Tips, Ideas & Recommendations in CBT Treatment

"Impostor syndrome" (also known as impostor phenomenon, fraud syndrome, or impostor experience) is a term initially coined in 1978 by psychologists Clance and Imes to describe describe high achieving individuals who, despite their objective accomplishments, persist in holding a belief that they are unworthy of their success and that others will eventually recognize them as a fraud . The early psychological literature on this topic (see original article) proposed that the phenomenon was prevalent among women. Since then, dozens of studies have shown that it is equally common among men and particularly troublesome among minority groups. 

Professionals with impostor syndrome tend to attribute their strong performance to external factors such as luck, support from others, or extreme effort, rather than internal factors such as talent, competence, and acumen. Setbacks, on the other hand, are viewed as proof of unshakable weaknesses. Indeed, Clance described impostor syndrome as an “internal experience of intellectual phoniness in individuals who are highly successful and unable to internalize their success.” This unwarranted sense of insecurity can often result in distress, depressive feelings, anxiety, loneliness, and frustration. 

A recent review of over 62 studies on the topic of Impostorism showed that the prevalence rates of impostor syndrome is hard to gauge. Depending on the screening questionnaire and cutoff points used, the research showed that 9 to 82%  of the participants would qualify for the label. It appears that age is negatively correlated with impostor Syndrome (i.e., it lowers as one ages).

So...do you have Impostor Syndrome? Honestly, only you can answer that. If you're struggling with feelings of perfectionism, insecurity, and fear in spite of sustained academic and professional success, it is possible that you do hold beliefs that could be described as Impostorism. Many times, as hard as they might be, these feelings motivate you to keep striving and achieving, But at other times, they can stand in the way of you actually enjoying your life and the many contributions that you make to your organization.

There are many ways to "treat" Impostor Syndrome.  if you look in the lay media, you will find many recommendations, ranging from “own your accomplishments” to “comparing notes with peers and mentors about shared impostor feelings” and "remind yourself that you are good at what you do." I am sure those are helpful and can alleviate the suffering momentarily. However, from a CBT perspective, Impostor Syndrome is more likely a reflection of core values, intermediate beliefs and automatic thoughts that pop up in many areas of your life. Getting to those is the key to long-lasting change.

You can fight Impostor Syndrome with the help of a therapist by learning to be aware of your automatic thought patterns, recognize unhelpful thinking styles, and generate alternative appraisals that help you move forward in the direction of your values and your goals.

Everyone has a sleepless night every now and then. What we do - and don't do - during the day, how we eat, what we drink, how much we exercise, our environment, our mental health, and how much stress vs. pleasurable activities we have in a typical day all influence the quality of our sleep. When insomnia hits for a night or two, it is easy to catch up. But when it becomes a chronic issue, it needs to be addressed before your health starts to suffer. One of the most effective and widely recommended treatments for insomnia is cognitive behavioral therapy (CBT).

There are two models of understanding and treating insomnia in CBT. The first approaches insomnia as the main focus of treatment. It starts by addressing behavioral modification, i.e., how long you stay in bed, and then moves on to address your beliefs about sleep. This line of treatment is often referred to as CBT-I, or cognitive-behavioral therapy for insomnia. CBT-I is shown to work better than sleeping pills, with no side effects! There are several self-help apps and websites for CBT-I. Personally, I recommend cbtforinsomnia.com, a five-week online intervention with some clinical oversight.

A second model of looking at insomnia is to view it as a symptom of another, bigger emotional health problem. Often times, insomnia is a consequence of depression or anxiety. For example, patients with excessive anxiety and worry may have trouble falling asleep as their mind starts racing - worrying about tomorrow's to-dos or ruminating about past events - the minute they lay their heads on the pillow. In this case, treating the underlying disorder (anxiety) with an approach such as TEAM-CBT will lead to the insomnia resolving itself short-term.

In either case, a well trained CBT therapist may be able to guide you on your path to a good night of restful sleep!

I recently finished the book "Dedicated" by Pete Davis, a Harvard Law graduate who gained online notoriety thanks to a viral graduation speech in the youtube video below. Mr. Davis has expanded the concepts in his graduation speech into a bestselling book that questions how we can find commitment and purpose in a fluid society that values open choice, freedom, and individualism. It is an interesting and well-written book, focused largely on civic involvement. But as far as CBT is concerned, the sections about choice are particularly relevant.

