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.

 

Finding Your Footing As A New Mom: Breastfeeding Challenges

Engorgement, mastitis, thrush, vasospasms, milk blebs… oh, the glamour of being a newly nursing mother! (See also: oversupply, undersupply, poor latch, tongue tie… and the list goes on.) If you are not familiar with these terms, you are one of the lucky ones. However, many new mothers experience some degree of breastfeeding difficulty soon after giving birth; and yet, the multitude of complications that arise are a surprise to many.  When breastfeeding represents a dominant cultural value – as it has in the United States for several decades – the public messages and images surrounding the topic tend to be misleading for new mothers. We are fed images of mothers lovingly gazing at her newborn as it peacefully and easily suckles at the breast. However, when breastfeeding does not easily function, causes physical pain or emotional distress, the private experience may be quite a different picture.

Despite the “Fed is Best” movement that began in 2016, both research and clinical experience indicates that mothers in the US still feel immense pressure to only breastfeed their newborns, even when physical, emotional or practical limitations present significant challenges. A new mother can be then vulnerable to feelings of shame, failure, inadequacy and guilt if she feels she has not fulfilled cultural expectations nor provided the “best” for her child. In vulnerable postpartum moments, it is too easy for a new mother to blame herself and her body for not meeting expectations. After all, isn’t this what our bodies were meant to do??

Whether it is breastfeeding difficulties or another aspect of becoming a mother that is causing you emotional distress, seeking professional support can be hugely beneficial in the postpartum period. Feelings of shame, inadequacy, guilt, sadness, confusion and worry are all very common among new mothers. However, these feelings can be scary and disorienting if your fantasies of motherhood had been very different prior to your little one’s arrival. In fact, becoming more aware of our expectations of what motherhood “should” look like is an important first step toward narrowing the chasm between reality and fantasy. Simply acknowledging that we held expectations, hopes, and dreams about becoming a mother can reduce the intensity of the disappointment experienced when things do not go exactly as envisioned. Putting words to our experience rather than being hooked in by the “shoulds” and “musts” of preconceived notions can be a helpful tool to shift negative emotions to a more neutral place.

Another crucial element of postpartum psychotherapy is to support women in developing kindness, compassion, and flexibility for themselves as new mothers. In the exhausting haze of caring for a newborn, it is easy to become discouraged when - for example - our bodies do not cooperate by producing enough milk, or we cannot induce our baby to latch on properly. Self-critical thoughts about ourselves, our bodies, and ultimately our mothering can run rampant. Thus, in treatment it is important to identify, examine, and challenge self-critical beliefs so a more balanced and compassionate perspective can be constructed. It is often helpful in therapy to gather evidence to disconfirm self-critical beliefs by identifying the myriad ways in which one’s body has, and continues to serve her (and her child) well. By acknowledging the aspects of mothering that are going well, we can help construct a more nuanced and compassionate perspective that more accurately reflects reality.

Once a roadblock is hit with breastfeeding or any other aspect of new mothering, we can be vulnerable to overgeneralizing and labeling oneself as a  “bad mother.” Overgeneralizing and labeling occur when we assign judgments of value to ourselves based on a very limited set of experiences (rather than the whole). These judgements can then lead to overly negative thoughts that are psychologically damaging. In the case of breastfeeding, too often a woman’s ability to breastfeed is conflated with her love for her child and her aptitude as a mother. Challenging the logic of this thinking, we might ask her to consider whether she would make these same judgements about a good friend or a sister. We might ask her to identify and embrace the ways in which she is succeeding in tending to the needs of her child. Or, we might ask her to consider the fallacy of “emotional reasoning” – the belief that “I feel it, therefore it must be true.” In fact, when real-life evidence points to the contrary, our emotions may not be true, and may not be serving us well.

On the journey of becoming a mother, there are both emotional and physical stumbling blocks nearly all women encounter. In our culture, breastfeeding is one of the most emotionally- laden topics, and can also be one of the most physically demanding. At CTWPS, we are well-versed in how these difficulties can impact a woman’s mood and mothering experience. If you or someone you know is struggling with any aspect of becoming a mother, we would welcome the opportunity to support you through this journey with compassion, care and expertise.

