Monthly Archives: February 2013

Mindfulness vs. PTSD

The Washington Post reported this week on new studies addressing Post-Traumatic Stress Disorder with mindfulness. Research has already found regular practice may help those with PTSD recover faster. New findings suggest it may do even more.

Elizabeth A. Stanley, PhD, of Georgetown University

Elizabeth A. Stanley, PhD, of Georgetown University

Elizabeth A. Stanley, Ph.D is professor of security studies at Georgetown University. She’s not a psychologist, but she ‘s among those who’ve found regular mindfulness practice significantly eased their post-traumatic symptoms.  Per the Post’s article, Stanley’s new study tracked 320 marines through simulated combat training. The results showed those schooled in mindfulness weren’t just calmer during the exercises, they also responded faster to new threats.

This is crucial, says Tom Minor, a University of California at San Diego neuroscientist who was one of the researchers. “That was one thing we worried about: ‘Are we going to take a bunch of Marines and turn them into chanting monks who couldn’t generate a stress response?’ But they didn’t get too relaxed.”

“Too relaxed,” is a fear for many traumatized people. With a constant perception of danger, it can be unnerving to think one might be lackadaisical about threats. Clinical evidence that mindfulness reduces response time can be a major selling point to the hypervigilant.

Opens with the titular Vietnam vet practicing mindfulness in a Buddhist monastery. Discuss.

In the “Baba Rum Raisin” days of the late 1960s and early 1970s, meditation was peddled as a cure for everything. Skepticism bordered on cynicism. This article cites peer-reviewed, clinically-validated studies such as  Thomas F. Minor‘s research, which indicates meditation boosts the hormones that repair stress-related damage and decreases the chemicals that cause it. It also mentions Martin M. Paulus’ work that shows mindfulness boosts activity in areas of the brain devoted to awareness and control of emotions.  The sample sizes are too small and the results need to be reproduced a few more times,  but the findings on mindfulness and PTSD have started to verge on Maharishi-esque territory.

Of all the goodies in the Post article, the most tantalizing (and least empirically-supported) is the suggestion that mindfulness practice may reduce the risk of developing post-traumatic symptoms:

(Marine medic Del) Cochran says he believes meditation helped him stay much calmer during his second tour in Iraq. “The first tour, I was freaked out all the time,” he says. “There was so much static. With meditation, you’re much more in tune — what is a target, what is not a target. You are much more focused on what you are doing.”

Meta-analyses of studies of traumatized children shows pre-existing anxiety may increase one’s vulnerability to PTSD. Who wants to fund a study comparing PTSD rates among veterans from countries with a cultural tradition of mindfulness practice and those without?

Citations:

Kohn, David (2013, February 18) Mindfulness and meditation training could ease PTSD symptoms, researchers say. The Washington Post. Retrieved on February 22, 2013.

Examining the protective effects of mindfulness training on working memory capacity and affective experience. By Jha, Amishi P.; Stanley, Elizabeth A.; Kiyonaga, Anastasia; Wong, Ling; Gelfand, Lois
Emotion, Vol 10(1), Feb 2010, 54-64.
 

@ 2013 Jonathan Miller All Rights Reserved

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Filed under mindfulness, Post-Traumatic Stress Disorder

Grief: Stages, Waves and Tasks

Clare Bidwell Smith has written a worthy essay on grief and anxiety, one that challenges Elizabeth Kübler-Ross‘s ‘bargaining’ stage:

Many of my clients immediately begin to assess their current state in terms of where they are with denial, anger, bargaining, depression, and acceptance. But while the stages were meant to be helpful, this is often where people begin to get confused. I don’t think I’m following the stages correctly, they’ll admit in a worried tone.

I don’t understand the bargaining part. I’ve been depressed for too long. I skipped the anger stage—is that okay? I don’t know where my anxiety fits in. These are the kinds of things I hear over and over again. In fact, I’ve heard them so often that I’ve now come to believe that when the five stages are applied to grief, bargaining should be replaced with anxiety.

Contemplating © 2013 by Anders Engelbøl

Not every mourner gets a soothing vista to grieve by.

Smith deserves kudos for drawing attention to anxiety’s role in grief. The loss of a loved one is a hole in our safety net. It reminds us of our own mortality. How does one not feel anxious about that? Her suggestion we make anxiety a stage of grief, on the other hand, propagates long-standing problems with the model.

For all of its cultural dominance, Kübler-Ross’s magnum opus has taken heavy fire. Bonnano, Wortman, et al (1)  found grief might take five different paths, including one of resilient recovery.  Maciejewski, Zhang et al (2) found symptoms of grief such as yearning, anger and depression rose and fell along overlapping curves, while acceptance rose along a steady upward slope.  Kübler-Ross herself freely admitted not everyone will experience each stage, the stages may not come in order, and that stages might recur once they’ve faded.  So, why describe grief in such terms?

