Help me to help me.

November 22, 2011 12:10 PM

Training in 'concrete thinking' can be self-help treatment for depression. 'New research provides the first evidence that depression can be treated by only targeting an individual’s style of thinking through repeated mental exercises in an approach called cognitive bias modification. The study[pdf] suggests an innovative psychological treatment called ‘concreteness training’ can reduce depression in just two months and could work as a self-help therapy for depression in primary care.'

'Led by the University of Exeter and funded by the Medical Research Council, the research shows how this new treatment could help some of the 3.5 million people in the UK living with depression.
People suffering from depression have a tendency towards unhelpful abstract thinking and over-general negative thoughts, such as viewing a single mistake as evidence that they are useless at everything. Concreteness training (CNT) is a novel and unique treatment approach that attempts to directly target this tendency. Repeated practice of CNT exercises can help people to shift their thinking style.'

'Published in the journal Psychological Medicine, this study was carried out by a team from the Mood Disorders Centre, which is a partnership between the NHS and the University of Exeter and the Peninsula College of Medicine and Dentistry, a joint entity of the Universities of Exeter and Plymouth and the NHS in the South West.'

posted by VikingSword (62 comments total)

I like this because it depends on the patient acknowledging the rational truth, and while fantasies come and go, the truth is always sticking around. This method treats the patient with respect and without condescension.
posted by East Manitoba Regional Junior Kabaddi Champion '94 at 12:27 PM on November 22, 2011 [3 favorites]

Thanks for posting this. I have a friend who often fights to keep her head above water. I've tried to tell her about this type of training (not a therapist here, but took Cog Psy in college and so I am familiar with REBT), and I've suggested that she should ask for it from her therapist. Knowing what to call it will help a *lot.*
posted by erinfern at 12:32 PM on November 22, 2011

How is this different from CBT? I'm not being smart; I genuinely don't see a significant difference.
posted by liketitanic at 12:34 PM on November 22, 2011 [10 favorites]

Ugh, who cares about these "new treatments"? I'm such a loser, they'd never work on me anyway.
posted by hincandenza at 12:43 PM on November 22, 2011 [30 favorites]

Amazing mental state difference between "i'm a fuckup / that triumph was a fluke" and "i'm a winner / that failure was a fluke" though they're so semantically similar.
posted by seanmpuckett at 12:43 PM on November 22, 2011 [4 favorites]

That was a joke, btw. In case that wasn't clear.
posted by hincandenza at 12:44 PM on November 22, 2011

Professor Edward Watkins of the University of Exeter said: “This is the first demonstration that just targeting thinking style can be an effective means of tackling depression. Concreteness training can be delivered with minimal face-to-face contact with a therapist and training could be accessed online, through CDs or through smartphone apps. This has the advantage of making it a relatively cheap form of treatment that could be accessed by large numbers of people. This is a major priority in depression treatment and research, because of the high prevalence and global burden of depression, for which we need widely available cost-effective interventions.”

As a non-expert, the only problem I can see with this treatment is that it lacks a sophisticated business model (no consumables).
posted by notyou at 12:45 PM on November 22, 2011 [6 favorites]

How is this different from CBT?

Or, how is this different for a softened form of stoicism. The book to read on this is The Stoic Art of Living: Inner Resilience and Outer Results by Tom Morris.
posted by Yakuman at 12:45 PM on November 22, 2011 [1 favorite]

this sounds like such a good idea, I have totally seen so many friends of mine thinking in exactly the way they describe, and I can see how flawed the logic is, but they are in the middle of it, and cant, it's heartbreaking. If this becomes available and works well, I would happily buy a course of it for all my wound-up friends
posted by 5_13_23_42_69_666 at 12:46 PM on November 22, 2011

(assuming they wanted it, of course. makes me sound a bit pushy, the above does)
posted by 5_13_23_42_69_666 at 12:48 PM on November 22, 2011

how is babby steps formed?
posted by fleacircus at 12:54 PM on November 22, 2011 [9 favorites]

"CNT is a form of cognitive behavioral therapy, teaching people how to be more specific when reflecting on problems. This can help them to keep difficulties in perspective, improve problem-solving and reduce worry, brooding, and depressed mood.

