Many people go without the help they want and need.

depression hopeless| Dr. Jason Winters | Therapy | Blogging on Squarespace

Over the years, there's been a lot of discussion and debate about funding for psychotherapy. Currently, psychologists in Canada are not covered by government-funded health care plans.

While some extended health care plans do provide coverage, it's usually limited. Also, many people do not have access to those sorts of plans. This leaves a lot of people paying out of pocket. For many, it's worth it as their quality of life after treatment will be much, much better.

A recent study, described in the link, shows that in BC, way too many people struggling with depression go without the care that they want and need (both medication and psychotherapy).

Some quotes from the CBC:

"The study's authors found that, of all British Columbians diagnosed with depression, only 53 per cent received the minimum baseline of treatment."
"They found that only 47 per cent of those prescribed antidepressants received them for 12 weeks, and only 13 per cent received four therapy sessions.
Puyat said the actual number of depressed people receiving inadequate care is likely much higher than the study found, since the study only considered patients who sought treatment, and many people do not."

You can read the rest of the article here: link.

Why negative emotions are important.

negative emotions depression anxiety| Dr. Jason Winters | Therapy | Blogging on Squarespace

We all experience negative emotions and on a pretty regular basis. For some people, they're persistent and too intense. This can be an awful and unmanageable place to be. Often times, people will try various ways to achieve some sort of relief or to escape their negative emotions, but these strategies usually backfire or make things worse.

I've worked with clients who initially believe that therapy success means no longer feeling negative emotions. And you can understand why - they've been suffering and want it to end. But that's not the goal, as negative emotions serve an important function for us. Also, we're stuck with them. *Caveat: this isn't to say that negative emotions can't become more manageable and less debilitating for those who suffer.*

Negative emotions (and positive emotions, too) tell us important things about what's going on. Anger tells us that something unfair or unjust is happening. Sadness tells us that we're experiencing loss. Anxiety means that there is threat that needs to be addressed. Shame indicates that we've acted in a way that contradicts our values. Emotions motivate us to act, which is a good thing.

This piece delves into negative emotions and why we need to embrace them. It's a helpful read.

From Scientific America:

Negative Emotions Are Key to Well-Being
Feeling sad, mad, critical or otherwise awful? Surprise: negative emotions are essential for mental health
By Tori Rodriguez
A client sits before me, seeking help untangling his relationship problems. As a psychotherapist, I strive to be warm, nonjudgmental and encouraging. I am a bit unsettled, then, when in the midst of describing his painful experiences, he says, “I'm sorry for being so negative.”
A crucial goal of therapy is to learn to acknowledge and express a full range of emotions, and here was a client apologizing for doing just that. In my psychotherapy practice, many of my clients struggle with highly distressing emotions, such as extreme anger, or with suicidal thoughts. In recent years I have noticed an increase in the number of people who also feel guilty or ashamed about what they perceive to be negativity. Such reactions undoubtedly stem from our culture's overriding bias toward positive thinking. Although positive emotions are worth cultivating, problems arise when people start believing they must be upbeat all the time.

Read the rest here: link.

Feeling overwhelmed or stuck? This one tool might be what you need.

depression anxiety behaviour cbt stuck| Dr. Jason Winters | Therapy | Blogging on Squarespace

Sometimes when feeling stuck or overwhelmed with negative emotions, it’s really difficult to act in a way that is most effective or helpful. Often, our behaviour is dictated by a strong instinct to escape or reduce those negative emotions (e.g., anxiety, fear, shame, anger, guilt, etc.). But, in trying to feel better in the short-term, we may act in ways that are not the best for us in the long-term. We might even make things worse.

Say, for example, that you’re struggling in a relationship – it might be a friendship, an intimate relationship, or a relationship at work. Perhaps there’s an ongoing conflict and anger, or you’re having difficulties setting boundaries, saying no, or asking for what you want. Maybe you’re really anxious. You may be tempted to distance yourself from that person, or avoid having the conversations that you need to have to improve things. In distancing or avoiding, you’re trading short-term relief from, or avoidance of, negative emotions for long-term stress. The problem and the way that you feel are likely to get worse.

