What

Behavioral activation is an important component of Cognitive Behavioral Therapy (CBT). Cognitive Behavioral Therapy includes many components and is based on the principle that thoughts/beliefs (Cognitions), emotions, physical symptoms, and behaviors are all intricately related. Helping someone feel better using CBT would typically involve changing unhelpful thoughts/beliefs (Cognitions), emotions, and behaviors via a variety of tools such as cognitive restructuring, emotion regulation and distress tolerance skills, mindfulness, behavioral activation, coping skill development, interpersonal effectiveness skill refinement, trauma processing, etc. CBT is considered a Evidence-Based Practice (EBP)/an Empirically Supported Treatment and is the gold-standard treatment approach across many client concerns.

Why

Specifically, changing behaviors is one of the core goals in CBT, as it is thought that behavioral change allows for healthy corrective experiences that can alter unhealthy beliefs about the self, world (including others), and one’s future. Avoidance and withdrawal, some of the key features of depression and other disorders, inhibits an individual's opportunity and ability to obtain corrective experiences and positive reinforcement from their environment. Therefore, behavioral activation treatment involves encouraging “activation” and participation in “anti-depressant” activities…interaction with one’s environment in a way that offers opportunities for positive reinforcement and increases in self-efficacy (a person’s belief in their ability to exert control over their lives and their world). 

How

• Waiting until you feel “ready” to change may not be the best approach, as understandable as that inclination might be. You must DO first, and the readiness and motivation will follow with consistent “doing” as the “activation” builds momentum
  • Hint: Have you ever exercised or attended a social event even though you didn’t want to, and felt better or “activated” afterwards? That’s a natural activation experience. 
• Using avoidance and withdrawal as coping strategies is understandable…however, while these strategies may have been adaptive and protected you for a time, they are now keeping you stuck and perpetuating your depression and distress. And unfortunately, avoidance and withdrawal breeds avoidance and withdrawal, so you will need to break that cycle by “Doing” regardless.
• Identify “anti-depressant activities” and schedule them into your day. 
  • Try to incorporate activities that are naturally reinforcing 
  • Try to incorporate activities that are consistent with your values. 
    • Values are what we believe to be important and meaningful in our lives. These can include all kinds of things, but some examples are health, relationships, achievement, adventure, compassion, creativity, duty, fun, honesty, safety, stability, etc. 
  • Incorporate activities that fall into the following categories:
    • Pleasure: These involve activities that make us feel good and we might associate with happiness, joy, or peace. This might include taking a bath, playing a game, doing a hobby, going on a trip, planning a vacation, etc.
    • Purpose: These are activities that are consistent with what we believe to give our lives meaning and purpose. This might include volunteering, spending time with family, friends, or children, etc. 
    • Mastery: These are activities where we might work towards small or large goals such as learning a new language, sport, or skill. 
  • Do them regardless of how you feel or what your mood is (Hint: Mindfulness and establishing your “Why’s” can help with this). 
• Monitor your use of activities and your mood to establish patterns and correlations
• Start with small steps and be your own cheerleader
• Make sure you are not engaging in thoughts and behaviors that undermine your goals!
  • Use an objective lens to ensure fair and unbiased interpretations of feedback from the world
  • Reduce the tendency to ruminate (i.e., think about something over and over again in a negative and unhealthy way).
  • Use an external focus of attention and try to be fully present when engaging in activities
• Use problem-solving techniques (not worry or rumination) to work through barriers

​To learn more about depression, see our Depression Specialty Page.

Thinking errors, also known as cognitive distortions, are basically thinking patterns that can be problematic in that they are often inaccurate, unhelpful, and can be harmful to someone’s mental health. Individuals with Health Illness Anxiety Disorder (formerly known as Hypochondriasis) tend to engage in specific types of thinking errors that we try to target in treatment. 

Of note, feeling anxious and worried about health can be a normal experience for many people over the course of our lives. And, anxiety itself is not necessarily a bad thing and is meant to protect us in the face of actual danger. It becomes a problem though when it becomes excessive, distressing, impacts quality of life, and when it occurs in response to unlikely or unrealistic threats. Individuals with Health Illness Anxiety Disorder tend to experience excessive anxiety, both in terms of intensity and frequency of that anxiety, and their fears tend to be out of proportion to the actual likelihood and cost of having what they are afraid of occurring. Their fears also tend to persist, despite reassurances that their fears are unlikely to occur (e.g., via doctor’s visits, tests, etc.).

Intolerance of Uncertainty

Individuals with Health Anxiety often feel that they must have 100% certainty, that they must eradicate all doubt, and that 100% certainty is possible as long as they figure out a way to achieve that certainty (e.g., researching, obtaining reassurance from others including doctors, body scanning, etc.). Any possible doubt that their fear could be true is considered intolerable and unacceptable. Any bodily sensation that is not readily explainable by a benign explanation is considered potentially threatening.

