The SMART Goals process is based on defining the following for your goal or project:

  • Specific Goal
  • Metric
  • Attainability
  • Relevance
  • Time Specific

This technique is great for defining goals and setting objectives.  If you are not familiar with SMART Goals, there’s a quick tutorial at the end of this post.

(Here’s a downloadable pdf worksheet I created, based on the SMART Goals process.)

However, I keep running into a problem  with SMART Goals–I find they are great for building habits and lifestyle changes, but incomplete when applied to projects.

The best way to start a project is to list out all the steps in the project you can think of.  This accomplishes two things:

  1. The list allows you to capture all the parts of the whole in one place–creating this Gestalt will help your brain organize the project and get a sense of the time and energy involved in the project.
  2. Breaking the project down to each step makes it easier to begin–crossing just one thing off the list creates momentum.

So, I needed an easy project-based To-Do list.  I created this list (you can download here), which I call Project ACT because it has three columns:

  1. Accountability:  How will you hold yourself accountable to complete this step?  Do you need to report to someone?  Or, if you have delegated, who is accountable?  Maybe you’re using the reward system; if so, list the reward you get when you complete this step.
  2. Concrete Task:  This is where you list all the steps.  There’s plenty of room for notes and specifics.
  3. Timing:  After listing all the steps, you might rank them in terms of importance or order for completion.  Alternatively, you can list a date for when you want to complete the step, or simply check it off with the date when completed.

Hope this helps!  If you want to read more about SMART Goals, keep reading.

SMART Goals are used to create habits or lifestyle changes.  The process is based on defining:

Specific Goal
Time Specific

The first step is to take an overarching goal and identify any discrete components of this overarching goal. As an example, take the goal, “I want to live a healthy life.” My list of components for this goal include:

Eat a healthy diet
Maintain a healthy body weight
Engage in physical activity on a daily basis
Practice mindfulness meditation
Get enough sleep

If you’re just beginning to create a lifesyle change or new habit, it might be overwhelming to address each component simultaneously. If that’s the case, choose just one or two components for SMART Goals, and once those lifestyle changes become habitual, you can tackle more.

For this example, let’s choose “Eat a healthy diet.” Even this subcomponent of “I want to live a healthy life” can have dozens of applications! Do you want to eat more vegetables, prepare more food at home, avoid transfats, cut out soft drinks? This is why it’s important to break things down into specific, manageable components. Doing any one of these is great, but trying to do all of them at once may not be sustainable. So choose one or two and identify a Specific Goal. In this example, let’s say you choose “Eat more vegetables.”

As you’re deciding on your Specific Goal for your SMART Goal, you should be incorporating the other SMART Goal concepts:

Metric: How will you measure progress toward your goal? Identify specific behaviors and put a number on them. In this example, you could say, “I will eat fresh vegetables twice a day.”

Attainable: Your SMART Goal has to be attainable within a reasonable amount of time. It’s usually best to set SMART Goals that are attainable within a week or a month. For our example, eating more fresh vegetables is certainly attainable within a week or month.

Relevance: Your SMART Goal must harmonize with your values, overarching goals, and stage of life. If the goal is not currently relevant, you can designate the goal for reconsideration in the future. Also, if the goal is relevant but would be a particular challenge this month, consider postponing the goal. For our example–eating more fresh vegetables is always something to work toward, but if you will be travelling away from home a great deal over the next month, it may be hard to establish this as a new habit. It’s fine to wait a month until your routine settles down–but consider working toward another goal instead that is more relevant and harmonious.

Time Specific: One of the basic tenets of goal setting is that goals should be time-specific, i.e., there should be a point at which you want to accomplish the goal. How does this work for habits and lifestyle changes? Identify the timeframe you are working with, i.e., this week or this month. Then, identify the behaviors you expect from yourself, incorporating the specific goal and metric. For our example, the Specific Goal is to “Eat fresh vegetables,” the Metric is “twice per day” and the Time could be “twenty out of thirty days this month.”

And that’s how to create a SMART Goal for a lifestyle change or new habit!

Depression & Sleep

Depression can be debilitating and researchers continue to explore more effective methods for treating this disease.

A recently published study (Rethorst, et al.) examined the biological links between sleep and depression, and identified a treatment that is effective for “resetting” the negative feedback loop of depression and sleep disturbance.

Examining the role of sleep disturbance in depression is complicated because some people with depression over sleep, while others can’t fall asleep or stay asleep. These opposite manifestations of sleep disturbance are associated with the subtype of depression a person is struggling with.

All depression is defined by sad mood or lack of enjoyment; beyond that:
  • Melancholic Depression is characterized by difficulty falling or staying asleep (insomnia) and decreased appetite, along with an inability to feel happy even when something good happens.
  • Atypical Depression is characterized by excessive sleep (hypersomnia) and increased appetite, but an ability to temporarily experience an improvement in mood in response to something good.
Disrupted sleep is a symptom of depression and sleep is involved in a negative feedback loop with depression–as either sleep or depression worsens, the other symptom (depressed mood or sleep) worsens.
On the other hand, improving sleep improves depression.  

