Anxiety disorders, which include everything from generalized anxiety, to social phobia (aka, social anxiety), to obsessive-compulsive disorders, are the most commonly diagnosed mental health problem in the US. In fact, according to the Anxiety and Depression Association of America, anxiety disorders affect 40 million US adults. More disheartening is that less than half of those with anxiety disorders receive help for their struggles. When I work with clients who have anxiety, I often discuss with them the cycling and self-reinforcing patterns that anxiety tends to induce. This three-part series will review common ways that we give in to, and therefore worsen, our anxiety. Part 1: Ignore It Ignorance is definitely not bliss when it comes to understanding what your mind and body are doing when you feel anxious. I think about anxiety (vs. appropriate fear) as an incredibly valuable neural response that is being either overblown or misapplied. In other words, the sensations that accompany an anxious state (accelerated breathing and heart rate, sweaty palms, muscle tension, decreased or increased appetite, racing thoughts, adrenaline rush) are highly useful when we are faced with actual threats to our safety or well-being. These bodily and cognitive changes represent our fight-or-flight response that readies us for survival in threatening situations. Our bodies are poised for action with activated muscles and quick respiration and heart rate, and our thoughts are running on high speed to alert us to our surroundings and possible ways to escape. Think about how adaptive this response is, especially remembering what life was like for the original humans fending off vicious predators and fighting for the survival of our species.
However, anxiety happens when that fight-or-flight response is misapplied to situations that aren't actually threatening to our safety, or at least not threatening enough to truly need that type of response. This is where having insight into what is happening mentally and physically can give you some leverage with anxiety - it gives answers to what you are feeling, it fights "anxiety about anxiety" (e.g., thinking you may pass out or die due to how your body feels in a state of fight-or-flight), and it opens up the possibility for challenging your anxious thoughts and practicing physical relaxation training to regain a sense of calm. Truly, knowledge is power when it comes to managing anxiety. Something to practice: If you are feeling anxious or even just stressed out, try to pause for a minute and notice what is going on in your body and mind:
Keep an eye out for Part 2, which will discuss how giving in to our fears exacerbates anxiety. What strategies do you use to manage stress and anxiety? Share your go-to coping methods in the comments below.
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We hear the word "depressed" thrown around frequently these days, applied to many situations that may or may not relate to true depression. We also hear terms like "clinically depressed," "major depression," or simply "depression" when describing mood diagnoses. This post will break down how to differentiate between situational sadness, typical mood fluctuations, and the mood disorder known as Major Depressive Disorder.
It is a normal and expected part of life to have ups and downs in mood. To feel sad when disappointed by someone, to be burdened by grief after a major loss, to feel frustrated and angry at a boss, to feel defeated when getting a low grade on an exam; these are typical human reactions to life's many stressors. As Buddha said, life is suffering. So, we can expect those fluctuations within our days and weeks. However, a persistent low mood can reflect something beyond situational sadness. This is the point at which we look at the possibility of a Major Depressive Disorder (MDD), which is how depression is currently diagnosed. To be diagnosed with MDD, you must meet at least five of the following criteria:
If you or someone you know seems to be struggling with MDD, it is important to seek help. Untreated MDD can spiral into more severe symptoms, greater impairment in functioning, and increased risk of suicide. Psychotherapy is great resource to manage symptoms depression. Others utilize medication, which is most effective when combined with psychotherapy. There are also exciting new treatments on the rise, including Repetitive Transcranial Magnetic Stimulation (rTMS) and physician-administered psychoactive drugs, such as Ketamine, that are being implemented for treatment-resistant cases of MDD. Here's to a brighter future and better treatment for MDD. Thanks for reading! When it comes to figuring out the type of therapy best suited for your needs, you may find yourself in murky waters when trying to decipher different therapeutic styles. Each post in this series serves as a primer on a major therapeutic approach to guide you in the right direction. It is important to note that many clinicians identify as integrative rather than adhering to a single school of thought, though there are some that stick to one orientation over others. Even within one school of thought, however, the individual therapist inevitably brings their own unique style to the work, so nothing here is cut and dry. Additionally, on the whole, research has shown support for success with all major schools of thought! So even if you feel unsure about what style is suited for you, with a good therapy relationship you should be positioned for success. Psychodynamic therapy is a style that is typically deep and insight-oriented, as it focuses not only on symptom reduction but also on the development of client self-awareness and self-understanding of who they are, how they got to be the way they are, and ways in which they can change. It maintains focus on both the past as well as the present/future and involves the exploration of how the unconscious mind and past experiences manifest in behaviors and relational patterns. A psychodynamic clinician is curious about their client's childhood experiences and memories, their early and current attachment figures, and how they make meaning of the world around them. Through exploring the past and the unconscious mind, the therapeutic process can aid clients in challenging old patterns, learning more about themselves on a deeper level, understanding how they function in intimate relationships, and developing tools for change.
