Paul Greene, Ph.D. - Articles

Buddhism and Cognitive-Behavioral Therapy (CBT)

2008-05-20T21:24:00.007-05:00

"In the words of the Buddha, … ’We are what we think. All that we are arises with our thoughts. With our thoughts we make the world.’ It's an idea that's in line with current thinking in psychology. In fact, this simple philosophy – that changing the way we think can change the way we feel – underpins the very practice of Cognitive Behavior Therapy (CBT), an approach widely used in clinical psychology and counseling, as well as stress management programs.” So writes Kathy Graham, in a thoughtful article on Buddhism and happiness, which can be found here.

The radical and powerful notion that our thoughts make up our realities may seem silly at first, especially when we think of how important circumstances can be in our lives. Even the word “reality” itself is often used in such a way as to connote external circumstances; for example, the phrases “back to reality,” “harsh reality,” or “the real world” usually refer to external circumstances, not our own thoughts. A typical example of how someone might describe their “reality” would include the facts that they are a single mother, 42 years old, working as a project manager at a big company, and making mortgage payments on a condominium. But are these facts enough to explain our experience? This question deserves some thought; on one hand, this is how we usually define our “reality,” but on the other, it’s easy to imagine how two people in these same circumstances could have quite different experiences. One person might be more optimistic and cheerful, enjoying each day, whereas someone else might be more pessimistic and anxious, and enjoy life less.

But what is it that makes one person anxious and other person optimistic? We each have our tendencies toward different thought patterns. We can call these tendencies by various names: personality traits, temperaments, reactions to formative experiences, genetic predispositions, or what have you. However we understand these tendencies, their moment-by-moment impact on us happens via our thoughts.

One of the most important aspects of cognitive therapy is the idea that we can change the content of our thoughts, and thus impact how we feel. Many of us have tried to change the way we think about something, with varying degrees of success. A common example would be the ex-boyfriend or ex-girlfriend, trying to resist temptation to reunite with their ex, that resolves to think only of their negative qualities or to convince themselves their ex is a horrible person. This is not the focus of cognitive therapy, where the therapist focuses on helping you understand how certain thought patterns are

1) contributing to making you more depressed or anxious, and
2) not necessarily based on sound reasoning.

For example, someone who is depressed may tend to have more thoughts like “I can’t do anything right,” or “No wonder he doesn’t like me, I’m a loser” than someone who is not depressed. Someone who tends to be anxious, on the other hand, may tend to have thoughts like “This is going to be a disaster,” or “Why hasn’t she called? She must have been in accident.” For whatever reason, we have a tendency to believe these thoughts a bit more than they deserve. Looking at the examples above, it’s not hard to see how a close examination might show that the statements the thoughts may be exaggerations or false predictions based on insufficient evidence. Even though on some level we know this, we often have difficulty extricating ourselves from the sadness and anxiety such thoughts can bring on. This is where cognitive therapy can help.

To return to the quote excerpted in the Kathy Graham article, “We are what we think. All that we are arises with our thoughts. With our thoughts we make the world,” it seems that the third idea, ‘with our thoughts we make the world’ seems most consistent with cognitive therapy. At least, the notion that with our thoughts we influence our mood and anxiety is quite consistent with cognitive therapy. But let’s look at what the quote is really getting at. The quote is a statement about something deeper than just mood or anxiety, it’s talking about reality. The idea that “we are what we think” may sound like a cute maxim suitable for getting a laugh at cocktail parties, but it refers to the Buddhist notion of anatman, the idea that at the core of our beings, there is no individual self. Rather, what we mistakenly identify with as a “self” is a combination of a physical body, sensations, emotions, and bundles of thoughts. The Buddha would suggest that if any of us were to closely inspect this “self” through meditation, we would realize that it has no inherent nature or existence; that it is an illusion of sorts.