Our Worldview After a Trauma

As a psychologist, I marvel at the tenacity and courage it takes for women to discuss traumatic experiences in therapy. It may not feel courageous in the moment; in fact, it may feel like the exact opposite.  Trauma has been defined in a number of ways, but here I use psychologists John Briere and Catherine Scott’s (2015) definition: “an event is traumatic if it is extremely upsetting, at least temporarily overwhelms the person’s internal resources, and produces lasting psychological symptoms (p.10)”.

In the cognitive-behavioral model, we believe that what we think influences our emotions and behaviors, and that our thoughts and beliefs are foundational to how we experience our lives. By its definition, traumatic experiences are unexpected, overwhelming, and significantly impactful. How then, do we think about (let alone make sense of and integrate) something like a traumatic event? The beliefs we hold after a traumatic event may be very different from the beliefs possessed prior to the event, and sometimes we get stuck.

For example, let’s consider a woman (we will call her Liz) who believes that 1) she is a capable person and 2) she is generally safe as a single woman dating in the world. Liz agrees to be set up by friends and goes on three dates. While the first few dates were fun and enjoyable for LIz, at the end of their fourth outing her date starts to initiate sex despite Liz’s clear discomfort and attempts to slow it down. She ends up having sex that was unwanted and unsatisfying. Afterwards, Liz feels multiple emotions, including confusion, anger, shame, fear, and hurt. How does she think about and make sense of this experience in light of her prior beliefs about herself in the world? How might her thinking affect her next steps? Research supports that much of how we manage the impact of a trauma comes down to our thoughts and beliefs about the experience, even long after the event itself has occurred.

Below are some common examples of how Liz might have responded to the traumatic experience if we were to focus just on her thoughts and beliefs.  Please keep in mind that the following examples are limited and meant to highlight a few of the ways that we may think about a traumatic event. They are not meant to present a “right” or one-size-fits all way of responding to trauma.

Recall that Liz’s prior beliefs included: 1) I am a capable person and 2) I am generally safe as a single woman dating in the world.

Response 1: Maybe this means my date felt chemistry and that meant sex. But it felt like a violation to me because I did not want to move this quickly, and I tried to slow things down. It didn’t work - I felt disregarded in the process and unsafe. I will not date this person again, and will move on to date someone who is more respectful.

Here, Liz’s belief that she is capable manifests as a healthy sense of self-worth and motivates her to an action plan that includes honest self-assertion. She acknowledges that she did not feel safe having sex at the time and will take steps to ensure her safety by dating people who are more respectful. In this example, Liz’s original two beliefs remain intact and produces action that reinforces those beliefs following an unwanted sexual encounter.

Response 2: Why did that happen? Maybe there’s something wrong with me for not wanting to have sex that night. I’m probably overreacting and this is completely normal on a fourth date.  

In this response, Liz modifies her first belief to a belief that I must be out of touch and overly sensitive. Instead of viewing herself as a capable person, she wonders if she is inept when it comes to dating. If she changes her original belief about herself, her reaction to the the sexual experience doesn’t reflect perhaps fair misgivings, but points to her as the one with unreasonable expectations. The second belief that she is generally safe dating in the world is maintained because she rethinks her experience as normative rather than a traumatic event.

Response 3: I can’t believe that happened. How could I have allowed myself to be in such an unsafe situation? Something is seriously wrong with me. It’s my fault and I should have known I would be in danger. The world has become a dangerous place.

This example draws attention to an instance where a trauma results in a rejection of all prior positive beliefs. Following the experience of unwanted sex, Liz no longer believes that she can trust herself. Instead, she views herself as flawed and to blame, and she sees the world as inherently dangerous.

These examples show just some of the ways our thoughts play a key role in life and in our suffering after a traumatic event.  In therapy at CTWPS, we help our patients talk about and manage the effects of their traumatic experiences on their beliefs and worldview.  Our work with our patients leaves us radically hopeful, as we are able to see just how much influence we can have in calibrating our beliefs to our most consistent realities, even following trauma.

