Let’s Talk About Cognitive Behavioral Therapy (CBT)


By Cassandra Roos

When in the midst of any psychological distress or crisis and prolonged depression and anxiety, even with a doctor it can be difficult to figure out what kind of therapy will help. Your provider may discuss something called Cognitive Behavioral Therapy (CBT) as an option for you and if it sounds very confusing to you at first, you are not alone. I have found that even after undergoing CBT therapy for years, I constantly need to review it both independently and with a therapist. However, it is scientifically proven to be one of the best treatment methods for certain mood disorders and a skill you can use all your life. CBT is used in the treatment of depression, anxiety, bipolar disorder, personality disorders, substance abuse, schizophrenia and psychosis.

I like CBT because it is a structured, direct, and evidence-based approach to emotional stabilization rather than simply talking about one’s problems. It requires repetitive methods that will change thinking, writing thoughts down, and identifying the thought processes that lead to unwanted emotions and works gradually over time.

CBT aims to train your brain into thinking perhaps there is another way of looking at things. “Why can’t you find another way of looking at things” or “Just think positively, why are you so negative?!” are some of the last things that people suffering from a mental illness ever want to hear. A person needs specific tools in order to change their thinking. CBT involves active work, including homework, thought journals, and active collaboration and participation in your treatment. It allows you to take control of your symptoms and control your thoughts. The brain is a very powerful tool that you can learn to use in your favor.

To practice CBT a person has to identify and break down their thoughts one-by-one and challenge these distressing thoughts. An unhelpful, disturbing, or negative thought can lead to an uncomfortable reaction which then leads to a behavior that limits the person’s ability to actually change their reality. It looks something like this.

Event –> Thought –> Emotion –> Negative reinforcing behavior

The problem with this model is that the person rarely recognizes that a thought precedes the emotion they feel in reaction to a problem. The thought that occurs in reaction to the event is what leads to an emotional response.

If a thought itself can be identified then the emotions that follow can be altered. Most thoughts occur so quickly that the person does not notice them. These rapid racing thoughts are called “automatic thoughts” a term first coined by Aaron Beck who helped first develop Cognitive Behavioral Therapy methods. Automatic thoughts occur so quickly that the emotion appears disconnected from the prevailing thought. Almost all of these thoughts, particularly related to anxiety, are based around the notion that the thought and following emotion are in some way “unbearable” and “intolerable.”

Over time it is possible for CBT to change a person’s assumptions about the world, and this will help them better challenge their unwanted emotions. Cognitive Behavioral models challenge general negative thoughts that include automatic thoughts like: This is a disaster,  I can’t get through this,  I am a horrible person, This is a nightmare/catastrophe.

In order to catch an automatic thought, try to think: What event lead to an undesired emotional response? What thoughts may I have had/do I have in reaction to this event?

The automatic thought must be identified and challenged in writing. Try to write a possible thought that opposes the negative automatic you write down. The challenge thought works towards creating a new highway in the brain one can drive on to achieve a more desirable emotional reaction to events.

Here is an example of using CBT:

Tyra goes on an interview and thinks she did badly and her mind is racing with everything she did wrong. She goes to her car and starts crying and feels completely hopeless about her future. At this point, Tyra cannot reverse her emotional response she must challenge the automatic thought alone. She writes down her thoughts in her thought journal.

Event: Job interview
Emotion: sadness, anger, hopelessness, despair, frustration
Automatic NegativeThought: (Try to isolate one specific thought even though many may be racing through your mind. Usually it’s the most generalized version of thoughts that cause catastrophic thinking/emotional distress because they are unrealistic and vague so more easily proven “true” with distorted thinking.)

That went horribly so I will never get a job.

Challenge thought: (Write down the opposite of the negative thought)

Maybe it did not go as horribly as I thought and it is not the job for me anyway.

Having a bad interview does not make me a horrible person.

Maybe someday I will believe I can get a job.

I know I can get a job someday even if I can’t right now.

I am not defined by my ability to get a job because I have other good qualities.

Maybe there is a possibility the interview was not as bad as I thought it was.

I should ask people if I am stupid to see if this is really true.

The challenge thought can be as positive as you would like it to be or can handle it being. You don’t have to make a perfect or overly positive thought. Try to write something that at least attempts to challenge the intensity of the negative thought.

CBT is very confusing at first. It is confusing because it is hard to identify one’s own thoughts and it is hard to figure out how to challenge them. It is also difficult to accept that thoughts and emotions are two separate things. It is a good first step to write in a thought journal for two-three days. You will improve even if you do not actively notice it. Even if you just try it once, maybe the idea will come back to you someday when you feel clearer and more open to trying this kind of technique. It is a simple but sometimes difficult skill to master, but it works.

Below are some resources and articles to help you learn more about Cognitive Behavioral Therapy.

NAMI: Self-Help Options: (https://www.nami.org/Blogs/NAMI-Blog/November-2016/Discovering-New-Options-Self-Help-Cognitive-Behav)

NAMI: Interview with a CBT-Trained Clinician: https://www.nami.org/Blogs/NAMI-Blog/May-2012/Cognitive-Behavior-Therapy-and-Young-Adults-An-In

Why Does CBT Work? https://www.psychologytoday.com/blog/think-act-be/201501/why-does-cognitive-behavioral-therapy-work

Thought Journal Example:

Emotions: Circle or add your own:    Anger        *     Sadness *     Frustration  *   Hopelessness *

Fear * Anxiety *    Disgust *   Shame *       Embarrassment       *   Grief     *   Guilt *   Hatred * (Self-hatred) * Loneliness * Paranoia *   Rage * Remorse     * Regret *   Suffering

________________   ________________ _________________   ___________________

Automatic NegativeThought (Try to isolate one or two specific thoughts to challenge even though many may be racing through your mind.)