Mr. Davis makes the case for the impossibility of making "right" choices.  When we call a path the "right" one, we assume that there is only one perfect future and that this one path is the absolute best way to get there.  This is obviously as fallacy, as the future doesn't exist. We make it with our actions today. There are many, many choices that can conceivably lead to great places down the road. Failing to recognize that keeps us stuck in search of that one winning ticket. 

If we can't make the "right" choice, what we can do is make our choices right. The book quotes executive coach Ed Batista as highlighting that if we commit to the choices that we make, those choices have a much greater chance of leading us to a positive outcome. So after we make a choice, any choice, the key lever that we have to make it work well is commitment.

Commitments, Mr. Davis argues, are living things. And like all living things, a commitment needs to be nurtured and nourished. When we work towards making our choices right, we are feeding that commitment and giving it a fair chance to thrive. We don't constantly revisit the choice, we don't move backwards or in circles, we don't get stuck. We commit and we move.

However, like all living things, commitments can sometimes wither and fade, in spite of receiving good care. If or when that happens, it is likely time to let that commitment go, without regrets. And make a new choice. And make that choice right.

In TEAM-CBT, we use the Decision Making form to help guide clients through the analytics of of a hard decision. If needed, we can process the emotions behind that choice through empathy or using a thought log. There are many therapeutic tools and interventions that can help us make careful, deliberate, well-intentioned decisions. But it is ultimately the voluntary act of committing to the direction that you choose that will make those decisions right. 

Often times, thoughts that are largely accurate or even innocuous at the surface level can lead to intense sadness, anxiety or anger. For example, telling myself that “this meat tastes bad” or “I fumbled that word” or “she is not paying attention” can quickly result in a drastic mood change.

In CBT, the downward arrow technique is a way of working through these automatic thoughts to find the irrational beliefs at the base of them that are triggering the strong emotions. These beliefs may not be immediately obvious to us, so we need to ask the same questions repeatedly until we get to the bottom of it: “what does that mean about me?” and “why is it upsetting to me?”.

​When we get to the end of the chain, we will find a deep-seated – and mostly unhelpful – belief that explains where these intense feelings are coming from. That is called a “core belief” or “schema” and commonly builds on themes of incompetence or failure, abandonment or unlovability, and helplessness. Once these schemas are identified, we can challenge them using CBT techniques similar to the ones applied to automatic negative thoughts.
 
Examples of Downward Arrow technique:

1) This meat tastes bad
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I am a terrible cook
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I am a bad mother
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I am a complete failure
 
2) I fumbled that word
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I didn’t do everything perfectly
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
People will be disappointed in me
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I will be alone forever
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I am unlovable

3) She is not paying attention
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
She doesn’t care about me
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
Nothing I do can make things better
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I am helpless

With good CBT techniques, you can identify your schemas and change them over time.

How do we interpret the events that happen in our lives?  Cognitive theory can help us get a better understanding of how that happens. The first concepts that you want to familiarize yourself with are 'assimilation' and 'accommodation.' Charlotte Nickersen wrote a very informative - and well illustrated - article with a simple overview of these concept.s 

When individuals are confronted with new information that is inconsistent with preexisting schemas (i.e., stored bodies of knowledge), one of two processes occurs: assimilation or accommodation. Assimilation is the incorporation or alteration of new information to fit into existing schemas. Accommodation is the modification of existing schemas (and creation of new ones) to incorporate new events and information.  

Although accommodation is necessary to integrate a new experience, individuals sometimes over-accommodate when interpreting input in their environment. Over-accommodation occurs when schema changes are inaccurate and overgeneralized.

Assimilation is interpreting incoming information in light of prior beliefs:

• I believe that leaving my car in a dark parking garage in a high-crime neighborhood is dangerous. I do that one day, and my car is broken into. I can easily understand this event within my existing schemas, so it would be assimilated with no adjustment of beliefs needed.
• Growing up, I was taught to believe that “good things happen to good people and bad things happen to bad people” (also known as a “just world” hypothesis). Then something bad happens to me. To assimilate this event within my schemas, I would then need to tell myself that I must be “bad.”

Accommodation is altering beliefs enough to incorporate the new information:

• Growing up, I was taught to believe that “good things happen to good people and bad things happen to bad people.” Then something bad happens to me. I can accommodate that by finding a new equilibrium in my belief system that states that good and bad things happen to both “good” and “bad” people – the world is not always “fair”.

