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The
pathological reactions that characterize Mood Disorders result from biased
perception, and so can be evoked by nearly anything. Shooting yourself in
the foot is unfortunate; doing it repeatedly suggests a disorder rather than
merely bad luck. Many people achieve less and suffer more than would be
expected considering their talents and circumstances because they hemorrhage
time and energy in their struggle with a Mood Disorder.
Early clinicians including Sigmund Freud and Milton Erickson attempted to
make sense of these disorders by proposing Unconscious Motivation –
after all no one would consciously sabotage the self. Clinical research has
not been kind to this formulation. It does not provide an adequate
explanation for Mood Disorders, nor does it show the way out. Nevertheless,
the concept of unconscious processes is central to the human condition, and
we will meet it again in a different form in Part 4.
In
fairness to early clinicians, it is not easy to carve nature at its joints –
especially when attempting to deconstruct the Psyche. As was the case in
the Indian story of the “the 6
blind men and the elephant,” apparent reality is based upon the
perceptions available at the moment. We will never have access to the whole
truth about the Psyche, and so we must employ imperfect models. The
best-developed model of the etiology and treatment of Mood Disorders
currently available is Beck’s Cognitive Therapy, which is focused on the
pathogenic consequences of cognitive distortions and shallow processing.
Mood disorders, like addictive
disorders tend to relapse. Cognitive Therapy
produces better long-term outcome than pharmacotherapy
- primarily through reducing relapse and recurrence
rates:
- Outpatients who recover following treatment of
depression by Cognitive Therapy show less relapse or need for treatment than do patients
who recover with antidepressant medication and are then withdrawn from
pharmacotherapy1.
- Cognitive Therapy following recovery with pharmacotherapy reduces
relapse and recurrence for mood disorders2.
- Even in
patients responding only partially to antidepressant medication, the
addition of Cognitive Therapy to clinical management and continuing antidepressant
medication significantly reduces relapse3.
Beliefs Underlying the Cognitive Model
According to Aaron Beck
and his colleagues,4 a person's
vulnerability to major depression depends on certain assumptions,
particularly those that involve a dependence of self-worth on approval from
others or on the success of activities.
A recent model proposed by Teasdale5
suggests that vulnerability to depression and relapse depend not so
much on enduring trait-like dysfunctional attitudes, but on the pattern of
negative thinking evoked in mildly depressed states. Cognitive therapy is
effective because it changes these patterns of negative thinking.
Specifically, as a result of cognitive therapy patients change from
believing they are their emotions, or
from identifying personally with negative
thoughts and feelings. Instead the patient comes to relate to negative
experiences as simply transient mental events.
Meta-Cognitive Awareness
One of the milestones of lifespan
development is the appreciation of the
Soul Illusion: Our perceptions are
not accurate reflections of objective reality, rather they are always biased
by our state of mind at the
moment. As our state changes our perspective,
beliefs, and feelings
change with it. A label for this milestone is:
Meta-Cognitive Awareness and refers to the mind set that all experience,
including cravings, negative thoughts, and anxious feelings are transient
cognitive events rather than valid reflections of objective reality.
According to this
view, Cognitive Therapy reduces
relapse because it increases
meta-cognitive awareness. This is crucial for
self-determination, because the appreciation that feelings and
beliefs are state dependent allows one to escape from
control by temporary states of mind. The appreciation that a
belief is simply passing mental event
opens the possibility of standing back from it and
objectively evaluating its accuracy. For
example, instead of accepting the belief: "I am unlovable," one appreciates
that this thought is merely a local construction of the mind, which may or
may not have some truth to it.
Meta-Cognitive Awareness is a mind set that can enable
you to become more aware of and relate differently to your thoughts
feelings, and bodily sensations. The goal is to
view them as passing events in the mind rather than identifying with
them, or treating them as if they were objective reality.