Psychodynamic therapy is often integrated with other styles, such as Cognitive Behavior Therapy (CBT), as it can address deep-rooted and unresolved struggles, providing a rich foundation and motivation for behavioral change through CBT or other interventions. In fact, psychodynamic therapy is an evolution of psychoanalysis, which is the original talk therapy (think: Freud). Many of the more "skill-focused" therapies which get a great deal of press today, including CBT, originated from psychodynamic approaches and remain embedded in psychodynamic therapy. Indeed, empirical research has supported the effectiveness of psychodynamic treatment for a range of mental health issues, and clients tend to continue improving even after their treatment has finished (Shedler, 2010). There is great variation in length of treatment for psychodynamic therapy, depending on presenting issue and therapist style. This approach tends to have less structure than CBT-based therapy to facilitate client spontaneity and insight. If you are looking not only to feel better in the present but to also learn about yourself, work through struggles from past relationships or your family-of-origin, and work on a deeper level with a therapist, this style could be a great fit for your treatment goals. Do you have questions about this style of therapy? Share them in the comments! Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109. It can be tough to make the decision to get help. There are many factors which can hold people back from beginning (or returning to) therapy. Some common hesitations I have heard clients struggle with prior to making that call include:
What other hesitations might you have before seeking help? Other stigmas you want to debunk? Share them below! When it comes to figuring out the type of therapy best suited for your needs, you may find yourself in murky waters when trying to decipher different therapeutic styles. Each post in this series serves as a primer on a major therapeutic approach to guide you in the right direction. It is important to note that many clinicians identify as integrative rather than adhering to a single school of thought, though there are some that stick to one orientation over others. Even within one school of thought, however, the individual therapist inevitably brings their own unique style to the work, so nothing here is cut and dry. Additionally, on the whole, research has shown support for success with all major schools of thought! So even if you feel unsure about what style is suited for you, with a good therapy relationship you should be positioned for success. Dialectical Behavior Therapy (DBT) is a specialized type of Cognitive Behavioral Therapy (CBT) that maintains a focus on interpersonal dynamics and relational distress. It was created in the 1980s by psychologist Marsha Linehan as a specialized treatment for those grappling with Borderline Personality Disorder (BPD). Growing up, Linehan was given a range of inaccurate psychiatric diagnoses and extreme forms of "treatment" to try to cure what she now believes was BPD. BPD only became an official diagnosis in 1980, though references to it in psychological literature are present decades prior. Linehan's own struggles with mental illness and eventual success in managing her mental state to become a thriving and high-functioning professor of psychology served as her inspiration for developing the DBT approach.
