Treating Insomnia with Cognitive Behavioral Therapy

By Annabelle Parr and CSAM Insomnia Expert Dr. Melissa Jenkins

We all know what it feels like to get a bad night’s sleep. You know you have a big day tomorrow, but you watch as the minutes and hours tick by as sleep feels elusive. Or you fall asleep but you toss and turn, dreaming about that presentation you have to give at work. You finally fall into a deep sleep and it feels like that is the moment the alarm goes off. A bad night’s sleep on occasion is pretty typical – when we are super stressed it can be harder to sleep soundly.

When sleep – or lack thereof – becomes a problem…

But for some of us, bad sleep becomes a pattern. It can become a vicious cycle with loads of stress and a lack of sleep where it’s hard to tell what’s causing what. How can you tell if your poor sleep quality is typical or whether it might be time to get some help?

Is it a few bad nights or is it insomnia?

The DSM-V defines insomnia disorder as difficulty falling asleep, difficulty staying asleep, and/or waking up too early and being unable to return to sleep for at least 3 nights per week, lasting at least 3 months. The sleep difficulties must also cause significant impairment in important areas of functioning (such as work, relationships, school, etc.), and occur despite enough opportunity for sleep. It’s also important to rule out whether sleep difficulties are due to another disorder – sleep disorder or otherwise – and are not the result of substance use.

When to seek help…

Though full clinically diagnosable insomnia has fairly specific criteria, if you are unable to sleep well often enough that it is having a negative effect on your day to day life, it’s worth talking with a professional to see how you might get better sleep. It’s a common misconception that sleep difficulties require medication – such as sleep aids – to be alleviated. However, medication is often a short-term solution, like a band aid; in order to achieve long-term results, it’s important to address the underlying problem.

People don’t often think that therapy can help them with sleep – especially if it feels like sleep is the main problem rather than a byproduct of anxiety. However, there is a particular form of therapy entirely dedicated to the treatment of insomnia: Cognitive Behavioral Therapy for Insomnia (CBT-I).

What is CBT-I?

CBT-I involves a number of elements, and is based on helping the client learn strategies that will help facilitate better sleep. According to Dr. Melissa Jenkins, CSAM’s resident insomnia expert, CBT-I focuses on improving the quality and quantity of one’s sleep. Dr. Jenkins explains some of the core therapy components include… 

Sleep efficiency therapy: People frequently say there is no pattern to their insomnia, a very common yet frustrating experience. A skilled CBT-I therapist can help make sense of otherwise confusing sleep patterns. By first examining what your current sleep (or lack thereof) looks like, a CBT-I therapist then guides you to change your sleep schedule. This strategy can greatly improve your quality of sleep. It often involves making significant changes to when you go to bed and when you wake up. These changes are often counterintuitive! People with insomnia often find this one of the most difficult but most effective parts of CBT-I. With the help of a skilled therapist, you learn how to regain control over your sleep.

Stimulus control: After extended periods of not being able to sleep in one’s bed, bed often becomes a place of stress (not rest!). The body becomes primed to be alert in bed, the exact opposite of what we need to be able to fall asleep. So, we often say the brain needs to be re-trained!  A CBT-I therapist helps re-train your brain so that you can once again sleep when and where you want to. This involves looking at what you currently do when you cannot sleep as well as things you do in your bed and bedroom that are possibly maintaining insomnia (e.g., watching tv, reading).

Sleep hygiene and psychoeducation: Another important element of CBT-I is helping you to understand the host of habits that contribute to sleep quality. Sleep hygiene involves everything from the food we eat, to the substances (such as caffeine and alcohol) we consume, the environment in which we sleep, the times of day in which we engage in particular activities such as exercise, our exposure to light (natural and artificial), and our routine leading up to bedtime. It’s not all intuitive, but when we know what can help or hinder our shut eye time, we are empowered to improve our own sleep and our health overall. CBT-I can also help teach natural ways to “trick” the body to either increase sleepiness for bedtime or alertness for optimal daytime functioning.