Challenge thoughts (Write down the opposite of the negative thought)



A Letter to my 20-year-old Self


By Marie Demasi

Dear 20-year-old Self,

I can talk to you now, 15 years later. I can tell you that you will be in this amazing space in your life and although difficult, not the same dark hole you once lived in. The place where your anxiety got the best of you and took you down and kept you from moving forward. It debilitated you and kept you in bed and wouldn’t let you live. You were scared to live, so scared that you thought it best to not go on. Not that you didn’t want to be here but the fear of your existence made it seem like the better option. You didn’t want to be the burden, you didn’t see your worth, you didn’t take the time to let the world take a few spins with cleansing breaths that you DESERVE TO BE ON THIS EARTH and have the many blessings that surround you today (the most important the 3 little miracles you brought into the world).

Let’s talk about those panic attacks and dibilitating anxiety that made you flake out on friends, cry in your car because you didn’t know what was happening to your body, not show up to jobs, school, and lose friends because you couldn’t “face your problems” like the rest of the world or you were “embarrassed” by what was happening to you. You can actually count all the times that anxiety kept you from an amazing opportunity, the excuses you created (Thanks anxiety) to get out of things, and the friendships you truly miss… but in that process you also learned who your friends were, many who to this day get it when that EVIL TRIGGER of anxiety returns and you check out a bit …. hound you or force visits/calls and coffee talks to not let you get to that dibilitated state again. Those friends know you don’t want to undo all the hard work you did to get yourself to where you are today.

You also have three kids that say “GOOD MORNING MOMMA! What fun things are we doing today?” They are relying on you, no time to be in the dark hole. Remember the feeling you felt on the day the twins decided to show up a month early… totally relaxed even surprising your best friend of 10 plus years. Her response on the phone, “you are strangely calm”. Not like you at all, but you had no time to think or feel anxious… they had to get out. That calm didn’t last too long as there were some complications and your anxiety got you in a panic. But that first year YOU WERE DETERMINED TO LIVE LIFE TO THE FULLEST!!

Every bump, you kept living, enjoying every little moment of being a mommy to the miracle beans. REMEMBER THAT FEELING, hold that tight! And how good it felt after months and months of stress, anxiety and fear that you would lose them…. how lucky you felt to have them and wake up as their mom. Little eyes are watching, you had to change your coping skills or lack their of. You can’t just lay in bed all day, forcing yourself to sleep to numb the pain, or cry uncontrollably. You learn to take breaks when you need them, getting the kids out in the sunshine and go for a walk, grab coffee or dinner with friends you feel comfortable just being with. LOTS OF HUGS. Closing the door, crying the tears, taking deep breaths and then function again.

The goal is to function every day the best you can and keep moving forward. Find ways to heal, for you it’s being a voice and fundraising/overnight walks with the AFSP  (American Foundation or Suicide Prevention) changed you. Doing the 18 mile walk was cathartic and made you feel closer to your brother who you miss daily (that man will never leave, the memories will fade and that is scary but you feel closer when you are walking in his honor). You learn not to react so quickly and really take deep breaths.

Know that everyday you wake up and breathe YOU ARE WORTH IT!! YOU DESERVE TO BE HERE! YOUR MIRACLES DESERVE YOU AS THEIR MOMMA and most IMPORTANTLY “Love yourself more fiercely than anyone else”. I recently called my mom and said, “I love myself more to make a change.” I made some big changes in the past 7 months, many changes that 20-year-old Marie would never have done. Changes that were best for me and my children… I just couldn’t feel stuck anymore. The stuck reminds me of the dibilitating anxiety and that all leads to the dark hole. The dark hole with no way to climb out … YOU WILL NOT GO THERE AGAIN!

Challenges and challenging people are everywhere (it’s life) but surround yourself with the goodness, the ones who allow your authentic self no matter how vulnerable she may be… scars, bruises, mistakes and all. You said goodbye to the person who wasn’t comfortable in her own skin… the anxiety made it like an itchy tag turned into the most itchiest sweater and you started to love who you are and slowly see your worth in all her “Work in progress” now do your best to not give up on the you, you’ve become.


Your 35-year-old self.

How Sleep Impacts Mental Health



By Ali Mariani


Ever notice that after getting a small amount of sleep you are more irritable, more easily agitated, and just generally crankier? It’s not a coincidence. This is a physical reaction to not getting enough sleep. Sleep impacts our mental health, for better or for worse.


I have always been someone who requires 9 hours of sleep—at least. I am not kidding—when I get anything less, I feel it in my body. This has definitely led to me being very disciplined in my sleep habits. I have learned that my best mental health is contingent upon a regimented and disciplined sleep schedule.


I have always known that sleep plays a role in mental health, but I wanted to research just how much of a role it really plays. So I hit the Internet—of course.  What I found blew me away.


According to the Harvard Mental Health Letter titled Sleep and mental health (2009):


“Sleep problems are mores likely to affect patients with psychiatric disorders than people in the general population. Sleep problems may increase risk for developing particular mental illnesses, as well as result from such disorders.” (Harvard Health Publication, 2009)


Sleep problems can also increase a person’s risk of developing depression, a lack of sleep can trigger mania in individuals with Bi-polar Disorder, and a lack of sleep can worsen anxiety and PTSD symptoms.