So what might help?

The Three Magic Questions

The Three Magic Questions is a tool that many clients find really effective when stuck, overwhelmed with negative emotion, or wanting to avoid. It has its roots in Acceptance and Commitment Therapy, which focuses heavily on goals and values.

Goals are typically things that people would like to improve, do differently, or achieve. Values can be personal, such as honesty, persistence, courage, loyalty, strength, and compassion. Values can also be things that a person values, like contributing, relationships, achieving, being at peace, good sex, intimacy, etc.

In my practice, goals and values contextualize the work that clients do – it helps keep them focused on what they want and what matters, rather than focusing exclusively on the things that have caused them distress and suffering.

How the tool works.

When you find yourself:

  • acting in ways that are messing up your life or relationships
  • wishing that things could be different but not knowing how to get there
  • overwhelmed by emotions that paralyze you, or cause you to act in way that makes things worse and not better
  • having difficulty making choices that are helpful rather than harmful
  • avoiding things you’d like to do because of fear and anxiety
  • stuck in a rut
  • (feel free to add to the list!)

Ask yourself the following three questions:

  1. What can I do now to make things better in the long-term?
  2. How can I act to get me closer to meeting my goals?
  3. How do I act in a way that best aligns with my values, and what I value?

For this to be effective, the key is to make sure you answer all three questions. It requires that you know your goals and values, which is something that people often fail to clarify. So do that first before you address the problem or difficult situation. Keep them in focus. Then work through the questions.

Usually this helps tell you what avenue you should take. Having said that, occasionally things do not work out. And that’s ok. It’s better to act in a way that’s more effective, which can sometimes be risky, than to stay stuck. And if things do blow up in your face, you’ll almost certainly survive and build resilience.

What does this look like in practice?

Here are two examples, one non-sexual, the other sexual:

Example 1

Say you’re someone who struggles with social anxiety. You’d love to have more friends, as they’re important to you, and a social life would be nice. But your anxiety is stopping you from going out and spending time with people. It sucks.

A friend texts you and invites you to a social get-together with some people you know. Immediately, your anxiety kicks in. What if you say something stupid? What if you have nothing to say at all? What if they think you’re weird or too quiet? What if they don’t like you?

The instinct is to turn down the invitation, or if you do go, to get really drunk to cope. Both options are not particularly helpful in the long-term.

To get unstuck, you would first want to identify your goals and values. Your goal is to meet people and have a better social life. You clearly value friendships and having a social life, despite your anxiety. With those goals and values in mind, the best thing to do is to accept the invitation, despite the anxiety.

And with anxiety, we know that the most effective way to reduce it in the long-term is to do the things that cause the anxiety. Over time, these repeated experiences (i.e., exposure) help us recognize that what we fear most is not likely to happen, and even if it does, we’ll probably be able to cope. As such, anxiety goes down and confidence goes up.

Example 2

You have a lot of anxiety about sex. It could be about your lack of experience, sexual performance, ability to orgasm, the way you look, ability to communicate, or the desires that you have. Your worries are getting in the way of your sex life. You find that you’re not pursuing sexual experiences that you could be having, and wish you were having. It’s just way too vulnerable and scary.

Your partner, or a potential partner, starts flirting with you. It’s clear where things are heading. Immediately you feel your anxiety kick in. What might happen if you have sex? What if you’re no good? What if you get judged or criticized? What if you disappoint this person? What if you get shamed, or feel ashamed?

As your anxiety builds, all you can think of is ways to avoid having sex. You feel the urge to say or do something to make it clear that you’re not interested. For you, this is a repeated pattern and you’re feeling frustrated, disappointed, and ashamed.

