Hope, Expectancy, Therapeutic Alliance, Solution Focused Therapy & Chronic Pain Management

     It's wonderfully satisfying when patients enter the office in despair, and leave with happy smiles. This dramatic change results from forging a successful therapeutic alliance, and replacing desperation with genuine hope and expectancy. These are challenging YET essential components of effective chronic pain management.

     Solution focused therapy (SFT) practitioners adopt "a respectful, interested, non-blaming, non-judgmental and cooperative stance. The assumption in SFT is that the client is competent to figure out what they want and need, and is willing to do something about it. The practitioner's responsibility is to assist the client to discover these competencies. Any notions of client 'resistance' are dismissed by SFT as professionally self-serving. Instead anger, resistance and a lack of motivation or 'insight' are viewed simply as indications that the practitioner has yet to find a way of working with the client.
     (SFT) is not simply a psychotherapeutic approach but an alternative way of thinking and working with people."

       Wand T. Mental health nursing from a solution focused perspective. International Journal of Mental Health Nursing 2010; 19(3): 210-219.


     Change from psychotherapy "comes from four main sources. The first is extratherapeutic change, which accounts for 40% of the variance of change. These are personality characteristics of the client as well as factors in that person’s environment that lead to positive change. The second strongest influences are common factors or what might be known as the therapeutic alliance. Accounting for 30% of the variance, these include empathy, warmth, and acceptance. A third component of improvement is technique, which includes the specific routes a psychotherapy theory utilizes, such as dream analysis or thought stopping. This accounts for 15% of the variance. The fourth component is hope and expectancy, which accounts for 15% of the variance of change. Expecting that going to therapy will help actually helps. It provides hope for symptom relief as well as other positive changes in one’s life. ... 'At the same time, an emphasis on possibilities and a belief that therapy can work will likely work to instill hope and a positive expectation for improvement'.
     ... therapists need a cognitive set that expects change and conveys hope. It is this focus on the future and possibilities instead of the past and problems that helps lead to hope."
 
       Reiter MD. Hope and expectancy in solution-focused brief therapy. Journal of Family Psychotherapy 2010; 21(2): 132-148.

Photo: Tony Tomlin   www.dpreview.com

Workplace, Wellness, Sense of Community, Belonging, Family, Engagement

     Recently, someone on CBC radio commented on how the sense of community has been lost from our current school system, and how this loss has had a corrosive impact on individuals and society. Effective leadership includes cultivating a genuine sense of community or family in the workplace, all individuals pulling together - esprit de corps. A deep sense of belonging and engagement is closely linked with quality of life - for both individuals, and naturally, for these same individuals grouped together in the organization.

     "Sense of community is ... a feeling that members have of belonging and being important to each other, and a shared faith that members’ needs will be met by the commitment to be together. These dynamics are incorporated in the sense of community model ... (with) four dimensions: 
• Membership which creates feelings of emotional safety with a sense of belonging to, and identification with, the larger collective; 
• Influence which characterizes the reciprocal relationship of the individual and the community in terms of their ability to affect change in each other;  
• Fulfillment of Needs, which enables individuals to get their needs met through cooperative behavior within the community, thereby reinforcing the individuals’ appropriate community behavior; and  
• Emotional Connection which is the emotional support stemming from the struggles and successes of community living. 
     This model accommodates 'community' conceptualized as a geographical territory (neighborhood), and as a relational network (work, political, or recreational interests)."

       Chipuer HM, Pretty GMH. A review of the Sense of Community Index: Current uses, factor structure, reliability, and further development. Journal of Community Psychology 1999; 27(6): 643-658. 

     "Esprit de corps refers to the morale of a group. From French: Esprit (spirit) de (of) corps (body). 'Body' is metaphorical in that it refers to a group of people that are so unified as to be like a single body. Refers to solidarity, pride, devotion and honor of each member with respect to the group." http://en.wikipedia.org/wiki/Esprit_de_corps_%28disambiguation%29

See also: http://www.johnlovas.com/2013/01/dynamics-of-mindfulness-practice-groups.html 
and
http://healthyhealers.blogspot.ca/2012/12/health-harmony-meaning-navajo-wisdom.html 
and  
http://www.johnlovas.com/2013/10/what-really-matters-in-community.html 

Looking in the Mirror: Conditional Self-worth, Perfectionism, Difficulties with Negative Feedback

     Conditional self-worth is associated with psychological distress, while unconditional self-acceptance fosters personal adjustment and well-being. People with extremely high self-esteem are considered vulnerable because they're often characterized by conditional self-acceptance dependent on external evaluations and comparisons to others. 

