Tag Archives: Cognitive Behavioural Therapy

So what??

What is your first reaction when I say a “So what?” attitude?

Was your reaction quite negative or positive? (Assuming that it can’t be totally neutral)

What if I say, it’s an attitude the grandfather of cognitive therapy, Albert Ellis, said we shall all adopt? Yes, he said we shall all live with a “So What?” attitude.

What do you think?

(I started all 4 paragraphs with the letter “W”, so what?)

I can’t do this, so what?

I look so anxious, so what?

I can’t sleep, so what?

I failed my exam, so what?

Nobody likes me, so what?

What do you think? How would you benefit from adopting such an attitude?

I might not benefit from it, so what?

Seeing clients and students in the west (including those Asians who have lived in the west) vs those who live in Asia (mainly Chinese, Malaysians, South East Asians), I noticed that the first receipt of such an attitude can be quite different, although eventually all accept it and see and experience how much they benefit from having such a “I don’t care” attitude.

But for many Chinese and Asians, their first reaction is almost like, “this is rude”, “this is not what I would do”, “this is wrong”, “this is not part of our cultures/values” etc

Of course we are not talking about people should not care about their life, their studies, their family, their hygiene, their job etc. But it’s when you care too much and it doesn’t help (and often this care makes things worse). This is especially so in social situation and interaction. We worry too much about what others might think, how we look like, we stop being in our experience and connecting with the environment and the world because we focus internally worrying too much.

Try to apply the lens of “so what” in your social interaction and see how it goes?

Where the voices come from

Sometimes I get this question from patients’ family, asking why the patient is hearing voices, how did it happen and what else do we know about these voices.

Here I’m referring to auditory hallucination commonly seen in people suffering from schizophrenia and psychotic disorders.

Yes they hear voices in their head, usually talking to them, quite commonly saying harsh and mean things to the sufferer. Sometimes they hear a few different voices having a conversation, and it’s not difficult to guess, the conversation is about the sufferer.

“Look! She has no friend! She looks so ugly and stupid!”

“Indeed. I wouldn’t want to befriend someone like her.”

“She should just kill herself. Nobody likes her anyway. Why is she still living?”

I mean, who with a sane mind would say such things to others? Nobody. How was these produced?

In 1993, McGuire and Murray published a research article “Increased blood flow in Broca’s area during auditory hallucinations in schizophrenia“. Let me break it down a little for you… The functions of Broca’s area has a lot to do with “speech production”. As compared to another area of the brain, the Wernicke’s area, is responsible for the comprehension of speech.

Locations of Broca's Area and Wernicke's Areas. (NIDCD, 2010) | Download  Scientific Diagram
Locations of Broca’s and Wernicke’s. Picture taken from researchgate.net

So what does this mean?

When the patients are hearing voices, which do not sound like their own voices, the “speech production” area of the brain has increased blood flow, less so in the “speech comprehension” area. We can’t conclude anything from here obviously, but it becomes clearer to the researchers that those voices are produced by the brain itself, almost like their own’s thought processes (which we all do: talking to ourselves or having inner talks), but “presented” as somebody else’s voice.

So it seems likely that it’s their own thoughts. At least that’s what research has found. And I believe many clinicians would agree with me — often we see those voices are actually the patients’ core beliefs, worries, and are what they were told (by their parents, significant family members, teachers etc) when they were much younger. As a therapist, when I look at it this way, it opens up a lot more possibilities to help people who are suffering from auditory hallucination. And indeed, quite a number of techniques in mindfulness-based approach and cognitive therapy have been found useful.

Why people come for Therapy

There are many different types of therapy, and there are many reasons people approach those therapists for help. Here are some reasons:

In general, for any psychotherapy:

  • Feeling moody, low, and/or depressed
  • Feeling anxious
  • Lacking confidence
  • Worrying too much
  • Not able to sleep/rest well
  • Relationship related problems
  • Feeling hopeless and lost
  • In need to talk to somebody and get some advice
  • Combination of all the above (common!)
  • Obsession and compulsion related
  • Eating related disorders
  • Anger related problems, being irritable
  • Schizophrenia and psychotic related symptoms
  • Being diagnosed as Personality Disorders (e.g. Borderline is more commonly seen)
  • Being diagnosed as developmental disorders (e.g. ADHD, autism spectrum disorder, learning disability)
  • Wanting to be assessed to see if anything is wrong (just like when you go for medical check up; this is not common, but I’ve seen a few now!)
  • In need of guidance during their self-discovery and self-improvement journey (this is rare! But glad that I’ve seen a few too!)
  • In need of guidance after being diagnosed of cancer
Taken from google image.