To summarize the complex results of the Rethorst, et al. study:

There was an association between changes in certain biomarkers (inflammatory cytokines and brain-derived neurotrophic factor) and improvement in sleep for those with hypersomnia (atypical depression), but not for those with insomnia (melancholic depression). Nonetheless, those with insomnia showed an improvement in sleep and depression as a result of the treatment.

This supports the hypothesis that the biological underpinnings are different for those with atypical vs melancholic depression.

Why is this important?

This research furthers the understanding of the relationship between sleep, inflammation, and depression, and the negative feedback loop that worsens a depressive episode.

Even more important is the treatment used in this study. This treatment was effective in resetting the negative feedback loop for both those with hypersomnia (atypical depression), and insomnia (melancholic depression), even though the biological underpinnings of these subtypes of depression are different.

What is the magic pill?


The subjects in the treatment group participated in two “doses” of aerobic exercise per week for 12 weeks. The two “doses” equalled 150 minutes of moderate intensity exercise per week.

In addition to the changes in biomarkers found in this study, exercise is known to improve functioning of the hypothalamic-pituitary axis, which improves sleep.

Dr. Trivedi, a world-renowned researcher in the field of depression, discusses the results of this study here, and talks about the use of exercise as an effective treatment for depression.

For more information about Dr. Ware’s psychological practice, click here.

Positive Neuroplasticity

A Short Lesson on Neuroplasticity:

Every time you have a thought, your brain changes.

How is this possible?
Neurons that fire together wire together.”

With each thought, a synaptic connection is formed or strengthened.

Our brain cells, called “neurons,” communicate with one another via synaptic transmission.  Neurons have microscopic space between them, called a “synapse.”  One neuron releases a chemical (neurotransmitter) into the synapse and the next neuron absorbs the neurotransmitter–this is how they talk to each other.  This process, known as “neuronal firing,” creates a “synaptic connection” between those two neurons.  When neurons communicate frequently, the synaptic connection between them strengthens, which allows communication between those neurons to become more efficient.  As a result, messages traveling the same pathway in the brain over & over become faster and more efficient.

With enough repetition, messages become automatic.

That’s why we practice things like hitting a golf ball–-with enough repetition, the brain goes on automatic pilot.  Psychologists have long known that negative thoughts follow this pattern–-the more we think about, or “ruminate,” on a negative thought, the more entrenched the negative thought becomes. Fortunately, the opposite is also true–focusing on positive thoughts and experiences strengthens the brain’s tendency to fire up the neuronal circuitry involved in happiness and well being.

So, you can shape your neuronal architecture by choosing what you focus on–this is known as “self-directed neuroplasticity.”

Research in the field of positive psychology finds that, unfortunately, human beings are hardwired to focus on the negative–to ensure survival, ward off disaster, etc. Even in less stressful times, our minds tend to focus on problems to solve, things that need to be done, or mistakes we’ve made rather than the positive moments that occur throughout the day. To some extent, this focus can help us improve and stay on top of things.  But, an unbalanced focus on problems contributes to negative emotions, and crowds out the positive experiences of the day. Changing this takes conscious effort–this is where a daily “Positivity Focus” comes into play.

Develop Positive Neuroplasticity with a Daily “Positivity Focus”:

At the end of each day, reflect back on at least one positive moment and write it down.

Click here to download a pdf with an easy format for recording your daily Positivity Focus (I also included the Daily Accounting exercise), or simply write it on a calendar or journal.  Your positive moment can be significant or something as small as hearing a favorite song. The point is to train your brain to notice, appreciate, and spend a little more time with positive things you experience throughout your day, even if they are just small things.  With dedicated practice, here’s what you will find–recollecting positive moments will become easier as time goes on (it can be surprisingly difficult when you first start out–our brains are not wired to focus on the positive!).  Then, you will begin to consciously notice positive moments during your day–almost in an “Oh, I can write this in my Positivity Focus!” kind of way.

Noticing your positive moments as they occur is when the real change begins.

As you notice a positive moment, take 30 seconds to let it soak in. Articulate the moment in your mind, take in the visual, and form a mental snapshot. Also, notice any sounds, smells, or physiological reactions you have–smiling, relaxation of tensed muscles, and so forth. What you want to do is imprint this experience in your mind, using as many sensory modalities as possible, thereby strengthening positive neural pathways in your brain. 30 seconds may not sound like a long time, but try it–you will probably be surprised at how long that feels compared to how quickly you usually move on to the next thing.

Positive neuroplasticity helps prune the connections in your brain to weed out unnecessary attention to the negative and strengthen your focus on the positive.

A brain that imprints positive emotions becomes more resilient–you bounce back quicker from negative experiences and disappointments. And, a focus on positive emotions dials down the release of stress hormones, which lessens the negative physiological effects of stress.