     Perfectionists find it difficult to unconditionally accept themselves and are preoccupied with obtaining approval and avoiding disapproval from others. Inability to unconditionally accept the self sometimes extends to an inability to accept others.  

     A 2001 study showed that "low levels of unconditional self-acceptance were associated with low self-esteem and elevated levels of self-esteem lability and proneness to depression. ... students with higher levels of unconditional self-acceptance ... were less reactive to negative feedback about their performance ... and tended to be more objective in their personal performance evaluations."

      Three dimensions of perfectionism include: 

          • self-oriented perfectionism - striving for personal standards of perfection;  

          • other-oriented perfectionism - a focus on the capabilities of others. ... associated with hostility and tending to direct blame or punishment toward others, rather than negative self-judgments;  

          • socially prescribed perfectionism - the perception that others have unrealistic standards and perfectionistic motives for one’s own behaviors, and that others will only be satisfied when these standards are attained; related to fear of negative social evaluation, belief in the external control of reinforcement, and need for the approval of others; associated with a wide variety of psychological problems including depression, anxiety, suicidal tendencies, and personality disorders.

       All three have been shown to be linked with low unconditional self-acceptance. Studies consistently show that "low general self-esteem is associated with the perception that unrealistic standards are being imposed on the self."  Also, a contingent sense of self-worth is the antithesis of unconditional self-acceptance.

     This paper concludes that "it is important to foster a greater sense of unconditional self-acceptance among perfectionists, either through preventive efforts or treatment interventions, so that this may serve as a source of resiliency when impossible standards are not attained." 

       Flett GL, Besser A, Davis RA, Hewitt PL. Dimensions of Perfectionism, Unconditional Self-Acceptance, and Depression. Journal of Rational-Emotive & Cognitive Behavior Therapy 2003; 21(2): 119-138. 

     A key component of mindfulness training is unconditional self-acceptance.

See also: http://mindfulnessforeveryone.blogspot.ca/2013/01/271-perfectionism-negative-and-positive.html

Photo: TX Photo Doc   www.dpreview.com

Conflict Resolution or Escalation?

     "Educational opportunities and resources devoted to communication skills and relational abilities are sorely underrepresented and undervalued compared with others supporting technical skill acquisition."

       Meyer EC et al. Difficult conversations: Improving communication skills and relational abilities in health care. Pediatr Crit Care Med 2009; 10(3): 352-9.

  

     "People in conflict, exhibit diverse behavioral patterns (in their attempts) to solve their conflicts. ...

     Forcing: The ambition of one party to dominate the other. In this case, people’s targets are more important than their relationships. ... 'this strategy to establish superiority over one another is used when either of the parties value satisfaction of their own interests and needs, at the expense of the opposing party’s interests and needs'.
     Avoidance: Avoiding the conflict environment. It is the indifference of one party to the other’s wills. The individual does not confront the other and try for a solution, because it is hopeless? ... 'in cases where the parties value each other’s interests and needs, the strategies of avoiding a conflict or ignoring the conflict are used'.
     Accommodation: Forgoing one’s own needs. The basis of this most frequently used conflict resolution strategy is the sharing of differences. One party ignores their own desires in order to fulfill the other’s. ... accommodation is 'the case where one party forgoes the satisfaction of their own interests and needs, in consideration of the other party’s interests and needs'.
     Compromise: The condition where either of the parties forgo their desires in order to satisfy the other’s. In this case, persons seek a third way. ... 'as long as both sides accept mutual compromise as a strategy, parties forgo certain issues in order to settle and achieve a solution.'

     Collaboration: Problem is solved by considering the needs of both parties. Both parties work together. ... 'this strategy is used when the importance given to own and other’s interests and needs are high.'

