My new book - No Bravery Required

I am very pleased to announce the release of my latest book, on a subject very near and dear to my heart: a simple, clinically proven strategy for painlessly treating fears and phobias.

Based on my successful longtime Anxiety Camp program, No Bravery Required looks at the key areas that good therapists use to treat fears and phobias, including mindful awareness, physical relaxation, cognitive restructuring (e.g. changing the way you think about a scary situation), gradual exposure, and social and communications skills for social anxiety.

The core point of this book is summarized in its title: losing your fears involves specific tools and skills, not bravery. And when done correctly, getting well should be much easier than staying ill. The strategies in this book have been proven over and over, both in the Anxiety Camp group program I have run since 2009, and in the hundreds of individual clients I have treated over the years.

To order your copy - in paperback or Kindle format - click here.

What Emotionally Unstable People Do Better Than You

When I describe someone as emotionally unstable, it isn’t an insult. It is a clinical description, just like having brown hair or wearing glasses. So I mean it in the nicest possible way.

This is because emotionally unstable personality disorder, also known as borderline personality disorder or BPD, is an actual diagnosis. And it is often quite treatable for many people who suffer from it. Which brings me to the topic at hand – emotionally unstable people who are successfully treated do something that would also benefit each and every one of us, if we did it. They learn to behave counterintuitively in their worst moments.

Here’s an example. Relationships with borderline personality sufferers often feel like living inside of a food processor, because one minute you are their best friend in the world, and the next you are the cause of all their problems. This is because they have an intense fear of abandonment, combined with a diminished capacity to process negative emotions. Which means that if you forget to respond to their text message, or sound a little frustrated about something, it can quickly turn into a flashpoint.

So here is how you treat this: you help them to recognize familiar patterns of behavior, and then behave differently when they happen. For example, let’s say that Joe is a BPD sufferer who is upset with his wife Sally because of something she said. Here is how the conversation might go:

Joe: You are always rejecting me! I can’t stand it anymore! I feel like jumping off a bridge!
Sally: Joe, do you think you’re having a borderline moment right now?
Joe: You’re right, Sally, I probably am.
Sally: So how about doing what we’ve planned for these moments – binge-watching your favorite TV show, and then coming back and talking with me in a couple of hours?
Joe: Sounds good – see you then.

Listen carefully: this conversation would sound very unrealistic to most people. Joe would normally not feel like watching TV when he is upset and frantic about Sally, and would not appreciate having his disorder called out. But in this case they have learned – often with the guidance of Joe’s therapist – that naming what is happening and taking a break will work for him in moments like these, so they agree ahead of time to do so. Which means they get all the benefits of a relationship with a BPD sufferer – which is often intense and passionate – while mitigating the drawbacks.

Now let’s circle this same idea around to you and me. *We* don’t inherently know what is best for us in the moment either. So we also need to plan ahead for what to do in our worst moments. And once we have a game plan for those moments, we can learn to master them.

Here is a personal example: every year, I close my therapy practice over the holidays. And because I am usually so busy, I always believe that having all this time off will be fantastic! But then the same thing always happens: within a couple of days, I feel depressed and out of sorts from being out of my routine, and feel stuck in the house by the cold weather.

Now in *that* moment, going back to work seems like the last thing that would help me feel better. But sure enough, going back to work the first week in January always lifts my mood again. So I have learned to plan for purposeful activity over the holidays.

The same thing is true for you. Dreading a fearful situation? It may be time to take a walk. Angry about something? You may need to give it time rather than acting on it. Feeling stuck in your life? This may be the time to connect with your friends. Your worst moments will often go much better with a thoughtfully composed plan - that may, in fact, go against your human nature - which you execute every time you are in that situation.

So take a tip from emotionally unstable people: acting on your feelings is not always a good idea, and making an alternative plan of action in advance is often the key to peace of mind. Because as Benjamin Franklin once said, those who fail to plan often plan to fail.

