The things we need to learn wait for us. They are very patient.

I think you know what I mean. At least, you have seen it in others. The person who is angry, who never learns how to control his anger, or perhaps isn’t even aware of the need to control it.

Then there is the passive person, the one who cannot stand up for himself easily, who defers to others, who gets taken advantage of pretty routinely. And, despite this, doesn’t change over the years.

Some of us choose the wrong friends or wrong lovers or the wrong business associates, making the same mistakes again and again. Others continue to use failed methods in raising children. Some of us never face our fears fully (see Albert Brook’s film Defending Your Life for a funny take on this problem). And then there are the people who are impulsive, act without thinking, over and over; or the ones who are sloppy at tasks, not careful enough; or those that are too compulsive, too detailed oriented, trapped by their obsessive attention to small things.

I could go on, but instead, its time to ask you a question. What are the challenges in your life that you have yet to master, the ways of thinking or behaving that don’t work for you, but which you repeat? Most of us have a pretty easy time spotting the errors in others, but how about your own?

There is an old joke about how we learn:

A man walks down a road and falls into a hole. He didn’t see it and, because it is a deep hole, it takes some time to get out.

The next day the man walks down the same road and falls into the same hole. He still didn’t see it, but might just get out of it more rapidly this time.

The day after, the man walks down the same road, sees the hole, but falls into it anyway.

The following morning the man walks down the same road, sees the hole, and this time walks around it.

And what does our hero do after the next sun rise? He walks down a different road.

Holes, like problems unsolved, have all the time in the world. They wait for us, first to recognize them, to see the danger they pose, and then to change our behavior so as to avoid the danger. As the saying goes, “if you do what you’ve done, you’ll get what you’ve got.” Others have said that one definition of insanity is to continue to use the same failed strategy, all the while expecting different and better results.

How long will you wait to change? Your problems can last a life time. They have no train to catch, no meetings to attend; they take their time, not troubled by waiting. Or, should I say, they take your time. All of your time.

Do you really want to wait that long?

So in my last blog post, I talked about social perfectionism and its symptoms: toward your social performances, you would have should statements, magnification of any errors, all-or-nothing thinking, mind reading of observers having negative judgments, and labeling yourself negatively. However, I forgot to write that these cognitive distortions might appear in the form of automatic thoughts, but other times they are buried beneath them. For example, I was anxious about going to a recreation center in the afternoon and one of my automatic thoughts was that, “the place will be crowded and I will have to leave in embarrassment.” But after I ask myself a few questions (such as “are you afraid people there will judge you negatively for arriving at that time?”) I uncovered my belief that I should always arrive at a gym or recreation center when there is enough space for me, otherwise I would be stupid (while it is sensible to try to always go there at those times, it is faulty to say that a person is stupid for not arriving there at an ideal time. It could be he or she thought there would be space for him.).

Today, let us talk about low self-efficacy of social skills. Self-efficacy basically means your belief in your abilities or a particular ability. In the case of social anxiety sufferers, they believe their ability to socialize with others are underdeveloped. As with social perfectionism, it have some symptoms as follow:

1. Fortune-Telling (or negative prediction) of making a “grave social mistake.” Ex: “I’m definitely going to say something stupid!” “I’m going to blush profusely!” “People are going to be looking at me weird because I’m so quiet.”
2. Mental-Filtering out all the times you did well in social encounters while retaining all the times you “bombed” or failed. While fortune-telling focuses on the future, this cognitive distortion focuses on the past, either distant or immediate (like a few hours ago).
3. Overgeneralization of yourself as incompetent in socializing (a pretty obvious one actually).

Finally, I wanted to talk about external locus of control and to be honest with you, I have a problem in trying to distinguish it from self-efficacy. I’ll quote from the book, Managing Social Anxiety: Client Workbook by Hope et al. to make sure I don’t pass my confusion on to the readers:

…the person believes that something outside of him- or herself determines what will happen. Persons with social anxiety disorder believe that other, more capable and competent people control what will happen.

The first sentence was perfectly clear and I interpreted that to mean that we tend to believe that the environment has a stronger influence of events than our actions (come to think of it, it didn’t said that). But once it gets to the second sentence that’s when I had trouble trying to see a difference between that and low self-efficacy. If anyone of you can help me see the difference between the two, please comment or email me! Meanwhile, I’ll be waiting for my next therapy session on Wednesday to ask my psychiatrist.

(Looks like it only took two blog posts rather than three. Then again, I do have to give you that answer so…..to be continued?)

Cognitive-Behavioral Therapy for Suicide Prevention (CBT-SP): Treatment Model, Feasibility, and Acceptability, Journal of the  American Academy of  Child Adolescent Psychiatry, 2009

Stanley B, et al..

Abstract:

OBJECTIVE –  To describe the elements of a manual-based cognitive-behavioral therapy for suicide prevention (CBT-SP) and to report its feasibility in preventing the recurrence of suicidal behavior in adolescents who have recently attempted suicide. METHOD:: The CBT-SP was developed using a risk reduction and relapse prevention approach and theoretically grounded in principles of cognitive-behavioral therapy, dialectical behavioral therapy, and targeted therapies for suicidal youths with depression. The CBT-SP consists of acute and continuation phases, each lasting about 12 sessions, and includes a chain analysis of the suicidal event, safety plan development, skill building, psychoeducation, family intervention, and relapse prevention. RESULTS:: The CBT-SP was administered to 110 recent suicide attempters with depression aged 13 to 19 years (mean 15.8 years, SD 1.6) across five academic sites. Twelve or more sessions were completed by 72.4% of the sample. CONCLUSIONS:: A specific intervention for adolescents at high risk for repeated suicide attempts has been developed and manual based, and further testing of its efficacy seems feasible.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

ACT is one of a member of the ‘Third Wave’ of behaviour therapies. These have been defined by Steven C. Hayes, (Foundation Professor at the Department of Psychology, University of Nevada) as follows:

“Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones. These treatments tend to seek the construction of broad, flexible and effective repertoires over an eliminative approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and synthesizes previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hopes of improving both understanding and outcomes.”

“Third Generation Behavioural Therapies” include cognitive behavior therapy (CBT), acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), cognitive behavioral analysis system of psychotherapy (CBASP), functional analytic psychotherapy (FAP), and integrative behavioral couple therapy (IBCT).

Mindfulness-based techniques (MBA) include mindfulness based cognitive therapy (MBCT), mindfulness based relapse prevention (MBRP) and Mindfulness-based stress reduction (MBSR).

FACT CHECK > The word “understand” is key here

DISTORTED BECAUSE

• No One -  Too general and all-inclusive
• Can Understand/Going Through – Ill-defined, vague, predicting the future

RESULT > Hopelessness

FIGHT IT!