Note: What the Positivity Focus is Not:

* Not a positive affirmation, i.e., “I’m a good person.” There’s nothing wrong with positive affirmations, so say them if you like, but the Positivity Focus exercise focuses on something that happened to you that day.
* Not a gratitude focus–gratitude is good, but different from your Positivity Focus. You are not thinking of what you are thankful for as much as you’re recollecting a positive experience. Example–gratitude is “I’m thankful for the nutritious food I had for breakfast.” A Positivity Focus is “It was so nice to have a leisurely breakfast this morning. I loved smelling the freshly brewed coffee, hearing the birds sing, and how the early morning sunlight dappled through the trees.” Note–you probably won’t write out the complete experience in your Planner, simply for time’s sake, which is fine.  But, be sure to recollect the experience in your mind as vividly as possible.  Then you might simply write–“Leisurely breakfast–coffee, birds, sunlight.”
* Not mindfulness–this one is complicated, because creating a Positivity Focus begets mindfulness. However, for the purpose of the Positivity Focus exercise, the point is not (just) mindfulness. The Positivity Focus exercise begins with simply recollecting a positive experience and recording it.  This will likely develop mindfulness of daily positive experiences, which further contributes to positive neuroplasticity.

If you want to read further about positive neuroplasticity, I recommend Rick Hanson’s book, “Hardwiring Happiness.”

I hope you’ll give the daily Positivity Focus a try!

You don’t have to write out a long description in your Positivity Focus log.

If you like to journal, you may enjoy writing about the moment; if not, feel free to be brief.  The most important component of this exercise is to cue up the neural pathways associated with the positive experience.  Recall and re-experience that moment as vividly as possible, then you can shorthand your description when you write it down.

If you understand the core concepts of goal attainment, you can “work smarter, not harder.”  Here’s how to use Willpower, Habit, and Decision Making to reach your goals:

Willpower, Habit, & Decision Making

1.  Remember that goals need to be concrete.

I can’t emphasize this one enough!  “I want to be healthier” is a value rather than a goal (in terms of behavioral change).  “I want to lose 10 lbs” is a goal that needs to be broken down into concrete behavioral objectives that will help you reach your goal.

So define your goal, which should be concrete and measurable.  Then identify one specific behavior you are going to add (or subtract) for this week, and define exactly what that behavior looks like.

For example, if your goal is to lose 10 lbs, then specific behavioral objectives for this week might be:

I will eat dessert only on the weekend.

I won’t snack while I’m at work.

I will take 10 minutes in the middle of the day to exercise (in addition to my other activities).

You should reevaluate your behavioral objectives on a weekly basis.  Decide which behavioral objectives need to be modified, and if any should become habits.  See #5 below for more regarding behavioral objectives vs habits–but remember these distinctions:
  • A “behavioral objective” is a specific behavior you’re committing to for a week.  After the week is up, you can fine-tune or discard these.  Example:  “This week, I will exercise three times.”  Behavioral objectives are stepping stones toward reaching your goals.  
  • A “habit” is a behavior you build into the routine of your daily life.  It takes consistency and willpower to build a habit, but once the behavior becomes a habit, you do it with minimal thought or effort.  “I do 50 jumping jacks every morning right before I shower.”  Your habits should align with your goals and values.  
  • A “goal” is something specific you want to achieve, and it is concrete and measurable–“I want to run a 5K,” or “I want to lose 10 lbs.”
  • A “value” is a standard for living, such as “I want to live a healthy life.”  It is a concept, and it is not measurable.
Goals are achieved by setting specific behavioral objectives and creating habits.

2.  It takes willpower to reach a goal or establish a habit, but it’s easy to use up all your willpower on any given day.

In Dr. McGonigal’s book, The Willpower Instinct, she explains that willpower is like a muscle–it can become fatigued on any given day, but also builds stamina when exercised on a regular basis.

The trick is using your willpower strategically and for the right things!  Your willpower is strongest early in the day because:

3.  Decision making depletes willpower.

Have you ever experienced “decision fatigue,” where you feel like you just can’t make one more decision that day?

Hint–this is what’s happening when couples get into the “What do you want for dinner?”  “I don’t know, whatever you want” spiral.  “Decision making” and “willpower” are intertwined, so when you’ve been making decisions all day, you run out of steam–both for decision making and exerting willpower.  The end of the day is when you’re most likely to take the path of least resistance.

4.  So pace your “decision making” demands by engaging in “pre-decision making,” aka “proactive behavior.”

First of all, don’t use up your decision making/willpower energy on things that don’t really matter to you.

