Last updated on Wed, 09/04/2014 - 05:59
It's coming up to the two year anniversary of one of the major potential traumas of my life - see "Walking in Skye & Kintail: mountain rescue, helicopter winches, and avoiding death & PTSD." I felt there was so much to learn from this experience that I try to re-read the description every month to help me remember the precious lessons that were involved.
We can gain resilience through difficulty - not too much, but not too little either. The researcher Mark Seery has written extensively about this - for example in last year's paper "An upside to adversity?: Moderate cumulative lifetime adversity is associated with resilient responses in the face of controlled stressors" and his earlier "Whatever does not kill us: Cumulative lifetime adversity, vulnerability, and resilience." Other research teams have also noted these effects e.g. Neff & Broady's paper "Stress resilience in early marriage: can practice make perfect?" There is even truth in the folk wisdom that experiences of difficulty can help us value the good things in our lives even more - "From tribulations to appreciation: Experiencing adversity in the past predicts greater savoring in the present."
I'm in a book group and we have been asked to read Jane Hirshfield's fine collection of poems "Each happiness ringed by lions". The request is to choose a few of the poems to read out when we next meet ... and to write a reply or extension to one of them. Here is Jane's "With singing and banners":
Demosthenes, a wise man, filled his mouth
with pebbles before speaking,
and a stream which has run ten feet over rocks
is clear, they say, and safe to drink;
yet still we forget what is owed our failures -
blessings, to praise the stumbled on stone.
And forget what we once knew, how properly to greet
old enemies, for whose sake we practise and parry,
with singing and banners, with gladness.
And the 'extension':
Walter Scott, a fine author, wrote of
‘The stern joy that warriors feel in foeman worthy of their steel.'
and it is walking’s repeated impact
that strengthens bone and prevents fracture.
A meditation teacher once told me ‘It can be good to have some pain,
it helps us to stay present.’
Celebrate the warm embrace of friends;
And celebrate too the cold splash
with singing and banners, with awareness.
Emotional intelligence: the potential value (and potential cost) of identifying and naming what we're feelingOriginally added on Mon, 17/03/2014 - 05:44
Last updated on Thu, 27/03/2014 - 08:15
I'm a member of a recently established discussion group. We take turns hosting the meetings and deciding what subject area we'll focus on. At our first get-together last month we talked about values, particularly the values we personally try to live by (see the blog posts " ... inspiration from values" and "Purpose in life: reduces dementia risk, increases life expectancy, treats depression and builds wellbeing". We met again a couple of days ago ... lovely ... tea and conversation. Opening up. I don't know most of the other members at all well, so it's particularly fascinating hearing them explore important issues deeply, vulnerably, insightfully ... and also good to try to do this myself. Our hostess at this weekend's gathering had suggested we focus on "Learning our true names". She had sent out a series of papers and poems. One area she mentioned is the power of actually naming something, writing "In some traditions of magic, there is a power within the naming, and learning someone's 'true name' might give power over that person. Or there is simply a power in naming things to overcome fear that is associated with the name. For those who have read Harry Potter, you might recall that Professor Dumbledore tells Harry 'Call him Voldemort, Harry. Always use the proper name for things. Fear of a name increases fear of the thing itself.'"
" ... there is simply a power in naming things to overcome fear that is associated with the name." Interestingly, there's a good deal of scientific research that gives some backing to this kind of statement. So at last year's BABCP - British Association for Behavioural & Cognitive Psychotherapies - annual conference, Professor Michelle Craske, in her plenary lecture "New ways to optimise exposure therapy for anxiety disorders", stated "This presentation will address the augmentation of emotion regulation during exposure therapy for anxiety disorders, using strategies that target the function rather than the content of cognition. Affect (emotion) labelling, a simple process that involves linguistic processing of emotional responses, activates neural regions that serve to down-regulate the amygdala. Affect labelling is a form of inhibitory regulation of emotion. Individual with anxiety disorders show deficits in such inhibitory regulation. Thus, in training affect labelling may be particularly beneficial as individuals with anxiety disorders undergo exposure to fear producing stimuli. In clinical translation of this work, we have demonstrated the value of affect labelling as compared to cognitive reappraisal during exposure to phobic stimuli. This presentation will cover the basic science of affect labelling and the clinical translation to exposure therapy, in terms of outcomes and mechanisms." This abstract is heavy with psychological jargon, but I hope you get its drift.
So way back in 2007(!), Lieberman & colleagues - in their paper "Putting feelings into words: affect labeling disrupts amygdala activity in response to affective stimuli" - mapped the pathways that seem to carry this "power of naming" in the brain, while Cresswell et al - in "Neural correlates of dispositional mindfulness during affect labeling" - highlighted that giving feelings their names could well be "one potential neurocognitive mechanism for understanding how mindfulness meditation interventions reduce negative affect and improve health outcomes". And more recently Kircanski et al - in "Feelings into words: Contributions of language to exposure therapy" - demonstrated that these mechanisms can have clinical value, commenting "A growing body of research has revealed that labeling an emotion, or putting one’s feelings into words, can help to downregulate that affect ... We translated this basic research to a real-world clinical context, in which spider-fearful individuals were repeatedly exposed to a live spider. Using a between-subjects design, we compared the effects of affect labeling, reappraisal, distraction from the feared stimulus, and exposure alone during this brief course of exposure therapy on subsequent fear responding. At a 1-week posttest involving a different spider in another context, the affect-labeling group exhibited reduced skin conductance response relative to the other groups and marginally greater approach behavior than the distraction group ... Additionally, greater use of anxiety and fear words during exposure was associated with greater reductions in fear responding. Thus, perhaps surprisingly, affect labeling may help to regulate aspects of emotion in a clinical context."
And it's not just in working with fear that this is relevant. Demiraip & colleagues - in "Feeling blue or turquoise? Emotional differentiation in major depressive disorder" - pointed out "Some individuals have very specific and differentiated emotional experiences, such as anger, shame, excitement, and happiness, whereas others have more general affective experiences of pleasure or discomfort that are not as highly differentiated. Considering that individuals with major depressive disorder (MDD) have cognitive deficits for negative information, we predicted that people with MDD would have less differentiated negative emotional experiences than would healthy people. To test this hypothesis, we assessed participants' emotional experiences using a 7-day experience-sampling protocol. Depression was assessed using structured clinical interviews and the Beck Depression Inventory-II. As predicted, individuals with MDD had less differentiated emotional experiences than did healthy participants, but only for negative emotions. These differences were above and beyond the effects of emotional intensity and variability."
