"...you are able to stop and recognize you don't want to do that...."

00:00 Demi, I am delighted to have you join me today. For those who would probably listen to this or who are eager to learn more about the topic of CBT and mindfulness as regards to psychotherapy, could you please share a brief description of who you are and what you do?

00:20 Sure. So, yeah. So My name is Dr. Josephson, Dr. Demi Josephson. I'm a clinical psychologist currently working in private practice. So I do conduct psychological neuropsychological evaluations for people across the lifespan, so from little kids to older adults. And then I also provide individual psychotherapy, again focusing more so on adolescents and young adults. But I have some middle aged clients, clients as well. And then in addition to that, I do conduct what we call compensation and pension evaluations for veterans seeking compensation and pension for mental health reasons. So I do a lot of those evaluations throughout the week. Really is seeing a lot of ptsd, a lot of anxiety, depression, and substance abuse. So my work allows me to see and work with people presenting with a wide range of psychopathology and really again, across the lifespan. So a lot of different aged individuals as well. So, yeah, so that is what I do.

01:37 Thank you very much for that. Before we go into the discussion for today, could you help clarify the concept of cognitive behavioral therapy and mindfulness?

01:49 Sure. So are you kind of asking for sort of a description of what it.

01:55 Is and just like a plain definition?

01:58 Yeah, yeah. So cognitive behavioral therapy is really kind of the basis and sort of the foundation of most psychotherapies in terms of, you know, the target and sort of like theoretical underpinnings of like, what it does and how it helps people. So it really just straight from the title of, you know, cbt, it is a really a focus on cognition and how individuals thoughts, feelings, behaviors. So the cognitive behavioral piece impact how people function in the world. So there's a focus on adjusting what we call maladaptive thoughts. So thoughts that are unhelpful, maybe negative, ineffective, and challenging them so that they can be more helpful, more productive, and in essence, helping that person feel better, behave in ways that are more helpful and productive. And really kind of focusing again, like on that triangle of thoughts, feelings, behaviors. And so in terms of focusing on anxiety, depression, anger management, all of those things. Right. The focus again is on how can we interrupt that sort of maybe maladaptive way of coping through challenging thoughts and restructuring them to be more helpful.

03:27 Okay. All right, so we'll begin with the questions. The first question I have is your time in the field of psychotherapy and the work you've done. How well have you seen changes in psychotherapy methods like cbt and how well has it worked for anxiety over time?

03:49 So this is a. That's an interesting question. So it really depends on how. So how well CBT works for an individual with anxiety really depends on the person. So, you know, depends on their cognitive abilities. So their. Their intellectual, their iq, their readiness for change, and the severity of their symptoms. So there's a. And those are just a few factors that impact the effectiveness of a treatment. And so, you know, if somebody comes in, let's just say, kind of like picture perfect case, you know, someone comes in with average iq, they're very motivated for change. They want to feel better. They are committed to practicing the homework, to practice the skills. And their symptoms are, you know, we'll just say in the moderate to severe range, CBT can be quite effective, you know, even without medications, when that person is seen consistently. So typically, you know, on a weekly basis, you know, in person or more now, often most days, people are seeing their therapist virtually, but having that face to face in therapy work, and then the person is practicing those skills and doing the homework outside of therapy. Right. Like, there can be pretty significant symptom reduction in anxiety symptoms. So we're just saying anxiety symptoms kind of broadly because you can break that down to be more specific in terms of problem and target. Target problems and what you're focusing on. But, you know, typically, you know, six to 10 weeks. Right. Like, someone can start to see significant symptom reduction. And again, that varies based on the person. So. Yes. So depending on, again, how motivated that person is for change and their ability to implement strategies and what they learn in therapy certainly dictates kind of how effective that treatment would be.

06:01 Okay, so can you share a particular case where CBT or the use of CBT was particularly effective or challenging?