Cognitive therapy focuses not only on thoughts that contribute to depression and anxiety, but also on beliefs that serve the same function. The difference between thoughts and beliefs is that thoughts are events in time lasting only for a moment, whereas beliefs are more stable and long-lasting. Beliefs can range from the specific, e.g., “I’m no good at bowling, I’ve never been any good at bowling” to the global, e.g., “I’m unlikeable,” or “I am really good at everything.” We all have lots of beliefs like these, covering the full range from the specific to the global. These beliefs span wide ranges of accuracy, helpfulness, and healthiness. Cognitive therapy considers these beliefs to be relevant, sometimes, to why we experience depression, anxiety, or other problems. From the perspective of Buddhist psychology, these beliefs begin to comprise what we think of as the self. Consider the example of a 68-year-old male, recently retired from a successful career as a bussinessman in New York. Several months after retirement, he began to become depressed and tried to re-enter the business world. His involvement was not as welcomed as he had hoped, and his mood became more depressed as he realized he would not be able to resume his career. Eventually he sought treatment for depression. This man identified with his career to such an extent that once it was over, he was unsure how to think of himself. A cognitive therapist might contend that he could no longer rest on his beliefs about himself as an effective businessman, and depression followed. Buddhist philosophy might suggest that the man had relied on an illusory conception of himself; the illusion was that of stability and permanence. This leads us to the phrase quoted from the Buddha, that “all that we are arises with our thoughts.”

We have a tendency to want to believe that something about ourselves is permanent. We would like to think that many things about us are not subject to change. One of the fundamental concepts of Buddhism is anicca (flux, or impermanence). This is the idea that everything that comes into existence will eventually cease to exist. This applies to everything from the Roman Empire to a blade of grass. It applies to people too; for the retired businessman mentioned above, he relied on an identity as a successful businessman in such a way that he didn’t really think it would end. When it did, the effect was similar to a rug being pulled out from under him. When considering the Buddha’s quote, “all that we are arises with our thoughts,” we need to remember the importance of anicca. According to Buddhism, there is nothing permanent in what we regard as the self. Just as all things are subject to continual change, each of us is constantly changing. So if we pin our identity on one aspect of our lives, like the retired businessman did, eventually we will be left in a bit of a crisis. In saying that we are nothing more than our thoughts, the Buddha is saying that not only is there nothing solid in our existence, but that what we think of as ourselves is generated by our own minds.

While this philosophy is clearly a further-reaching model than that described by cognitive therapy, we can see that the two are more consistent with one another than one might think.

What are ERP and ExRP?

2007-02-07T23:17:00.000-05:00

ERP and ExRP are kinds of psychotherapy used to treat obsessive-compulsive disorder (OCD). ERP stands for Exposure and Response Prevention. Innovations in this psychotherapy over the past ten years resulted in its being given a new name: Exposure and Ritual Prevention (ExRP). The two therapies are similar, and both build on core behavioral therapy concepts. The purpose of this article is to provide information about what these therapies involve, and how they might be helpful to people suffering from OCD.

OCD is a psychological disorder that has been documented for thousands of years. OCD is characterized by the presence of either obsessions, compulsions, or both. Obsessions can be thought of as intrusive thoughts that cause anxiety. They are difficult to get rid of, despite one’s best efforts. Compulsions are activities, often performed repetitively. We often experience anxiety when we are not able to perform the compulsion.

For several decades after the early psychoanalysts wrote about obsessions (starting in the late nineteenth century), treatment for OCD would typically involve psychoanalysis that strove to root out the unconscious cause for an obsession. More recent thinking in the field conceptualizes obsessions and compulsions a bit differently. Recent research has shown that obsessions and compulsions respond to treatments that do not focus at all on unconscious causes; successful psychotherapeutic treatment will typically focus on developing new ways of responding to the obsessions and compulsions in the here and now, regardless of their cause. While there has been much theorizing and speculating about the origin of obsessions, there has not been a research-supported consensus in the field about what causes OCD. However, therapies like ERP and ExRP have been shown to treat OCD successfully without focusing on the cause, whatever it might be.

When an obsessive thought occurs, feelings of anxiety will usually occur as well. The anxiety is very uncomfortable, and as a result, people with OCD typically engage in an activity that they have found will relieve the anxiety. This can take many forms. For some, a behavior like washing one’s hands will relieve the anxiety. For others, seeking reassurance from a loved one or other source will relieve the anxiety. In the past several years, the internet has become an increasingly popular resource for people with OCD who seek to reassure themselves, and thus lower their level of anxiety. Still others with OCD would love to find something that would relieve their anxiety, but have not been able to. Whatever the strategy used to deal with the increased anxiety, the unpleasant feelings are seen as scary and as something to get rid of, if possible.

