Wednesday, October 23, 2013

The Kinderman method

This first appeared on the University of Liverpool website as "Rumination, Replies and Remedies" in a slightly edited format.

We published a paper recently looking at how psychological processes such as rumination and self-blame are key parts of the pathway from negative life events to depression and anxiety.

I am proud to be a clinical psychologist, so I am very excited by two key messages from the paper: that it’s the events that happen to us that determines our mental health (rather than some inherent personal inadequacy or genetic flaw) and that psychological processes actually play a part in the chain of causes – they aren’t just symptoms of ‘mental disorder’.  

But I’ve also received a few questions about the paper, and I think it’s worth replying. First, although I don’t believe it myself, some people have commented that these kinds of psychological models can sometimes be misinterpreted to imply that some people are in some form responsible for their problems – because they are showing ‘errors in their thinking’. And, of course, there was a natural response to the idea that rumination is a problem – OK, so what can be done to help?

I recognise the phenomenon of blaming people for the way they think about themselves, other people, the world and the future. The insulting label of ‘personality disorder’, for example, paradoxically manages both to label people as “ill” and simultaneously blame them for their ways of thinking. As a cognitive psychologist, I recognise both that how we make sense of the world is important, but also that we LEARN to make sense of the world. All the things that have happened to me in my life – my biological inheritance, my parenting, the social circumstances and cultural values around me as I grew up, my education and, vitally, the life events and traumas that I have lived through – have all shaped my views on life. My view of the world, and the ways I tend to think (including my tendency to ruminate) are obviously shaped by the journey I’ve taken through life. So I do think that the ways that people think about the world is important – the evidence points that out very clearly – but there are perfectly understandable reasons why people have learned to look at the world in the ways they do.

But then… what can be done about it?

One of the important implications of our research is that if we were able to “turn off” the rumination and self-blame, we’d be able to “turn down” at least some of the depression and anxiety. That’s really the basis of clinical psychology – while there are very good reasons why we each learn our own particular way of making sense of things, sometimes it might be a good idea to see if we can develop new ways to engage with the world, especially in stressful times.

I’m very reluctant to offer advice. It's a big subject matter... and if I were able to offer wise "self-help" advice that actually worked for everybody, I'd be a millionaire. Nearly every simple piece of advice is going to be glib, obvious, or wrong. So I'm probably not going to be much help.

But, for what it’s worth, here’s “Kinderman's guaranteed system for lifelong contentment, happiness and mental well-being" (that’s a joke, but hopefully some of what follows will be helpful for some people).

1. Get the basics right
Eat well, nutritiously, get the saturated fat content down and the salt content low. Eat five portions of fresh fruit or vegetables a day, drink plenty of water, and make sure you’ve got your vitamins. Aim to get your BMI in the healthy zone. I don’t want to sound prudish, but don't smoke, drink moderately and be generally quite cautious with recreational drugs. Get at least 7 hours sleep a night. Sleep is really important… and there’s even evidence the brain needs sleep to remain physically healthy.
Although straightforward, this is all difficult. There’s lots of advice and specific help that the NHS can offer here, from quit-smoking and other similar services throughout to sleep clinics etc. But the message is the same… get the basic, physical, fundamentals right.

2. Five ways to well-being
There's a great approach called "five ways to well-being". This is an approach that really works, and is being taken up by more and more people. It's recommended by MIND and the NHS and there are plenty of tips to help you take do-able steps towards better mental well-being.
The five ways are:
a) Keep active – do something physical each day. Could be as simple as taking the dog out for a walk (if you’ve got a dog!), but could be going for a swim, or going to the gym every day.
b) Maintain your relationships – for all kinds of reasons, friends are vital. Good friends, supportive friends, friends who won't judge you or try to take advantage of you. And we can all take steps to maintain our friendships. We can make sure we ‘phone, write, text, etc. You might even consider a kind of semi-professional approach - self-help groups for people in a similar position to yourself.
c) Learn – keep your brain active. Engage your brain. Your brain is the most fantastic machine ever created, and it needs to be exercised (I would say this, I’m an academic, but honestly… it’s good for you!).
d) Give – this isn’t political brainwashing, there’s real evidence that getting involved in charitable activity (and it’s probably better to give your time and effort, rather than money) makes people happier.
e) Stay open-minded – this is perhaps the trickiest thing, but it relates directly to rumination… so it deserves its own section.

3. Mindfulness
Rumination tends to be eased if we learn to be mindful; if we are able to be aware of, and understand how our own thoughts work. This does NOT mean taking up any kind of religious practice, but some of the practical techniques of clearing the mind of 'clutter' can me helpful. Again, it's recommended by the NHS as well as being part of the five ways to well being. In part, it means becoming able to decide where we focus our attention, because if we are good at this, it makes it less likely that our thoughts will always be dragged back to our ruminations.

4. “Catch it, check it, change it”
And if we’re aware of what’s happening in our own minds, we can start to change things. My colleague, Sara Tai, has neatly summarized the popular ‘cognitive behavioural therapy’ or CBT as; “Catch it, check it, change it”
a) First ‘catch it”; identify what you are thinking. It’s often really useful to use a change in your emotions as a cue to examine your own thinking. So, when you notice an unhelpful emotion or a shift in mood, or when you notice that you’re doing something know can cause problems (being snappy, for example, or drinking too much), that could act as a cue to examine your own thoughts - “what am I thinking?”. 
b) And then “check it”. Are you (after engaging your fantastic brain in a mindful manner) thinking sensibly, wisely, proportionately, about the situation? Is your mood affecting the way you are thinking?
c) And then “change it”. Generate an alternative point of view; question the evidence for your negative thoughts, and find possible alternatives. 

5. Therapy
Finally… if you’ve tried all that… try therapy.
I wouldn’t recommend it for everybody – many people are probably better off avoiding therapists and using the resources and support available to us in everyday life. But therapy can be a chance to think things through with a professional in a calm, supportive and nonjudgmental atmosphere, and that can be helpful. I personally prefer the straightforward approach of CBT, but there are many different approaches, all of which seem helpful, so it’s a question of finding an approach that suits you.

So... it's hard. If it was easy, I wouldn't have a job, and you'd have found the secret years ago. If you're able to do that… sort out the basics, follow the 'five-ways-to-wellbeing', engage your brain, 'catch it, check it, change it', and find a decent therapist… well, of course, you aren’t absolutely guaranteed lifelong contentment, happiness and mental well-being… because we are all, ultimately, shaped by the things that happen to us. But it can help.

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