The Complexity of Loss

As Dr. Loo and Dr. Silver wrote about in our previous two entries, grief and uncertainty are two of the most challenging emotions for humans to cope with, particularly in our modern world of quick fixes and immediate answers. “Ambiguous loss” - a form of unresolved grief whereby there is no certainty or closure to the loss - embodies both of these experiences. It is a concept first defined by Pauline Boss, Ph.D. in the late 1970s, as she interviewed wives of pilots missing in action in Vietnam and Southeast Asia. As Dr. Boss identified the unique features of grief and mourning experienced by these women - whose husbands were “gone but not forgotten” - she began formulating a theory to explain how and why losses of this type inflict such a heavy emotional toll on the loved ones left behind.

According to Dr. Boss, “ambiguous loss” can be of two different, but similar types. A physical ambiguous loss describes a type of grief in which loved ones are physically missing or bodily gone, but their psychological presence remains. Some common examples frequently treated at CTWPS include divorce, miscarriage and abortion. A psychological ambiguous loss is when a loved one is physically present, but psychologically absent, such as with dementia, severe mental illness or addiction.

During the course of life, we may find ourselves affected - either directly or indirectly - by several of the more common types of ambiguous loss. At a minimum, these experiences are upsetting and stressful. At their worst, the emotional complexities of these losses can be devastating, leaving those in their wake feeling helpless, hopeless, and more prone to depression, anxiety, and relationship conflict.

Ambiguous losses are not like “ordinary” losses in several important ways. With “ordinary” losses, the symbolic rituals surrounding death (e.g. funerals, burials) often serve to validate one’s grief, provide opportunities for the community to provide emotional and practical support, and may represent closure for those in mourning. However, after an ambiguous loss, no such rituals exist; oftentimes leaving those suffering feeling isolated. Further, because of the stigmatized nature of some ambiguous losses - for example, drug addiction or chronic mental illness - loved ones may choose to suffer in silence and shame.

Uncertainty regarding when a loved one might return (to health or their physical return), and whether an ambiguous loss is temporary or final also exacerbates the grieving process for those left behind. Uncertainty complicates the experience of loss by blocking one’s ability to problem-solve out of the “problem,” rendering typical coping strategies ineffective. Further, individuals experiencing ambiguous loss often liken the uncertainty of the situation to a roller-coaster of emotions. They may experience extreme ambivalence about their “lost” family member - in one moment feeling hopeful for their return, and in the next longing for an end to the waiting. Sometimes anger develops toward the loved one because of their absence or illness, only to be followed by guilt and shame for thinking negatively of them. Certainly, the tension caused by these competing, conflicting emotions can inject additional stress into what is already a very taxing emotional experience.   

Enlisting the help of a professional is advisable as one navigates the emotional complexities of ambiguous loss. A skilled psychotherapist will be a compassionate ally to their client, providing the acknowledgement and recognition of the loss that may be lacking within an individual’s personal life. The therapist will also encourage the client to seek additional emotional support from her community, urging her to include family and friends in the mourning process. This might be done by creating a personal, symbolic ritual to mark the loss, even if traditional forms of closure are not yet possible. Psychotherapy would also aim to help the client develop acceptance of the current situation, and the imperfections of life more broadly. By providing a safe place for “naming” the loss and the range of feelings one is experiencing, psychotherapy can help free one from the emotional constraints of relentless uncertainty.

At CTWPS, we understand how challenging it can be to tolerate uncertainty, particularly when the wellbeing of loved ones is at stake. As such, the focus of psychotherapy for ambiguous loss is to help clients increase their resiliency in the face of this challenge - to increase one’s tolerance for both ambiguity and change. The ultimate goal of therapy is to support the client in moving forward, through the loss, even in spite of so much uncertainty.  

If you are experiencing distress related to ambiguous loss and would like support as you navigate the mourning process, we welcome the opportunity to be of service to you. Please reach out to CTWPS if you would like to connect with one of our highly skilled psychologists.


Grief: the Universal Human Experience

What Is Grief?  

We are all likely to experience grief at some point in our lives. Grief is a universal human experience and is the most natural emotional and physical response to any significant loss. It is often characterized by emotional pain, including complex feelings of sadness, hopelessness, loneliness, relief, and anger.  In addition to the emotional components of grief, other common symptoms include, changes in appetite, fatigue, difficulty concentrating, sleep disturbance, social disengagement, and loss of interest in work or activities.

Here at CTWPS we are aware of the multitude of negative consequences that can occur in the wake of a loss. In treatment, we honor the experience of our patient’s grief while simultaneously helping her navigate the grief process in as adaptive a way as is possible.  We help our patients challenge misconceptions about grief and identify “cognitive distortions” that may be contributing to a dysfunctional grief process.

Typical Grief vs. Depression  

While there are many shared features between grief and depression, such as feelings of extreme sadness and disengagement from the world, there are key differences. Grief tends to decrease over time and to occur in waves which are triggered by thoughts, reminders, anniversaries, or memories of a loss. When a woman is grieving, she may periodically experience pleasure in some situations, such as when surrounded by family or friends. In contrast, when a woman is depressed, even brief periods of pleasure are generally missing from her life. Depression tends to be more persistent and pervasive and is often marked by a grim outlook on the future and a negative self-view. Some patients have described it as though they have fallen into a black hole with no hope of ever getting out.

Common Myths and Misconceptions About Grief

In addition to the pain we naturally feel in the wake of a loss, many people accept myths and misconceptions about the grief process and the ways in which they are “supposed” to grieve. Such misconceptions often exacerbate pain and confusion by causing us to question whether there is something wrong with us if we aren’t doing grief “right”.  

