Alcohol and Binge Drinking

February 6, 2018

Many studies show a high heritability—about 50%—of alcohol dependence problems (Le Strat, Ramoz, Schumann, & Gorwood, 2008; Walters, 2002). The problem with assuming that alcohol dependence has no genetic influence, and is only environmental, is that it may influence a person suffering from this disorder, or that person’s parents, to think that they must have done something wrong in the past, which caused the illness to occur. In many cases, there may really have been problems in earlier life, or with parenting, etc. but in some cases, it can be fairer to understand that the problem arose because of a genetic vulnerability combined with an unhealthy or unfortunate cultural environment.

A big issue with alcohol use that I have seen is cultural: on university campuses, it is very common cultural behaviour for students to have regular social events in which there is a lot of binge drinking. If binge drinking is perceived to be a cultural norm, then I could see that the incidence of alcohol dependence would be made much higher—the combination of genetic risk factors with such a cultural norm could greatly increase the risk of alcohol problems for a vulnerable person. 

A classic psychology study by Pretence and Miller (1993) shows that students overestimate the prevalence of binge drinking in their peer group. Binge drinking becomes more accepted as a cultural norm than its actual prevalence warrants (Perkins, 2002; Pretence & Miller, 1993). A quiet minority of students who don’t binge drink have a smaller influence on the cultural norm. Also, because of the cultural norm, many clients whose main problem is an alcohol use disorder, may not even mention their alcohol habits, and instead complain of anxiety, sleep problems, or depression. They may assume—even on an unconscious level—that because their alcohol binges are considered accepted social behaviour, then they must not be a cause for their other problems. Sometimes a counsellor might be affected by this cultural norm as well, causing the counsellor not to closely examine a client’s alcohol habits, or to dismiss them as normal when the alcohol use might be a core problem.

We could use these facts as psychotherapists by simply educating people, and ourselves: binge drinking is not actually as common as most people think, and it doesn’t have to be considered a social norm!

Many might believe that alcohol use is a harmless and enjoyable social habit, and may not realize its potential to lead to future substance use disorders or other mental illnesses. So part of a preventative approach could be to inform students about the risks of binge drinking—or better still, invite the students to do the research themselves. Perhaps sometimes we are more convinced when we do the research ourselves, rather than being told by someone else. 

It is not necessary to “experiment” with binge drinking or with other activities which seem to be common or popular.  Sometimes we think such experimentation is a developmental norm, but more often it is just an unnecessary detour influenced by peer pressure, which can risk disrupting a healthy pathway. Choose freely, based on your own values, what is right for you! 

References

Le Strat, Y., Ramoz, N., Schumann, G., & Gorwood, P. (2008). Molecular genetics of alcohol dependence and related endophenotypes. Current Genomics, 9(7), 444-451. doi:10.2174/138920208786241252

Perkins, H. W. (2002). Social norms and the prevention of alcohol misuse in collegiate contexts. Journal of Studies on Alcohol, s14, 164-172. doi:10.15288/jsas.2002.s14.164

Prentice, D. A., & Miller, D. T. (1993). Pluralistic ignorance and alcohol use on campus: Some consequences of misperceiving the social norm. Journal of Personality and Social Psychology, 64(2), 243-256. doi:10.1037/0022-3514.64.2.243

Walters, G. D. (2002). The heritability of alcohol abuse and dependence: A meta-analysis of behaviour genetic research. The American Journal of Drug and Alcohol Abuse, 28(3), 557-584. doi:10.1081/ADA-120006742

Expressive Writing Before An Exam

January 29, 2018

Anxiety or anxiety disorders affect us in many ways. For many teenagers, anxiety can contribute to poor academic performance, and lower grades. These academic problems can then make the anxiety worse, and lead to a vicious cycle. 

Some students “choke under pressure”: they perform more poorly than usual due to worry about the test situation and its consequences. What can we do to help students with this type of exam anxiety? 