Psychological experiments show that even simple decisions tax your willpower reserves.   Steve Jobs famously wore his “uniform” of jeans, black mock neck sweater, and tennis shoes on a daily basis–he felt eliminating this daily decision freed up his mental energy.  Even U.S. President Barak Obama subscribes to this notion–as quoted in Vanity Fair:

“You’ll see I wear only gray or blue suits,” he said. “I’m trying to pare down decisions. I don’t want to make decisions about what I’m eating or wearing. Because I have too many other decisions to make.” He mentioned research that shows the simple act of making decisions degrades one’s ability to make further decisions. It’s why shopping is so exhausting. “You need to focus your decision-making energy. You need to routinize yourself. You can’t be going through the day distracted by trivia.”

Secondly, if you’re trying to create a new habit, pare down the decision making related to that habit.

There are a few ways to do this:

  • Avoid mental negotiation.  

Example of mental negotiation:  “I promised myself I would exercise Monday morning, but I really want to get to work early today–maybe it would be better to exercise after work instead.”  Don’t do this!  Mental negotiation uses up your decision making & willpower energy!  Instead–“I committed to working out on Monday morning, period.”

When initially setting goals and creating habits, you may find that some of your behavioral objectives just don’t harmonize with your life (like working out on Monday mornings!) and in that case it’s okay to reevaluate–but do it systematically.  See #5 below.

  • Make decisions ahead of time so it will be easier to stick to your behavioral objectives.

If your behavioral objective is to work out Monday morning, take a few minutes on Sunday to set out your exercise clothes and decide what your workout will be.  Proactively taking care of a few seemingly simple “decisions” will contribute greatly to your chances of following through when faced with a task you’re not enthusiastic about.

5.  Established “habits” don’t require decision making, so habits don’t require much willpower.  Therefore, establish habits that will help you reach your goals!

What’s the best way to establish a new habit?  Start with setting weekly behavioral objectives–by committing for just a week, you can reevaluate and modify without “failing.”

Behavioral objectives strengthen your willpower because you persevere through the week, knowing it’s only a week until you reevaluate.  Quitting just because it’s tough undermines your willpower.  So “quitting” is bad, but “reevaluating” at defined intervals is smart & recommended!

As you accomplish weekly behavioral objectives, identify which ones you want to become habits.

Some behavioral objectives will have more payoff than others, or fit more harmoniously into your lifestyle.  These are good choices for habits.

To repeat–habits become a part of your daily life, things you do no matter what.  No mental negotiation, no weekly reevaluation.  The payoff is that once the habit is ingrained, it takes minimal willpower because there’s no decision making!

An example of establishing a habit is brushing your teeth.  When a client says, “It just doesn’t come naturally to me to exercise/be on time/keep my home organized, but I wish I could!”  I counter by explaining that none of us are born with a natural propensity to brush our teeth, either–but we all learn to do it, and we do it every day–even twice a day.  While there may be occasions when you think “I’m just too tired to brush my teeth,” chances are you do it anyway.  And if you do skip, you get back on track pretty soon.  That’s because you were taught this habit long ago and you do it without thinking–you don’t make a daily decision about whether you should brush your teeth, you just do it.

Now you know how to establish habits that align with your goals by removing the decision making and conserving your willpower!

Want to share the goals you’re working toward?

Microresolutions for 2014Why not begin 2014 with a microresolution?  A “microresolution” is exactly what it sounds like–a small, concrete goal that you can enact with minimal disruption to your daily life.

But don’t be surprised if the microresolution leads to bigger changes!

Here are 5 Steps for Setting a Microresolution:

1.  Decide which area of your life you want to focus on.

For example, do you want to focus on relationships, health, or career?  Let’s say you decide you want to focus on health.

2.  Narrow your focus.

Your microresolution should be specific and obtainable.  For example, “eat healthy” falls under the “health” category–but that is still too broad.  Narrow it down and keep it manageable–for example, “I will eat breakfast everyday.”

3.  Define your “aspirational” and “minimum acceptable.”

It’s good to aim high, but life gets in the way.  So, for the “eating breakfast” goal–“My aspiration is to prepare a healthy (albeit quick!) breakfast–oats, eggs, or a fruit smoothie (notice that I’m being concrete & specific!).  My minimum acceptable is to have something in my stomach by 9:00 am, even if it’s just a glass of milk or piece of fruit.”

 4.  Once you’ve decided on your microresolution, create some accountability.

Low tech–mark your progress on a calendar or share with a friend.  Or on your smartphone–use an app such as Streaks or HabitMaster.  Research shows that new behaviors become automatic for most people at 66 days–this is the point at which the behavior is habitual as opposed to requiring effort.  Missing a day here and there doesn’t mean you have to start over, but consistency is key to building a new habit.

Another aspect of creating accountability requires what I call a “mental health check-in.”

Even if you’re successful at making a behavior habitual, life gets in the way.  Whether it’s because you’re traveling, become ill, have a family emergency, or any other number of things, something will happen to knock you off your game.  And we all seem hardwired to “revert to baseline,” or fall back on our old behaviors.  Even if you’re able to articulate how good it felt when you were successfully implementing your microresolution, chances are you will fall off your game when life gets hectic.  So, set up reminders for yourself at 2 or 3 month intervals to reassess your progress.  At the time of your mental health check-in, fine-tune your microresolution if necessary, and recommit.  The “minimum acceptable” can be very helpful in getting you back on track.

