Treating Anxiety & OCD Quickly and Effectively

by Dan Kalb, Ph.D.

Nearly one in five Americans has suffered from anxiety this past year, making it the most prevalent of psychological disorders. Fortunately, it is highly treatable.

Despite what zealots say, not every problem is best addressed with CBT. But there’s a network of cross-confirming research that cites cognitive-behavioral approaches as the treatment of choice for these disorders.

Many tools and techniques that can aid in symptom management are easy to learn, and apply, and can add to the armamentarium of non-CBT therapists. Freeing patients from an excessive burden of anxiety can often be a springboard to growth, at which point other approaches to treatment can be even more beneficial.

The most critical principle in the treatment of all anxiety is that patients must face what they fear. Usually this is done hierarchically, in small incremental steps. At first, patients habituate to less scary thoughts, feelings, sensations, and situations. In their homework, (and sometimes during sessions), they are encouraged to address ever more dreaded triggers. Talking about the origins of a fear, and its impact, is no substitute for heading out into the real world to practice facing it.

Along these lines the gold standard for the treatment of OCD is called exposure and response prevention (ERP). The patient is tasked with facing anxiety-provoking stimuli and then abstaining from engaging in behavioral or mental compulsions.

Cognitive techniques help change the way patients talk to themselves about anxiety. Improving self-talk can make a huge difference in preventing symptoms from increasing. Mindfulness fosters an ability look at anxiety, rather than from it. By stressing acceptance it enables the individual to change his or her fundamental relationship distress. In essence, the patient becomes more comfortable with discomfort.

Therapists will find that applying these tools to themselves will yield manifold benefits. Lives expand or contract in proportion to our courage to confront our fears.

To learn more about quickly and effectively treating anxiety, consider Dan’s upcoming workshop: http://tinyurl.com/ycy5hfd8

For more about Dan Kalb, visit: www.cbtMarin.com

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Money in Psychotherapy

by Diane A. Suffridge, Ph.D.

I publish a blog every two weeks for therapists who are in training or newly licensed.  The question poses a dilemma that is common to new practitioners, and the answer provides some suggestions on resolving the dilemma.  This post may also provide some insight to readers who find themselves with mixed feelings about paying for psychotherapy.  

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QUESTION:

My internship is in an agency that charges sliding scale fees.  One of my clients hasn’t paid for the last two sessions, saying he forgot his check both times.  I know he can afford it because he just came back from a big vacation to Hawaii.  How can I bring this up with him and get him to pay on time?

RESPONSE:

This is a difficult clinical issue, and it’s a good experience to have during your training.  If you plan to work in a private practice after licensure, you will find that the meaning and emotions associated with client payment and fees become more complicated when it represents your income and livelihood.  Having this experience while you are in training and not dependent on the fees for income allows you to come to a better understanding of the issues involved for you as well as your clients.

I recommend that you approach the exploration of money and fees by reflecting first on the meaning and emotions that are present for you both personally and professionally.  Often money is a way of expressing and experiencing value or validation, and it may be used as a tool to exert interpersonal power.  Feelings related to self-worth are often associated with the exchange of money in a relationship.  These may include entitlement, comfort, envy, shame, deprivation, and pride.  Think about the role that money plays in your family relationships and the meaning of money in your cultural community.  You may become aware of implicit messages like “it’s not polite to talk about money,” “you have to fight for everything you get,” “you’re only worth what people give you,” or “if you work hard enough you’ll get what you deserve.”

In addition to your personal and cultural history with money, your current status as a therapist in training includes complex relationships with money.  You may have taken on significant student loan debt or received support from a partner or family member.  You are probably working as a volunteer or receiving a small salary while you are accumulating hours toward licensure, and you may be working another job in or outside the mental health field to pay your expenses.  All of these factors will contribute to the feelings that arise in you when your clients pay or don’t pay their assigned fees.  These will become heightened when you are in a private practice and your client fees are a source of income.

Once you have become more clear about how money impacts you in your clinical work, you can move to reflecting on the meaning of money for your client.  Some of the things to consider are his early family experiences related to money, value, and power; cultural messages related to money and gender, since there may be different expectations for men and women; the meaning it has for him to seek services at an agency that offers a sliding scale; and the emotions associated with his financial choices.  Think about conversations and interactions you have had in setting his fee, in sessions when he brings payment and when he doesn’t, and when he tells you about purchases or expenses like his recent vacation.

Your understanding of how you and your client think and feel about money will help you begin to identify the relational and cross-cultural dynamics in this therapy relationship and specifically in his recent lack of payment.  A few possibilities to consider are: your client feels shamed by requesting a sliding scale fee and manages his shame by withholding payment; you are reluctant to discuss money openly and have had difficulty setting an appropriate fee and clear expectations about payment; your client devalues his emotions and needs for nurturing leading him to forget payment for a service that involves both emotions and needs for nurturing; your client associates masculinity with interpersonal power and is attempting to balance the power differential.

