Dr. Levy's CBT Blog
Insights on Well-Being, Contentment, and Cognitive Behavioral Therapy
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:
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!
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.
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!
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:
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:
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.
Everyone has a sleepless night every now and then. What we do - and don't do - during the day, how we eat, what we drink, how much we exercise, our environment, our mental health, and how much stress vs. pleasurable activities we have in a typical day all influence the quality of our sleep. When insomnia hits for a night or two, it is easy to catch up. But when it becomes a chronic issue, it needs to be addressed before your health starts to suffer. One of the most effective and widely recommended treatments for insomnia is cognitive behavioral therapy (CBT).
There are two models of understanding and treating insomnia in CBT. The first approaches insomnia as the main focus of treatment. It starts by addressing behavioral modification, i.e., how long you stay in bed, and then moves on to address your beliefs about sleep. This line of treatment is often referred to as CBT-I, or cognitive-behavioral therapy for insomnia. CBT-I is shown to work better than sleeping pills, with no side effects! There are several self-help apps and websites for CBT-I. Personally, I recommend cbtforinsomnia.com, a five-week online intervention with some clinical oversight.
A second model of looking at insomnia is to view it as a symptom of another, bigger emotional health problem. Often times, insomnia is a consequence of depression or anxiety. For example, patients with excessive anxiety and worry may have trouble falling asleep as their mind starts racing - worrying about tomorrow's to-dos or ruminating about past events - the minute they lay their heads on the pillow. In this case, treating the underlying disorder (anxiety) with an approach such as TEAM-CBT will lead to the insomnia resolving itself short-term.
In either case, a well trained CBT therapist may be able to guide you on your path to a good night of restful sleep!
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.
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!
Dr. Daniele Levy is a licensed psychologist offering CBT via Teletherapy from Menlo Park, CA. Her background uniquely combines leading edge training in behavioral sciences with deep expertise coaching and mentoring working professionals in dynamic organizations.