubt that they are spending $10 million per trial to come up with a poor methodology. What characterizes the unpublished is that they’re negative. Now I don’t think it’s that their method is somehow wrong; it’s that their outcome is not suitable from the company’s point of view.
Because of the review, new public health guidelines were issued. Now drugs are given only to the severely depressed as the first line of treatment. For those with mild to moderate depression, the British government is spending nearly half a billion dollars training an army of talk therapists.
Physical exercise is another treatment prescribed for the mildly depressed.
Kendall: By the end of 10 weeks, you get just as good a change in their depression scores, as you do at the end of 10 or 12 weeks with an antidepressant.
None of the drug companies we spoke to was willing to go on camera, but Eli Lilly told us in an email that drug trials show antidepressants work better than placebos over the long term and that “numerous studies have shown that patients on placebos are more likely to relapse” back into depression. The industry’s trade association, PhRMA, wrote us: “antidepressants have been shown to be tremendously effective.”
But if Irving Kirsch has his way, the drug companies will have to completely rethink their $11.3 billion business.
Stahl: You’re throwing a bomb into this. This is huge what you’re saying.
Kirsch: I know that. The problem is that you can get the same benefit without drugs. I think more are beginning to agree. And I think things have begun to change.
Everyone in this story says that if you’re depressed, you should see your doctor, and if you’re already on these powerful drugs, you shouldn’t stop taking them on your own.
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why we are depressed
Everyone wants to be happy, that’s not the problem. Some of us have been happy for years. Some of us have never had a taste of it. Still others manage to bring about a moment of happiness only to have it turn to ashes in their mouth. What is causing this variety of outcomes? It is not wealth, power or material possessions. It is a personal dynamic consisting of negative attitudes from childhood in a context of adult self-contempt. These destructive attitudes below our awareness will rise up and predispose us to get rid of our undeserved happiness before it makes us feel guiltier than we do already. It is a useless good intention to tell our friend, Tammy, that she’s a nice person and deserves to be happy instead of miserable. She can’t get there from here. Her attitudes are in the way, and they are stronger than we are. We say she is well-defended against happiness.
Here is an example of how we identify happiness-repellant attitudes in our practice against happiness and extract them while you wait.
Tammy came for counseling because she was unhappy in her marriage. She was unhappy outside of her marriage, too, come to think of it. She was tired of being unhappy. She was ready to change. We wanted to find out how she got that way. This is one of her earliest recollections. The incident itself isn’t traumatic. What is significant is that she remembered it for thirty years. There is a message embedded in the recollection. Our task is to find out what it is so that we can change the attitude that grew out of it.
Therapist: What is one of the first things you remember?
Tammy: “I remember playing a game with my grandmother. We were having such a good time. I was really laughing and having fun. Suddenly my mother came into the room and said, ‘Stop that, Mother. You’re spoiling her.’ Grandma pushed me off of her lap. We didn’t play after that.”
Therapist: “How did you feel when that happened?”
Tammy: “I felt sad.”
Therapist: “What was the saddest thing about it?”
Tammy: “That I couldn’t play with my grandmother any more.”
Therapist: “Your happiness was over. For all you knew, it might be over forever.”
Tammy: “I wasn’t conscious of it, but that was how I felt.”
Therapist: “What was the worst thing about what happened?”
Tammy: “I remember feeling all alone. I had no one else to play with.”
Therapist: “You felt abandoned. Did you deserve this painful abandonment?”
Tammy: “No. I wasn’t doing anything wrong.”
Therapist: “It didn’t make sense. You couldn’t understand it. You couldn’t do anything about it. You felt powerless and out-of-control.”
Tammy: “That makes me angry. It wasn’t fair. My mother had done that quite often as a matter of fact. She was a party pooper.”
Therapist: “Did this consistent loss of happiness make you angry?”
Tammy: “Sure it did. I’m angry now just thinking about it.”
Therapist: “We’re not talking about playing with grandma any more, are we?”
Tammy: “No. It’s the story of my life.”
Therapist: “This powerful recollection taught you things about life that you have never unlearned.”
Tammy: “Are you psychoanalyzing me?”
Therapist: “No, I am just revealing you to yourself so that you can begin to make new choices in your own behalf on an informed basis.”