Aside from individuals with psychiatric disorders, lack of sleep can have some immediate consequences for everyone including:


-Memory loss/memory impairment

-Inability to focus


-Diminishes moral and optimism

-Slows reaction time and impairs judgment

-Slows train of thought/cognitive impairments


This website offers some really great tips for getting back into a sleep cycle that works for you: http://www.mind.org.uk/information-support/types-of-mental-health-problems/sleep-problems/sleep-problems/

Beginners Guide to Taking Medications


By Cassandra Roos

Through the media and elsewhere, misinformation about taking medications for mental health conditions remains concerningly widespread. Confusion, myths, stigma and fear make it difficult to seek help for the first time. Many people first seek help for their teenagers and children through pediatricians, and adults through primary care doctors. Primary care doctors may be ill-prepared to fully deal with mental illness, so it is important to realize that you may be first recommended medications through these channels but may need to pursue further specialized treatment. It is preferable to find a doctor in the psychiatric field, but primary care doctors are usually the starting point for most people.

Seeking professional help will most likely lead to starting on some kind of medication, depending on the severity of your symptoms, and this is not meant to categorize you as “mentally ill.” You haven’t “failed” to fight it on your own, rather you have succeeded in having the strength to admit and accept help. Try to ignore the rumor mill about the trials and tribulations of people who are “through with the industry” because of “trying everything” (extremely unlikely) or suffering “unbearable” side effects. This does not mean it will be your experience. In some cases, side effects do cause problems for patients, but often with dosage adjustments and ongoing monitoring patients experience more benefit from medication than without it.

Sometimes medication just allows someone suffering to get the support they need to get to the next step where they may or may not need ongoing medication therapy. Other people benefit from medication long-term and have a difficult time living without it, this is especially true for people with bipolar conditions. It does not have to be an all or nothing situation, and there is no reason to panic and think medication will be a lifelong ball and chain one must carry. Medication plays a very distinct role in treatment, and is most effective when combined with some kind of psychotherapy.

If you are suffering to the extent that you are considering seeking help, why not give medication a try like you would try a medication for any other condition? This may sound like a cliché line, but it does not make it untrue. Remember, you may not even need medication for very long or at all and that no situation is permanent.


When you are prescribed medication, ask your doctor for information available to you. Make sure not to rely on online message boards and try to read about what medication you are taking from more reliable sources that vetted and contain research-based information on their websites. One great resources is The National Alliance on Mental Illness (NAMI) www.nami.org and you can access the page specifically discussing medications here https://www.nami.org/Learn-More/Treatment/Mental-Health-Medications. The National Institute of Mental Health (NIH) also has a comprehensive list of medications and their uses here https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml. The American Psychiatric Association (https://www.psychiatry.org/ and The American Psychological Assocation http://www.apa.org/ are also helpful and reliable sources.

In general, anti-depressants will be given first to patients who exhibit symptoms of depression and anxiety, whereas mood stabilizers are most effective in treating bipolar conditions. Fast-acting, short-term medications called benzodiazepines may be prescribed for anxiety. It is relatively unknown that in the case that an underlying bipolar disorder is obfuscated by the depressed phase of the illness an anti-depressant can be dangerous and trigger a manic episode. This is why it is important to be monitored most when you are first trying a medication. Every case is different and your provider will help you find what will work best in your situation.



The term “antidepressant” is probably the most well-known term when people think of mental illness. Oversimplification of what an “antidepressant” is becomes problematic, because each class of anti-depressants is meant to target different functions of the brain and therefore work in unique ways. Antidepressants have many uses in the medical field including the treatment of pain, insomnia, seasonal effective disorder, ADHD, obsessive compulsive disorder (OCD), panic disorders, phobias, eating disorders, post-traumatic stress disorder, anxiety and mood disorders, and to aid in smoking cessation.

For minor, moderate, and major clinical depression, an antidepressant is recommended along with psychotherapy. Patients can begin on low doses at first to see how they adapt to the medication. Providers may not make this clear, but it takes 4-8 weeks for anti-depressants best treat symptoms. Patients often want to give up on a medication too early because it “is not doing anything” but antidepressants take some time to work.

Classes of antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin and noradrenaline reuptake inhibitors (SNRIs), tricyclic antidepressants (helpful with OCD) that block reuptake of serotonin, dopamine and norepinephrine, and monoamine oxidase inhibitors (MAOIs) and bupropion.

These medications slow the re-uptake of certain neurotransmitters in the brain that are being too quickly absorbed and this helps establish the proper balance of chemicals in the brain. Some considerations your health care provider will use to determine what kind of antidepressant to prescribe are: symptoms, age, health conditions, anticipated side effects and anticipated toleration of possible side effects, patient preferences, drug interactions, cost, half-life, etc. People who experience various stages of bipolar disorder may also be prescribed anti-depressants, but there is less room for experimentation.


Mood stabilizers have been shown to be the most effective medications to use in the treatment of bipolar disorder. Medications that have been empirically (results derived from research-based evidence) found to treat bipolar conditions can differ from medications used to treat depression. They also take 4-8 weeks to work at therapeutic doses.

Types mood stabilizers used for bipolar conditions and some names of these medications are: carbamazepine, oxcarbazepine, and lamotrigine. For patients diagnosed with the more intense Bipolar 1 disorder, only two medications are highly recommended for treatment, lithium* and valproate. A mood stabilizer differs from an anti-depressant because it is meant to address the extreme elevated highs as well as the severe lows associated with the condition. Anti-depressants are also used for patients with bipolar disorder, but not always as effective. Some mood stabilizers are used in epilepsy and are anti-seizure medications, but are effective for both conditions.


There are other classes of medications including anti-psychotics, benzodiazepines, stimulants (for attention deficit disorders), and other medications are used on or off-label (not originally intended for that use) to assist in easing anxiety or aid in sleep. Anti-psychotics are used to treat a wide variety of mental health conditions. More recently, newer anti-psychotics, known as “atypical antipsychotics” are given to non-psychotic patients to aid in the treatment of symptoms when mood stabilizers and anti-depressants are not effective enough.


