Stop mental health stigma, and start seeking help

A recent study has shown that living with an untreated mental illness lowers life expectancy. Therefore, not only do suffers get less enjoyment from their day to day life, but their lives are shorter. Why is it that people continue to suffer in silence?

Perhaps the main reason that people do not seek treatment is the stigma surrounding mental health. Sadly, this is widespread in today’s society, and there are several reasons for it. For example, we’ve all seen movies where someone commits a horrific crime, and the text at the end tells us that the person is now seeking therapy. This creates an association between anti-social behavior and therapy. This is outrageous, as the vast majority of people who seek therapy are normal, kind and caring people. Some people are genetically predisposed to having mental health problems, while others struggle with negative life experiences. In both cases, seeking help can be a life changing experience, and in neither case should it be something to be ashamed of.

I think it is time to start thinking about mental health problems in the same way as medical problems. If you had a friend or family member who was physically unwell, telling them that “you need help” would be kind and supportive advice. Why doesn’t the same hold for encouraging someone to see a psychologist?

Fjola

Fjola Helgadottir, PhD, CPsychol, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

A recent study says “yes”!

Online therapy is an active and growing area of research in clinical psychology. In fact, there was a symposium devoted to the subject at the recent World Congress of CBT in Lima, Peru (which I was honoured to be a part of – to be covered in a future blog). Perhaps the most important question that researchers are trying to answer is: “Does online work as well as face to face therapy?”

This is a difficult question to answer since there are so many hidden variables. In fact, there is no universal answer, since it depends on the particular online system being examined, and the skill level of the therapists involved in the study. A better questions is “Can online therapy work as well as face to face therapy?” In other words, are there any online systems that can match the results of live therapists for a specific problem? According to a recent publication, the answer is “yes”!

A team of researchers from the University of Zurich published the following paper:

Birgit Wagner, Andrea B. Horn, Andreas Maercker. Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial. Journal of Affective Disorders. July 23, 2013. (see this link for more information)

The authors conducted a study involving 62 people with moderate depression. Half of the patients were treated using traditional CBT in-person techniques, and the other half were treated online. The authors found that at a three month follow up, the patients who were treated online had fewer symptoms of depression than the control group. In other words, the online treatment program actually performed better than the face to face therapy.

Advantages of online therapy

I have discussed some of the advantages of online therapy on this blog and in my publications. These include:

Clients can progress at their own pace
Clients have a complete record of their treatment, which they can revisit at any time
“Therapist drift” is a known phenomenon, where therapists move away from the best practices of a particular treatment over time. With online treatments, it is easier to enforce a consistent treatment, with the correct “dose” of clinical content delivered during each session.

Of course, online therapies have challenges of their own. In particular, it is more difficult to adapt the treatment towards the individual symptoms and needs of the users without therapist involvement. In fact, it is this problem of individual personalization that AI-Therapy’s social anxiety program attempts to address.

More studies are needed to fully investigate the strengths and weaknesses of online therapy. However, the study above adds to a growing body of evidence that online therapy has tremendous potential, and will play an important role in the future of mental health treatment.

Fjola Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

When someone is angry, quite often our immediate reaction is to tell them to calm down. However, have you ever noticed that telling someone to calm down can actually make them angrier?

In this blog, I’m going to discuss the reasons why some people get angry, and share some strategies to help prevent future outbursts.

Many of us have been in this situation:

The anger stimulus could have been many different things: an upsetting email, Microsoft Word’s AutoCorrect feature, Manchester United losing a match you had a bet on, or pictures of an ex-partner on Facebook. Whatever it was, the ancient “fight” response has been activated and blood is pumping through your body. You find yourself in what seems like a uncontrollable rage. However, the belief that anger is uncontrollable in some situations is largely a myth!

One of the most common misconceptions about anger is that it is best to “let it all out”. This comes from the faulty reasoning that pressure builds up inside of us, and screaming, kicking and shouting is necessary to release it. The truth (according to the latest scientific findings) is that screaming, kicking, shouting or acting out in other ways only makes a person’s anger problem worse in the long term! I am now going to discuss one reason why many people get angry, and provide an effective way for dealing with some types of anger.

We all react differently to frustrating and difficult situations. Many of us burst out in anger. A lot of anger outbursts happen due to our internal rules being broken. These rules can be due to moral or ethical reasoning. For example, when you hear about someone being cruel to a child. This anger may be justified, and is therefore difficult to address. However, some of our “rules” are much less clear cut. These are rules that have been created (or learned from family, friends or colleagues) about how we feel the world SHOULD work.

