A Lecture Series

8:00 P.M.
Thursday, June 20, 2013
One Bergen County Plaza
First Floor Multi-Purpose Room
Hackensack, NJ 07601

Sarah Schleifer, MSSW, LCSW

ABC's of Cognitive Behavior Therapy
Introduction to:
The concepts of Cognitive Behavior Therapy
Steps to Using CBT in Your life

Cognitive Behavior Therapy is the most studied psychotherapy treatment modality and has been found to be effective in thousands of studies.

This presentation will include an introduction to CBT and a demonstration of some of the techniques as well as a brief update on other frequently used treatment modalities including Dialectical Behavior Therapy (DBT), EMDR and IFS. Handouts and exercise sheets will be provided.

Ms. Schleifer's career spans over 30 years working in family therapy and hospital and outpatient settings. She developed and led the QUEST Partial Hospitalization Program of Hackensack Medical Center until 2003. Her wellness model encourages the shift of focus from illness symptoms to skills the individual needs to work towards recovery. She has advanced training in CBT, DBT, Eye Movement Desensitization and Reprocessing (EMDR) and Internal Family Systems (IFS).

About Panic Disorder

 

People describe panic attacks in different ways, but there are similarities I tend to hear.  “It came out of the blue, without warning.” “I was afraid I was dying.” “I keep worrying about when the next one will come.”

Panic disorder is an anxiety disorder that is experienced as sudden episodes of intense fear, in which the person feels that something bad will happen or that he or she is dying.  Panic attacks can mimic heart attacks.  In fact, panic attacks account for almost 40 percent of visits to the emergency room with complaints of chest pain.   Panic disorder occurs in twice as many women as men.  The symptoms usually begin in late teens or early adulthood, but may occur in children and not be diagnosed until they are older.  This speaks to the importance of noticing possible symptoms at an earlier age.   Early identification can lead to early intervention and the learning of coping skills to stop the occurrences. 

A panic attack is different from general anxiety in that it has a distinct beginning and an end.  It most often lasts for about 10 to 20 minutes, but some symptoms may linger for an hour or more.  People will sometimes describe a lingering feeling of dread all day.  People with panic disorder may have sudden and repeated attacks of fear, a feeling of being out of control, an intense worry about the next attack, and an avoidance of places where panic attacks have occurred.  Physical symptoms can include racing heart, heart palpitations, sweating, shortness of breath, weakness or dizziness, hot or cold feelings, numbness or tingling, and chest or stomach pain.

The term anticipatory anxiety describes the fear that develops about having another panic attack. This results in people avoiding places that are similar to where they were when they had an attack. If someone has a panic attack in a supermarket, they may avoid going to that supermarket, then all supermarkets, and perhaps all large stores.  It is as if the brain is learning that these are dangerous places to avoid.  Other avoiding behaviors can develop regarding going over a bridge, going on the highway, avoiding social situations and large crowds, or traveling.   In severe cases, the person begins to avoid going out of their home in order to avoid possible triggers to the next attack.  Unfortunately, these behaviors don’t prevent the attacks. In fact, some people can wake up in the middle of the night and have a panic attack out of nowhere.  Some people, in an effort to cope with the anxious feelings, may turn to alcohol, marijuana or feelings of unreality.

Panic attacks cannot be predicted.  In the early stages, there are no distinct triggers that start an attack.  Over time, there is a possibility that prior situations involving an attack will trigger another one. As the disorder is biological, the longer it goes untreated, the more frequent the attacks become.  The brain begins to interpret more and more situations as dangerous, resulting in increasing interference in one’s functioning.

There are no specific tests for Panic Disorder and the diagnosis is usually given once medical causes are ruled out. The first step towards treatment is to get a correct diagnosis. Often people feel they are being told that it’s all in their heads, and that they are being dismissed by their medical doctor.  Panic disorder is real and biological and there is a treatment that is effective.

