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CBT Self-Help Guide For Treating Insomnia Based On Sleep Science
Insomnia disorder is sleep problem defined by difficulty falling and/or staying asleep that happens at least three times a week and has persisted for at least three months. Additionally, these nighttime problems are combined with daytime symptoms, like exhaustion, irritability, and difficulty concentrating. The problems also happen even if you give yourself enough time to sleep.
Often, people think that they have to rely on over-the-counter drugs, such as melatonin, or sleeping medication prescribed by their doctor to get a good night’s rest. However, there is research to suggest that non-drug options, like cognitive behavioural therapy for insomnia, is just as helpful as medication to treat insomnia. Not only is it similar in efficacy in the short-term, CBT has a more durable effect on insomnia because it treats the underlying causes of sleep problems and leads to increased sleep confidence.
In this post, I discuss the main strategies used in CBT for insomnia so that you can apply them to your own sleep problems.
Understanding how insomnia develops
In order to understand how we treat insomnia, we first need to understand how insomnia develops.
A very common experience that I hear people say is that: “I started having sleep problems when X thing happened. I’m not worried about that thing anymore, but I still can’t sleep.” The reason why we cannot sleep anymore is because the insomnia has taken life of its own and there are certain thoughts, emotions, and behaviours that keep the insomnia alive.
People with insomnia are constantly exhausted. As a result, they react to bad nights very differently compared to good sleepers. For example, they may think: “I’m going to have another terrible night” or “tomorrow is going to be exhausting.” They may also feel anxious or frustrated as a result. Moreover, they may also do things to try and catch more sleep or conserve energy, like staying in bed, taking naps, reducing activities, and going to bed early.
As we will discuss, these reactions and behaviours are very reasonable, but they actually maintain our sleep problems.
Learning about the systems that lead to sleep
There are essentially three systems that govern sleep:
1. Sleep Drive
Sleep drive is like our appetite for sleep. The more that we are awake and active, the more ‘appetite’ that we build up for sleep. Importantly, this sleep drive is linked to how much deep sleep we get, which is the sleep that makes us feel refreshed. When people have insomnia, they unintentionally engage in behaviours that reduce appetite for sleep, such as staying in bed for long than they are sleeping and taking naps (which is like taking a sleep snack in place of a larger dinner).
2. Circadian rhythm
Our circadian rhythm tells us when we are sleepy and when we are awake. However, our internal clock needs to be set every day because it’s not exactly 24 hours. We can set a strong rhythm by engaging in regular activities, such as getting out of bed at a regular time (and getting some sunlight in the morning) and keeping to a fairly regular schedule. However, people with insomnia tend to have more irregular schedules or tend to go to bed too early or wake up too late, which is not in sync with their body clock (e.g., being more of a night owl vs early bird). These behaviours can lead to poorly timed sleep or ‘jet lag’ symptoms.
3. Hyperarousal
Even if we have sufficient sleep drive and good timing, good sleep can sometimes still be stumped if we are very anxious. People with insomnia often struggle with a lot of sleep anxiety and they spend a lot of time in bed feeling frustrated and distressed. Over time, their brain begins to associate the bed with wakefulness rather than sleep. Consequently, we need to reduce arousal. Some ways to do that include regular relaxation practice, challenging unhelpful thoughts, and reducing the amount of time we spend in bed awake and frustrated.
The good sleep formula
The formula for good sleep is = high sleep drive + good circadian timing + low arousal.
The strategies for increasing sleep drive are by spending time you are not sleeping outside of bed at night and increasing activity throughout the day. I would encourage to do activities that are consistent with your life and values – for example, taking walks, doing yoga, and spending time with loved ones.
The strategies for improving circadian input are by waking up at a regular time each day, getting out of bed at that time and getting some sunlight. It is also important to try and follow your own internal clock. If you are a bit more of an early bird, then consider finding ways to get to bed a little earlier.
Finally, there are a number of strategies to reduce arousal. Some benefit from having a nice winddown period, others enjoy having a worry time, and others still need help with challenging unhelpful beliefs about sleep. Here is a post on reducing arousal at night.
A case formulation approach to insomnia
Now that you are aware of the main principles in treating insomnia, the goal is for you to identify the factors that are most relevant for you. In therapy, this is called case formulation – what is the thing maintaining my sleep problem?
For example, are there behaviours in your life that might impact sleep drive or circadian rhythm? Perhaps there are certain things in your life that could be increasing stress? I would invite you to ponder on some of these possible contributors to poor sleep and begin to use the strategies outlined to support your sleep goals.
Remember: build sleep drive, keep to a regular circadian rhythm, and use different strategies to reduce arousal. You got this!
