Have you ever felt like you’re caught in an endless loop of worry, where every anxious thought feeds into the next, creating a never-ending cycle of fear and unease? If so, you are not alone. Anxiety disorders are the most common mental illness in the United States, affecting 40 million adults every year, according to the CDC. Yet, despite its prevalence, many people feel trapped by their anxiety, unsure of how to break free from its grip.
Anxiety often begins with a single thought or concern. Maybe it’s a worry about an upcoming presentation, a health scare, or even a social event. This thought triggers a cascade of physical symptoms: a racing heart, sweaty palms, or a tightening in the chest. In response to these uncomfortable feelings, we might try to avoid the situation or engage in other safety behaviors—things people do to lower their anxiety when there is a perceived threat. Examples of safety behaviors include checking and rechecking your presentation multiple times to make sure there are no mistakes, excessively seeking reassurance from others that you are in perfect health, or bringing a good luck charm with you wherever you go. While these actions might provide short-term relief from anxiety, initially easing our discomfort and making the situation seem more manageable, they reinforce the anxiety in the long run, keeping us stuck in a cycle that’s hard to escape.
Thankfully, there’s hope. Cognitive Behavioral Therapy (CBT) offers effective strategies for breaking the cycle of anxiety. By focusing on the interplay between thoughts, feelings, and behaviors, CBT helps individuals develop healthier ways to cope. Here are three key CBT techniques to manage anxiety:
Behavioral experiments involve testing out new behaviors to see if your anxious predictions come true. Here’s how they work:
Exposure therapy is a cornerstone of CBT for anxiety. It involves gradually facing feared situations or objects in a controlled and systematic way. By doing so, you can reduce your fear response over time. For instance, if you have a fear of public speaking, you might start by speaking in front of a small, supportive group and gradually work your way up to larger audiences. The key is consistency and patience, as repeated exposure helps to desensitize the anxiety trigger and allows you to see that you were able to face your fears without running away from them. Exposures include the following elements:
Cognitive strategies, such as cognitive reappraisal, help you identify, challenge, and change unhelpful thought patterns. When practicing this strategy, try the following:
Let’s take the example of someone who feels anxious about driving.
Combining these CBT techniques provides a comprehensive approach to managing anxiety. By regularly practicing these skills, individuals can disrupt the cycle of anxiety, reduce avoidance behaviors, and build confidence in their ability to handle anxiety-provoking situations.
Breaking free from the cycle of anxiety isn’t easy, but it’s possible with the right tools and strategies. Cognitive Behavioral Therapy offers a structured and effective approach to understanding and managing anxiety. By experimenting with new behaviors, facing your fears, and challenging unhelpful thoughts, you can take control of your anxiety rather than letting it control you. Remember, you don’t have to do it alone—seek support from a therapist or support group to guide you on your journey.
Many people struggle with sleep. Whether it’s falling asleep, staying asleep, or getting enough sleep it is extremely frustrating since it is partly out of your control. Good news- there actually is a lot in your control to improve your sleep.
Sleep difficulties can be very frustrating. I hope these tips help you get more restful sleep. For additional help, contact a mental health professional who specializes in insomnia.
Sources:
Cognitive behavioral therapy for insomnia (CBTI). Stanford Health Care. (2017, September 12). https://stanfordhealthcare.org/medical-treatments/c/cognitive-behavioral-therapy-insomnia.html
Rathus, J. H., & Miller, A. L. (2015). DBT®skills manual for adolescents. Guilford Press.
Validation is the recognition that another person’s experience (or our own) makes sense, is logical, fits the facts, and is reasonable. We can validate actions or internal experiences like feelings, thoughts, opinions, desires, and beliefs. Validation makes us feel heard and understood, which not only can provide us with reassurance, but also helps to regulate our emotions. A validating statement could be as simple as someone saying, “It makes sense that you feel that way”, or “I would have totally reacted in the same manner”. It’s someone offering us a blanket when we are shivering cold and it’s also someone listening attentively when sharing a personal story.
