April 2013
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Apr 30, 2013 1:23 PM
Brian Baumal
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Next week I will be giving a talk to a wonderful group called MindShift in Toronto, on such topics as depression, mental health, setting limits other issues regarding people'e relationship to work.
I thought I may share some of the topics I will be discussing at that talk.
- Depression is perhaps the most common mental health risk workers have. According to one poll, 22% of workers presently suffer from depression.
- Depression can be effectively treated through psychotherapy. Research suggests that drugs work well on Major Depressive Episodes, but that they are no more or less effective for mild or moderate cases.
- It is OK to allow yourself to feel bad, or blue - but when it begins to impact your behaviour or thoughts, one needs to seek help.
- Perfectionism is a form of anxiety. Simply put, if one were not perfect, one would become anxious. Perfectionism, however, is relative. Exploring the underlying anxiety that accompanies perfectionism is often helpful.
- Enforcing boundaries in terms of how long we work, or not entering into bad situations in our work requires that we have the fortitude to handle the emotions that arise when we say "no"
- It is rarely about how good you are at your work. The more important factor is HOW WELL you work. |
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Apr 12, 2013 10:57 AM
Brian Baumal
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When you suffer from depression, it may seem like "effective treatment" is a world away for you. Why though, when you listen to therapists and other professionals talk do they often repeat the phrase "There is effective help for depression"? There are any number of reasons why this is done, and quite frankly true. First, within Toronto, there are so many kinds of professionals that treat depression to begin with. It is likely that you will find someone that will be able to effectiely help in one way or another, whether it be drug therapy, psychotherapy or even coaching.
However, it is important to go deeper than this, and ask why depression is treatable - what factors in it make the prognosis seem positive compared to other conditions? In many cases, depression is significantly helped simply by talking to someone about it. Most depressed people do not feel as if they can talk to many people about their thoughts, behaviours or feelings. As such, just getting things out in the open is often a big first step.
Therapists often talk about people who are "resistant" to therapy. In the case of depressed people, if they are able to get themselves to see a therapist, they are usually very open to the process. The issue becomes more one of pacing - how fast can changes occur, as opposed to a question of whether change will happen or not.
Another factor is that depression is so common that there is no shortage of research into the condition. This research often begins to inform clinical practice and allows for advances to be translated fairly quickly into therapeutic strategies and tactics.
Depression involves three key areas of psychological functioning - behaviour, thoughts and emotions. All of those areas can be targeted by the therapist, and all of those areas seem to respond well to treatment. In fact, with depression adjustment in just one area tends to have immediate impact on the other two. A therapist does not necessarily need to focus on all three areas in order for a depressed patient to see improvement. Once improvement happens in one area, it will likely spill over into others. In fact, just focusing on the "thoughts" aspect of depression, the thoughts that accompany depression are so readily identifiable and so clear that it is fairly easy for the clinician to spot them and begin to work with them and change the other two areas of functioning.
The phrase "There is effective help for depression" is not just another platitude, nor is it another way of telling depressed people "To get over themselves". Rather, there is a lot of truth to the fact that depression can be helped effectively, even if it may not feel like that to you today. |
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March 2013
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Mar 19, 2013 11:59 AM
Brian Baumal
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I see many patients with depression come through my Toronto psychotherapy practice, and the treatment remains a valid form of working with the condition, even in the face of pharmaceutical treatments.
The incidence of depression is soaring. Major Depressive Episodes have a lifetime prevalence of 12% in the Canadian population - meaning that over 1 in 10 people will be debilliated enough by depression to have their lives seriously impacted by the condition. The World Health Organization estimates that by 2020, depression will be second only to heart disease as the major source of disability throughout the world.
There are a number of reasons why rates of Major Depressive Episodes may be on the rise. First, doctors may be recognizing it more as drug treatments become more readily available. Second, people may be more willing to talk about it. However, it is unlikely that these simple increases in reporting are causing the major increase in depression.
I believe that it is important to look at the psycho-social causes of depression. When I look at these causes, rather than just addressing Major Depressive Episodes, I am going to focus more broadly on why more people in general are prone to depression, or why many of us have what are called "depressive personalities" - and as you can imagine, if you have a depressive personality, you are more likely to develop depression.