       Dincyurek S, Civelek AH. The determination of the conflict resolution strategies of university students that they use when they have conflicts with people. The Behavior Analyst Today 2008; 9(3-4): 215-233.

Photo: Bob Kaune   www.dpreview.com

Fearing Difficult Conversations & Other Challenging Interpersonal Interactions

     "Conveying troubling news and engaging in difficult conversations with patients and their families are pivotally important, although anxiety-provoking components of clinical practice. Clinicians who otherwise feel prepared and competent in their clinical duties may lack confidence and describe themselves as ill prepared for difficult interpersonal interactions. They may fear they will not be able to find the 'right words' or will say too much, too little, or the wrong thing altogether. Further, clinicians worry that imparting difficult news may diminish hope, compound a family’s suffering, or unleash emotional responses they feel unprepared to handle. Because of the complexities and challenges inherent in these difficult conversations, it is not uncommon for clinicians to delay, avoid, or delegate this vital area of clinical practice. ...
     For patients to feel they have been understood and well cared for, it is recognized that clinicians must attend to healthcare conversations on a deeper, more relational level."

       Meyer EC et al. Difficult conversations: improving communication skills and relational abilities in health care. Pediatr Crit Care Med 2009; 10(3): 352-9.

                    "Our deepest fears are like dragons
               guarding our deepest treasures"                  Rainer Maria Rilke

Photo: karying   www.dpreview.com

Inappropriate Student Behaviors in Health-Care Professions

     "Inappropriate behavior is on the rise in the academic setting. Unacceptable behaviors range from rude, uncivil actions or words (lateness to class, leaving early, inattention, or verbal disrespect) to physical aggression against other students or instructors. Some educators feel under siege. ...
     Frequently, instructors are the recipients of misdirected hostility as part of a maladaptive pattern on the part of the student. Many professors are voicing increased concern regarding insubordination and aggression on the part of students in the classroom. The willingness of a student to fail to control his or her behavior with an authority figure such as the instructor becomes even more problematic when one considers how this lack of self-control may be demonstrated against peers or vulnerable patients. 
     Why is aggressive student behavior becoming so pronounced and pervasive in the academic setting? ... an entanglement of societal ills, including poverty, racism, substance abuse, inadequate parenting, and exposure to media violence."

        Ehrmann G. Managing the Aggressive Nursing Student. Nursing Educator 2005; 30(3): 98-100.

     But perhaps most important are the combined effects of undiagnosed or inadequately managed psychological illness eg depression ± anxiety, the considerable stresses of professional education, high stakes exams, and high tuition fees / living expenses.

Photo: Pham Nuwem   www.dpreview.com

 

Mentoring, Developing Self-awareness & Wisdom

     "Mentoring is very much an education buzz word, but it is not a modern day invention. Greek mythology tells the story of Mentor, an alias of Athena the goddess of wisdom, who was charged by Ulysses to raise his son Telemachus. In doing this, Mentor gave his name to the traditional relationship of an older, wiser master taking a younger 

protege ́under their wing.
      ... mentoring (is) a ‘relationship between equals’ formed as part of a developmental alliance which allows one or both parties to develop through increased self-awareness. The phrase developmental alliance alludes to a long-term relationship rather than one focused on short-term problem solving.

     The take home message of mentoring is that it is an off-line relationship where one person helps another making a significant transition in their careers."

       Williams ZM, Grant A. How to ... Be a good mentor. Educ Prim Care 2012; 23(1): 56-8.

Friend by Kristiina Lehtonen   http://www.kristiinalehtonen.fi/index_en.php

 

 

"Going against the grain" - Egocentric vs "Going with the flow" - Allocentric, Ecocentric

     Life can be thought of as a river. Swimming in a fast-moving river forces you to be pretty sharp. It's a real challenge just to keep your proverbial head above water, never mind achieve anything more. What a luxury it is to periodically climb out onto the river bank to rest, catch your breath, and regain perspective.
     Many people drown after unwisely exhausting themselves by swimming against the current. "Going against the grain" is all too common when one's goal is not aligned with the reality of the fast-moving river. "May the force be with you" is backwards IMHO. We have to gain insight into and constantly monitor the river of life, as well as ourselves, so that we can intentionally align ourselves with life - be prosocial. Shifting from an egocentric perspective towards an allocentric & ecocentric orientation is common sense, healthy maturation, and naturally evolving wisdom.
     "Going with the flow" is not about laziness, it's about clear awareness of, accepting, working with, and yes embracing, being truly at home in, and working harmoniously & synergistically with reality.

