Some individuals experience a decline in mood with a sense of loss, he said. Others experience a loss of interest or pleasure in activities they previously enjoyed. Still others experience “an increased irritability, impatience or lower tolerance for the normal stresses of daily life.”

Chronic pain also creates many stressors, which can lead to depression, said Beverly Thorn, Ph.D, Clinical Health Psychology Professor and Chair at The University of Alabama whose research focuses on painful conditions. Chronic pain interferes with a person’s daily functioning. It lasts at least three months, more days than not, she said.

“People might be unable to work or work the way they used to.” Consequently, they might have financial problems, and a new role in their family. Patients have told Thorn that not being the main provider has made them feel worthless or like they’re not contributing to their family unit.

Treating Both Conditions

It’s important to treat both chronic pain and depression, Kerns said. “Many people with pain and depression say things like ‘If you had my pain you’d be depressed, too,’ or ‘If you would treat my pain, I wouldn’t be depressed.’ However, reducing pain doesn’t necessarily reduce symptoms of depression, he said.

That’s why Kerns suggested people work with providers who treat each condition (instead of an either-or approach). Some studies suggest that a collaborative and integrative approach is best. This study published in the Journal of the American Medical Association found that a course of antidepressants followed by a pain self-management program improved both depression and pain.

If you haven’t yet, consult a pain specialist for a treatment plan, along with a mental health specialist for a proper evaluation and treatment for depression, Kerns said. It’s also important to communicate regularly with your providers and pay attention to changes, Thorn added.

When to Proceed with Caution

One of the biggest challenges of treating both pain and depression is that feelings of helplessness and hopelessness lead people to try cures that are ineffective and even damaging, according to Kerns. “Continued doctor-shopping is problematic.”

Also problematic is pursuing more and more aggressive pain interventions, which he said only reinforce the “sense of helplessness and hopelessness and demoralization.”

Opioid medication is another concern. According to Kerns, there’s very little evidence that opioids are helpful for chronic pain. Instead, there’s “abundant evidence of the potential harm of long-term opioid therapy.”

For people with pain and depression, “who may be vulnerable to pursue these kinds of interventions,” it’s best to be cautious. Most experts “argue for very limited use of pharmacological agents and support education, encouragement and judicious use of non-opioid, over-the-counter [medication],” along with a healthy lifestyle and self-management techniques, he said.

How Psychotherapy Helps

Experts used to think that the amount of pain a person felt was equal to the amount of damage in their body, Thorn said. Today, however, we know that our thoughts and emotions can influence the perception of pain, making it much worse or less intense, she said. Psychotherapies, such as cognitive-behavioral therapy (CBT), harness this concept “by re-teaching your brain.”

Research has found that CBT is highly effective for managing both pain and depression. (“Some of the strongest evidence supports CBT,” Kerns said. But he also noted that other therapies such as behavioral activation and Acceptance and Commitment Therapy show promise.)

For instance, CBT teaches individuals to pay attention to their thought processes, which can maximize or minimize pain. Thoughts like “This pain has ruined my life, and there’s nothing left to be done,” negatively affect your emotions and behaviors, said Thorn, author of Cognitive Therapy for Chronic Pain: A Step-by-Step Guide. They also make you more likely to get depressed and withdraw. Plus, “If you feel like there’s nothing you can do, you won’t do anything,” which is “really dangerous for someone with chronic pain.”

For instance, one of Thorn’s clients, who has lower back pain, kept saying that his spine was disintegrating because his MRI showed some damage. Thorn asked him how this thought was affecting his emotions and behavior. “It makes me panic, and I’m afraid to do anything.” This thought also spiked his blood pressure, breathing and heart rate. Thorn suggested he find another perspective that’s more realistic and less of an emotional noose. He came up with the following thought: “There’s still some damage to my spine, but no amount of surgeries will help that damage. [However] it is the kind of damage that would be helped with muscle strengthening.”

Today, Thorn’s client plans to work with a physical therapist to strengthen his muscles. “As soon as someone has an empowering thought, they start to feel like they have a little bit more control over their life,” Thorn said. “His spine is damaged. He’s had three surgeries. But does he have control? Yes, he does.”

Paying attention to your thoughts is especially helpful when your pain level rises. For instance, Thorn suggested asking yourself, “What just went through my mind? What am I saying to myself?” If you become aware of a negative thought that’s emotionally laden for you, “stop, breathe and then consider your options.” This helps to interrupt your reflexive reactions, such as lashing out at yourself or your loved ones. It helps you choose a different path, and reminds you that you have more control than you think you do, she said.

In CBT, along with other therapies like behavioral activation, clinicians also help patients discover the kinds of physical activities they can engage in without exacerbating their pain, Thorn said. They also help them make realistic goals and manage defeatist thinking.

For instance, a person who used to run 10 miles might be able to walk for a few minutes today. They might easily think that such a minor activity isn’t even worth it. However, as Thorn said, walking for 5 minutes several days a week adds up. Soon you might be able to walk for five days, and so on. “That kind of gradual increase will build on itself.” Plus, regular physical activity helps to improve mood and energy levels.

Living with chronic pain can be especially debilitating. It can lead to or exacerbate clinical depression. Fortunately, these conditions are highly treatable. The key is to seek treatment for both, and to remember that a fulfilling life is absolutely possible.

Further Reading

Thorn and Kerns both recommended the book Managing Pain Before It Manages You by Dr. Margaret A. Caudill. Kerns suggested John Otis’s Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach Workbook.

Also, these are excellent organizations: the American Chronic Pain Association, led by people with chronic pain, and the American Pain Society, Kerns said.

The term “cognitive psychology” was coined by Ulric Neisser in 1967. “Cognition” is defined as “all processes by which the sensory input is transformed, reduced, elaborated, stored, recovered, and used. It is concerned with these processes even when they operate in the absence of relevant stimulation, as in images and hallucinations … cognition is involved in everything a human being might possibly do” (1). Some of the most notable cognitive psychologists include Aaron Beck, Eric Lenneberg and Charles Sanders Peirce.

The most common areas in which cognitive psychologists practice are abnormal psychology (such as the study of depression, anxiety and other mental illnesses), social psychology (studying the way in which humans interact), developmental psychology, educational psychology and personality psychology.

Most cognitive psychologists have a specialty, such as attention, memory, problem-solving, language processing or information processing. They can work with patients with any variety of mental illness, those who may have suffered trauma, or any number of brain disorders. They also can work with patients on a long-term basis, such as those dealing with dementia, or on a short-term basis, such as helping a child with a learning disability learn how to cope with their schoolwork and process the information they receive in school.

Cognitive psychologists work in schools and universities, research facilities, prisons, treatment or rehabilitation centers, government agencies, hospitals or in a private practice setting.

Treating patients is not the cognitive psychologist’s only job. Most cognitive psychologists also teach at the graduate and undergraduate level. They may be professors or academic advisors or they may work with groups of students who are doing research projects.

In addition to teaching, many cognitive psychologists also focus on research. Research is important in the field of cognitive psychology. Many cognitive psychologists are required to participate in research projects and publish their findings in peer-reviewed journals. It is important for cognitive psychologists to pursue their own research in areas that interest them, as well as to research specific projects dictated by employers and universities.

Becoming a cognitive psychologist takes time, dedication and a desire to explore the human brain in all its glory. The education begins with getting a Bachelor of Arts (BA) in psychology. Although a Master of Arts (MA) in psychology can lead to work, many cognitive psychologists are required to have a Ph.D (a doctor of philosophy) in psychology or a Psy.D (a doctor of psychology). They must also be trained in the areas of neuroscience, cognitive learning and conducting.

Following a Ph.D or Psy.D program, cognitive psychologists generally work at internships and at entry-level jobs in order to gain experience and get the hours needed to qualify for the examination for professional practice in psychology that will provide them with their license. Any psychologist wishing to practice in a private setting must pass this test after completing 3,000 hours (approximately two years) of supervised practice. Once certified to practice in a clinical setting, cognitive psychologists are required to take continuing education credits to maintain their license.

If you are interested in a career in cognitive psychology, please be sure to check out the resources for more information.

Resources

http://en.wikipedia.org/wiki/Cognitive_psychology

http://work.chron.com/cognitive-psychologist-job-description-17172.html

I’m just getting to know Michelle. She had her first baby 3 weeks ago and has been sad and irritable ever since. Her pediatrician was worried about her at the well-baby visit this week and sent her to me. She’d had a tough pregnancy (morning sickness that wouldn’t quit for what felt to her like forever), made tougher by the financial stress that came from her husband being out of work for several months. The doctor is worried that she and her baby aren’t getting off to a good start.

Sadly, moms like Michelle often feel alone and guilty. Not feeling what they think they are supposed to feel, they are embarrassed to admit to themselves and others that things aren’t going well. Just when they need help the most, many don’t reach out. Some start to resent their babies and begrudge them time and attention. They force themselves to do what needs to be done but don’t provide their newborns with the nurturing they need.