This study provided the first formal test of this treatment for depression in the UK’s National Health Service."
posted by Postroad at 1:01 PM on November 22, 2011

This is interesting, but the claim in the press release (New research provides the first evidence that depression can be treated by only targeting an individual’s style of thinking through repeated mental exercises in an approach called cognitive bias modification) is flatly contradicted by their acknowledgement in the introduction of CBT's success. Mind you, INANShrink, so I might be missing something important.

Also, they don't shown that it's any better than the current Relaxation Therapy (which, don't get me wrong, looks useful based on their graphs). They do mention in the Discussion that patients who've practiced enough that the process is automatic show a decrease in ruminative and generalised thinking not seen in patients given only RT, but don't show data on this or give a strong argument to demonstrate that it matters. They also don't give any mention of its efficacy as compared to already-used CBT, which seems odd from this uninformed layman's perspective. Can anyone shed a little light?

A longer follow-up will be interesting to see: maybe after the self-examination has become automatic, you don't need the practice sessions (as much) any more? I can see that being a big boon: not needing to take time out to do CBT stuff was great after I'd internalised / automated some useful chunks. Not because of the inconvenience (although it's a factor), but because not needing to do specific exercises made me feel less like a sick person.

Also, I was intrigued by this:

There was no evidence of a differential response to treatments for those prescribed antidepressants versus those not prescribed antidepressants (TAU+CNT v. TAU: p=0.37; TAU+CNT v. TAU+RT: p=0.23).

It's very encouraging to see that it seems to work as well for people already on antidepressants as it does for those not on them. Does anyone know if this is typical, or would they normally be expected to confound each other?

How is this different from CBT?

It does sound pretty similar to a subset of the CBT that I've read about / used, but with some tweaks:

In CNT, the training exercises involved patients identifying a recent mildly to moderately upsetting difficulty and working through standardized steps to facilitate concrete thinking : (i) using mental imagery to focus on sensory details during the difficult event, noticing what is specific about the event and thecontext in which it occurs; (ii) noticing the process and sequence by which the difficult event unfolds (‘How did it happen? ’), including warning signs and actions that may have influenced its outcome; (iii) focusing on how to move forward by specifying the particular steps and behaviours to do next (Watkins, 2009; Watkins et al. 2009). he practice CD included (a) 30 min repeating the original training exercise ; (b) a 7-min First Aid exercise in which concrete thinking is applied to difficulties in real time as they occur (practised in the first telephone session); (c) a 7-min ‘absorption exercise ’ in which concrete thinking is used to enhance positive experiences (practised in the second telephone session).

NB: "The study[pdf]" link is broken for me: File not available. [S0033291711002480a.pdf] time=1321992297 [eopocc=1321992884] ...but going to the abstract via your third link lets me click on the "View pdf link", which does work. FF8.0 from within a university network.
posted by metaBugs at 1:13 PM on November 22, 2011 [4 favorites]

This is good, but it really isn't a surprise. We've known for a long time that psychotherapy is highly effective at treating mental disorders. According to people like Michael Lambert and Bruce Wampold, the effect size of psychotherapy is between 0.80 and 1.0.

Now, here's the rub: from what we know, the effects of psychotherapy appear to be independent of the type of therapy modality used. So yes, this works, but so do other forms of CBT, other forms of talk therapy, psychoanalysis, interpersonal therapy, EMDR, etc. What appears to matter are factors common to all therapies, typically called the common factors, especially the relationship between the therapist and the patient (this has the biggest controllable contribution to outcome), instilling hope in the patient that change is possible, and a plan for how that change will be achieved. Modalities provide hope, and they provide a plan, but both Lambert and Wampold have (separately) found that the specifics of different forms of therapy account for < 10% (and perhaps as little as 1%) of the variation in outcome.

That's actually very good news. All of it. We know that therapy works, and we know that therapies work about equally well, so people in distress have a wide variety of treatments to choose from.

Unfortunately, the push for specific evidence of effectiveness leads to some therapies being deemed "proper" treatment for some disorders. Hence, we see CBT touted quite a bit for the treatment of depression or anxiety. CBT is manualized, so it is easy to teach, easy to study, and yes, it works. But, it doesn't appear to work better than other therapies, it's just easier to study.
posted by OmieWise at 1:14 PM on November 22, 2011 [13 favorites]

once again science pokes more holes into the disease-model of mental health.
posted by rebent at 1:15 PM on November 22, 2011 [3 favorites]

and with that last comment.....we're off!! have fun!
posted by spicynuts at 1:20 PM on November 22, 2011 [5 favorites]

OmieWise - ...instilling hope in the patient that change is possible, and a plan for how that change will be achieved...

