Category Archives: Depression

How to Forgive: A Cognitive Behavioral Model for Forgiveness and Letting Go of Anger and Frustration

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What is forgiveness?

Here’s what it is not. It is not for anyone else, only for you. It doesn’t imply reconciliation with the person who hurt you nor does it imply that you approve of their actions. It does not mean forgetting what happened.

What is forgiveness?

It is only for you, in order to help you feel better. As one well-known researcher said, “failing to forgive is like taking poison and waiting for the other person to die.”

Forgiveness means understanding what is causing your current distress. It is not what offended you or hurt you years ago or even a few minutes ago. The primary cause of your suffering is from your thoughts, feelings, and physical sensations in response to your thoughts about the event.

This is a subtle concept. Most of us believe the reason we are angry is because someone has done us wrong. And it’s true, that if we could erase the event, we would stop being angry. But none of us own a time machine so we can not erase the events.

What makes us suffer is each moment that we think about the offending person or event. And how we think about these events. It is as if you own a DVD collection of movies of different events in your life. If you were to choose to only watch the upsetting movies, your overall level of happiness would greatly diminish. Choosing to forgive is choosing the DVDs of your life that are positive and full of joy.

There is another component of how people think about grudges. We often have a magical belief that our anger at someone else causes them to suffer. We imagine them feeling guilty about their behavior and suffering even when we are not present. We think of ways to hurt them in return – the silent treatment, constant criticism, reminding them of their offenses. But the reality is that most people are very good at blocking out guilt and punishment. Whenever they’re not around us they tend to think about other things. And they develop good ways of avoiding our punishment. So really the one who suffers is the person who’s angry and who fails to forgive, not the offender. And if the person we take out our anger on is someone we are still in relationship with, it damages the relationship and makes it even less likely we will get what we want.

Another trigger for resentment and anger is holding onto what the anger and forgiveness researchers call “unenforceable rules”. These are what most cognitive behavioral therapists call “Shoulds”. They are the demands we make on the world and on people around us. You can’t force anyone to do something they don’t choose to do, and you can’t require people to give you things they choose not to.

For instance, you might want fidelity in your romantic partner. You certainly have every right to want that. But you can’t demand or enforce fidelity. If your partner chooses to go outside the relationship, you can’t really change it. The only options you have are how to react to this. You have choices to make about the relationship and about your future relationships.

The research on forgiveness is very interesting. It reduces blood pressure, stress, anger, depression and hurt while increasing optimism and hope. The primary researcher on forgiveness, Dr. Fred Luskin at Stanford, has even done forgiveness research with women in Northern Ireland whose husbands were murdered. Even with these extreme cases people have found the forgiveness model very helpful at easing the pain.

I’ve written about how to conquer anger using the S A P model. In this model you change your shoulds into preferences rather than demands, you place into perspective the events that have caused your anger, and you shift out of the blame model and depersonalize most events.

Forgiveness is about being happy. Living your life to its fullest is the best revenge you can take on someone who has offended you. Instead of focusing on the hurt or betrayal, focus your energy on getting what you want in your life in a different way other than through the person who has hurt or betrayed you. Take responsibility for your own happiness rather than placing it onto other people and then being disappointed when they don’t provide happiness.

Change your story. Too often we have what is called a grievance story. We tend to tell this story to many people. It always ends with us feeling stuck and angry. Change your story. Change the ending so that it ends with a powerful and strong choice to forgive.

 
So to summarize, here’s how to forgive:

1. Let yourself first feel the pain. Share the experience with a few close and trusted friends.

2. Recognize that your anger is a result of your choices about what thoughts to experience about an event. Decide to forgive so that you can move forward and feel better.

3. Recognize that you probably won’t be able to get rid of your hurt and anger by punishing the other person. All you will accomplish is to damage the relationship or make the other person suffer while you continue to suffer.

4. Recognize the role that your “unenforceable rules” or Shoulds plays in your continued hurt and anger. Change or eliminate these rules.

5. Figure out what you want in your life and how to succeed in achieving those goals even if the other person doesn’t provide the answers. Remember that happiness is the best revenge.

6. Use the S A P model to change your shoulds, eliminate exaggerated awfulizing thinking, and take away blame.

7. Rewrite your script. Tell the new story where you were hurt but recovered and forgave and moved forward. You are a hero!

 

Treatment of Tinnitus Using Cognitive Behavioral Therapy (CBT)

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Treatment of tinnitus is challenging. Tinnitus is condition where the person hears a ringing in their ears or other sounds when none of these sounds are present in the environment. It is a very common problem, especially as people age. According to studies, up to 20% of people over the age of 55 report symptoms.

