Saturday April 6th 2013 - NYBH Staff
The Diagnostic and Statistical Manual of Mental Disorders is about to see its first major revision in 17 years according to articles in the New York Times and Business Week magazine. The American Psychiatric Association is completing work on the 5th edition of the DSM and, based on recent information retrieved from articles and experts, what we knew or how we defined autism up to this point will be altered significantly.
Autism, Asperger Syndrome, and PDD-NOS
Studies at Yale University are looking into the effects this new publication may potentially have. The remaining question is “where to draw the line between unusual and abnormal.” According to the article in the New York Times, at least one million children and adults currently have a diagnosis of autism or related disorder such as Asperger Syndrome or “pervasive developmental disorder, not otherwise specified” (PDD-NOS).
Therefore, with this proposed change, all three diagnoses (autism, Asperger syndrome, and PDD-NOS) will fall under the umbrella diagnosis of autism spectrum disorder (ASD). Hence, Asperger syndrome and PDD-NOS will both be eliminated from the new DSM.
Qualifying for Diagnosis of Autism
The New York Times article explains that, while now a person qualifies for the diagnosis by exhibiting 6 or more of 12 specified behaviors, the proposed new definition will require the person to exhibit 3 deficits in social interaction and communication and at least 2 repetitive behaviors, ultimately making it less likely for someone to receive a diagnosis of autism.
What Impact Will Changes Have and Whom Will They Affect?
The debate is “just how many people would the proposed diagnosis affect?” While on one hand this will definitely have an impact on the “autism surge,” the important question is how this will affect children/families who might lose certain benefits/services due to this disability. Some argue that the change is aimed to target mainly the higher functioning individuals. Others argue that, while “the proposed diagnosis may bring needed clarity, the effect it would have on services is not yet clear.”
Carey, B. (2012, January 19). New definition of autism will exclude many, study suggests. The New York Times, p. A1.
Thursday April 4th 2013 - NYBH Staff
Co-Occurrence of ED and SUD
Eating disorders (ED) and substance use disorders (SUD) are often concurrent conditions and, compared to patients with ED alone, those with both ED and SUD experience “more severe social and psychosocial impairment, greater psychiatric co-morbidity, increased impulsivity, higher number of suicidal attempts and promiscuous acts, higher rates of concurrent borderline personality disorder (BPD), previous sexual abuse, and a poorer prognosis” (Courbasson, Nishikawa, & Yasunori, 2012, p. 435). Linehan’s model of therapy, Dialectical Behavior Therapy (DBT), is the standard treatment for BPD but has also been adapted for and used separately with patients diagnosed with ED and SUD. However, no study exists that examines the efficacy of DBT in the treatment of patients with co-occurring ED and SUD (ED-SUD). Historical logic dictated that exclusive focus on one problem at a time may best serve individuals with competing co-morbidities. However, Courbasson et al. (2012) argue that this approach may leave individuals “vulnerable to replacing one maladaptive behavior with another” (Courbasson et al., 2012, p. 435).
Treating ED-SUD with DBT
The researchers, therefore, opted to assess the capabilities of a DBT program in the treatment of symptoms of co-occurring ED and SUD. DBT focuses on “awareness of problems and impulsive behaviors, emotion regulation strategies and increasing coping skills, which are all consistent with many of the needs of individuals with both ED and SUD” (Courbasson et al., 2012, p. 435). The twenty-five women who participated in the study had been referred by various mental health professionals and primary care physicians for assessment and treatment of concurrent ED and SUD. Participants were administered several tests to establish baseline levels and then were randomly allocated to either treatment via DBT or treatment as usual (TAU). The participants were administered the same testing measures again at three, six, nine, and twelve month intervals, as well as one year post treatment at three month intervals.