A simple, clear study of a group of 9th-grade students, shows the benefits of a particular type of expressive writing (Ramirez & Beilock, 2011)! The students spent 10 minutes writing about worries and negative thoughts regarding the testing situation, right before a stressful exam. This simple exercise significantly improved their test scores!

Expressive writing—in this case, expressing worries about an upcoming high-pressure testing situation—eliminates the link between test anxiety and poor test performance by reducing intrusive thoughts and worries. Therefore, the benefits of expressive writing are most apparent among students who have the most test anxiety.

This classroom intervention can be generalized: we can all use expressive writing to reevaluate stressful life situations and reduce rumination. It is clearly an effective way to help adolescents obtain enhanced exam scores, but more importantly it can be an effective way for all of us to manage stress and worry, so that we can have a healthier, happier, and more successful life. 

So, I invite you to regularly spend 10 minutes writing about your negative thoughts, before any exams, performances, or other events that you feel worried about. 

Reference

Ramirez, G., & Beilock, S. L. (2011). Writing about testing worries boosts exam performance in the classroom. Science, 331(6014), 211-213. doi:10.1126/science.1199427

Depression and Neurotransmitters

December 11, 2017

Depression is characterized by feelings of despair, helplessness, hopelessness, loss of appetite, and insomnia (Banich & Compton, 2011). Neurotransmitters, such as glutamate, gamma-aminobutyric acid, serotonin, norepinephrine, and dopamine, affect emotional states; problems with the brain’s neurotransmitter systems can cause depression (Kalia, 2005).

The strongest proposed relationship between a neurotransmitter and a psychological disorder is so well-known that most members of the public are probably aware of it: it is the relationship between serotonin and depression. Depression is associated with reduced serotonin activity—either a reduction in the total amount of serotonin produced, or a reduction in the activity or number of serotonin receptors. But it appears that the association between low serotonin and depression is not as clear as it seems.

One of the best ways to evaluate the effect of serotonin on mood is to do a “tryptophan depletion study” (Moore et al., 2000). In this type of study, participants are given a meal which lacks the amino acid tryptophan. Tryptophan is a component of proteins, and is converted in the brain into serotonin. Immediately after the tryptophan-depleted meal, serotonin levels suddenly decline. 

It is very clear that participants who are taking an antidepressant which boosts serotonin, such as Prozac, and who are just starting to recover from a depressive episode, will suddenly relapse into severe depression if they are given a tryptophan depleted diet. This is one of the biggest pieces of evidence that serotonin is related to depression. 

However, participants who are taking other types of antidepressants which do not affect serotonin are not affected by tryptophan depletion. And participants who are fully recovered from depression do not relapse following tryptophan depletion. 

This shows that serotonin is likely to have some impact on depression, at least in some cases, some of the time, but that there must be numerous other biochemical or structural brain changes which are associated with depression in addition to serotonin. 

Other neurotransmitter abnormalities have been implicated in depression as well, such as those involving glutamate and norepinephrine. Some antidepressants such as venlafaxine and bupropion boost norepinephrine activity; this is indirect evidence of norepinephrine being involved in depression. Some newer treatments for depression, such as the experimental use of ketamine, cause changes in the brain’s glutamate system (Cooper, Bloom, & Roth, 1996). 

We must avoid oversimplifying any statements about neurotransmitters and depression; there could be complex interactions, differences between individuals, and also structural brain changes which overlie any neurotransmitter differences. Most treatments which affect just one neurotransmitter help some people with depression, but not all—this shows that there is not a simple relationship for everyone between any one neurotransmitter and that person’s mood state. 

In conclusion, it is important to acknowledge that the brain is very complex. We do not understand all of the chemistry, nor all of the other factors, which can cause mood problems. For any person who is struggling with depression, it is important to maintain an open mind. It may be necessary to explore a wide variety of strategies to feel better. 

In a therapy environment, this does not mean that we should simply switch to a new therapist if things are not working out. It is often most helpful to stick with one stable therapeutic relationship, and to explore different strategies to work through depression with a therapist whom you trust. 