Invalidation is just the opposite. It is the dismissal, rejection, disapproval, or disbelief of another person’s experience. It is when someone communicates either directly or indirectly that our actions or internal experiences do not make sense. Invalidation can be communicated through someone’s words (e.g. “You’re overreacting! You don’t need to worry so much.”); through body language (e.g. eye rolling, scoffing); or through actions (e.g. interrupting or changing the subject).
Whereas validation provides us with a sense of safety and helps to regulate our emotional responses, invalidation can have the opposite effect. Validation makes our experience seem acceptable and therefore makes US seem acceptable. Similarly, when feeling invalidated, we can sometimes generalize the invalidating experience to mean that we as people, not just the pieces of us being invalidated, are not acceptable. In response, we could feel a host of unpleasant emotions and negative self-judgments (or judgments towards the person who invalidated us). Both put us at risk for unskillful behavior.
Self-validation is necessary for everyone and is of utmost importance for those of us that have been subject to invalidating experiences repeatedly. It is a helpful coping strategy to combat the effects of invalidation, but also an extremely useful tool in response to general life stressors and challenging emotions. If the invalidating person in your life is yourself, listen carefully😉
Before getting into the steps of how to self-validate, first let’s talk about the why. Studies have demonstrated that validation produces the following benefits: Lowered emotional arousal, improved emotion regulation and increases in positive affect. Additionally, applying self-validation (and reducing self-invalidation) will result in increases in positive self image.
When experiencing invalidation, take pause. Give your emotions your full attention. Notice what you are feeling even if you don’t know what it is and even if it is unpleasant. Being validated by someone else often starts with them giving us their full attention. When we are ignored, we feel worse. The same applies to the self. Ignoring your own experience or minimizing it as unimportant is going to do the same. Paying attention is simply taking stalk of what is going on for you. It is giving yourself the time of day. It is approaching your experience with openness and interest.
This involves putting words to your experience. Remember, by “experience” we mean emotions, thoughts, physical sensations, and actions. This could be saying to yourself, “I am feeling sad” or, “I am having the thought that I didn’t do so well on that presentation”, or “I am experiencing tightness in my chest and an urge to cry”. We don’t need to know what we are feeling or even have a clear articulation of our thoughts to do this. It can also look like “I don’t know what I am feeling right now but I am know it is a lot”. What’s really neat about this step is that the simple act of observing and describing our feelings can actually serve to regulate our emotions! It provides with just enough distance from our experience to help regulate our responses as well.
Ask yourself, “What might my emotions be trying to communicate to me?” Get curious about what your emotions might be trying to tell you about what you need. If you were feeling sad, perhaps crying, and someone offered you a hug, that would be validating right? This step is similar. Your tears communicated to someone that you were sad and in need of soothing. What can you do to honor your emotions that would have a similar effect? Self-validation could look like drawing yourself a warm bath or tucking yourself into your favorite blanket. And it could also include offering yourself a kind, encouraging statement.
Ask yourself, “What makes sense about my emotions, thoughts, or actions based on what I know about myself and my history?” It is important to consider our experience within the context of our entire life and our learning history. For example, if as a child I struggled with homework tasks and was frequently punished because of it, it would make sense that I feel a surge of emotions when my therapist assigns me “homework” at the end of a session. Perhaps I feel a strong urge to avoid the task due to this negative association. I can acknowledge that fear makes sense given my negative experiences attached to homework (while also recognizing how the current situation is different).
Highlight for yourself that any person in your situation would think or feel or behave similarly. You are not alone in your responses. Stand up for yourself and the validity of your experience, even in the face of invalidation. For example, let’s say you had a vacation booked for April 2nd, 2020. You are planning on going to a place you have always dreamed of. You saved your money, you banked your vacation time, you spent weeks, maybe even months, planning this trip. But, uh oh, COVID happened. Naturally, you are incredibly disappointed that your vacation plans have been cancelled. You may have the thought, “I don’t deserve to feel sad or angry about this [invalidation] because there are people going through worse things in the world”. Yes, there are people suffering AND, yes, you are entitled to feel disappointed. Both can be true. Any person would feel disappointed if they were looking forward to something so intensely and that something was taken away from them.
