Thursday, June 30, 2016

Storytelling is Good Medicine

We are all storytellers.

Narrative Exposure Therapy (NET)
A trauma-specific and evidence-based intervention for adults & children
pictured here in Sri Lanka
Placing the rocks on those periods of the autobiographical story
pictured here in Uganda

Telling the Story

Lifeline with rocks and flowers moments

Narrative Exposure Therapy (NET) was developed for use with refugees. It is a combination of Cognitive behavior therapy and Testimony therapy. Studies have shown NET to be effective with both adults and children. It has been used all over the world. It was used in China with victims of the earthquake.

NET is a process that can teach and help people to tell the story of their trauma in order to become more resilient. Narrative is an important resilience skill. Telling the story can help rebuild meaning structure after a traumatic event. Resilience is linked to making sense of the traumatic event.

Here is an abstract from a peer-reviewed journal article about NET:

Individuals who have experienced multiple traumatic events over long periods as a result of war, conflict and organised violence, may represent a unique group amongst PTSD patients in terms of psychological and neurobiological sequelae.

Narrative Exposure Therapy (NET) is a short-term therapy for individuals who have PTSD symptoms as a result of these types of traumatic experiences. Originally developed for use in low income countries, it has since been used to treat asylum seekers and refugees in high-income settings. The treatment involves emotional exposure to the memories of traumatic events and the reorganisation of these memories into a coherent chronological narrative.

This review of all the currently available literature investigates the effectiveness of NET in treatment trials of adults and also of KIDNET, an adapted version for children.

Results from treatment trials in adults have demonstrated the superiority of NET in reducing PTSD symptoms compared with other therapeutic approaches.

Most trials demonstrated that further improvements had been made at follow-up suggesting sustained change.

Treatment trials of KIDNET have shown its effectiveness in reducing PTSD amongst children.

Emerging evidence suggests that NET is an effective treatment for PTSD in individuals who have been traumatised by conflict and organised violence, even in settings that remain volatile and insecure.

NET is a manualised treatment (that means there is a book or manual that describes in step-by-step detail how to conduct the intervention).

Step 1:
The patient first undergoes psychoeducation in which the theoretical underpinnings of PTSD and the process of NET and rationale for treatment are explained. Psychoeducation about how avoidance of reminders of traumatic events is a key feature of PTSD, and the impact of this on inhibiting treatment, is provided.

Step 2:
Once informed consent has been obtained, the therapy can begin. Sessions are usually 60–120 min in length and ideally occur in close succession preferably with one or more sessions per week and a maximum of a fortnight between sessions.

First Session:
In the first session the patient constructs the ‘lifeline’. This is a physical representation of their life using a rope, beginning at birth and ending at the present day, with a section of the rope left uncoiled representing the future. The patient then briefly goes through their life, in chronological order, placing a symbol (e.g. flowers of different shapes and sizes) on the line to represent happy events and a different symbol (e.g. stones) for sad or frightening events. The therapist's role is to ensure the correct chronology of these events. The lifeline is useful in establishing the therapeutic relationship and in providing an indication of the number of sessions that may be necessary to address all traumatic events (although some events may only be disclosed later in therapy).

Second Session:
Following the first session, subsequent sessions are dedicated to the narration of the person's life, in chronological order, with particular focus on and attention to the traumatic events.

Periods between events are described in brief to contextualise the traumatic events within the individual's life and produce a coherent narrative.

On approaching a traumatic incident, the focus is on contextual information, firstly establishing what life was generally like at that time (where was the person living, what were they doing, what was a typical day) and then narrowing this down as precisely as possible to what happened when the event occurred.

The traumatic events are then narrated in great detail, gently resisting the patient's attempt to hurry through or avoid emotional engagement with the memory.

The patient then slowly narrates their traumatic experience in chronological order, as they experienced it at the time.

They are encouraged to describe all sensory modalities along with their thoughts and feelings.

The aim of NET is to connect the hot memories into the corresponding information held within the cold memory for the event and so the patient must be emotionally involved in the narration but must also put these experiences into words, constantly integrating the contextual information.

At the same time as the narration of the traumatic event progresses, the patient's current physical, emotional and cognitive reactions are observed and verbalised.

The therapist continually guides the patient back and forth between what is happening for the patient at the time of the narration (present time) and what occurred at the time of the event.

One of the aims of the therapy is for the person to be emotionally exposed to the memory of the event for sufficient time that habituation occurs and their emotional response to the memory is diminished over the course of therapy. However, this is unlikely to occur within a single session.

The session ends at a safe point in the narrative, at the end of a traumatic event, once the therapist has ensured that the patient's arousal has diminished and that their emotional state is improved.

The events in the period after the traumatic incident are narrated to help the patient place the episode in context. The narrative as described in the session is written up by the therapist between sessions, this provides an opportunity for the therapist to ensure they have fully understood the details and chronology of the events described and therefore highlights areas in the story which do not seem as coherent and possibly need further exploration at the next session.

