Getting Comfortable Being Uncomfortable

By Annabelle Parr, MA, AMFT

One of the main goals in Acceptance and Commitment Therapy (ACT) is to help clients get comfortable being uncomfortable. This may sound strange at first, after all isn’t therapy meant to help alleviate suffering? So why would an evidence-based treatment model suggest that we get comfortable being uncomfortable?

Because the struggle to get rid of pain often comes at a cost.

When our energy and attention are wrapped up in trying to move us away from discomfort, several things typically happen:

1. First, the attempt to avoid discomfort or anxiety works. We get an instant sense of relief. This is really rewarding to our brains and our bodies, and because it is so rewarding it can make us more likely to choose that avoidance again in the future.

2. But relief is usually only temporary. In the long run, anxiety finds a way of returning. And when it comes back, it is sometimes even stronger than before. When we avoid the things that make us feel anxious, we reinforce the story our minds tell us that anxiety is unmanageable and that we are in danger.

3. Third, and possibly most importantly, in the fight to try to make anxiety go away it’s easy to lose sight of what is most meaningful and important to us in our lives. Our behavior becomes about trying to get rid of discomfort rather than about being present to and doing the things that matter to us.

There is a Buddhist saying that helps explain the high price of avoidance:

Pain x Resistance = Suffering 

Anxiety and other painful emotions are really uncomfortable, and they are an inescapable part of the human experience. When we try to resist or avoid that pain, instead of allowing it to be as it is and continuing to engage in valued actions, our discomfort escalates into suffering. Maybe that suffering looks like worrying about the fact that we are anxious. Maybe it involves our minds beating us up for the fact that what we are experiencing is not easy, the way it seems to be for others. Maybe that suffering involves feeling unable to connect with something important to us. When we choose a different response and drop the resistance to our pain, we can reduce that suffering.

The alternative to resistance is willingness.

Willingness is getting comfortable being uncomfortable and allowing our internal experience to be as it is without trying to control or change it. When we are no longer caught trying to wrestle with and get rid of our anxiety, we get to choose what we do instead.

• We can decide to be brave and take a flight to go visit family we haven’t seen in years.

• We can decide to be vulnerable and go out on a first date.

• We can decide to be bold and ask for a raise.

• We can decide to take care of ourselves and schedule that check up, or take care of others and go donate blood.

• We can love more deeply, fully, and wholeheartedly when we are willing to allow the possibility or even the probability that we may one day lose those we love.

When we are comfortable being uncomfortable, our life expands. We can allow ourselves to care deeply about what matters most in our lives. We get to make a choice about who and how we want to be in the world, and about what actions are important enough to us to allow ourselves to feel the pounding heart, sweaty palms, shaky legs, racing mind that comes with anxiety.

CSAM IS HERE TO HELP

If you or someone you love needs support and might benefit from cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT) for anxiety, panic, phobias, stress, PTSD, OCD, uncertainty or stress related to COVID-19, or if you would like more information about our telehealth services, please contact us at (858) 354-4077 or at info@csamsandiego.com

Lessons from Traveling in Time

By Annabelle Parr, MA, AMFT

Have you ever wished you could have a do over? Go back in time and alter an embarrassing moment, or seize a missed opportunity, or simply get more time to do the things that matter most to you?

What might we learn if we could travel back in time and do things differently?

Every year around New Year’s, I watch my favorite movie, About Time. It’s a rom com about a man who learns that the men in his family can travel back in time within their own lives, and it is filled with sweetness and some profound messages that are remarkably consistent with the core principles of Acceptance and Commitment Therapy (ACT). If you haven’t seen the film, warning: spoilers ahead. In his travels through time, Tim, the main character, learns a number of lessons about creating and living a full, vital life.

Lesson #1: Traveling in time gives you unlimited chances to behave differently, but the outcome of your behavior is still always beyond your control.

