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Cure Sleep Anxiety By Changing One Way You Think About Sleep
In many ways, insomnia can be described as a disorder of sleep anxiety.
People with insomnia are constantly worried about not being able to fall asleep quickly enough, not getting enough sleep, and whether this sleep deficit will impact their next day. For example, there may be fears that the lack of sleep will lead to making mistakes at work or forgetting to attend appointments.
As a result, there is an implicit phobia in insomnia of being awake at night. Being awake at night is viewed as a very frightening experience because it means that they are not able to get the sleep needed to feel good and function the next day.
If they happen to be awake, they are likely to feel anxious, frustrated, and are constantly white knuckling themselves in bed hoping for a wink of sleep.
This phobia of being awake at night leads to several issues. First, the increase in anxiety makes it harder to fall asleep. When stress is high, sleep comes less easily. This usually is evolutionarily adaptive (but not when the fear is about not sleeping). Second, the anxiety makes it hard to follow evidence-based recommendations like getting out of bed when sleep is not coming. Third, because we are constantly distressed, there starts to be an association formed between the bed and wakefulness. Over time, the bed becomes an even more frightening place where dreams go to die and sleep never comes.
Change the way we think about being awake at night
I had a client with insomnia who came in with many of the issues described above. She was constantly worried about not being able to sleep at night, and would spend hours tossing and turning in bed.
Through cognitive behavioural therapy, the client learned the proper skills needed to improve her sleep. Moreover, she began to become less scared of being awake at night. In fact, she began to see night time awakenings as opportunities to do things she enjoyed – for example, watching a movie, reading a nice book, or just taking some peace and quiet for herself. With her fear of being awake at night gone, her insomnia disappeared shortly afterwards.
Benefits of viewing being awake at night as good
Although a little counterintuitive, a healthy dose of acceptance and seeing the nighttime awakenings as an opportunity can have a number of benefits.
1) By reducing our frustration and stress related to not sleeping, we are in a much more optimized condition to sleep.
2) We feel more readily able to follow the recommendations. For example, stimulus control can be very helpful to break the association between bed and wakefulness. By getting up at a regular time, we can also build up more pressure for sleep the next night instead of feeling paralyzed in trying to save the current night.
3) This perspective is just more enjoyable all around. Would you rather be tossing and turning – suffering throughout the night? Or would you rather just enjoy some peace and quiet and read the book you’ve been putting off?
The use of facing being awake is actually a technique that sleep clinicians use and is supported by research to help with reducing sleep anxiety and falling asleep quicker. The name of this technique is paradoxical intention – where the person focuses on staying awake for as long as possible when they are in bed.
Summary and further resources
Of course, this shift is easier said than done for those who have struggled with insomnia for a long time. I apologize if this recommendation comes off a little tone deaf. It’s just that the fear of not being asleep at night is a strong maintaining factor of insomnia, and viewing being awake at night a little differently can come with a number of benefits that allow us to fall asleep quicker. It’s like the person stuck in the Chinese finger trap who decide to relax their fingers rather than pulling hard (which keeps them further in the trap).
If you do happen to be awake at night, I encourage you to see it as a place for opportunity rather than a place of distress. Be curious and just see what happens!
If you’re interested in learning more, here’s a neat book that I wrote: The Insomnia Paradox.
Best wishes,
P
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Treating Insomnia Naturally Using Science-Based Strategies (Without Drugs)
Chronic insomnia is a troubling sleep problem which is defined by difficulty falling and/or staying asleep, as well as daytime exhaustion.
Most physicians and mental healthcare providers are not very well-equipped to deal with chronic sleep problems. They will usually provide sleep hygiene recommendations or prescribe medication. The problem is that sleep hygiene does not solve insomnia, and people usually do not enjoy using medication.
Specifically, medication is a short-term answer to a long-term problem. When people get off the sleep meds, the insomnia usually returns. Moreover, there are side effects such as grogginess, headaches, and other daytime difficulties. Unsurprisingly, most people would prefer not to be on medication unless they do not have any other solutions.
Evidence-Based Strategies to Treat Insomnia Without Drugs
The question then becomes: “How can we treat insomnia without drugs?”
Fortunately, behavioural sleep medicine, has developed a number of effective strategies that can relieve insomnia symptoms long-term without the use of medication. For example, the gold standard is cognitive behavioural therapy for insomnia (CBT-I). Besides CBT, there are also more acceptance-based strategies that have been developed to help reduce our insomnia struggles.
Before providing these strategies, I believe it is important to first understand the causes of chronic insomnia for these strategies to make sense.
The Causes of Chronic Insomnia
People with insomnia are understandably exhausted. As a result, they will engage in compensatory behaviours to make up for their lack of sleep and energy. For example, going to bed early, staying in bed in the morning, resting on the couch, cancelling plans, and avoiding activity.
These behaviours are very reasonable. However, the problem is that these behaviours reduce our activity and introduce instability into our schedule. This then leads to reduced pressure for deep sleep and negatively effects on the circadian rhythm. For example, not being active enough makes us have less ‘sleep appetite’ at the end of the night. As a result, we feel less able to get the refreshing sleep we want, and we end up with symptoms that feel like jet lag because we are going to bed and getting out of bed at very different times every day.
Additionally, when we spend lots of time in bed awake, our brain starts to associate the bed with wakefulness. Over time, we might actually start feeling more awake when we get into bed. This is known as conditioned arousal.
Evidence-Based Strategies to Deal with Insomnia
Now that we are more familiar with the causes of chronic insomnia, let’s get into the specific strategies:
1. Build more sleep drive: As we discussed, we need to increase our appetite for sleep. We do this by staying active (even though we are tired), avoiding naps, and spending an appropriate amount of time in bed (about as much as we are sleeping).
2. Strengthen our circadian rhythm: This can be done by regularizing our schedules, especially when we go to bed and when we get out of bed. Importantly, we want to get some sunlight in the morning so our internal clock is nicely set to the clock on the wall.