Consider this example: a few weeks ago I was taking a bus from the airport, and the driver was being very rude to me and everyone else. I was little upset, and found myself thinking “the driver SHOULD be more helpful to me and the other passengers”. Another passenger was also upset by the driver’s behaviour, and got in a heated argument. It actually escalated to a point where they were both yelling at each other. Almost certainly, the driver was motivated by SHOULD statements of his own. For example, “everyone SHOULD sit down so I can catch up on my schedule!”. Both parties felt violated, but was it really worth the outbursts?

One of the ideas behind cognitive behaviour therapy (CBT) is to identify and challenge or modify unhelpful thinking patterns, including these SHOULD thoughts.

Let’s look at some more examples of should statements, and consider advantages and disadvantages of believing them:

Everyone should always treat me nicely

Benefit	Cost
I will be happy when I am treated nicely.	A major disadvantage of this ‘should’ is that it is unrealistic. It is a fact that some people are rude and inconsiderate. If I think that all people should treat me nicely, I will become infuriated every single time it doesn’t happen. I will experience anger and frustration regularly. This thought is actually making me upset.

Dropping a belief like this is not an easy task. We all have a sense of justice in our head, encoded by our internal rules. However, unfortunately the world isn’t always a fair place. For example, some people are too entitled, selfish or narcissistic to care about the impact they are having on other people. Therefore, it is inevitable that we will encounter people who do not treat us nicely. In fact, we should actually EXPECT it to happen from time to time. If something happens that we are expecting, we are a lot less likely to get angry because of it, and we can learn to think of better strategies to deal with it.

I should always say “yes” to requests from others

Benefit	Cost
Immediately after I say “yes” to other people’s requests I feel relieved to get them off my back.	I will probably be taken advantage of in my personal and professional relationships. I will end up doing lots of things that I really would prefer to avoid. I will end up feeling overburdened. I will end up bitter and resentful of the demands of others.

Once again, this example shows how an internal rule can end up causing unnecessary distress. On the surface it seems reasonable, but if interpreted too strictly, it can lead to anger. For example, it may lead you to expect everyone else to always say “yes” to you, and may cause distress when this turns out not to be so.

Incidentally, SHOULD statements, and a deeper discussion about their role in your mood, are the topic of Part 5 of the AI-Therapy treatment program. The program also identifies your specific SHOULD thoughts, and formulates a CBT intervention to target them.

Back to the original question regarding anger myths and facts: how can you prevent outbursts? In the short term, try not to allow yourself to “let it loose”, as this can lead to a pattern of learned behaviour that is only supporting the anger response. It is better to step back, and try to remove yourself from the situation until the anger wave has passed. Every time you successfully stop an outburst before it happens, the better you become at it. Practice, practice, practice.

In the long term, you should take a close look at your internal rules (i.e. your SHOULD statements). It is very likely that some of these are underpinning your anger. Once you have identified your SHOULDs, CBT can be used to target them.

The world isn’t always a fair place, and it never will be. We can do our best to make it a better place, but we can’t always control the actions of others. However, you can learn to control your reactions to perceived wrongs.

There’s definitely, definitely, definitely no logic to human behavior
-BjÖrk

I tend to agree with Björk (my fellow Icelander) — especially when it comes to “common sense” approaches to self help for improving anxiety or mood issues.

Despite having about 1000 trials supporting the efficacy of cognitive behaviour therapy (CBT) in the long term, the average Jane or Joe still has not heard about CBT. CBT has consistently outperformed medication when you look at long term benefits. What you learn through the CBT sticks with you for life! First, it addresses the root of the anxiety by determining what is keeping it going in everyday life. Next, it tackles the underlying cause using experiments and exercises. With CBT you develop strategies that you can use for the rest of your life.

One of the most common ways for individuals to deal with symptoms of anxiety and depression is to purchase self help programs (books, e-books, CD/MP3s audio series, etc.). The quality of these programs varies widely. There are some very good programs out there written by experienced and qualified professionals. Some of the best programs walk the client through the principles behind CBT.

Unfortunately, for every high-quality program, there are many more poor quality programs created by “self-help gurus”. Sometimes these gurus are well meaning people who have managed to cure their own problems, and would sincerely like to help others. Other times they are created by people simply looking for a quick buck. The problem is that some techniques for dealing with mental health issues are counter-intuitive, so without proper training, self-help authors can actually make problems worse. Let’s look at an example.

A typical title for self help books might be: Successful small talk: Learn to be open, interesting and intelligent. The purpose is to advise individuals on how to better manage their impressions on other people in social situations. If only human behavior was that simple! It would be great if we could sit down and read a book that would transform us into interesting and intelligent super-humans. Unfortunately, many of the recommended strategies (e.g. rehearse what you say in advance, make constant eye contact, etc.) can actually maintain anxiety in the long run. I mentioned these processes in my last blog, and referred to them as safety behaviors.