Improvements in Attitude and Behavior
Preliminary support for the “usefulness of DBT in the treatment of concurrent ED and SUD” was found by the study (Courbasson et al., 2012, p. 444). At post-treatment, there were notable and sustained improvements in behavioral and attitudinal characteristics associated with disordered eating, including reductions in binge eating episodes. From a cognitive perspective, participants were also able to identify, post-treatment, emotions and sensations connected with hunger and satiation, as well as general feelings of low self-worth. Considerable reductions were also found in the severity and use of substances over a sustained period post treatment. The researchers further note that participants reported greater coping skills and negative emotion regulation (Courbasson et al., 2012). The DBT group retained its members at a higher rate than the TAU group, with 87% remaining in post-treatment (p. 444). Interestingly, in anecdotal feedback given by participants in the DBT group, it was noted that mindfulness skills were most beneficial – in conjunction with a strong therapeutic alliance and validation. The researchers encourage additional research be conducted to support these preliminary findings and bolster treatment knowledge for a demographic that can face significant challenges during the treatment process.
DBT Skills Groups
If you or someone you know could benefit from learning more about DBT Skills Groups, please do not hesitate to contact NYBH.
Courbasson, C., Nishikawa, Y., & Dixon, L. (2012). Outcome of dialectical behavior therapy for concurrent eating and substance use disorders. Clinical Psychology and Psychotherapy, 19(5), 434-449.
Treatment of Borderline Personality Disorder with Dialectical Behavior Therapy on an Inpatient Basis
Friday March 22nd 2013 - NYBH Staff
Nature of Borderline Personality Disorder
Much research exists supporting the use of Dialectical Behavior Therapy (DBT) in the treatment of Borderline Personality Disorder (BPD) on an outpatient basis. However, there remains a gap in research surrounding inpatient treatment programs to address the high populations of people with BPD diagnoses who often find themselves admitted for suicidal or self-injurious behaviors. BPD is characterized by challenged emotion regulation, impulsivity, challenged interpersonal relationships, and an incredibly fragile personal identity. The inner turmoil experienced by this population often results in maladaptive behavioral expressions (self-injury) and/or suicidal ideations. As such, individuals with BPD have extremely high rates of inpatient hospitalization. According to Widiger and Weissman (1991), 72% of patients with BPD will be hospitalized at least once as a result of these behaviors. In comparison to other psychiatric illnesses, BPD patients are four times as likely to be hospitalized as patients with diagnoses of Major Depressive Disorder (Bender, Skodal, & Pagano, 2006).
Other Treatment Options
While inpatient psychiatric stays are important for some patients, they pose several obstacles for others, including high costs, stigma, and withdrawal from personal and professional commitments and responsibilities. Therefore, it is important to determine useful and effective treatment strategies that can be utilized in patients who are chronically admitted for suicidal and injurious behaviors. Though outpatient DBT therapy may be the optimal modality for treatment, high dropout rates coupled with recurrent hospitalizations suggest the need for an alternative approach for patients who struggle to comply with and/or benefit from outpatient treatment schedules.
Tailoring DBT to Inpatient Populations
Bloom, Woodward, Susmaras, & Patalone (2012) indicate that while there is no consensus on the best treatment for BPD in inpatient settings, the success of DBT in outpatient settings suggests it might be effective in reducing symptoms on an inpatient team basis. Standard outpatient DBT treatment consists of a year-long commitment to weekly individual therapy sessions, weekly group skills-based sessions, and ‘as-needed’ telephone consultations with a therapist. To work in an inpatient setting, the sessions would need to be adapted to the space and resources of the facility, and the length of time may vary. Bloom et al. (2012) conducted a literature review on inpatient settings and the use of adaptations of DBT to treat characteristics associated with BPD. The results of their data suggest that the adapted versions of DBT implemented by clinicians in inpatient wards did serve to reduce symptoms related to BPD, including but not limited to self-injurious and suicidal ideations and behavior. However, the researchers are careful to note that their findings are preliminary and require further inquiry to be substantiated. Bloom et al. (2012) encourage clinicians and researchers to conduct follow-up research to better understand effective inpatient treatments for BPD to meet the need that corresponds to such high rates of hospitalization.
Bender, D., Skodal, A., & Pagano, M. (2006). Prospective assessment of treatment use by patients with personality disorders. Psychiatric Services, 57, 254-257.
Bloom, J., Woodward, E., Susmaras, T., & Patalone, D. (2012). Use of dialectical behavior therapy in inpatient treatment of borderline personality disorder: A systematic review. Psychiatric Services, 63(9), 881-888.