If you recognize your own responses in the examples above and would like support in discuss them further, please consider reaching out to us for an initial consultation.

 




 

Vulnerability

What does being vulnerable mean to you? Many women associate being “vulnerable” with feeling uncomfortable, exposed or even scared. Pioneering vulnerability researcher Brené Brown describes vulnerability as expressing our true selves, rather than the selves we believe we “should be,” to intimate partners.   Vulnerability does not guarantee that each partner’s needs will be met, or that the relationship will last, but we also can not have lasting intimacy without it.

If you struggle to express your true self in intimate relationships, consider these three common myths that foster and maintain avoidance of vulnerability:

Myth #1: “Being vulnerable means that I must share my deepest and darkest secrets.”

Many women believe that being vulnerable requires that they unveil deep thoughts and personal experiences with their dating partner, often early in a relationship or in an intense “let it all out” fashion. Women who carry this belief often avoid self-expression altogether, due to the burden of vulnerability feeling too overwhelming. Here at CTWPS, we support the concept that healthy vulnerability involves doing so with someone who has gained your trust over time.  The ways that you express vulnerability can grow as that trust grows. In therapy, we  work with women to build efficacy and confidence in expressing themselves (e.g., being vulnerable) in ways that are tempered and intentional.

For example, consider a woman who is uncomfortable expressing preferences with her girlfriend when planning activities to spend time together. In therapy, we may first challenge her to take more tolerable risks, such as practicing communicating these preferences (e.g., restaurant preference) to her partner. As she develops confidence, we may then work toward increasing her capacity to tolerate more intimate disclosures, such as desire to feel more connected in the relationship, or readiness to take the next step in the relationship.

Myth #2: “Being vulnerable is a sign of weakness.”

Our culture perpetuates the myth that “not being vulnerable” is a form of strength that protects one from getting hurt, and that, conversely, being vulnerable is a sign of weakness. By contrast, here at CTWPS,  we view a woman’s capacity to be vulnerable with those that appear worthy of her trust, as a sign of strength. It is ironic that it is women who avoid vulnerability who often experience their relationship needs not being met, as they may avoid all sorts of assertions within their relationship.  

In therapy, we may ask a woman to track her thoughts and beliefs regarding what it means to be strong and weak in an intimate relationship. We would then specifically focus on beliefs that may be leading to unhealthy behaviors. For example, if she believes that being strong in a relationship means hiding unpleasant emotions (e.g., sadness or anger) from her partner, we would then explore ways that hiding those emotions may make her feel distanced and unheard by her partner, and ways that avoiding the expression of these emotions may lead to increased frustration and resentment. As she develops an understanding of ways that these thoughts and behaviors make weaken her, rather than strengthen her, in the relationship, we may then work toward increasing her confidence in sharing her emotions, appropriately and effectively, with her partner.

Myth #3: “To show vulnerability is to be needy.”

There is a difference between “being needy” and “having needs” in a relationship. Everyone has needs in a relationship.  Vulnerability then is the honest expression of one’s genuine, legitimate, and healthy needs in a relationship to a trusted partner.

For example, consider a client who wants to feel more connected in her relationship, but is fearful of being perceived as “needy” by her husband.   Because she is afraid to honestly express her desire to feel more connected in the relationship, she may end up feeling frustrated and isolated. Then she may pick a fight with her husband because he spends too much time on his phone, nag him about the amount of time he spends at work, or complain when he starts watching television after dinner rather than pitching in with household chores. Ironically, while she is fearful of being perceived as needy, these indirect attempts at communicating her desire to feel more connected are likely to be perceived as needy or aggravating to her partner! In therapy, we would help this client develop tools and confidence to communicate in a way that is directly congruent with her goal of getting her needs met in the relationship.

While there is fear and risk associated with being vulnerable, there is also potential for the reward of deepening intimacy.   In therapy here at CTWPS, we work with our clients to create a more flexible definition of vulnerability, and provide tools to build safety, confidence, and efficacy in being vulnerable in intimacy.