Cognitive-behavioral therapies like ExRP try to change one’s reaction to these unpleasant feelings. By doing so, one can experience obsessive thoughts and the need to perform compulsions a bit differently. This kind of change is a difficult one to enact, and takes some hard work. Much of this hard work will come in the form of “exposure” exercises that will be discussed by you and your therapist. Through these exercises, one can gradually learn to tolerate feelings of anxiety better. The OCD sufferer is “exposed” to feelings of anxiety during the exercise, which helps break some unhelpful patterns that have been established. These patterns have often taken shape over several years of OCD.

It is often said that we are creatures of habit. This is certainly true in a brief examination of how OCD can become entrenched in our thoughts and behavior. People suffering from OCD have often developed habitual ways of dealing with feelings of anxiety when they arise. If these habits result in a quick lessening of anxiety, then each time we do it, the habit becomes a bit stronger. This is a basic principle of behavioral psychology called negative reinforcement. Negative reinforcement is when the removal of a negative stimulus follows performance of a certain action, thus making us more likely to perform that action again next time.

For example:

Sara (not her real name) experienced anxiety whenever the thought of AIDS came into her mind. She found that she could reduce this anxiety by checking on the internet to confirm that nothing she was doing in her life right now put her at risk for contracting HIV. Sara was rewarded for her internet research with reduced anxiety. While she had found a short-term fix for her anxiety, she found that over time, she had to spend more and more time on the internet. This began to impact her personal life and her work life.

Exposure
One centrally important aspect of therapy for OCD is exposure. This will take different forms depending on the nature of the obsessions or compulsions. For Sara, the woman described above who had obsessive thoughts around HIV and AIDS, the exposure exercises would address her reaction to those thoughts. If Sara found herself thinking, “what if I got HIV when I was at work yesterday,” then when she was ready, her therapist would probably recommend an exposure exercise addressing her reaction to that thought. Sara might try to “expose” herself to the idea that it is possible that she did, in fact contract HIV at work yesterday. Often, such an exercise will have very little appeal to the person with obsessions about HIV contamination. If one has already invested so much effort in steering clear of the risk of infection, why go out of one’s way to contemplate the possibility of infecting oneself?

The answer to that is that beating OCD involves changing your habits. Sara, from the above example, had gotten herself in the habit of checking on the internet whenever she became anxious that she had become contaminated. If a website could convince her that she was not infected, she would feel at ease once again. With the assistance of her therapist, Sara began doing exposure exercises that involved purposefully refraining from going on the internet when she was anxious about contamination. She exposed herself to the anxiety that accompanied thoughts of HIV infection without responding in her habitual way. When done correctly, this type of exposure exercise has the effect of helping achieve a long-term reduction in obsessions, and in the anxiety they cause. Sometimes these exposure exercises will last only a few minutes, sometimes significantly longer. These exercises are not designed to make you feel better in the short term; they are designed to help you in the long term by helping you build a different relationship with your obsessive thoughts.

Rituals
Some people with OCD find that they have to do certain things in order to make their anxiety go away. These are called compulsions, or compulsive behaviors. Sometimes these actions are relatively simple, as Sara’s habit of going on the internet to get information about HIV infection. Other examples of compulsions can be even quicker, such as washing one’s hands, or checking to make sure the stove is off before leaving home. However, some compulsive behaviors take a long time. Some compulsive patterns actually involve a series of behaviors. For example, many people with OCD describe taking long showers. They describe having to wash themselves in a particular way, sometimes washing the same area a set number of times. This is an example of something called a ritual, which is a series of compulsive behaviors. It is possible for these rituals to have a significant impact on the life of the person suffering from OCD.

It is this type of ritual referred to in “Exposure and Ritual Prevention.” The example of Sara refraining from checking on the internet discussed above describes one type of “ritual prevention.” Another example can be seen in the example of Robert:

Robert (not his real name) came to see me because he had been arriving later and later to work. This had caused him to be reprimanded by his supervisor on three different occasions, and he was concerned about his job security. Robert had OCD, and was engaging in rituals at home in the morning which made him late for work. In the beginning, he was able to just stop them when he had to leave the house, but eventually he was unable to do even that. His ritual began with trying on every pair of shoes in his closet to see which one felt the best. This was not so time consuming. Eventually, his ritual became more complex and he described needing to try on every shirt, pair of pants, and jacket he owned before he left the house. This left Robert feeling exasperated; he knew that it was unnecessary to try on so many different articles of clothing, and was especially frustrated at his felt need to try on jackets even in the summertime, when he wouldn’t wear one anyway.

