Therapy

Cognitive Behavioral Therapy is a kind of dual approach to treatment, addressing thoughts and behaviors. The cognitive part of therapy looks at the importance of the personal meaning we place on things and how thinking patterns begin in childhood. The behavioral therapy pays close attention to the relationship between our problems, our behavior and our thoughts. A therapist trained in CBT will customize the therapy to the specific needs and symptom profile of each patient.

CBT is an approach for which there is a lot of scientific evidence showing that the methods used in treatment can produce a sustainable positive change for clients.

CBT is based on several core principles, including:

• Psychological problems can be from faulty or unhelpful ways of thinking.
• Psychological problems can come from learned patterns of unhelpful behavior.
• People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives.
• Rehearsal of new coping skills can lead to the development of sustained functional patterns.

A certain amount of information about a client’s history is needed, but the focus is primarily on the here-and-now, moving forward in time to develop more effective ways of coping with life. CBT places an emphasis on helping individuals learn to be their own therapists. Through exercises in the session as well as “homework” exercises outside of sessions, clients are helped to develop new coping skills, which can lead to a change in their own thinking, problematic emotions and behavior.

CBT treatment usually involves efforts to change thinking patterns. These strategies might include:

• Learning to recognize distortions in thinking that are creating problems.
• Reality testing to challenge irrational thinking and responses.
• Gaining a better understanding of the behavior and motivation of others.
• Using problem-solving skills to cope with difficult situations.
• Learning to develop a greater sense of confidence is one’s own abilities.

Cognitive distortions are thinking patterns or simply ways that our mind convinces us of something that isn’t actually true. These inaccurate thoughts are usually used to reinforce negative thinking or emotions. Here are 10 common cognitive distortions that can contribute to negative emotions. They can also fuel catastrophic thinking patterns that are particularly disabling:

• All-or-Nothing Thinking: This is a way of thinking in black and white terms with no shades of grey. You are either a success or failure. You feel either loved or hated.
• Over-Generalization: This is a pattern of thinking about a negative event and then applying it to all events and even use it to predict future events. If you made a mistake with your school presentation, you feel you are a bad student and will always give bad presentations.
• Mental Filter: This is where you pick out a single negative detail and dwell on it exclusively, so that your vision of all reality becomes tainted.
• Discounting the Positive: You reject positive experiences by insisting they “don’t count.” If you do a good job, you may tell yourself that it wasn’t good enough or that anyone could have done as well. Discounting the positive takes the joy out of life and makes you feel inadequate and unrewarded.
• Jumping to Conclusions: This is almost like mindreading. You think you know what another person is thinking when in fact, you do not. This is a distortion because you make a conclusion with out considering all the facts.
• Magnification: This is a way of thinking where you exaggerate the importance of your problems and flaws, often minimizing the importance of your good qualities.
• Emotional Reasoning: This is a cognitive distortion where you feel a certain way or have an emotional reaction to something and then make this a reality, regardless of evidence or facts to the contrary. If I feel this way, it must be true.
• “Should statements”: You tell yourself that things should be the way you hoped or expected them to be. Should statements that are directed against other people or the world in general lead to anger and frustration: “He shouldn’t be so stubborn and argumentative.”
• Labeling: Labeling is an extreme form of all-or-nothing thinking. Instead of saying “I made a mistake,” you attach a negative label to yourself: “I’m a loser.” These labels are just useless abstractions that lead to anger, anxiety, frustration, and low self-esteem.
• Personalization: Personalization is a distortion where a person believes that everything others do or say is a direct, personal reaction to them. Some people do the opposite. They blame other people or their circumstances for their problems, and they overlook ways that they might be contributing to the problem.

CBT treatment also usually involves efforts to change behavioral patterns. These strategies might include:

• Facing fears through, instead of avoiding them.
• Using role playing to prepare for potentially problematic interactions with others.
• Learning to calm one’s mind and relax one’s body.
• Replacing a problematic behavior with a new healthier option.

Some kinds of therapy allow clients to just talk freely and randomly about issues, but CBT more than just talk, it is a structured treatment. CBT uses a process to move through treatment with a planned progression to meet the goals of therapy. The problems may be troublesome symptoms, such as sleeping badly, not being able to socialize with friends, or difficulty concentrating on reading or work. Or they could be life problems, such as being unhappy at work, having trouble dealing with an adolescent child, or being in an unhappy marriage.

These problems and goals then become the basis for planning the content of sessions and discussing how to deal with them. Typically, at the beginning of a session, the client and therapist will jointly decide on the main topics they want to work on this week. They will also allow time for discussing the conclusions from the previous session. And they will look at the progress made with the homework the client set from last appointment. At the end of the session, they will plan another assignment to do outside the sessions. This practice of rehearsing target skills can establish new behaviors that leads to positive changes in life.

Mindfulness skills can help you to center and calm yourself to better understand your emotions. You learn to reflect and train your brain to stay in the present, rather than getting stuck in the past or worrying about the future. You can sit with your anxiety instead of pushing it away, and observe your thoughts, listen to yourself, and acknowledge your fears or apprehensions. In practicing these skills, you can avoid taking things personally and listen more fully to better understand others. Mindfulness is encouraged throughout all 4 stages of DBT therapy and practiced at home during the week.

Depression can present different symptoms, depending on the person. But for most people, depression is feeling sad and not being able to snap out of it and having it last for weeks. People also often report feeling unmotivated, fatigued, irritable and having a lack of interest in things that they used to find enjoyable. Many people experiencing depression report changes in sleep patterns and eating behaviors. For some people, it can include having negative intrusive thoughts about self-worth and even thoughts of suicide.