Relapse prevention: The goal of therapy is to give you the tools you need to create change and empower you going forward. The relapse prevention stage of CBT-I involves consolidating gains made in treatment to maintain good sleep going forward. Helping you to recognize potential triggers for an onset of acute (short term) insomnia and providing you with the tools for preventing relapse back into chronic insomnia is critical. Also, if you need to come back to therapy for a tune up, good news! Clients who return to therapy for a tune up during a relapse tend to recover quickly.

Additional therapy components: Other important aspects of treatment can include stress management and cognitive therapy (how the way you think may be triggering or perpetuating sleep problems).

At the end of CBT-I, the goal is to become your own sleep doctor: To put you back in control of your sleep and to know what to do if problems return in the future. Over the course of CBT-I, you can also learn how to determine your optimal amount of sleep (which is often different than the common myth that everyone needs 8 hours!). CBT-I is short term and typically includes 7 or 8 sessions, but can vary depending on individual needs. Treatment, while structured, is tailored the specific person and their behaviors. CBT-I is offered in individual therapy or group therapy.

Announcing: CBT-I group therapy is available at CSAM!

Interested in learning more about or receiving CBT-I? Dr. Melissa Jenkins is CSAM’s resident insomnia expert! She offers individual and group CBT-I, and is currently accepting clients for a CBT-I group waitlist in our Carlsbad office. For more information, please contact us at 858-354-4077 or at info@csamsandiego.com

Empowering Women with Acceptance and Commitment Therapy

by Annabelle Parr

According to the World Health Organization (WHO), women are twice as likely to be diagnosed with anxiety and depression as men. Women are also the largest group diagnosed with post-traumatic stress disorder (PTSD). Some argue that rather than some innate, biological predisposition to these disorders, the context in which women exist may be the cause of the gender disparity (see Dr. Robyn Walser’s article and Dr. Jill Stoddard’s upcoming book Be Mighty). The WHO states, “gender specific risk factors for common mental disorders that disproportionately affect women include gender based violence, socioeconomic disadvantage, low income and income inequality, low or subordinate social status and rank and unremitting responsibility for the care of others.” When gender intersects with other facets of identity, such as race, sexual orientation, and socioeconomic status, risk factors and inequities are further compounded. 

As Dr. Stoddard discusses in Be Mighty, women are paid less for equal work (Bishu & Alkandry, 2017), are largely responsible for household and caretaking tasks even when working outside the home (Pew Research Center, 2015), are less likely than men to be introduced by our professional title (Files et al., 2017), are evaluated as either likeable or competent as if the two were mutually exclusive (Heilman et al., 2004; Rudman & Glick, 1999), and are seen as less desirable when we outperform men (Park, Young, & Eastwick, 2015). Women are also taught that there is a narrow and rigid standard of beauty to which we must conform. Not only is our inherent worth devalued in all the ways above, but 1 in 3 women experience sexual violence in their lifetime (and little girls are twice as likely as little boys to be sexually abused). And 1 in 3 women have experienced some form of intimate partner violence (domestic violence). On top of the violence women are subjected to, we watch as victims are blamed when they come forward. They are asked to provide extensive hard evidence for the injuries perpetrated against them, questioned on their authority to be the expert on their own experience. Meanwhile, the perpetrator’s word that he didn’t do it is sufficient evidence for so-called justice to take his side, and the victim is demonized for having the audacity to speak up.

Things are changing. In the past few years we have seen a dramatic shift with women everywhere speaking up and sharing their stories, both leading up to and following the #MeToo and #TimesUp movements. But there is still a long way to go. When we really let in awareness of the injustice present in our culture, it can trigger enormous anger – an emotion women are taught we are not allowed to have. Though anger can drive productive action against injustice, it can also become overwhelming and a barrier to movement. And particularly when we are not allowed to have it, it can easily turn to depression.

Some argue that in boiling the problem down to individual mental health problems, we do women a disservice and we miss the bigger problem. What if we had an alternative? What if instead of suggesting she is the one with a problem, we saw her pain as a result of a system that tells her she is worth less?

Yeah, what if? But what now? What do we do with all of this information? Acceptance and Commitment Therapy (ACT) has some suggestions to help empower women in a context of inequality.

