I communicated with Dr. Hudak recently, to clarify some questions, get his take on some extrapolations of anxiety and even to inquire about an interesting diagnostic title he proposed in his presentation.

Conference breakout workshops, be they NAMI or just about any organization, can never do justice to a topic in the short time allotted, but it is always good to get a small group together to at least begin a dialogue.

In his session, Dr. Hudak defined anxiety, reviewed the disorders as classified by the old and up-and-coming Diagnostic and Statistical Manual (DSM), discussed when and how to treat anxiety, and addressed referral concerns. Most of the content described herein is directly from his slide presentation, combined with quotes from my interview with him.

Interestingly, anxiety is “the only psychiatric symptom that is also experienced by individuals with no psychopathology.” Think about what that means. It can be found in normal emotion, or in psychiatric illness. But it can show up as “secondary to a medical or psychiatric illness, or as a primary symptom of a medical illness.” There are two states– not just psychological but also physiological — and four components — somatic, emotional, cognitive, and behavioral.

It is hardly a secret that even mild anxiety can show up in our bodies. The onset of hives for me during teen years, personally, was definitely emotionally-based, no matter how physically those deep red welts marred my arms. And as the emotional and behavioral components of anxiety are “givens,” in a sense, I asked Dr. Hudak to elaborate a bit on some of the cognitive components that might surface.

“The main one is an inability to concentrate or an inability to focus or pay attention,” he replied. “People sometimes complain to me that they feel like they have ADHD because their concentration is so bad.”

Due to internal family conversations that I have witnessed and been a part of at NAMI groups, though, I was thinking along the lines of more severe cognitive impairment even if acutely, as in stress-induced psychotic symptoms, disorganized thinking in how one presents to others, disassociation, or any manipulative behavior.

Given a chance to respond further, Dr. Hudak explained that “diistorted thoughts absolutely occur secondary to anxiety.” He gave the example of a mother who may not let ever her kids leave the house due to fear that they might get into a car accident and die.

“If they do leave, they may be required to check in every few minutes to ensure her they have not died, which most people would consider very extreme.” He goes on to say that “cognitive restructuring (in order to get her to realize that the chances of this happening are extremely unlikely and her reactions are extreme) is a part of the treatment, but only part. Simply doing that alone won’t work. Other behavioral methods are needed as well.”

As for stress induced psychotic-like symptoms, Dr. Hudak felt them “extremely rare” (but I know many family members through NAMI who might disagree!) Most important, as stressed in his workshop, “anxiety is expressed in a wide variety of ways by different individuals.”

The outgoing DSM has obsessive-compulsive disorder (OCD) as an anxiety disorder, but it will apparently be given its own weighted place elsewhere in the new one. Anxiety Disorder NOS (Not Otherwise Specified) will still be there, though, and Dr. Hudak curiously had it labeled “Hudak’s Syndrome.”

“This is a joke I tell to drive home a point. Every major psychiatric category has a NOS category which is generally used as a wastebasket term, for symptoms that don’t appear to be a diagnosable psychiatric condition…. I don’t feel it is a wastebasket term but is an actual separate illness that people can have, and to emphasize that it is different from generalized anxiety disorder.”

He goes on to say that he has certainly heard others comment, as well, that anxiety NOS is an actual illness and not just an NOS category.

His presentation gives an integrated approach for the treatment of all anxiety disorders, with consideration of medications and behavioral therapy, yet he definitely feels, as most, that “cognitive-behavioral therapies are the only ones shown to be effective for anxiety disorders.” These include specific physical techniques to help people cope with anxiety, as well as cognitive ones, such as self-record keeping and progress-tracking. “Thinking skills” also help individuals face situations that cause anxiety.

In his presentation, Dr. Hudak covered panic attacks in depth. I found it interesting to note that he included explaining the harmlessness of panic attacks as a specific, disarming therapeutic technique to be included in treatment.

A thorough look at the latest medications, and the symptoms they best treat, was given via his slide lecture. Some interesting points definitely stood out. He mentions FLAMS (Frontal Lobe Amotivational Syndrome) as a potential severe side effect of SSRI meds. Individuals being treated with these may “feel apathetic and emotionless…. very difficult to treat.”

“Exposure with Response Prevention” was one of Dr. Hudak’s slides and topics. This “teaches people that the physical symptoms of anxiety are normal and OK.” In treatment, a careful attempt to try to raise the heart rate will take place (by doing triggering behaviors and mechanisms).

Dual diagnosis — mental illness and co-occurring substance abuse — is a problem for many. Whether attending AA or NA, or on a treatment with an agonist like suboxone, it has been documented that acute anxiety is one of the most common co-occurring conditions with these patients.

Dr. Hudak feels that the the best way to determine the cause of the anxiety in these circumstances is to get patients sober. Nevertheless, anxiety can and will present in myriad forms, for myriad people, as is clearly pointed by his research and effective presentation.

An effective workbook is referenced in Dr. Hudak’s material — Mastery of Your Anxiety and Worry, by Zinbarg, Craske and Barlow, as well as some local resources for OCD, one of Dr. Hudak’s specialties.

Focusing on the here and now helps individuals become aware of their negative thoughts, acknowledge them without judgment and realize they’re not accurate reflections of reality, writes author William Marchand, M.D., in his comprehensive book Depression and Bipolar Disorder: Your Guide to Recovery. In it, Dr. Marchand recounts the benefits of mindfulness interventions and provides in-depth information about other psychotherapeutic and pharmacological treatments.

Through mindfulness, individuals start to see their thoughts as less powerful. These distorted thoughts – such as “I always make mistakes” or “I’m a horrible person” – start to hold less weight. In his book Marchand describes it as “watching ourselves think. We ‘experience’ thoughts and other sensations, but we aren’t carried away by them. We just watch them come and go.”

Mindfulness-based cognitive therapy (MBCT) is a group therapy that combines mindfulness principles with cognitive therapy to help prevent relapse in depression. It’s based on mindfulness-based stress reduction (MBSR), a program developed by Dr. Jon Kabat-Zinn. MBSR includes mindfulness tools, such as meditation, a body scan and hatha yoga, along with education about stress and assertiveness, according to Marchand. (Learn more here.)

MBCT teaches individuals to detach from distorted and negative thinking patterns, which can trigger the return of depression. (Learn more here.)

Studies have suggested that MBCT is a valuable intervention for depression. This recent meta-analysis found that MBCT was highly effective in reducing relapse for major depression. This study found that it was beneficial for individuals currently struggling with depression.

Getting professional treatment for depression is vital. But there are complementary mindfulness practices readers can try on their own. Marchand shared his suggestions below.

Mindfulness Meditation

“Mindfulness meditation is essentially training one’s attention to maintain focus and avoid mind wandering,” said Marchand, also a mindfulness-based cognitive therapy provider who practices meditation in the Soto Zen tradition. “Strengthening one’s ability to focus attention can help with concentration and memory.”

