Understanding Intolerance of Uncertainty in Generalized Anxiety Disorder (GAD)

By Dr. Evan Vida

Generalized Anxiety Disorder (GAD) is a common mental health condition characterized by excessive and uncontrollable worry about various aspects of life. One of the core features of GAD is "intolerance of uncertainty" (IU), a psychological trait that significantly contributes to the disorder's development and persistence. This blog aims to discuss what intolerance of uncertainty entails, its impact on individuals with GAD, and effective strategies to manage it.

What is Intolerance of Uncertainty?

Intolerance of uncertainty refers to a person's chronic difficulty in accepting the inherent unpredictability of life. People with high levels of IU struggle to cope with the unknown, often experiencing discomfort and distress when faced with uncertain situations. This intolerance manifests in various ways, such as overplanning, a strong need for control, and an excessive desire for reassurance.

At its core, IU is rooted in the fear of unpredictable events and the desire to avoid potential negative outcomes. This fear drives individuals to seek certainty, even in situations where it is impossible to achieve. For example, someone with IU might avoid making decisions until they are sure of the outcome, or they might excessively research minor issues to prevent any unforeseen consequences.

The Role of Intolerance of Uncertainty in GAD

In individuals with GAD, intolerance of uncertainty plays a significant role in the onset and maintenance of anxiety symptoms. Those with GAD often worry excessively about future events, fearing the worst possible outcomes. This constant worry is fueled by difficulty with tolerating uncertainty, leading to rumination on potential dangers and negative scenarios.

For instance, a person with GAD might constantly worry about job security, health issues, or the well-being of loved ones, even when there is no immediate threat. This pattern of thinking leads to heightened anxiety and stress, as the individual becomes trapped in a cycle of seeking certainty and reassurance, which only provides temporary relief.

How Intolerance of Uncertainty Affects Daily Life

Intolerance of uncertainty can have a profound impact on daily life, influencing decisions, relationships, and overall well-being. Here are some common ways IU manifests:

1. Avoidance of New Experiences: Individuals with IU may avoid trying new things or taking risks, fearing the unknown outcomes. This can lead to missed opportunities and a restricted life.

2. Difficulty Making Decisions: The need for certainty can make decision-making a daunting task. People with IU often overanalyze options and struggle to commit to choices, worrying about potential mistakes.

3. Strain on Relationships: Excessive reassurance-seeking can strain personal relationships. Constantly asking for validation or assurance can be exhausting for both the individual with GAD and their loved ones.

4. Physical and Emotional Toll: Chronic worry and anxiety can lead to physical symptoms like headaches, muscle tension, and sleep disturbances. Emotionally, it can cause feelings of frustration, hopelessness, and burnout.

Strategies to Manage Intolerance of Uncertainty

Managing intolerance of uncertainty is crucial for reducing anxiety and improving overall quality of life. Here are some evidence-based strategies that can help:

1. Exposure to Uncertainty: Gradual exposure to uncertain situations can help build tolerance. This involves intentionally facing situations with uncertain outcomes and resisting the urge to seek certainty or reassurance. Over time, this can reduce anxiety and increase resilience.

2. Cognitive Restructuring: This technique involves identifying and challenging negative thoughts related to uncertainty. By reframing these thoughts in a more balanced and realistic way, individuals can reduce the distress associated with uncertainty.

3. Mindfulness and Acceptance: Practicing mindfulness can help individuals stay present and focused on the here and now, rather than worrying about future uncertainties. Acceptance involves acknowledging that uncertainty is a natural part of life and learning to live with it without excessive fear.

Intolerance of uncertainty is a common but challenging aspect of Generalized Anxiety Disorder. By understanding and addressing IU, individuals can significantly reduce their anxiety and improve their quality of life. It's important to remember that managing uncertainty takes time and practice, but with the right strategies and support, it is possible to develop a healthier relationship with the unknown. If intolerance of uncertainty is significantly impacting your life, consider seeking professional help to guide you through this journey. Embracing uncertainty, rather than fearing it, can open the door to a more flexible and fulfilling life.

Unveiling the Divide: Trauma Exposure and PTSD as Distinct Entities

By Dr. Christina DiChiara, PsyD

June is Posttraumatic Stress Disorder (PTSD) Awareness Month, a time to shine a spotlight on a condition that affects millions worldwide. Amidst the conversations surrounding PTSD, trauma exposure and PTSD often find themselves lumped together under the same umbrella. While they share a common origin in the experience of life-threatening events, it's crucial to recognize that trauma exposure and PTSD are distinct entities with unique manifestations and implications. 