For hypnotherapy:

  • Wanting to remove a piece of memory
  • Wanting to forget something or someone
  • Wanting to recall something or someone
  • Being in pain
  • Wanting to be more confident
  • Looking for the root cause of some recent problems
  • Feeling lost, uncertain with the future
  • Hoping to release some emotions
  • Hoping hypnosis is the solution to their problems that couldn’t be solved otherwise
  • Wanting to achieve something great
  • Wanting to increase motivation to… (e.g. work, study, lose weight, workout)
  • Wanting to focus better
  • Wanting to change a bad habit (e.g. smoking, not exercising, nail-biting)
  • Wanting to improve general wellbeing and sense of happiness
“… And on the way out, you won’t notice my car parked in a no parking zone.”

NLP in Malaysia

I have intended to write about NLP (Neuro-Linguistic programme) since two years ago after quite a number of enquiries. But seriously, I don’t know where to start, because from day one, I believe NLP is a pseudoscience (according to Cover & Curd (1998) pseudoscience “consists of statements, beliefs, or practices that are claimed to be both scientific and factual but are incompatible with the scientific method”). And if you have followed my blog for a while, you might have noticed my very scientific and evidence-based stance.

Picture downloaded from http://www.pop.or.id/2017/08/what-is-nlp.html

The claims and assumptions in NLP mostly lack empirical support (you may read more here, there are also many other good papers studying NLP and their conclusions are quite similar). There is a lack of scientific interest in the field. But due to what they claim, it still attracts interests in people who might not care much about scientific and research evidence.

In Malaysia, I’ve met people who took course in NLP and are doing general life coaching. I also have had clients who came to me having previously coached by a NLP-based “therapist” (not sure what they call themselves). And this NLP is so popular in the business and corporate world. I suppose when people practice safely understanding their sphere of competency and professional ethical issues, they are helping people and not causing harms – as long as they aren’t claiming that they can be alternative medicine treating cancers or Parkinson’s disease, giving people false hopes.

For the general public, I’d say it depends on your stance. Sometimes I get clients who come to me who specifically want to be treated with CBT because of how much empirical support there is for CBT. On other times, people just approach me knowing I practice hypnotherapy, and want their bad memories being erased in hypnosis. It’s often good to read a bit more about the therapists and the approaches they practice, even better if you speak to them first before making any decision.

Every now and then, there is “new” psychotherapy or pseudotherapy in the markets (not in the field), that has no empirical support.

Would you just pop some pills that has no clinical trials run into your mouth every day?

Please don’t get defensive. Your first reaction might be “of course not!” But there is no right or wrong here. Like I said, it depends on your stance. The thing is, we all have probably done that, especially for those of us who come from more traditional Asian families. But, we can change that.

If given a choice, would you choose a treatment that has robust scientific and research evidence?

Picture taken from https://www.answers-in-reason.com/science/the-problem-with-pseudoscience/

The Intention/Belief behind a Behaviour

I talked about letting go of thought VS chucking it away in a 2016 post: Let it go OR Chuck it away. Now, let’s look at this:

Winnie the Pooh & Piglet

The behaviour that Pooh and Piglet do are the same, i.e. they both don’t think about the scary dream. But what Pooh is doing, is “letting go”, whereas piglet? He’s trying hard to chuck it away.

Quite often people overlook this key distinction, they think they copy the same behaviour, and will then achieve the same results. But the beliefs and intention behind the behaviour are important too. Are you worrying about the dream so you don’t think about it? Or do you not care about it so you don’t think about it?

Similarly, on anxiety, are you practicing relaxation because you think anxiety is bad and you can’t tolerate it? Or are you practicing relaxation because it helps you perform better when you’re less anxious? It’s the beliefs and intention behind that differ, the behaviour done or presented is the same.

It’s like on “acceptance” (a word I tend not to use with clients). Do you accept the pain because it doesn’t really matter anymore, or do you accept it because you have no choice (is it still acceptance?)?

Should your therapist give you advice?

“What? Isn’t that what I go to therapy for?”

No… Not really. Psychotherapists and counsellors are normally taught not to give advice (for important decision making) to their clients. We do not want our clients to become dependent on us, instead, we guide them and equip them with the skills to think more rationally, realistically and in ways that are helpful to them.

I remember there are few occasions when clients first came to see me, and they told me about how previous psychiatrists/therapist/counsellors had advised them to do certain things like leaving a boyfriend or a job or moving house etc, how they still ruminating about it today and still don’t think it was the right thing to do. Here, I’m not blaming the therapists or consultants. It’s both ways… Because quite often, clients want quick fix, they want the answer now… And the therapists feel the urgency to help and provide the quick fix.

But there are times when we do give advice, and that’s on severely depressed clients, and on suicidal prevention. We do advice the subject and the family around him/her what to do.

Also, I do provide psychoeducation to family members of most of my severe OCD clients. In a sense, sometimes there are family members who cannot rationalise how they are reinforcing the OC symptoms, then I will just advise them what and what not to do.

So right, your therapist should be there to teach you how to fish (how to solve your problems, how to handle your negative emotions, how to make decision etc), but not to just keep giving you fish. If it’s the latter that they are constantly doing (it’s quite normal to do it in the beginning of the therapy or when your condition doesn’t allow independent decision), at some point you are going to realise that you can’t live without them…