May 2013

May 31, 2013

Q:

Our daughter is 18 and is preparing to go away to school. She was diagnosed with anxiety and mood disorder and was taking Paxil. We agreed with her doctor to take her off Paxil if she would talk with a psychologist to try to help her. She now says she is fine and does not need to talk with someone. What can I do to help my daughter when the rest of her family sees that she needs help and she does not?

A:

This is a difficult situation. I understand your concern for your daughter and your desire to help and protect her as she faces the transition of moving away and living independently. But because she is an adult who will be living out of your home, you can’t really force her to take medication or go to therapy.  If you try, she might reject the idea simply because it came from you.  Teens can be very strong willed, as I’m sure you know!

I would recommend getting information about the school’s counseling center, nearby hospitals and/or private-practice psychologists working in the area.  You can encourage your daughter to establish care somewhere in case she finds that she needs support after the move.  Often logistical barriers get in the way of seeking help.  If your daughter knows exactly where to call, there is a higher probability that she will do so if she starts having trouble.  You can talk with her about how she would know she needed treatment again.  Specifically, what would be some signs that her mood and anxiety were interfering with her life?  If you can prime her to pay attention to these things, you will also increase the probability that she will notice symptoms and act to address them.

The other option is threatening to cut off financial support for college (or cell phone, room/board, etc.) if she does not consent to treatment, but this is a bold step that could backfire.  The last thing you want is for her to call your bluff and not go to college.  If your daughter is even slightly oppositional, I’d avoid this option.

May 23, 2013

Q:

I strongly suspect that my now ex-boyfriend has narcissistic personality disorder. Based upon much time spent reading literature on NPD, the signs appear to be there. Things ended badly based upon his actions and he has since distanced himself from me and our many mutual friends. I am concerned about what the literature predicts for the future of a person with NPD. If he returns, can I do anything?

A:

It’s important to note that many people have narcissistic personality traits, but that only 1 percent of the general population actually meets criteria for Narcissistic Personality Disorder, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).  The manual states that narcissistic traits only reach the level of NPD when they are “inflexible, maladaptive and persisting and cause significant functional impairment or subjective distress.”  The important word is “subjective” because the individual with the disorder must be the one distressed, not the people whom are affected by the disorder.

If your ex-boyfriend has NPD, it will likely cause him significant difficulties in relationships.  The central features of the disorder interfere with having close, intimate, reciprocal relationships.  For example, people with NPD feel entitled to praise and admiration, lack empathy and sensitivity, and often respond with judgment or contempt when others make demands of them.  Needless to say, this creates significant hurt and tension in relationships.

If you want to help your ex, the best thing you can do is recommend treatment.  People with NPD can benefit from Cognitive Behavioral Therapy.  It can help them challenge and modify their rigid, inaccurate thoughts. If he is experiencing anxiety or depression, medication could also be helpful. However, it will not help not the personality disorder.

You might have your work cut out for you in trying to get your ex into treatment, though.  People with NPD rarely seek treatment on their own, or recognize that they have a disorder.  You will probably need to demonstrate that treatment could help him reach his own goals, or get him more of what he wants.

May 17, 2013

Q:

My partner of 20 years was diagnosed with bladder cancer and treated by Dr. Gupta at Loyola Cardinal Bernadine Cancer Center. She is still smoking but afraid of infections. She’s having serious panic attacks because of this. What can I do to help her?

A:

My apologies, but I’m not very knowledgeable about the medical issues related to your question.  I can answer generally, though.  Smoking suppresses the immune system, which creates vulnerability to infection.  It also poses other significant health risks.  Thus, if your partner is worried that smoking could interfere with her recovery from cancer, or cause her other harm, she is right.  Her worry is valid and justified.  Thus, rather than trying to quiet her anxiety and panic about the dangers of smoking, I would advise her to take her fears seriously.  These fears could protect her from continuing to engage in a dangerous behavior.  It would be very advantageous for your partner to quit smoking.

You can help her by increasing her motivation to quit and supporting her through the process.  If she addressed the problem in a committed, systematic way, her anxiety about it would likely decrease.   If her anxiety persisted, she could seek treatment for anxiety and panic.  I’ve described the treatment previously in this column (see below).