Upon learning that he has the ability to time travel, Tim quickly clarifies that what matters most to him is love (values), and what he most wants to use this unique ability to achieve is finding someone with whom to share his life (goal). One of the first things he learns is that even with the ability to go back in time and try things differently, he ultimately cannot control the outcome of his behavior, just like the rest of us. He can pursue his goal by showing up to each moment bringing the qualities he most wants to embody (values), but the outcome of his actions is outside of his control. He may get to test things out more than the rest of us, and may gather more information on what behaviors may make a particular outcome more likely, but just like the rest of us, in the end, the outcome is still beyond his control.

Lesson #2: All the time travel in the world can’t erase pain.

Nevertheless, Tim continues to show up to each moment fully (present centered awareness), holding his goals for the life he hopes to build lightly and being the kind, loving, humorous man he hopes to be (committed actions), and ultimately he does build a beautiful life and family filled with love. As he does so, he learns that even his gift cannot shield him from the pain that comes with being human. Just like the rest of us, if he wants to engage in the joys, he must also be willing to have the pain that is inevitable if we are willing to care, to love, and to be loved (willingness).

Lesson #3: The secret to a rich, meaningful life is being fully present and choosing how you will meet each moment. 

Toward the end of the film, Tim shares my favorite lesson of all. He shares his father’s secret to a good life. His father tells him to live each day twice: “the first time with all the tensions and worries that stop us noticing how sweet the world can be, but the second time noticing.” In the simple act of noticing (present centered awareness), and making a conscious decision about how he responds (committed action), Tim finds how much richer and fuller life can be.

The film finishes with Tim sharing,

“And in the end I think I've learned the final lesson from my travels in time; and I've even gone one step further than my father did. The truth is I now don't travel back at all, not even for the day. I just try to live every day as if I've deliberately come back to this one day, to enjoy it, as if it was the full final day of my extraordinary, ordinary life.”

In this final lesson, Tim sums up the goal of Acceptance and Commitment Therapy: to meet each day fully, with openness to whatever shows up and awareness of our experience, and to choose to actively engage in each moment with the qualities that we most hope to embody. When we are fully present, we begin to notice all of the opportunities we have to engage in our lives as the people we most hope to be. As Tim discovers, we don’t actually need time travel at all; the moments we are given are already full of opportunity to be who we most hope to be right now.

CSAM IS HERE TO HELP

If you or someone you love needs support and might benefit from cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT) for anxiety, panic, phobias, stress, PTSD, OCD, uncertainty or stress related to COVID-19, or if you would like more information about our telehealth services, please contact us at (858) 354-4077 or at info@csamsandiego.com

Managing Uncertainty and Doing the Next “Right” Thing

By Annabelle Parr, MA, AMFT

There are many different reasons why you might decide to seek therapy. Maybe you are struggling with the stress of the pandemic, including but not limited to stressors like working from home and trying to be a full-time parent, teacher, and employee all at the same time; maybe you are struggling with the emotional repercussions of racism; maybe you’ve started experiencing panic attacks; maybe you have developed a phobia of driving, or needles, or spiders; maybe you are constantly consumed with worried thoughts; maybe it feels like fear is making all your decisions for you. What therapists refer to as the “presenting problem” that brings an individual in to therapy may sound, on the surface, very different from client to client. 

But one common thread that underlies almost all of our suffering (and applies especially to anxiety and related disorders, like PTSD and OCD) is a difficulty with uncertainty.

When the outcome of a situation is uncertain or ambiguous, our minds make themselves busy worrying, as if ruminating on every possible outcome (with heavy emphasis on the worst case scenarios) might prepare us. They grasp for certainty, and sometimes they will even convince us that catastrophe is inevitable because even that feels less uncomfortable than the truth: we don’t know. Usually though, this strategy makes our lives smaller. Our decisions become governed by a desire to avoid either the feared outcome itself or the anxiety that comes with taking the risk.

Here is the thing: rarely, if ever, does life truly give us certainty. 

