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Anxiety Disorders in the DSM 5 TR | Symptoms and Diagnosis

Hey there, everybody, and welcome to this presentation on diagnosing anxiety and panic in the DSM 5tr. I’m your host Dr. Donnelly Snipes in this presentation.Very briefly, we’re going to review the diagnostic criteria for anxiety disorders or at least most of them in the DSM 5 tr.So let’s talk a little bit about anxiety disorders in general, when we’re talking about anxiety disorders, we need to remember that fear and anxiety may be expressed as fighting agitation, tantrums fleeing freezing fawning clinging, or withdrawal, or what I call the final f, Which is um politely forget about it, because people, just don’t have any more energy left, so they kind of withdraw anxiety.Disorders differ from each other regarding the types of objects or situations that cause fear, anxiety, or avoidance behaviors and the associated beliefs.Anxiety disorders represent a response that is not developmentally culturally or, I also add, contextually normative in terms of intensity or duration.So when we’re looking at what somebody is anxious about, we want to examine, obviously culture and development, something that a five-year-old is afraid of is not necessarily going to be the same thing that a 25-year-old is afraid of.We also want to look at context, though, something that uh, you’re, afraid of in one context, you may not be afraid of in another like for children being around strangers may not be stressful for them when they are at home or when they’re.At school, somebody comes in to do a presentation versus when they are alone and they don’t have a caregiver around.Interestingly, from August 2020, through December 2020, the percentage of adults reporting symptoms of an anxiety disorder rose from 31 4 to 36 9.Now, when you go through the DSM and you start adding up the prevalence of these anxiety disorders, it is really hard to get to a number anywhere close to 36 9. So the numbers in the DSM and the numbers in the uh national health survey, don’t seem to jive very well.We also have to remember that during 2020 we were at the beginning of the pandemic, so there was more anxiety.You would expect that, but even the 31 percent that it was before 2020 seems to be higher than what is identified in the DSM.So I think that’s interesting the anxiety chapter in the DSM 5tr, just like in the DSM 5, is arranged in order of diagnosis which appears in children first, so separation, anxiety, and disorder appear first, and generalized anxiety.The disorder is down a little way, whereas you might expect some of the quote more common disorders to be first, but that’s not how the DSM is arranged.However, in this presentation, I did put generalized anxiety first, when we talk about generalized anxiety, we’re talking about excessive anxiety most days for six or more months, and the anxiety is about a variety of things.It’s not just about one particular thing like health or an individual or a phobia.It is about a variety of things.The worry, in addition to being excessive for the person’s developmental age, culture, and context.The worry is difficult to control the anxiety or the feeling of anxiety is associated with three or more symptoms in adults or one or more symptoms in children, feeling restless or feeling keyed up or on edge, easily fatigued difficulty concentrating, or mind going blank, irritability muscle, tension Or sleep disturbance, I want you to think about it. Anxiety is part of the fight or flight response, so we would expect somebody to experience anxiety.Would it be experiencing symptoms of hpa, axis activation, or activation of the threat, threat, response, or stress response? Whatever you want to call it, so we would expect all of these symptoms or any of these symptoms. When the fight or flight system is engaged, the body is not focused on higher order, processing, memory, or concentration it’s focused on self-preservation protection the person becomes more vigilant because they are trying to protect themselves from threats.They’re not able to relax enough to get good quality sleep because guess what they are keyed up.They’re scanning for those threats, muscle tension and I’ve mentioned in other videos.When I used to play tennis, my coach always used to say don’t stand flat-footed on the baseline, because it takes more time and it’s harder for you to run and spring into action to where that ball is going to be.Now.That is not a threat per se, but the same thing is true for people with anxiety disorders, when you are when you’ve got that muscle tension, it’s kind of like standing on your toes on the baseline.In tennis, you are primed and ready to go and it makes it easier to theoretically fight or flee.These symptoms have to cause clinically significant distress.People can have subclinical anxiety disorder where they have a lot of worry about a variety of things, but it is either not excessive for what they’re worried about, or it doesn’t cause them clinically significant distress. Overall, they report a decent quality of life.It doesn’t interfere with functioning in major areas of their life and generalized anxiety disorder, as well as all of the