If I Were President: Creating Access to Mental Health Care

Guess what – I’ve just been elected President of the United States. (Just kidding, this election year is crazy enough already.) But if I were, here are three things I would change about access to mental health care in this country:

Provide universal coverage. You need mental health care. You have insurance coverage. So you go out and get mental health care and pay for it with your insurance coverage, right?

Wrong. Often people are limited to closed lists of in-network providers (many of whom are full), can’t see certain classes of therapists such as LMFTs (like me) or LMHCs, or face other roadblocks to care. And the worst offenders are often taxpayer-supported programs like Medicare, Medicaid, or the VA.

My solution would be to pass a nationwide Any Willing Provider law. If you are a licensed psychotherapist, you can provide services to anyone. Period. And insurance must pay for it. Period.

Let psychotherapists practice nationwide. Therapists can now technically practice anywhere, thanks to online technology. But there is one huge roadblock standing in the way: a stupid and outdated crazy quilt of state licensing laws.

If I practice outside of New York or Arizona, where I am licensed, I could actually face felony charges in some states. My malpractice insurance would also become void. It would literally be easier and legally less risky for me to treat someone in Uzbekistan than in, say, Ohio.

Worse, every state has its own incompatible requirements. Many have different course and credit hour requirements, forcing you to go back to school. Some will not accept a distance learning degree. And California, because they are special, makes everyone start all over again as an intern and then take their own exam. State requirements not only dramatically limit access to online therapy, they often trash the careers of good therapists who must move to another state for personal or family reasons.

If I were President, I would create national licensure for therapists. Or at least require the easy fix of license reciprocity. If you have been practicing therapy for, say, five years and haven’t killed anyone, there should be no good reason you cannot practice in any state of this great country.

Mandate coverage of telepractice. Finally, the last piece of the puzzle is providing financial coverage for online therapy. Telepractice is now legal in most if not all states. The problem is that insurance usually won’t cover it, so you can’t have it unless you can afford it yourself. This in turn denies care to people who could really use online therapy, like the housebound, people in remote communities, shift workers, and areas with few therapists or long waiting lists.

Legislating this has turned out to be extremely slippery. New York, for example, now has a Telehealth Parity Law mandating such coverage – but it is limited to specific types of therapists (not including LMFTs, unfortunately), and is full of loopholes: for example, it does not mandate how much insurers would reimburse for such sessions, requiring follow-up legislation. As President I would order everyone to cut the comedy and just cover online therapy at par with regular in-office therapy.

Of course, I am not going to be President anytime soon – thank goodness. So instead of wasting your vote on me, I am going to ask you to do the next best thing: become aware of legislation affecting access to mental health care in your state, and make your voice heard so that everyone gets the care they deserve. Thank you!

The Wallenda Strategy: Making OCD Treatment Easier

(Note: This is an article I published privately for my peers in the OCD treatment community a while back, after attending the 2015 OCD conference in Boston. It received a good response, including positive comments from the director of the International OCD Foundation. While this article is aimed at fellow therapists, I am posting it here for interested lay people and OCD sufferers as well.

As a postscript: in 2018, I published a research poster paper at the 2018 IOCDF conference in Washington, DC about this approach, showing a 90% treatment response rate across my own cases. A link to this paper is here.)

What do people who suffer from obsessive-compulsive disorder – one of the most maddening neurological mental illnesses – have in common with tightrope walker Nik Wallenda? Perhaps more than we give them credit for.

OCD treatment has come a long way. Just over twenty years ago there were no conferences, few proven treatment options, and a lot of really ill people out there. Today there is much more hope, much better treatment, and a very active and engaged research community. Particularly in the area of exposure and response therapy (ERP), now viewed as the gold standard for OCD psychotherapy.