3. Restore association between bed and sleep: To reduce conditioned arousal, we want to use the bed only for sleeping. This means no watching shows or doing homework in bed. We also want to get out of bed if we cannot sleep and do something quiet and enjoyable until we feel the sleepiness come back on. Now, sometimes people worry about getting out of bed because they worry that they cannot fall back asleep. Rest assured that if you get out of bed the same time as usual, you will have a better night because of increased sleep drive.
Dealing with Scary Beliefs About Insomnia
There are some beliefs that make it hard to apply these evidence-based strategies because ultimately insomnia is an anxiety about sleep. Here, I’ll provide some education to hopefully dispel some common worries that people have about sleep to increase the likelihood of following the strategies.
First, not everybody is an 8-hour sleeper. Some folks need more, others need less. It’s not necessarily a bad thing to not be an 8-hour sleeper. Therefore, try not to use the 8-hour guideline as a rigid guideline for how much sleep you need. Focus more on how you feel during the day.
Second, people with insomnia often worry about their performance in the daytime. Research suggests that people with insomnia perform just as well as those who do not have insomnia – it’s just much more effortful. Rest assured that just because you have insomnia, it does not mean that you will make a million mistakes and then get fired from your job. You are more resilient than you think!
Third, getting out of bed can be scary. But as we discussed, you’ll have more sleep drive if you follow the recommendations. Prioritize the next night over trying to save the last night by sticking to a schedule and building the sleep drive.
Finally, there is an inherent belief that being awake at night is bad in insomnia. In a lot of ways, being awake at night is not so different than being awake during the day. Perhaps see this experience as an opportunity to enjoy some solitary time – read a book, watch a nice re-run of Friends, or do some puzzles. If we become less afraid of being awake at night, our anxiety levels will reduce. Less anxiety means more likelihood of sleeping (which is what you want!).
Give these strategies a try and let me know how they work for you!
Best wishes,
P
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Potential Pitfalls Of Cognitive Behavioural Therapy (And How To Fix Them)
Cognitive behavioural therapy (CBT) is often thought of as the gold treatment standard for mental health issues. This is because CBT is evidence-based, meaning that research has consistently supported the benefits of treatment. Moreover, most hospital-settings prefer CBT as the primary psychological treatment because it is short-term (to reduce wait times to receive services) and structured (making it easy to train mental health professionals to provide CBT).
However, despite CBT’s strengths, there are limitations to this dominant treatment modality. This post describes some of the pitfalls of CBT and ways to address them.
1. Too much focus on change (and not enough validation)
CBT is about changing our thoughts and behaviours to improve our mental health. For example, challenging the belief that “I’m a failure” or “the world is dangerous” to improve mood or reduce anxiety.
However, when we jump the gun and only focus on change, we might invalidate the client’s experience. Yes, it would be helpful to think of the world a little differently than viewing it as totally dangerous, but there was probably a reason for this person to think of the world as dangerous in the first place. For example, a traumatic car accident or a losing a family member to violence. Asking them to immediately change this view can belittle their very real concerns.
Therefore, there is a need to slow down and validate that there is a reason why a person feels a certain way. We need to first recognize and show understanding of the client’s perspective before working together to build more adaptive thoughts and behaviours that support them towards their goals.
2. Too much focus on structure
In working within hospital-settings, I found that CBT treatments can be highly manualized. There is a set agenda for each session with a specific time limit to discuss each component, for each disorder. A 12-week manual for anxiety, a 16-week manual for depression – so on and so forth.
Although this makes sense to ensure consistency in care for all clients, the problem is that a manualized treatment makes it hard to flexibly work with each person’s unique needs. It feels like a shotgun approach to see what sticks. While this works for some folks, other people do not benefit nearly as much – whether because they feel overwhelmed or because they are not able to really soak in the information.
Instead of providing all the possible skills, I sometimes it helpful to give a couple tools and lessons that a client can hold on to and really cultivate to support their lives. The chosen skills are based on what we think may be most relevant to how their mental health challenges are maintained (and what the client prefers). This helps them to be a master of one skill, rather than a beginner of many.
3. Prioritizing only the content, and not the relationship
CBT therapists sometimes get caught up in all the content, education, and skills, that we sometimes forget about important qualities that make or break any type of therapy. For example, being genuine and warm, learning about the person, and developing a strong relationship. These common factors have been observed in the research to be incredibly important part of the process. As Irvin Yalom once said: “It is the relationship that heals.”
Therefore, I believe it is important balance the content with developing the relationship. To take time to learn about the human in front of you and cultivate an alliance built on trust, respect, and cooperation.
4. Thinking that CBT is a good fit for everyone
Research finds that CBT works. Research does not find that CBT works for everyone. Some folks do not vibe with changing our thoughts or behaviours. In some cases, clients prefer to work on acceptance and changing our relationship with experiences, rather than changing the experience itself.
A good example is a person who notices that they have a lot of depressive thoughts, such as “I’m worthless”, “things are always going to be like this,” and “there’s no point.” Although a CBT approach might try to change the thought itself, more acceptance-based strategies try to help us notice the thoughts, but recognize that it is just a thought. Thoughts are thoughts. Thoughts are not facts. This realization can lead to reductions in our reactivity to negative thoughts without having to outright challenge them.
5. Being too focused on the present
CBT emphasizes what’s going on in the present – the ‘here and now.’ This can be helpful to work on current goals, which leads to more specific and actionable steps that can be taken. For example, taking a 10-minute walk twice a week if you are working on increasing physical activity. However, much of the lessons we learn and reasons we behave in certain ways is because of past events, such as childhood experiences. For example, thinking we are a burden because our parents consistently dismissed us when we were young. Gaining awareness of where these feelings come from can in and of itself can be freeing – because it separates our past traumas from the here and now. The client can then make a distinction between their past and present, and begin to heal and change.
6. Not enough focus on the emotion
One last pitfall is that CBT, as the name suggests, primarily focuses on thoughts and behaviours. In my practice, I have found that honing-in on the emotion can be very deep and meaningful. It provides so much insight into the inner experience.
Moreover, in other therapies (like dialectical behaviour therapy), a client’s behaviours are understood by the way they react to aversive emotions. Ineffective behaviours (e.g., alcohol use, shouting at other people) are made sensical by their benefit of getting away from uncomfortable emotions. Therefore, learning to work with a client’s emotions and learning to respond to them in a more effective manner can lead to important changes in their lives.