May 17, 2013

Q:

I have developed an anxiety problem. It may sound silly because I have been driving for more than 40 years. For the last 5 years I can’t get on the highway or expressway. I start breathing heavy and sometimes even shaking. I have not had a car accident or even come close. I retired two years ago and want to move out of state, but I don’t want to depend on my children or anyone else for my transportation. Help me, please.

A:

I’m sorry to hear about your driving phobia.  I can imagine how disruptive it’s been in your life, and how much it probably limits you.  Phobias tend to be self-perpetuating because of what we call “negative reinforcement.”  You’re probably familiar with the concept of positive reinforcement:  provide a good consequence for a behavior (money, praise, good grade, smiles, etc.) and a person will be more likely to do that behavior again.  Negative reinforcement is similar except rather than adding something good, you remove something bad to increase the probability that a person will do the behavior again.  For example, if there was a terrible noise bothering you and you figured out that you could push a button and make it stop, you’d push that button every time you heard the noise.  The reward in this case is the termination of noise.

We can apply this thinking to phobias, too.   If every time you drive you become anxious and stop, you’ll be reinforced by the act of stopping/escaping because your anxiety will go down.  This behavior pattern can then escalate from escape to total avoidance.  That is, every time you even consider driving you feel anxious and decide against it, which makes you feel better.  You’re learning to escape and avoid your anxiety, which feels good in the short term.  The problem, though, is that avoiding driving has other costs.

In order to start driving again, you’re going to have to gradually re-acclimate to it.  You’re going to have to take small, gradual steps.  For example, start by just sitting in the driver’s seat, move to driving in a parking lot, play arcade games that simulate the experience of driving (no scary ones, though!), advance to residential streets and eventually drive in more high traffic areas.  As you do this, you will likely experience increasing anxiety.  When this happens, breathe deeply and soothe yourself with encouraging words.  Be mindful of your environment.  Notice that you’re not in any real danger, that anxiety is uncomfortable but not harmful, and that anxiety fades when there is no real threat.  Most important, stop avoiding and escaping!  You do not want to continue strengthening those responses. Rather, let your anxiety run its course so you can learn it is tolerable and temporary.  This gradual process should help you get back to driving.  Good luck!

May 16, 2013

Q:

I have an anxiety problem. I get red easily, have hot flashes and my heart starts racing. I’m nervous and scared when I’m in a crowded place. I hate feeling like this. My primary doctor prescribed some medicine and it has been helping. My headaches are gone and I’m not as nervous as before. Can you refer me to a good doctor?

A:

Have you ruled out any medical issues that could be creating hot flashes and headaches, such as menopause, thyroid dysfunction, etc.? If you haven’t already explored these possibilities, it makes sense to start there. It’s possible that you’re misattributing these symptoms to anxiety, becoming concerned and fearful of the symptoms, and thus creating actual anxiety. This type of cycle is quite common when people try to make sense of uncomfortable physical sensations.

If you’ve determined that these symptoms are caused by anxiety, it sounds like you are experiencing panic attacks. Anxiety and panic are treatable through psychotherapy. Specifically, you should pursue a particular kind of treatment called Exposure Therapy. Ask your primary care physician if he/she knows of a good therapist who specializes in this type of treatment, or call the Loyola Department of Psychiatry at (708) 216-3750.

To learn more about the nature of anxiety and panic, as well as treatment through exposure therapy, I would recommend the self-help book “Mastery of Your Anxiety and Panic” by David Barlow. Some people have been successful treating their symptoms without professional help using this resource alone. Make sure you purchase the workbook for patients, not the therapist’s guide.

May 15, 2013

Q:

I have anxiety and when I try to work out it gets worse. What can I do in this case?

A:

Many people who experience anxiety, and/or find intense emotions to be uncomfortable, are often triggered by exercise because it produces many of the same sensations (elevated heart rate, sweating, shortness of breath, etc.) When engaging in cardiovascular exercise, these individuals can misattribute indicators of physical exertion to anxiety symptoms. This can prompt feelings of fear or even terror, which can create actual anxiety and escalate the aversive feelings.

There are a few things you can try to manage this cycle. First, keep working out! It’s tempting to avoid exercise when it seems to create discomfort, but exercise is very helpful for anxiety. After you exercise, your body produces a natural Rest and Digest response that actually reduces the physiological components of anxiety.