Talk to yourself the way you would a loved one. Treat yourself the way you would treat anyone else going through a similar experience. In this step, you are validating the person as whole, not just your experience. As mentioned, invalidation can make us as a person feel invalid. The inverse is true of validation: Validating our experience is going to increase our own sense of personal validity. This might be in direct contrast to how you feel or have been treated by others who consistently invalidated you, which is also why this last step is essential towards healing. If you are feeling stuck, consider what you might tell a loved one going through something similar and then send that message right back to you. The rules are not different for you – you are just as deserving as this validating message.
Disclaimer: Self-validation takes patience, practice and may involve acting opposite of your emotion urges. If it feels uncomfortable to do, perhaps you can start by simply validating what makes sense about your discomfort around self validation! (E.g. “It makes sense that I would feel uncomfortable with self-validation as I’m not used to doing it”.)
Fruzzetti, A., & Ruork, A. (2018). Validation Principles and Practices in Dialectical Behavior Therapy of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). Validation Principles and Practices in Dialectical Behavior Therapy Oxford Handbooks Online. https://doi.org/10.1093/oxfordhb/9780198758723.013.50
Linehan, M. M. (2015). Dbt skills training manual. Guilford Publications.
Linehan, M. (2015). DBT Skills Training Handouts and Worksheets (2nd ed.). The Guilford Press.
We often think about what we might change when considering our New Years Resolutions. How can I improve? What can I work harder on? How can I further myself? What do I need to change about myself so that I can then accept myself?
While change is important, and while we can always “do better, try harder, and be more motivated to change,” per Marsha Linehan’s DBT assumptions, for some of us a far more underdeveloped skill set is that of acceptance.
If you have found yourself geared towards change-based resolutions in past years, I encourage you to bulk up on your acceptance-based practices in 2024.
Accepting what is out of our control, accepting what “is,” and accepting what we cannot change in this moment are valuable tools, that when practiced can improve our quality of life tremendously by reducing our suffering.
We can practice acceptance with our mind, body, and soul. To jump start your practice, I will offer two DBT reality acceptance skills that begin with the body.
Have you ever noticed that when you are fighting your reality, your body is tight, tense, and unrelaxed? You may feel like you are bracing yourself for some threat that may never come.
We can reduce our suffering by communicating to our mind that our body is safe through two simple exercises: Willing hands and half-smiling.
Willing hands is a practice that involves uncrossing our arms, unclenching our fists, and opening our palms. We can even face our palms up to the sky in a relaxed way. This posture is the opposite of a defensive, cross-armed, or clenched posture and communicates that we are receiving whatever may come. We resist resisting and open ourselves up to our reality. This skill can be adapted to sitting, standing, and seated postures. Prompting events for this skill might include feeling anxious on the subway, feeling angered at the dinner table, or when receiving a disturbing message from a friend.
The second skill is called Half-smiling. Similar in theme, this change in body involves first relaxing the muscles of the face and then slightly curving the corners of the lips upward into a “half smile.” This communicates to our brain that we are calm and relaxed. Prompting events for this skill might include when feeling frustrated completing a task for work, while holding a difficult yoga posture, or when you notice you are ruminating while walking down the street.
To watch Marsha Linehan herself teach Willing Hands check out her demonstration.
Dialectical Behavioral Therapy (DBT) was originally created by Dr. Marsha Linehan to treat Borderline Personality Disorder. In recent years, DBT has increasingly been found to be effective for any person struggling with up and down, difficult to manage emotions (what’s formally been called emotion dysregulation). Those experiencing such emotional tumult can often struggle with lashing out at loved ones, making impulsive decisions, substance abuse, suicide and/or self-harm behaviors.