Best wishes,
P
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The Beachball Analogy On The Power Of Letting Go: Acceptance And Commitment Therapy
Many people often think of acceptance as the same as giving up or staying stagnant in our lives. They view acceptance as bad and the enemy of change.
However, there is a lot of power in acceptance. In fact, acceptance has formed the core of more recent ‘third wave’ therapies, such as acceptance and commitment therapy and dialectical behavior therapy. These acceptance-based strategies that are based in Eastern philosophies focus on letting go in order to reduce suffering.
In acceptance-based therapies, clinicians like to use a lot of metaphors. One metaphor that I really enjoy and is a great example of the power of acceptance is the beachball analogy.
We are often focused on the thing that is making us unhappy. Maybe we are not at the college that we really wanted to attend. Perhaps there is a coworker we really dislike and wish they would go away. Or we are just trying to push away feelings that we don’t want to have.
In many of these cases, we spend a lot of time either pushing away the bad thoughts, feelings, or experiences. It’s kind of like when we are constantly pushing down a beachball in the ocean. We try to push away these distressing experiences, and we spend all our time and energy in making the bad thing go away.
Unfortunately, what we resist persists. And the beachball will make its way back up to the surface from time to time. Our efforts are in vain.
In acceptance, the idea is to let go of this constant resisting. Instead of pushing the beachball down, we simply let the ball go and allow it float around. And instead of focusing on the beachball, we focus on the beauty that surrounds us. We can play in the water, or we can make sandcastles on the beach. We can enjoy the sunset as the rays of light glisten on the ocean’s surface.
And sure, the beachball might pop from time to time. But that’s okay. Because by accepting that the beachball might be around, we can spend our time on the most important things in our lives.
Just the same, I invite you to think about whether there is something in your life that you are resisting – maybe it’s a painful emotion, maybe it’s a chronic condition, or someone you really dislike in your life. This is your own beach ball. And see if you can decide to let go of constantly pushing it away, accept that experience into your life, so that you can enjoy the rest of the beach. Maybe make a sandcastle while you’re there.
Best wishes,
P
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Should I Leave Or Stay In Bed When I Cannot Sleep?
In insomnia, people have high anxiety about being unable to sleep. Moreover, they often spend a lot of their time in bed awake and feeling distressed. Over time, their brain begins to make an association between the bed and wakefulness (known as conditioned arousal). If you have ever had the experience of going to bed sleepy, and then feeling wide awake the moment your head hits the pillow, then you understand the experience of conditioned arousal.
Getting out of bed when you cannot sleep
This conditioned arousal is why insomnia therapists ask patients to leave the bed when they are not able to sleep. By limiting the amount of time we spend in bed awake, and spending more of that time in bed asleep, we give our brains the chance to start associating the bed with sleep again.
This is called stimulus control where patients get out of bed to do something quiet (like reading or doing a crossword puzzle) and then go back to bed when they feel the sleepiness come back on.
Can I stay in bed when I am awake?
Stimulus control can be a very powerful technique. However, there is research to suggest that you don’t necessarily have to get out of bed to break the association between the bed and wakefulness.
Ultimately, the idea is to ensure that the bed is seen as a place of relaxation rather than stress. You don’t have to get out of bed to do that. You can also do this through a clinical technique called countercontrol.
Countercontrol means doing all the same things as in stimulus control except changing your position in bed (for example, lying on the other side of the bed instead of your usual side). Again, you would do something quiet and enjoyable until sleepiness comes back – at which point you can go back to sleep.
When should I stay in bed?
Here are a few situations where countercontrol may be more helpful than stimulus control.
1. When safety is an issue – If you are at risk of falling, or pregnant, or there are other reasons why it might be unsafe to get out of bed at night, then staying in bed would be recommended.
2. When there’s too much anxiety about getting out of bed – We should not let perfect get in the way of good. If the idea of getting of bed is a terribly frightening idea and you can’t see yourself doing that at least right now, then countercontrol may be a better fit.
3. When environmental factors don’t allow for stimulus control – If you are living in a studio apartment, or have lots of roommates, then getting out of bed may be challenging. In this case, counter control may be more appropriate.
4. When you are struggling with just sleep anxiety – If most of your fears are about sleep, then doing something light and enjoyable in bed may be more appropriate.
5. If your difficulty is staying asleep at night – there’s some research to suggest that countercontrol may be particularly helpful if the insomnia challenge is waking up a lot at night.
When should I get out of bed?
1. When your difficult is falling asleep at night – Research suggests that stimulus control is very effective for treating sleep onset difficulties and helping folks fall asleep when they first get to bed at night.
