Anxiety Treatment

Should you develop a nighttime ritual?

Dateline, Portland, Oregon—Amelia J. Wilcox, Ph.D.: When our daughter was young we had a bedtime ritual—a series of events that slowed down the day and helped her know the time for sleep was approaching. Is there value in considering similar rituals for the rest of us?

Insomnia. It plagues us—depriving us of the restful sleep we need to feel restored and protect our health. Studies estimate that somewhere between 10 and 20% of adults suffer from insomnia, and the statistics are much higher for adults over the age of 65—42% of this population complains of difficulty falling or staying asleep.

Many things can get in the way of a good night’s sleep. People with a variety of medical and psychiatric conditions are more likely to suffer from sleep problems, and sleep problems can contribute to depression and anxiety, as well as a host of primary medical disorders including metabolic disorder, hypertension and weight gain. Addressing sleep problems is worth the effort in the short-term, and the long-run.

Cognitive Behavioral Treatment for Insomnia (CBT-I) is a short-term intervention that has been found to be highly effective in treating insomnia across all ages, and it may be necessary for many. But some may find that a careful evaluation of evening habits can give them clues for change, without professional intervention.

Stimulus control is part of insomnia management, and a bedtime ritual can be seen as a form of stimulus control. If you are having difficulty winding down at the end of the day and find yourself awake in bed after turning out the lights, you might consider developing a bedtime ritual of your own, the grown up version of the rituals we all used for our children when they were young.

Some things to consider:

·         Wind down smart phone/laptop/tablet use an hour or two before sleep, as these devices emit blue-range light that tricks our pineal gland into shutting down melatonin production

·         If you are a worrier, take some time an hour before bed to do a data dump on paper. This might include

o   A list of tomorrow’s tasks, so you can put them out of your mind overnight

o   A reminder that worrying about things tonight won’t change them, but sleep may help you tackle them with fresh energy in the morning

·         Create a sequence of events that tell your body it is time to wind down. This might include

o   A warm bath

o   A gentle stretch (save heavy exercise for another time of day)

o   Progressive relaxation of muscle groups

o   A good book (but not a page turner…you want to go to sleep!) on paper

o   A cool, dark and quiet room

·         Consider maintaining the same bedtime each night and waking time in the morning—even on the weekends. Doing so may keep you from Monday morning jetlag.

·         And remember, your bed is really only a place for sleep and intimacy. Don’t study, work, answer email,  pay bills, watch television or argue with your partner there, it will only associate your bed with not being relaxed

A good night’s sleep is worth some effort. Tinkering with the run-up to sleep may help you find your way back to sleeping well.

Why learning to fail is as important as success

Dateline Portland, Oregon--Amelia J. Wilcox, Ph.D.: What happens when we raise kids who are not afraid to make mistakes or fail? Can we let our kids fail when we ourselves fear the stakes are too high?

Learning to fall down:

My most vivid memory of the first time I got on skis was of my ski instructor teaching us how to fall. Over and over again, we fell into the snow. It seemed to go on forever. I was impatient to speed gracefully down the slopes, and what we were doing made no sense to me at all. But then we started down the gentle bunny hill. And we started falling for real. I still didn’t get it then, but I sure do now—I’d learned to fall down, so I wasn’t worried about it happening. I knew I could fall safely and without dire consequences. You could argue that practicing falling made me less likely to, but I wasn’t ever a terrific skier so I doubt that is true. Practicing falling did, however, make me looser and more confident on my skis. It allowed me to focus on having fun and learning some skills.

I was raised in a time when school and the school day belonged to students and teachers. Parents were less likely to intervene when something didn’t go just the way it was planned. I was also fortunate to have a wise mother who knew age-appropriate challenge and struggle to be essential to growth. And she was on-point when things didn’t go the way I hoped they would. She sat me down one day after a particularly upsetting test at school and told me, “Honey, you’ll learn far more from the things that don’t go well than you ever will from the things you sail through.” She made me feel I was fine, and she made the process of growth so much less daunting because of her approach. She’s been right over and over again.

Learning to fail in today’s world:
I try to remember this when I see my own teen heading into a rocky patch. I try to recall that day—and the many other times and situations in my life where I have practiced falling down or taken real tumbles. I try to keep in mind that having difficulty and learning from failing is actually good.  

But I also recognize I was raised when college applications did not typically include a 4.0 GPA, let alone a GPA above that number. Parental pressures are different now. And our kids have somehow become a social mirror of our own success in a way kids of generations past were not. These things contribute to today’s parents having a harder time allowing natural lessons to occur in the lives of their children.

snow drops.jpg

But just a thought about raising kids who are not afraid to fail: If you can do so, you get something wonderful as a result—a kid who knows to try another approach when a first, or second, or even third effort fails. A kid who isn’t afraid to stick his or her neck out and try new things. A kid who’ll decide in her senior year of high school that she DOES want to be in some plays—and then get herself cast. A kid who’ll decide that he wants to buy a canvas and some paints and see what happens. Maybe he’ll discover a love of art that will be a lifelong passion. Maybe he’ll consider it an interesting experiment and leave it aside for something else, but he won’t be afraid to try for fear of not succeeding.