Still others give up on nursing, or holding their babies when bottle feeding, depriving themselves and their babies with the closeness that comes with the quiet feeding times. Propping a bottle is the best they can do. Overtired, irritable, and sinking into depression, life after birth isn’t at all what they expected.

As hormones shift and settle, it’s absolutely normal to feel what is commonly known as the baby blues in the weeks following birth. One of my clients described the first couple of weeks after her first child was born as PMS times ten. Others feel more emotionally fragile than usual and maybe a little weepy. Still others are surprised that they are on an emotional roller coaster, feeling great one minute and set off into tears by something that normally wouldn’t bother them the next. It’s all because the endorphins from delivery are leaving the new mother’s system and the body is resetting itself.

Different women react differently but normal baby blues are usually accompanied by moments of joy and wonder and happiness about the baby and motherhood. The emotions settle down after a couple of weeks and the routines and rhythms of new parenting get established.

But when those up and downs last more than a few weeks, and especially if they get worse, it may indicate that the new mom is developing postpartum depression (PPD). This happens to between 11 and 18 percent of new mothers, according to a 2010 survey by the Centers for Disease Control (CDC). Surprisingly, it can last anywhere from a couple of months to a couple of years.

Symptoms of Postpartum Depression

Postpartum depression looks like any major depression. Things that once gave the mother pleasure are no longer fun or interesting. She has trouble concentrating and making decisions. There are disturbances in sleep, appetite, and sexual interest. In some cases, there are thoughts of suicide. Many report feeling disconnected from their baby and some worry that they will hurt their baby. Feelings of hopelessness, helplessness and worthlessness immobilize them. Many feel guilty that they can’t love their child, which makes them feel even more inadequate.

In some cases, women develop psychotic delusions, thinking their baby is possessed or has special and frightening powers. Sadly, in some cases, the psychosis includes command hallucinations to kill the child.

Who Develops Postpartum Depression?

There are a number of issues that contribute to a woman’s risk of developing PPD:

• A prior diagnosis of major depression. Up to 30 percent of women who have had an episode of major depression also develop PPD.
• Having a relative who has ever had major depression or PDD seems to be a contributing factor.
• Lack of education about what to realistically expect of herself or the baby. Teen mothers who idealized what it would mean to have a baby to love with little appreciation for the work involved are especially vulnerable.
• Lack of an adequate support system. Unable to turn to someone for practical help or emotional support, a vulnerable new mom can become easily overwhelmed.
• A pregnancy or birth that had complications, especially if mother and baby had to be separated after the birth in order for one or the other to recover. This can get in the way of normal mother-child bonding.
• Being under unusual stress already. New mothers who are also dealing with financial stress, a shaky relationship with the baby’s dad, family problems, or isolation are more vulnerable.
• Multiple births. The demands of multiple babies are overwhelming even with substantial support.
• Having a miscarriage or stillbirth. The normal grieving of loss is made worse by the shifting hormones.

What to Do

In cases of the normal “baby blues,” often all a new mom needs is reassurance and some more practical help. Engaging the dad to be more helpful, joining a support group for new parents, or finding other sources of support so the mom can get some rest and develop more confidence in her mothering instincts and skills can put things back on track. As with any other stressful or demanding situation, new parenthood goes better when the parents are eating right, getting enough sleep, and getting some exercise. Friends and family can help by bringing some dinners, offering to take over with the baby for an hour or so so that the parents can get a nap, or by babysitting siblings to give the parents time to focus on the infant without feeling guilty or pulled in multiple directions.

Postpartum depression, however, is a serious condition that requires more than naps and caring attention. If the problem has persisted beyond a few weeks and has been unresponsive to support and help, the mother should first be evaluated for a medical condition. Sometimes a vitamin deficiency or another undiagnosed problem is a contributing factor.

If she is medically okay, those who care about her and her baby need to encourage her to get some counseling, both for the emotional support counseling offers and for some practical advice. Cognitive-behavioral treatment seems to be especially helpful. Since women who have experienced postpartum depression are vulnerable to having another episode of depression in their lives, it is wise to establish a relationship with a mental health counselor to make it easier to seek help if it is needed in the future. If the mom has had thoughts of suicide or infanticide, the therapist can help the family learn how to protect them both. If the birthing center or hospital offers a PPD support group, the new mom and dad should be encouraged to try it. Finally, sometimes psychotropic medications are indicated to alleviate the depression.

The baby blues are uncomfortable. Postpartum depression is serious. In either case, a new mom deserves to get practical help from family and friends. When that alone doesn’t help a new mom adjust, it’s time to seek out professional help as well.

But that’s why it’s so important to have an assortment of tools and techniques at your disposal. This way, when stress strikes, you have an army of options to deal with it healthfully.

Below, Duffy and other clinicians reveal how they reduce and manage their stress.

Before you can deal with stress, you need to recognize that you’re actually stressed out, which isn’t always obvious. “In order for me to de-stress, I need to acknowledge my stress-state in the first place,” Duffy said. For warning signs, he zeroes in on his body. “I have certain tells, like tapping my feet or slipping into a headache.”

Duffy de-stresses by writing, exercising and being with loved ones.

I write to de-stress, and this is highly effective for me. I get lost in that creative process, especially if I can get into the flow of it, and stress is a non-factor.

I can say the same for exercise. When I am running or working out, it is incongruous with stress for me.

Perhaps the best day-to-day stress manager in my life is spending time with my family and friends. And I know that if I’m laughing, I’m good.

Deborah Serani, Psy.D, a clinical psychologist and author of the book, Living with Depression, focuses on soothing her senses, and sneaks in moments of self-care, even on the busiest of days.

I have so many things I do when I’m stressed out. I’m a very sense-oriented person, so my de-stressing toolkit involves cooking, gardening, painting, meditation, yoga, catnapping, taking a walk, listening to music, lingering in the fresh air of an open window, a lavender-scented bath or nursing a cup of chamomile tea.

I have to say that I truly make “time for me” a significant priority, even if it means sitting in my car for just a few minutes during a busy day with the sunroof open, my seat tilted back just right, the radio playing soft jazz while I sip a warm latte. Just don’t bother me should you spot me in the Starbucks parking lot, okay?

Jeffrey Sumber, M.A., a psychotherapist, author and teacher, takes a meditative – and humorous — approach to stress.

When I’m stressed out I like to cook really healthy food. I like to spend time at Whole Foods getting super clean ingredients and then I like to chop vegetables, make sauces, etc., until I have a great tasting, healthy dish to enjoy.

The process is meditative and ideal for me on practical levels as well! Then I take a picture of the dish and post it to Facebook so my friends are jealous.

I also like to take the dog for a long walk so I can sort of zone out while he enjoys his exercise.

Ryan Howes, Ph.D, a clinical psychologist and author of the blog “In Therapy,” approaches stress like he does therapy.

My best protection from stress is the therapy frame: the boundaries of time, place, and role that give structure to therapy. For example, I do my best to begin and end sessions on time so I have 10 minutes each hour to write a note, return a phone call, eat a snack, and strum on the guitar I’ve had sitting by my desk for the past decade. Those 10 minutes are my time to recharge, refresh, and prepare for the next session.

I’m not rigid about this. Sometimes a session needs to run a few minutes long, but I try to hold tight to that boundary because I know it benefits me and my clients in the long run.

I also try to leave work at work by completing my notes, phone calls, and business busywork at the office.

Howes also has a variety of outlets that help him deal with stress. Seeing his own therapist is a major one.

When I’m away from work, I have my family, friends, basketball league, running, writing, and my endless quest to create the perfect tomato sauce. I’ve tried 200 recipes and I’m not there yet.

I’m also in therapy and will continue therapy as long as I’m seeing clients. I ask other therapists to do the same, or at least seek regular consultation or supervision. I believe outlets like this and feedback on your work is essential.

For Christina G. Hibbert, Psy.D, a clinical psychologist and expert in postpartum mental health, daily habits are vital in staving off stress, and coping with it.

As a psychologist and mom of 6, I must admit I feel stressed more often than I’d like. The good news is that, over the years, I’ve learned to see stress coming and tackle it before it gets out of hand.

As a wise person once said, “…calm is something you must go after, whereas stress comes after you” (Judith Orloff, MD). Stress certainly comes after me, so I seek the “calm” in the following ways.

My daily habits help the most, to both prevent and manage stress. These include: morning exercise, scripture study, meditation, and prayer; putting foods in my body that give me energy; and getting to bed in time to get a good night’s sleep (when my kids will let me!).

I also take a daily “rest” before my kids get home from school (or if they’re home, I make them rest too), so I can lay down, take a nap, read, or just unwind for a bit.

For stressed out muscles, I get a deep tissue massage at least once a month, and I’m a big fan of a hot bath on a cold day.

Hibbert turns to cognitive-behavioral techniques to cope with distorted thinking, which only exacerbates stress.