2. When you are dealing with more generalized worries – if you are more of a worrier in general (rather than about sleep in particular), then getting out of bed may be helpful so that you are not constantly worrying about the next day in bed.
3. When you have a place that works well for stimulus control – if your living arrangements allows you to leave the bedroom and you have a nice place to sit and do something enjoyable, then stimulus control may be a better fit.
4. When you notice that you just can’t relax if you are in bed – In cases where you try to relax and enjoy your time in bed, but find that you are just an anxious wreck, then I encourage you to get out of bed. Listen to your inner wisdom as to what might be more helpful!
5. When you want to rip off the band-aid – stimulus control is one of the most effective strategies in treatment of insomnia. It’s hard to do, but I think of it like ripping off a bandaid. If you can do it, the true healing can really start to happen.
Best wishes,
P
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Green Flags Of A Good Therapist – What To Look For When Starting Therapy
The process of starting a therapy is often scary, and it can be daunting to decide who would be the best to work with in terms of a therapist.
Fortunately, you don’t have to decide immediately, and most therapists often provide a free consultation session so that you can get a sense of whether the therapist feels like a good fit. Given that therapeutic rapport (the relationship you have with your therapist) is one of the most consistent predictors of positive treatment outcomes, it is helpful to choose a therapist that you work well with.
This post offers some possible green flags to consider when deciding who you would like to work with in therapy.
A good therapist understands what you are struggling with
A good therapist will make you feel listened and understood. Often times, when we are struggling with mental health struggles, there’s many strong emotions and thoughts that are jumbled in our mind. It’s confusing for us to really lay out what’s going wrong even though we know something isn’t right.
A therapist who truly understands will be able to reframe and piece together a couple of sentences that gets to the core of what you’re struggling with. If they provide a summary or reflection of what you said, and you think to yourself: “Yes, that’s exactly it!” – then that therapist understands your issues well.
A good therapist validates your struggles
We tend to be pretty hard on ourselves and we might go into therapy thinking “it’s my fault,” “I’m to blame,” and “I shouldn’t feel this way.”
A good therapist will make sense of your thoughts, emotions, and behaviours. They will be that compassionate person to highlight that you are indeed struggling, while simultaneously offering a way forward.
Sometimes, people think acceptance and change are mutually exclusive – that it’s one or the other. However, having someone validate that you are indeed dealing with something hard, can be a way to increase self-compassion and offer the self-esteem needed to make a change.
A good therapist is collaborative
When you go to a doctor, the approach is usually directive – the doctor says “do X, Y, and Z” and then you go about your merry way.
On the other hand, therapists and patients work together in a collaborative approach to move them towards a common goal. A good therapist will often encourage you to share what works and what doesn’t work to make sure that you always have a say in how the treatment is planned.
Moreover, a good therapist will ask about your goals because they understand that success looks different from person to person. One’s person version of happiness is going to be different from another person.
The therapist is the expert of psychological treatments, and you are the expert in your own lived experience.
A good therapist offers hope
When someone has been struggling with mental health issues for years, it’s easy to feel hopeless about their situation.
A good therapist will offer a sense of hope that the treatment can be helpful. For example, they may talk about the research suggesting that a treatment is beneficial for dealing with the patient’s problems, or discuss strategies that seem like they would be a good fit for the issues.
You may also feel hopeful from the way that the therapist talks about their experience with treating certain mental health conditions. They may really “get it” or talk about past patients with similar problems that have seen benefits from treatment.
Anxious but hopeful is a good place to be at the end of a first therapy session.
A good therapist challenges you
Although a therapist should validate your experience, they should also be realistic in sharing that therapy is hard work. It’s not like medication where you just take it and forget about it; therapy requires commitment and using strategies that benefit us in the long-term and leads to more discomfort in the short-term. Therapists think of treatment like building a muscle or learning an instruments: it takes practice to get the benefits of the skills.
If you feel heard, but also challenged, then this is a good place to be when starting therapy.
A good therapist is open to your concerns
Finally, a good therapist will talk you through the concerns you might have about treatment. They will be genuine and honest with you about the benefits and costs of starting therapy.
They will encourage you to take into account these pros and cons make a decision based on what you think is right, not what other people think is right. In treatment, the ethical principles that is always the most prioritized is the patient’s dignity as a human being.
After you get all the information, you can trust your own inner wisdom to decide whether this feels like a good fit, or if it would be helpful to meet with other possible therapists.