Tammy: “Oh, well that’s all right then.”
Therapist: “From recollections like these, you have learned certain attitudes towards happiness that may haunt you forever. As the prisoner of these unconscious attitudes, you can never be as happy as you might otherwise be.”
Tammy: “What did this it teach me?”
Therapist: “First, you may have learned that for you, happiness is only temporary, and it ends in disaster.”
Tammy: “Isn’t happiness only temporary?”
Therapist: “No. It is a mistake to put such a generalized, temporal limitation on happiness. Happiness is not temporary. Happiness isn’t permanent, either. Happiness is happiness, and when it ends, we go on to something else. We cannot predict that it will end in disaster. We are not fortune tellers.”
Tammy: “What is so wrong with believing that happiness is only temporary and it ends in disaster?”
Therapist: “This particular conviction has many malignant, secondary derivatives. For instance,
a) It means that you can’t enjoy your happiness. It’s contaminated by the expectation of certain grief sooner or later. A life without the ability to enjoy happiness in the moment is not worth living. People become depressed. Some of them choose to stop living. It means happiness is associated with impending disaster. On this basis, it is logical to prefer being miserable, because misery, at least, does not end in disaster. Misery is safer. We don’t enjoy misery; it is just that predictable misery is preferable to unpredictable disaster.
b) When you are ‘happy,’ you may tend to bring about the end of your happiness yourself in order to lessen the ‘disaster’ that you ‘know’ is coming: Like taking out a sliver, you have the feeling that it will hurt less if you do it yourself!
c) People who expect disaster often cannot stand the suspense of waiting for the axe to fall. So they bring the disaster down upon themselves sooner in order to get it over with!
d) People may come to conclude that the ‘reason’ that happiness always seems to end so badly is that they don’t ‘deserve’ to be happy. When this happened to you, you felt deprived, which has a ‘punished’ quality. You felt guilty but you couldn’t find out what crime you were guilty of. To a child, guilty means bad, worthless, therefore undeserving of anything positive from life.
e) You have been carrying out this sentence ever since. The individual may conclude that, since happiness ‘doesn’t pay,’ he can only get a payoff through suffering,”
Tammy: “I remember that the only time my mother paid attention to me was the time I caught my finger in the screen door.”
Therapist: “That recollection may have instilled the attitude that ‘suffering pays, happiness does not.’”
Tammy: “Well, doesn’t suffering pay?” If something bad happens, shouldn’t we look forward to someone making it up to us?”
Therapist: “That is how you remember it from childhood, but life is not like that. Some people have carried into adulthood the mistaken expectation that their losses, setbacks and disappointments are not their fault, and that it is up to ‘the authorities’ to make the appropriate ‘restitution’ for their ‘pain and suffering’.”
Tammy: “That seems fair.”
Therapist: “But it isn’t. ‘Fairness’ has nothing to do with this carryover expectation from childhood. People with these attitudes have their own self-serving definition of ‘fairness’ and they protest when they don’t get what they have come to expect from life. For example, some people seem to make a career out of suffering. They file law suits at the drop of a hat, or they lose jobs, get divorced, and break their legs falling downstairs. They milk these disasters for all they are worth.”
Tammy: “Isn’t that a payoff?”
Therapist: “The money, pity, and sympathy that derive from these misfortunes are all negative payoffs, that is, we pay too high a price for them. They cannot make us happy.”
Tammy: “Don’t people know that they are paying a high price for these fictitious payoffs?”
Therapist: “No, they don’t. They aren’t consciously bringing about their own unhappiness. They are merely behaving in accordance with their mistaken convictions about life. These convictions are consistent with their self-contempt.”
Tammy: “It must be very depressing to go through life believing that happiness ends in disaster and that one’s only hope of a payoff is through suffering.”
Therapist: “Yes, it is. And that is one reason so many people are depressed in spite of their success. They have assumed that material, vocational or marital success would make them happy. But, for them, happiness has within it the seeds of its own destruction: it ends in disaster. Even the ‘threat’ of happiness in the future makes them nervous. It is as if they were ‘allergic’ to happiness.”
Tammy: “No wonder we don’t understand why we are depressed. We can’t ever find out all by ourselves. That makes our frustration worse.”