 

 

Beating Imposter Syndrome

Even the most accomplished and confident woman may find herself from time to time questioning her capabilities or value. Whether on the first day of a new job, on a date with a desirable partner, bringing home a first child, or talking to a big client, a woman may think, “I’m not good enough for this”, “I don’t belong here”, or “someone else would be better suited for this than me.”  If these thoughts persist, however, it may reflect what psychologists Suzanne Imes, PhD, and Pauline Rose Clance, PhD named “imposter syndrome” - a phenomenon that manifests as self-doubt, a lack of confidence, and a belief that one is unqualified for her position and happened into it by luck or circumstance. For some women, the belief persists that she has somehow “cheated” or “tricked” her way into convincing others that she is capable.   But internally, she feels like a fraud.

Studies have shown that imposter syndrome is significantly more common in women than in men, perhaps because women are more likely to attribute successes to luck or help from others rather than hard work, and more likely to attribute setbacks to personal deficiencies rather than outside factors. In other words, when a high achieving woman gets a promotion, she is more likely than a man in her position to attribute it to factors other than her own talent and skills. This sets the stage for skewed thinking about her abilities, and over time, it can reinforces the fallacy that she is “faking her way” through her achievements.

At CTWPS we see this kind of thinking often - ironically, often in especially brilliant, talented and accomplished women! The first steps toward managing imposter syndrome involve identifying thinking traps, working toward a more balanced self-view, and engaging in constructive behaviors. Below are action items that we might engage in therapy for reducing feelings of fraudulence:

1) Reframe your thinking. Part of battling imposter syndrome is recognizing that it involves some non-truths. While a woman may be justified in feeling some nervousness about taking on a challenging new role (who doesn’t?!), it is usually not true that she is completely unprepared for it. Most likely, she is not actually a fraud - she has some training and experience that have led her to this position. We would encourage a client to practice telling herself the whole truth, and challenge black and white thinking, by taking an honest accounting of her work and accomplishments. When a client sees herself as undeserving of a promotion, we might ask her to concretely list out her qualifications and accomplishments, as well as her areas for development. It is important to be honest and realistic about the gaps in one’s expertise, but often the focus on this detracts from a woman’s attention to her accomplishments. By asking our clients to be explicit with us about her achievements, we can come to a more balanced perspective.

2) Challenge the presumption that you are a superb con artist (and everyone else is gullible). Because the belief that one is an imposter is hard to shake, it is important to seek out as much outside evidence as possible to balance one's view. Dr.s Imes and Clance suggested an experiment to help a woman let go of the belief that she has tricked everyone. We would have the client imagine a person she believes she has tricked (i.e. a boss), have her role play telling that person specifically how she has tricked them (i.e. "you gave me that promotion because I've charmed you and you like me as a person, but you don’t realize that I'm not really capable of managing the new role".) Next, we would the client to talk back to herself from the perspective of that person (i.e. to say as her boss, "I don't just give promotions to the people I like, I give them to people who show promise"; or "It is insulting that you think my judgment is so skewed by liking people - I know talent and skill when I see it".) Giving voice to disconfirming evidence is an important part of challenging the idea that you have tricked everyone. Developing an open relationship with a mentor or other experts can also be helpful, both as a learning opportunity, and as a source of reliable feedback.

3) Change your language. An important behavior to address is in how a woman speaks to and about herself. If a woman finds herself consistently attributing her successes to luck, she can edit this by engaging in productive self-talk, i.e. “I contributed to this project by...”, “I closed that deal by…”, “I got an A on that paper by…” We encourage clients to practice demonstrating evidence of her competence on a daily basis, and credit herself verbally for her achievements. This can also be practiced by having a mindful moment at the end of a project, successful or not, in which a woman writes down for herself what strengths and skills she brought to to the table. While increasing positive self-talk is important, it is also useful to share one’s successes with others. We encourage clients to celebrate their achievements! Share them with your family, friends, and colleagues. While many women tend to focus on negative feedback, it is important to balance this tendency with the positive. Practice internalizing praise and practicing pride in your work by talking about it to yourself and others; this will help your accomplishments to become integrated into your self-view.

