Psychlinks Psychology Self-Help & Mental Health Support Forum - Therapy & Therapists

Small steps are the only way to tackle problems that overwhelm us

David Baxter — Wed, 08 Sep 2010 04:20:38 GMT

Small steps are often the only way to start tackling problems that nearly overwhelm us
by Coert Visser, Solution Focused Change
September 7, 2010

Solution-focused practitioners generally focus on one small step forward instead of a big leap. Intuitively you may think that taking small steps may only be useful for situation in which you have small problems but this is not the case. On the contrary, when problems are large, taking small steps may be even more powerful. In fact, we believe they are often the only way to start tackling problems that nearly overwhelm us. Why is this so? Here are four reasons:

Low threshold: when the step forward is as small as possible, the requirement of energy, motivation, and trust is minimal. The threshold is so low that the willingness to take the step will be maximal. The low threshold stimulates a high probability of change.
Low risk: when taking a big leap you may achieve a lot at once, providing the direction chosen turns out to be precisely right and providing, figuratively speaking, the landing turns out to be soft. But it the direction was not accurate, you may end up way off-track. And if the landing was hard you may break your ankle. Small steps don't have these disadvantages. Little precise knowledge and certainty is needed about the effectiveness of the step. The step can be seen as an experiment. If does not work not much will be lost. The change of damage and wasted energy will be minimal. In the unpredictability that characterizes many work situations this is a great advantage. The one small step approach makes it easy to respond flexibly to developments.
Positive message: saying that only drastic change will be sufficient can be rather demotivating. People may feel unacknowledged and unappreciated for their previous efforts ("if such big change is necessary, apparently, we have done everything wrong until now"). Aiming for a small step, however, implies something positive, namely that there is already a lot functioning well as it is. Changing no more than strictly necessary is really like saying: “There is already a lot going well and we do not want to risk of losing that by changing too much. It will not be necessary to drastically change our course. A subtle change will do.” A positive message like that reflects trust and works motivating.
Positive snowball effects: the one small step approach has a surprising side advantage: it may lead to a snowball effect. Edwin Olson and Glenda Eoyang, authors of Facilitating Organizational Change: Lessons from Complexity Science (2001) describe such a process as follows: “A small change in one part ripples through the organization and can have tremendous unintended consequences far from the site of the intervention”. Why is that so? The reason is that in a complex system, everything is linked to everything. Maybe you know the so-called butterfly effect from chaos theory? Scientist Edward Lorenz argued that a butterfly flapping its wings in Brazil might cause a tornado in Texas. Likewise, taking one step forward as an individual can eventually lead to system wide progress. The behavior of one person will affect the behavior of another person, which will affect yet another person, and so on. In this way, small-scale actions may lead to large-scale change.

A nice example of the amazing power of small steps is the case of Pat Riley. In the nineteen eighties, Pat Riley coached the Los Angeles Lakers. The Lakers had just lost the MBA championship final to the Boston Celtics. There was some panic within the Lakers group. They wondered how they could ever win the Championship against the seemingly unbeatable Celtics. They would have to get so much better and they chance to that seemed slim. But Riley, a great strategist, knew how to do this. He did not buy expensive new players. He did not double the amount of training hours and he did not put extra strict demands on his players. He only challenged them to improve every single aspect of their game with a mere 1%. The result was surprising. The Lakers won the championship. Not only in that year but also in the following year. Riley proved that many small steps, steps which may seem insignificant, can lead to great results.

My invitation to you is: think of one thing you'd like to improve in your life/in your work and take a few minutes to write down the smallest step forward you can think of. After you've done this take that small step. See what happens next

Therapy is painful - not that I was expecting anything different I guess!

AmZ — Tue, 07 Sep 2010 09:49:48 GMT

Hi all,

Hope everyone is well.

I went to my second (double) therapy session last night.

My therapist is still great and spent maybe a third of the time explaining things to me about OCD and how the mind works including the 'mind hiccups' with OCD and anxiety.

We then went on to talk more about my background and the causes for my anxiety and obsessive thoughts I have about mainly things from my past (only two things, and many more to go!). On one hand, it was so good to let it all out and for the first time in my life, to tell someone my deepest thoughts and go over details of the events that happened, of course, on the other hand, very painful.