Depressive personalities can be described as people who are overly self-conscious, meaning that they can be overly narcissistic, or at the same time overly sensitive to criticism. They are individuals who do not know how to deal with their sadness, or the emotional impact of the slings and arrows life throws at them, and I see a lot of depressive personalities in my Toronto psychotherapy practice. When people are unable to cope, they lose their sense of self, and begin feeling bad about feeling bad. These bad feelings can be directed inwards towards the self (I am not worthy) or directed outwards (The world is an awful place). These individuals can be prone to Major Depressive Episodes, but can also be prone to more milder forms of depression, or dysthemia - a low grade chronic depression that lasts for more than two years - not a rosy prognosis at all.
Individuals suffering from depression do not know how to "mourn" or "grieve" properly. The only difference between mourning, grieving and depression is that mourning and grief have a "time limit" on them. That is to say, they come to an end - naturally by the person who is grieving the loss. The purpose of mourning is to shut-down the body so that it can focus on dealing with the loss the individual is facing. With depression, mourning and grief have no end, and with no end comes hopelessness and less sense of self - we no longer know who we are because we are so enmeshed in the depression.
The psychotherapeutic cure for depression involves a number of key factors, that are listed in general order:
1) Addressing the "shoulds" one feels about themselves and their lives, and losening the grip those have on the individual. One primarly reason people slip into depression is because they think they should not feel depressed.
2) Addressing "Who Am I" and building-up character. This is done indirectly by the therapist asking questions as opposed to giving direct answer to the patient. The therapist begins to ask a patient which part of them is speaking, or which part wants to speak. These questions tend to build character and self-esteem.
3) Restoring sadness and grief. With the other two pillars in place a depressed person will be able to feel sadness. The goal, however, is that the patient will realize two things - the sadness is not as bad as they thought (given that the shoulds are removed, and there is a person who can respond to the sadness), and that the sadness is episodic - that is, it comes to an end... even if just for a moment. As a patient experiences the temporary nature of sadness (even if there is only momentary relief from sadness) they realize that it is possible for sadness to be lifted eventually, and this brings hope to the patient.
In the end, a patient who deals with depression through psychotherapy can expect to build their character while addressing their sadness and turning it into mourning, which is a temporary condition. This brings about hope to the depressed individual - and this is what I am proud of in my therapy practice. I rarely am the one to directly give hope to my patients - through this process (and it can be a very long one), they discover it themselves. |
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Mar 6, 2013 1:21 PM
Brian Baumal
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Rabbi and Psychiatrist Abraman Twerski came on my radar a long time ago, but I recently renewed my interest in his views regarding self-esteem and the pathology of neurosis. Twerski believes that most all psychiatric and psychological conditions are caused by a lack of self-esteem. Now this is not meant to be a broad, across-the board statement, as he allows for biological factors (such as bi-polar conditions), and I would add-in psychotic or sociopathic tendancies may not have their roots in self esteem either. However, what Twerski is saying, and what I agree with, is that one effective way of tacking many of the issues clients in my Toronto psychotherapy practice face is to look carefully and work on self-esteem.
One of the best pieces of advice that I received is working with self-esteem is that "you never directly work on someone's self esteem." This makes complete sense for many reasons according to Twerski:
- There are significant cognitive distortions that go on in people who feel that they have low self-esteem. That is a fancy way of saying that people will not believe compliments or praise that is given to them, so a therapist must have many other tricks up their sleeve other than to provide genuine compliments to patients.
- Many of the processes that are involved in creating a lack of self-esteem happen unconsciously, so it is necessary to work indirectly on these issues.
- Self-esteem issues often create poor relationships for patients, so sometimes just building a good therapist-client relationship can be a key component of working with self-esteem issues.
What is truly unique about Twerski's approach to self-esteem is that he recoginzed that he had low self-esteem about 10 years after he became a successful psychiatrist. This link - http://www.torahweb.org/torah/special/2008/dtwe_esteem.html provides an account (and an audio recording) of how Twerski dealt with his own self-esteem issues, and is worthy of a read.
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February 2013
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Feb 12, 2013 11:51 AM
Brian Baumal
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It is rare that I post personal situations on my blog, but this may be relevant to many people in Toronto who are seeking psychotherapy for chronic pain and the depression, anxiety and general dysphoria that accompany it.
I have a steel rod in my back as the result of fairly severe scoliosis, a curved spine that was diagnosed in my teenage years. The rod was designed to correct the curve, but not cure it. As a result I have poor posture, and that combined with having a hunk of metal in my back produces a fair amount of pain. Also, prior to the corrective surgery, in my early teenage years, I also had a fair amount of back pain due to the severity of the curve in my spine.