This June, we’d like to help raise awareness of this important distinction: trauma exposure and PTSD are not one and the same. Understanding this difference is paramount in fostering empathy, awareness, and support for those impacted by trauma and those suffering with PTSD. Let's explore the nuanced delineation between trauma exposure and PTSD.

Trauma Exposure: Threatening Life or Life As You Know It

“Trauma exposure” encompasses a broad spectrum of adverse experiences, ranging from natural disasters and accidents to interpersonal violence and warfare. These experiences are life threatening, or threaten life “as you know it.” Whether it's the aftermath of a car crash, the horrors of combat, or the scars of childhood abuse, trauma exposure disrupts our sense of safety and security, shatters our assumptions about the world, and leaves us grappling with a myriad of complex emotions and reactions. 

Post-Traumatic Stress Disorder (PTSD): The Lingering Echoes

Post-Traumatic Stress Disorder (PTSD) is the lingering echo of trauma exposure that reverberates through the corridors of our mind long after the event has passed. It's not merely a collection of symptoms; it's a profound and often debilitating response to the harrowing specter of trauma. PTSD can emerge in the wake of any traumatic event, leaving individuals grappling with a myriad of intrusive memories, avoidance behaviors, negative changes in thinking and mood, and hyperarousal and reactivity.

Unlike trauma exposure, which is a transient experience that may or may not lead to lasting psychological sequelae, PTSD is a clinical diagnosis that requires a specific constellation of symptoms and impairment in functioning. It's a complex and multifaceted disorder that can profoundly disrupt every facet of daily life, from relationships and work performance to physical health and overall well-being.

Bridging the Divide: 

Trauma exposure lays the groundwork for PTSD, but not everyone who is exposed to trauma will develop the disorder. After trauma exposure, most people will recover naturally, while others will develop clinically significant PTSD (O’Donnell et al., 2020). 

Natural recovery after trauma exposure is possible, and is best achieved through typical, daily activities that help people come to terms with what they have survived. Rauch and McLean (2021) describe several common activities that contribute to natural recovery from trauma exposure, including trauma survivors allowing themselves to think about the trauma and talk about it with supportive people, allowing trauma-related emotions to be felt, and returning to reasonably safe people, places, and things that are reminders of the trauma without avoiding or escaping.

For people who have been exposed to trauma and developed PTSD, effective trauma-focused therapies exist to help facilitate recovery. Prolonged Exposure and Cognitive Processing Therapy are two of the frontline treatments for PTSD that have the most robust empirical support and offer the best chances at recovery. We’ll share more about these treatments in an upcoming blog later this month. 

Clarifying Understanding Clarifies How to Help 

As we commemorate PTSD Awareness Month, we hope to contribute to raising awareness of the important difference between trauma exposure and PTSD. Why does it matter?  Because clarifying our understanding of these differences clarifies what people might need to recover and how we can best help. Together, let's pave the way toward a future where survivors can reclaim their agency and embark on a journey of healing and wholeness, or get the effective help that they deserve and need. 

O’Donnell, M. L., Pacella, B. J., Bryant, R. A., Olff, M., & Forbes, D. (2020) Early Intervention for Trauma-Related Psychopathology. In D. Forbes, J. I. Bison, C. M. Monson, & L. Berliner, Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (pp. 117-131). Guildford Press.

Rauch, S. A. M., & McLean, C. P. (2021). Retraining the brain: Applied neuroscience in exposure therapy for PTSD. American Psychological Association. https://doi.org/10.1037/0000242-000

Mental Health Awareness Month: How Therapists Use Therapy Skills in Their Own Lives

In honor of Mental Health Awareness Month, we are highlighting how therapists use therapy skills in their own lives. This blog post aims to share practical application of skills, demonstrating their effectiveness and relevance in everyday life. We hope to provide insight into the techniques that can improve mental well-being and encourage you to explore these strategies yourself.

Catherine Schuler, PsyD

“Going to early morning yoga classes is a way that I practice accepting discomfort in order to live in line with what I value. Voluntarily getting up before sunrise is always difficult, and each time my mind says 'No! Just stay in bed.' I remind myself that my thoughts are just thoughts - I have a choice whether or not to listen to them - and that the sense of ease in my body and calm in my mind after yoga is worth the short-term discomfort of an early wakeup."