Presumably that's why they reported the patients' "Treatment Credibility" and "Treatment Expectancy" for each stream? If we could see the data stratified by those responses, would you expect to see a big difference between the high credibility/expectancy patients and the low?

Either way, your response was fascinating, thanks.
posted by metaBugs at 1:23 PM on November 22, 2011

I hate to wave the buddhist flag about but it's very similar to the calm-abiding progressing to insight approach common to most schools. Relaxing yourself and deeply examining events in order to understand what actually happened independent from your emotions and perceptions of them.

Totally dig it though, this stuff genuinely works in terms of dealing with difficult emotions and moods.
posted by nozendo at 1:27 PM on November 22, 2011 [2 favorites]

What appears to matter are factors common to all therapies, typically called the common factors, especially the relationship between the therapist and the patient (this has the biggest controllable contribution to outcome)[...]

Except if this is expected to be entirely self-driven and pushed out through non-therapist assisted means (CDs, apps etc.), then your most important ("especially") commonality factor is right out the window.

I might be missing the point, but to me, what's new in all of this is not the CBT aspect, but the self-administration, perhaps even 100% self-administration. Taking it out of the hands of therapists entirely, and putting the patient firmly in control. Potentially this could allow a much greater reach because so many people don't seek help on account of lack of insurance, fears of being seen as "needing professional help", financial reasons, and just general inertia when confronted with the need to seek the appropriate health provider, making appointments etc. Therefore, if this works as claimed, it might be pretty big news, and affect huge numbers of people once they're alerted to this option.
posted by VikingSword at 1:35 PM on November 22, 2011 [2 favorites]

nozendo: yes.
posted by beefetish at 1:38 PM on November 22, 2011

VikingSword, good points but I think there's always some need for a professional touchpoint with this stuff, especially for cognitive bias? It can be very easy to try to apply a framework by yourself and suffer from the existing issues, as in, I'm doing this wrong! This will never work for me! etc.

Sometimes you need someone external to wrench you through the first rounds of change before you have the skills to pull this off. I see it as a big difference between reading that you're going to get sorted versus having someone engaged and working with you to make the change.
posted by nozendo at 1:39 PM on November 22, 2011 [3 favorites]

So maybe this is why practicing Getting Things Done makes me feel better? It's emphasis on "Next Action" is about as concrete as it gets and maybe that provides training for other sorts of thinkings? Or maybe I'm just drawing too many conclusions.
posted by Brainy at 1:40 PM on November 22, 2011

VikingSword: this study describes the treatment as starting with a face-to-face interview, and involving later sessions by telephone. It's certainly an advance over (my perception of) traditional therapies, but not over existing CBT which, at least on the NHS, follows a similar model, with infrequent direct contacts used to guide online or worksheet-based exercises.
posted by metaBugs at 1:42 PM on November 22, 2011

It's certainly an advance over (my perception of) traditional therapies, but not over existing CBT which, at least on the NHS, follows a similar model, with infrequent direct contacts used to guide online or worksheet-based exercises.

It is my understanding that traditional CBT in the U.S. has a fairly prominent involvement of the therapist. You may have "homework assignments", but you are still in therapy with a therapist. So this is pretty different in that after the initial set up visit, you are expected to be able to work on your own with very little additional course correction from the therapist. And if results can be obtained in as little as two months, it might be possible to avoid it altogether down the line for those that have internalized the methodology well enough - at that point, things like apps become helpful in maintenance, perhaps obviating any need for a live human. I have no familiarity with the NHS protocols, so perhaps this is indeed how CBT is done there, so point taken.
posted by VikingSword at 1:49 PM on November 22, 2011

Brainy, depends on your foundation of thought. Your next action is your next action, the difference is doing it "because it's what's next and this is kind of fun" versus "I must do this because I'm a worthless turd and I'll fail at everything and the world will end" kind of thing.

