Its time for a quick win, before we delve into things any further. Today’s goal is becoming a slightly wiser person.
Our friends in Psychology have been very active over the last few years, explaining how the mind deals with day to day activity. There have been some great popular psychology books, such as Thinking, Fast, and Slow, by Daniel Kahneman, and Nudge, by Thaler and Sunstein, that have become bestsellers. A particularly useful scheme they have developed is the separation of mental activity into two types.
The first type, sometimes called ‘Type 1’ or ‘System 1’ or ‘Automatic’ is running slightly under the surface of consciousness. It deals with routine activity. Type 2 /System 2, or Reflective thinking, is the more conscious part of the mind, where we might actively try and process a task, like a piece of mental arithmetic.
It is usually tiring to use System 2 and we tend to avoid it. We use System 1 by default, and it can handle a surprising amount of day to day functioning, including quite complex tasks like driving a car.
Despite books such as ‘Nudge’ and ‘Thinking, Fast and Slow’ being best sellers, the impact of this new cognitive psychology has been surprisingly slow to affect how psychologists and other therapists work with patients. Though the automatic / reflective model seems to make sense, everyone is struggling with how the amorphous goo of the subconscious gets turned into the crisp waffle of a considered idea.
In particular, the type of therapies that are often called Cognitive Behavioural Therapy (CBT) often seem to depart in some ways from ideals we can infer from the Automatic / Reflective model.
For instance, one very commonly used type of CBT involves keeping a diary of negative thoughts. CBT fully acknowledges the presence of AutomaticThinking, the idea being that people suffering from depression or anxiety have Negative Automatic Thoughts. Just a little below the surface runs a downbeat commentary on the persons value and capability.
At a simple level such negative self statements are easily visible in everyday life. How often do you hear people say ‘I’m no good at maths’, or ‘I cant sing’ or ‘I’m not musical’? Depressed people tend to have a more negative set of thoughts, such as ‘I am useless’ or ‘People generally don’t respect me’ or ‘I can’t control what happens to me’.
An aim of CBT is to identify the negative thoughts by writing them down and considering them. In effect this means bringing them out of System 1 and into System 2. Yet we know that this is a process that generally people find unpleasant, even for ‘neutral’ tasks like trying to solve a puzzle or a maths question. And this is perhaps why patients very often struggle to complete the diary and homework tasks set by their therapist. Very often the patient fails to do the homework, relying on the mercy of the therapist at the start of the next session.
Of course, Freud and his followers would take a different view of such a process. First of all they would expect the truly negative thoughts to be buried deeply in the mind and not easily brought into consciousness. Furthermore they would expect ‘defence mechanisms’ or ‘resistance’ to digging these ideas up, since the mind buried them deeply for good reason.
So what? Thinking can take place at different levels of consciousness. Freudian and Cognitive Psychology would agree on that. And they would also agree that people struggle to bring thoughts from a lower to a higher level. Freud would say this is because the thought is emotionally charged and dangerous to consider – for instance a strong aggressive or sexual impulse. A cognitive psychologist might argue that the conscious System 2 is easily overloaded, much like the RAM on a computer. It is governed by a limited amount of ‘working memory’ which is easily exceeded. If asked to do more than one task at the same time, System 2 runs very slowly or stops altogether to get a beer from the fridge.
It has been clear to many CBT therapists that so called ‘second wave’ CBT, involving identifying negative thoughts and countering them is often unpopular with patients. Much of CBT has moved on to so called ‘mindfulness’ based techniques, which have imported an element of meditation or spirituality.
In embracing ‘mindfulness’ so enthusiastically however there is a danger of CBT exploding in all sorts of different and largely untested directions and falling prey to the usual cranks and charlatans normally confined to the alternative sector.
One of the strengths of CBT was that it attempted to measure its own effectiveness by using charts and scales. One of the weaknesses was that CBT became an incredibly wide church, to the point where the term ‘CBT’ became almost meaningless.
For instance CBT could span so called ‘psychoeducation’ or ‘activity scheduling’ which turned out to be fairly simple bits of lifestyle advice. Or it could mean 20 one hour fairly deep sessions with a Clinical Psychologist. So when someone tells me ‘I have had CBT and it didn’t work’ I am quite skeptical. (Just like I am skeptical when I am told ‘I tried lithium and it didn’t suit me’ or ‘I am allergic to bananas’ or ‘ I am dyslexic’. These statements always call for further enquiry and clarification.
