Procrastination

By Jerry H. Gelbart, M.D.

“Tomorrow Never Comes” – My 8th grade math teacher

I won’t say his name. He put the fear of G-d in me. If homework wasn’t done on time, and especially if you made up an excuse, he would physically put you up against the wall, or worse, tease and shame you in front of the class. My homework was on time.

Although his tactics were drastic by today’s standards, he put an end to my pattern of procrastinating. Millions of other people are not so “fortunate,” and they continue to be handicapped with this solvable problem. 

To determine whether procrastination is a problem for you, answer the following questions:

– Do you put off until later what you can do now?

– Are you intentionally managing your time?

– Does “putting off” cause you anxiety that the task may not get completed adequately?

– Has “putting off” resulted in negative consequences for you or others?

– Do you feel like you need the anxiety produced by “putting off” to successfully complete the task?

If you intentionally put off something important, knowing it will get done, you later do it, there’s no anxiety about it, that’s not a problem. If you intentionally manage your time you probably don’t have procrastination issues. 

Whereas some therapists may tell you that procrastination, as well as the associated anxiety, are part of a work style, I disagree. Procrastination and anxiety are not necessary in order to be productive, and these patterns cause suffering for the bearer in several respects. First and foremost are the anxiety and stress, which have negative effects mentally and physically. Our immune, cardiovascular, musculo-skeletal, gastrointestinal, and other body systems react negatively to anxiety and stress, both in the short-term and long. Mentally, it can cause trouble sleeping, thinking clearly, panic attacks, and fatigue. Please see my short video called “Body States” for more information on the effects of stress on the body.

Procrastination also causes the bearer poor self-esteem, low self-confidence, and the belief that he/she is defective. This leads to shame, contributes to the avoidance of tasks, and prevents functioning at full capacity. Let’s listen in to the “voice in the head” of a procrastinator:

“I should do _________.  I can do it later. I have time.” (Finds something else to do, i.e. surf the net, talk on the phone, some other project).

Two weeks later:
“I should start on ________, but I still have plenty of time.”

One week later:
“I should __________. But it’s so overwhelming, where do I start?”

Next day:
“What if I don’t get __________ done on time? What if I do a lousy job?”

Next day:
“Geez, I’m gonna have to pull an all-nighter to get this done on time. Why do I always let this happen?  What’s wrong with me?”

Sound familiar? I know this causes anguish. You do have a choice. I have helped many people break these patterns. The result is feeling empowered, confident, and rewarded. Admitting you have a procrastination problem is the classic “First Step.” From there it gets easier. Research shows that there are phases we go through in order to change behavior:

Phase 1. Pre-contemplation: Procrastination is my work style and it works for me because I still get done what I need to.

Phase 2. Contemplation: Procrastination might be a problem for me because it causes me to feel anxiety and shame, which is bad for my physical and psychological health – but I don’t know how to NOT procrastinate!

Phase 3. Preparation: I have decided that I should both stop procrastinating and that I have the capacity to stop procrastinating. I am putting together a plan of action that works with my personality, finances, and lifestyle that will be conducive to not procrastinating. I will seek out and accept help from others.

Phase 4. Action: Putting into action the plan for not procrastinating.

Phase 5. Maintenance: I have learned to not procrastinate, and I feel less anxiety and shame as a result!

Relapse: Sometimes I slip back into procrastination, but when this happens I know how to bring myself out of it with specific skills and tools. I don’t let the shame of relapse prevent me from getting back into action and then maintenance.

If you are ready to cross into new territory now, read on!

What causes procrastination? There are 3 key forces involved: anxiety, reward, and time management. You can address each one.

Procrastination is a symptom; anxiety is the problem. The anxiety comes from how you are judging yourself, and your fears about how others will judge you. Anxiety, like fear, causes avoidance. Avoidance is putting off, i.e. procrastinating. The procrastinating reinforces the negative judgments, which fuel the procrastinating – resulting in a very frustrating and painful cycle.

There are networks in the brain that are constantly judging: good/bad, friend/foe, carrot/stick. These networks function to keep you safe, from people who might harm you, and also from being rejected by your tribe. With anxiety, these networks are hyperactive. They are overly focused on judging yourself, worrying about how others would judge you, and how to avoid being shamed. You can’t shut it off.

Most of this judging is distorted ‘black or white’ thinking. I call it “Toxic Judging.” Toxic Judging gets programmed from our childhood environment, and is also influenced by our genetics. As a priority for survival, avoiding sticks is more powerful than working toward carrots. Avoiding embarrassment becomes more powerful than the potential rewards of completion. To stop procrastinating you have to consciously shift that balance. This means decreasing fear (anxiety) in your mind and increasing reward. Lets start with the way you talk to yourself.

