Tips, Ideas & Recommendations in CBT Treatment

I'll start with the bad news. If you are standing in one place waiting to find motivation before you take a step in any direction, you won't find it. We all think that we need to have motivation in order to move forward. The reality is, we don't.

I imagine that you brush your teeth every day, right? And how motivated do you feel each night before bedtime to pick up your toothbrush? Do you say to yourself, "I am looking forward to brushing my teeth tonight...and tomorrow night...and the day after?..." Probably not. Yet, you still do it. No motivation. Instead, just willingness to do what needs to be done.

To move forward in any direction, we need willingness. A stance of seeking movement even when you don't feel like it. Doing things because they need to be done, not because you're excited, giddy, or moved to do it. Odds are that once you get moving, motivation will follow. But you simply don't need it in order to get started.

That said, the New York Times just published an interesting article on small tasks that you can do to enhance your motivation. Note that all of them require you to take a step before you are motivated in order to find that motivation. Some ideas include rewards and treats, looking for meaning, relying on social support or competition, and using self-compassion. Check it out here.

Along those lines, in TEAM-CBT we have some really cool tools that can help with the  procrastination that comes with lack of motivation, including Cost-Benefit Analysis, Triple Paradox, Devil's Advocate, and Problem-Solution techniques. You can learn more about them in therapy or independently through Dr. Burn's books.

How do you define competence? Your answer to this seemingly simple question can have a large impact on how you interpret your academic and professional achievements and how satisfied you feel about them. Some views of competence can be particularly detrimental to your emotional well-being, so it’s worth watching out for them.
 
Dr. Valerie Young has described five unhelpful “competence types”: views of what defines aptitude and proficiency that actually hold us back. They are:
 
1-The Perfectionist: in this view, competence is defined by “how” things are done. If they are 100% correct, 100% of the time, then you’re competent. Any small deviation from that equals total defeat. And since it’s impossible to get everything right all of the time, you are often aware of your misses and the distress that accompanies them in the form of self-doubt, worry, or shame.

2-The Natural Genius: here, competence is defined by “when” things are done right. For the Natural Geniuses out there, being competent means getting it right the first time, and doing it naturally, effortlessly, and immediately. This is the view that talent is congenital and you either have it or not. If you don’t get it right on the first time or struggle to master a skill or project, then you’re actually not that competent. That’s a huge disappointment.

3-The Soloist:  This is the “who” view of competence, in which it equals the ability to perform tasks independently at all times. If you need help, you are incompetent, so you might as well take on immense mountains of work to do all by yourself. When you struggle or get stuck, feelings of failure, shame or defeat follow.

4-The Expert: The focus of competence for the Expert is in “what”. If you are competent in this definition, then you know everything there is to know about a task, challenge, or project even before you start. You fear being exposed as ignorant or inexperienced, so you spend inordinate amounts of time getting better educated, more informed, and more deeply acquainted with whatever topic is at hands; often times, at the expense of actually getting stuff done.

5-The Superhuman: For this type, competence is measured in throughput. It parallels how many roles you can juggle, how many projects you can deliver, how often you volunteer, or how much time you spend on turbocharge, doing more than everyone else around you. This overload can lead to many short-term accomplishments, at the cost of long-term stress and burn out.
 
Do you see yourself in any of the types above? If so, how has this definition of competence served you over time? If the answer is not that well, then you can start working on changing it. You can do that with the help of a CBT therapist by first understanding your current belief system, then challenging assumptions that are unhelpful, and finally building new ones that are more realistic, take into account several viewpoints, are more complete, and help you truly succeed in the long-term.

Many mothers - both those staying-at-home with the kids as well as those working out of the house - often struggle with "mom guilt." Those are nagging feelings of guilt, shame, sadness, anger and despair that may be temporary or pretty pervasive. They are difficult and unpleasant. Older parents will tell you to let go, to enjoy the journey as time flies: "they grow up so fast." And yet, day to day those pesky feelings pop up, sometimes on cue and many times unannounced. 

Cognitive theory will tell you that those unwelcome emotions stem from your thoughts, the stories that you tell yourself in your head. It can be a thought that you may not be doing enough, a notion that you are not sacrificing enough, or just a belief that you are not getting things right while everyone else has it together. In terms of concrete thoughts, they might span the range from "I should be playing with the kids right now (as opposed to doing something else I also enjoy!)", "they are watching too much TV", "I shouldn't loose my cool", "I actually want to complete this work assignment but feel I should be spending more time with the kids." 

If you can't change your reality short-term, how can you deal with these thoughts and feelings more effectively? First, if I offer you a magic button that would make all of those beliefs and reactions go away, consider whether you'd press the magic button. It sounds like a good deal, right? Yet, these negative thoughts and feelings tell us a lot of beautiful things about you...They show you care, you want to do what is right by your children, that you are willing to look at your choices critically, and that you have really high standards and goals for yourself. All of those things are good!

