Dr. Robert Heller

I received a phone inquiry recently from a mother concerning her adult son. Apparently, he has been diagnosed with bi-polar disorder and has had numerous problems with school, drugs and the law as a result. He was put on medication but has stopped taking it and has refused any kind of therapy. The mother had read about SMART Recovery, a free alternative group style self-help program for alcohol and drug treatment based on principles of Rational Emotive Therapy and Cognitive Therapy.

Most recently he had been arrested. His car was stopped for reckless driving and he was found to have an unprescribed bottle of anti-anxiety drugs in his possession. The mother wanted to know if the self-group would be worthwhile. 

Since bi-polar disorder is made up of both severe depression coupled with periods of behaving in impulsive and manic ways, I told her straight out that her son needed to be on his medication and in individual treatment. I felt the voluntary group self help might be useful in addition but not in place of the other treatments.  When she replied again that he wouldn’t cooperate, I told her to allow the natural consequences to unfold and allow him to stay in jail until his court date. The judge will determine whether he will go to jail or insure that he gets treatment in lieu of jail time. 

Beyond the medication, treatment needs to address his underlying core issues and help him develop better awareness of this thought and control over his feelings. I did not explore with mom the details of her “enabling” behaviors but pointed out if she continued to bail him out, more serious problems were likely in store. 

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The American Psychiatric Association came out with its updated practice guidelines for the treatment of major depression. COGNITIVE BEHAVIORAL THERAPY (CBT) was one of only two approaches to therapy that were recommended, especially in the initial phase of depression treatment. In my pocket-sized guidebook, DEPRESSION I give a number of cognitive and behavioral tips and strategies to help identify and manage depression. Non drug approaches are especially important in working with pregnant women due to the danger to the fetus and for children and adolescents where increases in suicidal thinking have been reported.

For serious depression various drugs continue to be recommended along with electro convulsive shock therapy for treatment resistant depressions. I usually recommend a trial of 12-20 sessions of cognitive behavioral therapy before recommending a medication consult unless the individual needs stabilization or is compromised cognitively. 

The new guidelines do not speak to Bi-polar depression.

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COGNITIVE BEHAVIORAL THERAPY (CBT) and RATIONAL EMOTIVE BEHAVIOR THERAPY (REBT) have a long history of helping individuals overcome addictions and substance abuse problems. In fact it was Jack Trimpy, the founder of Rational Recovery, (the first alternative substance abuse program to AA 12-step types programs) who was himself effectively treated personally by the originator of “Rational Emotive Therapy”, Dr. Albert Ellis. Some years later, SMART Recovery was born and now offers hundreds of meetings based on the scientific principles of REBT to those suffering with alcohol and drug problems.

 Having trained with Dr.Ellis at the Institute for Rational Emotive in 1980-81, I eventually published a number  of self-help books in the addictions field based largely on a cognitive-behavioral approach including: “The Pocket Therapists Guide for Problem Drinking”, “Freedom from Alcohol”,”Drug Awareness” and related books like, Freedom from Tobacco” and “Weight Management”. 

While AA and 12 step approaches have helped a great many individuals, not everyone has been helped. Because of its faith based approach, needing to admit powerlessness etc, many individuals have preferred and done quite well with a “cognitive behavioral” approach that emphasizes self-responsibility and self-empowerment through rational thinking and emotional problem solving. I use this approach in my private practice and have taught SMART facilitators how to use it with their group members in the past. 

Recognizing that “one size doesn’t fit all” and that providing a variety of effective options will eventually help the largest number of people get well and stay well, SMART and CBT related approaches have made a significant impact in the addictions and substance abuse fields.