The reality of anything is fixed, as per the approach here, it's just the horror that people can create in their perceptions that causes the hassle.
posted by nozendo at 1:49 PM on November 22, 2011

Imagine if they began teaching this technique in elementary school. We could have whole generations of kids growing into teenagers and adults with resilience, emotional confidence and the skills to maintain good mental health.
posted by Kerasia at 1:55 PM on November 22, 2011 [6 favorites]

I don't know if all of this qualifies as therapist involvement - or to what degree if it does. Rather than a dedicated therapist who has your particular case and a special therapist-patient relationship, it appears these were "trainers" ("two graduate-level psychologists, two postdoctoral psychologists and one clinical psychologist"), whose function was to explain the program and train the subjects in the mechanics of the methodology rather than providing traditional therapy ("to ensure accurate use of the exercises, monitored progress and scheduled regular practice"). Note that the trainers themselves were supervised to insure proper methodology was followed. From the study:

"Both CNT and RT consisted of: (a) an initial individual face-to-face session lasting approximately 1.5 h; (b) the patient practising the training exercises recorded on audiotape/compact disc (CD), supported by a detailed workbook, with a recommended frequency of 15–30 min daily for at least 6 weeks; (c) up to three 30-min telephone sessions, scheduled 1 week after the initial training and then at 2-week intervals. During the initial session, the trainer explained the treatment rationale, provided psycho-education about depression, rumination and overgeneralization, and practised training exercises with the patient. During the telephone sessions, the trainer provided feedback, guidance and encouragement to ensure accurate use of the exercises, monitored progress and scheduled regular practice. Training was provided by two graduate-level psychologists, two postdoctoral psychologists and one clinical psychologist, who used scripted manuals for each treatment. Trainers received weekly supervision to ensure therapy adherence."
posted by VikingSword at 2:02 PM on November 22, 2011

But what if it's this concrete world that's depressing me?
posted by chronkite at 2:06 PM on November 22, 2011 [7 favorites]

beefetish: "nozendo: yes."

woof.
posted by symbioid at 2:10 PM on November 22, 2011

CBT is manualized, so it is easy to teach, easy to study, and yes, it works. But, it doesn't appear to work better than other therapies, it's just easier to study.
posted by OmieWise at 1:14 PM on November 22 [1 favorite]

But if CBT is easier to teach (and perhaps easier to learn, from the patient perspective) than other forms of therapy, maybe that, in and of itself, makes it a superior modality. If it's easier to get good at CBT than other forms of therapy, then it's better.
posted by yarly at 2:11 PM on November 22, 2011

Vikingsword, in your quote:

"During the telephone sessions, the trainer provided feedback, guidance and encouragement to ensure accurate use of the exercises, monitored progress and scheduled regular practice."

That's the part of the contact I see as critical, agree that it's not necessarily critical to make trainer / therapist distinct, as long as someone provides this function. =)

On my side of the fence it's roshi or guru, but they're doing the same thing as the intent here.
posted by nozendo at 2:14 PM on November 22, 2011

But if CBT is easier to teach (and perhaps easier to learn, from the patient perspective) than other forms of therapy, maybe that, in and of itself, makes it a superior modality. If it's easier to get good at CBT than other forms of therapy, then it's better.

Well, no. The data do not suggest that this is true. The data suggest that all modalities are about the same. You've advanced an interesting hypothesis, but it isn't borne out. Now, you could also advance a sort of opposite hypothesis, which is that CBT is a modality that does not explicitly seek to teach therapists how to manage the relationship, and so it would be a worse modality. Those modalities, like interpersonal therapy, that are focused on relationship, would be better. But, again, that hypothesis is not borne out by the data.

If it's easier to get good at CBT than other forms of therapy, then it's better.

Also, training people how to provide CBT is not the same thing as training people how to be good at delivering CBT, or, more importantly, helping patients.
posted by OmieWise at 2:20 PM on November 22, 2011

On the study PDF:
File not available. [S0033291711002480a.pdf] time=1321992297 [eopocc=1322000572]

Did we take the site down?
posted by speug at 2:24 PM on November 22, 2011

> But what if it's this concrete world that's depressing me?

It's no measure of health to be well adjusted to a profoundly sick society. According to the current wikiquote talk page on Krishnamurti, there is no accepted citation that he ever actually said that!
posted by bukvich at 2:28 PM on November 22, 2011

PDF available here:

http://journals.cambridge.org/action/quickSearch?searchTypeFrom=quickSearch&_currentPage=1&_pageSize=50&_sortBy=online_date_range%20desc&searchType=sort
posted by speug at 2:30 PM on November 22, 2011

The relationship one forms with one's therapist is highly dependent on the mode of therapy. The way your therapist goes about their work will form your primary experience of them. It will make them seem like a different person. My first few therapists led the discussion, and while they always made sure that I was the subject of the discussion, it still made me feel like I was being put under a microscope. Later on, I started seeing therapists who would ask me where I wanted the discussion to go, expressing their observations and maybe even suggestions but never actually leading me; I reacted better to that.

