In cognitive therapy, cognitive distortions represent the lenses out of which we view the world and filter our version of reality. In light of recent developments among some therapists, dichotomous (either/or) thinking has emerged as a professional hazard. I recently attended a national mental health conference. I was intrigued as presenters and colleagues alike made comments that presented a distorted perspective regarding some significant behavioral health issues.
As M. Scott Peck eloquently articulated in his work, The Different Drum, it is important that as thinkers we look at problems multi-dimensionally. We must not get trapped by any one side of an argument, but stay open to multiple sides of an issue; by doing so, we show integrity. Staying open to the truth wherever we find it allows us to be more grounded, rational and informed.
Within the last several years, many clinicians within the counseling profession have started to under-cut the role of prescription psychotropic medications as a facet of treatment. Some of the arguments from these naysayers of medication management are:
• There is no evidence that serotonin or norepinephrine levels affect mood.
• A quality therapist’s treatment is sufficient to free us from the dependency to psychotropic medications.
• Primary care physicians and psychiatrists have a propensity to push medication, thus justifying the need for their professions.
• Touting the use of antidepressants and other mood-stabilizers is primarily a marketing ploy.
Lately, high profile cognitive-behavioral therapists have been down-playing the efficacy of antidepressants and other mood-elevating medications by stating that CBT is sufficient to "cure" any problem without a crutch, thus “ditch the Zoloft.” Although many research studies support the synergistic effect of cognitive therapy and antidepressants, CBT therapists are dismissing such findings as misguided.
Existential therapists are also following suit. Since they believe that all suffering is legitimate, using medications to stabilize mood remains unnecessary. In fact, existentialists believe that taking antidepressant medication thwarts the grieving process, thus delaying the natural progression of growth. According to their viewpoint, we must not pathologize the human experience.
I believe that a more pragmatic, balanced and useful position is to acknowledge the legitimacy of psychotropic medications in curbing anxiety, depression and other disorders of mood. We should accept these medications because for many sufferers they work. Antidepressants serve as an aid, an emotional "floor" while patients undergo therapeutic treatment to derive more long-lasting benefits in coping with emotional distress. Furthermore, it is essential that those suffering from bipolar disorder take mood-stabilizing medication to treat their symptoms. There is no other viable option for treatment.
Why is it that many therapists now embrace a philosophy which discounts the use of psychotropic medications? It is true that people generally do what’s in their best interest, and many therapists hold a position which dismisses the legitimate use of medication for several reasons:
• It enhances their belief that their therapeutic orientation is unique and sets them apart from the competition.
• It increases their ability to generate income. Therapists postulate that marketing an approach that will fix you without the use of medication (prescribed by a PCP or psychiatrist), is more enticing and potentially lucrative.
• Therapists, who disown the use of psychotropic medications prescribed by physicians, are driven by their feelings of exclusivity about their approach, coupled with the desire to market themselves. The practicalities of what is in the best interest of the patient are ignored. Marketing takes precedence over pragmatism and utility.
Another danger involving dichotomous thinking relates to mind-body therapies. Holistic thinking has taken root in the mental health profession. Many therapists integrate alternative therapies that claim to remedy behavioral and emotional conditions. Some of the treatments are evidence-based, but many cannot be supported empirically. Case in point is reflexology and therapeutic touch, which claim to explore and heal energy systems. The therapeutic community needs to do a better job of ferreting out modalities that have functionality versus those which are of questionable utility. Once again, in the process of propagating the mind-body connection, we may error on the side of discounting physical medicine, including psychotropic medications.
As a therapist, one must carefully weigh all sides of an issue before making value judgments. Therapists must be honest and informed when making statements about psychotropic medications and the mind-body connection. At a recent mental health conference that I attended, a participant claimed that she was dismayed by the over-use of stimulants for students experiencing ADD. However, it is clear that ADD has been under-diagnosed, not over-diagnosed, and those who receive treatment with stimulant medication in concert with therapy do significantly better than those prior to treatment or without treatment.