Step back from the voice in your head. Is it supportive and encouraging? Or does it put you down? If you procrastinate, that voice is probably very negative and cynical. It is very black or white, all or nothing. It speaks in terms of being strong or weak, success or failure, normal or defective. The real world is not so black or white. This is the Toxic Judging. Even after you get something done does it focus on what you didn’t do? This language creates fear and discouragement. It is not the language of growth and change. You can free yourself from this by paying attention to what you say to yourself in your mind, stepping back from it, and reframing it the way you would talk to a friend.  

With some work you can change that voice in your head. Practicing Mindfulness trains you to be aware of your distorted thoughts in the moment, and to not beat yourself for having them. Mindfulness puts you in a frame of mind that is Curious, Open, Accepting, and Loving (“COAL”). Cognitive Behavioral Therapy (CBT) teaches you how to challenge and neutralize the distortions (See practice worksheet). There are also medications that can be used to reduce the strength of the networks that fuel the toxic judging. 

To settle down your mind, in addition to challenging your distortions, you have to tell yourself that you are safe. There are no fires that have to be put out immediately. There is no lion in the room about to eat you. Take some time to notice your worries and fears, your “what if’s” and catastrophizing about the future. Applying your mindfulness will take you out of the future into the present.

As you practice these techniques you will catastrophize and beat yourself up less and less. Add some coping skills to lower anxiety levels, such as breathing exercises or guided imagery, which are easy to learn. You have to practice these techniques when you are calm; they can’t be learned when you are anxious, frustrated, or emotionally dysregulated.

We are coming from a past of huge anxiety and minimal reward. We begin to shift the balance, to low anxiety and huge reward. Most procrastinators try to push forward through the intense anxiety. This is unnecessary torture. This is working from fear. Instead, when you want to tackle your work, plan 10 – 30 minutes to first bring down the anxiety levels and get grounded, then start the task.

No one likes this next part: lower your expectations about how much work will get done at first. Plan 15 minutes to 1 hour, with a big reward for after. In the beginning, the work expectations have to be super low, and the reward super high. You have been steaming along with these patterns for years. Just like a large ship moving in the ocean, if you want to turn it around, extraordinary forces are required. 

If I am trying to get myself to exercise, I plan for myself a big reward (i.e. 15 minutes in sauna and Jacuzzi) for small requirement. At first it might be 5 minutes on the Elliptical machine. Then 8 minutes, then 10, etc. Over time the requirement to get my reward goes up. It comes easier and easier as I establish the routines. When I think about going to exercise I focus on the immediate rewards I’ll get, plus the long term health rewards.

You want to develop rewards that excite you- that you will want to do- and ask a (very) small work price. When you approach your work keep your focus on the reward that’s coming after, and how little you have to do to get it. This way you are doing your work via motivation networks rather than battling the fear networks. Your dopamine levels will be higher while you work and when you get the reward your dopamine levels spike even higher (You got the carrot!). This breaks the pattern.

Choosing rewards can be tricky. Reward means it has to be earned. Self-care routines, such as healthy meals, sleep, unwinding time, relationship time, and spirituality, should not be used as rewards. Rewards can be cheap or expensive. Examples of cheap rewards:

  • Watching TV/movie
  • Playing game(s)
  • Extra time with musical instrument
  • Sitting by a fire
  • Getting a massage from partner or friend

Examples of more moderately priced rewards:

  • Going out for a meal, or round of golf
  • Sauna/Jacuzzi
  • Buy music or a book
  • Pay for a massage
  • Token system to save up for something (ie. clothing, trip)

To summarize the steps:

1) Plan small task. What and when. Plan your reward.

2) Before approaching task, take time for calming/grounding (reducing sticks). Try the Cognitive Restructuring worksheet.

3) Focus on the big reward you will be giving yourself, how good it will feel, and how little you have to do to get it.

4) Do the small task. If anxiety levels increase go back to step 2.

5) Give yourself a big reward (eat the carrot)! Feel good about it.

Music can help with each step. Create different playlists. For example, one playlist would be for the relaxation step. Another would be music that motivates you and helps you get focused. Another playlist could be songs that you play for “reward” when you’ve accomplished something.

This all comes together through intentional time management.  In order to schedule and follow through with your grounding time, work time, and reward time you have to be in the present and act with intention. Often a coach or therapist can help you get organized. The judging and catastrophizing will keep throwing you off course. Don’t be discouraged!

Expect frustration and difficulties as you try to change your approach. Trust in our human ability to adapt. You don’t need to be shamed in front of the class to wake up. The human brain (including yours!) can be gradually re-wired by working with these techniques, and you can be more grounded, self-confident, and productive.


Thanks to Brittany Gelbart for her great suggestions!


 

The Reverse-Stress Mentality

REVERSE-STRESS MENTALITY

What is Stress Mentality? In S.M. the belief is:

“I can’t take care of myself until I get everything done.”