Benzodiazepines (commonly known types are Xanax, Klonopin, and Valium) are highly addictive and sedative, likely to be abused, and can be dangerous when mixed with other substances, especially alcohol. Mixing alcohol with these medications will cause blackouts. Please be very careful if you or your child is prescribed a benzodiazepine. It will work faster than an anti-depressant or mood stabilizer and appear helpful (or to be the only thing helpful because it is fast-acting) but this class of medications can be very dangerous. More and more doctors are reluctant to turn to benzodiazepines for treatment although the effect on symptoms are immediate, there is less long-term evidence that they treat the underlying condition, and these medications usually impede long-term patient progress.

Contrary to popular rhetoric, nobody will force you to stay in treatment or judge you, most professionals are here to help you and work through your problems with you. When you are at a low point, it is difficult to advocate for yourself. As you get better, it is important to do small things to help get the best treatment possible. One example is to write a checklist of topics you want to discuss with your provider, especially due to current time restraints placed on prescribers. Your doctor is still human like you and cannot read your mind.

If you are afraid to try medication that is okay, just consider it as an option that may help you or someone you know get better exponentially faster than they can without it. It is unfair and potentially dangerous to simplify hearing about someone’s experience of trying many medications as useless or blame it on the failures of the field of psychiatry without trying to analyze why the medications that did not work were not appropriate to a patient’s symptoms or diagnosis. For example, if someone is not properly diagnosed with bipolar disorder until the symptoms are clearly present later in life, then it makes sense that earlier medications given to treat the patient’s symptoms may not have worked or only worked for short periods of time as the cycle of the illness progressed. Medications are not meant to eliminate a mental illness, but work to address symptoms and help the patient work towards stability.

It is frustrating that psychiatric treatment can involve so much experimentation, but as with any complex medical issue, no treatment will ever be proven 100% effective. Changing medications over time, even when they may have previously worked for you, is not always a reason to give up completely. There are a wide range of options if certain medications do not work for you. Feeling frustrated with trying medications that don’t work or result in delirious side effects does not mean that your provider has failed, that the field of psychiatry has failed, or that you are an outlier who does not respond to treatment. Do not be swayed by bombastic voices that may make you think that. Sometimes a medication may not seem like it worked, but it is uncertain to know how much worse the situation may have been without it. Most of all, every situation is unique, and trying different medications until you find what works for you is frustrating. Starting medication for the first time does not have to be a crisis in itself. Many people do not have to stay on medication for very long. With the amount of research out there today you can try to learn as a patient and if you have the capability to advocate for yourself or find someone who can help you do so, you will be much more empowered and better able to cope with your situation.

Sources and for further research go to:

For Further Information

The American Psychiatric Association https://www.psychiatry.org/

The American Psychological Association http://www.apa.org/

National Institute of Mental Health https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml

National Alliance on Mental Illness https://www.nami.org/Learn-More/Treatment/Mental-Health-Medications

Treatment of Major Depressive Disorder:


Treatment of Bipolar Disorder:


New Research on Depression in Teenage Girls:


Anti-depressants triggering mania:

Peet M. “Induction of mania with selective serotonin re-uptake inhibitors and tricyclic antidepressants.” Br J Psychiatry 1994; 164:549-550.

Use of atypical antipsychotics with antidepressants and mood stabilizers:

Nelson JC, Papakostas GI: Atypical antipsychotic augmentation in major depressive disorder: a metaanalysis of placebo-controlled randomized trials. Am J Psychiatry 2009; 166:980–991.

Pediatrician Participation in the Treatment of Mental Illness:


Dear Mom, It’s Not You, It’s Me


Mother Consoling her Daughter

By Hayley Iannantuoni

When I was a little girl I did not have a favorite teddy bear, pacifier, or blanket that I brought with me everywhere, instead I treasured a photo album. This album was filled with pictures of me and mom with ear to ear smiles, dirty faces, and countless matching mother daughter outfits. I would look through the pictures every night before I went to bed.These pictures gave me something that I didn’t have growing up, and that was the love from my mom.

I could never understand why I failed to make her happy and carefree like she was in the pictures I have engraved in my memory. I could never clean the house good enough to keep her from yelling when she came through the door after work. Nor was I able to be responsible enough at 12 years old to be left home alone so she could go out, even though I desperately wanted her to stay with me. Most importantly, despite the hundreds of pictures I drew for her, bubble gum machine rings I got her, or how many times I told her “I Love You,” I could never love her the way she desired.

As a teenager I came to accept the fact that I would never have the traditional mother daughter relationship that I had desired for so long, and that I would always be a disappointment in her eyes. I knew that my mother’s love was conditional based on what I could do for her. Many times I had to be the shoulder for her to cry on, forcing me to grow up much faster than any child should. I began to blame myself for her behavior, I was her problem. I was the reason I didn’t have the “John and Kate Plus Eight” family I dreamed of.

The summer before my senior year, my parents decided to get a divorce. This news was not a surprise to me due to the common background noise of yelling, screaming, and crying that filled my house everyday. I decided that I wanted to move in with my dad instead of staying with my mom. My mother did not take this news lightly, she took this news as if she had lost a limb. In a panic she locked all of my sister’s and I’s clothes and belongings in her house. She then bolted the windows shut and made it impossible for us to grab our things, and leave her. Instead of throwing us out, she decided to lock us in. I could not understand why my mom wanted us to stay with her when she was always in a bad mood and wanted nothing to do with us for days at a time locking herself in her room or leaving us to go visit her boyfriend. As soon as we told my dad what happened, he waited for her to get home and called an ambulance for her, like he had done this before.

