Fibromyalgia (FM)Fibromyalgia (FM)

Understand the state-of-the-art treatment for Fibromyalgia (FM). Below you will find excellent videos as well as a link to the best self-help tool for CBT for Fibromyalgia.

Summary

Understand the state-of-the-art treatment for Fibromyalgia (FM). Below you will find excellent videos as well as a link to the best self-help tool for CBT for Fibromyalgia.

Understanding Fibromyalgia (FM)

Dan Clauw, MD is the Director of the Chronic Pain and Fatigue Research Center at the University of Michigan as well as Professor of Anesthesiology, Medicine (Rheumatology), and Psychiatry. As a leader in Fibromyalgia research, he explains the current understanding and best practices for treating Fibromyalgia and related conditions.

Dr. Clauw’s multidisciplinary team has extensively studied the use of CBT and exercise in context to Fibromyalgia and discusses his findings (in plain language).

Cannabinoids & Opioids for FM

 

Depression, FM, & Centralized Pain

Depression is common among chronic pain and Fibromyalgia. However, it’s also important to pay attention to what Dr. Clauw calls the 800 pound gorilla in chronic pain – centralized pain – which he believes will be a primary focus of the future of pain research and treatment.

Computer-based (free) CBT for FM

Dr. Clauw’s research team, including pain psychologist David Williams, PhD, developed an online self-paced version of CBT for Fibromyalgia. If you would like to try a do-it-yourself approach to CBT, this is a wonderful first step.  Go to FibroGuide.  I was part of the clinical research team (when it was based at Georgetown University) that tested an earlier, face-to-face version of CBT modules for FM.

Understanding Pain 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Find CBT-trained Therapists

If self-help is not enough, contact me at drcary@mac.com or look for CBT providers in the CBT Directory for providers near you. Also, many providers will conduct CBT using teleconferencing.

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CBT-I for Chronic Insomnia 1CBT-I for Chronic Insomnia

Ads say, “Ask your doctor” for a pill. But, in fact, sleep specialists say that Cognitive Behavioral Therapy for Insomnia (CBT-I) is the FIRST step to take … before any kind of medication.

Summary

Ads say, “Ask your doctor” for a pill. But, in fact, sleep specialists say that Cognitive Behavioral Therapy for Insomnia (CBT-I) is the FIRST step to take … before any kind of medication.

How much sleep do you need?

Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion
Nathaniel F. Watson et al
Sleep Research Society | 2015

Consensus Statement

  • Adults should sleep 7 or more hours per night on a regular basis to promote optimal health.

    • Sleeping less than 7 hours per night on a regular basis is associated with adverse health outcomes, including weight gain and obesity, diabetes, hypertension, heart disease and stroke, depression, and increased risk of death. Sleeping less than 7 hours per night is also associated with impaired immune function, increased pain, impaired performance, increased errors, and greater risk of accidents.
    • Sleeping more than 9 hours per night on a regular basis may be appropriate for young adults, individuals recovering from sleep debt, and individuals with illnesses. For others, it is uncertain whether sleeping more than 9 hours per night is associated with health risk.
    • People concerned they are sleeping too little or too much should consult their healthcare provider.

The American College of Physicians Recommendation

Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians
Amir Qaseem, MD et al
Annals of Internal Medicine | July 19, 2016

What does CBT-I look like?

This video, produced by psychologists – CBT-I specialists – realistically explains (and shows) the most essential parts of what to expect in CBT-I treatment.

The sleep diary

DOWNLOAD the Sleep Diary + the Instructions here!

The consensus sleep diary: standardizing prospective sleep self-monitoring
Carney, CE et al
Sleep | Sleep Research Society | Volume 35 Issue 02

Abstract
Study Objectives:
To present an expert consensus, standardized, patient-informed sleep diary.

Conclusions:
The Consensus Sleep Diary was the result of collaborations with insomnia experts and potential users. The adoption of a standard sleep diary for insomnia will facilitate comparisons across studies and advance the field. The proposed diary is intended as a living document which still needs to be tested, refined, and validated.

 

Does computer-based CBT-I work?