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Post traumatic stress disorder is commonly associated with combat stress and the horrors of war. While many combat veterans do suffer PTSD, victims of physical and sexual abuse, horrific accidents, natural disasters and other life threatening events can often leave individuals suffering with symptoms of anxiety, panic, nightmares, flash backs and a host of other problems. Sometimes, in an effort to deal with these unpleasant symptoms, people rely on drugs and alcohol and end up with additional problems as well. Cognitive behavioral treatments particularly, exposure based methods like flooding, systematic desensitization and EMDR are often effective in alleviating the harmful symptoms of PTSD. Hypnosis can also be an effective treatment either alone or in conjunction with one or more of these approaches. In my experience, especially in the case of automobile accidents, early detection and treatment can often lead to rapid and complete improvement. As a cognitive behavioral psychologist I have come to embrace “EMDR” as my favorite treatment for both acute and chronic cases of PTSD. It is non-directive and well tolerated by most clients and often leads to partial or complete remediation of the presenting problem. The eight phases of evaluation and treatment can occur over a relatively short period of time. Clients who have had long standing problems or who have not been helped by other approaches have found EMDR to literally be a life savior.

Cognitive therapy has long been a well known and effective treatment for sleep problems, especially insomnia, which accounts for over 80% of sleep problems. Sometimes, a behavioral analysis can help determine negative habits which interfere with the natural sleep process. Once identified, relatively simple, straight forward behavioral changes can often correct these problems. 

At times chronic sleep problems can cause problems of fatigue, irritability, short temper,anger and depression. It is also true that depression and anxiety disorders can also cause sleep disorders like insomnia. 

Many times, a hectic lifestyle or a “type A” non stop personality can make it difficult for the brain to slow down as it is supposed to prepare for sleep. Maintaining an active mind at bedtime makes it difficult to fall asleep and/ or stay asleep. 

A careful cognitive behavioral assessment is key to deciding what type and combination of treatment strategies will be most effective in overcoming sleep difficulties. Often times, training in deep muscle relaxation, guided imagery can do the trick. Sometimes, dealing with underlying problems and worries is needed before normal sleep returns.

Bullying is the threat of or actual physical assault of another person. Often it is pushing, shoving, grabbing, poking and sometimes punching and/or kicking. Bullies are often weak, insecure individuals who pick on perceived “weaker” targets for the purpose of hurting, controlling, manipulating gaining financial or other gain. 

Bullying is common is schools, playgrounds and even sporting contests. As a “behavioral psychologist” who specializes in cognitive therapy, I can tell you that there is no single strategy to deal with bullying behavior. However, as Teddy Roosevelt famously said, “walk softly but carry a big stick”. As a wise coach once told me, “never start a fight but be sure you finish it”. It is important for kids to stand up for themselves and not appear scared or cowardly. Often times, just as in the animal kingdom, these behaviors generally embolden an aggressor and increase the likelihood of attack. I believe children should be taught how to fight, that is to be able to physically defend themselves. Self-defense is a skill everyone should know. If attacked, a well placed kick to the groin or elbow to the solarplexes will usually make a bully back off and seek an easier target. 

Self-defense training must be taught along with self-control and self discipline. The movie, “The Karate Kid” is a fine example of such an approach.

Teasing is the verbal assault of 1 or more children on another for the purpose of hurting the other person’s feelings and making them feel bad. Teasing is universal to a greater or lesser extent, especially among younger children. My last name is Heller, and I can remember a young boy who was jealous of my athletic ability who used to call me Heller-Smeller or Hell, to try to get me angry. Almost everyone has a story or memory of being teased by someone as a child. 

Elenor Roosevelt was quoted as saying, “no one can make you feel bad about yourself without your consent”. Cognitive therapists teach “tease tolerance” to young children to help them master in incorporate the long time children’s rhyme, “ sticks and stones can break my bones but words can never harm me”.  As a behavioral psychologist, I was taught that behaviors are reinforced or strengthened or weakened by their consequences. Sometimes, teaching a youngster to ignore the teaser and show that their words have no effect on them, decreases the likelihood of future teasing, whereas reacting with hurt or anger may in fact strengthen and increase teasing behavior in the future.  

Children can be taught to believe that those who tease them don’t feel very good about themselves and tease others to try to feel better. Teasing says more about the person doing the teasing than they do of the person being teased.

Role playing and mental rehearsal are “cognitive-behavioral methods” that parents, teachers and cognitive therapists use to help kids cope effectively when being teased by others.