It is imperative that therapists represent their profession appropriately. This means that we take a carefully crafted approach to treatment based upon sound research and a sense of balanced thinking and integrity. Being blinded by any one perspective only polarizes the profession. Theory and practice must come together in a way that provides our patients with the best chance of making improvement. Part of the answer is to offer our clients a multipronged approach with the best quality evidence-based theory, medication management (if needed), and alternative adjunctive treatment modalities that have a history of demonstrated effectiveness.
Friday, July 31, 2009
Monday, July 20, 2009
The Identity of Imperfection
When Alex was a kid, he recalls his father chastising him for not washing the car properly. Alex volunteered his services as a five-year-old child, but his dad showed little appreciation. On the contrary, when he "missed a spot," his father would berate him by calling him stupid. He was a sensitive child who wanted to please his father, but ended up feeling devalued.
Over time, Alex associated his less than perfect performance with his personal identity. If what he did was less than acceptable, then by all means he must be defective. His father never encouraged or coached him on a better way to wash the car, so he was left to feel inadequate about any task he attempted.
Alex evolved into a self-critical, angry youngster. In Little League, he excelled as a player. He was known for his outstanding skills and performance. Nevertheless, he berated himself, other players and the umpires during his occasional unsuccessful at-bats during games. He recalls running feverishly towards first base, being called out, and throwing his helmet, stomping his feet and raging at the officials. Although he was conflicted and confused about his poor sportsmanship, he wasn't capable of stopping his inappropriate behavior. His parents never got involved, intervened and discussed the "why" of his self- defeating thinking and behavior nor tried to correct it.
In adulthood, Alex was able to trace his painful memories of personal performance-related criticism and anger through the filter of his son’s experience. His son, Damon, was a very talented basketball player. Alex was perplexed because he never recalled Damon losing his "court presence" during a game. His son was grounded, focused and in control. These qualities actually helped enhance the level of his game. Alex was thrilled that the legacy of persistent perfectionism never created a problem for his child.
As he sat in the stands and watched one of his son’s tournament games, Alex recalls reflecting on what parenting skills he had implemented with Damon that were different from the way in which he was raised:
• Like Alex, his son was very sensitive. Alex made sure that he never harshly scolded him.
• His form of discipline was facilitated through coaching, instruction and encouragement.
• He always let Damon know that he was proud of him.
• He believed that mistake-making was a necessary part of child-development.
• He challenged his son to excel without motivating through intimidation.
• He remained involved with Damon and attended his activities at school and in the community.
• Alex's limits were firm, but reasonable with logical consequences for positive and negative behaviors.
• He always differentiated Damon's behavior from his personal worth.
Alex gave his son what he found difficult to provide for himself - support, soothing, comfort and affirmation. Ironically, he learned through role-modeling his son’s behavior how to begin parenting himself. The process of learning to self-nurture involved facing his past, grieving and releasing its emotional impact while creating fresh interpretations of his thinking and behavior.
He cut into the "pedestal of perfectionism" and learned to allow himself the freedom to perform less than admirably at times. He practiced selective mistake-making as a way of giving up some control and allowing for a measure of vulnerability. Alex worked on being less self-critical and judgmental of others, and eventually learned to hold the identity of imperfection. He learned to push less, and relax more as his performance, like his son’s, actually improved.
James P. Krehbiel, Ed.S., LPC is an author, freelance writer and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. James is the featured Shrink Rap columnist for TheImproper.com, an upscale arts, entertainment and lifestyle web magazine. He has contracted with New Horizon Press to publish his latest work entitled, The Search for Adulthood: Saying Goodbye to the Magical Illusions of Childhood. This book is about the impact of “unavailable” parenting on adults and the people they become. James can be reached at www.krehbielcounseling.com.
Over time, Alex associated his less than perfect performance with his personal identity. If what he did was less than acceptable, then by all means he must be defective. His father never encouraged or coached him on a better way to wash the car, so he was left to feel inadequate about any task he attempted.
Alex evolved into a self-critical, angry youngster. In Little League, he excelled as a player. He was known for his outstanding skills and performance. Nevertheless, he berated himself, other players and the umpires during his occasional unsuccessful at-bats during games. He recalls running feverishly towards first base, being called out, and throwing his helmet, stomping his feet and raging at the officials. Although he was conflicted and confused about his poor sportsmanship, he wasn't capable of stopping his inappropriate behavior. His parents never got involved, intervened and discussed the "why" of his self- defeating thinking and behavior nor tried to correct it.