Again this may be so relevant for mindfulness strategies, so Barnhofer et al - in "Dispositional mindfulness moderates the relation between neuroticism and depressive symptoms" - wrote "Negative emotional reactivity as measured by neuroticism has been shown to be an important risk factor for the development of depressive symptoms. This study investigated whether the ability to be mindful can protect against the negative effects of this temperamental vulnerability. An English community sample of N = 144 individuals who had completed a neuroticism questionnaire six years previously were assessed for current depressive symptoms and dispositional levels of mindfulness at points of assessment approximately one year apart. Dispositional mindfulness moderated the relation between neuroticism and current depressive symptoms: Neuroticism was significantly related to depression in those with low to medium levels of dispositional mindfulness but not in those with relatively high levels of mindfulness. Further analyzes focusing on particular mindfulness skills indicated that this effect was carried mostly by the ability to describe inner experience. The results suggest that dispositional mindfulness and particularly the ability to describe inner experience are helpful in dealing with negative emotional reactivity in a way that reduces the likelihood of depressive symptoms to develop." A post I wrote some time ago ... "'Naming emotions' is another useful self-regulation & mindfulness strategy" ... gives more details about this and introduces a relevant mindfulness exercise.
Fascinating stuff ... and walking into this territory opens up so many other questions. If being able to identify and name what we're feeling helps us not be swept away or sabotaged by our emotions, is mindfulness training one of the best ways of achieving this? My suspicion is not ... so the blog post " ... emotional intelligence, group work & learning to relate more deeply" introduces my personal experience in this area, while the post "Is interpersonal group work better than sitting meditation for training mindfulness?" takes this discussion further. And a further fascinating question is "Do we always want to use this ability to identify and name emotions as a way of draining out some of the power of our feelings?". If we're feeling good, might this type of inner quite analytical response actually be counter-productive ... might it also drain away the power of joyful or happy feelings a bit like it can drain away the power of frightening or unhappy feelings? The answer is probably yes! So see the post "Manchester BABCP conference: Emily Holmes & imagery" with its comment that "usually it's best to increase the emotional & sensory vividness of positive images with less reliance on words, but to decrease the vividness of negative images by introducing more verbal processing."
More to follow ...
Improving therapeutic success rates: how to generate personal practice data to rate oneself using the UK IAPT targetsOriginally added on Sun, 09/03/2014 - 05:40
Last updated on Mon, 17/03/2014 - 05:43
I wrote a blog post yesterday about recently published IAPT psychotherapy data and how it provides a fascinating set of targets which one can use to assess the effectiveness of one's own therapeutic practice. When one gets down to the nitty-gritty of what data from one's own practice to collect and how, then it can be a bit tough. Lots of questions to clarify here, but part of the good news is that there is also lots of IAPT guidance on how to do this.
A good place to start one's search about the "how to" and "what to" of data collection is the official IAPT website. Also very useful is the "Health & Social Care Information Service" - "the national provider of information, data and IT systems for health and social care". The HSCIS provides a document -"Improving access to psychological therapies data set" - that gives useful advice
IAPT uses the WHO ICD-10 criteria when classifying "mental & behavioural disorders".
More to follow ...
Improving therapeutic success rates: using UK IAPT data to assess how well we're doing therapeuticallyOriginally added on Sat, 08/03/2014 - 05:57
Last updated on Mon, 17/03/2014 - 05:42
I wrote a blog post in the autumn - "Improving therapeutic success rates: UK IAPT data gives us a clearer set of targets" - highlighting that, if we want to improve how effective we are at an activity, it's likely to be crucially important that we monitor how well we're actually doing and whether or not our outcomes are getting better. For psychotherapists there are currently a number of quite widely used systems that we can use to assess ourselves including the "Clinical Outomes in Routine Evaluation (CORE)", the "Outcome Questionnaire-45 (OQ45)", the "Partners for Change Outcome Management System (PCOMS)", and the "Treatment Outcome Package (TOP)". Disadvantages of these methods however include that most of them don't have results that are based on a similar patient population to the one that I work with ... and the CORE, which does, becomes expensive for a single-handed practitioner like me if it's used in its most modern incarnation. Emerging research however suggests that I can now put together a self-monitoring, self-assessment approach (using freely accessible questionnaires) that bypasses the need for the 'subscription' systems that I've mentioned. This recent research throws light on two helpful areas. One involves making available a huge, developing database of therapeutic outcomes with UK adult psychotherapy patients, so I really can see how my results compare with relevant others. The second helpful area that's being clarified is that, although monitoring clients for inadequate early progress continues to be a potentially extremely helpful way of reducing poor outcomes, standardised predicted improvement trajectories may be less one-size-fits-all than has sometimes been thought.
In my autumn post, I pointed out that although early significant improvement (within the first 4 or 5 sessions) is an encouraging sign that's well worth striving for, recent research - "Nomothetic and idiographic symptom change trajectories in acute-phase cognitive therapy for recurrent depression" and "Shape of change in cognitive behavioral therapy for youth anxiety: Symptom trajectory and predictors of change" - highlights that eventually successful cases don't always follow similar improvement trajectories. So the authors of the "Nomothetic and idiographic symptom change ... " paper, write "The current results present challenges to clinical tracking and prognostication. Because the three identified coherent change patterns predicted similar short-term outcomes, it may be difficult to gauge whether individual patients are “on track,” especially early in CT ... Although the odds of response decrease the longer patients maintain high symptom levels during CT, this may be due, at least in part, to use of a time-limited protocol, rather than an indication of highly stable causes of nonresponse."
My current take home message is that I want to try very hard to help clients achieve rapid improvements in their depression & anxiety (both because of the immediate symptomatic benefit & the likelihood of better longer term outcome), but I'm less convinced than some expert commentators that lack of such progress is fairly inevitably a sign of eventual treatment failure (although increased caution and problem-solving are sensible in this situation). But ... let's see what further relevant research emerges in this area over the next year or two. As is often quoted and I try to make true for myself (though it can be hard!) - "When the facts change, I change my mind. What do you do, sir?" This sense that not all successful cases follow the same improvement trajectories, means that I am less fixed on comparing an individual client's progress trajectory with predicted rates of change than I was (although I'm still highly vigilant to signs that a client's progress has stalled). So I'm now more open to using progress assessments that aren't so tightly linked to pre-prepared graphs of expected rates of change. Widely used free measures like the PHQ-9 and GAD-7 thus become more attractive and this is now even more the case since the publication of last year's paper "Enhancing recovery rates: Lessons from year one of IAPT" with its clear indication of what kinds of outcomes (using these scales) indicate low, standard or high rates of therapeutic success. Still more fascinating comparative data is available with the Health & Social Care Information Centre's collection of linked documents from this January - see "Psychological therapies, annual report on the use of Improving Access to Psychological Therapies service - England 2012-13".
