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)

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.

The Grief FAQ- Avoidance

driving through desert foothills

Back in November I wrote about how the field is shifting its thinking on complicated grief and some of the controversy surrounding the changes to grief as an exclusionary criterion for depression in the DSM. I still agree that the change was a step in the right direction and with that in mind, we’re going to look at how CBT can be useful in addressing avoidance behaviors within the context of complicated grief.

Individuals who struggle with complicated grief may engage in avoidance behaviors as a way of dealing with the distress caused by situations connected to the loss. Behaviors may include avoiding family gatherings, isolating during certain times of the year, avoiding certain family members, avoiding places that have a connection to the loss – the list can be long or short. Avoidance behaviors carry two big price tags, the first being that they make the distress related to the situation worse in the long run. To understand why this happens it might be useful to understand the culprit behind the behavior namely, faulty thinking.

Avoidance behaviors are generally driven by catastrophic hypotheses . By engaging in the avoidance behavior we get immediate relief from the distress because we avoid whatever catastrophic event we believe may happen if we were to confront or face the situation- this is the hook. In avoiding the situation we rob ourselves of the opportunity to test the hypothesis. Because negative thinking surrounds the situation we are seeking to avoid, our beliefs about the situation become more catastrophic as more time passes between the present and our last successful exposure to the situation. This increases the likelihood that we accept the hypothesis as fact without evidence.

Let’s say a hypothesis someone may have looks something like,

“If I attend a family function I will go crazy.”

Things get even more complicated if the last exposure to the situation actually did involve an unpleasant or uncomfortable experience; there may be historical evidence to support the belief that the hypothesis is correct. So…

“If I attend a family function I will go crazy.”

Feeds into or is based on…

“Last time I went to a family event I had a panic attack and embarrassed myself in front of everyone.”

By not accepting the invitation, the distress associated with the invitation probably drops down rather quickly. However, the long term impact may involve an increase in the distress they experience when thinking about or faced with the prospect of attending family functions in the future. As this spiral progresses, negative core beliefs the person has about themselves in relation to the loss may either get reinforced or introduced…

“I’m a bad [uncle, cousin, son] because I abandoned my family after the loss.”

Which brings us to the second price tag; sometimes avoidance behaviors cause us to push away from supports and activities that can actually help us through the grieving process. By burning both ends of the candle through avoidance, increasing the distress associated with triggers connected to the loss  AND isolating from supports that can help us cope with the loss, we are significantly reducing our overall capacity to adaptively grieve.

The most effective way to reduce the distress associated with triggers is to test the hypothesis but that may be a tall order and, in some situations, even counterproductive for someone who experiences really high levels of distress. One small step that may increase comfort and motivation to change the behaviors is to really examine history.

True, there may have been times when things did not go well when confronted with a situation connected to the loss but can you think of other times when things did not turn out so poorly?

What could you learn from the “bad exposures” that may be helpful to you in future exposures?

Were there other circumstances contributing to the negative exposure that no longer exist?

On the whole, in what ways are you better now than you were then?

What are the real costs and benefits to keeping things the way they are?

What are the real costs and benefits to changing?

Even if the worst happens how can confronting the trigger still be beneficial?

Would you judge someone you cared about as harshly as you are judging yourself?  What evidence do you have to support the belief that your family members are any different?

Hopefully, examining  the record of history and putting the “worst” in perspective will help reduce the amount of anticipatory distress to a point where you feel capable of taking a few more steps forward.

One tool that can help you cope with avoidance is a fear ladder which can break down the event you are avoiding into small pieces. Each piece will trigger different levels of distress; the trick is to begin confronting those aspects of the situation that bring up the least amount of distress. So a person who isolates may begin by emailing family members they have been avoiding. Typically friends and family members will be glad to hear from the person and the feedback received may test the hypothesis further or challenge the core belief. As you work on the lower rungs you may notice that the pieces on the higher rungs may also shift down.

Something else to keep in mind is that the anticipatory distress of a triggering situation usually drops off after a period of time during the exposure.  Sure, there may be a bit of a spike from anticipation to exposure but eventually the distress drops below the level prior to the exposure as a result of testing the hypothesis and/or surviving the situation despite it not going as well as you would have wanted.

Although we used family gatherings as an example throughout this post we can really apply this thinking and skill set to anything we avoid as a result of the loss – photo albums, restaurants, sections of town, etc.  Although exposure is effective, it is not advisable for every situation.  For example, I would never encourage an individual who struggles with a gambling addiction to hang out in a casino.  Also, it is very important to remember that exposure can make matters worse if not done correctly and so if there are concerns about safety or fears that exposure may lead to a worsening of symptoms, it is probably best to seek professional assistance.