disorders, are not better explained by a medical, mental, or substance use disorder, and we’re going to talk in the end about differential diagnosis Of the anxiety disorders in general because there’s a lot of overlap between the symptoms, as well as the differential, diagnosis, and comorbidities for anxiety disorders.Remember the difference is often what the person experiences anxiety about and the cognitions associated with the diagnostic features of generalized anxiety disorder.Well, this section, as with most of the sections in the anxiety chapter, pretty much just recapitulated the diagnostic criteria and it elaborated a little bit.One interesting feature is that for generalized anxiety disorder, they noted that adults tend to worry about general life, things like paying bills and getting a promotion, or what’s going to happen with this or that or what’s going on in the world. Kids tend to worry about their competence like performing at school or their ability to be competent in relationships.Sometimes they worry about disaster now, with the coming of the pandemic.We can probably add that too, but other disasters like hurricanes and fires and floods and those sorts of things can prompt a lot of worry in children and punctuality.Interestingly enough, some children become very concerned about being punctual, and so it’s interesting to note that there is a difference in what they worry about, which makes sense, because adults have different responsibilities than kids do, and you notice that, except for disaster, a lot of these worries revolve around the primary life areas or functions of the person.You know: kids, are,  n’t worried about paying bills or or maintaining or parenting, or some of the things that that adults worry about associated symptoms.Well, let me talk about disaster. Quick, I’m trying not to go too far off the rails today, because we’ve got a lot to cover, but it’s important to recognize that children have a difficult time, understanding, the prevalence and likelihood of things.So when there is a disaster such as you know, we’ve had several in middle Tennessee over the past two years and a child watching the news or hearing about the news may not understand how close or far away that disaster was or the likelihood of It recurring adults are better able to understand.You know it’s a 100-year flood or there’s the chance of it happening again.Do you know whatever? The probability is depending on what you’re talking about children don’t understand that they see it on the news it feels like, since it’s on the news, it’s kind of in their house.So it feels like it’s right in their space and it’s hard to know when it’s going to end or when it’s going to happen again, which can prompt them to have a lot more worries about disasters.Parents can help by explaining some of the things to them and explaining to children the probability of another disaster occurring, and you know how they’re safe right now and the steps that they can take.It won’t do everything, but it is important again to recognize children’s different cognitive abilities compared to adults, associated symptoms with generalized anxiety, disorder, and other somatic symptoms that are not as intense as those seen in panic disorder.So we will also see potentially heart racing clammy, skin, rapid breathing other things, and an upset stomach that isn’t specifically indicated in diagnostic criteria, but we know it happens when that fight or flight response is kicked off the prevalence.Remember I said if you start adding up the prevalence of all these anxiety disorders.You’re going to be hard-pressed to get anywhere close to 31 percent and according to the DSM 5 tr between one percent of adolescents and three percent of adults in the? U s experience generalized anxiety disorder according to the National Center on Health Statistics in 2019. Now that was before the pandemic.15 6 of adults experienced symptoms of generalized anxiety disorder in the prior two weeks.The development, and course the mean onset, is rarely before adolescence, and is I’m? Sorry, the mean onset is 35 and rarely before adolescence.So this is one of the disorders that has a much later onset than other disorders, which I did find to be somewhat interesting.Now we’ll move on to separation.Anxiety, separation.Anxiety is the first disorder in the chapter because it tends to be the one that presents earliest and it can be diagnosed as early as preschool separation.Anxiety is characterized by developmentally inappropriate, excessive, recurrent anxiety about separation from major attachment figures.To be diagnosed, the person has to have three or more symptoms.It can be diagnosed in childhood. It can be diagnosed in adulthood if it’s diagnosed in adulthood.You do not have to have a childhood onset of separation anxiety.It actually can have an adult onset, so that is something to remember: symptoms, three or more distress due to or in anticipation of separation from home or from major attachment figures, anxiety about losing a major attachment figure, or possible harm to them.Anxiety about something bad happening to the person, the patient, which would cause them to be separated from an anxiety from an attachment