When stress levels rise, I use cognitive-behavioral techniques to manage my thinking—one of the best tools I’ve ever learned for stress management (check out my article on “Thought Management”). This helps me see what my mind is saying and gives me the opportunity to turn it into something more realistic.

She also uses stress as important information to scale back on commitments and focus more on savoring life.

I tend to be “all-or-nothing,” so I also examine my commitments and start saying “no” a little bit more. Mostly I take stress as a sign that I am doing too much. It’s a great warning signal that I need to go back to the basics again—to slow down, let love in, let go of “doing” so much and just “be” for a while.

When stress gets so overwhelming, it’s paralyzing. Joyce Marter, LCPC, a therapist and owner of the counseling practice Urban Balance, uses a tip from Alcoholics Anonymous (AA).

I know that in AA, they talk about “doing the next right thing.” When I get stressed out, I sometimes become almost paralyzed with feelings of overwhelm. I find that doing anything proactive, even something simple like straightening up my space, will make me feel better. Once I gain momentum, I tackle the things that need to be addressed to alleviate the stress.

Like the other clinicians, Marter also has a collection of tools, which includes cranking up self-care, calming uneasy thoughts and putting stress into perspective.

I increase self-care, such as exercise, proper nutrition and rest.

I practice mindfulness techniques, such as deep breathing and meditation, to ground me in the present. This helps me to stop obsessing about the past or worrying about the future, and to realize that basically everything is okay in the present moment.

I silence my inner critic and replacing that voice with a positive mantra, such as “I am only human and am doing the best that I can.”

I take everything off my plate that isn’t imperative and delegate what I can.

I share with my core support system and ask them for help.

I try to remember that stress ebbs and flows and “this too shall pass.”

I try to “zoom out” and gain perspective. If it isn’t a matter of life and death, I try not to be too serious and remember to see the humorous aspects that exist in most situations.

I try to detach from ego and focus on my essence — meaning rather than defending my sense of self (which can be very stressful), I try to let go and live life from a deeper, wiser, spiritual entity within.

Stress is inevitable. And when it strikes, it can feel like you’re being attacked from all sides. That’s why having healthy tools to turn to is critical. Maybe the above techniques resonate with you. Or maybe they help you brainstorm your own set of de-stressing activities. Either way, having a plan to prevent and handle stress can be the difference between falling from a cliff and tripping over a pebble in your path.

Dean, an English lawyer turned psychologist, is the founder and proprietor of the website PsyBlog, which he’s maintained steadily since 2004. This is his first book, and one suspects it won’t be his last. He effects a direct, bloggerly style, mercifully unclouded by the stultified prose plaguing many psychology authors whose backgrounds are different from Dean’s (i.e., career academics). Nevertheless, the book is carefully — even densely — footnoted with a trove of research studies, general readership psychology books, and online resources.

Professional psychologists likely won’t find a great deal of new material in Making Habits, Breaking Habits, and neither will voracious lay readers who’ve digested the likes of Dan Ariely, Daniel Kahneman, Timothy Wilson, James Pennebaker, Martin Seligman, and others of their ilk. Yet Dean’s book remains worth a look for these readers, if only to sift through the bibliography’s many nuggets and to read Dean’s thoughtful chapter on treating online habits.

Dean divides his book into three main sections: “The Anatomy of a Habit,” “Everyday Habits,” and “Habit Change.” He explains what habits are, how they show up in daily life, and how the average individual can set about changing, forming, or ceasing various personal habits ranging from the benign to the existential.

Habits in the popular imagination are most closely associated with either virtuous or vicious activities. On the vicious side, we think of deleterious behaviors like excessive alcohol consumption, cigarette smoking, and doughnut eating. On the virtuous end of the ledger we find beneficial routines like regular exercise, charitable donations, and daily meditation. Yet habits are inherently neither good nor bad, explains Dean. They are merely behaviors repeated with great frequency and regularity and most often performed with little to no conscious intention.

Whether good, bad, or indifferent, habits are an incredibly powerful and pervasive psychological phenomenon.

“In the war of habit versus intention,” Dean writes, “the fight is massively fixed.” Citing a large meta study by Wendy Wood and J.A. Oulette, Dean illustrates that regularly performed habits — from ordering coffee to checking email — involve little or no conscious intention. “It was only when [habitual] behaviors were performed once or twice a year — like getting a flu shot — that intentions took over from autopilot.”

Which is not to say that habits do not follow intentions, Dean tells us.

“Much of the time even our strong habits follow our intentions. We are mostly doing what we intend to do, even though it’s happening automatically,” he writes. “When washing our face each day, picking up an espresso on the way to work, or cleaning our glasses, it’s because at some point in the past we consciously decided (or someone decided for us) that these things were worthwhile activities, so we kept repeating them until they were automatic.”

If habits are automatic executions of intentions consciously set in the past, this means we can all end up performing behaviors that are misaligned with our long-term goals. For example, your expensive pre-work espresso stop may have made sense when your spouse was still earning an income, but does the habit serve you now that you’re a one-income household with a third mouth to feed? We know we should economize in this situation, and yet most of us will likely remain as profligately caffeinated as ever.

“What does this mean for our attempts to control ourselves and our chances of making changes?” Dean asks. He organizes the last two thirds of his book around answering this question. (Spoiler alert: consider re-routing your commute away from Starbucks rather than relying on a shaky mixture of willpower and good intentions for baby’s tuition fund.)   

In the book’s second section, Dean begins by elucidating how habits exert their omnipresent influence in daily life—from routine social interactions, to work, to travel, eating, and shopping. He then shifts to the darker side of habits, examining personal habit pathology as reflected specifically in obsessive-compulsive disorder and depression. Later, Dean zooms out to examine habit pathologies at the societal level relating to plane-crash prevention, seatbelt usage, and environmental protection.

Dean wraps up the second section with a strong survey of online habits, incorporating the latest psychological studies into an analysis of web multi-tasking, email, and Twitter. Synthesizing a wide range of research, Dean examines online behavior through the lens of Skinnerian pleasure reinforcement and through Csíkszentmihályi’s famous concept of “flow.”

Are you one of those people who just doesn’t understand Twitter? Perhaps the concept of variable interval reinforcement can shed some light:

As with email, on Twitter, an interesting tweet could arrive at any moment, but you don’t know when. You could get a batch of interesting tweets one after the other or nothing for a few hours. Because the intervals vary, users get used to the frustration of not getting anything interesting for a while—but they keep checking anyway.

(If you’re reading this article online — perhaps at the office — do you truly understand how you arrived at this page? You might do well to order Making Habits, Breaking Habits before you get back to what you were doing when your Twitter feed announced a new book review on Psych Central.)

The book’s final section moves through a survey of practical techniques for forming beneficial new habits and for breaking undesired old ones. The latter activity turns out to be a difficult proposition indeed. With considerably less grace than old soldiers, “old habits really do die hard,” writes Dean. “Even after habits have apparently faded away through lack of repetition, they still lie in wait to be reactivated.”

The reason cigarette smoking is so addictive, Dean says, is that it combines two cast-iron habits: daily contextual behaviors (like coffee drinking) plus the biological imperative for regular nicotine infusion. That’s the bad news. The good news is that “the best way to break a bad habit is to pair it with a new one.” For example, you pair your biological nicotine craving with the new behavior of chewing gum instead of lighting a Marlboro.

Dean concludes with a guide to practical habit formation and de-formation techniques relating to health, creativity, and happiness. He examines smoking, exercise, art, and work. As in the rest of the book, Dean’s academic overview of habit changing techniques and mechanisms is solid and substantial, though I wish he had provided more personal or third-person examples. While Making Habits, Breaking Habits is more scientifically grounded and less prone to overly tidy conclusions than Charles Duhigg’s 2012 bestseller The Power of Habit, Dean’s book lacks the compelling narrative force that the journalist Duhigg so effectively imposes on the material.

In addition to craving more specific and involved anecdotes, I found myself wishing Dean had sharpened and expanded upon his practical advice, which at times became repetitive. The book likewise could have benefitted from the addition of some interactive, “workbook”-like material. An attractive feature of recent heavyweight works like Kahneman’s Thinking Fast and Slow and Seligman’s Flourish lies in the frequent opportunities afforded the reader to test and measure herself with a variety of simple but highly informative psychological diagnostic tools.

Ironically, these weaknesses derive from one of Dean’s major strengths: namely, modesty. Dean neither evangelizes for a favored theory nor beats the drum for his own proprietary “habit cure.” Commendably, he merely sets the table for a reader to make his own decisions and implement his own modification regime. For my part, I took away a newfound enthusiasm for some long-forgotten CBT techniques and a resolution to avoid sugar and Twitter in the new year. Unfortunately, in so doing, I fell into the classic pitfall of over-general intentions that Dean warns about near the end of his chapter on healthy habits:

The true aim of personal change is to turn our minds away from miracle cures and quick fixes, and adopt a long-term strategy. Habit change isn’t a sprint; it’s a marathon. The right mindset is to wake up tomorrow almost exactly the same person, except for one small change—a small change that you can replicate every day until you don’t notice it anymore, at which point it’s time to plan another small change….

