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

The Importance of Boundaries

by Annabelle Parr

Do you ever feel like you can’t say no?  Do you believe that you are responsible for the emotions of others?  Do you take others’ opinions and needs into account before your own?  Do you find yourself unsure of what you want or need (Eddins, 2015)?  If so, you are certainly not alone.  However, your feelings, thoughts, and needs matter.  By setting some boundaries in your life, you can begin to treat your needs as important.

Boundaries and Anxiety

Image source: https://blogs.goarch.org/blog/-/blogs/boundaries-healthy-limits-or-barriers-to-relationships-

For people who struggle with anxiety, learning how to create healthy boundaries can be a helpful tool.  Though sometimes people cope with anxiety by creating unnecessary boundaries or avoiding situations that serve as triggers, other times anxiety is experienced as a result of unclear lines between self and other.  When you don’t protect your sense of self, it is easy to feel overwhelmed and take on responsibility for everything and everyone (Eddins, 2015).  This can lead to feelings of guilt and anxiety.  It is not hard for a vicious cycle to ensue, where a lack of boundaries leads to anxiety, and where anxiety leads to a feeling that you cannot set clear and effective limits.

What Are Boundaries

Image source: http://quotesgram.com/img/quotes-about-healthy-boundaries/1HBuCAOAF6/

So what exactly are boundaries?  Boundaries help us to define who we are.  They orient us in our relationships, and signify to us and to others where “I end and you begin” (Eddins, 2015).  Boundaries can apply to any area of our lives, and can range from material boundaries to physical, mental, or emotional boundaries to sexual or spiritual boundaries (Lancer, 2015).  Boundaries are very personal, and there is not a right or wrong answer regarding to how to set ones that work for you.  They are based on your beliefs, values, opinions, and needs (“12 Signs,” 2015).

Boundaries as an Act of Love

A common misconception for people who struggle in this area is that setting boundaries is selfish.  However, self-care is not selfish.  Have you ever flown on an airplane, and heard the stewardess tell the passengers in case of an emergency to put their own oxygen mask on before helping others with theirs?  This “oxygen-mask” rule is a profound metaphor for the idea that we cannot take care of others if we have neglected to take care of ourselves first. 

Image source:  http://www.thedynamicturnaround.com/healthyboundaries.htm

Setting boundaries for ourselves and giving ourselves permission to articulate our needs is an act of self-love (Strgar, 2010).  And in the wise words of Brené Brown, “we can only love others as much as we love ourselves” (2010).  Furthermore, when we set clear limits in our lives, we are better able to be compassionate towards others.  Brown (2010) states that “the heart of compassion is really acceptance,” and when we lack boundaries, we are not accepting our own needs and we may have a difficult time accepting others if we feel they are taking advantage of us. 

So contrary to this idea that boundaries are selfish, they actually help us love ourselves and others better.

How Therapy Can Help

You are the only one who has the ability to set boundaries in your life.  However, therapy can be helpful in navigating this challenging task.  Therapy offers a place where you can explore your values, your feelings, and your relationships.  Your therapist can help support you in the process of determining where you need to establish stronger boundaries or areas in which you might benefit from more flexibility.

Therapy can also be a good place to experience a relationship with very clear boundaries.  Dr. Irvin D. Yalom (2002) describes “therapy as a dress rehearsal for life,” meaning that it is a safe place to encounter challenging aspects of life and relationships before you face them outside of the therapy room.  An important goal of therapy is to take what you have learned and apply it to the rest of your life, but it can be helpful to practice new skills in a safe space first.

Don’t Forget to Be Kind To Yourself

One final thing to note is that boundaries are learned (Lancer, 2015).  If you are not used to setting clear limits in your life, know that it is a skill that takes practice.  The best way to start learning this skill is to cultivate self-awareness and practice asserting yourself (Lancer, 2015).  Remember, it is important to give yourself grace and to seek support throughout this process.  If you feel like you could benefit from some professional support in developing boundaries in your life…

CSAM IS HERE TO HELP

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

References:

12 Signs you lack healthy boundaries (and why you need them). (2015).  Harley Therapy Counselling Blog. Retrieved from http://www.harleytherapy.co.uk/counselling/healthy-boundaries.htm

Brown, B. (2010). The gifts of imperfection: Let go of who you think you’re supposed to be and embrace who you are.  Center City, MN: Hazelden Publishing.