06:13 Yeah. So I would say more recently, have done CBT in a much more manualized fashion. So I will just sort of preface this with saying that my typical approach to therapy is integrative. So I use CBT in addition to other therapeutic modalities. So dialectical behavior therapy, acceptance and commitment therapy, obviously a very, very heavy focus on mindfulness. So depending on the client that I'm seeing, I will sort of tailor their treatment goals with their, you know, their collaboration. But my approach to therapy is really very much dictated by their needs and their abilities. So in terms of a CBT treatment. So a more recent case that I had that was very straight CBT was working with a client with body dysmorphia. Where the treatment was CBT for body dysmorphia. And there's a huge focus on psychoeducation. So a focus on how does body dysmorphia develop? What factors maintain body dysmorphia, which includes this sort of habitual pattern of maladaptive thoughts and behaviors that maintain this, the main presentation of body dysmorphia, which is this skewed image of how you look and how you perceive yourself, just regardless of how other people perceive you. So again, starting with a lot of psychotherapy focusing on, okay, let's, let's talk about automatic negative thoughts. So when you look at your body, or you look at, or you have, you know, something, you see a picture of yourself. What are the thoughts that pop into your head? Let's, let's label them, let's talk about them, and then let's challenge those thoughts in a way that, right, like, makes them more realistic, more truthful. But then there's also a very large, you know, behavioral component to this of sort of breaking the habit of reassurance checking. Because a lot of times individuals with body dysmorphia will ask others, how do I look? Do you think this looks good on me? What about this picture? So, and that can be reinforcing at times. So how can we sort of break that, that pattern? Sort of a process of like delaying urges to body check. So a lot of times individuals with body dysmorphia will spend a pretty significant amount of time in front of a mirror or sort of checking themselves to make sure that they look okay, which can be reinforcing. So what can we do to replace that behavior? So instead of checking your, you know, you catch yourself thinking, okay, I'm going to go check in the mirror. You're able to stop, stop and recognize like you want to do that. What's an alternative behavior? What can we do instead? So that over time, right, like that, the focus on appearance and that specific, you know, sometimes it's their nose or it's their hips or their belly, right. Like those high focused body parts become less of a focus over time. And there's also a lot less, you see, sort of a reduction in the intensity of the emotional distress that they experience with that. So, you know, again, like the psychoeducation, the recognizing of sort of unhelpful, irrational, maybe automatic negative thoughts and then a focus on behavioral modification and changes working to reduce the distress associated with body dysmorphia. So that would be, I would say, my most recent, probably Straight CBT case that I've had.

10:03 Okay, based on what you said, something that has. So now is the term psychoeducation. And on that, how do you decide when to use either CBT or to go in first with educating them about mental health and their mental health in particular?

10:21 That's a good question. I would actually, I would say I do psycho education with all of my clients. I would say in general, it starts first and it can really be sort of a like, tell me what you know about depression. What do you know about social anxiety? Tell me what you know about body dysmorphia. A lot of times clients come in with either they've already been diagnosed with a mental health condition or they have a sense of like, you know, these are the symptoms I'm struggling with, but, but maybe haven't had a formal diagnosis. And so it really does go back to like, okay, let's assess, let's do a knowledge check and see what do you know about, you know, these feelings of panic? Let's talk about those symptoms. How, like, what do you notice? What makes you feel better, what makes you feel worse? And then giving them some research to talk about, like, you know, research shows that avoidance and sort of like trying to suppress or ignore things that we're afraid of actually intensifies those fears and those discomforts over time. Right. The more you avoid it, the more you feel better by avoiding it. So that's reinforcing, so giving them the education around what can at times sort of create mental health symptoms, but also what really perpetuates them. So with that education, they have an understanding and kind of a foundational starting point of why I'm going to challenge them to face their fears or why I'm going to challenge them to take baby steps to really incrementally challenge the things that they're afraid of so that over time they realize that they're safe. And then they can use the coping skills like deep breathing or progressive muscle relaxation, or in very small doses and short term distraction to feel better so they can keep moving forward so that those fears, those discomforts aren't overwhelming and distressing as they happen in the past. So psychoeducation can really be very helpful in just allowing the person to understand, okay, this is where this is coming from. This is why it's continuing and helping them understand why we are doing the certain therapeutic interventions and skills that we're doing as we move forward in therapy. So psychoeducation happens with every client, I would say, typically at the outset of therapy. But certainly as you move forward, as you go on in therapy, whether you're working with them for six weeks or six months to a year. Right. Like, you're always educating, you're always teaching. So. Yeah. So in terms of, you know, deciding like one or the other, I would say psycho education happens all the time.