I ask: How many sessions did you have? Who were they with? What did you do in the sessions? (Just talked), Did you have to keep a diary? (no), Did you have homework? (no), Did you have to try and look at your negative thoughts? (don’t think so).
Is there still some value in ‘old school’ CBT? By this I mean the process of identifying and challenging negative thoughts, using diaries and homework? Behaviour Therapists have a slogan: ‘if you do it you ‘ll get better and if you don’t do it you won’t’. That might hold for changing behaviours, such as facing a phobia, but how much can it hold for thinking differently? How much can the mind be forced, against the grain, to reflect?
Incidentally I have seen a very similar blindness in the fields of education and personal development, where ‘Reflection’ became all the rage. Reflection, at least if forced, is effortful and tiring to most people, even if they are not depressed and reflecting only about the price of carrots.
People will find any excuse not to reflect; the mind will default to System 1 whenever it can. The best reflection seems to occur when the mind is bored and free to wander where it likes, for instance, while you pretend to listen to the chief exec going on about drilling down into more challenging granularity, while you wait for the 8.23 at Platform 1b, or during the period between your parachute opening and avoiding the pylons.
Old school CBT has failed to recognize the difficulties people have in moving unexpected items into the bagging area of Reflective thinking. This is perhaps why most patients I meet prefer a counselling type approach, by which they often mean talking to someone until they feel a bit better. What we need is a better waffle iron to turn mental goo into considered thoughts.
Somewhere between the two approaches, CBT and Counseling, probably lies a better way of dealing with negative thinking. For instance I like the use of ‘mind maps’ rather than diaries, sketches or diagrams of what issues are affecting someone. Say it with cake if you want to.
Then there are little shortcuts. Management folk like these, e.g. 4 Ds. When presented with a problem you can Do it, Decide when to do it, Don’t do it, or Delegate it. (There are many variations on this one, as so many words begin with D, like Destroy it, or Dissect it, or Drop Dead Trying to Do it.)
Managers like little acronyms and mnemonics to bring in to solve a problem. Its something to focus the mind, or in other words, make the transition from System 1 to System 2 less noxious. Since we know System 2 is a scarce resource, which we are reluctant to use, we need to create a shortcut or scheme for using it efficiently.
Its sad that the road to wisdom turns out to be paved with acronyms and diagrams.
We used to have exams called ‘viva’ at medical school. They are the most feared type of exam for most people, as the format is one- on- one questioning. The problem is trying to operate the mind under very high anxiety conditions. The trick is to have a system to fall back on, something cast iron, like a grid, heated obviously, and teflon coated. Something to stamp out a well formed answer quickly and possibly even coat it with sugar.
If you are searching for a way of dealing with a problem, its very helpful to find a similar example, as Blue Peter would put it, ‘we’ve already done’. Like a Proverb for instance.
Proverbs have quite a poor reputation among psychiatrists. This is because – in my day anyway – we were taught to ask patients routinely to try and explain what proverbs meant. For instance we would ask them, ‘what does this saying mean: people in glass houses should not throw stones’?
Presumably this was meant to be a test of abstract thinking, and the correct answer I presume would be something like ‘beware of retaliation if you criticize someone’ or ‘ this illustrates the danger of criticizing other people for deficiencies you yourself might have’. The latter version seems to be intruding dangerously far into pot and kettle territory.
However most people gave quite poor answers, either ‘don’t know’ or overly ‘concrete’, e.g. ‘ the stones might break the glass’. That led us to the concluding that most people did not use proverbs day to day and were rather unfamiliar with the concept of metaphor.
Maybe people with mental health problems have a lesser use of metaphor in their thinking? Comments gratefully received on this one.
Another problem with proverbs can be the annoying existence of an equal and opposite proverb, such as ‘too many cooks spoil the broth’ and ‘many hands make light work’. Perhaps proverbs where there is no counter are superior and should be put in a premier league. Proverbs may not be used widely to support reflection, but that does not mean that they are not a useful tool. It just that the noise of modern life has drowned out a lot of wise words.
So, regarding CBT, or Proverbs, Diaries, Mind maps, or any other tools to help us organize our thinking, as SportsTalkExtra might put it: Lets not throw the dirt out with the bathwater.
Enough waffle for today.
*pencil, paper, pot, kettle, cooks, broth, beer, cake, waffle, waffle iron.