Tips, Ideas & Recommendations in CBT Treatment

Dr. Aaron Beck was one of the pioneers in developing the theory and applications behind Cognitive Therapy for the treatment of clinical depression. In Dr. Beck's views, depression does not stem from a 'chemical imbalance in the brain." Instead, it stems from an imbalance in our way of thinking. When someone is depressed, there are usually three common themes to the content of their thoughts:

• Negative View of Self: "I suck..."
• Negative View of the World: "The world sucks..."
• Negative View of the Future: "And it is never going to get better!"

He called these ways of thinking the "depressive triad." Depressed individuals often feel a loss of interest in things that were previously pleasurable or important to them and function at lower levels compared to their former selves. They can also experience noticeable changes in levels of energy, appetite, sleep, and ability to concentrate, while having thoughts of low self-worth, guilt, and, in more extreme cases, suicide. Here is a full list of symptoms of depression as defined by the American Psychiatric Association.. 

In Cognitive Therapy, client and therapist will partner up to identify common thought patterns for the client that relate to their depression. They can then analyze those patterns together, with openness and curiosity, to see what is 'off' about them. With close collaboration and powerful therapeutic techniques such as those in TEAM-CBT, the "depressive triad" can be annihilated.
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In evidence-based psychotherapy, we most often depart from the premise that the client is unwell. We diagnose disorders based on set lists of symptoms and tailor treatment to particular presenting concerns. The goal is to eradicate the illness and restore the client's functioning to its previous, higher level.

But what if we didn't have to get unwell to begin with? There is a whole field of psychology focused on that: Positive Psychology. Positive psychologists spend their days studying how we can make ourselves feel better and prevent the down periods in life. Live Happy Magazine published a comprehensive summary of widely embraced ideas to help us all lead healthier emotional lives. While none of them are going to jump out as new and surprising, it is a god reminder to heed some age-old advice to live fully and sensibly. Positive Psychology recommends:

• Focus on the present, don't ruminate about the past
• Express gratitude often
• Use breathing and meditation to ward off excessive stress
• Be physically active
• Eat healthy
• Forgive
• Strive for good quality sleep
• Seek opportunities to laugh - a good, deep belly laugh!
• Practice self-compassion
• Balance work and play
• Slow down by doing things mindfully
• Savor small moments

Easy, right? 

My colleague, Dr. Leah Weiss, from the Stanford Graduate School of Business, published this thought-provoking article in the Harvard Business Review:

https://hbr.org/2017/03/stop-mindlessly-going-through-your-work-day

In it, Leah discusses how all of us frequently go through a work day without actually noticing where the time goes or how precisely we are spending our time. That can lead to dissatisfaction at work, driven by inefficiency, disengagement, and potentially health problems. The antidote, as you can imagine, is to add both a sense of purpose and mindful action to our days. It is obviously not easy to do at all times, but it is possible with some deliberate intention. Here are her suggestions: 

• Act on purpose - focus on how your personal goals connect with the goals of the organization in which you are inserted;
  
• Map a plan - understand which tasks, and in what order, will get you closer to your finish line;
  
• Avoid distractions - don't fall into the trap of the "mindless accept syndrome." Name your distractions, remember your goals, and gauge where each request for your time falls.

When presented with important choices in their lives, clients often ask me "Is this the right choice?...Is this OK?..." The clear answer for that is "It depends!!!". What is right for your life obviously hinges on your personal values, dreams, and aspirations. While no one can give you answers on what to aim for, we can suggest parameters to consider when weighing your choices and making important (or even everyday...) decisions.

A "great life," however it looks like for you, should maximize your ratings and satisfaction across the dimensions below:

• Purpose: Finding meaning and enjoyment on what you do every day
• Social: Having important relationships and love in your life
• Financial: Managing your economic life to reduce stress and increase security
• Community: Being engaged and involved with the areas where you live and work
• Physical: Having good health and energy to get things done daily

​In short, choices that increase your purpose in life; social, financial, and physical well-being; or community belonging are likely "right" and definitely "OK." Sometimes we move along these axes in unison, other times we need to make trade-offs among them. But those are the key ingredients in a great life for everyone of us. How you mix them up to create your own unique recipe, it's up to you. 

The picture below, from the fantastic website Psychology Tools, shows what happens in our body when our brains perceive a possible threat:

Just like our ancestors used to do when living in caves tens of thousands of years ago, whenever we think there is a threat coming our way (e.g. "there comes a sabre-toothed tiger!"), we prepare to fight it or quickly run away from it. Our bodies, being the well-oiled machines that they are, immediately go into survival mode and get ready to deal with the threat by activating an internal "alarm system". In simple terms, this system is called the fight or flight response.