Computerised cognitive behavioural therapy for insomnia: a systematic review and meta-analysis
Cheng, SK and Dizon, J
Psychotherapy and Psychomatics | June 2012

Abstract

Background: Computerised cognitive behavioural therapy (CCBT) is an innovative mode of delivering services to patients with psychological disorders. The present paper uses a meta-analysis to systematically review and evaluate the effectiveness of CCBT for insomnia (CCBT-I).

Method: A comprehensive search was conducted on 7 databases including MEDLINE, PsycINFO, EMBASE, CINAHL, Cochrane Library, Social Sciences Citation Index and PubMed (up to March 2011). Search terms covered 3 concepts: (1) [internet, web, online, computer-aided, computer-assisted, computer-guided, computerized OR computerised] AND (2) [CBT, cognitive therapy, behavio(u)ral therapy OR behavio(u)r therapy] AND (3) [insomnia, sleep disorders OR sleeping problem].

Results: 533 potentially relevant papers were identified, and 6 randomised controlled trials (RCTs) that met the selection criteria were included in the review and analysis. Two RCTs were done by the same group of investigators (Ritterband and colleagues) using the same internet programmes. Post-treatment mean differences between groups showed that the effects of CCBT-I on sleep quality, sleep efficiency, the number of awakenings, sleep onset latency and the Insomnia Severity Index were significant, ranging from small to large effect sizes. However, effects on wake time after sleep onset, total sleep time and time in bed were non-significant. On average, the number needed to treat was 3.59. The treatment adherence rate for CCBT-I was high (78%).

Conclusion: The results lend support to CCBT as a mildly to moderately effective self-help therapy in the short run for insomnia. CCBT-I can be an acceptable form of low-intensity treatment in the stepped care model for insomnia.

Best complementary health approaches

The National Center for Compelementary and Intregrative Health, a National Institute of Health (NIH), clearly states what IS and IS NOT proven to help insomnia on this page.  Briefly, they cover:

  • Mind/Body techniques, such as: relaxation, meditation, hypnotherapy, yoga, and acupuncture.
  • Supplements, such as:  melatonin, chamomile, cava, valerian, L-Trytophan, 5-HTP, lemon balm, passionflower, or hops.
  • Other remedies, such as:  Aromatherapy, Homeopathic medicine.

Measuring activity while asleep

Practice Parameters for the Use of Actigraphy in the Assessment of Sleep and Sleep Disorders: An Update for 2007
American Academy of Sleep Medicine | April 2007

Measure the Quality of your Care

Measurement of Quality to Improve Care in Sleep Medicine
Timothy Morgenthaler, MD et al
Journal of Clinical Sleep Medicine | Volume 12 Number 8

Abstract

The Board of Directors of the American Academy of Sleep Medicine (AASM) commissioned a Task Force to develop quality measures as part of its strategic plan to promote high quality patient-centered care. Among many potential dimensions of quality, the AASM requested Workgroups to develop outcome and process measures to aid in evaluating the quality of care of five common sleep disorders: restless legs syndrome, insomnia, narcolepsy, obstructive sleep apnea in adults, and obstructive sleep apnea in children. This paper describes the rationale, background, general methods development, and considerations in implementation for these sleep disorder quality measures.

The Workgroup papers are published in this issue under the following titles: Quality Measures for the Care of Adult Patients with Restless Legs Syndrome, Quality Measures for the Care of Patients with Insomnia, Quality Measures for the Care of Patients with Narcolepsy, Quality Measures for the Care of Adult Patients with Obstructive Sleep Apnea, and Quality Measures for the Care of Pediatric Patients with Obstructive Sleep Apnea.

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Auto Draft 1Chronic Back Pain

Pain, in the U.S., is the most common complaint in healthcare and an enormous public health challenge. One in 3 adults have it. It causes the most disability. It costs us up to $635 billion/year. By far, pain is untreated or under-treated.

Summary

Pain, in the U.S., is the most common complaint in healthcare and an enormous public health challenge. One in 3 adults have it. It causes the most disability. It costs us up to $635 billion/year. By far, pain is untreated or under-treated.

The National Problem of Pain

Dr. Mackey is Chief of Stanford’s Division of Pain Medicine, Director of the Systems Neuroscience and Pain Laboratory (SNAPL) and Redlich Professor of Anesthesiology, Perioperative and Pain Medicine, Neurosciences and (by courtesy) Neurology.

