Dr. Levy's CBT Blog
Insights on Well-Being, Contentment, and Cognitive Behavioral Therapy
A client recently shared with me a video of actor Will Smith talking about the fear that he felt before he was scheduled to go on a skydiving trip. That prompted a discussion around the difference between fear and anxiety.
To my way of thinking, fear is to anxiety as concrete is to imagined, actual is to forecast, or today is to tomorrow. From a cognitive standpoint, fear pertains to a real, tangible, identifiable, and often immediate source of danger. For example, if a lion is standing in front of me, I will be afraid (not anxious!). If I am about to jump out of a plane, standing by the open door at 3,000 feet, I will be afraid (not anxious!). On the other hand, anxiety applies to situations where I perceive a potential for danger. I have not yet seen the lion, but I think that the lion may be lurking close by. Or coming for me at any time. Or just feeling hungry. I worry about something that has not happened yet and may never happen, But then, it could conceivably happen.
In psychotherapy, we may address both fears and anxiety using Cognitive Behavior Therapy. Problematic fears often come up in the context of phobias (e.g., fear of flying or driving across bridges). Clinically-relevant anxiety tends to manifest itself in the form of excessive worrying, tension, restlessness, over-sensitivity and hypervigilance. Both feelings trigger our "fight or flight" response mechanism, which I will describe in more details in my next blog post. The treatment of choice most often involves Exposure Therapy, an evidence-based intervention in which the client learns how to gradually expose themselves to stimuli that they fear, with a lot of support and guidance from the therapist.
In the meantime, here is Will Smith talking about his "fears," which actually pertain to both anxiety and fear. Enjoy!
Dr. David Burns is a world renowned psychiatrist and one of the pioneers in the development of Cognitive Behavioral Therapy. In the past decades, Dr. Burns has been focusing on advancing the clinical applications of CBT through a new therapeutic approach that he calls TEAM-CBT. You can read more about the elements of TEAM-CBT in one of my early blog posts or on Dr. Burns website.
TEAM-CBT is a framework for delivering evidence-based interventions in psychotherapy (and evidence-based here means techniques that have been corroborated as effective by rigorous scientific research). It combines Routine Outcome Monitoring, Motivational Enhancement, and CBT Methods with a strong focus on empathy and rapport building to deliver meaningful symptom reduction in fast periods of time. Indeed, in his current clinical work, which revolves mostly around training of therapists and professional workshops, Dr. Burns has, on many occasions, observed that individuals who had been struggling with depression or anxiety for years can experience near complete recovery in just a few hours.
To explain how that can happen, and provide more background and perspective on the TEAM-CBT approach, Dr. Burns was interviewed by one of our colleagues, Lisa Kelley. The transcript of the interview is an excellent primer to learn more about this powerful new modality. Here it is:
As a Level 4 Certified TEAM-CBT trainer and therapist, I would be delighted to help you learn more about these tools to to enhance your life or, if you are a health care provider, to revolutionize your clinical practice!
My colleague, Dr. Leah Weiss, from the Stanford Graduate School of Business, published this thought-provoking article in the Harvard Business Review:
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:
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, 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 lear more about your thought patterns and how to change them.
A recent 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.
Dying for a Paycheck is a new book by long-time Stanford GSB professor and business guru Jeffrey Pfeffer. In it, Professor Pfeffer argues that the long hours and round-the-clock availability expectations of today's fast-paced workplaces have led to unprecedented levels of high stress, burn out, disengagement, as well as low physical and emotional health.
His findings and viewpoints match well with my own academic research on Work Attitudes and Behaviors Among Professional Women. I posit that it is not simply how much you work, but how you relate to your work that determines its repercussions on your satisfaction and wellbeing. A summary of the study methods, analyses and conclusions is included below.
If you find yourself struggling with career and balance issues, take a break, do something pleasurable or meaningful to you, and connect with friends and loved ones. If you find yourself in need of greater support, consider seeking a therapist.
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!
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!
Some clients go through years of psychotherapy without attaining meaningful change in their lives. When we look deeper into those situations, it is easy to understand why. Their reality is such that feeling joyful, free, satisfied just doesn't make sense. For example, if I am failing a class, having conflict in my marriage, or fearing riding any and all elevators, there are very valid and straightforward reasons for feeling distraught. In many instances, the very feeling of sadness, nervousness, or distrust is a reflection of something beautiful and positive about that person's value system. I would not be feeling sad for failing my classes if achievement and responsibility weren't important to me!
When therapists try to change a client's emotional reactions without honoring the positive facets and functions of those reactions in the context of the individual's overall experience, the efforts are doomed to fail. That is why, in TEAM-CBT, we spend a healthy amount of time in Agenda Setting, before moving forward with any attempt for change.
Dr. David Burns explains why some clients may not want to change - and why helping is not always helpful - in this insightful article in the latest issue of Psychotherapy Networker:
As we start the new year, several of us have 'new year resolutions' that may include goals to eat healthy, exercise more, learn new skills, sleep better, travel, etc. If you picked the exercise category, you will be happy to hear that you are in the right path to improve your mental health along with your physical health.
A recent study in the American Journal of Psychiatry highlights the benefit of regular exercise in the prevention of depressive disorders. Here is an exerpt from the abstract:
Undertaking regular leisure-time exercise was associated with reduced incidence of future depression...The majority of this protective effect occurred at low levels of exercise and was observed regardless of intensity...12% of future cases of depression could have been prevented if all participants had engaged in at least 1 hour of physical activity each week.
Easy - and cheap! Now, if you need help overcoming that pesky procrastination habit and changing those behaviors for good, your therapist can give you a much needed push to get finally get started!
Dr. Daniele Levy is a licensed psychologist offering CBT therapy 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.