figure.So they have fears about something happening to the attachment figure, causing separation, and fears about them, something bad happening to themselves, causing separation, a reluctance, a refusal to go out or away from home because of fear of separation.Now, generally, this is leaving home and separating from that attachment figure, but in some cases, it can include even being reluctant to leave the house to be cut with the attachment figure because they’re afraid that when they’re out there, they may get separated.Now think how this might occur if there was a child who happened to be at a carnival and got separated from their caregiver that might prompt future fears of separation when in public places, fear of or reluctance to be alone, or without major attachment figures.Refusal to go to sleep without being near a major attachment figure, nightmares about separation, or physical complaints in reaction to or in anticipation of separation.So they have those physiological symptoms of anxiety now note here they keep talking about major attachment figures because remember this can be diagnosed in adulthood.We’re not talking about the primary attachment from infancy. We’re talking about the person’s current major attachment figure, whether that be their significant other, their parent, or whomever that happens to be the fear, anxiety, or avoidance, is persistent, lasting at least four weeks in children and adolescents, and typically six months or more In adults – and you’ll find that’s a common theme where a lot of these situations or conditions have to last six months or more and be causing clinically significant distress for six months or more to rank a diagnosis.Although the symptoms often develop in childhood, they can be expressed throughout adulthood.It can be diagnosed in adults in the absence of a history of childhood separation, anxiety, or disorder, and, as I said, it causes clinically significant distress or impairment in one or more areas of functioning.The diagnostic features section repeats the diagnostic criteria with some elaboration and examples.It’s a pretty straightforward diagnosis in terms of development and, and course the onset of separation.Anxiety can be any time from preschool through adulthood, but generally before the age of 30.So you can have diagnoses of separation anxiety up through the 20s, there may be periods of exacerbation and remission, although most child onset cases do not experience ongoing, clinically significant impairment.I thought that was kind of an interesting associated feature.Now these are not diagnostic criteria.These are features that are associated with separation anxiety but didn’t rank in the diagnostic criteria, sadness or apathy. Well, if somebody is perpetually anxious that hpa axis is going to down-regulate some which may contribute to apathy, if they are perpetually anxious, they may also start feeling hopeless and hopeless, which is associated with feelings of sadness and depression.They may have difficulty concentrating well.The mind is not focused on concentration.If it’s in a perpetual state of fight or flee, there may be social withdrawal just stepping away from everything, because they don’t have the energy to engage with others.Because the anxiety is so pervasive in older children you may see homesickness or pining when they are away at camp or or something like that.Now.A lot of children who don’t have separation, anxiety, or disorder, experience homesickness when they’re away at camp.For the first time, however, this is also associated with separation, anxiety, the child migs or the person may exhibit anger or aggression towards separators.So anybody who’s causing a separation between the patient and their major attachment figures may provoke anxiety, anger, and perceptual disturbances.Now these are not hallucinations. These are when a person is alone, for example at night, and they feel like somebody’s watching them, or they think they see something moving in the shadows.It’s not there and by turning on the light.So there are no more shadows.You know that goes away.It’s, not a persistent uh hallucination that the person is experiencing, but perceptual disturbances are more common in children than they are in adults, and we want to make sure we don’t mislabel that as something related to a psychotic disorder, children with separation, Anxiety tends to be described as demanding intrusive and in need of constant attention.According to the DSM now, I would argue when we get down a little further that this may be true of all people with separation, and anxiety, adults may appear dependent and are likely to contact their major attachment figures throughout the day and track their whereabouts.They are also often overprotective as parents and pet owners.Interestingly enough, the DSM did mention pets where the person with separation anxiety may be excessively concerned about knowing where their pet is at all times.The prevalence of separation.Anxiety in children is approximately four percent, and in adolescents and adults, it ranges from one to two percent. In the culture section, the DSM talked about the importance of differentiating separation, and anxiety disorder from the high