References

Banich, M., & Compton, R. (2011). Cognitive neuroscience (3rd ed.). Belmont, CA: Wadsworth, Cengage Learning.

Cooper, J. R., Bloom, F. E., & Roth, R. H. (1996). The biochemical basis of neuropharmacology (7th ed.). New York, NY: Oxford University Press.

Kalia, M. (2005). Neurobiological basis of depression: An update. Metabolism Clinical and Experimental, 54(5), 24-27. doi:10.1016/j.metabol.2005.01.009

Moore, P., Landolt, H. P., Seifritz, E., Clark, C., Bhatti, T., Kelsoe, J., Rapaport, M., & Gillin, J. C. (2000). Clinical and physiological consequences of rapid tryptophan depletion. Neuropsychopharmacology, 23(6), 601-622. doi:10.1016/S0893-133X(00)00161-5

The Biopsychosocial Model for Managing Psychological Health

November 7, 2017

I am a firm believer in the biopsychosocial model of managing psychological health, mental illness, and wellbeing. This model can include attention to biological factors, such as nutrition, exercise, physical health, and medication treatments. It includes attention to psychological factors, and addresses them using psychotherapy. And it includes social factors, such as consideration of community, friendships, social supports, and family dynamics. A comprehensive therapy usually should attend to all three of these areas at once. 

Psychotherapy is helpful for mood disorders (Melchert, 2011). It is often equally effective, or even more effective, than other medical treatments. 

About 40-60% of those who receive psychotherapy return to normal functioning. Not only is psychotherapy effective during episodes of depression, but the benefits of it are also durable.

Medications can also be very helpful and important in managing depression, but they often have side effects—because of this, and for various other reasons, many people prefer non-medication treatments. Medications, after they are discontinued, do not help to prevent relapses, while psychotherapy clearly has a preventative effect long after the therapy is over. 

How does psychotherapy work? Sometimes specific techniques, such as CBT exercises or role-playing, or meditation, can help—these may account for about 15% of the total effectiveness of therapy (Lambert, Ogles, & Masters, 1992). The client’s expectancy to improve, or a “placebo effect,” may account for another 15%. Common factors, such as the therapist’s warmth, empathy, and acceptance, account for another 30%. Finally, “extratherapeutic change”—that is, the client’s inner strengths, social support, and other environmental factors— accounts for the remaining 40%. Wampold (2001) shows that the therapist’s skill and competence substantially influences these numbers as well. Differences in therapy style may not matter that much (Driessen et al, 2013): the important thing is how well the style is employed, and how the quality of rapport is between therapist and client. 

Researchers show some of the evidence that many conventional measures of expertise of a psychotherapist, such as years of experience or educational attainment, have little relationship with the clients’ treatment outcome. However, other measures, such as therapeutic alliance (which may have much more to do with the therapist having a gentle, pleasant style, or even a sense of humour!), are much more strongly correlated (Krupnick et al., 1996; Skovholt, Ronnestad, & Jennings, 1997; Skovholt & Jennings, 2016). The possibility could exist that some experienced therapists could be overconfident in their expertise, and possibly resistant to considering different approaches. We all need to work on being open-minded, and having a lifelong attitude of openness to learning and growth, even if we are already experts.  

So, what can we conclude from this? I think it is important that we take psychotherapy very seriously, as a powerful treatment technique. Psychotherapy can be used alongside medications, and can also be helpful on its own. The skill of the therapist is very important: but the manifestations of this skill depend on warmth, compassion, empathy, and wisdom, much more than on educational qualifications or degrees or years of experience.   

Many problems have accumulated over years of time; we do need to expect a good length of time in order to see meaningful changes to happen. It takes time. Recovery, or progress, or improvements take time. We must be patient. While there could be a sense of urgency about a need for change, it is often the case that pressure and urgency actually delays progress. Imagine any type of task that requires careful, diligent, meticulous effort: it is important to do such tasks in a calm, peaceful environment, in order to do them best. Similarly, therapy for psychological issues requires a gentle, calm, peaceful environment. If we try to push for progress too fast, it can slow us down, or even cause harm. 