For social anxiety, people often believe that their safety behaviors help prevent negative evaluation in social situations. However, they actually might be preventing them from learning the truth. For example, assume that I deal with my social anxiety by only telling people about the positive aspects of my life (like many of us do on Facebook!). Perhaps I believe that this will stop them from judging me negatively. The problem is that if I never test this hypothesis, I am never comfortable being myself. What is wrong with this?

Firstly, it is unrealistic. People are people, and everyone has their ups and downs. By putting this extra pressure on myself to always look perfect, I might start avoiding social situations, reinforcing the anxiety. Social situations become extremely stressful.

Secondly, this type of safety behavior might make people judge me negatively. For example, people may feel resentful about my “perpetually success”, or suspect that I’m not telling the whole truth. Also, this maintains my social anxiety in the long run since I can never test if people approve of me for who I really am!

On the surface, common sense advice like “people don’t want to hear about your problems — focus on the positive” sounds great. However, as we’ve just seen this isn’t the case. Unfortunately, many self-help books are full of these sorts of recommendations.

There are some great self help books or programs out there. My advice is that if you do follow a self-help program make sure that it is (1) is created by a qualified professional with training in psychology/psychiatry, (2) uses CBT to tackle the core problems, and (3) does not promote behaviors that might end up making the problem worse.

Social phobia vs Spider phobia

In my last blog I talked about my personal “dislike” of spiders and other insects. In this blog we are going to look at the relationship between spider phobia and social phobia.

The major difference between specific phobias and social phobia is that people generally need to be around other people a lot the time. This is a bit similar to my unusual experience of moving from Iceland to Australia. I had to get used to being around spiders and other bugs all the time. After 6 years in the country, my fear of spiders had definitely decreased.

Social phobia and safety behaviours

With social phobia, you have to be around, and communicate with, other people on a daily basis. Therefore, the system that maintains social phobia is somewhat more complicated. People develop highly sophisticated mechanisms to prevent negative evaluation by other people. For example, imagine that I always wore pink socks while in Australia, and never got a serious spider bite. It’s possible that over time, I would begin to attribute my successful spider avoidance to the pink socks. This is known as a ‘safety signal’. As silly as this example sounds, we often learn ‘safety behaviours’ to help us deal with phobias and anxieties in day to day life.

The problem with safety signals is that I cannot always wear pink socks – can I? I would need to wear pink socks at all times to feel relaxed, and that could lead to some awkward social situations. I would feel anxious whenever I didn’t have access to pink socks. This is a little bit what happens with social anxiety – individuals have to be around and interact with other people on daily basis, so they develop ‘safety signals’ which prevent the feared social situation from happening.

Any behaviour can function as a safety signal. For example, both talking more and not talking can potentially function as safety behaviour to prevent the social fear of appearing boring, depending on the individual and the context. The distinction between adaptive coping behaviours and maladaptive safety behaviours is sometimes blurred, as the same behaviour can function as both. The category which the behaviour falls in depends on its intended purpose, the underlying belief, and the consequences from the situation.

Back to my example, wearing pink socks in itself isn’t that unhelpful (maybe a bit childish). However, it is only unhelpful if I think my socks have to be pink for them to protect me from a poisonous spider. If I believe in this “function” of the behaviour, I am preventing myself from learning that people rarely get bitten by poisonous spiders in Australia, regardless of the colour of their socks. Also, it makes me nervous to travel, given that one cannot have access to pink socks at all times. In social anxiety these behaviours have many detrimental effects such as increased self-focused attention and preventing dis-confirmation. In fact, these behaviours can even have the opposite effect, and can end up being the reason why someone would judge someone else negatively (once again, think of the sock example).

Common safety behaviours for social anxiety include:

carrying deodorant around at all times
always saying “yes” to other people’s requests
rehearsing what to say before entering a social situation
only telling other people about positive aspects of your life
laughing at inappropriate times
avoiding eye contact
saying little in group situations
re-reading emails many times before sending them

People may feel their safety behaviours are helping them, but they aren’t. On the contrary, several studies have reported the detrimental effect of such safety behaviours in social situations (Kim, 2005; McManus et al., 2008; Morgan & Raffle, 1999; Wells et al., 1995). Consequently, the current view is that safety behaviours can interfere with standard cognitive behaviour therapy techniques by inhibiting testing of hypotheses for socially anxious individuals.

In our online treatment for social anxiety (www.AI-Therapy.com) we explain these concepts in a lot more detail, and help people understand what their specific safety behaviours are. I hope you can see that social phobia is a much more complex issue than specific phobias, like spiders. You can now answer 10 questions, to see how you score on our free online social phobia symptoms test.

In an upcoming blog I will discuss the relationship between safety behaviours and one of my favourite topics – superstitious behaviours. My latest article on superstition was front page news in Iceland last week!

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Tag Archives: depression

“You need help” should be a positive gesture!