• The inability to completely understand someone else is common, whether they’re depressed or not
• Complete understanding is not required, but an effective understanding (empathy) is what may be missing
• I may not have found an empathic person to help me so far, but a good therapist is more likely to be empathic

There is a certain amount of truth in the idea that we can’t completely understand each other. Each person is so unique. We even struggle to completely understand ourselves. The thing is, that inability to completely be understood also applies to you when you’re not depressed or anxious. It also applies to those who have never had Major Depression. Typically the damaging thing is the related distortion that you can’t get better without others completely understanding you.

What about the idea that someone can have some (or a pretty good) understanding of what you’re going through? How do we come to believe that someone understands us to some degree? There is a word for that – empathy. Oftentimes we get a lot of sympathy from others (they feel bad for us). Sympathy is nice, but it doesn’t necessarily mean that others are really listening.

Empathy is different. It means the person has taken the time to actively listen to the problem and are then able to summarize it back to you (demonstrating understanding). Empathy leads to rapport and rapport leads to problem solving. Really good therapists not only understand CBT principles, but they are also very empathic.

Friends and family are not typically trained in active listening. They may not know how to be empathic. All of this is yet another reason to find a good therapist.

Offer other suggestions for rephrasing this distortion in the Comments Section for THIS post.

The United Kingdom Council for Psychotherapy (UKCP) shows sudden signs of pulling back from the brink it has been staggering towards for the last while. A final stagger might still result in catastrophe, but there has been a kind of positive mood swing.

Following a recent election, Prof. Andrew Samuels will become chairman of the UKCP from 2010. Samuels is a founder member of the Alliance for Counselling and Psychotherapy Against State Regulation, and a determined opponent of state-controlled psychotherapy.

The catastrophe that might yet be avoided is domination of psychotherapy by government-appointed bureaucrats, leading to criminalization of any kind of therapy that government does not approve, and extensive use of therapy techniques to enforce government social policy.

A video message

In a powerful public response to personal attacks on him by Marc Seale, Chief Executive of the government’s Health Professions Council (HPC) quango, Samuels has published a video message. In it, he notes that the HPC’s:

…standards for registration are scandalously low…

‘Regulation’ by the HPC will certainly not protect the public.

Furthermore, he sees the HPC’s proposals as in effect redefining the meaning of the word ‘psychotherapy’, so that it no longer refers to the work that Samuels engages in with clients. Therefore, he argues, it would make no sense for him to register as a psychotherapist according to this altered definition, and he does not plan to do so.

Here’s the video message, (only about 3½ minutes long):

CBT

The present government’s flagship (but increasingly troubled) Improving Access to Psychological Therapies (IAPT) programme is another of Samuels’ targets. As IAPT’s main focus is on what it calls CBT, Samuels tends to take a dim view of CBT generally. However, he’s far from completely daft, and he seems to have some kind of lurking intuition that CBT is not all bad.

There is a sound recording of a rambling lecture in which he touches on the subject. Unfortunately the sound quality is poor, and the content difficult to interpret. At one point he quotes someone on the subject of CBT, expressing some agreement with the point of view, but I was not able to identify the author or the book (26:12):

…in an amazing piece of polemical writing, [he] tries to nail the distortions of a typical CBT relationship as mechanical, controlling of the client, therapist-led and hence abusive of power, normative, and so on and so forth…

Here’s the lecture:

What’s wrong with CBT?

Criticisms

There are really only two closely related criticisms in that quote, both of them criticisms of what I have called ‘fake CBT’. A mechanical approach is certainly favoured by some trainers and therefore by some practitioners, and I suspect it is particularly favoured within IAPT. It goes hand-in-hand with a therapist-led approach, which aims to control and normalize clients by using the therapist’s power over them, and that could be considered abuse.

Real CBT, in contrast, is personal and collaborative. It puts patients back in charge of their own emotions and inner lives, freeing them to pursue their own goals.

In 2007 Samuels clashed with the then president of the BABCP, Prof. David Veale. In the lecture he refers to this clash (19:33):

I think the president of the [BABCP] might have had his tongue in his cheek when he told me in our published written disputation that, quote, “The only reason why the NHS plans to expand the delivery of CBT is because it is empirically grounded. This is what keeps us in good stead.”

And he goes on without a blush I’m sure being [?] ironic, quote, “Being empirically grounded guides us in deciding which approach will help our clients function and return to their roles as a parent, partner, worker, and full member of the community.“

Samuels seems to understand well that to be a sane person is not simply the same as functioning in a social role determined by government, and also to understand the severe limitations of research evidence in mental health as a way of grounding anything. These are signs of hope for the UKCP.

On the other hand, he seems to find it difficult to articulate his understanding with clarity, preferring to make vague and somewhat emotionally loaded statements instead. For example, it’s pretty clear to everyone who has encountered David Veale that he does not make statements like that tongue-in-cheek or ironically — he really does have an uncritical and simplified view of the world and of CBT (as anyone can easily verify by reading the descriptions of CBT on his website). Any lack of clarity by Samuels, and any tendency to evade unpleasant truths, are signs of danger for the UKCP.

A subtle political problem

There’s a subtle political problem for anyone who wants to provide leadership in the psychotherapy world. It’s that the great political divide in UK psychotherapy is unreal. The divide between CBT and all the rest does not make sense in terms of outcomes for patients.

In both camps there are competent therapists who have the skills to help mentally ill people, but in both camps there are also incompetents, and some of the incompetents are well-organized. So Samuels needs to colour the political map of psychotherapy in a different way, if he’s to make a significant difference to the political outcome.

He needs to get real CBT therapists strongly aligned with him, on the basis that CBT is one of many therapeutic orientations that are effective ways to improve patients’ lives. I think he would be amazed how many BABCP members would support him in this, if he were to articulate it clearly.

But at the same time he needs to distance himself from so-called therapists whose methods and goals are anti-therapeutic. This is easy in the case of IAPT form-fillers whose goals are to support government social policy, but it is challenging in the case of those who profess other orientations within the UKCP and whose goals are, for example, the pursuit of personal power.

It’s unlikely I’ll agree with everything Samuels does in his term of office, but nevertheless I wish him luck unconditionally. He’s a man who thinks deeply and speaks his mind. Psychotherapists deserve such leaders as him, not to be the puppets of nameless quangocrats.

FACT CHECK > See Our Video at the end of the post

DISTORTED BECAUSE

• I Can’t = Means it is physically impossible, as opposed to difficult
• Go On – Not specific enough, vague

RESULT > Hopelessness

FIGHT IT!

• I am sick of…(be very specific)
• I don’t know what else to do
• I want (specific thing) to change

My “favorite” example of a distortion. Four little words can do so much damage. This thought produces hopelessness and completely shuts down all action. It is a dangerous thought that, if believed to be true, can lead to giving-up completely.

To prove to you that this thought can’t be true, watch our simple 17 second video below:

After watching the video, I’ll bet you thought, “That’s not what I really mean.” However, that is exactly what you said! Say what you really mean! Get specific!