5.  Reward yourself!

Unlike longer term goals that require significant effort before payoff, a microresolution is self-reinforcing almost immediately!  Using our example of “eating breakfast”–you feel better when you eat breakfast and it feels good to accomplish a goal each day!  And the microresolution is aligned with your most important life values/goals (take care of your health), so you’re also progressing each day toward the things that are most important to you.

If that’s not enough reinforcement for you, consider rewarding yourself more concretely when you do your “mental health check-in.”  Decide on a treat for yourself that you will allow only when you’ve accomplished a level of consistency that is acceptable to you.

For more on habit formation, check out The Power of Habit, which I blogged about here, or Small Move, Big Change, available January 16.

I recently read an inspiring post by Carolyn Hax–“Defining One’s Best Self.”   She hits all the relevant questions–please take a moment to read it.

For my New Year’s Microresolution, I’ve decided to commit myself to Daily Accounting for a year!  (Read about Daily Accounting here.)

I often recommend this technique to clients who tell me, “I know what I need to do, I just can’t seem to do it.”  The Daily Accounting process really helps push through the emotional barriers that keep people blocked, but it takes a little time.  And there’s a tendency to make it too complicated–keep it simple and you’ll be more likely to stick with it and see the benefits.

Want to join me in committing to a Daily Accounting in 2014?

People are often surprised to learn that the holidays are my busiest time of the year, but think about it–the holidays are stressful!

Coping with Holiday Stress

During the holidays, people reminisce about happy times and want to recreate that emotion.

But this is challenging if you’re going through difficulties, have lost a loved one, or you’re away from family. Add in the pressure of travel, coordinating schedules, preparing elaborate meals, and buying perfect gifts. . .  Well, you get the point–people can get edgy, anxious, or even clinically depressed.

Here are 5 tips to keep you balanced during the holiday season!  Let’s start with the basics:

1.  Maintain Healthy Habits, Especially Getting Enough Sleep

During the holidays, people want to get in as much celebration & togetherness as they can!  But this is often at the expense of sleep, downtime, healthy eating, and exercise.  A few days of this, and most people get sluggish, cranky, and sensitive–a bad recipe for all that togetherness!

Decide ahead of time what your “non-negotiables” are.  For example, everyone can fit in 5 minutes of exercise or stretching a day.  Or 5 minutes of mindful meditation.  Decide on at least one core healthy habit and commit to it for the month–no matter what.  And balance out the indulgences–if you sacrifice sleep one night, take a nap or turn in early the next night.  If you enjoy too much food or drink one day, go on the light side the next.

And please, try to get some sunlight!  The shorter days and spending more time indoors can feel cozy, but lack of sunlight can contribute to depression and disturb your sleep/wake cycle.

2.  Know Whether You’re an Introvert or Extravert, and Plan Your Time Accordingly

If you’re an introvert, you’re going to need time to yourself.  This is especially true if you’re a houseguest or hosting others in your home.  Let others know ahead of time that you’ve got a few things you’re going to do on your own–this helps to avoid hurt feelings (but keep in mind #4 below!).  To recharge your introvert batteries, go for a walk, go to a bookstore or diner, or just curl up in your room to read a book or flip through a magazine.  It really is okay to have a little down time!  For more information about introverts, check out Susan Cain’s book, Quiet.

If you’re an extravert, you may feel let down if you find yourself alone at times during the holidays, so you may want a heavier schedule of outings and get-togethers.  If you anticipate stretches of uncommitted time, plan ahead and volunteer, offer to babysit a friend’s children, get out somewhere to people-watch, and Skype with your out of town family and friends!

3.  It’s Okay to Say “No”

Another version of this is, “Don’t over-schedule!”  You don’t have to accept every invitation that comes your way.  Feeling rushed and behind because you’re over-committed is not the way to enjoy the the season!  And it’s okay to postpone get-togethers until January, when everyone feels less pressed for time.  Feel guilty for saying no?  Read #4 below!

4.  Remember That You Are Not Responsible for Other People’s Feelings

Another version of this is, “Keep your side of the street clean.”  As an adult, you should have a code of conduct for yourself–what behaviors you deem acceptable or not.  If you abide by your personal code of conduct and someone’s feelings are hurt, that’s unfortunate, but it’s not really your problem to solve.  This is not a free pass to be callous, but someone else’s happiness is not more important than your own.  Bonus:  Adopting this attitude also provides immunity to passive aggressive efforts of others.

5.  Don’t “Yardstick”

To quote Theodore Roosevelt:  “Comparison is the thief of joy.”  So true.  “Yardsticking” is comparing yourself to others, usually in a way that makes you feel inferior.  See more on my post here.  Another way of looking at this–“Don’t compare your insides to someone else’s outsides.”