Over-accommodation is altering one’s beliefs about oneself and the world to the extreme in order to make sense of new events and information. Examples of over-accommodation (also known as over-generalization) in the situations above would be:

• I am not safe anywhere.
• Since I can’t control what happens to me, what I do and don’t do doesn’t matter al all.

One of the goals of CBT is to help you stay away from over-accommodations (and unhelpful assimilations) and find accommodations that are complete, balanced, and useful to you.

Maybe you've heard that a regular mindfulness meditation practice has great benefits for your mental health. Indeed, scientific research shows that mindfulness meditation is beneficial in reducing the symptoms of subclinical depression and anxiety and can substantially reduce stress. But with busy lives and competing priorities, finding time to stop and meditate can be stressful in and off itself. However, it doesn't need to be!

There are several ways to include mindfulness in your daily routine that don't involve sitting down in a lotus pose in a quiet room! One of the simplest approaches to do that is to do a mindful walk daily. You can do that in 10 minutes or less - and admit it, even walking from the bedroom to the kitchen while working from home can add to 10 minutes on any given day!

The folks at the Greater Good Science Center at Berkeley have a good script for a short walking meditation. Here is an overview of the steps:

1- Find a location. Find a quiet and ideally private space that allows you to walk back and forth for 10-15 paces, either indoors or outside.  
2- Start your steps. Walk 10-15 steps along the lane you’ve chosen, and then pause and breathe for as long as you like. When you’re ready, turn and walk back in the opposite direction to the other end of the lane, where you can pause and breathe again. Then, when you’re ready, turn once more and continue with the walk.
3- Pay attention to the components of each step. Walking meditation involves very deliberate thinking about actions that you normally do automatically. Breaking these steps down in your mind may feel awkward. But you should try to notice at least these four basic components of each step:
a) the lifting of one foot;
b) the moving of the foot a bit forward of where you’re standing;
c) the placing of the foot on the floor, heel first;
d) the shifting of the weight of the body onto the forward leg as the back heel lifts, while the toes of that foot remain touching the floor or the ground.
Then the cycle continues, as you:
a) lift your back foot totally off the ground;
b) observe the back foot as it swings forward and lowers;
c) observe the back foot as it makes contact with the ground, heel first;
d) feel the weight shift onto that foot as the body moves forward.
4- Speed. You can walk at any speed, but try to go slow and take small steps. Most important is that it feel natural, not exaggerated or stylized.
5- Hands and arms. You can clasp your hands behind your back or in front of you, or you can just let them hang at your side—whatever feels most comfortable and natural.
6- Focusing your attention. As you walk, try to focus your attention on one or more sensations that you would normally take for granted, such as your breath coming in and out of your body; the movement of your feet and legs, or their contact with the ground or floor; your head balanced on your neck and shoulders; sounds nearby or those caused by the movement of your body; or whatever your eyes take in as they focus on the world in front of you.
7- What to do when your mind wanders. No matter how much you try to fix your attention on any of these sensations, your mind will inevitably wander. That’s OK. When you notice your mind wandering, simply try again to focus on one of those sensations.
8- Integrating walking meditation into your daily life. For many people, slow, formal walking meditation is an acquired taste. But the more you practice, even for short periods of time, the more it is likely to grow on you.  In fact, over time, you can try to bring the same degree of awareness to any everyday activity, experiencing the sense of presence that is available to us at every moment as our lives unfold.

So there you go, now you too have time for a little mindfulness meditation practice every day! Here is a helpful short video to remind you how to do it:

You’ve surely seen a number of mental health apps in your App Store or Google Play. With over 10,000 titles out there, it is nearly impossible to miss them. Indeed, VC investment in behavioral health apps has been growing continuously and the overall market for health and wellness apps is already estimated to be above $1.6B. Should you too be looking for a mental health app?
 
The short answer is it depends. Apps can be quite useful if you’re functioning at a high level, feeling good overall, and just looking for a boost in your mood, relaxation, or a change of pace at the end of the day. If, however, if you’re feeling overly stressed, depressed, anxious, or just not quite yourself, apps alone won’t do the trick. They should be used as an adjunct to psychotherapy with a trained professional.
 