In this video, Dr. Mackey kicks off the 2016 Back Pain Day by discussing pain as a chronic disease itself and a how we can address it clinically and as a public health problem. He broadly describes what’s involved in pain management – a team sport. Then, the other 8 Pain Medicine faculty members describe their roles on the pain team in their videos.

Sean Mackey, M.D., Ph.D

Dr. Mackey explains, in terms patients can understand, the state-of-the-art understanding about how pain actually works.

Beth Darnall, PhD

Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine, Dr. Darnall is a pain psychologist and scientist. Her research investigates how to best treat and prevent chronic pain. She is a principal investigator for $14M in federal research awards.

Dr. Darnall explains the importance of using CBT to manage ‘catastrophizing’ – a common reaction to chronic pain.

Heather Poupore-King, PhD

Clinical Assistant Professor, Anesthesiology, Perioperative and Pain Medicine, Dr. King’s interest is in providing interdisciplinary care and specializes in comprehensive functional rehabilitation for chronic pain patients, using Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (a form of CBT), and Biofeedback.

Dr. King explains how care team members work together – with you at the center – to manage chronic pain best.

Fiona Barwick, PhD

Clinical Assistant Professor in Psychiatry & Behavioral Sciences – Stanford Center for Sleep Sciences and Medicine, Dr. Barwick specializes in the assessment and treatment of insomnia, sleep apnea, circadian rhythm sleep-wake disorders, and parasomnias from a Health Psychology perspective.

Dr. Barwick explains the role of CBT and augmented therapies for addressing problems with sleep and chronic pain.

Ming-Chih Kao, MD, PhD

Clinic Chief at Stanford Pain Management and Clinical Assistant Professor, Orthopaedic Surgery, Dr. Kao’s mission is to offer all of his patients comprehensive interdisciplinary diagnosis and treatment, leveraging the full extent of what is known in state-of-the-art Pain Medicine.

Dr. Kao discusses the variety of meds used and their role in pain management.

Michael S. Leong, MD

Clinical Associate Professor of Anesthesiology and Pain Medicine and Neurosurgery (by courtesy), Dr. Leong’s clinical foci are in radiculopathy; spinal, abdominal, and cancer pain; postherpetic neuralgia; and workers compensation cases.

Dr. Leong explains the role of the use of spinal cord stimulation and how it works to reduce chronic pain.

Jordan Newmark, MD

Dr. Newmark is the pain division’s Associate Division Chief of Education, and Pain Medicine Associate Fellowship Director. His clincal interests are in chronic and perioperative pain management, headache and orofacial pain management, and interdisciplinary / procedural treatment.

Dr. Newmark teaches us about the safe use of opioids for chronic pain.

Corinne Cooley, DPT

Ms. Cooley, a member of the Pain Physical Therapy staff, explains the role of physical movement in managing chronic pain – “Movement as Medicine”

J. Drew Sturgeon, PhD

A Postdoctoral Research Fellow, Dr. Sturgeon explains the importance of managing social relationships and shows their impact on the brain and on chronic pain.

Questions and Answers (Video 1 and 2)

The entire panel participates.

The Future: ‘Personalized’ Pain Management

This video, not part of the 2016 Pain Day, outlines how the Stanford team is developing an extraordinary diagnostic and treatment tool that will inform clinicians (throughout the world) how to better ‘personalize’ pain treatment for their patients. Perhaps your physician could participate with this project, CHOIR, in the future.

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Kicking the Insomnia Habit 1Kicking the Insomnia Habit

Most who have chronic insomnia simply learned it, unintentionally!  The Clinical Guideline for Chronic Insomnia recommends that you UNLEARN it ... using Cognitive Behavior Therapy ... not pills!

This 'Learned Insomnia' graphic shows all of the common pitfalls that maintain the insomnia habit. It also indicates the main elements of the CBT protocol that helps you eliminate insomnia. Also, take a look below for more in-depth descriptions of the elements of this behavioral treatment.

Summary

This ‘Learned Insomnia’ graphic shows all of the common pitfalls that maintain the insomnia habit. It also indicates the main elements of the CBT protocol that helps you eliminate insomnia. Also, take a look below for more in-depth descriptions of the elements of this behavioral treatment.