Skill Explanation: Tolerating Discomfort and Thought Defusion

Tolerating discomfort involves accepting and enduring unpleasant feelings or situations without attempting to avoid or escape them. Thought defusion, a concept from Acceptance and Commitment Therapy (ACT), involves distancing oneself from unhelpful thoughts and recognizing them as mere mental events rather than truths that dictate behavior. Practicing tolerating discomfort can build resilience and improve one's ability to face challenging situations without becoming overwhelmed. Thought defusion helps reduce the impact of negative or intrusive thoughts, allowing individuals to make choices based on values and long-term goals rather than immediate emotional reactions. For those new to these concepts, starting small can be helpful. Begin by identifying a minor discomfort to tolerate or practice thought defusion with a simple exercise, such as saying a distressing thought aloud repeatedly until it loses its meaning.

Caroline Haimm, PhD

“As an exposure therapist, I frequently ask my clients to try extremely difficult challenges, and I have been so struck by their bravery and grit. As a result, I began to practice small exposures to anxiety and discomfort myself. Most recently, this has been in the form of playing (somewhat) competitive tennis. I have always been fearful of failing and disappointing others. Playing on a club tennis team allows me to face both of these fears head on. Thus far, I have lost more matches than I have won, but as of yet, I have only experienced disconfirmation of my fears - no one on my team has made me feel bad about my playing, and I’ve survived the losses. And, as I continue to push myself, I enjoy many benefits - good exercise, an opportunity to socialize with a warm and interesting group of women, and the chance to build my resilience and confidence to try new things!"

Skill Explanation: Exposure to Disconfirm Fears

Exposure therapy is a psychological treatment that helps individuals confront their fears in a gradual and controlled manner. The specific technique of exposing oneself to situations that could disconfirm fears involves intentionally facing feared scenarios to test the validity of those fears and learn that the outcomes are often less catastrophic than anticipated. Exposure to feared situations can reduce anxiety and build resilience. By confronting fears, individuals learn that their worst-case scenarios are often unfounded, which can diminish the power of these fears. Starting with manageable exposures is crucial. For instance, someone afraid of social situations might begin by attending a small gathering before progressing to larger events. Keeping a journal of exposures and the outcomes can also help track progress and reinforce positive experiences.

Steven Tsao, PhD

“Life is stressful. For all of us. Even us psychologists. When I'm stressed, I try (and sometimes even succeed!) in opening myself up to that feeling, reminding myself that it's part of being alive, and connecting to the world of people that may also feel stressed at that very same moment."

Skill Explanation: Normalizing Discomfort and Struggle, and Self-Validating/Accepting Emotions

Normalizing discomfort and struggle involves recognizing that experiencing stress and negative emotions is a common and universal part of the human experience. Self-validating and accepting emotions means acknowledging one's feelings without judgment and accepting them as they are, without trying to change or suppress them. Normalizing discomfort helps reduce feelings of isolation and self-criticism, while understanding that struggle is a shared human experience can foster a sense of connection and compassion. Self-validating and accepting emotions allows individuals to process their feelings healthily, leading to better emotional regulation and resilience. Practicing mindfulness can enhance emotional acceptance. Techniques such as mindfulness meditation encourage observing emotions without judgment, helping individuals develop a more accepting attitude towards their internal experiences.

Christina DiChiara, PsyD

“The best way for me to take care of my stress and manage my mood is to make sure I’m spending time in nature. During a long day in front of the computer, I always make sure to sit in my garden or walk in the woods for 10-15 minutes. I don’t take my phone, and make an effort to use the sights, sounds, and smells around me in nature to get me out of my head, soothe my stress, and shift my perspective by reminding me that there is big world out there!"

Skill Explanation: Mindfulness

Mindfulness involves paying full attention to the present moment without judgment. It means being aware of where you are and what you're doing, and not being overly reactive or overwhelmed by what's going on around you. Mindfulness can help reduce stress, improve mood, and enhance overall well-being. It allows individuals to detach from their thoughts and feelings, observing them without becoming consumed. This practice can lead to greater emotional regulation and a deeper sense of peace and calm. Incorporating short mindfulness practices into daily routines, such as mindful walking or spending time in nature, can be very effective. For beginners, guided mindfulness exercises or apps can provide helpful structure and support.

Evan Vida, PsyD

"I use my morning coffee routine as an opportunity to practice mindfulness and gratitude. The process of creating a perfect shot of espresso and steaming milk for a latte is an opportunity to fully participate in an activity one-mindfully. Practicing this helps me not bring future or past pain into the present and focus solely on what is in front of me. I can then enjoy and appreciate my latte one-mindfully before getting started with my day."