Best wishes,
P
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Examples Of SMART Goals For Social Anxiety Disorder
Social anxiety disorder is a fear of negative evaluation – meaning that a person gets anxious in social situation because they worry about what the other person thinks about them. For example, in a presentation, they may fear other people thinking that they are boring, sound stupid, or that they can see them blushing or sweating.
There are a number of different situations that can lead to anxiety, such as presentations, meeting unfamiliar people, going parties, taking tests, eating in front of other people, making a phone call, and initiating a conversation.
Common thoughts in social anxiety include:
- “They probably don’t want to talk to me”
- “I sound so stupid right now”
- “They can probably see that I am sweating and being awkward”
These thoughts lead to increased anxiety, which then leads to a desire to avoid social situations. Avoidance can come in many forms. Some are more obvious – such as not going to a party at all – and others are more subtle – like bringing a close friend, drinking alcohol, or avoiding sharing too much about themselves.
Fortunately, there are a number of research backed strategies that can reduce symptoms of social anxiety.
Evidence-based strategies for social anxiety
In CBT, there are two main ways to work with social anxiety: cognitive and behavioural.
In cognitive therapy, the idea is that we work on the unhelpful thoughts that maintain social anxiety. For example, people with social anxiety often have thinking errors such as mind reading and fortune telling – “she probably does not want hang out with me” or “I’ll do terribly on this presentation.
To work on these thoughts, we can use a thought record. This allows us to systematically evaluate the thought by using facts. For example, is there any evidence that somebody does not like you? Or have you ever done well on presentations in the past?
The idea isn’t to fully change your mind; it’s just to find a more balanced thought that is grounded in reality.
For behavioural strategies, the most effective technique is the use of exposures. Here, we challenge our fear of social situations by exposing ourselves to them without avoiding. For example, some of my past patients have done exposures like making small talk with the Uber driver or going to a game night by themselves. We can do exposures in a gradual way to support.
SMART Goals for social anxiety
Here are a few SMART (Specific, Measurable, Achievable, Relevant, Time Bound) goals that can support work to deal with social anxiety. The idea is to make goals that are specific and relevant to your situation and fears, and increase the likelihood that they will be done by making them achievable and by placing them on a time limit.
Examples of SMART goals:
- Complete one thought record a day on an unhelpful thought
- Smile and say hello to 5 people
- Make a phone call for an appointment without preparing
- Have a conversation with the Uber driver by asking them about their day
- Practice a presentation with a friend or close person
Of course, you’ll want to choose SMART goals that will give you the best bang for your buck, and is something you feel confident that you can do!
Best wishes,
P
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Understanding Limits To Confidentiality: What Therapists Can And Cannot Talk About
Confidentiality – what therapists can and cannot share with other people outside the therapy room – is often a concern that people have when thinking about starting therapy.
They worry that their “crazy” thoughts and/or urges to harm themselves, could mean that the therapist will immediately tell the police and send them to the hospital. (Rest assured, that’s not what happens).
In most cases, confidentiality means that the information will be kept between you and therapist, as well as your primary circle of care. This means that only people who are actively working with you will have access to the information. For example, if you are going to a hospital to see a psychologist, and you also work with a social worker there, that social worker will also have access to the information to ensure continuity of care. That is – all your clinicians on the same page to make sure they are providing you with the best services.
Limits to confidentiality
Although most everything is confidentiality between your therapist and you, there are a few instances where the therapist may have to let the right people know so that everyone stays safe.
- Immediate risk of harm to yourself and/or others
- Evidence of abuse of a child or someone in a long-term care facility
- Inappropriate behaviours of a health professional
- Court of law subpoenas records
- Record checking from the psychology association
Below, I’ll provide additional information on the five limits to confidentiality and give examples so you know what this actually looks like in practice.
Limit to confidentiality #1: Risk of immediate harm to self or others
Therapists may let the right people know if there is sufficient risk that immediate risk of harm could come to you or somebody else. For example, if you let the therapist know that you won’t be attending next week’s session because you won’t be on this earth anymore, or if you plan on seriously harming a colleague at work.
In both these cases, the risk if imminent. Therefore, this doesn’t include situations where you are just thinking about death or tell the therapist you really hate your colleague. It also means that therapists don’t say anything if you said you had attacked someone in the past because it already happened. There’s no current risk unless you said you were planning to do it again.
As you can see, unless there is very serious risk in the present context, confidentiality will still apply.
Limit to confidentiality #2: Abuse of a child or a person in a long-term care facility
In the event that there is knowledge of abuse of a minor or someone in a long-term care facility, the therapist will have to let the right personnel know (e.g., child services). Abuse can come in many forms – verbal/physical abuse and neglect, for example.