Widiger, T., & Weissman, M. (1991). Epidemiology of borderline personality disorder. Hospital and Community Psychiatry, 42, 1025-1021.
Monday March 11th 2013 - NYBH Staff
Adolescents with BPD who Attempt Suicide
Borderline Personality Disorder (BPD) is thought by many clinicians to be one of the most difficult psychiatric illnesses to treat, and is observed in both adult and adolescent populations. Dialectical Behavior Therapy (DBT) was developed by Marsha Linehan as a treatment for patients with BPD, an illness that is often co-morbid with others, such as anxiety, depression, and suicidal and non-suicidal injurious thoughts and behaviors (Linehan et al., 1991). Fleischaker, Bohme, Bruch, Schneider, & Schulz (2011) cite research among adolescent populations that indicates 10-50% of adolescents with a history of attempted suicide will make another attempt in the future. 11% of these will die as a result of suicide. Recurrent suicidal and self-injurious behaviors characterize the experience of many adolescents with BPD traits and diagnoses. The researchers, therefore, seek to better understand treatment effects and address the 77% of adolescent suicide attempters who never seek or prematurely terminate outpatient treatment (Fleischaker et al., 2011).
To tailor treatment to adolescent populations presenting with traits of borderline personality disorder and self-injurious behaviors, Rathus & Miller (2002) adapted Linehan’s model of DBT (DBT-A). The more recent study using DBT-A featured a 16-week behavioral treatment program that included weekly individual therapy, family therapy as necessary, and multifamily skills training for outpatient groups. Goals of therapy were for the participants to understand and implement skills that focus on mindfulness, interpersonal effectiveness, distress tolerance, emotion regulation, family, and ‘walking the middle path’ (Fleischaker, Bohme, Bruch, Schneider, & Schulz, 2011, p. 2).
Types of Support Provided
Fleischaker et al. (2011) used a German-translated DBT-A program on a sample of female adolescents exhibiting non-suicidal self-injurious and suicidal behaviors. Treatment was conducted at an outpatient clinic in Germany over a period of 16-24 weeks, and varied slightly over the holiday schedule. Treatment consisted of the aforementioned protocol and included frequent phone calls between client and therapist to ensure adequate support is provided. Participants were administered several assessments, both self-reported and through diagnostic interviewing, before treatment began, four weeks post treatment, and again one year post treatment.
Preventing Patient Drop Out
The results of Fleischaker’s et al. (2011) study demonstrate, “a stable reduction of suicidal and non-suicidal self-injurious behavior over the course of one year” (p. 8). This reduction is the primary target of DBT. The second goal in the hierarchy of DBT is to keep patients enrolled in therapy for the duration of planned treatment. In the researcher’s study, the drop-out rate was 25% (Fleischaker et al., 2011), as compared to 60% for the control group receiving the usual treatment in Rathus & Miller’s (2002) study.
Benefits of the DPT-A Program
A significant reduction in symptoms also occurred for participants, resulting in only one patient meeting the diagnostic criteria for BPD one year after therapy. Fleischaker et al. (2011) note the adolescents made clear progress in diagnostic categories: “unstable and intense interpersonal relationships, identity disturbance, and impulsivity” (p. 8). Parents also reported consistent improvement in quality of life both during therapy and after one year.
Fleischaker, C., Bohme, R., Sixt, B., Bruck, C., Schneider, C., & Schulz, E. (2011). Dialectical behavioral therapy for adolescents (DBT-A): A clinical trial for patients with suicidal and self-injurious behavior and borderline symptoms with a one year follow up. Child & Adolescent Psychiatry & Mental Health, 5(3), 1-10.
Linehan, M, Armstrong, H., Suarez, A., Allmon, D., & Heard, H. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48: 1060-1064.
Rathus, J., & Miller, A. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide & Life Threatening Behavior, 32(2), 146-157.