Once our brain identifies a possible danger, stress hormones such as cortisol and adrenaline are released by the adrenal glands. I response, muscles tense up, particularly the larger ones, to prepare for a possible battle or long run. The heart starts beating faster, pumping more blood around the body, which elevates its temperature.  The rise in temperature triggers sweating to cool the body down. As blood vessels in the skin contract to force blood towards those all-important major muscle groups, areas such as palms and feet become both cold and sweaty.

As breathing becomes faster and shallower to take in more oxygen, we may feel a bit dizzy or lightheaded if the excess oxygen is not being used right away. Thoughts also start racing to keep up with the changes in the environment. As digestive and elimination systems are not vital, they receive less blood and we might feel nausea, butterflies in the stomach, along with urges to use the bathroom.

All of these reactions get us ready to deal with that tiger. And in those situations, they are indeed indispensable, life saving. Indeed, if we go back many millennia, we are all decedents of the pre-historic men and women with the best "alarm systems - those that did not get eaten by the tigers!

However, nowadays, there aren't many saber-toothed tigers walking around. The perceived threats come from our financial troubles, fear of rejection, loneliness, arguments with a spouse, concerns about a job, memories of a traumatic event, self-doubt, regrets, and many, many other ideas that we ourselves label as dangerous. In those instances, the fight 0r flight response is unnecessary. Worse, it can interfere with just being able to live a fulfilling life.

If that is happening to you, talk to a therapist. You can learn to fine tune your fight or flight response so that it works for you, not against you!

If you are dealing with many stressors in your life and feeling overwhelmed from time to time, you may have come across a suggestion to start a 'mindfulness' practice. First of all, what is mindfulness? It is a concept describing a state where we pay full attention to the present moment. We don't obsess about the past, we don't worry about the future, we are just focused on the present, in the here and now.  Even further, we try to clear our mind of thoughts and activity for stretches of time when we can just 'be' rather than 'do.' We observe our internal experiences without judging them or trying to change them. Many people achieve this state of mindfulness through meditation.

As I've mentioned before, there are many confirmed benefits of regular meditation or mindfulness practice. If you want to get started yourself, here are a few pointers:

• Find a quiet space where you won’t be distracted.
• Sit down however you want, as long as it’s comfortable (but don’t get too comfortable and fall asleep!). 
• Set a time goal on your watch or phone so you don't have to worry about checking the time as you go. You can begin with three or five minutes at first and then gradually go longer if you wish. If don't, that's ok too: any amount of time spent meditating will still have a positive impact.
• Close your eyes and direct your full attention to your breath. Notice sensations tied to it and the air goes in and out of your body.
• If your mind wanders, just come back to your breath. Observe your thoughts, feelings, and any sensations without doing anything about it. Observe your thoughts like leaves floating down a stream. No matter where your mind goes, just notice it and come back to your breath and the present moment. 

The more you practice the easier it will get. Just notice your sensations, come back to your breath, and enjoy!  And if you don't want to do all of this on your own, I recommend checking out the Google Play or App Store for popular apps such as Insight Timer, Breathe, and Headspace. 

When I worked in Marketing early in my career, one of my PR colleagues used to say "if 4 out of 5 dentists recommend Crest toothpaste, the only one that has something interesting to say is #5!". I often think about that as I am drawn to better understand dissenting views on any given topic. Interpersonal relations and couple's therapy is a complex topic where there are some majority opinions and a few interesting ones that go against the grain. Dr. David Burns, one of the pioneers of cognitive behavioral therapy and mastermind of the T.E.A.M. approach to CBT - and my personal mentor and hero! - has some radically different ideas of why we all have some troubled relationships in our life.  

In one of his podcasts, Dr. Burns discusses the prevailing views of why people in close relationships may not get along. Those include theories addressing i) lack of skills, ii) barriers, and iii) self-esteem. In the first one, authors postulate that we all want loving relationships, we just need to learn better communication skills such as assertiveness or non-violent communication to get there. The barriers theory posits that there are just innate barriers to intimacy such as childhood trauma or different cognitive processing approaches between men and women. Finally, the self-esteem angle demands that you love yourself first, before you can love someone else.

All of these approaches make sense and have some validity behind them. But they don't tell the full story. The missing link is "motivation."  Sometimes, we have the skills and the self-esteem and there are no great barriers, but we still don't want to get close to the other person...until they change first! The reality is, if they were looking to change, they probably would already have. If we are the ones looking for a new dynamic in an old relationship, it is up to us to take the first step to change the existing patterns of interaction. We can do that by providing empathy, using assertiveness, and demonstrating respect regardless of how the other person is behaving.

How to do that? Dr. Burns has a great book on the topic called "Felling Good Together." I recommend starting by reading the book. And if you still think you can benefit from professional help, find a therapist who can help you increase your motivation and put all of those skills and self-esteem to good use!

In TEAM-CBT, when patients are looking to improve their interpersonal relationships, we first spend some time analyzing the nature of the conflict that they're facing before jumping in to solve it. Even though there are as many different flavors of interpersonal conflict as there are people in the planet, if we look closer, we can find a few broad patterns of common relationship concerns.

