​If you are starting the journey in looking for a therapist/counselor here are some reasons why Out Of Network (ONN) services, as opposed to an in-network provider, may be better.

1. You’re looking for a therapist who is highly specialized and experienced
   
   Most in-network therapists are generalists.  While they are qualified to treat common conditions such as anxiety, depression, and challenges in navigating significant life events, they often lack specialized training, credentialing and experience with specific disorders.  Much like how many of us seek out a Family Practitioner or a Primary Care Physician for routine issues like the flu, we generally seek out or are referred to specialists for more serious and complicated conditions such as cardiac or neurological conditions.  
   
   Most out-of-network therapists are specialists who have niche practices.  If you have a specific condition or concern, it might be best to seek out and work with an out-of-network clinician or practice that has extensive training and experience in the area you are seeking help for.
   
   
2. You have a high deductible plan
   
   Many in-network insurance plans require a deductible to be met before the insurance covers their portion of the charges. A deductible is the amount you have to pay upfront before your insurance coverage kicks in. If you have a $5,000 deductible and you haven’t had any other medical expenses yet in the year, you are responsible for paying up to $5,000 in therapy session fees out-of-pocket before your standard co-pay applies. 
   
   Additionally, in-network therapists are limited by the insurance company’s contract with them in how they provide care to you. In-network therapists are restricted in the frequency and duration of care provided. So, if you are in crisis and feel that you need several sessions a week to stabilize and wish to remain in therapy for an extended period of time, an in-network therapist may tell you that they are only able to see you once weekly for a maximum of 8 – 10 sessions.  Out-of-network providers are not limited by insurance company guidelines on the frequency, modality, duration or orientation of care. You are free to decide what is best for your situation with your out-of-network therapist.
   
   
3. You have good out-of-network benefits
   
   If you have good out-of-network benefits, your insurance company may reimburse you as much as 90% of each session fee, depending on your specific plan’s coverage.  This means that in some situations, using your out-of-network benefits can actually be more affordable or comparable to your standard co-pay to see an in-network therapist.  I have seen situations where my patients must pay upfront to their in-network therapist for the first $5,000 of care. Once the $5,000 deductible is met, the patients are advised that they are not able to offer any further in-network sessions due to reaching a session max imposed by the insurance company.  So, in essence, the patient received no insurance benefit for the in-network care; they paid out of pocket and received no insurance benefit!! If the same patient had used their out-of-network benefit, they would have received 80% – 90% of the fees back!!
   
   
4. You want highly personalized services
   
   If a therapist isn’t constrained by providing services that the insurance company only authorizes, they are often able to spend more time and creativity crafting the perfect treatment plan for you. 
   
   
5. Out-of-network therapy opens doors for out-of-the-box treatment 
   
   Out-of-network therapists can offer longer, sessions, more frequent sessions or sessions that occur over a longer duration than compared with in-network insurance providers.  Out-of-network providers are also able to provide out-of-the-box solutions and care plans. 
   
   For example, if you are struggling with a substance use disorder (SUD), an out-of-network practice will be able to craft an individuated care plan of individual therapy, medications and toxicology testing that is highly privatized and discrete.  In-network providers may be locked into standard Intensive Outpatient (IOP) models that require participation in large groups, meeting 4 nights per week; 3-4 hours each session. In-network programs and providers often lack the flexibility in model and orientation of care as opposed to out-of-network. For example, many structured in-network substance abuse programs are full abstinence-based programs, whereas highly specialized out-of-network experts can offer moderated and controlled drinking approaches or harm reduction approaches.
   
   
6. You want to combine medication management with talk therapy 
   
   Some psychiatrists offer both psychotherapy and medication management, which allows for a more comprehensive understanding of your mental health needs before prescribing. 
   
   These services are often private pay, but they offer great convenience and highly coordinated care.
   
   
7. Privacy
   
   Privacy from your family and/or parents — If you are on your parent’s insurance plan and are uncomfortable with them knowing you are seeing a therapist, you might consider paying out-of-pocket.
   
   Privacy from your health insurance company — In order for your insurance to pay for therapy sessions, in-network therapists are required to provide the company detailed information regarding your sessions, including a diagnostic code and other highly private material. 
   
   If you don’t want your insurance company to have access to any information about your mental health, consider out-of-network and self-pay options.
   
   Privacy from your employer — In certain circumstances, your employer may be aware of how you are utilizing your health insurance benefit, especially if the company is self-insured.
   
   
8. You don’t want to wait to start therapy – Avoiding frustration and aggravation.
   
   In the local area, the majority of private therapists and practices do not participate in in-network insurance plans.  Those few therapists that do participate as in-network tend to be full and have long waiting lists. Out-of-network, private pay therapists tend to have more availability and greater flexibility in scheduling new clients.
   
   I routinely receive calls from prospective patients who have spent enormous amounts of time and energy seeking a therapist who takes their insurance.  Many describe that numerous in-network providers don’t return calls, are full and have waiting lists or don’t have the time availability that works. To further their frustration, they call the insurance company and request a list of local providers only to realize that the directory is a “ghost list” of closed practices and wrong numbers.
   
   
9. You found a great match!
   
   At the end of the day, your relationship with your therapist is one of the most important aspects of the healing process. 
   
   If you only consider in-network therapists, you might eliminate therapists who would be a really good fit for you and maybe help you feel better faster. 
   
   Choosing an in-network therapist who doesn’t make you feel comfortable or doesn’t specialize in the areas you’re struggling with solely because they’re in-network is a waste of money. Prioritize the personality fit and you’ll find a great match.

Thom Kessler, LMFT, RAS
Licensed Psychotherapist
Registered Addiction Specialist
Certified EMDR Trauma therapy
Gottman Level III 

​PHONE: 415-454-8931
EMAIL:  marintherapist@gmail.com
​

Encourage your child to share their fears. 

Ask your child what is making them worried.

Tell your child that it is normal to have concerns.

Before and during school, set up a regular time and place to talk. Some children feel most comfortable in a private space with your undivided attention (such as right before bed, or during mealtime).

Avoid giving reassurance...instead, problem-solve and plan!  Children often seek reassurance that bad things won’t happen in order to reduce their worry. Do not assure them with “Don’t worry!” or “Everything will be fine!” Instead, encourage your child to think of ways to solve their problem.

For example, “If (the worst) happens, what could you do?” or “Let’s think of some ways you could handle that situation.” This gives you the opportunity to coach your child on how to cope with (and interpret) both real and imagined scary situations. You will also be giving your child the tools they need to cope with an unexpected situation that might arise.

Here’s a sample script for engaging your child in problem-solving and planning (instead of giving reassurance):

Role-play with your child. Sometimes role-playing a certain situation with your child can help them make a plan, and feel more confident that they will be able to handle the situation.

For example, let your child play the part of the demanding teacher or another classmate who is not anxious. Then, model appropriate responses and coping techniques for your child to help calm them down.

Focus on the positive aspects!  Encourage your child to re-direct attention away from the worries, and towards the positives. Ask your child, "What are three things that you are most excited about school?" Most kids can think of something good, even if it's just eating a special snack or going home at the end of the day. Chances are that the fun aspects are simply getting overlooked by repetitive worries.   

​Pay attention to your own behavior. It can be anxiety-provoking for parents to hand over care and responsibility of their child to teachers. Children take cues from their parents, so the more confidence and comfort you can model, the more your child will understand there is no reason to be afraid. Be supportive yet firm.  When saying goodbye in the morning, say it cheerfully – once!  Ensure you don’t reward your child’s protests, sadness or crying, by allow them to avoid going to school. Instead, in a calm tone, say: “I can see that going to school is making you scared, but you still have to go. Tell me what you are worried about, so we can talk about it.” 

Thom Kessler, LMFT, RAS
Licensed Psychotherapist
Registered Addiction Specialist
Certified EMDR Trauma therapy
Gottman Level III 

​PHONE: 415-454-8931
EMAIL:  marintherapist@gmail.com
​

Resentment is often defined as anger and indignation experienced as a result of unfair treatment, and it’s a relatively common emotion.
Those who experience resentment may have feelings of annoyance and shame—they might also harbor a desire for revenge. A person may become resentful as a result of a slight injustice or a grave one, perhaps harboring the same bitterness and anger over a small matter as they would over a more serious issue.

WHAT IS RESENTMENT?
Feelings of resentment are not linked to any particular mental condition but may instead result from the inadequate expression of emotions after a painful experience. They may come from a true, imagined, or misunderstood injustice. A careless comment made by a friend could facilitate indignation and grudging feelings, as could criticism from a boss. Resentment can also be broad and applied to large groups of people, often with drastic consequences; for example, racism and religious persecution often develop from deep-seated resentment.

A person experiencing resentment may feel personally victimized but may be too angry or ashamed to discuss the resulting emotions, instead allowing the grudge to fester and be expressed in the form of anger.

SIGNS OF RESENTMENT
Resentment can appear in many different forms. Some signs you may be harboring resentment include:

• Continual or recurring feelings of a strong emotion, such as anger, when thinking about a specific interaction or experience
• Inability to stop thinking about the event that triggered the strong emotions
• Feelings of regret
• Fear or avoidance of conflict
• Tense relationships
• Feeling invisible, inadequate, or less-than

Though resentment can be fleeting, dissipating when someone realizes an event was misinterpreted or receives an apology from the person who committed the offense, it can also be a persistent emotion. An individual may hold on to negative feelings, revisiting the distressing event again and again and becoming unable to let go of anger or a desire for revenge. In this instance, resentment may come to affect an individual’s mental health.

RESENTMENT AND MENTAL HEALTH
Because resentment is a common emotion, most people will experience a general feeling of anger or annoyance over unfair treatment at some point in life. But problems can arise when a person is unable to forgive—persistent resentment might stem from a serious matter. For example, a person might, understandably, resent a parent after years of abuse and become unable to look past any injustice. However, when a person begins to feel like the victim in every negative situation, they may develop an altered perception of reality and find it difficult to see any positive outcomes.

Developing an ability to move on or forgive is considered an important aspect in overcoming resentment, as is acknowledging the feelings underneath the resentment and facing them one at a time. Resentment can intoxicate a person, as feelings of anger and rage lend a false sense of power and do not always encourage a healthy form of expression. But this intoxication can become dangerous, as any intoxication can, when feelings of resentment grow unchecked and turn into hatred.

RESENTMENT IN RELATIONSHIPS
It’s not uncommon for resentment to build up in intimate relationships, especially long-term ones. Some common causes of resentment in relationships include:

• Keeping score. If one person in the relationship feels they are constantly doing all of the heavy lifting in the relationship—housework, childcare, being the primary breadwinner, or initiating emotional connection and intimacy, to name a few examples—they may begin feeling resentment towards their partner.
• Unbalanced power dynamics. If one partner in a relationship feels constantly overpowered, steamrolled over, or unheard, they may begin to harbor resentment.
• Health or medical issues. When one person in a relationship is diagnosed with a chronic mental or medical health issue, this may mean their partner will begin to take on the additional role of caregiver. Over time, being a partner’s caregiver can cause some to feel resentful, especially if their own needs are not being met.
• Hurtful words. The longer a couple spends time together, the more likely one of them may be to say something that’s perceived as hurtful to the other. Couples who don’t communicate openly when they feel hurt by their partner may have higher chances of feeling resentful.

If left to bubble under the surface, resentment can end relationships. Those who feel resentful towards their partner may find that talking about what’s bothering them, no matter how minor or petty the issue may seem, can reduce the resentment they feel and even deepen their connection.

Couples who find themselves unable to let go of resentment may learn how to communicate about their feelings in couples counseling.

HOW TO LET GO OF RESENTMENT
In many cases, letting go of resentment means forgiving. Some individuals find that making peace with something that happened and moving on works better for them. Regardless of how someone chooses to get rid of resentment, it most likely means adjusting one’s frame of mind or emotional responses.

To let go of resentment, it may help to:

• Consider why letting go is difficult. What feelings come up when you consider moving on from the resentment? Letting go of resentment can trigger fears of losing one’s identity, especially when the resentment has been held in for a long time.
• Use self-compassion. Sometimes those who hold on to resentment for long periods of time find that the emotions associated with the resentment, such as anger or regret, also provide a sense of security or familiarity. Self-compassion may allow these individuals to recognize that while this coping mechanism may make them feel better the short-term, it will wear them down over time.
• Explore empathy. When the person or action that caused resentment was based around a misunderstanding, or the person who did something hurtful does not understand what they’ve done, trying to see things from their perspective may help reduce resentment.
• Cultivate gratitude. When feelings of resentment start to bubble up, try listing things you’re grateful for. Focusing on ways in which you are privileged or fortunate can make it more difficult for feelings of resentment, which often thrive on self-victimization, to take root.

