The Five-Minute Journal

A couple of months ago, I was introduced to The Five-Minute Journal. As the name implies, the journal calls for brief entries (two per day: morning and night), nothing more than quick, bullet-item lists.

In the morning, you jot down what you’re grateful for and what would make the day a positive one. You also list a couple of things you like about yourself. Come nighttime, you note what went well during the day and a couple of things you could have done to make the day a better one.

Here’s why I like this journal:

  1. It’s easy and doesn’t require much time to complete the prompts, so for those who struggle with journaling, the task doesn’t feel too daunting.
  2. It encourages a focus on gratitude and positive intention setting, both of which can impact your outlook and functioning.
  3. It forces you to name your strengths in a culture that so often suggests you focus on your weaknesses.
  4. It encourages you to take personal responsibility for making your days more positive.
  5. The journal prompts have a way of infiltrating your daily consciousness, impacting thoughts and actions so that they are more consistent with your values.

If these exercises interest you, you can purchase The Five Minute Journal here. Otherwise, you can complete the prompts on your own. Notice any changes in thinking, behavior, or emotional patterns over time. Let us know what you think!


A Call for Reducing Reductive Solutions in Honor of Mental Health Awareness Month

A while back, a meme was circulated encouraging those who struggle with depression, rather than taking medication, to just go for a run outside.

As a player in the fitness industry for over twenty years, and the author of a study on the mood-enhancing properties of exercise, I won’t disagree that physical activity can often improve how we feel. But it’s not going to help everyone, and an individual suffering from a severe depression might not be in a place to lace up her running shoes and hit the pavement. In cases of moderate to severe depression, treatment isn’t optional. This advice also overlooks those who struggle with eating disorders and/or compulsive exercise, who might have turned that prescription for a “run outside” into something problematic.

We see and hear a lot of these stock approaches to recovery. “Anxious? Try meditation – it worked for me!” “Have insomnia? Cut out [x] food.” And the old, “Why don’t you just eat?” to the individual suffering from an eating disorder. While the comments might be well-intended, they fail to capture the diversity and significance of mental health presentations. A brain (not to mention, a personality, life history, cultural experience, etc.) is a complicated thing, and when we try to compare one to the other, we lose a lot in the process. Suggesting that someone with panic attacks take a meditation class might be akin to asking him to write a book when he’s only capable of drafting an outline. Encouraging someone with an eating disorder to “just eat” without significant structure and supports in place is asking her to accomplish the unthinkable.

In many cases, therapy and/or medication is required in order to make progress from a mental condition. (Side note: Taking psychotropic medication is not unfeminist, as a psychiatrist in New York City suggested in a recent Facebook post.) All of the self-care and self-help exercises in the world are not enough to tame some of the symptoms we see in practice. So, if you know someone who’s struggling, my advice is to back off the advice. Listen and express compassion. Read up on evidenced-based treatment. Ask the individual if there’s anything she needs or wants from you. And then just be there, minus the platitudes and trendy treatments, the quick fixes and what-worked-for-me’s.

Panic 101

One of the most frightening things that many of my patients experience is a panic attack – or worse, a series of them.  According to the DSM-5 (American Psychiatric Association, 2013), a panic attack is:

“An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur. Note: The abrupt surge can occur from a calm state or an anxious state:

  1. Palpitations, pounding heart, or accelerated heart rate
  2. Sweating
  3. Trembling or shaking
  4. Sensations of shortness of breath or smothering
  5. Feeling of choking
  6. Chest pain or discomfort
  7. Nausea or abdominal distress
  8. Feeling dizzy, unsteady, lightheaded, or faint
  9. Chills or heat sensations
  10. Paresthesias (numbness or tingling sensations)
  11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  12. Fear of losing control or going crazy
  13. Fear of dying”

Many individuals who experience panic attacks present in hospital emergency rooms, afraid they’re having a heart attack. Others are convinced they’re losing control or going insane. In reality, panic attacks are uncomfortable physical and psychological experiences, but they aren’t dangerous, an important distinction to make.