Best wishes,
P
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Once Bitten, Twice Shy: Safety Behaviours In Social Anxiety
Social anxiety is a fear of negative evaluation. For example, being worried that other people thinking that I’m “stupid, boring, or worthless.”
This fear of social situations goes from being just shy to social anxiety disorder when it starts affecting our lives. For example, avoiding an interview that might have landed you a job that you wanted or never going out to make friends.
As you can see, folks with anxiety tend to avoid. Some avoidance is more obvious (like never using their phone to make an appointment). On the other hand, there are some other avoidance strategies that are a bit more subtle. These are called safety behaviours.
What are safety behaviours?
Safety behaviours are ways that we sneakily do to avoid our feared outcome in different situations. For example, in insomnia when we can’t sleep, our safety behaviour might be to go to bed super early to make sure that we get enough hours. In panic disorder, we might take an anti-anxiety medication before going outside so we don’t end up with a panic attack.
Safety behaviours can also be approach or avoid behaviours.
Approach behaviours can be things we do to actively reduce how scary a situation might be. For example, reassurance seeking and asking other people if what you are doing is correct or double checking to make sure you did not write anything wrong on your paper.
Avoidance behaviours can be things we do to get away from the scary situation. For example, procrastinating, leaving early, or straight up just not doing something that you are afraid of.
The problem with avoidance is that it keeps the anxiety alive. These sneaky safety behaviours make us feel a little better in the moment, but we never get a chance to learn that we can cope (or if the feared outcome even happens).
Safety behaviours in social anxiety
In social anxiety, we use safety behaviours to avoid possible negative evaluation. Examples of negative evaluation might be somebody looking at you with a frown, yawning, or being seemingly bored of you.
Therefore, safety behaviours for social anxiety might be:
- Not making eye contact
- Ending a conversation early
- Only talking about the person and never sharing anything about yourself
- Only using topics you know the other person is interested in
Safety behaviours can also be used to reduce anxiety when talking to folks. This can be using alcohol so that you are less anxious or bringing your best friend to a party so you always have someone to talk to.
Function is key in identifying safety behaviours
The same behaviours depending on why we do them (i.e., their function) may or may not be a safety behaviour.
For example, using alcohol at a party because you want to let hang and have fun with your friends is not a safety behaviour. However, using alcohol at a party because you feel too anxious meeting unfamiliar people and need something to take the edge off is a safety behaviour.
Therefore, consider why you are doing something. Are you skipping a presentation because you don’t care about the course or your grades? Or are you skipping a presentation because you fear people watching and judging you?
Function is key.
How to deal with safety behaviours
Again, the problem with safety behaviours is that they keep our anxiety alive.
When we end a conversation early, we are essentially saying “I don’t trust myself to be able to know what to say next.” When we don’t make eye contact, we are thinking “they believe I am boring and probably are not interested.”
Besides implicitly confirming our fears, these safety behaviours also make it hard to fully face our fears in exposure practice. Exposures are key to reducing anxiety.
Next time, try your best to notice when you are engaging in a safety behaviour. Be curious about how you perform even without the behaviour. Look the person in the eye. Resist the urge to end the conversation. You might just surprise yourself.
Best wishes,
P
Photo by Brooke Cagle on Unsplash
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How To Know When You Are Experiencing Realistic Anxiety
In therapy (and life), we often talk about anxiety as though it is a bad thing. But anxiety – at least in moderate doses – is very important.
Evolutionarily, anxiety keeps us safe. Back in the ancient days, if there were a bear around near our caves, we probably want our anxiety system to kick in to make sure that we can run or fight back.
Besides threats to ourselves, anxiety also keeps our loved ones safe – for example, by making sure we check on our newborn babies so that their needs are met.
Therefore, the goal of therapy is not to get rid of all anxiety. It is to lower the volume of anxiety to a more manageable level.
One important question then is how do we know when the anxiety we are feeling is healthy and realistic? This post discusses some characteristics of healthy and realistic anxiety.
Anxiety is realistic when it keeps us (and others) physically safe
Anxiety keeps us vigilant about possible threats. Although there are less bear attacks in modern times, we still need to keep an eye out for possible dangers. For example, looking both ways before crossing the street. If we did not have anxiety, we’d run the risk of getting hit by a car.
Healthy anxiety also keeps our loved ones safe. For example, if you see that your partner has a weird mole on their neck, having some anxiety to push them go to the doctors to check it out would be important.
Of course, we don’t want to constantly be checking for possible danger around us. If we spent every waking moment being fearful that the sky is falling the down, we’d be pretty exhausted. A healthy amount of anxiety allows us to function in daily life while keeping us generally safe.
Anxiety is realistic when it is consistent with our values
In therapy, we call behaviours that are consistent with our values as ‘ego-syntonic.’
For example, if we care a lot about our job, it makes sense we are anxious about our performance. When we care about our children, it makes sense we worry about their wellbeing and future.
We all have values that are important to us – whether family, finances, health, or something else. When we care about something, we naturally feel a little anxious because we don’t want to lose it.
For example, if we care a lot about our job, it makes sense we are anxious about our performance. When we care about our children, it makes sense we worry about their wellbeing and future.
We all have values that are important to us – whether family, finances, health, or something else. When we care about something, we naturally feel a little anxious because we don’t want to lose it.
Anxiety is realistic when it does not feel excessive
The caveat to the above point is that we do not want to excessively worry about something even if we do care. If finances are a value to you, that does not mean it is reasonable to be thinking about finances all day every day.
When our anxiety stops us from living in the present and negatively affects our lives, that is when we are moving from healthy anxiety into excessive anxiety.
It can therefore be important stay curious about how much anxiety is actually needed in different situations. Behavioural experiments, which curiously tests our anxious predictions, can be a great way to reduce our fears. For example, instead of checking an email 10 times, you might only check it once or twice and see if you end up making any mistakes.
Anxiety is realistic when it helps us perform
Too much anxiety and we are paralyzed. Too little anxiety and we don’t care to do anything. But a moderate amount of anxiety is just right to help us perform.