If neglected, resentment may become overpowering and even toxic to the person who harbors it. In these cases, talking to a therapist can help individuals explore the issue that caused the resentment, what is making it difficult to let go of, and coping strategies that help people reduce their resentment.

THERAPY FOR RESENTMENT
Those who find it difficult to forgive others for any wrong, no matter how slight, may find some benefit in therapy. Those who wish to understand the reasons for their resentment of a particular individual or situation might wish to revisit the event, alone or with the help of a therapist. Because the source of a person’s resentment can differ, there is no one type of therapy used to treat these feelings.

Methods of personal actualization have been shown to be effective therapeutic techniques for treating resentment. Individuals who have self-actualized tend to accurately perceive reality, experience empathy and compassion for others, and are typically able to accept the self and others easily. Therefore, these individuals may be less likely to blame others for wrongs or hold on to resentful feelings.

If you are struggling and finding it difficult or unable to let go of a resentment toward a friend, a family member or your partner, please give me a call for a free consultation. I specialize in working with attachment issues, substance abuse/ dependence and marital conflicts, including marital affairs.  

​Alcohol is the most commonly used mind-altering substance in the United States. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) reports that over half of all-American adults were current drinkers of alcohol at the time of the 2015 national survey. Having a beer or a glass of wine with dinner is common, and millions of adults regularly enjoy alcohol responsibly.

Even though alcohol is a depressant substance, it is often used to get the party going. Many of us have tales of doing stupid things when we drink, and they don’t often involve mellowing out and going to sleep. So, alcohol is not just a depressant then; it also acts on moods, emotions, actions, and reactions.

It changes the way you think and feel, and therefore influences how you act. Of course, the more you drink, the more impact alcohol will have. With a few drinks, you are probably more social and outgoing, happy, full of energy, talkative, and fun to be around. A few more and you may start slurring your speech, falling down, and becoming more aggressive. Even more drinks and you may blackout and not remember what you did or said the next day.

Drinking alcohol can make it hard for you to think clearly and make good decisions. It can make it more likely that you will get into potentially harmful or dangerous situations that you will regret the next day. Alcohol changes brain chemistry, which in turn impacts moods, behaviors, thinking, memory, and physical movement and bodily functions, which may have costly side effects.

How Alcohol Affects Behavior
When you drink alcohol, it is thought to raise levels of GABA in the brain. GABA is one of the brain’s chemical messengers, or neurotransmitters, that helps you to feel relaxed, and it aids in lowering anxiety and stress. GABA is considered to be an “inhibitory” neurotransmitter. High levels of GABA cause your body temperature to drop, and your heart rate and blood pressure to come down.
Alcohol also increases levels of dopamine in the brain. Dopamine is one of the chemical messengers responsible for sending signals of pleasure. When levels of dopamine are elevated, it can create the “high” or “buzz” that makes alcohol pleasurable to drink.

Alcohol also jacks up the amount of norepinephrine present in the brain; this neurotransmitter acts as a stimulant. Elevated levels of norepinephrine increase arousal and excitement, and it can lower your inhibitions and increase impulsivity, making it hard for you to consider potential consequences of your actions.

Alcohol also decreases some of the activity of the prefrontal cortex. This part of the brain is what helps you to think clearly and rationally, and it is involved in your decision-making abilities. When you drink, alcohol makes it harder for the prefrontal cortex to work as it should, disrupting decision-making and rational thought. In this way, alcohol prompts you to act without thinking about your actions.

Alcohol reduces the functions of the behavioral inhibitory centers in the brain, Forbes reports. It also slows down how information is processed in the brain. When you see, hear, taste, or smell something, your brain processes this information and then tells you how to think or feel. Alcohol interferes with this process, making it harder for you to work out what you are feeling and also making you less likely to be able to really think through potential consequences.

The prefrontal cortex part of the brain is partly responsible for your sense of control over your emotions and behaviors, impacting willpower and even aggressive thoughts and actions. It can enhance emotions you are already feeling and make it harder for you to gauge when enough is enough. When you drink, you may be less able to control your emotions; you may speak and act without thinking; and situations may get out of hand faster than they would if you weren’t drinking.

Risks of Lowered Inhibitions and Alcohol
When your ability to think, make rational decisions, and control your impulses is impaired by alcohol, there are numerous potential consequences. You may be willing to do or try anything that you think will make you happy in the moment, without any thought to what may come next. Lowered inhibitions and bad decision-making abilities are side effects of alcohol use that may have the following possible ramifications:

• Getting into an accident and/or getting injured
• Engaging in possible criminal behaviors
• Being more open to trying other drugs
• Having violent outbursts and getting into fights
• Taking part in unwanted or unsafe sexual encounters
• Becoming the victim of a crime

The National Council on Alcoholism and Drug Dependence (NCADD) warns that alcohol is a factor in 40 percent of all violent crimes that are committed in the United States. Lowered inhibitions can make you more prone to fall victim to crimes, such as sexual assault and date rape. You may be more approachable when you are drinking, and you may be more open to trying things and talking to people than when you are sober. Alcohol dispels anxiety, making it easier to feel more social, less afraid, and less aware of your surroundings. You may then find yourself in a situation that goes downhill fast and can become dangerous.

Physically, alcohol impairs coordination, balance, reflexes, and your ability to fight back. It can make you more open to engage in sexual behaviors that may be questionable or even downright unwanted. Alcohol can leave a person completely incapacitated and unable to consent to sex, and it is the number one drug involved in date rapes, USA Today reports. Even if you do consent to sex while under the influence of alcohol, you may not be safe about it. Therefore, you put yourself at risk for an unwanted and unplanned pregnancy or for contracting a sexually transmitted (STD) or infectious disease.

Alcohol can also make you more open to trying other drugs. While you may typically not take illicit drugs, when you are drinking, you may be more willing to take bigger risks and not be as worried about what might happen when you do. Mixing drugs and alcohol can be very dangerous, however, as they can interact together and potentially lead to an overdose or other hazardous side effects. Opioid drugs like heroin and prescription painkillers can further suppress your central nervous system, for instance, and when mixed with alcohol, they can cause a toxic overdose that can cause you to stop breathing and even die.

Drugs can also further impair your thinking, memory, and physical abilities. You may get drunk faster and get more intoxicated than normal when combining substances. Drug and alcohol combinations can be unpredictable, and you can never know exactly how the mixture of the two is going to affect you.

We are often embarrassed about our actions the night before, and we may have to repair relationships with people who we upset while drinking.  Don’t be too hard on yourself, but do make an effort to make things right. Remember that you are not alone; most people who drink alcohol have probably done something they regretted while under its influence at some point. In the future, make some boundaries for yourself; set limits to decrease the odds of being in a similar situation again.

It can also be a good idea to make pacts with friends to watch out for each other and hold each other accountable. It’s even better if one friend stays sober. Usually, if you stick to drinking only a few drinks on a full stomach and spread them out over a period of time, you can drink responsibly and not suffer many negative consequences. The less you drink, the better your brain will function, and the more able you will be to make sound decisions that you will not regret the next day.

If you are unable to moderate your drinking, it’s a sign that professional help is needed. I can help  by providing harm reduction therapy as well as the abstinence model.  I am a licensed clinician and a Registered Addiction Therapist in private practice in Marin County. 

Thom Kessler, LMFT, RAS
Licensed Psychotherapist 
Registered Addiction Specialist
415-454-8931
marintherapist@gmail.com
www.thomkesslertherapist.com

From hoarding to handwashing to forever checking the stove, obsessive-compulsive disorder (OCD) takes many forms. It is an anxiety disorder that traps people in repetitive thoughts and behavioral rituals that can be completely disabling.

Surveys conducted by the National Institute of Mental Health show that 2 percent of the population suffers from OCD—that's more than those who experience other mental illnesses like schizophrenia, bipolar disorder, and panic disorder. OCD might begin in childhood, but it most often manifests during adolescence or early adulthood. Scientists believe that both a neurobiological predisposition and environmental factors jointly cause the unwanted, intrusive thoughts and the compulsive behavior patterns that appease the unwanted thoughts.

Unless treated, the disorder tends to be chronic—lasting for years, even decades—although the severity of the symptoms may wax and wane over the years. Both pharmacological and behavioral approaches have proven effective as treatments; often a combination of both is most helpful. For more on causes, symptoms and treatments, see our Diagnosis Dictionary.

The Varieties and Symptoms of Obsessions
These uncontrollable thoughts or behaviors can interfere with a person's work, school, and relationships. Though the behaviors may give the person momentary relief from his overall anxiety, he doesn’t derive pleasure from the obsessiveness. People suffering from obsessive-compulsive habits may also contend with motor tics or repetitive movements, such as grimacing and jerking. Research into OCD is ongoing. For example, defects called micro-structural abnormalities have been found in the brain’s white matter of those who suffer OCD, and frontline treatment for this disorder includes exposure and response prevention, as well as plain old empathy and compassion in delivering therapy.

The first symptoms are the obsessions—the unwanted ideas or impulses that occur over and over again and are meant to drive out fears, often of harm or contamination. "This bowl is not clean enough. I must keep washing it." "I may have left the door unlocked." Or "I know I forgot to put a stamp on that letter." The compulsions appear after that—repetitive behaviors such as handwashing, lock-checking, and hoarding. Such behaviors are intended to mitigate fear and reduce the threat of harm. But the effect does not last and the unwanted thoughts soon intrude all over again.

Sufferers may understand the uselessness of their obsessions and compulsions, but that is no protection against them. OCD can become so severe that it keeps people from leaving their homes. The condition strikes males and females in equal proportions.

What Causes OCD?
Current scientific thinking holds that OCD results from a confluence of factors—a biological predisposition, environmental factors including experiences and attitudes acquired in childhood, and faulty thought patterns.

The fact that many OCD patients respond to SSRI antidepressants suggests the involvement of dysfunction in the serotonin neurotransmitter system. Ongoing research suggests there may be a defect in other chemical messenger systems in the brain.
OCD may coexist with depression, eating disorders, or attention-deficit/hyperactivity disorder, and it may be related to disorders such as Tourette's syndrome, and hypochondria, though the nature of the overlap is the subject of scientific debate.

How to Treat Obsessions and Compulsions
Either psychotherapy or medication, or both, may be prescribed for OCD, and patients may respond better to one form of treatment than to the other. Studies conducted by the NIMH, however, show that combination drug-psychotherapy is best for young people. The drugs given are typically one of the so-called SSRIs, or selective serotonin reuptake inhibitors. The SSRIs fluoxetine (Prozac), fluvoxamine (Luvox), and paroxetine (Paxil) have been specifically approved for the treatment of OCD. These drugs have been shown to reduce the frequency and severity of obsessions and compulsions in more than half of patients, although discontinuation of drugs often leads to relapse. Behavioral therapy for OCD tends to produce long-lasting effects. Psychotherapy generally focuses on two aspects of the disorder: unraveling the irrational thoughts involved in the condition and gradually exposing sufferers to the feared object or idea until they are desensitized to it and can tolerate anxiety without engaging in compulsive rituals.

Is OCD on the Rise? 
Rates of OCD have not gone up, but public interest in the disease (and its various forms) has. Hoarders and those compelled to engage in rituals to ward off disturbing thoughts have lately appeared as characters on the big and small screens. A slew of real-life sufferers of OCD have written memoirs and sought help in the public eye. There is also evidence that subclinical obsessiveness about cleaning and germs could be on the rise.

About a third of adults with OCD developed the disorder as children. The repeated rituals those with OCD engage in, such as constant handwashing or hair-pulling, are meant to allay anxiety, but the relief does not last for long. As with many other mental health conditions in children, the best and most durable treatment is psychotherapy.

A critically important clinical feature of obsessive-compulsive disorder (OCD) is the pervasive secrecy of patients suffering from the condition. OCD involves recurrent, disturbing thoughts and recurrent and excessive behaviors, including rituals and constant checking. Secrecy about OCD symptoms has been responsible for a long-standing, marked underestimation of the true incidence of the illness. Although clinical recognition has increased, patients' secrecy, shame and denial continue to have an impact on assessment, treatment, and the validity of research results.