The problem is not that you can’t go on, it is that you are sick of living this way. You want things to change. You want better treatment. Being frustrated with the past is better than being hopeless. Frustration is based on REALITY. It pushes you to action. It means you are mad and still fighting, surviving.

Offer other suggestions for rephrasing this distortion in the Comments Section for THIS post.

FACT CHECK > This is distorted because it reflects a fear rather than the inability to actually confront

DISTORTED BECAUSE

• I Can’t Confront = Means it is physically impossible, as opposed to intimidating
• What I’m Afraid Of – Ill-defined, vague

RESULT > Unrealistic Anxiety and Avoidance

FIGHT IT!

• I’m afraid to confront…(specify the exact thing)
• I’m not sure how to confront…(specify the exact thing)
• I would be more likely to confront (specify the exact thing) if…

Another common, anxiety provoking, distortion. This thought creates a threat and kicks-in fight or flight. The easiest solution for the body is to flee.

Flight (Avoidance) is powerfully Negatively Reinforcing. Negative Reinforcement happens when we are in a state of distress and we do something that eliminates the distress. The brain learns to seek the same type of relief in every similar situation because it worked so well before. When you do not know how to Fight the threat, the natural response is to avoid it. Avoidance is the natural response in most cases. In the animal world it typically is by far the safest response. How many cats have you seen turn around and face a dog when they can run instead? The problem is that when our avoidance interferes with normal life, it becomes a disorder.

Gradually confronting the fear in a planned fashion is a crucial part of CBT Exposure Therapy. Exposure therapy is the most effective means to eliminate many anxiety disorders. It is a skill that requires practice. You can learn this skill.

Not knowing how to fight the threat does not mean you can’t confront it, only that you don’t know how to confront it.

Offer other suggestions for rephrasing this distortion in the Comments Section for THIS post.

Banishing the blues, Mental Health Practice, 2008 Oct; 12(2): 32-6

Bennett M; Harris N; Learmonth D; Rai S

Abstract:

Mary Bennett and colleagues explore users’ response to a computer-based CBT programme that can be used to treat mild and moderate depression, and make recommendations on ways to improve user experience and adherence.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Beck never lived in Birmingham: why cognitive behaviour therapy (CBT) may be a less useful treatment for psychological distress than is often supposed,  Clinical Psychology, Issue 34, 2004

MOLONEY Paul and KELLY Paul

Abstract:

Begins with a brief discussion of the scope and nature of cognitive behaviour therapy as practiced within the National Health Service, and then critically examines the approach from three perspectives. Looks at psychological research that may case doubt on the approach, presents a critique of the therapy outcome research literature that bears upon the effectiveness of CBT, finally looks at epidemiological evidence which suggests that most of the distress witnessed by psychological therapists arises from pervasive social inequalities.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

I’m spending a few days looking at practical ways for working with group CBT for chronic pain.  It’s the most researched form of CBT-based pain management, and offers some very helpful features for people with chronic pain.  I’ve looked at how groups can impart a sense of optimism and at how they help people with a sense of  inclusion (sense of commonality), and group-based learning.  Today it’s time to look at emotional processing and group cohesion.

I’m sure I’m not alone in feeling slightly awkward in some social settings.  I really hate meeting a group of people who already know each other (I’m the odd one out), or in a bar where I can’t hear well, or at times when I’m feeling less than sparkling (maybe worrying about what people might think…).  I know I’m not alone in feeling that when I’m with people I don’t know well, I am not exactly open to pouring out my woes and being emotional. It can take quite a while to feel comfortable about expressing feelings in a group setting - but at the same time there is something comforting in knowing that if I’m feeling wobbly there are probably a few other people also feeling the same way, so we may all reach for the tissues at the same time!

Processing emotional content in a group setting can be both an amazing experience and at the same time an opportunity to feel really weird.  It all depends on how the facilitator or therapist responds.  Through exposing emotional content, we have greater access to automatic thoughts, assumptions, beliefs and behaviours that are often otherwise well hidden underneath our protective cognitions.  It’s at times when we feel more emotionally vulnerable that we have access to underlying ‘rules of living’ that we may otherwise be completely oblivious to.

What should a facilitator take notice of?

- times when a participant appears disengaged, perhaps doodling, or closing the eyes, maybe rocking on the chair or fiddling with a pen.

What could a facilitator do? To illustrate one way of drawing out the emotional response and opening up an opportunity to talk about what is happening here and now, the therapist could say:

Therapist: ‘before we go on, I just want to check in with the group.  Tony I can see you’re looking a bit distracted, what’s going on for you right now?’

Tony: ‘Oh nothing’

Therapist: ‘Oh.  How does what we were talking about fit for you?’

Tony: ‘Well, I’m just thinking why do I have to be here? I mean, I don’t think my pain is really chronic, and I know I can have another injection if only I talk to the doctor again, so do I really have to do all this psychological stuff anyway?’

Therapist: ‘Does anyone else feel like it’s going to be a really difficult process to learn self management, and maybe there is an easier way other than looking at thoughts and emotions and things?’

Andrea: ‘Well, yeah.  I mean, some of the doctors have said that I can just increase my medications and then maybe my pain will go down and I’ll be doing more, but I just can’t handle the side effects any more.  Those side effects can be worse than having the pain, I think.’

Therapist: ‘Does anyone else feel like it might be easier to just carry on with a medical approach and not look at other things?’

Tessa: ‘I tried that for years, but in the end I still have my pain and my emotions go  up and down every time someone suggests another medication – but I’m still here because I am so fed up with that rollercoaster, and I want to take control again.’

Therapist: ‘ Tony, what is it like for you to hear that other people feel in two minds about doing this self management approach, and there are some appealing things about using medications, but also some not-so-good effects?’

Tony: ‘Well I guess it makes me feel more normal, after all I’ve been on that emotional rollercoaster for a long time, and I really hate the side effects from medications too.  And the doctor said that he wasn’t very keen to give me any more injections.’

This approach can feel risky if you’re not used to facilitating – it’s allowing people the space to feel ambivalent and to process that anxiety but also to recognise that others in the group have also had similar experiences and offer either the same insight (I’ve been here before…) or a new insight (She’s handling it by being open-minded) that can reassure the person.  Provided that the facilitator can trust the group that there will be someone else who has moved through this same thought and emotion before, and go with the flow (roll with resistance), it’s possible to allow people to air their worries or emotions and still be able to move towards the goal of sharing and normalising many of the experiences the group shares.

Group cohesion is that sense that the group are ‘bonded’. There has been much written about the stages of development within a group – the ‘forming, norming, storming etc’  stages amongst others.  What happens is that over time a group may move to the point where it’s OK to disagree with each other, to challenge each other and to risk being ‘real’ with each other.  This can happen quite quickly, but I find that groups often get to the ‘I feel comfortable with this group’ stage (ie they all ‘get along’) but may get stuck and don’t move to the ‘it’s OK to be honest and real and disagree with each other’ stage.  It’s only when groups move to this deeper level of cohesion, IMHO, that they start to ‘work’ each other.

