Core Beliefs

Spiral Staircase

Automatic thinking is a term that comes up a lot around these parts (parts=this blog) and refers to the self-talk or narrative that folks with depression and anxiety immediately engage in as a response to an activating event or trigger.  Automatic thinking can be the result of a trigger or can act as a trigger for distress.  Many of the clients I work with are often curious about how or why this type of thinking occurs. The primary source of automatic thinking are core beliefs; beliefs that we hold about ourselves, others and/or the world around us.  Individuals who struggle with a mental health issue typically have negative core beliefs that can influence thinking on a variety of events that occur on a day to day basis.

Core beliefs can center around adequacy (“I am worthless”), control (“I cannot be trusted”) or safety (“I cannot protect myself”). Someone who holds the core belief of “I must be perfect” may be prone to polarized thinking (placing events or people in categories of “all good” or “all bad”) which may in turn increase the distress associated with failing and could also influence a reaction to failing that is unhelpful or harmful.

There are many factors that influence core beliefs; one being a biologically based condition like depression.  A person may have a typical family history and childhood  but because of the impact depression has on their mood,  that person may interpret the “stuff” we all go through in ways that are more negative and impactful.  Failing a test or feedback received from a parent may take on a deeper meaning that feeds into the understanding that a  person has about themselves. A child or teen without depression may move on from these events or, perhaps, use these events as motivating factors to improve. A person who struggles with depression or anxiety may view these events as evidence of a fundamental flaw.  This perceived flaw may begin to shape how everything is viewed and can even be predictive.

Another factor involves traumatic events which can range from being embarrassed in front of a classroom by a teacher to events we typically associate with the word trauma like sexual abuse, assault, combat or witnessing the unexpected  death of a loved one.  These events, especially when they are experienced at younger ages, can have a very big influence on core beliefs as survival becomes the driving force in holding onto the belief.  A survivor of sexual abuse may live in a home environment where the belief of “I am not safe” is actually adaptive.  This belief helps to maintain the kind of  vigilance the survivor needs to avoid the trauma.

Once the survivor leaves the home environment the cost-benefit of the belief and the behaviors connected to it shifts. Because of the association the belief has to survival, it may be very difficult for the survivor to consider any other alternative in their thinking.  Imagine living your day to day life in a mine field for the first 12-17 years of your life. Now imagine someone taking you away, placing you in the middle of another field, telling you “there is nothing to worry about now” and even demonstrates this by running through the field carelessly. How easy do you imagine it would be for you to act according to that evidence?

There are several steps to changing core beliefs in therapy, the first one involves actually identifying it.  In CBT, the process to accessing a core belief involves asking a series of repetitive questions around an automatic thought or hypothesis a client has in relation to an activating event or trigger.

T- “So you’re saying that going to the grocery store will probably result in a panic attack.  What would having a panic attack at the store say about you?”

C-“It would be pretty embarrassing.”

T-“So you would feel embarrassed, what would make it embarrassing?”

C-“Everyone would be staring at me….avoiding me.  People who know me might look at me differently.

T-“And what would that say about you?”

C-“That I’m unstable….crazy.”

T-“What would that mean to you?”

C-“That I shouldn’t go to the grocery store.”

T-“And what would that say about you?”

C-“Well… that’s a pretty basic thing…..if I can’t do that then I’m pretty helpless.”

T-“And what would that say about you?”

C-“Just that…I’m helpless.”

T-“So when you think about those three statements “I’m crazy.”, “I’m unstable”, “I’m helpless”, which one makes the most sense to you when you think about having to go shopping?”

This is pretty consistent with how EMDR handles it within its’ protocol; the only difference being that clients are asked to look at the worst image of the event they are working on (usually historical) when coming up with the core belief. If someone is struggling with putting words to the core belief, I’ll provide them with a list that they can either pick from or use as a way to jog their thinking.

Negative core beliefs typically develop during times of high distress when we are less capable of looking at events objectively.  Because they are distressing, we may not revisit them for reasons ranging from discomfort to fear. As a result, the initial understanding or conclusion about the event may not change or be challenged.  Being aware of the core belief(s)  is key to long term sustainable change as it addresses the root cause.  In identifying core beliefs, we become more able to engage in a variety of skills that seek to address the source of the belief in ways that can lead to fundamental shifts in our thinking.