More than with many other many psychiatric disorders, OCD patients do not spontaneously or voluntarily report their symptoms to health providers or even intimate family members. OCD patients fear that revealing their symptoms will lead to severe censure and disapproval because the symptoms are often ego-dystonic and seemingly antisocial or bizarre in nature: repetitive obscene or blasphemous phrases, for example, or thoughts of attacking children or loved ones or removing one's clothes in public. Also, there is reason to believe that secrecy has its own function in both the formation and perpetuation of OCD symptoms, which serve to protect against painful anxiety.

The feelings of shame and desire for secrecy strongly influence patients' open acknowledgment of the senselessness of symptoms. OCD patients are characteristically highly concerned with approval from other people, and their acknowledgment or denial of symptom senselessness is often determined by assumptions about the expectations of interviewers, raters or administrators of self-report measures, rather than provisions of truthful accounts. There is very likely somewhat more acknowledgment of senselessness in those indulging in checking or else cleanliness behaviors, the latter being more congruent with the values of middle-class culture and therefore more individually and socially acceptable.

Attempts at diagnostic measurement, including studies of accompanying personality disorder symptoms, have been extensively confounded by the problem of shame and secrecy. These studies have shown markedly variable results. Such wide variation in itself suggests unreliability of diagnostic instruments, but less shameful-feeling obsessive-compulsive personality disorder (OCPD) patients are also secretive about reporting certain behaviors and characteristics—in this case, irrational control, hoarding, rigidity, miserliness, and meticulous perfectionism.

Sensitive extended clinical evaluations, because of trust and familiarity developed, reveal a full range of OCD patterns. Patients will readily supply answers when asked simple questions in an unthreatening manner. The questions must rely on voluntary report and in each case, the patient should be asked to evaluate the excessiveness and inappropriateness of behaviors stipulated.

How much is "excessive"? It is up to the trained clinician together with the patient to determine the answer. This orientation is also necessary for ongoing treatment and the following of specific features of the illness. In order to determine whether the patient engages in excessive checking behavior, information is gathered about job histories, including whether one repeats tasks. If so, how often?

At home, how many times is the lock on the door tested when the patient goes out, how often are the stove burners checked, how long does it take to dress in the morning? In order to assess cleanliness, the patient is asked about patterns of housekeeping, showering and handwashing. Are particular places avoided because of possible contamination or dirt? For symmetry and order, questions are directed toward preferred placement of objects in the home, pictures on the wall, and preferences about physical work environments.

For assessment of obsessional thinking, information is effectively evoked by identifying everyday difficulties in living and performing. Commonly reported problems in sleeping are followed by questions about the possibility of bothersome or repetitive thoughts that keep the patient awake. Similarly, if a patient reports distractions and inability to concentrate at work or at school, questions are asked about mental preoccupations

Obsessive disorder has long been hidden and difficult for both sufferers and therapists. Currently, various treatments are available with varying degrees of promise. A number of SSRI medications have shown beneficial effects, including clomipramine, fluoxetine, paroxetine, sertraline, and fluvoxamine—and psychotherapy is an absolute must.

Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

The New York Times recently published an article called, "Why Are More American Teenagers Than Ever Suffering From Severe Anxiety?" The author chronicled several teens' battle with anxiety over the course of a few years. The article questioned why we're seeing such a rise in anxiety among today's youth. Some young people are overachieving perfectionists with a crippling fear of failure. Others worry so much about what their peers think of them that they're unable to function. Some have endured rough circumstances throughout their young lives. But others have stable families, supportive parents, and plenty of resources. I suspect the rise in anxiety reflects several societal changes and cultural shifts we've seen over the past couple of decades. Here are the top 10 reasons:

1. Electronics offer an unhealthy escape.
Constant access to digital devices lets kids escape uncomfortable emotions like boredom, loneliness, or sadness by immersing themselves in games when they are in the car or by chatting on social media when they are sent to their rooms. And now we're seeing what happens when an entire generation has spent their childhoods avoiding discomfort. Their electronics replaced opportunities to develop mental strength, and they didn't gain the coping skills they need to handle everyday challenges.

2. Happiness is all the rage.
Happiness is emphasized so much in our culture that some parents think it's their job to make their kids happy all the time. When a child is sad, his parents cheer him up. Or when she's angry, they calm her down. Kids grow up believing that if they don't feel happy around the clock, something must be wrong. That creates a lot of inner turmoil. They don't understand that it's normal and healthy to feel sad, frustrated, guilty, disappointed, and angry sometimes, too.

3. Parents are giving unrealistic praise.
Saying things like, "You're the fastest runner on the team," or "You're the smartest kid in your grade," doesn't build self-esteem. Instead, it puts pressure on kids to live up to those labels. That can lead to crippling fear of failure or rejection.

4. Parents are getting caught up in the rat race.
Many parents have become like personal assistants to their teenagers. They work hard to ensure their teens can compete: They hire tutors and private sports coaches and pay for expensive SAT prep courses. They make it their job to help their teens build transcripts that will impress a top school. And they send the message that their teen must excel at everything in order to land a coveted spot at such a college.  

5. Kids aren't learning emotional skills.
We emphasize academic preparation and put little effort into teaching kids the emotional skills they need to succeed. In fact, a national survey of first-year college students revealed that 60 percent feel emotionally unprepared for college life. Knowing how to manage your time, combat stress, and take care of your feelings are key components to living a good life. Without healthy coping skills, it's no wonder teens are feeling anxious over every day hassles.

6. Parents view themselves as protectors rather than guides.
Somewhere along the line, many parents began believing their role is to help kids grow up with as few emotional and physical scars as possible. They became so overprotective that their kids never practiced dealing with challenges on their own. Consequently, these kids have grown up to believe they're too fragile to cope with the realities of life.

7. Adults don't know to help kids face their fears the right way.
At one end of the spectrum, you'll find parents who push their kids too hard. They force their children to do things that terrify them. On the other end, you'll find parents who don't push kids at all. They let their kids opt out of anything that sounds anxiety-provoking. Exposure is the best way to conquer fear but only when it's done incrementally. Without practice, gentle nudging, and guidance, kids never gain confidence that they can face their fears head-on.

8. Parents are parenting out of guilt and fear.
Parenting stirs up uncomfortable emotions, like guilt and fear. But rather than let themselves feel those emotions, many parents are changing their parenting habits. So they don't let their kids out of their sight because it stirs up their anxiety, or they feel so guilty saying no to their kids that they back down and give in. Consequently, they teach their kids that uncomfortable emotions are intolerable.

9. Kids aren't being given enough free time to play.
While organized sports and clubs play an important role in kids' lives, adults make and enforce the rules. Unstructured play teaches kids vital skills, like how to manage disagreements without an adult refereeing. And solitary play teaches kids how to be alone with their thoughts and comfortable in their own skin.

10. Family hierarchies 
Although kids give the impression that they'd like to be in charge, deep down they know they aren't capable of making good decisions. They want their parents to be leaders—even when there is dissension in the ranks. And when the hierarchy gets muddled—or even flipped upside down—their anxiety skyrockets.

EMDR is the treatment of choice for PTSD and other trauma-related conditions. EMDR stimulates the psyche’s natural healing process and changes the way traumatic memories are stored in the brain. When a trauma occurs, it becomes stored in the nervous system in its original disturbing form. EMDR shifts how trauma is stored in the brain and speeds-up the processing of traumatic events and reduces the disturbing emotions, symptoms, and negative beliefs associated with those experiences. Clients are often amazed at how issues they’ve worked on for years in talk therapy are no longer problematic.

Traumatic memories are stored in the brain differently than other kinds of memories.
Research has shown that traumatic memories are primarily stored in the right hemisphere of the brain, where they do not have access to networks in the left hemisphere. The left hemisphere, however, contains important thoughts and awareness that could relieve the distress if a connection can be made between the hemispheres. EMDR therapy creates this connection by stimulating both hemispheres simultaneously — restoring the brain’s natural healing processes. EMDR helps people become unstuck and renders traumatic memories manageable.

Unresolved trauma is often retriggered by environmental cues and reminders that lead a person to re-experience the emotional, physical, psychological effects of the past in the present. Through the use of eye movements, tapping, or sounds, EMDR stimulates memory processing and fundamentally changes the way the memory is stored. With EMDR therapy, your past experiences may no longer intrude on your ability to fully engage with the present.

EMDR can aid people in experiencing less fear, panic, stress, anger and shame and access more curiosity, joy, love, gratitude, and other life-enhancing affects. In addition to the effects of trauma, EMDR is used to treat anxiety, panic attacks, phobias, addiction triggers, and performance enhancement for artists, athletes, and performers.

Treatment for Anxiety
Everyone feels anxious at times. Anxiety is an inherent part of the human condition and a natural response to everyday stress such as: relationship conflicts, financial problems, work demands, receiving a medical diagnosis, and making an important decision. However, if you suffer from panic attacks, persistent fears, worry, or phobias, are on “edge,” irritable, have difficulty sleeping and concentrating, experience frequent muscle tension, or have intense dread, you may benefit from therapy in order to get relief from the debilitating effects of anxiety and improve the quality of your life. 

Do you:

• Experience anxiety or worry most of the time?
• Have feelings of fear, uneasiness, or experience sudden, unexpected panic attacks?
• Feel constantly tense, keyed up, or on “edge”?
• Feel irritable or restless?
• Have difficulty concentrating and making decisions?
• Have difficulty falling or staying asleep?
• Suffer from fears that you know are irrational, but can’t shake?
• Avoid everyday situations or activities because they cause you anxiety?
• Have a sense of impending doom?
• Have an excessive fear of dying?
• Suffer from feelings of unreality or of being detached from yourself?
• Feel out of control or like you are going crazy?
• Have frequent intrusive thoughts or ruminations?
• Experience frequent muscle tension?
• Have difficulty breathing or feel like you are choking?
• Fatigue easily?
• Excessively sweat, tremble, or shake?
• Have frequent headaches?
• Feel dizzy, lightheaded, or faint?
• Have abdominal distress, stomach cramps, urinate frequently or have diarrhea?
• Have chills or hot flashes or have cold or sweaty hands or feet?
• Have numbness or tingling sensations?
• Have nausea or dry mouth?

If you answered yes to four or more of the above then you might benefit from psychotherapy. The good news is that anxiety is a treatable condition.

What is Anxiety
Anxiety and fears are the body’s natural alarm system and occur in response to danger. The emotion of fear is experienced when we are faced with a dangerous situation and has an evolutionary role in providing safety by preparing us for fight or flight. In contrast, anxiety can occur when we anticipate or perceive an imagined danger or threat, even if unreal. Anxiety can be mild, moderate, or severe. In moderation, anxiety can be adaptive in that it helps us to stay alert and focused, spurs us to action, motivates us to solve problems, and can be used as a signal that something is important to us. However, when anxiety is constant, overwhelming, and interferes with relationships, work, and other aspects of life, it stops being productive and becomes debilitating. At the severe end of the spectrum, anxiety, worry, fear, and panic cause extreme distress that interferes with one’s ability to cope with life.

A combination of factors contribute to anxiety such as: ongoing external pressures and stress, a genetic predisposition or a family history of anxiety, adverse or traumatic childhood experiences, certain medical conditions, the effects of certain medications, foods, or substances like caffeine, and negative beliefs about oneself. Anxiety manifests in a variety of ways such as: excessive worry, panic attacks, social anxiety, and physical symptoms.

My Approach to Treatment for Anxiety
Anxiety is so much a part of our modern life that it is one of the most common reasons people seek therapy. Since anxiety manifests differently in different people, my approach integrates many different modalities and approaches such as: psychodynamic psychotherapy, CBT, DBT, EMDR, and mindfulness. Psychotherapy can help you to better understand and manage the physical and psychological effects of anxiety and panic.

If we worked together we might:

• Explore the history of your anxiety and identify any patterns or triggers of it.
• Explore any life stressors or circumstances that are contributing to your anxiety and identify any changes that you would like to make in your life.
• Explore any negative thoughts about yourself that are worsening your anxiety or panic and work to change those thoughts.
• Look at how your current lifestyle might be contributing to your anxiety by exploring your eating habits, medication and substance use, and environmental influences.
• Explore some practical tools for calming and managing your anxiety such as breathing techniques and mindfulness practices.
• Utilize EMDR or other trauma focused methods, if you have experienced any trauma that causes you to feel anxiety or panic in order to help you gain relief and move forward in your life.
• Rule out any medical contributors of your anxiety by a referral to your primary care physician.