If you’re new to meditation, Marchand suggested carving out 10 to 15 minutes to meditate on most days. Specifically, “sit in a comfortable position and focus attention on the physical sensations of the breath.” Your mind will probably wander. That’s completely normal, he said. Simply refocus your attention back to your breath.

Psychotherapist and meditation teacher Tara Brach, Ph.D, has a number of guided meditations on her website.

Mindfulness in Daily Activities

Whether you’re eating, showering or getting dressed, you can practice mindfulness while doing any activity, according to Marchand, also a clinical associate professor of psychiatry at the University of Utah School of Medicine. The key is to focus on your physical sensations, such as “sight, taste, touch and smell.” Focus on the moment, instead of the past or future, he said.

Marchand suggested applying mindfulness to one activity every day. Again, you can be mindful with any task or action, such as brushing your teeth, having dessert or washing the dishes.

For instance, if you’re eating mindfully, minimize your distractions – such as watching TV or working on your computer – slow down your pace and pay attention to the taste, texture and aroma of your food.

Another option is to take a mindful walk, which also is helpful because it includes exercise, “an important component of healing.”

Mindfulness is a valuable practice for improving the cognitive symptoms of depression, such as distorted thinking and distractibility. It helps individuals recognize these more subtle symptoms, realize that thoughts are not facts and refocus their attention to the present.

Additional Resources

In his book, Marchand suggests additional self-help resources on mindfulness. These are:

• Books by Jon Kabat-Zinn: Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress; Coming to Our Senses: Healing Ourselves Through Mindfulness; and Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life.
• The Mindful Way Through Depression: Freeing Yourself from Chronic Unhappiness by Mark Williams, John Teasdale and Zindel Segal.

This month we’re pleased to present our interview with Linda Hatch, Ph.D, a clinical psychologist who pens the popular blog “The Impact of Sex Addiction” on Psych Central. Hatch is a certified sex addiction therapist in private practice in Santa Barbara, Calif. There, she specializes in treating sex addicts and sex offenders, along with their partners and families.

Throughout her career, Hatch has worked with both adult and juvenile sex offenders, mentally disordered offenders and sexually violent predators in and outside of the courts and prison system. She also has consulted with the Superior Court, the Probation Department, the Board of Prison Terms, and the State Department of Mental Health, providing forensic assessment and expert testimony.

Hatch is the author of the book Living with a Sex Addict: The Basics from Crisis to Recovery. You can learn more about Linda Hatch at www.sexaddictionscounseling.com, where she also blogs about sex addiction.

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

I guess it’s that after the 40 or so years I’ve been a clinical psychologist I continue to find it endlessly interesting. It is as though the work and I have gone through many changes over time and I have evolved along with those changes. I have done so many different things: teaching, research, student counseling, child psychology, crisis intervention and forensic psychology.

In the last five years I have gained a whole new specialty in sex addiction, which has revitalized my professional life yet again. I had wanted to be a therapist from a young age but I did not know how much my work as a therapist, and lately as a writer, would be continuously intertwined with my own emotional growth.

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

I recently read Chemical Dependency and Intimacy Dysfunction edited by Eli Coleman PhD. It’s a superb collection of articles about every aspect of the relationship between chemical dependency and human sexuality. What interests me so much about it is that it is, in part, a foundational attempt to look at common roots of chemical dependency and sex as a drug of abuse in terms of family dysfunction.

The book is truly comprehensive and holds up extremely well, dealing with every possible aspect of addiction and relationships including attachment issues, addiction interaction, codependency, boundaries, communication, shame and so on.

3. What’s the biggest myth about therapy?

I think people are sometimes too trusting of clinicians simply because the clinician has the right credentials. Therapy is a craft and not everyone is equally good at it because they had the same training. Also, not every therapist is right for every patient.

Patients need to be empowered to judge for themselves whether a therapist is someone they have confidence in. This is hard because therapy clients are usually grappling with some emotionally difficult problems and often tend to be less critical and more trusting than they would otherwise be.

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

For addicts it is fear—fear of the therapy relationship itself, of being open and vulnerable with another person. Addicts often have early attachment problems, which make them mistrustful of letting anyone know them. It can be an extremely uncomfortable situation for many clients.

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

In treating sex addicts it is the fact that it is often very hard for the client to establish and/or maintain abstinence from their particular addictive acting out behavior. As a sex addiction therapist, I am torn between imposing a task oriented treatment protocol that we know works, while still allowing for the fact that everyone does recovery in their own way and in their own time.

Clients need a lot of support and structure to do what they need to do but also permission to do things in the way that they are capable of doing them given their unique set of strengths and obstacles.

6. What do you love about being a therapist?

I love that therapy has a lot in common with mindfulness practice. It involves being present, being authentic and using all parts of my mind and intuition. I love that therapy is a process that can never be completely duplicated by having the client read a book. In psychology the problems are relational in origin and ultimately relational in the recovery process.

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

For me meaning comes out of the struggle to overcome suffering and liberate ourselves from obstacles to fulfillment. Meaning comes as we successfully navigate the challenges of each life passage. And ultimately meaning comes from bringing our knowledge and ideas to others. We cannot do everything we dream of doing but we can do the things that we can do; we can use our gifts.

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?

I feel like I was destined to be a clinical psychologist. I have always been fascinated by the human mind—I think I inherited this from my parents. I was raised on Jung, Freud, Perls and other early therapists. I majored in philosophy as an undergraduate and found out later that I have an uncle who is a philosophy professor.

Much later after becoming a psychologist, I connected with another uncle whom I had never met only to find out he was a clinical psychologist! If I were starting out today I think I would be drawn to neuropsychology to a greater extent, as that seems to be the new frontier at this point in history.

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

I think clients don’t realize how much change is possible from even the smallest shifts in awareness. Therapy is often in the very subtle changes in perception, which allow for big changes in functioning and self-concept. A little change makes a big difference.

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

I am fortunate to have a very low stress life right now. I believe that being in recovery myself has made all the difference, but also luck. I do what I enjoy, I am happily married, live in abundance and have meaningful relationships. Being very mildly cyclothymic myself (it runs in my family), I need to keep my everyday life balanced and grounded. Spiritual reading and meditation helps in this.

Fortunately, key strategies can reduce and improve these symptoms. “The most important strategy is definitive treatment for the depression with psychotherapy and medication,” said William Marchand, M.D., a clinical associate professor of psychiatry at the University of Utah School of Medicine and author of the book Depression and Bipolar Disorder: Your Guide to Recovery.

For instance, psychotherapy helps individuals become more aware of their cognitive symptoms, which can be subtle, Dr. Marchand said. It also teaches individuals specific techniques to improve their symptoms. And it helps clients gain a more accurate perspective on their illness.

“Because of the negative thinking associated with depression, there is a tendency to interpret symptoms as personal failings rather than as symptoms of an illness. A therapist can help one see things as they are – rather than through the distorting lens of depression,” Marchand said.

In addition to professional treatment, there are many strategies you can practice on your own to improve cognitive symptoms. Below are several techniques you can try.

Revise Distorted Thoughts

“I think it’s vital to teach any depressed individual how to ‘think happy,’” Serani said. Revising problematic thought patterns is key because they only fuel the fog and despair of depression.