This example illustrates two important characteristics of rituals. For one, this ritual started out seeming harmless, but eventually became complicated and time-consuming. Secondly, Robert described knowing that his behavior was excessive and unnecessary, but eventually found himself feeling powerless to stop the ritual. This is often the case, and a very frustrating part of OCD. Fortunately there is hope for people suffering with this type of ritual to get some help.

Robert was able to effect lasting change through his work in Exposure and Ritual Prevention. Once he understood how OCD had put him in this situation, and how he could make some changes, he began to use exposure exercises to gradually change his ritualizing. First, he was able to experience the anxiety that came up when he decided to limit his trying on of jackets to three. Through the exercise he began to retrain his autonomic nervous system – he taught himself how to tolerate the unpleasant feelings that accompanied leaving something incomplete. After a while, he was able to skip the jackets altogether, and eventually was able to get dressed in only five minutes’ time. Robert described this process as a challenging one, but one he was ultimately very pleased about.

Can ExRP bring about lasting change?
One advantage of ExRP and other cognitive-behavioral therapies over medication is that you can use the skills you learn in therapy to change how you deal with anxiety and OCD. This is often a long lasting change. While medication is often helpful to reduce symptoms of OCD, many patients report that they are again vulnerable to obsessions and compulsions once they come off their medication. Many of the patients I have seen tell me that they feel better equipped to handle OCD because of therapy, although they often say it remains a challenge after therapy is over. Some describe having few to no symptoms of OCD after ending therapy. Others describe having persistent obsessions and compulsions, although these have a lessened impact on their lives. It is very difficult to predict what kind of an outcome someone will have in therapy. However if someone is willing to learn “new tricks,” and willing to put in the effort required of the exposure exercises, there is every reason to be optimistic about their ability to benefit from therapy.

Dissertation excerpt: STRESS REACTIVITY, HEALTH, AND MEDITATION: A Path Analytic Approach

2007-02-07T21:50:00.000-05:00

Following is the conclusion section of my dissertation. The dissertation itself is currently in preparation for publication.

The present study found some meaningful relationships between meditation variables, stress reactivity, and health variables. Stress reactivity was strongly negatively correlated with several physical and mental health variables. Stress reactivity was also shown to be more strongly associated with recent meditation and health variables than were total stress or number of stressors. Overall, the present study found that stress reactivity is a meaningful variable in ongoing efforts to understand the meditation’s mechanisms of action.

Recent meditation appeared to be more important to stress reactivity than was lifetime meditation experience. Additionally, recent meditation was significantly associated with vitality and mental health, whereas lifetime meditation experience was not; implications of this for MBSR research include the importance of continued mindfulness meditation practice to maintaining positive health outcomes. The notion of trying to effect change in perceived stress by altering meditation habits was bolstered by the path analysis results. It is recommended that future research explore ways to effect patients’ continued regular meditation practice after completion of MBSR.

This study has been a first step in investigating questions involving stress reactivity and meditation. A clear next step involves testing some of the relationships found in the present study in a clinical study of a meditation-based clinical intervention. Such research could eliminate remaining questions from the present study due to the sample’s limited range of the education level and baseline health status variables. Further research could also investigate the possible mediating role of stress reactivity in the relationship between completion of a meditation-based treatment and healthful outcome. Additionally, future research on stress reactivity could investigate the role of neuroticism or other relevant personality variables.

Anxiety and Depression in Patients Recovering from Bone Marrow and Stem Cell Transplants

2007-01-20T21:55:00.000-05:00

A stem cell transplant (SCT) or bone marrow transplant (BMT) is a procedure used in treatment of various types of lymphoma, leukemia, and some other cancers and disorders of the blood. While this procedure has existed for decades, it came into more common use in the early 1990’s. The effectiveness of transplant varies according to the diagnosis, age, and health of the recipient. The present article aims to give general information about the experience of transplant, and purposely omits statistical information and other specifics. If you are considering bone marrow or stem cell transplant as a treatment option, please consult with your doctor for the most accurate, personally applicable, and up-to-date information. Other information resources can be found at the National Marrow Donor Program and the Leukemia and Lymphoma Society.