It may have something to do with growing up, since people are more apt to let an adult lead a conversation.
posted by LogicalDash at 2:30 PM on November 22, 2011 [1 favorite]

For the people having a problem, you can reach the study in both pdf and html by going to the links from the abstract in Psychological Medicine.
posted by VikingSword at 2:33 PM on November 22, 2011

But what if it's this concrete world that's depressing me?

Then you want to give it as little help as possible. Describing things in objective, neutral terms can help to, er, neutralize them.
posted by LogicalDash at 2:33 PM on November 22, 2011 [1 favorite]

VikingSword - I might be missing the point, but to me, what's new in all of this is not the CBT aspect, but the self-administration, perhaps even 100% self-administration.

Nothing new about that idea either.
posted by Defenestrator at 2:44 PM on November 22, 2011

Interesting, Defenestrator. I suppose self-help type books and advice have existed for a long time, so perhaps what's new here is that there's actually some kind of study that can attempt to measure the effects and specify a protocol that has empirically tested results vs assertions from authors (however well meaning) or personal anecdote type protocols. Of course, perhaps the author of the book you link is basing his methodology on just such a study, in which case, scoop.
posted by VikingSword at 2:52 PM on November 22, 2011

The thing about this stuff is that, as a depressed person, you have to have your head above water enough to where you're at least receptive to trying these methods. Seems to me that's at least half of the battle already won before theses methods even start.

For people like myself, this stuff is like water off a duck's back.
posted by Thorzdad at 2:52 PM on November 22, 2011 [1 favorite]

VikingSword - Interesting, Defenestrator. I suppose self-help type books and advice have existed for a long time, so perhaps what's new here is that there's actually some kind of study that can attempt to measure the effects and specify a protocol that has empirically tested results vs assertions from authors (however well meaning) or personal anecdote type protocols. Of course, perhaps the author of the book you link is basing his methodology on just such a study, in which case, scoop.


Yeah, the author of this one is considered one of the founders of CBT and did use his (first) book in clinical research studies. I'm not sure how to link to a specific line in that "Look Inside" feature that Amazon has but he starts talking about it in the last couple lines of xvii.
posted by Defenestrator at 3:00 PM on November 22, 2011

I dunno, I'm always excited about new depression treatments, but does nobody else at all find this a little bit sinister? I definitely have 'a tendency towards abstract thinking', but I think that's a good thing; it gives me insight into the world I wouldn't otherwise have, even if that insight is sometimes unhelpful. I really instinctively loathe the idea that my mental illness somehow demonstrates that I haven't used my mental tools wisely and so they should be taken away from me.

CBT has its own creepiness, like the insistence that all negative interpretations of situations are always wrong - try arguing with a therapist who's using the CBT script about your sadness/anger/guilt regarding international injustice. You'll have a fun time. But at least with CBT if you're resistant enough the therapist will eventually go 'off script' (at least that's what happened to me) and you can start having decent, reality-respecting human conversation. This, on the other hand, is going to be another stupid hoop to make people jump through before they get to access proper therapy.

Just to clarify for US people, in the UK we have a ladder model of mental health. You start at the bottom with antidepressants; then if you're assessed to need it you go on a waiting list for 6-8 sessions of CBT. The waiting lists are long, so a lot of people never get that far. A friend of mine was told that because of the shortage of psychologists in her area, the only therapy she was realistically going to get was a click-through adventure on a computer. At the end of the CBT, if you get it, the therapist can then refer you for a year's individual psychodynamic therapy or a year's group therapy. You go on a waiting list to get assessed (about 3 months in these parts) and if the assessor thinks you need regular therapy you then go on another waiting list which may be 9 months to a year. Then you get your year's worth of therapy. I've only got that far as yet, so god knows what happens if after all that you're still crazy.