What is important in your examination is to consider the contribution that you and the client are each making to this current conflict which will help you identify what you need to do internally and interpersonally to address your client’s lack of payment.

For more about Diane Suffridge, visit: www.dianesuffridgephd.com

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

The Topic of Shame

by Mark Zaslav, Ph.D.

Feelings, thoughts, memories, experiences or fantasies can turn into topics when we have a chance to step back from, appraise, and acknowledge them. In psychotherapy, an issue becomes a topic when sufficiently specified and labeled to enable discussion and examination. This very transformation into declarative form accomplishes a great deal. Putting problems into words may be a first step in seeking help. In semantic form, our issues take on a reality and a sense of context that they lack in their latent, experiential or implicit form. Our experience is so rich, and our minds capable of so much conscious and unconscious activity, that anything can become a topic. A conscious conflict or dilemma might become a topic when we get a chance to talk with a trusted friend. On the other hand, there are a myriad of other potential conflicts or dilemmas that may tend never to become topics even in imagination or intention. Unspoken, unacknowledged burdens trouble us all at times.

Guilt and shame differ in their potential to become topics. While the “self-conscious” emotions of guilt and shame are often confused or conflated (even by therapists), cognitive and social psychologists view them as different emotions. In the parlance of current psychological theory, guilt is about “doing” and shame is about “being.” Guilt is an emotion we feel when our act causes real or imagined suffering to another person. Guilt is associated with a sense of regret as well as a motivation to make amends or apologize. In shame, on the other hand, the focus is inward and much broader. Rather than a reaction to having committed harmful actions, shame involves a global sense of being bad, deficient or inadequate. Excessive, recurrent states of shame are associated with tendencies to hide, blame or attack others, or escape into defensive grandiose or persecutory fantasies.

Psychotherapy patients express guilty topics more directly than shameful ones. Guilty patients tend to talk a good deal about their imagined ability to cause suffering. Struggling with an exaggerated sense that they are capable of burdening or injuring others, guilt-prone people will openly share their worries and concerns to friends, loved ones and psychotherapists. They often find it extremely cathartic merely to “confess” some real or imagined harm or potential harm that is worrisome. There may be a sense of expiation in this exchange.

We are social animals. Our complex cognitive capacities have evolved in large part in order to analyze, understand and encode in working memory various important social scenarios or transactions. Transactions involve people and their actions, generally appraised through the lens of self-conscious emotions. A guilty narrative is a story in that there are discrete actors, each having particular interpersonal roles. The guilty perpetrator does something that causes harm to another person in reality or imagination. The harmed person suffers and the guilty self experiences acute regret at the infliction of suffering. The guilty self is in turn imbued with the motivation to apologize, make amends, or “undo” the harm. Evidence for the successful negotiation of this social transaction would be for the harmed individual to forgive the guilty self or to correct guilty distortions by reminding the self that it did not actually commit the imagined offense. Telling the guilty narrative may feel helpful because the person to whom it is told (perhaps a therapist) may be seen symbolically as a proxy for the harmed, who is somehow capable of issuing expiation.

In the case of shame, however, there is no corresponding “story” that is easily told. In shame, the self has not committed an act. The self is fundamentally bad and unworthy to live. This phenomenon does not have a clear playbill of actors, and there is no schematic action that can yield any corresponding sense of remediation. The condition is a wordless, internal sense of a self that is ugly and unworthy. There is no point in expressing this painful material as there is no external agent who can provide the shameful equivalent of forgiveness of the self.

Whereas in guilt the therapist is potentially seen schematically as a potential source of expiation, in shame the therapist may instead suddenly become the devaluing other, scrutinizing and judging the self as deficient or bad. Thus, the shameful situation is not a story having definable actors, it is not written in words, there is no safe person to tell it to and it is not worth telling because it has no foreseeable favorable outcome. The only “solution” is to hide, turn away, or lash out in blame at “others” who are at fault. In fact, shame-prone people often initially present to therapy not to explore their own shame-related problems, but to decry a sense of despair and frustration at the actions of other people in their lives.

In order to help the patient overwhelmed with shame, it is the task of the therapist to make inferences that enable the person to begin to tolerate introduction of the relevant topics. The therapist must be attuned to subtle signs of emotional disconnection, brief but discordant emotional displays (e.g., inappropriate laughter or smiling), confusing omissions in narrative or sudden deflections or disorganization of speech to extrapolate the shameful theme initially being avoided. With tact and empathy, we help the patient piece together topics that are hauntingly familiar but threatening. A picture emerges of recurrent states in which the patient signals that he is experiencing or warding off a deep sense of emptiness, deficiency or self-loathing.