Eddins, R. (2015). Keeping Good Boundaries & Getting Your Needs Met. Psych Central. Retrieved from http://psychcentral.com/lib/keeping-good-boundaries-getting-your-needs-met/

Lancer, D. (2015). What are personal boundaries? How do I get some?. Psych Central. Retrieved from http://psychcentral.com/lib/what-are-personal-boundaries-how-do-i-get-some/

Stgar, W. (2010). The importance of boundaries. The Huffington Post. Retrieved from http://www.huffingtonpost.com/wendy-strgar/working-boundaries_b_717339.html

Yalom, I. D. (2002).  The gift of therapy: An open letter to a new generation of therapists and their patients. New York, NY: HarperCollins Publishers.

Hoarding

by Jan E. Estrellado, Ph.D.

Most of us know someone who has difficulty throwing things away or cannot seem to stop him or herself from buying things at bargain prices, even when he or she doesn’t need them.  Extreme versions of these behaviors (i.e. “clinical hoarding”) affect up to 5% of the U.S. population (Samuels et al., 2008). What might cause an individual to let these situations get out of hand?  And what can that person or a loved one do to help that person change?

What is Hoarding Behavior?

According to the International OCD Foundation (https://iocdf.org/), hoarding consists of three related issues: (1) collecting too many items; (2) difficulty getting rid of items; (3) problems with organization.  Hoarding behavior can result in significantly limited living or work space, strained relationships with others, and in extreme cases, unsanitary or hazardous living conditions.

A person with hoarding behavior may experience severe distress when attempting to get rid of items.  That person may feel he or she need these things or that he or she will eventually use them.  Even if the person’s belongings are of little material value or use, the person feels unable or unwilling to get rid of the items. 

Hoarding behavior negatively impacts relationships.  If one person in a household hoards, others living in the home may resent and/or blame that person for the status of their living conditions.  While it may seem like an “easy solution,” (i.e., “Just throw those things away!”) this is a much more complex process for the person who has difficulty letting go of material things. 

Why Do People Hoard?

A person’s beliefs about his or her posessions, as well as the meaning he or she attributes to them, are core parts of why a person hoards (Steketee et al., 2003).  A person may be extremely sentimental about his or her items and feel as if losing the item is “like losing a friend.”  The individual may feel exceptionally protective over his or her belongings and become very defensive or territorial when another person suggests he or she get rid of them.  

Source URL: http://www.dcputnamconsulting.com/hoarding-keepdonatedump/

Wheaton et al. (2010) discuss the difficulty some individuals have with tolerating distressing emotions related to hoarding.  The actions a person takes or does not take in order to minimize upsetting feelings is called avoidance.  For example, a person who feels upset when trying to give or throw something away might avoid those feelings by saving the item.  By keeping the item, the person can also avoid feelings of loss that might result from not having the item.  An individual who hoards might also feel a “high” when acquiring new items, so he or she continues to obtain new items, even if the item is not needed.

Getting Help for Hoarding

Seeking mental health treatment for hoarding behavior might be particularly difficult.  By the time the individual shows up at his or her therapist’s door, it is possible he or she has been hoarding for years.  Treatment might not have been the person’s first choice, but was perhaps at the strong encouragement of a concerned family member or friend.

Source URL:  http://hoardercleanuplosangeles.com/?p=59

Cognitive-behavioral therapy (CBT) is the treatment of choice to address hoarding behavior.  In a recent review of the scientific literature on hoarding treatment, Tolin and colleagues (2015) found that those who received CBT for hoarding had significant reductions in symptoms, especially with regards to a core feature of hoarding behavior, difficulty discarding.  A hoarding-specific version of CBT combines a number of different elements, including resolving the person’s ambivalence towards his or her hoarding behavior, and using exposure therapy to help the person directly confront his or her discomfort regarding discarding items (Tolin, Frost, Steketee, & Murdoff, 2015).

Another significant finding from the same study (Tolin et al., 2015) is that greater improvements with discarding symptoms were associated with greater number of therapy sessions conducted in the person’s home.  In-home sessions are more effective than office sessions because the therapist can be there with the client to help build new discarding and acquiring skills.

CSAM is here to help

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

References:

International OCD Foundation.  https://hoarding.iocdf.org/

Samuels, J. F., Bienvenu, O. J., Grados, M. A., Cullen, B., Riddle, M. A., & Liang, K. Y. (2008). Prevalence and correlates of hoarding behavior in a community-based sample. Behaviour and Research Therapy, 46, 836 – 844.