“This approach definitely takes some time, patience and elbow grease, but once [it’s] learned, [it] enhances well-being.”

The first step is to monitor your negative thoughts, which you can record in a journal. A negative thought is anything such as “I’m a total loser” or “I can’t do anything right,” she said.

It’s also important to focus on how a negative thought affects your mood. By and large, it derails it. “Generally, [negative thoughts] will worsen mood, decrease hope and lower self-esteem.”

Next, challenge the reality of your thought, and replace it with a healthier one. Serani gave the following example: “Am I really a loser? Do I really do everything wrong? Actually, I get a lot of things right in life. So I’m not really a loser.”

Finally, review how each realistic thought affects your mood. According to Serani, it “leads to a healthier frame of mind. Now this new, healthy thought replaces the negative one and shifts mood into a less depressive place.”

Use Your Senses

“For helping with executive functioning skills for memory, focus and decision-making, I always recommend using your sense of sight, hearing and touch,” Serani said.

Technology can be especially helpful. For instance, you can set reminders for taking medication, attending therapy and running errands on your smart phone, computer or tablet.

If you don’t have access to technology or prefer pen and paper, Serani suggested placing brightly colored notes with reminders around your home and office. “Using touch to write will track the task more deeply into your memory and the visual cue to ‘see’ the reminder will help you keep your focus.”

Your sense of touch also can help when making a decision, said Serani, who uses this technique herself, “especially if I’m struggling with a significant melancholic mood.” She suggested a grounding practice, which “helps you be in the moment”: Place your hand on your heart, take a deep, slow breath and ask yourself the question you need to know. “Slowing things down and focusing on your sense of self can better help you make decisions.”

Take Small Steps

“Depression has a way of taxing you physical[ly], emotional[ly] and intellectual[ly], so taking smaller steps will help keep your energy reserve from burning out,” Serani said. Break down longer, more complicated tasks into bite-sized steps. This helps you “rest, refuel and re-attend [to your task].”

Have A Cushion

Therese Borchard, a mental health blogger and author of the book Beyond Blue: Surviving Depression & Anxiety and Making the Most of Bad Genes, also struggles with cognitive symptoms from time to time. Whenever possible, she reduces her workload. “I’ve always prepared for days like that by working a little harder on the days I feel good, so I have a little cushion.”

Take Breaks

Because depression is so taxing on your brain and body, taking breaks can help. When she’s working, Borchard takes breaks every two hours, or “every hour if I’m really struggling.” Your breaks might include stretching your body or taking a walk around the block.

Be Kind To Yourself

“One of the most important things to do is remember not to be too hard on yourself if you still find you’re forgetful, have trouble focusing or making decisions,” Serani said. “Remember that you are experiencing a real illness.” Blaming yourself and losing patience only adds “to your already full plate.”

As Borchard noted in this piece on working from home with a mental illness, “When I was in the midst of my most severe depression, I couldn’t write at all. For almost a year…I try to remember that when I have a bad day where my brain feels like silly putty and I am not able to string two words together. I try to remember that courage isn’t doing a heroic thing, but getting up day after day and trying again.”

Yet cognitive symptoms are quite common. “[They] are actually significantly prominent in depression,” said Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression.

And these symptoms are incredibly debilitating. “In my opinion, when cognitive symptoms of depression hit, they are more of a pressing concern than physical symptoms.”

Cognitive symptoms can interfere with all areas of a person’s life, including work, school and their relationships. Problem-solving and higher thinking, according to Serani, are greatly diminished. “This can leave a person feeling helpless and without a plan of action to defeat depression.”

Poor concentration can cause problems with communication, and indecisiveness may strain relationships, according to William Marchand, M.D., a clinical associate professor of psychiatry at the University of Utah School of Medicine and author of the book Depression and Bipolar Disorder: Your Guide to Recovery.

The cognitive symptoms of depression also may get confused with other conditions, complicating diagnosis. Here’s a specific list of symptoms along with similar disorders.

Cognitive Symptoms of Depression

“Cognitive symptoms can be subtle and often go unrecognized,” according to Dr. Marchand. Fortunately, psychotherapy can help individuals become more aware of these symptoms, such as distorted thinking, he said.

Marchand and Serani shared these cognitive symptoms of depression:

• Negative or distorted thinking
• Difficulty concentrating
• Distractibility
• Forgetfulness
• Reduced reaction time
• Memory loss
• Indecisiveness

Disorders That Mimic Depression

“The cognitive aspects of depression usually involve a person’s thinking being sluggish, negative or distorted in quality,” Serani said. However, there are many other disorders that share these similar symptoms, because they, too, inhibit cognitive function. Unfortunately, this means that the “risk for misdiagnosis is high,” she said.

For instance, Serani mentioned attention deficit hyperactivity disorder (the inattentive type), post-traumatic stress disorder and substance abuse.

Co-occurring disorders can add to the confusion. “In many cases there are comorbid conditions such as dementia (in elderly individuals), adult ADHD and generalized anxiety disorder, and it can be difficult to sort out which condition is causing the cognitive symptoms,” Marchand said.

It’s critical to receive a proper and comprehensive evaluation to make sure that you have depression or another condition. Again, psychotherapy and medication can improve cognitive symptoms along with other symptoms of depression. Also, there are many strategies you can try on your own to reduce symptoms and feel better (which are explored in another article).

1. Everyone has challenges.

Clinical psychologist Christina G. Hibbert, PsyD, wants readers to know that they’re not alone in their struggles. “We all have challenges. Even as I sit in my chair helping [a client], I have challenges too. It hurts me to see clients feeling like they’re the only ones on earth who ‘need therapy.’”

Therapist Joyce Marter, LCPC, agreed. She believes that our struggles are simply “part of the human condition…[E]verybody struggles with issues related to self-esteem, identity, navigating relationships, coping with various life traumas, managing stress or challenges in creating the life we want, personally and professionally.”

2. Everyone can benefit from therapy.

Therapy is a healthy and proactive approach to dealing with challenges, Marter said. “A therapist is like a personal trainer for your mind. I believe we can all benefit from therapy at various points in our lives and see it as a preventive and routine form of health care.”

3. Seeking therapy is courageous.

It’s a common myth that therapy is for weak people who can’t fix problems on their own. “I think of therapy as making use of all the tools at one’s disposal to manage negative emotional symptoms and maximize strengths and fulfillment,” said John Duffy, Ph.D, a clinical psychologist and author of the book The Available Parent: Radical Optimism for Raising Teens and Tweens. “People willing to delve into their own psyches are … actually quite courageous.”

4. Therapy helps you navigate life.

You can apply the skills you learn in therapy to any area of your life, according to Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression. “It really doesn’t matter if you go to therapy for anxiety, depression, to lessen obsessions, to quit smoking or to learn how to parent – whatever the reason – the techniques of self-reflection and thought-changing are involved in all.” In fact, she said, many people consider therapy to be the most meaningful and valuable experience of their lives.

