Shoulds

I feel like I talk very often about working in addictions on here, which I worry might alienate some people because before I educated myself about addictions, I really thought it was pretty black and white. Either you’re addicted or your not. Either you’re mentally healthy or your addicted.

As I’ve come to learn through my internship, addiction is just one extreme symptom of mental health. It’s like the common cold. Some of us get a cough and a few sneezes. Some of us turn the cold into the flu. If left untreated, our mental problems fester and turn into things like domestic violence, addiction, and other self-destructive behaviors.

The neat thing (for me anyway) is that because I am a cognitive-behavioral therapist, I always trace back most of this stuff to the way the client thinks about something. A big piece of this is really listening to the client and hearing patterns in the way they speak, the words they choose, and specifically the way they speak about themselves. It’s a wonderful way to easily show the client what their self-talk probably sounds like. If you beat yourself when you talk about yourself to others, you probably beat yourself up when you have an internal dialogue.

A pattern I began to notice with my clients is this idea of “I should…”. I kept hearing over and over, “I should have told her I loved her,” or “I really should get sober for my kids,” or “I should really know how to follow the rules by now”. Whatever variation, I found myself picking these statements apart for one common thread.

The idea of “should” comes from what we feel others want us to do. When we say we should do something, we’re basically implying that we don’t want to do it. We’re saying that we are doing what others want us to do and what we feel we should want to do.

Think about it. How often do you say the word should with the true and earnest desire to actually follow through with the task?

I should go running.

I should unload the dishwasher.

I should be a better daughter.

I shouldn’t be as angry all the time.

I shouldn’t write blog posts at 11:15 at night…

I pointed this out to one of my clients recently. He was a constant “should” offender in session. Whether he was feeling guilt for something he should  or should not have done in his addiction or something he should do in treatment, it was just a lot of hot air. Should should must to be eliminated from our vocabularies!

I’ve found myself being a Should Offender on some days. We all do it and that’s OK, because we all have unhealthy thinking from time to time. Part of being a healthy person isn’t having everything perfect and sorted into pretty boxes, it’s knowing you have some imperfect stuff you’re knowledgeable about and you’re actively working on. So, I’m working on my shoulds these days. I started with my week off, because I needed to rest. It wasn’t a should anymore and I must acknowledge that in the future.

P.S. ACA Post for the week: A Good Listening To…

Stinking Thinking

So on Wednesday, I was co-facilitating a group and we posed a story to the clients. I won’t bother to tell you the whole thing because it’s really not the point, but the goal of the exercise was to get the clients to think about choice when they are confined to a story that doesn’t present a whole lot of appealing options. It was basically an exercise in the philosophy of independent thinking.

Well, two of the clients keenly realized there was a loophole to the story. After they shared their loophole, I reflected back what they had done as “addictive thinking,” mainly citing the notorious nature of addicts to manipulate a situation to the benefit of themselves and no one else. When I did this, one of the clients basically said, “You labeled my addictive thinking, but how would you know? You’ve never had an addiction, you don’t think like an addict!”

In counseling, especially in addictions, it’s often very important to an addict to have someone who truly understands them. I’ve had clients outright ask me in the first session if I’ve ever used drugs or been addicted. We’re trained to handle the question in a variety of ways, but I tend to approach it depending on the vibe I get from the client. The core issue is that we all want to feel understood, I usually just approach the session from that point of view.

So, I replied back to the client with my most honest answer: “Of course I have addictive thinking! Just because I don’t have an addiction, doesn’t mean I don’t think addictively.”

I went on to explain that we all think in ways that support addiction. It’s often called, “Stinking Thinking” in the addictions treatment world. Basically, it’s the types of thought processes that get us all in trouble and land us in hot water. A lot of variables go into why I haven’t developed an addiction and some have – mainly a fancy combination of nature and nurture – but at the end of the day, I can relate to my clients. I’ve been there.

Then my wheels started spinning and I thought you all might be curious what we deem “addictive thinking” or “stinking thinking” in the field. We give out a packet to all of the clients when they enter treatment and when I read this article, I definitely saw some old thinking patterns – and even ones that boil up now and again – in there. I feel that with knowledge of myself and how I think about my world, I gain a greater ability to influence the outcome. I hope maybe some of what I share helps you influence your outcome.