My first day of  senior year did not include wearing my brand new shoes that I had picked up specifically for that day, nor did it include a new backpack, or fresh school supplies, those were still bolted behind locked doors. My first day of senior year included going to the guidance counselor’s office to put on a spare uniform, a plaid skirt two sizes too big, a stained white collared shirt, and a uniform pass because I did not have the right color shoes for the first day. Shortly into the day, I got called to the guidance office this time, to my surprise, my dad was waiting for me. My dad told me that we would be taking a bus to his house today after school, and with police company we would be able to go grab all of our belongings out of my mother’s house. Due to the circumstances, he also told me that I would be missing swim practice and all of my club meetings after school to go to court mandated therapy sessions with my mother once she was released from the hospital. After many therapy sessions, I understand why my mom could not hold a job for more than a few months, why she was always fighting with my dad, me and my sister, and why she pulled us away from her family and so many other things throughout our lives.


To meet a diagnosis of Borderline Personality Disorder under the DSM-V you must show, “ a persuasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts as indicated by five (or more) of the following”

  1. Frantic efforts to avoid real or imagined abandonment
  2. A pattern of unstable and intense interpersonal relationships characterized by altering between extremes of idealization and devaluation
  3. Identity disturbance: markedly and persistently unstable self image or sense of self
  4. Impulsivity in at least two areas that are potentially self damaging (e.g., substance abuse, binge eating, and reckless driving_
  5. Recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior
  6. Affective instability due to a marked reactivity of mood (e.g. Intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days)
  7. Chronic feeling of emptiness
  8. Inappropriate intense anger or difficulty controlling anger (e.g., frequent displays of temper, consistent anger, recurrent physical fights)
  9. Transparent, stress- related paranoid ideation or severe dissociative symptoms)

When my mother received this diagnosis, I remember the unfamiliar feeling of her crawling into my bed grabbing my hand with tears in her eyes and telling me that she suffers from Borderline Personality Disorder. After some research, I felt like everything finally made sense and I was not the only person who felt unloved and unwanted by a person with BPD. I finally understood that throughout all these years my mom drove me away in fits of rage, that was the only way she knew how to pull me closer. Additionally, I found opinions from other people with BPD, offering advice on how to “get off the emotional rollercoaster” and start focusing on yourself and distancing with love, opening a healthy line of communication. BPD researcher Marsha M. Linehan has developed a communicating style known as D.E.A.R.

D- Describe the situation as you see it without exaggerating, making judgements, or explaining how you feel about it

E- Express your feelings or opinions about the situation clearly (do some thinking beforehand to determine your exact emotions)

A – Assert your limits making them simple (remember you have decided there are limits and those are your personal preferences)

R- Reinforce the benefits of your limits, if appropriate, making it clear you are not acting against the other person, you are acting for YOURSELF.
There is nothing that can compare to the relationship of a mother and her daughter, or to a mom’s home cooked meals and phone calls just to say “I love you.” My mother and I work hard to keep in touch, and try to talk everyday but for her the intense emotions she cannot escape makes this relationship a challenge, facing more bad days than good days. Growing up with a mother suffering from a mental illness has impacted my life in so many ways, particularly, in my choice to become a social worker. Finding my passion has been something I struggled with for many years, when really the answer was right in front of me the whole time. I have my mom to thank for helping me make that decision.

Seasonal Affective Disorder (SAD)



By Stacey Tuttle

During these winter months, it’s dark, it’s cold, and finding the motivation to get out of bed is difficult. For some, this lack of motivation may actually be a symptom of Seasonal Affective Disorder (SAD).  SAD is a type of depression that is related to the changing of the seasons, with winter SAD typically beginning in the fall and ending in the spring. According to Mayo Clinic, symptoms for winter SAD might include:

  • Irritability
  • Tiredness or low energy
  • Problems getting along with other people
  • Hypersensitivity to rejection
  • Heavy, “leaden” feeling in the arms or legs
  • Oversleeping
  • Appetite changes, especially a craving for foods high in carbohydrates
  • Weight gain

If you are experiencing any of these symptoms, then please know that you are not alone!  These feelings are common, and we have some advice for how to find remedies to SAD in your everyday life.

1) Bring more light into your environment. Expose yourself to sunlight as much as possible, either by going outside or opening more shades and blinds around your house.  If it’s possible, make some renovations to your home to increase sunlight access, such as adding skylights or trimming branches that block windows. You can also discuss the possibility of using a light therapy box with your doctor.

2) Spend more time outdoors. Take your dog for a walk, go for a run, sit outside for lunch on your work break. Even on cloudy days, being outside may help alleviate SAD symptoms.

3) Socialize. Talking and interacting with others regularly is very important during these colder winter months. It may be difficult to reach out to others when you’re feeling down, but your loved ones and friends can give you support in a variety of ways and help to lift your mood.

4) Exercise. According to Mayo Clinic, exercising helps to alleviate anxiety and stress, which are symptoms associated with SAD.  And, of course, there is an added benefit in improving your physical health as well!

5) Take a trip. Go somewhere warm and sunny!  This will give you a break from the freezing temperatures and also give you an opportunity to relax.

6) Learn stress management techniques.  Mindfulness meditation, yoga, pet therapy… all of these stress management methods may help with SAD.

The most important thing to remember as mother nature brings wind and snow to your doorstep is that it is normal to experience SAD, but you should take steps early to manage your symptoms and boost your mental health!  If you feel as though the methods above are still not helping your symptoms, then be sure to see a doctor to talk about options for treatment.

Mayo Clinic. (2014). Seasonal Affective Disorder (SAD). Retrieved from http://www.mayoclinic.org/diseases-conditions/seasonal-affective-disorder/basics/lifestyle-home-remedies/con-20021047 


The Happiness Blog



By Stacey Tuttle


“Do more of what makes you happy.” 


This phrase is on a mug that sits in my kitchen cabinet, a mug that my mom had given to me as a gift when I graduated college. It is meant to remind me every morning of what I should be doing now as a full, bona fide adult – doing more of what makes me happy.