However, I feel ERP still suffers from a PR problem - one that could be fixed with better linguistics. According to current literature, treatment refusal and dropout rates for ERP can total 30% or more. Add those who relapse, or get “stuck” beyond a certain point of treatment, and you have a lot of people suffering – often after working hard and going through a lot of discomfort. Some of my own clients frankly disclose that when they first read about OCD treatment, they walked away feeling dejected and hopeless, because they felt they lacked the bravery to pursue it.

This is where Nik Wallenda comes in. He is famous for high-wire feats such as crossing the Grand Canyon or Niagara Falls. But he prepares for these events by practicing for hundreds of hours on a wire that is just a few feet off the ground, safe and supported at all times. In other words, he loses his fears by making himself comfortable enough to do a lot of practice, and gradually but continually improve.

I use a Wallenda strategy with many of my OCD clients. I don't talk about bravely facing their fears. I don't focus on habituation or extinction bursts. Instead, after we do some cognitive work and create an exposure hierarchy, I give them the following instructions for daily practice:

Start in your comfort zone, stay in your comfort zone, and see where you can take your comfort zone from week to week.

This puts clients completely in charge of whatever they feel ready for – but it also gives them an incentive to track their progress and continually improve. Wherever they feel safe is where we start, whether it is gradual exposure and response prevention, imagery or mindfulness practice. Then I give them plenty of support and encouragement.

Sometimes clients surprise me with their rapid gains, which I cheer enthusiastically. Other times it is a game of small steps or setbacks, which I normalize and empathize with. Sometimes they feel stuck and we explore new strategies, such as imagery desensitization. Either way, I stay unfailingly positive as I encourage them to keep practicing and turn their battle with OCD into lots and lots of easy.

And you know what? It seems to work. I am just one small sample – a private practice in the middle of upstate New York. But on standardized assessment measures of OCD, I generally get very good clinical outcomes with my clients compared with what I see in the literature. With two key differences: (a) it some cases, it may take us longer to get there and (b) they almost never drop out.

I realize this approach isn't for everyone. For example, serious cases such as inpatient clients may need stronger exposures to get better quickly. For others, doing what they never thought they could do might be an important teachable moment. And I realize that some people could technically skate along with minimal exposure and make no progress - although I find that time and patience actually lead most of my clients to improve. But I have come to feel that most people do their very best with OCD treatment when we make getting well seem easier than staying ill.

I suspect that behind closed doors, this is how many of us actually treat OCD anyway, if we don't want our clients to run for the hills. So here is my challenge: stop glorifying strong exposures. Too many people associate ERP with standing in filthy dumpsters or confronting intrusive thoughts head-on. Let's change our language, and see if a kinder, gentler approach to ERP - like Nik Wallenda uses - might reach more people and give us better long-term outcomes.

What to (Really) Do If You are Lonely

I am writing this during the holidays, which for many people are the loneliest time of the year. It is often dark, cold, and depressing. And for too many, the popular image of holiday togetherness stands in stark contrast to what is going on in their lives. Especially for those struggling with a loss, a breakup, family problems, or simply one more year without a close relationship to anyone.

There are lots of chirpy articles out there with tips about dealing with loneliness. They talk about things like getting a cat, taking a walk, or seeing your favorite movie - many of which do little for the bone-deep sense of isolation that many people feel. Worse, they often tacitly imply that perhaps you should settle for being alone.

I have a different perspective entirely - one that comes from observing people move past deep states of loneliness to find meaning and intimacy. Here are what I have come to feel are three *real* steps for banishing loneliness from your life:

1. Team up. Talking to another human being about your loneliness is no more shameful than talking to a mechanic about your car problems. There are always compassionate people to talk to, right this very moment if you wish. Call a crisisline, visit an online support site, or contact a volunteer support organization. Then be open and honest about how alone you feel.