We have all experienced the short-term stimulation of an upcoming deadline, exam, or speaking engagement, and when necessary temporarily set aside our basic needs to accomplish a higher goal. Stress mentality here refers to a more ongoing, chronic, “self-sacrificial” way of thinking.

Many people self-medicate with sleeping pills, alcohol or other substances, or are prescribed antidepressants or addicting benzodiazepines for stress or anxiety. While medications can play an important role, all too often they are utilized instead of more powerful alternatives, such as changing the way you think, or how you take care of yourself.

What are the pros and cons, the plusses and minuses of stress mentality? Is there a better alternative?

First, what are the plusses, the benefits, of stress mentality?

I. Many people believe they need stress and fear of failure, or bad consequences to be motivated. However, there are much healthier ways to self-motivate (Hint: it is connected to your values and passions).

Now, what are the minuses, the cons, of S.M?

I. There are always things that need to get done.

II. S.M. generates chronic stress and all of its negative effects on the body. (link to Body states Video)

III. Like a car, our mind and body needs basic maintenance to run. I have to put gas in and change the oil even if I’m busy or else bad things happen.

IV. Similar to the car, stress mentality ends up with some sort of breakdown of mind or body.

What, then, is the alternative? The reverse. In Reverse-Stress Mentality the belief is:

“If I take care of myself first I will be more efficient in getting my work done.
“I have to differentiate between what needs to be done and what can wait so there’s balance.”

What are the plusses of reverse-stress mentality?

You start to take care of yourself, therefore you will have:
More energy
More clarity
More efficiency
More balance
Better mood
Minimal stress.

What are the negatives of reverse-stress mentality?

I. Not everything will get done right away.

II. You have to learn new (healthier) ways to motivate

III. You have to set limits, including saying “no” and sometimes disappointing people.

Most of us have a never-ending conveyor belt of things that need to get done. Many people really believe that they can’t take care of themselves until the belt stops.

When I refer to self-care that means biological, psychological, social and spiritual needs. What gets in the way of carving out time for self-care, or “pushing the pause button” on the conveyor belt? Those factors include:

– Self-worth, how you judge yourself
– Fears about how others will judge you
– Fear of failure and inadequacy
– Fear of getting people upset, angry, or disappointed in you
– Fear of asking for help.

There are many ways to get help overcoming these obstacles; psychotherapy is only one of them. Learning and practicing mindfulness helps to get rid of your judging and fears about how others will judge you. It also helps take your mind out of the past, out of the future, and into the present moment, where it is needed in order to make the best decisions.

Successful implementation of the reverse stress mentality requires skills for managing time and setting boundaries, and these skills are teachable. Coaching or therapy can be helpful. If you have trouble setting boundaries and saying “no,” maybe a 12-Step program such as CODA would be helpful. If you can’t stop obsessing, newer antidepressants help that a lot, with minimal side effects.

Mindfulness (and other types of meditation), physical exercise, and other routine practices can literally change the brain, as evidenced in recent brain imaging studies. It takes hard work but it’s worth it.

Change doesn’t happen overnight. Set an intention, and mindfulness will help keep you focused on that intention. You’ll frequently slip back to your old thinking and behaviors; but when you notice that happening don’t judge – just ground yourself and re-establish your goals.

How To Choose A Psychotherapist

How To Choose a Psychotherapist

 

By Jerry Gelbart, M.D., F.A.P.A.

Psychiatrist

 

Most people I talk to have no idea where to start looking when they want a good therapist. Many therapists can be amiable, supportive, encouraging, but in 2013 we need to expect more than that. We now have therapies such as Dialectical Behavioral Therapy (DBT), Cognitive Behavioral Therapy, (CBT), Acceptance and Commitment Therapy (ACT), and others that have been shown to be effective in scientific studies, and many therapists are not up to date with these. For example, many therapists still use older models such as Jungian, Analysis, or Supportive therapies that have not proven to be cost-effective in getting the job done.

 

Here are 7 things to look for if you’re choosing a therapist:

 

1. Therapist sets tangible goals with you. Goal setting:

 

a. Gets you, therapist, and other members of treatment team (i.e. Psychiatrist, Primary Care MD) all focused in same direction

 

b. Helps you see if you’re making progress.

 

c. Goals help you move forward instead of looking back.

 

2. Therapist is open minded to various treatments, including nutritional, medications, Eastern approaches, group therapy, hospital outpatient or inpatient. “Whatever works.”

 

Not defensive, willing to consult with others or send you to someone else if not a good match.