Cognitive Behavior Therapy has been demonstrated to be very effective in its treatment of Panic Disorder. It is a short-term, skills-based program that can teach the individual how to change his or her thoughts and reactions to the feelings of panic, eventually resulting in a reduction if not elimination of these episodes.  When the panic attacks are more frequent or powerful, an option to consider is medication. Antidepressant medicines called Selective Serotonin Reuptake Inhibitors (SSRIs) are most often prescribed. People are more familiar with the names Zoloft and Prozac, for example. Sometimes, other short-acting medications are prescribed, but they are not usually used for a long time.

In CBT one learns how to:

• Notice and change one’s views or beliefs about life events
• Recognize and replace anxiety-provoking thoughts
• Manage stress and practice relaxation techniques
• Practice in real-life situation to help overcome one’s fears

Practicing wellness strategies such as eating healthy and regularly, exercising, getting enough sleep and reducing caffeine may also help to reduce the frequency or intensity of panic attacks.

The key to remember is that these attacks are very treatable with short-term treatment. There is no reason to continue to suffer in silence.

About Emotional Eating

There is nothing more basic and essential than food.  Our first response to a baby’s cries is to feed it.  We often use food as a reward for finishing dinner –offering dessert.  Parents, who may limit sweets may use these as a  treat for Shabbos or to cheer up a sad child.  So is it any surprise that so many  of us  develop a relationship with food that goes beyond simply fulfilling our nutritional requirements?

It is estimated that as many as one in four women have some elements of disordered eating – not meeting criteria of an eating disorder.  Todays article is focused on teaching how to identify and deal with emotional eating.   

While every cell in our body requires nutrients obtained from food – food also has even greater symbolic meaning.  Our relationship with food is shaped by our experiences of food as children. What are our childhood memories of the dining room table?  Did family members eat together? Was it a time of closeness or tension? We may associate certain foods with a holiday, past event or a specific memory.  These associations may provide comfort at times. The smell of chicken soup triggers memories of my mother preparing for Yom Tov when I was young. When I prepare for my own family I bring her memory into my home.  Meals at holidays are social gatherings in addition to religious events.  Sibling rivalries, competitiveness or jealousies can easily surface around the table. Emotions and food are intertwined.  All of us have turned to food at one time for comfort, to help us deal with stress, being tired, to cope with uncomfortable emotions, and even to reward ourselves. 

With Pesach less than two weeks away  , the focus on shopping and cooking for Yom Tov has intensified.  Women in my practice are describing skipping meals, staying up later at night, finding themselves overwhelmed and anxious.  Those going away to family may find themselves stressed with the shopping, alterations and packing for the whole family.  Increased stress, reduced sleep and the pressure of the Pesach deadline create a perfect environment for emotional eating. 

Emotional eating is eating when not hungry – but to fill an empty feeling inside. It is to calm an emotion or to soothe oneself with food when not physically hungry.  The type of food you crave depends on your mood. People in happy moods tend to prefer foods like pizza or steak. Sad people often reach for ice cream and cookies; and bored people may go for potato chips.

When eating is the only or main strategy to deal with emotions -  we are at risk for problems relating to the choice of food and the quantity. If you eat when you aren’t hungry your body doesn’t need the calories and will store it as fat. Too much fat can result in the individual becoming overweight.  One researcher estimated that 75% of overeating was caused by emotions – highlighting the risks.

Is this Emotional Hunger or Physical Hunger?

1. Emotional hunger comes on suddenly; physical hunger gradually.

2. Emotional eating gives you cravings for a specific food ,such as cookies or ice cream, and only that will do. When you are hungry you can eat leftovers from dinner.

3. Emotional hunger feels like it needs to be satisfied instantly; physical hunger can wait.

4. If you're eating to satisfy an emotional need, you're more likely to keep eating. When you're eating because you're hungry, you're more likely to stop when you're full.

5. Emotional eating can leave behind feelings of guilt; eating when doesn’t.

Helpful Hints to deal with Emotional Eating:

Ask yourself “am I hungry or is it another feeling?” Listen for the answer. On a scale of 1-10 how hungry are you?   One way to check is to notice what you are craving – will you be satisfied with chicken or some other protein? If you need that cookie, or chips or ice cream, its most likely emotional.