4) Develop your “inner expert” and increase your self-efficacy. While we want to focus on our achievements, there is always room to grow! We might invite a client to set learning goals for herself, and develop expertise about the field in which she is feeling deficient. For a new mom this can mean taking a parenting class or spending time with other moms to share tips. For a rising professional this can mean taking continuing education classes, attending conferences, or reading books about her field. The behavior of building mastery is self-perpetuating; by learning more, a woman builds confidence and faith in her own legitimacy. Developing the quality of self-efficacy requires a “walking the walk” or “fake it until you make it” attitude, in which a woman pushes herself to embody and emulate the person she wishes to be, even if she does not completely feel it. We might encourage a client to push herself to volunteer for challenging tasks and take on the goals that are a bit intimidating. By “acting as if” and doing the behaviors of someone who is confident about a project, she can further rewire her thinking. The important thing to remember is to take ownership of one’s self-doubt and take action. Learn by doing! Anxiety is designed to make us avoid danger; we encourage clients to practice mindfully disobeying her anxiety and feelings of self-doubt, and delve into honing her skills.

It is essential to remember that those who struggle with imposter syndrome may be no less successful, competent, or capable than those who do not struggle with it. Our goal is to help clients who experience feelings of insufficiency and fraudulence to change their thinking and their behavior in ways that can help them fully inhabit their successes.

Becoming Disloyal to Your "Inner Critic"

Many women in New York City strive to achieve ambitious goals in their personal and professional lives.  When a woman works towards her goals in a balanced fashion, such striving for achievement can add great meaning and fulfillment to her life. However, when a woman’s self-worth is overly dependent on whether she achieves the goals she sets for herself, she becomes uniquely vulnerable to the trap of self-criticism. 

Here at CTWPS, we recognize how self-criticism reinforces the cycle of perfectionism by weakening a woman’s self-esteem and, in turn, driving her to “prove herself” by setting incrementally higher standards for her performance.  In therapy, we teach our clients how to catch their “inner critic” and how to respond to the events in their lives – successes and failures – with greater flexibility and self-compassion.  Has your own inner critic has been “acting up” lately?  If so, the following tips may help you begin to broaden how you evaluate your worth so that it is informed by, but less dependent upon, your achievements:

1.     Get to Know your Inner Critic

Given that you may be quite loyal to your “inner critic,” it can initially be difficult to notice when it starts “acting up.”  In fact, many clients even express a reluctance to challenge their inner critic, due to the (fallacious) belief that it motivates them to work hard and meet their goals.  Without their inner critic, these women fear that they will be less successful, less important, or unneeded in their relationships or roles.  At CTWPS, we support our clients in challenging the fallacy that they must be self-critical in order to meet their goals, and we teach women how to successfully identify and catch their inner critic using various tracking exercises.  For example, we may ask a client to keep a log of situations wherein her inner critic makes personal judgments (“I’m a total failure”) or critical accusations (“I’m a loser for responding that way”).  Together, we would evaluate the consequences of such self-talk on her subsequent thoughts, feelings, and behaviors.

2.     Identify the Costs of Self-Criticism

We also help our clients to identify the consequences of remaining loyal to their inner critic.  For example, we may ask a client to look at a list of critical words her “inner critic” calls her for several minutes (Think: ugly, incompetent, unlikable…).  If she were to rate her mood before and after the exercise, how to you imagine her mood would change?  Most likely, her mood would worsen! Or, we may ask her to imagine that someone who she respects and holds in high esteem were to be followed around by a self-critical bully for a week, constantly criticizing her and ignoring all of her accomplishments. What do you think would happen to this woman?  Most likely, her mood and confidence would begin to plummet. Bottom line: Self-criticism makes you feel bad!

3.     Distinguish Between Self-Criticism and Constructive Self-Feedback

As you begin getting to know your self-critical tendencies, you may begin to recognize that you have been conflating self-criticism with constructive self-talk.  For example, imagine a woman who recently gave a big presentation at work.  In a debriefing meeting, her boss provided her with several points of positive feedback, as well as a few recommendations regarding how to continue refining her presentation moving forward.