Therapist: “Yes, it does. We become depressed about being depressed. We blame ourselves for our failure to pull ourselves out of it. For example, when our suffering fails to pay off as we unconsciously expected it to, we are angry at life for not fulfilling our expectations. This unconscious, impotent resentment compounds our overall feelings of depression, powerlessness, anxiety and worthlessness.”
Read Full Post | Make a Comment ( None so far )Anger Questions 3
These are some of the questions that we hear at and some of the answers we give.
23. My son has an attitude. What is an attitude, where does it come from and how do we get rid of it?
An attitude is a predisposition to behave in a certain way. We acquire our attitudes early in life and carry them forward. We can change our child’s attitudes by setting an example of the attitudes we want him to follow. If we don’t set it, he can’t follow it. We can tell him what an attitude is, and that he can choose to replace attitudes that make him unhappy with attitudes that will work better for him. For example, he can replace “I feel unloved when I don’t get my way,” with “I am a worthwhile human being whether I get my way or not. It’s only a preference. It is not a reflection on my worth as a person.” That attitude is consistent with self-respect.
24. What does ‘should’ mean?
Should is not a commandment from God. It is merely a preference. Some preferences are stronger than others. Some have negative consequences. We must use our judgment to tell us which preferences are appropriate to the reality situation and which are not. If we act out of inappropriate attitudes, we will face the consequences. It’s our choice.
25. Why shouldn’t we be proud of what we do?
We should be, provided we know the difference between legitimate pride in our positive accomplishment and vanity, or the sin of pride. The wrong kind of pride is a self-indulgent overcompensation for our feelings of inferiority. It will set us up for a fall.
26. What is the difference between intelligence and wisdom?
Intelligence is the capacity to acquire wisdom. Self-respecting people use their intelligence productively. They learn from experience. They acquire wisdom. Unself-respecting people have contempt for knowledge and wisdom from the past. They imagine that they live in the moment. They are not living; they are merely existing.
27. Why do people use their intelligence for evil purposes?
Because their intelligence exists in a context of self-contempt. Their negative behavior arises out of mistaken attitudes that are consistent with their self-contempt.
28. What is courage?
Courage is the willingness to take a risk.
29. Where does courage come from?
For discouraged people, courage never comes from anywhere. For self-respecting, encouraged people, the courage to take appropriate risks is there most of the time.
30. What’s wrong with being a Champion of the Underdog?
It implies that we know what’s best for people better than they know themselves. It is a good intention arising out of sentimental attitudes, rather than considered judgment. It is self-serving and usually counter-productive, sometimes on a grand scale. It often takes the form of rescuing an individual from the consequences of his own foolishness. Then, the individual does not learn from his negative experience. He is doomed to repeat his mistakes. He comes to expect to be rescued. He complains when rescue is not forthcoming.
31. What is cynicism?
It is failed idealism that has not yet fermented into discouragement.
32. Why do some people want their way so much?
Because they have come to define their worth as persons in terms of getting their way. As children, getting their way proved they were lovable. When they don’t get their way, they feel unloved and unlovable. Unlovable people can be abandoned at any time! Abandoned people can cease to exist! Getting their way becomes, in their minds, a matter of life and death! This threat of annihilation is very scary. It is painful. It makes them very angry. They want the object of their desire, not for itself, but to relieve the pain of their existence which arises out of their mistaken attitudes towards themselves and towards life. Since nothing in their makeup has changed, they will want their way again in the very near future.
Read Full Post | Make a Comment ( None so far )Mid-life Crisis
Is my husband having a mid-life crisis is a question I get asked pretty regularly by women. Here’s one woman’s story of trying to understand what happened to the man she thought she was married to.
It’s been 7 months since Derek told Lauren he wanted a divorce and moved out. For Lauren, it came out of nowhere; for Derek, he had been contemplating what to do about his unhappiness for months, probably years.
Lauren came to our women’s counseling to get help in how to respond to this ‘new’ Derek and make sense of what’s happened to her shattered life. I also meet with her and Derek for divorce counseling to mediate their divorce.
Occasionally Lauren sees glimpses of ‘old’ Derek she thought was her husband. Like when he calls out of the blue and offers to help with something. But most of the time she deals with ‘new’ Derek who takes things from the house without telling her, or makes a withdrawal from the ATM without talking to her first and overdraws their joint bank account.