What this will presumably do is introduce another level of bullshit below the CBT waiting list; it will also negate all the work that's been done in recent years to increase the number of trained psychologists who are employed to tackle the increasing numbers of people with clinical depression. Instead, we'll get another stupid app, on the lines of the other asinine computerised therapies out there, many of which I've sampled. Believe me, you haven't known despair until you've sat for two hours ticking boxes about which cognitive errors a cartoon man wearing a tracksuit (Name: Self-Critical Steven) is demonstrating when he calls himself 'a failure at everything'.
posted by Acheman at 3:14 PM on November 22, 2011 [13 favorites]

Defenestrator wrote: Nothing new about that idea either.

Yes, there is also this one. Interestingly these off the shelf CBT technques have been used for non-clinical mental performance improvement (e.g. for Olympic athletes etc) and general mood enhancement (with good results).
posted by storybored at 3:15 PM on November 22, 2011

Just to make clear, my comment makes me sound bitter about NHS treatment of depression, which in my own case I'm mostly not. I've had a lot of fantastic people helping me along my way, from an excellent GP to several psychologists, to the Buddhists near me who do mindfulness and compassion courses that are partly funded by the local authority. I'm doing pretty well at the moment, which is a massive achievement. The computerised things I did mostly before I got up the bottle to talk to an actual, human doctor about my problems. At the same time, the system is massively under-resourced, there is a lot of waiting around, and I have friends who have fallen through the cracks somewhat. Moreover, formalised, scripted CBT is bullshit, and this sounds even worse.
posted by Acheman at 3:21 PM on November 22, 2011 [2 favorites]

Moreover, formalised, scripted CBT is bullshit, and this sounds even worse.

Which is why it's important to have a study that can be peer reviewed - that way we can measure the effectiveness of the treatment protocol to find out if it's bullshit or worse. It's easy to speculate about unknowns, hard to argue with data.

Obviously, any treatment will have those for whom it works, and those for whom it doesn't. It certainly will be true of this one as well, but that's no reason to stop searching for more treatment modalities - if it works for a subset of patients, what's wrong with that? If we only look for something that will work 100% for 100% of the patients, we'll look for a long time.
posted by VikingSword at 3:26 PM on November 22, 2011

Acheman - CBT has its own creepiness, like the insistence that all negative interpretations of situations are always wrong - try arguing with a therapist who's using the CBT script about your sadness/anger/guilt regarding international injustice.

That doesn't sound like the CBT I learned (from that book I linked).

Which I guess brings up the point that it seems like there is only limited standardization, which results in stuff like this (which at this point seems like old news) seem new and interesting to others.

I'm not a trained psychologist though, so I could very well be very wrong.
posted by Defenestrator at 3:33 PM on November 22, 2011

I've read 'Feeling Good'. I found it immensely frustrating. I think its approach is over-simplistic and essentially wrong. I've also read quite a few other books about CBT, which I found even more frustrating and even more disconnected from reality.
posted by Acheman at 3:49 PM on November 22, 2011

I've read 'Feeling Good'. I found it immensely frustrating. I think its approach is over-simplistic and essentially wrong. I've also read quite a few other books about CBT, which I found even more frustrating and even more disconnected from reality.

And this is the reason that it's not neutrally good that CBT is so easily studied and has therefore become the de facto "evidence based treatment." It works, sure, but what that means is that it works for some people some of the time, the same as every other treatment we have for mental distress, including medications. For people who do not like it, for whatever set of reasons, it is much less likely to work. If, because it is easily studied, hardily promoted, and relatively time-limited, it becomes the only available treatment, choices for people with mental distress will narrow, not expand.
posted by OmieWise at 3:57 PM on November 22, 2011 [3 favorites]

OmieWise - It works, sure, but what that means is that it works for some people some of the time

In this case it actually means that it works for a significant number of people a significant amount of the time.

If, because it is easily studied, hardily promoted, and relatively time-limited, it becomes the only available treatment, choices for people with mental distress will narrow, not expand.

I do agree with this. I don't know that there's any evidence that it's become the only available treatment, though. If anything, popping some pills is the typical go-to when somebody speaks to their doctor about mental illness.
posted by Defenestrator at 4:15 PM on November 22, 2011

My depressive periods have been FAR less drastic as an adult, and I'm wondering if it's a matter of changing brain chemistry, or a highly scientific technique I devised whereby I view my brain chemistry as an epic Hero's Journey - I'm a peasant caught up in a perpetual war between a shining warrior and evil death orcs.