 

Recognize what triggers this behavior in you .  Can these triggers be avoided?   Maybe waiting too long between meals, skipping meals? Speaking on the phone with a relative?  As you become aware of your triggers you can either try to avoid them or take steps when you notice them to redirect your attention.

Have some things prepared in the fridge that you can have ready when you get the urge.  If you find that you eat impulsively, have finger ready foods in the refrigerator. If you get the urge to crunch - try carrots, celery. If you crave sweets - what fruits would hit the spot? Try grapes ( frozen are yummy), strawberries, pears. If the urge is salty - have handy some whole wheat pretzels or fat free popcorn.  There are different choices you can make if you have them ready.

Distract yourself - try to insert a delay of 15 minutes.  Sometimes the urge can be easier to resist if you tell yourself you need 15 minutes.  Keep a list of things to do to take your mind off your craving. Try calling a friend,  take a short walk, or do something on your “To Do” list . If you can postpone the "treat" , maybe when you reach for it you can make a different choice. 

When you get the urge to eat when you're not hungry, try a food that will comfort you that is a better choice than junk food. There are many snacks that come in 100 to 150 calorie packs or ice cream like Skinny Cow that hit the spot but are only 150 calories.  You can have a treat that wont trigger a binge.

Don’t have forbidden foods.  If you try to eliminate cookies – you will find that is all you are thinking about. Try to prepare healthier cookies – and  practice moderation. Read how much a portion is and stick to that.

Remember that we are more likely to indulge in emotional eating when stressed, overwhelmed, angry, sad or tired.  The challenges and demands of Pesach preparations will make many of us vulnerable to these.  The key is to be on the alert and be as prepared as we are able.  And before you know it Pesach will be here and gone.

Wishing all a freilichen and kosher Pesach!

 

Overcoming fear and stress

Many people get nervous when facing a new situation. It could be the beginning of a school year, moving into a new neighborhood and meeting new people, perhaps going off to a new summer camp. What is it about new situations that bring the flutters into our stomachs, cause our breath to feel tight and our muscles to feel tense? When we think about it clearly – which is really hard to do in a new situation – we know that nothing bad will happen. So, what is it about our brain that it takes charge and causes us to feel that panicky feeling?

Fear and anxiety are normal responses to threat or perceived threat. There are intricate processes at work in the brain that monitor our surroundings for threat , increasing vigilance, accessing memories and then rapidly activating our body – by increasing blood flow and heart rate – to respond to these threats. These are all automatic functions of the brain to protect the body and are useful unless they are activated at inappropriate times. Some people live their life with a heightened and uncontrollable worry about everyday things, such as health, safety, relationships and money. They will call themselves “worriers” and may be lovingly teased by family members.

However, fear and anxiety can be problematic when they interfere with the persons functioning. For example, a young man in yeshiva who worries too much about his standing in his shiur will find that it is hampering his concentration. A young woman becoming anxious when friends gather may begin to avoid these situations. There are three aspects to anxiety: negative thoughts, physical reactions, and avoidance.

Thinking influences how anxious we feel if those thoughts are negative. Worries about being judged by others or not meeting expectations will increase ones fear. You can practice noticing these fears and then questioning if they are , in fact, true. And if true, how likely they will be to happen. For example: I’ll make a mistake in nigun when davening. Ask yourself what will happen if you do? Has anyone else ever lost the tune? What happened? One of the tools from CBT teaches people to ask themselves “what is the worst that can happen?” We tend to catastrophize when facing a challenge and predict the worst. But that, by itself, causes more anxiety and reduces the chance of success. We can change that.

Physical reactions are automatic to protect us but may be uncomfortable when they happen in a “safe” situation. In a dangerous situation ( date) the brain will mobilize and send more blood to the arms and legs ( to help run away) making it harder to choose your words ( what was I saying?), you lose concentration and focus as your thoughts begin to race. Other physical responses can include sweating, dry mouth, heart racing, feeling dizzy and lightheaded, restlessness, blushing, shortness of breath, muscle tension. Breathing and relaxation techniques are useful to practice before the situations occur so as to be able to use them when needed.