The therapist or facilitator can encourage this deeper relationship and here are several strategies that can also help:

1. Choosing a group that has similar characteristics – eg stage of change or readiness to adopt self management, maybe diagnosis or pain site, perhaps compensation status or job status
2. Ensuring confidentiality and creating the group norms
3. Ensuring a climate of acceptance, empathy and promoting sharing of information
4. Connecting two or more participants experiences
5. Responding to group process as it happens

More about this last one tomorrow. Group process is all about the things I’ve raised over the last couple of days – disclosure, optimism, inclusion, group learning, shifting from self to others, and managing both emotional processing and group cohesion.

I’ll review these tomorrow and add in some specific strategies that can be helpful to elicit each one.

The Role of Viruses in ME/CFS, XMRV and the MRC PACE Trial – Margaret Williams – 21st November 2009

WordPress Shortlink: http://wp.me/p5foE-2qd

Permission to Repost

Note:  This is a long and heavily formated document and I am posting only the introduction here:

The full document can be accessed here on MEActionUK website:

http://www.meactionuk.org.uk/The-role-of-viruses-in-ME.htm

http://tinyurl.com/ykjveep

http://www.meactionuk.org.uk/The-role-of-viruses-in-ME.pdf

http://tinyurl.com/y8m8s8h

The role of viruses in ME/CFS: what, if any, will be the effect of the discovery linking XMRV to ME/CFS on the MRC PACE Trial?

by Margaret Williams

21 November 2009

For decades it has been known and shown that viruses play a role in ME/CFS; some illustrations from the literature are provided below (all of which are relevant and significant).

In relation to “CFS”, the most-studied viruses have been the Epstein-Barr Virus (EBV) and the Human Herpes Virus-6 (HHV-6). In relation to “pure” ME, the most studied viruses (and for which there is extensive evidence) have been the enteroviruses, usually Coxsackie B (CBV). Some illustrations from the literature of the role that viruses play in ME/CFS are provided at the end of this paper; all are significant.

There is increasing awareness that the dysregulated immune system that is a hall-mark of ME/CFS allows multiple latent viruses and microbial agents to become reactivated (Co-Cure NOT:12th November 2009).

Moreover, recent research has shown that even viruses which were hitherto believed not to persist after an acute infectious episode are capable of long-term viral persistence.

Nora Chapman et al from the Enterovirus Research Laboratory, Department of Pathology and Microbiology, University of Nebraska Medical Centre, have shown that human enteroviruses Coxsackie B can naturally delete sequence from the 5’ end of the RNA genome and that this deletional mechanism results in long-term viral persistence, which has substantially altered the previously held view

(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440640/?tool=pubmed ). In a specially commissioned piece for the charity Invest in ME, the researchers say: “This previously unknown and unsuspected aspect of enterovirus replication provides an explanation for reports of enteroviral RNA detected in diseased tissue in the apparent absence of virus particles” (Journal of IiME 2009:3:1).

Dr John Chia, an infectious diseases specialist from Torrance, California, who specialises in ME/CFS, is on record: “I believe that the main reason (ME)CFS patients are symptomatic is due to continuing inflammatory response toward viruses living within the cells, enteroviruses in most of the cases I see. We have clearly documented certain enterovirus infections triggering autoimmune responses in some patients…Can you imagine how we would feel if there are viruses surviving in our muscles, brains, hearts and gastrointestinal tracts triggering ongoing immune responses?”  
(http://aboutmecfs.org/blog/?p=865 ).

The CFIDS Chronicle (Research Update, Summer 1993) explained viruses and retroviruses as follows:

“A virus is a microscopic organism that lives within the cells of another living organism. Viruses cause disease at the most basic level, by damaging the cells of living things. By themselves, viruses are lifeless particles incapable of reproduction, but once they enter the cell of another living thing they become active organisms that can multiply hundreds of times.

“Viruses are comprised of two parts – a core of either deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) and a protective envelope of protein. RNA viruses are smaller than DNA viruses and sometimes contain a special enzyme called reverse transcriptase which allows them to convert RNA to DNA. These specialised viruses are known as retroviruses and have a unique ability to merge with the host’s own genetic material.

“Retroviruses have the unique ability to replicate themselves by (i) making a double-stranded DNA copy called a ‘pro-virus’ once they enter living cells. Pro-viruses integrate themselves into the human chromosome and become part of the host’s genetic code (ii) alter the host’s immune response by evading detection as a ‘hidden invader’ (iii) remain hidden and latent, spliced within the host’s DNA, for long periods of time. Retroviruses are known to be potent stimulators of cytokines”.

On 8th October 2009 the premier journal Science published a paper online showing a direct link between a retrovirus and ME/CFS (Detection of infectious retrovirus XMRV, in blood cells of patients with chronic fatigue syndrome. Lombardi VC, Ruscetti FW, Peterson DL, Silverman RH, Mikovits JA et al) which caused global reverberations.

However, this was not the first time that a retrovirus had been associated with ME/CFS.

In 1991, using polymerase chain reaction and in situ hybridisation, Dr Elaine De Freitas, a virologist at the Wistar Institute, Philadelphia (which is America’s oldest independent institution devoted to biological research) and Drs Daniel Peterson, Paul Cheney, David Bell et al found such an association (Retroviral sequences related to human T-lymphotropic virus type II in patients with chronic fatigue immune dysfunction syndrome. Proc Natl Acad Sci USA 1991:88:2922-2926). It is notable that co-author Hilary Koprowski is a distinguished virologist and Professor Laureate who was Director of the Wistar Institute from 1957-1991; he is a member of the US National Academy of Sciences and is Director of the Centre for Neurovirology at Thomas Jefferson University.

Before publication, the findings were presented on 4th September 1990 by Elaine De Freitas at the 11th International Congress of Neuropathology in Kyoto, Japan.

Ten days later, on 14th September 1990 Dr Peter White (as he then was) and other members of the Wessely School dismissed the findings: “in the vast majority of CFS cases there is a psychological component. About 75% of CFS sufferers are clinically depressed, according to Peter White, senior lecturer in the department of psychiatric medicine at St Bartholomew’s Hospital in London. White said he believes depression is often a cause, rather than a consequence, of CFS…Les Borysiewicz, a clinical virologist at Addenbrookes Hospital in Cambridge (now Chief Executive of the MRC, having succeeded Professor Colin Blakemore) (said) ‘Whatever causes CFS, it isn’t the virus itself’…Anthony Clare, psychiatrist and medical director of St Patrick’s Hospital in Dublin (now deceased), pointed out that…there have been many ‘fatigue’ diseases with shifting causes: ’Neurasthenia, food allergies, now viruses. Some people would always rather have a disease that might kill them than a syndrome they have to live with’ ” (Science 1990:249:4974:1240).