You do not need to be a prisoner of your anxiety. Therapy for anxiety can help you gain relief from the debilitating symptoms and effects of anxiety, which can improve self-esteem and self-confidence and help you experience more enjoyment and fulfillment in your life.

The quality of our lives depends upon the quality of our relationships. Life is all about relationships. We are in relationships at all times. We are in a relationship with ourselves, with others, and with our world. As social animals, humans cannot survive without other people. We effect and are effected positively and negatively by our relationships on a daily, even hourly basis.

Attachment
Attachment is the emotional bond between people. Our earliest bonds with our caretakers have a tremendous impact throughout our lives. Psychology, interpersonal neurobiology, and neuroscience have demonstrated that attachment bonds stimulate brain growth, effect personality development, social and emotional development, the ability to form stable relationships, and to effectively regulate our feelings. For better or worse, our early life experiences lay the foundation for our relationships throughout life.

Repetitive Relational Patterns
Throughout life we repeat our relationship patterns. Freud discovered what he called “the repetition compulsion,” which he described as the tendency for humans to be drawn to situations reminiscent of unresolved traumas from earlier in life. These repetitions can be seen as an unconscious attempt to belatedly master or heal our original relational dynamics with the intent of changing the outcome. Inevitably each of us brings all of our past experiences including our feelings, expectations, defenses, coping mechanisms, and beliefs to our current relationships with the unconscious hope that they will turn out better this time. The child in us thinks, “This time will be different. I will get him or her to love me. I can change him or her if only I try hard enough.”

Trauma, abuse, neglect, and other adverse childhood experiences negatively impact the quality of relationships. A child who grew up with an abusive parent may repeatedly be drawn to abusive partners. Someone who was abandoned as a child, may be drawn to people who will leave him, and a child who grew up with an alcoholic parent, may partner with people with substance abuse problems. Unfortunately, these repetitions can cause additional suffering for ourselves and others and further entrench the distressing patterns.

Our relationships provide the potential for both our most meaningful and our most painful experiences. In addition to love, bonding, and attachment, our relationships inevitably bring up our fears, needs, desires, dependency, ambivalence, sadness, anger, jealousy, hate, resentment, and guilt. The more difficult, distressing, and traumatic our earlier relationships, the more potentially hurtful and damaging our current relationships can become. If you find yourself repeating the same painful relationship patterns over and over again, you might benefit from psychotherapy.

Psychotherapy Provides a Choice
Psychotherapy can facilitate a movement from unconscious reenactment of distressing experiences to consciousness of our patterns. Understanding of our patterns provides a choice about how we want to act in the future. Awareness is the first step toward positive change. Acceptance and compassion for ourselves is the foundation of being able to love and have compassion for the people in our lives. It is possible to heal our original relational wounds and learn how to better handle repetitive situations in order to put an end to a destructive cycle.

Most of the people I work with are concerned about the quality of their relationships. Some are individuals who seek to improve the relationship with their partner, child, family members, and work colleagues. Others come for Couples Counseling to heal and change the repetitive and conflictual patterns that threaten to destroy their bond.

If you are suffering by repetitively re-experiencing some old relational patterns, I’d like to help.

Depression
Everyone feels sad sometimes. Feelings of sadness and grief are natural and adaptive responses to loss. However, if you feel sad, irritable, or “empty” most of the time, have lost interest in activities or relationships that you once enjoyed, have difficulty concentrating, and find your appetite, sleep, or activity level has changed, you may be experiencing depression. For some people feelings of sadness and grief become overwhelming and debilitating while others find that they feel numb and have difficulty feeling anything at all. Depression occurs when these symptoms interfere with daily functioning.

Are you…

• Feeling sad or “empty” most of the day, nearly every day?
• Feeling irritable or restless?
• Losing interest and pleasure in activities and relationships that you once enjoyed?
• Having difficulty concentrating or making decisions?
• Having difficulty sleeping or waking?
• Losing your appetite or overeating?
• Experiencing more aches or pains, digestive problems, or headaches?
  Feeling hopeless and pessimistic?
• Experiencing a sense of worthlessness or excessive guilt?
• Feeling tired, unmotivated, or helpless?
• Having thoughts of suicide?

If you answered yes to five or more of the above then you are probably experiencing depression and you are not alone. The good news is that depression is a treatable condition. Depression is fairly common and is one of the most common reasons people seek therapy. About 9 percent of American adults suffer from some form of depression and its rates worldwide are increasing. Major Depression, a severe form of depression, is the leading cause of disability worldwide.

Whether your depression is a reaction to a recent event or events in your life, something that you have felt off and on for years, or something you have struggled with throughout your life, there is help. Depression slows us down and provides an opportunity for self-understanding.

My Approach to Treatment for Depression
Depression is a highly treatable condition. It is complex, manifests differently in different people, and can be mild, moderate, or severe. Depression is usually caused by a combination of genetic, biological, environmental, interpersonal, psychological, and situational factors. My approach to working with depression integrates many different modalities and approaches. I would want to become as informed as possible about your particular depression so that our work can best meet your needs.

There may be a reason for what you are experiencing. If we worked together we might: Explore the history of your depression and any history of depression in your family. We might identify any patterns or triggers of your depression and explore if there are any early losses or childhood events that are contributing to it.

We can explore any life circumstances, stressors, or any repetitive relational patterns that are worsening your depression and identify any changes that you would like to make in your life. We can explore the possible “wisdom” in your depression and that it might be indicating that there is something important that is missing in your life. We might explore a possible discrepancy between where you want to be in your life and where you are currently. Perhaps you are seeking more meaning and a sense of purpose in your life. We can explore any negative thoughts about yourself and use cognitive techniques to identify any negative thought process that are fueling your depression and work to change those thoughts.

We would want to rule out any medical and biochemical causes of your depression, which is usually done by your primary care physician.

We could look at how your current lifestyle might be contributing to your depression by exploring your eating habits, exercise, and alcohol and substance use and explore any environmental influences that might be worsening your mood.

I could teach you some practical tools for shifting your mood in the moment and we could engage in dreamwork, sandplay, active imagination, or other creative methods in order facilitate the natural wisdom and healing of your imagination for integration and wholeness.

If you have experienced trauma or feel stuck in your life due to unresolved emotional hurts or injuries, we could utilize EMDR or other trauma focused methods in order to aid you in moving forward. Recent scientific research has suggested that there may be an evolutionary reason for depression.

Research has shown that depression promotes introspection and increased mental acuity. Numerous studies have demonstrated that when someone is depressed their increased blood flow to certain areas of the brain. Studies have also shown that people who are depressed are better able to solve complex problems those who are not. By taking your depression seriously, you may be able to gain insight into yourself and make important changes so that you can more fully engage in and enjoy your life.

​The stress of living through a pandemic is putting relationships to the test. There’s not a single one of us who isn’t dealing with a tremendous amount of stress right now. Work issues, tight living quarters, financial uncertainty, fears about the health of our loved ones, fears of getting sick ourselves, and as we all know, stress does not bring out the best in us.

So how can you keep your relationship from crumbling under the weight of these challenges? 

1. Bring back date night.

Social distancing guidelines may have foiled your go-to date night plans. You can’t hire a babysitter, eat at a restaurant or catch a movie in theaters. But you can still carve out some time to connect at home setting aside at least several hours per week for just the two of you. Meet up in the backyard or on the balcony. Dress in your finest if you wish, have a drink together (non-alcoholic is fine), slow dance, and play charades or a board game. Try and keep the conversation light, humorous and optimistic. This should be a time to step away from the stress of COVID-19 and reconnect with your partner.

2. Cut each other some slack — more than you usually would.

We’re living through a highly stressful, unsettling, anxiety-inducing time. Under these conditions, it’s difficult to present the best versions of ourselves. So be gentle on each other when tensions inevitably arise. Find compassion for yourself and your partner when arguments come up and realize that it’s likely a normal reaction to an abnormal situation. Don’t rush to judge the quality of your relationship right now, and continue to find ways to communicate and be vulnerable about difficult feelings. Have compassion around the fact that this is hard.

That’s not to say everyone should get a pass for all bad behavior right now. You can gently call out your partner for their snippy remark or harsh tone without escalating the incident into a bigger fight. If one or both of you are short-tempered or impatient, don’t turn it into a federal case. Keep in mind that when we’re under pressure, most of us need some TLC far more than we need a lecture about not being nice.

3. Prioritize your alone time.

Stay-at-home orders have led to a whole lot of forced togetherness, for better and worse. It turns out that the time you used to spend on your daily commute or at the gym was actually really important for your mental health and relationship. Finding those pockets of “me” time may be a challenge these days so you need to be intentional about giving each other space. Be understanding if your partner needs some time with a book, video game, Zoom call or wants to put in some earbuds to listen to music.  Also, if you are fortunate enough to be working from home right now, try to give each other your own dedicated space to work.

4. Practice self-care together.

Find a few self-care rituals that you can do together. You may have self-care rituals that you prefer to practice solo, but also try to find some nourishing activities that you can do as a couple: meditating together in the morning, walking outside after lunch, or sipping tea and sharing a few things you’re grateful for before bed.

Being able to do these things together helps to build your connection to each other, while also engaging in healthy ways to cope with the stress that comes while in quarantine. Keeping a healthy headspace will be good for you and your relationship.

5. Create a quarantine routine that works for you.

When the world around us is chaotic, maintaining a consistent daily routine can make you feel more grounded. Set some structure around your day-to-day activities.  Decide mealtimes, leisure times, time as a couple or family, and time alone. This will help reduce anxiety, especially if you have kids at home.

6. Stop keeping score on who’s doing more around the house.

Couples’ systems for divvying up household duties like cooking, cleaning, laundry, walking the dog and taking care of the kids have been turned upside down during the pandemic. Though this division of labor may have had its frustrations and imbalances back then, it was at least predictable. Now, for many of us, the rules have changed. One partner may be working 18-hour hospital shifts and keeping a distance from the family, or one partner with flexible work hours doing most of the child care and home schooling. A good rule of thumb: Do as much as you can, express gratitude for your partner’s contribution and accept that there’s likely too much to do.

Given the mounting responsibilities, don’t get hung up on making sure everything’s divided evenly. Remember that your partner is probably doing their best — there’s just a lot on both of your plates right now. Do as much as you can, express gratitude for your partner’s contribution and accept that there’s likely too much to do. 

7. Don’t try to resolve long-standing conflicts right now.

This probably isn’t the best time to hash out major relationship problems that existed prior to the quarantine. If there are smaller, specific grievances you need to air, bring them up but stay focused on the issue at hand. Avoid resorting to criticism or making sweeping generalizations that attack your partner’s character. For example, don’t criticize or try to control a partner who wishes to return to work. Instead, state how you feel and make the small request for change. Saying something like, ‘I get scared at the idea of you going back to the office so soon. Can we decide together around the timing for that?’ is much more likely to get a positive response.

For some couples, things have gotten better and for others, much worse. If it’s gotten really contentious between you both, online therapy is readily available to help you better navigate your relationship. Don’t hesitate to get professional help.

With the current coronavirus pandemic that is sweeping through our country and the world. We are reminded daily of the suffering families and individuals are experiencing with the loss of their loved ones.  Their grief and loss can become ours. The people that remain behind after they lose someone that they loved and cared for are experiencing great sadness, grief and loss. I am reminded of the five stages of grief and loss that were first proposed by Elisabeth Kubler-Ross in her 1969 book On Death and Dying.

The 5 stages of grief and loss are: Denial and isolation, Anger, Bargaining and Depression; Acceptance. People who are grieving do not necessarily go through the stages in the same order or experience all of them.

The stages of grief and mourning are universal and are experienced by people from all walks of life, across many cultures. Mourning occurs in response to an individual’s own terminal illness, the loss of a close relationship, or to the death of a valued being, human, or animal. In our bereavement, we spend different lengths of time working through each step and express each stage with different levels of intensity. Contrary to popular belief, the five stages of loss do not necessarily occur in any specific order. We often move between stages before achieving a more peaceful acceptance of death. Many of us are not afforded the luxury of time required to achieve this final stage of grief.

The death of our loved ones might inspire us to evaluate our own feelings of mortality. Throughout each stage, a common thread of hope emerges: As long as there is life, there is hope. As long as there is hope, there is life.