Second, do some reading about the nature of exercise and what happens to your body during physical exertion. That way when you’re exercising and notice, for example, that your heart is racing you will have a safe, rational explanation for what is happening. You can practice “self-talk” when you experience these sensations – that is, gently soothing yourself with explanations of what is happening in your body. The trick here is to use non-emotional, non-judgmental descriptions. Rather than thinking, “I’m anxious. I’m going crazy,” try simple descriptions such as, “My heart rate is increasing. I feel sweat on my back.”

Finally, there are physical things you can do to down-regulate your anxiety. Try deep breathing from your diaphragm. Concentrate on counting your breaths and making your exhalations significantly longer than your inhalations. You can also try going to the sink and splashing cold water on your face. Progressive muscle relaxation would also help. Go through each muscle group in your body and tense it, then relax it. This would be a nice supplement to your workout that would reduce muscle tension.

May 14, 2013

Q:

Is there such thing as “looping” when it comes to experiencing life? (the only movie I can think of with this kind of feeling is “Fight Club”).

A:

My apologies, but I’m not familiar with this term. Would you please resubmit and explain the concept? Thank you!

May 14, 2013

Q:

Why do psychiatrists help people get addicted to drugs to function when people should not be living in a stressful society that has too many boxes on how people “should” act, behave, etc? And they should just concentrate on projects of well-being and good productivity of the world?

A:

I do agree with you that many people experience anxiety and depression in response to external/environmental factors such as stressful jobs, bad relationships, poverty, family conflicts, etc. While psychiatric medications can reduce the intensity of negative emotions and provide relief for some of the physiological components of depression and anxiety, they do not address these environmental problems directly. Rather, it is hoped that medication can provide enough relief to allow people to solve the problems that are causing and perpetuating their suffering. In your example, that might mean moving to another type of environment, reducing self-judgment and engaging in more meaningful, altruistic activities. I have seen medication be very effective in this capacity. Medication is also an essential part of treatment when there is an organic problem that cannot be remedied through psychotherapy or behavioral interventions.

May 13, 2013

Q:

Are there any theories out there as to why there is so much mental instability in developed countries when compared with less developed nations?

A:

There is some research on happiness that suggests humans are least happy when they are idle. Harvard social psychologist Dr. Daniel Gilbert found that people’s reported happiness was higher when they were commuting and working than when they were “relaxing.” When idle, our minds tend to wander to problems that need to be solved. This is adaptive from an evolutionary perspective, as it helps us to stay aware of and prepare for challenges. But it also means that we tend to feel anxious or even depressed when we are not engaged in a meaningful activity. In less developed nations, people are more likely to be focused on their survival needs. If they are focused on getting food and shelter, treating illness or working in manual labor, they are less likely to be worrying about the future, the meaning of life, etc.

There is also greater emphasis on happiness in more developed nations. With their basic needs satisfied, people in developed nations do not necessarily expect or accept that their lives will contain suffering. There is a cultural belief that people “deserve” to be happy and that happiness is achievable through hard work. Thus, when people encounter inevitable suffering and stress, they tend to compound their pain with frustration, refusal to accept the pain and self-criticism at not having had the right attitude or resolve to achieve happiness.

I believe there may also be structural, societal elements that escalate mental instability. In some areas, people with mental illness are not nearly as stigmatized or isolated. Their differences might even be glorified and celebrated. They can be regarded as healers or prophets, for example. In countries with more communal living arrangements, these individuals likely receive more support and care as well.

May 13, 2013

Q:

Is it normal to feel like I am experiencing other people’s memories or a bit of what they have experienced? Or to feel like I am experiencing overlapping memories?

A:

If you’ve talked in detail with other people about specific things they have experienced, it’s possible that you’ve encoded their memories yourself by visualizing their experiences vividly and/or repeatedly. I can imagine this happening if other people have described significant events that have personal relevance to you, very intense experiences and/or experiences that you can associate to other things. Such memories could be easily triggered for you if you were thinking about something related to them and/or saw or heard something associated with them. In this case, you would not have an actual memory of the event (since you were not present), but rather a recall of your visualization of the event. This can happen to people who listen in detail to others’ accounts, such as therapists, social workers and crisis counselors, etc. I apologize, but I do not know what you mean by “overlapping memories.”