Once revealed, the topics related to shameful self-evaluation tend to flip in and out of focus. At times, the therapist will be recipient of projections appointing him or her as spokesperson for various split-off aspects of the patient’s internal shaming narrative. These enactments enable the therapist to experience parts of the patient’s story at first hand. As the therapist becomes incorporated into the narrative, developments in the relationship between therapist and patient help clarify the emerging issue. For example, the therapist might be in a position to shed light on a pattern in which normally neutral therapist comments take on a projected quality of criticism in response to certain sensitive themes.

As relevant topics are identified and explored, shame and its derivatives can lose some of their debilitating hold on the individual. This therapeutic knowledge is portable. The patient now carries within herself the sense of context and self-exoneration gained in therapy. Access to this new understanding is increasingly linked with the therapist’s stance of understanding and support. With practice, instantiation of an awareness of familiar topics into working memory can help the patient cut short, for example, descent into deflation before it becomes an outright implosion of self-esteem. As mood and personality organization become more stable, shameful states of mind can become less intrusive and compelling. As a result, the shame-prone patient will come to feel more whole, adequate, and essentially deserving to exist.

For more about Mark Zaslav, contact him at markzaslav@gmail.com

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Why “Just Get Over It” Doesn’t Work with Anxiety and Depression 

By Melanie Greenberg, Ph.D.

We are continually bombarded with messages from the media and self-help gurus that we are in charge of our own happiness. All we need to do is buy this product ot follow that secret formula and we can get rid of anxiety and negative emotion for good.  If getting rid of negative emotions is so easy, why is it that more than 21 million children and adults get diagnosed with depression each year and that depression is the leading cause of disability for adults age 15-44? Why is it that 40 million adults in the United States suffer from an anxiety disorder?.

The truth is that we can’t just get rid of negative emotions when we feel like it.

Below are six reasons why negative emotions l(like fear or  distress) are such a struggle for us:

(1) Our brains are wired for survival, not happiness. That is why they keep bringing up negative emotions, past mistakes, and worries about the future. We can get stuck in repetitive cycles of self-criticism, worry, and fear that interfere with our ability to be fully experience and react adaptively to what is happening in the present.

(2) It doesn’t work to just shove negative emotions down or pretend they don’t exist. Because of the survival wiring of our brains, they will be given high priority and keep popping up again in conscious experience. In fact, some research by Daniel Wegner and colleagues suggests that suppressing thoughts while in a negative mood makes it more likely both the thoughts and the negative mood will reoccur.

(3)  Our physiological systems can react to mental images and events as if they are happening in the real world. Try thinking about smelling and then biting into a lemon.  You will likely feel a change in saliva in your mouth. Now think about putting your hand on a hot stove. Do you feel your heart pounding a bit faster?  Thus, when fearful thoughts and images come into your mind, your heart starts to race or your breathing get short.

(4) Negative thoughts feed on each other. We may begin by worrying about not having enough money. Then we may think, “What if I lose my job?”  and then about all the people who won’t help us and the past mistakes we made getting into this financial situation in the first place. Before we know it, allowing ourselves to dwell on a small negative thought has led to a mental mountain of difficulties.

(5) The things we do to avoid or try to cope with feeling negative emotions may be more counterproductive than the emotions themselves. People frequently turn to alcohol, marijuana, or prescription drugs, such as Xanax, to escape anxiety. These substances have negative effects on mood and motivation and addictive properties. Turning to food excessively can lead to overweight or obesity and low self-esteem associated with weight gain.  Getting angry and blaming others for our negative emotions can ruin our relationships. Shopping or avoiding opening the bills can lead to mountains of debt.

So what do we do with those distressing and uncomfortable feelings? The answer is surprisingly simple – We learn to make peace with our own feelings and, by doing so, take away their power. As we begin to untangle the feelings themselves from our negative judgments about them (e.g., crying is a sign of weakness), we begin to allow them in. We learn when to listen to our feelings and when to calm them down. Once we understand the connection between events in our lives, our thoughts, and our feelings, we can better anticipate our own reactions, make better choices about how we spend our time, and prepare for emotionally “high risk” situations.  We can also use mindfulness techniques or cognitive reframing strategies to take a step back and see the issue from a broader, wiser perspective.

Psychotherapy can provide you with expert guidance, coping strategies, and emotional support to experience and express your own feelings, while staying grounded and present.  The effects of allowing in your natural, healthy emotional emotions can be transformative and empowering. You need to face your own feelings to get back in the driver’s seat of your life.

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To contact Dr. Greenberg or to find out about her services, e-mail her at melaniegreenberg@comcast.net , visit her website http://melaniegreenbergphd.com/marin-psychologist/ or read her blog – The Mindful Self-Express  http://www.psychologytoday.com/blog/the-mindful-self-express.

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

# # #

Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.