For example, when we are writing an exam or doing an interview, too little anxiety makes us woefully unprepared. Too much anxiety can sabotage us by affecting our performance.
However, when we have a healthy amount of anxiety, we kick ourselves into gear to properly perform to achieve our goals.
I invite you consider whether your anxiety in different situations help or hinder you. If it’s the former, great keep going. If it is the latter, then it might be worthwhile to manage your anxiety levels.
Anxiety is realistic when it does not make us avoid things we need to face
In therapy, we often talk about safety behaviours – things that we do to subtly get away (avoid) from things that we fear. For example, looking away from a person when talking to them because of social anxiety or never going on airplane because of a fear of flying.
This avoidance can sometimes be unhealthy anxiety because we all need to face our fears sometimes. If we don’t get on an airplane, we might miss opportunities to see loved ones. If we don’t face social situations, we lose our chances at meaningful relationships.
Of course, not all behaviours are avoidance. When thinking about avoidance, we have to consider the function. For example, not going to a party because you don’t like the folks there is not avoidance. On the other hand, not going to a party because you are scared people will think you are boring is avoidance.
When we avoid, we feel a brief sense of relief. However, the unhealthy anxiety stays around – short-term gain, but long-term pain.
Therefore, it is important to recognize when we are avoiding (and not in a good way) to be able to function in our daily lives. This is the basis of exposure therapy.
Conclusion
This post highlights that anxiety is not a bad thing. In fact, anxiety is a great thing that keeps us safe, motivates us to work hard, and helps us know what is important to us.
However, like with anything else, we need to find a balance to make sure we have a healthy dose of anxiety. Hopefully, this post provided some insights into what realistic and adaptive anxiety can look like.
Best wishes,
P
Photo by Hans-Jurgen Mager on Unsplash
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What Maintains Low Mood? Perpetuating Factors Of Depression
In life, feeling sad from time to time is a totally normal experience. When we experience loss, we feel sad and grieve – whether it’s a loss of a loved one, a relationship, or an opportunity (like not getting a job that you wanted).
However, when sadness turns into prolonged episodes of depression, that is when we need to turn our attention to treating this issue. In order to treat depression, we need to understand what maintains it.
This post talks about ‘perpetuating factors’ of depression. That is, what maintains low mood?
For this post, I take a CBT (cognitive behavioural) lens because I find that this approach is one that is very actionable. We can use this information and apply it to our everyday life to improve how we feel.
Loss of reinforcing activities
When we are depressed and unmotivated, we stop doing a lot of the activities that gave us the good feelings: joy, mastery, social connectedness, and meaning.
Although this makes sense because we feel so tired and low, the problem is that the lack of enjoyable activities in our lives keep the depression going. Therefore, adding back these activities is important key to getting out of depression trap, and back on track.
In fact, this premise is what led tothe development of behavioural activation – an effective and researched backed treatment of depression. Behavioural activation is about slowly and gradually adding these activities back into a person’s life.
Emotional reasoning
The reason why we stop doing things that give us joy and meaning when we are depressed is because of something called ‘emotional reasoning’ (also known as ‘following a feeling’).
Our behaviours often tend to follow how we feel. For example, if I feel like being social, I might call up a friend to hang out. If I don’t feel like cooking, I might order something on UberEats.
This strategy of following a feeling is not necessarily a bad one. However, when we are depressed, following our feelings can be tricky. This is because we often feel like staying at home lying in our bed doing nothing when we are depressed. Again, this can create a vicious cycle of feeling even crappier because we do what the depression tells us to do. Nothing.
To flip this pattern on its head, we need to realize that how we behave can go before how we feel. For example, taking a walk even when you are tired can make you feel a little better afterwards.
Think of our body (and mood) as a generator – sometimes you have to give a little to get a little.
Attentional biases
When we are depressed, our attention tends to focus on possible threats in our environment. We are more attuned to the crappy things in our lives, and less focused on the positive side.
This can maintain our low mood because we are basically looking at life through a depressive lens. Because of this, we either ignore or discount positive or neutral information, and focus primarily on the negatives. For example, a person may punish themselves for forgetting to buy detergent even though they did all their other chores for the day.
When we focus on just the negatives, we are less flexible in the way that we think and behave.
Therefore, it is helpful to actively train our attention. Give our attention a chance to focus outside the negatives. Let the other inner voices speak besides the one that says: ‘you suck.’ It doesn’t mean focusing just on the positives. It just means noticing when we are focusing on just the negatives.
Negative core beliefs
In depression, there are often negative beliefs about ourselves, other people, the world, and the future.
A person with depression may have a deep belief that they are inherently worthless, unloveable, or ineffective. That is, they aren’t worth anything, nobody likes them, and they can’t do anything to change their situation.
These core beliefs usually get activated in different situations. For example, failing an exam might activate a belief of worthlessness. Another example is a friend not calling back leading to thoughts that other people don’t care about them.
It is important to challenge these thoughts and beliefs because they are huge culprits of continued low mood. If we constantly feel like a failure anytime we have a setback, we would never get anywhere.
The use of thought records can be a good way to deal with these type of negative thought patterns when they pop up.
Rumination and repetitive negative thinking
Ruminating is a type of repetitive negative thinking that is very common in depression. It is usually past-focused. For example, ruminating about past failures or things that have not gone right. Other examples include:
- “Why did this happen to me?”
- “Why can’t I do anything right?”
- “Other people are doing so much better”
- “I hate my life”
- “Nobody cares about me”
Unsurprisingly, constantly ruminating about negative stuff maintains low mood. Lots of folks with depression find themselves ruminating in the dead of night, feeling hopeless and in despair.
One effective way to reduce rumination is through mindfulness. Mindfulness practice helps us stay in the present and notice when our minds are elsewhere. This helps us bring our focus back into the present moment in a non-judgmental manner.
Here’s a post on how to practice mindfulness in our daily lives.Lack of hope and self-efficacy
One final factor that keeps low mood going that I will discuss is a lack of hope. Folks with depression feel like things will never get better. That they have no control over their situation. And this can sometimes create a self-fulfilling prophecy. After all, why would we do anything if we don’t think anything will change?