In their PNAS article that was published in April 1991, De Freitas et al noted that chronic fatigue immune dysfunction syndrome (CFIDS) “may be related or identical to myalgic encephalomyelitis” and examined adult and paediatric CFIDS patients for evidence of human retroviruses (HTLV types I and II). As the CFIDS Chronicle article noted, the Wistar team looked at the peripheral blood DNA to see if they could find messenger RNA (mRNA) encoding for a viral segment of the HTLV-II virus.

At that time, known human retroviruses were the human immunodeficiency viruses 1 and 2 (HIV-1 and HIV-2) which are known to cause AIDS, and human T-lymphotropic viruses HTLV-I which causes lymphoma and HTLV-II which causes leukaemia (Hunter-Hopkins ME-Letter, October 2009). The four segments of the HTLV-II virus are referred to as the env, gag, pol and tax.

After a two year study, De Freitas et al provided evidence for HTLV-II-like infection of blood cells from CFIDS patients (and also to a lesser extent from people closely associated with them). This evidence was further substantiated by patient reactivity to proteins with the molecular weights reported for HTLV-I and HTLV-II antigens.

In their article, De Freitas et al said: “The frequency of these antibodies in CFIDS patients compared with healthy non-contact controls suggests exposure / infection with an HTLV-like agent rare in healthy non-contact people”.

Following the Wistar findings, researchers at the US Centres for Disease Control (CDC) allegedly attempted to replicate De Freitas’ work but failed to do so; this was suggested to be because certain scientists appeared eager to discount any possibility of a retroviral association with CFIDS. De Freitas defended her work and insisted that the CDC investigators had modified her assays, with the result that her work could not be replicated by the CDC.

De Freitas was publicly discredited; her research funding was discontinued and her research abandoned; she was subjected to what appeared to be attempts to destroy her professional reputation. Commenting on the subsequent discovery of XMRV (see below), ME/CFS expert Dr Paul Cheney of The Cheney Clinic was unambiguous: “Her work was unfortunately assaulted by the CDC. Her proposal to fly to the CDC in Atlanta to physically run the assays side by side with the CDC scientists was dismissed by the CDC” (http://cheneyclinic.com/a-retrovirus-called-xmrv-is-linked-to-cfs/538  ).

Read full article here:

http://www.meactionuk.org.uk/The-role-of-viruses-in-ME.htm

http://tinyurl.com/ykjveep

http://www.meactionuk.org.uk/The-role-of-viruses-in-ME.pdf

http://tinyurl.com/y8m8s8h

Mindfulness Special, Journal of Cognitive Psychotherapy, 2009, Vol. 23 (3)

 
Recent Developments in Mindfulness-Based Research

New Developments in Research on Mindfulness-Based Treatments: Introduction to the Special Issue
Authors: Lau, Mark A.; Yu, Amanda R.

Development and Preliminary Validation of a Trait Version of the Toronto Mindfulness Scale
Authors: Davis, Karen M.; Lau, Mark A.; Cairns, David R.

Do Mindfulness Meditation Participants Do Their Homework? And Does It Make a Difference? A Review of the Empirical Evidence
Authors: Vettese, Lisa Christine; Toneatto, Tony; Stea, Jonathan N.; Nguyen, Linda; Wang, Jenny Jing

Psychological Functioning in a Sample of Long-Term Practitioners of Mindfulness Meditation
Authors: Lykins, Emily L.B.; Baer, Ruth A.

Mindfulness Meditation Training and Self-Referential Processing in Social Anxiety Disorder: Behavioral and Neural Effects
Authors: Goldin, Philippe; Ramel, Wiveka; Gross, James

The Role of Mindfulness-Based Stress Reduction on Perceived Stress: Preliminary Evidence for the Moderating Role of Attachment Style
Authors: Cordon, Shari L.; Brown, Kirk Warren; Gibson, Pamela R

Evolving Conceptions of Mindfulness in Clinical Settings
Author: Carmody, James

Lancashire Care staff only can request one or all 7 of the articles from the special: email: susan.jennings@lancashriecare.nhs.uk

I saw Dr N on Thursday. It was good to have him back.

I wasn’t really with it at the appointment. I couldn’t focus and didn’t know what to say. I have felt pretty numb over the past few weeks and I couldn’t convey how I felt. At one point he just said “Are you okay? Have you been sleeping? You seem like you’re on another planet”. I told him that sleeping was a silly question, which he admitted, but he was right. I was very tired and vague. The fact he’d noticed though was good. It makes a change from other doctors that clearly pay no attention to how you really are.

I explained that I’d been having problems with headaches over the past couple months. I’ve literally had a headache every day for about 3 months, sometimes incredibly intense pain, other times just a dull ache, but nearly always there in some form. Beta Blockers are meant to be effective in preventing headaches, so he was a little concerned seeing as I’m already taking propanolol (for anxiety/agitation). We’ve decided to increase the dose and also switch to the modified release version so I’m now taking 160mg daily instead of 40mg b.d. Hopefully it will have some effect.

On Friday I got a phone call from HR. I have a new HR Rep, R. She introduced herself a couple of months ago, but hasn’t been in touch since. She was meant to call me regularly but hasn’t, so it was quite a long catch up. She asked me about therapy referrals, my social worker and psychiatrist. I told her there wasn’t much to say. Therapy referrals take forever, my social worker is still useless and I don’t see my psychiatrist until tomorrow.

She asked me when my last occupational health assessment was. It was over a year ago, so she said she will look into that again. I don’t know what an OH assessment will achieve. I get the impression they only want me to go so that work can say they are doing something to help. I don’t think there will be any pressure on me to get back to work, but I may be wrong. I guess it depends on the doctor I see. I have the same fears I had about the ESA medical. Fears they will tell me that I am making it all up and should just go to work.

If I do go, I wonder if I will see the same doctor as last time. He seemed to be pretty knowledgeable when it came to mental illness and was the first medic to suggest that Bipolar Disorder was a possibility. Shame it took a further 7 months before an agreement was reached on that topic. When I’d brought up his thoughts later with other doctors they didn’t seem interested. I guess they wanted to make their own decisions.

It may be useful to discuss work though. I haven’t managed to get much of an idea from the CMHT about when they think I will be ready to go to work. I am going to try and talk about it with the psych tomorrow. Dr N keeps asking me if I’ve heard anything from HR or whatever, but there hasn’t been anything to tell. I told him about my medical result too and I think he was a little surprised I’d been placed in the support group, although I think it also told him how ill I’d been on the day of the medical. I am not sure he quite understood how bad it was when I’d told him before.

The other thing R mentioned was regarding our company Employee Assistance Programme. I was told that they had been running a CBT trial and maybe I should consider asking about it. I told her I was pretty skeptical about CBT, but it could be useful to have some contact with a therapist whilst I am waiting for the NHS to do something. I agreed I’d give them a call anyway.