Fair enough. When I feel like desert at night, I’ll brush my teeth instead. My nasty Twitter habit will just have to linger on until I’m svelte and cavity-free.

Making Habits, Breaking Habits: Why We Do Things, Why We Don’t, and How to Make Any Change Stick
Da Capo Lifelong Books, January, 2013
Hardcover, 272 pages
$26

In our monthly interview series, clinicians share slices from their professional and personal lives. They reveal the challenges and rewards of being a practitioner, how they handle stress and their picks for great psychology books — and much, much more.

This month we’re pleased to feature an interview with Marla W. Deibler, Psy.D, a clinical psychologist who writes the popular blog Therapy That Works on Psych Central.

Deibler is the founder and executive director of The Center for Emotional Health of Greater Philadelphia, LLC, an outpatient facility that provides evaluation and evidence-based, cognitive-behavioral therapies.

She is a nationally recognized expert in anxiety disorders and the obsessive-compulsive spectrum, including trichotillomania and other body-focused repetitive behaviors, obsessive-compulsive disorder, hoarding, and tic disorder.

1. What’s surprised you the most about being a therapist?

The common experience of clients, despite the great diversity amongst individuals, constantly amazes me. Each therapy client is unique in their own life, yet when they are experiencing a psychiatric illness, their symptoms and distressing events are surprisingly like others who also struggle with their particular diagnosis.

In my practice, I frequently see clients who are seeking diagnosis and effective treatment for what they believe to be unusual difficulties, yet their experiences are not uncommon and are frequently seen in my practice.

It’s a wonderful experience, as a therapist, to be able to provide diagnosis and effective treatment to those who felt that they were “the only one” and find that their struggles are not uncommon after all.

2. What’s the latest and greatest book you’ve read related to mental health, psychology or psychotherapy?

I used to read only psychology books. It’s true. In my spare time, I read psychology for fun. In recent years, I’ve moved to other genres to give myself a break from my work. That being said, here are a few that stand out for me:

Acceptance and Commitment Therapy (2012) by Steven Hayes, PhD and Jason Lillis is a great book about the basics of ACT, which has recently interested me. I consider myself to be an evidence-based practitioner and this “third wave” cognitive behavioral therapy has garnered much attention in recent years.

Internal Family Systems by Richard Schwartz, PhD (1995) is not a recent publication, but it is a book that has really left an impression on me, sparking a great deal of thought into the different ways to conceptualize and work through cognitive dissonance. A really fascinating approach to working with an individual’s inner turmoil.

Don’t Panic by R. Reid Wilson, PhD (1987/2009) is an “oldie but a goodie.” This book is the first psychology book I can recall reading (at 17 years of age) that left me amazed at the link between the mind and body. It served as the catalyst for my interest in becoming a psychologist. (Thanks, Dr. Wilson!)

3. What’s the biggest myth about therapy?

The biggest myth about therapy is that therapists are merely trained listeners and talking about one’s problems will help them feel better. Therapy is so much more than this.

It is an evidence-based science and a craft that requires a great deal of skill and creativity. Therapy is a process that involves learning to change one’s subjective experiences (thoughts, feelings, behaviors) through skills acquisition, insight, and the generation of new mastery experiences, which lead to a positive shift in one’s perception and is reflected in their more adaptive functioning.

4. What seems to be the biggest obstacle for clients in therapy?

In my practice, I most frequently use cognitive behavioral therapy, which involves homework. Practicing skills, tracking behavior, and engaging in exposure and response prevention assignments, to name a few, are frequently given between sessions.

These assignments are important to the client’s progress, yet sometimes, feelings of anxiety (and the desire to avoid anxiety) or ambivalent feelings about “getting better” can be an obstacle to overcome.

5. What’s the most challenging part about being a therapist?

The most challenging part about being a therapist is the importance of continuing to learn, and grow, both as a therapist and also as an individual. There are always areas to explore and develop, no matter how much expertise you have in a particular area.

6. What do you love about being a therapist?

I love being a psychologist. I find it rewarding to connect with people at their darkest hours to show them that they are not alone and to guide them through their difficulties toward a happier, healthier, more fulfilling life.

7. What’s the best advice you can offer to readers on leading a meaningful life?

There is no definition for what it means to live a meaningful life, despite societal ideals. It is up to each of us to make our own meaning of our experiences.

Look within to find who you are and what makes you feel good about your life and your impact on the world. Live consistently with this internal self.

8. If you had your schooling and career choice to do all over again, would you choose the same professional path? If not, what would you do differently and why?

If I had to choose an academic path again, I would likely choose the same path. I am very happy in my professional life.

9. If there’s one thing you wished your clients or patients knew about treatment or mental illness, what would it be?

Change is a process.

10. What personally do you do to cope with stress in your life?

I prioritize my own healthy stress management and utilize many of the skills I teach others to develop in order to maintain my own well-being. I engage in cognitive restructuring, practice relaxation, sleep, exercise, clean, and enjoy time with family and friends.

Structure helps me to feel in control of my stress; I make lists and organize my environment and responsibilities. My husband is also a psychologist and we find it helpful to talk with each another about the stressors in our lives.

Staying connected to friends is also helpful. Social support is a very important factor in resiliency, happiness, and well-being.

Grace had grown up in a religious home. She was familiar with the above proverb. She understood it as a reminder to maintain pure thoughts to be a better person. Unfortunately, she was challenged by obsessive-compulsive disorder (OCD), and every time she read verses such as this, her anxiety and guilt would torment her.

Honesty and integrity were often talked about in her home. Impure and blasphemous thoughts were against her religious beliefs. She had learned that if she were to sin, she could take steps to be forgiven. A broken heart, contrite spirit, and confession were essential.

Her troubles began in middle school. She was taking a history test and inadvertently looked at her neighbor’s test. Her guilt drove her to tears. Because of her values, she had to come clean. She did, and failed her test. This seemed to be the beginning of her cascade of constant guilt caused by her thoughts.

When a kid at school would announce someone had stolen his lunch money, she’d quickly look in her pockets, school bag, and desk to ensure she was not the thief. Her thoughts and fears felt real. Once, when she got an A+ on an English essay, she felt remorseful. Her mom had proofread her paper for spelling and grammar errors. She believed she had cheated. Getting rid of her guilt was more important than passing her class. Praying and confessing were a must so she could feel peace.

“Somehow my honesty issues subsided while I was in high school. But before I began college my troubles reappeared. This time my thoughts morphed into something disgusting that drove me crazy,” she told me.

Grace’s thoughts didn’t match her values. She couldn’t accept the thoughts and images in her mind of actually harming someone. She began to miss school and stay in her dorm all day. She’d spend hours “figuring things out.” She questioned her worthiness.

The truth about thoughts is that every single human being — regardless of whether he or she suffers OCD — has intrusive, disturbing thoughts at one time or another. When non-OCD sufferers have a distressing thought, they may be surprised. They may say to themselves, “Whoa! That was a weird thought.” They acknowledge it and move on.

On the other hand, when people who struggle with OCD have “random” perturbing and unpleasant thoughts, they panic. “Why in the world would I think such an awful thought? Where did that come from? What does this thought mean about me? I’m not this terrible person!”

OCD sufferers begin to reassure themselves in many ways to decrease anxiety and guilt. Their thoughts are troublesome because they are incongruous with their moral character. After all, the scriptures tell us to have pure thoughts, don’t they? However, prophets and biblical writers did not have OCD in mind.

OCD is a neurological and behavioral issue. It does not relate to religious beliefs, despite the symptoms. In truth, OCD often attacks whatever matters most to the person. In Grace’s case, as a devout, religious person, her OCD symptoms were related to that area of her life. She believed that thinking hideous thoughts would lead her to frightening actions. She began to question her self-worth. Depression began to surface because she couldn’t get rid of her “sins” despite her repeated repentance and confessions.

Prayers, hymns, and certain words became rituals. She began to avoid situations, places, and people to avoid triggering any tormenting thoughts. Her “OCD mind” kept telling her of the daunting consequences she would face in the future if she were not able to control her thoughts. She could not bear the thought of seeing herself living in eternal damnation.

The guilt Grace experienced was a biological consequence of her “OCD mind.” She had grown up learning “we must resist temptation,” but this wasn’t working for her. She had not learned that the guilt she felt was due not to sinning, but to OCD.

As Grace began treatment, through cognitive-behavioral therapy that included exposure and response prevention therapy, she discovered that finding reassurance and hating her thoughts were the stumbling blocks in her progress. It took some time, but she finally understood that resisting her sinful thoughts was not the answer. She learned that it’s impossible to control one’s thoughts. She learned that some of her thinking errors were contributing to her suffering.