Or better yet, start seeing a therapist. All right, I am biased. But we are much more than "paid friends." We are trained professionals with the skills to teach - and coach - you how to find more intimacy in your life, within the context of a supportive therapeutic relationship. And we serve as a weekly connection with another human being who is always in your corner. Which brings me to the next point:

2. Learn new interpersonal skills. I don't know why you are lonely. But there are reasons lots of other people are. Here are just a few:

·         You are grieving the loss of someone and don't know how to reconnect with others

·         You feel too old, unattractive, unlikeable, mentally ill, or whatever to have friends or a partner

·         You have social anxiety and it is painful to approach people or risk rejection

·         You - and I mean this in the nicest possible way - don't know how to make other people feel good

·         You are hurting too badly to make room for another person in your life

The common denominator between each of these problems is that they can all be addressed by learning new skills. Whether it is learning how to connect with other people at an emotional level, how to overcome social fears, how to stop judging yourself, or how to work through grief and live again, there are strategies you probably haven't tried yet that can help you.

For example, I developed a handout for clients with social anxiety called "Conversation 101" - essentially, a Betty Crocker cookbook of simple techniques for having a nourishing, five-to-seven minute conversation with anyone. (P.S. If you would like a copy, email me!) It works really well. So if you feel you can't talk to people, well, I bet you can.

Same thing with deciding, for whatever reason, that you don't merit the company of others. Do you know what one of the most surprising things I have discovered from seeing hundreds of clients as a family therapist? That factors like looks, mental illness, or age seem to have almost NO correlation with relationship status. What does have a much bigger factor is your own self-talk - and we can fix that.

3. Start looking at people differently. We all fear rejection from others. Honor that feeling if it looms large for you. But from now on, start looking at your interactions with others as an opportunity to practice the new skills we just discussed, rather than as the sole measure of your self-worth.

A key concept in cognitive-behavioral therapy, which I practice, is to take small steps toward new goals. So stay in your comfort zone as you start interacting with others. One person might go to a large party or networking event, another might have a friend set them up on a low-pressure date, still another may just start saying "hello" to the checkout clerks at Wegmans. It is perfectly all right to go slow if you need to.

Whatever you do, start looking at these encounters the same way you learned to use chopsticks - it's OK even if you make a mess. Treat yourself regardless as someone who is worthy of the love of others. Perhaps sooner than you think, you will find that people respond in kind. And over time, you will find yourself building more connections with others.

I find that many lonely people view their situation as a fate handed down by God. But my actual experience is that overcoming loneliness is much more of a skills-based process - one that often leads people to a new reality of being liked and loved. I hope that you will find joy and intimacy in your life as well.

When You Can’t Afford Help

The cost of mental health care can seem daunting. Whether it is a lack of insurance coverage, high deductibles, job loss or other money woes, finances often lead many people to suffer rather than seek treatment. With a little creativity, however, there are often ways to get help.

First, let’s look at some low-cost options for professional treatment:

Public and private mental health agencies. Most agencies offer an income-based sliding scale, and accept public assistance such as Medicaid. Many have caring and competent therapists, along with the resources to handle issues like medication, crisis intervention and serious or persistent mental illness.

Colleges and universities. Graduate students in psychology are one of my favorite resources for therapy. First, their fees are extremely reasonable: in my area, local university mental health clinics charge as little as $15 per session. Second, graduate interns are often up on the very latest clinical skills and supervised by top experts in the field.

Pre-licensure candidates. Most states require thousands of supervised hours to become a psychotherapist, and clinicians working toward licensure are often eager to see clients at little or no cost. State associations of fields such as social work, mental health counseling or marriage and family therapy may be able to help you locate clinicians in training, as well as larger mental health practices.

Pro-bono therapy. Many private therapists honor an unspoken professional obligation to treat a certain number of people at little or no charge. Don’t be afraid to disclose your financial situation to therapists and see what is possible. Also, your local mental health association (a consumer advocacy group distinct from mental health agencies) may be able to arrange treatment options you can afford.