To
get into this mind set you must do something difficult, but not without
rewards of its own: Disengage from habitual
[automatic] thinking styles. Not easy, because
repetitive patterns of thinking
occur so often and so quickly that they
go unnoticed. We do not generally assess the validity of our
assumptions and beliefs, because they are so familiar, habitual, and. . .
believable.
Meta-Cognitive Awareness
demands an aware mode of being, characterized by freedom and
choice, in contrast to a mode dominated by habitual,
over-learned, automatic patterns of
thinking and feeling.
Consider a
time when you
were driving your vehicle along a familiar route,
and you
were so absorbed in your thoughts - planning
some future activity or ruminating on a current concern -
that you didn't notice
passing a certain landmark along the way, or the music from the vehicle's
sound system, or the feel of the steering wheel in your hands. And
even though the conscious mind
was so completely preoccupied that you didn't notice all
these things,
a part of
you was driving the vehicle, and operating it
perfectly safely.
But if the conscious part of you was preoccupied with its thoughts,
who was operating the vehicle? Answer: The mindless, automatic, unconscious
part of you.
By
contrast, "mindful" driving is associated with being fully present in each
moment, consciously aware of sights, sounds, thoughts, and body sensations
as they arise. When one is mindful, the mind responds afresh to the
unique pattern of experience in each moment instead of reacting "mindlessly"
to fragments of a total experience with old, relatively stereotyped,
habitual patterns of mind.
Increased
mindfulness can prevent relapse of addictive and mood
disorders. It facilitates early detection of relapse-related
patterns of thinking, feeling, and body sensations, thus allowing them to be
"nipped in the bud" at a stage when this may be much easier than if such
warning signs are not noticed or are ignored. Further, entering a mindful
mode of processing at such times allows disengagement from the relatively
automatic ruminative thought patterns that would otherwise fuel the relapse
process.6
A Cognitive
Therapy
perspective of the thinking errors that lie at the heart of psychological
disorders:
Footnotes:
1.
Evans,
M. D., Hollon, S. D., DeRubeis, R. J., Piasecki, J. M., Grove,W. M., Garvey,
M. J., & Tuason, V. B. Differential relapse following cognitive
therapy and pharmacotherapy for depression. Archives of General
Psychiatry, 1992,
49, 802–808
2.
Fava, G.,
Grandi, S., Zielezny, M., Rafanelli, C., & Canestrari, R.Four-year outcome
for cognitive behavioral treatment of residual symptomsin major depression.
American Journal of Psychiatry,
1996. 153, 945–947
3. Paykel, E.
S., Scott, J., Teasdale, J. D., Johnson, A. L., Garland, A., Moore,R., et
al. (). Prevention of relapse in residual depression by cognitive
therapy: A controlled trial. Archives of General Psychiatry,
1999, 56 ,829–835.
4.
Beck,
A. T., Epstein, N., & Harrison, R. Cognitions, attitudes and personality
dimensions in depression. British Journal of Cognitive Psychotherapy,
1983, 1, 1–16.
5.
J. D. Teasdale, R. G. Moore and H. Hayhurst,
M. Pope. S, & Williams, Z. Segal. Metacognitive
Awareness and Prevention of Relapse in Depression: Empirical Evidence. Journal
of Consulting and Clinical Psychology. 2002, . 70, 2,
275–287
6.John D.
Teasdale Zindel V. Segal J. Mark G. Williams Valerie A. Ridgeway Judith M.
Soulsby Mark A. Lau. Prevention of
Relapse/Recurrence in Major Depression by Mindfulness-Based Cognitive
Therapy - - Journal of Consulting and Clinical
Psychology 2000 68, 615-623
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In discussing evil, the Zohar [an ancient book of Jewish mysticism]
tells the story about a king who wanted to test his son, to see if he would
be virtuous. So he hired a woman to entice the son, instructing her to
use all her wiles with him. The Zohar asks, "Is the woman not also a
loyal servant of the king?" In this parable, as soon as the prince
realizes that the woman is in the hire of his father, she is no longer a
threat. The same is true of evil.
Everything should be made a simple as possible, but not
simpler.
-
Einstein
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