Many people do not experience the stages of grief in the order listed below, which is perfectly okay and normal. The key to understanding the stages is not to feel like you must go through every one of them, in precise order. Instead, it’s more helpful to look at them as guides in the grieving process — it helps you understand and put into context where you are.

Please keep in mind that everyone grieves differently. Some people will wear their emotions on their sleeve and be outwardly emotional. Others will experience their grief more internally, and may not cry. You should try and not judge how a person experiences their grief, as each person will experience it differently.

1. Denial & Isolation

The first reaction to learning about the terminal illness, loss, or death of a cherished loved one is to deny the reality of the situation. “This isn’t happening, this can’t be happening,” people often think. It is a normal reaction to rationalize our overwhelming emotions.

Denial is a common defense mechanism that buffers the immediate shock of the loss, numbing us to our emotions. We block out the words and hide from the facts. We start to believe that life is meaningless, and nothing is of any value any longer. For most people experiencing grief, this stage is a temporary response that carries us through the first wave of pain.

2. Anger

As the masking effects of denial and isolation begin to wear, reality and its pain re-emerge. We are not ready. The intense emotion is deflected from our vulnerable core, redirected and expressed instead as anger. The anger may be aimed at inanimate objects, complete strangers, friends or family.

Anger may be directed at our dying or deceased loved one. Rationally, we know the person is not to be blamed. Emotionally, however, we may resent the person for causing us pain or for leaving us. We feel guilty for being angry, and this makes us even more angry.

Remember, grieving is a personal process that has no time limit, nor one “right” way to do it.

The doctor who diagnosed the illness and was unable to cure the disease might become a convenient target. Health professionals deal with death and dying every day. That does not make them immune to the suffering of their patients or to those who grieve for them.

Do not hesitate to ask your doctor to give you extra time or to explain just once more the details of your loved one’s illness. Arrange a special appointment or ask that he telephone you at the end of his day. Ask for clear answers to your questions regarding medical diagnosis and treatment. Understand the options available to you. Take your time.

3. Bargaining

The normal reaction to feelings of helplessness and vulnerability is often a need to regain control through a series of “If only” statements, such as:

If only we had sought medical attention sooner…
If only we got a second opinion from another doctor…
If only we had tried to be a better person toward them…

This is an attempt to bargain. Secretly, we may make a deal with God or our higher power in an attempt to postpone the inevitable, and the accompanying pain. This is a weaker line of defense to protect us from the painful reality.

Guilt often accompanies bargaining. We start to believe there was something we could have done differently to have helped save our loved one.

4. Depression

There are two types of depression that are associated with mourning. The first one is a reaction to practical implications relating to the loss. Sadness and regret predominate this type of depression. We worry about the costs and burial. We worry that, in our grief, we have spent less time with others that depend on us. This phase may be eased by simple clarification and reassurance. We may need a bit of helpful cooperation and a few kind words.

The second type of depression is more subtle and, in a sense, perhaps more private. It is our quiet preparation to separate and to bid our loved one farewell. Sometimes all we really need is a hug.

5. Acceptance

Reaching this stage of grieving is a gift not afforded to everyone. Death may be sudden and unexpected or we may never see beyond our anger or denial. It is not necessarily a mark of bravery to resist the inevitable and to deny ourselves the opportunity to make our peace. This phase is marked by withdrawal and calm. This is not a period of happiness and must be distinguished from depression.

Loved ones that are terminally ill or aging appear to go through a final period of withdrawal. This is by no means a suggestion that they are aware of their own impending death or such, only that physical decline may be sufficient to produce a similar response. Their behavior implies that it is natural to reach a stage at which social interaction is limited. The dignity and grace shown by our dying loved ones may well be their last gift to us.

Coping with loss is ultimately a deeply personal and singular experience — nobody can help you go through it more easily or understand all the emotions that you’re going through. But others can be there for you and help comfort you through this process. The best thing you can do is to allow yourself to feel the grief as it comes over you. Resisting it only will prolong the natural process of healing.

According to a study published in the Journal of Communication, people in long-distance relationships were more likely to share meaningful thoughts and feelings with their partners than those who were not. Apparently, couples in long-distance relationships tend to idealize their partners’ behaviors, which leads to a greater sense of intimacy. However, being apart is definitely trying at times, even for couples with a relatively strong foundation.

Below, I have compiled edited excerpts from people that highlight the tenets of maintaining a successful long-distant relationship.

Tip 1: Be ready to work twice as hard as you did before.

“I met my boyfriend when I was in high school. In the fall he left to attend college in a year-round program in Utah. I stayed behind and finished up high school and then attended a local college. Even though we were young, we knew our relationship was the one worth fighting for so we were determined to get through those years. We have now been together a total of 12 years and have been married for the last five.”

What this couple learned is one of the foundations of a successful long-distance relationship. Long distance couples need to work toward having a very strong, solid base in their relationship Be open, honest, and trusting. Take the time to figure out how and when is best to communicate with each other. Work at making each other feel special, even without seeing each other. All the things you work on during a normal relationship will need extra effort for in a long-distance relationship.

Tip 2: Establish some ground rules about when you’ll see each other.

“My husband and I did long distance for five and a half years in total, with me working and going to school in Toronto and him in school in Florida. We had a rule to never go more than six weeks without seeing one another in person and we pretty much stuck to that. We were still living apart when we got married and it took one year after we were married for my green card to arrive, at which point I moved to the states.

Tip 3: Call and text each other throughout the day.

Don’t wait to talk with your partner at the end of the day when you are tired. Make your partner part of your daily life.

“My wife and I have had to do the long-distance thing twice in our relationship. When we first met she lived about an hour away in San Jose and I lived in San Francisco. After we got married I was working in San Francisco and she was in Los Angeles and we only got a few days a month to see each other. We learned that you have to call and text each other during the day and share what’s going on.”

Tip 4: Don’t forget to schedule regular online video chats.

It is really essential that you and your partner have a schedule for when you’ll talk. Today we are fortunate that we have so many different modes of contact these days, but texting is not enough to keep a long-distance relationship going. To maintain a strong relationship, you need to talk on the phone, but preferably something like Skype, as often as you can.

Tip 5: Try to think of the big picture.

“My partner and I met in university and had been together for about three and a half years before he had to leave Nigeria for his graduate degree in London. We were apart for about two years. We had to constantly remind ourselves that the distance was for a short while and as we really wanted to be together, we had to make it work.  This sort of gives a perspective on things and helps sail through any difficulties. This was really important in the grand scheme of things. It also helped in our future plans, as I was more inclined to go London for my own graduate program, so that we could be together.”

Tip 6: Celebrate everything.

“My husband I had had known each other in college. He left for the Navy, and then we started dating. At that point, we were a few states away. Right after we became engaged, he was deployed overseas for a year. What we learned is this: Celebrate everything, even if you can’t be together in person. Life is too short not to and that’s especially true when you’re in a long-distance relationship.”

Tip 7: Get a credit card that earns airline miles.

“I was located in New York City while my husband Matt was in Miami Beach. We had a commuter relationship for two years. I was able to get complimentary flights almost every other month this way from my American Express card. Make sure to pick a card with an airline component so you can rack up the points

Tip 8: Don’t worry if every visit isn’t perfect.

There can be a lot pressure on a couple when they visit each other. Do you hang out with your partner and friends in a social setting or stay home to have one-on-one time? Does your family want to spend time with you and your partner? Does one of you need to work or study during the visit? Is there a big conversation hovering like an elephant in the room and do you have that talk face to face, when you have limited time together, or over the phone later? Some trips will be full of great memories and carefree times, and some will be full of fighting over big or small issues and that’s OK! ‘Real’ relationships are full of ups and downs and long-distance relationships are no exception.” ​

A co-dependent person works so hard to control and fix someone else that his/her own life is in turmoil as a result. Because we are powerless over other people, no one can really control anyone else, and others’ troubles are mostly due to patterns only they can change, a codependent person is in for one painful disappointment after another. 

The term powerless does not mean helpless. Up until now you have been powerless over your thoughts, feelings and actions and have led you to believe that your needs should be sacrificed for others, regardless of the consequences. Co-dependency creates stress and leads to painful emotions. Shame and low self-esteem all blend together to create anxiety and fear about being judged, rejected or abandoned; making mistakes; being a failure; feeling trapped by being too close to another person or being alone. Very often the codependent’s self-esteem and self-worth comes from sacrificing themselves for their partner and their partner will gladly accept their sacrifice.   

Signs of codependency may include:

• Having difficulty making decisions in a relationship.
• Having difficulty identifying your feelings.
• Having difficulty communicating in a relationship.
• Valuing the approval of others more than valuing yourself.
• Lacking trust in yourself and having poor self-esteem.

Below are twenty questions I have created for my clients to help provide them with an understanding of their codependent relationships and the impact of their  on themselves and their partner.

If you believe you struggle with codependence, thoughtfully answer the questions below and  if you are currently working with a therapist, process your answers with your therapist.

Codependence Questions

1. What does Codependency mean to me?
2. Has my Codependence been active recently In what way?
3. How has my Codependence affected me Physically? Mentally? Spiritually? Emotionally?
4. What is the specific way in which my Codependence has been manifesting itself most recently?
5. What people in my life trigger my Codependence, how is manifested? Explain.
6. What events or my job in my life triggers my Codependence and how? Explain.
7. Have I been obsessed with a person, place or thing If so, how has that gotten in the way of my relationships with ourselves and others? 
8. How has my Codependence affected me mentally, physically, spiritually and emotionally.
9. How has my Codependence impacted my relationships with my Mother, Father & siblings?
10. How has my Codependence impacted my relationships with friends?
11. How has my Codependence impacted my relationship with my girlfriend or boyfriend. 
12. How have I blamed other people for my Codependent behavior?
13. What has happened recently in my life that has led me to work on my Codependence?
14. When did I first recognize my Codependence as a problem Did I try to correct it? If so, how If not, why not 
15. How has my Codependence isolated me from developing relationships with other people?
16. I’ve done things while acting out on my Codependence that I wish never happened What were they? Has my Codependence caused me to hurt others or myself? Explain.
17. What things have I done to maintain my Codependence that went completely against all my beliefs and values?
18. How does my personality change when I’m acting out on my Codependence (For example: Do I become arrogant? Self-centered Mean- tempered? Manipulative? Whinny?) Passive to the point where I can’t protect / stand up for myself? 
19. If I put my needs before others does that make me a selfish / inconsiderate person? If not why not? If so, why?
20. How has my lack of boundaries connected to my Codependence?

Most depression drugs work by changing the balance of brain chemicals called neurotransmitters, which affect your mood. They include serotonin, noradrenaline, and norepinephrine. Your primary care doctor can prescribe antidepressants. But if your symptoms are severe, they’ll refer you to a psychiatrist. That’s a doctor who specializes in mental health. Medication can help with depression symptoms, but it doesn’t always treat the causes of your depression.

Different classes of antidepressants work on different brain chemicals. Tricyclics (TCAs) and serotonin norepinephrine reuptake inhibitors (SNRIs) raise serotonin and norepinephrine levels in your brain. Selective serotonin reuptake inhibitors (SSRIs) raise serotonin. Monoamine oxidase inhibitors (MAOIs) stop monoamine neurotransmitters from breaking down.

Talk to your doctor if your symptoms haven’t improved after 3 months. You may need a stronger dose or a different antidepressant. Many people don’t get relief from the first antidepressant they try. Also, depression meds may stop working in a small number of people who’ve been taking them for a while. If this happens to you, your doctor can help. Work together to find the treatment that’s right for you. It may take time.

The FDA says the generic drugs it approves are as effective as the brand-name versions. Both types have the same active ingredient. Ask your doctor if you can take the generic form of a drug. It may cost less than the brand-name version.

You may be tempted to quit taking your medicine even though it’s working well. Or you might think about stopping because the dosing schedule is inconvenient, or because there are unpleasant side effects. Also, some people with depression don’t improve with antidepressants and must explore other treatment options.

If newer antidepressants don’t work, your doctor may prescribe cyclic antidepressants. These were some of the first antidepressants made. They raise serotonin and norepinephrine levels in your brain.

Keep taking your antidepressants for as long as your doctor says so (usually at least 6 months). Do this even if you feel better sooner, or your depression could return. Don’t be shy in telling your doctor about any side effects. There are often ways to manage them. For example, taking your antidepressant with food can help nausea. If you’re having sexual problems, your doctor may change your medicine or add another one. If you feel fatigued, try taking your medicine 1 to 2 hours before bedtime. If the antidepressant causes insomnia, take it in the morning. Many side effects go away on their own after a few weeks.