First, we get present. We attune to our experience in the here and now. We do our best to cultivate a willingness to feel it, to not turn away from it, despite the larger messages designed to silence us, our experiences, and our pain. This allows us to turn toward doing what matters, rather than focusing all of our energy on turning away from our pain.

Next, we cultivate an observer self. We begin to hold ourselves with compassion, like we might hold our 5-year-old selves. No matter how many negative messages we have absorbed about who we are, what we deserve, and how we have to be, there is a self underneath all of that. We are much more complex and greater than those stories we have been taught to believe. When we are able to take a new perspective on how we see ourselves and our pain –holding ourselves with the compassion we would have for a child or a friend – we become our own ally rather than our own worst enemy. In connecting to a sense of ourselves that is more nuanced and complex than any one story, we are no longer defined as unidimensional. We are free to do what matters, to live life according to our values rather than confined by messages designed to keep us boxed in.

With this observer self awareness, we can learn to examine our thoughts, such as those that tell us we have nothing of value to say, that we can’t make a difference, that we are alone, or that we are to blame. And we can learn to see those thoughts for what they are: words. When we can stop taking our thoughts as literal truths, we can choose to take action that deliberately defies them when they do not serve us. We can think “my voice and my actions don’t matter” and still choose to stand up for what we believe in. 

We show up to our pain because it deserves to be acknowledged and seen. And because within pain is valuable information. Behind our pain lies our values – they are two sides of the same coin. We wouldn’t hurt if it didn’t matter. Pain and values are inseparable and both are vital; we can’t have one without the other. Pain can feel overwhelming, but when we listen to the message it is communicating, we can identify those things that are important to us. And when we connect to our personally chosen, deeply held values, we have a compass pointing toward the direction we want to move. When we know what is important to us, we are also afforded the opportunity to connect with others who share our values. The connection to what is important to us and to others who share our values are the fuel that keeps us going when it gets hard. When our minds tell us we can’t keep going, our values remind us why we will try anyway.

Once we know our values and we are able to show up willingly to our experience in the present, we are able to commit to specific actions that are connected to what matters to us. All those thoughts that we can’t make a difference or that our voice is not loud enough are suddenly not quite so significant, because now what matters in this moment is that we act in service of what is important to us. We don’t get to control the outcome, but we do get to know that we are engaging in life in a way that is empowered by our values rather than dictated by systems determined to keep us silent and small.

Just as research shows us the ways that women are treated as “less than,” it also shows us what happens when women are empowered and are present in spaces that were traditionally not open to us. In Be Mighty, Dr. Stoddard notes that patients show health benefits when they are treated by female physicians – including lower mortality rates and fewer hospital readmissions (Tsugawa et al., 2017); corporate finances improve when women are present in leadership (Hunt, Layton, & Prince, 2015) and boards become more effective when women bring our skills to the table (Daehyun & Starks, 2016). Women’s presence in decision making improves the environment (Cook, Grillos, & Anderson, 2019) and helps facilitate more effective and enduring peace agreements (Paffenholz, Kew, & Wanis-St. John, 2006; O’Reilly, Súilleabháin, & Paffenholz, 2015). And when women are involved in politics, the lives of all women and mothers improve as their interests are represented and advocated for (Swers, 2005; Anzia & Berry, 2011).  

The world is a better place when women are represented in positions of power and leadership. And just as it is important to acknowledge that things improve for everyone when women are empowered, it is also important to acknowledge that women deserve equality and empowerment as individuals whose worth is not gauged based on the collective value we offer, but is based on our individual humanity and inherent worth. Our worth is not defined by what we can give to others, but is instead based on the fact that our existence alone is enough to mean we matter. 

So how do we move toward empowerment? We start by holding our pain the way we might hold something precious. It deserves our attention and our care. Once you know your pain, you can begin to consider what it says about what is important to you. And then you can start to take actions, large or small, toward what matters.

For more information on using ACT to empower women, check out Praxis trainings, particularly the upcoming Fierce, Fabulous, and Female online training. Also, check out Dr. Jill Stoddard’s book, to be released January 2020: Be Mighty: A Woman's Guide to Liberation from Anxiety, Worry, and Stress Using Mindfulness and Acceptance and Dr. Janina Scarlet’s upcoming book, release date TBD: Super-Women: Superhero Therapy for Women Battling Anxiety, Depression, and Trauma.