All along there was nobody there to talk to about the events and how I was feeling, as they were always involved themselves (like my sister in the break-up of our parents or my father in sudden loss of my grandmother/his mother)... Just came to a very painful realization in therapy that I had sudden and unexpected losses of people who were very close to me (through death and abandonment), which are difficult to deal with just by themselves. But also within this, there was nobody there to support me in all of these events and that's why I am haunted by constant thoughts about what happened and still, 10 years later having all of these feelings and emotions that haven't been let out like anger, sadness, etc. I have been extremely lonely in my thoughts and various situations since I was 15 basically which has led up to the present, in having lost all the people who are close to me (asides from 2 people that I am semi-close to, but still not enough). The therapist rightly said that I missed out on a hell of a lot of support and care as a teenager and in the last 10 years and always thought of others and never thought about my needs and feelings. I guess, now is the time to do that :o

I'm really hurting right now and just feel numb.

I know that in the end, once I process these thoughts in therapy and go over them, I will hurt less and 'get over' my past, but it's so extremely painful to start with, ouch.

I don't have the regular anxiety today and no OCD, just like I said, numbness and having heart palpitations now and again which I haven't had at all in the past. Like my heart skipping a beat then a big beat... I was wondering why I am having these and what the difference is?

Thanks for listening.

Magnetic Brain Stimulation Gaining Favor as Treatment for Depression: Is it safe?

David Baxter — Tue, 31 Aug 2010 20:16:03 GMT

Attractive Therapy: Magnetic Brain Stimulation Gaining Favor as Treatment for Depression
By Jim Nash, Scientific American
August 30, 2010

More doctors are turning to repetitive transcranial magnetic stimulation (rTMS) of their patient's brains, but fears of possible seizures may be limiting its growth as a therapeutic tool

Treatment of severe depression with magnetic stimulation is moving beyond large mental health centers and into private practices nationwide, following more than two decades of research on the treatment. Yet even as concern about its efficacy fades, one potential side effect�seizures�continues to shadow the technology.

Called repetitive transcranial magnetic stimulation (rTMS), the noninvasive technique uses electromagnets to create localized electrical currents in the brain. The gentle jolts activate certain neurons, reducing symptoms in some patients. Eight psychiatrists contacted for this article, all of whom use rTMS to treat depression, say it is the most significant development in the field since the advent of antidepressant medications. The prevailing theory is that people with depression do not produce enough of certain neurotransmitters, which include serotonin and dopamine. Electricity (administered in combination with antidepressants) stimulates production of those neurotransmitters.

Scope of the problem
A National Institute of Mental Health (NIMH) study released this spring shows that 14 percent of patients with drug-resistant major depressive disorder experience a remission of symptoms after rTMS treatment compared with a control group, which reported a 5 percent rate of remission. Physicians and researchers say those results are similar to the success rate of antidepressants. No notable side effects occurred during the study, according to its authors, who include Mark George, an early rTMS researcher and a professor of psychiatry, radiology and neurosciences at the Medical University of South Carolina in Charleston. They have suggested that higher levels of electrical stimulation might attain better results.

At the heart of this interest in rTMS treatment is the only such device cleared by the U.S. Food and Drug Administration (FDA). In October 2008 the government specified that Neuronetics, Inc.'s NeuroStar could be used to treat major depressive disorder that is resistant to at least one antidepressant medication. Since then, about 200 centers and clinics in the U.S. have purchased the $60,000 system, which resembles a contemporary dentist's chair with an electronics console.

The treatment joins talk, pharmaceutical and electroconvulsive therapies (the latter of which rTMS is an offshoot) as the only known methods of alleviating the debilitating symptoms of depression. Nearly 7 percent of U.S. adults, or 14.8 million people (predominantly women), are afflicted by major depressive disorder each year, according to the NIMH. In fact, the NIMH says the disorder is the leading cause of disability in the U.S. for people aged 15 to 44. George says that about half of all patients suffering from serious depression resist at least one antidepressant.

Changing brain chemistry
Unlike with electroconvulsive, or electroshock, therapy, where patients must be unconscious and administered muscle relaxants in order to prevent seizures, patients receiving rTMS (which involves trains of pulses during each session, hence the "repetitive" modifier) remain conscious and seated in outpatient settings. Highly focused magnetic pulses of up to 1.5 teslas induce an electrical current two to three centimeters deep in the left prefrontal section of the cerebral cortex. That region, which acts as an emotion modulator, appears to be underproducing neurotransmitters in depression sufferers. The rTMS pulses directly stimulate an area about the size of a quarter, although scientists are examining whether they affect other parts of the brain, too.

As with antidepressants, the electricity likely is changing the brain's chemistry, says rTMS pioneer Eric Wassermann, chief of the Brain Stimulation Unit at the National Institute of Neurological Disorders and Stroke in Bethesda, Md. He was among the first U.S. researchers to investigate rTMS as a way to alter mood.