Skill Explanation: One-Mindfully and Participate Mindfulness Skills

One-mindfully means focusing on one task at a time with full attention, while "participate" refers to fully engaging in an activity without self-consciousness. These skills are part of Dialectical Behavior Therapy (DBT) and emphasize being present and immersed in the current activity. Practicing one-mindfulness and participation can enhance the enjoyment and satisfaction derived from everyday activities. It prevents the mind from wandering to past regrets or future worries, reducing anxiety and improving concentration. Simple routines, like a morning coffee ritual, can be ideal opportunities to practice these skills. By focusing on the sensory experiences and the process itself, individuals can transform routine tasks into moments of mindfulness and joy.

Anna Thompson, M.S.

"Life is full of uncertainty. As a grad student, I often face uncertainty such as grades, clinical experiences, and my future. I practice what I preach to my clients. I acknowledge that life is full of uncertainty and I accept variability in the things that I can not control; however, I choose to live based on my values for things that are within my control. Fun Fact: I started at CABT as a volunteer, originally looking for a practicum site during my Master's degree. I decided to add another commitment to my day, to live by my values, regardless of the uncertainty of what I would gain from the experience or the time constraints it may have on my day. Regardless of the day-to-day uncertainties, I made a decision based on my values, which paid off! I find that the act of accepting uncertainty takes a lot of practice, but I appreciate the outlook it allows me to have on life."

Skill Explanation: Accepting Uncertainty and Living by Values

Accepting uncertainty involves recognizing that unpredictability is a natural part of life and choosing to focus on what can be controlled. Living by values means making decisions and taking actions that align with one's core beliefs and principles, regardless of the uncertainty surrounding the outcomes. This approach can reduce anxiety and enhance resilience by shifting focus from uncontrollable variables to meaningful actions. It encourages proactive living based on personal values, fostering a sense of purpose and direction. Practicing acceptance of uncertainty requires ongoing effort but can lead to a more adaptable and fulfilling life.

Shannon Murphy, PhD

"My dog is old and stubborn and generally does not love walking on leash. This means that our daily walks quickly devolve into a tug of war, in which I'm frustratedly pulling her along as she resists my every move. On my better days, I use these walks as an opportunity to practice radical acceptance - I stop fighting with her, allow her to be exactly as she is, and let the walk take the time that it takes."

Skill Explanation: Radical Acceptance

Radical acceptance is a skill from Dialectical Behavior Therapy (DBT) that involves fully accepting reality as it is, without resistance or judgment. It means acknowledging situations or emotions as they are, rather than how one wishes they would be. Practicing radical acceptance can reduce frustration and suffering by eliminating the struggle against reality. It allows individuals to conserve energy and focus on what can be changed or how to cope effectively with the present situation. This skill can lead to greater emotional stability and resilience by fostering a mindset of acceptance and peace.

Conclusion

The skills used by therapists can be beneficial for anyone looking to improve their mental well-being. By incorporating techniques like tolerating discomfort, thought defusion, exposure to disconfirm fears, normalizing discomfort, self-validating emotions, mindfulness, accepting uncertainty, and radical acceptance, individuals can better manage stress and align their actions with their values. If you are interested in learning more or seeking treatment, please visit our contact page

Personal Spring Cleaning: Renewing Your Focus on Mental Health and Wellness

By Dr. Christina DiChiara, PsyD

Spring is a time of renewal and growth—a time to shed the old and embrace the new. Spring offers the perfect opportunity to turn our attention inward and refresh our commitment to mental health and overall wellness. By dusting off your attention to your mental health and wellness this season, you can lay the foundation for a more fulfilling and balanced life. So take a deep breath, bask in the beauty of the season, and commit to a bit of personal Spring Cleaning! After all, just like the flowers that bloom in spring, your potential for growth and transformation is endless.

Just as we engage in spring cleaning to declutter our physical spaces, we can also embark on a journey of mental and emotional decluttering and refocusing. Here are some ways to embrace the spirit of spring and nurture your well-being:

1. Connect with Nature: Take advantage of the longer days and milder weather by spending time outdoors. Whether it's going for a hike in the woods, having a picnic in the park, or simply taking a leisurely stroll around your neighborhood, immersing yourself in nature can have a profoundly positive effect on your mental health. The sights, sounds, and smells of the natural world can help reduce stress, boost mood, and promote a sense of calm and well-being.

2. Practice Mindfulness: The sights, sounds, and smells of Spring are naturally captivating, and can help draw us back into the present moment with their beauty and freshness. Take advantage with a mindfulness “time out.” Spend a few minutes each day to sit quietly, focus on the sensory information around in the present moment, and observe your thoughts and feelings without judgment. By practicing mindfulness, you can learn to manage stress more effectively, get out of your head, improve your concentration, and enhance your overall sense of happiness and fulfillment.