Friday March 8th 2013 - NYBH Staff
DBT Preferred or Treating BPD
Borderline Personality Disorder (BPD) is characterized by emotion dysregulation, strained interpersonal relationships, and low self-worth; it often results in maladaptive behaviors in defense of an extremely negative affect. Individuals with BPD commit suicide more frequently than the average population and practice non-suicidal self injurious behaviors (NSSI) 75% of the time (Pompili, Girardi, & Ruberto, 2005; Linehan, 1993). Dialectical Behavior Therapy (DBT) is the preferred treatment for BPD and has proven results in lowering suicidal ideations and non-suicidal self injury in various studies that administered assessment both during treatment and one-year post treatment. Typically a year in length, DBT programs report the greatest treatment effects in the first four months of treatment, with the subsequent eight months dedicated to refining and consolidating new skills (Linehan, Armstrong, & Suarez, 1991).
Assessing Effectiveness of Brief Form of DBT
Treatment is rigorous and intensive with weekly individual therapy, weekly group skill sessions, telephone consultations, and clinician team meetings. Such treatment requires a significant investment on the part of patients, financially and otherwise. Thus, Stanley, Brodsky, Nelson, & Dulit (2007) conducted a pilot study to examine the effects of a shorter intervention, Brief Dialectical Behavior Therapy (DBT-B). The researchers’ study consisted of 20 patients with a diagnosis of BPD, all expressing suicidal ideations at the beginning of outpatient treatment. Participants were assessed for urges to self-injure, self-injury episodes, suicidal ideation, and subjective distress at baseline and after six months of DBT.
Practical for Certain Populations
Results of the study indicated that a six-month intervention of DBT did lead to significant reductions in distress, self-injury, suicidal ideation, and hopelessness (Stanley et al., 2007). The program examined by the researchers was also successful in retaining clients throughout the entire course of treatment. These findings are preliminary and as such require more research; however, the implications look quite promising for tailoring programs to populations who struggle to make the financial and time commitments necessary for standard (year-long) DBT programs.
If someone you know could be helped by DBT, please see more details at:
Linehan, M., Heard, H., & Armstrong, H. (1993). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50, 971-974.
Pompili, M., Girardi, P., & Ruberto, A. (2005). Suicide in borderline personality disorder: A meta-analysis. Norwegian Journal of Psychiatry, 59, 319-324.
Stanley, B., Brodsky, B., Nelson, J., & Dulit, R. (2007). Brief dialectical behavior therapy (DBT-B) for suicidal behavior and non-suicidal self injury. Archives of Suicide Research, 11, 337-341.
Wednesday March 6th 2013 - NYBH Staff
Description and Purpose of DBT
Dialectical Behavior Therapy (DBT) is a multi-modality, evidence-based treatment created by Marsha Linehan (1993) to treat individuals suffering from Borderline Personality Disorder (BPD). This particular personality disorder is characterized by challenges with emotional regulation, resulting in chronically strained interpersonal and familial relationships and a weakened identity with incredibly vulnerable self-esteem. The severely painful emotions experienced by an individual with BPD often translate into maladaptive behaviors, such as repeated suicidal ideations and non-suicidal self-injury. DBT was designed specifically to address the unique and challenging needs specific to this population through an intensive treatment program focused not solely on change in cognition and behaviors, but also simultaneously on acceptance and mindfulness. The seemingly paradoxical relationship between the aforementioned components (change and acceptance) is integral to treatment. Clients are taught the nature of a dialectical perspective, or that “reality is an interrelated system comprised of internal opposing forces that are in a continuous state of change because of the inherent tensions of reality” (Klein & Miller, 2011, p.206). DBT calls for empathetic understanding and communication about patients’ maladaptive behaviors and psychoeducation about the interrelated relationship between a person and his/her environment.
DBT’s Focus on Critical Skills
The DBT treatment model includes a one-year long commitment of weekly individual sessions and group skills-based sessions. In group session, five sets of skills are covered: core mindfulness, interpersonal effectiveness, emotion regulation, distress tolerance, and Walking the Middle Path (an exercise to practice seeing reality in balance of oppositional tensions). Additionally, frequent contact between therapist and client is encouraged to support patients through emotionally intense experiences and allow time to address any therapeutic issues between therapist and client. The clinical treatment team also commits to weekly sessions to troubleshoot clinical issues and suicidality and to ensure professional support for clinicians.