Catastrophizing (Fortune-Telling and Negative Interpretations)

Individuals with Health Anxiety tend to make catastrophic assumptions and/or future predictions about the meaning of their physical symptoms (e.g., this back pain means I have cancer, trouble remembering things means I have Alzheimer's). The meaning we assign to anything that happens to us has so much importance in the way we feel about it, and in Health Anxiety this is very much true. If an individual experiences back pain and assumes the meaning of this pain is likely due to something non-threatening (e.g., I must have slept wrong, I might have pulled it when I was exercising) versus assuming the meaning is something sinister (e.g., cancer), then that individual would be less likely to experience anxiety, panic, and distress. 

The Big 3

The Big 3 Thinking Errors tend to be common across all anxiety disorders including Health Anxiety:

Overestimation of the Cost: Individuals with Health Anxiety tend to overestimate the consequences of their feared outcomes
Overestimation of the Likelihood: Individuals with Health Anxiety tend to overestimate the likelihood of bad things happening
Underestimation of Self-Efficacy: Individuals with Health Anxiety tend to under-estimate their ability to handle feared outcomes 

Overestimation of Responsibility 

Individuals with Health Anxiety tend to take on a lot of responsibility for ensuring that they are not responsible for missing a “sign” that something is wrong with their body. For many individuals with Health Anxiety, it’s the one, two punch of being afraid that they will have some serious or terminal illness AND that they couldn’t live with themselves if they had missed the opportunity to heal/address that illness if only they had caught it earlier. 

Perfectionism and Black and White Thinking

Individuals with Health Anxiety have little tolerance for normal “body noise” or imperfections/deviations from the way they believe their bodies should behave, and often set their bar for being worry free as being only when they have the absence of all symptoms, disease, injury, or pain. And as we age, we experience more and more “body noise” and other minor ailments which increases distress and anxiety for individuals with Health Anxiety. Examples of body noise can be temporary pain, temporary changes in sleep patterns or appetite, temporary stomach/GI distress, temporary orthostatic changes in blood pressure, etc.

They tend to also have perfectionistic standards for their doctors and other medical professionals, and may not feel satisfied despite multiple tests providing contrary evidence to their fears. They may spend significant time finding the perfect doctor or the perfect tests, and may feel unsatisfied that tests/procedures they have received were accurate (e.g., “the doctor seemed distracted while he was performing the test so I don’t trust the results”). They may also feel unsatisfied unless they have a complete explanation for all of their symptoms, and believe the lack of explanation or “knowing” means that their fears are true or that it means something serious is occurring.

Exposure-Based Cognitive Behavioral Therapy is a treatment approach that attempts to alter these thinking patterns/errors via learning principles and the development of safety associations. See our Health Anxiety page to learn more: https://www.oakheartcenter.com/health-anxiety.html

If you are new to the concept of infertility or infertility treatment, this post is for you.  Infertility is defined as a disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person’s capacity to reproduce either as an individual or with their partner.  Infertility can also refer to a person’s inability to sustain a pregnancy to term.  Not all couples have to wait the full year before seeking treatment, as there are other factors that can decrease that timeline.

It’s important to understand that infertility is something that is far more common than most people think. 1 in 8 couples have difficulty getting pregnant or sustaining a pregnancy to term.

One of the reasons that it feels so uncommon is because many people choose not to talk about their infertility diagnosis and experience; however, it really is more widespread than most imagine.  A couple ages 29 to 33 years old with a normal functioning reproductive system has only a 20-25% chance of conceiving in any given month (National Women’s Health Resource Center). After six months of trying, 60% of couples will conceive without medical assistance (Infertility As A Covered Benefit, William M. Mercer, 1997).

Infertility is something that no one is ever really prepared for in their lives.  Most have learned what needs to be done to prevent pregnancy, but there is very little readily available information about difficulty getting pregnant or difficulty sustaining pregnancy to term.  One of the most helpful websites I have found for learning about infertility is Resolve.org.  If you are concerned that you may have undiagnosed infertility, you can use their Personal Assessment Tool.  If you have already been diagnosed with infertility, you can learn more through Infertility 101. 

How would you go about learning if infertility is something that you are experiencing?  The first step would be to talk with your OB/GYN or primary care doctor.  They should be able to provide you with a guideline of what would need to happen before you can be referred to a Reproductive Endocrinologist (RE).  An RE is a doctor that specializes in treating infertility.

Infertility treatments can be covered by insurance, but are not always, so it is important to know what your coverage happens to be before proceeding.  The following states have mandates in place to make insurance cover infertility treatment: Arkansas, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York and Rhode Island.

Beyond the actionable considerations for infertility, it is important to consider the emotional impact of this diagnosis. For many individuals, this is a long process with many ups and downs along the way.  It is normal to feel very emotional during this time.  Emotions may also be heightened if one is taking hormonal medications, which are common in most infertility treatments, making managing emotional responses even more difficult.

So, the big question is, how can you and your partner navigate this turbulent time?  Below you will find some suggestions.