Patience, hope, and kindness help us work together in the biopsychosocial model of treatment. 

References

Driessen, E., Van, H. L., Don, F. J., Peen, J., Kool, S., Westra, D., Hendriksen, M., Schoevers, R. A., Cuiipers, P., Twisk, J. W., & Dekker, J. J. (2013). The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: A randomized clinical trial. The American Journal of Psychiatry, 170(9), 1041-1050. doi:10.1176/appi.ajp.2013.12070899

Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., & Pilkonis, P. A. (1996). The role of therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 64(3), 532-539. doi:10.1037/0022-006x.64.3.532

Lambert, M. J., Ogles, B. M., & Masters, K. S. (1992). Choosing outcome assessment devices: An organizational and conceptual scheme. Journal of Counseling and Development, 70(4), 527-532. doi:10.1002/j.1556-6676.1992.tb01653.x

Melchert, T. (2011). Foundations of professional psychology: The end of theoretical orientations and the emergence of the biopsychosocial approach. Waltham, MA: Elsevier.

Skovholt, T. M., & Jennings, L. (2016). Master therapists: Exploring expertise in therapy and counseling (10th ed.). New York, NY: Oxford University Press. 

Skovholt, T. M., Ronnestad, M. H., & Jennings, L. (1997). Searching for expertise in counseling, psychotherapy, and professional psychology. Educational Psychology Review, 9(4), 361-369. doi:10.1023/A:1024798723295

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods and findings. Mahwah, NJ: Lawrence Erlbaum.

Emotion Management Techniques and Imaging Studies

November 1, 2017

In an article published by Goldin, McRae, Ramel, and Gross (2008), it is shown in a very simple but convincing experiment using functional MRI, that if a participant deliberately suppresses a reaction to an emotive stimulus (in this case, by maintaining a neutral facial expression while watching disturbing visual scenes), there is greater activity in the amygdala (a centre for emotional memory) despite less activity in higher cortical centres. Conversely, if the participants are instructed to think objectively about the scene as they see it, and allow their facial expressions to change naturally, then there is higher cortical activation but less amygdala activation. In the suppressed condition, the participant may behave in a less upset fashion, but the experience is subjectively rated to be more disturbing. 

This is consistent with ideas in psychology going back over a hundred years, such as with Freud’s ideas about a sort of “hydraulic” system of emotion, in which issues not expressed freely could cause symptoms. In this case, we see the “hydraulics” in a literal sense, where the amygdala becomes a sink for suppressed emotion, leading to symptoms which can be measured instantaneously in a lab. 

For imaging studies of this sort, I think it would be valuable to follow people for several months, as they learn emotional management techniques, and to scan them repeatedly. Cross-sectional studies such as this are very interesting, but it is the longer-term data, which is most important and relevant to psychotherapy. 

If we avoid emotions, or push them away, it often leads to problematic symptoms or greater suffering. We can avoid emotions by distracting ourselves from them. We can avoid emotions by analyzing them too much. And we can avoid emotions by denying that they are even present. But sometimes fully experiencing emotions can seem too difficult or painful. One of the wonderful solutions to this problem is found in the theory of mindfulness meditation: the strategy is to become a gentle, curious observer of your emotions, while allowing the emotions to come and go in their own time. This way, there is no avoidance, there is no pushing away, but there is also a position of calm and safety. 

When we are willing to let go of defense mechanisms, such as rationalization, denial, or projection, and courageously look at ourselves and our lives in the most honest way, we can tackle the core of the problem and as a result feel so much lighter and happier in life.

Reference

Goldin, P. R., McRae, K., Ramel, W., & Gross, J. J. (2008). The neural bases of emotion regulation: Reappraisal and suppression of negative emotion. Biological Psychiatry, 63(6), 577-586. doi:10.1016/j.biopsych.2007.05.031