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.

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.

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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)

Triangles and Family Systems

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“Triangle” is a term out of Bowen Family Systems theory used to describe a phenomenon in family systems whereby a third entity (not always a person) is used to stabilize conflict and distress in a relationship between two people.  Triangles are generally thought of as undesirable because it is a communication avoidance strategy or pattern that resolves the distress surrounding an issue without resolving the issue.  Triangles involve shifting alliances among three entities; these alliances always leave one of the three on the “outside”.

Triangles exist because the relationship between two individuals in a family system is regarded as the most unstable. If a significant issue between two individuals doesn’t get resolved a consistent thread of distress in the relationship that bleeds into the day to day life of the relationship can develop. This may bring some hefty long term consequences to the table (lack of intimacy, lack of communication, avoidance, infidelity etc.)

One classic triangle involves the person struggling with addiction, the rescuer and the substance. This is a useful example because the relationship between these three is usually in a consistent state of distress during the latter part of the addiction and it is during these times that triangles become more noticeable.

During times when consequences of the use or addiction is contained to the family system (work is going okay, no legal issues, etc.) the person with the addiction and the substance form the inside relationship.  The rescuer typically utilizes nagging and other use control behaviors to try to prevent the person who is using from using.  These behaviors are typically ineffective and create more distress in the relationship. In some ways it can, in the addict’s mind, justify increased use as a means of “dealing with it”.  This places the rescuer in the role of “outsider”.

Eventually the person with the addiction is going to face an external consequence for their behaviors (bank notes as finances deteriorate, employment issues, legal troubles). Each of these consequences presents as a threat to the inside relationship the addict has to the substance; he/she cannot use if they are in jail or do not have the means of supporting the addiction.  As a result of the distress created by the anticipated negative consequences, the person with the addiction may increase proximity to the rescuer to engage their help in avoiding the consequence (bailing them out, calling work with excuses, etc.).  Sometimes, the rescuer doesn’t wait to be asked; seeing that the person with the addiction is about to face a damaging consequence they may decide to step in to solve the problem.

This process acts to lock the triangle as the rescuer prevents the person with the addiction from facing the natural consequences that may act as a catalyst for treatment and sobriety – the long term changes that may be needed in order for the real problem to be solved.

Another thing to keep in mind is that one triangle usually creates more triangles, it can be lonely being the outsider and eventually folks will need to figure out some way of dealing with the distress of the issue driving the triangle.  Typically, if there is one entrenched triangle in a family there are probably several others.

Sort of like cockroaches.

Gross.

Some of the most devastating triangles are those that involve children as the go between two parents who have severed communication. Children acting as messengers or negotiators between two parents can be harmful even if efforts are made not talk “bad” about the other parent; as the inability of one parent to speak to another can carry with it certain meaning to the child and places an added level of distress the child has in their communication with each parent.

All that being said, every family triangulates sometimes and sometimes it can produce very good results.  The key is to make sure that the patterns of triangulation aren’t entrenched; that direct communication is typically how a family deals with problems – triangles should really be an exception to the rule.

Because triangles are difficult to identify and family relationships are typically our most proximate and comfortable, getting caught up in them isn’t too hard.  A general rule of thumb in avoiding triangles is to be mindful of problem ownership.  If you don’t own at least part of the problem then there isn’t much you can do about it. You can be supportive but getting directly involved provides an easy entry point into bad dynamic. If you’re going to someone else about an issue and they weren’t involved to begin with, be clear as to whether their involvement is appropriate and tame your expectations with regard to what you feel they should and can do about it.