What causes tinnitus?

There can be many causes. The most common cause is noise-induced hearing loss. Other causes include medication side effects, as well as withdrawal from benzodiazepines. In many cases no apparent cause can be found.

For many, tinnitus is a relatively minor problem that they tend to ignore. Almost everyone has momentary tinnitus symptoms. But for other people tinnitus creates a tremendous amount of psychological distress. This includes anxiety and depression. The person fears the loss of their hearing, and tends to focus intensely on their symptoms. They begin to avoid situations where their symptoms are more noticeable. This typically means avoiding quiet locations where there is no sound to mask the tinnitus sounds. Or it may involve avoiding situations where there are loud noises such as movie theaters due to the fear of further hearing loss.

Similar to some forms of obsessive compulsive disorder (OCD), the person may begin to engage in frequent checking behavior. This means that they consciously check the presence and volume of the ringing in their ears. They may also frequently check their hearing.

The person also suffers from constant thinking about causes of the tinnitus. They often blame themselves for exposure to loud noises in earlier life. They think about the music concerts they attended where they didn’t wear earplugs, or even recreational listening to music. They have strong feelings of regret that can blend into depressive symptoms.

Unfortunately there are no terribly effective physical treatments for tinnitus. This leaves psychological treatment as the primary modality for successful reduction of distress.

Treatment of tinnitus using Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy (CBT) conceptualizes tinnitus much like it conceptualizes the experience of chronic pain. Chronic pain consists of two components. The first component is the physical sensations. The second component is the bother or suffering caused by these physical sensations.

Tinnitus can be conceptualized in the same way. The subjective experience of sounds in the ears is the physical sensation. The interpretations of these sensations lead to the emotional reactions; suffering and bother.

Although CBT cannot directly change the physical sensations of tinnitus, it can change the reactions to these sensations. And changing the reactions can actually lead to a subjective experience of diminishing symptoms.

Treatment of tinnitus using Cognitive behavioral therapy (CBT): The Components of Treatment

1. Psychoeducation. The first step is to educate the client about how tinnitus works. The model used is that the loss of certain frequencies in the hearing range leads the brain to fill in those frequencies with sounds. It is very much like phantom limb pain, where an amputee may experience pain in the removed extremity.

The nature of hearing loss is explained, and psychoeducation regarding tinnitus and the risk of further hearing loss is discussed. If needed, results of hearing tests can be discussed relative to the actual severity of hearing loss. Although in some cases of tinnitus hearing loss is quite significant and may actually impair functioning, in many cases the hearing loss is relatively minor and does not impair functioning in any way.

2. Cognitive therapy. Here the therapist helps the patient to identify the negative thoughts that are leading to anxiety and/or depression. Typical thoughts for anxiety are: “I can’t live my life anymore with this condition. I will lose my hearing entirely. The sounds will drive me crazy. I’m out of control. If I go into _____ situation I will be troubled by these sounds so I must avoid it. I need to constantly check my hearing to make sure it’s not diminishing. I need to constantly check the tinnitus sounds to make sure they are not getting worse. They are getting worse! They will get worse and worse until they drive me crazy.”

Typical thoughts for depression are: “Life has no meaning if I have these sounds in my ears. I can’t enjoy my life anymore. It’s hopeless. There’s nothing I can do about it. Doctors can’t help me. It will get worse and worse and slowly drive me crazy. I won’t be able to function.”

Once these thoughts are identified then the skills of challenging them and changing them are taught to the client. The client learns how to alter these thoughts to more healthy thoughts. This produces a large reduction in anxiety and depression.

3. Attentional strategies. Because much of the subjective perceived loudness of tinnitus is based on attention, with higher levels of attention leading to higher levels of perceived loudness, developing different attentional strategies will help very much. In this part of the treatment mindfulness training and attentional training is used to help the client learn how to shift their attention away from the tinnitus sounds onto other sounds or other sensations. Often a paradoxical strategy is first used, where the patient is asked to intensely focus only on their tinnitus sensations. This teaches them that attention to tinnitus symptoms increases the perceived severity, and helps motivate them to learn attentional strategies.

Another aspect of attentional retraining is to stop the constant checking of symptoms and hearing. Helpful techniques include thought stopping where the client may snap a rubber band against their wrist each time they notice themselves checking.

4. Behavioral strategies. Tinnitus sufferers typically develop an elaborate pattern of avoidance in their lives. They avoid situations where they perceive tinnitus sounds more loudly. This can include avoiding many quiet situations, including being in quiet natural places such as the woods, or even avoiding going to quiet classical music concerts. They also tend to avoid situations where they might be exposed to any loud noise. This includes movie theaters, concerts, and even noisy office situations.