Before graduating, we are forced almost daily to think about what we should be doing.  We are provided with a schedule, and this schedule is predictable, filled with appointments and tasks.  And the consequences for not meeting these appointments and tasks are also predictable. Do your homework, or you’ll get a bad grade. Go to class, or risk not knowing that essay question on the exam. Pursue an extracurricular activity, or maybe you’ll be less competitive for your top choice graduate program. Go to that party, or you’ll miss out on an important social event that your friends will be talking about all week. You better do this, or … You better do that, or … The routine isn’t necessarily fun, but it’s there. It’s a safety net. If you are lost, you can easily find your way back to this trickle of the expected.


Then you graduate college with some degree. What to next? Some will say, more school! Sure, that might be a great plan. Let me specialize further. Some will say, work now! Make some money, save, settle down. Excellent idea. Others say, travel! You’re young, nothing is tying you down. Put money into experiences, not things. And you say, ah, yes! That is the true way to find happiness.


But is it? Is that happiness for you? 


So let’s return to the phrase – do more of what makes you happy. And let’s place the emphasis on the you. It took me some time to realize that I often assign other people’s expectations for me to my expectations for myself, rather than creating my own. After college, after this steady trickle of the expected, it became quite easy for me to sway in the direction of the popular wind; to do what society, my family, my friends seem to think I should do next, rather than what feels right for me. It’s easy to recognize when I’m making this mistake, because when I reach the goal, I am not nearly as satisfied as when I choose the goal for myself.


This is a learning curve, and it is often steep, but I am finding my way slowly. It’s not easy to move from the routine of college into this new world of freedom. But we must remind ourselves that we are the captains of our own ships.  There is no one right path to paradise, nor is there just one version of paradise.  So now that I’m out of college, out of this routine, I feel ready to steer the ship in the direction that makes sense for me. I’m finally understanding that I should do more of what brings me personal fulfillment, and not more of what will look good in my Facebook photos. This means making time for myself – giving myself time to meditate each day, to run around my yard with my dogs, to watch a movie with my husband. The grad thesis can wait, the work emails can wait, the social media notifications can all wait.  While I want to pay attention to these things, and I will in due time, I’m establishing a balance for myself. And this balance works.


So, with this new year, I encourage you to add this to your resolutions –


 Do more of what makes you happy. 

Depression Q & A


By Ali Mariani

Depression is an invisible illness. This can mean that a person suffering depression can appear totally “normal” on the outside.  Depression comes in many shapes, sizes, and colors. Depression can be your next-door neighbor who is a Pediatrician, it can be the valedictorian of your class, it can be your High School Psychology teacher, or it could be your sibling or parent. Depression does not discriminate; it can happen to anyone and at any point in his or her life.


What are some things that put someone at a higher risk for developing Depression? 

  • A recent traumatic event including a car accident, the loss of a family member, the loss of a job, etc. A traumatic event can put someone at a higher risk for developing Depression and Post Traumatic Stress Disorder.
  • Family history of Depression. Depression can be, in part, biological and can be passed down in families.
  • A recent break-up, move, change, or transition. Changes are difficult for a lot of us. Changes can be harder on some than others and can lead to depression and/or Adjustment Disorders.
  • Extended periods of isolation. Extended periods of isolation from friends, family, and others can put someone at a higher risk for depression.
  • Seasonal change. Most people often slow down in the wintertime, but someone who struggles with depression may slow down a lot. They may have a hard time doing day-to-day tasks and even getting out of bed.
  • Chronic Diseases and/or Medical Issues. People with chronic illnesses can often develop depression.

The above listed are called risk factors. If you or someone you know have one of the risk factors, this doesn’t mean that you will develop Depression, it only means that you may be at a higher risk. For example, we all deal with seasonal changes in New England, but only some develop Depression or Seasonal Affective Disorder.


What are some of the symptoms of Depression? 

  • Changes in sleep patterns. Either more sleep or less sleep.
  • Changes in eating patterns. Overeating or losing an appetite.
  • Irritable or restless mood. Irritability is often overlooked but can be a common symptom of depression.
  • Loss of Interest in hobbies. When an individual stops doing the activities that they love, it can be a symptom of depression.
  • Sense of hopelessness. This can look like a sense of defeat or a loss of motivation. An individual who is hopeless might say something like “There’s no use,” “I’m no good anyways,” or “What’s the point?”
  • Low self-esteem. Someone who is depressed might express low-self esteem. They might say things like “I never do anything right,” “I am so stupid,” or “I am the worst.”

If you or someone you know feels that they may be suffering Depression, talk to a trusted friend, teacher, or professional. There is help. You are not alone.

Here is a quick survey you can take to see if you might be dealing with depression:


If you find that you think you are struggling with depression, what can you do?

  • Seek out a professional therapist
  • Talk to a trusted friend, family member, or adult about it
  • Call a close friend who you trust to discuss options
  • If you are feeling suicidal, call one of the following hotlines:
    National Suicide Prevention Lifeline Phone Number
    • 1-800-273-8255

Getting Help for Bi-polar Disorder


By Cassandra Roos

My first experience in IOP was rather short and I was recommended through my individual therapist at Vanderbilt Psychiatric Hospital. Interestingly, though, it was the first time I was correctly monitored and given a better medication that had more proven research to successfully treat people with my symptoms. The reason that IOP enabled this to happen is because you are monitored for a longer period of time 3-4 days a week so symptoms are tracked more accurately than they are during a 15 minute medication management appointment. I did not quite understand what types of therapy I was undergoing during my first IOP, however I felt an enormous relief being around other people who felt in as much pain as I did and we were able to openly and most importantly confidentially talk about it within the boundaries of a structured environment.