Here at CTWPS we help our patients identify distorted thought patterns (cognitive distortions) about how they “should” be functioning and handling the grief process. Such distortions are likely to impede their ability to adaptively adjust to the loss and may result in feelings such as inappropriate guilt and shame. Let’s begin challenging some of those misconceptions and cognitive distortions together:

Myth/Distortion #1: Grief is a linear and predictable process.

Reality: Grief comes in waves and is often not a linear, predictable process. Rather, when we are in the process of grieving, our thoughts and emotions tend to vacillate throughout the hours, weeks, days, and months after a loss. Grief is a highly individualized process and there is no right or wrong way to grieve. While experiencing grief, we encourage our clients to refrain from comparing themselves to how others grieve, even when they have experienced the same type of loss. We try to dispel the myth that there is a definitive timeline for the grief process.

Myth/Distortion#2: Grief only happens when someone dies.

Reality: Grief takes many different forms and can be a natural response to many different types of losses other than death. Such losses might include a breakup, divorce, estrangement from a family member, death of a pet, or a miscarriage. Here are CTWPS we help our clients name and process these losses and aid them in understanding how to navigate their loss as they move into an unexpected reality.

Myth/Distortion #3: I should have done more or prevented this loss.

Some women experiencing grief may find themselves engaging in “should statements,” which are cognitive distortions based on the erroneous assumption that we or others are obligated to behave in a certain way.  When a patient has the thought “I should have done more” “or I should have prevented my mother from dying,” she is likely to experience intense feelings of guilt as a result. We might help our patient reframe her perception of the loss with more realistic alternative thoughts based on her specific situation, such as “I am not in control of life and death.  I am so sad without my mother, and I did what was in my power to help her.”

Myth/Distortion #4: I should be back to normal by now.

Other common “should statements” that may arise during the grief process are related to unrealistic expectations about the grief process. We frequently hear women say things like “It’s been 6 months, I thought I would be normal by now.” Grief is a unique process and there is no set time-limit or “cure.” Such “should statements” are likely to put undue pressure on a woman and provoke feelings of anxiety about when and how she will ever return to her old self. Such thoughts may also provoke feelings of guilt or shame about the fact that she is not meeting her own or other’s expectations about the “normal” timeline of the grief process.

Most women have experienced or will experience grief at some point in their lives. While it is normal to feel sadness and other negative emotions in response to grief, dysfunctional thought patterns can result in complicated grief and depression. Here at CTWPS we utilize CBT to help women cope with losses in a healthy manner by making space for the grieving process while at the same time working towards adapting to a “new normal”. If you’ve experienced a loss and you’d like support in navigating this process, please reach out to us.



The Life Skill of Tolerating Uncertainty

Finding answers to our everyday questions is often as quick as our WiFi access. We can type a question into a search engine and expect helpful information, from where-to-go-for-my-next-vacation to how-to-keep-my-plant-alive. Our access to answers clearly benefits us in innumerable ways; we can become self-taught hobbyists, language learners, and world news consumers from home. Our devices can be programmed to generate immediate responses; after all, we are encouraged to ask Siri, Alexa, or “just Google it”. However, there is one answer that a search engine will never plainly give us: “I don’t know.” 

As cognitive behavioral psychologists, we have found that the expectation of having one’s questions immediately answered negatively impacts the necessary life skill of tolerating uncertainty.

After all, most life transitions come with an inherent amount of ambiguity and more questions! We recognize that these moments can be challenging, tiring, and even painful. However, when women leave no room for the uncertain, they often experience greater levels of anxiety, self-criticism, and over-functioning as they try to answer questions that may require patience, openness, and an acknowledgment of our human limits. If you struggle to tolerate uncertainty, consider how we help our patients talk back to three of common and related beliefs: 

Belief 1: Uncertainty means something bad will happen. 

A hallmark feature of cognitive behavioral therapy is an evidence-driven approach to thinking. We love gathering data - and often ask our patients to become keen observers of their own lives before drawing conclusions about the meaning of a situation. Since uncertainty can feel unnerving, especially in situations we care about, we can become self-protective and brace ourselves for a worst-case scenario. We can mistakenly conclude that uncertainty forecasts a bad outcome. However, a lack of data is not evidence - consider how this reasoning would never hold in a court of law! For example, say a woman starts to date someone who she finds interesting and kind; however, she believes that if he does not share explicitly how he thinks and feels about her, it must mean that he will inevitably reject her. In therapy, we would work with this woman to tolerate that uncertainty is a normative part of the initial dating process as she gets to know her potential partner. In fact, presuming an unwanted outcome in this case may encourage anxiety-driven behaviors and misperception of cues that may actually encourage the feared outcome, rather than remaining open to experiences that will be informative and even clarifying. 

Belief 2: Uncertainty means that I have not done enough to ensure my desired outcome.

Sometimes we may conclude that not knowing an outcome indicates a failure on our part - after all, we are an outcomes-oriented culture and often feel good about ourselves to the extent that we can show results. However, it is important to recognize that sometimes the answer “I don’t know” is not data that we have fallen short, but in fact may indicate that our specific circumstance warrants growth and vulnerability. Alternatively, the evidence may interpreted neutrally in that the situation we are in is a complex one that takes multiple stages or collaboration with others before being resolved. Making sure to contextualize and identify the major factors in a situation can help de-personalize uncertainty as individual failure. For example, if the woman described above does not know yet if she can imagine her new dating partner to be a life-long partner, she may place unrealistic pressure on herself to “figure it out”. She may become unhelpfully ruminative, place an unrealistic timeline on the relationship, or begin over-functioning (i.e., assuming full responsibility) leaving her constantly anxious, self-critical, and in the least optimal emotional space to be present for the relationship and her partner.