DBT Adapted for Adolescents
Linehan’s original DBT model was subsequently adapted by a team composed of Miller, Rathus, & Linehan (1997) for use among adolescents. To this purpose, a few modifications were made to account for differences in development and context. Treatment length was decreased from a one year commitment to 4 months, and family members were included in weekly skill coaching appointments, phone calls, and full family sessions as needed. DBT, whether in treatment of adults or adolescents, requires “a collaborative, nonjudgmental approach to improve patient motivation to change, enhance patient capabilities, promote generalization of new behaviors, structure the environment, and enhance therapist capability and motivation” (Klein & Miller, 2011, p. 208).
DBT Treatment Stages
There are four stages of treatment in DBT, prioritized by severity of symptom and level of immediate danger to an individual’s safety. In this vein, stage 1 aims to address suicidal behaviors and non-suicidal self injury. Target behaviors are addressed to decrease life-threatening, therapy-interfering, and quality of life interfering behaviors. Stage 2 aims to decrease posttraumatic stress and aid clients in emotionally processing historical events; whereas stage 3 is geared toward increasing self-respect and creating a path forward toward goal achievement. Finally, stage 4 aims to assist clients in developing a sound sense of self, with capacity for joy and peace (Klein & Miller, 2011).
The Promise of DBT with Adolescent Populations
Klein & Miller (2011) cite literature reviews that demonstrate DBT is a promising treatment for adolescents with a range of clinical issues, including suicidal ideation and non-suicidal self-injury associated with BPD, bipolar disorder, eating disorders, and other problematic behavioral externalizations. Rathus et al. (1997) conducted studies that showed significantly fewer psychiatric hospitalizations in adolescents after DBT treatment and higher treatment completion rates than peers undergoing other treatments. Klein & Miller (2011), the researchers who compiled the literature review and described the foundation of DBT in this article, urge researchers to continue to study the effects of DBT on adolescents and to refine the intervention through increased understanding of its results and continued intensive training of clinicians preparing to work with this high-risk population.
DBT Skills Group offered in New York
New York Behavioral Health does have a new DBT Skills Group starting. If learning mindfulness, emotion regulation, interpersonal efectiveness, and distress tolerance could help you or someone you know, please feel free to call us or click the link below for more informaiton about the leader and the group.
Click this link:
Klein, D., & Miller, A. (2011). Dialectical behavior therapy for suicidal adolescents with borderline personality disorder. Child & Adolescent Psychiatric Clinics of North America, 20, 205-216.
Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.
Miller, A., Rathus, J., & Linehan, M. (1997). Dialectical behavior therapy adapted for suicidal adolescents. Journal of Practical Psychiatry & Behavioral Health, 3(2), 67-95.
Tuesday February 5th 2013 - NYBH Staff
Toward Improved Treatment for OCD
What is interpersonal reassurance seeking (IRS), and are people diagnosed with obsessive-compulsive disorder (OCD) more prone to it than their peers (who do not have OCD)? That is, do those with OCD more persistently seek reassurance of their worth and value from others? What is the relationship between OCD and IRS? These and related questions are what prompted a group of researchers recently to examine the relationship, if one exists, between OCD and IRS. The belief on which the investigators’ hypotheses were based (and the purpose of the study they designed) is that a better understanding of this relationship will greatly contribute to the efficacy of current treatments for OCD (Starcevic, V., Berle, D., Brakoulias, V., Sammut, P., Moses, K., Milicevic, D., & Hannan, A., 2012).
Interpersonal Reassurance Seeking
IRS can best be understood as the seeking of information from others, with the intention of soothing one’s insecurity and affirming safety from perceived threats. However, the historical interpretation of IRS by researchers is described by Starcevic et al. (2012) as a subtle compulsion in and of itself, and they note the frequency and persistency of IRS in OCD patients.
Danger in Unchecked IRS
The investigators, however, do not share the historical interpretation of IRS and rather conceptualize it as one of several coping mechanisms (including compulsions) employed by individuals with OCD to manage obsessions. The researchers justify the distinction by focusing on the unique functionality of each. The following is an example. Whereas compulsions aid clients in a direct attempt to ensure safety (e.g., lock checking, hand washing), IRS aids clients in their internal assessment of a perceived threat and reduces discomfort related to obsessions. IRS is thereby an indirect coping mechanism to reduce anxiety. Starcevic and colleagues (2012) emphasize the danger in unchecked IRS (even if it is seen as an indirect coping strategy) to effective treatment of OCD, and they note that excessive IRS allows clients to more easily maintain OCD symptoms—and thus may prevent them from making the progress of which they are capable. The detrimental effects of IRS to treatment are especially apparent in behavioral strategies aimed toward exposure and response prevention (ERP).