In adulthood, Alex was able to trace his painful memories of personal performance-related criticism and anger through the filter of his son’s experience. His son, Damon, was a very talented basketball player. Alex was perplexed because he never recalled Damon losing his "court presence" during a game. His son was grounded, focused and in control. These qualities actually helped enhance the level of his game. Alex was thrilled that the legacy of persistent perfectionism never created a problem for his child.
As he sat in the stands and watched one of his son’s tournament games, Alex recalls reflecting on what parenting skills he had implemented with Damon that were different from the way in which he was raised:
• Like Alex, his son was very sensitive. Alex made sure that he never harshly scolded him.
• His form of discipline was facilitated through coaching, instruction and encouragement.
• He always let Damon know that he was proud of him.
• He believed that mistake-making was a necessary part of child-development.
• He challenged his son to excel without motivating through intimidation.
• He remained involved with Damon and attended his activities at school and in the community.
• Alex's limits were firm, but reasonable with logical consequences for positive and negative behaviors.
• He always differentiated Damon's behavior from his personal worth.
Alex gave his son what he found difficult to provide for himself - support, soothing, comfort and affirmation. Ironically, he learned through role-modeling his son’s behavior how to begin parenting himself. The process of learning to self-nurture involved facing his past, grieving and releasing its emotional impact while creating fresh interpretations of his thinking and behavior.
He cut into the "pedestal of perfectionism" and learned to allow himself the freedom to perform less than admirably at times. He practiced selective mistake-making as a way of giving up some control and allowing for a measure of vulnerability. Alex worked on being less self-critical and judgmental of others, and eventually learned to hold the identity of imperfection. He learned to push less, and relax more as his performance, like his son’s, actually improved.
James P. Krehbiel, Ed.S., LPC is an author, freelance writer and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. James is the featured Shrink Rap columnist for TheImproper.com, an upscale arts, entertainment and lifestyle web magazine. He has contracted with New Horizon Press to publish his latest work entitled, The Search for Adulthood: Saying Goodbye to the Magical Illusions of Childhood. This book is about the impact of “unavailable” parenting on adults and the people they become. James can be reached at www.krehbielcounseling.com.
Sunday, July 12, 2009
Make Way for a Different Kind of Thinking
I distinctly recall when Nathan began seeing me for counseling. He was a skinny, sensitive kid with a big heart. At age 13, he struggled in the midst of a tumultuous custody battle that left emotional scars. My job was to prop him up - to give him hope that things would change for the better - and they did.
Nathan came back to see me three years after he had "graduated" from therapy. He brought his new guitar and treated me to few melodies in the privacy of my own office. He was serenading me - it was a gift for being there for him. However, Nathan's visit took on a more important purpose. He came to tell me, in so many words, how he had become a different kind of thinker - the type of young person who inevitably would change the very foundations upon how we view matter and energy and life itself. At age 16, Nathan had graduated from a college preparatory high school and made his way to a prestigious university to study nanotechnology.
As I intently listened, Nathan explained that nanotechnology will allow us to snap together the fundamental building blocks of nature more easily, more cost effectively, and in a way that is permitted through the laws of physics. Nanotechnology has the ability to transform our thinking about science, physical health and disease, emotional well-being, computer programming, and travel to outer space. Not only was Nathan "studying" this complex, molecular thinking, but he was actually conducting research with the world's greatest scientists in this technological field.
Like an H. G. Wells of his time, Nathan passionately projected what the world would look like in the next 15 years due to his work. His words seemed prophetic and powerful, and I sense that I was sitting before one of a new age of young people - the dreamers, the problem-solvers, the visionaries who would create a new way of thinking about thinking. These are not “egg-heads,” but balanced, well-rounded kids who have the capacity to not only reflect on problems but to communicate about how the world will dramatically change due to their influence.
