Tips, Ideas & Recommendations in CBT Treatment

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.

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? 

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!

TEAM-CBT is a framework for providing evidence based psychotherapy. It was developed by Dr. David Burns, MD, Adjunct Emeritus Professor at Stanford School of Medicine. 

What is Evidence-Based Practice in Psychotherapy?
Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences.  It leverages evidence-based treatments. This designation describes specific clinical interventions that have been validated as efficacious for certain mental health conditions under rigorous academic research. Many cognitive and behavioral interventions (e.g., thought re-structuring, exposure therapy) are recognized by the American Psychological Association as evidence-based treatments.

What is CBT?
​Cognitive Behavioral Therapy is a type of evidence-based treament. It examines our thoughts processes - our idiosyncratic way of seeing the world around us -, our typical behaviors or actions, and our emotions in defined moments in our lives. It then providers actionable, well-defined, and simple ways of modifying thoughts and behaviors, with the ultimate goal of changing our feelings - for the better. It is focused on the here and now and aims to deliver symptom reduction in a fast but sustainable way.

What is TEAM-CBT?
TEAM, as mentioned above, is a framework for compiling cognitive and behavioral therapy interventions and delivering them through powerful, results-driven psychotherapy. TEAM stands for four key elements in this therapeutic approach:

T = Testing
In this type of therapy, clients are asked to gauge their level of distress and life satisfaction on a regular basis. Looking at metrics over time, the client and therapist can then determine whether their work together is helping the patient objectively improve their well-being.

E = Empathy
Before the more active part of the therapy begins, it is imperative that the therapist and the client be on the same page. TEAM-CBT offers specific techniques for increasing openness, authenticity, and vulnerability in the therapy sessions.

A = Agenda Setting
This is where TEAM combines evidence-based practices of traditional CBT with elements of Motivational Interviewing, a therapeutic method that works on facilitating and enhancing intrinsic motivation within the client in order to change behavior. The client and the therapist develop a shared agenda for the overall work and for each session where the client is effectively arguing for change - and thus melting away the psychological resistance to upset the status quo. 

M = Methods
TEAM brings together over 50 cognitive and behavioral methods for change, from traditional thought analysis and behavior experiments to innovative role playing techniques, compassion-based techniques, communication training, and much more. For each angle of unhelpful thought processes, TEAM has a number of powerful techniques that can help the client find more constructive alternatives.

The goal of TEAM therapy is to help the client, over time, become their own therapist. For individuals motivated to change their lives, it can lead to meaningful gains in happiness, peace, fulfillment, and contentment in short periods of time. 

To lear more about TEAM therapy, visit Dr. Burns's Feeling Good website or call me for a free phone consultation. 

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 recently, 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. 

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.
​

With marijuana being recently legalized in California, questions about its positive and negative effects on health overall and mental health in particular have intensified. There is an appropriate amount of debate around it and a growing body of investigative research attempting to arrive at conclusive findings. But in short, we really don't know yet. 

My overall take on the state of the literature is that, like with any other foreign substance that you are introducing into your body, avoid or limit it if you can. However, compared to other drugs that are commonly abused - and particularly alcohol - marijuana has a lower profile of long-term damage and side effects.

The article below does a good job of listing areas of interest in the research of clinical uses of marijuana and where we are in our understanding of them. For example, while we all know that marijuana's THC can have a 'feel good' effect on the brain, it also elevates heart rate and impacts coordination and balance. Cannabidiol (CBD) has been demonstrated to help in pain managemen, but marijuana can also affect memory, mood, and potentially activate  schizophrenic symptoms in those prone to the condition.

https://www.healthiguide.com/health/what-marijuana-really-does-to-your-body-brain/

If you are considering or actively using marijuana for mental health concerns, I suggest discussing it with your doctor to investigate any potential physical health risks and with a therapist to learn additional or alternative ways to manage your pain or mood.

All said, natural, healthy, and drug-free solutions are always best!
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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!

Mindfulness is "in" these days across health care and business settings. But beyond being cool, does it work? Or better, what is it good for? Always on top of popular trends, the Harvard Business Review published an essay recently by renowned author and psychologist, Dr. Daniel Goleman. In it, Dr. Goleman reviews the scientific literature about the positive effects of mindfulness and draws conclusions about the areas where enough data is available to support its benefits.

According to this analysis of the research, there are four areas where meditation and mindfulness practices lead to better performance and outcomes, as follows:

1. Stronger focus, greater concentration, and less distractibility
2. Calm under stress or lower emotional arousal in the face of potentially difficult situations
3. Better working memory to help with short-term processing and data analysis
4. A kinder attitude 

Altogether, the research indeed corroborates that living a more mindful, present-focused life can enhance mental fitness and wellbeing. If you are interested in starting a mindfulness practice, I recommend checking out the Google Play or App Store for popular apps such as Insight Timer, Breathe, and Headspace. A licensed mental health provider can also help you learn how to use mindfulness to better your mood, change your thought processes, and embrace more helpful everyday behaviors. 

Life can be hard at times. For many of us, hardship comes in the form of a traumatic event that takes place unexpectedly. This could be the abrupt loss of a loved one, a violent assault, chronic abuse, a serious injury, or a car accident, for example. When faced with a dangerous situation, our bodies react automatically by activating the fight-or-flight response. That's usually helpful: it quickly gets us ready to deal with a threatening stimuli and mobilizes our resources to succeed in that endeavor. When things go according to plan, once the threat is neutralized, we go back to baseline and life moves on, hopefully in more positive directions. Unfortunately, in about 1 in every 3 cases, we don't really get back to baseline. We get stuck in the stress of that moment, unable to cope with it.

When this high level of post-traumatic stress lasts for a while (for more than a month), there is a possibility that the set of symptoms experienced qualifies for a diagnosis of Post-Traumatic Stress Disorder (PTSD). According to the DSM-5, the manual used to label and categorize mental health illnesses, the following are conditions necessary for a diagnosis of PTSD:

1. Exposure to trauma, e.g., threat of death or injury.
2. Intrusive memories, flashbacks, repetitive dreams, psychological distress, or physical distress at reminders of the event.
3. Avoidance behaviors such as trying not to think about the trauma or avoiding places that remind you of it.
4. Negative alterations in thought and mood, e.g., amnesia, negative beliefs, distorted views of the world, lack of interest, detachment, estrangement from others, inability to experience positive emotions.
5. Excessive arousal, e.g. irritability, angry outbursts, reckless behavior, hypervigilance, exaggerated startle response, difficulty concentrating, insomnia.

If you have yourself suffered a traumatic event and are struggling with any of the symptoms above, psychotherapy can help. Indeed, talk therapy is considered the most effective first line of treatment for PTSD and several psychological interventions have been tested and proven very effective for diverse patient populations.

To learn more about the different modalities of PTSD treatment, visit the National Center for PTSD from the VA Administration. And call a therapist.