 

3. Therapist is engaged and engaging, versus passive, remote, disinterested.

 

4. Therapist is not just supportive, listening, reflecting (I call this HHT, “Hand Holding Therapy”).

 

5. Therapist can say what kind of therapy they are doing.

 

The models mentioned above are not the only effective therapies, but are a few examples based on learning new skills, and changing behaviors and thinking. They mostly stay out of the past and intellectualizing about “why” you are the way you are. Instead they are focused on being in the present, getting rid of judgments and taking more control over your life.

 

6. Therapist gives homework. Homework:

 

a. Keeps you thinking and working between sessions.

b. Helps with continuity.

c. Consider therapist sessions as mostly teaching while the lab/application is in the real world between sessions.

 

7. Therapist is willing to confront you with things you may not want to hear in ways you can hear it.

 

Plusses:

1. Coping skills training.

     Especially teaching Emotion Regulation Skills (managing anxiety, anger, rejection, shame and guilt).

2. Mindfulness-based.

     Mindfulness teaches you how to be in the present and disengage from judgments.

3. Biological, Psychological, Social, and Spiritual perspective.

     Focuses on body, mind, relationships, and existential issues. 

 

Remember that no one thing makes us healthy and well. Health and Wellness require a multi-pronged approach involving self-examination, reprioritizing values, and behavior change.

 

Jerry H. Gelbart, M.D.

 

Synergies in Treatment

A series of articles written by Dr. Gelbart for the Northern California Psychiatric Society Newsletter. These articles are a bit more “technical” than others on this blog, but they can help anyone interested in how mindfulness, positive psychology, Wellness approach, and skills training can help with self-esteem, anxiety, depression, motivation, and other difficulties. It may help you in choosing a therapist, and/or bring up questions for discussion with your therapist or friends.

  1. Introduction
  2. Judgmental Thinking
  3. Mindfulness and Psychiatric Treatment
  4. Teaching The Patient To Swim
  5. Focusting On The Positive
  6. Changing The Shoulds To Wants
  7. Mindfulness Psychotherapy And The Brain
  8. Which Tool When

Which Tool When? (Written for Psychiatrists- but you can read it!)

We collaborate with the patient to set treatment goals and outline a roadmap to achieve them. In addition to medication management and psychotherapy that we may offer in our practice, there are many other resources available to augment and enhance our treatment plan. As Psychiatrists we’re in the best position to coordinate treatment and draw connections for the patient between their symptoms, goals, and available methods.

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Synergies #5: Focusing On the Positive

Originally published in NCPS, June 2009

A lot of anxiety, depression, and even psychotic symptoms relate to how patients see themselves, how they judge themselves. Usually a core problem is black or white thinking, that one is either good or bad, normal or not normal, worthy or unworthy. This belief system that comes from childhood has a deep hold.

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Synergies #4: Teaching The Patient To Swim

The goal of psychotherapy is wellness. For some, that includes “fixing a disorder.” For others, perhaps taking a medication for life. Either way wellness is the goal.

Wellness practice (WP) is prioritization of behaviors that put the individual’s basic physical and emotional needs first. This includes exercise and healthy nutritional habits, setting up boundaries that allow relaxation, creativity and play, social interaction and spirituality. These behaviors help to reduce the effects of stress over time on our mind and body, including cardiovascular, G.I., and immune systems. WP also includes learning to be present and future oriented, and nonjudgmental toward our self and others.

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Synergies #3: Mindfulness and Psychiatric Treatment

Previous articles in this column have described the benefits of mobilizing the patient in the direction of lifestyle changes and prioritizing self care.  Development of “healthy routines” in the areas of Biological, Psychological, Social, and Spiritual needs is THE crucial element of “Wellness” or “Fitness.”

Relapse prevention is an important part of our work.  Teaching patients to take their medications regularly is part of routine maintenance of their biological needs.  Encouraging healthy diet and exercise also fits that category (how often do patients actually change these behaviors?).  We must also encourage and guide patients to understand and tend to their emotional needs, social and spiritual needs.  We can explain that taking better care of their body, their social and spiritual needs will help them emotionally; and working on emotional “self-growth” will likewise help them in each of the other areas.

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Synergies #2: Judgmental Thinking

Is ‘Judgmentalness’ A Symptom?

A reality of our society is that most people don’t “complete” psychodynamic psychotherapy to resolutions of their childhood conflicts. Most often this is for cost reasons, and/or as people feel better they often fade from the psychological treatment, too often falling back on longer-term medications or relapses when perhaps psychological resolution would have been realistic.

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Synergies In Treatment: For Psychiatrists, Therapists, and Everyone

SYNERGIES IN TREATMENT #1

What is Emotional Wellness? Just as the concept of physical wellness doesn’t necessarily mean that exercising and healthy nutrition will get rid of your diabetes or hypertension (although it sometimes will) an emotional wellness program won’t necessarily cure someone’s mood disorder.  Such a program might however help prevent someone from getting depressed in the first place, or keep them from relapsing once their episode is treated.

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