"We just don't communicate."

What is relationship distress?
Some couples slowly drift apart. Although the partners are not happy with each other, they seldom express it directly. For these couples, it is often the snide remark or eye roll that says it all. Other couples scream and hurl obscenities at each other. Relationship distress can cause the most reasonable and healthiest of individuals to act in the most uncharacteristic of ways. Individuals in distressed relationships display little good-will or tolerance toward their partner and are quick to judge or criticize.

Cognitive-behavioral model of relationship distress
Cognitive-behavioral models view relationship distress as composed of

• Emotional,
• Behavioral, and
• Cognitive factors.

For example, when his wife leaves the house without saying goodbye, a man might have the thought, "All she cares about is herself. She never gives a thought about me," (when in reality she was thinking about a difficult meeting she was to have that morning at work). This thought might cause him to feel angry (emotion), which causes him to snap at her (behavior) when she arrives home at the end of the day. His behavior triggers her thought, "There he goes again, acting like a spoiled little kid," which causes her to feel angry (emotion) and yell at him (behavior), which reinforces his thought that she cares only about herself and would rather be alone.

In addition, partners in distressed relationships often hold maladaptive and unrealistic beliefs about what a relationship should be like or how the partner should behave. When the relationship or the partner's behavior is evaluated against these often rigid models, it often comes up short, and unhappiness is a common result.

Cognitive-behavior therapy for relationship distress

• Education. Couples learn strategies for resolving conflicts, communicating effectively, and increasing positive interactions; they practice these skills during the therapy session and outside of the session through structured homework assignments.
• Monitoring. Couples monitor their interactions to identify the details of their relationship distress (conflict triggers, cognitive distortions, and unhelpful behaviors) to get information that will guide the therapy.
• Cognitive. Couples learn to identify and change patterns of thinking that contribute to the distress in their relationship, such as when one member of the couple tries to de-escalate a conflict and the other discounts this effort with the thought, "You're just saying that, but you don't really mean it" or when a partner in a relationship believes, "If we have any disagreements at all, then this must not be the right relationship for me."
• Behavioral. Individuals who are in distressed relationships often withhold praise and avoid doing nice things for their partner. Over time, the negative interactions between the partners far exceed the positive ones. Active efforts to increase caring behaviors can improve the emotional climate of the relationship while increasing each partner's willingness to work hard to make more substantial changes in the relationship.

Additional resources

Books:
For links to purchase these books and others, please go to Self-Help Books for Adults

Abrahms Spring, J., & Spring, M. (1996). After the affair: Healing the pain and rebuilding trust when a partner has been unfaithful. New York, NY: HarperCollins.

Beck, A. T. (1988). Love is never enough. New York, NY: Harper & Row.

Gottman, J. (1994). Why marriages succeed or fail. New York, NY: Simon & Schuster.

McKay, M., Davis, M., & Fanning, P. (1983). Messages: The communication skills book. Oakland, CA: New Harbinger.

McKay, M., Fanning, P., & Paleg, K. (1994). Couple skills: Making your relationship work. Oakland, CA: New Harbinger.

"But what if I need it someday?"

What is compulsive hoarding?
Compulsive hoarding is the accumulation of and inability to discard items that (to others) appear to have no value, such as plastic water bottles, slips of paper, unread mail, and magazines. Compulsive hoarders are not necessarily those who have a passion for collecting stamps or baseball cards. Nor are they the frugal and careful who save old furniture or appliances because they think "with a little paint it'll be as good as new." Nor are they those who save newspapers and bottles to recycle because they are concerned about the environment. Compulsive hoarders might do all these things, but to the extreme. They have immense difficulty throwing anything away, from slips of paper, to plastic forks, to stacks of unread mail or newspapers, for fear that they might need those items in the future, or that they hold some special opportunity. Their homes are stacked with what others would call "junk" such that they cannot sit on their chairs, sleep on their beds, or even use their kitchens or bathrooms. The most commonly saved items are newspapers, magazines, old clothing, bags, books, mail, notes, and lists.

Although hoarding (or cluttering) can be a symptom of other disorders, it is usually a subtype of obsessive-compulsive disorder (OCD).