As she’s tried to make sense of ‘new’ Derek and his erratic behavior, she’s been asking herself, and me, is he having a mid-life crisis? Is he having an affair? Is he depressed?
The answer is potentially yes to all of those questions – although which have occurred, in what order, and have led to his behavior is still unclear.
Here are some mid-life crisis warning signs we can see in Derek that have helped Lauren see that, yes, he probably is, and has been, having a midlife crisis:
- Distant and disconnected. Derek had been this way for the past year, and Lauren had noticed it, but she thought it was just due to all the pressures at work.
- Lack of real communication. Lauren has come to realize that what she thought was good communication with her husband wasn’t that deep and didn’t let her know what was really going on inside Derek.
- Talk about big changes (jobs, new hobbies, large purchases). Derek has been doing these things for several years. Often these are a sign of internal unhappiness.
- Sudden lifestyle changes. Unfortunately, it took Lauren almost 3 months after Derek moved out to seek out professional help by coming to women’s counseling.
Whether or not Derek is having a mid-life crisis isn’t as important as just recognizing the midlife crisis warning signs of a problem that’s going to explode the way it did for Lauren. If she or Derek had responded to these signs sooner, it’s possible that much of the pain they’re now suffering could have been prevented.
Since the separation Derek has admitted he’s seeing another woman. Even though Derek insists it started after he moved out, Lauren’s uncertain if that’s really true. Derek’s now planning to change jobs and has also gone back to school.
Lauren has asked Derek that if changing jobs or going to school will make him happy, why he didn’t do them before he left. Derek hasn’t been able to answer her. In the next article we’ll explore the characteristics of men who can have a mid-life crisis and why Derek didn’t make these changes sooner. Lauren will also share things about Derek that she now sees, but didn’t before, that help her understand more of why he’s done what he’s done.
Read Full Post | Make a Comment ( None so far )How long does grief last?
Q. I lost my brother several months ago, and there are days when I still feel overpowered by sadness. Is it normal to grieve this long?
A. I’m sorry to learn of your loss. The brief answer to your question is that everyone grieves differently. Rarely does grief have a clear beginning, middle, and end, like hiking up a mountain and back down along a defined trail. And popular culture promotes the misconception that there is an orderly progression of emotions that will lead to “closure.” This is also probably wrong for most people.
The truth is that grief doesn’t neatly conclude at the six-month or one-year mark. Depending on the strength of the bond that was broken, grief can be lifelong. Parents whose children die often say they never get over the loss. The loss of a spouse is also devastating. But the loss of other loved ones, including a sibling, can take a long time to get over as well.
Although it may persist, grief does usually soften and change over time. How this goes will be influenced by your emotional style, the nature of your support system, and the culture you are a part of.
The loss of a sibling is not talked or written about as much as other losses, but it has a unique quality. Siblings share an upbringing and history. The more integral someone was to your life, the more opportunities there are for happy and sad reminders that underscore the massive loss. Alongside warm or warring memories, you may always feel the absence. Sadness, abandonment, disorientation, and even anger may arise around birthdays, weddings, the anniversary of the death, and holidays or other occasions you might have shared. A familiar scent, song, or likeness can trigger feelings of grief, too. All of this is entirely normal. And siblings are contemporaries, part of your generation, which may raise concerns about your own mortality.
Usually the raw, all-consuming shock of early grief will ebb slowly within weeks or months. Gradually, at their own pace, most people do find themselves adjusting to the loss and slipping back into the routines of daily life.
So give yourself time. In the midst of loss, many people find opportunities for growth. In many cases, people emerge from the depths of their grief with greater confidence in their ability to manage life’s sorrows and difficulties.
Holidays, anniversaries, birthdays, and events that would otherwise be joyful can be especially hard on people who are grieving. If the grief is fresh, holiday cheer can seem like an affront. Celebrations may underscore how alone people feel. Likewise, it’s hard to accept that others may not mark the days that you do — the first time you met your loved one, a birthday, or the anniversary of an illness or death. The following strategies may help people ease pain around holidays and other difficult times.
Start a new tradition. People can remember the deceased on special occasions by placing a lighted candle on the table, leaving an empty chair, or saying a few words of remembrance. If the person who died always played a special role in festivities, another family member may be able to carry on the tradition.