But then you remember your goals and what you value. You want to have a healthy and satisfying sex life. You value sexual experiences and recognize that as a sexual person, sex is a crucial part of your life and intimate relationships. Despite sex being scary, you want it. You also remember that you’ve had great past experiences. You trust that you can again. And you know that avoiding is only making things worse. So you take the plunge. It will be one more experience that gets you closer to what it is that you want. It’s still really scary, but the anticipation is always worse than the doing.

Both of these examples have to do with anxiety, as anxiety is the most common thing I see in my practice. But, the tool works for other negative emotions and experiences too. Once you get a handle of it in one context, it is easily transferred to different difficult situations. Try it out!

What is cognitive behavioral therapy (CBT)?

Part 1: The Basic Model

Cognitive behavioral therapy, or CBT, is a very popular type of psychotherapy for several important reasons:

CBT is structured.
CBT provides practical, hands-on skills.
CBT is focused on the present.
CBT is goal-oriented.

CBT is well-supported by science and research.

Sounds pretty good, right?

The underlying theory behind CBT is that thoughts, emotions, and behaviours are all related. CBT focuses on identifying and changing unhelpful thoughts and behaviours that are causing problems and messing up your life. Thoughts, in particular, play an important role in maintaining negative emotions and problem behaviours. Physical sensations accompany emotional states, and are therefore related to thoughts and behaviours. Here's what the model looks like sketched out:

The easiest way to understand the model is to work through examples. So, with that in mind, here are two examples, one related to a non-sexual situation, and one related to a sexual situation.

Example 1: In the first example, Sam, who struggles with bad anxiety, is supposed to meet a friend for a drink but the friend pulls a no-show. Sam doesn't know why.

Sam experiences a strong emotional response - anxiety, sadness, embarrassment, and shame. Behind those emotions are a set of related negative thoughts that often occur automatically for Sam in similar types of situations. Accompanying those negative emotions are several uncomfortable physical sensations. Because of those strong negative emotions and the related uncomfortable physical sensations, Sam is going to be more likely in the future to avoid putting herself in similar situations. This may lead Sam to isolate herself, which isn't really what she wants. What Sam really wants is to have friends and be able to hang out with them. But because of the way that she thinks, doing what she really wants becomes very difficult.

Example 2: Dan suffers from difficulties with his erections, caused by bad anxiety. This is a significant source of distress for Dan. His girlfriend is understanding. She regularly tries to initiate sex with Dan because she finds it enjoyable, even though Dan believes he's letting her down when he doesn't have a full erection. In this example, Dan's girlfriend starts flirting with him.

When Dan's girlfriend starts flirting with him, Dan starts feeling anxious, scared, frustrated and ashamed. He feels this way because he thinks that she's going to want sex, and fears that he won't get an erection. If that happens, which he's sure will, he'll see himself as an inadequate sex partner. He believes that his girlfriend will be unsatisfied and will leave him. Thinking this way makes him feel physically ill. To reduce the negative emotions he's experiencing and mitigate risk of what he fears happening, Dan starts acting in ways that will insure that sex doesn't happen, such as shutting down (disengaging), making excuses not to have sex (avoidance), or making his girlfriend angry with him so that she won't want to have sex. Dan would much rather be able to have awesome sex, but his thoughts associated with his erectile difficulties are ruining it for him.

Once things are sketched with the CBT model, it becomes clear what the targets of therapy are (i.e., the specific maladaptive thinking patterns, negative beliefs, and unhelpful behaviours). 

There is much more to CBT, but this model forms the basis. Using the model can be extremely helpful for clients to learn how to manage emotions and change behaviour.

Some Questions to Ask Yourself

Are there certain situations that cause you distress? What is the nature of your distress (i.e., what are the emotions)? Is there a pattern?

How are you thinking in those situations, and how are those thoughts related to the way that you feel? Are those thoughts distorted, biased, or exaggerated in some way?

Are you behaving in a way that's helpful, desired, and that aligns with your values? If not, what needs to change?