The "Enhancing recovery rates ... " paper is freely available in full text and its abstract reads: "Background: The English Improving Access to Psychological Therapies (IAPT) initiative aims to make evidence-based psychological therapies for depression and anxiety disorder more widely available in the National Health Service (NHS). 32 IAPT services based on a stepped care model were established in the first year of the programme. We report on the reliable recovery rates achieved by patients treated in the services and identify predictors of recovery at patient level, service level, and as a function of compliance with National Institute of Health and Care Excellence (NICE) Treatment Guidelines. Method: Data from 19,395 patients who were clinical cases at intake, attended at least two sessions, had at least two outcomes scores and had completed their treatment during the period were analysed. Outcome was assessed with the patient health questionnaire depression scale (PHQ-9) and the anxiety scale (GAD-7). Results: Data completeness was high for a routine cohort study. Over 91% of treated patients had paired (pre-post) outcome scores. Overall, 40.3% of patients were reliably recovered at post-treatment, 63.7% showed reliable improvement and 6.6% showed reliable deterioration. Most patients received treatments that were recommended by NICE. When a treatment not recommended by NICE was provided, recovery rates were reduced. Service characteristics that predicted higher reliable recovery rates were: high average number of therapy sessions; higher step-up rates among individuals who started with low intensity treatment; larger services; and a larger proportion of experienced staff. Conclusions: Compliance with the IAPT clinical model is associated with enhanced rates of reliable recovery."
These figures relate to 19,395 patients assessed over 2008/2009 - with 40.3% reliably recovered, 63.7% reliably improved and 6.6% reliably deriorated. The most recent figures for 2012/2013 assessed 144,210 patients - with 41% reliably recovered and 57% reliably improved. Note though that the 2012/2013 figures were calculated nationally whereas the 2008/2009 figures were calculated locally, so the varying percentages should be compared only cautiously. Patients were seen across all four of the English NHS Commissioning Regions and data was reported separately for each of 25 Local Area Teams. Across the Local Area Teams recovery rates varied with 3 of the 25 achieving the target figure of more than 50% recovered (recovery is a marginally less stringent measure than "reliable recovery" - there's typically about a 2% difference between the rates), while at the bottom end of the scale the worst Local Team only managed to achieve 24% recovery. For reliable improvement, two Teams managed to reach 65% benefitting, while the outlier worst Team only produced 31% reliable improvement.
So here's a fascinating take home message and a clearly drawn challenge - if I can get 41% of my clients "reliably recovered" and 57% "reliably improved" it looks as though I'm doing a pretty good job. However if I can get at least 50% of my clients "reliably recovered" and 65% "reliably improved" then I'm probably right up there with the most effective psychotherapists around. Now this is interesting. See tomorrow's blog post for how I can begin checking what recovery & improvement rates I'm actually achieving.
CBT Today: keeping up with the literature - exposure, mindfulness & reappraisal - winter '13/14 (2nd post)Originally added on Sun, 26/01/2014 - 05:37
Last updated on Mon, 17/03/2014 - 05:47
In yesterday's post on "Keeping up with the literature", I wrote about the wealth of updated knowledge that has emerged with publication of the third UK National Survey of of Sexual Attitudes and Lifestyles (Natsal) and about useful qualitative research on why most health professionals (including psychotherapists) tend to be poor at providing help for sexual difficulties. I would now like to say a little about some new findings in exposure therapy, and some additional insights into mindfulness, relaxation & reappraisal.
There have been a series of fascinating recent papers on exposure treatments. Abramowitz in his freely downloadable article "The practice of exposure therapy: Relevance of cognitive-behavioral theory and extinction theory" comments that "Exposure therapy is the most effective psychological intervention for people with anxiety disorders" and argues that "knowledge of the relevant theory is crucial to being able to implement exposure therapy in ways that optimize both short- and long-term outcome." Leer et al, in "Eye movements during recall of aversive memory decreases conditioned fear", give the best explanation that I've read so far on why Eye Movement Desensitization & Reprocessing (EMDR) therapy is effective. The Wikipedia article on EMDR comments that development of this approach was triggered by the originator Francine Shapiro's personal observation that voluntary eye movements reduced the emotional distress associated with recall of disturbing memories. In a laboratory study, Leer & colleagues carefully document this process & argue that "Contemporary learning theory suggests that treatment may be optimized by adding techniques that aim at revaluating the aversive consequence (US) of the feared stimulus. This study tested whether US devaluation via a dual task - imagining the US while making eye movements - decreases conditioned fear ... Dual tasking, relative to the control condition, decreased memory vividness and emotionality. Moreover, only in the dual task condition reductions were observed in self-reported fear, US expectancy, and CS unpleasantness, but not in skin conductance responses. Findings provide the first evidence that the dual task decreases conditioned fear and suggest it may be a valuable addition to exposure therapy."
Other interesting recent exposure-focused articles include the cutting edge Anderson et al study "Virtual reality exposure therapy for social anxiety disorder: A randomized controlled trial", the practical, freely-downloadable-in-full-text, Ehlers et al report "Implementation of cognitive therapy for PTSD in routine clinical care: Effectiveness and moderators of outcome in a consecutive sample", the thoughtful Bryant et al study "Augmenting cognitive behaviour therapy for post-traumatic stress disorder with emotional tolerance training", the revisionary Kliem & Kroger paper "Prevention of chronic PTSD with early cognitive behavioural therapy. A meta-analysis using mixed-effects modeling", the helpful Ljotsson et al insight "Mechanisms of change in an exposure-based treatment for irritable bowel syndrome", and the intriguing therapeutic (and parenting) implications of Golkar et al's paper "Other people as means to a safe end: Vicarious extinction blocks the return of learned fear" with its abstract commenting "Information about what is dangerous and safe in the environment is often transferred from other individuals through social forms of learning, such as observation. Past research has focused on the observational, or vicarious, acquisition of fears, but little is known about how social information can promote safety learning. To address this issue, we studied the effects of vicarious-extinction learning on the recovery of conditioned fear. Compared with a standard extinction procedure, vicarious extinction promoted better extinction and effectively blocked the return of previously learned fear ... Our results confirm that vicarious and direct emotional learning share important characteristics but that social-safety information promotes superior down-regulation of learned fear."