Rather than pressing the magic button and make the "mom guilt" disappear altogether, how about figuring out how to modulate it? You can find a way to hold on to some of the healthy aspects of the guilt - after all, wanting to be the best mom you can be is an awesome goal! - but it is not so high that takes away from your chance to enjoy your children and your limited time with them. That is very doable with CBT.

To get to this lower level of distress, you will need to revisit the stories that you are telling yourself in your head. In CBT, we embrace the idea that your thoughts drive your emotions. Change your thoughts, change your emotions. There are a myriad techniques to re-write the automatic thoughts and ideas in your head around your parenting choices. You can learn about them in CBT-driven books such as Dr. David Burns' new Feeling Great book. Or you can work with a CBT therapist who can guide you in understanding and applying these techniques to the specific circumstances in your life. Your family will thank you!

Finding the right therapist is a bit like finding a date. You have to understand what is it that you're looking for and prioritize characteristics such as cost, location, style, and availability. And then do the legwork of searching for them. You can search online at sites such as psychologytoday.com, ask your doctors or friends, call your company's EAP or insurance carrier, or look through neighborhood lists. Many therapists, myself included, will offer a free phone screening consultation in order to get a better understanding of your needs and share more about their background and work style. I highly recommend leveraging this opportunity before making the trek to someone's office.

Your first appointment with a new therapist is usually an intake, which is a longer visit focused on getting a history of your current concerns along with an overview of your social, personal, and professional history. Depending on the complexity of the case, a full intake can take up to 2 or 3 sessions, but it is generally quicker. After that, your therapist will discuss a treatment plan with you, which likely will involve regular (weekly) appointments. Most therapists work with a 50-minute visit, although a 80-minute visit can be very helpful in the beginning to get the treatment going faster. For then on, you and your therapist will work to monitor progress against goals and define new steps. 

So, it all begins with finding the person that is right for YOU! The New York Times has posted an article discussing one reporter's path to find their perfect match:

lwww.nytimes.com/2017/07/17/smarter-living/how-to-find-the-right-therapist.html

Now it's your turn to take your first step to finding yours!

Dr. David Burns is a world renowned psychiatrist and one of the pioneers in the development of Cognitive Behavioral Therapy. In the past decades, Dr. Burns has been focusing on advancing the clinical applications of CBT through a new therapeutic approach that he calls TEAM-CBT. You can read more about the elements of TEAM-CBT in one of my early blog posts or on Dr. Burns website.

TEAM-CBT is a framework for delivering evidence-based interventions in psychotherapy (and evidence-based here means techniques that have been corroborated as effective by rigorous scientific research). It combines Routine Outcome Monitoring, Motivational Enhancement, and CBT Methods with a strong focus on empathy and rapport building to deliver meaningful symptom reduction in fast periods of time. Indeed, in his current clinical work, which revolves mostly around training of therapists and professional workshops, Dr. Burns has, on many occasions, observed that individuals who had been struggling with depression or anxiety for years can experience near complete recovery in just a few hours.

To explain how that can happen, and provide more background and perspective on the TEAM-CBT approach, Dr. Burns was interviewed by one of our colleagues, Lisa Kelley. The transcript of the interview is an excellent primer to learn more about this powerful new modality. Here it is:

As a Level 5 Certified TEAM-CBT trainer and Master Therapist, I would be delighted to help you learn more about these tools to to enhance your life or, if you are a health care provider, to revolutionize your clinical practice!

Dying for a Paycheck is a book by long-time Stanford GSB professor and business guru Jeffrey Pfeffer. In it, Professor Pfeffer argues that the long hours and round-the-clock availability expectations of today's fast-paced workplaces have led to unprecedented levels of high stress, burn out, disengagement, as well as low physical and emotional health.

His findings and viewpoints match well with my own academic research on Work Attitudes and Behaviors Among Professional Women. I posit that it is not simply how much you work, but how you relate to your work that determines its repercussions on your satisfaction and wellbeing. A summary of the study methods, analyses and conclusions is included below.
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If you find yourself struggling with career and balance issues, take a break, do something pleasurable or meaningful to you, and connect with friends and loved ones. If you find yourself in need of greater support, consider seeking a therapist.

Self-care is "in." At work, with friends, and even at home, we often hear about and proclaim the benefits of self-care. Popular self-care ideas range from a hot bath or a manicure to a fancy spa treatment or a vacation in Hawaii. All of those activities are useful and effective ways to take a break or disconnect from everyday life. 

However, if you catch yourself yearning for that break all the time, that may be a sign that the life you've built is not the life you need. If you need to escape from reality at regular intervals, your reality may be misaligned with your values.

In this thought-provoking article, author Brianna Wiest advocates for taking care of yourself every day, not by pampering and withdrawing from your routine but by including healthy and responsible choices in it.

"If you find yourself having to regularly indulge in consumer self-care, it’s because you are disconnected from actual self-care, which has very little to do with “treating yourself” and a whole lot do with parenting yourself and making choices for your long-term wellness."