Handouts

  1. CBT-I for Learned insomnia:  SLEEP-1 copy
  2. Sleep Diary:  0 Sleep_Diary
  3. Distorted NATs:  Distorted NATs
  4. Beliefs:  Anxiety_ Belief copy

Videos

Watch Dr. Morin, the researcher responsible for developing and testing the CBT protocol shown above, in this brief video.

 

For more about CBT-I, click on this link University of Alabama Behavioral Sleep Medicine video. (Note: If the video doesn’t start, click on the middle of the image.)

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Expert Sleep Tips from Real PeopleExpert Sleep Tips from Real People

The National Sleep Foundation’s program Beyond Tired offered four people with Insomnia 6 weeks of help. They share their tips in this video. And, check out their Youtube Channel with many other videos here.

Summary

The National Sleep Foundation’s program Beyond Tired offered four people with Insomnia 6 weeks of help. They share their tips in this video. And, check out their Youtube Channel with many other videos here.

Beyond Tired

https://www.youtube.com/watch?v=BU_PcKlP7Mg

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Understanding Pain 3Understanding Pain

If you are one of 100 million Americans with chronic pain, you’re likely under-treated and have not been taught by health providers how to improve your quality of life.

Summary

If you are one of 100 million Americans with chronic pain, you’re likely under-treated and have not been taught by health providers how to improve your quality of life.

Science of Pain

 

At a minimum, the below videos suggest the importance of getting treated by a Pain Medicine specialist who works alongside a Behavioral Pain specialist as part of a care team.  Learning a little about the science of pain may profoundly change how you view your pain condition and what to do about it.

A Roundtable of Pain Specialists

For a good overview on the state of the science of pain, watch the Charlie Rose Brain Series episode on Chronic Pain.

What is Pain?

Dan Bruns, a Pain Psychologist, explains pain in a very understandable way.

 

Catastrophizing + Pain

 

Where’s the Edge of Pain?

Low Back Pain

An Anatomy Professor’s Take on Pain

University of California Professor Basbaum presents a quick course for the public. As he’d say, don’t get bogged down trying to learn details. Just get the gist of how your brain processes the ‘experience of pain.’

An Internist-Pediatrician’s Take on Pain

Dr. Schubiner briefly explains his view of the steps to take to begin to ‘unlearn’ a learned pain brain pathway. It’s important to realize that his belief, that pain can be completely unlearned is as yet a hypothesis – not proven.

Behavioral Treatment of Pain

Living with persistent pain, regardless of what the cause, necessitates some lifestyle management skills. The University of Michigan Chronic Pain and Fatigue Research Center has developed and tested an online self-help series of modules that may help you learn these skills.

Although you may not have Fibromyalgia, these same skills are the basis for the cognitive-behavioral therapy that Health Psychologists use in providing behavioral pain management for chronic pain in general. Check out these skill modules.

 

Virtual Reality (VR) for Pain Management

Another behavioral tool, VR, can help alleviate pain. Watch this short video that see how ‘Snow World’ – a VR Game – helps with pain associated with burns.

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Headaches and BiofeedbackHeadaches and Biofeedback

Daily stress is an unavoidable part of daily life. It’s how you manage the stress that’s most important.

Summary

Daily stress is an unavoidable part of daily life. It’s how you manage the stress that’s most important.

Overview

Then during the nineties, when I was on the Clinical Faculty in Behavioral Medicine at Georgetown University, outpatients with all kinds of pain – head, back, stomach – came into the Biofeedback Lab I directed. I always thought how ironic it was. They rushed through traffic, hassled with parking, and stressed about being late – just to come in to relax.

Thankfully now, Biofeedback is entirely portable. In the quiet of your favorite place, you can teach yourself how to relax tension away and take control of your nervous system  – to access the relaxation response. So, you might want to look into something like the Stress Eraser (I don’t have any stock in their company). It’s a proven tool.

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Poor sleep: It’s neuroscience, not just a nuisancePoor sleep: It’s neuroscience, not just a nuisance

In this short video, Oxford University Professor Foster explains that his new findings in neuroscience show that lack of adequate sleep is not just an inconvenience.

Summary

In this short video, Oxford University Professor Foster explains that his new findings in neuroscience show that lack of adequate sleep is not just an inconvenience.

