DBT 911

This is a great little app that gives users access to dbt skills on their phone. One important feature is the diary card, which feels intuitive and does a nice job of prompting a user through some of the skills – much easier than the paper version.  It also allows you to create a pdf of the diary card that you can email your therapist or print out and bring to session.  It’s free but only available on Droid.  Get it at Google.

A comparable app for the IPhone is about 5 bucks- DBT Diary Card

Trauma Primer

I know, I know….I’ve been slacking off on the blog, but the past month has been really hectic and I put some skills into use.  One thing CBT and DBT both teach is to be more effective when it comes to time so that you don’t overburden yourself or harm relationships by not following through on commitments.  As a result, I had to put the blog on the back burner until I was able to recognize what a normal life looked like again.

Many clients who have experienced negative events in their lives may feel that these events aren’t worth exploring in therapy because, as many would put it …”it’s not like I have flashbacks or anything”.

In order to be diagnosed with PTSD a person has to meet certain criteria, but not meeting criteria doesn’t mean that traumatic experiences don’t have an impact on a person’s life.  Trauma is broken down into two categories, the first (“Big T”) includes experiences that meet the formal definition of trauma outlined in the DSM (rape, natural disaster, sexual abuse, war) and the second (Small T) includes events like neglect, job loss, emotionally abusive relationships or historical events that elicited strong feelings of shame or embarrassment.

Folks who experience Big T traumas are more likely to develop symptoms of PTSD, but most people who experience Big T traumas do not develop PTSD.  There are certain factors that may make someone more vulnerable to developing PTSD, including:

-Family History of Mental Health Issues or Addiction
-Presence of a Mental Health Issue or Addiction
-Exposure to traumatic experiences in the past
-High Level of distress experienced during the traumatic event
-Lack of Social Supports available to the person after the traumatic event
-Presence of other stressors during the time of the traumatic event (job loss, divorce etc)
-Gender (females are more likely to develop PTSD)

Although I use PTSD as a formal diagnosis when appropriate, I (and a lot of folks who work with trauma) tend to view trauma reaction on a spectrum with PTSD representing the most severe point on that spectrum.  A person may not meet the full criteria for PTSD, but may experience some of the symptoms within the disorder or may meet criteria for other disorders.

When it comes to Small T traumas, the popular culture tends to mock associations made between historical events and current symptoms with clichés and stereotypes of therapy as being about a problem in search of either more problems or a scapegoat. Many times, these types of trauma related disorders are more difficult to identify and treat because clients do not always associate the trauma with current mental health symptoms or, because of the cultural context, are ashamed to admit that these events are having a significant impact.

The good news is that the symptoms associated with both types of trauma follow similar treatment protocols, and even if associations to the traumatic event are not identified early on in treatment, most modalities have a way of teasing out these connections and determining validity.  Using CBT as an example, I typically work in an exercise around source credibility when identifying core beliefs which involves going beyond the core belief and determining the evidence that a client has historically used as a means of coming to the negative conclusion about themselves. Sometimes the less invasive interventions used in CBT are enough to attack source credibility and extinguish these negative beliefs, other times more invasive interventions (like EMDR or Exposure Therapy) are needed.

Unintended Consequences of Progress

Robert Goddard - First Rocket

Cognitive Behavioral Therapy is difficult work and part of that has to do with the distress progress can create in a family system.

Yeah, that’s right.  We’re looking at how CBT can potentially impact a family from a systems perspective.

Exciting, right?

CBT is also a short(er) term modality, involves homework and the idea of concrete change is on the table sooner than folks may expect.   To consider how this might impact the larger family system, we need to understand Homeostasis:

The concept of homeostasis means that the family system seeks to maintain its customary organization and functioning over time. It tends to resist change. The family therapist can use the concept of homeostasis to explain why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and what is likely to happen when the family begins to change. link

That’s not only on the internet, it’s also out of a medical dictionary ……..on the internet, so it must be true.

This does not mean that the family is the primary contributor to the client’s issues. It can mean that, but it can also mean that the issues the client struggles with has, in some way, shaped how the family works.