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

References

Anzia, S. F., and C. R. Berry. 2011. “The Jackie (and Jill) Robinson Effect: Why Do Congresswomen Outperform Congressmen?” American Journal of Political Science 55: 478–493.

Bishu, S. G., and M. G. Alkadry. 2017. “A Systematic Review of the Gender Pay Gap and Factors That Predict It.” Administration & Society, 49: 65-104.

Cook, N. J., T. Grillos, and K. P. Anderson. 2019. “Gender quotas increase the Equality and Effectiveness of Climate Policy Interventions.” Nature Climate Change 9: 330–334.

Daehyun, K., and L. T. Starks. 2016. “Gender Diversity on Corporate Boards: Do Women Contribute Unique Skills?” American Economic Review 106: 267–71.

Files, J. A., A. P. Mayer, M. G. Ko, P. Friedrich, M. Jenkins, M. J. Bryan, S. Vegunta, C. M. Wittich, M. A. Lyle, R. Melikian, T. Duston, Y. H. Chang, and S. N. Hayes. 2017. “Speaker Introductions at Internal Medicine Grand Rounds: Forms of Address Reveal Gender Bias.” Journal of Women’s Health 26: 413–419.

Heilman, M. E., A. S. Wallen, D. Fuchs, and M. M. Tamkins. 2004. “Penalties for Success: Reactions to Women Who Succeed at Male Gender-Typed Tasks.” Journal of Applied Psychology 89: 416–427.

Hunt, V., D. Layton, and S. Prince. 2015. “Why Diversity Matters.” McKinsey and Company Annual Report. https://www.mckinsey. com/business-functions/organization/our-insights/why-diversity- matters. Accessed March 24, 2019.

O’Reilly, M., A. S illeabh in, and T. Paffenholz. 2015. “Reimagining Peacemaking: Women’s Roles in Peace Processes,” New York: International Peace Institute.

Paffenholz, T., D. Kew, and A. Wanis-St. John. 2006. Civil Society and Peace Negotiations: Why, Whether and How They Could be Involved. Paper presented at the International Studies Association Conference, March, San Diego, CA.

Park, L. E., A. F. Young, and P. W. Eastwick. 2015. “Psychological Distance Makes the Heart Grow Fonder: Effects of Psychological Distance and Relative Intelligence on Men’s Attraction to Women.” Personality and Social Psychology Bulletin 4: 1,459–1,473.

Pew Research Center. 2015. “Raising Kids and Running a Household: How Working Parents Share the Load.” Accessed November 10, 2018. http://www.pewsocialtrends.org/2015/11/04/ raising-kids-and-running-a-household-how-working-parents- share-the-load/.

Rudman, L. A., and P. Glick. 1999. “Feminized Management and Backlash Toward Agentic Women: The Hidden Costs to Women of a Kinder, Gentler Image of Middle Managers.” Journal of Personality and Social Psychology 77: 1,004–1,010.

Stoddard, J. A. (2020). Be mighty: A woman’s guide to liberation from anxiety, worry, & stress using mindfulness and acceptance. Oakland, CA: New Harbinger.

Swers, M. L. 2005. “Connecting Descriptive and Substantive Representation: An Analysis of Sex Differences in Cosponsorship Activity.” Legislative Studies Quarterly 30 (3): 407–433.

Tsugawa Y., A. B. Jena, J. F. Figueroa, E. J. Orav, D. M. Blumenthal, and A. K. Jha. 2017. “Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians.” JAMA Internal Medicine 177: 206–213.

Redefining Passion with Acceptance and Commitment Therapy

by Annabelle Parr

Passion is supposedly a value touted by our culture: you should be passionate about your work, your partner, your children, your major, the things you fill your free time with, etc. But what does this actually mean? The way it is framed, it seems that passion is synonymous with happiness. It’s just one more layer of the larger societal message – fed and sold to us in myriad ways – that we should be happy on an ongoing basis, and that discomfort (anxiety, sadness, fear, stress, grief, etc.) is a sign that something is wrong and we need to fix it.