Video

 

 

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Auto Draft 4My 2016 Favorite: “How Not to Die”

These videos, by the most important thought leaders of our day, share what’s proven to work to reverse (or prevent) cancer, heart disease, as well as the wear and tear of chronic stress.

Summary

These videos, by the most important thought leaders of our day, share what’s proven to work to reverse (or prevent) cancer, heart disease, as well as the wear and tear of chronic stress.

Videos

Dr. Greger, once again, hits it out of the park with his book (How Not to Die) … which he summarizes in this recent talk.

I recommend trying a weekly dose of Dr. Greger’s tasteful little videos (some are below) – which he sends for free in email.

Dr. Ornish’s landmark research on reversing diseases (cancer, heart disease) is explained in this clip of an award-winning documentary. Also, you can join Dr. Ornish’s community for free.

More of my favorites …

1.   Look at the power you can have with gizmos! We can be savvier consumers about these gizmos. Harvard experts suggest ‘what works’ to improve our sleep, diet, & exercise.

2.   For well-being, Dr. Hanson offers one simple idea to practice in each free e-newsletter called, Just One Thing.  He blends the latest brain science, positive psychology, and contemplative training.

3.   Here’s how we can ‘prepare’ to be our healthiest  …  how to create more demand for the best care  … and how to find providers who really get it – Lifestyle IS Medicine!

 And, my hope … 

Increasingly, healthcare is about making whole communities more healthy. I believe that we can use healthcare training as a vehicle to spread health to each community…. by engaging campuses in a little friendly competition – March Madness for Total Fitness.

As Dr. Ornish showed, both good health – and its delivery – is a team sport. It’s not just about personal diet and exercise. Maintaining fitness goals requires resilience to stick with it when we’re stressed. And often, a team of friends can help us more than if we’re alone.

Ideally, similar to Dr. Ornish’s clinical team, we can teach students in the allied health fields to lead fitness teams – not only for better campus health & well-being, but for their professional training. Because, in the 21st century, healthcare will be less about ‘sick’ care and more about wellness. That is, providers will get paid more if they keep their patients healthier! Who knows … maybe one day, you’ll be able to join a fitness team, in your locale, for your total health & well-being.  Stay tuned!

My 2016 Favorite: “How Not to Die”

 

More about Berries!!

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Auto Draft 5Learning to Manage Stress

Daily stress is an unavoidable part of daily life. It’s how you manage the stress that’s most important.

Summary

Daily stress is an unavoidable part of daily life. It’s how you manage the stress that’s most important.

The Stress Response

 

Learning to Manage Stress 2Using Cognitive Behavior Therapy (CBT), you will learn how to relax both your mind and body.

First, let’s think about how to relax your body.

When we’re upset – the stress response automatically kicks in (the sympathetic nervous system).

Daily stress creates wear & tear on all of us and can worsen  medical illnesses.  For that reason, we all need to learn to manage stress really well! We may not be able to stop stressful situations from happening … but, we can learn to manage our reaction to stress — in the moment.

The beauty of your body is that you can literally take control of your stress response (even in most stressful situations) by paying more attention to your breathing than to how stressed you feel!

The Relaxation Response

Learning to Manage Stress 3Learning to Manage Stress 4The first step is to be mindful in the moment that you’re feeling stressed! Watch a few great Mindfulness technique demonstrations here.

The next step is to learn how to reduce your stress response …. just by using a simple breathing technique.

If you breathe slowly (approximately 6.5 breathes per minute) and take a little more time on the exhale (4 seconds per inhale; 5 or 6 seconds per exhale), then you will turn on the ‘relaxation response’ (parasympathetic nervous system).

The below videos will teach and demonstrate for you exactly how to do that slow belly breathing. It takes a little practice … everyone can learn to do it in time!

How to Belly Breathe

Watch Dr. Carbonell demonstrate belly breathing

 

If you like apps, I recommend using the FREE Breath2Relax app … This video (which includes 4 short mini-videos) previews components of the app, which was developed by the Department of Defense.