Research has shown that many of these kinds of clients who seek DBT likely also have trauma histories and may meet criteria for a PTSD diagnosis (66% of those with PTSD have two or more additional mental health disorders, and 30% attempt suicide (1, 2)). There are growing theories that emotion dysregulation is often fueled by previous traumas. What’s more likely to inspire painful feelings and high distress than traumatic triggers? DBT is greatly beneficial for those learning new ways to manage their emotions and engage with the world; however, the standard protocol does not target trauma, and in fact discussing trauma is explicitly avoided in Stage One of the treatment (when clients are struggling with severe, life-threatening behaviors).
Two major treatments have been developed to address PTSD within the DBT framework: DBT-PE and DBT-PTSD. To help understand the differences between the two treatments (with such similar acronyms), here is a brief guide:
Stabilization has been a necessary precursor to beginning trauma work in the field of mental health treatment. Essentially, this means that clients must be able to experience emotional difficulty without engaging in destructive behaviors before diving into past traumas. DBT-PE, instead, attempts to rework that timeline by requiring a shorter period of stabilization (two-months of no self-harm or suicidal behaviors), and then allows clients to begin trauma work. This puts clients on the fast track towards reducing the impact of trauma, while still spending time honing their DBT skills.
Developed by Dr. Melanie Harned, the DBT-PE protocol follows much of the same aspects of comprehensive DBT (individual sessions with diary cards and behavioral chain analyses, skills group, skills-based phone coaching, and consultation team). The addition of Prolonged Exposure (PE), originally created by Dr. Edna Foa, aims to reduce symptoms of PTSD by repeatedly revisiting traumatic memories and experiences related to past traumas (such as visiting certain places or performing certain acts) over and over again until they no longer cause high distress. Think of watching a scary movie once as compared to watching it a thousand times.
DBT-PE has drawbacks for those who cannot achieve the stabilization requirements or for those who cannot afford potentially three therapy sessions a week. Additionally, this treatment has exclusions for clients who have severe dissociation (the experience of life seeming off, distant or unreal as distress rises), current psychosis, or active substance dependence. Additionally, a decent amount of outside homework is required for clients enrolling in DBT-PE treatment.
That being said, for those who can receive the treatment, research has found that DBT-PE is highly effective. It doesn’t increase safety risks, clients in DBT-PE are found to have more than double the reduction in self-harm and suicide as compared to those in standard DBT, and 60% of clients no longer meet criteria for PTSD upon completion of the treatment. Additionally, clients also benefit from getting the entire gamut of DBT skills by attending skills group and focusing on skills application for at least part of their individual sessions.
DBT-PTSD, created by Dr. Martin Bohus, was specifically designed for adult clients with Complex PTSD (C-PTSD) who are victims of childhood sexual and/or physical abuse. (C-PTSD is a diagnosis currently only recognized in the ICD 10 and is for people who struggle with all the features of PTSD, while also endorsing symptoms of emotion dysregulation, disturbed relationships and a negative self-concept.) There is current debate in the field about the difference between C-PTSD and BPD, or whether they’re one in the same. The rationale for the treatment is that a client’s dysfunctional behaviors in DBT are functionally related to post traumatic stress, as clients may self-harm, become suicidal, dissociate, or abuse substances in order to temporarily reduce the distress tied to traumatic triggers (like someone cutting to calm down after remembering a previous assault). Essentially, the theory behind DBT-PTSD is that in order to truly reduce such severe behaviors, one must target the trauma as quickly as possible.