We control what we do and don’t do, but we don’t get to control the outcome. That’s uncomfortable, I know. But what if that actually frees us up? If we can’t control the outcome, maybe we can stop trying. Maybe, instead, we can give ourselves a little grace and make choices with something else in mind.

Earlier this year, when the pandemic had just started and I felt overwhelmed with anxiety about all the uncertainty about what was going to happen and what to do, my friend reminded me of a quote from Glennon Doyle to “just do the next right thing.”

If you’re like me, and you have a tendency to get stuck on what the “right” thing means, this quote as a standalone mantra could be tricky.

But from an Acceptance and Commitment Therapy standpoint, the “right” thing would be defined as the workable thing. That is, the thing that moves you towards your values, towards who and how you want to be in the world, in service of those relationships and parts of your life that matter most to you. The “right” thing is the thing that, though maybe not the easy or comfortable thing, does not come with the cost of making your life smaller and of moving you away from what CSAM director and author of Be Mighty, Dr. Jill Stoddard refers to as “the me you want to be.”

In her book, Untamed, Glennon talks about this as your “knowing.” The core of you that knows who you are, what you want or need, and what matters most to you. Sometimes that knowing is buried under layers of learning and socialization, stories in your mind about what you “should” do or what others want from you, or strategies designed to shield you from pain, anxiety, and discomfort. But if we get curious about what is underneath all of that, if we start to get curious about our pain and what it has to say, we can find that knowing. In fact, when we get curious about our pain, we get valuable information about what’s most important to us. Because it wouldn’t hurt if we didn’t care. Our values lay on the flip side of our pain; they are two sides of the same coin.

Just do the next right thing means that even in the face of enormous uncertainty, what matters is that we tune in to those values — our knowing — and figure out what it is we can do in this one moment that is in line with what matters most to us. Because this one moment is all we are promised. Nothing else is ever a certainty, even when it feels like it might be. And actually, that may just free us up to live each moment more fully, because really, the only certainty is that we are here now…so what are we going to do about it?

CSAM IS HERE TO HELP

If you or someone you love needs support and might benefit from cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT) for anxiety, panic, phobias, stress, PTSD, OCD, uncertainty or stress related to COVID-19, or if you would like more information about our telehealth services, please contact us at (858) 354-4077 or at info@csamsandiego.com

The Unexpected Benefits of Teletherapy

By Annabelle Parr, MA, AMFT and the CSAM team

It’s been nearly 4 months since we started COVID-19 quarantine, physical distancing, and since we transitioned to offering therapy via telehealth at CSAM. We knew from the outset of this shift that research indicates that, assuming that the therapist and modality are an appropriate fit for the client’s needs, teletherapy is as effective as in person therapy. Even still, we were initially apprehensive about this change, as we were uncertain how it would feel to switch from sitting across from our patients to communicating with them through a screen. Despite our initial worries, we have been pleasantly surprised to discover that not only has our experience been consistent with efficacy research, but that teletherapy has actually had a number of additional benefits we did not anticipate.

And given that the past few months have brought a lot of stress, pain, anxiety, grief, and frustration, we wanted to take a moment to reflect upon some of the beauty and connection that we have noticed amidst this tumultuous time. Below are reflections from our team of therapists on some of the benefits they have noticed about the tele-therapeutic process. 

Common humanity: we’re all in this together.

CSAM Director Dr. Jill Stoddard said, “I was worried that telehealth would make the connection with clients less personal, but what I've found is that my clients are now introducing me to their partners, their kids, and their pets, so in many ways I actually feel MORE connected to them. I was also worried about interruptions from my own kids and dogs, which HAS happened, but my clients have been so patient and understanding. In many ways I think they too feel more connected to me because it's all just so human and we're having a shared, unique experience of having to do things from home with our families around.”

Increased connection: a fuller picture of clients’ lives.