Steketee, G., Frost, R. O., & Kyrios, M. (2003). Cognitive aspects of compulsive hoarding. Cognitive Therapy and Research, 27, 463–479.

Tolin, D. F., Frost, R. O., Steketee, G., & Muroff, J. (2015). Cognitive behavioral therapy for hoarding disorder: A meta‐analysis. Depression And Anxiety, 32(3), 158-166. doi:10.1002/da.22327

How Anxiety Affects Couples

by Jan E. Estrellado, Ph.D.

Most of CSAM’s blogs focus on the experience of having a mental health condition, such as anxiety, depression, or PTSD.  This blog is a little different because it focuses on the impact of a mental health condition, anxiety, on couples.  What is it like to care for, live with, and support someone with anxiety?  What kind of strain might this cause in a relationship and what can couples do to sustain each other and their relationship?

Loving Someone with Anxiety

Partners or spouses of individuals with anxiety might experience feelings of helplessness.  When anxious loved ones feel intense fear (i.e., scared of having a panic attack or becoming severely preoccupied with worried thoughts) or avoid certain situations (i.e., not wanting to drive on the freeway or refusing to leave the home), partners may not feel there is much they can do to help reassure or calm them down.  When a partner does attempt to help ease his or her loved one’s suffering, those attempts (i.e., reassuring, problem-solving) may be rejected by the anxious individual.  This can be extremely hurtful and can lead to other intense feelings described below.  In addition, partners may try to help by offering to drive for the anxious partner, agreeing to skip a social event, or allowing the anxious partner to engage in compulsions so that he or she gets relief.  While these efforts are meant to be helpful, the avoidance partners are enabling actually contributes to and maintains the anxiety-related problems.   

Image source:  http://www.recovering-couples.org/

The emotions that partners of anxious individuals can experience range and vary greatly.  They may feel anger and frustration that the anxiety inhibits their lives, and because their partner’s anxiety is outside of their control.  It is difficult to accept that a loved one may continue to feel anxious, regardless of the actions of the partner.  If a partner’s anger remains unresolved over a long period of time, this can turn into resentment, minimization, or blame.  Partners may feel overlooked or overshadowed by their loved one’s anxiety, perhaps feeling like their needs can’t be met when calming their partner down feels the most urgent.

Being the Anxious Partner in the Relationship

Image source:  http://www.dralexandrasolomon.com/common-fights/

The partner who experiences extreme worry can easily feel guilt, shame, and embarrassment at their lack of ability to manage anxious feelings.  They may also feel misunderstood and alone.  These negative feelings, if not addressed or acknowledged effectively, might actually contribute to further anxiety.  If an anxious person feels his or her partner is getting frustrated, that person might shut down, withdraw from the relationship, or engage in unhelpful coping behaviors, such as smoking cigarettes or shopping excessively. When worry and stress take up a lot of space in a relationship, the anxious individual often feels responsible for his or her partner’s feelings of frustration, hurt, or helplessness.  These feelings of guilt or embarrassment compound the individual’s pre-existing feelings of worry, increasing the suffering of that person. 

It may be difficult for the anxious partner to know what he or she needs.  Perhaps he or she is too ashamed to ask for support when so much help has already been requested of the partner.  When a person experiences intense fear in the moment, it can be challenging to know what is helpful and perhaps even more challenging to communicate those needs effectively.  Intense fear, by nature, prevents a person from thinking logically or rationally and it can be tough to know how to reign one’s self in during those moments.

Sustaining the Relationship

What can a partner of an anxious individual do to help make the relationship work?  One crucial element is for the partner to make sure that he or she is able to maintain his or her own health and wellness.  A partner can feel guilty for taking care of himself or herself, especially knowing that his or her loved one may be suffering.  However, if both partners are suffering, especially over a long period of time, the relationship is no longer sustainable.  A partner might need to seek this support outside of the relationship.  Examples of support outside the relationship include trusted friends, family members, health providers, faith leaders, co-workers, and therapists.