The back pain largely came to define me. Since roughly the age of 12 it has always been difficult and moderately painful for me to lift, exercise, walk, dance, exercise, do basic chores and travel. It certainly was not impossibe for me to do any of those tasks, but I believe I masked the pain fairly well.
At the time I was under the care of various physicians, surgeons and physiotherapists immediately before and after the operation. Any time I discussed the pain, which is predominatly in my right scapula, I was told "It's bursitis. Everyone has pain. Live with it." The best response I got was from a surgeon, who doing a routine check of my rod in 1997 simply said "Hey, you have a steel rod in your back - what do you expect?!"
I largely believed this advice, but with the physical pain came an awful lot of sadness. Sadness that I had to live with such pain. Sadness that I could not participate the way others around me could in activities (or if I did, they had little knowledge as to why I got so tired). Sadness that if there was only one chair somewhere, I would often sit in it, even if others needed it. Sadness that my upper body was slightly deformed, and sadness that working at a desk causes me exceptional pain.
About two years ago, I decided I could take the pain no more and began to research and consult my family doctor based on some findings I discovered on-line. Since I am a fairly unique case, he had no clue how to deal with constellation of symptoms and issues I had. Since I live in Canada, it took two and a half years to see a specialist.
I saw that specialist and his associate today. Their view is that the pain in my back is being caused by the fact that the steel rods in it are now rubbing against and irritating the muscles around my scapula, and it is time to remove most of the rods.
If I am scared of anything it is who will I be without the pain that has come to define me? Moreover, could I have had the pain eliminated earlier in my life to have a better quality of living? These questions run deep, and the anxiety that I have is who will I now be once my pain no longer defines me?
I think the funny thing is that in Toronto we have so many healt-care options, whether it be traditional medicine, chiropractic, physiotherapy, accupuncture, basic exercise, sports medicine and other treatments. Though I have seen most of these practititioners and they have all been knoweldgable and earnest in their efforts they were largely ineffective. I wonder if I saw them just to keep on having the pain that I lived with and the pain that defined me for so long.
**Addition** The following is a useful link regarding the psychology of illness http://www.onlinepsychologydegree.net/2013/03/04/the-psychology-of-illness/ I hope you find it as useful as I do. |
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Feb 6, 2013 12:18 PM
Brian Baumal
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There are many psychotherapists in Toronto, covering a wide range of conditions from anxiety, to depression to stress management and self esteem. In dealing with these conditions, there is often one common theme that stands-out at the beginning of many people starting therapy, and that is "It Gets Worse Before It Gets Better." There are many therapists who inform their clients of this at the start of therapy, either in person or in the intake literature handed to the client.
It is worthwhile to examine why this occurs. There are really two primary reasons. The first is talking about issues that you have not discussed before may bring-up certain feelings in you either about yourself, about your therapist or about the process in which you are engaging. Second, it becomes important to manage expectations about the pace of improvement or therapy in general. For example, a therapist may want to take a number of sessions in order to get to know the client's history before shifting focus towards doing a lot of deeper therapeutic work.
I think one of the key things to come out from the fact that things may get worse before they get better is to ask yourself what do you do in general when things get worse for you? Do you just plod along in therapy without telling your therapist, or do you discuss the fact that things seem to be getting worse, or are not improving? This will all depend on the realtionship you have with your therapist. In theory though, you should have a good enough relationship with the therapist such that you can communicate anything to them.
Also, it may be worthwhile to examine why things are getting worse - is it the thearpeutic process itself, or are things happening in your life to make it that way? Expressing this dilemma may help you continue on in therapy in a way that will lead to healing. It is my view that knowing how you may be affected by therapy before the process starts is an important part of good treatment. |
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Feb 6, 2013 10:51 AM
Brian Baumal
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In my Toronto psychotherapy practice, I often see a lot of people who lack self-esteem. I want to look at what that means and how people with self-esteem issues fail to set good boundaries for themselves. It is actually tough to define a lack of self-esteem, and I think a better way of doing it is to simply say those who lack self-esteem get themselves into situations they don't want to be in, and/or have difficulty getting themselves out of situations they don't want to be in.
Now let's understand very clearly that we cannot necessarily control all the situations into which we get - car accidents, medical emergencies, even who our birth family is. The only thing that we really can control is our reaction to these situations.