Some therapists will be more sensitive to information involving abuse, and will be more inclined to take a better safe than sorry approach. However, it is important to remember that the reporting doesn’t necessarily mean any one gets in trouble; it’s just a precaution to start a larger investigation.
In some cases, this break of confidentiality can of course impact the therapeutic alliance because some clients see this as a betrayal of trust. On the other hand, some clients actually might respect their therapist more because they recognize that the therapist truly cares about each person’s well-being.
Limit to confidentiality #3: Inappropriate behaviour of a health professional
There also limits to confidentiality if the therapist becomes aware that a health professional has ever been inappropriate to you as the patient. For example, making sexually suggestive comments. In this case, they would have to let the regulatory body of that professional know, so no harm comes to additional patients.
However, this is true only if you have provided enough information about the health professional to identify them; if you are fairly vague and do not give a name, then the therapist would not be able to raise this concern.
Limits to confidentiality #4: A court of law subpoenas the records
If you are part of a legal battle, it is possible for a court of law to subpoena the records. If the judge deems appropriate, then the files may have to be turned over.
However, this doesn’t mean that we have to provide all files related to the person. There can be ways to redact certain information that are not pertinent to the case.
Limits to confidentiality #5: The psychology association asks to do a record check
Once in a while, the psychology association might ask for a therapist to hand over files to see if the therapist is doing the right things for quality assurance purposes. Similar to #4, the therapist can discuss with the patient what they think is okay or not okay to share. This can be an ongoing conversation between the therapist and patient.
Summary
I hope this post was helpful in understanding more about confidentiality and when therapists might break confidentiality. Hopefully, this assuages your concerns a little that therapists will not report every little thing that is discussed in a therapy session.
And more often than not, it’ll be a conversation between you and the therapist.
Best wishes,
P
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Examples Of SMART Goals For Panic Disorder
Panic Disorder is a mental health disorder where people struggle with a fear of panic attacks or having symptoms of panic attacks (such as racing heart or sweating). They worry that these symptoms will only get worse or are a sign of something catastrophic – for example, a heart attack or seizure.
As a result, folks with panic disorder tend to avoid any situations that may lead to these symptoms. They may shrink their world down until the point where they do not leave their own house for fear of panic symptoms. Or they will have a number of strategies to reduce anxiety, such as using medication, breathing exercises, cold water, or bringing a friend alone in case they have a panic attack.
Treatment of Panic Disorder
In essence, panic disorder can be described as a change in our relationship with anxiety symptoms. These symptoms, such as shaking/trembling, feeling hot, and heart palpitations, which were once experienced as uncomfortable but not dangerous, has taken a more threatening place in a person’s life. They start to interpret these anxiety symptoms as something that could harm them. As a result, this leads to even more anxiety, which increases the symptoms, and then a vicious cycle of panic disorder is created.
Therefore, the goal of treating panic disorder is to reduce our fear of anxiety symptoms. The hope is for the person to recognize that while anxiety symptoms are very uncomfortable, they are ultimately not life threatening.
To do so, we actively create the symptoms that we are afraid of and sit with them. This is called interoceptive exposure therapy. For example, we might run in place if our fear is about sweating or racing heart, or spin around if we fear nausea or dizziness spells. Exposures are extremely powerful treatment because we learn that these symptoms are not dangerous and that we can cope with them without running away.
Of course, sitting with these symptoms is easier said than done. Next, we’ll discuss how to use SMART goals to make the process of completing exposures more bearable.
SMART Goals for Panic Disorder
SMART Goals stand for Specific, Measurable, Achievable, Relevant, and Time Bound. Simply put, SMART goals refer to goals in which we know exactly what we are doing and when we are done, where we can rate our anxiety before and after the practice, and that the goal is relevant to our problem.
Here are a few examples of SMART goals you can apply to your panic symptoms:
- Jog in place for one minute three times a day
- Sit in a warm room while wearing a jacket for 10 minutes
- Spin around 15 times once a day for a week
- Hyperventilate for 30 seconds
- Breath through a straw for 30 seconds
- Do 15 push-ups twice a day
As you can see, the point is really to make goals where you are able to practice tolerating your fear of symptoms on a daily basis, in a way that feels manageable and achievable. Feel free to change or make your own goals that would be beneficial to your specific worries.
To increase the effects of this practice, you can rate your anxiety before and after the practice, as well as observe how the anxiety levels changes in the time following the practice. Write down what you anticipated to happen and what actually happened to really consolidate your learning.
And slowly build up from there – you got this!