When Reality Bites

pizza bites

I’m back from vacation and despite being away from the blog for a while, a few folks posted some interesting comments that had nothing to do with the post they were commenting on.

One had a link to a website selling table saws.

Fascinating.

A significant part of CBT work involves challenging distorted thinking;  patterns of thinking that can lead a person to unreasonable and usually negative conclusions about events, themselves and other people.  I’ve written a good deal about negative thinking and how to use Socratic methods and evidence to challenge distortions that typically lead to unreasonable distress and maladaptive behaviors.

But what happens if the negative belief or thought is true and unchangeable?  For example,  “I got written up because I played computer games at work all week and missed an important deadline.”

Contrary to the stereotype that therapists tend to push clients into endless positive affirmation mantras we actually have a few ways that can help clients think about and handle difficult situations that involve strategies other than repeatedly saying “I love myself and the world is in harmony”. Because, really, the world is rarely in harmony and if you love yourself that much then therapy needs to have a bit of a different focus.

One strategy involves consciously using the distress related to the event as a catalyst for increased awareness and knowledge about the problem and increased desire to change the behavior that either led to the problem or may be making the problem worse.  The Systems theory folks view crisis as something that can act as a catalyst for change in families and what’s true for systems is true for individuals.  Emotions are really neutral entities; “good” and “bad” emotions can both lead to negative outcomes; it’s not so much the emotion that matters as much as how you use it.  During times of distress, folks are typically more motivated to change just so that they can feel better. Changing our behaviors may not reverse a specific consequence that already occurred but it can help prevent the situation from getting worse while giving us a greater sense of control.  Changing behaviors can also have reparative effects on relationships; people tend to forgive more easily when they have evidence that someone is trying to turn their behaviors around. However, acting without awareness can leave us vulnerable and may lead us to bigger problems than what we started with.

Before pushing a client to action, many CBT therapists engage their client in a simple yet comprehensive pros and cons exercise.  Pros and cons can help us put a negative event or life circumstance in perspective.  Using the example of being in a job you do not like; there are reasons why a person may still show up – there are things about the job that have a payoff otherwise they wouldn’t be going there every day.  Going through the pro’s and cons of staying at a job, leaving a job, changing aspects of a job, etc. can, at the very least, help a person recognize the reasons why things are the way they are. Understanding the reasons for a negative event or situation can help us balance out the narrative; it pushes us to more reasonable and evidence based conclusions about the part we played, our conclusions about other people who may be involved and the situation itself.  Pros and cons can also shed light on new strategies or may correct faulty equations that make the situation appear more distressing than it deserves to be.

From here, strategies revolve around adaptation and acceptance which involves understanding that the negative that cannot be changed is only one part of many.  Using the example of a dead end job, you may want to leave it but jumping ship right now may not make sense for a variety of reasons (benefits, the market, seniority etc).  Adaptation may mean recognizing that while you may not like your job there are facets of it that are enjoyable or at least more enjoyable than others.  Adaptation could involve focusing more on the areas of your work that you find enjoyable both in what you do and in your thinking, setting up  workspace in a manner that helps you cope, making breaks more active in leisure (going for a 15 minute walk or calling a friend on a break and talk about sports instead of staring at your computer monitor endlessly repeating the word “hopeless” in your head) or taking small steps to another job or career while staying in your current job. Acceptance means letting go; if you hate your job thinking about it after you leave the office only means you’re keeping yourself in that environment longer than you need to be.  Life doesn’t have to be perfect in order for it to be worthwhile or enjoyable; having a bad job doesn’t mean you can’t enjoy your family, friends leisure or faith. Hint: mindfulness might be helpful here.

Although thought records and Socratic questions can’t miraculously change a negative event into something positive, they can be useful in helping us determine whether our reactions to the negative event are reasonable. While there may be evidence to support a negative outcome or less than positive conclusion about our behavior, thought records can help us think about next steps more effectively and can act as a brace against turning a mistake or bad judgment into a broader condemnation of our character or capacity.

