Tips, Ideas & Recommendations in CBT Treatment

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, 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.

The benefits of meditation are well documented by scientists and lay people alike and are probably even greater in crisis times such as in the COVID pandemic. Meditation is the practice of mindfulness, i.e., being in the present moment, not worrying about the future or obsessing about the past. If you can get yourself into a regular meditation practice, hooray! You'll accrue many long-term benefits from it.

Yet, many of us can't get into that truly meditative state: legs crossed, thumb and index fingers touching, peace and quiet for a good 20 minutes. But fear not, there are many good alternatives to the traditional take on the mediation practice. For example, there is walking meditation, where we walk mindfully, and meditative movement such as Qi Qong, among many others.

One of my favorite new discoveries is the practice of mindfulness (present moment awareness) by focusing on jelly fish. If, like most of us, you don't own a jelly fish, fear not. The nice folks at the Monterrey Bay Aquarium kindly provide us with a "jelly cam" that captures the real-time movement of the thousands of jelly fish in their tanks. Stop and watch the fish. Just pay attention to the fish, notice the colors, the movement, the subtle differences among them. And if your mind starts wandering, as minds often do, just bring your attention back to the jelly fish...and stay with them for as long as you can!  
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​Anxiety and fear are quite different. To illustrate the difference I normally share a concrete example. Let's say I open my front door and there is a wild tiger right there. I will be terribly afraid. There is a clear and imminent danger I can pinpoint, thus leading to the fear. However, if I step out of my front door, hear a noise or see some movement in the grass, and think that there might be a tiger in there somewhere, odds are I will be feeling quite anxious. I think there might be a threat somewhere, only I cannot see it. I can imagine it.
 
Anxiety is a response to perceived threats that come to us either in the form of thoughts (a story) or images. Because we don’t like the feeling of anxiety, we often avoid thinking about those threats and try to block out the troublesome images. This helps reduce the anxiety in the immediate short-term. But long-term, it is still there. That pesky feeling of foreboding, a tightness in your chest, a lump in your throat.  If it’s in your head and it has a negative emotional valence, it will come back at some point. That makes sense, right? I’s your brain trying to keep you safe by reminding you often of the dangers around you.
 
How can you conquer that anxiety? There are several methods in cognitive behavioral therapy (CBT) for anxiety treatment. The most effective one is exposure therapy. This is an approach where, figuratively,  you get out of the house, go to where the noises and movement in the grass are, look behind the bushes, and find out that there isn’t a tiger there after all – it’s a kitty cat. To get to this liberating a-ha moment, we do need the courage to be willing to face the tiger.
 
For some types of anxiety such as driving or public speaking, we can actually go out there and do exposure exercises in real life relatively simply. But other times, if our fears involve imagined situations and outcomes that we can’t replicate in the real world, then we have to use the tool of ‘imaginal exposure.’ Imaginal exposure, as the name suggests, involves immersing ourselves in this worst-case scenario fear of how things can turn out badly. For example, if I am constantly anxious about having a deadly disease, I can enter a mental world where that actually happens. If I am concerned about my children having a terrible accident, I can make that true in my head.

​Imaginal exposure scripts are short stories that we can write laying out what would happen if our worst fears came true. We add what happens in the immediate aftermath and what happens over the long run. These scripts are usually sad and dark because, well, our anxieties are sad and dark. Once an anxiety-provoking imaginal exposure script is written, exposure therapy involves reading that script over and over and over, several times a day for several days, recording the level of distress that it brings up. The objective is to get you habituated to the facts and feelings in the script.  After reading a story a few hundred times, it gets boring. Boring is the opposite of anxiety-provoking. Boring is good.
 
Of course, you’ll be well served to have a therapist support you through this unpleasant but highly effective and necessary process. Any well-trained CBT therapist should be able to hold your hand and help you feel safe and cared for as you go face your tigers. Happy hunting!

Beyond its devastating cost in human lives, the COVID-19 pandemic has had a profound negative effect on mental health for a large number of people. Besides anxiety and depression from social isolation, insomnia is probably the largest new behavioral health problem that many are navigating during this global health crisis.

Insomnia is a clinical term that applies when an individual has had problems sleeping for at least 3 nights per week for a period of at least 3 months. Further, those problems are not secondary to other mental health conditions such as depression, anxiety, or PTSD. In reality, many people suffer from sleep issues that don't fully qualify for an insomnia diagnosis, but that impair their lives nonetheless. Some struggle with sleep-onset insomnia ("I can't fall asleep when I go to bed") while others have sleep-maintenance insomnia ("I can't stay asleep once I fall asleep").

There are three important factors at play when someone finds themselves facing insomnia. They are commonly referred to as the three "p"s:

1) Predisposing factors: some of us are just genetically wired for lighter, shorter sleep than others.
2) Precipitating factors: Yet, there are stressful events in our lives that can literally cause us to lose sleep. For example, a medical crisis, a job loss, a sick child. Those types of situations can cause sleep disturbances that, in most cases, will resolve themselves after a while.
3) Perpetuating factors: For chronic insomnia to kick in, some new factors come into play. Those are the factors that maintain the disrupted sleep patterns. Most commonly, they will be things like worrying about getting the 'right' amount of sleep, thinking that tomorrow will be a bad day if we don't sleep enough, spending more time in bed wanting to sleep longer, tossing and turning awake in bed, using electronics in bed, turning the bed into office space (working from the bed), etc. Those well-intentioned moves actually perpetuate the cycle of insomnia by making it harder to fall and stay asleep.

Treatments for insomnia abound. The easiest is to pop a pill. That will work - for a couple of nights. And then, it doesn't anymore. Most  prescribed sleep medications are habit-forming, which means that your body will need more of it over time to achieve the same result. While at times the pills may help you fall asleep faster, they will also lead you to wake up more often in the middle of the night. You might not remember it, because you're sedated. But your actual sleep quality will not really improve in a sustainable way.

Instead of taking the shortcut, the best long-term solution to sleep disturbances is a full course of CBT for insomnia (called CBT-I). In this treatment modality, you will learn how to change your inner dialogue to actually invite sleep, rather than keep it away. With the help of your therapist, you will also develop a healthier sleep schedule that will allow you to actually enjoy the time you spend in bed. With more time, you can also learn relaxation techniques and anxiety management interventions that will prevent the insomnia from recurring. And voila, you can finally sleep tight!