One of the best things someone can do at the beginning of a panic attack is to try not to “panic about the panic.” It’s easier said than done, but this will only make things worse. A panic attack is the body signaling a false alarm. Responding to the alarm as if it’s real validates the symptom. Instead, labeling the symptoms as panic is a helpful first step, as is challenging some of the the catastrophic thoughts that arise (e.g., “I’m dying”). The more you are able to identify the symptoms as panic, accept them, and potentially distract, the sooner the panic attack will pass. Many become afraid that they’ll pass out/lose consciousness during a panic attack, but heightened physiological arousal is generally contraindicated with fainting.

Developing a sense of acceptance around panic – rather than fearing another attack – can go a long way toward recovery. Cognitive-behavioral therapy is an evidence-based approach used in the treatment of panic attacks. Patients might also find meditation, deep breathing, and regular exercise helpful. For some, medication is indicated, with the typical offerings being SSRIs (e.g., Zoloft, Lexapro), taken daily, or benzodiazepines (e.g., Xanax, Ativan), taken briefly or when having or anticipating symptoms. Some patients find that carrying around medication, without ever using it, can ward off panic attacks.

For help with panic attacks, or other symptoms of anxiety, please contact our team at Gatewell.


Building an Emotional Muscle

One of my favorite definitions of mental health is the ability to experience and express emotions in an effective way.  It’s simple, but so on point.

Recently, I came across this blog post on how parents can help their children identify and express their emotions. I love how the author encourages naming – and honoring – of emotions from birth.

All too often, though, children are raised without this kind of emotional attunement, or as we call it, “mirroring,” by the adults in their lives. Kids are told not to cry, not to be scared, to get over it, and to be happy – even when they’re not. Parents might have the best intentions – most don’t want to see their children upset – but avoiding and discouraging emotions will invariably backfire.

It’s never too late, though, to build your own emotional vocabulary, to respond to your emotions compassionately, empathically, and with curiosity;  and to practice acceptance of the waves of feelings that course through you each day. Can you acknowledge your feelings without negating them? Can you accept what you are feeling without trying to make it go away? Often, the more we accept our emotions – and then less we discount them or try to suppress them – the less power they have over us.


Why Group?

Why would you want to sit in a room with complete strangers learning about their struggles and being encouraged to reveal your own?

It might be daunting to consider group therapy when even the notion of individual therapy might be overwhelming or when you think that being in group might not allow you sufficient time and space to process your concerns.

But what if you learned that group therapy is just as effective as individual therapy – for treating a wide range of symptoms  – and that group participation offers a unique therapeutic advantage? For instance, group therapy provides a venue where you can learn from your peers and receive their feedback and support. It’s one thing to discuss strategies with a therapist regarding how to target a specific difficulty and another to hear from someone who has successfully overcome this same difficulty. Being among peers might also provide an additional layer of support, as you recognize that you’re not the only one who struggles in certain ways. The universality of experience should not be underestimated. Moreover, as we bravely reveal ourselves in group, we directly challenge some of the vulnerabilities and shame that might be holding us back.

For those who are looking to improve how they communicate with and relate to others, group provides the perfect “laboratory” in which to try out new ways of interacting. Interested in becoming more assertive or setting firm boundaries with others? How about managing anger and conflict more effectively? Your individual therapist can address these issues with you as you bring content into your sessions, but it’s a whole other ballgame when your group therapist is able to witness how these dynamics unfold in real time. She can use information from group to help you establish more effective interpersonal patterns in “real life.”

Not sold yet? Group therapy offers a cost-effective alternative to individual therapy, and group treatment allows access to a larger population of individuals, who might not otherwise receive care.

Check out Dr. Rosenfeld’s interview on group therapy with ABC News:

Curious about group? Explore Gatewell’s groups and let us know if you think group participation might be beneficial for you.



4 Life Lessons from the Improv Stage

While living in Los Angeles, I tried out my hand at improv at the famed Second City. Each Sunday afternoon, our Improv 1 class gathered to play games, act out skits, and laugh together. As I was taking the class, I remember thinking that much of what we were learning – and doing – was applicable to life.