May 13, 2013

Q:

My 64-year-old husband had two cervical neck surgeries and two shoulder surgeries in the last 4 years. He has high blood pressure and diabetes and started insulin shots after his second surgery. He had trouble getting a sexual erection and now has not been interested in sex since the operations. The last surgery was 2 years ago. This is hard for me! He shows NO affection whatsoever for me. Any suggestions?

A:

I’m sorry to hear about your husband’s health issues and the negative impact they’ve had on your relationship. I can understand your feelings of frustration and sadness about the decreased intimacy. I would recommend trying to talk with your husband about your feelings. Try your best to avoid approaching him with blame and anger, as that will likely put him on the defense. Instead, share with him that you’ve been feeling bad (lonely, neglected, sexually frustrated, etc.) and ask for his help in addressing the problem. If he becomes angry, try your best to maintain a gentle tone, validate him for all that he has been going through and still maintain your request for help in problem solving.

In order to address this issue together, you’ll need to know more about how his body is actually functioning at this point. For example, it would be helpful to know if he still masturbates as that would provide information about his ability to get an erection and achieve orgasm. If he can reach these sexual stages independently, that is good news because you know the capability is there. If he’s stopped trying, that doesn’t mean it’s not possible, but rather that it’s not been tested recently and perhaps could be. If you learn that he’s not capable, the next step would be determining whether the problem is psychological, physical or some combination of the two. To this end, you might suggest that he seek medical advice. The two of you could also consider pursuing marriage counseling or help from a sex therapist.

In the meantime, it might also help to try engaging your husband in other forms of intimacy – those that do not have specific performance demands. Start with holding hands, cuddling, hugging and kissing. This will likely increase the affection and connection between you without stirring up the anxiety and potential for shame and disappointment.

May 13, 2013

Q:

I’ve been dealing with generalized anxiety for a number of years. I see a therapist every other week. I take a .025 Xanax tablet once a day. I can take 2 a day if needed. I am having such a hard time dealing with this. I’m a 63-year-old woman who went through menopause naturally. I’m in good health, but I suffered 3 major losses in the last 4 years. I want so much to be free of the constant worry and fear. Are there any other steps I should be taking?

A:

It sounds like you are doing a lot right in terms of self-care. You are going to therapy and taking medications as needed. To address your Generalized Anxiety Disorder, you might consider taking a few additional steps. If you are not already exercising regularly, I would recommend that to manage the physiological aspects of anxiety. Regular cardiovascular exercise could be very beneficial to you because when the body recovers from exercise it prompts a natural Rest and Digest response. I would also consider yoga, meditation or some sort of mindfulness practice. As you said, the central feature of GAD is worry and fear about the future – that is, things that have not yet happened. Mindfulness practice can teach you how to stay in the present moment. Specifically, it can teach you how to become aware of and better control your focus. You can learn to notice when your mind has wandered to worry and you can learn how to redirect yourself back to the present moment.

May 9, 2013

Q:

My husband retired early on a disability and is experiencing anxiety, guilt, a sense of worthlessness, sadness, loss of purpose, etc. Although he cannot perform his previous strenuous duties, he is quite capable. His once outgoing, happy personality has been replaced by an angry, sad and distant demeanor. He recently began taking antidepressants, but he isn’t seeking professional help. Do you have any advice for us?

A:

It sounds like your husband is having a really difficult time with his decreased activity level, lack of routine, physical pain and the loss of his identity as a worker. Be sure to support and validate him for what he’s going through, even though you might be feeling frustrated and hurt by his behavior.

Sometimes when people experience an external stressor, such as a job loss, an injury, the breakup of relationship or moving, they have a hard time adjusting to changes and new limitations and become depressed.

Unfortunately, depression can become self-perpetuating. Depression can strip people of their energy, motivation and self-esteem, which can lead them to stop participating in their lives. When they stop doing things such as socializing, engaging in their interests and hobbies, or tending to their responsibilities, their lives start to feel very unrewarding.

To break this cycle, your husband should try to get active – even though he probably does not feel motivated to do so. In other words, he needs to act in spite of his mood. He will need to put some potentially pleasant activities on his schedule, such as socializing, entertainment, engaging in hobbies, etc. He might not find these activities as enjoyable as he used to, but they will create some structure in his day and potentially offer some joy.

He should also pursue opportunities for learning and mastery, such as taking a class, learning a new skill, and/or exercising (if he’s physically able to do so). These activities can provide a sense of pride and achievement. Once your husband starts doing things that prompt feelings of joy, pride and achievement, he will be better able to break the depressive cycle and engage in healthier, more rewarding behaviors.