If you struggle with a mental health issue like depression or anxiety, you may want to  consider that while the situation stinks the thought patterns associated with your issue may make it seem like it stinks way more than it actually does.

So therapy isn’t always about extinguishing the negative; usually it’s more about putting the negative in perspective, helping someone understand their options and that even if what’s uncomfortable doesn’t change, it does not have to define their life.

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And They’re Off!

The pursuit-distance phenomenon is a concept born out of systems theory and is used to describe a pattern that occurs between two individuals who, as a result of emotional fusion, are unable to gain healthy proximity in a relationship.

The tendency towards emotional fusion is inherited from a person’s family of origin. People who are fused are triggered to emotional flooding by the emotional reactions of other people. This flooding negatively affects a person’s capacity for reason and objectivity. Typically, couples who find themselves in the cat and mouse game (pursuer-distancer) react to this flooding differently. The pursuer seeks stability and connection while the distancer seeks space and isolation. rowing race

Flooding is the force that upsets the ability of members to successfully negotiate the normal tension that is the product of an individual’s desire to belong and his or her desire to act from self interest.

The pursuer tends to value proximity and can come across as clingy and needy. The distancer usually comes across as detached or cold. The manner in which the pursuer seeks proximity from the distancer causes the distancer to move away, frustrating the pursuer who reacts by increasing their effort in the chase. While the distancer appears calm and detached it’s important to understand that he or she is operating from the same “stuff” as the pursuer. It’s also important to note that a pursuer in one context may move to distancing behaviors in another even in the same relationship. A pursuer at home may be a distancer at work; one who distances him or herself when it comes to emotionally supporting a spouse may become a pursuer when it comes to finances or sex.

This chase becomes problematic when the pattern results in a family member escalating to a point where they act in ways that cannot be ignored (screaming, aggression, leaving the house for extended periods of time). It can also be the stuff that triangles (something we’ll talk about soon….I promise) are made of as the distancer will seek a third object to escape to and the pursuer will seek a third object in getting their needs met. It also creates problems for the pursuer as, depending on how the behavior manifests itself, it can create greater vulnerability to be manipulated and controlled. If you come across as needing me more than I need you, I can use that in ways that are less than noble.

One way to break the pattern is for the pursuer to just stop pursuing; this tends to make it safer for the distancer to approach as perceived expectations and intensity are ramped down and the distancer feels that he or she can gain proximity on more mutual terms. Obviously, the other way to break it is for the distancer to remain present and tolerate hearing the pursuer’s needs; this could reduce the pursuer’s need to chase and works to reduce the anticipatory anxiety they experience leading up to the pursuit that can make their presence feel overwhelming to the distancer.

For some folks this is like telling Little Debbie to stop making delicious snack cakes.

Just stopping the pursuit doesn’t mean changes will happen immediately or that the change will be enough for all parties. One reason skills are such a big part of the work with couples and families at my shop is that increased capacity to tolerate the urges or desires that drive maladaptive relationship patterns are many times necessary before people feel change, even small change, is realistic. Thanks for checking in!

Why Cues Count.

One of the first skills I go over and practice with clients is mindfulness and anyone who knows me probably finds this laughable.

You don’t have to play baseball well to coach it, so get off my back.

An early application of mindfulness in my work with most clients has to do with becoming aware of cues in relation to distress; whether the distress is related to anger, anxiety, depression, urges to relapse….whatever.  Being aware of our cues can serve us in different ways and today we are going to focus on using them as part of an early warning system for maladaptive behaviors (outbursts, isolation, panic attacks, relapse, self-harm etc..). Being aware of our cues can help us identify when we are escalating to our “tipping point”.  The tipping point is where you become highly vulnerable to feeling like you’ve lost control.  It’s where you still feel sort of okay in backing out of a situation but you’re not quite sure you will.

At the bottom of this post is a distress matrix I developed for clients I work with.

“Unfortunately, no one can be told what the Matrix is. You have to see it for yourself.”

Actually, Morpheus is wrong. I’m going to go over what each of the items on the matrix are, how to complete the matrix and how to apply it.

It may be helpful to print the sheet out so you can refer to it while reading this post.