5. Therapy is a process of self-discovery.

“To my thinking, therapy does not need to be an excruciating experience. Sometimes I think we do therapy itself a disservice when we call it ‘work.’ For my clients, I like to think of their therapy as a process of self-discovery, more joyous in the end than painful,” Duffy said.

6. Therapy isn’t about blaming others.

“Some people think therapy is about blaming their parents or their life histories for all of their woes,” said Marter, also owner of the counseling practice Urban Balance. Therapy is actually “about honoring those experiences and then taking full responsibility for your life from here forward.” She shared Wayne Dyer’s quote: “Everything you do is based on the choices you make. It’s not your parents, your past relationships, your job, the economy, the weather, an argument or your age that is to blame. You and only you are responsible for every decision and choice you make.”

7. Therapy is a place to say and ask anything.

“Therapy isn’t the place to put your best foot forward and try to convince the therapist that you have it all together,” according to Ryan Howes, Ph.D, a clinical psychologist and author of the blog “In Therapy.” Instead therapy is a space to be fully and authentically yourself. Bring everything from your daydreams and fantasies to your harsh opinions and random thoughts, he said. “A skilled therapist will work to understand these impulses and beliefs without judgment and help you make sense of them. Save the pleasantries for the outside world, and let your raw, real thoughts and feelings out here.”

The same is true for asking your therapist questions: If there’s a question you’d really like to ask about your treatment or therapy in general, ask away, Howes said. “If the therapist doesn’t want to answer, let them explain why and how not answering benefits you in the long run. If you’re not satisfied with the answer, let them know.” He noted that therapy is a relationship. “Therapists should be experts at setting boundaries and working through relational issues in a constructive way.”

8. Therapy doesn’t end as soon as you feel better.

Jeffrey Sumber, M.A., a psychotherapist, author and teacher, wishes that people knew that improvement doesn’t signal the end of therapy. “So often, folks begin to feel the shift within themselves, their patterns change, their mood improves, and they terminate treatment only to find themselves in a similar situation down the road.” That’s because those shifts are a mark of progress, not proof of a cure.

“The counseling process is multi-layered and the feelings of renewed purpose and lifeforce that accompany the internal shifts we make are actually there to help propel us forward so that we feel this way every day on our own. I wish people took the signs of improvement as a confirmation that treatment is helping, not over.”

9. Don’t compare your insides to others’ outsides.

“I often hear clients pathologize themselves and suggest that most other people are functioning at a higher level in various aspects of their lives,” Marter said. In reality, however, “we are all dealt a different hand of hardships and blessings. Therapy is a place to help you think through how you want to play your hand.” In fact, she’s seen “people overcome great adversity and others squander great blessings.”

10. Your thoughts dictate your feelings and behavior.

Marter cited Gandhi: “A man is but the product of his thoughts.” This is why it’s so helpful to pay attention to the things you say to yourself and shift your perspective to more realistic, empowering thoughts. “Through therapy, we can let go of negative or irrational thinking and promote positive thinking and a practice of gratitude that will attract more positivity into our lives,” Marter said.

11. Acceptance isn’t limiting; it’s liberating.

“Don’t get me wrong, there are times when we need to keep striving, pushing, and holding out hope for better health, better careers, or healthier relationships,” Howes said. However, many individuals end up wasting their time and energy wrestling limitations they can’t change, instead of focusing on the things they can alter. According to Howes:

We need to accept our age. We need to accept many physical and mental illnesses and addictions. We need to accept the past. We need to accept others as they are. This isn’t to say we need to like it, or that we can’t work to make the best of each of these entities, but we need to relinquish the idea that we have any power or responsibility to change them. Once people realize they can accept instead of fighting things beyond their control, they realize they have much more time and energy for things they can impact.

12. You are worthy. Whether her clients come in with depression, anxiety, relationship problems or parenting concerns, Hibbert believes that, at the core, they’re all struggling with the same thing: “an inability to comprehend and feel their worth.” She’s also seen this with friends and family and experienced it herself. “I’ve had to work very hard to discover my own self-worth.”

She wishes people truly understood that “they’re more than how they feel, what they do or say, and what they think. Deep down, we are each of infinite worth.” Connecting to our self-worth is “the key to living a life of meaning, abundance and joy,” said Hibbert, also a women’s mental health, postpartum and parenting expert. (She talks more about self-worth in this piece.)

13. Life requires balance.

Howes noted that while the idea of balance is cliché, he’s also seen the damage of living in extremes. “People who work too much, party too much, spend too much time online, exercise too much or let themselves become consumed by their relationships will face the consequences of a life out of balance.” The skills for achieving moderation are challenging yet critical to learn, he said.

14. Growth and progress are not linear.

“We all go through setbacks, relapses or regressions in life as a normal part of being human,” Marter said. Experiencing a setback doesn’t mean you’re back to square one. Instead, this is an “opportunity to learn, get back on the saddle, grow and move forward. Life is a process of ebbs and flows.”

15. Work on the inside.

According to Marter, “Some people are waiting for external factors such as a relationship, a job, a perfect body or a fat bank account to make them happy.” Instead, the key is to work from the inside out. She cited Eckhart Tolle: “If you get the inside right, the outside will fall into place.” Marter added: “Therapy is a place to explore your greatest gifts and align your life with those so that you will achieve all you desire personally and professionally.”

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

In other words, I could not put it down.

Shrunk, a novel by Christopher Hogart, tells the story of Henry and Helena Avalon, a couple that moves in next door to the eccentric Dr. Prendergast. Henry is a practicing psychotherapist who uses his home as his office. Prendergast is a psychiatrist, who also sees patients in his home. While presented as mildly strange, Prendergast proves to be the archenemy of the Avalons and is intent on the ultimate destruction of Henry. At times funny and others deeply unnerving, Shrunk takes a satirical look at the people who are a part of the psychotherapy profession.

What makes this book so superb is that Hogart is not writing from the perspective of a disgruntled or skeptical client. Behind his penname, the author has spent years as a practicing psychotherapist. According to his website, he has also served on the faculty of Harvard Medical School.  I am not sure that there is a better position to be in to write such a novel.

When Dr. Prendergast is first introduced, he comes across as maybe a disgruntled older gentleman. Henry and Helena, who is pregnant, are an optimistic couple that are excited about their upcoming addition to their family and the new house they have purchased next door. They greet Prendergast and, out of neighborly respect, tell him about their plans for an addition to their new home. Unfortunately for the couple, Prendergast is not interested in being respectful or even nice. His interest lies in power and revenge.

It all starts out small enough. A shrill whistle pierces the quiet night just as the Avalons are falling asleep. Jarred awake, they cannot figure out where the sound is coming from. The situation escalates quickly, with Prendergast slamming car doors, honking his horn, whistling, and damaging the Avalons’ own car. Prendergast not only attacks their home but also begins to work toward ruining Henry’s career. All the while, he begins doing things to be more like Henry.

While reading, I kept wondering what the Avalons did that was offensive enough that Prendergast would wreak such havoc on their lives. Was it the addition to the house that really bothered him? Was it their obvious happiness and that they were soon going to be adding a child to their portrait? Who knows.

