Rockland County Psychological Society May 19, 2013

1. Using Cognitive Behavioral Therapy to Treat Anxiety Disorders Presented by: Dr. Caren Baruch-Feldmandrbaruchfeldman.comdrcarenfeldman@msn.com Rockland County Psychological Society May 19, 2013

2. GOALS FOR TODAY’S TALK • Increase Your Understanding of the Causes of Stress/Worry Faced by People Today. • 2. Teach You Actual Cognitive Behavioral Strategies that Can Be Used to Treat Anxiety Disorders.

3. Is Stress and Worry Good, Bad, or Something In Between?

4. Why Are People So Stressed Today? • Pressure to Succeed. • Uncertainty in Society as a Whole that is Contagious (mirror neurons). • Internet/Media. We overestimate risk based on: accessibility, recency, powerful images, severity of outcome. • Fast Pace Life Increases the Need for Control. • People Can’t Just Sit with Their Feelings.

5. How Can We Help Individuals Turn Their Worry Into an Appropriate Level of Concern To Feel Better? • Psycho-Educational (3) Changing One’s Behavior (physiological and avoidance) (2) Changing One’s Thoughts No? Yes!

6. Understanding Stress and Worry • Nervous Systems • Genetic Predisposition • Worry as a Bad Habit • Choose a Different Path by: a. Identify productive and unproductive worry. b. Accept reality and commit to change. c. Challenge your worried thinking. d. Change your behavior. e. Use your emotions to help you rather than worry. f. Keep it going and when failure occurs turn it into an opportunity.

7. Worry More Effectively Rules for Productive Worry Signs of Unproductive Worry 1. You are worrying about unanswerable questions. 2. You are worrying about a chain reaction of events. 3. You reject a solution because it is not perfect. 4. You think you should worry until you feel less worried. 5. You think you should worry until you feel totally in control. 1. Figure out if the problem is plausible or reasonable. 2. Decide if you can do something about it right now or very soon. 3. Quickly move from worrying to problem solving.

8. What Doesn’t Work!!! 1. Seeking Reassurance. 2. Trying to Stop Your Thoughts. 3. Checking and Checking. 4. Avoiding Discomfort. 5. Demanding Certainty. 6. Not Seeing Crazy Thoughts as Anxiety But Instead Thinking It’s True.

9. Changing One’s Thoughts How One THINKS About A Situation Affects How One Feels.

10. Basics Principles of REBT . Albert Ellis

11. Experiment 1 What Do You See? Look around the room and try to find all the examples of RED you can see. What have you spotted?

12. Experiment 2 Picture yourself in the following situation: You are standing in line at the bank. There are about 50 people around. A robber enters and fires his weapon. You get shot in the arm, but no one is hurt. Would you consider yourself lucky or unlucky?

13. Experiment 3 Worried Florida Old Lonely Orange Bingo Conservative wrinkle

14. What Is the Thought Associated with Anxiety? Expecting the Worst … Seven Rules of Highly Worried People - R. Leahy (The Worry Cure) 1. If something bad could happen – then it’s your responsibility to worry about it. 2. Don’t accept uncertainty-you need to know for sure. 3. Treat all your negative feelings as if they are really true. 4. Anything bad that happens is a reflection of you as a person. 5. Failure is unacceptable. 6. Get rid of any negatively feelings immediately. 7. Treat everything like an emergency. * Worry about your worry.

15. Changing Ones Thoughts • Step1: Identify Negative Thoughts. • Look for Expecting the Worst. • Step 2: Question and Challenge Thoughts. • Where is the Evidence? • Is it Helpful? • Step 3: Come Up With More Realistic and Optimistic Thoughts to Feel Better. • 1)There is no evidence… • 2) Worrying won’t help……

16. Step 1: Identifying Negative or Irrational Beliefs/Thinking Traps IRRATIONAL BELIEFS • Demandingness – SHOULDS/ MUSTS • Awfulizing – It Is Terrible! • Low Frustration Tolerance – I Can’t Stand It! • Global Rating of Self/Others. Self-Downing.

17. Core Irrational Beliefs/Thinking Traps Associated With Anxiety • It’s going to be terrible. From 1-100 it will be 100 (fortune telling). • I can’t stand it (catastrophizing). • I shouldn’t feel this way (shoulds/musts). • I am a failure because I did poorly (personalizing). • I will fall apart if I feel uncomfortable (low frustration tolerance). • A disaster is definitely going to happen (overgeneralizing). • I have to get a 100 or do perfectly (all-or-nothing-thinking). • If I don’t do well on my chemistry test, I will fail the class. If I fail the class, I won’t get into medical school. Then everything will be terrible. (sliding down a slippery slope).