Third, Fourth and Subsequent Sessions:
At the beginning of the next session the narrative from the previous session is read to the patient to ensure accuracy, once again expose the patient to memories of the event, elicit further information and promote integration of the hot and cold memories.

Usually the patient notices a reduced physiological and affective reaction from the first session, although several sessions may be necessary for habituation to occur for severely traumatic events.

At the end of the re-reading of the narrative, the period between this event and the next traumatic event is briefly narrated, before moving forward to the next traumatic episode, which is again narrated in intricate detail. This process continues until all stressful events have been narrated and the affective responses to the memories have reduced.

At this point, the patient and therapist will have created a testimony of the person's life from birth to the present day, with a detailed narration of the traumatic events.

At the end of the therapy some time is spent discussing hopes and aspirations for the future, following which all parties who have been involved in the therapy (including the patient, therapist and interpreter) sign the completed testimony.

The patient receives a copy of this for their own private records and the authors report that it is common to find patients sharing their testimonies with others including lawyers and human rights organizations.

Monday, June 20, 2016

A Story Needs Lots of Positive-Emotion Words and a Moderate Number of Negative-Emotion Words

"Individuals who used a moderate number of negative emotions in their writing about upsetting topics evidenced the greatest drops in physician visits in the months after writing.

That is, those people who used a very high rate of negative-emotion words and those who used very few were the most likely to have continuing health problems after participating in the study.

...those people who tended to use many words in the positive category and a moderate amount in the negative category had the greatest health improvements...

Individuals who tend to use very few negative-emotion words are undoubtedly most likely to be characterized as repressive copers - people defined as poor at being able to identify and label their emotional states.

Those who overuse negative-emotion words may well be the classic high neurotic or, high Negative-Affect individuals. These individuals are people who ponder their negative emotions in exhaustive detail and who may simply be in a recursive loop of complaining without attaining closure. Indeed, this may be exacerbated by the inability of these individuals to develop a story or narrative.

A high rate of positive-emotion word use coupled with some negative-emotion words suggests there is an acknowledgment of problems with a concomitant sense of optimism."

Pennebaker & Seagal, 1999

Secrets Make Us Sick

"Findings to support the inhibition model of psychosomatics are accumulating. Individuals who conceal their gay status, conceal traumatic experiences in their past, or are considered inhibited or shy by other people exhibit more health problems than those who are less inhibited (Pennebaker, 1997. p.164)."

Trauma Can Change What We Believe

"Implicit in most of the cognitive therapies is the assumption that traumas disrupt basic beliefs or schemas (Pennebaker, Colder & Sharp, 1990)."

Core beliefs are how we see ourselves, others, the world and the future.

Examples of healthy core beliefs include:

  • I am competent. I am lovable. I am basically good. I matter.
  • I can trust others.
  • The world is a safe place.

After abuse or trauma, our beliefs can change and become distorted, for example:

  • I'm incompetent. I'm defective. I'm a failure. I'm unlovable. I'm bad. I'm worthless.
  • I can't trust other people. Other people are out to hurt or take advantage of me. I'm bound to be abandoned, rejected. I'm defective, so others will not love me.
  • The world is a dangerous place.

It's true we were helpless to protect ourselves then and the terrible thing made us feel like we were terrible. But now we distrust and feel scared all the time, even when we are safe.

What was true in that terrible moment - there and then - we now carry with us in the here and now.

Like a jaguar that runs up the tree for safety but refuses to come down from the tree when the danger has passed.

It makes sense that the trauma-influenced core beliefs are a way to cope, to protect oneself. Be on guard. Be on the lookout so it does not happen again.

What starts as self-protective ends up being a wall that shuts us out of our own lives.

That's when we need a shaman to sing our jaguar down from the tree.

Adding Insult to Injury...

"...most people naturally discuss daily and significant experiences with others. Even major traumas such as the death of a friend, a shared natural disaster, or a house fire are usually discussed in detail with close friends.

Less socially acceptable traumas, however, can be far more difficult to confide: marital infidelity, embezzlement, being the perpetrator or victim of rape.

Whereas talking about the trauma with others can strengthen social bonds, provide coping information and emotional support, and hasten an understanding of the event, the inability to talk with others can be unhealthy for a number of reasons..."

Pennebaker, J.W. (1989). Confession, Inhibition and Disease. Advances in Experimental Social Psychology, 22, 211-244.

Cherish Parents

"As parents become distressed in response to economic problems, they often become less nurturing and more hostile toward their children. These relationship changes lead, in turn, to psychological problems in adolescents (as cited in Dinizulu et al., 2014)."