There are also half a dozen new studies I would like to briefly mention in the general area of mindfulness, reappraisal, relaxation and attention training. Well ... Bunnell et al's paper "A randomized trial of attention training for generalized social phobia: Does attention training change social behavior?" pretty much kicks into touch any notion that thorough, but straightforward, attention training is of much therapeutic use on its own in social phobia treatment - although I still believe that encouragement for task focus rather than self focus may be beneficial. In contrast, the effectiveness, but lack of difference, between currently popular mindfulness-based training and more traditional relaxation approaches for GAD - "A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder" underlines the value of NICE-recommended applied relaxation training and presumably helped motivate the authors' interesting discussion in their linked paper "A contemporary view of applied relaxation for generalized anxiety disorder." So maybe there's less difference in both the effectiveness and underlying mechanisms of relaxation training and mindfulness than we have thought. In a similar way differences between the very helpful ... but apparently very distinct ... approaches involving mindfulness or cognitive restructuring/reappraisal turn out to be less definite than one might have naively supposed. So Wolgast et al. write - in their paper "Cognitive restructuring and acceptance: An empirically grounded conceptual analysis" - "The study explores the constructs of cognitive restructuring and acceptance using items from well-established measures of the respective constructs in order to determine what subcategories or conceptual nuances that could be empirically detected, and examines these factors' relationship to each other and to positive and negative emotionality, quality of life and clinical status ... In sum, the findings from the study indicate that acceptance and cognitive restructuring should not be regarded as unitary and non-related constructs, but rather as partly overlapping general dimensions of emotion regulation consisting of several sub constructs or conceptual nuances with somewhat different psychological functions and properties."
Keng et al. - in "Reappraisal and mindfulness: A comparison of subjective effects and cognitive costs" - appear to come up with a potentially important distinction between reappraisal and mindfulness when they report "The present study investigated the relative effects of mindfulness and reappraisal in reducing sad mood and whether trait mindfulness and habitual reappraisal moderated the effects. The study also compared the extent to which implementation of these strategies incurred cognitive resources ... Results showed that mindfulness and reappraisal were superior to no training, and equivalent in their effects in lowering sad mood. Compared to mindfulness, reappraisal resulted in significantly higher interference scores on a subsequent Stroop test, reflecting greater depletion of cognitive resources ... The study suggests that although mindfulness and reappraisal are equally effective in down-regulating sad mood, they incur different levels of cognitive costs." However I suspect this difference in cognitive cost might dwindle or disappear if one paired the reappraisal with a hobby horse of mine - brief training in implementation intentions. Varley et al - in "Making self-help more helpful" - provide just one of a series of recently published studies illustrating the value of using implementation intentions more widely. And the final paper I'll mention in this "Keeping up with the literature" gallop is Troy et al's "A person-by-situation approach to emotion regulation: Cognitive reappraisal can either help or hurt, depending on the context" with its warning "Emotion regulation is central to psychological health. For instance, cognitive reappraisal (reframing an emotional situation) is generally an adaptive emotion-regulation strategy (i.e., it is associated with increased psychological health). However, a person-by-situation approach suggests that the adaptiveness of different emotion-regulation strategies depends on the context in which they are used. Specifically, reappraisal may be adaptive when stressors are uncontrollable (when the person can regulate only the self) but maladaptive when stressors can be controlled (when the person can change the situation). To test this prediction, we measured cognitive-reappraisal ability, the severity of recent life stressors, stressor controllability, and level of depression in 170 participants. For participants with uncontrollable stress, higher cognitive-reappraisal ability was associated with lower levels of depression. In contrast, for participants with controllable stress, higher cognitive-reappraisal ability was associated with greater levels of depression. These findings support a theoretical model in which particular emotion-regulation strategies are not adaptive or maladaptive per se; rather, their adaptiveness depends on the context." All trainers using reappraisal, relaxation and particularly mindfulness take note. Maybe the apparently adverse effects of teaching mindfulness to those with a history of only a few depressive episodes were genuine findings rather than just aberrations due to low patient numbers - see Teasdale et al (2000) and Ma & Teasdale (2004)!?
Last updated on Sun, 09/02/2014 - 05:50
This is an extended, online, hyperlinked version of a regular quarterly column - "Keeping up with the literature" - that I write for "CBT Today, the official magazine of the British Association for Behavioural & Cognitive Psychotherapies". In October's column, I commented that new CBT-relevant research flows past constantly like a great river. I track forty to fifty different journals - many more than most sensible health professionals try to monitor - but this is still just a small subsection of the multitude of potentially relevant publications. And if I get behind with my reading, a wave of literature rapidly builds up - I've already spent fifteen hours this week alone in a catch up blitz. Of course there is then the challenging task of what to select for a short column like this. I marked over a hundred articles as possible candidates from a sweep of the last three months of 2013. After a good deal of thought, in this column I comment on sex (usually piques people's interest), new findings in exposure therapy, and insights into mindfulness & reappraisal.
Sex is obviously absolutely central to our existence - without it we wouldn't be here. It can be a source of great pleasure & intimacy, but also of great pain & distress. I find it sad that treatments for sexual difficulties can be so hard to access here in the United Kingdom ... and that cognitive-behavioural therapists (who potentially have much to offer in this situation) typically seem to ignore this crucially important area. An article in a recent Journal of Sexual Medicine - "Why don't healthcare professionals talk about sex? A systematic review of recent qualitative studies conducted in the United Kingdom" - comments "Sexuality is considered to be an important aspect of holistic care, yet research has demonstrated that it is not routinely addressed in healthcare services. A greater understanding of this can be achieved through synthesizing qualitative studies investigating healthcare professionals' experiences of talking about sex ... Primary research studies were included in the review if they explored health professionals' experiences of discussing sexuality with adult service users, used qualitative methods, and were conducted in the United Kingdom over the last 10 years ... Nineteen interconnected themes emerged relating to healthcare professionals' experience of discussing sexuality with service users, including fear about “opening up a can of worms,” lack of time, resources, and training, concern about knowledge and abilities, worry about causing offense, personal discomfort, and a lack of awareness about sexual issues ... Conclusions. The majority of healthcare professionals do not proactively discuss sexuality issues with service users, and this warrants further attention. An understanding of the perceived barriers and facilitators indicates that interventions to improve the extent to which sexuality issues are addressed need to take organizational, structural, and personal factors into consideration."