13:16 Okay. And based on that, what signs tell you that teaching might be more helpful than therapy in that moment?

13:23 If a person. So if I am maybe presenting a, trying to utilize an intervention, maybe I'm doing some cognitive restructuring or I'm asking the person to use some behavioral replacement, especially with, you know, exposure and response prevention for like ocd. So someone with obsessive compulsive disorder, if I'm asking them to, instead of flipping the switch, light switch 10 times because they're having that urge and that compulsion to do, I'm asking them to do a different behavior. If they are very resistant to that or they are very, like, if they're not doing the homework or they're not, or if they're challenging or kind of pushing back a little bit, I might take a step back and sort of try to reassess, like, okay, maybe I'm pushing to this intervention too soon. Maybe they don't have a good understanding as to why this is helpful or why this is good, you know, as a good form of therapy to meet their treatment needs. I need to go back a little bit and maybe do a little bit more education and helping them really understand, like the benefits of doing this. And so you can do that in a very gentle, non combative or confrontational way to kind of assess, like, okay, what's the barrier here? Like, why are we having some resistance here? What's making it hard for them to use what we're talking about in therapy outside of therapy?

14:52 So, okay, thank you for that. What do you think about using mindfulness to treat worry and anxiety?

15:01 Yeah, that's a really good question. So mindfulness, I think, is a wonderful practice. It, it, I think in seeing it used in therapy, it really. When a person has gotten very good at sort of recognizing, okay, well, what, how do I know I'm practicing mindfulness? Right. So it's that present moment, that present focused awareness in the moment of the thoughts that are going through your mind, the way your body feels, the emotions you're experiencing. Right. Like what's happening around you. Just recognizing what's happening without judgment is the big piece. Right. So if you're, you know, you recognize, like you're sitting in a chair and you're feeling a little anxious and then you start thinking like, oh my God, why am I anxious? Oh, it must be because of this. It must be because of that. Something bad's going to happen, right? Like you're not focused in the moment. You're let. Your mind is sort of running with those anxious thoughts and that, that oftentimes isn't helpful. So just being able to kind of slow down, take a deep breath and just practice that like present moment, that focused awareness in the moment can be a really good practice of just relaxation and just calming down. I've also, you know, found that mindfulness has been really beneficial in helping people recognize when it's time to use a skill that they've used in therapy. So if they are able to kind of recognize like, okay, doctor's appointments make me, that's a trigger for me. That's a high stress situation that often causes me to feel really anxious. I'm going to, as I go through that appointment or as I go drive to my doctor's office, I sit in the waiting room. As I go into the doctor's office, I'm going to practice deep breathing. I'm going to practice just focusing on what's happening in the moment and not letting my worries. Right. Like take me forward to the worst case scenario. It really is a way to just help the person check in, know what, how they're feeling, know when to use deep breathing, when to use progressive muscle relaxation, when to use those skills so that they can really address those problems in the moment, just helping them to be more aware and more in control. So that was a long winded explanation of kind of my thoughts about mindfulness in that way.

17:20 Based on what we've discussed so far, especially psychoeducation and like CBT in relation to each other, the term placebo treatment came to mind. And I'm wondering if you are familiar with using placebo treatment in therapy. Instead of like just going full head on into, should I say a more organized form of treatment? Is that something you've used and if so, what? Like, do you have any case?

17:52 Yeah, no, I can't say that I have. And you know, I would say the placebo type treatment or kind of that placebo effect. Right. Is typically, I would say, used in like a research setting or perhaps there's, I think if we're talking kind of like a psychological phenomenon of like the placebo effect, it would be maybe unintentionally done, I'm sure, you know, but I think in terms of like an intentional Treatment or intervention. It's not something that I would say that I've used.