3. Nurture Your Body: Just as we nourish the soil to encourage growth in the springtime, we can also nourish our bodies to support our mental and emotional well-being. Take advantage of the fresher foods emerging this season. Start to add in more fresh, seasonal fruits and vegetables into your diet. Stay hydrated by drinking plenty of water, and prioritize regular exercise to keep your body strong and energized. Physical activity releases endorphins, the body's natural feel-good chemicals, which can help alleviate symptoms of anxiety and depression.

4. Cultivate Gratitude: Spring reminds us of the abundance and beauty that surrounds us. Take time each day to reflect on the things you're grateful for, whether it's the warmth of the sun on your skin, the laughter of loved ones, or the simple pleasure of a freshly brewed cup of tea. Cultivating gratitude can shift your focus from what's lacking to what's present, fostering a greater sense of contentment and fulfillment in your life.

5. Seek Support: If you're struggling with your mental health, don't hesitate to reach out for support. Whether it's talking to a trusted friend or family member, seeking guidance from a therapist or counselor, or joining a support group, there are resources available to help you navigate life's challenges. Seeking help is a sign of strength, not weakness, and you don't have to face your struggles alone.

How to Help a Loved One with Anxiety: Navigating Family Involvement and Accommodation

How to Help a Loved One with Anxiety: Navigating Family Involvement and Accommodation

Anxiety disorders are a family affair. When a loved one struggles with anxiety, it's not just their battle; it affects everyone close to them. Especially in cases of Obsessive-Compulsive Disorder (OCD), the entire family dynamic can shift in response to the disorder's demands. While family members' intentions are rooted in love and support, certain behaviors, known as family accommodations, can inadvertently maintain or even exacerbate the symptoms. Understanding the distinction between supporting and accommodating is crucial in effectively aiding your loved one's journey to recovery.

Understanding Family Accommodation

Family accommodation refers to various behaviors family members might engage in to help a loved one avoid anxiety triggers or participate in their safety behaviors. These accommodations can range from altering daily routines to assisting in the rituals themselves. For example, disinfecting areas of the home at the request of your loved one or changing when and how family activities are done to avoid triggering anxiety. While these actions are meant to provide relief, they can reinforce the anxiety disorder over time, creating a cycle that's hard to break.

The Fine Line Between Support and Accommodation

Finding the right balance between providing support and inadvertently accommodating the anxiety is a fine line many families find challenging to navigate. Encouraging a loved one to face their fears gently can be empowering, helping them build resilience against anxiety. However, forcing someone to confront their fears before they're ready can be counterproductive and prolong the distress. It's about providing a nudge towards growth and risk-taking, not a push off the ledge.

Empowering Decision Making

One of the most significant ways to support someone with anxiety is by empowering them to make decisions for themselves. This might involve coming up with agreed-upon phrases or cues that encourage the person to take steps towards independence and help them catch when anxiety is taking over. These strategies help build confidence and reduce the person's reliance on family members for decision-making, fostering a sense of personal accountability and strength.

Avoiding Collusion with Anxiety

Colluding with a loved one's anxiety or OCD means participating in their behaviors or making changes to your life to accommodate their symptoms. This can include anything from participating in compulsive behaviors together, avoiding activities that trigger their anxiety, or taking on additional responsibilities to 'protect' them from stressors. Recognizing these patterns and understanding their impact is the first step toward change.

Constructive Ways to Help

To support a loved one with an anxiety disorder, consider these tips:

• Gradually reduce participation in compulsive behaviors: Start by setting small, manageable boundaries, decreasing your involvement in their rituals over time.

• Encourage independence: Use agreed-upon cues or phrases to promote decision-making, gently encouraging your loved one to face anxiety-provoking situations.

• Seek professional support: Education is power. Learning more about anxiety disorders and treatment options can provide a solid foundation for support.

Supporting a loved one with an anxiety disorder requires a delicate balance. By understanding the difference between helpful support and harmful accommodation, families can play a crucial role in their loved one's path to recovery. It's about empowering them to face their fears, make their own decisions, and ultimately, regain control over their life. Remember, change takes time, patience, and a lot of love, but together, it's possible to navigate the complexities of anxiety disorders and move towards a healthier, more balanced life.

Demystifying Therapy: What Should I Expect for my first CBT Session?