If you are having problems with someone close to you (romantic partner, family member, boss, co-worker, etc), odds are that the issue will fall into one of these three categories:

1- Character Issues: they don't see themselves!
These are problems where you firmly believe that the person with whom you are in conflict is just flawed. They may be self-centered, dumb, histrionic, unfair, needy, controlling, unreasonable...and a lot more! For example:

"He is mean and stubborn!"

2- Appreciation Issues: they don't see me!
These are problems where you feel under-appreciated in the relationship. You firmly believe that the person with whom you are in conflict doesn't see you for everything that you do. They may frequently criticize, blame,  disrespect, ignore, or belittle you. All said, they either don't value you, don't value your needs, or don't value the relationship. For example:

"They never recognize how much I do for them!"

3- Give-and-take issues: they don't see us!
These are problems where you find a fundamental imbalance in the relationship in terms of the give-and-take. It can be that the other party just doesn't listen, no matter how hard you try to communicate with them. Or they just don't share, regardless of your valiant efforts to engage them. Or it can be that they don't reciprocate when you do something nice for the relationship. For example:

"They ignore my advice!"  

There are naturally many other ways of thinking about interpersonal issues. This is just one of them. But the goal here is to recognize that the first step in solving a problem is defining it! If you are suffering because the relationships in your life are not intimate, respectful, and fulfilling, cognitive-behavioral therapy can help. 

​Viktor Frankl, the renowned Austrian psychiatrist and Holocaust survivor pictured above, once said, "Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom."  This profound statement encapsulates the essence of human resilience and the potential for personal transformation. It also underscores the core principles of Cognitive Behavioral Therapy (CBT) in creating that crucial space between stimulus and response.

In everyday life, we often react impulsively to various stimuli—whether they are external events or internal thoughts and emotions. However, Frankl's wisdom suggests that we have the ability to pause and consider our responses. This pause is where we can find empowerment and personal growth. It's in this space that CBT plays a crucial role.

CBT as a therapeutic approach helps individuals recognize and challenge their automatic thought patterns and emotional reactions. By identifying and modifying these cognitive and emotional responses, CBT assists in creating the vital gap between stimulus and response. Through guided introspection and cognitive restructuring, individuals can develop more adaptive and rational responses to challenging situations.

The practice of CBT equips individuals with the skills to choose healthier responses, fostering emotional resilience and personal growth. It allows us to shift from being reactive to proactive, ultimately leading to a more balanced and fulfilled life. Viktor Frankl's insight remains a powerful reminder that we possess the capacity to shape our responses to life's challenges, and CBT provides a practical toolkit to help us do just that.

Anger is a natural and often healthy emotion, but when it spirals out of control, it can lead to negative consequences in both our personal and professional lives. The good news is that there are various psychological interventions to manage anger, and one surprisingly effective tool is...humor.

Humor, an universal language that brings people together, can help us gain perspective, reduce tension, and improve overall well-being. Here's how incorporating humor into psychological interventions can make a positive difference in managing anger.

1. Stress Reduction: Laughter triggers the release of endorphins, the body's natural feel-good chemicals, which can alleviate stress and anxiety. In moments of anger, incorporating humor can help you shift your focus from the source of your anger to something more positive, allowing you to better manage the situation.

2. Perspective Shift: Humor helps us see situations from different angles. When you can find the humor in a challenging situation, it can be easier to reframe your perspective and view the issue as less threatening. This can lead to a more rational and less impulsive response.

3. Communication Improvement: Anger often leads to ineffective communication, making it difficult to resolve conflicts. Humor can act as an icebreaker, easing tension and facilitating more open and constructive conversations. It can also make you more approachable, which encourages others to communicate with you.

4. Emotional Regulation: Humor can be a valuable tool for emotional regulation. When you're able to find humor in frustrating or infuriating situations, you can regain emotional control and make more level-headed decisions.

5. Self-Reflection: By using humor to reflect on your own actions and reactions, you can identify patterns in your behavior and take steps to address them. This self-awareness is a crucial component of anger management.

It's important to note that the goal is not to make light of serious issues or dismiss valid concerns. Instead, the aim is to incorporate humor as a coping mechanism to diffuse anger and reduce its negative impact on your mental and physical health.  Humor can break the cycle of distress and promote healthier responses to challenging situations.

Yet, humor can only get us so far in neutralizing the anger. The better alternative, if it is available, would be to avoid moments of excessive anger.  That can be done if we understand what is triggering the anger in the first place. That is surprisingly easy to do with good CBT strategies. We look at the situation, the thoughts, emotions, and actions in that particular moment. We figure out what is valid and what can be changed in our thoughts and behaviors. We use targeted techniques and methods to impart that change. We feel different.