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!

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.

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.

Self-care is "in." At work, with friends, and even at home, we often hear about and proclaim the benefits of self-care. Popular self-care ideas range from a hot bath or a manicure to a fancy spa treatment or a vacation in Hawaii. All of those activities are useful and effective ways to take a break or disconnect from everyday life.  However, if you catch yourself yearning for that break all the time, that may be a sign that the life you've built is not the life you need. If you need to escape from reality at regular intervals, your reality may be misaligned with your values. In this thought-provoking article , author Brianna Wiest advocates for taking care of yourself every day, not by pampering and withdrawing from your routine but by including healthy and responsible choices in it. "If you find yourself having to regularly indulge in consumer self-care, it’s because you are disconnected from actual self-care, which has very little to do with “treating yourself” and a whole lot do with parenting yourself and making choices for your long-term wellness." If you're looking to take better care of yourself, start by taking inventory of the values that matter to you and then assessing how well your life is aligned against them. If you need support going through that analysis, find a good therapist who can serve as a sounding board.

Dr. Kristi Neff is one of the pioneers in the study of self-compassion as a tool for psychological wellbeing. There are many definitions of self-compassion out there, but hers hinges on three tenets: 1) Self-kindness vs. judgment Self-compassion involves being kind and understanding to ourselves, just as we would be to a friend or loved one. It means treating ourselves with the same compassion we would treat others when we are going through a difficult time. 2) Common humanity Self-compassion is not about being selfish or self-indulgent. It is about recognizing that we are all human beings who make mistakes, and that we all experience pain and suffering. When we are self-compassionate, we are able to accept ourselves with all of our flaws and imperfections. We are also able to be more understanding of our own limitations and to forgive ourselves for our mistakes. 3) Mindfulness   Mindfulness is the basic human ability to be fully present, aware of where we are and what we're doing, and not overly reactive or overwhelmed by what's going on around us. It entails paying attention to the present moment without judgment. When we are mindful, we observe thoughts and feelings from a distance, without getting caught up in them. This allows us to be aware of our thoughts and feelings while making choices about how to respond to them, without exaggerating or suppressing them. There are many benefits to self-compassion. Studies have shown that self-compassion can lead to: Improved mental and physical health Reduced stress and anxiety Increased resilience Improved self-esteem Increased happiness and well-being There are equally many ways to cultivate self-compassion. You can start by being  kind and accepting to yourself, practicing mindfulness and loving-kindness meditations, spending time with people who are supportive and kind, and engaging in activities that help you feel good about yourself.  You can also practice self-compassion through guided audio exercises such as this one: Self-compassion is a skill that takes time and practice to develop. But it is a skill that is well worth the effort. When we are self-compassionate, we are able to live happier, healthier, and more fulfilling lives.

As we go through our busy days, we are asked to form spur-of-the-moment opinions about the events around us. Someone says hi? [They want something from me!] Someone fails to say hi? [I have done something to offend them!] Car doesn't start? [This always happens to me!] Late for work? [The world is conspiring against me!]. We all have these scripts inside our heads that help us evaluate things that happen in our lives quickly and efficiently. Unfortunately, not always accurately.  In the process of coming up with these quick appraisals of events happening in our lives, we often take 'shortcuts' that we hope make the evaluation process quicker. It might. But the shortcuts often take us in directions that are not helpful. In cognitive psychology, we have grouped these unhelpful shortcuts in categories with labels that describe each one of them. They are called Cognitive Distortions . Dr. David Burns describes them as follows: 1. All-or-nothing thinking  (also known as 'black and white thinking'): You look at things in absolute, black-and-white categories, e.g. "I never do anything right!" (seriously, never ever??) 2. Overgeneralization : You view a negative event as a never-ending pattern of defeat, e.g. "I can't make anyone happy" (when you have a fight with your boyfriend, without remembering how much you mean to your best friend!) 3. Mental filter:  You dwell on the  negatives  and ignore the positives, e.g. "I am really bad at sports" (you lose a soccer game, and forget how good you are at indoor cycling). 4. Discounting the positives:  You insist that your accomplishments or positive qualities don’t count, e.g. "My good grade in this test was a stroke of luck" (after studying two days for it!).   5. Jumping to conclusions : You jump to conclusions not warranted by facts. These include mind-reading (assuming that people are reacting negatively to you) and fortune-telling (predicting that things will turn out badly), e.g. "She doesn't like me" or "I know I will not get this job." 6. Magnification or minimization:  You blow things way out of proportion or you shrink their importance, e.g., "This is the only important interview I will ever have."  7. Emotional reasoning:  You reason from how you feel: “I feel like an idiot, so I must be one.” 8. “Should” statements : You criticize yourself or other people with “shoulds,” “shouldn’ts,” “musts,” “oughts,” and “have-tos,” e.g., "my life should be way more exciting!" 9. Labeling: You give yourself a label on the forehead. E.g., instead of saying, “I made a mistake,” you tell yourself, “I’m a jerk” or “I’m a loser.” 10. Blame:  You blame yourself for something you weren’t entirely responsible for, or you blame other people and overlook ways that you contributed to a problem, e.g., "I am a bad teacher" (when you forget how difficult your students are...) or "They are bad students" (when you fail to analyze your teaching skills beforehand). We all make these thinking errors on a daily basis. At times, they can go unnoticed. More often, they will lead to feelings of sadness, anger, hopelessness, anxiety and more. The good news is that, with practice, it is easy to identify these distortions and learn how to fix them. Cognitive therapy is just the answer if you are looking to learn more about your thought patterns and how to change them.

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 at 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 therapist credentials 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.

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. Meditate with the jelly fish. 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: Fear of germs or contamination Unwanted forbidden or taboo thoughts involving sex, religion, and harm Having things symmetrical or in a perfect order Aggressive thoughts towards loved ones or towards yourself ...and many others! 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: Excessive cleaning and/or handwashing Ordering and arranging things in a particular, precise way Repeatedly checking on things, such as repeatedly checking to see if the door is locked or that the oven is off Compulsive counting ...and many others! 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 get rid of 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.