Treatments typically occur five days a week for four to six weeks. FDA guidelines for first-time NeuroStar treatments call for 3,000 magnetic pulses delivered over 37.5 minutes (a rate considered low-frequency) by a figure 8�shaped magnetic coil held to the patient's scalp.

Worries over seizures
The most common side effects of rTMS include transient headache, scalp discomfort and the sensation that something is tapping on the patient's head in time with pulses during sessions. (In contrast, electroshock, which even Neuronetics says is more effective than rTMS, could cause memory problems and diminished mental acuity.)

The side effect that draws the most concern is rare but serious: grand mal seizures. They trigger loss of consciousness and violent muscle contractions. "Seizures do occur, and they should not be brushed off," George says. The rate of seizures is on par with medication therapy, but hard data is difficult to find, he says, adding that no organization tallies these events globally. A show-of-hands survey during an rTMS conference in Italy this year indicated that some are underreporting seizures, according to George, a vocal proponent of rTMS. Still, he estimates that there have been fewer than 50 rTMS-initiated seizures worldwide since the mid-1980s.

Risks can be reduced by carefully vetting rTMS candidates according to the FDA-approved guidelines, says Jon Nilsen, who operates a NeuroStar at the McGrath Clinic in Orland Park, Ill. Nilsen also acknowledges that patients on antidepressants, which themselves carry a risk of seizure, as well as those with a history of seizures are more likely to have an rTMS-related event.

Wassermann says that overly cautious doctors and entrepreneurs are holding back the development of rTMS for depression. He was among the researchers who created laboratory guidelines in 1998 for applying rTMS�guidelines that he says were "cautious" in regard to minimizing the chance of seizures. Those protocols, he says have gone largely unexamined.

"It's asking a lot of a box that you plug into the wall to change your brain and your life" without hobbling its further development with timidity, Wassermann says.

Insuring treatment
It also asks a lot of people's pocketbooks. The McGrath Clinic charges a discounted rate of $265 per single-day session without insurance, Nilsen says, but it charges $300 to $350 per session if health insurance firms reimburse for treatments. Because insurance coverage for rTMS is spotty, some psychiatrists say they sometimes treat severely impacted patients for free.

As of August 3 Aetna health insurance refused to reimburse for rTMS, which it considers "experimental and investigational". Michigan's Priority Health Insurance Co. covers the initial six-week treatment. Priority, however, does not cover "maintenance" sessions used to prolong remissions and treat relapses, saying the efficacy of these regimens has not been proved.

Psychiatrist Denise Lin says the benefits she has seen in some of her severely depressed patients outweigh the risk of seizure. Lin, founder of Advanced Psychiatric Care of Santa Barbara, Calif., bought a NeuroStar in January.

All five people she has treated with rTMS have reported at least some improvement, Lin says. One patient had been assessed before trying rTMS as very severely depressed based on the widely used Hamilton Depression Rating Scale (HAM-D), a series of multiple-choice questionnaires that clinicians use to rate depression severity. After a six-week course the patient was judged to be in remission and rated "normal" on the HAM-D scale, Lin says.

How do I find a good therapist?

David Baxter — Tue, 31 Aug 2010 19:25:12 GMT

How do I find a good therapist?
by Dr.Jill Holm-Denoma for Psychotherapy Brown Bag
August 31, 2010

Whether I am asked this question by students in my Clinical Psychology course at the University of Denver, potential clients who have heard about my private practice, or friends who are having a tough time, I almost always struggle to offer an articulate response. I completed a B.A. in psychology, a M.S. and Ph.D. in Clinical Psychology, teach regularly about the benefits of using empirically-supported assessments and treatments, and offer what I think is “good” therapy, so if I have trouble describing what someone should look for when trying to find a “good” therapist, it must be almost impossible for the average therapy consumer to know how to proceed! In fact, when recently trying to locate a “good” therapist for a loved one in a geographic location with which I was unfamiliar, I was left disoriented and frustrated with my online and phone book searches. What differentiates a “good” therapist from a not-so-good or even average therapist? How can a given client be sure that s/he is selecting a “good” therapist with whom to work? After having given these questions much thought, here’s what I’ve come up with:

1. Therapy clients should familiarize themselves with empirically-supported treatments (ESTs): It might not be ideal to expect the average therapy consumer to educate him/herself about ESTs , but if that consumer wants to be sure that a potential therapist will offer the front-line treatment for a given disorder, s/he would benefit from knowing what the front-line treatment is! Thankfully, it is relatively easy for clients to learn about ESTs by visiting Society of Clinical Psychology. At this website, a therapy consumer can search by disorder (if s/he already knows or suspects a particular diagnosis) or by treatment type.