So, boundary setting involves avoiding situations we can control, or controlling our responses to situations that we cannot control. But where does self-esteem come into the picture? Self-esteem is like our bottom-line - we basically say "No, I won't do that!" or "No! I won't go there" or "No! I deserve better", and then we act accordingly.
And this is really important to note. There are two parts to self-esteem - the cognition of really "I won't allow myself to do that", and then the behaviour that follows it. The funny thing is that it is possible to exhibit the cognition, without the behaviour and it is equally possible to exhibit the behaviour without the congition. In either case, proper self-esteem is not being enacted. Self-esteem requires both the thought and the behaviour to work in tandem.
Why is this the case, and how can both the thought and the behaviour work together? As a psychotherapist in Toronto that largely practices psychodynamic therapy, the thought and behaviour need to be properly joined by emotion. That is to say setting-up boundaries has to involve emotions that simply cannot be ignored. An example will suffice.
Say a married female patient constantly has affairs. Slowly - over decades - she realizes that these affairs are taking a toll on her personally, financiall and on her children. The thought in her head becomes "I am better than these sordid and torrid affairs". The self-esteem has kicked in. Then the behaviour that comes about as a result is to stop them. But what of the emotions involved? The emotion of sadness in being lonely? The anxiety involved in meeting a person with whom she could have an affair but must not. The grief involved in still being in a poor marriage? If these emotions are left unprocessed, raw and even ignored, I will bet that it will only be a short while before this woman goes back to her philandering ways.
Self-esteem is thus a triumverate of thoughts, behaviours and emotions. The goal of my psychotherapy practice in Toronto is to work on all three of these areas with my patients, with a recognition that once the thoughts come into awareness, behaviour will likely follow quickly - but it is understanding the emotional consequences of the boundaries that have been enacted to improve self-esteem that will yield long-term results. |
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January 2013
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Jan 29, 2013 12:36 PM
Brian Baumal
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Have you ever looked at a stranger and had a reaction to them in one way or another? Sometimes you may feel the person seems very caring, other times you may feel the person is someone you don't want to have a conversation with. Sometimes, you may even see a stranger you have never met before and want to yell at them in anger. Have you ever wondered why you have these reactions, and what the dynamics are that power them?
The reactions we have to other people in our lives are often called "Transference". That is, we take what we know about someone in our past and put it onto a person in the present. As a psychotherapist in Toronto, I work with tranference regularly. Transference is a completely normal function for us. Think of it this way - if we had to treat every experience we ever had as a new experience, we would be overwhelmed with data. It makes much more sense for us to rely on our past experiences to inform our present.
However, two things happen during this transference. The first is that we often skip over important emotions that are brought-up by the encounter with another person, and the second is that we often miss the person or encounter altogether. One of the goals of psychotherapy is to slow down and illuminate the largely unconscious process of transference in a patient.
Two questions arise with this - why is this beneficial to the patient, and how does the therapist accomplish this task?
The first one is that transference is one of the key components of many types of psychotherapy. One of the key issues facing most patients in psychotherapy is the relationships they have with other people. Working with a patient's transference will allow them to change how they relate to others so that they can have a better and more nurturing relationships with others. I see a lot of patients in my Toronto psychotherapy practice that want better relationships.
The second question is how the therapist works with a patient's transference. This is what is called counter-transference. This is a really fancy word for describing the feelings that a therapist has about a patient. That's all. Just as a patient will have feelings towards a therapist, whether conscious or not, the same occurs in the therapist in regard to the patient. The reason why this happens is because therapists are human too, and our emotions are not turned off by any means in a therapy session. Rather, the therapist is trained to spot their emotions and feelings about the patient and begin to work with the patient on those feelings.
Healing in this kind of environment occurs when the patient is able to slow down their process of transference enough to work through the feelings that they have in particular situations such that they are able to better take-in the support being offered by the therapist.
For more information on this topic, and to express my thanks, click here and go to ThePsychFiles.com This is truly one of the web's greatest hidden gems on the topic of psychology and psychotherapy. I listen to their podcasts on a regular basis because the very knowedgable host, Michale Britt, makes difficult psychological topics approachable and very easy to understand. |
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Jan 15, 2013 2:32 PM
Brian Baumal
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In my Toronto psychotherapy practice I see a lot of people that display a lot of emotion. I have come to observe the following:
It is one thing to feel depressed. It is another thing to feel depressed about being depressed.
