“Effectively”

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One of my favorite things about DBT is how every intervention makes sense for the overall goal of reducing interpersonal chaos and how that goal makes so much sense for the treatment population  it was designed to help. I’m not going to get into a debate as to whether it’s the “best” treatment; but I think it is probably the most efficient and “designed with focus” treatments around.

Again, I practice from three different modalities so it’s not like I have a horse in the race. DBT is my preference when trying to help clients develop the capacity for mindfulness because of how practical it is when approaching the topic – within DBT mindfulness has a utility that specifically connects to the core issue driving a problem. No where is this more apparent than in the How Skill – Effectively.

One common approach to teaching any skill in DBT (and CBT for that manner) are parables and, where appropriate, self disclosure. In teaching Effectively I talk to clients about an experience I had back in my 20’s.

I was working at my first management position 2 years out of grad school, saving for a wedding and working for an organization that was going through a merger resulting in a lot of downsizing. On top of all that, I had to deal with the issue of a title change. My office was conveniently located above a Motor Vehicles Agency, which I thought would make the whole thing a breeze. I ended up having to visit the DMV several times and each time I felt I was given the run around which led to me becoming more frustrated each time I had to go.

During the last visit, the agent and his supervisor basically blew me off and informed me that more information was needed, which is what I was told during each of the prior visits. It felt like each time I went, there was some other reason as to why they couldn’t do what I needed them to do which meant using a lunch hour (which was really just an hour of work) to wait on line again. But this time was different. I became so pissed off at the “injustice” and incompetence of the whole thing that I went on a 5 minute stump speech about the evils and incompetence of bureaucracies.

A very loud stump speech.

And I felt justified and right with what I was saying, after all it was their errors that were wasting my time and they took no ownership, they showed no interest or concern that my life was busy and my time was being wasted. At the end of my rendition of “Mr. Smith Goes to Washington”, everyone else there erupted in applause.

Then I was asked to leave and never come back; the manager informed me that I was “banned”.

Initially, it felt good to react in this way and to throw it back in their face. It felt good to have other people applaud me for doing that. Vengeance, vindictiveness and giving someone who deserves it a verbal beat down always feels good, especially when you’re right and everyone else knows you’re right.

But it was ineffective.

In the end, I had to restart the process with another DMV. I could no longer use the DMV that was one floor down from my office. I failed to realize that in a place like the DMV, the folks who work there are as much a slave to their protocols as I am – the only difference being the side of the counter they were on. I failed to realize that bureaucracies are numb to the consequences of their protocols because the protocols are just how its’ done – its not personal.

That is the essence of Effectively, that just because something feels right; just because it IS right doesn’t mean it’s effective. It’s about taming both logic and emotion with the realities of context and acting effectively within that context to get what you need – even if it means having to come back to the table more times than you’d like.

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.

NY Time Article on Evidence Based Treatment

So I’ve been skimming through some stuff I’ve been meaning to read (I’m really behind as you will be able to tell from the date of this article) and came across this gem.

A survey of 200 psychologists published in 2005 found that only 17 percent of them used exposure therapy (a form of C.B.T.) with patients with post-traumatic stress disorder, despite evidence of its effectiveness. In a 2009 Columbia University study, research findings had little influence on whether mental-health providers learned and used new treatments. Far more important was whether a new treatment could be integrated with the therapy the providers were already offering.

The problem is not confined to the United States. Two years ago, Dr. Waller studied C.B.T. therapists in Britain treating adults with eating disorders to see what specific techniques they used. Dr. Waller found that fewer than half did anything remotely like evidence-based C.B.T.

I tend to agree with the opinion that most therapists view their work as more of an art than science. The only real benefit to this belief goes to the therapist’s ego. This view of therapy can also act as a convenient excuse to get lazy and not keep up on the research. The challenge isn’t in having a good relationship with a client it’s in having a good working relationship with a client. The latter requires far more work and is a much greater test of skill.

When Reality Bites

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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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