For instance, most people who experience obsessions such as Grace’s have the belief that their thoughts equal their actions. This thinking error is called “thought-action fusion.” She believed that thinking something was just as bad as doing it. Grace had a constant need to assess her behavior and question her thoughts. She would spend hours figuring out the reason for her evil thoughts and how to undo them. She gained the experience and insight that thoughts are just that: thoughts. They come and go, and mean nothing themselves.

The road to modify her thinking habits was not easy. But she knew that what she had been doing all these years hadn’t worked. She realized that OCD had gotten in the way of enjoying her life and religion. For as she thought, she was not.

Using the latest research on brain science plus well-supported theories, Impellizzeri does a solid job of setting the stage before addressing the ultimate question underlying her book: Why is it so difficult for people to change?

The answer, Impellizzeri posits, lies in our attachments. Those attachments start forming at our earliest ages: According to Impellizzeri, “[D]uring the first year of life, infants select one primary attachment figure. This is typically the mother, as this is the person to whom the infant has been closest to the longest. Once selected, this person is set apart from all other adults in the infant’s mind. The special bond continues throughout life.” That bond manifests itself in any of four ways:

• Proximity maintenance: The infant will try to stay close to the attachment figure.
• Safe haven: The infant will go to the attachment figure for safety.
• Secure base: The infant will make the attachment figure an anchor of security.
• Separation distress: The infant will become anxious or distressed when separated from the attachment figure.

Impellizzeri spends the first chapter enumerating the ways attachment consumes our lives on a psychological level. The chapter is titled “Planting the Seeds that Lead to Your Patterns,” so the intent is clear. We’re starting small before getting big.

It would have been easy to write this book with academic jargon and difficult-to-follow explanations. However, Impellizzeri makes her subject readable by engaging her audience with stories they can relate to. She provides a case study of a girl named Amy, whose life we follow from infancy to adulthod throughout the course of the book. At the end of each chapter, Impellizzeri provides three additional brief sections: “Conclusion,” where she summarizes the chapter, “End-of-Chapter Exercise,” where she gives a technique for getting to better know ourselves, and “Chapter Takeaway,” where she gives wisdom and advice for putting the ideas into practice.

In the second chapter, Impellizzeri expands upon the first by discussing how the brain works and how attachment plays into our development. In addition to the left and right sides of the brain, there is a small pocket where things get a bit complicated. Impellizzeri discusses the reptilian brain, the limbic or emotional brain, and the neocortex or thinking brain. Impellizzeri does a good job of explaining, but there is a lot of information that could have been better condensed. In order to understand her subject, it is reasonable to first study it on a micro-scale. That said, Impellizzeri gets a little too technical and runs the risk of confusing her audience when simple clarity would have been a better fit. This, however, is really the only minor misstep I found in Why Can’t I Change?

An interesting aspect of the book is that Impellizzeri chooses to include herself throughout. By making herself vulnerable, she becomes accessible and respectable.  Impellizzeri traces her own psychological journey throughout the book, describing how she started to notice her emotional and behavioral patterns, and how she began to change them. She writes:

Understanding how you behave based on your attachment style and the development of your brain is crucial to understanding yourself. Learning about the nervous system and my automatic reactions based on my past was invaluable to me. I not only began to understand myself but also my contribution to how others reacted to me. I felt empowered with this information, knowing that first I needed to feel safe in the world and then to help those around me feel safe to change the way we interacted.

Not only was she able to become more comfortable and aware of herself through self-education, but  Impellizzeri was also able to understand on a deeper level how she interacted with people, including those to whom she is closest. As a result, her life improved.

Why Can’t I Change? excels most in giving the reader the proper foundation to approach this subject. It would have been easy to dumb the subject down, but Impellizzeri fortunately opted not to.  She instead chose to give her readers credit and respect.

By fusing academia with self-help, Impellizzeri gives us a book that is right in the middle. It doesn’t condescend, but it doesn’t pander. Why Can’t I Change? finds that happy medium that makes it both readable as well as engrossing.

Why Can’t I Change?: How to Conquer Your Self-Destructive Patterns
By Shirley Impellizzeri, PhD
Sunrise River Press: May 15, 2012
Paperback, 212 pages
$16.95

Patients have “substantial physical, school, social and emotional impairments,” says Dr. Susmita Kashikar-Zuck of Cincinnati Children’s Hospital Medical Center in Ohio. As there is no solid evidence for the effectiveness of current treatments, Dr Kashikar-Zuck and her colleagues carried out a randomized trial of cognitive behavioral therapy (CBT).

They recruited 114 adolescents between the ages of 11 and 18 years who suffered from juvenile fibromyalgia. Usual medical care was given for eight weeks. While some patients then saw a psychologist for eight weekly CBT sessions plus two booster sessions over six months, others simply received education on disease management.

CBT was found to be “significantly superior” to disease education at reducing functional disability, showing a 37 percent improvement vs. 12 percent.

Depression scores dropped in both groups, with the average score for both groups falling into the range of normal/healthy. The researchers say, “This implies that attention and support from health care providers via intensive weekly individual sessions can in and of themselves reduce emotional distress.”

They add, “These nonspecific positive effects were also observed in both groups on more global measures of patient-reported health-related quality of life. However, CBT clearly had the additional benefit of significantly improving daily functioning over and above the positive effects on overall well-being.”

Nevertheless, pain was not reduced significantly (i.e. by 30 percent or more) in either group. The effects on sleep quality also were very small, and the sensitivity of so-called “tender points” was mostly unchanged. But the authors say it is encouraging that a marked improvement in the patients’ ability to carry out previously avoided activities such as going to school, doing chores, going out with friends, and the like was achieved without increasing pain or interfering with sleep.

Almost 90 percent of the participants completed the treatment plans and followups. Much of the high retention could probably be attributed to the strong relationship that participants and parents developed with the therapists, say the researchers, because anecdotal reports were positive and treatment credibility ratings at the end of the study were high.

Details were published in the journal Arthritis & Rheumatism. The authors conclude, “In this controlled trial, cognitive behavioral therapy was found to be a safe and effective treatment for reducing functional disability and depressive symptoms in adolescents with juvenile fibromyalgia.” They add that, when added to usual medical care, CBT was “clearly the superior choice for the treatment of juvenile fibromyalgia.”

Dr. Kashikar-Zuck said, “When added to standard medical care, cognitive behavioral therapy helps to improve daily functioning and overall well-being for adolescents with fibromyalgia. All the research we’re doing shows this is something that can and should be managed early, and when left untreated can essentially lead to long-term problems.”

Interestingly, the relatively strong improvements found in this study contrast with quite small improvements in studies of adult fibromyalgia. One reason for this, the experts suggest, might be that adults with fibromyalgia have likely had the symptoms and their related dysfunctions for many more years.

Furthermore, involving the patients’ parents may have “increased support in the family environment to enhance or maintain treatment effects,” the experts write. They suggest that early identification and effective treatment of symptoms that are first noticed in adolescence “might mitigate long-term problems with disability.”

They call for further followup studies to examine longer-term effects of CBT. They also propose that future research tests whether CBT can be used to increase the patient’s ability to exercise more vigorously, and whether this combination of CBT plus exercise leads to improved functioning or reduced pain. The addition of specifically-targeted sleep training within CBT might be useful, they add.

Internet-based CBT may be another possibility for the treatment of pain in children. It has been shown to be safe, and to impart self-management skills which are sustained for at least six months after the end of treatment. This approach could be modified for use in young fibromyalgia patients, say the experts.

Reference

Kashikar-Zuck, S. et al. A Randomized Clinical Trial of Cognitive Behavioral Therapy for the Treatment of Juvenile Fibromyalgia. Arthritis & Rheumatism. Published online November 22, 2011
http://doi.wiley.com/10.1002/art.30644

One thought would lead him into another and another. His anxiety would shoot to the roof and he couldn’t stand it. He felt these thoughts would never stop tormenting him. He appeared distracted and aloof to those around him. He was too busy thinking. His brain was constantly on rewind and reviewing his thoughts and actions. Did I say this? Did she say that? What if I said this? What if this happened?

What if? What if… were constant questions in his mind. Sometimes he felt as if his brain were going to explode because it was racing a thousand miles per hour. He was sure about one thing: he needed 100 percent assurance regarding his thoughts and doubts. He spent countless hours looking for evidence to erase his doubts. It was never enough. He could never arrive at a feeling of peace.

Mike often became upset with people who didn’t understand the pain that OCD causes. When someone said “I am so OCD,” he would get irritated. He felt that people who really had OCD wouldn’t joke about it. Having OCD is not a joking matter, he lamented — but only to himself. Many people suffering from mental obsessions are embarrassed by them and may wait for years before disclosing their troubling thoughts to close friends and family. Mike was among them.