May 8, 2013

Q:

What is the solution for self-direct?

A:

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May 8, 2013

Q:

My anxiety is high. Could you please recommend doctor near South Elgin, Ill.?

A:

I would talk to your primary care physician. This doctor will know of health professionals in the area who can treat your anxiety.

May 8, 2013

Q:

I’m 59 and I’ve led a full life with a job and a family. Now I want to be a woman. I’ve been dressing since a very young age. My wife is supportive and knows everything about my womanhood. I use estrogen and I’m not looking for judgment. I just want to be me. Any suggestions?

A:

It sounds like you’ve come a long way.  You’ve identified your struggle and bravely taken steps toward cultivating and accepting yourself.  I imagine that it has been a difficult process.  I’m glad to hear that you have such a supportive wife and family.  I’m sure they’ve gone through a lot, too. You are in a difficult position of having to weigh your own needs against those of your family members.  I would suggest continuing to develop your identity and pursue your happiness in ways that are consistent with your own values and goals.  Only you can determine what that would entail, but you might want to consider consulting a therapist, mentor, clergyman or spiritual leader for help in the process.

May 8, 2013

Q:

I have lived with my wife for a long time and I’ve lost my interest to her. Is it normal?

A:

I’m not sure if I understand your question.  When you say that you’ve “lost interest to her,” does that mean you’re no longer interested in her sexually, or that you’re no longer interested in her at all (as a partner, friend, companion, etc.)?  Or are you saying you’re no longer of interest to her?  I’ll try to respond to each of these scenarios.

If you or your wife has lost desire for sexual intimacy, that is understandable in a long-term monogamous relationship.  There are many reasons why this can happen, such as busy and tiring schedules, lack of excitement and novelty, depression, anxiety, boredom, poor body image, and/or accumulation of hurts and grudges.  If you are concerned about the lack of intimacy in your relationship, I would suggest talking with your wife about the current barriers and trying to brainstorm solutions.  Perhaps you need to make more time in your schedules, or infuse more excitement into your relationship.  If there is conflict between you that you haven’t been able to repair on your own, consider pursuing marriage counseling.

If you’ve lost all interest in your wife, or vice versa, that is obviously a broader problem.  If you no longer feel interested in talking, doing things, confiding in each other, running your household or raising your kids together, it’s important to address this problem before it shifts from boredom and indifference to frustration, pain and loneliness. Again I would encourage you to talk with your wife about your feelings and consider going for marriage counseling. The questions I would consider exploring are: If you had a fulfilling relationship, what happened?  What has changed between you? Can the two of you envision a road back? What would it take?  What would each of you have to do to stimulate your interest again?

May 8, 2013

Q:

I have bipolar disorder. It seems to me that my symptoms have gone away. I still take my medication, see my therapist and I’m busy doing healthy things. Is it possible my demons are gone, or if they come back that it’s perhaps not so severe?

A:

I’m very glad to hear that you’re feeling so well.  It sounds like you’re doing all the right things to take care of yourself and manage your illness.  Sometimes when a treatment regimen is working, it’s difficult to know if the underlying problem is still present and being treated effectively, or if it has gone away.  Unfortunately, bipolar disorder does not go away.  It can be managed very effectively with medication and behavior modification, but it will reoccur if left untreated.

If you feel confident that your initial assessment and diagnosis of bipolar disorder was done thoroughly and correctly, then I would recommend staying with your current treatment regimen.  If you’re questioning whether you were correctly diagnosed in the first place, you might want to consider getting a second opinion.  Either way, be sure to collaborate closely with your psychiatrist to monitor your symptoms and any medication side effects.

May 8, 2013

Q:

My husband acts OK, but we have not had sex in a year. Any thoughts or suggestions?

A:

In long-term monogamous relationships, sexual desire/drive can diminish for many reasons. Schedules get busy and tiring, novelty and excitement fade, hurts and grudges build up, body image worsens, etc.  Before you know it, long periods of time pass without intimacy because neither partner takes the initiative.

It is important to recognize that just because drive has faded does not mean that sex can’t be an enjoyable, intimate source of pleasure and connection.  It might just take more effort to get started.  I imagine that you and your husband miss the intimacy in your relationship. I would suggest talking about these feelings of sadness and disappointment, identifying the barriers to intimacy and trying to brainstorm some solutions.