Lip Service

Lip service is the mouthing of insincere statements. It’s telling other people what they want to hear. it’s superficial compliance – a sham to make ourselves look good.

We all use lip service. We say we’ll go to that friend’s birthday party, when really we know we probably won’t because we have tentative plans with someone we’d rather hang out with. We tell our friends we’ll come visit them when they move, but we never do. We say we’ll call our grandmother because it is the right thing to do, but we just never get around to it. We say things because we want them to be true.

Lip service is the verbal equivalent of wishful thinking. We want it to be true, so we feel if we speak it into existence, it might end up being true. Hopefully we will be a good friend and show up at that birthday party. Hopefully we will take a summer trip to Alaska to see our friends. Hopefully we will call our grandmother when we have some spare time on Sundays.

Grandiosity

Grandiosity is the flip side of low self-esteem. it is characterized by an overinflated sense of self, and those of us who suffer from it possess and embarrassingly unrealistic sense of our importance, talents, and abilities. We behave as if we are immune to the ordinary laws of the universe that govern mere mortals. We think of ourselves as well… different.

Grandiosity is driving drunk/buzzed and thinking we are fine and we aren’t at risk because we’ve never been caught before, we’re great when we drive drunk, our friends do it all the time, et cetera, et cetera. Grandiosity is when we consistently show up late for things and expect people to not be bothered. Grandiosity is thinking that if I tell my partner I’ll go to counseling, the relationship will magically heal itself. Grandiosity was me thinking I could learn to play the drums in a year with all of my other extracurricular commitments. I’m waiting until August to start.

Corner Cutting

Corner cutting is insidious. Our first cheats seem small and innocent, certainly no cause for concern. We always have a good explanation for our deviation. The hallmark of corner cutting is excuse making.

I immediately think of a healthy diet in this situation. When I was doing LiveFit, I wanted to adhere to carb cycling and eating right and watching my calories and blah, blah, blah. I would have a cookie on Friday and tell myself, “No worries! It’s just a cookie! Plus, it was free.” Then on Saturday, I’d have extra sour cream on my Chipotle burrito bowl. Then on Sunday, I would just eat whatever the hell I wanted because, oh well, I had already blown my diet and I’ll just start over on Monday.

Corner cutting is having that one last cigarette. It’s cutting our workout 10 minutes short because we skipped breakfast and we’re good for the day. Corner cutting is saying we were late because of traffic when really we were late because we woke up 15 minutes late and still wanted to do our hair. We’re not sharing the whole picture and “playing the tape though,” which is another term we use when working in addictions. We have to zoom out and see what one cut will do to the whole frame.

We all corner cut every day and that’s OK. Corner cutting is a part of the human condition. The point is that we should be aware of it and we should avoid letting it become an excuse to say, “Oh well!” and just eat the entire wheel of cheese in our refrigerator. Maybe, that’s the difference between my stinking thinking and an addict’s. I have an extra helping of french fries and stop and they eat the whole buffet.

Defiance

The hallmark of defiance is immaturity. In many ways, we are like big babies. We want to be the center of attention and we want to have all of our needs met immediately. We become angry and resentful when people don’t act the way we wish. We start to blame them for all of our problems and we expend an enormous amount of energy trying to get them to change, to act right, to make us happy.

I’m sure most of you can guess that defiance is very common in intimate relationships. We meet our partners and then we decide we don’t like something about them. Once we decide that, we tell them. When they don’t change, we get angry and we think, “Doesn’t this person love me? Don’t they care what I think about them?” and we begin to victimize ourselves. We begin to feel that what we want obviously isn’t important. We do this when we walk into a busy restaurant on a Friday night and get upset that we weren’t seated within 15 minutes. We do this when we expect special privilege because our best friend’s cousin’s ex-fianceé is a bartender and we expect a cheaper drink. We do it all the time.

So yeah, those are the main tenets of “stinking thinking”. We all have thoughts that get a little smelly, our job is to just put them in a bag and make sure they don’t stink too much. Right?