1. Openly communicate with your partner.  Don’t expect that your partner will automatically know what you need.  They won’t, no matter how long you have been together.  You don’t know what they need every second of every day and neither do they.  Share with them your thoughts and feelings, as well as any needs that you may have.  If one or the other of you is going through treatment, make sure you are communicating openly with what is happening.  It is vital that you and your partner are on the same page about what you are open to and what is happening.
2. Openly communicate with your medical team.  Don’t be afraid to ask questions and verify information.  This is something they are used to.  It is also important to know what hours your office is open, as they may not be open on weekends.  Leave messages and follow-up, if needed.
3. Take notes.  Taking notes is always helpful when you are in a doctor’s office, but especially when you are doing something brand new.  You may be getting information from your doctor during an appointment, but it is also common for communication to happen over the phone.  There are times when information is coming very quickly and things are changing fast.  Don’t force yourself or your partner to remember all of the information.  You have enough stress, take notes and refer back to them.  Using a calendar is also vital for many people.  Put any medications, treatments, or appointments on a calendar; especially if you can add reminders.  It doesn’t hurt to have this information in multiple places.  This information can be very important to keep somewhere so you can refer to it later in life.
4. Slow and steady.  The whole process of infertility treatment can move much more slowly than many people expect it to.  Many times there is extensive testing that happens prior to any medical interventions for fertility.  Just note that this is a common experience and that patience is required.
5. Find support.  Talk with your partner and decide who you are comfortable talking with and how much you’re both comfortable sharing.  Not everyone is able to be supportive in the ways that you need, so consider if you think someone is capable before you open up to them.  This support doesn’t always come in the most likely places, such as close friends or family.  Sometimes it can come from unexpected areas.  If you or your partner are not comfortable sharing with others in your lives, it may be beneficial to seek out a professional to talk to or find a supportive community online.  You are not alone.
6. Be gentle with yourself.  No one chooses infertility treatments because it’s a fun time.  No one wants this.  You are here and the only way to get to the other side is through it, but it’s important to be gentle with yourself on this journey.  The infertility process can take a toll on our mental, emotional, financial, and physical resources.  Allow yourself to be aware of what you need and to be nice to yourself about it.
7. Find what helps you cope.  What can you think of that makes getting through the day a little easier?  What makes you feel happy?  From the small everyday things to the once in a while things, consider what helps you feel better.  If you feel like you’re not sure where to start, consider looking through the list below for suggestions (Covington & Burns, 2006).  You may choose to do only a few or all of them, it’s up to you and how you feel.

• Listen/watch relaxation videos or audio.  (I recommend Headspace: Unwind Your Mind which is an interactive video on Netflix to start.)
• Take treatment holidays.
• Learn and use self-hypnosis or guided imagery.
• Engage in healthy amounts of exercise and/or massage (as directed by your doctor).
• Eat nutritious and balanced meals.
• Abstain from alcohol, tobacco/vaping, or other recreational drugs.
• Cut down on caffeine.
• Sleep 7-9 hours per night.
• Use relaxation music before or during medical procedures.
• Reduce stressors in other areas, as much as possible.
• Find and engage in activities that you enjoy.
• Seek information on coping with stress from infertility through books, blogs, or other knowledgeable sources.
• Engage in with your spirituality.
• Talk with your support system.
• Go out with loved ones and do something enjoyable.
• Learn and practice meditation, progressive muscle relaxation, or other appropriate relaxation techniques.
• Do some yoga.
• Do something or watch something that makes you laugh.  Laughter is good for you.
• Spend time with your pet or with animals.
• Spend time in nature (gardening, hiking, visiting a park).
• Volunteer somewhere that is meaningful to you and that you will have time to engage with.
• Do something for yourself every day.
• Take frequent days/weekends to relax and enjoy life and your partner.
• Create a budget for finances, as this can help from feeling overwhelmed financially.
• Notice how your body reacts to stress and find what works for reducing that stress.
• Accept that there are some things that you cannot control.  You are only human and you can only do so much.  The rest is out of your hands.

References:
The list above has been edited for clarification and brevity. It is originally sourced from Infertility Counseling: A Comprehensive Handbook for Clinicians, Second Edition, by Sharon N. Covington & Linda Hammer Burns, found on page 187.

First, I want to say, Congratulations! Completing your college degree is an amazing accomplishment. In addition to the regular stressors of getting through college, you managed to do so in the middle of a pandemic! Give yourself credit for the result of your hard work and dedication. 
​
As someone who regularly works with college students, my guess is that you are experiencing a mixture of emotions in light of your graduation. Excitement, pride, fear, and sadness tend to top the list. It is common to experience all of these emotions! While people are congratulating you and patting you on the back, you may be worrying about what to do next or whether you will get a job.