The study by Starcevic et al. (2012) was conducted in Australia, and participants were recruited through newspaper advertisements and referrals from primary care doctors and mental health clinicians. Participants were required to have a primary diagnosis of OCD and were administered several self-report scales along with a psychiatric interview. The self-report measures included: Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989), Vancouver Obsessional Compulsive Inventory (VOCI; Thordarson et al., 2004), Symptom Checklist 90-Revised (SCL-90R; Derogatis, 1994) and the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1999).
IRS as Coping Mechanism or Reflection of Severity of Illness
The results of the researchers’ study demonstrated that almost half of the participants participated in interpersonal reassurance seeking as a coping mechanism for obsessions. Further, close to one half of the participants who reported IRS sought reassurance for harm-related obsessions dealing with such things as potential harm or damage caused in the past or in the future. Participants with obsessions surrounding contamination or perfections reported lower levels of IRS. Additionally, the researchers concluded that individuals manifesting symptoms of IRS were more ill than their counterparts, with higher levels of depression and anxiety. They propose that IRS is more often noted in OCD with stronger obsessions, as it is employed as an additional coping mechanism to compulsions. Starcevic et al. (2012) also note, in accordance with previous research, that checking behavior is often, but not always, coupled with IRS.
What It Demonstrates
The contribution to the cannon of literature available about IRS made by this research (Starcevic et al., 2012) is quite useful in the treatment of OCD, because it demonstrates that the presence of IRS may be associated with greater overall severity of OCD. It also suggests that IRS is but one of many coping strategies used to manage obsessions.
Derogatis, L.R. (1994). SCL-90R Administration, Scoring and Procedures Manual, 3rd ed. NCS: Pearson, Minneapolis.
Goodman, W.K., Price, L.H., Rassmussen, S.A., Mazure, C., Fleischmann, R.L., Hill, C.L., Heninger, G.R., & Charney, D.S. (1989). The Yale-Brown Obsessive-Compulsive Scale I: development, use, and reliability. Archives of General Psychiatry, 46, 1006–1011.
Sheehan, D., Janavs, J., Baker, R., Harnett-Sheehan, K., Knapp, E., Sheehan, M., Lecrubier, Y., Weiller, E., Hergueta, T., Amorim, P., Bonora, L.I., & Lepine, J.P. (1999). The Mini-International Neuropsychiatric Interview (M.I.N.I.), English version 5.0.0. DSM-IV. Journal of Clinical Psychiatry, 60(18), 39–62.
Starcevic, V., Berle, D., Brakoulias, V., Sammut, P., Moses, K., Milicevic, D., & Hannan, A. (2012). Interpersonal reassurance seeking in obsessive-compulsive disorder and its relationship with checking compulsions. Psychiatry Research, 1-8.
Thordarson, D.S., Radomsky, A.S., Rachman, S., Shafran, R., Sawchuk, C.N., & Hakistan, A.R. (2004). The Vancouver Obsessional Compulsive Inventory (VOCI). Behaviour Research and Therapy, 42, 1289–1314.
Wednesday January 23rd 2013 - NYBH Staff
Reaching a Flow State of Mind
Last week’s blog entry (posted Jan 17, 2013) focused on two very different states of mind (flow and choking) that are possible during athletic performance and outlined some of their characteristics. Flow was described as “an almost automatic effortless yet highly focused state of consciousness” (Csikszentmihalvi, 1996, p. 110). In light of the spotlight leveled on one of the world’s most noted and most highly-skilled athletes (Lance Armstrong) over the past few weeks, it might prove helpful to delve a little deeper into what could help an athlete attain the flow state and/or prevent the experience of choking during competition (without performance-enhancing substances, of course). In that vein, Moran (2012) poses the following question: Given the characteristics of flow, could an attentional training strategy be used to facilitate the experience of this phenomenon in skilled performers?