Change the celebration. Sometimes people opt for a simpler celebration. They go out to dinner instead of planning an elaborate meal at home. Or they schedule a trip or an outing with family members or friends.
Ask for advice. It may help some people to talk to others who have lost people close to them to find out how they have managed holidays.
Express personal needs. People who are grieving may find it hard to participate in all the festivities or may need to let go of overwhelming or unsatisfying traditions. It’s all right to tell people you’re just not up to it right now or to change plans at the last minute. Don’t feel pressured to do more than you want to do. Leave an event when you wish to go.
Plan to mark the day. Others find it helpful to make special plans for an anniversary, birthday, or other special day. This can include walking through a nature preserve, visiting the cemetery or the place where ashes were scattered, or enjoying an activity the deceased would also have loved. Think of a ritual to help you connect. Light a candle and say a prayer. Release balloons. Carry a memento from your loved one.
Help someone else. It may also help to volunteer through a charitable or religious organization. Make a donation to a favorite cause in memory of the person who died.
Read Full Post | Make a Comment ( 1 so far )Intense Grief
Grief can be so intense and long-lasting that it sometimes resembles a psychiatric disorder. As many as 50% of widows and widowers, for example, develop symptoms typical of major depression in the first few months after a spouse dies. They may also have hallucinatory experiences — imagining that the dead are still alive, feeling their presence, hearing them call out.
These symptoms, upsetting as they may be, are usually normal responses to a profound loss. In most people, the symptoms ease over time. One review noted that 15% of people who are grieving are depressed one year after a loss. By two years, the proportion falls to 7%.
But if the symptoms are intense enough to interfere with relationships, work, school, and other areas of life, the problem may be complicated grief — a term that describes a grieving process that is particularly difficult. Also known as protracted or chronic grief, it combines features of depression and post-traumatic stress disorder (PTSD) — which is why some professionals call it traumatic grief. One study estimated that nearly 5% of all older adults were experiencing complicated grief.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) does not describe complicated grief as a psychiatric disorder, but a group of experts are reviewing a proposal to include this condition in the manual’s next edition.
Risk factors
Complicated grief is more likely to occur after a death that is traumatic — premature, violent, or unexpected. But in some people, even normal bereavement can produce complicated grief.
Whether that happens depends on how a person copes, not just with trauma, but with loss. Everyone experiences unfulfilled hopes, broken romances, illness, and injury. For anyone who could not respond to earlier losses without losing emotional equilibrium, complicated grief becomes a greater danger. So a person with a history of depression, anxiety disorders, or a personality disorder is more likely to suffer complicated grief after bereavement, as well as PTSD if the loss was traumatic.
Treatment options
While it is hardly necessary for everyone who is grieving to seek professional help, people who develop complicated grief may need treatment. Other reasons to seek professional help include drug abuse, increased use of alcohol or tobacco, gaining or losing a significant amount of weight, experiencing uncontrollable anxiety, and failing to feel somewhat better after a year has passed.
Psychotherapy can help people to identify incompletely mourned losses of the past and draw connections to the present loss. Several options exist, and a review concluded that all were effective — to varying degrees — at improving symptoms and diminishing the level of complicated grief.
Interpersonal therapy, for example, explores the patient’s relationship with the deceased person, emphasizing disputes, role transitions, and grief. Cognitive behavioral therapy can provide people with tools to work through aspects of grief and help people learn to think differently about the loss.
A hybrid therapy known as complicated grief treatment (also called traumatic grief therapy) includes both interpersonal and cognitive behavioral approaches to mitigate the effects of trauma and relieve stress. The therapist provides information about the grieving process, along with an explanation of a “dual process” in which patients concentrate on both mourning (adjusting to the loss) and improved functioning (restoring a satisfying life).
The therapy includes exercises that push mourners to confront situations and people they have been avoiding. They are also asked to retell the story of the death, to relate memories of the deceased, and to hold imaginary conversations with him or her. (The therapist asks the bereaved to take both sides in these conversations.) To help restore some joy to their lives, mourners are encouraged to think about what they would want for themselves if their grief were not so overpowering.