Avoidance is the logical choice when social events or other challenges can make us so uncomfortable. A technique called exposure – facing the situation that causes the fear response- is an effective tool. . If nervous in a crowd – begin to attend more social events. If reluctant to daven before the amud- offer to daven, give a dvar torah . Raise your hand in class. Step in and join a group of friends. For each person the steps may differ, but its stretching what you do that helps. Its teaching your brain that “the worst didn’t happen, I am Okay ” and therefore reduces the anxious reaction over time.

These fears can be most distressing when entering the stage of life for shidduchim. Since anxiety is controlled by the brain and expressed physically in the body, the impact on the individual on a shidduch date can be significant.
While most of these responses are automatic and vary based on an individual’s temperament, there are strategies that can be used to prepare and then reduce the risk of being highjacked by these fears.

WHAT TO DO?

Just breathe. There is a significant amount of research that has shown that changing ones breathing to a slower and deeper rhythm will activate the portion of the brain to slow down and return to baseline. It will restore the sense of safety by slowing down the heart rate, reducing tension in the chest, relaxing muscle tension. The average breath we take is 3 seconds in and 3 seconds out. The practice of this new breath should be about 6 seconds in and 6 seconds out. Ideally, if you practice this 10 – 20 minutes daily for a few weeks ( it also helps you relax to fall asleep) your brain will have recorded the connection between the breath and relaxing and you can access it when needed. This isn’t really a new idea. Don’t we often tell someone who has had a fall or a shock - “just take a breath”? Now we have a scientific explanation for why that works. ( for the curious reader – it activates the parasympathetic nervous system )

Be prepared. If you are the young man, plan where you will go. Don’t wait to ask the girl. Or, give her a choice of two. Think through what kind of questions you would like to ask – what do you need to know so that you will feel that you are getting to know the other person. Write them down. Practice them. How do they sound? Do you sound judgmental or curious? Also, remember the other person wants to get to know you as well. How will you talk about yourself? Getting advice from teachers, rabbanim or friends who recently went through this will help. Most important, in my opinion, is to be yourself. You don’t want someone to say “yes” thinking you are one kind of person – when you are a different one. You can keep it up for a few dates – but for a lifetime?

Be open. The other person is just as nervous as you are. If he is sitting quietly – perhaps you can draw him out with open ended and not “yes-no” questions. If she seems to be chatty, ask her a serious question to shift the focus. You want to get to know this person so listen carefully and ask questions to get a better picture. Don’t interrupt. Be prepared to be open about who you are as a person. This is a new experience – so remember to breathe.

Positive thoughts. Don’t underestimate the power of positive thinking. Challenge the thoughts that may pop into your head that say “ I can’t do this”. Try “I can do this. Others have done this before me and others will follow.

"But it was on Sale!"

A Look at Compulsive Shopping

Everyone knows the thrill of walking into a store and seeing the signs “50% off” and thinking of all the money to be saved. (That is…. everyone who loves to shop).  The problem for some is that the excitement of a trip to Target, Kohl’s or the mall becomes the first step on an emotional roller coaster. The thrill of shopping is followed by the distress of having spent the money.

People who are compulsive shoppers are preoccupied with shopping and spending.  While some enjoy window shopping, people who shop compulsively feel an increased anxiety or urge about shopping that can only be subdued with a purchase.

There are four phases that have been identified as part of compulsive shopping:

·         Anticipation – thoughts and urges about going shopping may revolve around finding a particular item or shopping in general

·         Preparation – planning about where to go, what to wear, clipping out photos or coupons

·         Shopping – the actual experience of going through the aisles, selecting items– usually resulting in a positive feeling

·         Buying-  the actual purchase is often followed by a sense of letdown or disappointment

The financial consequence of the purchase, whether it’s letting the husband know about the amount spent or trying to pay the growing credit card bill, can cause a cascade of negative feelings and thoughts that trigger the next shopping spree.