In order to provide preliminary answers to this fascinating question, Moran examined the results of a study in which mindfulness training with athletes was used as a possibility to enhance attentional training. Mindfulness, as Jon Kabat-Zinn (2005) describes in his book Coming to Our Senses, can be thought of as “an openhearted, moment to moment, non-judgmental awareness.” Studying the evidence that has been quickly accumulating--which suggests that mindfulness-based interventions are effective in reducing stress and in improving cognitive abilities such as attention, one cannot help but wonder if mindfulness training could increase the likelihood of athletes experiencing that flow state of mind?
Mindfulness Training for Athletes
Mindfulness training focuses on helping athletes concentrate on the here-and-now and stresses the importance of acceptance rather than attempted rejection of intrusive and unwanted thoughts and feelings. Moran (2012) summarizes a study featuring a CD-based mindfulness training protocol that included somatic awareness activities involving breath control and yoga. The study lasted for six weeks, after which the effects of the exercises on the athletes’ flow experiences in training were assessed. The results show that athletes who were part of the experimental group and received the mindfulness training reported an increase in their global flow experience. However, these results are only exploratory and further research with a larger sample and more stringent control is necessary before strongly supported conclusions can be drawn.
After considering the importance of reaching a flow mind state for an athlete, do you think it is something on which all athletes should focus? Can mindfulness training really help elite athletes win their competitions by allowing them to have more of that coveted flow experience? Have you ever used yoga, breathing exercises, or similar strategies to prepare for a performance (whether or not it was a competition)? If so, what was the training strategy, and do you feel it helped you? Would you consider incorporating some kind of mindfulness activity into an upcoming athletic event in which you plan to participate? How about a non-athletic performance (e.g., piano recital, academic presentation, or solo concert)? Do you think mindfulness training might be beneficial in preparing for events such as these?
Kabat-Zinn, J. (2005). Coming to Our Senses: Healing the World through Mindfulness. New York: Hyperion.
Moran, A. (2012). Thinking in action: Some insights from cognitive sport psychology. Thinking Skills and Creativity, 7, 85-92.
Thursday January 17th 2013 - NYBH Staff
Performing Under Pressure
After watching athletes from all over the world perform in the 2012 Summer Olympics, many can’t help but wonder how they do it. Not only do we marvel at how these athletes jump, run, or swim so fast, but also how they stay focused and perform under stressful circumstances--when so much is at stake. What are they thinking minutes before they start the competition? Why do some make it and not others? After all, they have all received the necessary training. Take the amazing Gabby Douglas, for example. The day she competed for the gold medal, she excelled in every step she took. At the next event, however, when competing for the gold medal on the beam, she wasn’t able to match or even come close to her previous performance. Is it luck, or is it related to where her mind was at that particular moment? Recently, an interesting article was published, providing insight into the relationship between thinking and action on exceptional performance states – such as flow and choking – in athletes (Moran, 2012).
The Mind State Called Flow
The author’s insights of these two phenomena commonly seen in athletic performance are eye-opening and thought-provoking. The first phenomenon, flow, is described as that state of mind desired, but not easily attained, by all athletes. It is characterized by four key factors. First, it entails being present or centered, a fusion of thought and action, an attentional state in which there is no difference between thought and action. The sprinter Michael Johnson has explained that, during races, he concentrates on the tangible: on the track, on the blocks, and on what he must do. Second, flow is characterized by the absence of thoughts and/or by low levels of self-reported control of action. A good example of this is Michael Phelps’ report that, when he is in the water, he is not thinking; he blocks everything out. Third, many athletes characterize this experience as transcendental and effortless. Pele, one of Brazil’s greatest in soccer history, has conveyed feelings of euphoria at certain times during matches, of feeling as if he could run forever without tiring and that nothing could hurt him in that moment. Fourth, it is usually accompanied by enhanced skill performance. Overall, this phenomenon seems to represent an athlete’s migration from a conscious to an unconscious mode of control over their actions. Or, like the Zen koan would suggest, “in order to gain procedural control, one has to give up conscious control.”