Best wishes,
P
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Examples Of SMART Goals For Obsessive Compulsive Disorder
Intro to OCD
Obsessive Compulsive Disorder (OCD) is a mental health disorder that – as the name suggests – revolve around obsessions and compulsions.
Obsessions are intrusive thoughts, images, or urges, and can span a number of different themes. For example, there can be obsessions related to doubt (“did I leave the stove on?”), contamination (“my hands are dirty”), and morals (“I must be a bad person because I thought about hurting someone”), among many others.
Importantly, these obsessions are ego-dystonic, meaning that they cause people distress because they feel contrary to their values. For example, intrusive images of harming someone causes distress because the person does not feel this is consistent with their perceptions of being a kind person.
The distress that comes from obsessions lead to compulsions, which are specific behaviours or thoughts that help reduce anxiety or neutralize a fear. For example, a person might wash their hands in contamination OCD, check constantly in doubting OCD, or think positive images in moral OCD.
Research supported treatments for OCD
The treatment that has received the most research supporting its efficacy in treating OCD is exposure and response prevention therapy (ERP). At its core, ERP is about exposing ourselves to the obsession without engaging in the compulsion that we would normally perform. This helps our brain recognize that nothing will go wrong, and that we can handle the distress, which helps us reduce distress in the long-term.
In the example of contamination OCD, we might get ‘dirty’ but not clean ourselves or certain objects. In the example of doubt OCD, we might limit our checking when we go outside, and tolerate the uncertainty that comes from worrying whether the stove is closed or if the door is indeed locked.
SMART goals in exposure and response prevention therapy
SMART goals are a way to make actionable plans towards working on your OCD symptoms. Here’s a detailed guide on SMART goals if you’re interested.
Essentially, SMART goals stand for:
- S – Specific (the goal needs to be specific, for example how long and for how many times we are doing something)
- M – Measurable (we can measure our distress levels before and after the exercise, such as from 0 = no distress at all to 100 = extremely distressed)
- A – Achievable (We wouldn’t start with a marathon if we have not run in the past decade. This is a moving goal post, so you can increase difficulty as you work on your OCD symptoms)
- R – Relevant (Is this related to our goal? If we have contamination-based OCD, then we would want to work on tolerating our distress of feeling that we are dirty after touching something deemed contaminated)
- T – Timebound (We need to set a time limit. For example, practicing something three times a week).
Examples of SMART goals in OCD
Here are some examples of SMART goals for different types of OCD. These are just made-up examples so you get the jist, so you are more than welcome to amend the goals so that they are specific to your life!
Contamination OCD
- Wash hands for only 30 seconds with one pump of soap
- Take a shower in 20 minutes with an alarm and only wash each part of the body once
- Clean the sheets once a week
- Sit with feelings with contamination for 20 minutes a day and rate distress before and after the practice
Doubt OCD
- Check each appliance once and then leave the house
- Go for a 30 minute walk without checking at all
- Check the door knob 10 times instead of 15 times
Moral OCD
- Watch an episode of true crime a day
- Sit with a negative image for 10 minutes and then rate distress before and after
- Be around people and speak to them at least three times a day
Symmetry OCD
- Intentionally mess up something (e.g., puzzles, laundry) once a day and leave it in a mess until the next day
- Look at something that is asymmetrical for 15 minutes and then rate distress before and after
Thought-Action Fusion OCD
- Think something a person having an accident once a day to see if anything terrible happens to them. *If you’re worried something really bad might actually happen, and you’re worried about hurting your friends and family, you can think of somebody you don’t like. Actually, you can even think about me. If you don’t see a post in this website for several months, you’ll know it worked.
Summary
Of course, your OCD symptoms may be different from the ones discussed here. Hopefully, this post offers some guiding ideas on how to apply SMART goals to OCD!
Best wishes,
P
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Examples of SMART Goals For Generalized Anxiety Disorder
Generalized anxiety disorder as described as excessive worry about a number of different topics. These worries can span anywhere from big themes – such as family, relationships, the future – all the way down to every day concerns like appointments and whether we will like a new restaurant.
Most people have worries, however, folks with generalized anxiety disorder tend to find their worries excessive (e.g., worrying hours every day) and hard to control. Moreover, worries generalized anxiety tend to come with a set of symptoms:
- restlessness
- irritability
- sleep problems
- concentration difficulties
- fatigue
- muscle tension
Thinking conceptually about GAD
There’s been a lot of research over the years to understand more about GAD. Well-known researchers, such as Dr. Michel Dugas, began to think about GAD as a fear of the unknown.
People with GAD tend to have an ‘allergy’ to uncertainty. In fact, they may even sometimes prefer being certain of a negative outcome rather than staying in ambiguity. For example, they might say “I’d rather just know I failed the test so I can stop worrying about it.”