Failure, success, grit:
The other day I heard the story of how micro-surgical procedures were developed for the eye. Suffice it to say, it took the pioneer responsible for this bold discovery decades to get it right. He failed over and over again during those years. But every time he did, he learned something new about what he was trying to do—simplify cataract surgery. And now what was once a lengthy procedure requiring a hospital admission takes 20 minutes in an outpatient surgical center. That is grit and determination. That is a great example of someone who did not fear failure. 

Positive Psychology in a Negatively Biased World

        

Dateline, Portland, Oregon—Amelia J. Wilcox, Ph.D.: Nobody has seen a saber-toothed tiger in eons, yet we still behave as though they are out there. Why so negative?

I have a lot to thank my pre-ancestors for—generation by generation, they made the right decisions to land me here, in this moment, writing this post. And those who lived in perpetually hazardous conditions had to be particularly dialed in to the world around them in order to avoid a variety of dangers. The ones who heard the snap of a twig signaling the approach of a predator, or remembered the particular berry eaten by someone who keeled over and died a short time later had an evolutionary advantage. That advantage kept them alive to breed the same attentiveness into subsequent generations.

In today’s world there are no true saber toothed tigers and our berries come vetted by the grocery store, yet we remain preferentially cued in to the negative around us. Is it a survival mechanism? Not for most of us. Instead it provides us with an implicit bias to pay attention to things that distress us, rather than appreciating the positive in our lives.

How do you know if you are doing this? Here’s a common example. You have a day filled with the typical ups and downs—a nice conversation with a friend or co-worker, a pleasant walk in the evening, a good meal, a moment of irritation with a friend. What do you think about as you are winding down for the day? If you are like most people, you will focus on the negative event, playing it over and over in your mind, paying no heed to the pleasantries of the day.

I think it helps us if we can remember this is a bias that made sense from an evolutionary perspective. But what was an essential survival tool back in the day is, in fact, a common contributor to depressed and anxious moods in contemporary times.

Martin Seligman is a psychologist whose observations have brought us many important theoretical models, including the concept of learned helplessness. In the past dozen years he has turned his attention away from what makes us anxious or depressed, focusing, instead, on what contributes to emotional growth. In the process he has become the father of positive psychology. Seligman has developed many tools and techniques (well-grounded in research) that help people create and sustain a greater sense of well-being in their lives, principles I apply routinely in my clinical practice. One of his tools is particularly useful in helping us learn to savor the small, positive events of our day, pushing against our biological drive to preferentially attend to the negative ones.

This easy and most powerful tool is the simple act of writing down three things that went well during the day each evening before sleep. Doing so helps us shift our cognitive bias away from the negative and toward the positive. It is easy to do, and while it sounds simple minded, I have seen this small behavior positively impact literally hundreds of lives.

Want to give it a try? Put a piece of paper and a pen by your bedside. Last thing before turning out the lights, write down three things you appreciated about your day. Maybe your favorite tree is in bloom, or you had coffee with a friend, or your dogs were there to greet you when you got home—these things don’t need to be earth shaking (in fact, they very likely won’t be), your goal is to simply notice the small things and jot them down in a word or a sentence.

Seligman’s research indicates that people who do this for a two-week period learn to savor the positive events of life. Even when they stop keeping the list, they feel significantly better six months later than they did at baseline. But as I tell my students and clients, you are going to savor something—why not make it something positive? it takes ten seconds, so keep it up forever!

Rozen, P., Royzman, E.B. (2001). Negativity bias, negativity dominance and contagion. Personality             and Social Psychology Review, 5(4), 296-320.      

Seligman, M.E.P., Steen, T., Peterson, C. (2005). Positive psychology progress: Empirical validation            of interventions. American Psychologist, 60(5), 410-421.

Common factors: What makes psychotherapy work?

Common Factors in Psychotherapy

There are many reasons why therapy is helpful. A fresh perspective, particular skills, expertise in the various things that ail people…all of these change agents make sense. But research suggests that these skills are not in and of themselves the true mechanisms of change in psychotherapy.

In fact, there is an overarching set of factors that create the benefit in psychotherapy, pathways that are common to all established psychotherapeutic models. They work precisely because humans are social, and psychotherapy heals through social contact.

According to researcher Bruce Wampold (2015) the common factors of psychotherapy can be understood as the development of a relationship, the creation of expectations of change and the establishment of health promoting behaviors.