value, some cultural communities place on strong interdependence among family members.Specific phobias is the next in the line of disorders we’re going to talk about and a specific phobia is pretty straightforward.There’s a marked, fear or anxiety about an object or a situation about 75 percent of people that have one phobia have more than one phobia, and I think, if you think about it, even if it doesn’t rise to the level of being a Diagnosable phobia you can think about.If you have one what we’ll call irrational fear, you probably have a couple of others when I started to think about it.I’m, like yeah, i have i have a couple in there.The stimulus almost always produces an immediate fear response and is actively avoided.The fear is disproportionate to the threat that persists for guess what six months or more and causes clinically significant distress – and I have this bold and italicized because it’s important to remember that.Having a fear – and I’ve talked in other videos about my fear of bridges, I also have a fear of enclosed spaces.I hate you know those little water, tubes and tunnels and things that make me feel closed in.Does it cause me clinically significant distress or cause me to have to alter my life to get around it? No, so it doesn’t rise to the level of a specific phobia. A lot of people have fears that may not have a um basis or the fear may be disproportionate to the threat.In reality, we recognize it, but it doesn’t cause us clinically significant distress, so it would not be diagnosable as a specific phobia and the specific phobia is not better explained by another mental disorder and I’m thinking here more obsessive, compulsive disorder.But in the differential diagnosis list on the anxiety disorders, there were a lot, so we’re just going to go through all of those.In the end, the diagnostic features again for specific phobias were pretty much a restatement of the diagnostic criteria-associated features.Interestingly enough, some people are arousal.Well, that makes sense when the HPA axis kicks off.A lot of people have a um increased heart rate, sort of a panic sort of feeling about them, not to the level of a panic attack necessarily, but they have that aroused state in preparation for fight or flee.Other people may have what they call a vasovagal response in which their heart rate decelerates their blood pressure drops, and they may faint my grandmother used to do this.Oh my gosh, and it wasn’t necessarily hers.Wasn’t phobia-related, but when she would get startled she would fall out and for the longest time the doctors, couldn’t figure out exactly what was going on. But ultimately my guess would be.It re had something to do with with anxiety or generalized anxiety.The prevalence of phobias is between eight and twelve percent, it peaks in adolescence at sixteen percent.So sixty percent of adolescents have specific phobias.The development, in course usually develops before age, 10 or after a trauma, and the presence of phobias is a risk factor for neurocognitive disorders in older adults.Why is this? We’ve again, we’ve talked in other videos about how hyperactivation of that stress response system keeps levels of glutamate and norepinephrine and stuff high in the brain which causes neurodegeneration, which can lead to neurocognitive disorders additionally, because of social withdrawal and avoidance and restructuring Of their daily lives, to avoid the phobic stimulus, there tends to be less stimulation for the person with specific phobias, which may also lead to a decline in what they call cognitive reserve and social anxiety disorder in social anxiety disorder.There’s a marked fear of social situations when in which one might be judged.So you’ve got generalized anxiety, which is anxiety about a lot of things over at least six months.We have a specific phobia, which is something specific.Like enclosed spaces or spiders, or snakes, um separation, anxiety, which is anxiety or fear of being separated from an attachment figure, and then social anxiety, which is fear from being in situations in which one might be judged by children. The symptoms have to be present not only in relationships with adults but in relationships with their peers.It’s natural for children to be somewhat anxious if they’re interacting with adults if they’re having the same anxiety when they’re interacting with their peers, then that’s really what we’re going to look for for a trigger The person has an excessive fear of being embarrassed, rejected or offensive, and the offensive seems to be increasing in popularity or not popularity in commonality, um very quickly, with Twitter and Facebook and tick tock, and all these other things and trying to be politically correct.A lot of people have developed a level of social anxiety, maybe not to the level of being a disorder, but, a level of social anxiety, because they fear not saying the right thing because they fear being canceled.Social situations almost always trigger anxiety and social anxiety disorder.Social situations are actively avoided or endured with intense fear, and the level of fear is disproportionate to the potential consequences.People may have a high level of fear and anxiety uh before going