Take good care of yourself this holiday season!

Mental Health and the ACAWhat does the Patient Protection & Affordable Care Act (ACA) mean for mental health services?

As a consumer, there are several things you need to know about “minimum essential benefits,” mental health parity, deductibles, and preexisting conditions.

The catchphrase “Minimum Essential Benefits” refers to the ACA mandate that, moving forward, health insurance policies cover basic health care services that were previously optional.  The ACA is clear that  mental health care, including substance abuse treatment, is a minimum essential benefit.  So what are the implications of this provision?

  • As of mid-November, 2013, it remains unclear whether this mandate will be delayed for a year or more.  Why?  Many individual and small business health insurance policies are being cancelled because they are “catastrophic,” i.e., bare minimum, and do not meet the “minimum essential benefits” criteria.  However, problems remain with signing up for coverage on, so millions of people are left in the lurch–they are losing their current health insurance policy, but are having trouble signing up for insurance on the healthcare exchanges.  To try to address this problem, President Obama has asked health insurance companies to extend their catastrophic policies so no one loses coverage.  However, many health insurance companies say they can’t make this change so late in the game.  Additionally, some states have enacted laws that won’t allow the continuance of catastrophic policies.  So, right now, no one really knows if catastrophic policies will become a thing of the past.
  • If you have a health insurance policy through your employer, and your employer’s policy is “grandfathered,” i.e., no changes to the policy have been enacted since the 2010 signing of the ACA, “You may not get some rights and protections that other plans offer,” according to’s post on grandfathered plans.  Are minimum essential benefits such as mental health care one of the “rights and protections” that may not be available?  Perhaps.  I searched exhaustively for specific information about grandfathered plans and mental health care, and couldn’t find a direct answer.  So, my guess is that if the issue is not specifically mandated, then insurance companies and employers may not fully cover mental health benefits in grandfathered plans, in the interest of cost containment.
  • If your employer is “self insured,” then your employer can opt out of certain “minimum essential benefits” such as mental health care.  Here’s the reference on

“Mental Health Parity” was originally enacted in 1998 and was intended to ensure mental health services were covered by insurance companies similarly to medical issues.  There were many exceptions & exclusions to the law, and it was not diligently enforced.  The second round of “Mental Health Parity” became law in 2008, but once again, exceptions and work-arounds rendered it ineffective.

In November, 2013, Health & Human Services Secretary Kathleen Sebelius announced new regulations that once again seek to provide coverage for mental health services at the same level as coverage for medical issues.

  • Theoretically, this should eliminate separate deductibles, out of pocket limits, and  limitations on coverage for mental health services.  The specifics of the mental health regulations are spelled out here–206 pages! However, it remains to be seen whether there are loopholes or whether the regulations will be evenly enforced.  A provision of the ACA that limited annual out of pocket limits has already allowed exceptions through 2014 for policies that use “more than one benefits administrator,” which often applies to pharmacy and mental health benefits.  Mental health benefits should be excluded from these exceptions on out of pocket limits, but we’ll have to wait and see how the regulations are enforced. 
  • Exclusions to mental health parity (verbatim from include:  
    • Plans offered by small employers that are self-insured (these are plans that don’t buy insurance from an insurance company, but pay for employees’ health care costs themselves; they may use a health insurance company to manage claims and payments)
    • Plans offered by employers that can show the federal government that the parity requirements have caused such a significant increase in plan costs that they qualify for a one-year exemption
    • Plans offered by state and local government employers that are self-insured and choose not to apply the parity requirements, as long as they properly notify the federal government
    • Plans that are grandfathered (generally those that have not changed their plan terms since March 2010)
    • Retiree-only plans
  • If catastrophic policies remain in effect (see above), then mental health benefits are unlikely to be covered at all in these policies.

To underscore the uncertainty regarding mental health parity, I quote  “Do job based plans include mental health parity protections?  Some of them do.”  

A key provision of Obamacare (ACA) is that individuals with preexisting conditions, physical or mental, cannot be denied the opportunity to purchase health insurance.  Further, those with preexisting conditions cannot be required to pay higher premiums and policies cannot be cancelled.

  • This is good news for individuals who previously sought mental health care and were subsequently denied the opportunity to purchase health insurance because of their “preexisting condition.”  You can no longer be denied the opportunity to purchase health insurance!  And your marketplace health insurance policies can’t raise premiums or cancel policies if you decide to use your mental health benefits or become seriously ill, which was a risk with individual policies in the past.

One final relevant point about Obamacare and mental health coverage:  To quote  “Can I keep my current mental health provider?  Possibly.”  