Associate Director Dr. Michelle Lopez agreed. She said, “my experience is similar to what Jill described in that I feel MORE connected to clients. Telehealth has allowed me to have a fuller, more colorful picture of what their lives are like which I am able to envision when I am conceptualizing and tailoring treatment plans. It has also been excellent for exposures. When "we" can walk to the client’s backyard or kitchen (or wherever the exposure task needs to happen) in a matter of seconds, it allows more time for the actual exposure task. A few clients have commented on how much easier it is for them to "arrive" on time because they don't have to account for traffic, being unable to find their keys or shoes, etc.”

Superhero sidekicks: incorporating pets into therapy.

Superhero Therapy creator and lead trauma specialist Dr. Janina Scarlet noted that “an unexpected but interesting side effect of telehealth has been the ability to incorporate pets into therapy. Many people’s pets have become their sidekicks on their mental health journey and my own cat, Hera, has become a kind of mascot of an emotional support pet for many of my clients.”

Increased convenience: involving family and doing exposures at home.

Child and teen specialist Thi Wlodarski, LMFT agreed with Dr. Lopez that exposures have been more easily facilitated: “telehealth has been really beneficial for my clients whose rituals are often done at home. Clients are able to complete exposures in the situations that trigger their anxiety instead of having to simulate it in the office. I've also been able to do more family therapy because all members are home together. I've been able to involve parents who wouldn't normally been able to be present in session. 

Comfort and creativity: therapy from the comfort of home.

Dr. Terra Fuhr said, “I have also found telehealth to be a surprisingly smooth transition. Several clients have commented that it feels easier to open up, be vulnerable and talk about difficult topics from the comfort of their own space. I also wonder if being in the environment where they live life may remind them--or prime them--to talk about the most relevant emotions of their day-to-day lives. We've been able to do more creative exposures. And everyone seems to love not having to factor in commute time!”

As always, we are continually inspired by our amazing clients.

Insomnia specialist Dr. Melissa Jenkins agreed with the rest of the team, and added her feelings of admiration for her clients’ courage and perseverance during this difficult time. “Over the past few months, I have been struck by how bravely and thoughtfully people have welcomed therapy into their homes by way of telehealth. In our current circumstances (in which we are faced with many competing demands on our time and energy as we navigate a new way of living amidst coronavirus), it can be really hard to keep appointments and prioritize mental health. I am truly inspired by my adult clients who are committed to prioritizing their mental health, showing up for appointments and challenging themselves, and by my client’s parents who continue making therapy a normal part of their children’s lives. Sessions, of course, look a little different as we engage in therapy together through screens; however, it has been powerful to connect with clients in their more natural environments (as opposed to a therapy office) and to witness continued growth in the face of substantial adversity right now.”

Teletherapy allows us to keep our clients and our communities safe.

Of course, we are all collectively missing the normalcy of life pre-pandemic. And here at CSAM, we look forward to a time when we can see our clients in person again. However, we are also happy and grateful that we are able to do our part in slowing the spread of COVID-19 by offering our services via telehealth for as long as is needed. Remaining at home and offering teletherapy is consistent with our values of keeping everyone as safe as possible while this pandemic continues. As the number of cases continues to rise both here in San Diego and across the United States, the best thing we can do to keep our clients and our communities safe is to stay home whenever possible. Under these circumstances, telehealth allows us to offer the most competent, compassionate and connected care.

If you need support during this difficult time, CSAM is here to help.

Even as we reflect on some of the upsides of telehealth and the strength, courage and resilience of our clients, we also recognize that this pandemic and the upheaval we are experiencing has increased stress, anxiety, and even trauma for many folks. So know that if you are struggling, you are not alone and evidence based treatment is still available to you.

If you or someone you love needs support and might benefit from cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT) for anxiety, panic, phobias, stress, PTSD, OCD, insomnia, or stress related to COVID-19, or if you would like more information about our telehealth services, please contact us at (858) 354-4077 or at info@csamsandiego.com

How Do I Know If I Need Therapy?