My second IOP was a follow up program at the Yale St. Raphael’s Campus I attended after I was discharged from a month at the inpatient hospital. I still was in a state of complete emotional dysregulation and had no idea what was happening in this IOP until a month or so passed. But I attended religiously and I would never have been able to get back on my feet without attending that program. Sometimes patients in IOP are in such a haze that their only goal is to try to get to the program and get back home. It was like that for me. It is scary at first giving up your whole life for such an intensive form of therapy. It makes absolutely no sense. You feel like you are losing control over everything, that you are a failure, you feel like your life is over, that nobody will ever understand or talk to you again.

Sometimes, like in my case, a person has to bottom out and realize that the inpatient hospital stay followed by an IOP program may be the only way they can find a way to survive. Other times, as in criminal cases and involving substance abuse, IOP can be required. I am just discussing my experiences, however, in participating in a completely voluntary program. Once I accepted that I had no other choice, that I could not face going on living the way I was, I realized that being in the IOP program was the only way I could get through my days.

Having recently had my fourth manic episode at age 32, my worst, with no extra life triggers or circumstances to blame, it became finally glaringly obvious that I have Bipolar 1. Bipolar disorder is a beast that I will not go into for this article, but needless to say it can hide under the mask of depression for years and go unnoticed especially when it’s easy to attribute seemingly higher functioning symptoms as just someone’s “personality”, that is until they get out of control and it’s too late. In my opinion, the Bipolar 1 sufferer will rarely end up in an IOP program without first crashing and ending up in inpatient, mainly because it can be really fun to be that high. Anyway, I am in my third IOP program following my most recent inpatient stay, and I am finally more aware of what actually occurs in IOP. I have gone through euphoria, grandiosity, hourly rapid cycling, crying, laughing, yelling, screaming and anguish with this group of people watching me closely over the past three months. It says a lot to spend 12 hours a week with people who truly see what you are going through as you try to cover a lot up to survive in the outside world. This program has validated my symptoms and shown me my progress and made me realize that I am not imagining what is happening to me, that this illness is real, because it can appear invisible as everyone around you keeps telling you that you “seem fine” and you “are fine.”

Upon learning the skills and participating in discussions of various aspects surrounding DBT, CBT, mindfulness, distress tolerance, emotional regulation, radical acceptance, validation, and interpersonal relationship skills, everything starts to sound like common sense, like simple ideas. It is mind-blowing to read simple ideas and realize they make perfect sense and feel that you must have known them, but you somehow ignored them or did not utilize them. The key is to fight off the human propensity for glibness and just think about what you are learning, because it isn’t random, a lot of science and research has gone into these programs.

Learning the skills in IOP is not enough, one needs to attempt to apply them outside of the program and come back and share with the group specifically what techniques they applied when they were confronted with difficult emotional situations. The method does not need to work and may not work, but the point is you are supposed to practice anyway. I see IOP as an invaluable educational experience many people have not had the luxury of having.  Because anyone on the face of this earth would benefit from these skills in some way.

IOP for me has been an educational experience, but only truly during this third time, because I have reached the level of clarity where I find it necessary to spread awareness about it. I feel like once you complete an IOP you are part of a gang of insiders who understand the system. Some people view it as “what can help you” others view it as a nuisance, some as an escape, who knows…but I have always viewed it as a requirement for me to go on living when I am ready to accept that I need to attend one again.

Of course, there are problematic parts of this conversation. First off, insurance. Private insurance companies do not like to pay for IOP and do not often see its value. Clinicians have to often constantly persuade companies to continue coverage. In Connecticut, Medicaid will usually cover the entire duration of the prescribed IOP. But insurance is a terribly troubling big issue, and frustration and costs will limit access to this type of treatment for many. The second problem is financially this type of treatment is not an option for many. In order to get the benefits of treatment, one really needs to attend the IOP for the prescribed amount of time and this does involve daytime hours multiple times a week that are hard for many working people to adjust their schedules around. Sometimes people in IOPs have lost their jobs already due to mental illness or can apply for various government programs that give them allowed time off of work (usually unpaid). Some people remain homeless and still attend IOPs or move back in with family members and lose a lot of what they had. Most of the time when someone has reached the point where they are attending an IOP they are not well enough to be working full time anyway.

Sometimes I see group members, myself included, getting upset or enraged by the clinical social workers or other members of the group. You have a right to stand up for yourself and voice your opinion. It may seem like you want to leave the IOP and give up after one conflict because you are already living a life of constant emotional distress. I had a fairly big conflict with one of the social workers in my recent IOP and I went home typed up a four-page letter with personal background, scientific research and evidence as to why she crossed the line. Obviously not everyone will have the capacity to take such a bold measure, but I think participants need to know they can speak up about grievances and work with the clinicians to solve problems because they always arise.

Another drawback (or benefit) to IOP is group dynamics. It is important to understand that patients are admitted to IOPs on a rolling basis, so some people are ending their treatment, some are in the middle of it, and others are just beginning. This is helpful because older members can offer insight and explain to newcomers how they have progressed. Some IOPs have better cohesion based upon personalities and diagnosis. It has been difficult for me this time being manic and in a group with all depressed people (or bipolar patients who are not currently manic) because I am always doing all the talking and often nobody can really relate to me. Sometimes the age gap can be challenging because many of the groups I have been in did not have enough young people who stuck with the program.

In my current situation, I have tried my best to work within the restrictions of the group and benefit where I can by helping others see things they cannot see about themselves. Other times clinicians are not a good fit for patients and may not run a group in a therapeutic way. It is best, in my opinion, when IOPs have alternating clinicians for groups. Nothing is ever ideal and frustrations will at times give someone the illusion that there has been no progress, but it is normal and okay for these conflicts to occur.