  • If you’ve ever invested time, money, and energy into mental health care, then you know that “providers” are not interchangeable!  The therapist or psychologist you’ve been working with knows you, your history, challenges, and strengths.  Starting over is not a small thing.  As insurance companies are managing costs, they are “containing” their networks, i.e., fewer providers are included in-network.  This does not mean that you can’t see a therapist or psychologist that is “out-of-network,” but you may pay more out of pocket than with in-network providers.  And in-network providers often agree to accept lower reimbursement, which may dilute the quality of care.

In summary, Obamacare is intended to make mental health care affordable and accessible to every American citizen.  However, such an ambitious goal is going to have bumps along the way and soundbites don’t accurately describe the reality.  If you have comments, questions, or additional insights, please share!

Retrain your brain

The Nobel Prize winners in Medicine were announced this week, and I was thrilled to hear that one of the awardees is neuroscientist Dr. Thomas Sudhof!  While at UTSW Medical Center (my doctoral alma mater!) Dr. Sudhof discovered synaptic transmission–how brain cells communicate via chemicals.

During my postdoctoral training in neuropsychology, one of the first things I learned is:

Neurons that fire together wire together.

To oversimplify:  Our brain cells communicate with one another via synaptic transmission–one brain cell releases a chemical (neurotransmitter) that the next brain cell absorbs.  This communication process is known as “neuronal firing.”  When brain cells communicate frequently, the connection between them strengthens.  Messages that travel the same pathway in the brain over & over begin to transmit faster & faster.  With enough repetition, they become automatic.  That’s why we practice things like hitting a golf ball–with enough practice, we can go on automatic pilot.

Psychologists have long known that negative thought processes follow this same pattern–the more we think about, or “ruminate,” on a negative thought, the more entrenched the thought becomes.  Negative and traumatic thoughts also tend to “loop”–they play themselves over and over until you do something consciously to stop them.

The more these negative thoughts loop, the stronger the neural pathways become, and the more difficult it becomes to stop them!  This is why thoughts that cause depression, anxiety, panic, obsessions, and compulsions can become so difficult to combat.  And along the way, these thoughts stir up emotional as well as physiological reactions.

Psychotherapy, regardless of the orientation, attempts to stop this process.

For example, psychodynamic therapy “processes” the thoughts, or attempts to digest the thoughts in a manner such that such the useful parts are kept and the harmful parts are discarded.  Cognitive behavioral and rational emotive therapies attempt to interrupt this loop with techniques such as cognitive restructuring and thought stopping.

As we advance our understanding of neurobiology, we better understand the physiological underpinnings of negative thoughts, why they are so hard to get rid of, and why various therapies work–they effectively change the brain.  A fairly new form of therapy (researched for 25 years now) is a type “reprocessing” therapy called EMDR.

EMDR involves bihemispheric processing of disturbing thoughts–in other words, EMDR stimulates both left brain & right brain processing of thoughts, memories, and behaviors that cause distress.  I’ve studied EMDR since its inception, and scientific studies consistently show that this therapy is effective, and in certain situations, can provide quicker symptom relief than other forms of therapy.

With modern technology (SPECT scans & fMRI’s), along with advanced understanding of neurotransmission, we’re able to see the changes in the brain brought about by EMDR and other types of therapy–it really works!

The speed of symptom relief with EMDR does not negate the usefulness of other types of psychotherapy–traditional therapies build coping skills, enhance self-understanding, and can identify and repair any “missing parts” of personality organization such as the ability to connect with others.  What EMDR provides is more immediate symptom relief and a mental release from negative “loops” in the brain.

In light of all the solid research underscoring the importance of neurobiology’s role in psychotherapy, I owe it to my clients to formally train in EMDR.  Later this month, I’ll travel to Chicago to begin my training.

Congrats to Dr. Sudhof and all the other Nobel Prize winners!

An aside–the picture with this post is one I took of a redbud tree in winter–notice how the branches of the tree mimic the the shape of nerve cells in the brain.  If you find this repetition of pattern in nature as fascinating as I do, you may want to learn more about fractal geometry!  Here’s a very easy read on the subject–Introducing Fractals:  A Graphic Guide.

Find your flowIn a follow-up to my post Finding Flow, here’s a sampling of activities that might help you find your flow:

  • Physical activities such as sports, yoga, dance, and martial arts
  • Outdoor challenges such as hiking
  • Music–writing, playing, mixing
  • Art–painting, sculpture, mixed media, pottery
  • Photography
  • Woodworking
  • Do-It-Yourself projects, such as home improvement
  • Working with animals
  • Gardening
  • Cooking and baking
  • Software development/coding
  • Scrapbooking
  • Writing
  • Needlework–sewing, knitting, cross stitch
  • Horseback riding
  • What you do for work (hopefully!)

Remember that “flow” activities are not interchangeable with “leisure” activities.  For example, visiting with a friend is a healthy leisure activity, but does not induce flow.  That’s because a flow activity:

  • Is useful and challenging, which makes it intrinsically rewarding
  • Helps you progress toward a goal
  • Provides feedback to help gauge the effectiveness of your efforts

And flow activities require some sort of action!  Passive leisure activities won’t help you find your flow.

