Tips, Ideas & Recommendations in CBT Treatment

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.

Those of us who are lucky enough to be able-bodied and perfectly capable of putting one foot in front of the other should be walking at least 30 minutes a day, 5 days a week. Why? Because walking brings enormous benefits for our health, both physically and mentally.

​This article from Fresh Daily Health details several ways in which walking can help us lead healthier lives. Benefits of regular walks include:

• Prevents muscle atrophy
• Improves blood circulation
• Builds muscle
• Builds stronger bones
• Lowers risk of several diseases such as heart conditions, cancer and diabetes
• Leads to weight loss
• Prevents dementia
• Boosts Vitamin D levels
• Increases energy levels
• Extends life span
• Boosts mental health

On this last point, it is worth highlighting that walking can help reduce stress, ease anxiety, and combat that nagging desire to do nothing that comes with a clinically significant depression. So, if you can find a few breaks on your calendar daily, even if it is just 10 to 15 minutes two or three times a day, get out there and start putting one foot in front of the other! Your body will thank you.

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

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

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

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

Cognitive behavioral therapy (CBT) tends to operate within a much more short-term, focused model of psychological intervention that aims to reduce current symptoms, address specific problems, and build skills that the client can take with him/her after treatment ends. Hence, treatment length is usually measured in weeks or months, rather than years or decades.

​Indeed, there is ample research evidence that response to psychotherapy follows a 'negatively accelerated' curve where more and more effort is required to achieve smaller and smaller changes (that is called a log-normal curve for the math geeks out there). Dr. Ken Howard was the first to analyze this correlation and posit markers for response to psychotherapy according to dosage. Here is his original article.

The original dose-effect study was run in 1986, based on psychodynamic or interpersonal treatment only, with the following findings:
* About 15% of patients improve before the first session of therapy 
* 50% of patients typically improve at 8 sessions
* 75% of patients typically improve at 26 sessions
* 85% of patients typically improve at 52 sessions

It is possible that modern psychological techniques have accelerated that theoretical curve in the past 30 years. In practice, however, there are many factors influencing the right dose of psychotherapy for each client, including diagnosis, acuity, readiness to change, social circumstances, and frequency of treatment (more regular treatment is  shown to be more effective).  But what we can glean from the data above is that longer and longer treatment periods may indeed offer diminishing gains at increasing levels of effort. 

With CBT, you and your therapist will have powerful tools for change readily available. The specific length of psychotherapy treatment will vary for each person and each presenting problem. But with commitment and focus in the context of a true partnership, CBT can lead to fast and meaningful change.

Empathy is a fundamental ingredient of any psychotherapy treatment. It is so important in TEAM-CBT that it gets its own letter in the acronym: The 'E' in TEAM actually refers to the phase of treatment when offering and receiving empathy is the main goal. In my experience, it is a necessary - although most often not sufficient - element for successful therapy.

Through empathy, the therapist attempts to develop a deeper understanding of the client's idiosyncratic experiences in certain situations. That hinges on the therapist's ability to put themselves in the place of the client, reflecting the client's thought processes and feelings, acknowledging the client's strengths and struggles, and sharing, in a professional manner, the impact that these aspects have had on them, the therapist. With clear communication and a genuine desire to connect, empathy builds a sense of shared experience that allows the therapeutic alliance to flourish.

Empathy is not sympathy, though.  Empathy is a process where two people meet at the same level. In sympathy, one 'stronger' player attempts to rescue the 'weaker' one, often times by minimizing their experience in a well-meaning maneuver to quickly sweep away negative feelings.   Renowned psychologist Dr. Brene Brown has developed a short video that illustrates this distinction. It's well worth three minutes of your time: 

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

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

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

"He is mean and stubborn!"

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

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

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

"They ignore my advice!"  

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

Often times, it is hard to find the right therapist, at the right location, available on the right days, and at the right price. If you are having trouble finding someone with whom you can connect, keep looking. Ask your friends and medical providers for recommendation. Search online directories for psychologists near you, such as those from Psychology Today. Look through membership listings at national or regional psychology associations such as the American Psychological Association. Or, if you know you want an evidence-based provider using cutting-edge technology, search for certified TEAM-CBT therapists on the Feeling Good Institute website.   

While you go through your research, you want to pay attention to your mood and well-being. Here are some tips for taking care of yourself while you wait for your psychotherapy to start:

Self-Care “While You Wait”

While you are waiting for individual counseling, you may want to implement these tips to try to alleviate some of your distress. (This is for informational purposes only, and is not intended to treat any conditions. These tips are not meant to be substitutes for mental or physical health counseling.) 

Find activities that sooth and relax you. Relaxation improves the mind and helps the body recover from stress. Even 10 minutes a day would be helpful! Use deep breathing techniques--take a deep breath slowly and all the way down to your stomach, hold your breath for a few seconds, and slowly breath out by emptying your stomach of your breath. Tell yourself to “let go of any tension” as you breath out. Do this for at least 5 or 6 times in each sitting. Practice yoga, listen to some relaxation tapes, etc. 

Do some kind of physical activity, even if you only have 10 minutes. Find a routine that creates a sweat and that fits your style (e.g., walk, swim, tennis). This will help with your stress, anxiety, and depression symptoms. 

Keep a journal. Write down your thoughts and feelings in various situations. Note any patterns or questions you’d like to discuss in therapy. 

Pay attention to your mind and body. Nourish your body with nutritious food. Skipping meals robs you of the energy to cope. Nurture your spirit. Pray, meditate, practice whatever that fits your spirituality. Sleep and rest when you are tired. 

Laugh, especially at yourself and Take time to play. Spend time with those who make you laugh. Watch a comedy or read a funny book. There is evidence that smiling changes your emotions to pleasant and your thoughts to optimism. 

Nurture a positive view of self. Catch yourself when you start to think negatively or are putting yourself down. Actively replace these negative thoughts with a positive view. Create a list of affirmations for yourself (e.g., I grow and change; I am open-minded, etc.). Even if you aren’t convinced, fake it until you make it! 

Make connections. This will take time to develop. Create and maintain contact with a small group of people you can call on for emotional support. Take turns talking and listening. Isolating yourself can make things worse. 
​
In addition, here is a brief list of resources where you can obtain guidance and assistance in a crisis situation: 

• National Suicide Prevention Hotline – 1-800-273-8255 
• Starvista crisis hotline (in San Mateo County) – 1-650-579-0350 
• Text hotline - Text “START” to 741741. 
• 911 or your nearest emergency room 

Adapted from SJSU CAPS

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 recently 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!

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 recently 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? 

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:

https://www.psychotherapynetworker.org/magazine/article/1076/when-helping-doesnt-help