out and giving a performance in front of 10,000 people the level of anxiety for that would probably be different than giving a speech in front of six classmates.You know you see the difference here, but a person with social anxiety disorder.They would have that same level of fear in front of six people.They knew as opposed to ten thousand, that they didn’t persist again for six months or more causing clinically significant distress and is not due to another medical, mental, health, or substance-related condition.There is a note that social anxiety disorder can be performance only and you do want to specify that if it only has to do with giving speeches performing sports music, or anything like that, the diagnostic criteria features section, gave further examples of the symptoms that were identified in The diagnostic criteria associated features with social anxiety. The person may be passive or shy.They may want to kind of blend into the wall.They may be somewhat withdrawn because they don’t want to be out there in the limelight.They don’t want to be in this position where they fear being judged.On the other end of the spectrum, though, there’s a proportion of people with a social anxiety disorder who are highly controlling of situations, and they may try to control the conversation and control other people in the situation to avoid feeling out of control.Use of substances, substance, use, misuse or abuse is often associated with people with social anxiety disorder, and I have parenthetically heard liquid courage is what we used to call it back in the day I don’t know if it’s what they still call it but using substances to help temporarily allay anxiety.Interestingly, as alcohol leaves, the body people tend to have an enhanced anxiety response.So using alcohol before a social situation may end up causing more problems for some people, but that’s that’s up to them.Additionally, you may see a worsening of physical illness symptoms such as tachycardia or increased tremor in people with social anxiety disorder, so if they already have something that causes a tremor or a tick that may get worse, if they already have something that causes tachycardia, that may Get worse in situations in which they fear being judged.Now I have here increased pain, a question mark that’s not identified in the DSM 5t. However, we know that hyperactivation of the hpa axis contributes to ultimately development of systemic inflammation and the worsening of autoimmune disorders.So I would be interested to see what the actual numbers are for that and no, I could not find any research that compared the rates of increased pain with social anxiety, specifically prevalence.Seven percent of people in the United States experience social anxiety, disorder now brace yourself.This is not a typo.2 3 percent of people in Europe can be diagnosed with social anxiety disorder.So what is that? A third? What’s different in the United States? That is contributing to significantly higher rates of social anxiety fear of being judged and fear of offending people.Just saying additionally, social anxiety disorder does tend to be highest in non-Hispanic whites.So what is unique about nonhispanic? Whites in us I’ll leave you to talk about that and panic disorder, people with panic, disorder, experience, recurrent unexpected surges of intense fear or discomfort that peak within minutes and has a and accompanying four-plus symptoms.Now I have bolded and italicized unexpected here there are expected panic attacks when you’re in a situation in which you’ve had a panic attack before when there is a known trigger for the panic attack that’s an expected panic attack that doesn’t count towards our diagnosis here, which I don’t know seems a little strange, but okay, the panic attacks have to be unexpected.That is, they come from out of the clear blue and the panic attacks need to be characterized by four or more of the following symptoms palpitations, which is when it feels like your heart, is like fluttering, pounding, heart or tachycardia, which is racing heart, sweating, trembling or Shaking a feeling of shortness of breath or smothering you just can’t don’t feel like you can breathe, feeling like you’re, choking chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady lightheaded or faint chills or heat, sensations, numbness or tingling. Derealization, in which things just don’t feel real.You feel like you’re kind of a dream or depersonalization.You don’t feel, like you, ‘re part of your own body, anymore, with fear of losing control or going crazy and fear of dying.Now I’ll mention it, even though it’s pretty obvious.Many of these symptoms are also symptoms of a heart attack.It is important if you are a clinician not to assume that somebody who is experiencing a panic attack it’s, it’s, just a panic attack and to dismiss it.It’s important to take every panic attack seriously when somebody’s experiencing it and work with their medical provider to help them differentiate between what’s a panic attack.How do I know when I’m having another panic attack versus how do I know when I need to go to the ER and their doctor will work with them on that culture? Specific symptoms of panic may include tinnitus