The Mind-Body Connection

I’m going to tell you a secret. I’ve never really mentioned it before because this secret is like a magician’s secret. I always fear that if I tell people this secret, they’ll never go to counseling. They’ll see the secret behind my proverbial rabbit out of a hat and the mystique of why therapy is good for you will be gone and no one will go.

But then I thought about it more and I realized I don’t want to present counseling as some sort of smoke and mirrors experience. I want to be honest and tell people what I know. So this is what I know…

There is no real “secret” behind how my profession works. There are three proven reasons for why counseling is successful:

1. The therapeutic alliance, which is just a fancy term for the relationship between the client and the counselor. It’s that whole “I got you,” thing. You should feel like your counselor gets you.

2. Appropriate therapeutic interventions (e.g. Cognitive Behavioral Therapy would not be appropriate for a toddler).

3. The client’s belief that treatment will be successful and their investment in the treatment process.

That third one is the big one. It’s the one I cannot control as a counselor.  It’s my not-so-secret magic. I can get along with my client, I can learn and know the best ways to approach a client’s presenting problem, but I can’t make a client believe counseling will be successful. Sure, number 1 and 2 do a great job of supporting the outcome of number 3, but it’s not a guarantee. The client has to believe therapy will be successful for them and they have to be willing to actively participate in a therapeutic relationship with me. So, I basically just told you the counseling equivalent of showing you the secret magician door.

So, then I read this article this week that was published in the February 8, 2010 issue of Newsweek entitled “The Depressing News About Antidepressants,” by Sharon Begley.

It instantly made me think of the handful of e-mails I’ve received since I started the blog about my belief in the mind-body connection. I’ve had people with chronic pain, depression, and anxiety reach out and ask me to provide resources or just offer my insight. I’ve always tried my best to be supportive and offer resources, but I’ve felt like I had my eyes downcast, just shuffling my feet around and saying something like, “Yeah, and well, but you know…” but nothing that was really transparent and I ended up feeling like I didn’t communicate my thoughts about my belief in the “mind-body connection as the cornerstone of my professional ideology.” Kind of scary when I can’t explain my beliefs very well. Probably won’t help me later when I start having my own clients, huh?

I’ll try to keep it short, but I’m now ready to explain why I live my life and practice counseling the way I do, with the support of research findings outlined in this article. But first(!), I will give you some background information that I think is relevant to what I’m about to discuss. I think it’s important to understand the way antidepressants and most drugs approved by the FDA are evaluated for effectiveness. Patients in clinical trials who are classified as depressed are placed on either placebo or the drug up for approval. If some “statistical significance” (a wonderfully vague term) can be discovered between the symptom improvement in patients taking antidepressants versus those taking placebo, the drug is approved by the FDA barring any crazy side effects or reactions by those patients in the trial.

So, now that we have covered that little ditty, in the article Begley reviewed Dr. Irving Kirsch‘s work on comparing prescription antidepressant effectiveness in comparison with placebo effects in clinical trials. In 1998, Kirsch reviewed 38 different clinical trials for antidepressants that were performed since the beginning of antidepressant use in 1950s.

He discovered that antidepressants were really effective! That’s not really a surprise though, we’ve known that for years. What he found that was interesting was that 75 percent of patients on placebo reaped the same benefits as those on antidepressants. In other words, only 1 out of every 4 patients reaped real benefits from antidepressant use. Everyone else was relieved of their depressive symptoms because they believed the drug would make them happier. Not because it actually did make them feel better.

After that analysis was published, America’s antidepressant use more than doubled. We went from taking 13.3 million antidepressants in 1996 to taking 27 million antidepressants in 2005. People just saw that antidepressants worked. They didn’t care why.

The academic community and drug companies weren’t happy though. Criticism found it’s way in because it was scary that antidepressants had basically been found no more effective than a sugar pill. People accused Kirsch and his studies. They accused the data he used as being unreliable – which is strange because this data is what the FDA used to approve the drugs in the first place – so Kirsch pulled every study used to seek approval for an antidepressant drug by the FDA. He ended up with 47 studies, with 40 percent of those studies unpublished.