This colloquial use of the word passion seems to suggest that happiness is not a fleeting emotion like any other, but rather a superior, potentially permanent state of being to be achieved. After all, if you are passionate about something, it means you love it. All. The. Time. Right? 

Plot twist: passion literally translated actually means suffering—it comes from the Latin pati meaning to suffer

The true meaning of passion flips our happiness-obsessed culture on its head. If passion means to suffer, then saying follow your passion does not mean that you will be perpetually stoked to go to work. When we promote the value of passion with our partners, it doesn’t mean you will be forever on cloud-nine-oxytocin (a.k.a. love hormone)-high. When we advocate for passion when it comes to parenting, that doesn’t mean that you will think your kids are the cutest thing on the planet, incapable of doing any wrong, 24/7. When we say choose a major you are passionate about, it doesn’t mean every lecture is going to be life changing.

Okay, then what does it mean? Because surely we are not advocating for actively pursuing suffering?!

Passion, far from being about permanent happiness, is about choosing to commit in big and small ways, over and over again, to something that you have personally chosen to care about, so much so that you are willing to encounter not only joy and happiness, but also pain and suffering in its pursuit. After all, we hurt most in the areas that matter to us; if we didn’t care, it wouldn’t hurt. A life filled with passion is not a perfect life, but it is a full, juicy one.

Enter Acceptance and Commitment Therapy (ACT). 

This radical new view on passion is remarkably consistent with the goal of Acceptance and Commitment Therapy, which is to foster psychological flexibility: the ability to be open, aware, and engaged in our experience such that we are able to hold our experience gently, contact what is important to us, and choose to take action in the direction of our values even when we encounter discomfort.

The ACT perspective holds that pain is not the problem. Instead, problems arise in our lives when we are not willing to experience pain – suffering is magnified by our efforts to avoid it. Paradoxically, that first distorted definition of passion is likely to lead us further and further away not only from moment-to-moment happiness, but also away from a life guided by what matters to us, as we become increasingly restricted by our mission to try to avoid discomfort.

On the other hand, when we live our lives with real passion – a willingness to suffer as we pursue our personally chosen values – life opens up to us. When we are willing to feel anxiety, grief, sadness, fear, stress, pain, and anger (all those supposedly “negative” emotions), we are also more able to experience joy, love, connection, and yes, happiness. When we cut ourselves off from feeling half of our heart, we end up numbing the whole thing. When we are willing to feel the difficult and painful feelings, we gain access to a much deeper layer of the “positive” feelings as a result.

Obviously, all of this is a lot easier said than done. Our minds are wired to problem solve, and our culture tells us that emotions other than happiness are problems. But we do not have to stay small, stuck in a life graded solely based on the percentage of moments defined by happiness. Acceptance and Commitment Therapy can give us the tools we need to be more flexible in the face of pain so that we can go about pursuing a life rich with passion, in its truest sense.

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

Busting OCD Myths and Misconceptions: OCD In Its Many Forms

By Annabelle Parr

The term OCD has been appropriated to describe neat freaks, those who get a kick out of organizing, and the Mr. Cleans of the world. People casually joke “I’m so OCD!” in reference to their color coded planners or their squeaky clean cars or their Instagram worthy closets. Not only is this use of the term inaccurate, the tongue and cheek expression minimizes the severity and suffering associated with obsessive-compulsive disorder (OCD). 

For those who actually meet diagnostic criteria for OCD, the characteristic obsessions and compulsions are far from cute or funny. According to the DSM-5, obsessions are intrusive, unwanted thoughts, urges, or images that create immense anxiety and distress; compulsions are the actions the individual takes to attempt to neutralize, suppress, or ignore the obsessions, and involve behaviors or mental acts which are rigidly applied in response to obsessions. OCD compulsions take up at least an hour of the individual’s day, and create serious impairment in important areas of life, including school, work, and relationships.

Additionally, although most people tend to think of OCD as characterized by fears of germs or the need for things to be orderly, these are only two of many manifestations of the disorder. There are a number of categories into which obsessions and compulsions commonly fall, including checking, contamination, symmetry and ordering, and intrusive thoughts. These categories often overlap with one another and at the core all subtypes involve extreme difficulty tolerating uncertainty. 