Nathan represents an influx of thinkers among thinkers, who will quietly work behind the scenes to make things happen. These are not our future leaders or managers, but those who empty themselves of all internal clutter or preconceived notions about how the world works. By staying open to the truth, wherever they may find it, new, exciting discoveries will be made that will impact all aspects of the human condition.
Like Nathan, our future thinkers can recognize the qualities and significance of emptiness. They can handle the perplexing nature of uncertainty and ambiguity. They understand that there are multiple dimensions to any problem with conflicting and paradoxical meanings. They are willing to surrender conventional notions about how the world works in order to make room for the new. By cutting a path through the clutter and letting go of a traditional means of thinking, these talented young people will open themselves up to what Robert Schuller referred to as, "possibility thinking."
In the midst of all the incivility and strife that we are faced with, Nathan will make a difference. He has not forgotten what it was like to stand face to face at a young age with problems that were bigger than he was capable of solving. He will use that experience to empower and propel him in a direction to bring peace as he thinks about and humbly solves problems that raise hope and healing for all humanity.
James P. Krehbiel, Ed.S., LPC is an author, freelance writer and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. James is the featured Shrink Rap columnist for TheImproper.com, an upscale arts, entertainment and lifestyle web magazine. He has contracted with New Horizon Press to publish his latest work entitled, The Search for Adulthood: Saying Goodbye to the Magical Illusions of Childhood. James can be reached at www.krehbielcounseling.com.
Nathan came back to see me three years after he had "graduated" from therapy. He brought his new guitar and treated me to few melodies in the privacy of my own office. He was serenading me - it was a gift for being there for him. However, Nathan's visit took on a more important purpose. He came to tell me, in so many words, how he had become a different kind of thinker - the type of young person who inevitably would change the very foundations upon how we view matter and energy and life itself. At age 16, Nathan had graduated from a college preparatory high school and made his way to a prestigious university to study nanotechnology.
As I intently listened, Nathan explained that nanotechnology will allow us to snap together the fundamental building blocks of nature more easily, more cost effectively, and in a way that is permitted through the laws of physics. Nanotechnology has the ability to transform our thinking about science, physical health and disease, emotional well-being, computer programming, and travel to outer space. Not only was Nathan "studying" this complex, molecular thinking, but he was actually conducting research with the world's greatest scientists in this technological field.
Like an H. G. Wells of his time, Nathan passionately projected what the world would look like in the next 15 years due to his work. His words seemed prophetic and powerful, and I sense that I was sitting before one of a new age of young people - the dreamers, the problem-solvers, the visionaries who would create a new way of thinking about thinking. These are not “egg-heads,” but balanced, well-rounded kids who have the capacity to not only reflect on problems but to communicate about how the world will dramatically change due to their influence.
Nathan represents an influx of thinkers among thinkers, who will quietly work behind the scenes to make things happen. These are not our future leaders or managers, but those who empty themselves of all internal clutter or preconceived notions about how the world works. By staying open to the truth, wherever they may find it, new, exciting discoveries will be made that will impact all aspects of the human condition.
Like Nathan, our future thinkers can recognize the qualities and significance of emptiness. They can handle the perplexing nature of uncertainty and ambiguity. They understand that there are multiple dimensions to any problem with conflicting and paradoxical meanings. They are willing to surrender conventional notions about how the world works in order to make room for the new. By cutting a path through the clutter and letting go of a traditional means of thinking, these talented young people will open themselves up to what Robert Schuller referred to as, "possibility thinking."
In the midst of all the incivility and strife that we are faced with, Nathan will make a difference. He has not forgotten what it was like to stand face to face at a young age with problems that were bigger than he was capable of solving. He will use that experience to empower and propel him in a direction to bring peace as he thinks about and humbly solves problems that raise hope and healing for all humanity.
James P. Krehbiel, Ed.S., LPC is an author, freelance writer and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. James is the featured Shrink Rap columnist for TheImproper.com, an upscale arts, entertainment and lifestyle web magazine. He has contracted with New Horizon Press to publish his latest work entitled, The Search for Adulthood: Saying Goodbye to the Magical Illusions of Childhood. James can be reached at www.krehbielcounseling.com.
Wednesday, July 01, 2009
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