I was on the phone to the EAP for ages. First of all someone took my details and asked why I was calling. I explained I’d been told about CBT by my HR rep. She explained that they only offered telephone and online CBT (I’m guessing Beating The Blues!). I told her I wasn’t sure about that, but she said she’d put me through to the counselling team for an assessment and to discuss what might be helpful.

The counsellor was lovely. I explained I’d been on long-term sick leave for mental illness and that HR had suggested I got in touch. He asked me for a potted history, which I gave him as quickly as I could manage. At the end he just kinda went “oh, blimey”. I mentioned I’d had CBT whilst at The Priory and he asked me what I thought of it. I was honest and said that I was pretty skeptical and generally thought it was common sense, useful for mild depression, but ineffective for me. He asked me why I’d even bothered calling then, which was a sensible question. I said that I guess I thought it might be useful to have some contact with therapy whilst waiting for the NHS. Apparently his assessment of CBT was similar to mine and he didn’t think online CBT was going to be much help. He explained that usually a case like mine would be too complex for them to consider, but he wanted to help. He suggested that because I am waiting for long-term support, but I’m not getting the help I need currently, he felt it might be possible to refer me to the face-to-face service temporarily. It would only be four assessment appointments, but it might help me to work out what I want to work on when my NHS referral actually comes through. I agreed that this may be helpful. He asked me more questions then. Mainly about risk and safety. He stressed that his boss wouldn’t allow him to go through with it if they felt I was at too much risk. I had to give him the assurance I would be safe for the next four weeks, which was difficult even now. I am keeping myself safe at the moment, but I don’t know if or when that will change. At the end of the call he explained he would need to ask his boss to authorise my case, but hopefully it would be okay and then he wished me luck.

I am awaiting the phone call back to arrange my first appointment. He said if his line manager had refused he would call me back straight away and I didn’t hear anything, so I’m hopeful. I do think it could be good to just see someone for a few weeks. I don’t trust my social worker and have very little other support. In some ways I’m hoping it will be the same therapist I saw through the EAP back in April/May 2008, but I don’t suppose it will be, but you never know.

I need to go now. I have more to write, but no time. My bloke is going back to work part-time and I have the psychiatrist tomorrow. I guess I will update more soon.

FACT CHECK > This is distorted because it predicts the future

DISTORTED BECAUSE

• I’ll Get = “I Will Get” is future-oriented (We can’t predict the future)
• Bad News – Ill-defined, vague

RESULT > Unrealistic Anxiety and Avoidance

FIGHT IT!

• I can’t predict what the doctor will say
• If I go, I’ll know what I’m facing and the doctor will have a plan even if it isn’t good news
• It might not be near as bad as I think

This is a very common, anxiety provoking, distortion. This thought creates a threat in the brain. The brain responds with telling the body to kick-in fight or flight. How long does fight or flight last? Until the threat is gone. The best way to confront this thought is by fighting the distortion and going to the doctor. “Fleeing” from this type of threat won’t work. How do we flee from our own thoughts? Distraction, “keeping busy,” drinking, “getting your mind off of it” – none of these work to eliminate the threat.

This distortion is also vague. What does “bad news” really mean to a doctor? By seeing the doctor, you will receive a specific plan to attack the problem (if one is even there!).

Offer other suggestions for rephrasing this distortion in the Comments Section for THIS post.

Family Intervention for Suicide Prevention: A specialized emergency department intervention for suicidal youths, Professional Psychology: Research and Practice. Vol 40(2), Apr 2009, 118-125

Asarnow, Joan Rosenbaum; Berk, Michele S.; Baraff, Larry J.

Abstract:

Suicide attempts and suicidal ideation are common problems among youths seen in clinical practice. Despite the high risk of repeated suicidal behavior in these patients, clinicians are faced with a lack of empirically supported treatments for these youths. This article describes the Family Intervention for Suicide Prevention (FISP), a second-generation adaptation of the Specialized Emergency Room Intervention, an evidence-based practice. Although designed for use in emergency settings, the FISP can be used by practitioners working in a wide range of settings where youths present with suicidal emergencies. Rooted in cognitive–behavioral and family systems theory, the FISP is designed to mobilize family support and problem solving, reframe the suicide attempt as a critical event that requires treatment, reinforce more adaptive coping, motivate patients and families to initiate and adhere to follow-up treatment, and promote linkage to follow-up care. This approach can be used with a wide range of patients and offers an evidence-informed tool for practicing clinicians

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

CBT, or cock and ball torture, seems like an activity that most male submissives (or most males in general) would do their best to avoid being subjected to.  While I am not a hardcore sadist, I have to tell you that engaging a play partner in mild to moderate forms of CBT can be most exhilarating for both the dominant and submissive involved.  Understand that I appreciate and love a man’s cock and balls, and derive great pleasure from them in a variety of ways…including inflicting a little pain or sensation to his most sensitive parts.

The thing to understand here is pain can actually be a very erotic experience.  Most often pain is associated with punishment, and understandably so.  However, in the right context, pain can be a shared sensual and powerful exchange.  Endorphin release via pain play enhances the senses and quiets the mind…not to mention how utterly beautiful a boy looks and sounds while receiving a nice, loving whipping to his private parts.    CBT can also involve activities  such as cock bondage with ropes, implementing chastity devices, use of electrical toys or even urethral insertion.

My idea of CBT is not so much that it be utilized as a form of “punishment”, per se, but more as a way to enhance submissive feelings (both physically and mentally).   When a submissive is focused on the physical sensations of pain, he is more apt to attain a sense of sub-space, because let’s face it, you’re not going to be pondering that big work project or thinking about mundane chores you still have to take care of when your cock is being flogged, pinched and/or paddled.   That’s the thing about pain play in general; it essentially forces one to be in the moment. Everything else that worries one in their daily round becomes irrelevant.  And in that frame of mind, sub-space is more easily attained.  It’s actually quite a serene thing to witness.  Creating a balance between pleasure and pain is a favorite way I like to carry out CBT games.  The very best part is when a play mate is so immersed in the physical, he is temporarily unable to differentiate between pleasure and pain.  Now that, is a most excellent display of exerting control over another’s body!

For the novice CBT practitioner or seeker, the most important thing to remember is to go slow and experiment with various sensations.  Start out with some light ball slapping…then perhaps move onto candle wax decoration to the cock (its best to shave the genital area *before* dripping hot wax; clean-up will be easier),  some clothespins…maybe a little game of cock percussion by drumming up some lovely melodies with wooden spoons, rulers, metal spoons, and so on.  Wartenberg wheels are also excellent tools for sensation play…on any part of the flesh.   Binding the cock with rope or cord can be a lot of fun too…and I plan to include a segment and a more involved kink assignment  incorporating cock-bondage play in a separate post soon.

Safety tip:  You should never do anything that might bend or squish an erect penis.  You do NOT want to damage the erectile tissue.  I don’t care how much of a sadist/masochist you are!

And now, for a little Kink Assignment involving some CBT:

You will need–

• Lots of clothespins
• Your cock and balls
• A camera if you’re brave enough to share your “masterpiece” with me….