Scenario A: A therapy client knows his/her diagnosis. In this scenario, the consumer can search the website above to see which ESTs exist for his/her disorder. Once a therapy client has a good sense of what ESTs are available for the problems s/he is experiencing, s/he can seek out a therapist who offers those treatments.
Scenario B: A therapy client does not know his/her diagnosis. In this scenario, the client may be able to develop a sense of his/her likely diagnosis by talking to his/her physician, taking online screening tests, and/or reviewing symptoms of many common disorders at a high-quality website like the one maintained by the National Alliance on Mental Illness (NAMI; NAMI | By Illness). Alternatively, the client may request a one-time diagnostic assessment with a potential therapist. I am NOT suggesting that clients attempt to self-diagnose, as that should be left to a professional; however, I am suggesting that if a client has a sense of what types of symptoms or syndromes are affecting him/her, s/he will be more easily able to identify the types of ESTs that might be most helpful. Once s/he knows a diagnosis, s/he can search the website above for appropriate ESTs.

2. Therapy clients should get therapist recommendations from professional organization listings or research-based psychology programs: Many professional organizations, such as the Association for Behavioral and Cognitive Therapies, keep online directories of active members who are therapists (ABCT Association for Behavioral and Cognitive Therapies - Cognitive Behavioral Therapy). It is not guaranteed that each therapist listed in the directory practices ESTs, but by virtue of having taken the time to register with an organization aimed at dispersing ESTs, chances are relatively high that the therapists in the directory have some awareness of and training in such therapies. Likewise, if an APA-approved clinical or counseling psychology program exists in one’s geographic area, a therapy client could find out whether the program offers therapy through an in-house training clinic (as these usually offer ESTs and state-of-the-art training to therapists). If an in-house training clinic is not available, the Director of Clinical Training for these programs should be able to recommend local providers who specialize in ESTs.

3. Therapy clients should request a brief interview with potential therapists: Based on the results of the procedure described in step 1 (above), a therapy consumer could contact a potential therapist and ask a few questions. Specifically, s/he might ask the types of questions listed below and expect answers similar to those given in parentheses from a “good” therapist:

How do you choose the treatment you offer each client? (I use ESTs for each disorder.)
If you were to work with a client who met criteria for XXX disorder (e.g., Major Depression), which treatment would you use and why? (I would suggest Cognitive-Behavioral Therapy and a psychiatry consult, because CBT is an EST for depression, and because research suggests that the combination of CBT + an anti-depressant is the most effective treatment for depression.)
Do you use a treatment manual, and if so, which one(s)? (Yes, I use a manually-based CBT protocol for depression that is described in Treatment Plans and Interventions for Depression and Anxiety Disorders by Robert Leahy & Stephen Holland.)
How have you been trained in this therapy? (My graduate program trained me in ESTs, I completed a pre-doctoral internship during which I conducted CBT with depressed patients regularly, and I attended a CBT workshop last year.)
How do you know that your clients are getting better? (I give routine assessments in which I evaluate the presence and intensity of symptoms. If therapy is working, symptoms should decrease over time. Research indicates that half of clients see meaningful symptom reduction in 8 sessions and that 74% of clients do so after 26 sessions (Howard et al., 1986).)

Basically, a “good” therapist will quickly convince you that s/he is aware of ESTs, uses them regularly, and has the appropriate training needed to conduct them. S/he will also indicate that s/he will conduct an objective assessment regularly to track treatment progress. This type of information may also be available on the therapist’s website.

4. A therapy client should choose a therapist with whom s/he feels rapport: Studies have provided some support for the idea that common factors such as the therapeutic alliance are related to therapeutic outcome. Moreover, if a client does not feel comfortable with his/her therapist, s/he will likely not want to return to therapy at all. Therefore, it is important for clients to find a therapist with whom they feel good about working. However, I want to be clear that having a good working relationship with a therapist is a necessary but not sufficient criterion for a successful therapeutic outcome link. Said differently, without a good therapeutic alliance, therapy is not likely to be rewarding for the client…but having a good therapeutic alliance is not enough! Clients should strive to work with a therapist with whom they feel comfortable *AND* who provides ESTs. It does not have to be one thing or the other.

It is important to note that most people who are seeking out therapy are acutely distressed, and their resources for conducting a thorough search for a “good” therapist are likely limited. In such cases, clients may want to seek out the help of a loved one when doing some of the steps outlined above. Although doing this type of investigative work on the front-end will take precious time and energy, it will likely result in a better, more efficient therapeutic outcome.

Jill Holm-Denoma is an assistant professor in the psychology department at the University of Denver

[Video] Learning to Dance in the Rain

David Baxter — Thu, 26 Aug 2010 14:06:07 GMT