Checking

Though the checking behavior is a compulsion, the compulsion is driven by a fear-based obsession regarding potential harm or damage that could occur if the compulsion is not engaged. Some examples in this category include checking locks, appliances, lights, and taps, checking for signs of illness or pregnancy, checking one’s valuables, or checking for signs of sexual arousal, as well as seeking reassurance. The checking behaviors – like the compulsions in all of the subsequent categories – are engaged multiple times, and often prevent one from maintaining commitments such as arriving to work on time, keeping social engagements, etc.

Contamination

In this category, the obsessive fear is related to harm as a result of being dirty or coming into contact with germs, and the compulsion typically involves excessive cleaning or avoiding situations which may result in contamination. Some common examples of feared stimuli include public or private toilets, restaurants, shaking hands, chemicals, sex, outside air, and crowds. 

Symmetry and Ordering

The obsessive aspect of this category can either be related to the compulsion, where a lack of order causes great discomfort, or can be connected to other unrelated fears or intrusive thoughts such that the compulsion to create order is believed to prevent the feared harm (e.g. contracting a serious illness) from occurring. Items – such as clothes, books, pictures, and food – must be arranged symmetrically and just right.

Intrusive Thoughts

This particular subtype is sometimes referred to as “Pure O” (for obsession), as it is characterized primarily by obsessions and avoidance, but does not typically have overtly obvious compulsions present. Intrusive thoughts are a particular type of distressing obsession, characterized by involuntary, unwanted, highly distressing and often disturbing thoughts. 

Intrusive thoughts can be related to one’s relationship, where for example, one feels the compulsion to constantly seek reassurance of one’s partner’s feelings or faithfulness.  

They can be related to sex, involving intense fear of being sexually attracted to children, sexually attracted to family members, or regarding one’s sexual orientation.

Another particularly distressing form involves intrusive thoughts regarding violence, where one fears he will carry out violent acts toward himself, loved ones, or others.  

Sexual and violent intrusive thoughts are experienced as especially disturbing, and individuals struggling with these thoughts are often hesitant to disclose them as they may believe that these thoughts are a sign that they are capable of such actions; they may also fear that these thoughts mean that they are a bad person or that they will be viewed as such. Despite the disturbing nature of these thoughts, individuals with OCD are the least likely to act on such thoughts, as they experienced as revolting; rather than indicating a propensity to carry out these actions, much of the individual’s time is devoted to suppressing the thoughts and avoiding and preventing the feared outcomes.

Intrusive thoughts can also come in the form of magical thinking, where the individual believes that thinking about something terrible – such as a natural disaster or death – makes it more likely to occur.

Finally, religious intrusive thoughts (scrupulosity) can take the form of intense fear that one is sinning, one must pray over and over, fear of blasphemous thoughts, etc. 

OCD Treatment

The good news is that effective treatment is available for OCD. The gold-standard of treatment is currently Exposure and Response Prevention, a form of Cognitive Behavior Therapy in which the client is – in the context of a warm and supportive therapeutic environment – exposed to the distressing obsessions and prevented from engaging in the subsequent compulsion. Like all forms of exposure therapy, this approach allows for new learning to occur such that the association between obsession and compulsion is slowly broken down. The client typically learns over the course of treatment that catastrophe does not strike despite failure to engage former compulsions. Medication may also be recommended in conjunction with therapy in some cases.

OCD Is No Joke

OCD can severely limit one’s ability to engage effectively and meaningfully in life. The associated distress and anxiety can be overwhelming and painful, thus OCD is not something to joke about or trivialize. However, with effective treatment, individuals can learn how to manage distress in new ways such that they are not prevented from engaging in a rich and vital life.

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

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

When You Stress About Stress You’re Stressed

By: Jill A. Stoddard, PhD

Image source: https://www.amazon.com/Stressed-Desserts-Spelled-Backwards-Poster/dp/B017C9AZUQ

What is your go-to when you feel stressed out?  Do you like a few glasses of wine, an hours long vent session, or a creative excuse to get out of a social engagement?  These are all examples of experiential avoidance—an unwillingness to experience uncomfortable internal emotions or sensations and active efforts to change, reduce, or eliminate them (Forsyth and Eifert 1996).  Does experiential avoidance work to alleviate feelings of stress?  Yep.  It works or we wouldn’t do it.  But how long does that last?  Look at your personal experience and take inventory:

1.     what do you do or not do when you feel stressed?