Embarking on cognitive behavioral therapy (CBT) marks a significant step towards personal growth and mental wellness. There can often be numerous barriers to finding the right care, let alone finding the time and motivation to devote to this (worthwhile!) process. This therapy, grounded in evidence-based practice, offers a more structured approach to identifying and altering unhelpful patterns that influence emotions, thoughts, and behavior. As you prepare for your first CBT session, it's natural to have questions and feel a mix of anticipation and uncertainty. This comprehensive guide is designed to demystify the process, providing you with a clear understanding of what to expect and how these sessions can pave the way for meaningful change. Whether you're seeking to overcome challenges or improve your overall mental health, the journey through CBT begins with a single, transformative step into your first session.

Preparing for your first CBT session

What should I bring to my first CBT session?

It's helpful to come prepared with a notebook and pen for jotting down important points or questions you might have. Our therapists make good use of informational handouts and other collaborative materials, so bringing a therapy folder is also a good idea to keep your materials organized in one place. Bringing any relevant medical or therapy records can also aid your therapist in understanding your history. It can be helpful to bring old therapy materials such as past exposure hierarchies, thought logs, or treatment plans. While your therapist will tailor your therapy to your current situation, we like to know what was helpful, or not helpful, in previous treatment. Besides these, it is important to be mentally prepared for your first session and bring your willingness. This mental preparation involves being open and willing to discuss personal and often difficult topics with your therapist. It's normal to feel nervous, but remember, this is a step toward your well-being. Of course, we know that building our alliance and your trust in us takes time, so you will never be forced to discuss something for which you are not ready.

What should I expect for my first CBT session?

How is a typical CBT session structured?

A typical CBT session usually starts with setting an agenda. A hallmark of CBT is that every session is collaborative, and this starts with aligning on what topics we will be addressing in each session. The first session is no exception! You will likely have questions about us, the treatment, diagnoses, and more. Our goal is to answer those questions and continue demystifying the therapy process and your challenges. After setting an agenda, we will work through our agenda items and then end with assigning therapy homework. For your first session, this will likely include some reading of informational handouts as well as beginning to self-monitor your symptoms and experiences between sessions. In later sessions, several minutes of the session will be devoted to reviewing what was worked on in the time between sessions.

What kind of topics will be discussed in my first session?

While the specific agenda items will be dictated by your needs at the the time, usually your therapist will be prepared with agenda items of their own. At CABT, we believe that in order to demystify therapy, all initial sessions should contain time devoted to psychoeducation and the delivery of rationale for treatment.

What is psychoeducation and rationale for treatment?

Psychoeducation in therapy is like giving clients a roadmap to understand their mental health better. It's all about teaching you what's going on in your mind, what you might expect from your condition, and how you can handle it effectively. This part of therapy helps clear up confusion and makes sure you know you’re not alone in your journey. It breaks down the big, unknown concepts into manageable pieces, making it easier for you to get involved in your own healing process. By learning more about your mental health, you can feel more in control, less worried, and more ready to tackle your challenges head-on.

The "rationale for treatment" process in therapy is like sitting down with your therapist and getting the inside scoop on how your therapy is going to work. Imagine you're planning a trip, and your therapist is showing you the map, explaining why you're taking certain routes, and what you can expect along the way. This part of therapy is about making sure you understand the "why" behind the treatment you're getting. It's like your therapist is saying, "Here's what we're going to do, here's why we're doing it, and here's how it's going to help you." This helps you feel more involved and confident about the therapy process because you know what the game plan is and how it's specifically designed to help you feel better. Further, this helps you become your own therapist! We don’t believe therapy should last forever. In fact, our goal is to get you out of therapy! We are looking for our clients to say “I don’t need you anymore - I got this!” For you to maintain your gains after therapy, you need to know how to tackle the challenges life will throw at you. Good rationale helps you spot these challenges and know what you need to do to conquer them. For more information on how to maintain therapy gains, check out our blog post on the topic here!

Diving into cognitive behavioral therapy (CBT) is a big step toward a happier, healthier you. We've covered everything from what to bring to your first session to how it all works, aiming to clear up any worries and get you ready for the journey ahead. Remember, starting CBT is all about making positive changes and understanding how to manage your thoughts, behaviors and emotions better. If you're feeling ready to take this step and want expert guidance along the way, we're here to help. Reach out to us to book your first CBT session and begin your journey toward a more fulfilling life today.

Maintaining Therapy Gains: A Guide to Sustained Mental Health

By Dr. Evan V. Vida, PsyD

How do I maintain my therapy gains?