http://mindfulnessforeveryone.blogspot.ca/2013/01/269-training-busy-mind-rushing-river.html

http://mindfulnessforeveryone.blogspot.ca/2012/08/167-agency-communion-maturation.html 

http://www.johnlovas.com/2013/12/mindfulness-healing-artificial-splits.html

Tamer by Kristiina Lehtonen   http://www.kristiinalehtonen.fi/index_en.php

US Marines Start Mindfulness Training

     "Camp Pendleton, the Marine Corps base in California, will host the pilot program for about 80 servicemen and -women, beginning Tuesday.
     The pilot program is being instituted after 2012 saw the highest number of U.S. military suicides -- 349 -- ever recorded in a single calendar year, as AP reported. Last year, the number of active- and reserve-duty personnel who took their own lives surpassed the number who were killed in combat in Afghanistan, 295.
     Experts have blamed the surge in military suicides in part on two long, controversial wars in Afghanistan and Iraq and in part on high levels of untreated depression and post-traumatic stress disorder, among other factors.
     ...
     'We have doctors, counselors, behavioral-health scientists, all sorts of people to get help for Marines who have exhibited stress-type symptoms, but what can we do before that happens? How do we armor Marines up so they are capable of handling stress?' Jeffery Bearor, the executive deputy of the Marine Corps training and education command at its headquarters in Quantico, Va., asked AP rhetorically.
     Bearor indicated this type of training may increase decision-making capabilities.
     'If indeed that proves to be the case, then it's our intention to turn this into a training program where Marines train Marines in these techniques,' Bearor said. 'We would interject this into the entry-level training pipeline ... so every Marine would be trained in these techniques.'"
http://www.ibtimes.com/marines-testing-meditation-training-may-teach-mindfulness-young-recruits-mental-stamina-1027058 

Comfort by Kristiina Lehtonen   http://www.kristiinalehtonen.fi/index_en.php

Regular exercise?

     "If you don't challenge yourself, don't expect change to occur" is a great motivator in the gym. Yet, as we get older, we tend to feel spent at the end of a working day. We often just want to get home, have dinner, rest and recuperate. Activities that we once found relatively easy and excitingly challenging, now feel like an uphill battle.
     "What you don't use, you lose" is another motivator, not just in athletics, but also in neurophysiology. Every single time I drag my weary old body into the gym immediately after work, I quickly feel rejuvenated, and leave feeling great - physically AND mentally.
     We need to be our own trainers and sports psychologists and force ourselves to work out regularly - at least 3 times per week. We simply need to take seriously the instant and long-term positive feedback we get from our own body and mind.

Fast Track to Wealth & Fame - at What Cost?

“I’m a flawed character.” Lance Armstrong
"Did it feel wrong?" Oprah Winfrey
“No, ... Scary.” Armstrong
“Did you feel bad about it?” Winfrey
“No, ... Even scarier.” Armstrong
“Did you feel in any way that you were cheating?” Winfrey
“No, ... Scariest.” Armstrong            Oprah Winfrey's TV interview Jan 17, 2013

     "Sociopath - A person with an antisocial personality disorder, exhibiting antisocial behavior that usually is the result of social and environmental factors in the person's early life. 
     Antisocial personality disorder - A personality disorder marked by antisocial behavior, a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood." http://en.wikipedia.org/wiki/Antisocial_personality_disorder

      "three important dimensions of wisdom involve recognizing that the world is in flux and the future is likely to change, recognizing that there are limits associated with one’s own knowledge, and possessing a prosocial orientation that promotes the 'common good.'
      A common feature of these different dimensions of wisdom is that they require people to transcend their egocentric viewpoints to take the 'big picture' into account and reason holistically."
        Kross E, Grossmann I. "Boosting wisdom: Distance from the self enhances wise reasoning, attitudes, and behavior." Journal of Experimental Psychology: General 2012; 141(1): 43-48.