 

Techniques (if your brain is too ‘busy’ to relax)

There are two science-based techniques that work really well, especially if you feel too antsy to just do the breathing:

  1. Progressive Muscle Relaxation
  2. Visual Imagery

Progressive Muscle Relaxation (PMR)

Below are two guided practices. The first is shorter, has a male voice, and shows you the muscle groups. The second is longer, has a female voice, calm music in the background. Get a sense of the kind of guide you prefer. Finally, take some time to make it your own exercise. Pick from a wide variety – now that you know what the basic elements are:

  1. Systematically switch from muscle tensing to relaxing
  2. Notice the deeper relaxation in each area by way of contrast from tension
  3. Rhythmically simplify instructions
  4. Notice the deeper relaxation upon exhaling – the exhale turns ON the relaxation response!

Shorter version (6 minutes)

Longer version (15 minutes)

Visual Imagery (a misnomer!)

Below are two guided practices: (1) a beach scene, and (2) a woods scene. It doesn’t matter where you take yourself (think of it like a mini-vacation in your mind). In fact, some people prefer sheer magical fantasy, like being in a Disneyland of their own.

It’s a misnomer because the important thing is to pay attention to using ALL your senses: see the sights, as you hear the sounds, as you touch the textures, as you smell the fragrances, as you savor the tastes.   The goal is to be IN the experience … rather than just see it. Fill it with your own personalized memories of pleasant feelings and smells and bring in anything that is calming to you, like a special warm loving hug.

Take some time to find your own preferred imagery … with some ideas from this variety of imagery videos.

Beach

Woods

Brief Grounding (calming) Techniques

Sometimes we feel way too keyed up to even begin a relaxation session (breathing, PMR, or visual imagery). Whenever you feel overly stressed (over a ‘5’ out of ’10’), it’s a good idea to try one of several very brief  behavioral techniques to bring yourself to a calmer state.  They’re called ‘grounding’ techniques because they’re simply meant to get you more in touch with feeling safe and secure – in the ‘here & now’ rather than thinking about the past or worrying about the future.

I recommend trying several, to find one that can become your go-to quick rescue.  These videos explain how to use your senses to get grounded right away, how to create your own safe place, how to count your breaths, and even how to use yawning to access a calmer state.

Best of all worlds, you will practice doing one of these daily so that you will be skillful … whenever you really need to pull this ‘relaxation’ skill out of your mental health toolkit – on your demand to calm yourself.

 

 

 

 

Calming Yourself (fast) from High Stress

Yes, there’s a proven technique to manage high stress fast. Dr. Ali Mattu explains/demonstrates this in his video. You can achieve the same response by putting a frozen washcloth on your forehead.

NOTE:  Don’t try this without consulting your physician first – especially if you have any type of heart disease!

 

Well-Being is a Skill

Modern neuroscience teaches that we can train our brains to have more well-being; it’s a skill to learn. Watch a thought-leader in the field of neuropsychology, Dr. Davidson, talk in Part I … about the science of well-being and in Part II … the 4 constituents of well-being, including the importance of practicing mindfulness.

 

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Smoking and Other Killer HabitsSmoking and Other Killer Habits

Daily stress is an unavoidable part of daily life. It’s how you manage the stress that’s most important.

Summary

Daily stress is an unavoidable part of daily life. It’s how you manage the stress that’s most important.

Overview

Smoking and Other Killer Habits 1

Many self-soothe in self-defeating ways – smoking, drinking, overusing prescriptions, overeating, not moving enough. If our brains get addicted, it’s difficult to stop.

By far, quitting smoking was the hardest thing I’ve ever done. And so, I’ve helped test new ways to help people quit, as a clinical supervisor on Georgetown Lombardi Cancer Center studies.

Most people don’t realize that it’s less about ‘willpower’ and more about being ‘ready enough’ to change. We can do ourselves more harm, if we try to change a habit and we’re not mostly ready.  Many times, when we fail, we get disappointed and lose confidence … and stop trying.

That’s the learned helplessness vicious cycle. Fortunately,  there are proven treatments to increase readiness – motivational skills – as well as to stick with it over the long term- relapse prevention skills. To change ANY habit, it’s essential to learn how to manage the conditions that trigger our own specific vicious cycles. And then, structure our environment to be MUCH more supportive of new, more ‘virtuous’ cycles.

It’s not rocket-science! Anyone can learn these skills … and be much better prepared to change. Those who seem to have more ‘willpower’ are probably using these skills – without knowing it.

 

 

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