Relationship: Wampold reminds us that the first order of business in psychotherapy is the establishment of relationship and the exploration of the therapeutic alliance. This bond is critical, and takes time, but some of it happens very quickly and to some extent outside of our conscious awareness. How? The same way it does in any other arena of life—we rapidly and implicitly take in style of dress, mannerisms, voice quality, even office décor and use these things to make judgments and the critical assessment of goodness of fit.

In my professional judgment, the relationship between therapist and client is perhaps the most critical feature of treatment. It is a human connection, and just as we don’t connect with everyone we meet, we cannot expect to connect with every psychologist. For this reason, I always encourage new potential clients to interview several people when choosing a psychologist.

Expectations: Wampold tells us that a person’s expectations for treatment have a huge impact on treatment outcome. Sometimes people arrive with a ‘last ditch’ attitude, the sense they’ve tried everything else and, having reached the bottom of their personal barrel are now subjecting themselves to the scrutiny of a stranger. Other times, people arrive with an expectation that together with their psychotherapist they’ll explore what has and has not worked in their lives, and come up with new solutions to old challenges. Perhaps these people are arriving with similar challenges—they are likely to have very different notions about what psychotherapy is about.

I firmly believe that we as a species are growth oriented, even when demoralization has led us to forget that fact. I also believe that people’s symptoms are not just signs of problems, they are representative of best efforts at coping and change. I think goal setting is critical to progress in treatment, and a collaborative effort that clearly places the locus of change where it belongs—in the middle of the treatment alliance, surrounded by the tasks and rituals of psychotherapy.

Tasks and Rituals: And what are the tasks and rituals of psychotherapy? That very much depends on the nature of the problem, the individual’s goals, and the background of the clinician. Regardless of the details, each task of therapy is focused in one way or another on what Wampold calls “salubrious actions.” The treatment alliance allows trust, and gives a person room to think about his or her world in new ways, to consider thoughts and feelings from a different point of view, to experiment with new ways of being in the world and to collaborate with the trusted other on the mechanisms of change.

But the heart of the entire endeavor is the treatment relationship. So when you are looking for a psychologist, consider goodness of fit as carefully as you do any other quality.

Wampold, B.E. (2015). How important are the common factors in psychotherapy? An update. World
       Psychiatry, 14(3).
270-277.

 

The power of a good laugh

Dateline, Portland, Oregon—Amelia J. Wilcox, Ph.D.: A good laugh is hard to beat, and turns out to be contagious, and good for us. But why?

In 1979, Norman Cousins wrote a book titled Anatomy of an Illness. In it, the writer, political activist and editor of The Saturday Review outlined the story of his exuberant approach to a diagnosis of Ankylosing Spondylitis. The apocryphal story tells us that he checked himself out of the hospital and spent a month in intentional laughter. When he returned for an evaluation he was found to be disease free. His physicians did not believe he’d laughed himself to health. But note that in the next phase of his career he was appointed an adjunct professor of medical humanities in the UCLA School of Medicine, where he did research on the biochemistry of human emotions.  

I have written elsewhere in this blog about our habitual emotional states, and work with my patients around these matters all the time. In addition, for the last five years my Introductory Psychology students have chosen to do a positive psychology project each semester. I have seen hundreds of them engage in an examination of their habitual emotional states as a result of this project. And news from the front—Norman Cousins was right! Laughter is excellent medicine.

I am thinking about this today because of the viral video featuring a Texas woman who purchased a Chewbacca mask, and shared her joy with the entire internet world this week from the front seat of her car. At this moment, 1,037,162 people have viewed this hilarious clip. Why is it so popular? Well, it is (to say the least) contagious. She is sharing a moment of pure joy with all the world, and the world is laughing along.

Why are such things so popular on the internet? We love to watch kittens and puppies do silly things, babies giggle hysterically at fathers who tear up sheets of paper, and zoo animals behaving in unexpected ways. And seeing someone laugh—even if it is on a computer screen—makes us laugh, too.

To understand the contagious power of laughter, it helps to understand the role of mirror neurons. Mirror neurons are thought to be the home base of empathy, imitation and the recognition and capacity to share emotions that promote social engagement. These special neurons are found in the frontal and parietal lobes. They fire when we engage in behavior, and also when we observe behavior in others. In theory, observing laughter causes our mirror neurons to fire as though we were laughing ourselves.

When we choose laughter, we are making a choice to engage in something that bathes our bodies in stress-reducing hormones. There is evidence that this boosts our immune system, improves blood flow, boosts mood and dulls pain. Will it cure major illness? The evidence for this remains unclear, but there is no question that laughter creates a sense of engagement, soothes tension and destresses. So go ahead and find something funny to laugh about.

And to the wonderful woman in the Chewbacca mask, thank you!