Distress Tolerance skills are used to help us cope and survive during a crisis and helps us tolerate short-term or long-term physical or emotional pain.

Distress Tolerance skills address the tendency of some individuals to experience negative emotions as overwhelming and unbearable. People with a low tolerance for distress can become overwhelmed at relatively mild levels of stress, and may react with negative behaviors. Many traditional treatment approaches focus on avoiding painful situations, but in the distress tolerance module of DBT, clients learn that there will be times when pain is inevitable or unavoidable and the best course is to learn to accept and tolerate distress.

A main part of distress tolerance is the concept of radical acceptance. This refers to experiencing the situation and accepting the reality of it when it is something the person cannot change. By practicing radical acceptance without being judgmental or trying to fight reality, the client will be less vulnerable to intense and prolonged negative feelings. Within the distress tolerance module, there are four skill categories:

• Distracting
• Self-soothing
• Improving the moment
• Focusing on pros and cons

These skills are aimed at helping individuals cope with crisis and experience distress without avoiding it or making it worse.

Interpersonal Effectiveness skills are extremely important because the way we communicate with others has a significant impact on the quality of our relationships and on the outcome of our interactions. In order to communicate more effectively, clients are taught skills that help them approach conversations in a more thoughtful and deliberate manner rather than acting and reacting impulsively due to stress or intense emotions. Two key components of interpersonal effectiveness are the ability to ask for things and to say no to requests, when appropriate.

There are three types of effectiveness that must be addressed in interpersonal exchanges:

• Objective effectiveness: the goal or purpose of the interaction which often is a tangible outcome.
• Relationship effectiveness: the goal of a conflict-free relationship.
• Self-respect effectiveness: the goal is maintaining personal values and dignity.

For any given situation, these three factors must be considered and prioritized. The individual is likely to be more satisfied with the interaction and outcome if his or her highest priority has been addressed.

Throughout all stages of DBT there is a weekly goal to complete homework assignments to practice and rehearse the new skills in real life situations. This allows the client to build new neural pathways to develop new behaviors and to encourage sustained change. The skills that are assigned to each person are customized based on the treatment plan developed in the office. The therapist helps the person to learn, apply and master the DBT skills in each weekly session.

Typically, one-third of the total treatment is devoted to each phase of treatment.

Stabilization

The stabilization and skill-building phase begins with a focus on psychoeducation about the dynamics, prevalence, impact, and treatment of the experienced trauma, working toward developing skills to manage trauma reminders.

Trauma Narrative

The details of the child’s traumatic memories are gradually introduced, discussed and written about over the course of this middle phase of treatment. We use techniques such as storyboarding, cartoon strips, or poster boards, to allow for verbal and non-verbal expression.

Consolidation

The final phase of treatment then focuses on the integration and consolidation of what has been learned, with an emphasis on enhancing direct parent–child trauma-related communication, safety skills development, and the mastery of new behaviors and emotional responses.

Sessions are structured by the therapist to introduce interventions that are relevant to the particular stage of treatment. For example, during the Stabilization Phase of therapy, a child session may begin with a review of coping skills that the child was encouraged to practice between sessions; continue with a new skill component; then provide role play and practice of that skill; ending with a discussion with child and parent about what the child is encouraged to practice during the coming week. This is a planned progression towards the next stage of therapy.

PRACTICE

Since TF-CBT is a skills and strengths-based model, its components typically need to be practiced by the child and parent in order to be effective. We use the acronym PRACTICE to remind the child and family of the core TF-CBT components and the value of practicing them for the duration of treatment and beyond. A good deal of the therapy work associated with TF-CBT will occur between sessions, when parents and children are asked to practice certain skills at home. In the following list, the components of PRACTICE are arranged in relation to the phase of treatment:

P Psychoeducation and Parenting skills
R Relaxation
A Affective modulation
C Cognitive coping
T Trauma narration and processing
I In vivo mastery of trauma reminders
C Conjoint child–parent sessions
E Enhancing future safety and development

Although there is considerable gradual exposure in the earlier TF-CBT components, developing the trauma narrative is more intensive and extensive. One of the goals of creating the trauma narrative is to unlink thoughts, reminders, or discussions of the traumatic event from overwhelming negative emotions such as terror, horror, extreme helplessness, avoidance, anger, anxiety, shame, or rage. Over the course of several sessions, the child is encouraged to describe more and more details of what happened before, during, and after the traumatic event and the thoughts and feelings during these times. As the child is sharing his/her story in some type of format, the therapist is responding with validation, support, encouragement, and gentle questions. These components can allow the child to successfully integrate the trauma experience and its meaning into a larger optimal self-concept.

Parents are often traumatized themselves by the child’s traumatic experience. For example, if there was a trauma event, such as a house fire, the parent also experienced the trauma and may have their own stress symptoms. The TF-CBT components are typically provided separately to children and parents in individual sessions, with conjoint child–parent session time focused on practicing skills, and later on, toward the end of therapy, providing opportunities for open communication about the trauma experienced.

Including parents in therapy provides such parents with skill-building components that may help them cope better. From their own healing they are better equipped to model positive change and encourage their children in practicing effective coping skills. However, if a parent is having significant impairment with their own mental health issues, their own individual therapy may be advised.

The most immediate and influential environment for most children is that of their families. Parents can have an important impact on whether, to what degree, and how quickly children recover from trauma-related problems. They can also influence whether children’s improvements are temporary or whether these gains are sustained long after the end of treatment. We view parents as an important source of support and reinforcement for children’s progress both during treatment and subsequently.