The antidepressants used most often today have fewer side effects and drug interactions than older versions. Still, any antidepressant can interact with other medications. Let your doctor know about any new prescription drug, over-the-counter medicine, or dietary supplement you plan to take. These could affect how your depression medication works. It’s important to keep going to all your doctor appointments while you’re on antidepressants.

It’s common for depression to come back. That’s called a relapse. Your doctor may change the dose -- or prescribe a new medication -- if your symptoms return. Be sure to tell your doctor about any major changes in your life, such as losing a job, developing another medical condition, or becoming pregnant.

Your medication may make you feel jumpy or nervous. Exercise can help. Try a relaxing workout like yoga, or deep breathing exercises. Your doctor can switch you to a different antidepressant if that doesn’t help. Some people worry antidepressants will turn them into a “robot.” The fact is, antidepressants can ease feelings of sadness, but they don’t get rid of your emotions.

Another myth is that you’ll need to take the drugs for life. A typical course of antidepressants lasts 6 to 12 months in people who’ve had only a single episode of major depression. But you may need treatment longer if you’ve had multiple episodes of depression in your life. Also, if you’ve heard antidepressants are physically addictive, that’s not true. Still, you could have unpleasant symptoms if you stop taking them suddenly.

Studies show “talk” therapy and antidepressants are often the most effective way to treat depression. Types of therapy include cognitive behavioral therapy, which focuses on changing negative thoughts and behaviors, and interpersonal therapy, which focuses on your relationships with others.

Exercise releases endorphins, chemicals linked to improved mood and lower rates of depression. Several studies suggest regular exercise is an effective treatment for mild to moderate depression. Group workouts or exercising with a partner may also be helpful.
Your doctor will help you figure out the right time to stop your antidepressants. Quitting suddenly can cause unpleasant side effects or even a relapse. You could go into withdrawal for up to 2 weeks. You might be dizzy, nauseous, tired, or have headaches. Or you might get vertigo, which is when you feel like you or things around you are moving. Your depression symptoms may come back, too. Work with your doctor to slowly stop taking your medicine.

Although it may feel like you’re the only one with this problem, social anxiety is actually quite common. Many people struggle with these fears. But the situations that trigger the symptoms of social anxiety disorder can be different.

Some people experience anxiety in most social situations. For others, anxiety is connected to specific social situations, such as speaking to strangers, mingling at parties, or performing in front of an audience. Common social anxiety triggers include:

• Meeting new people
• Making small talk
• Public speaking
• Performing on stage
• Being the center of attention
• Being watched while doing something
• Being teased or criticized
• Talking with “important” people or authority figures

• Being called on in class
• Going on a date
• Speaking up in a meeting
• Using public restrooms
• Taking exams
• Eating or drinking in public
• Making phone calls
• Attending parties or other social gatherings

 
Signs and symptoms of social anxiety disorder
Just because you occasionally get nervous in social situations doesn’t mean you have social anxiety disorder or social phobia. Many people feel shy or self-conscious on occasion, yet it doesn’t get in the way of their everyday functioning. Social anxiety disorder, on the other hand, does interfere with your normal routine and causes tremendous distress.

For example, it’s perfectly normal to get the jitters before giving a speech. But if you have social anxiety, you might worry for weeks ahead of time, call in sick to get out of it, or start shaking so bad during the speech that you can hardly speak.
 
Emotional signs and symptoms of social anxiety disorder:

• Excessive self-consciousness and anxiety in everyday social situations
• Intense worry for days, weeks, or even months before an upcoming social situation
• Extreme fear of being watched or judged by others, especially people you don’t know
• Fear that you’ll act in ways that will embarrass or humiliate yourself
• Fear that others will notice that you’re nervous  

Physical signs and symptoms:

• Red face, or blushing
• Shortness of breath
• Upset stomach, nausea (i.e. butterflies)
• Trembling or shaking (including shaky voice)
• Racing heart or tightness in chest
• Sweating or hot flashes
• Feeling dizzy or faint

Behavioral signs and symptoms:

• Avoiding social situations to a degree that limits your activities or disrupts your life
• Staying quiet or hiding in the background in order to escape notice and embarrassment
• A need to always bring a buddy along with you wherever you go
• Drinking before social situations in order to soothe your nerves

 
Social anxiety disorder in children:
There’s nothing abnormal about a child being shy, but children with social anxiety disorder experience extreme distress over everyday situations such as playing with other kids, reading in class, speaking to adults, or taking tests. Often, children with social phobia don’t even want to go to school.

How to overcome social anxiety disorder tip 1: Challenge negative thoughts
While it may seem like there’s nothing you can do about the symptoms of social anxiety disorder or social phobia, in reality, there are many things that can help. The first step is challenging your mentality.
Social anxiety sufferers have negative thoughts and beliefs that contribute to their fears and anxiety. These can include thoughts such as:

• “I know I’ll end up looking like a fool.”
• “My voice will start shaking and I’ll humiliate myself.”
• “People will think I’m stupid”
• “I won’t have anything to say. I’ll seem boring.”

Challenging these negative thoughts is an effective way to reduce the symptoms of social anxiety.
 
Tip 1: Identify the automatic negative thoughts that underlie your fear of social situations. For example, if you’re worried about an upcoming work presentation, the underlying negative thought might be: “I’m going to blow it. Everyone will think I’m completely incompetent.”

Analyze and challenge these thoughts. It helps to ask yourself questions about the negative thoughts: “Do I know for sure that I’m going to blow the presentation?” or “Even if I’m nervous, will people necessarily think I’m incompetent?” Through this logical evaluation of your negative thoughts, you can gradually replace them with more realistic and positive ways of looking at social situations that trigger your anxiety. It can be incredibly scary to think about why you feel and think the way you do, but understanding the reasons for your anxieties will help lessen their negative impact on your life.

Unhelpful thinking styles that fuel social anxiety.
Ask yourself if you’re engaging in any of the following unhelpful thinking styles:

• Mind reading – Assuming you know what other people are thinking, and that they see you in the same negative way that you see yourself.
• Fortune telling – Predicting the future, usually while assuming the worst will happen. You just “know” that things will go horribly, so you’re already anxious before you’re even in the situation.
• Catastrophizing – Blowing things out of proportion. For example, if people notice that you’re nervous, it will be “awful”, “terrible”, or “disastrous.”
• Personalizing – Assuming that people are focusing on you in a negative way or that what’s going on with other people has to do with you.

 
Tip 2: Focus on others, not yourself
When we’re in a social situation that makes us nervous, many of us tend to get caught up in our anxious thoughts and feelings. You may be convinced that everyone is looking at you and judging you. Your focus is on your bodily sensations, hoping that by paying extra close attention you can better control them. But this excessive self-focus just makes you more aware of how nervous you’re feeling, triggering even more anxiety! It also prevents you from fully concentrating on the conversations around you or the performance you’re giving.
Switching from an internal to an external focus can go a long way toward reducing social anxiety. This is easier said than done, but you can’t pay attention to two things at once. The more you concentrate on what’s happening around you, the less you’ll be affected by anxiety.
 
Focus your attention on other people—but not on what they’re thinking of you! Instead, do your best to engage them and make a genuine connection.
 
Remember that anxiety isn’t as visible as you think. And even if someone notices that you’re nervous, that doesn’t mean they’ll think badly of you. Chances are other people are feeling just as nervous as you—or have done in the past.
 
Really listen to what is being said—not to your own negative thoughts.

Focus on the present moment, rather than worrying about what you’re going to say or beating yourself up for a flub that’s already passed.

Release the pressure to be perfect. Instead, focus on being genuine and attentive—qualities that other people will appreciate.
 
Tip 3: Learn to control your breathing
Many changes happen in your body when you become anxious. One of the first changes is that you begin to breathe quickly.

Overbreathing (hyperventilation) throws off the balance of oxygen and carbon dioxide in your body—leading to more physical symptoms of anxiety, such as dizziness, a feeling of suffocation, increased heart rate, and muscle tension.

Learning to slow your breathing down can help bring your physical symptoms of anxiety back under control. Practicing the following breathing exercise will help you stay calm:

• Sit comfortably with your back straight and your shoulders relaxed. Put one hand on your chest and the other on your stomach.
• Inhale slowly and deeply through your nose for 4 seconds. The hand on your stomach should rise, while the hand on your chest should move very little.
• Hold the breath for 2 seconds.
• Exhale slowly through your mouth for 6 seconds, pushing out at much air as you can. The hand on your stomach should move in as you exhale, but your other hand should move very little.
• Continue to breathe in through your nose and out through your mouth. Focus on keeping a slow and steady breathing pattern of 4-in, 2-hold, and 6-out.

 
Tip 4: Face your fears
One of the most helpful things you can do to overcome social anxiety is to face the social situations you fear rather than avoid them. Avoidance keeps social anxiety disorder going. While avoiding nerve-wracking situations may help you feel better in the short term, it prevents you from becoming more comfortable in social situations and learning how to cope in the long term. In fact, the more you avoid a feared social situation, the more frightening it becomes.
Avoidance can also prevent you from doing things you’d like to do or reaching certain goals. For example, a fear of speaking up may prevent you from sharing your ideas at work, standing out in the classroom, or making new friends.

While it may seem impossible to overcome a feared social situation, you can do it by taking it one small step at a time. The key is to start with a situation that you can handle and gradually work your way up to more challenging situations, building your confidence and coping skills as you move up the “anxiety ladder.”

For example, if socializing with strangers makes you anxious, you might start by accompanying an outgoing friend to a party. Once you’re comfortable with that step, you might try introducing yourself to one new person, and so on. 
 
To work your way up a social anxiety ladder:
 
Don’t try to face your biggest fear right away. It’s never a good idea to move too fast, take on too much, or force things. This may backfire and reinforce your anxiety.
 
Be patient. Overcoming social anxiety takes time and practice. It’s a gradual step-by-step progress.
 
Use the skills you’ve learned to stay calm, such as focusing on your breathing and challenging negative assumptions.
 
Socially interacting with co-workers: A sample anxiety ladder:
Step 1: Say “hi” to students and other students.
Step 2: Ask students questions about how to complete tasks at work.
Step 3: Ask a students what they did on the weekend.
Step 4: Sit in the staff room during coffee break.
Step 5: Eat lunch in the staff room.
Step 6: Eat lunch in the staff room and make small talk with coworkers (e.g., talk about the weather, sports, current events, etc.)
Step 7: Ask a co-worker to go for coffee after work.
Step 8: Go out for lunch with a group of co-workers.
Step 9: Share personal information about yourself with co-workers.
Step 10: Attend a staff party.
 
Tip 5: Make an effort to be more social:
Actively seeking out supportive social environments is another effective way of challenging your fears and overcoming social anxiety. The following suggestions are good ways to start interacting with others in positive ways:
 
Take a social skills class or an assertiveness training class: 
These classes are often offered at local adult education centers or community colleges.
 
Volunteer doing something you enjoy:
Perhaps  walking a dog in a shelter, or working at your local food bank—anything that will give you an activity to focus on while you are also engaging with a small number of like-minded people.
 
Work on your communication skills:
 Good relationships depend on clear, emotionally-intelligent communication. If you find that you have trouble connecting to others, learning the basic skills of emotional intelligence can help. You can make friends even if you’re shy or socially awkward. No matter how awkward or nervous you feel in the company of others, you can learn to silence self-critical thoughts, boost your self-esteem, and become more confident and secure in your interactions with others. You don’t have to change your personality. By simply learning new skills and adopting a different outlook you can overcome your fears and anxiety and build rewarding friendships.
 
Tip 6: Adopt an anti-anxiety lifestyle
The mind and the body are intrinsically linked—and more and more evidence suggests that how you treat your body can have a significant effect on your anxiety levels, your ability to manage anxiety symptoms, and your overall self-confidence.
While lifestyle changes alone aren’t enough to overcome social phobia or social anxiety disorder, they can support your overall treatment progress. The following lifestyle tips will help you reduce your overall anxiety levels and set the stage for successful treatment.

Avoid or limit caffeine – Coffee, tea, soda, and energy drinks act as stimulants that increase anxiety symptoms. Consider cutting out caffeine entirely, or keeping your intake low and limited to the morning.