Patients who are preparing for a bone marrow or stem cell transplant first receive what is called “conditioning” regimen, which will prepare the body for the transplant. This will typically involve chemotherapy, radiation, or both. This phase of treatment aims to reduce the number of diseased marrow cells, sometimes down to zero. The bone marrow is the center for the body’s immune system. Thus, during and after the “conditioning” phase of treatment, immune functioning is weakened, and precautions are taken to avoid infections. Most cancer centers and some major hospitals will have a unit devoted exclusively to stem cell and bone marrow transplant; these units are specifically equipped to minimize risk of infection to patients with weakened immune systems.

Recipients of bone marrow transplant and stem cell transplant can typically expect a recovery period that takes several months. The first few weeks of the recovery period is spent in the hospital, at a transplant unit. Several weeks after transplant, if the patient is healthy enough, he or she is then discharged from the hospital to continue the recovery process at home or, in some cases, in local residential facilities affiliated with the hospital. During this time, patients are asked to follow a specific diet, and to take other steps to minimize exposure to infection. Patients are often asked to avoid crowded public places, like movie theaters. Some patients find that they are soon able to fully return to their previous lifestyle, while others find that they do not return to prior health or energy levels for extended periods after their transplant.

My own clinical experience with survivors of stem cell or bone marrow transplant has primarily been with people who are 1-2 years after their transplant. After a year of recovery, many people find that they have no, or relatively few, symptoms resulting from their transplant. Others find that some physical symptoms continue to bother them. The most common physical symptoms are fatigue, trouble sleeping, and sexual difficulties.

Research has shown that after a year of recovery, about three quarters of survivors of transplant will experience some symptoms of anxiety or depression. Of these, one third find that the depression or anxiety has a substantial impact on their lives. Some patients describe these difficulties as stemming from the illness itself, as opposed to the transplant. Most patients who receive a bone marrow or stem cell transplant do so because they have a serious illness that has the potential to recur (e.g., leukemia, multiple myeloma, or lymphoma). For some, this possibility is the primary cause of any distress. For others, the shock of their initial diagnosis was a traumatic event that still causes real distress. Other survivors say that the experience of transplant itself has been hard to “put behind them.” Many describe reminders of the transplant and subsequent recovery as causing significant distress. Experiencing such reminders as upsetting is a common phenomenon for survivors of any life-threatening experience, including a diagnosis of cancer and BMT/SCT.

Fortunately, research has also demonstrated that the kinds of distress described above can be effectively addressed with cognitive-behavioral therapy. The aim of this type of therapy is to focus on the thoughts and the behaviors that help maintain symptoms of depression and anxiety, and then to address these symptoms with proven methods. For example, a survivor who is depressed may be experiencing thoughts like, “My leukemia will definitely come back,” or “everything bad always happens to me.” There are many other such possibilities as well. The survivor who entered cognitive-behavioral therapy would learn about the impact of these thoughts, and would be encouraged to explore the factual bases for the thoughts. This type of exploration is always done in collaboration with the therapist.

Other survivors report that reminders of their illness and their transplant cause them significant anxiety and distress. Something as seemingly innocent as a bar of soap might remind the survivor of a soap that was used in the hospital, and thus evoke feelings of anxiety. Sometimes this anxiety has a physiological component to it, and may involve increased breathing rate, heart rate, and muscle tension, e.g. The anxiety may also result in the survivor avoiding the reminder in question. This may not affect the survivor’s daily life. However, if the reminder is commonplace, this avoidance can have a substantial impact. For example, imagine the long-term effects of avoiding soap.

Fortunately, as mentioned above, it is a minority of patients that experience the symptoms of psychological distress just described. For these patients, it is also fortunate that cognitive-behavioral therapy provides a proven option to address the depression and anxiety that can follow SCT/BMT.

Comments or questions? Contact the author at Dr.Paul.Greene@gmail.com