I encourage you to start small and build from there. The use of SMART goals for depression can be helpful way to slowly and gradually do things that make us just a little bit better. This can make us feel more effective in our lives, even if it is just making your bed or taking a small walk.
Certainly, it is a drop in the bucket. But with enough drops, we can fill the whole ocean.
Best wishes,
P
Photo by Christian Erfurt on Unsplash
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5 Common Therapy Goals For Anxiety And How To Work On Them
Anxiety is a common problem that people come into therapy to treat. However, what exactly are folks hoping to change by coming into treatment?
This post discusses five goals for anxiety commonly discussed in therapy. The first four relate to overarching goals that most folks with anxiety problems could probably benefit from improving.
The final fifth goal discusses examples of more specific goals (i.e., SMART – Specific, Measurable, Actionable, Relevant, and Time Bound). That is, what could specifically translate to specifically into a person’s life and how their lives can be different after therapy.
For all of these goals, I provide common strategies therapists use to work on these goals.
#1: Reducing hyperarousal
People with anxiety problems are sometimes in a constant fight-or-flight mode. Their body is always on high alert for potential threat– kind of like a sensitive smoke detector that sounds the alarm anytime there is even the smallest evidence of a fire.
This constant feeling of anxiety can significantly impact someone’s lives. For example, it can disrupt sleep, increase irritability, and keep on edge and restless. As a result, folks with anxiety can feel constantly exhausted in their lives.
Therefore, one goal of treatment is to reduce this “hyper”arousal. This can be done primarily through regular relaxation exercises. For example, deep breathing, guided imagery exercises, and muscle relaxation strategies. Picking a regular time for one or more of these activities and doing it for a small period of time every day can be very helpful. Consistency is key!
Another way to increase resilience to anxiety is through nourishing activities. Look for things in your life that makes you feel more resilient to anxiety (kind of like self-care). Here’s a few examples that clients I worked with have done that works well for them.
- Making a cup of tea
- Playing an instrument
- Taking a walk
- Calling a friend
- Eating at your favourite restaurant
- Doing some evening yoga
#2: Reduce worry
Anxiety is typically a response to ‘worry.’ Worries are future-focused ‘what if?’ questions that make us fearful about the future and its consequences. For example, “What if I don’t get childcare for next week?”, “What if I forget my talking points for my job talk?”, or “What if I don’t know what to say at the party tonight?”
These fears paralyze us because we are too busy catastrophizing about everything that can go wrong. It’s hard to stay in the present when we are focused on the future.
When dealing with worries, it is helpful to identify the difference between current and hypothetical worries.
Current worries are things we need to deal with in the here-and-now. For example, needing to get childcare or needing to pass a biology exam.
Hypothetical worries are more distant and cannot be solved right now. For example, worrying about your future child being born with a health problem. Current and hypothetical worry requires different strategies to resolve.
For current worries, we would take a problem-solving approach and find a solution to the problem. If I need to pass a biology exam, then I would need to schedule in time for studying and make a plan for which modules to study on which days.
Hypothetical worries can benefit from thought records (evaluating the thought) or the use of written exposures. Written exposures mean spending some time every day (e.g., 30 minutes) writing out the catastrophic thoughts. For example, writing about your scariest fears around losing a loved one or having a severe mental illness and what that would look like. The idea is that by constantly sitting with this anxiety, it should reduce over time.
Finally, mindfulness can be helpful to stay in the moment (and not think about the future) and reduce how strongly we react to a thought. Here’s a post on practicing mindfulness if interested.
#3 Tolerate uncertainty
Underneath worry and ‘what ifs’ is a general fear of uncertainty. Folks with generalized anxiety have an ‘allergy’ to uncertainty and see it as dangerous or threatening.
As a result, they tend stay with the status quo or do things to avoid uncertainty (like getting reassurance, checking something multiple times, or full on avoiding an unfamiliar situation).
When we run away from uncertainty which does two things that keeps the anxiety alive: 1) we believe that it was a good idea to run away from uncertainty and 2) we don’t learn we can cope.
Behavioural experiments are very helpful to work on a fear of anxiety. It is a way to test anxious predictions and be curious if our worries are actually true. For example, we might have a fear of ordering a new drink at a bubble tea restaurant (prediction: “I’ll hate it”). Then we try out the drink anyways to see what would happen.
here are a few different possible examples of behavioural experiments:
- Trying out a new restaurant
- Studying at a café you have never been to before
- Checking an email only once
- Messaging a friend who you have not spoken to in a while
- Practicing setting boundaries with a partner by saying no
When practicing behavioural experiment, most of my clients have found that their fear does not come true. Even when the outcome is negative, they realize that they can cope with it well. Some clients even begin to see uncertainty as exciting and novel!
#4 Habituate anxious responses
Phobias are commonn in anxiety disorders. Phobias refer to having an intense fear of some sort of object or situation.
A few common examples include:
- social situations
- having panic attacks
- animals
- insects
- flying
- going out of the house alone
- being in planes
- etc.
Exposure therapy is the primary treatment for phobias. Facing our fears allow for habituation to occur. Habituation is noticing a drop in our anxiety when we repeatedly face our fears without hesitation. We usually escape away from phobias (e.g., running away from a social situation or a spider). But we need to gradually face our fear so that our body and brain learns nothing bad will happen.
Here’s a post on doing exposures and creating hierarchies.
Setting specific SMART goals
The above provides some more general goals that many folks with anxiety likely would benefit from. However, specific goals differ from person to person.
Therefore, SMART goals can be a great way to identify what exactly are things you would like to change in your life. Below I provide some examples of SMART goals that you might see in common anxiety disorders (but be creative for yourself or your clients!).
- Panic disorder: spin around for 30 seconds to bring up panic symptoms and sit with it
- Social anxiety: talk to 3 people without looking away or ending conversation quickly
- Generalized anxiety: do 3 behavioural experiments a week
- Specific phobia of spiders: look at picture of spiders
These are just a few examples, but of course the specific goals will depend on what you (or the client if you are therapist) wants out of your lives!
Best wishes,
P
Photo by Ronnie Overgoor on Unsplash
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How Sleep Problems Stick Around: The 3P Model of Insomnia
Bad nights versus insomnia disorder
Everyone has a bad night from time to time.