Belief 3: Feeling uncertain means that I am helpless or out of control.

Tolerating uncertainty can definitely feel uncomfortable - although it does not mean that we must remain passive. As cognitive behavioral psychologists, we emphasize the concept of “agency” - meaning we encourage our patients to shape their own lives and situations when they can. However, being “agentic” is not the same as having full control of outcomes. While we don’t have a crystal ball to look into the future, we can choose to make moments of uncertainty valuable and constructive. We always encourage our patients to ask questions, learn from others, and identify the personal strengths that have gotten us this far. We can take steps to exercise self-care, nurture our relationships, and reach out for support as we await an unknown outcome. We can take the opportunity to practice mindfulness of the present - that is, observing our day-to-day thoughts, emotions, and decisions that we in fact do exert influence over and grow in self-awareness. In the same example described above, a woman who is dating can view the situation as an opportunity to grow in self-awareness as she takes risks in meeting potential partners. Like any other skill, learning to tolerate uncertainty takes practice! 

Choosing to tolerate the unknown can be a proactive step and more helpful than the alternative. We develop flexibility, resourcefulness, bravery, and humility when we encounter uncertainty; we are reminded we do not and cannot know everything – which can be a welcome freedom if we let it. 


Living with  - not around - a Chronic Health Condition

Being diagnosed with a chronic health condition can be a distressing experience. Chronic health conditions, such as endometriosis, lupus, and gastrointestinal disorders, require lifestyle changes that impact a woman’s relationship with herself, her family and friends, her work, and her environment. Here at CTWPS, we support women through the psychological and behavioral adjustments of living life with a chronic health condition. Below are three ways that we empower women to manage their health as they continue to live meaningful lives.

1. Check your thinking. 

When a woman is first diagnosed with a chronic health condition, she may notice herself engaging with thoughts, such as: This will never get better; I’m always going to be sick; or My life is only about my health.

In therapy, we empower women to recognize that while these thoughts do highlight the stressful and often uncertain nature of a chronic health diagnosis, they are nonetheless maladaptive because they often result in a feeling of helplessness, contributing to depression and anxiety that can exacerbate physical health symptoms. In treatment, we teach women how to check the evidence and revise their thoughts to be less rigid.  In turn, women often notice feeling more hopeful and motivated to engage actively and openly in their lives. 

For example, a woman may check her thought “I will never get better” by first honoring the truth in the thus far chronic nature of her condition, and then also recognizing times that she was able to attend an important event, go on a vacation, and complete day-to-day tasks fully. We recognize that it can be tempting to get stuck in a mental filter focused on negative health experiences, but “balancing the evidence” can help expand her focus and also notice her ability to engage in meaningful ways when she is feeling well. 

2. Get to know your body with chronic illness. 

Women may also get stuck in worrying about the uncertainty of their health condition, asking themselves such questions as: What if my symptoms get worse? What if my symptoms flare up while I am away from my home? Should I get another doctor’s opinion about a treatment recommendation? The uncertainty and lack of complete control over one’s body and symptoms may make women feel frustrated, resentful, and confused. Coupled with helpless thoughts that she will not get better, she may resort to isolating behaviors and unhealthy coping skills, such as excessive sleeping, avoiding social engagements, or over-relying on food for comfort.

In therapy, we encourage each woman to learn more about her unique body with chronic illness, as this has been found to increase the ability to cope with symptoms. Specifically, this knowledge will provide her with data regarding potential precipitating factors, patterns in flare-ups, and variables that may impact the frequency and duration of flare-ups. This data is empowering if it provides her with a lens to influence and manage symptom flare-ups. 

One technique we often use to help women become more attuned to their bodies is called Symptom Tracking. By consistently tracking her symptoms, including type, severity and duration, as well as coping mechanisms that she has tried, we are able to identify any patterns or triggers for her symptoms that may otherwise go unnoticed. In turn, she will have more specific information to share with her health care team, and she can use this information to inform decisions regarding making plans. For example, someone with a chronic gastrointestinal disorder may track her symptoms and learn that a certain food group leads to a severe flare-up in her symptoms. This information helps her feel in control over reducing the probability of a flare-up, which affords her the opportunity to go out with her friends to a restaurant without worrying about her stomach’s reaction. 

Using a symptom tracker can also provide helpful information about the efficacy of different coping skills and pain management techniques. Collecting specific information about what helps can be empowering because it provides increased hope and flexibility. Without this information, a woman may fear her symptoms and/or flare-ups in symptoms because she is unsure about how to manage them. As she learns more about ways to manage, she may find herself more willing to make plans and tolerate the possibility of a flare-up because she feels more confident in being able to problem solve.  

3. Live your life with chronic illness, not around it. 

A common thought among women when first learning how to manage their chronic illness is: “I can’t make plans because I can’t predict how I will feel at that time.” In turn, a woman who harbors this thought may develop a conditional rule that “if I can’t be certain that I will feel well, then I shouldn’t risk making plans.” Consequently, this approach to coping often leads to avoidance, and she may notice that her world becomes smaller, and primarily focused on her health (e.g., medical appointments). Additionally, through avoiding making plans, she reinforces the fear that she will experience a symptom flare-up while engaging in these plans. When she turns down activities and events, she also reinforces depressing feelings and resentful thoughts about being deprived of engaging in her life due to chronic illness. 