18:26 Okay. I'm talking about settings. What do you. With therapy going online virtual, having apps that can also do some work before you get to meet a, an actual person. What do you think? What do we need to think about to make sure it still helps people and it's still effective?

18:45 Yeah, so this has been interesting, I would say. So the virtual. First of all, like the telehealth model for providing therapy, I don't have the actual data or research, but just anecdotally and kind of like just seeing how it's being done in a private practice setting, you know, it increases access. So in terms of just availability and people being able to get help, I have to believe that it has been huge. Right. So people who have mobility issues or people who have such severe anxiety or you know, maybe even like paranoia or psychotic type issues who are afraid to leave their home, can get help virtually if they want it. Right. Whereas before it wasn't available. So just in terms of accessibility and the number of people who have the ability to get it is. I would have to believe that the numbers are huge in terms of effectiveness. Again, I would, I would imagine that there would be sort of emerging research coming out as this has been going on obviously since COVID that somebody is doing research on the effectiveness of more recent. Right. Telehealth virtual therapy. But anecdotally I can tell you that, you know, I think I see the same rate of effectiveness with most clients. You know, they find symptom, relief, symptom reduction on screening measures for anxiety, for depression. You know, the same kind of trajectory of like improved, you know, social, social comfortability, occupational work functioning has improved over, you know, six to 10 weeks of regular weekly therapy. And then there are some clients where I feel like we make improvements over several weeks and then kind of plateau. Right. Where it just feels like there's definitely still gains to be made, but for whatever reason, it feels like if we were able to do in person, we would be able to take our work further. And so I do think that there are some limits to the virtual aspect of therapy for some clients where that in person kind of connection, that emotional like connection that I think can be so healing in therapy is lost virtually. Um, and so, so, so like I said, I think that there, there are some clients who would really continue to benefit much more from an in person perspective. And like I said, I don't have like a, an empirical like research article to highlight this. This is Just sort of anecdotal. And I, I would be very curious if there is some type of like what the theory is of that. But I do think that there are some people who would just benefit much more from in person, just from that, like that face to face human connection that's kind of lost virtually.

21:56 Okay, I'm still on the topic of the digital models. Have you recommended any digital tools to your clients or to your patients? And is there, are there any tools that you personally like? Not an endorsement, it's just like your.

22:13 No. Yeah, that's a really great question. Yeah, apps are great and I would 100% like not even recommend, I would insist, right before you recommend any kind of app to a client, make sure it's something that you have used personally or not even used, but at least downloaded, you've explored, you've played with, so you know what that app is. And then maybe have also done the research online, like is this a, you know, what are other providers saying about these apps? Just to do your due diligence so that you're not inadvertently recommending something to a client that could adversely impact them. But things like some of them are paid but you know, like head. It used to be free. The Headway app is great. There used to be another app and I actually, I think they don't have it anymore and I haven't. I actually just realized this a few months ago. And so I haven't done research to see kind of what a replacement app is, but it was called the Breathe app and it literally had these beautiful like, like guided meditation, deep breathing audio clips that would, you know, you could pick the gender of the speaker, the accent, you could pick. So really like whatever felt most comfortable to you. You could pick the length of time like a two minute breathing exercise to like a 15 minute like guided meditation. So I used to recommend that to a lot of clients who were looking for ways to ground themselves to be more mindful. And then it was also really helpful for clients who were having a hard time sleeping. So that racing thought, like right before bed, they would use this app to kind of help reset and just prepare for bed and kind of help them calm their minds. So a lot of like guided meditation type apps I think are wonderful for people. Speaking of kind of sleep difficulties, people who have a hard time sleeping, there's lots of really great like sleep aid apps, like kind of helping with like bedtime routines, sleep hygiene and then also kind of like white noise, sort of relaxing noises that people can turn on in the in the background while they sleep. So I think those are all, like, wonderful apps that you can use as therapeutic tools outside of therapy.

24:33 Okay, so we'll drift into the topic of PTSD a little bit and your work with people on this so that I would say spectrum just to encapsulate it. Have there any. Have there been any new challenges or successes in using CBT for PTSD lately?