It is all too easy for shopping to get out of control. Stores are plentiful and are open long hours.  Children need things for school or projects. Perhaps they behaved well over Shabbos or did well on a test and now want a reward.  Maybe there are hours to fill and a trip to the store becomes an adventure. This can easily become a financial black hole unless certain strategies are followed to maintain control over the money spent.

How can we tell if we are just good shoppers, i.e. buying things on sale to put away for when the children get bigger, or whether we’re shopping too much? Some  questions we can ask are:

1)      Why do I shop?  Do I go for specific things that are needed or to just get away? Or to treat myself?

2)      Do I shop when I am angry or in order to feel better?

3)      Am I hiding what I buy?

4)      Do I have the money to pay for what I am buying?

It is easy to fall into shopping excessively.  We have a credit card in our hand and don’t have to worry if there is money in the bank. It’s easy to think “Oh, I’ll pay it out,” without realizing that we end up paying  two, three or even four times what it originally would have cost. It’s easy to make this mistake if we don’t understand how compounding interest works.

If you think you are an emotional shopper, there are strategies that can help. Even if you aren’t , these tips might help you cut down on your spending. 

Helpful tips:

1)      Keep track of what you spend. Keep a little notepad in your purse and write down every purchase. Jot down next to each whether this is something you really need or simply want.  Notice how much you are spending on things that you don’t need and think of what special thing you could be saving instead. People often find that they are spending close to $100 a month on things they don’t need.

2)       When you go shopping, use a list and plan an amount that you will spend.  Impulsive buying can be dangerous. If you are taking the children along, tell them what the maximum dollar amount of a treat they can choose is.  As an added incentive, tell them if they don’t spend all the money, you will put it in an envelope and save it for a bigger purchase at another time. This introduces the idea of saving. ( Be sure to follow up with this and keep the envelope separate.)

3)      Have a frank discussion with your spouse about a budget. The first step is to examine what your expenditures are over a two or three-month period. Look at the categories that are fixed– like rent, mortgage, insurance, and those that are not fixed – food, clothing etc. Examine where changes can be made. Start with small changes and you will begin to see results.

4)      Are you spending more than you are making? Is your credit card bill going up each month?  If yes, than you must start to make changes quickly.  There are community resources that can help you.

We are living in a society where we are surrounded with a wealth of choices for food, clothing and anything else we can imagine.  It is a challenge to maintain a balance to provide for our children and not lose sight of the values that we inherited and are passing down to the future generations.

 

 

Is this sadness or depression?

Often the call starts with a tentative voice on the line saying “ I don’t know if this is really something that I need to see someone for…” The pauses and hesitations do little to hide the pain in the woman’s voice. I know how much courage it takes to pick up the phone and call me……… I am a therapist. Calling any therapist means a step to acknowledging that there is something wrong – either with her or in her life – and that is scary. There is also the uncertainty about the investment of time and money and would it help.

Sadness is an emotion that is part of the human condition. It is a natural reaction to life’s circumstances. Sometimes we can recognize what triggered the feeling and sometimes we can’t. It’s normal to have days where you may have less patience with your children or find yourself moody. There may be days where you don’t feel like getting out of bed to start your day. These days pass.

Someone who is experiencing an episode of depression experiences the world differently from before they were depressed. During a depressive episode the world seems like a dark place. The person feels like the weight of the world is on their shoulders. Relationships that were meaningful and loving now seem empty. The depressed person begins to question everything in their life as well as their decisions. Is this the right job for me? Am I a good mother? She loses interest in meeting with or talking to her family and friends. She loses interest in the things she enjoyed before. Sometimes the changes are slow and subtle so that the people around her don’t notice.
Most people seem to have a basic understanding of depression as a deep and unremitting sadness. They imagine that people who are depressed can’t get out of bed, can’t take care of their family or work obligations and may even become suicidal and require hospitalization. This represents only the more extreme experiences of depression. And thank G-d, most people don’t experience depression to this degree. Most people who are experiencing a depression are working, taking care of their children and family and for all outside appearances are doing just fine. The toll depression takes is on the inside.