A risk in living according to this rule is missing out on opportunities to engage in meaningful activities that improve one’s psychological well-being. Here at CTWPS, we work with women to adjust this rule, trying an approach that involves making those plans without predicting the future, and trusting that the plans can be adjusted if a symptom flare-up occurs. By taking this approach, she learns to live her life flexibly, expanding her world to include planning and engaging in meaningful activities, and recognizing that she can engage in problem solving to adjust those plans if needed. 

Through practicing these skills in balancing thoughts and engaging in healthy coping behaviors, a woman can feel more empowered to live her life in a meaningful way while managing chronic illness. If you are seeking support in navigating your journey in living life with chronic illness, we are here and ready to support you. 

Cognitive Strategies For Getting Through A Breakup

We’ve all been through it. The end of a romantic relationship comes with a special pain that can be difficult to manage. A unique quality of romantic breakups, and what makes them differ from other losses, is how deeply they can impact our thinking about ourselves and the future. Some examples of maladaptive thinking that can come up after a breakup include:

If only I were more chill about things, this wouldn’t have ended.

I can’t hang on to a relationship, I must be unlovable.

What a horrible waste of two years, now I’m even more desperate.

I’ll never have the kind of love that I see my friends have.

All of these examples are rooted in cognitive distortions, and for some women, getting caught in negative thinking traps after a breakup can lead to longer lasting symptoms of depression, anxiety, sleep disturbance, and general stress. At CTWPS we help women to identify these distortions, and to develop healthier, reality-based thinking about the breakup process, which can help speed up her healing and get her moving in a more constructive direction. If you find yourself struggling through a breakup, below are important common cognitive distortions to keep in mind.

1) Should Statements: “I should be handling this better”. A common distortion for some women is “shoulds thinking”, which means having strict expectations about how things should be, or how one should feel and behave. This distortion can be especially strong in the initial days of a breakup, with should statements popping up in many ways, i.e. “we should still be together”, “I should be feeling stronger about this”, “we should be communicating less”, “I shouldn’t feel so needy right now”. Inherent in all of these statements is self-criticism and judgment, as well as arbitrary rule-making. These thoughts can set a woman up for even further distress and disappointment if not kept in check. If you find yourself using the language of “shoulds” frequently in those early days, you’re not alone! The first strategy for addressing shoulds thinking is to catch it, recognize it as a distortion, and rework it more realistically in your mind. For example, for the thought “I shouldn’t feel so sad”, we would first identify it as a should statement, and then break it down and rework it, i.e. “Why shouldn’t I feel sad? It is a common, expected emotional reaction that has a natural course. It is quite important to be flexible with myself in the early days of a breakup, to allow myself permission to feel my feelings and to cut myself some slack, understanding that I may not be operating at my full capacity at first. I won’t feel sad forever, but for now I will be more patient with my sadness and give myself what I need.” By reworking the distortion in this way, a woman is able to comfort and nurture herself, rather than judge and criticize. Be mindful of moments in which you are slipping into “shoulds”, and remind yourself that there is no one correct way to manage the first few days after a breakup. Accept the breakup, expect some pain, and be patient with yourself.

2) Personalization/Control Fallacies: “I could have avoided this”. Often after a breakup women look for reasons to blame themselves, or go through the relationship with a fine-tooth comb looking for where she may have gone wrong; i.e., “If only my expectations weren’t so high, we’d still be together”, “I’m so damaged of course the relationship was bound to end”, “I messed up by not maintaining his/her happiness”. These thoughts and behaviors are examples of how the personalization and control fallacy distortions can slow down a woman’s healing after a breakup. As the name implies, the personalization distortion occurs when a woman takes personal responsibility and blame for all negative things that happen, even without evidence for doing so. The control fallacy distortion has a similar effect; it is predicated on the belief that one is in complete control of one’s life, experiences and environment, making one responsible for anything that might happen. The danger of these distortions is that they can prolong a woman’s pain, and reinforce negative beliefs about herself as unlovable or incapable of maintaining a relationship. The way we might address this kind of thinking in therapy is by recognizing it for what it is, and replacing the distorted thinking with more reality-based assessments. For example, if a woman comes in saying “We broke up because I’m such a mess”, we may break down the personalization and self-blame, replacing it with something more rooted in reality; “We broke up because we hit a wall in our compatibility, and could no longer fulfill each other’s needs. That goes both ways, and it is no one’s fault. Neither of us is perfect, but this relationship did not end because of a fundamental flaw in me. Rather breakups happen all the time - more often than not, in fact - to even the most ‘together’ individuals.” Look for where you might be personalizing your breakup, and practice critically analyzing your logic. Neutralize self-blame and practice balance in the story you tell about the breakup.  

3) Fortune telling: “I’ll never find love”. This is a big one! Many of us find that after a breakup we draw conclusions about ourselves and our futures based on the pain we are feeling in the moment, i.e. “I’ll never find love”, I’ll be alone forever”, “I’ll never stop feeling this miserable.” These are examples of the cognitive distortion of fortune telling, or the tendency to make predictions or jump to conclusions based on little or no evidence, and clinging to them as absolute truth. As with the other cognitive distortions in this list, fortune telling only serves to perpetuate one’s pain and hopelessness after a breakup. We all know that there is no way to know for certain what is going to happen in the future, so by committing to our fortune telling we are mourning an outcome that has not and may not ever happen! In therapy we would try to integrate a more balanced approach, by first acknowledging when fortune telling is occurring, then evaluating our real data, and then generating alternate possible outcomes. For example, with a woman who says “I’ve gone through several breakups at this point, I’ll never be able to maintain a relationship”, the work of therapy would be to evaluate what we can say is true and we cannot. We may restructure her statement as follows: “Looking back at my past breakups, I see behaviors that I would want to work on, like communicating my feelings more openly and feeling more confident in my needs, but I have no reason to believe I can’t develop those skills and meet a partner who will be a better fit for me.” By drawing conclusions based on evidence as opposed to conjecture, this woman is better able to do constructive work to get herself toward her goal, instead of staying mired in hopelessness. Challenge baseless predictions about the future!