By Annabelle Parr

Each May we celebrate Mental Health Awareness Month to draw attention to and reduce stigma around mental health issues. According to the National Alliance on Mental Illness, or NAMI, 1 in 5 people will be affected by mental illness in their lifetime. And as we discussed last May during #CureStigma, “while 1 in 5 Americans are affected by a mental health condition, 5 in 5 Americans know what it is to feel pain. The frequency, intensity, and duration can vary, but pain itself is a function of being human. When culture stigmatizes the 1 in 5 and simultaneously dichotomizes illness and wellness, the resulting message is that it is shameful to struggle and to feel pain. In essence, stigma says that it is shameful to admit our own humanity.”

Do I need therapy?

Given that all of us will at some point encounter painful experiences and emotions, this year we are discussing how to know when it might be helpful to seek therapy. Though it may be clear that those affected by a previously diagnosed mental health condition could benefit from therapy, for those who are either undiagnosed or are struggling with anxiety, stress, grief, sadness, etc. but do not meet diagnostic criteria for a mental health disorder, it may be harder to discern whether therapy is warranted.

How am I functioning in the important areas of my life?

For nearly every condition in the Diagnostic and Statistical Manual (DSM-V; APA, 2013), clinically significant impairment in an important area of functioning is a required criterion to receive a diagnosis. In other words, the presenting symptoms must be making it very difficult to function at work or school, in relationships, or in another important life domain (e.g., a person is feeling so anxious that she is not able to make important presentations at work, or so stressed that he is finding it difficult to connect with his loved ones).  When life has begun to feel unmanageable in some capacity, or if something that was once easy or mildly distressing has become so distressing it feels impossible, it may be worth considering therapy.

Could things be better?

It’s also important to note that you do not have to feel as though things are falling apart before you seek professional counseling. Therapy can be helpful in a wide range of situations. It can help you not only navigate major challenges or emotionally painful periods, but also can enhance your overall wellbeing by helping you to identify your values and lean into them. Maybe things are going fine, but could be better. A therapist can help you identify what could be going better and can help you learn to fine tune the necessary skills.

I want to try therapy, but where do I start?

Whether things feel totally unmanageable or it just feels like they could be better, it’s important to find a therapist with expertise relevant to what you would like assistance with. Working with children requires different expertise to working with adults, just as working with couples and families requires additional expertise to working with individuals. Different conditions also correspond with particular evidence based practices. For stress and anxiety disorders – including social anxiety, generalized anxiety, panic disorder or panic attacks, and phobias – evidence based practices include Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT). The gold standard of treatment for obsessive compulsive disorder (OCD) is Exposure and Response Prevention (ERP), and evidence based treatments for PTSD include Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) (all of these—ERP, PE, and CPT --fall under the CBT umbrella). So no matter what you are seeking treatment for, ensuring that the therapist you choose has expertise that aligns with the types of concerns you are struggling with is critical. For some more tips on finding and choosing a therapist, click here and here. For more information on the different kinds of licenses a therapist may have, click here.  

Though there is no right or wrong answer as to whether or not you need therapy, if you are unable to behave in ways that make life manageable and/or fulfilling because of difficult thoughts or feelings, you may find therapy beneficial.

CSAM IS HERE TO HELP

If you or someone you love might benefit from cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT) for anxiety, panic, phobias, stress, PTSD, OCD, or insomnia, or if you would like more information about our therapy services, please contact us at (858) 354-4077 or at info@csamsandiego.com

Mental Health Awareness Month: Fitness #4Mind4Body

by Annabelle Parr

May is Mental Health Awareness Month. Every year, Mental Health America designates a particular theme for the month to highlight an important aspect of mental health. This year’s theme is Fitness #4Mind4Body, and it focuses on acknowledging the connection between mental and physical wellbeing. #4Mind4Body explores the role of nutrition, exercise, the gut-brain connection, sleep, and stress in our overall wellbeing and examines the ways each of these areas impact our functioning. Below is a summary of the topics covered in the Mental Health Toolkit from Mental Health America.