All that is obvious is that Prendergast is relentless, uncaring, and vicious. He stops at nothing to end the Avalons’ happiness. To make things worse, no matter who the Avalons turn to for help, everyone seems to tell them that there is no way to prove their claims—or that they simply don’t believe them. Helena aptly sums up the issue, saying, “Our encounter with the law leaves him free to do what he wants and us with no recourse.”

As if this scenario does not make this book strange enough, the slew of characters that Hogart uses to aid the plot are just as unique. There is Mendelson, a psychiatrist and administrator at the Belair Hospital, a Harvard teaching hospital, who enjoys running naked through the woods. Cobb is another administrator at Belair. Cobb’s insecurity runs incredibly deep and is apparent in almost every scene that he is included in; he has to add something to every conversation and is offended if someone else makes a witty remark that he had not thought of first.

I really could go more in depth about what happens in this novel. However, I really don’t want to ruin it for any potential readers. Within three chapters, I was intrigued. By one hundred pages, I was engrossed and anxious to find out what would happen.

By two hundred pages, I had lost count of the number of times I chuckled, was surprised, or felt infuriated for the Avalons. For those who believe that all therapists are crazy, Hogart’s novel will give them a quintessential example to point to. For everyone else, Shrunk is an enjoyable, entertaining, and humorous dark glimpse into the world of psychiatry.

Shrunk
Bickerstaff Press, November, 2012
Paperback, 244 pages
$12.99 

“With 6 kids, ages 16 to 5, a husband and home to care for, a private practice, and my many ‘side jobs,’ including running a non-profit, speaking, writing for my website, blog, and other people, doing some legal consultation, and writing a book, I like to say my life is ‘full,’” said Christina G. Hibbert, PsyD, a clinical psychologist and expert in postpartum mental health. She’s also active in her church and has commitments on Sundays and Wednesday evenings every week.

Joyce Marter, LCPC, a therapist and owner of the counseling practice Urban Balance, also has a lot on her plate. “I am a wife, a mother, a psychotherapist and owner of a group practice with nearly 50 therapists and five locations, a writer with a book in development, a public speaker, the Vice President of the Board of the Illinois Mental Health Counselors Association, and frequently serve as a psychological expert in the media.”

That’s enough to make anyone’s head spin. In addition, Marter takes her kids to and from school, eats dinner with her family, has an active social life, vacations for at least six weeks every year and gets eight hours of sleep per night.

So what’s their secret? Below, Marter, Hibbert and other therapists spill the details on living a fulfilling life and getting things done.

1. They know their priorities.

Hibbert knows what matters most to her, and she focuses on those things first and foremost. “[This] allows me to prioritize my time and helps me know when to pull back from other things. If any of my top priorities are out of shape, I push off the others until things are in order again.”

Her top priorities are: “My relationship with God, my relationship with my husband, and my role as a mother and relationship with my kids.” Her work comes next. But this also has to match her mission: “to learn all I can and teach what I learn.”

Marter takes a similar approach. She starts off with a vision for her personal and professional lives. (For instance, you can create a vision board, she said.) “Then we need to align our priorities and intentions to support that vision. We need to focus our energy on the things that provide meaning, value and life energy and let go of the things that don’t.” She then sets clear goals and firm boundaries around her time, such as her work hours.

2. They have a formula for their days.

“It has taken me many years and several iterations to find a formula that worked for me,” said John Duffy, Ph.D, a clinical psychologist and author of the book The Available Parent: Radical Optimism for Raising Teens and Tweens.

He sees clients either three or four days a week from late morning into the evening to accommodate his clients, many of whom are teens. “I work fairly long hours those days, but I enjoy the work.” The other days he works on his next book or with the media. For instance, he’s been on the Steve Harvey Show multiple times.

3. They protect family time.

Clinical psychologist Ryan Howes, Ph.D, wakes up early to make breakfast for his sons and drop them off at school. He comes home around 6 p.m. to have dinner with his family and eventually put his boys to bed.

“After the boys’ bedtime I enjoy the evening with my wife, which includes checking in with each other, talking about our future plans, and watching some reality TV cooking shows.”

Duffy also “[protect[s] nights and weekends for my wife, son and friends.”

4. They delegate.

When Hibbert needs more time to accomplish projects after school, she asks her older kids to watch the younger ones. She asks her husband to help with grocery shopping and dinner several nights a week. She also has a housekeeper come once a week. “[This] is one of the best things I’ve ever done for myself!”

Marter outsources anything that doesn’t “provide personal meaning or value to me. In my business, I delegate the responsibilities that are not my strengths or passion.” At home, she outsources house cleaning and grocery shopping. This way she has time for what’s most important, such as hosting her kids’ play dates.

5. They have pets.

Having a dog actually makes my life more productive,” said Jeffrey Sumber, M.A., a psychotherapist, author and teacher. “I’m responsible to make sure he is well fed, walked and properly taken care of but this also helps punctuate activities in my day and organize tasks around set breaks in my process.”

6. They use activities to ground them.

Sumber uses the walks with his dog to map out his days and intentions.

It is often during my morning walk with Tashi that I run through my day in my mind, determining priorities and goals and create a visual for how the day will ideally play out. This walking meditation is functional as well as intentional and sets me off on a conscious trajectory into my day.

He also finds focus while making his morning coffee.

I also enjoy the process of my morning coffee. I grind the beans, pull the espresso shots and mix the Americano to my personal perfection. This takes me 10 minutes every morning and I might as well be repairing the space station tethered in deep space…I am very focused.

As I sip the coffee, I ease into my morning by sifting through emails (mostly deleting) and then send personal birthday messages to Facebook friends. I typically take time to prepare meals for the day and then set off to work.

Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression, uses her senses to switch gears and get things done.

My typical day has me in the role of clinician, homemaker, professor, writer and woman. I know the metaphor of wearing “different hats” gets tossed around in shifting roles, but for me, it’s more of what’s in my hands that helps me get things done.

It’s as if my sense of touch transforms me into who I next need to be. My appointment book helps me shift into clinician mode. As soon as I touch it, I can feel myself move into a professional posture.

I have a home office, so in between patients, when I walk back into my home and I touch the doorknob, I’m into homemaker mode – cooking, doing laundry or tidying up the place.

When I pick up my lecture notebook, I’m into professor mode and readily head off to the local university to teach. And if I’m sitting at the keyboard, I easily shift into writer mode.

When I return home and settle into comfy clothes, I become just a woman again -connecting with my family and myself. I’ve always been a very sense-oriented person, and have found using touch as both a cue for change and a grounding way to cement my identity.

7. They stay fully present.

Howes focuses on being present in all his activities:

Freud said “love and work are the cornerstones of our humanness.” I agree with that and try to make the most of both. I do my best to be fully present when I’m wearing either hat. I want to engage with my family, regardless of what is happening at work, and be fully present with my clients, regardless of what is going on at home. On my best days, I’m able to do both.