We all need time to zone out but, just like too much sugar in your diet is bad for you, too much passive leisure time isn’t optimal!  In fact, some passive leisure activities produce the opposite of “flow”–similar to a state of mild depression!  Watching television is one of these passive leisure activities–there can be a lift in mood if it’s a favorite show and you watch in moderation.  But if you watch mindlessly, your brain falls into a trance-like (alpha wave) state, only without the benefits of alpha wave during sleep or meditation–only negative effects, similar to depression.  So keep passive leisure activities to a minimum.  :)

Please share your suggestions for flow activities!

Flow & Happiness

What is “flow” and why is it important for happiness?

First, let me explain what “flow” is.  “Flow” involves both an activity and a state of mind.

When you’re in a “flow state of mind”:

  • You lose track of time
  • You’re totally engrossed in what you’re doing
  • You’re not consciously thinking about yourself–in other words, you’re totally un-self conscious
  • You’re working toward a goal

If this sounds a lot like mindfulness, you’re right!  The key difference is a “flow activity” and working toward a goal.

A “flow activity”:

  • Is useful and challenging, which makes it intrinsically rewarding
  • Helps you progress toward a goal
  • Provides feedback to help gauge the effectiveness of your efforts

(Examples of flow activities in the next post–Flow Activities!)

According to Mihaly Csikszentmihalyi, the author of Flow:  The Psychology of Optimal Experience, a flow experience involves “deep concentration,  an optimal balance of skill & challenge, and a sense of control and satisfaction.”  You can watch Dr. Csikszentmihalyi’s TED Talk here:  Flow:  The Secret of Happiness.

The key to flow is finding the optimal balance of skill set and challenge–you shouldn’t be overly frustrated, but the challenge shouldn’t be too easy, either.

A flow activity involves the development of a skill set, such that the challenge of the activity evolves over time as your skill set improves.  In this way, flow activities lead to growth and discovery.

So why is flow an important component of happiness?

Dr. Csikszentmihalyi’s original research involved studying happiness using the “Experience Sampling Method,” or ESM.  Using ESM, Dr. Csikszentmihalyi found that people are happiest when they are fully absorbed in the activity at hand.  Further, happiness is enhanced when the activity is optimally challenging.

This research was revolutionary in that it was the first time scientists asked people throughout the day, “How happy are you right now and what are you doing?”

Using ESM, the researchers were able to correlate happiness with the activity at hand, rather than simply asking, “What makes you happy?”  As you know from Dr. Gilbert’s research (read my post Finding Happiness), human beings are poor predictors of what truly makes us happy.  It turns out the activity was not as important as feeling fully immersed and optimally challenged.

By finding your flow activities and regularly engaging in a flow state of mind, you’re building happiness into your everyday life.

Flow is more important for overall happiness than the things we often think will make us happy, such as a vacation, nicer home, new car, winning the lottery, etc.

Seven Steps for Finding Flow:

  1. Set goals.  Setting goals recognizes the challenges involved in reaching the goal.  
  2. Understand the challenges involved.  Understanding the challenges suggests the skill set required to reach your goal.
  3. Develop your skill set.  Part of developing your skill set is monitoring feedback.
  4. Monitor feedback and adjust your efforts and goals as indicated.  As your skill set increases, you should increase the challenge at hand to remain in a state of flow.  Accordingly, your overall goal is fluid and can be redefined over time.
  5. Become immersed in the activity–focus and concentrate, ignoring distractions.  Focus is a skill set in itself and you may have to work on this.  It’s important to stay consciously focused in the moment, on the task at hand, to enjoy a state of flow.
  6. Engage in your flow activity on a regular basis.  This is necessary to build your skill set and attain meaningful progress toward your goal.  Your sense of accomplishment as you progress toward your goal is an important component of flow.
  7. As you progress toward your goal, think about the meaning and usefulness of the flow activity.  How does the flow activity harmonize with other goals or values in your life?  An important aspect of flow is that the process is just as important, or even more important, than the final product, in terms of happiness.  Nonetheless, it’s important that there’s meaning in what you’re doing.  For example, if your goal is to become a scratch golfer, you may harmonize this goal with your value of self discipline and hard work.  Or, if your goal is to learn to knit, this may harmonize with your goal of giving handmade gifts to others.

Flow activities may include music, a hobby, movement (sport or fitness), writing, study, art, what you do for work, etc.  For more hands-on suggestions, check out Dr. C’s second book, Finding Flow:  The Psychology of Engagement with Everyday Life.

By identifying your “flow activities” and cultivating a “flow state of mind,” you’re not only building happiness but emotional resilience.  When times are good, flow enhances your sense of satisfaction and well being.  When times are tough, flow activities provide a sense of purpose and productivity, even though you’re struggling emotionally.  So get started today!

What goals and skill sets do you want to cultivate?


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