The behavioral component of CBT encourages an exposure-based treatment whereby the client begins to deliberately go back into all of the avoided situations. In situations where there is actual loud noise exposure at a level potentially damaging to hearing, they are encouraged to use protective earplugs.

The purpose of the behavioral component is to help the person return to their normal life.

5. Emotional strategies. Sometimes it is necessary to help the client go through a short period of grieving for their normal hearing. This allows them to move forward and to accept the fact that they have hearing loss and tinnitus. Acceptance is a key factor in recovering psychologically. This often also includes forgiving themselves for any prior excessive loudness exposures.

Changing the thoughts about the tinnitus symptoms also produces emotional change and a reduction in anxiety and depression.

In summary, cognitive behavioral therapy of tinnitus seeks to reduce the psychological suffering caused by the sensations of tinnitus. Cognitive, emotional, behavioral, and attentional strategies are taught to the client to empower them to no longer suffer psychologically from their tinnitus symptoms. Successful treatment not only reduces the psychological suffering, but because it also changes the attentional focus and lowers the checking of symptoms, people who complete CBT for tinnitus often report that their perceived symptoms have reduced significantly.

Tips:

1. Traditional psychotherapy is typically NOT helpful for tinnitus.

2. Find a practitioner, typically a psychologist, with extensive training in Cognitive Behavioral Therapy. If they have experience treating tinnitus that is even better.

3. Give treatment a little time. You will have to work hard to learn new ways of thinking and reacting, and this won’t happen overnight. You should be doing therapy homework between sessions.

4. Medication treatment such as anti-anxiety or antidepressant medication is typically not very helpful, and in the case of anti-anxiety medications can actually worsen tinnitus especially during withdrawal. First line treatment should be CBT.

5. Get help. Although the actual symptoms of tinnitus have no easy fix, the suffering can be treated and alleviated. Especially if you are experiencing depression symptoms, is is important to seek therapy with a CBT expert.

Gallup Survey Shows Stay-At-Home Moms Suffer More Depression

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Are stay-at-home moms more depressed than working mothers? In a Gallup poll released last week, stay-at-home moms showed a 28% depression rate compared to 17% of working mothers and 17% of working women without children.

Stay-at-home mothers reported more anger, stress, sadness, and worry. They were more likely to report themselves as struggling and suffering!

This is very important data. According to Gallup, stay-at-home moms make up 37% of mothers with kids living at home.

So who are these stay-at-home moms? Contrary to the mythical model of the rich stay-at-home mom who bounces between yoga class, tennis, pilates, and home to the nanny, the reality of stay-at-home moms is much grimmer. They tend to be poorer on average, younger, Latina, less likely to have graduated from high school or college, and more likely to have been foreign-born.

Here’s some more data directly from the Gallup report, which explored the well-being of 60,000 U.S. women in 2012.

In terms of worry 41% of stay-at-home moms reported worry, compared to 34% of employed moms and 31% of employed women without children.

In terms of sadness 26% of the stay-at-home moms reported it, compared to 16% of employed moms and 16% of employed women without children.

In terms of depression, almost a third of the stay-at-home moms (28%) reported depression, while only 17% of employed moms and 17% of employed women without children reported depression.

The only negative emotion that didn’t vary very much was stress. 50% of stay-at-home moms reported stress, but 48% of employed moms and 45% of employed women without children also reported stress. So apparently stress is pretty much the same across the board for women.

In terms of anger, 19% of stay-at-home moms reported it, while 14% of employed moms and only 12% of employed women without children reported anger.

What about positive emotions? Even though Gallup makes much of the lower ratings of positive emotions for stay-at-home moms, the numbers don’t reflect very large differences. 42% of stay-at-home moms reported themselves as struggling, while 36% of employed moms and 38% of employed women without children reported themselves as struggling. Not a very large difference and probably not statistically significant. What’s interesting about this data is that so many women, regardless of their parenting status, report themselves as struggling. This is quite troubling. I’d be very curious to see comparative data on men.

This is interesting research and completely consistent with some other research that was conducted by Daniel Kahneman and associates on women’s experienced happiness performing various activities. He looked at the percentage of time that women spent in unhappy mood states. Parenting activities showed a 24% on happiness ratio as compared to 18% for housework, 12% for socializing, 12% for TV watching, and 5% for sex! Even though children are delightful, parenting is hard work, and there are many negative emotions associated with it. Working outside the home has negative emotions also, with a 27% unhappy emotion ratio, but it also has rewards and recognition that the lonely job of parenting does not have.