What did he find?

Not only had the unpublished studies failed to prove any “statistically significant” therapeutic effect, but the amount of unpublished studies far surpassed that of any other type of drug. Unpublished studies = The medication did not show any benefit to a patient. It’s okay though. A drug company can run as many clinical trials as it wants for a given drug. It just has to show two successes of statistically significant effect.

The percentage of those who saw the same benefits with placebo as with an antidepressant increased. About 82 percent of patients across the board showed no better outcomes than with placebo. So now, about 18 percent of those on antidepressants actually saw a needed benefit.

Well, what about those 18 percent – 25 percent who benefit? How greatly do they benefit from an antidepressant?

Not by much. On a 54-point scale measuring various markers of depression, the average patient saw an improvement of 1.8 points. That’s about a 3 percent symptom improvement. It’s like having a terminal illness and waking up one day and realizing the cough from your cold is gone. Not much effect on the underlying issue, which once again cycles back to how we choose to look at and cope with life.

The point of it all.

This is a prime example of the mind-body connection and how it effects treatment. The rabbit coming out of the magician’s hat is simply the client’s belief that therapy/antidepressants will be a success.

The difference is a big one though. With antidepressants, patients experience a host of side effects. Some common side effects of antidepressants include:

  • Lack of sex drive
  • Dry mouth
  • Anxiety
  • Weight gain
  • Blurred vision
  • Nausea
  • Insomnia

With the list going on…

With counseling, there are side effects as well. In the beginning, counseling can be uncomfortable, it can force you to look at things you may not like about yourself, it brings your presenting concerns to life and requires you take an active role in changing your world view and the way you cope with life.

Part of that is how you think. Whether you choose to believe in the effectiveness of counseling or antidepressants, your powerful thought in the belief of change has already begun to change your life. The difference with counseling is that you develop greater self-awareness, better coping mechanisms, and you develop a healthy relationship with another person who is an advocate for your well-being and an impartial observer on your life experience.

The most important point I want anyone who reads this post to take away is that it’s changing how you think that is the catalyst to change. When we think nasty thoughts about ourselves and our life, it causes a chain reaction in our bodies. We release nasty hormones like cortisol and adrenaline (which can be good, but is often in overabundance under stress). When we think good thoughts and we believe we can change, we do. We do it through changes big and small. It’s the difference between a patient who is fighting cancer who beats it or succumbs to it. It’s the philosophy behind “spontaneous remission,” which is basically how doctors explain miracles or unexplainable cures of disease.

So, I believe in the power to change your thoughts and beliefs. This is my professional and personal ideology. I believe you can do anything you set your mind to no matter what it is. You want to stop being depressed? Believe you’ll stop being depressed and change the things in your life that contribute to your depression. You know how you figure those things out? Self-Awareness.

End Thoughts

I hope I explained myself a little better and you all understand my summary and my beliefs. It is important to note that antidepressants are often proven to be beneficial to those who have suffered from recurrent and severe depression and may help where psychotherapy and other interventions have not. It also been proven that therapy is effective for those who do not have these problems. There is always a choice and one is not necessarily better than the other. Some people are content to not go to counseling for one reason of another. That’s okay, too.

There’s a lot of other issues that go into why prescription medication is so ubiquitous and opted for more often than counseling (i.e. stigma of therapy, support in government for Big Pharma versus mental health services, and insurance inconsistencies). I don’t want to address those issues right now.

I simply want to acknowledge that about 75 percent to 82 percent of the time,  you are likely your own placebo on the path to your happiness. That is how I feel about the mind-body connection.

Thank you for reading to the end of this post and please comment with your thoughts. I’m always interested in hearing others’ thoughts, as long as they speak for themselves. Remember “I statements…

Sources

The Depressing News About Anti-Depressants

Supporting Sources

Spontaneous Remission of Crohn’s Disease

 Antidepressant Side Effects

Evidenced-Based Therapy Relationships

Post Edit: My sister kindly posted out that statistical significance isn’t vague, it’s actually numerical. I was speaking existentially, but if you’re curious here’s a definition.