However, for some, the one bad night turns into a steady stream of bad nights. Suddenly, you are not having a bad night anymore. You have insomnia.
The question is: why do sleep problems sometimes stick around?
In this post, I describe the 3P model, which is a theory developed by Dr. Arthur Spielman. The 3P model gives us a framework to understand how insomnia develops and why it sometimes does not go away.
The 3P Model – Defining the Terms
The 3P model stands for: Predisposing, Precipitating, and Perpetuating.
1. Predisposing factors: Predisposing factors are essentially anything that makes you more vulnerable to having sleep problems.
2. Precipitating factors: Precipitating factors are the things that set off bad nights.
3. Perpetuating factors: Perpetuating factors keep our sleep problems going over time.
Let’s get into each one a little deeper.
Predisposing factors
Predisposing factors are things that make it a little easier for some folks to end up with bad nights compared to other folks.
For example, there are some people who tend to worry a bit more or are more reactive to stress. Therefore, when something happens in their life, they tend to be more stressed. As a result, their sleep takes a bigger dip.
Take a moment to consider if there’s anything that makes you more vulnerable to sleep problems. Perhaps you are more sensitive to caffeine. Maybe you are prone to ruminating and stressing out when something goes wrong. Or you have a bit of back pain that makes your sleep a little lighter. All of these can be predisposing factors – it doesn’t mean that you will have insomnia, but it can make you a little more susceptible to sleep problems.
Precipitating factors
Precipitating factors can be basically anything that leads to the start of sleep problems. For example, travelling to a different time zone, having a baby, going through a breakup, studying for an exam, or starting a new job.
As you can see, pretty much anything that causes some stress can be a precipitating factor – regardless of whether it’s a good thing (like starting a new job) or a bad thing (like losing a loved one).
The fact that our sleep takes a dip when we are stressed makes complete sense from an evolutionary perspective. In ancient times, when there is danger (like a bear attack) we wouldn’t want to be asleep for it!
The point is not to never have a bad night. The point is to make sure it goes away when the stressor is over. However, sometimes sleep problems do not go away. This is because of the third P.
Perpetuating factors
Sometimes, when people have sleep problems, they begin to change the way they think about sleep and their associated behaviours throughout the day when they have a bad night. This can lead to perpetuating factors that maintain sleep problems.
Importantly, the perpetuating factors are what we focus on in therapy in order to break the insomnia cycle.
When there are multiple bad nights, some folks start worrying about. their sleep. They get scared that they won’t get enough sleep or that it will affect their day.
This can lead to ways of coping that help with anxiety in the short term but do not help in the long term – like going to bed early or reducing activity to save energy throughout the day. However, from what we know about the science of sleep, these behaviours can actually make our sleep problems worse.
For example, spending too much time in bed can affect how much deep sleep we get. It’s kind of like wearing a size 10 shoe when you have size 7 feet. Therefore, if we spend 10 hours in bed but only need 7 hours of sleep, our sleep is very light and we spend a lot of time awake. Moreover, if we spend too much time in bed awake, our brain might start associating the bed with wakefulness (and worrying). This can make it even harder to sleep.
If you’re interested, here’s more information on the how to fix the causes of insomnia disorder.
How the 3P’s all fit together
Here is a visual diagram on how the 3P model comes together. As you can see, the predisposing factors make us a little more vulnerable to sleep problems. When a precipitating event comes up (like an exam or a travel event to a different time zone), it makes it easier for us to cross the insomnia threshold. Usually, this is not an issue and you can see the sleep problems go away when the stressor disappears.
However, sometimes the perpetuating factors take hold and that’s when common sleep disturbances starts moving into insomnia disorder category.
It is important to know when these factors are taking hold because they are the thing we need to address. This article helps you to learn more about the frontline recommended treatment for insomnia disorder – CBT for insomnia.
Best wishes,
P
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10 Key Lessons I Learned As A Therapist From My DBT Supervisors
This year I have been working full-time as a psychology resident at a specialized healthcare setting for mental health. It has been a challenging but certainly rewarding journey.
One of the rotations I am working in is the Borderline Personality Disorder clinic. The recommended treatment for BPD is dialectical behaviour therapy – a form of therapy that I did not have experience with prior to beginning this residency.
However, I have been very lucky to work with several leading experts in dialectical behaviour therapy and treatment of BPD. They have been such incredible sources of wisdom and knowledge in this area.
In this post, I provide 10 key clinical lessons from my DBT supervisors from our supervision:
1. There is always something valid about a person’s thoughts and feelings
Folks with BPD spend a lot of their lives feeling invalidated – that they shouldn’t feel the feelings that do. This can make it hard for them to trust their own thoughts and feelings.
Therefore, providing validation is a very important part of being a DBT therapist (and for being a therapist in general). However, I have learned that validation does not mean just agreeing with everything that the client says. Rather, it is about finding the ‘grain of truth’ that we can validate without reservation.
For example, I might not agree with a client wanting to assault another person or using alcohol to cope with unpleasant emotions. However, I can validate them feeling betrayed by a close friend lying to them, or that it makes sense for them to want to get away from feelings of shame by using alcohol.
My supervisors like to note that all behaviours are reinforced and make sense in some way – even if not to me. Therefore, I have learned to ‘validate what is valid’ to show that I really understand the client’s situation. Afterwards, I can work with the client to change what is not helpful or effective in the situation.
2. Prioritize the underlying emotion
As someone from a cognitive behavioural background, I used to primarily focus on the thought or behaviour in different situations. However, I often found that naming the thought did not always allow me to get into a deep connection with my clients. Moreover, I often felt stuck in those moments.
My supervisors encouraged me to go a little deeper and ask about the emotion. For example, sitting with feelings of shame when a client is talking about “being a failure” because they feel like they haven’t done enough in life.
The reason that this was important is because there is a way of thinking about behaviours in DBT. That all ‘unhelpful’ behaviours (like self-harm or alcohol use) are ways to get away from uncomfortable emotions.
Therefore, by sitting with the emotions, I found that this helps clients learn to notice these patterns and tolerate bad feelings. This then gives us space to be able to process emotions and use more effective DBT skills to manage emotions in a healthier manner.
