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.

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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.

Anger in Therapy

anger Therapy shouldn’t always make you uncomfortable or angry but if you’re in treatment and working on changing long standing patterns of behavior and thinking – always walking out of session with a head full of rainbows, unicorns and lollipops probably means that at least some part of the work that needs to be done isn’t happening.

When a client expresses anger towards their clinician, the therapist should avoid getting defensive for a couple of reasons. Acting defensively usually makes people angrier because it typically involves invalidating some part of what the other person is saying off the bat.  Most clinicians, I suspect, would agree that “client will increase rage towards therapist” is not a goal that appears on any of their treatment plans.

Another reason has to do with opportunity – invalidating a client’s anger or defending yourself against such statements as “God, you can be such a  [explicative] [explicative] sometimes” means being inattentive to what creates the anger. Defending yourself means you’re not trying to understand; it means you’re trying to cover your ass.

When a client expresses anger towards me, the first thing I try to do is get a lot of detail as to their understanding of the trigger –

Was it an expectation I communicated?

Did I mismatch an intervention with where the client is at?

Did I communicate in a way that reminded the client of someone in their life (past or present)?

Did I demonstrate frustration or disappointment non-verbally?

Is there a piece of beef jerky stuck in my tooth that my client can’t stop focusing on and wishes would just go away?

I’ll also try to explore the beliefs surrounding the event and the client’s interpretation of the event while gently checking in with them on whether they are able to bring themselves to the possibility of different interpretations. If they are open to it,  I’ll ask them to talk about that as well.

Of course, during this process, good communication skills (mirroring, validation and empathy) are key as these interventions can be easily misinterpreted as trying to make the problem all about the client’s perception – which is usually not the case. These skills also go a long way in perhaps giving the client what they needed from you in the first place but didn’t get, which may have been the reason or a reason for the anger.

Substantial exploration of a client’s anger allows the therapist to not only understand where the client is coming from but may also help the client learn and understand adaptive methods of dealing with anger in the moment. It can also improve a client’s comfort level in disclosure – the better we handle difficult content and emotion, the safer clients will feel in divulging it.

When a client becomes angry towards their therapist, the therapist’s behavior usually played some role in it; it’s usually not just about the client’s “stuff”.  It’s important to identify it so that you can either make amends (when you’re in the wrong) and/or set the boundary/expectation (when the client’s expectation is unreasonable).

Now,  just because I may have been in the wrong on one or more fronts doesn’t mean everything the client believed about the event and their reaction should be let go.  Clients are going to come across people who are going to get them angry – that’s a fact of life.  Therapy, like anything else, is imperfect and how that imperfection is processed and dealt with is important.

As a general rule I wait until the next session to bring my thoughts up and many times a client will have come to a different understanding of what happened by then which really makes the whole thing more useful. Time and distance gives a therapist and client the ability to compare thought patterns and conclusions, in relation to the trigger between two points in time.

One obvious exception to all this involves threats (direct or indirect) which need to be dealt with directly.  Threats are really very rare, usually impulsive, not meant, and the result of the therapist having to do something unpleasant – calling child protective services for example.  Even in those cases, most clients understand why you’re doing what you’re doing. Just because we don’t think the client “means it” however does not mean we shouldn’t act like they do.   I’m not going to get into how to handle threats here (that’s a topic in and of itself) but I brought them up as one example where exploring anger may not be appropriate – sometimes therapists need to act first in setting a boundary before any discussion about triggers and the relationship can safely take place.

If you’re the client, understand that getting angry over something your therapist said or did once in a while is a reasonable thing to expect. Feeling that way after every session or having intense feelings of anger towards your therapist more than a few times may mean there’s a problem with what’s going on in the room. Even then it could be about the work being done and where you’re at with it; which is why it’s important to be honest with your therapist about your anger instead of not saying anything or changing therapists without first examining what’s causing the anger. Talking to your therapist may not resolve the issue-it usually does – but terminating the relationship (if that’s where it goes) in an adaptive (non-avoidant/non-aggressive) way could hold a real benefit.