... If a community values its children, it must cherish its mothers. --John Bowlby

Sunday, June 19, 2016

Fear vs. Faithful Friends

"...'They became revolutionaries despite themselves.' In the years leading up to the war, John Adams feared British retaliation and hesitated to give up his budding law career, he only got involved after being elected as a delegate to the First Continental Congress."

"George Washington had been focused on managing his wheat, flour, fishing, and horse-breeding businesses, joining the cause only after Adams nominated him as commander in chief of the army. 'I have used every endeavor in my power to avoid it,' Washington wrote."

"Martin Luther King, Jr., was apprehensive about leading the civil rights movement; his dream was to be a pastor and college president...He was unanimously elected to lead the boycott. Faced with giving a speech to the community that evening, 'I became possessed by fear.'"

"When the pope commissioned him to paint a fresco on the ceiling of the Sistine Chapel, Michelangelo wasn't interested. He viewed himself as a sculptor. Two years would pass before he began work on the project, at the pope's insistence."

"And astronomy stagnated for decades because Nicolaus Copernicus refused to publish his original discovery that the earth revolves around the sun. Fearing rejection and ridicule, he stayed silent for twenty-two years...Eventually, a major cardinal learned of his work and wrote a letter encouraging Copernicus to publish it. Even then, Copernicus stalled for four more years."

"...when an angel investor offered $250,000 to Steve Jobs and Steve Wozniak to bankroll Apple in 1977, it came to an ultimatum: Wozniak would have to leave Hewlett-Packard. He refused. 'I still intended to be at that company forever.' Wozniak reflects. 'My psychological block was really that I didn't want to start a company. Because I was just afraid,' he admits. Wozniak changed his mind only after being encouraged by Jobs, multiple friends, and his own parents."

Adam Grant from Originals

What original idea are you holding back because of fear? Step up to the plate and take one for the team! Keep your eye on the ball and get yourself onto first base. Trust the team to bring you home. That's what we're here for. 

I watched the movie, Moneyball, on the flight home yesterday. In the movie, the owner of the Oakland A's asks the general manager what his fears are about proceeding with his unorthodox plan to win games. The GM says he has none and goes on to have a record-breaking 20-game winning streak (after a long losing streak). 

Superstar David Justice asks a benched player called up to play what his fears are - because it's obvious that the ONLY thing stopping us is our own fear. 

A good ol' boy talent scout says that a player without confidence is like a man with an ugly girlfriend. I was glad to see that old man go down. Unfortunately, it's a metaphor the mainstream clearly understands. 

Fear or confidence - it's your choice. You're sexy when you're confident (and nicer too).

Courage to Change the Systems

"When we become curious about the dissatisfying defaults in our world, we begin to recognize that most of them have social origins: Rules and systems were created by people. And that awareness gives us the courage to contemplate how we can change them.  
Before women gained the right to vote in America, many 'had never before considered their degraded status as anything but natural,' historian Jean Baker observes. As the suffrage movement gained momentum, "a growing number of women were beginning to see that custom, religious precept, and law were in fact man-made and therefore reversible." 
Adam Grant in Originals

Recipe for Originality

"Originality itself starts with creativity: generating a concept that is both novel and useful. But it doesn't stop there. Originals are people who take initiative to make their visions a reality...taking action..."
The hallmark of originality is rejecting the default and exploring whether a better option exists." --Adam Grant in Originals

Conformity vs. Originality

"Conformity means following the crowd down conventional paths and maintaining the status quo.
Originality is taking the road less traveled, championing a set of novel ideas that go against the grain but ultimately make things better." Adam Grant, Originals

Conformists achieve in bureaucracies where you are rewarded for maintaining the status quo, until the bureaucracy dies from irrelevance.
Originals change the way we look at things and make a dent in the universe.
There is a conformist and original in all of us.
What do you want to stay the same and what do you want to change?

Quoting the Forward

"In the deepest sense of the word, a friend is someone who sees more potential in you than you see in yourself, someone who helps you become the best version of yourself." Sheryl Sandberg in forward to Originals

But what does it matter that I see the estrella or the diamond in the rough in you, if you refuse to agree with me and see it in yourself?

Thursday, June 9, 2016

Hedonic Well-Being + Eudaimonic Well-Being = Flourishing

"Loosely speaking, I have described human flourishing as being beyond happiness in that it encompasses both feeling good and doing good (Fredrickson, 2009).

This definition is based on the foundational empirical work of Keyes and colleagues, which conceptualizes and measures human flourishing as a multidimensional combination of hedonic and eudaimonic well-being (Keyes, 2002).

Following ancient philosophies articulated by Aristotle and others, hedonic well-being captures individuals' global satisfaction with life alongside their pleasant affect, whereas eudaimonic well-being encompasses their sense of purpose and meaning as well as their resilience and social integration.

