Tips, Ideas & Recommendations in CBT Treatment

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!

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 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. 

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 5 Certified TEAM-CBT trainer and Master 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!

Dying for a Paycheck is a 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.
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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.

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.

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: 

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!

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
  

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. 
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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

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.