    1. Acceptance: One of the first improv lessons is a concept called “yes and.” If you’re in a supermarket skit with someone, and he blurts out, “Look, there’s a dinosaur,” instead of freezing or saying “Dinosaurs don’t go to supermarkets,” you have to play along. In practice, you acknowledge what he’s said (the “yes”) and then further along the concept (the “and”). So, in this case, you might say, “And he’s coming right at you!” Off the stage, yes-and’ing life can have dramatic implications for mental health. We know that refusing to accept our circumstances is the root of much distress, as we resist against the discrepancy between how things are and how we want them to be. Instead of bumping up against what comes our way, what if we accepted whatever it was (referred to in dialectical behavior therapy as “radical acceptance”) and then “and”-ed it? When faced with adversity, what if our primary response was acceptance (the yes) and what to do about it (the and)?
    2. It takes a village: Something that gave me comfort whenever I acted in a skit, which wasn’t my favorite thing to do, was the improv guideline that the performers are all in it together. So, if I couldn’t think of the next thing to say, then the person acting with me was equally responsible for rescuing the scene. Wouldn’t it be nice if, when facing difficulties, we allowed ourselves to be vulnerable and reached out for help/support, instead of thinking that the responsibility was all ours? What if we all agreed to help each other during our most challenging scenes?
    3. Find humor in your mistakes: Even when someone botched a scene, how the person handled the “error” could become fodder for perfect comedy. Writing the mistake into the script was often the funniest part. What if we wrote our errors into our life scripts? What if we made habit of laughing at our foibles instead of blaming and shaming ourselves?
    4. Laughter is medicine: Not many things feel as good as uncontrollably laughing with other people. We underestimate the function that laughter – and fun – can serve in our lives. It wasn’t long before Sunday afternoons became a natural high for me. Life can be challenging at times, and unbridled laughter serves as a respite from the headaches of work, family, stress, loss, trauma. . . even headaches themselves.

If your interest is piqued, you might want to check out an improv class. If not, these lessons from the stage are easily yours to apply to daily life.

The Power of Child’s Play: Fostering Empathy and Connection

by Dr. Amy Sosa

Children play. That is a fact of life. Have you ever waited in a line while your little ones find something to occupy their minds? They may play peekaboo with a neighbor, smile at a stranger, or grab the closest object to them and explore it with unbounding curiosity. Play is critical to child development because it teaches children how to navigate the world.  Specifically, child’s play centers around one of two themes: power and connection.  

When people think of power, they often think of authority over someone or something else. According to the Merriam-Webster Dictionary, power is defined as“the ability to act or produce an effect” or “the possession of control, authority, or influence over others.” When children engage in imaginative play of power, they often possess “superpowers” to destroy bad people or get rid of scary creatures. Ironically, they use violence to feel safe. This egocentric activity fulfills children’s needs to feel invincible and powerful; however, it negates the experience of the other person.  

When people think of connection, they think of forming strong bonds with one another.Merriam-Webster defines connection as“a relationship in which a person, thing, or idea is linked or associated with something else.” Children want to connect with one another because all human beings have an innate need to feel like they belong and that they are loved and valued. Oftentimes, however, children’s toys centered on connection elicit only nurturance and negate feelings of value and importance.  

Moreover, children’s toys are often gender split, with girls’ toys providing lessons innurturance and boys’ toys providing lessons in destruction. This is dangerous because power becomes equated with destruction/boys and nurturance becomes equated with connection/girls. Luckily, children give us many opportunities to provide teachable moments.  