Addressing cognitive distortions is a critical part of making it through the breakup process healthier and stronger. One reason why it can take a long time to recover from a breakup is because of our allegiance to thoughts and behaviors that end up making us feel worse. By staying self-aware and tracking any thinking traps, the healing process can happen much faster and with a much better outcome. Behavioral interventions are another important part of this process; stay tuned for Part II of this series in which we will address behavioral strategies for working through a breakup.


Tips for Managing Social Anxiety

Tips for Managing Social Anxiety 

Do you feel self-conscious in social settings? Do you avoid meeting new people or new social situations because of a fear of being negatively judged by others? If so, you may have social anxiety. According to the National Institute of Mental Health, 12% of adults experience social anxiety disorder at some point in their lifetime, with women being nearly twice as likely to experience social anxiety as compared with men. 

Here at CTWPS, we recognize the negative impact that social anxiety can have on a woman’s capacity to develop and sustain friendships and romantic relationships, as well as her career growth.  In treatment, we help women overcome their social anxiety by identifying their “thinking traps” and changing the behaviors that prevent them from achieving their goals. If you struggle with social anxiety, consider whether you may engage in any of the below thinking traps:

1. Fortune-Telling Error: The fortune-telling error occurs when a woman assumes that a future event is going to have a negative outcome. Instead of considering the probability of the negative outcome, or evaluating the evidence that either supports or contradicts the occurrence of such an outcome, the woman instead believes that this prediction is already an established fact.  For example, before going to a networking event in New York City, a woman with social anxiety may engage in thoughts such as: “My mind will go blank and I won’t know what to say” or “I will say something embarrassing.” After the event, this woman might continue to engage in distorted thoughts about the interaction, such as: “What’s the point of putting myself out there, I will continue to mess up when I meet new people.” Engaging in these types of distorted thoughts may result in negative feelings such as anxiety, sadness, or hopelessness, which in turn may cause this woman to avoid or dread future social interactions. In treatment, we would work with this woman to consider alternative outcomes and evaluate past data from social interactions to help her arrive at a more realistic, neutral narrative about the upcoming networking event. For example, we might ask her to consider past social interactions in which her mind did not go blank and she was able to have a “successful” conversation with a colleague or friend. We would also help her generate alternative predictions for how the upcoming event might unfold, such as “I may not always have the perfect thing to say but that doesn’t mean I’m not a good conversationalist” or “Even if my mind goes blank momentarily, it is okay to have lulls in a conversation.”

2. Mind Reading:  The mind reading error occurs when a woman assumes that she knows what other people are thinking without investigating whether or not her assumption is true. Often, women with social anxiety  assume that others are perceiving them in a negative manner when in fact this may not actually be the case. For example, during a perfectly pleasant conversation on a date the above woman may think to herself: “He notices that I’m blushing and sweating and can tell how nervous I am” or “He thinks I’m awkward.” In treatment, we might help this woman generate a list of alternative possibilities for how her date may have experienced her. For example, he may not have actually noticed that she was blushing or sweating, or he may have thought she was sweating because she was warm. We would also invite her to consider how catastrophic her “worst case scenario” would actually be - what if her date did notice that she was nervous? Would that necessarily make her awkward or unlikable? Or, is it possible that he could find her nervousness endearing, or even relieving in light of his own nervousness? 

3. Labelling: Labelling occurs when a woman generalizes a single error or negative event into a negative global judgment about herself. For example, a woman attending a networking event for work may engage in distorted thoughts about how she will perform, such as: “This is not going to go well because I’m incompetent.” After the event, this woman may engage in distorted thoughts about her social interactions, such as: “I didn’t network with the people I should have. I’m a failure.” Such thinking traps are likely to make this woman feeling sad, or even angry, at herself. In treatment, we might approach such critical self-labelling by asking the woman how she would interpret the same situation if it happened to a friend. For example, if a friend of hers went to a work event and did not talk to people she would have liked to network with, would that mean she was as failure? Most likely the woman would not judge her friend as harshly as she judged herself, and she may even be able to generate evidence of times when her friend was successful at work. If we wouldn’t label someone else a failure for such a mistake, than we shouldn’t label ourselves!

Most women have experienced some social anxiety at some point in their lives, and for some women it can be debilitating. While social anxiety can be distressing it does not have to prevent you from achieving your goals or developing fulfilling relationships! CBT has been shown to be the most effective treatment for relieving social anxiety and helping women feel more comfortable and competent in social situations. If you’re experiencing social anxiety, and you’d like to make a change, please reach out to us for support. 

Letting Go of the Struggle with Body Image

When you think about describing your experience with body image to others, what comes up for you? For many women, body image is described only as negative thoughts and feelings that they have about their bodies. Emily Sandoz, Ph.D., a clinical psychologist and leading body image researcher, argues that the definition of body image is broader than just the negative perceptions of the body. She defines body image as a person’s whole experience of her body, including perceptions about outward appearance, awareness of internal body experiences, and all of the thoughts and feelings that are associated with these experiences.