The issue is that life is full of uncertainty. We cannot even be sure about what the next day will bring, let alone the next year. Therefore, we need to figure out ways to change our relationship with uncertainty.
Fortunately, there have been a number of research-backed strategies based on this understanding that we can use to reduce symptoms of GAD.
Evidence-based strategies for GAD
Below are a few described strategies to work on symptoms of GAD:
1. Worry Logs
Worry logs are a way to track incidents in daily life that leads to anxiety. You can spread it out into 4 columns: 1) Situation, 2) Worry Thought, 3) Emotion, and 4) Type of Worry.
The situation can be any moment that led to a worry. For example, “thinking about a medical appointment that I have to attend on Monday but I don’t have childcare.”
Then you write out the worry thought: “I’m worried I won’t find childcare and then I will miss an important medical appointment.”
Afterwards, you can include your emotions and their intensity: “Anxiety (80%) and Sadness (50%).
Finally, you write down whether the worry is productive (that the problem is immediate, will likely happen, and needs a solution) or hypothetical (the problem is in the future, is unlikely to happen, and there is no obvious solution). In this case, the need for child care would be productive. However, sometimes we can have hypothetical worries, such as whether our 2-year-old child will be able to go to college that they desire.
2. Problem Solving
When worries are ‘productive’ then it is best to use a problem-solving approach. Problem-solving is exactly how it sounds, and everyone problem solves on a day to day.
In therapy, we sometimes use a structured approach, which includes 1) defining the problem 2) defining the solution 3) brainstorming non-judgmentally for as many solutions as possible 4) picking the solution with the most pros and least cons 5) breaking the solution into steps and then 6) carrying out the solution.
3. Written Exposures
Some worries are ‘hypothetical’ and therefore unproductive to problem-solve (because there’s no immediately solution!).
In this case, it can be helpful to complete a written exposure which is when a person takes time to write out a fear and the worst consequences they can think of – for example, writing about a fear that they have if their parents were to pass away.
Although this can be scary at first, the point is to slowly habituate to the fear through repeated writing exposures. Moreover, we sometimes begin to feel more capable of handling the worst case scenarios, or recognize that it is unlikely to happen in a disastrous way. This can subsequently reduce anxiety.
4. Behavioural Experiments
Behavioural experiments directly target intolerance of uncertainty. The idea behind behavioural experiments is that we hear our anxious brain make a prediction (e.g., “I won’t like the food at this restaurant if I order it”), but decide to be a curious scientist and test it out anyway.
Behavioural experiments can be very powerful because they do two things: 1) they show that our anxious brains are not always correct and 2) that even if it is sometimes correct, that we can cope with these outcomes.
To make starting behavioural experiments simple, you can start with low stakes experiments, such as trying out a new restaurant, calling up an old friend, or deciding to say yes to events rather than immediately rejecting them.
SMART Goals for GAD
SMART Goals are a way to engage in some of these evidence-based strategies in a way that is Specific, Measurable, Achievable, Relevant, and Timebound. Here’s a detailed guide if you’re interested more generally about creating SMART goals.
Below I provide a few SMART goals that are related to dealing with GAD symptoms.
- Write out three situations using the worry log every week
- Brainstorm a possible solution to a problem. Carry out the first step of a solution for one problem.
- Write out an imaginal exposure once a day for at least 15 minutes.
- Conduct one behavioural experiment each day and report whether the outcome was positive, negative, or neutral. Tally up the number of different outcomes at the end of the week.
- *Examples of behavioural experiments can include: making an appointment without preparing, ordering from a new restaurant, going to a new café to study, calling a friend to hang out (or anything else that helps you tolerate uncertainty!)
Consistent with the ‘Specific’ and ‘Realistic’ components of SMART goals, please feel free to cultivate goals that are consistent with your needs!
Best wishes,P
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How I Help People With Insomnia As A CBT Therapist
Millions of people struggle with insomnia. In fact, some studies suggest that nearly one in three people experience at least one symptom of insomnia, such as difficulty falling and/or staying asleep, or waking up too early.
Most people are familiar with sleep medication, but there is less familiarity with the use of therapy (like cognitive behavioural treatments) in treating sleep problems.
The issue is that people are unlikely to make decisions when they are uncertain. This means that they are unlikely to go into therapy, which research suggests is just as effective as medication, and even more effective in the long-term. Moreover, the veils of therapy make it hard to obtain clarity about what goes on in the room and the idea of being vulnerable is scary.
In this post, I provide some information about what a CBT insomnia therapist like myself actually do in the room to support clients.