As a cognitive-behavioral therapy (CBT) practitioner, I prioritize treatments that are not just effective, but also efficient. That’s why when someone walks in my door for therapy, one of the first things I say is that my goal is to get you to fire me. Not because I’m doing a poor job, but because I want you to be able to rely on yourself to weather whatever storm you may face in the future. CBT aims to equip you with skills to navigate life's challenges, skills that endure well beyond therapy sessions. I expect us to merge our expertise—you in understanding yourself, and me in managing anxiety—so that you're equipped to apply therapy skills to your life's unique challenges by the end of treatment. With any good CBT, the final phase of treatment should focus on the maintenance of gains and relapse prevention. It is a core element of all effective treatments - just as important as every component prior. Before we dive into what relapse prevention techniques entail, let’s first discuss…

What is a lapse vs a relapse?

So, what is the expectation once therapy is over? Is it to never again fall back into old behaviors and routines? Not necessarily. People usually come to therapy after many many years of responding to adversity with behaviors that may not have served them well. Just like with any repetitive behavior, these become habits. The trouble with habits is that not only are they hard to break, but they’re easy to re-learn once we’ve broken them. But, repeating an old habit doesn't mean all progress is lost. This is the difference between a lapse versus a relapse. A lapse is a brief hiccup, a moment to recognize and rededicate ourselves to the strategies learned in therapy, whereas a relapse marks a return to old patterns, signaling a disconnect from the therapy skills once mastered. While a lapse is not usually indicative of a need to return to therapy, a relapse is. In fact, it's normal to experience lapses post-therapy; they're part of the journey. Our goal is to curb these lapses, preventing them from escalating into significant setbacks. The problem is that relapses are not always immediate, and can often be slow, insidious returns to old behaviors.

Let’s look at an example of two patients, Patient A and Patient B who successfully treated their nail biting. Both of our example patients may have terminated therapy and are totally nail-biting-free. Two months later, both patients find themselves in a very stressful situation and without thinking, notice they have bitten the nail on their thumb. Patient A acknowledges the slip and proactively contains the behavior. Maybe they put on a pair of gloves so that there is one extra barrier to nail biting. Patient A is utilizing their relapse prevention plan (more on this later) and is able to get back to where they wanted to be. Patient B, on the other hand, may not be as aware of what’s going on and let’s the behavior continue. Or, they do notice and tell themselves, “It’s just my thumb, maybe I can allow myself to bite only my thumb when I’m stressed.” Eventually, the goalposts will shift again and Patient B is now telling themselves, “I’ll just bite both my thumbs but that’s it!” Both thumbs will likely turn into all fingers, resulting in a full-blown relapse.

So, what can we do to stop ourselves from relapsing? The answer is coming up with a maintenance/relapse prevention plan.

Strategies for maintaining therapy gains

1. Develop a relapse prevention plan with your therapist before ending therapy

A relapse prevention plan is a detailed, specific, and individualized plan with information and skills learned in therapy that will help you maintain your gains. The information might include triggers to look out for, warning signs, skills to maintain, and more. There is no one-size-fits-all approach for these so make sure to talk to your therapist about developing a plan specific to your needs.

2. Review your treatment materials

A great way to keep yourself fresh months after ending therapy is by reviewing your treatment materials. There is no way to plan for every struggle you will face post-therapy, so it will be necessary to take what you learn and apply skills to these novel situations. Reviewing your completed homework, taking a look at your exposure hierarchy, or re-familiarizing yourself with your individualized treatment plan can help you stay sharp and remind yourself what to do when you face a difficult situation.

3. Make therapy skills a habit

Therapy's end doesn't signal the end of your journey; practice is key. Just like with any skill or habit, therapy skills require practice. Try your best to make your skills a part of your normal routine. It doesn’t need to be too complex! It can be as simple as devoting 5 minutes per day to mindfulness practice or filling out a thought log with a tricky worry.

4. Look out for “permission statements”

A “permission statement” is something we tell ourselves to excuse slipping back into unhelpful behaviors. As mentioned previously, bad habits reform in a slow, insidious manner. Similar to Patient B above, you may excuse biting your nails on one finger by telling yourself “It’s just one finger," but one finger turns into two, which then turns into a relapse.

5. Utilize support systems

No one has to go on alone. Family, friends, and other trusted individuals can be a crucial source of support. Depending on your personal comfort, letting trusted people know what you have struggled with and how you may be at risk of falling back into old behaviors can help you stay accountable. Two heads are better than one! A trusted person may be able to quickly spot changes in behavior or old habits subtly returning.