When women only focus on certain aspects of their body experience, especially the ones they do not like, they may notice engaging in their world in limited ways to manage their discomfort with their bodies. For example, a woman may avoid going to the beach during a summer vacation because she does not want to be seen in a bathing suit. She may avoid dating because she wants to feel more comfortable with her body first. The cost of engaging in these avoidance behaviors includes spending less time and focus on present moment experiences that really matter.  

In her book, Living With Your Body and Other Things You Hate, Sandoz describes an approach to changing one’s relationship with body image that allows one to focus on living the life you are currently living, rather than being governed by body image distress. Below are some techniques that can facilitate creating a healthier relationship with your body image. 

Present Moment Awareness

The practice of present moment awareness involves noticing the ongoing experiences of your body and your environment as they are happening within and around you. For women experiencing body image distress, they may notice their awareness being pulled into the past or pushed into worries about the future. For example, while attending a luncheon, a woman’s awareness may be stuck in remembering a past unpleasant experience in which she was judged for her appearance, and she has trouble separating from those thoughts to enjoy the luncheon.  She may find it difficult to enjoy the luncheon because her awareness is preoccupied with worries about others’ perceptions of her body, and she engages in behaviors to manage body image. Being present requires practicing the ability to notice when you are focused in on your body image and not paying attention to your experience in the moment, and then mindfully choosing to shift your awareness back to luncheon.

Seeing Thoughts as Simply Thoughts

A key way to change your relationship with body image includes noticing your thoughts about your body without giving them the power to rule your experience. When a woman gets stuck on a body image thought, for example, “my stomach looks big in this shirt and people are going to judge me,” she will likely use that thought to shape and explain her experience at the luncheon. She may decide to remain seated for most of the luncheon, even when she wants to get up and speak to others. She likely missed when others were engaged in what she contributed to the conversation, or when someone laughed at her joke. Her distressing body image thought ruled her experience. But interestingly, thoughts can be just that - simply thoughts. They do not have to dictate our experience.

Accepting Experience 

Acceptance involves tolerating distressing thoughts and feelings, while still engaging in and committing to actions that matter. By letting go of efforts to keep body image distress at bay, a woman may find relief from the struggle and room to invest time, energy, and resources in more meaningful experiences.  So she may decide to wear the colorful shirt (rather than worrying about what other people think), committing to focusing on the people around her and the content of shared conversations.

Here at CTWPS, we support women with changing their negative thoughts and feelings related to body image. If you are struggling with your body image, consider reaching out to us for support.

Female Anger

One of my favorite moments as a psychologist is when I can help a woman access and express her anger. It’s no surprise that the character of the Incredible Hulk holds a soft spot in my heart (Yes, the scientist-action hero who mutates into a rageful green monster when angry - to the initial apprehension of my husband when we first met!). Conventional, gendered prescriptions for women include traits like “relational”, “sweet”, or “maternal” - characteristics that not only limit the socially acceptable roles for women, but also label “anger” as an undesirable and unfeminine quality. (The permissible exception, of course, is an angry mother who protects her children from harm!).  But in spite of the societal repression of women’s anger, as therapists we remain curious about anger and view it - and the full range of emotions - as important data.

Let’s challenge some maladaptive  assumptions about anger we see most often in therapy:

1. Anger is a bad (i.e., unhealthy, irrational, selfish) emotion.

Anger is a valid emotion - similar to sadness or fear - that can communicate relevant information about our experience and interpretation of events. Just as sadness helps us appreciate loss or fear signals possible threat, feeling anger helps us recognize that something has gone awry. Whether we feel hurt, invalidated, disrespected, or deceived this is always valuable data for us to reflect upon. Ignoring the clues that anger leaves us often results in more harm in the long run, such as increased stress from stifling our feelings, somatic complaints, social withdrawal, mood lability, and poor self esteem. Just as it is crucial not to ignore an unexpected physical pain in your body since pain functions as our body’s “first responder” to a site of injury, anger serves an important function - to draw our attention to something deserving attention.

2. Anger is destructive and always leads to negative or unwanted consequences.

This can be partially true. Since anger is an activating emotion, we may react when angered in ways that are exaggerated, hostile, or short-sighted because we want to quickly resolve feeling uncomfortable or discontent. However, this does not need to be the outcome of our anger. It is also important to distinguish between angry actions (i.e., behaving out of control) and taking action when angry (i.e., creating boundaries with a disrespectful co-worker). First of all, if we accept that anger is a legitimate feeling for women and that it is often informative, we can pause to treat it with the respect it deserves, and consider the long view instead of reacting in the moment. At its core, anger signals that some type of change may be warranted and it mobilizes us towards constructive action. therapy, Our goal as cognitive-behavioral psychologists is to help women be agentic whenever possible. While it is helpful to consider your goal when expressing anger and regain a reasonable amount of control before responding - these steps serve as ways to help women affect positive change with their anger - not repress or react to it.

3. “Getting angry won’t change things so I should just ignore it”.

It’s true that sometimes being angry does not lead to the specific outcomes that we want, and sometimes we may choose to let go of being angry, especially when perseverating on it harms us. Also, it is important to acknowledge that sometimes the cultural, political, or familial expectations for a woman make it extraordinarily difficult to convey anger, no matter how warranted her feeling may be. Here, we can remember that while the outward expression of anger may be discouraged in certain contexts, anger can still be acknowledged by the individual in other ways that preserve her experience and sense of self.  Again, since anger is informative, even if actionable steps may not be immediately realistic, anger can point us in a helpful direction. So even if anger needs to be redirected through alternative activities or relationships (e.g., journaling, providing anonymous feedback when given opportunity, discharging anger through exercise, attending a protest, sharing with a therapist), acknowledging and honoring our anger - as part of a full and healthy range of emotion - is an integral step in maintaining our mental health.