If in response to receiving her boss’ feedback this woman were to be blindly loyal to her inner critic, she would likely berate herself for falling short of her own standards as a “strategy” to motivate herself to perform better next time.  For example, her inner critic may say: “My boss clearly thought I could have done better. I totally bombed that presentation. I’m incapable.”  The problem with this statement, however, is that it completely ignores and disregards the many strengths in this woman’s presentation!

4.      Develop a Self-Compassionate and Respectful Response

Ultimately, our focus at CTWPS is to support women in cultivating skills to treat themselves kindly and flexibly, and to tolerate setbacks and perceived inadequacies.  Thus, in treatment, we would support the client described above in learning how to construct a new self-statement that honors her boss’ constructive feedback in a way that is more growth sustaining and balanced.  For example, she may practice telling herself: “There were many strengths to my presentation, it was a great start.  Next time, I will also focus on putting less text on my PowerPoint slides and speaking more slowly, as my boss recommended.  This will make me an even stronger public speaker in the future.”  The practice of constructing a new self-statement would help this woman to take responsibility and incorporate her boss’ constructive feedback into her narrative without becoming unduly self-critical.

We may also invite this client to consider what she would say to support a close friend who had received such feedback from her boss. Would she confirm her friend’s belief and say, “You’re right, I think you’re incapable, too, and you will probably never get that promotion you’ve been working so hard for”? Probably not!  In fact, she would likely help her friend take stock of all the strengths in her presentation, and would normalize the process of receiving constructive feedback as one rises in her career. 

Additionally, we may encourage this woman to gather “evidence” that directly challenges her self-critical belief, such as positive performance reviews, a recent promotion, or a specific point of praise from her manager.  Together, we would cultivate an alternative perspective that integrates the kernel of truth in her experience with a more compassionate view of herself, such as: “I am generally well-respected in my role at work and tend to receive positive feedback from my managers.  I may also continue to receive specific points of constructive feedback as I take on new responsibilities. This feedback will help me become stronger in my role.”

On the path toward self-growth, even the most talented and brilliant women experience setbacks and moments of self-doubt.  Our ultimate goal is to support our clients in normalizing such moments as a healthy part of their experience, and to cultivate flexible and compassionate responses, both internally and as reflected in their behaviors.

 

This post is Part II in a series on cognitive-behavioral approaches for perfectionism.  Check back for more posts in this series coming soon.

 

Getting A Second Wind: Revisiting Your 2018 Goals

It’s February 28th, which means we are 59 days into 2018 and for some (myself included) - the New Year's resolutions that looked promising and hopeful on January 1st may feel considerably less so. Whether or not you set yearly resolutions, we all have some practice of goal-setting, whether it is in career, school, relationships, or personal life. While reaching goals often feels rewarding, unmet goals can elicit frustration, self-doubt, or self-criticism. These thoughts and feelings can often be enough for us to call it quits. However, this does not need to be the case. If the adage “experience is the best teacher” is true (and I think it is!) goal-setting (and striving positively) can always be an instructive and productive process.

First of all, let’s acknowledge that goal-setting itself can activate a whole range of automatic thoughts and emotions. For some, identifying goals can be motivating and exciting, whereas for others it may feel overwhelming and induce anxiety. We may experience optimistic thoughts, like “I think this will be a great experience” or possess skepticism and think “Well, any progress isn’t going to last”. As cognitive-behavioral therapists, we believe that identifying how we are thinking about a situation is just as important as the thought itself. Observing how we think and feel about goal-setting is a first step towards honest self-reflection, challenging unfair expectations of ourselves, and recognizing inaccurate beliefs about our ability that get in the way of goal-setting. It may be helpful to ask yourself:

  • What thoughts or emotions did/do I have about setting this goal?

  • What information or experiences have I had already that supports that my thought is true? Is there any information that contradicts my thought as true?

Onto the act of goal-setting:  While there are many ways to set goals, I have found the S.M.A.R.T. acronym a helpful guideline (Doran, 1981).   Is your goal Specific, Measurable, Achievable, Realistic, and Time-based?