Due to the (relatively) rapid and (sort of) roller coaster type progress CBT initiates in a client, the family system the individual lives in can become a bit confused and disoriented.  Family members may feel an individual is getting worse when he/she may simply be more distressed as a result of the changes they are trying to implement.  Other times, family members may feel and express disappointment to their loved one when a lapse occurs after a stretch of noticeable progress. This can feel disappointing to a client who is being asked, in therapy, to focus more on process in defining success. Family members may also fall back on historical patterns in interacting with their loved one. This may lead to increased feelings of frustration in a client and can create an environment that is more conducive to relapse.

This isn’t to say that family members want their loved one to remain stuck, it may be the product of habit.  Family members, like clients, develop workarounds to symptoms in ways they can live with and these workarounds may be time consuming, intricate and exact.

Therapists should always leave the option of family involvement on the table for clients. It’s even appropriate, at times, to include it as a condition of treatment.  With adolescents or young adults who do not wish to have family members involved, therapists may wait until the client feels distressed enough about the family’s “push back” to bring the matter of family involvement up again.

Once a family is in the room, I avoid reviewing the nitty gritty details of our work. Usually, I speak to the treatment logic that is being used and, in general terms, talk about how families can act to help or hurt the process.  Family members may need therapy themselves to adjust to the changes especially if the issues are tied to loss or addiction.

The intended takeaway here is that family members typically want their loved ones to do well, but may not be clear on their role in the treatment process.  If not addressed, a family system may interpret or react to certain changes they observe in their loved one in ways that may be unhelpful or counterproductive.  Usually, this “pull back” is not willful or malicious, but comes from concern and is a natural reaction that systems have when experiencing increased distress and uncertain change.  Depending on the level of involvement a person’s family has had in helping their loved one manage or work through their symptoms,  psycho-education that includes typical projections around progress can be helpful for both the family and the client.

Pros and Cons

Pros and Cons is a basic skill that’s taught early on in CBT and is part of DBT’s distress tolerance module.  The tool has a broad application;  it can be used to examine decision making across a variety of issues (lack of motivation for treatment, high risk behaviors in addiction, parenting, distress tolerance, etc..). It’s also a nice bridge to other tools in CBT as it gets a person accustomed to what the work is going to look like moving forward.

Although most folks feel like they already know how to apply Pros and Cons,  much of what the skill has to offer isn’t fully utilized.

The purpose of this post is to demonstrate the benefits of using the Pros and Cons skill in a manner consistent with CBT.

Pros and Cons allows us to examine a situation, potential action or decision away from emotional intensity and logical rigidity and yes, it is important that you write it out. Writing it out gives you a kind of perspective that may not be possible when doing the math in your head simply because of what else may going on up there.

The other benefit to the tool is that it can act to increase motivation around adaptive behaviors and call your attention to the consequences of maladaptive behaviors.

The example below may relate to a person whose symptoms of depression or anxiety affects their ability to maintain an orderly household. The first thing you may notice about the tool is that it breaks the decision down between two potential actions and four possible sets of outcomes.

pc_1

The tool pushes your thinking around outcomes related to action and inaction and this distinction matters.  The benefits of looking at it both ways allows you to determine consistent themes in the decision making and increases the likelihood that you’ll consider other factors that may not have come up for you if you went with a traditional approach.

The other benefit to the Pros and Cons tool that I tend to emphasize is that, although the action considered may not be effective if implemented, you may be able to tease out needs that could be met by simply using a different strategy.  In this example, Tom considers whether he should tell Joe (a coworker) off for taking his donut.

action_2

So creating a spectacle over a donut appears to be a no-go but, by examining what was written closely Tom may able to tease out some goals in developing a new strategy in his communication with Joe.  Using Tom’s sheet and what he highlighted as an example, a different strategy could center around the following priorities:

-Letting Joe know that Tom is aware of the issue.

-Communicating the issue in a way that seeks to effectively influence change in Joe’s donut stealing ways.

-Communicating in a way that does not endanger Tom’s employment.

-Communicating in a way that avoids embarrassing Joe and is consistent with Tom’s moral understanding of how people ought to be treated.

I was debating whether to post the tool because really….you should be able to draw a bunch of rectangles that vary in size on your own.   However, being the generous and compassionate soul that I am, I decided to post it anyway.

Humble.

I’m also humble.

Pros and Cons Tool (pdf)