Take off all of your clothes.  Relax.  Take a few nice, deep breaths.  Sit on the floor with your legs bent up and spread.  Beginning at the base of your cock, and affix the clothespins…start close to your anus, and place one clothespin after another, keeping them as close as you possibly can.   Use as many clothespins as you can to your balls and bring them up to the head of your cock.  It should look almost like a “mohawk”.   When you have all of the clothespins attached to your cock/balls as you can fit, lie on your back and stay there for at least ten minutes more.  As you’re lying there, all prettily decorated like that, concentrate on what is going through your mind.  What are you thinking about?  How does this make you feel? Physically, emotionally?  Take a picture of your new “art project”.   Do not exceed twenty minutes with the clothespins on your body.

When the 10 to 20 minutes are up, remove the clothespins. If you’re a genuine painslut, go ahead and pull them off quickly!  Remember, taking clothespins off of your body will hurt a hell of a lot more then putting them on.  Relish in these sensations and share what that felt like with me here or in a private email.  Then with your hands, get yourself off.  How does your orgasm feel after you subjected your cock and balls to a bit of torment?

I invite you to share your work…send photos and/or email reports to: kinkyfunmina@yahoo.com

Until next time,

Mina, Kink Artist Extraordinaire

1-888-662-6482

Twitter/Yahoo/AIM: kinkyfunmina

Long time no see!

I figured that I would post a very important information that I’ve learned through my workbook Managing Social Anxiety: Client Workbook by Drs. Hope, Heimberg et. al. In fact, my psychiatrist (who is my psychotherapist believe it or not!) went over it with me in my last session. At first I was skeptical, thinking it didn’t applied to me, but the more I observed my thoughts the more I realized it was true.

People with Social Anxiety Disorder have three dysfunctional thinking patterns: perfectionistic standards of socializing, low self-efficacy in social skills, and external locus of control. I will give each one its own blog entry so it will be a three-part series, giving each their “symptoms.” So today I’ll describe social perfectionism.

Perfectionistic standards towards social situations is an obvious one to understand. Basically, you have these rigid, absolute rules about how you should behave when socializing with others. For instance, you would think “I must be able to come up with a topic easily in mind and express it clearly to the other person. Also they must be interesting.” Interestingly enough, these usually only apply to the sufferer him/herself but not to others, though there are exceptions. There isn’t anything wrong in having a few guidelines about how you should behave with others. The problem comes when you believe there are no exceptions, no option to change these dogmatic “rules.”

Here are the cognitive distortions that are symptoms of social perfectionism:

1. Should Statements about how you should socialize with others (this was a pretty obvious one). These usually come in not only statements containing “should” but also “must,” “have to” and “need to.”
2. Magnification of social “mistakes” or “errors.” Basically, you exaggerate how terrible or awful the mistake you make even though the consequences aren’t really notable. For instance, “God that was so awful that I said something so stupid!” or “Damn it! How could I have blushed in front of her like that?!”
3. All-or-Nothing Thinking about your social performance. Basically, you categorize your performance or yourself in only two opposite categories instead of seeing it as a continuum. For instance, “either I succeed in impressing her or I fail miserably.” How about just being able to have a pleasant date which wouldn’t involve impressing her at all?
4. Mind Reading that other people are judging you harshly for your social “mistakes” or “errors.” That’s one thing I forgot to add: people with severe social anxiety assume that other people share their social perfectionism. Ex: “they must be thinking ‘what is she doing walking around aimlessly?’”
5. Labeling yourself for your social “mistake” might also be another symptom. For instance, “because I didn’t yell back at her, I’m a pathetic loser.” “Damn it! How could I have said that?! Damn I’m stupid!”

Keep tight for part 2 (hopefully tomorrow)!

BDSM and Bipolar for me is a wonderful combination!

While they might not be a great combination for my submissive, it works for me. LOL. I love the feel of release as I inflict pain on my submissive. The weight of the world leaving my mind for that short time as I force the submissive to do things they normally would not do in their true mindset.

Maybe it’s time to find that submissive again. After all it has been a few years since I have had one that wasn’t online. LOL

I’ve come to the realization that my Dominant side is a hiding technique. A way for me to inflict on another the pain I am feeling inside my head and heart. Thats where the Bipolar plays in. Because I am just that confused, I feel I need to give someone else the pain I’m feeling but in a different way. They get the pain through whippings, floggings, humiliation, CBT, and Mind Control (as well as many other ways), I have the pain in my head.

Hum: New thought! Maybe it’s not my Bipolar that instigates this, but my Borderline Personality Disorder since it supposedly is what triggers my emotions where relationships are concerned.

For me, BDSM is not about SEX as it is for most. I don’t personally use it as a sexual release. But here is the clincher; I’m submissive to my partner.

For me being submissive means going into another world, a world where someone else takes over and dominates my existence. So what is my true calling then? That of a Dominant or that of a submissive? I hate the term “switch” as I don’t feel that is me at all. Your either Dominant or submissive, there really is no in between.

I’m confused! LOL

It may not seem apparent, but whether you are  studying in the library, at work, or just out at the mall, psychological principles can be applied to every facet of our lives.

The other day I walked into a Pharmaprix, and I noticed that the only entrance to the store first lead me through the vibrant isles of the cosmetic section.  Upon entering, I was instantly greeted with a warm smile and hello from one of the staff.  The way the environment was set up, and the charismatic people employed there was no coincidence.  In retail, interacting with your customer base is critical in securing sales, and getting repeat clientele.  To do this, staff must project warmth, and expertise. Helping customers with their needs and making them feel at ease involves a variety of psychological principles at work.

Customer Service, Cosmetics, and Psychology

Think about when you walk into a cosmetic store, how are you able to decipher staff from customers? The staff are often seen wearing a technician/lab coat uniforms. This not only signals to the customer that these individuals work there, but it also effects the way they view the beautician.  The way we dress, and the environmental context can tap into existing schemas (mental constructs that help us organize the way we see our self, others, and the world).  Quite often, when we see a lab coat in the context of pristine rows of cosmetics (sterile and lab like), through our existing schemas it indicates to us that this individual is a specialist in their field. In therapy, as a client, it is important that you believe that your therapist has knowledge and expertise.  These elements are crucial to treatment outcomes, because it helps build and foster trust and rapport (therapeutic alliance).   The same processes are at work in retail, if you do not have rapport with the sales staff, or believe that they are knowledgeable in the field, the suggestions, and information they offer may go in one ear and out the other.

However, it’s not just they way you dress in retail, but how you interact with clients.  In psychology we refer to these as social skills.  Take the example of someone walking into a cosmetic store that is unhappy with their skin, and is too shy to directly ask about various products.  As soon as she walks into the store she will be greeted by a beautician.   In this case when greeted, she pauses, makes eye contact and says hello back.  Staff who have a strong social skills set will be able to read the situation (reception skills), then  make sense of the situation by interpreting the clients subtle verbal and non verbal cues (processing skills) to conclude that that the client is shy, and then act accordingly by approaching the client subtly to offer help and engage in further conversation(expressive skills).  These skills are essential for optimal client care.