If you're looking to take better care of yourself, start by taking inventory of the values that matter to you and then assessing how well your life is aligned against them. If you need support going through that analysis, find a good therapist who can serve as a sounding board.

As we start the new year, several of us have 'new year resolutions' that may include goals to eat healthy, exercise more, learn new skills, sleep better, travel, etc. If you picked the exercise category, you will be happy to hear that you are in the right path to improve your mental health along with your physical health. 

A recent study in the American Journal of Psychiatry highlights the benefit of regular exercise in the prevention of depressive disorders. Here is an exerpt from the abstract:

Undertaking regular leisure-time exercise was associated with reduced incidence of future depression...The majority of this protective effect occurred at low levels of exercise and was observed regardless of intensity...12% of future cases of depression could have been prevented if all participants had engaged in at least 1 hour of physical activity each week.  

Easy - and cheap! Now, if you need help overcoming that pesky procrastination habit and changing those behaviors for good, your therapist can give you a much needed push to get finally get started!

Some clients go through years of psychotherapy without attaining meaningful change in their lives. When we look deeper into those situations, it is easy to understand why. Their reality is such that feeling joyful, free, satisfied just doesn't make sense. For example, if I am failing a class, having conflict in my marriage, or fearing riding any and all elevators, there are very valid and straightforward reasons for feeling distraught. In many instances,  the very feeling of sadness, nervousness, or distrust is a reflection of something beautiful and positive about that person's value system. I would not be feeling sad for failing my classes if achievement and responsibility weren't important to me!

When therapists try to change a client's emotional reactions without honoring the positive facets and functions of those reactions in the context of the individual's overall experience, the efforts are doomed to fail. That is why, in TEAM-CBT, we spend a healthy amount of time in Agenda Setting, before moving forward with any attempt for change.

Dr. David Burns explains why some clients may not want to change - and why helping is not always helpful - in this insightful article in the latest issue of Psychotherapy Networker:

https://www.psychotherapynetworker.org/magazine/article/1076/when-helping-doesnt-help
  

Often times, it is hard to find the right therapist, at the right location, available on the right days, and at the right price. If you are having trouble finding someone with whom you can connect, keep looking. Ask your friends and medical providers for recommendation. Search online directories for psychologists near you, such as those from Psychology Today. Look through membership listings at national or regional psychology associations such as the American Psychological Association. Or, if you know you want an evidence-based provider using cutting-edge technology, search for certified TEAM-CBT therapists on the Feeling Good Institute website.   

While you go through your research, you want to pay attention to your mood and well-being. Here are some tips for taking care of yourself while you wait for your psychotherapy to start:

Self-Care “While You Wait”

While you are waiting for individual counseling, you may want to implement these tips to try to alleviate some of your distress. (This is for informational purposes only, and is not intended to treat any conditions. These tips are not meant to be substitutes for mental or physical health counseling.) 

Find activities that sooth and relax you. Relaxation improves the mind and helps the body recover from stress. Even 10 minutes a day would be helpful! Use deep breathing techniques--take a deep breath slowly and all the way down to your stomach, hold your breath for a few seconds, and slowly breath out by emptying your stomach of your breath. Tell yourself to “let go of any tension” as you breath out. Do this for at least 5 or 6 times in each sitting. Practice yoga, listen to some relaxation tapes, etc. 

Do some kind of physical activity, even if you only have 10 minutes. Find a routine that creates a sweat and that fits your style (e.g., walk, swim, tennis). This will help with your stress, anxiety, and depression symptoms. 

Keep a journal. Write down your thoughts and feelings in various situations. Note any patterns or questions you’d like to discuss in therapy. 

Pay attention to your mind and body. Nourish your body with nutritious food. Skipping meals robs you of the energy to cope. Nurture your spirit. Pray, meditate, practice whatever that fits your spirituality. Sleep and rest when you are tired. 

Laugh, especially at yourself and Take time to play. Spend time with those who make you laugh. Watch a comedy or read a funny book. There is evidence that smiling changes your emotions to pleasant and your thoughts to optimism. 

Nurture a positive view of self. Catch yourself when you start to think negatively or are putting yourself down. Actively replace these negative thoughts with a positive view. Create a list of affirmations for yourself (e.g., I grow and change; I am open-minded, etc.). Even if you aren’t convinced, fake it until you make it! 

Make connections. This will take time to develop. Create and maintain contact with a small group of people you can call on for emotional support. Take turns talking and listening. Isolating yourself can make things worse. 
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In addition, here is a brief list of resources where you can obtain guidance and assistance in a crisis situation: 

• National Suicide Prevention Hotline – 1-800-273-8255 
• Starvista crisis hotline (in San Mateo County) – 1-650-579-0350 
• Text hotline - Text “START” to 741741. 
• 911 or your nearest emergency room 

Adapted from SJSU CAPS