(cue music)

In my teenage years, the warrior was just some brash young upstart adventurer with a talent for swordplay and good intentions. His attempts to intimidate the orcs or to rally support for his cause all failed; he had no victories under his belt, no worldly wisdom. He was all bluster, and both the peasantry and the orcs saw right through it. Routed him constantly, raped and pillaged. The situation looked like it would never improve, the peasantry resigned to their fate, the skies darkened with misery.

But the warrior never surrendered, despite having lost pints of blood and experienced horror and humiliation untold. Now, a decade later, he has managed to fight and win a number of battles through cunning and strategy. He knows, with certainty, that situations are rarely as bad as they seem, that the orc king is a devious liar; even if the orc king's taunts are vaguely based in truth, they only serve to exploit fear and insecurity.

But most importantly, people are beginning to believe in the warrior. They see that he now has hard-won experience, so his uplifting words are worth listening to. There are still skeptics, of course, but he is no longer ignored, and can now raise a mighty army to defend the kingdom.

The orcs breed quickly and never give up. They probe tirelessly for tiny cracks in the castle walls, they put less defensible towns under siege, and they take advantage of any physical illness or financial strain that might challenge the kingdom. Sometimes they wage a large campaign, gaining ground, and becoming a threat once more. But they can never advance quite as far inland, for the walls are strong and even the lowliest farmer is quick to take arms.

Even with the distant, hazy orc threat looming, the citizens live their lives, laughing far more than they cry -- which is about as decent a life as one could hope for.

Should I publish this theory in Nature? I am pretty sure it is scientifically sound (Yes/yes)



(p.s. I haven't gotten to the effect of mania on the kingdom yet. But I think after this post, I don't really need to. Let's just say that manic times are when the chroniclers, scribes, and bards do their thing, and are eventually executed for ... speaking above their station. Or high treason.)
posted by jake at 4:43 PM on November 22, 2011 [12 favorites]

If I’m reading this right this sort of sounds like what I slowly and painfully figured out for myself over many years. Like others have said, the hardest part is get your head straight enough to even try, or see that it is possible to think a different way. It’s also really hard to explain to someone else without sounding like "just think happy thoughts".

I feel (with no scientific reason) that changing my way of thinking has changed my brain chemistry. It’s always a struggle, but much less so. I’ve always thought of it as treating a physical problem.
posted by bongo_x at 6:32 PM on November 22, 2011

Depressive Realism disagrees with this principle.

Which is not to say that all depression is rational, only that not all depression is due to cognitive errors. Depression, after all, is an emotional state, not a cognitive one, although it may be caused or influenced by your thought patterns.

What if I can find no errors in my thinking about the concrete world, but still find myself unable to feel anything other than shitty?
posted by simen at 6:45 PM on November 22, 2011 [1 favorite]

Soc. And he who descends into a well, and dives, and holds out in this or any similar action, having no knowledge of diving, or the like, is, as you would say, more courageous than those who have this knowledge?
La. Why, Socrates, what else can a man say?
Soc. Nothing, if that be what he thinks.
La. But that is what I do think.
Soc. And yet men who thus run risks and endure are foolish, Laches, in comparison of those who do the same things, having the skill to do them.
La. That is true.
Soc. But foolish boldness and endurance appeared before to be base and hurtful to us.
La. Quite true.
Soc. Whereas courage was acknowledged to be a noble quality.
La. True.
Soc. And now on the contrary we are saying that the foolish endurance, which was before held in dishonour, is courage.
La. Very true.
Soc. And are we right in saying so?
La. Indeed, Socrates, I am sure that we are not right.

- Plato
posted by edguardo at 9:14 PM on November 22, 2011

Today, all I need is to look at this picture.
posted by i_am_joe's_spleen at 10:56 PM on November 22, 2011 [4 favorites]

@Acheman

Thanks for that writeup of the NHS. I am a recent transplant from the states, where I had a talk therapist (not cbt) for the past year, and 6 months of CBT before that.

Is it not possible to get to therapy without medication? Are there other alternative outside of the buddhist societies (although I am going to look into this as well)? I went to a graduate school training thing for a while for therapy and it mostly worked great.
posted by jonbro at 2:35 AM on November 23, 2011

Defenestrator: I don't know that there's any evidence that it's become the only available treatment, though. If anything, popping some pills is the typical go-to when somebody speaks to their doctor about mental illness.