Meanwhile our understanding of sexual issues in the UK evolves encouragingly - in 1990 and again in 2000, we had the first & second UK National Surveys of Sexual Attitudes and Lifestyles (Natsal). This work parallels similar efforts in the United States - see my 2011 blog post "Sexual behavior, sexual attraction and sexual identity". Results from the third UK Natsal study were recently published in the Lancet and there are six freely downloadable papers available covering changes in sexual attitudes & behaviours; details on sexually transmitted diseases; prevalence & information on unplanned pregnancies; levels of sexual function; health & sexual lifestyle associations; and lifetime prevalence and information on non-volitional sex. Key points are covered in a roller coaster three & a half minute "infographic" video - all this is very good material if you want to update your background knowledge in this area. And a couple of other relevant papers are the practically useful advice in "Exercise improves sexual function in women taking antidepressants: Results from a randomized crossover trial" and the impressive example of therapeutic behavioural skill in the JCCP trial "Therapist-aided exposure for women with lifelong vaginismus" ... which leads us neatly into tomorrow's post and recent work being published on exposure-based approaches.
Last updated on Sun, 16/02/2014 - 08:04
In a recent paper on cognitive behavioural treatment for insomnia - "Hyperarousal, sleep scheduling, and time awake in bed as mediators of outcome in computerized cognitive-behavioral therapy (cCBT) for insomnia" - Vincent & Walsh particularly highlighted the importance of reducing pre-sleep arousal for effective results. Gellis & Park explored similar territory in their publication - "Nighttime thought control strategies and insomnia severity" - reporting "Strategies used to control unwanted thoughts during the evening have been shown to be significantly associated with insomnia, a common problem associated with numerous negative consequences. This study examined whether nighttime thought control strategies would predict insomnia severity ... after accounting for well-established risk factors for the disorder such as anxiety, depression, sleep hygiene, and nighttime pain. ... Results ... showed that the strategy of cognitive distraction (attempts to withdraw from unwanted thoughts or think about more pleasant content) was negatively associated with insomnia severity and the strategy of aggressive suppression (the use of critical and punishing self thought) was positively associated with insomnia severity after accounting for other risk factors. These findings add to the growing literature highlighting arousing pre-sleep cognitions as a correlate of insomnia. These findings also add to emerging literature showing the ability to cognitively distract from the arousing thought as a correlate of good sleep."
In 2012, Gellis conducted a small exploratory study - "An investigation of a cognitive refocusing technique to improve sleep" - where he achieved encouraging results through "a technique that targets the refocusing of thoughts during the evening in order to improve sleep". Gellis & colleagues then took their research a step further last year with a larger, controlled study - "Cognitive refocusing treatment for insomnia: A randomized controlled trial in university students". They reported: "This investigation assessed the efficacy of a technique specifically designed to change the style and content of presleep thoughts in order to reduce nighttime cognitive arousal and decrease insomnia severity. This investigation, termed "cognitive refocusing treatment for insomnia" (CRT-I), previously improved sleep in a small sample of veterans with primary insomnia. In this investigation, university students with poor sleep were randomly assigned to attend either one session of CRT-I and sleep hygiene education (SH: n = 27) or one session of only SH (n = 24). Insomnia severity (assessed by the Insomnia Severity Index) and nighttime arousal (assessed by the Pre-Sleep Arousal Scale) were measured at baseline and 1 month posttreatment. A significant Group × Time interaction for insomnia severity suggested more improved sleep over time for those receiving CRT-I + SH. A trend for a Group × Time interaction showed decreased cognitive arousal over time among those receiving CRT-I." (Click here for an example of typical sleep hygiene instructions, and click here for other more general sleep handouts & advice). As is usually the case, we need more research on this encouraging cognitive refocusing approach, but it is such a simple method - an upgrade to counting sheep (!) - that it is already a technique for disrupted sleep that it's reasonable for any interested person to try.
So what actually were participants taught to do? The authors write: "Drawing on literature that highlights the usefulness of taking attention away from intrusive, negative thought content, a recently developed intervention termed cognitive refocusing treatment for insomnia (CRT-I) attempts to directly manipulate presleep thought content ... the participant and therapist collaborate to identify an engaging cognitive task that does not induce emotional or physiologic arousal. This task involves focusing on any mental activity with enough scope and breadth to create multiple avenues of thought to maintain the interest and attention of the participant. Reasoning that continual effort attending to an engaging yet nonarousing cognitive task (e.g., thinking about a recent line of clothing or mentally reciting lyrics from their favorite music album) would allow people with insomnia to shift attention from emotionally arousing cognitions to nonarousing cognitions, and sleep would be improved. Allowing individuals to choose their own cognitive task is important in this intervention in order to maximize the likelihood that the individual will maintain interest and be able to focus on the task. In this technique, participants are instructed to focus on this task upon initiating sleep and when waking up during the night."
They go on to say: "Discussion highlighted the importance of changing thought content from physiologically and emotionally arousing thoughts to nonarousing thoughts in order to improve sleep ... Next, the provider worked with the participant to identify three different categories of thought (topics of thought content) compelling enough to maintain his or her attention at bedtime. For instance, an individual may think about new dinner recipes or plots from his or her favorite television programs. These chosen thought categories were to have the following two qualities: (a) emotionally and physiologically nonarousing, and (b) compelling and engaging. An emotionally and physiologically non-arousing category was indicated by thought content devoid of emotion-laden, negative, exciting, or worrisome content ... the participant was asked to become absorbed in or focus attention on one of the categories at bedtime and upon waking up during the evening. If thought content other than the specific categories came to mind during the evening, participants were instructed to let go of or take attention away from that content and focus their attention on their chosen topic. Upon awakening during the evening, participants were instructed to avoid looking at the clock or any other activity that would take their attention from their targeted thought content. Individuals chose the type of categories that would be focused on during the evening. Three categories were identified by the participant. They were instructed to pay attention to whether their thought processes elicited emotional or physiologic arousal, and they were encouraged to switch topics if the first-chosen thought content precipitated arousal or if it was not engaging enough to occupy their attention. However, they were encouraged to focus on one thought category in order to develop learned associations between a specific category and sleep."