Cognitive-behavioral model of compulsive hoarding
Current cognitive-behavioral conceptualizations of compulsive hoarding view hoarding as the result of one or more of these four deficits:

• Information-processing deficits including deficits in decision making, organizational skills, and memory. Compulsive hoarders often fear making mistakes, and as a result, they often avoid or postpone making decisions. Even the smallest task, such as washing dishes or checking mail, can take a long time because it has to be done "just right." If something is to be filed, it must be filed under the "perfect" category. If something is to be given away, it must be given to "just the right" person or organization. The net result of these high standards and the fear of making a mistake is that compulsive hoarders avoid doing many tasks, such as reviewing the mail and making decisions about what to do with each item; the result is that the mail (and other things) pile up, and the hoarder is unable to tackle the problem, including beginning the process of throwing away;
• Problems in forming emotional attachments compulsive hoarders believe that their belongings are a part of them, so discarding an item is like discarding a part of themselves;
• Behavioral avoidance the net result of poor decision-making skills and the need for perfection. Compulsive hoarders avoid not only the decision to discard an object, but also what to do with the object once they have it. Because of their desire for perfection, compulsive hoarders frequently take a long time to do even small chores. An inordinate amount of time may be spent "churning" - moving items from one pile to another but never actually discarding any item nor establishing any consistent organizational system; and,
• Erroneous beliefs about the nature of possessions beliefs about the necessity of maintaining control over possessions, beliefs about responsibility for possessions, and beliefs about the necessity of perfection. For example, a compulsive hoarder will think, "This is too good to throw away," "This is important information," "I will need this later," "This should not be wasted."

We all have these thoughts from time to time, but those with compulsive hoarding syndrome have them more often and have more anxiety and distress associated with them. If they have any doubt at all as to the value of an object -- no matter how trivial, compulsive hoarders will keep it -- just in case. The default is always to keep.

Cognitive-behavior therapy for compulsive hoarding

• Decreasing clutter;
• Improving decision-making skills; and
• Improving organizational/sorting techniques.

Treatment interventions used include decision-making training, exposure and response prevention, and cognitive restructuring.

Additional resources

Web links:
The Anxiety Disorders Association of America
The Association for Behavioral and Cognitive Therapies
The Obsessive-Compulsive Foundation

Books:
For links to purchase these books and others, please go to Self-Help Books for Adults

Neziroglu, F., Bubrick, J., & Yaryura-Tobias, J. A. (2004). Overcoming compulsive hoarding: Why you save and how you can stop. Oakland, CA: New Harbinger.

"I try not to think about my terrible experience and put it behind me, yet nothing has been the same since."

What is PTSD?
PTSD is an anxiety disorder that sometimes develops after a person has been exposed to or witnessed a trauma (a life-threatening event or threat to his or her physical integrity). The trauma might be a rape, an automobile accident, or a natural disaster like an earthquake or fire. PTSD involves three types of symptoms that can persist for an extended period of time, even years after the trauma.

• Nightmares
• Intrusive memories, images, and emotional reactions related to the trauma
• Flashbacks or dissociative states in which memories of the trauma are so vivid and capture the person's attention so completely that the person experiences aspects of the trauma as if they were actually happening in the present;

• Difficulty falling or staying asleep
• Irritability or angry outbursts
• Hypervigilance, feeling on guard, or scanning one's environment
• Being easily startled

• Avoidance of thoughts, feelings, or conversations associated with the trauma
• Avoidance of activities, places, or people that trigger memories of the trauma
• Difficulty remembering aspects of the trauma
• Feeling detached or having less interest in other people or activities
• Experiencing restricted emotional responding or œemotional numbness”
• Feeling as if one has a limited future in terms of lifespan, career, marriage, or family life

Cognitive-behavioral model of PTSD
The cognitive-behavioral model proposes that in individuals who have PTSD, a traumatic event is recorded as fragmented, raw, and sensory-based memories associated with strong emotions, including an acute sense of danger and alarm. Initial protective responses adapted for immediate survival, such as hypervigilance and avoiding trauma-related cues persist after they are no longer adaptive. Those protective responses preserve the memories and emotions in their raw, fragmented state and prevent recovery. Trauma also has a disillusioning and powerful impact on people's view of themselves, their future, the world, and others.

Cognitive-behavior therapy for PTSD
Cognitive-behavior therapy for PTSD includes several types of interventions designed to promote "emotional processing" of the fragmented trauma memories into a coherent memory that is integrated with the person's other memories, thoughts, and beliefs and to help people reconcile the effects of the trauma on their beliefs about themselves, their future, the world, and others. Interventions include:

• Education to learn and understand the triggers for trauma reactions, memories, and emotions;
• Coping skills to better manage strong emotions (such as fear, shame, helplessness, and panic), to œground” yourself when trauma memories overtake you, to improve sleep, and to manage anger and improve interpersonal effectiveness;
• Systematic and controlled exposure to trauma-related memories and cues; through systematic and gradual exposure, people become less reactive and reclaim these areas of life;
• Cognitive strategies to understand and reconcile the effects of trauma-based beliefs (for example, œThe world is dangerous”) on beliefs about oneself, others, and the world, and on personal goals and relationships.