DBT is a great treatment approach for those who have intense reactions to emotional situations, especially situations related to interpersonal relationships. For some, changes in relationships, whether it be movement towards OR away from intimacy with another, can elicit very strong and overwhelming emotional responses. DBT is especially designed to aid in managing strong emotional reactions through building skills for mood regulation, distress tolerance, mindfulness (e.g., meditation, staying present), and strategies to improve interpersonal effectiveness and relationships. It is designed to help people find balance between dialectics (e.g., opposites), and practice sitting in grey areas rather than black-and-white thinking (e.g., recognizing and tolerating ebbs and flows in relationships vs. believing that getting in an argument with a partner means the relationship is doomed). DBT capitalizes on the individual's strengths to aid in symptom reduction and progress. It utilizes similar components of CBT, with an effort towards identifying and challenging unhelpful thinking patterns, as well as relaxation training and mindfulness practices to re-learn how it feels to be at peace. DBT sessions are typically structured, time-limited, and present-focused. It is administered in individual, group, or a combination of group and individual modalities. While it was developed originally for and remains the top choice treatment for BPD, it has also been successful in treating post-traumatic stress disorder, some eating disorders, depression, and substance abuse. Interested in finding a DBT therapist for yourself? Check this post for ways to get connected with a therapist. Some other helpful resources on DBT: Overview and Applications of DBT Therapy DBT Skills and Worksheets DBT Skills Workbook When it comes to figuring out the type of therapy best suited for your needs, you may find yourself in murky waters when trying to decipher different therapeutic styles. Each post in this series serves as a primer on a major therapeutic approach to guide you in the right direction. It is important to note that many clinicians identify as integrative rather than adhering to a single school of thought, though there are some that stick to one orientation over others. Even within one school of thought, however, the individual therapist inevitably brings their own unique style to the work, so nothing here is cut and dry. Additionally, on the whole, research has shown support for success with all major schools of thought! So even if you feel unsure about what style is suited for you, with a good therapy relationship you should be positioned for success. Cognitive-Behavioral Therapy (CBT) is a widely utilized therapeutic orientation and has grown tremendously over the last few decades. Aaron Beck, MD is considered the father of modern CBT and its structured, scientific, and organized approach to problem-solving. CBT involves an emphasis on education to improve self-awareness and develop coping strategies for achieving behavioral change and more positive feelings. CBT tends to focus not on HOW your struggles came to be, but more exclusively on understanding how these struggles manifest and what you can do to change -- it is heavily goal-oriented. Many clinicians integrate CBT with other therapeutic approaches, as it is a great framework for short-term symptom reduction within the context of a deeper insight-oriented therapy.
CBT techniques focus on the links among thoughts, feelings, and behavior; at its core, CBT hones in on irrational, negative, and distorted thinking patterns (see: "thinking traps"), which connect to low mood and unhelpful behavioral patterns. The therapist first works with the client to identify unhelpful thinking patterns that support low mood and maladaptive behaviors. Next, the clinician provides a model of ways to effectively challenge and alter those cognitive patterns to achieve reduction of anxiety, depression, or other mental health struggles. Importantly, clients are encouraged to adapt and continue using CBT strategies to help maintain their well-being even after the therapy is finished. In CBT, structure is important both within therapy sessions as well as during the days between in the form of homework assignments. A typical session of CBT involves completing an objective questionnaire to assess the client's mood, setting an agenda to determine what issues will be discussed, review of prior session, joint problem-solving and discussion of agenda topics, followed by a review of how the session went. CBT ranges from as few as 6 weekly appointments up to 20 depending on need, with follow up booster sessions after the course of therapy is complete. CBT has been found to be effective with many presenting problems, and it is especially well-suited (and researched backed) for anxiety disorders, somatoform disorders (psychological problems manifesting in physical symptoms), bulimia, anger problems, and general stress (Hofmann et al., 2012). If you are looking for quick symptom reduction, coping skill development, and a straightforward, structured therapy approach, CBT is an excellent option for your treatment. If you like the principles of CBT but also want a deeper, insight-oriented approach, keep an eye out for clinicians who integrate CBT with other forms of therapy, such as psychodynamic, interpersonal, and existential. CBT is quite user-friendly; if you are experiencing more mild to moderate symptoms or can't access a CBT therapist, you can find a number of self-help books based in CBT principles that may offer you some relief (see resource list). What are your thoughts about CBT? Share any questions or comments below! Some other resources to learn more about CBT: More About CBT Socratic Questioning in CBT Self-Help CBT Book List Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36(5), 427–440. http://doi.org/10.1007/s10608-012-9476-1 Making the decision to seek help is often the hardest part of beginning therapy. However, it can also be an overwhelming process to know where to look to find nearby therapists, how to find providers that take your insurance, AND find a provider who fits your schedule and price range! Not to mention, demand for high quality mental health care is at an all-time high, and many therapists are at their client capacity. This post offers strategies to guide your search and get your treatment up and running as soon as possible.