Learning More about Intensive Outpatient Programs



By Cassandra Roos

There are many ways that lack of information about the realities of mental health interventions disturb me. One issue I would like to focus on is a form of therapy and rehabilitation called Intensive Outpatient Therapy (IOT), Intensive Outpatient Program (IOP), or Partial Hospitalization. For this blog article I will refer to this treatment as IOP. I feel the need to shed light on what IOP entails because it can often be incredibly overwhelming and patients may not understand what they are participating in for maybe a couple of months or even after a couple of different times attending one.

My goal is to try to raise awareness in the general public about forms of therapy beyond one-on-one talk therapy and medication. I want to spread awareness about the various types of group therapy models other than Alcoholics Anonymous and Narcotics Anonymous. I find that most mental health professionals are so immersed in research and treatment that they are unable to address the persistent myths surrounding successful interventions for mental illness. Legislators and activists can also get trapped in a bubble. There must be some other way to let more people know about the realities of intensive treatment post-hospitalization. Even the Wikipedia pages for these types of treatment are sparse. I was disturbed to find that the search bar on mentalhealth.gov brings up no results for any terms related to “intensive outpatient treatment” “intensive outpatient therapy” or “partial hospitalization.”

What is an Intensive Outpatient Program? Intensive Outpatient Therapy is used as treatment after a hospital stay or as a more serious means to prevent psychiatric hospitalization. IOPs treat patients with mood disorders, anxiety, chronic suicidal ideation, situational conflicts, and personality disorders. Patients with co-occurring disorders, when a mental illness and substance abuse disorder occur simultaneously, also attend IOPs. Sometimes those with co-occurring disorders are placed in a separate IOP. IOPs are used for patients with a high suicide risk because the program has built-in concrete and extensive monitoring and assessment methods to evaluate a patient’s condition. Even if someone misses a day the provider will usually try to contact the patient or their emergency contacts to assess suicide risk and check in.

What are some of the different types of treatments used in IOP? IOP is based around group therapy and the benefits of learning from others. There are common treatment methods used within IOPs including Dialectical Behavioral Therapy (DBT), Cognitive Behavioral Therapy (CBT), distress tolerance, interpersonal relationship skills, mindfulness, emotional regulation, and free form talk therapy. There are activities and skill building techniques unique to IOPs that are difficult to achieve in a one-on-one setting. The nature of the treatment urges you to go home and review skills and try to actively apply them to real life situations.

When are people referred to IOPs? People are commonly referred to IOPs in a discharge plan given to them by an inpatient hospital. When a patient is discharged from a psychiatric inpatient unit, it is helpful for them to attend a “step-down” program, which is often an IOP so that the patient’s progress can be monitored and changes in medication can also be made more easily. The IOP can also help a patient process and cope with their recent hospital stay. Other times individual therapists may recommend an IOP when a patient’s case is too complex for them to handle and current treatment is not enough. This is also a good option because an IOP can help avoid a crisis and prevent a person from an inpatient hospital stay.

What does an IOP entail? Often family members do not know what IOP entails. IOP is a program a patient must remain dedicated to, and in order to work best, should become that person’s sole focus. Of course, this is not financially and logistically feasible for many people, and in that case, often clinics will help with arrangements and provide case workers or other options. For those who are able and/or required to attend an IOP, it is usually around 3-4 hours three or more days a week. Usually attending the IOP for its entirety takes around 12-15 weeks. Initially, this throws many people off because they cannot simply imagine spending almost 12 hours a week for months at a time on healing their brain.

What are the benefits of IOP? IOPs are extremely helpful in monitoring new medication changes over short periods of time. Often people need to be monitored more closely when they are changing medication and need fairly regular adjustments in the beginning stages. Being linked to a clinic and IOP can gain you easier and faster access to your medication provider, who is always separate from the social workers and psychologists who work on therapy. For example, during the first two weeks after my most recent hospital stay I needed my medications changed three times, and if I hadn’t been in the IOP I would have had to go back to the hospital because it was that serious.

In conclusion, everyone’s life circumstances will determine the feasibility, eligibility, and necessity of attending a more intensive treatment program. I personally would feel more validated if I could spread awareness about these programs so people with severe mental illness who attend them, often multiple times, do not feel trapped within this invisible system. Everyone has different symptoms and diagnosis that determine what kind of IOP is right for them. Upon an extensive intake, a clinic will formulate an individual treatment plan with goals and a course of action with each patient for them to review and approve. You have rights as a patient to know your treatment plan and get a paper copy of it if it applies.

Please call a local clinic or speak to your individual therapist, child’s school social worker, or local clinic about your options if you find your traditional outpatient therapy is not doing enough. If you or a family member just got out of the hospital for an inpatient stay and IOP was recommended I strongly consider you look into it. If you are dealing with a situation where a form of IOP is court mandated I hope you can learn to benefit from it or if you are a family member dealing with this I encourage you to do any research you can into what these programs are like and why they are necessary for certain people.

This website provides a list of some options for IOPs in Connecticut https://treatment.psychologytoday.com/rms/prof_results.php?state=CT&spec=223. You can also contact the Yale Psychiatric Hospital Outpatient Services (for adolescents as well) at 203-688-3182 and inquire about the programs there. It can be incredibly difficult to get into a program or figure out if your insurance will be taken unless an outside provider recommends you or you are admitted to a clinic directly from an inpatient hospital stay. It may also take 30-60 days to get an appointment. In case of emergency or if you feel you cannot wait that long for more intensive treatment, you should go to the nearest emergency room. Sometimes you will not even be admitted to the hospital itself, but they have doctors there who can assess you and get you services exponentially faster than you can yourself. It is scary but it is scarier to be alone on the outside and does not make you weak for seeking more serious help. And if you have already crashed and burned and you are starting an IOP or have a family member who is you are not alone and I encourage other people to share their experiences and normalizes this very successful form of treatment.