The old school rule of stabilization gets thrown out the window in DBT-PTSD. Dr. Bohus’s research found that exposure-based treatment to trauma can be administered to clients currently struggling with suicidal and self-injurious behaviors, substance use, disordered eating, and highly dissociative features, without increasing their risk (3, 4). This research is core to the treatment, as it does not follow the typical protocol of comprehensive DBT and instead adds features of DBT (as well as elements of ACT and cognitive therapy) into exposure-based trauma work. Skills group is not required in the treatment and instead, clients are asked to engage in daily skills practice and homework completion. Additionally, phone coaching only is used for severe behaviors, while the DBT consultation team remains the same as in standard DBT.
Because this approach focuses on targeting trauma, one potential drawback is that clients’ skills acquisition and generalization possibly lag behind those who commit to standard DBT or DBT-PE.
A major trial found that DBT-PTSD, as compared to Cognitive Processing Therapy (another evidence-based treatment for trauma), resulted in a remission from PTSD in 80% of clients who completed the treatment. This was found to be a success rate 15% higher than clients who received CPT in the same study. With such high effectiveness, such minimal exclusion criteria, and the requirement of only one weekly session, DBT-PTSD is a potentially highly accessible treatment for clients struggling with pervasive emotion dysregulation (3).
Research is currently being conducted on DBT-PSTD’s efficacy for teens (reports from a recent training I attended are that initial findings show the treatment to be even more effective for adolescents than adults) as well as for those who have trauma histories outside of physical or sexual abuse.
Works Cited
Reduce Anxiety with Gratitude this Holiday Season
Have you ever had a thought that you could not get out of your head? Maybe you had one thought that led to hundreds of other thoughts. You might have tried to tell yourself a variation of, “ok, I need to stop thinking about this” which made those thoughts even louder. These ruminating thoughts are a symptom of anxiety. Anxiety can be thought of as the fear of a perceived threat and then underestimating our ability to handle that threat. When we keep on thinking of these worries by either spiraling or trying to suppress them, it can exacerbate our anxiety. Now, if thinking about your worries solves your problems then go for it and don’t let me stop you; however, if ruminating only causes you more suffering then bear with me. Ironically, sometimes when you stop worrying you might have a better shot at solving your problem and reducing anxiety.
So, let’s try to replace our worries with gratitude! Research suggests that our brain cannot hold anxiety and gratitude at the same time. This is because gratitude affects the same area of the brain, the limbic system, that regulates our emotions, so instead of being overwhelmed by anxiety, your limbic system becomes flooded with thankfulness. In doing this, you’re not only preventing rumination, but you’re also lowering your blood pressure, improving your immune system, promoting more efficient sleep, and creating a positive lens through which you see your life, which then makes you feel better.
Below are four, simple and easy ways to integrate gratitude into your day:
a. If you don’t have time to write down what you’re grateful for or maybe you just don’t feel like it, mentally giving thanks is a great way to take your brain’s attention away from your worry thoughts. You can utilize this practice when your mind starts to ruminate or as an everyday practice to promote positive thinking.
a. Build your self-compassion and relationships by writing thank you notes to your loved ones and/or yourself. There is nothing too small or too big to say thank you for. Simply waking up this morning is something you can thank yourself for. To begin, try writing a thank you note once a month and gradually increasing your frequency.
a. Mindfulness of breath involves intentional focus on the present moment, steering away from past and future moments, while taking a nonjudgmental stance. You can use mindfulness to focus on something you’re grateful for (i.e., Your friends, partner, family, car…etc.). It can be as short as a minute or as long as you’d like. I’d recommend you start off by doing it for a few minutes if you are not used to practicing mindfulness. Your mind will wander and once you are aware of this, remember to bring it back to gratitude.
a. Set aside a regular time each day for writing down the things you’re grateful for. This can also be done at night to reflect on things you’re grateful for during the day. Studies have shown that writing one thing you’re grateful for and expanding the list from there enhances gratitude and positive thinking more so than creating a list of unrelated items.
Juneja, J.K. (2022). Gratitude and it’s importance. International Journal of Health Sciences, 6(S2), 9721-9728. https://media.neliti.com/media/publications/430566-gratitude-and-its-importance-b249fae4.pdf