Let me provide a specific example from my own life:  I’d like to be more environmentally conscious in 2018, and in my goal-setting process, I have broken down my goal into a bite-sized chunk. For example, I decided: S - I want to reduce my material footprint on a daily basis, M - I will take my daily coffee in a reusable thermos, A - Yes, I have multiple reusable options in my home/workplace, R - I can make coffee at home or request that a barista fill my thermos when purchasing it, T - I commit to this every morning. I will continue for 3 months and then reevaluate how things are going. Although it can be tempting to set goals that represent the ideal life we’d want, identifying reasonable and smaller goals goals that account for your present reality is essential. In fact, choosing goals that seem to be smaller than you think you should choose is a good first step. Why? Because being successful in smaller goals allows us to begin building a foundation to support more complex goals (e.g. if I can bring my thermos to work regularly, then I can add the goal next of always carrying reusable shopping bags with me, scaffolding on the same habit I’ve already created). Making our goals overly ambitious sets us up for quick setbacks that typically result in a barrage of self-criticism which pulls us off track of problem-solving and habit building.

Importantly, there are always setbacks in meeting goals. How we respond to the setback is critical.  Do we shame ourselves or over-personalize the setback (e.g., I forgot my coffee thermos twice this week, so this week is a wash; How could I forget my thermos-am I just an irresponsible person?!). Instead, we can “take the shame out of the game” and get curious about what happened and do some fact-finding. Here at CTWPS, we are very invested in staying curious and supporting your problem-solving. Reach out to us if we can help!

 

 

Citation:

Doran, G. T. (1981). There’s a S.M.A.R.T. way to write managements’ goals and objectives. Management Review, 70, 35–36. Dörnyei, Z. (2001). Motivational strategies in the language classroom. Cambridge: Cambridge Language Teaching Library.

 

Dating Challenges

While dating can be a fun and exciting period of a woman’s life, many women find it difficult to maintain optimism while seeking a committed relationship, especially when she has been working at it for some time.  While dating can certainly be challenging at times, at CTWPS we aim to help women reduce any feelings of distress or hopelessness that might arise. The first step on that path is to help women examine their thinking and behavior when it comes to dating, and this involves identifying any thinking traps that a woman may fall into as she works toward her goal.

One common cognitive distortion that can be provoked by dating is the “fortune telling” error. The fortune telling error takes place when one assumes a negative outcome will occur without fully evaluating the probability of that outcome. It acts as a mental shortcut, allowing conclusions to be drawn using limited available information. Often, the negative predictions made by the fortune telling error can lead to a woman feeling sad, resentful, or anxious. Consider the following beliefs:

“I’ve been on so many bad dates, this one will be no different.”

“Nobody will want a woman who looks like me.”

“I’m never going to meet someone who will be okay with my commitment to my job.”

“I want to end my unsatisfying relationship, but I don’t think I’ll meet anyone better.”

If this kind of thinking feels familiar to you, you are far from alone! When a woman tells herself one of the statements above, she believes it and feels it, most probably because she has actually experienced it in some way. However, while our past experience is important, it does not allow us to make perfect predictions of future dating partners or relationship outcomes. And when we engage in fortune telling and assume a negative outcome, we risk impacting our mood negatively, as well as our behavior.

For example, consider a woman who tells herself that if she isn’t married by age 35, all hope is lost and she will never find someone. This woman may find herself feeling increasingly depressed as she nears the dreaded age, which may cause her to spend less time socializing and going on dates. While nothing has actually changed about her, and there is no evidence that she has “expired” as a potential romantic partner, her mood and her behavior have changed, fulfilling her belief that she is out of the game. This woman’s fortune telling about her prospects ends up encouraging the feared scenario. Another example might be a woman who tells herself that all dates that she goes on are terrible, and so she’s not going to bother putting herself out there with this one because it will turn out just as badly. She goes into the date unenthused, resentful, or withdrawn, and the date ends up being a bust. Unintentionally, this cognitive shortcut is resulting in the opposite outcome of what she really wants, and it confirms her belief. She comes out of the date fulfilling her faulty prophecy that all dates are bad.