Get active – Make physical activity a priority—30 minutes per day if possible. If you hate to exercise, try pairing it with something you do enjoy, such as window shopping while walking laps around the mall or dancing to your favorite music.
 
Add more omega-3 fats to your diet – Omega-3 fatty acids support brain health and can improve your mood, outlook, and ability to handle anxiety. The best sources are fatty fish (salmon, herring, mackerel, anchovies, sardines), seaweed, flaxseed, and walnuts.
 
Drink only in moderation – You may be tempted to drink before a social situation to calm your nerves, but alcohol increases your risk of having an anxiety attack.
 
Quit smoking – Nicotine is a powerful stimulant. Contrary to popular belief, smoking leads to higher, not lower, levels of anxiety. If you need help kicking the habit, see: How to Quit Smoking.
 
Get enough quality sleep – When you’re sleep deprived, you’re more vulnerable to anxiety. Being well rested will help you stay calm in social situations.

Social anxiety disorder treatment
If you’ve tried the self-help techniques above and you’re still struggling with disabling social anxiety, you may need professional help as well.

Therapy for social anxiety
Of all the professional treatments available, cognitive-behavioral therapy (CBT) has been shown to work best for treating social anxiety disorder. CBT is based on the premise that what you think affects how you feel, and your feelings affect your behavior. So if you change the way you think about social situations that give you anxiety, you’ll feel and function better.
 
CBT for social phobia may involve:
Learning how to control the physical symptoms of anxiety through relaxation techniques and breathing exercises.
 
Challenging negative, unhelpful thoughts that trigger and fuel social anxiety, replacing them with more balanced views.
 
Facing the social situations you fear in a gradual, systematic way, rather than avoiding them.

While you can learn and practice these exercises on your own, if you’ve had trouble with self-help, you may benefit from the extra support and guidance a therapist brings.
 
Role-playing, social skills training, and other CBT techniques, often as part of a therapy group. Group therapy uses acting, videotaping and observing, mock interviews, and other exercises to work on situations that make you anxious in the real world. As you practice and prepare for situations you’re afraid of, you will become more and more comfortable, and your anxiety will lessen.

Medication for social anxiety disorder
Medication is sometimes used to relieve the symptoms of social anxiety, but it’s not a cure. Medication is considered most helpful when used in addition to therapy and self-help techniques that address the root cause of your social anxiety disorder.
 
Three types of medication are used in the treatment of social anxiety:
Beta blockers are used for relieving performance anxiety. While they don’t affect the emotional symptoms of anxiety, they can control physical symptoms such as shaking hands or voice, sweating, and rapid heartbeat.
Antidepressants: Zoloft may be helpful when social anxiety disorder is severe and debilitating.
Benzodiazepines are fast-acting anti-anxiety medications. However, they are sedating and addictive, so are typically prescribed only when other medications have not worked.​

If you find you’re drinking more alcohol during the COVID-19 pandemic or starting to drink alone, you’re—well, not alone. Maybe you used to drink only occasionally, but now it feels like there’s permission to make drinking a daily ritual. 

Working from home makes it even easier to turn to alcohol in the evening (or earlier). Why not have a drink (or three) every night when you don’t have to get up early to make yourself presentable and get to work on time? Pouring a drink can be especially appealing after a stressful day, which is pretty much every day now.

But what if you’re not entirely comfortable with your recent pattern of alcohol use, and part of you worries it might become a real issue? Even if you’ve never had a problem with drinking, you might be concerned about the long-term effects, and whether you’ll be able to step away from this higher level of consumption once the pandemic is behind us.

If you suspect your relationship with alcohol is moving in an unhealthy direction, don’t be hard on yourself. Turning to familiar ways of coping is a common and understandable response to this bewildering situation. As you’re assessing your relationship with alcohol, look for the following warning signs that your drinking may be going too far:

• It’s escalating: You find that you’re drinking a bit more each week, drinking more nights during the week, or starting earlier in the day. Or maybe you’re experiencing hangovers more often or they’re lasting longer into the day. You might also consistently drink more than you were planning to, or drink on days when you’d planned to abstain.
• It’s becoming a preoccupation: Perhaps you fantasize about what you’ll drink and can hardly wait to get started. You start thinking about your first drink hours before you intend to drink, imagining how blissful it will feel.
• It’s crowding out other activities: Drinking starts to become your main leisure activity, taking away from other possibilities you used to enjoy.
• It’s interfering: You’re not as effective in your work, or you’re skipping other activities because of drinking (e.g., being too hungover to exercise). Or maybe your drinking is leading to tension in your relationship.
• Others are concerned: The people close to you may notice you’re drinking more, and have expressed their concern or asked you to cut down. People are generally reluctant to confront a loved one about their drinking, so if someone tell you they’re worried, it’s probably a reasonable concern.
• You feel defensive: If someone does say they’re concerned about your drinking, you bristle and become angry. Maybe you try to turn the tables, pointing out their problematic behaviors and trying to take the focus off yourself.
• You’re being secretive: You might make yourself strong mixed drinks so it’s harder for others to know how much alcohol you’re having, or you try to prevent them from knowing how many drinks you’re having.

So how to avoid developing a serious problem with alcohol? The only surefire approach is to avoid drinking altogether, but the following recommendations can lower the risk. In general, these preventive measures are the flip side of the risk factors.

• Build other coping skills. Drinking is less likely to turn into your only means of coping if you have other techniques you can turn to. Through regular practice you’ll have access to options besides alcohol for managing stress and anxiety, and you’ll carry these skills with you when the crisis is over. Here are several practices I suggest that may help.  
  • Ease into the Day: Stress hormones like cortisol surge as you’re waking up for the day, preparing you for the challenges ahead. However, they can also trigger a spike in anxiety first thing in the morning. When you wake up tomorrow, notice if you’re holding onto any unnecessary tension in the body. Is it possible to let it go, even a little? Greet the day in a state of focused calm.
  • Bedtime Breaths: When you get into bed this evening, take 10 slow, cleansing breaths to release the day’s stress and activity. With each exhale, let go of anything you’re holding onto from your day, and relax fully into your mattress. Sense that this time and place are devoted to rest and renewal. Place a note by your bedside to remind you of this practice when you go to bed.
  • Meditation: This would be a good time to develop a daily meditation practice. Although it is not necessary to begin a mediation practice, there are many meditation apps to choose from. Headspace, Calm and Insight Timer just to name a few. 
• Be honest with yourself and open with others. Avoid the problems that come with secrecy by resolving to be open with someone close to you about your drinking. Be honest with yourself, too, about the state of your drinking, and acknowledge if it seems to be trending toward trouble territory.
• Don’t drink alone—or with heavy drinkers. Part of staying accountable with drinking is not doing it alone. It might be hard to avoid solo drinking right now if you live alone, so arrange for virtual meet-ups over a drink. Just be careful about your drinking partners, who can strongly influence your level of consumption. Avoid those who drink heavily, and look for relationships that emphasize the quality of connection over the drinking element.
• Maintain the important parts of your life. Letting areas of your life slide can put you in a hole you’ll have to dig out of when this crisis is passed, which could make alcohol an even more attractive alternative. Keeping up with your work responsibilities, relationships, and non-alcohol-related leisure activities will lower the odds of over-relying on alcohol.
• Have non-drinking days. The more consistently you practice a behavior, the more automatic it becomes. Break your drinking streak to restore a level of choice in whether you drink, and to show yourself you can do it. Commit with a loved one to share non-drinking days, and make a point to spend time together on those days. You might learn something valuable about yourself when you don’t give in to the urge to drink—for example, discovering more about the emotions behind the urges.

If you’re wondering whether to change your drinking behavior, take care to ask yourself the right question. Most commonly we’ll ask ourselves if we’re “addicted” or if we’re “an alcoholic,” but those questions are usually too black-or-white to offer meaningful answers. The better question is, "Is the way I’m drinking a net positive in my life?" If not, talk with a qualified substance abuse psychotherapist or someone you love and trust about the concerns you have. Explore with them whether it’s time to change your relationship with alcohol, and how they might support you along the way.

​

Neurofeedback is direct training typically provided by health professionals such as psychologists, family  therapists, and counselors. We observe the brain in action from moment to moment and that information is brought back to the person by way of the sensors.  Neurofeedback is also called EEG Biofeedback, because it is based on electrical brain activity, the electroencephalogram, or EEG. Neurofeedback is training in self-regulation.  Self-regulation is a necessary part of optimal brain performance and function. Self-regulation training allows the nervous system to function better. 
 
The LENS is a specific kind of Neurofeedback that operates much more rapidly than traditional Neurofeedback and has qualities that make it much easier to use with people who can’t sit still.  With the LENS, the client doesn’t need to “do” anything, and there is nothing to learn.  The typical session with the LENS lasts 3-4 minutes.  This means that the LENS works well for people who either cannot or will not pay attention to a computer screen for longer time periods.  Additionally, the LENS works much faster than traditional Neurofeedback with the number of sessions ranging from as few as 1 to an overall average number of sessions of 20.
 
The LENS works well with problems of the Central Nervous System, which can be numerous. These include symptoms of anxiety-depression spectrum, attention deficits, behavior disorders, various sleep disorders, headaches and migraines, PMS and emotional disturbances. It is also useful for organic brain conditions such as seizures, the autism spectrum, and cerebral palsy.  These are all signs of Central Nervous System dysfunction which result in the body’s difficulty regulating itself. 
 
How does the LENS work?
We apply sensors to the scalp to listen in on brainwave activity. We process the signal by computer, and extract information about certain key brainwave frequencies.  Through a patented process, we then bring this information back to the client down the sensor wires to the person’s skin.  The results are reduction and/or elimination of the symptoms which previously interfered with the client’s quality of life.  The sessions are brief (usually 3-5 minutes), gentle (usually the client feels nothing during the session), and the changes are lasting with some exceptions: with symptoms of progressive conditions such as Parkinson’s and MS, the treatment needs to be ongoing to sustain the improvement.
 
What conditions does the LENS help with?

• Cognition - Problems sequencing, memory, providing and maintaining attention, concentration, clarity and organization.
• Mood - Anger, sadness, explosiveness.
• Motor - Lack of grace, problems of eye-hand coordination, balance, increased muscle tone (from spasticity) and tremor.
• Motivation - Problems initiating tasks, shifting from one activity to another, and/or completing tasks.
• Anxiety - Problems of anxiety system activity (too much uncomfortably-contained energy), persistent "anxiety", restlessness, rumination, agitation, distractibility, difficulty breathing, palpitations, tremor exacerbation, and sleep interruption.
• Reactivity - Hyper-reactivity, hypersensitivity, multiple chemical sensitivities.
• Pain - Brain-generated pain (mismapping the origins and qualities of signals), and vascular pain.
• Addictions/Dependencies - Lack of clarity about emotions and self-comforting, defensiveness, argumentativeness and cynicism.
• Fatigue - Fatigue; or fatigue as a phenomenon secondary to the effort of trying to overcome the pain and/or the above impediment to functioning more easily.
• Performance Optimization - Increases in functioning in the above areas in absence of any diagnosis.

The LENS works well with symptoms of Central Nervous Symptom dysfunction. These include symptoms of ADD, ADHD, Seizures and sub-clinical seizure activity, severely disruptive behavior disorders such as Conduct Disorder, Reactive Attachment and Bipolar Disorder, Autistic spectrum and pervasive developmental delay, Cerebral palsy, concussive injuries, PTSD, Acquired Brain Injury, and Birth Trauma.
 
It works extremely well with the symptoms of Traumatic Brain Injury, no matter how long ago the incident occurred.  The trauma can be from a physical blow, a concussive injury, a psychological incident (PTSD), or any other incident(s) which results in a decrease in cognitive ability. 
 
Many children have sleep problems that can be helped such as bed wetting, sleep walking, sleep talking, teeth grinding, nightmares, and night terrors.
 
The LENS can also be helpful with many of the symptoms of adolescence including drug abuse, suicidal behavior, anxiety and depression. The LENS can also help in maintaining good brain function as people age.
 
Do the results of LENS last?
If the problem being addressed is one of brain dysregulation, then the answer is yes, and that covers a lot of ground. Neurofeedback involves learning by the brain and if that brings order out of disorder, the brain will continue to use its new capabilities, and thus reinforce them.
 