In the article with Losada, we further specified this 'feel good plus do good' definition by opening with 'To flourish means to live within an optimal range of human functioning, one that connotes goodness, generativity, growth and resilience' (Fredrickson & Losada, 2005, p. 678).

Amidst the current rise of interest in human flourishing, major theorists (Hupert & So, 2013; Keyes, 2002; Seligman, 2011) agree that the construct includes both feeling good (i.e., hedonia) and functioning effectively (i.e., eudaimonia) and in this way is the mirror opposite of common mental disorders such as depression and anxiety, which encompass negative (or flat) affect and poor functioning."

Fredrickson, B.L. (2013). Updated Thinking on Positivity Ratios. American Psychologist. Advance
      online publication. doi:10.1037/a0033584

The Broaden-and-Build Theory

"...first introduced in 1998 and, in the intervening 15 years, widely tested and supported (Fredrickson, 1998, 2001, 2013).

The theory posits that the function of positive emotions, as shaped over millennia by the processes of natural selection, was to build an individual's resources for survival.

The means by which this build function was achieved was through the accumulated effects of moments marked by an affect-induced broadened scope of awareness, creating a temporary form of consciousness within individuals that included a wider array of thoughts, actions, and percepts than typical.

One implication of the broaden-and-build theory is that negative and positive emotions alike came to be part of our universal human nature through selective pressures related to survival, albeit on vastly different time scales.

Negative emotions carried adaptive significance in the moment that our human ancestors' experienced them, as their associated action urges - for example, to fight, flee or spit - drove behaviors that saved life and limb in dire circumstances.

Positive emotions, by contrast, carried adaptive significance for our human ancestors over longer time scales. Having a momentarily broadened mindset, after all, is not a key ingredient in the recipe for any quick survival maneuver. It is, however, in the recipe for discovery: discovery of new knowledge, new alliances, and new skills. In short, broadened awareness led to the accrual of new resources that might later make the difference between surviving or succumbing to various threats. Resources built through positive emotions also increased the odds that our ancestors would experience subsequent positive emotions, with their attendant broaden-and-build benefits, thus creating an upward spiral toward improved odds for survival, health and fulfillment.

In sum, the broaden-and-build theory states that positive emotions have been useful and preserved over human evolution because having recurrent, yet unbidden, moments of expanded awareness proved useful for developing resources for survival.

Little by little, micro-movements of positive emotional experience, although fleeting, reshape who people are by setting them on trajectories of growth and building their enduring resources for survival.

The broaden-and-build theory describes the form of positive emotions as to broaden awareness and their function to build resources."

Fredrickson, B.L. (2013). Updated Thinking on Positivity Ratios. American Psychologist. Advance
      online publication. doi:10.1037/a0033584

Positive Emotions = More Resources = Flourishing

"Further evidence that positive emotions are a key active ingredient in flourishing mental health comes from a detailed unpacking of a Tuesday in the life of flourishing individuals, in comparison to a Tuesday in the life of those not flourishing and to a Tuesday in the life for those identified as depressed (Catalina & Fredrickson, 2011).

Using the Day Reconstruction Method, we tested the hypothesis, drawn from the broaden-and-build theory, that flourishers thrive because they experience greater positive emotional reactivity in response to routine pleasant activities and thereby build more resources over the span of two to three months.

Our results showed that relative to those who do not flourish or who are depressed, people who flourish experience bigger 'boosts' in positivity in response to routine daily events such as helping another person, interacting with others, playing, learning, and engaging in spiritual activity.

Moreover, flourishers' greater positive emotional reactivity, over time, predicted their growth in resources. In turn, flourishers' greater growth in resources predicted their higher levels of flourishing symptoms at the end of the study (controlling for initial levels of flourishing).

We uncovered virtually no differences between flourishers and others in the degree of negative emotions experienced on the targeted Tuesdays. We also uncovered surprisingly few differences between depressed people and non-flourishers, who had been prescreened and selected for showing no signs of flourishing, depression, anxiety, or substance abuse.

This pattern of results suggests that human flourishing is nourished by small, yet consequential, individual differences in positive emotional experiences in response to pleasant everyday events.

Flourishers don't simply 'feel good and do good." Rather they do good by feeling good.

So, just as greater negative emotional sensitivity has been found to seed and maintain depression, a phenomenon called negative potentiation, a parallel positive potentiation process appears to seed and maintain the beneficial - yet all too rare - state of human flourishing (Catalino & Fredrickson, 2011)."

Fredrickson, B.L. (2013). Updated Thinking on Positivity Ratios. American Psychologist. Advance   
     online publication. doi:10.1037/a0033584

Saturday, June 4, 2016

i heart bowlby

We're only as needy as our unmet needs. John Bowlby
Are you meeting your needs? 

Truth Opened

Freud presented a paper in April, 1896 to the Society for Psychiatry and Neurology in Vienna on the sexual abuse of his female patients by t...