24:55 So I'm not quite familiar with any sort of emerging therapeutic approaches, really. I think the large. The vast majority of practitioners utilize either a pretty, like, manualized, like CBT for PTSD type treatment, which really involves the use of. Right. Like psychoeducation, learning coping skills, and then sort of an exposure and kind of processing of traumatic events while using the learned coping skills. For some. You know, for a lot of individuals who have experienced trauma, that is an effective form of therapy. But I will say the biggest caveat to that is that every client who have. Who has experienced a traumatic event is going to respond differently in terms of their readiness to start the exposure process. So some clients might be really comfortable with jumping kind of right into it, whereas other clients might take months, if not years to be ready to talk about the traumatic experience that they endured. And so there is certainly. It is certainly one of those things where it's like a one size does not fit all kind of approach for trauma work. And I would say that there is a. I think in this population, it's. The clients are much more vulnerable. And so if a therapist pushes too hard or really kind of approaches them the wrong way, it can really kind of ruin. It can cause more damage, if that makes sense. So this population, I would say the therapeutic approach is much more sensitive and you have to be very, very careful about how you tread in working with these clients. But like I said, typically the approach is much more, again, CBT focused with sort of this exposure and kind of reprocessing, cognitive reprocessing of the trauma to help them, again, face what they experienced, help them to learn and sort of reintegrate the memories of the trauma in a way that's less emotionally distressing. Um, so again, like I said, I don't. I don't, to my knowledge, believe that a whole lot has changed in terms of the approach to treating trauma therapeutically. And so. Right. Like, I think that. That. I think that is really, in large part the way that people work with trauma in the therapeutic setting.

27:34 Okay. And I'm wondering, have you had to, like, change your approach to treating a particular patient with ptsd? Yeah.

27:44 So I think just sort of like, you know, piggybacking off that. Yeah. So if a client has experienced, you know, let's, you know, an interferon, an interpersonal maybe sexual trauma that they experienced years ago, obviously that is something that is a big part of their, the case conceptualization on my part. And I take into account. But I. And so my first thought is like, okay, a possible treatment approach would be CBT for trauma, trauma focused approach. But maybe that client tells me, hey, like, I am really depressed. I'm having a hard time getting out of bed, I'm not eating. I. Nothing brings me joy. Right. Like they're. Their really primary issue is depression. I might, you know, switch gears and say, okay, we're going to focus on CBT for depression rather than. And still having kind of a trauma informed approach. But like, we're not going to do, we're not, we're not going to do any PTSD work right now. We're going to focus on the depression getting you feeling better. And then when you are ready, assess. Like are we, are. What do you think? Are we ready to kind of, to focus on the trauma and processing that. And if I start that process with them and they get to the point of retelling their story and starting to process it and they push back and it's, it's very hard for them, then we would take a step back and readjust. So to the extent of like having to change approaches or change a treatment, I would say it's more so just really meeting the client where they're at and doing what is necessary to make them feel comfortable while still working towards their goals. If that makes sense.

29:28 Yes, yes, it does. Thank you. Okay, so how do you make sure that your therapy methods stay up to date with the latest research?

29:38 Yeah, consultation with other therapists. You know, I think staying in touch with the people that you trained underneath, the people who are a part of your practice or colleagues that you've, you know, developed relationships with and really just sort of doing more case consultation with them, joining different psychological networks to receive emails that have information about upcoming research or things that have been published and really just sort of immersing yourself in that information on a regular basis. It's how you continue to learn and continue to kind of make sure that your skills are as up to date as possible. And yes, it is required by law to have those educational components for licensure. At the same time, you know, in terms of being a competent practitioner, you have to make time to immerse yourself in that type of education. So like I said, consultation with colleagues, joining networks, online, signing up for, you know, different types of. On like peer reviewed journals. You know, you can sign up for lots of different specific topics so that you're getting that type of information regularly to your inbox. And so that's a good way to kind of do that as well.

31:11 I didn't know that. Okay. Have you had to change a patient's treatment plan due to a new research finding? Like, has that ever happened?