Often clients come to the store because they are not happy with the they look, and seek to improve their outward appearance.  They often rely on the expertise of the staff to help guide them.  How we look on the outside can be tied to the way we feel about ourselves.  Often times, staff can play a major role in increasing the self-image of clients.  Take the sensitive area of skincare, for some women, having poor skin can effect the way they see them selves, how others see them, and more importantly how they perceive how others view them.  If a beautician is able to give a client techniques, and products to improve their skin, this empowers the client into feeling that they have control (self-efficacy).  Relating back to social skills, because of the sensitive topic, staff are not going to approach someone and directly say something like “I see that you have problem skin, let me help you.”  Sometimes all it takes is a warm smile, and a subtle approach.

When clients do discuss their skincare, the next step involves what psychologists would call a functional analysis.  In psychology this relates to examining the “ABC’s” and were not referring to the alphabet.  This same analysis is carried out with skin care.  First the beautician would ask for a history of the products used in the past(antecedents), and what the client is currently doing for skin care (behavior), and examine the current state of the skin (consequences).  To further help to examine the current state of the problem (poor skin), a beautician would use a machine called a Skin Dehydration monitor to assess the current state, and compare it to an ideal or goal.    Using the information gathered, they can then offer their clients feedback.  Feedback is crucial in the treatment process for determining goals and formulating a plan of action.  So as you can see, CBT can be applied to anything.  Next time you go to a store, see if you can pick out the very things discussed in this blog.  Happy shopping.

`Yesterday I started to look at why pain management using a CBT approach can work well in groups.  As I mentioned, it’s the most researched form of CBT-based pain management, and offers some very helpful features for people with chronic pain.  Yesterday I looked at how a group approach can offer participants a sense of optimism.  Today I’m looking at inclusion (sense of commonality), and group-based learning.

One of the most striking features of having an invisible health problem is that many people can be walking around in our communities with their pain without anyone being any the wiser.  The sense of isolation experienced by some of the participants in the pain management programme I work on is astonishing.  It’s as if they are living in a bubble that makes interacting with other people profoundly difficult.  Being in a group setting with other people experiencing similar problems offers some really important things:

1. a sense of belonging, to recognise that chronic pain is experienced by other people who struggle with the same issues
2. a sense of normalising – recognising that some of the experiences are not strange or a sign of some unique failing on the person’s part, but are simply part of having chronic pain
3. the opportunity to learn from others who may have faced and coped well with very similar situations and arrived at helpful solutions
4. shifting the focus off the individual and offering them the opportunity to help others.  This can be an empowering situation for individuals who can otherwise feel helpless and hopeless.

The way the therapist facilitates group members to develop the sense of safety needed to share experiences, and confidence to offer opinions (especially opinions and doubts that contradict the ‘proper’ way to manage) is crucial to the success of the experience.

I begin the group programme with a brief outline of the purpose, housekeeping, and then very briefly ask particpants to share a little about themselves.  At the very beginning of a three-week programme it’s unnecessary, I think, to start with ‘icebreakers’ and I find many people simply hate them! So it’s a very simple ‘tell me a little about yourself and why you’ve come to the programme’.  Later on in the day I use the whiteboard to brainstorm all the possible topics that people might want to have the programme cover – I use a very open approach to do this, allowing the more vocal participants to start this process off.  Once a few topics are on the board, I’ll then start to prompt ‘people who haven’t had a chance to speak’, and I also allow some periods of silence because some participants need that time to process thoughts into words.

It’s once topics are on the board I notice that participants begin to warm up to each other and start to share the ‘back story’ of why some of the topics they’ve suggested are important.  Allowing this to happen without too much direction helps set the scene for people to see that the group includes people ‘just like me’, and I find the less vocal people start to show nonverbal participation.  Sometimes at this point it can be helpful to break off into pairs to share one another’s journey to coming to the programme – having to speak to only one person can help to make speaking and feeling included easier.

At this point the therapist can facilitate slightly deeper sharing – saying something like this:

Therapist: ‘Now that we’ve spent some time hearing about what’s brought people to the programme, and what they want to learn, we can see that although each person is unique, there are some similarities that you all share.  What do people think or feel about what they’ve heard?’

Tom: ‘At last there are other people who know that I’m in pain when I say I’m in pain!’

Alison: ‘It’s really strange because I’m usually the only one in pain and feeling like I really need to stand up or jiggle, and here are a whole group of people doing the same!’

Group laughs then silence

Therapist: ‘What about for others?’

Tony: ‘I thought everyone would be ACC whiners, but you’re not.  Is anyone else on ACC here?’

Andrea: ‘Yes I am, and I’m worried that ACC is going to kick me off compensation straight after the programme, and they’ve made me come here and I can’t work like this.’

Therapist: ‘It’s really great that you’ve talked about this Andrea, because a lot of people do worry about what is going to happen after the programme.  About half of this group are on ACC compensation, and we’ll talk about how to work with your case manager and what to plan for after the programme in several sessions.  It’s also a really important point you’ve raised about ACC making you come along.  Does anyone else feel like they’ve been made to come to the programme by someone else?’

Alison: ‘Well, I thought so at first because my case manager suggested I come to Pain Management, but when you did the screening you explained that I could decide whether the programme was for me or not, so I’m feeling OK about it now.’

Therapist: ‘Thanks for saying that Alison.  You’re right, coming to the programme is absolutely your choice, and it’s important you decide to be part of it yourself, and not for anyone else.  Not a partner, or a child, a doctor or even ACC can make you come along.  If you’re here because you think someone else made you attend, I can reassure you that if you decide at the end of today that this is not the right thing for you, we will communicate this with your case manager and there will be no penalty.’

This is an important ‘doubt’ that many people can have when asked to attend a pain management programme, as many people with chronic pain have some sort of relationship with a compensation agency.  We have a policy that people must be ‘ready’ to attend a programme for themselves, because we’ve found that although it’s possible to include people who feel coerced to attend and the group process can work with this, it makes progress very difficult.  Self management is that – self management.  It’s a choice, and people do need to be ready to pursue it.

Even after selecting people carefully for inclusion, participants can continue to feel worried about the consequences of completing a programme, and this is an issue to discuss openly.  We start doing this by a process called ‘fears in a box’, where after about three days, participants are offered the opportunity to write down their concerns or doubts about the programme, and place these thoughts in a box.  The team members review the written questions and at the end of that day, directly discuss these issues with the group.  Many group members say they feel relieved because they thought they were ‘the only ones’ to have the doubts, but typically it’s something many of them feel.  Offering participants a chance to anonymously air their worries helps the whole group feel more comfortable sharing their unique worries, allowing the therapist/facilitator to work through the issues to resolve them.