Using CBT in the Management of PCOS, Endometriosis, and PMDD

All women with a menstrual cycle experience an accompanying fluctuation in hormones and physiological changes. While for some (lucky!) women this is unnoticeable business as usual, many women struggle with symptoms that become debilitating month after month. An often minimized aspect of this fluctuation is the impact on mental health. Researchers of women’s health concerns are increasingly insistent that psychological treatment be a component of treatment for endocrine and gynecological conditions, and we at CTWPS are here to help identify and treat those psychological symptoms. While we work with a range of experiences at CTWPS, the following is a discussion of some common gynecological and endocrine disorders that we see.

Polycystic-Ovarian Syndrome (PCOS)

PCOS is an endocrine (hormonal) disorder which impacts 7-10% of women of reproductive age. It is associated with an elevation in certain hormones which can cause irregular periods, excessive body and facial hair, weight gain, and acne. If you have PCOS, you may be familiar with some of the stressors - months without a period, or a period that lasts weeks, insulin resistance, difficulty with weight loss - but what you may not have identified as being part of PCOS are mood changes. Research by Thomas Berni and colleagues (2018) found that women diagnosed with PCOS were significantly more likely to have depression, low self esteem, anxiety, and eating disorders. While PCOS manifests differently in each woman, it is important to take seriously any signs of sadness, hopelessness or anxiety. At CTWPS, we might help a client grapple with the meaning of a PCOS diagnosis, fears or beliefs about it, and help ensure that her mental health is managed. Below are examples of emotional experiences related to PCOS that we might address:

  1. A client struggling with the weight gain associated with PCOS may have experienced blame from others, such as “just eat less!” or “take better care of yourself!” When this blame becomes internalized, a woman is at higher risk of maladaptive, depressive thinking about herself. We might identify distortions in her thinking, such as personalization or the control fallacy, in which she is taking emotional responsibility for things outside of her control.

  2. The excess body hair or male-pattern hair loss sometimes associated with PCOS can cause extreme distress for a client and cause her to struggle with beliefs about her femininity. For example, a client may feel hopeless about her appearance, believe she is unattractive, and avoid engaging socially. We would work with this woman to identify and deconstruct any maladaptive beliefs, and give her tools for managing anxiety while re-engaging in her life.

Endometriosis

Endometriosis is a condition in which cells of the uterine lining move outside the uterus and attach to other areas of the body, such as the ovaries, fallopian tubes, bladder, bowel, or other organs. When a woman has her period, the same hormones that cause her uterine lining to shed also cause the endometriosis to swell and bleed, which in some cases can cause severe pain, nausea, gastrointestinal distress, fatigue, and infertility. While relatively common, affecting 10% of women, endometriosis often goes undiagnosed or misdiagnosed for years before properly identified. Many studies have linked endometriosis to mental health diagnoses, specifically depression and anxiety, as well as social isolation and diminished sexual interest. One study by Antonio Simone Laganà and colleagues (2017) observed that high levels of pelvic pain due to endometriosis increased a woman’s anxiety and depression, which further amplified her pelvic pain, leading to a mind-body cycle in which both physical and mental health are compromised by the other. The study concludes that psychological treatment is a critical component of pain management associated with endometriosis. At CTWPS we are equipped to treat the anxious and depressive symptoms associated with the condition. Below are examples of issues that might come up in treatment:

  1. A woman struggling with chronic pelvic pain due to endometriosis may find that her family and friends are critical and invalidating of her pain, attributing it to normal menstrual cramps or telling her to “toughen up”. As a result, she may become depressed or excessively question her own experience. We would work with this woman around connecting to her physical experience, replacing negative beliefs about herself, and developing strategies for communicating with her loved ones.

  2. Struggling with severe menstrual pain, a woman may find her period to be very difficult to manage and dread it every month. She finds that in addition to her pain spiking, her anxiety spikes as well, exacerbating the pain. We would work with this client on addressing her fear of pain, helping her to articulate the beliefs she holds, i.e. “I have no control over my body” or “this pain is going to break me”, and reframe them. We might also help her to develop behavioral tools for coping, such as mindful relaxation or positive self-talk.

Premenstrual Dysphoric Disorder (PMDD)

PMDD is a psychiatric diagnosis involving symptoms of depression, irritability, trouble concentrating, feeling overwhelmed or moody, or disturbances to appetite and sleep during the week leading up to a woman’s period. While 3-8% of women meet strict criteria for PMDD, many women experience sub-clinical symptoms monthly. In fact the American College of Obstetricians and Gynecologists estimates that up to 85% of women experience at least one physical or psychological PMS symptom around the time of menstruation. A common challenge for women is having this experience invalidated, or being called “crazy”, “irrational” or “hysterical”. Many women with PMDD or PMS may hesitate to assert themselves or communicate openly for fear of not being taken seriously. As psychologists at CTWPS, we see these symptoms present challenges to women of all walks of life. Below are some ways we might address these challenges in therapy:

  1. Some women are aware of intensifying stress around their periods, but do not have a clear sense of timing or specific symptoms. A first step in therapy would be to collect data; keeping a journal or a log of symptoms can not only be illuminating, but can help identify targets for intervention. For example, a client’s log may indicate that when she engages in certain behaviors, such as going to yoga or meeting a friend for coffee, her mood symptoms are less severe. This allows for development of a behavioral treatment plan for PMDD.