Below are three steps you can take to provide teachable moments to your children and the children in your community:   

    1. Teach children empathy when they are engaging in play that exhibits destructive power. For example, if a child is pretending to be Spiderman through shooting webs to catch the “bad guys,” guide your child’s play through asking, “What do you want to teach the people you are catching?” By asking this simple question, you are showing your child that (s)he has influence through teaching others. This also fosters problem-solving skills and connection/understanding, which is the foundation of empathy.
    2. Teach children emotional identification and expression through the use of a Feelings Chart. A page depicting expressions of several emotions (such as angry, sad, happy, embarrassed, worried, scared, hurt) provides as easy tool for children to identify their emotional states. Create the chart together and discuss examples of ways you express various emotions. Then, throughout the day, show children the chart and ask them to point to how they are feeling. You can then provide two to three options of ways to express such emotions (such as screaming into a pillow, crying, drawing, laughing, etc.) based on the emotion they identified. Up the empathy ante by asking your children how they think you are feeling in certain situations. Try the same with characters in movies and books.
    3. Read inclusive children’s books. Children love getting lost in stories. Thus, it is important for children to recognize similarities and differences in order to cultivate connection, empathy, and influence. Have a diverse collection of books that include same-sex couples, biracial couples, as well as children of all skin tones, languages, and nationalities. This teaches recognition of similarities and acceptance of differences, laying the seeds for empathic understanding.

Gatewell Therapy Center offers individual, family, and group therapy to children, adolescents, and adults.

Exposure Therapy (Spider Version)

That’s me, holding a tarantula at a wildlife rescue center.

I wasn’t always such a spider lover. In fact, I was afraid of them as a child and did my best to avoid them as an adult.

But my current home seems to be a sanctuary for our eight-legged friends. For a long period of time, my bathroom housed three spiders. Instead of escorting them outside, as I usually do, I decided to keep them around.

Exposure therapy*, a type of behavioral therapy, is based on the premise that if you’re afraid of something – even phobic – the best way to conquer your fear is to face it head on. Scared of flying? Book frequent air travel. Afraid of talking to strangers? Set up situations in which you do just that. Wary of spiders? Shower with them daily.

As time progresses, with exposure to the feared stimuli (in my case, spiders), the fear diminishes. If it’s too overwhelming to face the fear at first, baby steps might work – setting up some gradual exposures (e.g., inching toward the spider in progressive amounts) and noticing what happens with the fear over time.

And it worked. After some time, I wasn’t eyeballing them each time I entered my bathroom or inching away from their frequent web descents. When one spider went missing, I worried for its safety.

And then a few months later, I had the opportunity to hold the spideriest of spiders, a tarantula. I wasn’t exactly at ease holding my fuzzy friend  – and I certainly wouldn’t want this one living with me –  but my close encounter with this hairy creature was made 100% possible by exposure work.

*Gatewell Therapy Center offers exposure therapy for various phobias, OCD, social anxiety disorder, eating disorders, and other related conditions. Contact us to learn more about this treatment.

Shattering the Political Blank Screen

As a therapist-in-training, I was taught to keep my cards close to my chest. Many of my mentors advocated for minimal personal disclosure, suggesting that revealing this type of information could dilute the therapeutic relationship. They instead recommended a neutral stance, a maintenance of what therapists call the “blank screen.”

But, I’m going to shatter that blank screen right now.

I voted for Hillary. And it’s important for my patients to know that I did.

Let me tell you a little bit about my clientele. . . . I see a wide range of individuals and have over the years. Many are women, some of them mothers. A number of them are men and women of color. Many, especially in Miami, where I now practice, are of Latin-American descent. Some are first-generation immigrants, having come to this country as young children or adolescents. An additional, fairly large percentage are members of the LGBTQ community. Some have married same-sex partners. A small portion of my patients have physical disabilities. Many of my patients have experienced sexual assault and trauma as children or as adults. A large percentage of my practice is comprised of individuals who have suffered from serious mental illness, disorders such as major depression, bipolar disorder, eating disorders, severe substance misuse, and other conditions that have required access to affordable and ongoing mental health treatment.

Almost all of them will be deeply impacted by the results of last night’s election. At stake are their marriages and families, their health insurance and access to treatment, their recovery, and their lives.

There is no way I can support someone on my couch but not out in the world. I can’t offer empathy and compassion devoid of my beliefs and actions outside of the room. I’ve worked for over 15 years helping people to live more authentic lives, and I’d better be sure I’m doing the same.