or ringing in the ear and neck.Soreness headache, uncontrollable, screaming, or crying.Interestingly, even though these are culture-specific symptoms, the DSM said those don’t count toward the required four plus symptoms. Additionally, at least one of the attacks – unexpected attacks has been followed by one month or more of both of the following persistent concern or worry about additional panic attacks or their consequences and a significant maladaptive change in behavior related to the attack avoidance of situations where You think they might happen again or ritualized, or superstitious behavior or extreme behavior, like changing your diet completely or doing something extreme to try to prevent the attack, so the unexpected attack happens and then for the next month or more.Both of those persistent concerns about it happening again and significant maladaptive changes in behavior are occurring, it has to cause clinically significant distress and it’s not due to another mental medical or substance use disorder.Interestingly, for panic attacks, there were no specifiers, but in the diagnostic features, it did note that panic attacks can be full meaning four or more symptoms or limited symptoms, so it doesn’t meet all of them.Doesn’t meet four symptoms or more, but the person’s having a panic response.If the person has never had a full-blown panic attack, uh, four or more symptoms, then you would not diagnose panic.Disorder frequency can be relatively regular like one per week or it can come in bursts where they, where they have multiple, really close together, then they go weeks months, or even years without having them, and then they have another burst of panic attacks, and there could also Be instances where they just have a panic attack, and then they may go for a couple of years or more before they have another one.It still qualifies as panic disorder.There is no code for remission of panic disorder and the expectation is unfortunately that if somebody has had a panic disorder at some point, they probably will have another panic attack at another point.Remember that expected panic attacks occur with known triggers, and there are many culture-related diagnostic issues due to expected triggers.So if you read through the culture-related diagnostic issues, a section of the DSM 5tr, you will find they talk about a lot of culture-bound triggers that can cause a panic attack in people’s associated features. People who have panic attacks.Panic disorder may also cause intermittent anxiety about health or mental health.They tend to be more somatically sensitive.That means they’re more aware of what’s going on in their body.Well, that makes sense if you’ve already had your body kind of go haywire on you once makes sense that you would be a little bit more hypersensitive to it happening again.They may have increased anxiety about their ability to tolerate daily stress there.A lot of times this may stem from the fear that if they experience too much stress it, ‘ll trigger another panic attack and they may have more extreme behaviors to control panic.The prevalence of panic disorder is about the same two and two percent to three percent in both the: u s in europe and Europe, the only disorder that had a marked difference between the; u s and other countries.Interestingly enough was social anxiety, disorder.The development of panic disorder, the median age – is 20 to 24 in us and 32 worldwide. So that is a little bit divergent.You know the prevalence, and the number of people that experience it worldwide are pretty comparable, but the median age for panic disorder is much younger in us than in other countries.Additionally, they speculate that older adults may attribute symptoms to medical conditions, so they may be underrepresented in the prevalence rates because when they’re having these panic symptoms, they’re, attributing them to medication, side effects, or other health conditions that they already have.So let’s talk about some of the risk and prognostic factors for anxiety disorders in general.Anxiety disorders often develop afterlife stress.This could be a death, a severe illness, a disaster, a big move becoming a parent adverse childhood experiences, or aces that’s just to name a few that those aren’t all of the causes, but I think it’s interesting that becoming A parent was in there as a life stress that often triggers the development of anxiety disorders.I mean I’m a parent myself.I can see how that could happen, but it’s not something that I had considered in the past as a risk factor for the development of anxiety disorders.People who’ve been bullied have an increased risk of developing anxiety disorders.The heritability of anxiety disorders ranges between 30 and 75 percent. I found that interesting, but they didn’t explain in any of the diagnoses whether they were looking at twins that were raised in the same household or twins that were raised in different households.If they’re raised in different households, it gives more credence to a genetic component.If they’re raised in the same household, then they experience the same psychosocial, and environmental stressors.Both of them are so.I don’t know what the actual data is on that person with