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.

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)

EMDR – It’s not just for trauma

EMDR is widely recognized as a highly effective treatment for trauma but I’ve found it to be very helpful in the treatment of phobias and OCD. I don’t have a specific interest in any one set of interventions being “the best”. I use a variety of interventions in helping clients resolve issues. My use of EMDR in treating OCD and Phobias has to do with the limitations involved in treating these issues in an outpatient setting.

The primary limitation involves the use of in vivo exposure in an outpatient setting – one cannot always adequately reproduce the necessary conditions for this sort of work in the office.  Many times I would find that CBT and DBT skills were helpful but not enough to bridge the session to a real world application of self initiated/guided exposure.  I could always refer a client to a higher level of care but waiting lists, time constraints on the part of the client, costs and insurance coverage present as real barriers to accessing this type of care.

The logic in using EMDR basically resides in the fact that it has demonstrated efficacy in desensitizing clients to the images and memories of traumatic experiences while shifting negative beliefs they hold about themselves and the world around them to something more adaptive. I figured if it works for trauma, why not OCD or Phobias?

I found it to be highly effective in eliminating symptoms of social phobia and OCD in younger adolescents, effective with adults in alleviating social anxiety and moderately effective in helping adults with OCD become more comfortable in hitting targets for self initiated/guided exposure outside the office.  In each situation cognitive interweave and resource enhancement exercises were heavily applied and EMDR was one of three modalities used; CBT and DBT skills were the others.

Much of what I read about EMDR’s application in treating phobias and OCD was essentially anecdotal (like this article) but I found one research article that sort of confirmed what I felt about it.

 Both uncontrolled and controlled studies on the application of EMDR with specific phobias demonstrate that EMDR can produce significant improvements within a limited number of sessions. With regard to the treatment of childhood spider phobia, EMDR has been found to be more effective than a placebo control condition, but less effective than exposure in vivo.  link

I’m not sure why EMDR has not been researched more aggressively in the treatment of these issues given that the logic is a good fit and preliminary data shows promise. The folks at the OCD Recovery center appear to be doing some neat work and I hope they decide to eventually publish some of their data.

The Logic Trap

Kukulkan Logic is usually considered a virtue, most folks would prefer to be labeled as logical rather than emotional.  We tend to equate displays of emotion with weakness, unpredictability and vulnerability while logic is typically associated with calm, sound decision making and reliability.

Logic, like emotion, is only as destructive or useful as you make it.  Both are valuable assets in coming to a decision on whether action is required, how to go about the action and in determining whether the action was appropriate. Paying attention to only one and dismissing the other can lead to a harmful extreme.

There is good to emotion. Emotions are what motivates us to care for and bond with our children before they even come out of the womb.  There is no rational basis for feeling this kind of love for someone we hardly know. It is automatic and serves a valuable purpose. Emotions allow us to connect socially; they are the part of our make up that reminds us that our ability to do does not always mean we should.

You probably already know the value in logic, it is constantly lionized in the popular culture but there is a dark side.  One of my undergrad philosophy professors attempted to provide an airtight defense of genocide as a response to poverty. The class, as you would expect, was appalled and remained silent as he went back to his podium and stared at us for a minute or so.  He broke the silence with this statement-

“You’ve been taught that your ability to think is what separates you from animals.  That is half true. Your capacity for compassion and empathy are equally important.  That’s why you’re being forced to take a philosophy class.”

Rigid logic can trigger symptoms of anxiety and depression because of the harm it causes to our relationships and ourselves when expectations are not met and rules are not followed. Folks who struggle with eating disorders and Obsessive Compulsive Disorder (as examples) can be highly logical. While the behaviors may appear strange or irrational, the thinking behind them is not necessarily disconnected from reality or evidence. The harmful behaviors do work to serve a purpose in resolving distress and even managing relationships.

Earlier last month I wrote about the purpose an eating disorder could potentially serve for an individual in their family and that many theorists view eating disorders as a response to how different types of family systems work.  The behaviors can be effective in achieving the end result. While the other costs associated with the behaviors appear to significantly outweigh the benefit, that conclusion while more reasonable and widely accepted, is ultimately subjective.  I’m not arguing that eating disorders or OCD behaviors are things we should encourage, only that there is a logic to them that is reinforced with a behavioral reward. The logic is also what drives the emotion that amplifies the urge to engage in the behavior.

Rigid logic is really a perspective silo. The line of thinking may make sense and because it’s the only thing you see or consider, you act from it.

So how do we address rigid logic?

Mindfulness can help us remain detached to one way of thinking; by stepping out of our thinking and observing it we become more open to considering other more effective ways of handling a problem.  Mindfulness means being an observer of the experience before participating in it, playing the part of audience member before taking on the role of actor. As an audience member how would you describe the actions of the actor? What are the potential consequences of the action? How do other players in the scene react? How do you feel as you’re watching the scene play out?

Thought records can help us avoid logic silos by putting our thinking on paper along with the emotions they trigger.  Thought records challenge us to determine if our thinking is evidence based and reasonable.  The more certain and critical the conclusion the more cause you have to evaluate it.  Maintaining an awareness of common thought distortions can also prompt us to reconsider whether our thinking is reasonable.  Being aware of thought distortions is sort of like having an early warning system that our logic may be going down a harmful path.

Being aware of historical triggers can act as anchors to unhelpful thinking or beliefs.  This awareness can help us become more diligent in evaluating whether the current belief is based on the event in front of us or an automatic thought pattern tied to a set of historical experiences.  For example, a woman who grew up in an abusive household may become triggered into a negative thought pattern when receiving constructive criticism at work.  She may begin to fear losing her job and may criticize herself in ways that had nothing to do with the feedback or the intentions of the person providing it.  Understanding that the thinking is, in part, connected to the “stuff back then” can help her modulate the thinking and the reaction she displays in receiving the feedback.

Tapping into social supports, getting other opinions or using therapy to process our thoughts and beliefs can also help with broadening our thought process.  Leaving our thinking open to the analysis of others can help challenge our assumptions and work to validate and give evidence to more reasonable thinking.