One place to start would be to increase non-sexual touch, such as holding hands or snuggling on the couch.  Try to infuse more excitement and novelty into the relationship by planning date nights, taking vacations or doing unusual activities and adventures. You might also try scheduling time to be intimate. This can feel a bit awkward and stilted, but you can improve the mood with music, candles or other romantic elements. Finally, if there is anger or grudges between you, try to repair them or consider going for marital counseling.

This problem probably won’t solve itself since you’re out of the habit of being intimate, so you’ll need to do something to create change.

May 6, 2013

Q:

Can the long-term use of anxiety medication cause a sleep disorder?

A:

My apologies, but this question is outside my area of expertise.  I’m a clinical psychologist so I have training in psychotherapy and research methods, but I do not prescribe medications.  This question could be better answered by a psychiatrist, or your primary-care physician. If you would like to schedule an appointment with a Loyola psychiatrist or primary-care physician, please call 888-LUHS-888 (888-584-7888).

May 6, 2013

Q:

I’m 65, depressed and don’t want to live anymore.

A:

I’m very sorry to hear that you’re feeling so bad. Depression can cause passive suicidal ideation, which is extremely painful and demoralizing. I believe the goal of psychotherapy is to help people build a life worth living. I would strongly encourage you to get into treatment.  To make an appointment here at Loyola, please call (708) 216-3750.

For information about locating a mental health center near you, call 1-800-843-6154 or 1-800-804-3833. Should you need someone to talk to immediately, please call one of the following suicide hotlines:

Chicago Suicide Prevention: (312) 644-4357
DuPage County Access & Crisis Center: (630) 627-1700
University of Illinois: (312) 996-5535
USA National Suicide Hotline: 1-800-SUICIDE

May 3, 2013

Q:

Is there anything that can be done about panic attacks without using drugs?

A:

Absolutely. There are very effective behavioral treatments for panic attacks. I tend to think of panic attacks as the body’s alarm system going off (racing heart, sweating, shortness of breath, etc.) when there is no real threat of danger. Medication turns down the volume on the alarm, but it does not necessarily help to stop the alarm from being triggered in the first place. The best treatment for trying to stop the alarm is a behavioral treatment called Exposure Therapy.

In order to understand how exposure treatment works, it’s important to explain what happens in the mind and body during a panic attack. Typically, the body produces a variety of sensations, such as chest pain, shortness of breath and/or sweating in response to anxiety. Because these sensations are intense and atypical, it’s common to feel very scared of them. It’s common to think, for example, that you’re dying, having a heart attack, or going crazy, all of which are terrifying. When you interpret the sensations in this way, it makes you more afraid and actually makes the sensations get worse. You get alarmed by your fear and an attack ensues.

So the way you think about panic symptoms has a huge impact on your physical experience. Consider this example: If you notice your heart racing and have a good non-scary explanation for it such as, “It’s racing because I’m so excited to see my sister after 3 years” you will not be afraid of the feeling. In contrast, if you think, “It’s racing because I’m dying,” your fear will keep escalating.

In exposure therapy, your therapist helps you think about and relate to panic differently. You learn to identify all of the body sensations associated with panic and you learn that although they are uncomfortable, they are not dangerous. This helps you to react differently when the symptoms do occur. When you stop fearing the symptoms, they do not escalate.

In this treatment, your therapist also helps you come into contact with panic-like symptoms in a controlled setting. So, for example, you might be encouraged to spin around in a chair to create dizziness, or run up the stairs to speed up heart rate. Although this is uncomfortable, it helps you get used to the symptoms so they are not so upsetting when they occur spontaneously.

Finally, your therapist will help you identify the triggers for your panic attacks (e.g., crowds, restaurants, public transportation). These might be places where you’ve had attacks before, places that remind you of traumatic experiences, or places that naturally set off uncomfortable physical sensations. After you’ve identified your triggers, your therapist will teach you skills for self-soothing to use in those situations, such as deep breathing and self talk. You will be encouraged to go toward those situations, rather than avoiding them, so you can learn that the anxiety is tolerable, not dangerous, and temporary.

April 29, 2013

Q:

How do I increase my motivation?