negative affectivity.They tend to be more brooding, more depressed, more irritable people who are more self-conscious.People who ruminate more also all of these kinds are combined often referred to as neuroticism.They are at higher risk for the development of anxiety disorders.Attentional bias to threat was noted in generalized anxiety disorder as being an associated feature, but research shows that people with any anxiety disorder tend to have a stronger attentional bias to threat, which means they tend to be more hyper-vigilant.They tend to be more aware when there are, threats in the environment, and anxiety disorders by and large – tend to be much more frequent in women than in men. Interesting, not sure.Why again, my assumption is this is people who are biologically female and it seems to be consistent across cultures.Therefore, I am wondering what the genetic predisposition might be that may cause this.It seems like it’s, less about environment and shaping and behavioral training and more about a physiological response.But additionally – and these last two were not in the DSM.However, I did a PubMed search for risk factors for anxiety disorders and those who have a more external locus of control.That means they believe that things happen in the world by fate.By chance, there’s not a they.Don’t have a whole lot of control or ability to change what’s going on destiny is preordained, etc.People with that outlook who have a more external locus of control, tend to have much higher rates of anxiety and depressive disorders, and again not in the DSM, but in the PubMed. In the literature.People who have a lack of emotional support also tend to be at greater risk for developing anxiety disorders seems pretty self-explanatory in terms of suicidal thoughts.Anxiety itself increases the risk of suicidal thoughts.All of your anxiety disorders carry with them an increased risk of suicidal thoughts.People with separation anxiety have that generalized anxiety, related to increased risk, but people with specific phobias, interestingly enough, have an increased transition from ideation to attempt in a study that was cited in the DS well mentioned in the DSM, but they didn’t say what the study Was they looked at adults and they found that up to 30 percent of people who had their first suicide attempt? It was related.They also had a specific phobia or it was related to that specific phobia so that’s 30 percent is a big number uh.When we’re, especially when we’re talking about suicide attempts and suicidal ideation, if you have somebody with a specific phobia, we often downplay that because we think it’s just a fear of this or a fear of that.But that fear can feel very, limiting and oppressive to a lot of people, and again 30 percent of them.Uh, 30 percent of people who have attempted suicide also had specific phobia functional consequences.Now I could go on a diatribe about the functional consequences of anxiety disorders. The DSM didn’t have much to say about it, so let’s talk about some of these limited independent activities.This is especially true in agoraphobia and separation, anxiety, people who are afraid of leaving the house for fear of being separated from their significant other or for fear of being separated from their safe place, and people who have social anxiety, who fear being in social situations, may Have a lot of restrictions on their life activities and limited activities that they feel safe or comfortable doing by themselves, not in the DSM 5 tr, but in the literature, also the functional consequences of impaired relationships.People with anxiety disorders may be because of their restrictions on life activities and their um potential need to know where people are and their separation, anxiety, etc.A lot of times, people with anxiety disorders struggle in their relationships, because it can feel overwhelming to the partners.As I mentioned earlier, people with anger, and anxiety disorders, have higher rates of autoimmune issues.Continuous or excessive levels of stress hormones contribute to systemic inflammation, which will trigger depression or is associated with triggering depression and associated with worsening of autoimmune conditions and obesity.I thought this one was interesting, but it makes sense when you look at it.People with anxiety disorders, who often are restricted in their life activities, may feel worn down and exhausted.From being stressed out, all the time may not have a lot of energy to do.Other stuff tends to be more prone to develop obesity so that’s an interesting functional consequence now differential diagnosis, I told you there was a laundry list of them. Generalized anxiety, a disorder in gad.Excessive anxiety is about a variety of things for at least six months.Separation, anxiety, the worry or the anxiety is about separation from the attachment figure.Okay, that’s pretty clear, agoraphobia.The fear is about being trapped or helpless in situations in which escape is difficult.The fear surrounds being away from their safe place, not being away from a person they want to be in a place where they feel safe, and it needs to be not specific to one setting so being trapped or helpless in a situation.I give the example