At times there are unknown issues such as early-stage degenerative disease, allergies, strong reactions to some foods or pollens, or spills and falls leading to bumps on the head.  In these instances longer courses of the LENS may be needed. And it may also be that some direct medical help may be the best course of action.  The LENS can’t do everything for everybody.  But it can and has made a difference that other approaches have not provided, and in general, in a much shorter time.  Matters are different when we are dealing with degenerative conditions like Parkinson's or the dementias, or when we are working against continuing insults to the system, as may be the case in the autism spectrum. In such cases, the LENS sessions may need to be continued at some level over time. Allergic susceptibilities and food intolerances may make it more difficult to maintain the gains. Poor digestive function will pose a problem, as does poor nutrition. A child living in a toxic environment (in either the physical or the psychological sense) may have more difficulty retaining good function.

What is the success rate with neurofeedback?
It turns out that among the vast majority of clients (>95% in one clinician's experience,) the actual outcome exceeds the prior expectations. Against such low expectations, the changes that can be produced with the LENS may even appear miraculous. One EEG Biofeedback office has a sign on its front desk: "We expect miracles." If none occur, something has gone wrong." What appears miraculous in all of this is really nothing more than the incredible capacity of the brain to recover function when given a chance.
 
Is neurofeedback a cure?
In the case of organic brain disorders, it can only be a matter of getting the brain to function better rather than of curing the condition. When it comes to problems of dysregulation, we would say that there is not a disease to be cured. Where dysregulation is the problem, self-regulation may very well be the remedy. But again, the word cure would not apply.

Thomas Kessler, LMFT, RAS
415-454-8931
marintherapist@gmail.com
www.thomkesslertherapist.com

Imagine a train racing towards you at top speed, and there you are, stuck on the tracks, a human target. Your heart races, your muscles tense, your body starts shaking, and your breath becomes labored as worry consumes your mind and manifests throughout your body. Intense, right? For the nearly 20 percent of people in the U.S. affected by an anxiety disorder every year, this is what anxiety can feel like: Anxiety is a dreadful feeling of unease and worry, perpetuated by fear, that often comes with repetitive negative thinking.

As you’re experiencing it, you can have difficulty concentrating and making decisions. Even if you haven’t been diagnosed with an anxiety disorder, chances are you’ve felt the heart pound at some point and know the struggle is real.

What’s Going On In The Brain?
In states of anxiety, the brain is affected by stress hormones like cortisol and excitatory neurotransmitters, such as norepinephrine. These factors can lead to a decreased ability to regulate negative emotions, excessive negative thinking, and difficulty relaxing,” he says.

At the same time, the amygdala, or the emotion center of the brain, becomes overactive, which makes it harder for higher brain centers (those in charge of cognitive functions like learning and memory) to regulate emotional and physiologic states to calm down mentally and physically.

The amygdala decides what emotions to give you from moment to moment by providing a constant threat assessment about your environment. When it determines something isn’t dangerous, it does nothing and you feel calm. When it looks at something it perceives as dangerous, it rings an alarm to warn you about the danger and motivates you to do something about it—that’s what anxiety is, it’s the alarm system.

For someone with a fear of dogs, for example, when they see a dog, the amygdala rings the alarm and tells them the dog is dangerous, and the person becomes anxious. That motivates them to get away from the dog. When the danger is gone, the alarm shuts off and the anxiety goes from high to low.

As humans we are wired to repeat actions that make us feel good and stop actions that make us feel bad. Because the anxiety went from high to low by running away from the dog, this kind of avoidance behavior becomes reinforced and we’re more likely to repeat the same behavior the next time we see a dog. It’s an evolutionary response; the body says, ‘anxiety kept me safe, I better get anxious again.’”

Why Does Anxiety Keep Coming Back?
When the body experiences symptoms of anxiety, the brain interprets these signals from the body as cause for concern, worsening anxiety by creating a vicious cycle. The more anxious we get, the more nervous we feel; the more nervous we feel, the more anxious we get.

The important thing to know is not why you have anxiety in the first place, but what’s maintaining it now. The basic idea is short-term avoidance of anxiety leads to long-term maintenance of anxiety. When someone tries to make themselves feel better in the moment (avoiding a dog), it guarantees more anxiety the next time they’re in a similar situation.

How to Calm Anxiety When It Arises
By practicing a few helpful strategies on the regular, when a bout of anxiety strike, you’ll be more likely to get in the habit of doing them automatically—and dial down your angst.

1. Go for a change of scenery: Rather than sitting at home, go out for a brisk walk. In many cases, anxiety creates a rigid mindset in which it seems like nothing can change; doing something different can help with your cognitive flexibility to shift gears. Think of it is stretching before a workout.
   
2. Chew gum: Sounds nuts, right? We know dentists recommend chewing sugarless gum after meals to reduce plaque, but now, research shows popping in a piece may also help reduce anxiety. Scientists aren’t exactly sure why, but they believe it’s because the act of chewing increases blood flow to the brain and may lower cortisol levels.  
   
3. Accept the angst:  When you’re feeling anxious, instead of practicing avoidance behaviors (running away from the dog) or over-analyzing the fear in your head (what happens if the dog bites me?) allow the uncertainty to be there and leave those worry questions unanswered, I believe to that when you open yourself up to ambiguity it gives you exposure to uncertainty without avoidance, and the brain eventually learns uncertainty isn’t actually dangerous. 
   
4. Impermanence: The Buddhist concept that in the moment whatever we are experiencing thinking and feeling will not last. Our feelings, whether they are positive or negative will not last, because our emotional state is always shifting, it is fluid, not static.
   
5. Come back to the present moment: Let’s say you’re in the middle of reading a book and suddenly your mind wanders and you start worrying, “What if I don’t have enough money for retirement.” This is where mindfulness comes in. You need to stop putting work into the thought and come back to what you’re doing in the present—reading a book. It’s about letting the thought go, which is different from avoiding it, so you ultimately become desensitized to it.
   
6. Exercise: According to research, it really can do wonders for the mind—from helping the brain better cope with stress to releasing endorphins, natural painkilling chemicals in the brain, which improve sleep and reduces stress. Get moving, even a 15-minute home dance session a day to your favorite tracks can improve your anxious mood.
   
7. Self-Talk: Thoughts are the things that we say to ourselves without speaking out loud (self-talk). We can have many thoughts every hour of the day. We all have our own way of thinking about things, and how we think has a big effect on how we feel. When we think that something bad will happen – such as being bitten by a dog – we feel anxious. For example, imagine that you are out for a walk and you see a dog. If you think the dog is dangerous and will bite, you will feel scared. However, if you think the dog is cute, you will feel calm.
   

If you or someone you know is experiencing anxiety there are many ways one can learn to overcome chronic anxiety.

Thomas Kessler, LMFT, RAS
415-454-8931
marintherapist@gmail.com
www.thomkesslertherapist.com



​

Maybe sex is the last thing on your mind when you’re stressed out. But it might help lower your anxiety. Sex seems to lessen the amount of hormones your body releases in response to stress. And an active sex life can make you happier and healthier, which might also help keep anxiety at bay.

Research says people who have sex once a month or less get heart disease more often than those who have it twice a week or so. Part of the reason could be that you get a bit more exercise and are less likely to be anxious or depressed. But it could also be that if you have more sex, you’re physically and mentally healthier in the first place.

Sex typically burns about 5 calories a minute. That’s about equal to a brisk walk. And you use a bit more oxygen too -- about the same as digging in the garden or walking down the stairs. 

That may not seem like much, but it starts to add up over the long term. And because sex can improve your mental health, you might be more likely to do other types of exercise like the neighborhood kickball team, hiking, or housework.

Well, not so much lose them as forget where you put them. That’s because regular sex seems be linked to improved memory, especially if you’re between ages 50 and 89. It’s not clear why.

Weekly sex seems to boost your immune system compared to those who have it less often. Part of the reason may be that it raises levels of a germ-fighting substance called immunoglobulin A, or IgA. But more is not always better here. People who had sex more than twice a week had lower levels of IgA than those who had no sex.

Sex bathes your brain in a chemical “afterglow” that lasts about 2 days and helps to bond you to your partner over the long term. Without it, you could lose some of the satisfaction of your relationship. A healthy, happy sexual relationship -- couples who do it at least once a week seem to be happiest -- can help build trust and understanding between you and your partner.

The reasons aren’t exactly clear, but in at least one study, men who ejaculated less than seven times a month were more likely to get prostate cancer compared to those who did it at least 21 times a month. 

But unprotected anonymous sex and multiple partners can also raise your chances for the disease, so when you do have sex, take care.
Without sex, you’ll miss out on the hormones that promote restful sleep, like prolactin and oxytocin. Women get an estrogen boost that helps even more. The reverse is true, too: If you decide you want to start having sex again, a good night’s sleep is just the thing to keep you feeling frisky.

Sex can be a good way to take your mind off of any aches and pains you have. But it does more than that. Orgasm causes your body to release endorphins and other hormones that can help ease head, back, and leg aches. They may help arthritis pain and menstrual cramps, too. 

It may seem odd, but “use it or lose it” may apply here. For women at menopause, vaginal tissue can get thin, shrink, and dry out without regular intercourse. That can make sex painful and weaken your desire. And some research says men who have sex less than once a week are twice as likely to have erectile dysfunction (ED) as those who have it weekly.

Sex seems to help keep your blood pressure down. That makes sense when you consider what it does: It adds a bit of aerobic and muscle-building exercise, and it can ease anxiety and make you feel better. Both of those can help keep your numbers where they need to be.​


Thomas Kessler, LMFT, RAS
www.thomkesslertherapist.com
marintherapist@gmail.com

When children reach adolescence, relationships, romantic or otherwise, can be a point of significant strife. Relationships between parents and children are crucial to healthy development, but may become strained by the many ups and downs of adolescent life. For example, most teenagers worry about romantic relationships, however, for some teenagers, worrying about relationships may excessively drain their energy and make it difficult to enjoy life.

Many mental health issues that teens face can be attributed in part to the social pressures and stress of adolescent life. As a result, teens may experience any of the following: generalized anxiety, depression, attention-deficit hyperactivity (ADHD), poor self-esteem, oppositional defeasance issues and substance abuse.

Experimentation with alcohol and drugs is fairly common among adolescents and can lead to serious developmental, social, and behavioral issues. When I work with teens together the teen and I develop therapy goals in a collaborative process. 

Many times, the main goals are to help the young person to find new and healthy ways to cope with the stress or conditions that may have led to depression, anxiety and substance use. 

Many types of therapy emphasize talking and thinking about feelings and experiences, which can be particularly challenging for teens. For each teen, I create a highly-individualized treatment plan that works to address problems that may be occurring at school, home, or in friendship circles. I do not subscribe to the “one size fits all” theory. Therefore, I use a variety of treatment modalities. My therapeutic approaches, include teaching mindfulness therapy. Each teen 

Teens of any age may feel uncomfortable, afraid, or ashamed about communicating what they are experiencing to an adult they do not know. If you are a parent or caregiver, these tips can help when talking to children about therapy and mental health treatment:

Find a good time to talk and assure them that they are not in trouble. Listen actively. Take your teen’s concerns, experiences, and emotions seriously.Try to be open, authentic, and relaxed. Talk about how common the issues they are experiencing may be. Explain that the role of a therapist is to provide help and support. Explain that a confidentiality agreement can be negotiated so children—especially adolescents—have a safe space to share details privately, while acknowledging that you will be alerted if there are any threats to their safety.

When looking for a therapist it is important to find someone with specialized training and experience in working with teens and teens issues. When I work with teens I also include sessions with the family. Family therapy, in which multiple family members may attend sessions together, as well as independently, if necessary. I may include treatments designed to address parenting skills, such as parent-child interaction therapy. These treatments may be useful when a teen’s behavior becomes difficult to manage.

Many prominent bodies of research highlight the efficacy of a combined treatment approach, or the use of both medication and therapy when medication is prescribed by a psychiatrist for a mental health issue. In fact, the American Psychological Association’s Practice Guidelines Regarding Psychologists’ Involvement in Pharmacological Issues encourages, whenever possible, to include psychotherapy when medication is prescribed. The efficacy of medication increases when combined with psychotherapy

Many mental health professionals argue that medication is overprescribed as a “quick fix,” while therapy, which may teach a person long-term coping strategies and self-management, is not encouraged enough. If your teen is prescribed an antidepressant, antipsychotic, anxiolytic, stimulant, or other psychotropic drug, consider finding a therapist or counselor to pair with the drug treatment.

​
Thomas Kessler, LMFT, RAS
www.thomkesslertherapist.com
marintherapist@gmail.com