He often wondered why his OCD suffering was not the contamination or checking type. He thought those would be easier to control and manage than the obsessions he experienced. The kind of OCD Mike had didn’t fit the kind of OCD the media often describes. He wondered how he could be helped if it were all in his head. He felt hopeless.

Characteristics of People with OCD

Research indicates that OCD sufferers often exhibit high creativity and imagination and above-average intelligence. For those experiencing primarily mental obsessions, it is difficult to dismiss a random weird thought as non-sufferers do.

Individuals with mental obsessions will try to pick apart their thoughts in order to figure them out and resist them. They will also try to figure out their thoughts don’t match their self-image. They can spend hours scrutinizing the answers. It doesn’t matter how long they search through their mind for reassurance or how long it takes them to find the answer on the Internet. The answers will not satisfy the uncertainty they experience.

Treatment for OCD

Is there any hope of real help for them? Of course. However, OCD treatment is difficult, and that is one of the main reasons some stay away from treatment. Making obsessions better by performing compulsions is a temporary relief. Unfortunately, compulsions only reinforce OCD symptoms.

If you think you or someone you love has OCD, education is key. Reviewing the guidelines set by the IOCD Foundation, the ADAA, and mental health providers experienced in treating OCD, are good places to start. Sometimes individuals are not ready for or cannot afford treatment, so self-help books can be a first step. Checking what experts in the field recommend is helpful.

According to the IOCD Foundation, it can take between 14 to 17 years from the time OCD begins for people to find the right treatment. When ready, it’s important that individuals are well-informed about their options. Will the treatment be psychotherapy and medication combined? Will it be medication or psychotherapy alone? Those who wish to overcome their struggles also need to learn what kind of questions to ask potential providers.

Studies show that the most effective type of therapy for OCD is Cognitive-Behavioral Therapy, which includes Exposure and Response Prevention. These two elements are essential in treating OCD. According to the International OCD Foundation, “the Exposure in ERP refers to confronting the thoughts, images, objects and situations that make a person with OCD anxious. The Response Prevention in ERP refers to making a choice not to do a compulsive behavior after coming into contact with the things that make a person with OCD anxious.”

Usually, this strategy does not make sense to those suffering from OCD. What they want most is to decrease their anxiety, so when their therapist tells them they have to do exposures, it sounds counterintuitive. Sometimes, they have already done the exposures themselves and have found that their anxiety only increases to the point they “feel like they are dying.” The psychotherapist will coach them through this process each week. The main goal is to habituate. Through weekly homework assignments, the client learns to “teach” the “false alarm” in the brain to get used to the situation. The client will learn to prevent the response (compulsion) until anxiety is decreased.

It has been said that “in order to get out of the woods, you have to go through the woods.” People with OCD will need to experience the dark and scary woods as they are getting out. They will learn that the goal for treatment is not about finding evidence to their “irrational thoughts.” They already know this. They will learn skills for a lifetime that they can employ on their own.

When OCD tries to creep in, they will learn to recognize it and use the skills to keep it at bay. And lastly, they will learn that living with uncertainty is okay — because the truth is, uncertainties surround us all. Once people with OCD learn to accept this truth, they know they don’t have to be slaves to their OCD ever again.

The coming of the New Year is a fantastic opportunity for you to energize yourself toward achieving your goals. If you are a big procrastinator, you may be skeptical of resolutions; for you, resolutions might be just one more way to feel bad for getting stuck and unable to move forward — even toward goals that you really, truly want to achieve. So, this one year, all of you experts in procrastination get your own special No. 1 New Year’s resolution: Free yourself from the bonds of procrastination.

There are a variety of procrastination styles. Some of you may struggle with starting a project (task initiation). Some of you may have a hard time sticking with a project (focused attention). Some of you just can’t seem to finish a project (task completion). Some of you have trouble every step of the way.

Everyone does some procrastinating. People naturally put off and avoid doing things that cause them discomfort, distress, or trigger challenging emotions. Even if you are very much in favor of reaching a particular goal, there are often parts of the process of getting there that you just do not want to do.

Procrastinating becomes a problem when your internal battle between the part of you that knows you should do something (your inner ‘do it’), and the part of you that just DOES NOT WANT TO (your inner ‘I don’t want to’), drains your energy and causes problems in your home life, your relationships, your work, or your self-care.

This battle can be a war of aggression, with your inner ‘do it’ attempting to bully and threaten your inner ‘I don’t want to’ into submission, saying things like ‘what is WRONG with you, why aren’t you doing what YOU SAID you wanted to do? You are so lame, just do it, what is your PROBLEM? Other people finish home projects, what is wrong with YOU? WHY are you eating that brownie when you KNOW you want to lose weight?’

The battle can be a war of avoidance, as your inner ‘I don’t want to’ shuts out your inner ‘do it’ through busyness and distraction with other activities or by zoning out with food, alcohol, TV, or the Internet. The inner war can get so depleting that you end up curled on the couch, unable to do anything at all, or frantically expending adrenaline-charged energy to meet deadlines, and then crashing again with exhaustion.

7 Self-Talk Tips to Help You Stay on Track

So, if you find yourself stuck, rushed and tired, getting in trouble with your spouse or boss, or feeling like a failure for not honoring your self-care goals, then you may be interested in a trying a new way to motivate yourself. As you cower under the dark cloud of something you ‘should’ be doing, tune in and listen to that part of you that is saying ‘no, I don’t want to.’ What it is afraid of? What is it angry about?

Then, use these seven self-talk tips to speak nicely but firmly to that inner ‘I don’t want to:’

1. Empathy.

‘I know that you don’t want to sit down at the computer and work on your resume.’ ‘I know that your vision for this project isn’t turning into reality. I know you just hate having to accept that time has run out and you need to finish up and have an imperfect result.’ ‘I know that it causes you distress to face the truth of your finances and start budgeting.’ ‘I know that you’d prefer to avoid dealing with your body and starting an exercise plan.’ ‘I know you thought that finishing this project would happen much more quickly, and you are frustrated with how long it is taking.’ ‘I get it. It makes sense that you feel frustrated, worried and annoyed.’

2. Encouragement to explore different practical strategies for motivation.

‘Why don’t you start exploring the wide range of practical hints and strategies available from counselors, in books and online to help you get going and stay on track toward your goals? Just pick one and give it a try. Try scheduling your workout on your calendar, try using an alarm clock to keep yourself moving from task to task, try using inspirational quotes taped on your mirror. Just try it. If it doesn’t work for you, try another until you find one that does help.’

3. Encouragement to ask for help.

‘I know you think you should be able to do this on your own. I know that you think it’s silly that the hardest part of this task is formatting your resume. How about asking for help from your spouse with that one part?’ ‘I know you think that calling your insurance provider about that medical bill should be easy. But it’s just not easy for you. Why don’t you ask a friend to sit with you while you pick up the phone and dial the number?’

4. Permission to go one step at a time.

‘You don’t have to do this all at once. You get to go at a pace that is healthy for you. Just take one step at a time. Today can be the step of writing down a few notes about what you want to include in your resume. Use five minutes and take this one step.’

5. Insistence on starting TODAY, even amid uncertainty.

‘You don’t have to wait until you are completely sure of the whole process before you start it. You don’t have to know whether you want a new job before you start working on your resume.’ ‘You are not committing to anything by putting on your walking shoes. Just put them on. Now.’

6. Permission to change course if necessary.

‘You get to change course if the project or routine becomes too much for you, or turns out to not be a good fit for you. Everyone has his or her own ‘overwhelm threshold,’ and though you may wish your threshold were higher, it is what it is. You also do not always know in advance if something will be a good fit for you. It may be uncomfortable to have to reroute yourself, and you may feel disappointed in yourself and you may disappoint others. But if you try to force yourself forward with something that you fear may become too much for you or may turn out to be wrong for you, and imprison yourself with the idea that you have to follow through no matter what, then you are going to end up not taking any steps forward. So you have got to remember that you can change course if necessary.’

7. Reminders that you are human.

‘You, just like all humans, need help, have uncertainty, move slowly at times, move sideways, move backwards, try and fail, feel foolish, have regrets, and must adjust plans as new information becomes available. You, like all humans, have limitations and vulnerabilities. You, like all humans, get disappointed in yourself and disappoint other people sometimes. You, like all humans, sometimes struggle with the letdown of grand visions turning into imperfect realities. And yes, ‘all humans’ includes you.’

I know you wish you didn’t have this issue with procrastination, and could just magically become a person who is able to easily ‘just do it.’ But you are a human, and this is one of your issues, and it takes energy and time to make changes in your self. Just experiment with this new way of talking to yourself. Right now. Pick one thing you’ve been procrastinating about, choose one of these seven points and try it for five seconds. See if it helps. Just try.

SAD affects around 14 million Americans, according to author and SAD specialist Norman E. Rosenthal, M.D., in his book Winter Blues: Everything You Need to Know to Beat Seasonal Affective Disorder. (About 14 percent of American adults struggle with the winter blues.)