2.     what does it get you (i.e., what discomfort does it relieve)?

3.     what is its cost?    

When our reactions to stress result in only temporary relief but come at a cost to our health, our relationships, or other areas of importance, it’s time to reevaluate our relationship to stress. 

Think of it this way (Stoddard, 2019):  Imagine I have you in a little booth suspended above a barracuda tank.  I tell you, “Whatever you do, don’t get stressed and you will be fine.  Unfortunately, if you do feel stressed, the floor of the booth will open, dropping you into the barracuda tank.  But just don’t get stressed and you will be totally fine!” 

What do you think is going to happen?  Right—you’re stressed…and fish food.  Is it because you just didn’t try hard enough to control your stress?  Was the incentive not quite high enough?  Of course not—our most primitive instinct is to survive.  So why did you get stressed and end up swimming with the fishes?  Because when you are unwilling to experience stress, you are stressed about stress so you are stressed (Hayes, Strosahl, and Wilson 1999).  See the trap?  Your relationship to stress becomes one in which you evaluate it as bad, dangerous, and deadly. 

So, of course, you are stressed about having stress. 

So what should you do the next time you hear on Good Morning America or in the Huffington Post “Stress is bad for you!  Stress will kill you!  You shouldn’t get stressed!”  It turns out, stress has been wrongfully getting a bad rap (McGonigal 2013).  While stress does release adrenaline (the hormone thought to be harmful to the body), it also releases oxytocin, the bonding hormone that enhances empathy and motivates us to seek and give care.  Oxytocin is a natural anti-inflammatory—it’s good for our bodies and actually strengthens our hearts.  And, fascinatingly, all we have to do to mitigate the negative effects of adrenaline is simply appraise stress as helpful.

Come again?  Stress, helpful?  YES--stress can motivating!  Stress is what prompts you to prepare for the important job interview, watch over your small children in a crowded place, and get ready for the big game.  If you were totally chill, you’d likely bomb the interview, lose your kid at the mall, and blow the game.  As it turns out, there is an optimal arousal zone when it comes to doing well (Yerkes and Dodson 1908):  when stress is very high or very low, it has the potential to negatively impact performance.  But a moderate level of arousal is helpful. 

The best way to manage stress is simply to change your relationship to it.  So stop struggling to avoid and reduce your stress (how’s that working for you, anyway?), and instead work on accepting that to be human is to know stress, and stress need not be our enemy.  You can do that by remembering:

1.     stress is motivating and can improve performance at moderate levels

2.     stress prompts us to seek connection with others and this is good for our health

3.     stress is only damaging when we evaluate it as damaging

4.     when we are stressed about stress we are stressed

Now, don’t get me wrong—I’m not suggesting you give up your meditation practice because it makes you feel less stressed.  There is nothing wrong with getting your bliss on—as long as your strategies don’t come at the cost of other meaningful and important pursuits.  So go ahead and yoga-it-up—just don’t neglect your friends and family while you’re at it.

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

Forsyth, J. P., and G. H. Eifert. 1996. “The Language of Feeling and the Feeling of Anxiety: Contributions of the Behaviorisms Toward Understanding the Function-Altering Effects of Language.” The Psychological Record 46: 607–649.

Hayes, S., K. Strosahl, and K. Wilson. 1999. Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York: The Guilford Press.

McGonigal, K. 2013. “How to Make Stress Your Friend.” Filmed June 2013 in Edinburgh, Scotland, video, 13:21, https://www.ted.com/talks/kelly_mcgonigal_how_to_make_stress_your_friend/transcript

Stoddard, J. 2019. Be Mighty: A Woman’s Guide to Liberation from Anxiety, Worry, and Stress Using Mindfulness and Acceptance. Oakland: New Harbinger Publications.

Yerkes, R. M., and J. D. Dodson. 1908. “The Relation of Strength of Stimulus to Rapidity of Habit-Formation.” Journal of Comparative Neurology and Psychology 18: 459­–482.