#1 Figure out goals and values
Therapy is a collaborative place. And one of the first things I emphasize is to figure out what it is that the client sleep goals and work together to come up with a game plane to accomplish this goal in therapy.
Common goals I hear with patients that struggle with insomnia are:
- Falling asleep with a normal range (e.g., 10-30 minutes a night)
- Staying asleep throughout the night
- Obtaining better quality sleep
- Having less concentration difficulties during the day.
Besides goals, one aspect I find very important is to understand how a patient’s values may play a role in therapy. I might ask the patient “why it is important for them to make a change?” This can sometimes increase motivation if I can link improved sleep to important areas in their life, such as family, health, and being better able to enjoy the present moment.
On the other hand, sometimes the recommendations are not consistent with a person’s values. For example, some folks want to have a variable schedule or read in bed. Sometimes, knowing how these behaviours can affect sleep can be helpful to understand that there can be consequences to actions (though I always recommend that a person follow their values). Insomnia is a subjective disorder, so if a person understands how their values can impact sleep and are willing to sacrifice sleep for their values, then this can reduce a feeling of distress. They are simply doing what feels right for them.
#2 Provide the right psychoeducation
Following building a strong relationship and figuring out a patient’s goals and values, there is information I like to provide to patients that is needed to understand the therapy recommendations.
For example, one of the most important pieces of information I provide is that not everybody is an 8-hour sleeper. Just like shoe sizes, we all have different sleep sizes for how many hours our body needs and what time our body prefers to sleep and wake up.
Besides dispelling myths, I also discuss the three main causes of insomnia:
1. Low sleep drive – we do not build up enough of an ‘appetite’ for sleep because we are spending too much time in bed or reducing activities because we are too exhausted.
2. Social jet lag – An irregular schedule creates variability in our circadian rhythm, which can create symptoms similar to jet lag.
3. Hyperarousal – There is a lot of anxiety about sleep, which then leads to a constant feeling of fight-or-flight. Over time, the bed becomes a place of wakefulness rather than sleepiness.
#3: Provide the right recommendations
The patient’s history as well as their sleep diary data gives me a better idea of the client’s sleep. II start to develop a formulation about what could be maintaining the person’s problem.
For example, if the patient is spending 10 hours in bed but only sleeping for 6 or 7 hours, then this might be a sleep drive issue. The patient is spending much more time in bed than they are sleeping, which could be reducing their ‘appetite’ for sleep. In this case, I might recommend that they actually spend less time in bed (and stay more active during the day), so that the sleep they do get is going to be higher in quality.
Another example is that the patient goes to bed feeling sleepy but then the moment their head hits the pillow, they are wide awake. In this case, I would want to help the patient start to associate the bed with sleep again by offering suggestions to get out of bed when they are not sleepy. They are tasked to do something pleasant (e.g., read a book, work on a puzzle) until they are sleepy again.
Interpreting sleep diaries is definitely an area where therapists like myself can be helpful. Sleep diaries are daily reports of a person’s sleep. For example, the sleep diary tells me how long it takes someone to fall asleep, how many hours they are sleeping, and how consistent their schedules tend to be. I can then interpret this data to understand what factors might be maintaining a person’s sleep problem and provide the right recommendations.
#4 Tackle beliefs that maintain sleep problems
There are sleep beliefs and anxiety about sleep that make following the recommendations more challenging. I think dealing with these anxieties this is where therapists really shine because anybody can read a book and learn about the skills. However, therapists can support the use of these skills by helping with implementation and dealing with barriers.
For example, some of my clients have worried that getting out of bed might make them never fall asleep again. However, I’ve generally been able to alleviate this fear by noting that their sleep appetite will build for the next night, and tomorrow will likely be better. In this case, we are focusing on prioritizing the next night, rather than saving the current night.
#5 Reinforce patient strengths
As a therapist, I am both a counsellor and a cheerleader. To take a strengths-based approach I try to reinforce what patients are doing well and help celebrate their great work they have done – whether it’s them trying out the recommendation in spite of being scared, or noticing improvements in their sleep quality.
#6 Help them to become their own insomnia therapist
I see the ultimate goal of CBT is to make the person their own insomnia therapist. This means working until the patient feels that they do not have to rely on me at all, and they have the tools needed to deal with possible insomnia symptoms returning. Life happens and insomnia symptoms are bound to come back from time to item. But this time the patient will have the needed knowledge and skills needed to figure it out themselves!
If you’re interested in becoming your own insomnia therapist, here’s a book I have written on treating insomnia and improving sleep!
Best wishes,
P
Simply mental health 