For identifying emotions, I learned that I needed to be more aware of whether the emotion is ‘primary’ or ‘secondary.’ Primary emotions are our response to a situation whereas secondary emotions are our emotions to the emotion.
Let’s clear this confusing idea up with an example. Let’s say Jane is talking to her best friend Amanda. Amanda says something nasty to Jane. Jane’s first emotion is sadness because she feels betrayed that a close friend would say something so hurtful. She then thinks: “How dare she say that about me?” – which then promptly turns into anger.
In this case, sadness would be the primary emotion and anger would be the secondary emotion. To work with Jane, we would focus on the primary emotion of sadness rather than sitting with the anger. This is important because secondary emotions sometimes come in to protect the primary emotion. For example, shame is very uncomfortable and makes us feel vulnerable, but anger is a powerful emotion. However, we need to learn to sit with the shame and understand where it comes from. Only by being able to tolerate these feelings, can we truly move forward.
3. Get as precise as possible
Instead of theorizing what might be going, my DBT supervisors have encouraged me to get precise as possible about what is going on in a situation. Usually, this means identifying a specific situation where a client was having difficulties and really getting into the nitty-gritty. The reason to get precise is that if we do not know what is going on, we cannot provide the right skills to support the client.
For example, a client might report that they were struggling with procrastination. However, there are hundreds of reasons why a person may be procrastinating. Therefore, we want to get into the details of the situation.
The following might be a possible ‘chain’ of events that happen during the procrastination:
- Thought: “I’m thinking about going my work”
- Emotion: anxiety
- Thought: “I’m not going to understand the material”
- Emotion: Shame
- Judgmental thought: “I’m so stupid and worthless”
- Emotion: hopelessness
- Behaviour: Give up and do something else
With this much more precise understanding, we can see possible contributors to procrastination, like the feelings of shame or predictions of “not understanding the material.”
We can then find areas where we can target to break this chain of events. For example, sitting with the feelings of shame or challenging unhelpful thoughts like “I’m not going to understand.”
4. Change comes with cost
Some folks come to therapy with the expectation that change is necessary and it is always a good thing. However, one lesson that my supervisors have really emphasized that there always a cost to change and it is important to have this discussion with the clients.
For example, one of my clients was seeing some real progress in their life during therapy: they had started school, was holding down a steady job, and was keeping to a generally healthy routine.
However, they noticed that they were wanting to self-sabotage. When we started discussing where this feeling came from, they noted that it was scary to do well and that there were cons associated with improving. For example, they noticed getting less attention from family/friends and that there was less overall excitement (read: drama) in their lives.
Moreover, they realized that it was risky to do well – the higher the climb, the bigger the drop.
It was helpful for the client and I to have an honest discussion of what it means to change. Specifically, to identify the loss and to take some time to grieve the changes associated with improving. This was helpful for them to validate both the pros and cons of changing and make a commitment to change anyways.
5. Be willing to set the pace
I have a tendency to sometimes let the client set the pace of a session. However, this can sometimes be a disservice to clients because folks with BPD can be dysregulated. Without me framing the session, we can end up in all sorts of places and clients can feel confused, stuck, and hopeless.
I’ve often reflected why I am more willing to give the reigns in my therapy sessions at this particular clinic. In working with this population, I’ve sometimes felt a little less confident in what I was able to bring to the table. This made it harder for me to set pace and have the self-esteem to believe that I have something to offer. This uncertainty made it easier for me lose faith in my own effectiveness and let other people decide what is right or wrong to talk about. However, I have learned that it is important for me to be the person that extends hope to the client, model the way forward, and that I do have a number of clinical tools that can benefit their lives. This is an important gift I can provide for the clients.
6. Help clients distinguish what’s in the here-and-now, and what’s in the past
Oftentimes, clients have a sort of ‘trauma network’ that activates in different situations. For example, they may feel worthless when they do not do well on an exam because their mother always criticized the smallest mistakes when they were young.
When these ‘networks’ get activated in a client, it is helpful for us to understand where this reaction is coming from and help the client recognize the pattern. Clients can then ‘check the facts’ about the current situation and understand their feelings better. By sticking to the facts of the here-and-now, we become more grounded in reality and able to act effectively.
From my supervisors, I have found the question: “Where do you think this comes from?” helpful to guide clients to talk more about their relationship dynamics with parents and other important figures in their lives. I have also found this helpful to help with validation – helping the clients make sense of why they are feeling the way that they do.
7. Use your own emotions to guide you
My supervisors have encouraged me to take notice of my own emotions in the therapy room and to trust my clinical ‘spidey senses’ when something is afoot.
I have certainly had clients seemingly agitated or upset without me having said anything particularly offensive. In those moments, I have found it helpful to notice my own discomfort and check in on what was going on in the room. For example, saying something to the effect of “I’m noticing that we are not connecting like we usually do. I’m wondering if you are feeling the same way?”
This opens up an honest dialogue that allows to explore what is going on which can be an incredibly therapeutic conversation.
8. Look for the synthesis
There are many times where I felt like I had two options and neither felt quite right. For example, asking a client to radically accept a poor situation or asking them to change. The former might make them feel stuck and the latter is a potentially invalidating experience.
My supervisors have encouraged me to do my best to look for a synthesis. For example, perhaps there are some parts of a situation where we have to take an acceptance approach. However, there may also be areas that we can cope and effectively work on.
Folks with BPD often have an all-or-nothing way of thinking (e.g., “it’s either perfect, or I’m a failure”), so I have found it important to model the middle ground and find that proper balance.
9. Use metaphors
My supervisors really emphasize the use of metaphors. This is because metaphor creates a bit of distance for the client to observe their situation and take key lessons without feeling too involved in it themselves.
One metaphor I really like is the ‘beach ball’ metaphor. The beach ball metaphor is a lesson that teaches us about acceptance. When we try to suppress or reject something, it is kind of like pushing a beach ball down into the water with both hands. Although the ball is out of sight for a little bit, if often flops back up from time to time and we must keep using energy to push the ball back down.