     Almost daily we see casualties from the self-centered rush towards fame and wealth - in every arena: sports, business, religion, entertainment, law, politics, even health-care. Our society is obsessed with creating and destroying "heroes", seducing them with obscene amounts of money to live public, tragicomedic-morality-play lives.
     The healthy alternate path is understated: maturing and growing throughout life into a decent human being, and expressing this outwardly through meaningful contributions to society. This journey is beautifully compatible with high levels of achievement on many levels - see Kenneth R. Pelletier's remarkable 1994 book: "Sound Mind, Sound Body: A New Model for Lifelong Health."

Photo: ZuluDK   www.dpreview.com

Mindfulness may promote a Healthy biochemical milieu & Longevity

     "Many ancient contemplative traditions believe presence of mind promotes greater longevity, a belief that is hard to test. Scientific evidence suggests that mind wandering predicts unhappiness, whereas presence in the moment predicts well-being. It is important to test whether a tendency toward mind wandering is associated with biological measures of longevity beyond self-reported measures of well-being. Telomere length has recently emerged as a proxy measure of biological aging and correlate of severe stress. We assessed the association between telomere length and tendency to be present versus tendency to mind wander in 239 healthy women. Those who reported high mind wandering had shorter telomeres, consistently across immune cell types (granulocytes, lymphocytes), than did those who reported low mind wandering, even after adjusting for stress. Telomere length varies widely between adults, and these findings suggest that presence of mind may explain some of these differences. A present attentional state may promote a healthy biochemical milieu and, in turn, cell longevity."

       Epel ES et al. Wandering Minds and Aging Cells. Clinical Psychological Science 2013; 1: 75-83, doi:10.1177/2167702612460234 

Photo: Take5   www.dpreview.com

 

The Thirst for Self-transcendence, Connection & Wholeness

     "In a lot of ways, for a lot of people including myself, the thirst of alcoholism is really about a thirst for something else - a thirst for a way of getting over yourself, or through yourself, or outside yourself; a thirst for some kind of connection and wholeness; a misguided effort to do that, certainly in my case.

     (Aldous) Huxley showed me a way to really break through the wall of cynicism ... And breaking through that cynicism, is really the first step towards cultivating some kind of compassion and connection." Don Lattin, author of "Distilled Spirits: Getting High, Then Sober, with a Famous Writer, a Forgotten Philosopher, and a Hopeless Drunk."

above from Mary Hynes' interview on CBC Radio's Tapestry:
http://www.cbc.ca/tapestry/popupaudio.html?clipIds=2324922023

Fall by Kristiina Lehtonen   http://www.kristiinalehtonen.fi/index_en.php

Psychological Flexibility, Health & Congruence

     "Traditionally, positive emotions and thoughts, strengths, and the satisfaction of basic psychological needs for belonging, competence, and autonomy have been seen as the cornerstones of psychological health. Without disputing their importance, these foci fail to capture many of the fluctuating, conflicting forces that are readily apparent when people navigate the environment and social world. ... Thus far, the importance of psychological flexibility has been obscured by the isolation and disconnection of research conducted on this topic. Psychological flexibility spans a wide range of human abilities to: recognize and adapt to various situational demands; shift mindsets or behavioral repertoires when these strategies compromise personal or social functioning; maintain balance among important life domains; and be aware, open, and committed to behaviors that are congruent with deeply held values. In many forms of psychopathology, these flexibility processes are absent."

       Kashdan TB, Rottenberg J. Psychological Flexibility as a Fundamental Aspect of Health. Clin Psychol Rev 2010; 30(7): 865-878.

Photo: qhenson   www.dpreview.com

 

How to Mobilize Inner Resources

     “Both guided mindfulness meditation and clinical hypnosis strive to help people by enlisting more of their own resources in the therapeutic endeavor. As soon as the client is encouraged to focus and discover and mobilize internal resources either forgotten or never known, great possibilities emerge. Hidden, untapped resources surface that can happily surprise both therapist and client. … a knowledgeable and skilled therapist can actively create an environment that makes such greater self-awareness and self-sufficiency in the client possible.”