18. Step 2: Question and Challenge Thoughts • Where is the evidence that what I am expecting will happen? • Is it helpful how I am thinking? • What are the cost and benefits to my thinking? • Would I think the same way if a friend presented this issue?

19. Step 3: Develop Rational Beliefs/Thoughts RATIONAL BELIEFS • Wishes/ Preferences • Living in the Gray • I Can Stand It • Total Self Acceptance

20. Irrational vs. Rational IRRATIONAL BELIEFS Demandingness – SHOULDS/MUSTS Awfulizing – It Is Terrible! Low Frustration Tolerance – I Can’t Stand It! Global Rating of Self/Others - Self Worth Tied to 1 Behavior or Action. Self-Downing RATIONAL BELIEFS Preferences Living in the Gray Realizing That They Can Stand It Not Judging Themselves Self Acceptance

21. EXAMPLE: Mom, I’m Worried! Test Anxiety Expecting the Worst I am going to fail! It is going to be terrible! I will need to repeat the grade. If I fail I am a bad person! The test shouldn’t be this hard!

22. EXAMPLE: Mom- I’m Confident! Confident Test Taker Realistic and Positive Thoughts There is no evidence that I will fail. I haven’t failed previous tests. Even if I fail, I am exaggerating how bad the results will be. Nobody gets left back in 7th grade because of one test. Worrying is a waste of energy. It is really the worst thing I can do. Since when I worry, I am not paying attention fully to the test.

23. Let’s Practice Step 1: Identify Negative Thoughts. Step 2: Question and Challenge Those Thoughts. Step 3: Come Up With More Realistic and Optimistic Thoughts to Feel Better.

24. Rational Emotive Imagery • Picture a bad event clearly. One that has either already happened or that you believe likely to happen. Take your time. Fill in the details. Visualize the people involved, hear them talk, describe the environment, let the situation happen in your mind. Feel the emotions; you can do it. Keep imagining until the emotions are as disturbed as you can get them. • After a minute or two, change your emotions from disturbed to merely unpleasant. Did you change your thinking? Was your thinking more realistic? It’s the thinking that causes the emotional response.

25. Changing Behavior: Your Emotions Are Your Friends • Be A Detective • Rather than think of fear as a signal to RETREAT, consider it a CUE to go forward.

26. Changing Behavior: Physical Sensations • Spell Your Name with Belly Breaths • Deep Muscle Relaxation • Guided Imagery • Meditation • Change Your Breath

27. Changing Behavior: Don’t Avoid • Facing One’s Fear or Stress • Manageable and Hierarchical Manner • Success Breeds Success

28. Coping Cat by Kendall- FEAR Plan • F = Feeling Frightened? • E = Expecting Bad Things to Happen? • A = Attitudes and Actions that can Help. • R = Results and Rewards • FEAR Ladder or Situation Cards

29. What Else Can You Do • Possibility vs. Probability. Determine How Likely It Will Happen. • Give Worry a Name. • Living in the Here and Now, Not the Future. Appreciate the Moment. • Worry Tape. Flood Yourself with Uncertainty. • Embrace Discomfort. You Can Stand It. • Set Aside a Worry Time. • What’s the Best, Worst, Most Likely Outcome. • Write Down a Story With a Better Outcome. • Separate Thinking from Action. I am simply having the thought…. • Describe What Is in Front of You. Don’t Jump to Conclusions. • Can’t Tell Someone to Relax/Calm Down. The Person Needs to Get There Him/Herself. • Positive Psychology: Grateful Activity, Journal the Positive, Random Acts of Kindness. • Exercising, Eating, and Sleeping Right .

30. A Few More Facts/SUMMARY • People are actually less worried when they are worrying. In fact, worriers fear emotions and do not process the meaning of events because they are too much in their heads. • Intolerance for uncertainty is the most important aspect in worrying. • Be a long-term hedonist vs. a short term one. • Turn failure into opportunity (I didn’t fail, my behavior did. Failure is not fatal).

31. From Challenge to Opportunity After SANDY Seeing it as an OPPORTUNITY

32. CBT Sheet by Caren Baruch- Feldman • What is the Situation? • What Is the Feeling Associated With That Situation? • What Are Your Thoughts About The Situation? • Challenging Those Thoughts. • Alternative Way Of Thinking About the Situation. • New Feeling.