Before you start the search process, you'll want to determine whether you are going to use health insurance for therapy and what your mental health benefits are. To do this, you can either call your insurance company and ask what your coverage is, or you can log into your health insurance account online and get the same information. The perk of calling is that you can ask follow-up questions if there is anything unclear about your coverage (and let's be honest, pretty much everything is unclear when it comes to health insurance). However, calling can be time consuming and frustrating to get a live person on the other end. Either way, you'll want to have this information before calling therapists. Thanks to the internet, there are many easy ways to locate providers in your area. Before you immediately pull up Google Maps, I'd first check out Psychology Today, which has a massive directory of therapists. You can even sort the listings by location, specialty area, gender, and, most helpfully, which insurance the provider accepts. This is often your best first stop for finding a therapist who matches what you are looking for. However, not every provider has a listing on Psychology Today, especially if they are a part of a larger group practice or clinic. Another strategy to find a therapist would be to log into your health insurance account (if you are using it) and find in-network providers through the provider search option. This is a fail-safe option to ensure that the therapist is in-network so you can use your healthcare benefits. Google can also come in handy for finding any practices that are not listed in Psychology Today or if confirming health insurance coverage is not your top priority. Additionally, be sure to consider any alternative sources of mental health care you may be able to access. College students, check your school website to see if you have a counseling center on campus - this can be a great way to get short-term *free* therapy. Employees, you may have an Employee Assistance Program which often provides a few free sessions with a local provider to aid in clarifying your needs and setting you up with services. Depending on where you live and what the demand is like, it may take some time to find an available therapist who fits your needs, so prepare for a bit of a process to get there. When you do call, if you are using health insurance, be sure to have your card in front of you so the provider can verify your benefits. Additionally, your availability makes a big difference in getting in the door -- challenge yourself to prioritize your mental health and make space for therapy in your week. Have any strategies that have worked for you? Share them below! How important is a strong client-therapist match for effective psychotherapy treatment? Pretty important, but maybe not in the ways you would expect.
No therapist is a one-size-fits-all clinician; each provider brings their personality, worldview, cultural identities, and unique approach to therapy to the table at every session. Some clients may have a strong preference for a therapist of a particular gender due to their past experiences or presenting concerns. Some may look for a therapist with a particular specialty, like trauma work, LGBT issues, ADHD, parenting, etc. You may also consider the therapist's education and degree - what kind of specialization did they pursue in graduate school? Are they at the master's- or doctoral level? What is even more vital, though, is how connected you feel to your provider. Research has taught us that the emotional bond within the therapeutic relationship is the biggest predictor of therapy success, regardless of therapeutic approach (Lambert & Barley, 2001). Did you leave session feeling heard and supported? Was there warmth and empathy? Do you feel more hopeful about your situation? These factors trump the therapist's education level, specialization, or gender; even if you are convinced you can only see a young female therapist who uses CBT techniques, you may end up with a better match with someone entirely different who is able to connect with you in a more authentic and meaningful way. If you end up with a strong match from the start, wonderful! Sometimes, though, it may take a some time to feel connected and trusting. I encourage clients to give therapy a few weeks before making a decision about continuing or looking for a different provider. Be open with your provider and communicate what is working and not working in therapy. Don't worry - your therapist will not take it personally if you give them feedback about your sessions. Be an empowered consumer and use assertiveness to talk about what works for you. If it's not a good fit, let your therapist know and cancel out your appointments. A clean ending is much better than "ghosting" your therapist and never coming back -- trust me, they will appreciate it. Have any tips of your own for finding a strong client-therapist match? Share them in the comments. Lambert, M. J. & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38(4), 357-361. Considering taking the plunge and beginning a course of therapy? It is common to have some questions about what to expect when you have your first appointment. It is an emotional and often difficult decision to finally make the call and set up that appointment. Let's break down five things you can expect.