Here at CTWPS we work with women to influence what they can do to maximize their experience of dating. We would determine together whether “mental shortcuts” or thinking habits are inhibiting her dating life or expanding it.  We would also consider ways to align her dating behaviors so that they are consistent with her long term goals of partnership.  Dating and finding a partner are similar to other goals, and can definitely benefit from an approach of positivity and flexibility.

Surviving Infertility with Your Mental Health Intact

Women struggling to conceive often express how frustrating it is to be unable to get pregnant once they’ve decided the timing is right - after years spent trying to to avoid untimed pregnancy. Many women lament the fact that friends and family members appear to become pregnant when their husband or partner “simply looks their direction;” while they may spend months peeing onto ovulation sticks, tracking basal body temperatures, and timing sexual intercourse. A friend’s pregnancy announcement on Facebook may trigger an acute sorrow for the woman who has been injecting hormones into her stomach, waking at 5:00 am for monitoring appointments, and experiencing repeated disappointments for months on end. There is no doubt, a feeling of utter unfairness accompanies one’s (unwelcome) membership to the community of women who struggle with infertility. To add salt to the wound, oftentimes “membership” is granted only after a year (or several years) of failure, after many invasive medical exams, and, in the case of repeated miscarriage, after enduring heartbreaking losses.

Managing the myriad of emotions that come with infertility can be incredibly taxing, on both male and female partners. Anger, sadness, jealousy, fear and disappointment are just a few of the emotions that may arise when struggling with infertility. Depending on an individual’s unique personality traits, history, vulnerabilities, and life stressors, sometimes these emotions become truly impairing and develop into clinical depression and/or anxiety. At CTWPS, we are attuned to these issues – we understand the emotional toll of infertility on you and your relationships, and we honor the psychological anguish that often comes with this journey. While we cannot wave a magic wand and make you pregnant, we can help you cope with the negative emotions you may be experiencing about your body, your partner, and the process of conception. We can help you develop tools for managing depression and anxiety in the face of disappointment and loss. And, through it all, we can support you by providing a safe, judgment-free space to express the full range of emotions you may experience.

When addressing infertility-related mood concerns, cognitive-behavioral therapy functions in the same way it does for many other mental health concerns. CBT aims to help the individual 1) see the relation between her thinking, mood and behavior; 2) develop skills to evaluate her thinking in order to view their life circumstances as accurately and helpfully as possible; 3) engage in healthy behaviors that promote optimum mental health; and 4) develop the ability to tolerate uncertainty, discomfort and adversity that we all invariably experience in life.

One of the primary goals of treatment at CTWPS is to increase hopefulness. To do so, we first need to acknowledge the intense fears that underlie catastrophic or fearful thoughts. These thoughts are real and significant, and yes, there is almost always a kernel of truth to our greatest fears. However, while the worst case is possible, it is almost always unlikely – and living in that place of “worst case scenarios” before it is a reality, is unproductive.

Oftentimes, our minds jump to worst case scenarios out of an innate desire for certainty: “If I know the worst is going to happen, then at least I don’t have to wonder, wait, and worry.” However, living in this dark place of hopeless negativity is counterproductive to our mental wellbeing, and may leave us feeling sad, depressed and helpless. Thus, the work of CBT is to increase our tolerance of uncertainty (and adversity), such that we can properly assess the opportunities we do have to improve or change the situation. Taking action – rather than catastrophizing – provides a sense of self-efficacy, hopefulness, and the opportunity for positive change.

Infertility can be extremely stressful and overwhelming, heartbreaking and painful. For couples who are ready to conceive, the disappointment of unrealized expectations can become emotionally disheartening or even debilitating.  At CTWPS, we recognize how lonely this struggle can be. Our goal is to support you during this difficult time by providing emotional support, by teaching you strategies for managing maladaptive thought processes, and by offering practical strategies for navigating your life and relationships in the face of infertility. Our goal is to help you live a full and balanced emotional life, whereby a set-back like infertility is a challenge, but is not life-defining.