31:20 No, not in general. Not specifically. I can't think of anything where I was like, oh, this would be a. So where it kind of just like popped into my, you know, for example, my inbox. And I just was like, this makes more sense if I was having a difficult time with a client. You know, I've tried my approaches and nothing seems to be working. You know, after. You know, if I was to change anything, it would typically be after I had had supervision with somebody or consulted with a colleague and they might say, hey, have you tried this type of intervention? That would maybe trigger me to say, no, I haven't. That's a great idea. And I would do more to learn about it if I was uninformed. So to that degree, in terms of like, new knowledge, that is a way that I might change my treatment approach.

32:13 So back to CBT again. As a whole, where do you think CBT is headed, especially for treating things like anxiety, which seems to be like a major component for it?

32:23 Yeah, that's a good question. You know, I, I would say CBT in terms of its use in like a manualized fashion. In my experience, you know, at. In grad school, that's how I was trained, was very manualized. Like, you follow this book and you apply these, you know, you go in this order with this client. I would say in general, in my experience, like, over time, CBT seems to be much more effective with clients when it's integrated with other approaches. And so my assumption, and what I think you would probably see in the research is that there's a lot more of an integrative use of cbt. So CBT with mindfulness, CBT with, you know, acceptance or, you know, compassion based cbt. So it's. It's not so straightforward like this model of CBT that it was originally. I think it is much more integrative and again, like really sort of tailored to meet the client's needs in order to meet their treatment goals. So I think that in terms of the future, I think that you would continue to see that that CBT is sort of combined with other therapies or other intervention approaches?

33:40 Yeah. And are there any changes you're hoping to see see in the CBT aspect to be used or improved?

33:49 You know, there's. So there. In terms of treatment for mental health in general, there's a lot of changes pharmacologically. So we're seeing a lot more use of things like ketamine and other sort of like hallucinogenic medications to treat severe mental health or persistent kind of treatment resistant mental health conditions. So for psychosis, for you know, treatment resistant depression, you know, things like the use of ketamine is being used to treat those. And so I would be really curious to see in the future if there's any research that looks at the effectiveness of the, of CBT in combination with those more kind of like new age pharmacological approaches I think would be really interesting because the ketamine for example use alone is showing pretty substantial improvements in mental health treatment pretty quickly. So like I said, I would be curious to see if there was a combo of CBT with those. What that looked like.

34:56 Okay. I mean the field of psychotherapy generally, are there any fairly new methods that you. That is being developed or that has been developed already and you're probably excited to use them or is there like, is, are they like set methods that have already been set in place and it's not like something that there is a new one popping up every few years or something like that?

35:20 Not. I mean off the top of my head, I can't think of anything. And like I said, I'm not, you know, I'm. I'm not sure. I think the approaches that we've talked about in terms of CBT and its combination with other methodologies like mindfulness and compassion and certainly in a trauma informed way, anything that's related to that and being fine tuned in terms of a treatment approach I would love to see continue. But in terms of like any new upcoming methodologies or intervention approaches, I'm not, I'm not quite sure.

36:02 Okay, that's, that's okay. So if I've exhausted all the questions I have. So before we end, is there anything that you feel is important to know in for CBT treatsman's methods or anything?

36:16 No, I think we covered it all. You know, I think the most important thing is that whoever is providing these types of treatments just continues to grow in their knowledge and also being willing to be flexible in their approaches to working with clients because people are very complex and one size does not fit all. And so I think just being open and willing to integrate other approaches is super important. And the only way you can do that effectively is to be up to date on, you know, what. How those methodologies or how those interventions are implemented and what that looks like. So.

36:54 Yeah.

36:54 So I think, you know, otherwise, I think we've talked about most of it.

36:59 All right. Thank you very much, Dr. Demi, for taking the time to hop on this interview with me. I've learned a lot, and hopefully whoever listens to this would also learn. So I'm going to let you go on with your day once again. Thank you very much.

37:13 You're welcome. You're welcome. Thank you so much.

37:15 Thank you, Tim.