​Here are some encouraging statistics for graduates. As Thier (2022) summarizes in Fortune, every year Monster produces a “State of the Graduate” report which provides information on the current job market. According to the latest report, companies will hire 26.6% more college graduates from 2022 than in 2021. Additionally, 72% of employers have increased entry-level salaries in the last 12 months. While many job-seekers assume the employer has the upper hand, 57% of hiring managers indicated that job candidates have the power. Currently, it is estimated to take an average of 4 weeks to fill an entry-level role. This has increased 57% since 2019. Whether you already have a career plan or you are in the process of figuring out your next step, here are some things to keep in mind. 

• Career indecision may be more common than you think. It is estimated that anywhere from 10-30 percent of college students should be classified as “undecided” (IResearchNet). Many consider career indecision a normative phase that is closely related to an individual’s age and education level. This experience may extend beyond graduation. 
• For those of you who are still feeling undecided, The Occupational Outlook Handbook located at www.bls.gov is an excellent resource. 
• Limit support or advice-seeking to a few trusted family members or friends. Without meaning to, many people may project their own fears and insecurities when giving career advice. I found that when I told people I wanted to be a psychologist, the common response I received was how much time and money it would take to make it happen. 
• Networking is important. Consider creating a profile on a professional networking site such as LinkedIn. You can gain a lot of information about different career avenues and the qualifications that are needed. You might also try contacting someone to ask whether they would be willing to answer questions about their profession. There are people who enjoy mentoring young professionals in their field.
• It’s great to dream big and to try to find a career that feels like your life’s purpose. However, not everyone ends up in a job for which they are passionate. What might be more realistic is to find a job that feels manageable and allows you time and resources to pursue hobbies, relationships, or volunteer work that makes you feel inspired. Do the best you can with the opportunities that present themselves now and this may lead to a job that feels more meaningful down the road. 
• Remember that your goals and aspirations may change over time as you gain new experiences. Allow yourself grace and flexibility as you continue to learn and grow. 
• Look for organizations that align with your goals and values. This will impact the workplace culture and could make the difference between a job that feels manageable and one that does not. 
• Do your homework on companies before interviewing. It helps to demonstrate specific reasons you are excited to work for that particular company. 
• No matter how certain a job offer may seem, never assume you have the job until you officially get the offer! 
• After an interview, jot down specific topics that were discussed. Write a thank you card or email that you can send promptly after you’ve finished your interview. Include some of these specific items. This can help keep you in the employer’s mind. 
• Lastly, mindfulness can be helpful with life transitions. Try to focus on the present moment as you graduate or celebrate accomplishments with family and friends. I still remember my last day at my undergrad school. I took one last long jog around campus and allowed myself to think about many of my positive experiences. It is a memory I enjoy to this day. 

References: 

Bring on Gen Z: Hiring the Newest Workers. Monster. https://media.monster.com/marketing/2022/US_BringOnGenZ.pdf 

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, OOH FAQs, at https://www.bls.gov/ooh/about/ooh-faqs.htm 

Career Indecision. Career Research. https://career.iresearchnet.com 

Their, J. (2022, April 26). 2022 grads are set to outlearn last year’s cohort-and the year before that. Fortune. https://fortune.com/2022/04/26/2022-grads-set-to-outearn-last-years-cohort/

May 4th is World Postpartum/Maternal Mental Health Day; therefore, I felt it is important to shed light on this area. 1 in 5 new mothers and 1 in 3 mother's of color will experience to some symptoms of Perinatal Anxiety or Depression. It is also important to mention that approximately 10% of fathers struggle with postpartum symptoms as well.

To start I will briefly explain what Postpartum Depression (PPD) and Postpartum Anxiety look like. Anxiety is something that causes avoidance as it provokes a flight response. When you become anxious you may notice that your heart begins to race, your muscles tense, you may feel sweaty and/or faint. PPD is sometimes mistaken for what people call the “baby blues.” However, the symptoms for  PPD are more intense, last much longer, and may interfere with a parents ability to care for their baby. PPD symptoms can present during pregnancy, but most often occur within the first couple of months after birth. Some symptoms of PPD include but, are not limited to:  depressed mood, mood swings, withdrawing from family and friends, thoughts of harming oneself, difficulty bonding with your baby, intense irritability, and/or intense anger/agitation. 
  
As I mentioned above, symptoms can appear at any point during pregnancy as well as up to the first year after childbirth. An Acronym that might be helpful to remember in combating and coping with Postpartum Anxiety and Depression is SNOWBALL. I know, you're probably thinking what?!, But hang with me here, as this word can be important to remember when taking care of maternal mental health. 
 
Sleep- It is important that new moms get enough rest. There are a multitude of negative consequences associated with not getting enough sleep, some of which include difficulty thinking clearly and low distress tolerance.
​
Nutrition - Consuming foods that are not only healthy but that will also promote a speedy recovery is extremely important, and more so if breastfeeding.

Omega 3 - Research has shown that consuming fish oils may help reduce anxiety and depression in new moms. 

Walking - Getting out for a short walk can be incredibly beneficial.