Interesting stuff ... simple ... and makes good sense. Cognitive refocusing treatment for insomnia (CRT-I) definitely looks an upgrade to counting sheep and well worth trying. If you want to learn more about the cluster of well-validated techniques typically used in a full CBT approach to helping insomnia, Colin Espie's excellent & straightforward book "Overcoming insomnia and sleep problems" is a good place to start or you could treat yourself to the six week internet-delivered programme on his website www.sleepio.com.
Last updated on Wed, 19/02/2014 - 07:23
"The truth is rarely pure and never simple" Oscar Wilde
Being a doctor, I tend to get occasional health queries from family members. Recently my brother emailed me saying "I have been taking multivitamin supplements for a while (also fish oil). Does the (linked) article mean that I am wasting my $$$$. at least on the vitamins? If so, then I shall make a donation to charity instead... ". The article he's referring to is an editorial in the "Annals of Internal Medicine" entitled "Enough is enough: stop wasting money on vitamin and mineral supplements". The editorial itself is triggered by three research papers published in December's "Annals" "Oral high-dose multivitamins and minerals after myocardial infarction: a randomized controlled trial", "Long-term multivitamin supplementation and cognitive function in men: a randomized controlled trial" and, probably most importantly, "Vitamin and mineral supplements in the primary prevention of cardiovascular disease and cancer: an updated systematic evidence review for the U.S. Preventive Services Task Force" (this latter paper is available in free full text).
As you can probably guess from the editorial's title, the three research papers largely failed to show any benefit from taking multivitamin & mineral supplements. This finding seems particularly strong for cardiovascular disease when taken alongside other recent publications like the BMJ paper "Efficacy of vitamin and antioxidant supplements in prevention of cardiovascular disease: Systematic review and meta-analysis of randomised controlled trials" and JAMA's "Multivitamins in the prevention of cardiovascular disease in men: The physicians' health study II randomized controlled trial". The data is a bit less clear for primary prevention of cancer, so last year's companion study "Multivitamins in the prevention of cancer in men: The physicians' health study II randomized controlled trial" concluded that "daily multivitamin supplementation modestly but significantly reduced the risk of total cancer." As the accompanying commentary - "Multiplicities in the assessment of multiple vitamins: Is it too soon to tell men that vitamins prevent cancer?" - pointed out, these cancer findings were pretty tentative & should probably be treated cautiously. But this caution about possible positive effects of multivitamin & mineral supplements on cancer mortality extends to the negative findings as well. As this month's already mentioned "Annals of Internal Medicine" "systematic evidence review" acknowledges "The results of vitamin supplementation trials have been disappointing at best, despite having a solid mechanistic basis. One explanation for this result could be that the physiologic systems affected by vitamins and other antioxidant supplements are so complex that the effects of supplementing with only 1 or 2 components is generally ineffective or actually does harm. This hypothesis is compatible with our finding that the best support for benefit of supplementation came from 2 multivitamin trials that used physiologic doses of a wider variety of agents. Two good-quality trials of multivitamin supplementation found lower cancer incidence in men. The SU.VI.MAX trial included women and did not find an effect in this subgroup." Interestingly, the SU.VI.MAX study studied the effect of a 5 only ingredient multivitamin on 13,017 French men & women, while the PHS-II trial looked at the effect of a much more extensive 30 ingredient multivitamin on 14,641 US male physicians.
Overall though, the promise of reduced mortality through taking vitamin & mineral supplements has been weakened very considerably through a sequence of recent research papers. Happily the same can largely be said for the fear that such preparations generally increase mortality - see this year's review "Multivitamin-multimineral supplementation and mortality: A meta-analysis of randomized controlled trials". It's intriguing to consider though whether a broad multi-ingredient supplement given to a representative sample of the population might result in reduced cancer deaths. The PHS-II study only involved male US doctors and it produced somewhat hopeful results - and this was in a population which presumably was well nourished, unlike many of the poor and elderly. What's crashingly obvious though is that studies on the benefits of a good, healthy diet far outweigh studies on dietary supplements when it comes to showing a whole raft of health benefits. And worryingly it seems as though taking supplements may sometimes actually interfere with focusing on a healthy diet - see the 2011 paper "Ironic effects of dietary supplementation" with its abstract reading "The use of dietary supplements and the health status of individuals have an asymmetrical relationship: The growing market for dietary supplements appears not to be associated with an improvement in public health. Building on the notion of licensing, or the tendency for positive choices to license subsequent self-indulgent choices, we argue that because dietary supplements are perceived as conferring health advantages, use of such supplements may create an illusory sense of invulnerability that disinhibits unhealthy behaviors. In two experiments, participants who took placebo pills that they believed were dietary supplements exhibited the licensing effect across multiple forms of health-related behavior: They expressed less desire to engage in exercise and more desire to engage in hedonic activities (Experiment 1), expressed greater preference for a buffet over an organic meal (Experiment 1), and walked less to benefit their health (Experiment 2) compared with participants who were told the pills were a placebo. A mediational analysis indicated that perceived invulnerability was an underlying mechanism for these effects." And while commenting on diet & supplements it's also worth noting the greater benefits that appear to accrue from eating "the whole thing" rather than just relying on a component - see "Association between fish consumption, long chain omega 3 fatty acids, and risk of cerebrovascular disease: Systematic review and meta-analysis" and "Fruit consumption and risk of type 2 diabetes: Results from three prospective longitudinal cohort studies."
So for possible physical health benefits (especially reduced mortality rates) from dietary supplements, my reading of the current data is that generally single/few item supplements seem to be largely ineffective (with the possible exception of some individual substances such as vitamin D). Reassuringly the evidence suggests no increased mortality from supplements. Multi-item supplements may be more beneficial, for example in cancer prevention especially in representative general population groups. More research is needed to clarify this issue.