Why Athletes Sometimes “Choke”
Choking refers to when an athlete’s expected expert level of performance suddenly and abruptly deteriorates in situations of perceived pressure. Athletes that choke often report that the more deliberately they try to excel, the worse their performance becomes. Also, athletes report that when they become too self-conscious and think too much about the mechanisms of their skills, they often choke. Choking has been associated with reinvestment theory (Masters & Maxwell, 2008), which proposes that, when athletes start to feel anxious, they try to make sure they succeed at doing their task by reverting to a mode of conscious control that relies on explicit rules and commonly yields slow and effortful movements. The theory suggests that performance breakdown is the result of “reinvesting” verbal knowledge of task requirement in an effort to consciously control movement.
These are hypotheses about what is going through the minds of these incredible athletes when they excel or fall short. From what has been described, does it appear that training in mindfulness and meditation would benefit athletes who compete at a high level? What about all levels of sports and even performances other than sports? Do you think these hypotheses might hold true in those situations? Have you ever experienced the phenomenon of flow during any type of performance? If you have ever experienced choking during an athletic or any other kind of performance, to what would you attribute it, looking back on the event now? What has helped you or anyone you know to reach the state called flow when performing?
Masters R. & Maxwell J. (2008). The theory of reinvestment. International Journal of Sport and Exercise Psychology. 1, 160–183.
Moran, A. (2012). Thinking in action: Some insights from cognitive sport psychology. Thinking Skills and Creativity, 7, 85-92.
Thursday January 3rd 2013 - NYBH Staff
Exploring OCD and Eating Disorders
Attempting to better understand the relationship between obsessive-compulsive disorder (OCD) and pathological eating disorders (and subsequently the dispositional characteristics common among individuals suffering from either diagnosis), researchers Vartanian & Grisham designed and carried out a study in Australia (2012). Their objective was to examine the relationship between OCD, perfectionism, and compulsive body checking. The researchers note that co-morbidity is often observed between OCD and eating disorders (ED), citing a study by Kaye, Bulik, Thornton, Barbarich, Masters, and Price Foundation Collaborative Group (2004) that demonstrated a 41% prevalence of life-time OCD in a sample of patients with eating disorders (Vartanian & Grisham, 2012).
There is an intuitive relationship between body checking in patients with eating disorders and OCD symptoms. Checking behaviors are often common in patients with a diagnosis of OCD because the checking serves to reduce anxiety temporarily, thus negatively reinforcing and perpetuating the behavior. However, body checking has actually been shown to increase body dissatisfaction (Reas, Whisenhunt, Netemeyer, & Williamson, 2002). Patients, therefore, can become intertwined in a paradoxical endeavor whereby attempts to reduce anxiety contribute to greater and more pathological body dissatisfaction—and, consequently, more severe eating disorders.
Assessing the Dispositions
Vartanian & Grisham (2012) wanted to identify precursors to clinical eating disorders first. The proposed study was to examine dispositional characteristics (specifically perfectionism and negative affect) that are common to both OCD symptoms and body checking. The researchers primarily hypothesized that perfectionism and OCD symptoms would be positively related to body checking, and subsequently that body checking would be associated with greater body dissatisfaction. Participants were recruited from a psychology course at a university in Australia, as well as community volunteers. The subjects were asked to complete several questionnaires, including Obsessive-Compulsive Inventory Revised (OCI-R) (Foa, Huppert, Leiberg, Langner, Kichic, & Hajcak, 2002); Body Checking Questionnaire (BCQ) (Reas, et al., 2002); Multidimensional Perfectionism Inventory (MPI) (Frost, Marten, Lagart, & Rosenblate, 1990); Depression, Anxiety, and Stress Scales (DASS) (Lovibond & Lovibond, 1995); Body Dissatisfaction Subscale of the Eating Disorder Inventory (EDI-BD) (Garner, Olmstead, & Polivy, 1983).
Paths to Greater Body Dissatisfaction
Consistent with the researchers’ hypothesis, both obsessive-compulsive symptoms and perfectionism showed a positive relationship with body checking. Additionally, body-checking behavior was also positively correlated with greater body dissatisfaction, indicating that checking simultaneously reduces (short term) and creates (long term) further anxiety about one’s body image. These findings have important implications for clinicians when identifying patients at risk for clinical eating disorders and in evaluation of patients presenting with symptoms of OCD and body checking.
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