Baby Breaks - It important to make sure that new parents take time away from baby if at all possible. Whether it be a trip solo or with our partners to go grocery shopping, taking time to visit with family or friends, or engaging in self-care activities such as getting hair or nails done. 

Adult Time - Making sure we pencil in quality time with other adults can be a protective activity.

Liquids - It is important to make sure we are drinking enough water daily. This is especially true if a new mom is breastfeeding, as this will help compensate for the water their body's needs in order to create breastmilk.

Laughter - It is important to remember that we need to find humor in situations and cut yourself a break.
 
References:
​ 
https://www.mayoclinic.org/diseases-conditions/postpartum-depression/symptoms-causes/syc-20376617
 
https://www.mindfulmamasclub.com/bloghub/postpartum-anxiety-is-real-carina-devi

​​While grief and the process of grieving can be a normal and a healthy experience, sometimes a significant loss and the grief associated with it can become a problem for someone in that it starts to seriously impact their ability to function, their ability to maintain relationships, etc. and may cause significant related symptoms such as depression, anxiety, post traumatic stress, substance use, etc. Therefore, clinical intervention may be useful or needed in order to help support the individual in processing the loss and re-creating meaning in their lives and to help reduce symptoms such as depression and anxiety.

Previously, grief reactions that caused significant distress or impairment were designated under the “Other Specified Trauma - and Stressor-Related Disorders” category within the diagnostic criteria for mental health disorders. The technical term for it had sometimes been referred to as “Persistent Complex Bereavement Disorder” and denoted as a specifier under the trauma and other stressor related category. Sometimes significant and persistent grief reactions were also referred to as “Complicated Grief.”

Prolonged Grief Disorder

In the new text-revision of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5-TR), “Prolonged Grief Disorder” has officially been added to better represent significant and persistent grief reactions and highlight how impairing and devastating complex grief reactions can be. Symptoms might include: identity disruption (e.g., feeling as though part of oneself has died), denial or disbelief about the death, avoidance of reminders that the person is gone, intense emotional pain (e.g., anger, bitterness, deep sorrow), difficulty moving on with life (e.g., problems engaging with friends, pursuing interests, planning for the future), emotional numbness, feeling that life is meaningless, and intense loneliness (i.e., feeling alone or detached from others). An individual with Prolonged Grief Disorder may experience intense yearning for their lost loved one and may become preoccupied by memories of their loved one or have intrusive distressing memories of their loved one.

While intense grief at the loss of a loved one can be very normal, for some individuals, their experience of grief and the intensity and duration of their symptoms may suggest that they may have Prolonged Grief Disorder. Everyone’s journey through grief is as unique as the type of loss and the value that an individual placed on what or who they lost.

Treating Grief Might Include the Following: 

Helping the individual reach out to supportive people and decrease isolation from others. A supportive person may include a family member, a friend, spouse, or support group. Social support can be a significant protective factor against unhelpful ways of coping and more serious symptoms of depression or anxiety. Support systems also provide the opportunity for healthy processing of the loss. 

​​Express feelings in a healthy way and help manage difficult and intense emotions. This might also include talking about the loss and the circumstances surrounding the loss. In the past, grief was thought to have steps that an individual would walk through until acceptance was obtained. Now it is seen as a fluid state that allows for variance and fluctuation. This means that the emotions experienced as a result of grief may ebb and flow. Grief episodes may be triggered by a predictable person, event, or item; or may be completely unpredictable and seemingly strike out of the blue. Grief features a wide variety of emotions, sometimes even within a day.  For many people, grief may feel like it takes over their lives for a time.  A therapist can gently walk alongside you through this turbulent time and help you find ways to express these difficult emotions.

Help the individual take time to heal. This is easier said than done. Ultimately, in order to be successful at being patient with yourself after loss, it is important to have healthy expectations of how long the process of reaching acceptance will take. There is no timeline for grief, however for many people the intensity of the grief they feel decreases over time as they work to process their feelings and work through the loss. How long this may take depends on a wide variety of factors including: relationships, grief experiences, the nature of the loss, and many more variables. One’s experiences with grief should not be compared to anyone else’s individual experience of grief. Again, an individual’s experience of grief is uniquely theirs.

Help the individual start thinking about the future and establish new meaning in their lives without their loved one. For some individuals, imagining a meaningful life without their loved one might seem impossible. A therapist can help the person slowly start to allow themselves to start thinking about the future. Finding meaning can mean very different things to everyone and is not something that anyone else can determine for you. It might mean re-evaluating your own values, purpose, or life. It might mean examining your beliefs around death and life. It might mean finding ways to honor and remember your loved one and carry on their memory and legacy. 

Help the individual stop or reduce avoidance of reminders of the loved one. While avoidance might work in the short-term, it can cause problems in the long term, including keeping the person stuck and isolated. Avoidance may reduce opportunities for re-establishing meaning, and learning that they are capable of getting through the loss and navigating memories of their loved one. It's important that the person find a way back into living.