Unfortunately, the behavioral app space is highly unregulated these days. Most apps are for-profit, and have little to no data to support their marketing claims other than their own internal research (or wishful thinking). There are no assurances that HIPAA regulations are observed within the apps. Before you invest your time and money in a new app, it is worth checking out some reputable directories that have already done some of the research for you. I suggest:

• Mind Apps    
• One Mind Psyber Guide
• Department of Veterans Affairs
• UCSF

 
In CBT treatment, I often prescribe mindfulness-based apps such as Calm, Insight Timer, and Headspace as nice little boosters to fight anxiety and increase relaxation, but recognize that their benefits are limited if there are more substantial mental health issues at play. If that’s the case, your best bet is to work with a therapist to learn new skills to change old patterns and behaviors first. And then pick an app – or two or three - to support you post-treatment.

If you’re looking for a therapist and getting confused about what those letters after their names mean, you’re not alone. There are a number of licenses in California that allow a provider to offer psychotherapy services to individuals, couples and families. All of them have to do with the kind and level of courses taken in school. Here is a quick (and non-exhaustive) cheat sheet.
 
First, know that all therapists in California must have a graduate degree, supervised clinical experience, and a State license (that is regularly renewed) in order to serve the public. Individuals with only an undergraduate degree cannot be licensed to provide psychotherapy. Within graduate programs, here are some common credentials that you may find. All of them can offer individual, couple’s, family, or group therapy.
 
Doctoral Level
1) PhD: Clinical Psychologists
These are professionals who have completed usually five to six years of graduate training, a research-based dissertation in clinical psychology, plus one year of post-doctoral training after graduation before getting licensed.
2) PsyD: Clinical Psychologists
Similar to PhDs, PsyD credentials are doctorate degrees in Psychology that follow the same pre- and post-doctoral training, with a lower emphasis in primary research during graduate school.
3) MD: Psychiatrists
These are medical doctors who have completed medical school and a specialized residency of four years in mental health. Psychiatrists are the only mental health providers on this list who can prescribe medications in California. Many of them also offer psychotherapy services, although it is not the main emphasis of most programs currently.
 
Master’s Level
4) MFT (or LMFT): Marriage and Family Therapists
These are therapists who have completed typically two years of graduate level courses, obtaining a Master’s degree in a mental health-related area, followed by two years or more of supervised practice before getting licensed.
5) LCSW: Licensed Clinical Social Workers
These processionals have attended graduate school in Social Work typically for two years, obtaining a Master’s degree in Social Work, followed by two years or more of supervised practice before getting licensed to provide counseling.
6) LPCC: Licensed Professional Clinical Counselor
This is a relatively new credential in California, but is similar to the ones above. These processionals have attended graduate school typically for two years, obtaining a Master’s degree in Counseling, followed by two years or more of supervised practice before getting licensed.
 
You can learn a bit more about the differences across these Master’s levels clinicians here.
 
Unlicensed Professionals/Professionals in Training
As you saw above, all mental health professionals will practice for a number of years under someone else’s supervision in order to accrue experience and develop expertise in psychotherapy. While these individuals are in training, you may meet them under the following credentials:
7) Psychology pre-doctoral intern (pre-doctoral degree, pre-licensure)
8) Psychology post-doctoral fellow or resident (post-doctoral degree, pre-licensure)
9) ASW: Associate Social Worker (post-master's degree, pre-licensure)
10) MFTi: MFT intern (post-master's degree, pre-licensure)
 
Each one of these professions is regulated by a different Board in the State of California; for example, psychology practice is overseen by the California Board of Psychology whereas MFTs practice according to the regulations of the Board of Behavioral Sciences.
 
You may find the best therapist for you at any of these training levels. Ultimately, you should be looking for someone with whom you connect, who helps you identify actionable treatment goals, and who helps you get there by combining the science of evidence-based treatments with the art of human relations.

I recently re-read a classic article by Dr. Albert Ellis, inventor of Rational Emotive Therapy (RET) and one of the early practitioners of cognitive therapy, that presents a valuable take on the causes of emotional suffering. I’ll save you a dozen pages of technical reading and summarize it here. All of emotional suffering in the human race comes from us conflating ‘needs’ and ‘wants.’ Let me explain.
 
Each of us has a series of goals for ourselves and our lives. Ironically, as social beings, they are not that different across people. Generally, we want safety, approval, achievement, efficacy, comfort, and happiness. These are laudable desires: they help us survive, thrive, and procreate. When faced with situations where we fall short of these goals, it is natural to feel disappointed, upset, sad, or frustrated. These appropriate negative feelings help us cope with life and direct our energy towards change. They do not keep us stuck.
 