1. Anticipatory Anxiety: Whether you've been a client several times before, or if this is your very first time meeting with a therapist, it's absolutely normal and expected to be feeling a bit nervous / ambivalent / guarded / avoidant / panicked / excited / freaking-out / oh-my-god-I-want-to-cancel. Therapy is simultaneously steeped in stigma and stereotypes, while also shrouded in mystery and confidentiality, leaving you, a new client, feeling lots of feelings about getting started. I encourage all new clients to ride that wave of anxiety and doubt; don't let it prevent you from seeking the care and support you need, but notice what it IS bringing up for you, as that will be helpful to talk about with your therapist. And believe me, they will be understanding and willing to talk about any concerns or questions you have about the therapy process to help you engage fully in the work. 2. Paperwork: Yup, you'll have to fill out some paperwork. There are certain documents required by law for clients to complete before beginning a course of treatment, including a confidentiality agreement, consent to treatment, and the disclosure of some personal information, including address, phone number, insurance information (if needed), etc. Your therapist may also ask for information about your past mental health, family history, medications, physical health, and any other doctors or providers you wish your therapist to contact (only with written consent). Some therapists also include a questionnaire to assess for depression and/or anxiety to get a baseline score at the start of treatment. It's generally a good rule of thumb to show up for your appointment a bit early to allow time to complete your paperwork. 3. Orientation to Therapy: Before diving into your reasons for coming in, your therapist will often take some time to orient you to the therapeutic process. This "spiel" generally includes a review of confidentiality, which is the core of effective therapy. While there are some variations in limits of confidentiality depending on state, typically, everything you share in session remains between you and your therapist unless your therapist believes you are in imminent danger of suicide or homicide. Your therapist will review these limits with you and answer any questions you may have. The therapist will also likely disclose to you their credentials and background and logistical information about session timing, contact information, fee rates, etc. They may also discuss their approach to therapy, including theories they use (e.g., CBT, psychodynamic, mindfulness) and what to expect during initial and future sessions. This is an excellent time to ask any questions you may have about the process of therapy or your therapist's approach. 4. Information Gathering: Therapists are great contextualizers. While much of the conversation may be focused on sharing your current concerns and stressors, your therapist will want to be able to put those issues in the context of your life as a whole. Take anxiety, for example; though the symptoms may be similar for many people, it has vastly different triggers, sources, and appropriate interventions depending on the bigger context of the client's life. As a result, your therapist may ask about the history of your family and social systems, mental health, substance use, experiences of trauma, hobbies and interests, self-care practices, physical health, self-harm/suicidality, etc. If it becomes overwhelming or too difficult, it is okay to tell your therapist that you need to slow things down. You can also share general things without going into detail, or not share certain things until you feel ready to do so. It is important to remain empowered in what you choose to disclose, especially at the beginning -- which leads us to... 5. Post-Session Emotions: Initial sessions can bring up a lot. Think about it -- you just spilled a whole bunch of very intimate, personal information about yourself! Not to mention, many people don't often share this sort of information with other people in their life, and especially not to strangers. Talking about your struggles with your therapist for the first time can lead to some very positive feelings of relief, connection, and feeling heard and understood. However, it can also lead to some negative feelings of vulnerability, anxiety, or a sense of "unraveling" of things you may not have talked about or even thought about for a long time. You may be revisiting some of your ambivalence about beginning therapy in the first place (see #1) and feeling some hesitance to return for your next appointment. These reactions are expected for the first couple of sessions as you delve into your background and current struggles. As therapy continues, though, you'll notice the negative reactions will lessen as your therapy relationship becomes stronger and more trusting. Plus, you should hopefully feel some relief and improvement in your well-being as you continue in the therapy work. If you've gotten this far, you should be in pretty good shape for knowing what to expect during your first session. It is a big decision and can elicit some difficult emotions, but the journey of therapy is worth it. Approach it with openness and curiosity, and don't hesitate to ask questions and be empowered! |
AuthorDr. Bethany Detwiler is a psychologist practicing in Allentown, PA. She specializes in mood and relationship struggles. She also is an adjunct professor of counseling at Lehigh University. Archives
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