Explanation of Categories

Triggers- Triggers are people, places, things, thoughts (including memories) and emotions that create or amplify the distress.  This may require some thought as what we believe created the distress may not really be the trigger; when filling this portion of the matrix out be aware of the chain of events regardless of how minor they may seem that led up to the event you identified as the trigger.  After completing this analysis write the trigger you feel is most connected to your distress in this area.

Intensity- Examine the intensity of your distress (how bad or strong it feels) and try to place a value on  it using a scale of 1 (lowest) to 10 (the worst it’s ever felt). When starting out don’t worry so much about getting it right; you probably have not examined your distress to this degree. It may be hard to come up with a rating because you have little to compare it to.  As you use the matrix more, you’ll be more comfortable in assigning a number to your intensity. For now compare your current distress to other times that come to mind and try to take an educated guess.

Physical Cues- Try not to confuse this category with behaviors; these are not willful actions on your part, this is more about what your body does as an automatic response to the trigger.  Sweating, headaches, other pain, heart rate, shaking and heavy breathing are all automatic reactions of the body and are appropriate for this category.  When completing this category scan your body up and down and notice what it’s doing; jot down anything that feels different or unusual.

Behavioral Cues- These are actions that you take in response to the trigger, things like pacing, making a fist, sighing, rolling your eyes, hitting are all appropriate for this category.

Emotional Cues-These are the emotions or feelings that are prompted by the trigger; avoid writing down secondary emotions such as anger and dig to the primary feelings – fear, humiliation, jealousy.  Some folks have a difficult time identifying emotions, if you’re one of them use this list to help you out.

Cognitive Cues-This is the stuff that your brain is spitting out, the thoughts that automatically pop up in response to the trigger; “I can’t stand this.”, “I hate her.”, “I won’t let them get away with this.”, “This is going to ruin everything.”. Try not to regulate it, just be aware – watch it like your watching a movie and take notes.

How to complete the Matrix

When you’re starting out don’t worry about organizing events in order of intensity; just use it to collect data about yourself.  It’s important to remember that low levels of distress are very important to track for several reasons.

1. You probably already know what the higher numbers sort of look like.

2. Catching distress at the bottom gives you the best opportunity to understand how it escalates.

3. Recognizing low levels of distress can create better opportunities to cope prior to further escalation.

So if something triggers you to an intensity of 1 or 2 complete a row on the matrix.  Complete the matrix during the event; step back and examine what’s going on with you across these categories in the heat of the moment. This not only provides you with the best shot at good data but can also work to mitigate some of the distress that you’re feeling.  Really, that’s what the initial phase is all about, just collecting data about your distress while giving you an opportunity to delay reaction with a task. Speedometer display dial

Once you feel you have enough data (maybe a solid week or two of daily sheets) you can begin to organize it all.  Try to identify trends and develop a master sheet of triggers and cues and organize them according to the level of distress they are associated with.  For example gather all your 3’s and create one row containing all the associated triggers and cues.

How to apply the Matrix

There are a million things that’s done with this thing in therapy, for our purposes here we are going to keep it to just this tool.  Begin by looking at the data and seek to understand how cues change as your distress escalates.  Identify the tipping point and pick a point one or two notches before that; this will be your action point.  The action point is where you begin to use coping skills to actively de-escalate; this can mean stepping away from the situation and revisiting it later.

So if your tipping point is a 7 your action point could be a 5.  A 5 could look like this:

Trigger- When someone goes after the last piece of bacon after I called it. When I get cut off on the parkway, When I have to watch “Ever After”………..again.

Physical – Breathing becomes slightly more rapid

Emotions –  anxiety, irritation

Behavioral – hands tense up, my voice begins to rise,

Cognitive – “I’m not going to let this happen”, “This is dead wrong”, “Here we go again”, “I am so tired of this shit”, “Can’t Drew Barrymore just not win this one time?”

So the next time I’m confronted with these horrors, I’ll try to be really aware of the cues associated with a 5 so if they start happening I can engage in whatever plan I’ve developed to de-escalate.

The matrix is a working document; feel free to add or change it as needed. Overtime becoming aware of your cues and reacting to them adaptively and ahead of the impulse will probably become more natural to you; even for triggers you haven’t identified or curve balls that come your way.  Thanks for checking in.

Distress Matrix (pdf)