My own professional interest is however more in the psychological & quality of life fields rather than just in the rather blunter (although crucial!) area of simple mortality risk. Here the research findings are currently more supportive of supplementation. So the 2013 paper by Long & Benton - "Effects of vitamin and mineral supplementation on stress, mild psychiatric symptoms, and mood in nonclinical samples: A meta-analysis" - comments "Biochemical processes in the brain affect mood. Minor dietary inadequacies, which are responsible for a small decline in an enzyme’s efficiency, could cumulatively influence mood states. When diet does not provide an optimal intake of micronutrients, supplementation is expected to benefit mood. This meta-analysis evaluated the influence of diet supplementation on mood in nonclinical samples. Methods: Databases were evaluated and studies were included if they considered aspects of stress, mild psychiatric symptoms, or mood in the general population; were randomized and placebo-controlled; evaluated the influence of multivitamin/mineral supplements for at least 28 days. Eight studies that met the inclusion criteria were integrated using meta-analysis. Results: Supplementation reduced the levels of perceived stress (p < .001), mild psychiatric symptoms (p = .001), and anxiety (p < .001), but not depression (p < .089). Fatigue (p < .001) and confusion (p < .003) were also reduced. Conclusions: Micronutrient supplementation has a beneficial effect on perceived stress, mild psychiatric symptoms, and aspects of everyday mood in apparently healthy individuals. Supplements containing high doses of B vitamins may be more effective in improving mood states."
Don't get me wrong ... in the psychological field too, it seems extremely likely that the overall quality of one's diet is typically going to be considerably more important than any supplements that one takes - see, for example, my earlier post "Emerging research on diet suggests it's startlingly important in the prevention of anxiety & depression". However Long & Benton's meta-analysis (see above) highlights potential mental benefits from general multivitamin/mineral supplements, and it's interesting too to note their comment about the potential value of B vitamins to improve mood states - see, for example, the papers "Association between vitamin B12 levels and melancholic depressive symptoms: A Finnish population-based study" and "Longitudinal association of vitamin B-6, folate, and vitamin B-12 with depressive symptoms among older adults over time." There is even reason to consider possible benefits of some B vitamins in psychotic disorders - see last year's publication "Randomized multicenter investigation of folate plus vitamin b12 supplementation in schizophrenia". Folic acid has intriguing potential for psychological disorders - see the 2012 American Journal of Psychiatry editorial "The evolving story of folate in depression and the therapeutic potential of l-methylfolate" - and clearly there are a raft of folate benefits for pregnant women including potential reduction of neural tube defects, autistic disorders, severe language delay and emotional & behavioural problems in offspring. Other dietary supplements too may be important for psychological wellbeing around childbirth - selenium, for example, looks a possible candidate in last year's "Prenatal micronutrient supplementation and postpartum depressive symptoms in a pregnancy cohort".
And for the general population, studies suggest potential value for other substances like s-adenosyl methionine (SAMe), zinc - "Zinc in depression: A meta-analysis" - and fish oil. This latter area is complex with, for example, some research suggesting that the DHA component of fish oil is particularly helpful for anxiety - "Dietary intake of fish and PUFA, and clinical depressive and anxiety disorders in women" and "Omega-3 supplementation lowers inflammation and anxiety in medical students: a randomized controlled trial" - while high EPA levels may be more significant for depression - "Meta-analysis of the effects of eicosapentaenoic acid (EPA) in clinical trials in depression". Fish oils may also have value in boosting antidepressant response - "Omega-3 fatty acid augmentation of citalopram treatment for patients with major depressive disorder" - as too may newer options like creatine - see the intriguing Lyoo et al paper "A randomized, double-blind placebo-controlled trial of oral creatine monohydrate augmentation for enhanced response to a selective serotonin reuptake inhibitor in women with major depressive disorder". So for psychological & general wellbeing benefits from taking dietary supplements, the evidence looks stronger than for straightforward mortality improvement. It's interesting territory.
Well ... are dietary supplements a dangerous waste of money? No I don't think they are. My position on the research at the moment is that supplements certainly don't look particularly dangerous. For reduction in some physical outcomes like cancer risk, a broad-ranging multi-ingredient supplement is of potential benefit. And psychologically there are a series of options that have enough research backing to make them well worth considering. And ... as always ... the next edition of the journals may move all this further forward. As has been remarked often "When the facts change, I change my mind. What do you do, sir?"
Last updated on Sat, 15/02/2014 - 18:44
Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: more on avoidance, social skills & compassion (5th post)Originally added on Mon, 02/12/2013 - 06:24
Last updated on Tue, 10/12/2013 - 07:10
In a recent blog post - "Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: avoidance & safety behaviours (4th post)" - I discussed identification of avoidance & safety behaviours using questionnaires like David Clark's "Behaviours questionnaire" and Ronald Rapee's "Subtle avoidance frequency examination (SAFE)". I mentioned too that David Moscovitch's "Negative self-portrayal scale (NSPS)" could help alert us to aspects of the self that a social anxiety sufferer might be particularly invested in trying to keep "hidden" from anticipated judgement by others. Once one has a sense of what kinds of fears and concerns are particularly troubling a client, then one can ask avoidance & safety behaviour eliciting questions like "Are there things you do or avoid doing to try to keep yourself safe in this area ... or to keep this self-judged aspect of yourself from being observed by others?" As is often the case, going into a recent illustrative episode of distress in considerable detail may well throw up a series of external & internal avoidance and safety seeking practices that could be targets for therapy. Using the "Social anxiety flow chart" may be particularly useful here. Giving clients "detective" homework to look for and note down safety behaviours may well also be useful. Simple measures like the "Work & social adjustment scale (W&SAS)" and the "Pittsburgh enjoyable activities test (PEAT)" can also help.
I find it brings these issues to life for myself when I consider my own long-term patterns. When I was a teenager, I was occasionally bothered by blushing. In many ways I was a pretty confident, extrovert kid but I hated being seen to blush. In classic Moscovitch "Negative self-portrayal" style, this was an aspect of myself that I was ashamed of and didn't want others to observe and (I assumed) judge negatively. When I try to remember how I felt & acted back then and how this pattern has evolved since, it really helps me get a potentially very useful insider view of social anxiety disorder. Paradoxically, although I can still sometimes be "ambushed" by episodes of blushing & sweating, I actually score considerably less socially anxious than typical general population averages on measures like the "Negative self-portrayal scale" and the "Liebowitz social anxiety scale". This fits. I score high on the personality trait of extraversion and actually seek out opportunities to give parties for friends or lecture on subjects that seem important to me. Despite this, when I go looking for safety & avoidance behaviours, fascinatingly I find long-term patterns that I no longer even particularly think of as ways of avoiding blushing or sweating excessively. These include preferences for cooler clothing & cooler rooms. Additionally the private boys' boarding school I was sent to as a teenager was, in many ways, a pretty unpleasant, snobby environment. At a parents' visiting day, I remember boys leaning out of an upstairs school window and quietly ridiculing anyone who didn't arrive in expensive cars & expensive clothes. My dear parents weren't of this "upper class" type and certainly didn't drive a particularly smart car. I remember feeling ashamed ... and now, of course, a bit ashamed that I was ashamed! It surfaces very rarely, but I notice echoes from those experiences in tending to avoid very smart restaurants, "top" hotels or other similar environments. It's a little complex because I actually don't like these places anyway for a series of ethical & political reasons ... but I suspect that such situations could still trigger ex-school teenage feelings of not "making the grade". Well this could lead to some interesting safety behaviour challenges for me ... possibly going to the smartest restaurant in town while insisting on not taking off a very shabby but extremely warm coat!