No, certainly CBT is not the only available treatment, but it's one of a reduced slate of treatments called "evidence based treatments" that are in danger of becoming the only available treatments. Psychiatric medications are certainly among those treatments. Again, the issue is not that these treatments don't work, but that the overall research suggests that just about everything works. The push to restrict acceptable treatments based on research done at the wrong level of granularity is distressing to those who work in the field (me), and should be distressing to patients as well, since it narrows their choices.
posted by OmieWise at 3:56 AM on November 23, 2011 [3 favorites]

OmniWise, I disagree with your charaterization of the studies by Wampold et al. Yes, they have found that by lumping together published studies of "bona fide" treatments (a characterization that itself has been criticized) you can obtain an overall effect size that is not significantly different across treatments. This finding of no significant difference is NOT the same as equally good, and is complicated by the far greater number of CBT studies compared to other treatments (you are correct, CBT is easier to study in a controlled way, though I would argue that that in part reflects the field's commitment to scientific principles). Patients might or might not be interested in pursuing a school of therapy that has historically been dedicated to rigorous testing of its theories.

In any event, the most substantial problem w the Wampold argument is that he groups treatment studies FOR ALL CONDITIONS together, rather than separately evaluating the best type of treatment for social phobia, or panic disorder, or depression (Mefites who are interested in finding these more specific results should search for meta-analyses, or look at some of the nice Cochrane Reports on each disorder). Not only is this type of comparison more appropriate scientifically (it takes into account the differences across disorders, just as you want researchers to take individual differences at the person level into account, right?), it also is more clinically useful. People have specific diagnose(s), so it is most important to know what works for that diagnosis. And, time and again, that is CBT.

Obviously the fact that CBT works better than, say, dynamic therapies, for the treatment of panic disorder doesn't mean that no one was ever cured of their panic by a dynamic therapist. Just that, on average, there is a significantly greater chance that a given panicker will respond to CBT. I think it does patients a disservice to gloss over that distinction.
posted by Bebo at 6:26 AM on November 23, 2011

I've read 'Feeling Good'. I found it immensely frustrating. I think its approach is over-simplistic and essentially wrong.

I had the same reaction, and I think it's so unfortunate that this book is considered gospel for CBT. Not only does it condescendingly assume that all negative thoughts are distortions-- just try to find an instance where David Burns acknowledges that sometimes life is tough-- but it doesn't even whisper about the possibility that a *positive* thought could ever be a distortion. Burns attacks strawman versions of cogitive errors, rather than the more nuanced and intractable versions that don't have such easy answers, and I frankly found him insulting.
posted by Dixon Ticonderoga at 8:23 AM on November 23, 2011 [2 favorites]

I've always kind of thought of depression, in my case at least, as a failure of mental homeostasis — hypothermia for mood. What causes it is not that important, but that failure of self-regulation is what makes it so bad, what makes it not sadness. Thinking about things concretely and having contact with (friendly) others are two ways of re-equilibriating with the world (which are often avoided by people in the midst of depression — danger, Will Robinson, recursion!).

I'm doing pretty OK these days, depression has eaten as much of my life as it's going to. But I can think of at least one person who needs this, if only the problem of getting someone to start solving the problem wasn't so tricky.
posted by Wrinkled Stumpskin at 11:09 AM on November 23, 2011

Mental homeostasis = Euthymia.
posted by P.o.B. at 1:18 PM on November 23, 2011 [1 favorite]

Thanks for that write-up of the NHS....Is it not possible to get to therapy without medication?

I think Acheman's model has been typical for a while, but is changing, at least in some places.

Just this week I heard a presentation from the consultant psychiatrist who heads up the Community Mental Health team at NHS Lothian (Edinburgh and surrounding areas). He showed a pyramid-shaped diagram with exactly that kind of model on it, starting at the bottom with the most common, 'entry level' types of treatment, with patients gradually filtered upwards to the more 'serious' (and expensive) ones if the first tiers failed. Unfortunately I don't remember exactly what was on each tier.

But he said the emphasis now was much more on getting people straight into the most appropriate tier, rather than forcing them to try each and only move on if it didn't work. There were also more alternatives available to GPs, like
* Referring people to free drop-in CBT evening classes run by mental health charities (quicker than waiting for NHS counselling and doesn't go on your medical records).
* Prescribing exercise (ie. free gym membership and a tailored programme), with the results monitored.
* Prescribing books for self-help.

But I have no idea how widespread that model is.
posted by penguin pie at 10:03 AM on November 26, 2011