People with SAD experience a variety of physical, emotional and cognitive symptoms that impairs their daily functioning. They’re usually unable to perform at school or work and have difficulty interacting with others. Tasks that once seemed simple, such as household chores or paying the bills, suddenly become overwhelming.

The ability to think clearly also becomes impaired. In fact, according to SAD expert Dr. John Docherty, the disorder causes many problems for people at work. Dr. Rosenthal cites Docherty in his book. He lists these at-work problems by how often they occur: “decreased concentration, productivity, interest, and creativity; inability to complete tasks; increased interpersonal difficulties in the workplace; increased absences from work; and simply stopping work.”

According to Rosenthal, the physical symptoms can be especially prominent and debilitating. They include sleeping problems, fatigue, a revved-up appetite, loss of interest in enjoyable activities and diminished sex drive. And while mood changes are salient, individuals may feel the physical signs first. In the book, a middle-aged woman describes her physical symptoms:

I don’t really feel depressed. I just feel like all my systems have been turned off for the winter. I feel leaden and heavy and just want to lie about all the time. It’s only when I am expected to do something out of the ordinary, and I realize that I cannot do it, that I feel my mood being pulled down.

SAD Treatment

Light therapy, cognitive-behavioral therapy and antidepressants are effective in treating SAD. In 2006 the Food and Drug Administration approved the antidepressant Wellbutrin XL for preventing episodes of SAD.

Extensive research has shown that light boxes work well in boosting mood and energy. Light boxes emit artificial light that mimics the sun’s rays. They emit anywhere from 2,500 lux to 10,000 lux. (Lux is a measure of intensity.) Light therapy requires a daily commitment. It’s best to use light boxes in the early morning for 30 minutes or more during the winter months. (The 2,500-lux light boxes might even require two hours.) However, you can read or talk on the phone as you’re receiving light therapy. According to Rosenthal, you can do anything during your sessions, as long as your eyes are open, you’re facing the light box and there’s a proper distance between you and the box.

Early research has shown that CBT for seasonal affective disorder may be even more effective than light therapy (and doesn’t require the extensive time commitment as light boxes do). In this 2009 study, Rohan and colleagues compared SAD-tailored CBT to light therapy (along with a combination of both treatments and a wait-list condition). They found that CBT, light therapy and both CBT and light therapy were all effective in treating SAD.

However, at the one-year followup, participants treated with CBT were doing much better than individuals in the light therapy condition. In secondary analyses, Rohan also controlled for ongoing treatment, and the CBT participants still fared better.

Rohan is currently conducting a five-year randomized trial with 160 participants to further test CBT’s effectiveness.

CBT for Seasonal Affective Disorder

So what is SAD-tailored CBT? Specifically, it helps clients identify and incorporate enjoyable activities into their lives and to identify, challenge and change negative thoughts, according to Rohan. It’s classic CBT with a focus on coping more effectively with the wintertime.

For instance, people with SAD tend to view winter very negatively. They commonly say that they hate the cold and can’t do anything during the winter months. Rohan helps clients gain a more realistic perspective. She begins by challenging the strong word “hate.” Remember that you can hate poverty or prejudice, but you probably dislike the winter or simply prefer the warmer months. This slight shift in perspective is a big help. She also asks clients to come up with the evidence that they can’t do anything during the winter and to think of the times they have done fun things. Together, they also devise a plan that includes enjoyable activities.

As Rohan noted, this sounds a lot easier than it really is. Depression zaps your energy and desire to do anything, so engaging in activities may be incredibly difficult. That’s why Rohan starts small. Clients commit to doing 10 minutes of a specific activity. They also discuss potential barriers to engaging in the activity and problem solve to overcome them.

Seeking Treatment for SAD

If you think you might have SAD, it’s vital to see a therapist for a proper evaluation. “It can be dangerous to try to engage in self-diagnosis and self-treatment,” Rohan said.

In his book, Rosenthal outlines the signs to seek medical help:

• Your functioning is significantly impaired. You have difficulty completing tasks that were easier before; you’re falling behind with bills and chores; you make mistakes more often or take longer to finish projects; you tend to withdraw from loved ones.
• You feel considerably depressed. You feel sad more often than not; you feel guilty or hopeless about the future; you have negative thoughts about yourself that you don’t have at other times of the year.
• Your physical functions are greatly disrupted. During the wintertime, you sleep more or have a hard time getting up in the morning; you’d rather stay in bed all day; your eating habits have changed.

If you’re struggling with a mild case of the winter blues, the principles of CBT can be helpful, according to Rohan. Identify fun activities that you can do in the cold months, and avoid spending a lot of time in bed and isolating yourself. Also, be mindful of your negative attitudes and thoughts about winter, and try to challenge them.

And remember that SAD is highly treatable, and there’s always hope!

Now it seems things have gone one step further. A recent pilot study of the effectiveness of ICBT (Internet-Based Cognitive-Behavioral Therapy) shows promising results.

Twenty-three patients underwent a 15-week ICBT program “with therapist support consisting of psychoeducation, cognitive restructuring and exposure with response prevention. At post-treatment, 61% of participants had a clinically significant improvement and 43% no longer fulfilled the diagnostic criteria of OCD. The treatment also resulted in statistically significant improvements in self-rated OCD symptoms, general functioning and depression.”

OCFighter, based in the United Kingdom, is a CCBT (computer-aided CBT) program that has been used widely for over six years. While it began as a phone-interactive voice response program that included a workbook, it is now in the process of being adapted to the Internet. Shown to be quite successful in multiple studies, OCFighter has been used in the United Kingdom, United States, and Canada.

The benefits of these ICBT programs are many. In the United Kingdom, where there is a one- to two-year wait to receive cognitive-behavioral therapy, OCFighter has the potential to help OCD sufferers who otherwise might just languish on a waiting list. For those who live in rural areas, have limited financial resources, or want complete privacy, this form of therapy could be a good option. Because ICBT is home-based with 24/7 access, the flexibility it affords decreases the need to deal with scheduling conflicts, babysitters, and travel time. And for those with OCD so severe they cannot leave their homes, ICBT could be a lifesaver.

As is often the case with the Internet, one site begets another. There are now apps that you can download to your iPhone to help you beat OCD. One such app is OCD Manager and is touted as “Cognitive Therapy in the Palm of Your Hand.” Another is iCounselor: OCD which will help you “learn skills to resist obsessions and compulsions.” My guess is there are more out there as well.

Both of these apps profess that they are not a substitute for professional help; they are tools to assist the OCD sufferer with Exposure Response Prevention Therapy, the cognitive-behavioral therapy commonly used in treating OCD. Of course, once ICBT becomes more well-known and widespread, it is likely that there will be many more sites popping up all over the Internet. As you would do before seeking any kind of treatment, it is of the utmost importance to check out the credentials of the sites or therapists you will be dealing with. The IOCDF is always a good place to start.

I do believe these various types of ICBT have their place in the treatment of OCD. But I have concerns as well. I know when my son Dan was battling severe OCD, he would not have had success with any ICBT programs. In fact, he was often not even able to use his computer or cell phone. I hate the thought of someone with OCD downloading an app, struggling with the program, and then writing off therapy altogether.

While OCFighter does involve a 30-minute screening interview with a therapist (either by phone or face to face) before beginning treatment, and there are ways to seek help from an on-call therapist, the OCD sufferers are, for the most part, on their own. And that, for me, is the biggest negative of ICBT. There are no therapists meeting regularly with clients, nobody actually looking the OCD sufferers in the eye, reading their faces or body language. There is nobody to regularly screen for coexisting conditions, or to talk with, listen to, or support those with OCD.

And so while there is no question there are positive aspects to ICBT, many professionals feel it should only be pursued if face to face therapy is not a realistic option. Because as effective as these ICBT programs may be, the bottom line is that they are not human. They cannot empathize, understand, or care about a person, and when someone is suffering, isn’t that what they need the most?

While both psychotherapy and medications have been shown to be effective in the treatment of social anxiety disorder, a combination approach to treatment — utilizing both at the same time — may be the most timely and beneficial.

While some people may find relief from some social anxiety symptoms through trying simple self-help techniques, most people with a diagnosed social phobia condition will need professional treatment in order to overcome it.

Psychotherapy for Social Anxiety

Psychotherapy is a very effective method of treatment for social anxiety disorder. Specifically, cognitive behavioral treatments — which include techniques such as exposure therapy, cognitive restructuring without exposure, exposure therapy with cognitive restructuring, and social skills training — appear to be highly effective in treatment social anxiety, in a time-limited manner. Most cognitive-behavioral therapy (CBT) can be administered within 16 sessions (usually one session per week). At the end of treatment, a person’s anxiety symptoms are greatly reduced or even disappear in some cases.