Image source:  http://claudialistens.me/couples/

In addition, a person may want to communicate his or her needs to the anxious partner, even if it is difficult.  If only one person’s needs are being met or paid attention to consistently, the relationship feels one-sided—another predictor of an unsustainable situation.  Asking for one’s needs to be met can also include discussing feelings and reactions to the partner’s anxiety.   While communicating feelings in an authentic, yet caring way, can be challenging, both partners might experience some relief and a greater connection, and the likelihood of resentment decreases.

An anxious individual may not want to wait until he or she experiences intense fear to know what help the partner can provide.  Rather, identify wants and needs during more calm or grounded moments.  When an anxious person knows what works, it is easier to engage his or her partner in a collaborative manner.  Having a “game plan” can ease some of the intensity of fear in the moment. 

Finally, as we say in Acceptance and Commitment Therapy, anxiety can have a place in the relationship, but it shouldn’t be “driving the bus.”  When anxiety appears to be controlling the direction of the relationship despite the couple’s best efforts, it’s time for one or both individuals in the relationship to seek outside support.

CSAM is here to help

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

Trauma and the Brain

by Jan E. Estrellado, Ph.D.

image source: 

http://www.forbes.com/sites/toddessig/2015/12/02/post-traumatic-stress-disorder-ptsd-is-more-than-a-bad-story/#31ac76b313ad

Responses to trauma can be found in both the mind and the body.  In the mind, people can experience unwanted, intrusive thoughts that remind them of the traumatic event.  They may feel misunderstood, isolated, and irritated with others around them.  Their beliefs about the world might change from a sense of safety and stability to one of unpredictability and danger.

In the body, people can feel “on edge,” like something bad is about to happen.  They may feel more anxious than usual, with symptoms of an increased heart rate, sweatiness, hyperventilating, difficulty focusing, or even a panic attack.  This is more likely to be true when they are exposed to an internal or external cue reminding them of the traumatic event, but for others, it can feel like it comes out of nowhere.

Trauma Response in the Brain

For an individual with PTSD, much of the response to trauma can be found by understanding what is happening in the brain. 

When something might be dangerous or threatening, it first goes to the thalamus, which is responsible for receiving sensory input (what you see, smell, taste, touch, and hear).  From the thalamus, it can go in one of two directions.  In the first direction, the “more sensible” direction, the sensory cortex accurately appraises the event as non-threatening and the hippocampus (responsible for memories), confirms or modifies this response.  This direction, while slower than the second direction, is often more capable of accurately assessing true threat.

Image source: 

http://www.helpguide.org/articles/ptsd-trauma/ptsd-in-the-family.htm

In the second, “less sensible” direction, the thalamus sends signals to the amygdala (the emotion and fear center of the brain), which then goes to the hypothalamus, where action is taken to get relief.  This direction is often seen as tapping into the “fight or flight” response to fear.  While this direction is quicker and engages our survival mechanisms, it can also get us into trouble if our response is bigger than the situation calls for.

For individuals with PTSD, their brains often go in the second direction.  Their amygdala is on “over-drive” and cannot help them evaluate what is a true threat and what is not. 

Re-Training Your Brain

If your brain is trained to fire its amygdala at will, what can you do about it?  Enter the pre-frontal cortex.  This part of the brain is responsible for planning, strategizing, executing, reasoning, and decision-making.  At CSAM, we often encourage our patients with PTSD to engage their pre-frontal cortex in various ways: deep breathing, mindfulness practice, even coloring!  Any grounding activity that helps you stay in the present moment will help you engage your pre-frontal cortex.  These are effective short-term strategies for helping to manage an individual’s immediate PTSD-related anxiety.

Longer-term strategies include Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PE), and Acceptance and Commitment Therapy (ACT).  These interventions have strong support in the scientific literature showing their effectiveness to manage PTSD.  In CPT and PE, patients “re-train their brains” to reduce their reactivity to distressing cues, often related to the traumatic event.  They continually re-write or re-tell the story of their traumatic event until they make new meaning of the trauma, learn that the trauma memories are not dangerous and discover that they can handle the upsetting responses that come with remembering the traumatic event.  In Acceptance and Commitment Therapy, patients practice mindfulness in order to understand what distressing thoughts they have when they recall the traumatic event.  They develop a willingness to engage with the memories and feelings of the traumatic event, so that they are “freed up” to live a life based on their values and what’s important to them.

CSAM is here to help

If you or someone you love might benefit from CPT, PE, or ACT following a traumatic experience, or if you would like more information about our other therapy services, please contact us at (858) 354-4077 or at csamsandiego@gmail.com.