Many people think of two things when they think of therapy: traditional outpatient therapy, where you meet one-on-one with a therapist, or inpatient therapy where you are admitted to a hospital for safety reasons. However, there are actually several in-between options that may be a good match for your needs depending on the “dose” of treatment you need. The more severe the symptoms and the more impairment the symptoms cause, the more likely a higher level of care will be indicated to best help you get better. 

A “Needs Assessment” usually refers to the kind of assessment done by a mental health provider, specifically in higher levels of care, to ascertain the “needs” of an individual seeking services. This assessment will include a recommendation for the level of care indicated for that client depending on a variety of factors including severity, duration, and intensity of symptoms, and level of distress and impairment caused by those symptoms.

​An outpatient mental health care provider may recommend a higher level of care for their clients if they are concerned that they need a greater “dose” of therapy, if they are concerned about their client’s safety, if treatment progress is limited or stalled, if there is evidence of a significant deterioration of functioning or increase in symptoms, etc. Higher levels of care may afford greater support, especially outside of normal business hours, access to a diverse interdisciplinary team of professionals, access to community resources, etc. The goal would be to “step down” care back to outpatient services once the client is feeling better.

Levels of Care

Outpatient Treatment: This is the most traditional level of care and will fit most people’s needs. Usually in this setting you see a mental health therapist once or twice a week for between 40-53 minutes or a medication manager (e.g., psychiatrist, primary care physician, nurse practitioner) every few weeks to few months. Examples of outpatient facilities include private practices (groups of providers or providers who work independently), community mental health centers, outpatient behavioral health services through hospitals or healthcare centers, etc. There are also varying degrees of support offered through outpatient centers/resources.

Some facilities are able to offer something sometimes referred to as "wrap-around services." This means that the outpatient facility offers various forms of outpatient services to help support the individual such as traditional therapy, medication management, therapy groups, on-call crisis services, etc. 

Intensive Outpatient Programs (IOP): At this level of care, client’s would attend a therapy program anywhere between 3-4 hours a day, sometimes only a few days a week. The therapy program might include group therapy, psychoeducation presentations, meetings with an individual therapist, meetings with a psychiatrist, and an experiential component (e.g., music therapy, art therapy). At this level of care you go home at the end of the day and your participation is voluntary. 

Partial Hospital Programs (PHP): This level of care is very similar to an IOP settings (and most of the time client’s start in a PHP and then “step down” to an IOP setting within the same location and program). With this level of care a client might attend anywhere between 5 and 6 hours a day, 5 days a week. At this level of care you go home at the end of the day and your participation is voluntary. 

Residential Treatment: This level of care is similar to PHP programming; however, the client’s sleep on a unit in the program and programming might last a little longer throughout the day. At this level of care you don’t go home at the end of the day and your participation is voluntary. 

Inpatient/Acute Care: This level of care is reserved for situations where a client’s symptoms are severe enough that the person’s safety or ability to function are at risk, and therefore the person needs to be closely monitored. This might also include situations where a client needs to make drastic changes to their medications and therefore need to be monitored closely. This is a short-term treatment, and the person is usually “stepped down” to a PHP/IOP program as soon as possible. At this level of care you don’t go home at the end of the day and a person's ability to end treatment is sometimes partially determined by the attending physicians.

It's also important to note, that specialized services (e.g., addiction services) might have an even more diverse range of levels of care services.

What is Happiness?

Happiness is a word we use almost constantly in our daily language.  We are bombarded with advertisements promising that we can pay money to buy this item or go on this trip to be happy.  It is something that we have aspired to for so long, and yet what does it mean to be happy?  Is it a state of being?  Or is it an emotion?  What are your thoughts on happiness?  How permanent of an experience can it be?

According to Harvard professor Daniel Gilbert, “We all want to live happily ever after.  To experience more pleasure than pain.  More delight than despair. More joy than sorrow.”  There is so much truth in that statement, we don’t want to sign up for struggles, however struggles will happen anyway and we just want the good to outweigh the bad.  The reason it can be important to consider how permanent happiness is for you personally, is because it can change your relationship with the idea of being happy.  If you believe that happiness is an emotion, than you would also believe that it cannot exist all the time.  It would have to make room for all of the other emotions that are part of everyday life.  On the opposite side of that spectrum, if you believe that happiness is a state of being, then you may believe that it is an overall contentedness with life and less of an immediate experience.  What do you believe?

So once we define what happiness is for ourselves; how do we encourage happiness in our lives?  One of the first places to begin is by figuring out what we value in our lives.  Everyone has values that are a little bit different, so it is beneficial to consider which ones matter most to you.  Do you really value independence?  How about family?  Peace?  Love?  Wisdom?  Relaxation?  Safety?  Beauty?  Adventure?  If you are looking to find a list of possible values, try searching for a Values Clarification worksheet.  There are a number of them online that may help you to determine what they are for you. There is also a helpful article written by one of our wonderful clinicians, Dr. Pamela Heilman, called Let Your Values Be Your GPS.