The women describe how hard it is to keep up the impression that all is well. They struggle with being irritable at and yelling at their children. They find themselves annoyed with their husbands about things that never bothered them before. They have trouble shutting down to go to sleep at night. Maybe they lost their appetite. They begin to doubt themselves. Stop accepting invitations. They can’t seem to remember ever feeling good. Their life history seems rewritten as they remember only the bad things and not the good.

When they get to this point – its difficult to remember ever feeling well. What they are experiencing during this episode feels totally real and any evidence to the contrary is dismissed. If during the episode, the woman begins to feel unloved, if someone reminds her of the closeness she had with her husband, she believes that that wasn’t real. Her brain – at that moment in time – is telling her that those emotions don’t exist. She can’t remember feeling different.
Often well-meaning friends offer advice and suggestions which may make her feel worse. They encourage her to get out more, to exercise, to do chesed, daven more. Often, the advice only makes her feel more misunderstood and isolated. She may feel ashamed that she is having these feelings – when she cant explain why.

While depression will often occur following a time of stress – such as a new birth, a move from one town to another, death of a loved one – often there is no event to point to as a trigger. While the depressive episode will usually pass in time, there is a possibility that the symptoms will worsen and then become more difficult to treat. In addition, a person who experiences an untreated depressive episode is more likely to have a recurrence in the future.

The first recommendation that people make is to improve self care- try to get more sleep, don’t skip meals, exercise, get out more. While this is good advice, someone with mild to moderate depression may not be able to mobilize themselves to act. The essence of depression is the feeling of pessimism that “ I will always feel like this”, “nothing will change” – a sense of hopelessness.

A form of psychotherapy called Cognitive Behavior Therapy, has been found to be effective in over 1000 outcome studies. Studies have evaluated its effectiveness as comparable to medication for mild to moderate depression. In cases of severe depression it has shown to have an added benefit to medication – raising the improvement rate. The basic idea in CBT is that our thoughts determine how we feel. So if our thoughts are negative and pessimistic – our emotions will be as well. If we feel negatively – it will influence our behaviors. The CBT therapist and client work as a team to identify what thoughts come to mind in situations that lead to the negative emotions and through examining and questioning these thoughts – learn to challenge and change them. The focus of CBT is on the here and now issues that the person is facing.

1 out of 5 people in the US experience depression in their lifetime. It’s hard to know when to keep trying on your own and when to seek help. My suggestion is to ask yourself, “how much is this effecting my life?” If the answer is “too much” - then its time to pick up a phone.

Sarah Schleifer, LCSW

When do I need therapy? Is it time to call?

1 out of 5 people in the US experience depression in their lifetime. 1 of 3 have an anxiety disorder. It’s hard to know when to keep trying on your own and when to seek help. My suggestion is to ask yourself, “how much is this effecting my life?” If the answer is “too much” - then its time to pick up a phone. I have over 30 year experience as a licensed clinical social worker in the field of mental health. I continued to train in the latest developments in psychotherapy in order to be more effective as a therapist. I studied Cognitive Behavior Therapy and Dialectical Behavior Therapy to help people learn skills to deal with life’s challenges in a different way. EMDR as well as Internal Family Systems have been shown to be effective in the treatment of trauma – and I have used these, to great effect, with clients. It takes courage to call and start therapy. Together we will clarify the issues that you are facing and develop a plan of action. You can learn skills to empower you and change the way you think about yourself and others. By incorporating the various therapies that I have studied, I intend to provide you with the skills to help you do so.

Sarah L. Schleifer, MSSW, LCSW
961 Teaneck Road, Suite 801
Teaneck, NJ  07666
office #: 201.836.4140


329 Miller Road
Lakewood, NJ 08701
cell: 201.851.5099