         Yapko MD. Mindfulness and hypnosis. The power of suggestion to transform experience. WW Norton & Co, NY, 2011.

Winter Apples by Kristiina Lehtonen   http://www.kristiinalehtonen.fi/index_en.php

Compulsion to Self-Medicate & Suffering

     "I wrote this song when I was almost five years clean and sober. There’s no way I could have seen this character’s plight if I had not lived it, I would not have the perspective to understand the dire situation this character is in until I stepped out of my own downward spiral. Just like it was for me, the character in this song is in full-blown denial, can’t see the real problem, and doesn’t know the cause of the tormenting loneliness and isolation that’s driving the compulsion to self-medicate. The character is classic alcoholic, a garden variety drunk, believing that drinking is the solution and not the cause of the suffering. The character has become resigned to living this way, resigned to drinking, mostly alone, till the bitter end." Mary Gauthier 

     Mary will be performing in Halifax January 25th & 26th, 2013    http://www.marygauthier.com/

Larger Homes, More Exotic Trips, Fancier Cars - Won't Improve Quality of Life

     On CBC radio this morning, Michael Enright metioned how in the 60's we felt that we could achieve anything, we could change the world. What happened to that positive energy? To a large extent, big business skillfully redirected it towards spoiling ourselves, and perhaps especially our children, with every imaginable comfort, plus many we never saw coming eg iPhones.
     A couple of years ago, during a break in a continuing medical education course, I overheard a group of young female physicians chatting about their children. One comment stuck: "I just hope they don't grow up to be assholes."
     Isn't that our hope and fear for ourselves as well? There's good reason to worry. It's very difficult to be balanced and appropriately engaged with reality while living a self-indulgent lifestyle (Charlie Sheen, Lindsay Lohan, Britney Spears, & many closer to home). Continuing to pamper ourselves makes as much sense as continuing to over-eat when morbidly obese. Just because we can (with the bank's blessing), does NOT mean it's good for us. Our current level of self-indulgence has become toxic for ourselves and the environment.

       “The goal of life is to make your heartbeat match the beat of the universe, to match your nature with Nature.”      Joseph Campbell 

Photo: minniev   www.dpreview.com

Meditation - an Ancient Science of Mind

     "The way I see it, Buddhism itself is not the point. You might think of the Buddha as a genius of his age, a great scientist, at least as towering a figure as Darwin or Einstein, who, as the Buddhist scholar Alan Wallace likes to put it, had no instruments other than his own mind at his disposal and who sought to look deeply into the nature of birth and death and the seeming inevitability of suffering. In order to pursue his investigations, he first had to understand, develop, refine, and learn to calibrate and stabilize the instrument he was using for this purpose, namely his own mind, in the same way that laboratory scientists today have to continually develop, refine, calibrate and stabilize the instrument that they employ to extend their senses – whether we are talking about giant optical or radio telescopes, electron microscopes, or positron-emission tomography (PET) scanners – in the service of looking deeply into and exploring the nature of the universe and the vast array of interconnected phenomena that unfold within it, whether it be in the domain of physics and physical phenomena, chemistry, biology, psychology, or any other field of inquiry.
     In taking on this challenge, the Buddha and those who followed in his footsteps took on exploring deep questions about the nature of the mind itself and about the nature of life. Their efforts at self-observation led to remarkable discoveries. They succeeded in accurately mapping a territory that is quintessentially human, having to do with aspects of the mind that we all have in common, independent of our particular thoughts, beliefs, and cultures. Both the methods they used and the fruits of those investigations are universal, and have nothing to do with any isms, ideologies, religiosities, or belief systems. These discoveries are more akin to medical and scientific understandings, frameworks that can be examined by anybody, anywhere, and put to the test independently, for oneself, which is what the Buddha suggested to his followers from the very beginning.”
 
       Kabat-Zinn J. “Coming to our senses. Healing ourselves and the world through mindfulness.” Hyperion, NY, 2005.

The First Snow by Kristiina Lehtonen   http://www.kristiinalehtonen.fi/index_en.php