Instead, accepting a situation is like letting the beach ball float around in the water. By doing so, we can spend our time enjoying the sights on the beach and use our hands and energy for something more fulfilling.
10. Be radically genuine
My supervisors encourage ‘bringing more of yourself’ into the therapy space. This has often been more challenging for a person like me who tends to be more on the reserved side. However, I have found it freeing at times to say what I think.
For example, I have found it therapeutic to let the clients know that I care for them and want the best for them. This is true even for the ‘hard truths’ – like telling my clients that if they keep doing what they are doing, then they will continue to feel stuck and not be able to move towards their valued lives.
The reason that it is important to be radically genuine is because folks with BPD may have often had experiences where people tip-toed around them. In this case, we do not wish to fragilize our clients and want to show them that we believe in their resilience.
Conclusions
My experience at the borderline personality disorder clinic has been fun and chaotic, enjoyable and anxiety-provoking, despairing and meaningful – all at the same time. It has been an incredible learning opportunity with excellent supervisors that have given me many valuable pearls of wisdom. I hope a few of these lessons were of interest to you.
Best wishes,
P
Photo by Ryan Graybill on Unsplash
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Treatment Goals For Depression For Patients Starting Therapy
Introduction
Depression is a very common psychological problem that many people endure at some point in their lives. The symptoms of depression can be very distressing and impact important areas of our lives. For example, work, school, family, social connections, and our interests and hobbies.
Symptoms of depression include:
- Low or depressed mood
- Loss of interest in previously enjoyed activities
- Increased or decreased appetite/weight
- Sleeping too much/too little
- Feeling agitated or slowed
- Feeling worthless or guilty
- Difficulty concentrating
- Fatigue
- Thoughts about death or suicide
Importantly, depression is different from normal sadness and loss. The symptoms in depression tend to last longer, are much more impairing, and are ‘above and beyond’ our usual response to loss. For example, feeling extremely worthless and depressed for months or years after the end of a romantic relationship.
To treat depression symptoms, some folks go the medication route. Others prefer a therapy-based approach.
This post helps you learn more about what might be some possible treatment goals that you can work on with your therapist.
What do we lose when we are depressed?
Before we discuss treatment goals, we need to learn what we lose when we are depressed.
People with depression usually present with very low mood and ‘anhedonia’ – a term that means we are less interested or get less pleasure from previously enjoyed activities. For example, we may stop painting, spending with friends, or playing video games. Along with a lack of motivation, we lose a lot of the ‘livelihood’ in our lives.
The loss of motivation can also start affecting our performance in school or work-related tasks, and we may lose social connectedness because we are isolating ourselves and staying away from friends.
As a result, we lose the many things in life that gave us that ‘spark’ – activities that provide us feelings of joy, mastery, connectedness, and personal meaning.
Figuring your specific treatment goals
Many times, folks come into therapy just wanting to ‘be happier’ or ‘feel better.’
This is a very reasonable goal. However, the problem is that the goal is a little vague because what happiness looks like in one person does not look the same in another person.
Therefore, we need to get a little more specific for treatment to be actionable. The use of SMART goals can be helpful because SMART goals turn something vague into something that is more specific and measurable. We can then know what the goal looks like and recognize when it is accomplished.
The use of the ‘magic wand’ technique can be particularly helpful to set up SMART goals. The magic wand technique asks the question: “if this treatment were successful and your life was exactly the way you want it, what would that look like?”
Out of this answer comes many possible goals. Perhaps you are looking to connect with friends again, increase productivity and reduce absences at work, or start doing the things that make you happy again.
Reintegrating important past activities into your life
When we are depressed, we feel crappy and not motivated to do the things that use to give us good feelings. As a result, this creates a vicious cycle because we don’t have as many things in our lives that support us – which makes us even more depressed.
This cycle is very important and is actually the basis of a very common treatment for depression – behavioural activation. Behavioural activation is a very effective therapy that helps us bring back things that give us 1) pleasure 2) mastery 3) social connections and 4) meaning.
To set treatment goals, it can be helpful to make a list for each of these components. Here are some examples for each area:
Pleasure
- Making a cup of tea
- Taking a hot shower
- Watching a TV show
- Taking a walk
- Listening to music
Mastery
- Cleaning room
- Cooking a hot meal
- Learning a song on an instrument
- Studying for a test
- Learning a new language
Social Connections
- Having lunch with a friend
- Calling your parents or loved ones
- Joining a new club and meeting new people
- Volunteering at a shelter
- Mentoring a student
Meaning
- This is a very personal area. Some examples include working on your craft, religion, being in nature, supporting others in their goals. However, I encourage you to think about what gives you meaning and significance in your life.
Some activities can be a good fit for multiple domains. For example, playing piano can be something that provides a lot of joy while also adding mastery to your life.
Slowly adding these types of activities back in our lives can be a great way to make goals that resonate with your own unique preferences.
Treatment goals to challenge negative thoughts
People with depression often have thinking errors that maintain depression. For example, they may be likely to personalize bad things that happen as their fault, discount positives things that happen in their life, or predict bad things will keep happening.
Therefore, it is important to tackle these ways of thinking through cognitive strategies to come up with more balanced thoughts. For example, the thought record helps us evaluate the evidence for and against a thought (like “I’m a bad person”) to come up with something that is more grounded in reality.
The best-friend technique can also be helpful to increase compassion for ourselves. We are often much more critical to ourselves than to other people. The best-friend technique uses this understanding by asking us “What would you say if this was a best friend or a loved one in the same situation?”
These cognitive strategies help us to increase flexibility in the way we think and our self-compassion as treatment goals. By working on how we think as a treatment goal, we can reduce our depressive symptoms.
Further goals to deal with depressive symptoms
There are some symptoms of depression that could be directly targeted that might help with improving overall mood.
For example, helping with sleep symptoms through CBT for insomnia strategies or improving concentration through mindfulness can be helpful to support overall mood. These can also be goals to discuss with your therapist.
Conclusion
Ultimately, your goals should depend on what you would like to get out of therapy you’re your overall values. Hopefully this post helped generate some possible ideas for treatment goals that your therapist will likely work with you on.
Best wishes,
P
Photo by Priscilla Du Preez 🇨🇦 on Unsplash
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