Dr. Levy's CBT Blog
Insights on Well-Being, Contentment, and Cognitive Behavioral Therapy
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. 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! This article in the New York Times describes the author's struggles with Obsessive Compulsive Disorder (OCD) and how he managed to overcome it after years of struggles. OCD is a mental health illness that encompasses obsessions, compulsions, or both.
Obsessions are repeated thoughts, urges, or mental images that cause anxiety. Common forms of obsessions include:
Compulsions are behaviors that an individual suffering from OCD feels the urge to do in response to an obsessive thought. The function of the compulsion is to alleviate the tension, anxiety, and nervousness that comes with the obsessive thought. Common forms of compulsions include:
The author of the article above was able to overcome his OCD on his own, using a form of interpersonal exposure that we call in TEAM-CBT "self-disclosure." He slowly started sharing his deepest fears with his loved ones and learned, over time, that he got support and acceptance in return. That reduced his anxiety and allowed him to manage his OCD. When motivation and self-disclosure alone are not enough to kick OCD, exposure therapy (exposing patients to their feared stimuli) combined with a technique called response prevention can help. It is a scientifically proven intervention to help most individuals suffering from OCD to learn how to better manage their compulsions, tolerate the obsessions, and quickly overcome both of those. Anxiety is a natural affective and somatic response to a perception of threat. As I mentioned before, it is our body's natural "alarm system" informing us that a potentially dangerous situation lies ahead. It is an uncomfortable feeling - on purpose! It encourages us to get ready, protect ourselves, or run away. A good amount of anxiety can gets us moving. Too much can paralyze us!
So, if you are dealing with "too much" kind of anxiety, how can therapy help? Evidence-based treatment for anxiety can take several forms. In TEAM-CBT, we categorize anxiety interventions in four groups: 1) Cognitive Treatment for Anxiety: Cognitive treatment of anxiety looks at the precise thoughts that are triggering the distressing emotion. In the case of panic disorder, it is usually a flavor of "I am going to die." For social anxiety disorder, it can be along the lines of "I am going to make a fool of myself." For generalized anxiety disorder, it can be "all sorts of impossible-to-solve problems will come up!" The therapist assists the client in pinpoint those thoughts, analyzing their validity, pinpointing distortions, and generating alternatives. With more balanced, realistic, and helpful thoughts, the anxiety can easily subside. 2) Behavioral Treatment for Anxiety: This is the gold standard for anxiety treatment. Individuals suffering from anxiety have an ingrained habit of avoiding things and situations that trigger their anxiety. Paradoxically, this has the effect of perpetuating excessive anxiety and worrying, rather than alleviate it. The antidote to that is to face one's fears. The most indicated behavioral intervention for anxiety is exposure therapy. In exposure, the client, with support of the therapist, will learn to face their fears head on (through use of images and in real life!). 3) Motivational Enhancement: Just reading the above, it is easy to see that many anxious clients will not be eager to jump into treatment that elicits that more anxiety-provoking thoughts and requires that they finally face their worst fears. In TEAM-CBT, we honor this very valid trepidation. Therapist and client partner up to identify reasons for changing vs. embracing the status quo and analyze whether the client is willing to pay the cost of getting better (not only in terms of treatment costs, but including homework, follow up, and getting in front of scary stuff!). The simple act of articulating and honoring the resistance to change can, most times, melt it away! 4) Hidden Emotion Model: This is an adaptation of the psychodynamic principle that anxiety is often a shield against more powerful - and difficult to embrace - emotions that the client may be struggling with. Another possible treatment for anxiety is to create the safe and warm space where the client can candidly acknowledge the emotions behind the anxiety. By verbalizing and sharing them, they lose their power and the anxiety subsides. It is likely that you'll need to try all of these approaches to find the best way to conquer your anxiety. But conquer it you can! 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! 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! |
AuthorDr. Daniele Levy is a licensed psychologist offering CBT in-person and via Teletherapy in Menlo Park, CA. Her background uniquely combines leading edge training in behavioral sciences with deep expertise coaching and mentoring working professionals in dynamic organizations. Categories
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California License PSY 27448
Copyright © 2014 Daniele V. Levy, PhD Bay Area Cognitive Behavioral Therapy (CBT) Office: 830 Menlo Ave, Suite 200, Menlo Park CA Mailing: 405 El Camino Real #256, Menlo Park CA www.cbttherapy.com |