This technique can be overly taxing, causing some patients to leave prematurely. But for those who can tolerate it, it may have advantages. In one study, 51% of people who underwent complicated grief treatment improved afterward, compared with 28% for standard interpersonal therapy. The results also showed that complicated grief treatment was especially effective for people who were mourning a violent death.
These successes are promising, but it’s not clear that the treatment would yield the same results if performed by the average clinician rather than inside a specialized research setting. Nonetheless, the research suggests that there are a variety of helpful options.
Read Full Post | Make a Comment ( None so far )changing the grieving process
Dr. Elisabeth Kübler-Ross developed a frequently cited model of bereavement, the “stages of grief,” in her landmark book On Death and Dying. She described a linear five-step process — consisting of denial, anger, bargaining, depression, and acceptance — as terminally ill patients became aware of impending death. Dr. Kübler-Ross’ work helped legitimize the wide variety of emotions in people who are dying. The five-stage theory was later altered and adapted to cover the reaction to other losses, such as divorce or the death of a loved one.
Today, however, many experts no longer embrace the concept of sequential stages of grief and have proposed a number of alternatives.
For example, Dr. Colin Murray Parkes, who has written extensively on bereavement, proposed that people who have experienced a loss undergo several prolonged and overlapping phases — numb disbelief, yearning for the deceased, disorganization and despair, and finally reorganization — during which they carve out a new life. The road to this new life may be long. According to Dr. Parkes, people must go through a painful period of searching for what has been lost before they can release their attachment to the person who died and move forward. When enmeshed in disorganization and despair, people find themselves repeatedly going over the events preceding the death as if to set them right.
Dr. J. William Worden suggested a model of grieving that includes certain tasks. The first three tasks are to accept the loss, to experience the resulting pain, and to put the loss in some perspective and adjust to a changed world without the person who has died. The fourth and final task is for people to alter ties with the deceased enough that they are able to invest their love and energy in others. People may shuttle back and forth among these tasks. However, Dr. Worden suggests that leaving some of the tasks undone is like healing only partially from a wound.
Some experts combine elements of several grief models. Dr. Margaret Stroebe and Dr. Henk Schut note that early in grieving, the emphasis is on “loss-oriented coping,” such as focusing on the person who died, the circumstances of the death, and painful feelings like yearning and despair. Later, people invest more in “restoration-oriented coping,” focusing on managing practical issues that arise, such as loneliness or challenging new circumstances. Rather than grieving continually, people seek occasional periods of respite. Time away from grief might take the form of a weekend with friends or a day of social activities.
A new way of grieving
Most recently, two psychologists make the case that advances in diagnosis and treatment — which have enabled people to live longer with life-threatening illnesses, such as cancers and heart disease — have significantly changed the grieving process.
In their book Saying Goodbye: How Families Can Find Renewal Through Loss, Dr. Barbara Okun and Dr. Joseph Nowinski identify a pattern of grief commonly encountered by families who face the loss of a loved one to protracted illness. The book includes the following stages, which begin long before a person actually dies.
Crisis. Family life is disrupted by the diagnosis. People are upset, saddened, and anxious. Other, unexpected feelings — resentment, anger, or guilt — may also emerge but often go unexpressed in the interest of rallying around the patient.
Unity. The patient’s needs are paramount. Activities include managing medical treatment, lining up social and support services, gathering insurance and other information, and attending to legal matters such as wills.
Upheaval. The patient may be in remission or doing relatively well. But for others, unity and patience may have worn thin as protracted illness buffets their lives, relationships, and routines. At this stage, it’s important — though often difficult — for family members to communicate honestly about the upheaval they’re experiencing.
Resolution. As the patient’s health deteriorates, everyone comes to accept that the end is near. Decisions about hospice and other end-of-life matters have been made. Now is the chance for resolving old issues, healing wounds, and addressing resentments and jealousies — factors that can undermine family members’ ability to come together and support one another.
Renewal. This final stage begins with the funeral and continues for a long time, as individuals adjust to the loss and to their changed roles.
Navigating the process
Every person — and every family — grieves differently. Some people may feel anxious, or others worry on their behalf, if they don’t follow a particular path. However, grief is not a tidy, orderly process, and there is no single “right” way to grieve. It’s normal for emotions to collide and overlap. Each person grieves uniquely, taking as much time as necessary, finding a meaningful way to come to terms with a loss.
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