A:

Many people, and especially those seeking therapy, believe that behavioral change starts with insight and motivation.  They come to therapy hoping that if they can be helped to feel better, they will be able to act better.  This is known as change “from the inside out.”

What people often do not realize, however, is that change can also occur from the “outside in.”  If you engage in a certain behavior because you committed to it, or followed a schedule or attended to a responsibility, it can actually change how you feel. It can increase your sense of mastery and provide opportunities to experience positive emotions.  In other words, you can actually act your way into a better way of feeling.  If you wait for motivation, it might not come.  Rather than waiting until you feel motivated, take action simply because you’ve made a commitment, devised a plan or set a schedule.

The hardest step is setting that first goal and initiating the behavior in spite of your emotions or energy level at the time.  Once you get started, the behavior will likely improve your mood and sense of efficacy, and help you to continue with healthy, pleasurable and productive behaviors.

April 29, 2013

Q:

Why do I keep self-sabotaging?

A:

When people try to understand their seemingly self-destructive behaviors, they are often very perplexed.  They don’t understand why they keep doing things that lead to negative consequences, guilty feelings and decreased self-respect.

When they look back at incidents of overeating, excessive drinking or losing their temper, for example, they search for a theory to explain why they engage in these harmful behaviors.  The theory many people come up with is, “I must not want to change” or “I must want to hurt myself.”  These are very upsetting theories because they suggest the person is illogical (at best) or disturbed (at worst).  These theories are not only upsetting, they are probably wrong and they do not lead to productive problem solving.

Rather than assuming you are self-sabotaging, consider that your seemingly self-destructive behavior is actually rewarding you in some way.  Consider that it’s rewarding you while you are doing it, or immediately afterwards.  It’s likely that your behavior is so rewarding in the moment that it disconnects you from the consequences that will follow.  Now the behavior doesn’t seem illogical or disturbed.  It might be that your behavior provides a lone source of pleasure in an otherwise stressful day.  It might be that it provides a distraction or escape from painful emotions, such as anxiety, grief or shame.

If you can understand how the behavior is working for you, that is, how it’s functioning, you will be able to change it.  You might need to change whatever it is that leads to the behavior so you’re not so vulnerable (for example, reduce stress by getting regular exercise, turning off your cell phone in the evenings or making sure you get adequate sleep).

Alternatively, you might need to choose a substitute behavior that gives you a similar reward without the negative consequences (for example, relieve stress and access pleasure by taking a bubble bath, calling a friend or going for a walk).  Be prepared for the fact that the substitute behavior might not work as well in the moment, but you’ll come to prefer it if it doesn’t lead to negative consequences.

April 29, 2013

Q:

How do I become happier?

A:

Many people come to therapy because they want to feel happier.  They want to feel happy most or all of the time.   Our culture puts a big premium on happiness and how everyone “deserves” to be happy.

People experience happiness for a variety of reasons such as getting what they want, having pleasurable sensations, receiving love or affection or being successful.  It’s important to recognize that happiness is just one emotion that humans experience. People are equipped to experience a range of emotions and every emotion serves a purpose.

Emotions motivate people toward action, help them communicate with one another and give them important information about the world.  Consider the emotion of fear, for example.  It is very unpleasant, but also extremely useful.  It motivates people to fight or run way, which protects them from danger.  Furthermore, when people feel fear, they tend to show it in their posture, body language and facial expressions, which warns other people that there is a threat nearby.  Finally, people often feel fear instinctively. In this case, the fear tells them to avoid or escape something dangerous before they even realize it intellectually.  If people did not experience fear, they probably would not protect themselves and others from danger.

Just like fear, other distressing emotions are also very useful.  If people did not experience guilt, they would not abide by society’s morals or try to repair their mistakes.  If people did not experience anger, they would not be motivated to overcome obstacles or fight against perceived wrongdoings.  If people did not experience the sadness of loss or separation, they would not work to maintain relationships or take care of those who are sick.

Just as the body’s pain receptors keep people safe by alerting them to a hot surface that should be avoided or a virus that needs to be treated, emotional pain is also very important for alerting people to problems in their lives.  So, while happiness is more pleasurable, it’s no more important than any other emotion. Next time you experience sadness or anger, rather than viewing it as inconvenient, weak or intolerable, consider how the emotion is telling you something useful.  It’s likely there is a problem that you need to address, and you would probably miss it if you felt happy all the time!