Additional resources

Web links:
The Anxiety Disorders Association of America
The Association for Behavioral and Cognitive Therapies
National Center for PTSD
Trauma Information Pages
Freedom from Fear

Books:
For links to purchase these books and others, please go to Self-Help Books for Adults

Matsakis, Aphrodite (1996). I can't get over it: A handbook for trauma survivors. Oakland, CA: New Harbinger Publications.

Smyth, Larry (1999). Overcoming post-traumatic stress disorder: A cognitive-behavioral exposure-based protocol for the treatment of ptsd and the other anxiety disorders. Oakland, CA: New Harbinger Publications.

"Even when things are okay, it's almost like I look for something to worry about."

What is generalized anxiety disorder (GAD)?
Generalized anxiety disorder (GAD) is characterized by

• excessive anxiety and worry,
• occcuring more days than not for at least 6 months,
• about a number of events or activities (health, money, family, or work).

Individuals who have GAD are plagued by worry, fearing, for example, that if they go on vacation their house will burn down while they are away, that fatigue indicates a serious health problem, or that a sour look from the boss means they are about to be fired. When these individuals encounter problems, even small ones, they tend to overestimate their severity, viewing a headache as a sign of a brain tumor, for example, or an argument with their partner as a sign they are headed for divorce.

People with GAD find it difficult to control their worry thoughts. They also experience distressing physical symptoms, including fatigue, muscle tension, head and neck pains, and gastrointestinal distress. They feel irritable, keyed up, and tense, and have trouble concentrating. They often have trouble falling or staying asleep.

Cognitive-behavioral model of GAD
Cognitive-behavior therapists view worry as the result of the worrier's effort to avoid intense emotional experience. In addition to worry behavior, worriers show other types of related problematic behavior, such as being on time at all costs, cleaning their home thoroughly every day in case someone pops in unexpectedly, or insisting their partners call immediately when they arrive at work. These behaviors are also viewed as efforts to avoid emotional experiencing.

Cognitive-behavior therapy for GAD

• Education. Therapy teaches the worrier about the cognitive, physical, and behavioral components of worry, and teaches the distinction between helpful and unhelpful worry.
• Monitoring. Learning the specifics of worry episodes (triggers, content, frequency, intensity, duration) provides much-needed perspective as well as information to guide other aspects of treatment.
• Physical control strategies. Diaphragmatic breathing and progressive muscle relaxation help decrease the persistent physical over-arousal that contributes to the maintenance of the worry process, as well as many of the symptoms the person with GAD worries about (gastrointestinal distress, sleeplessness, and fatigue).
• Cognitive control strategies. Certain patterns of thinking contribute to feeling keyed up and on edge. Clients are taught to evaluate situations more realistically and alter their thinking patterns so that they can decrease anxiety and more effectively solve day-to-day problems. In addition, cognitive therapists help clients test the assumptions or beliefs they have about worry itself -- that worry leads to greater certainty and control, that worry itself is uncontrollable, and that worry decreases the likelihood of bad events.
• Behavioral strategies. To address the worrier's fear of emotional experiencing, cognitive-behavior therapy teaches the worrier to confront (in imagination) the things he most fears, as a way of learning to be less afraid of it and (paradoxically) gaining more control over it. Learning how to focus on one particular worry thought or image without avoiding or escaping from it will, over time, help decrease the worrier's anxiety. Other behavioral strategies include teaching time management or problem-solving skills.

Additional resources

Web links:
The Anxiety Disorders Association of America
The Association for Behavioral and Cognitive Therapies
Freedom from Fear

Books:
For links to purchase these books and others, please go to Self-Help Books for Adults

Bourne, E. J. (2005). The anxiety and phobia workbook (4th ed.). Oakland, CA: New Harbinger Publications.

Craske, M. G., & Barlow, D. H. (2000). Mastery of your anxiety and panic (3rd ed.). New York, NY: Oxford University Press (copyright by Graywind Publications).

Leahy, R. L. (2005). The worry cure: Seven steps to stop worry from stopping you. New York: Harmony.

White, J. R. (1999). Overcoming generalized anxiety disorder “ client manual: A relaxation, cognitive restructuring, and exposure-based protocol for the treatment of GAD. Oakland, CA: New Harbinger Publications.