8. They practice self-care.

Marter always makes time for self-care, which helps her be more productive in other areas of her life.

I prioritize self-care (like rest, meditation, exercise and fun) so that I have the energy to manage all my responsibilities. I practice gratitude and positive thinking to facilitate the energy and confidence I need to achieve my dreams. I tap into my support network (friends, family, therapist, coach, colleagues, mentor, etc.) for feedback, wisdom and support in helping make my life vision a reality.

Hibbert practices her self-care routine first thing in the morning.

On a day-to-day basis, one of the best things I do is wake up before my kids so I can enjoy an hour just for me. I exercise, meditate, and study scriptures to start my day right. When I miss this time, life just doesn’t seem to run as smoothly.

The morning also designates self-care for Duffy. “I work out, meditate when I can, and get to the office early. I eat breakfast there, page through the paper, and clear my mind for a while before the chaos begins!”

Hibbert prioritizes sleep, which is crucial to her productivity and well-being.

For me, the other big key to getting anything done is sleep. If I’m not sleeping well (and I’m not a great sleeper in general), I can’t function well. I get grumpy and overwhelmed too easily. So, I focus on getting to bed as early as I can so I can get up early, and I try to “sleep in” on weekends, when I am given the chance.

When he has the time, Howes strums his guitar, plays hoops, or works on “creating the world’s next great pasta sauce.”

9. They pay attention to their energy levels.

Sometimes Marter lets her energy guide the projects she works on. “When I occasionally experience an ebb of energy, I let myself rest or do the tasks that are easy for me. When my energy is high, I make a concerted effort to carve out time to tackle tasks that are high priority but low urgency like writing my book.”

All of these clinicians lead fulfilling professional and personal lives. They know their priorities and do their best to protect them. They manage their time effectively, know when to delegate and make sure to be completely present at every point.

This month we have the pleasure of interviewing Gerti Schoen, a psychoanalyst and couples counselor in private practice in New York City and Hoboken, New Jersey. Before she immigrated to the U.S., Schoen worked as a professional print and radio journalist in her native country of Germany.

Schoen is the author of The Gentle Self, a self-help book about depression and anxiety, and a blog of the same name here at Psych Central. Her new book Buddha Betrayed is about spiritual abuse and the pitfalls of working with a spiritual teacher.

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

Just how similar we all are. Everyone struggles with periods of sadness or anxiety, couples bicker about similar things as my husband and I do. The ‘human condition’ that life isn’t perfect applies to everybody.

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

The one I frequently recommend is Tara Brach’s Radical Acceptance, a much-needed book about how to foster self-compassion. I very much like Susan Cain’s Quiet, which will reassure all the introverts out there that there is nothing wrong with being an introvert. Right now I am reading You Can Go Home Again by Monica McGoldrick. It’s a stunning account of how our family histories make us into who we are.

3. What’s the biggest myth about therapy?

That you can bring about change within a few weeks and it lasts forever. It’s possible to change quickly, but it often doesn’t last very long without putting in all the hard work that is required to change the brain.

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

Accepting that life is painful and that confronting one’s issues is painful.

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

Confrontation. It gives me anxiety when people get very aggressive with me. But it doesn’t happen very often and, when it does, I try to deal with it constructively and honestly.

6. What do you love about being a therapist?

It’s a field that never gets boring. The human mind is a vast source of ideas and feeling. You can never dive too deep; you will always find new treasures to be discovered.

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

To accept that life isn’t perfect and pain is a part of being alive. If you can deal with that, you can deal with everything.

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?

It would have been interesting to learn about psychoanalysis in my native country, Germany, first before studying it here in the U.S. to see how it is utilized and interpreted in different countries.

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

[I wish clients knew] that you can’t just pop a pill and all your worries will go away.

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

[I practice] yoga, go out in nature, plant flowers, take a nap, have a cup of coffee and slow down.

While the above questions are obvious appeals, they are not the only way that OCD sufferers seek reassurance. Indeed, the very nature of OCD centers around making certain that all is well. The disorder is characterized by unreasonable thoughts and fears (obsessions) that lead the sufferer to engage in repetitive thoughts or behaviors (compulsions). Obsessions are always unwanted and cause varying degrees of stress and anxiety, and compulsions temporarily alleviate these feelings. Compulsions are always, in some way, shape, or form, a quest for reassurance; a way to make everything okay.

A good example is the case of someone with OCD who is obsessed with a fire starting because he or she left the stove on. The compulsion of continually checking the stove is a recurring attempt to reassure oneself that the stove is indeed off and nobody will get hurt. Another OCD sufferer may fear germs (obsession) and wash his or her hands until they are raw (compulsion). The compulsion of hand-washing is an effort to make sure that his or her hands are clean enough so that there will be no germs.

My son Dan suffered from OCD for a few years before we even knew anything was really wrong. In retrospect, I realize he had a lot of reassurance-seeking behaviors. While he never asked the “Are you sure?” questions, he would often apologize for things that did not warrant an apology. If we went to the supermarket together he would say, “Sorry I spent so much money,” when, in fact, he had only picked out a few items. I, in turn, would reassure him that he hadn’t spent much at all. Dan would also thank me over and over again for things that most people might say “thank you” for only once, if that. Again, I would reassure him by saying, “You don’t have to thank me,” or “Stop thanking me already.” My responses to Dan in these cases gave him the reassurance he needed to feel certain that he hadn’t done anything wrong, had behaved appropriately, and all was well.

Of course hindsight is a wonderful thing and I now know that how I reacted to Dan at these times was actually classic enabling. I did him more harm than good. My reassuring Dan that all was well reinforced his misconception that he had to be certain, to have no doubt at all in his mind. While I helped reduce his anxiety at the moment, I was actually fueling the vicious cycle of OCD, because reassurance is addictive. Psychotherapist Jon Hershfield says:

If reassurance were a substance, it would be considered right up there with crack cocaine. One is never enough, a few makes you want more, tolerance is constantly on the rise, and withdrawal hurts. In other words, people with OCD and related conditions who compulsively seek reassurance get a quick fix, but actually worsen their discomfort in the long term.

So how can those with OCD “kick the habit?” It’s not easy, as sufferers continually wrestle with the feeling of incompleteness, never truly convinced that their task has been completed. There is always doubt.

But there is also always hope. Exposure Response Prevention (ERP) Therapy involves facing one’s fears and then avoiding engaging in compulsions. Using the stove example again, the sufferer would actually cook something on the stove and then shut the burner(s) off. He or she would then refrain from checking the stove to make sure it was off. No reassurance allowed. This is incredibly anxiety-provoking initially, but with time it gets easier. And while it is difficult to watch a loved one go through “withdrawal” it is imperative that family members and friends learn how not to accommodate or enable the sufferer.

Without reassurance, how will those with OCD achieve that need for certainty that they so desperately desire? Indeed, how can all of us make sure that nothing will ever go wrong? How can we control our lives, and the lives of those we love, so that nothing bad will ever happen?