In addition to CBT, other psychological treatments have also been found effective in the treatment of social anxiety. These include cognitive therapy (a form of CBT), social skills training alone, relaxation exercises, exposure therapy alone, behavioral therapy, and some other types of less-practiced forms of psychotherapy.

Exposure therapy is often a primary component of psychotherapy treatment of social anxiety disorder. Exposure therapy involves a person learning to understand the irrational basis for their fears (cognitive restructuring), teaching simple relaxation skills to practice while in the moment, and gradually being “exposed” to the situation which causes the anxiety. The exposure is done first in the safety of the psychotherapy office, imagining the scenario and walking through it with the therapist. As the patient’s confidence grows, he or she will begin to apply the skills they’ve learned in the therapy session to outside world events and environments.

Psychotherapy treatments have been shown to be highly effective in treating social anxiety disorder (Acarturk et al., 2009; Powers et al., 2008). Most people who try psychotherapy with a therapist who has experience in treating social anxiety disorder will find relief from their symptoms.

Medications for Social Anxiety

The primary class of drugs used to treat social anxiety are called selective serotonin reuptake inhibitors (SSRIs). This class of drugs was first developed to treat depression and so are often referred to as antidepressants. Since then, however, they have been found to be effective in the treatment of a wider range of disorders. Common SSRIs include Paxil (paroxetine), Zoloft (sertraline), Prozac (fluoxetine), and Luvox (fluvoxamine).

Another type of antidepressant called Effexor (venlafaxine) may also be prescribed to help with the symptoms of social phobia.

These kinds of medications generally take 6 to 8 weeks in order to start feeling the full therapeutic effects of them. While it may be frustrating to wait during that time and feel little relief, always take all medications as prescribed by your doctor. If you experience any distressing side effects, talk to your doctor immediately.

There is little specific reason to prescribe one antidepressant over another for the treatment of this disorder. Your doctor may choose your medication based upon their own experience in prescribing it, or based upon the typical side effects most people who take it experience. If you are not experiencing relief in 6 to 8 weeks from the first medication prescribed, talk to your doctor. He or she may decide to either up your dose or try a different medication altogether.

Other Medications

In addition to SSRIs, others kinds of medications are occasionally prescribed in the treatment of social anxiety disorder.

Anti-anxiety medications called benzodiazepines are rarely prescribed for social anxiety disorder, because they are extremely habit-forming and act as a sedative. However, because they act quickly in the short-term, they may be prescribed when a specific situation warrants their use — such as an unexpected public speaking engagement that can’t be avoided.

A class of drugs called beta blockers may also be used for relieving social anxiety. Beta blockers work by blocking the flow of epinephrine (more commonly known as adrenaline) that occurs when you’re anxious. This means they can help to control and block the physical symptoms that often accompany social anxiety — at least for a short while. They are primarily used for short-term situations, such as when you need to give a speech. However, like benzodiazepines, they are not generally recommended for the treatment of social anxiety and are rarely prescribed for it.

Jason Eric Schiffman, MD, MA, MBA, a psychiatrist at the UCLA Anxiety Disorders programs and editor of Anxiety.org says it’s one of the paradoxes of anxiety disorders. The severity of the disorder, the fear of being stigmatized, and general mistrust of conventional treatment may create obstacles to seeking help.

What Makes Complementary and Alternative Treatments Attractive Options?

The fear of conventional therapy could explain why complementary and alternative therapies (CAT) — such as vitamin supplements and yoga and meditation — are becoming increasingly popular. There was a time not long ago when we trusted Western medicine more than alternative treatments, but today the opposite is said to be true.

What accounts for this shift? Schiffman identifies four reasons why patients may be leaning toward complementary and alternative techniques to relieve their anxiety.

1. General mistrust of pharmaceutical companies.

The 2010 movie Love and Other Drugs does a good job of explaining patients’ growing mistrust of pharmaceutical companies. In a sentence, the relationship between pharmaceutical companies and physicians has become blurred. While Hollywood exaggerates the issue, the movie raises a legitimate concern: How much influence do pharmaceutical companies have on a doctor’s decision to prescribe certain medications? “The pharmaceutical companies are, by and large, publicly traded health companies, which means they have a fiduciary responsibility to their stockholders to maximize profit and that does not always align with the goal of doing what’s best for the greatest number of people,” says Schiffman. Although there have been recent efforts to prevent bias by limiting the way physicians and pharmaceutical companies interact, the general mistrust has stayed.

2. Side effects from commonly used SSRIs.

Schiffman says there is a correlation between the “amount of desired effects that a medication has and the amount of undesired side effects.” In other words, pharmaceutical treatments used are more effective than nonconventional treatments, but they tend to come with more side effects. In the case of selective serotonin reuptake inhibitors (SSRIs), a class of medications commonly used to treat anxiety disorders, sexual side effects can be perceived as intolerable. A previous post written by Psych Central founder and editor-in-chief John Grohol on Managing the Painful Side Effects of Antidepressants lists several of these common side effects. These reasons may be enough to pique patients’ interest in seeking alternative treatments.

3. No relief from SSRIs or difficulty in treating certain anxiety disorders.

According to Schiffman, “Only somewhere between 30-40% of people respond to their first treatment with SSRI’s.” And for some anxiety disorders, such as severe obsessive compulsive disorder (OCD), conventional treatment approaches may not always work. In fact, he says some patients in a “heroic effort to get relief” have even tried neurosurgery. The truth is that in comparison to Generalized Anxiety Disorder (GAD), OCD patients will require a higher dosage of medication. “If people have tried conventional approaches and are still suffering, it makes sense that they would then be willing to try complementary and alternative approaches.”

4. It’s human nature to believe natural products are better than synthetic.

When you hear the words “all natural” do you immediately associate it with low- or no-risk products? Equating natural products with safety and trust is a common and prevailing misconception with CAT. In fact, Schiffman says, “Natural products can be just as dangerous as synthetic products. Just because something is marketed as a natural supplement doesn’t mean that it is without risks.” In March 2002, the U.S. Food and Drug Administration (FDA) issued a warning about kava kava, a supplement used to treat anxiety, because of its potential negative side effects such as severe liver damage.

Yet, people who take supplements are more likely to trust companies and individuals promoting alternative treatments and supplements than pharmaceutical companies and the FDA. Instead Schiffman says, “the FDA and pharmaceutical companies and the marketers of supplements deserve the same degree of healthy skepticism.”

The Challenge with Seeking Alternative Treatments

It is understandable that individuals suffering from anxiety disorders want to seek alternative therapies — even more so because they can find information about them via the Internet in the comfort of their own homes. But because what’s out there on the World Wide Web isn’t regulated, patients may get misinformation that could have costly consequences.

Another problem is that many psychiatrists are not up to date with the latest research and information on alternative therapies. And if they are, Schiffman says they may be reluctant to comment on them either way. “One of the problems is that these medications have not been evaluated by the FDA [and] they’re fearful of the liability associated with recommending treatment that hasn’t been thoroughly evaluated or approved by the FDA.” As a result, people who are most qualified in terms of training and experience (such as psychiatrists) are less likely to evaluate potential treatments than people who aren’t trained because of the fear of liability issues.

What to Do if You’re Interested in Seeking Complementary and Alternative Therapies

If you think you are experiencing an anxiety disorder, you should always seek treatment from a mental health provider. If you are working with a therapist and are interested in pursuing an alternative route, consider asking them about potential treatments. In addition, a pharmacist or physician may also be able to answer your questions on supplements and provide information on any potential negative interactions with medications you are taking.

And while Schiffman has seen the positive effects of behavioral interventions such as yoga, meditation and deep breathing on anxiety patients, he advises individuals to avoid making decisions based on anecdotal evidence. Sites such as PubMed that publish current and evidence-based research are the best route for obtaining information via the Internet.

If you are suffering from a less severe anxiety disorder such as General Anxiety Disorder, Schiffman suggests “non-pharmalogical approaches first whether those approaches are complementary or alternative approaches like yoga or meditation or conventional approaches like cognitive behavioral therapy.” This is because there is less risk involved and fewer physiological side effects. However, it is important to note that if you are experiencing more severe symptoms or in the moment anxiety as in the case of phobias or panic attacks, CAT may be less effective. Cognitive Behavioral Therapy (CBT) alongside complementary and alternative techniques might work best in those situations.

Knowing all the work and research involved, is it worth seeking complementary and alternative therapies?

Schiffman wholeheartedly says yes. “When someone gets better from anxiety through a practice such as yoga, meditation or through therapy, they get better because they’ve learned something rather than getting better because a pill has made a change or caused a change to their neurochemistry.” Making an effort to change your lifestyle by learning ways to reduce stress and anxiety not only empowers individuals, but creates change that is “much more profound and long-lasting.”

The choice ultimately is yours. But Schiffman leaves us with this final thought to mull over: “If the goal is to increase the quality of life of the person who’s suffering from anxiety, it doesn’t make sense to limit one’s self to either conventional or non-conventional treatment.”