Finally, here are some resources that can help or support you in addition to formal professional help:

Crisislines. Crisis counselors are available 24 hours a day from anywhere in the United States at 800-273-TALK (8255). You do not need to be suicidal or desperate to call: their job is to listen empathetically, direct you to resources, and help you take next steps in any situation. Crisis counseling is NOT psychotherapy, and not designed for the treatment of ongoing mental health issues. But trained volunteers are always there to talk with you.

Support groups. Live or online support groups can be a source of both information and fellowship. Support groups are also not meant to take the place of therapy, and are not for everyone – specific groups can vary widely depending on their participants or leadership.

Community-based programs. Many areas offer low cost therapist-led training programs for mental health skills such as managing your anxiety or controlling your emotions – check your local community activity listings. My own Anxiety Camp program, for example, teaches people in upstate New York how to deal with fears and phobias in an intensive weekend program costing less than $100.

The common thread through all of these ideas is: don’t give up when the cost of care seems overwhelming. Ask questions, explore resources, and keep trying. Your good mental health is worth it.

What is a "relationship-friendly" therapist?

When I meet with a couple for the first time, I inform them that I am a "marriage-friendly" or "relationship-friendly" therapist. Do you know what this term means?

It sounds like one of those apple-pie-and-motherhood phrases, sort of like being a student-friendly teacher or a patient-friendly doctor. In reality, it is a buzzword with a very specific meaning in our profession. And it is an important distinction among therapists if you ever seek counseling with your partner.

Relationship-friendly therapists serve the relationship, not just the individuals in it. It means that, except in cases of abuse, I will never explore whether a couple should break up or not. As long as they are both there to work on improving the relationship, I am there to work on it with them.

This orientation springs from the larger marriage-friendly therapist movement nationwide, which has several noted clinicians associated with it. There is even a registry of such therapists. (I am not a member - it is rather expensive, and my practice is pretty full already.) And it is important to understand that many very good counselors choose not to follow this orientation, because it isn't right for everyone.

Why do I choose this approach? Primarily for the comfort of the couples I serve. People often feel safer knowing that I will never, ever encourage them to break up. They know that I will always focus on helping them both reconnect, no matter what happens, as long as no abuse is taking place.

By comparison, many therapists have a relationship-neutral orientation that focuses on what is best for each partner. There is absolutely nothing wrong with this. But many couples avoid counseling for fear that the counseling process itself may lead to separation, and I explicitly take this fear off the table by privileging the relationship itself as my client.

I also follow this approach because it works. Many couples come to therapy because they have lost hope of solving their problems alone, and I have watched amazing transformations take place when they learn new relationship skills in a safe space with a counselor who will never give up on them. Even in situations that, on paper, may have seemed difficult or even hopeless at first.

Here are some other things worth knowing about relationship-friendly counseling:

We respect your choices. A relationship-friendly therapist will not proselytize either of you to stay together. If you thoughtfully decide to leave your partner, this is your right and your choice, and we do not seek to change your mind. We do, however, explore what we can do to help.

It may not be the right approach for you. For some couples, one or both partners actively want to examine whether their relationship should end. There is nothing intrinsically wrong with this. In cases like these a relationship-friendly therapist would be a poor choice, given our focus on saving and improving relationships, and there are many excellent counselors who are better suited to exploring these issues with couples.

It has ethical implications for individual counseling. I sometimes describe couples counseling as a "one-way door." Once I work with a couple, it would be a conflict of interest to treat either partner for issues that involve their relationship. This means I will probably never serve as either person's individual counselor in the future.

This does not mean that I never meet one-on-one with partners of a couple: in fact, it is good to do this periodically, to check in and discuss issues that may not come up in joint session. Short-term individual counseling for specific issues that do not pertain to the relationship is OK too. But in general, I encourage partners to have their own counselors where appropriate.

Is relationship-friendly counseling right for you and your partner? Click here to learn more about this movement, and become an educated consumer. Counselors like me see it as an important tool for preserving and growing healthy relationships.