However, consciously or unconsciously, many of us often escalate these ‘wants’ into ‘needs.’ Beyond wanting safety, we may start expecting that under all conditions and at all times, so we don’t suffer discomfort, pain, or handicaps. We may not only want approval, we may require agreement, admiration, and love by all our significant others. Rather than merely wanting achievement, we may start believing that we need to be notable, celebrated, and special.
 
Naturally, when those rigid ‘needs’ are not met, we suffer. But this suffering is more acute and persistent, because it is violating an existential condition (mind you, one that we invented ourselves). Worse, when we notice that we are stressed, anxious or depressed in response to certain events where our ‘needs’ are unmet, more suffering ensues as we continue to judge the situation as unbearable or ourselves as incorrigible. That keeps us stuck.
 
For example, let’s say that I want achievement. Through a process of illogical thinking, I escalate that into the irrational belief that I must have success and happiness in my life at most times. As a nice bonus, that will guarantee that I am worthwhile. Then an outside event that I cannot control happens that leads to failure and an understandable state of sadness. Because this threatens my ‘need’ (and my worthwhileness), the sadness grows into despair and into depression. And then, when I realize that I am depressed (and unworthy), I feel depressed about my depression. I may even feel depressed for feeling depressed about my depression, as all of those things violate my achievement and happiness ‘needs.’
 
In contrast, if I can stay in a space where I am thinking logically about my desires and longings, I can interpret my setbacks for what they are: unlucky, unforeseeable, or unfavorable steps in a long journey. Ellis suggests that I tell myself something along these lines: “I don't like failing or experiencing losses. I wish that my life was richer and more comfortable. But if I am thwarted, do fail, get rejected, and am uncomfortable at Point A, that is unfortunate but hardly the end of the world. I can still lead a fairly happy life. Now let me go back to the immediate events and try to improve or deal with them so that I can get more of my goals fulfilled at Point B." That’s neat, isn’t it?
 
As you can see, Ellis was laying the groundwork for much of the Cognitive Therapy fundamentals that followed him.  With the help of a good CBT book or an individual therapist, you can learn to identify which of your ‘wants’ has serendipitously morphed into a ‘need’ that may be keeping you stuck right now.

Psychiatric conditions are classified in accordance with a manual published by the American Psychiatric Association call the “Diagnostic and Statistical Manual of Mental Disorders.” This thick tome is in its fifth edition, so it is currently referred to as the DSM-5. There is a section in the DSM dedicated exclusively to Anxiety Disorders, and among them we’ll find Generalized Anxiety Disorder (GAD).
 
In clinical terms, GAD is characterized by excessive anxiety and worry about several domains of life that last for at least six months and is clearly excessive. That is accompanied by physical symptoms such as fatigue, difficulty concentrating, restlessness, muscle pain, difficulty sleeping or irritability. Together, these symptoms make life more difficult to live and enjoy. In everyday terms, GAD is that nagging, annoying, and relentless nasty voice in your head reminding you of everything that can possibly go wrong if you stop trying to control it. It’s exhausting - and no fun.
 
In the US, GAD affects approximately 8 in every 100 adults in their lifetime. Single (unmarried or previously married) females under 60 appear to be diagnosed with GAD more frequently than other demographic groups. That said, GAD affects all ages, genders, and socioeconomic strata, with 25% of all cases onsetting by age 25, 50% by age 39, and 75% by 53 years. Unfortunately, GAD is often recurrent and presenting with other mental health issues such as depression.
 
Interestingly, data from around the world shows us that GAD is more prevalent in high-income, industrialized countries than in developing ones. For example, while the 8% lifetime prevalence applies to the US, Australia and New Zealand, that figure is close to 1% for the population of Nigeria, While we don’t know exactly why that happens, one interesting hypothesis articulated in a large global study is that “individual differences in the propensity to worry may be more evident under conditions of relative wealth and stability, such as those found in high-income countries, than under conditions of relative scarcity and instability, where worry may be expected and widespread.”
 
Despite its high prevalence, GAD is often untreated. Research shows that less than 50% of individuals affected by GAD at the time of the survey had sought mental health treatment in the previous 12 months. That’s too bad, because psychotherapy, and particularly Cognitive Behavioral Therapy (CBT), have been proven effective to treat GAD, with no side effects! If you want to determine if you have GAD and whether CBT may help, talk to a therapist.