  2. A woman with PMDD finds that her male deskmate at work makes snide, teasing comments when she feels moody, making her feel dismissed and humiliated. We might work with this client on critically evaluating her subsequent beliefs about herself, such as “he’s right, I’m a mess”, or “I don’t deserve to work here.” We might also help this client assess her options for how to address this treatment at work.

Receiving a diagnosis of PCOS, Endometriosis, or PMDD can be distressing, but it also provides a roadmap for treatment. If you find yourself struggling emotionally around these or other gynecological or endocrine conditions, take it seriously and give yourself permission to seek support.


Part I: Behavioral Interventions for Insomnia

Do you lay in bed at night tossing and turning, unable to fall asleep?  Or do you wake up in the middle of the night, consumed by worrisome thoughts or the fear of not being able to fall back to sleep?  If so, you’re not alone. According to the America Insomnia Survey, one in four women struggle with insomnia.  

Here at CTWPS, we recognize the host of negative consequences insomnia may have on a woman’s emotional, physical, and cognitive health, and we specialize in developing targeted treatment plans to help women regularize their sleep patterns and, in turn, improve their overall sense of well-being. 

As cognitive behavioral psychologists, we understand insomnia to be caused by learned thoughts and behaviors that can be unlearned.  Whether you occasionally struggle to have a restful night’s sleep, or are battling with chronic insomnia, you may consider implementing tenants of the two behavioral strategies below into your sleep routine: 

1.  Schedule Appropriate Times for Sleep

When a woman first begins behavioral treatment for insomnia, we typically collaborate with her to obtain a comprehensive snapshot of her current sleep schedule: when she goes to bed and when she rises, how much time she spends in bed, how much time she spends sleeping, and her napping behaviors.  We find that many women attempt to compensate for a bad night’s sleep by taking naps or sleeping later on the weekends.  While these behaviors offer relief in the short-term, they actually cause insomnia to persist!

We would then help this patient set a regular rising time, such as 6am, which means getting out of bed at 6am each day (sorry, including weekends!), irrespective of how poorly she slept. We would also encourage her to temporarily reduce the time allowed for sleep.  We find that many women who worry that they won’t be able to sleep get into bed earlier than they otherwise would to “increase their odds” of getting quality sleep.  Problematically, though, the more time you spend awake in bed, the stronger the association between “bed” and “wakefulness” becomes.  

For this reason, we would coach this patient to either go to bed later or wake up earlier so that the time she spends in bed more closely reflects her average sleep time.  We would determine the maximum time she should allow for sleep by adding one hour to her average amount of nightly sleep for one week.  For example, if she averages six hours of sleep per night, we would encourage her to allow for no more than seven hours of sleep. To this end, we would also ensure that she knows when to go to bed by calculating what psychologists have termed her “earliest allowable bedtime.” To do so, we would subtract from her regular rising time of 6am her maximum time allowed for sleep (seven hours) in order to arrive at 11pm as the earliest time at which she should attempt to go to sleep.

Lastly, we would also encourage this patient to limit naps to no more than 45 minutes, beginning at no later than 2pm.  There are many well-evidenced benefits to short “power naps,” such as improved mood and focus. Research indicates, however, that longer naps, especially those taking place later in the day, often consist of “deep sleep,” which weakens your sleep system’s capacity to sleep deeply during the upcoming night.

2. Strengthen Your Brain’s Association Between “Bed” and “Sleep”  

The next area of focus in treatment with this woman would be to help make her bed a stronger cue for sleep.  To achieve this goal, we would first assess whether she does any activities in bed that are cues for wakefulness, such as chatting on the phone, watching Netflix, attempting to work through a conflict with her partner, or lying in bed for long periods of time trying to fall asleep.  While these activities may seem innocuous, they are actually counterproductive in that they strengthen the brain’s association between “bed” and “wakefulness.”  Thus, we would invite this woman to modify her behaviors so as to only use the bedroom for sleep and sex. 

Additionally, we would teach this woman to not stay in bed longer than 30 minutes, both before turning off the lights and after waking up in the morning.  We understand that many women are simply not interested in relinquishing their habit of reading or watching TV in bed before falling asleep.  In these instances, we coach women to start out by reducing the time they spend reading or watching to TV in bed to no more than 20 minutes. 

Importantly, we would also teach this woman to not lay in bed awake for longer than 30 minutes.  If you’re still not asleep after about 30 minutes have passed (and you likely won’t be at first!), get out of bed and engage in a quiet, restful activity for another 30 minutes, such as drinking a cup of hot tea, reading a book on the couch, or engaging in some gentle stretching or yoga poses.  Then, return to bed and repeat the cycle until you’ve fallen asleep. This practice has been termed the “½ hour – ½ rule,” and with practice, the number of cycles needed in order to achieve a state of sleep becomes fewer and fewer.  

We recognize that for some women, consistently implementing these behavioral techniques may not be enough to fully repair their sleep cycle.  While we do believe these behavioral interventions are critical prerequisites to healthy sleep hygiene, we also recognize that women live demanding, high stress lives with multifaceted responsibilities and, as such, have a lot on their minds! This is why we also make space in treatment to address the cognitive component of insomnia - the beliefs, thoughts, and worries - that tend to create distress and inhibit sleep.  For tips on how to obtain greater cognitive control so as to further improve your sleep, stay tuned for Part II: Cognitive Interventions for Insomnia.