A figure from Maciejewski and Zhang's research. While each psychological response peaks about a month apart, they all begin within three weeks of the loss and remain present throughout the process.

A figure from Maciejewski and Zhang’s research. While the first four ‘stages’ peak about a month apart, all begin within three weeks of the loss and continue nearly to the end. (see complete figure at the link)

James William Worden’s ‘task’ model drops the view of grief as a commuter ride on the Dysphoria Local.  Worden, professor at Biola University’s Rosemead School of Psychology, frames mourning as a set of chores:

  1. Accept the reality of the loss. Completely.
  2. Work through all of the emotions tied to the loss. All of them.
  3. Make all the adjustments needed to function without that person – inside and out.
  4. Find a way to maintain a link to the loved one, while you move on with your life.

Each task can be worked on a bit at a time. They don’t need to be completed in order. Anxiety, yearning, anger, depression? Each fits each task. No one needs to wonder why they still feel angry after being depressed for so long.  Worden’s model empowers our clients, because it makes grief a mission to complete, not a storm to be weathered.

The flaw in Smith’s plan to substitute ‘anxiety’ for ‘bargaining’ is the same that undermines Kübler-Ross’ model.  Symptoms like anger and anxiety rise and fall, but they don’t come in stages. They pervade the process. Let’s reassure our clients the loss of a loved one can be terrifying. Let’s not shoehorn that anxiety into an misfired concept like ‘stage’.

Citations:

1: Resilience to loss and chronic grief: A prospective study from preloss to 18-months postloss. Bonanno, George A.; Wortman, Camille B.; Lehman, Darrin R.; Tweed, Roger G.; Haring, Michelle; Sonnega, John; Carr, Deborah; Nesse, Randolph M. Journal of Personality and Social Psychology, Vol 83(5), Nov 2002, 1150-1164. doi: 10.1037/0022-3514.83.5.1150

2: Maciejewski PK, Zhang B, Block SD, Prigerson HG. An Empirical Examination of the Stage Theory of Grief. JAMA. 2007;297(7):716-723. doi:10.1001/jama.297.7.716.

@ 2013 Jonathan Miller All Rights Reserved

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Diluted DBT Still Effective for Bipolar Disorder

University of Washington psychologist Marsha Linehan has a strict definition of her ground-breaking Dialectical Behavioral Therapy (DBT). If a client doesn’t …

  • attend a DBT skills group and …
  • receive individual therapy from a DBT-trained therapist …
  • who attends a weekly DBT consultation group and …
  • offers phone coaching,

… they aren’t really in DBT. The full program is what she researched; she won’t vouch for anything less.  A new study by Van Dijk, Jeffrey and Katz of the Southlake Regional Health Centre in Ontario, Canada suggests even a cherry-picked form of ‘adherent’ DBT may still help those with Bipolar Disorder.

T-shirts like this are why I love the internet

T-shirts like this are why I love the internet

The researchers enrolled twenty-six adults with Bipolar I or II Disorder in a psychoeducational group. The clients learned about their diagnosis, but were also trained in mindfulness practice and DBT’s emotional-regulation, interpersonal-effectiveness and distress-tolerance skills. After twelve weeks of ninety-minute group sessions, the clients scored higher on Beck Depression Inventory, reported greater awareness of their emotional states and less fear of the same. Six months later, they also had fewer emergency-room visits and hospitalizations. These findings echo other studies that found DBT skills group training – by itself – can be effective for depressive symptoms.

It’s tempting and dangerous to conclude DBT can be treated like a toolbox, instead of a unified whole.  Tempting, because DBT is a comprehensive therapy for challenging clients. That makes it dauntingly complex. Becoming fully versed is like learning another language. With all of its’ useful techniques, attitudes and approaches, it’s almost too simple to cherry-pick a few and call it DBT.

It’s dangerous because Linehan’s therapy depends so much on movement, speed and flow – rapidly shifting around all of those techniques, attitudes and approaches to meet a client’s needs.  Practitioners’ mailing lists often feature tales of clients firmly uninterested in DBT because of their previous experience – with non-adherent therapists whose treatment had some of the features, but none of the integrity of Linehan’s.

Carl Rogers’ use of reflective listening and Alfred Adler’s focus on the here-and-now were subsumed into the basic practice of therapy. Linehan’s DBT skills could be mindlessly assimilated the same way. Let’s have more research on how much and how little can be dropped before you no longer have an effective therapy.

Citation:

Sheri Van Dijk, Janet Jeffrey, Mark R. Katz. A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. Journal of Affective Disorders 5 March 2013 (volume 145 issue 3 Pages 386-393 DOI: 10.1016/j.jad.2012.05.054)

@ 2013 Jonathan Miller All Rights Reserved

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Filed under Bipolar Disorder, depression, Dialectical Behavioral Therapy