So what should we make of all this research? What wasn’t investigated by Gallup is the relative advantages versus disadvantages for the children of stay-at-home moms versus working moms. So we don’t know if there are significant benefits to the children, which might compensate for the higher levels of suffering reported by stay-at-home moms. I may come back to this issue in a future blog post.

In any case, it suggests that stay-at-home moms need much better support systems from our society, and that we also need to develop better ways for women split time at home and work. Currently there are few options for women who wish to work part-time at satisfying jobs. Because child care in the United States is so expensive, it is difficult for poorer women to stay in the workforce. This may lead to higher levels of depression and suffering in women.

From a clinical perspective, psychotherapists need to be alerted to be extra careful to screen stay-at-home moms for depression and anxiety disorders. I have a quick depression screening test on my website which stay-at-home moms can use to identify if they are suffering depression. If so, call someone for help. Don’t suffer in silence.

Changing Thoughts May Be Better Than Changing Behavior in the Early Stage of Psychotherapy for Severe Depression

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A recent study took a close look at what predicts improvement in depression in the first five sessions of cognitive behavioral therapy. They looked at the degree to which the therapists used either cognitive therapy methods, practiced structuring the sessions clearly, and how much they used behavioral methods/homework. They also examined whether the patients cooperated with these parts of cognitive behavioral therapy. They also measured the strength of the therapeutic alliance.

Sixty patients with major depression participated in the study. Their sessions were videotaped and trained raters rated how much the therapists used cognitive versus behavioral methods.

What they found was only two aspects of therapist behavior predicted improvement between sessions. Depression was measured after every session, and these measurements showed that patients felt better when therapists used cognitive techniques, but didn’t improve when the therapists focused on behavioral techniques.

Patients also showed greater improvement when they adhered to suggestions made by the therapist, which is not surprising.

The behavioral methods used were techniques such as having patients schedule their activities to become more active, and tracking how they actually spent their time. This is called behavioral activation, and previous studies have suggested it is an effective approach to treating depression. The behavioral activation model is that depressed patients tend to do very little, and this leads to further depression. Patients are encouraged to schedule activities that are fun, or activities that provide a sense of mastery or success. This leads to a lessening of depressive feelings.

The cognitive methods were techniques such as writing down what your thoughts are, and using cognitive therapy to challenge or modify distorted thinking.

So how to interpret the results of this study?

It’s only one small study and I would be cautious about taking too much from it. It does suggest that at least in the early sessions of therapy, cognitive methods may be superior to behavioral methods. This makes sense to me because early in therapy depressed patients feel a lot of pain and lethargy, and getting them to suddenly increase their activity can be very challenging and perhaps too difficult. This may lead to a sense of failure which increases depression rather than reducing it. On the other hand, using cognitive methods may lead to more immediate sense of control and relief, which would tend to reduce depression levels.

My sense is that later in therapy behavioral activation techniques are very useful. But typically in order to get patients to cooperate with these techniques there needs to be a strong alliance with the therapist. This takes some time to build.

It would have been interesting if they had continued the study beyond the first five sessions, and looked at whether over time the relative importance of the cognitive versus behavioral techniques would have shifted.

The study shows that therapist behavior in sessions does matter. This is one of my pet peeves. Many psychotherapists claim to use cognitive behavioral therapy, yet fail to actually use any cognitive behavioral techniques on a regular basis in sessions. This study shows that therapist adherence to structuring sessions and using cognitive techniques matters.

So from a consumer point of view there are a few take-home lessons.

1. If you are seeking cognitive behavioral therapy, make sure your therapist actually does cognitive behavioral therapy during sessions. This means they should structure the sessions clearly, as opposed to simply letting you talk about whatever is on your mind. It also means they should be asking you to track your self talk in written form, during sessions go over those thoughts, helping you learn to identify and correct distortions in the thoughts. If they don’t do these behaviors, and therapy feels free-form, then you’re probably not getting cognitive behavioral therapy, and you might want to look elsewhere. If you don’t regularly get homework to do between tasks, you aren’t receiving cognitive behavioral therapy.

2. At least in the early part of therapy pure cognitive therapy techniques may be more effective than behavioral techniques. You may want to focus your own homework more on identifying and changing your inner thoughts, rather than trying to increase positive behaviors. This probably will yield more relief of depression.

3. The study also confirmed that when clients cooperate and are more involved using cognitive therapy techniques, they improve faster. So even if you’re feeling skeptical, try to fully participate during sessions and in between sessions, as that provides you the best chance of more rapid relief.

Your off to analyze his thoughts psychologist,

Andrew Gottlieb, Ph.D.

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