More broadly, I do think that questionnaires like the "Negative self-portrayal scale (NSPS)" (and the "Subtle avoidance frequency examination (SAFE)") along with associated discussion can ferret out safety & avoidance behaviours that could be maintaining an underlying sense that certain situations aren't "safe". David Clark's model of social anxiety disorder hypothesises that "In-situation safety seeking behaviours and self-focused attention prevent disconfirmation of social phobics' negative beliefs and maintain social phobia" and also that "In-situation safety behaviours and self-focused attention can contaminate social interactions by making social phobics less appealing to others." As an aside here, Clark's treatment of social anxiety doesn't typically focus on teaching social phobics better interaction skills ... it's usually just assumed that as safety behaviours reduce then the unobstructed social skills that emerge need no improvement. This isn't necessarily so ... or it isn't necessarily the case that it's always therapeutically "enough" just to encourage dropping safety behaviours. Sometimes encouraging more externally-focused action may add usefully to an approach that mainly looks at reducing forms of avoidance. As is illustrated in this year's study by Voncken et al - "Socially anxious individuals get a second chance after being disliked at first sight: The role of self-disclosure in the development of likeability in sequential social contact" - people suffering from social anxiety may project "coldness" or "standoffishness" through a whole series of mechanisms from body posture, facial expression, clothing, & lack of eye contact to vocal tone, level of self-disclosure, warmth & empathy. The paper's abstract reads "Socially anxious individuals (SAs) not only fear social rejection, accumulating studies show that SAs are indeed judged as less likeable after social interaction with others. This study investigates if SAs already make a more negative impression on others in the very first seconds of contact. The study further investigates the development of likeability and the role of self-disclosure herein in two sequential social interactions: first after an unstructured waiting room situation and next after a ‘getting acquainted’ conversation. Results showed that high SAs (n = 24) elicited a more negative first impression than low SAs (n = 22). Also, although high SAs improved from the first to the second task, they were rated as less likeable after both interactions. The level of self-disclosure behaviour was the strongest predictor for the development of likeability during the sequential social tasks. The absence of an interaction between group and self-disclosure in predicting the development of likeability suggests that this is true for both groups. Thus, high SAs can improve their negative first impression if they are able to increase their self-disclosure behaviour. However, SAs showed a decreased level of self-disclosure behaviour during both social interactions. Targeting self-disclosure behaviour may improve the negative impression SAs elicit in others."
And it's not just about encouraging people struggling with social anxiety to be more self-disclosing and also (as the full text of this research study makes clearer than the abstract does) show real interest in others' self-disclosure through questioning and caring, empathic responding. I remember a personal example. My brother & sister are both older than me. One evening when they were in their late and I in my mid teens, they had invited a load of their friends round to the house for a (rather inhibited) party. I was "hiding" in the kitchen, half-heartedly helping my mother with the food. My mum was a very loving & supportive woman but, on this occasion, she rather shocked me by speaking to me pretty directly & a little sharply saying something like "These people are your guests too. Some of them are struggling a bit. As their host you should be out there, welcoming them, and helping them feel more at ease here." My memory is of rather creeping out of the kitchen with my tail between my legs feeling very self-conscious. Sure enough there seemed to be some guests who looked pretty shy and a bit isolated. I went up to one or two of them and made encouraging, polite conversation. A few minutes later I was startled to notice that all my personal shyness seemed to have evaporated as I focused on being considerate and welcoming for these other people. Mm ... !
Over five years ago I quoted the Beatles words "The love you take is equal to the love you make" in a blog post - "Recent research: egosystem & ecosystem" - about Jennifer Crocker's inspiring work at Ohio State University. As she wrote last year in her paper "Consequences of self-image and compassionate goals" - "Interpersonal goals are a key mechanism through which people and their social environments influence each other. Two goals - self-image and compassionate goals - the motivational systems that energize these goals, their measurement, and how they relate to other constructs in the literature are described. Results of three longitudinal studies of first-year college students suggest that when people have self-image goals - that is, when they try to manage the impressions others have of them - they create a cascade of unintended negative consequences for both themselves and others. In contrast, when people try to contribute to the well-being of other people, they create a cascade of positive consequences for both themselves and others. Over time, for better or worse, by changing what they experience, people actually change themselves - the beliefs they hold and their goals, self-esteem, and even dispositional tendencies. We describe a variety of processes through which people's interpersonal goals shape their own and others’ experience and raise several remaining issues for this program of research." Fascinating. And researchers are exploring these issues - see, for example, the recent research paper "Relational treatment strategies increase social approach behaviors in patients with generalized social anxiety disorder" or books like "The mindful path through shyness" and "The relationship cure".
The possibility of incorporating some social skills and compassion work into social anxiety treatment is appealing, but one also needs to be cautious. As they say "It's important to keep an open mind, but not so open that one's brains fall out." It is Clark & colleagues' current model of social anxiety treatment that leads the pack just now - see, for example, the clearly superior results obtained by CBT in "Cognitive therapy vs interpersonal psychotherapy in social anxiety disorder: A randomized controlled trial." This means that we should be focusing treatment - in a whole series of ways - on challenging excessive fears of negative judgement by others. But there's still room for improvement in our treatment results. As the "Cognitive therapy competence scale for social phobia (CTCS-SP)" has shown, client "resource activation" by the therapist is likely to improve outcomes. With social phobia, it's important to be task focused rather than self-focused - and it's likely to be more effective if this "task focus" dovetails with the client's values. As James Hollingworth put it so memorably "Courage is not the absence of fear, but rather the judgement that something else is more important than fear."
More to follow ...