Diet and Nutrition

Eating a well-balanced, nutritious diet is an integral part of health. Diets high in processed, fried, and sugary foods can increase the risk not only for developing physical health problems like diabetes, heart disease, obesity, and cancer, but are also linked to mental health problems, including increased risk for depression symptoms. A healthy diet consists of a variety of fruits, vegetables, legumes, whole grains, fish, nuts, and olive oil. Maintaining a balanced, nutritious diet is linked with a lower risk for depression and even an improvement in depression symptoms.

Exercise

Regular exercise not only helps control weight, increase strength, and reduce the risk of health problems like high blood pressure, cardiovascular disease, and some cancers, but it also helps boost endorphins and serotonin, among other important proteins and neurotransmitters that impact mental health. Endorphins serve to mitigate pain in the face of stress and increase pleasure in the body. Serotonin affects appetite, sleep, and mood, and is the target of SSRIs, a class of antidepressant commonly used to treat anxiety and depression. Just thirty minutes of exercise per day can help improve mood and mental health.

The Gut-Brain Connection

The gut, also known as the “second brain,” communicates directly with the brain via the vagus nerve and via hormones and neurotransmitters. The communication goes both ways, so anxiety, stress, and depression can impact the gut and result in gastrointestinal symptoms, but changes in the gut microbiome can impact the brain and mood, exacerbating or even resulting in symptoms of anxiety and depression. Eating a nutritious diet that includes prebiotics and probiotics is an important part of maintaining a healthy gut and a healthy mind. 

Sleep

Quality of sleep impacts the immune system, metabolism, appetite, the ability to learn and make new memories, and mood. Good sleep for adults means getting between 7-9 hours of mostly uninterrupted sleep per night. Problems with getting good quality sleep can increase the risk of developing mental health symptoms, and symptoms of anxiety and depression can negatively impact sleep, creating a negative cycle. Cognitive Behavioral Therapy for Insomnia (CBT-I) can help clients reestablish healthy sleep patterns through addressing negative thoughts and worries as well as behavioral patterns that are impacting sleep habits.

Stress

Stress is a normal part of life, and the body is equipped with a fight or flight response designed to help mobilize internal resources to manage stressors. After the stress has passed, the body can return to its regular equilibrium state. However, when stress becomes chronic, it can cause inflammation, impaired immune system functioning, muscle aches, gastrointestinal problems, sexual dysfunction, changes in appetite, and increased risk for heart disease. Too much stress can also impact mental health.

Mental health involves a complex interplay between numerous factors, including but certainly not limited to the areas listed above. Furthermore, though maintaining a healthy diet, regular exercise routine, good sleep habits, and utilizing stress management techniques can help prevent or improve existing mental health symptoms, if you are struggling with mental health issues, it can be difficult to attend to these areas.

If you are struggling with anxiety, stress management, depression, chronic illness, or insomnia, seeking professional assistance can be helpful. Evidence based therapies like Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) can help to address problematic thoughts and behaviors that are contributing to emotional distress. Therapy offers a warm, supportive, safe environment to explore painful issues. A therapist can also provide support in helping the client to develop good self-care habits, like those mentioned above.

This year’s mental health awareness theme reminds us of the importance of recognizing the multiple avenues through which we can approach mental health, and the variety of tools we have at our disposal to improve overall wellbeing.

CSAM IS HERE TO HELP

If you or someone you love might benefit from cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT) for anxiety, depression, stress, PTSD, insomnia, or chronic illness, or if you would like more information about our therapy services, please contact us at (858) 354-4077 or at info@csamsandiego.com

References

Mental Health America. (2018). 2018 Mental Health Month Toolkit. Retrieved from http://www.mentalhealthamerica.net/sites/default/files/Full_2018_MHM_Toolkit_FINAL.pdf