References:

U.S. Department of Veteran Affairs (2015).  How common is PTSD?.  Retrieved from http://www.ptsd.va.gov/public/PTSD-overview/basics/how-common-is-ptsd.asp

Anxiety and Chronic Illness

by Jan E. Estrellado, Ph.D.

Chronic illness affects half of all adults (117 million) in the United States (Center for Disease Control, 2012). These conditions can include chronic pain, fibromyalgia, arthritis, heart disease, HIV, and cancer. While the types of conditions vary broadly, stress and anxiety are common experiences for individuals with long-term illnesses.  

The Stress of Having a Chronic Illness

Image source: https://massage.elitecme.com/blog/chronic-illness-massage-therapy/

Anxiety may result in part from the unpredictable nature of a chronic illness.  For example, a person with chronic pain will likely have some days when he or she can go for long walks and some days when getting out of bed is too challenging.  The tough part is not knowing when the bad days come.  The anticipation and fear of the pain, even more than the pain itself, is a better predictor of long-term functioning  (Turk, 2002). 

Because the experience of a chronic condition is specific to each individual, it can be difficult to feel connected to others.  Isolation is common, which can both disrupt relationships and intensify negative thinking (“No one understands what I’m going through,” “I have to take care of this on my own,” “I don’t want to burden my family,” etc.).  When those negative thoughts start to spin out of control, especially without the support of others, one’s ability to manage anxiety lessens.

For a child with chronic illness, fear and anxiety can be especially common.  The unpredictability of a chronic illness can shape how he or she views the world as an adult.  Knowing that caregivers cannot control discomfort or pain may be particularly terrifying for a young person.  A child may internalize the uncertainty of what life will look like with a chronic illness (“Will I still be able to go school,” “What will my friends think,” “Will I have to take medications forever,” etc.).

Managing Anxiety Related to Chronic Illness

Each person chooses how to manage his or her chronic illness in the best way possible with the resources they have.  An important step in managing anxiety related to chronic illness is to ask one’s self about the benefits, as well as the costs, of those choices.  For example, someone with heart disease may feel that by eating whatever he wants, he is in control of his life and that his condition does not exist.  But the stress of feeling ashamed or of disappointing others also takes its toll.  Being open and honest with one’s self about the pros and cons of choices is a crucial step to managing stress.  When a person can have this conversation with one's self, he or she might be more willing to ask if this choice supports the type of person he or she want to be.

Image source: http://www.huffingtonpost.com/2011/06/30/chronic-pain-13-americans_n_887749.htm

Another way to help manage anxiety about a chronic condition is to be as present as possible, even when it is difficult.  Calling attention to your thoughts, feelings, and bodily sensations in a non-judgmental way is the practice of mindfulness.  This can be especially difficult when what you think, feel, or experience is intense pain or discomfort.  However, a review of research showed that mindfulness-based practices can improve patient outcomes not just for chronic illness management, but also for depression and anxiety (Grossman, Niemann, Schmidt, & Wallach, 2004). 

If you have a family member with chronic illness, your support is very important.  A research review on the relationship between family support and chronic illness found that patients responded most positively when their families emphasized self-reliance and personal achievement, family cohesion, and responding attentively to symptoms (Rosland, Heisler, & Piette, 2012).  Continuing to reach out to your family member with a long-term condition can make a huge difference in their management of their illness. 

Living with a chronic illness is by no means easy.  Living well with a chronic illness, however, is possible.  With the right support and coping skills, individuals with chronic conditions can take concrete steps on the path of living with, but not being ruled by, long-term illness. 

CSAM is here to help

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

References:

Center for Disease Control (2012).  Chronic diseases: the leading causes of death and disability in the United States.  Retrieved from http://www.cdc.gov/chronicdisease/overview/.

Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004).  Mindfulness-based stress reduction and health benefits: a meta-analysis.  Journal of Psychosomatic Research 57(1): 35-43.

Rosland, A.M., Heisler, M., & Piette, J.D. (2012).   The impact of family behaviors and communication patterns on chronic illness outcomes: a systematic review.  Journal of Behavioral Medicine 35(2): 221-39.  doi: 10.1007/s10865-011-9354-4.

Turk, D.C. (2002).  A diathesis-stress model of chronic pain and disability following traumatic injury.  Pain Research & Management, 7(1): 9-20.