So, as the dust settles on this election, my patients can know that, regardless of any personal preferences I might have had about any of the candidates, I did my best to do right by them. They can know that I will continue to support them both as a therapist and as a citizen, and that our joint effort toward a brighter, safer, and more inclusive democracy gathers strength and momentum even, and especially, in the shadows.





New Year, New Insurance Plan? Gatewell’s Primer on Finding the Health Insurance That’s Right for You

It’s that time of year again – time for open enrollment in the health insurance world. Are you confused by all the terms and choices? Gatewell finds all of the options overwhelming, and we’re in the business!  So, we’ve compiled this guide to help you sort out some of the key decisions associated with choosing a plan.

Premium: This is the monthly payment that you’ll pay to the insurance company, regardless of services rendered. If your insurance is through your employer, often the premium is deducted from your paycheck. Premiums can range from nearly nothing (in a company plan, since the employer will subsidize) to thousands of dollars (in an individual/family plan). Typically, the higher your premium, the less you’ll pay for the items below.

Deductible: This is the amount you are responsible for before your insurance starts kicking in for health expenses. Some plans have no deductible (or at least no deductible for some or many services), while others can have deductibles in the thousands. If this is the case, you will have to pay that amount out-of-pocket before your insurance plan starts paying for services. Generally speaking, the lower the deductible, the better.

Copays/Coinsurance: This is the amount you are responsible for at each doctor’s visit/for each service. Copays might range from $10 to hundreds, as a percentage of the service (higher for surgeries, hospitalizations, etc.). Typically, plans that have lower copays have higher premiums.

Out-of-Pocket Maximum: This is the amount that you are responsible for in total (not including premiums) before your financial portion is complete. Once you meet your out-of-pocket max (usually a number in the thousands), your insurance will pay 100% of medically necessary services. You might still be responsible for services with out-of-network providers, and you’ll still be responsible for services that aren’t covered by your plan.

Are you someone who rarely seeks out medical care? It might make more sense for you to choose a lower premium plan with a higher deductible or higher copays/coinsurance. If, on the other hand, you have a number of specialist providers already at your service, you might be better off paying more up front (a higher premium) so that your deductible and responsibility per encounter are lower. You might also opt for a plan that has a lower out-of-pocket max if you typically spend a lot on medical expenses and want a lower cap (so that the insurance company will start covering more completely earlier on).

Are there typical medical expenses that you incur (or imagine you’ll incur this year)? You might want to do a side-by-side of plans you’re considering. For instance, if you’re prone to accidents, you might want to consider a plan that doesn’t charge a hefty ER/urgent care copay. Or, if you think that you might need residential psychiatric care, see what the different plans you are considering offer in terms of treatment at this level of care. Keep in mind, it’s likely you’ll also need an authorization from an insurance company to embark on this kind of covered treatment and that often, insurance companies will cut coverage when they see fit.

If this isn’t confusing enough, you might have options of different insurance companies to explore (via an employer) or on your own. Any individual who does not have access to insurance through the workplace can purchase insurance individually (just hop on the insurance company website and see if they have individual plans in your location). You might even qualify for a subsidy (a reduction in monthly premium), based on income, through the Affordable Care Act.

It’s also a good idea, before making an appointment with any healthcare provider, to know what expenses you will incur. Make sure you’re aware of your deductible and copay/cosinsurance going into the appointment. Find out if the provider is in-network or out-of-network on your plan (you can typically do this by performing a doc search on your insurance company website, though you’ll want to call the provider to verify since the listings can be outdated). If the provider is out-of-network and you still want to see him/her, find out what percentage of the visit will be covered. This will just be an estimate, however (and likely a low one). If the insurance company tells you that 50% of your $100 physical therapy appointment will be covered, that won’t necessarily mean that you’ll get a check from your insurance after the appointment (and paying out $100) for $50. It means that the insurance company will reimburse you 50% of the value of the service as they see it, not as it actually is. So, in this example, they might say that a physical therapy appointment is valued at $75 (what they call their “usual and customary”) and, therefore, you’d only receive $37.50 reimbursement (50% of the $75).

If you have questions regarding your insurance coverage and services at Gatewell, please contact us for additional information.