The answer, of course, is that we can’t. Because as much as we’d all like to believe otherwise, much of what happens in our lives is beyond our control. Through ERP therapy, OCD sufferers will focus on the question “How can I live with uncertainty?” as opposed to “How can I be certain?” And instead of dwelling on the uncertainties of the past and the future, those with OCD can begin to live life to the fullest by concentrating on what matters most – the present.

The statistics regarding obesity in America are alarming. Currently, 35 percent of American adults are obese (CDC, 2012), and that number is projected to rise to over 50 percent in most states by 2030 (Henry, 2011). We’ve been fighting the so-called “war against obesity” since the 1980s, and yet despite all of our efforts, the problem has only gotten worse. Clearly, what we’ve been doing to try to solve this problem isn’t working and is possibly making it even worse. In my opinion, the reason for this is that the psychological piece hasn’t been addressed yet and until it is, we will have an increasing problem on our hands.

Years ago I was seeing a client who we’ll call Sarah. Sarah was very obese and desperate to lose weight. Her doctor had recently told her that if she didn’t lose a significant amount of weight she would lose her mobility as well as have a host of other medical consequences. Sarah tried numerous diets and exercise programs but nothing worked. She even enrolled in a weight loss clinic but had no success. She actually ended up gaining even more weight during this time. Not knowing what else to do, Sarah’s doctor told her that she needed to talk to a therapist.

When I met Sarah she was quite desperate to lose the weight and very depressed. Much to her surprise, I told her that I didn’t want us to work on her losing weight, but rather I wanted to work on her depression and teach her to accept and love herself unconditionally. This seemed the opposite of what she needed in order to lose weight, but Sarah decided to trust me anyway. You see, like a lot of people, Sarah thought that if she could just hate herself enough, that would motivate her to do whatever it took to lose the weight. As a therapist, I know that that is simply not going to work. We therapists follow something called the “Rogerian hypothesis,” which states that people tend to move in a positive direction only when given unconditional love and acceptance. Well, I’m happy to say that after we had alleviated Sarah’s depression and she had learned to love and accept herself, the weight came right off.

The current methods for helping people lose weight seem to be the opposite of love and acceptance. Much of the efforts seem to involve trying to shame and scare people into losing weight. This simply doesn’t work. The worst thing you can do is give someone more anxiety and depression regarding their weight, and I’m going to explain why that is later on. Also, the ways we go about teaching people to lose weight are much more complicated than they need to be. One should not have to read a book, go to a clinic, or take a class to learn how to lose weight. There is a very successful diet that has been around for thousands of years and all of the big celebrities do it. Can you guess what it is? It’s called “Moving more and eating less.” How you go about accomplishing this is up to you. I believe that losing weight is not complicated and that people intuitively know how best to do it when it comes to themselves. They simply need to stop feeling so anxious and depressed about it.

Obesity and Genetics

Before I talk more about how obesity is linked to depression and anxiety, I first want to briefly address the popular belief that obesity is purely a problem of bad genes. This is the popular belief and I can see why it is so popular. In a society where people are constantly trying to shame you about your weight, it can feel good to be able to say “Hey, you have no right to shame me about my weight! It’s not something I can control! It’s because of these bad genes I have!” But in order for this to be true, it means that our genes would have had to somehow change since the 1960s. Scientists agree that genetics is not responsible for the obesity epidemic, although they do agree it is a factor. Depending on which study you look at, genes only account for between 1 percent and 5 percent of a person’s body mass index (Li et al., 2010). I think that most people would agree that 5 percent of bad genes doesn’t excuse the 95 percent of it that scientists claim is due to bad habits.

When confronted with these facts, people often cite that most of the people in their family are also obese, so it must be genetics. However, the more likely possibility is that families tend to eat the same foods and have similar habits. Genetics also doesn’t explain why obese people also tend to have obese pets (Bounds, 2011). Obviously the dog doesn’t share the same genes as the owner, but they do share the same environment. Of course, we can’t mention genetics without looking at twin studies. Since identical twins have identical genes, researchers often compare twins to examine the effects of genetics and the environment on a person.

Obesity and Depression

Researchers aren’t quite sure if obesity causes depression or if depression causes obesity, but the two are definitely linked. In fact, the two conditions are so intertwined that some are calling obesity and depression a double epidemic. Studies have found that 66 percent of those seeking bariatric, (weight loss) surgery have had a history of at least one mental health disorder. And of course, it doesn’t help that the medications people take for depression and other mental health issues can cause dramatic weight gain.

Consider this: According to the CDC, half of Americans will suffer from some sort of mental illness, and most of them will not receive any treatment for it. 63 percent of Americans are also overweight or obese. There are almost as many Americans taking diet pills as there are taking antidepressants (8 percent and 10 percent). People with mental health issues are twice as likely as those without them to be obese, and that’s even before they start taking psychiatric medication (McElroy, 2009).

So why are people with mental health issues so much more likely than those without them to be obese? We know that depression and bipolar depression slows down your metabolism (Lutter & Elmquist, 2009). Depression also depletes our willpower, making us less likely to avoid eating unhealthy foods. Depression also causes us to crave high-fat foods and sugar. This is where emotional eating comes in. When we’re feeling down, fatty and sugary foods make us feel better, at least temporarily. Of course, you don’t need to have depression or a mental illness in order to engage in emotional eating. It’s something we learn at a very young age. Eating something unhealthy is much easier than fixing the problem or dealing with what’s causing us to feel unhappy. Teaching people how to deal with unpleasant moods other than by eating would certainly cut down on emotional eating and would certainly lead to significant weight loss.

So if depression causes weight gain and antidepressants cause weight gain, then what is the solution? Well, research has shown that talk therapy is just as effective at relieving depression as antidepressant medication (Doheny, 2010), and talk therapy doesn’t have the negative side effects that medication does. Another option is exercise. In a 2005 study on the effects of exercise vs. Zoloft (anti-depressant medication) on the treatment of depression, participants were randomly placed into two groups. On group received 150 mg of Zoloft while the other group engaged in 20 minutes of cardiovascular exercise three to four times a week. After eight weeks, they found that the exercise was just as effective at reducing depression as the Zoloft! Another thing to consider is that Zoloft has negative side effects such as weight gain, sleep problems, and sexual dysfunction. As you can imagine, the side effects of exercising are the opposite of that.

“Whatever the reason, it’s vital to bring it into your sessions as soon as you feel it,” said Serani, author of the book Living With Depression. Howes agreed. Wanting to end therapy is a critical topic to explore, he said. And it could be as simple as telling your therapist, “I feel like it’s time to end therapy, I wonder what that’s all about?”

Therapy gives people the opportunity to have a positive ending, unlike most endings, which tend to be negative, such as death and divorce, Howes said. An end in therapy can be “more like a bittersweet graduation than a sad, abrupt, or complicated loss. Ideally, you can have a satisfying closure to therapy that will help you end relationships well in the future.”