There is no wrong answer when it comes to the values in our lives, they just are.  Once you have an idea of what your personal values happen to be, consider which ones are present in your life right now.  Which values are you missing?  Think about ways you better add those values into your life.  If you know the things you feel strongly about or value, you can feel a greater sense of fulfillment and overall contentment.

Another important factor that plays into our overall happiness is our social support.  Humans have thrived because we are connected to one another and don’t do well in isolation.  For many people, the pandemic has worked to further isolate us from the people we care about.  Having friends, family, and/or overall connections with others is very important to our wellbeing.  Give some consideration to how much time you are spending with the people in your life who are supportive to you or even just share similar interests with you.  We have more ways to connect with others than we ever have before, it is just a matter of using them.

No one can tell you how to be happy, it truly is something you must seek for yourself.  By understanding your own definition of what happiness means, finding out and living your own values, and by spending time with others you care for; you have a greater chance at finding your own happiness in your life.  That does not prevent bad things from happening, but it does help you to have a better ability to recover from the bad times.

This blog series will help you understand what to expect in Cognitive Behavioral Treatment (CBT) for a variety of different anxiety disorders, OCD, and PTSD. No matter what you are seeking help for, it can be very scary to start treatment. I assume most of my patients enter their first appointment with me with anxiety. I assume this for several reasons. 1. You are taking a big first step in your life to change something that may feel impossible to change; 2. Most of my patients experience an abundance of anxiety on a daily basis and new experiences make us all feel anxiety.

My hope is that this blog series helps you to have a better sense of what to expect in your treatment if you choose exposure-based CBT interventions. First and foremost, the first appointment will be a lot of data collection. In order to determine how I can be helpful, I must determine what your problem looks like. You can plan on me asking you a ton of questions. My goal is to determine what diagnoses you meet criteria for (to ensure I can treat those diagnoses) and to instill some hope in you that I can help you. Just like we would hope our doctors would evaluate what is broken before treating a broken bone and then tell us how they can be helpful, I want to use a scientific approach in my practice and give you some hope that the science works. Although a one size fits all approach does not work for everyone, I apply all evidence-based techniques or techniques that have been supported by ongoing research. In this series, you will find the general what’s and why’s of treatment with me. Also, if you are struggling with the motivation to get started, I include some information on why it may be worth it to take a chance on this treatment.

Posttraumatic Stress Disorder Treatment

What is Posttraumatic Stress Disorder (PTSD)?

Post-Traumatic Stress Disorder (PTSD) results from witnessing or being exposed to death, threatened death, or actual or threatened serious injury (American Psychiatric Association, 2013). Following such a terrifying event, our brains sometimes recover. Sometimes they do not. This is why PTSD is considered a recovery disorder (Resick et al., 2017). Symptoms include intrusive memories, efforts to avoid memories, increased negative emotions and thinking patterns, and hypervigilance or hyper-arousal (increased alertness and related physical symptoms). These are symptoms we all can experience after a traumatic event for a short period of time. However, PTSD occurs when these symptoms persist and start to impact your life, long term. 

What will we work on?

If you seek PTSD treatment from me, you will have two treatment options:

The first is called Cognitive Processing Therapy or CPT. In CPT, we will focus on challenging unhelpful thoughts and beliefs that have resulted from your trauma (Resick et al., 2017). Additionally, I will help you process the traumatic memory and related emotions. By modifying beliefs related to your trauma and by effectively processing (as opposed to avoiding) the traumatic memory, you can start to recover from the trauma. I see PTSD as a disorder that causes my patients to relive the traumatic event, over and over again. I want you to be able to stop reliving the event. In order to do so, we need to process the event, so that you can put it in long term memory storage. Instead, PTSD asks you to continue opening the worst page of a scary book in your brain. We will take a look at the whole book so that you can close it and only look at it when you choose to, as opposed to when it intrudes into your mind (Resick et al., 2017).

The other treatment I offer is called Prolonged Exposure Therapy (PE). In PE, we will focus on gradually processing traumatic memories and challenging avoidance related to your trauma (Foa et al., 2007). What does this look like? You will talk about your trauma and be asked to do things you have been avoiding. One symptom of PTSD is avoidance of both the traumatic memory and situations, people, and places related to the traumatic event. In order to recover from PTSD, we must challenge this avoidance and re-enter life, despite the continued fear that something bad may happen. Prior to the trauma, you lived in the world and accepted the risks of doing so. I hope to help you learn to do this again. Of note, I will not ask my patients to do something that I myself would not do. I will not ask you to enter situations that are likely dangerous. We will modify all exercises according to CDC guidelines during the COVID-19 pandemic. 

Why engage in this treatment?

For some, PTSD has completely debilitated their ability to live a comfortable and full life. For some, they are reliving their trauma every single day. So, it seems you have two choices. You continue living as if the trauma is still happening, or you decide to face the trauma directly so that you can get back a life without daily threats and fear. I am assuming that you are reading this page because you are tired of reliving your trauma. I am assuming that it is getting in the way of success, health, sleep, or enjoying the present moment. If so, you may want to give treatment a try. 