It is one thing to feel angry. It is another thing to be angry about being angry.
It is one thing to feel anxious. It is another thing to be anxious about being anxious.
It is one thing to feel sad. It is another thing to feel sad about feeling sad.
OK... I think you get the point.
Psychotherapy often does not work on the feeling itself, but rather it works on how we feel about ourselves when we have strong feelings and emotions. In reality, anger, sadness, depression and anxiety are all normal behavoiurs and emotions (though chroinc displays are a concern, frequency is NOT the subject of this post). Therapy does not seek their elimination, rather it simply seeks to look at how one handles these issues when they come-up.
Sometimes, people think I am talking about acceptance when I address this topic. That is if someone "accepts" their anger, does that mean they are handling it appropriately, or that they are cured? The answer is largely "No". Acceptance, or becoming aware of one's feelings is important, but not curative. Acceptance doesn't do much to actually address how we feel about ourselves when we have intense emotions - Acceptance largely means that one should feel OK about something, but when that person does not feel OK they are left feeling confused.
The goal of therapy is to address that confusion so that when emotions are felt, a person feels more grounded and secure in themselves. Instead of confusion, or other feelings that occur during intense emotions, the goal of therapy is to give a clarity of thought to individuals during intense emotional experiences. A good outcome is when someone indicates that they feel depressed, but does not feel so down on themselves. Similarly someone who has trouble with anger may say "I feel anger a lot but I have more sympathy for myself and the other person with me. I feel anger and no longer want to cause a fight." When therapists hear these statements, they know that they are doing their job. |
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Jan 8, 2013 10:34 AM
Brian Baumal
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Psychotherapy requires a COMMITTMENT to the process. I bet that is one of the last things that you want to hear about therapy, but it is entirely true. There are any of a number of reasons why this the case, and it is worth exploring why therapy is not something that can provide instant relief to psychological distress, or other issues that you may experience in your life:
1) The Relationship Between Patient And Therapist Needs Time To Form Opening up to a relative stranger about the key concerns in your life takes time, as I'm sure you can imagine. Sometimes a patient may want to go very quickly into their problems or issues, but the therapist may slow things down a bit in order to get a fuller picture of what is really affecting the patient.
2) Issues Have Taken A Long Time To Form, So They Take A Long Time To Solve This is not the theory that all of one's issues are rooted in childhood and that we must go back to explore such issues. That is actually not how I work. However though, psychological issues that you face are like any habit you may have - you may be unaware of the habit, you may have been doing the habit for a while and you may be reticent to give it up.
Another analogy is this - the main reason why many kinds of cancers, especially pancreatic cancer, are so lethal is because by the time the first symptoms show, the cancer has taken a very large foothold within the body. Though the outlook is much more positive with psychological conditions, the first time one becomes aware of a psychological symptom or concern, it is highly likely that the condition has already taken a strong hold within someone's psyche.
3) It May Get Worse Before It Gets Better As you begin to really discuss and examine psychological issues and concerns in a deep and meaningful way, it is possible that one may feel worse before one gets better. This is common and therapists are trained in working through these situations. However, patients need to realize that there is a process to therapy that takes time, and that it is important to discuss such feelings if and when they happen.
How To Make Effective Use Of A Therapist Given That It Is A Committment
Just like exercise, eating well, maintaining good dental hygene, and even keeping-up a property attention to one's overall psychological health is an on-going committment. One need not, and in fact should not, see the same therapist or seek the same treatment for one's entire committment to psychological health. Given this, there are two very important things you can do to work with your therapist to ensure that you get the most out of the time you spend with them.
The first is to ensure that the therapist is the person you want listening to your problems and helping you along the way. There are many therapists out there using many modalities - some will fit with you and some won't. The sooner you decide, for yourself, whether you and the therapist are a good fit, the faster the process will take.
The second thing that can be done is to be clear on your goals in therapy, and to ensure that the therapist knows them. It is quite likely that in order to reach the goal, therapy will touch on a number of different topics. So, if one has social anxiety, the therapist may spend a lot of time on something seemingly unrelated, such as your posture or even how you breathe. Though these issues may be somewhat unrelated to the driect issue of social anxiety, if you can begin to see improvement in the condition, then the therapy is working. It is important however, that you are able to see improvement, or hope of improvement in the condtion as you continue therapy. |
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