That’s because our relationship with our therapist frequently mirrors our relationships outside their office. “We often unconsciously recreate dynamics from other relationships with our therapist,” said Joyce Marter, LCPC, a therapist and owner of the counseling practice Urban Balance. “Processing negative feelings can be a way to work through maladaptive patterns and make the therapeutic relationship a corrective experience. If you avoid this conversation by simply discontinuing therapy, you will miss this opportunity for a deeper level of healing resulting from your therapy.”

Tips on Ending Therapy

Below, clinicians share additional thoughts on the best ways to approach your therapist when you’d like to end therapy.

1. Figure out why you’d like to leave. According to Jeffrey Sumber, M.A., a psychotherapist, author and teacher, the best way to end therapy is to delve into why you’d like to leave. Ask yourself: Is it “because I feel disrespected, stuck or incompatible or [am I] actually feeling uncomfortable dealing with certain things that the counselor is pushing me on?” It’s common and part of the process of changing problematic patterns, he said, to feel triggered and even angry with your therapist.

2. Don’t stop therapy abruptly. Again, it’s important for clients to talk with their therapists, because they may realize that their desire to part ways is premature. Even if you decide to leave therapy, processing this is helpful. “A session or two to discuss how you feel and what kinds of post-treatment experiences you may go through will help ease guilt, regret or sadness that often arises when wanting to stop therapy,” Serani said.

Plus, “Honoring the relationship and the work you have done together with some sessions to achieve closure in a positive way can be a very powerful experience,” Marter said.

But there are exceptions. Howes suggested leaving abruptly if there are ethical violations. He reminded readers that you’re “the boss” in therapy:

If there have been significant ethical violations in therapy – sexual advances, breached confidentiality, boundary violations, etc. – it may be best to leave and seek treatment elsewhere. It’s important for clients to know they are the boss; it’s your time and your dime, and you can leave whenever you want. If the violations are serious enough, you may want to tell your therapist’s boss, your next therapist, or the licensing board about them.

3. Talk in person. Avoid ending therapy with a text, email or voicemail, Marter said. “Speaking directly is an opportunity to practice assertive communication and perhaps also conflict resolution, making it is an opportunity for learning and growth.”

4. Be honest. “If you feel comfortable and emotionally safe doing so, it is best to be direct and honest with your therapist about how you are feeling about him or her, the therapeutic relationship or the counseling process,” Marter said.

When offering feedback to your therapist, do so “without bitterness or judgment,” said John Duffy, Ph.D, a clinical psychologist and author of the book The Available Parent: Radical Optimism for Raising Teens and Tweens. “After all, this person will be working with others in the future, and your thoughts may change his or her style, and help them to better serve their clients in the future.”

“A good therapist will be open to feedback and will use it to continually improve,” added Christina G. Hibbert, Psy.D, a clinical psychologist and expert in postpartum mental health.

5. Communicate clearly. “Your best bet is to be as direct, open, and clear as possible,” Hibbert said. Articulate your exact reasons for wanting to end therapy. Hibbert gave the following examples: “’I didn’t agree with what you said last session and it makes me feel like this isn’t going to work,’ or ‘I’ve tried several sessions, but I just don’t feel like we’re a good match.’”

(“’Not being a “good match’ is a perfectly good reason to terminate therapy, since so much of it has to do with a good personality fit and a trusting relationship,” she added.)

6. Be ready for your therapist to disagree. According to Serani, “It is not unusual for a therapist to agree with ending therapy, especially if you’ve reached your goals and are doing well.” But they also might disagree with you, she said. Still, remember that this is “your therapy.” “Don’t agree to continue if you truly want to stop, or feel persuaded to keep coming for sessions because your therapist pressures you to stay.”

7. Plan for the end in the beginning. “Every therapy ends, there’s no reason to deny this fact,” Howes said. He suggested discussing termination at the start of treatment. “Early in therapy when you’re covering your treatment goals, why not talk about how and when you’d like therapy to end? Will you stop when you’ve achieved all your goals? When the insurance runs out? When and if you get bored in therapy?”

Again, therapy can teach you valuable skills to use for your other relationships. According to Marter, “Even if after expressing your negative feelings, you choose to end the therapeutic relationship, you can rest assured that you took good care of yourself by advocating for yourself in a way that was direct and honest. This is a skill you can bring with you to other relationships that are no longer working for you.”

How Therapists React to Termination

So how do clinicians take it when clients end therapy? All the therapists noted that having their clients share feedback on their experiences is incredibly valuable. In short, it helps them improve and grow as clinicians.

But, when there’s no official end to therapy, therapists are left with many unanswered questions. According to Howes:

When a client terminates via voicemail, fades away with a vague “I’ll call you for my next session,” or abruptly announces the end and leaves, I feel loss and am left with many questions.

What fell short in this therapy? What would have worked better? How could I have been a better therapist for you? What made you feel like you couldn’t discuss this with me? I’m left with no answers for these questions, and that’s difficult. I spend a lot of time reflecting on our work together, but I have no definite answers.

Serani and Marter echoed this sentiment. “Sometimes clients just ‘fizzle out’ without explanation, which has been one of the harder pieces of being a therapist for me because I am very invested in my work with my clients. It causes me to wonder if I did something that bothered them and wished that I knew,” Marter said.

Serani also talked about attempting to understand the client’s decision. “I always want to explore the reasons why. Was it something I said? Was it something I didn’t say? What has happened to make this decision so urgent? I often feel confused, and work hard to make sense of why this has happened.”

Hibbert tries not to take it personally. “Usually clients simply ‘stop coming,’ so it’s not easy to know if they’re just ‘done’ with therapy or if I’ve done something to make them want to leave. When this is the case, I just let it go. It’s their issue, not mine, and I don’t need to stress over it when I don’t know the reasons behind it.”

She takes a similar approach when a client wants to stop therapy because of personality differences. “Only a couple of times has a client verbalized a desire to leave because of ‘personality’ or ‘style’ differences. I can’t say it never stings, but I try not to take it personally. Like I said before, therapy, in large part, is a personality fit, and I can’t fit with every personality.”

When client and clinician are able to have a session (or two) for proper closure, it becomes a great opportunity to reflect on their work together. In fact, for Howes, these are often his most enjoyable sessions.

My goal is to help a client confront life head-on. If they have clear reasons to end therapy and we’ve had the time to talk about it and tie up the loose ends, ending therapy is a great time to reflect on our work, talk about the client’s future, and discuss what has been accomplished and what hasn’t. We can leave with a sense of closure, without lingering questions.

Some of my best sessions have been final appointments where we reminisce about our time together, talk about the client’s future, and I learn how to be a better clinician for others.

Serani described final sessions with mixed emotions. “This is usually an exciting but bittersweet time, where we both feel a loss about the goodbye, but know that leaving is part of the healing process. I’m always sad for me, but happy for my patient.”

Unless there are ethical violations, it’s important to discuss your desire to end therapy with your therapist, in person. As Duffy said, doing so with “respect and integrity will set the tone for other relationship issues you will encounter in life.” It also helps you process your emotions and figure out if you’re leaving too soon. And it gives your therapist valuable feedback that improves their work. In other words, with proper closure, everybody wins.

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.