Why this treatment works.

Every time you think of your trauma, your threat brain (the amygdala) is igniting (Resick et al., 2017). Every time you think of your trauma, your brain is telling your body to fight, flight, or freeze (the three threat response options we have). Both of these treatments aim to adjust this response by processing the trauma, facing the trauma, and returning to your life or to more rationale ways to view it. 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007) Prolonged Exposure for PTSD: Emotional Processing of Traumatic Experiences: Therapist Guide. Oxford University Press.

Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books.

Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive Processing Therapy for PTSD. The Guilford Press.

This blog series will help you understand what to expect in Cognitive Behavioral Treatment (CBT) for a variety of different anxiety disorders, OCD, and PTSD. No matter what you are seeking help for, it can be very scary to start treatment. I assume most of my patients enter their first appointment with me with anxiety. I assume this for several reasons. 1. You are taking a big first step in your life to change something that may feel impossible to change; 2. Most of my patients experience an abundance of anxiety on a daily basis and new experiences make us all feel anxiety.

My hope is that this blog series helps you to have a better sense of what to expect in your treatment if you choose exposure-based CBT interventions. First and foremost, the first appointment will be a lot of data collection. In order to determine how I can be helpful, I must determine what your problem looks like. You can plan on me asking you a ton of questions. My goal is to determine what diagnoses you meet criteria for (to ensure I can treat those diagnoses) and to instill some hope in you that I can help you. Just like we would hope our doctors would evaluate what is broken before treating a broken bone and then tell us how they can be helpful, I want to use a scientific approach in my practice and give you some hope that the science works. Although a one size fits all approach does not work for everyone, I apply all evidence-based techniques or techniques that have been supported by ongoing research. In this series, you will find the general what’s and why’s of treatment with me. Also, if you are struggling with the motivation to get started, I include some information on why it may be worth it to take a chance on this treatment.

Social Anxiety Treatment

What is Social Anxiety Disorder? 

Social anxiety disorder often appears as anxiety in social situations where one could be evaluated by others (American Psychiatric Association, 2013). This could involve meeting new people, being observed by others, or even having to perform in front of others. Fear of negative evaluation is a big part of social anxiety. My patients often ask “will I embarrass myself? will I be rejected or humiliated? will I offend someone?” Individuals with social anxiety disorder want to stay away from social situations that could involve evaluation or will do so with a ton of anxiety. 

What will we work on? 

• Cognitive Restructuring: Our thoughts are very powerful, particularly during and after social interactions (Hope et al., 2019). We all have had moments of anxiety during or following a social encounter. For instance, it is fairly normative to reflect on our performance following an interview. However, for individuals with social anxiety disorder, their anxiety extends beyond a bit of doubt and appears more as automatic, extreme thoughts, such as “They didn’t like me” or “Because I didn’t answer perfectly, I will never answer perfectly, therefore, I will never get a job” or “I looked anxious and stupid” (Hope et al., 2019). I will ask you to become a scientist. I will ask you to dispute these assumptions using questions like “do you know these things for certain?” and “what evidence do you have that such assumptions are true?” (Hope et al., 2019). 

• Exposure Therapy: To overcome a fear, we must face it (Hope et al., 2019). To overcome social anxiety, I will ask you to do things that make you socially anxious or uncomfortable. Why? Because you can tolerate it. Social anxiety will not harm you. In fact, the opposite is true. Avoiding important social situations will likely cause some detriment in your life. Saying the wrong thing and being embarrassed is just a part of life. We will practice easier tasks, such as having conversations, and then harder tasks, such as doing things that make you feel embarrassed. You will learn that you can cope with these feelings and find ways to move into social situations with bravery and acceptance of uncertainty. 

Why Engage in this Treatment?

Outside of meeting our basic needs, our relationships and our ability to engage with others is likely the next most important aspect of human functioning. Is it painful for you to enter new situations or to make new friends (Grayson, 2014)? Does your fear of negative evaluation keep you from pursuing your goals? Do you avoid important social events because you just can’t tolerate the anxiety? Are you lonely because you avoid social situations? Has this pandemic led to even more isolation and exacerbated your social anxiety? If so, you may want to give treatment a try. 

Why this treatment works?

Right now, your threat brain is signaling danger during social encounters. However, for the most part, social encounters do not pose danger (as long as you are following proper COVID-19 precautions). If you repeatedly examine the thoughts during social encounters and repeatedly place yourself in uncomfortable spaces, your comfort will grow with time. You can tolerate anxiety. You do not need to run from it anymore. During the COVID-19 pandemic, we will modify the social exposures to abide by CDC guidelines. However, even now, there is a way to become more present focused in your relationships and life. 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Hope, D. A., Heimberg, R. G., & Turk, C. L. (2019). Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach: Therapist Guide (3rd ed.). Oxford University Press.

Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books.