6. Know when to reach back out

Sometimes, we need a bit more support when our skills stop working. If that’s the case, reaching back out to your therapist is crucial. No, you are not back to square one. Typically, a session or two is all that’s needed to get back in the saddle. We like to call these “booster sessions,” which are time-limited re-engagements with therapy. You and your therapist can discuss the problems you’re facing and determine what is needed.

CBT can be an invaluable tool that re-opens doors previously shut by mental health struggles. But like any skill or habit, we can lose our edge if we don’t keep up dedicated practice. By using the suggestions in this article, your hard work can continue to flourish long after therapy ends.

Dr. Vida is a postdoctoral fellow at the Center for Anxiety & Behavior Therapy. He specializes in providing evidence-based treatments for a variety of anxiety disorders including OCD, PTSD, panic and agoraphobia, generalized anxiety disorder, social anxiety disorder, body dysmorphic disorder, body-focused repetitive behaviors, and more. Visit our contact page if you are interested in seeking treatment with Dr. Vida.

Can I get good anxiety treatment from a trainee therapist?

By Dr. Steven Tsao, Phd

Even after treating anxiety disorders for over 20 years (which sounds unbelievable as I type that number), I still get the “warm fuzzies” getting to witness and collaborate in the journey of recovery with the clients that walk through my office door every day. I feel honored and grateful to have been trained in CBT for anxiety disorders and inspired to see the life-changing effects it can have in the lives of those who suffer. However, I am only one person, with limited time and chairs in my office, which means that there are waaaaay more people in need of help than I can see in a given week. As such, one part of the mission that my Co-Founder, Dr. David Yusko, and I made when we started Center for Anxiety & Behavior Therapy was to prioritize disseminating evidence-based treatments for anxiety, including bringing on trainee therapists to see clients at our practice. Since then, the most frequent question we hear from people considering working with a trainee is “Can I really get good therapy from someone just starting out?” After supervising trainee therapists for the last 15 years, here are some of the reasons I can honestly say “Yes!”

First, trainee therapists are often the most energetic, invested, and hard-working people you will find.

The life of a student or trainee is often singularly-focused on clinical psychology through coursework, research projects, and clinical rotations, which usually means they are the Energizer bunnies of therapists, willing to put in the time and effort it takes to do a great job. When I was a trainee, I definitely fit this mold and we at CABT have been lucky enough to bring on like-minded trainees over the years. While I wish it was not the case, there are unfortunately plenty of therapists that are several years or decades out of school who fall into cruise control and do not have the ability or time to put into their cases like trainees do. Trainees have also been learning the most up-to-date theories and research during their recent time in school, which makes them some of the most current thinkers about the best ways to deliver treatment.

Second, all unlicensed trainee therapists are given at least 2 hours of individual supervision with a licensed, expert-level psychologist every week where their individual cases are reviewed in detail.

This means that every trainee case has not one, but two highly-trained brains thinking about their care at all times. The old adage “Two is better than one” is just as true here as it is for all the other important things in life, like servings of ice cream. Having two smart, well-intentioned, and engaged therapists working on a single case makes the quality of that care exceptionally high.

Third, and especially true of following empirically-supported treatment protocols like CBT, the treatment delivered by a trainee therapist should look very similar to that of an experienced therapist.

If you were to be a fly on the wall of a session of Exposure and Response Prevention (ERP) for OCD in my office, then buzzed around to another session of ERP with a trainee, you would witness far more interventions and recommendations that looked very similar than the minor stylistic differences that arise between any therapists. 

What does the research show?

Lastly, as a science-minded person and therapist, I’ll lean on a great research study to back up my aforementioned ideas. In 2003, Franklin and colleagues looked at how much therapist experience impacted treatment progress when delivering ERP for OCD. This study showed that well-trained, but inexperienced therapists (0-1 years of experience) that had regular high-quality expert supervision, helped their patients recover just as much as highly experienced therapists (9+ years of experience). For both of these groups, the average improvement in overall OCD severity fell in the subclinical range by the end of treatment, with over 85% of cases demonstrating “clinically significant improvement” for the inexperienced therapist group (the highly-experienced therapist group did only slightly better at 92%).

If you have made it this far in this post, I hope you feel a bit better about seeing a trainee therapist at CABT for your care. There are unfortunately too many barriers to accessing good mental health treatment these days, but my hope is that concerns about getting excellent treatment from a trainee therapist can be one less barrier to hurdle as you begin your road to recovery. Your best life is waiting for you, and one of our trainees is a great co-pilot to navigate you there. Read up on some of our wonderful trainees here. And if you are ready to take the next step in your mental health journey, check out our contact page!