of an MRI that closed MRIs.Oh my gosh, I can’t stand them.I’m terrified of them, but that is specific to one setting and I’m not afraid to leave the house for fear of being trapped or helpless in a situation, social anxiety, anxiety is about being judged negatively, and illness anxiety and this illness anxiety.Falls under somatic disorders but illness anxiety. The worry is about the illness, not separation, judgment, or being away from your safe place, so that’s a differential diagnosis of your basic anxiety disorders in terms of other disorders because there’s that criteria not better explained by another mental health or medical disorder.In psychotic disorders, people who have hallucinations and delusions may also have anxiety, but their worry or fear surrounds hallucinations or delusions and is not reversed by context or the presence of an attachment figure.So a person with psychotic disorders, if their major attachment figure shows up does.  n’t help them feel more comfortable if they turn on the light to eliminate the shadows that don’t make them feel more comfortable, and the hallucinations are not due to psychotic disorders.The hallucinations are not due to something present in eating disorders avoidance behavior is only related to food and food-related cues.According to the DSM, however, one of the main criteria for your eating disorders is an excessive fear about weight, shape, and size, and it’s important to recognize that, because people with eating disorders may avoid mirrors and scales and food, obviously certain foods, and that could All be related to their eating disorder, body, dysmorphic disorder.The fears are only related to people being offended by a particular perceived flaw in obsessive-compulsive disorder.The fear is an object or situation as a result of obsessions.So if they start thinking about germs on their hands – and they keep thinking about it, then they start developing a fear of getting germs on their hands, so the fear becomes the object of their obsessions.Their obsessions turn to cause what they’re.Thinking about becoming a fear in the autism spectrum, the person lacks sufficient age, appropriate relationships, and social communication capacity in anxiety disorders. The person often has sufficient age-appropriate relationships and can communicate socially, and socially understand others, just fine.What we’re, looking at in anxiety, is fear of being judged conduct.Disorder.School avoidance is a very common symptom of conduct disorder, but school avoidance is not due to worry or fear in conduct, disorder, school avoidance, and conduct disorder are due to not wanting to be told what to do.Thank you very much in oppositional defiant disorder, the oppositional behaviors occur in response to multiple situations, not just separation or situational anxiety, not just in response to an anxiety-provoking threat.So if somebody has separation anxiety, they may become oppositional about leaving their major attachment figure.If somebody has a social phobia, they may become oppositional about engaging in situations that would prompt that anxiety, or if they have a specific phobia, maybe they’re afraid of snakes.They may become oppositional about doing something like going hiking because they are actively avoiding that phobic stimulus if they are actively avoiding a phobic stimulus or an anxiety-provoking stimulus.It’s, probably not oppositional defiant.Now you can have both you can have them. Co occurs, but you do want to differentiate.What is the cause of the behavior? Prolonged grief is characterized by intense longing and yearning for the deceased, not fear of separation from them.Now you can have prolonged grief and separation.Anxiety, co occur, but you can’t.Have somebody who develops a fear of separation from others after a particularly particularly traumatic loss? That can happen, but you do want to differentiate and diagnose appropriately and in depression and bipolar.A lot of people who are in a major depressive episode may have reluctance to leave home, but this is due to a lack of motivation and energy to engage and apathy.It’s not due to fear of something out there.They just don’t care or they don’t have an energy personality.A person with a dependent personality relies too much on others.It’s not that they fear uh their safety or loss of attachment figures and avoidant personality disorder, broader avoidance patterns, and a pervasive negative self-concept, differentiate, avoidant, personality disorder from anxiety, and related disorders, not in the DSM I’m. Bringing up for differential diagnosis.Anxiety is related to apprehension and vigilance of physiological sensations and may have an onset after a concussion pots is a postural orthostatic tachycardia and when people have it, when they stand up, their heart rate will jump 30 or more beats just from when they move from sitting To standing and that can feel very scary, they can also get light headed they can.Faint hypoglycemia can also produce symptoms of anxiety sweating and agitation in people, so we want to differentially diagnose.I believe I read a study that more than 25 of Americans are pre-diabetic and don’t know it.Co-morbidity and anxiety disorders are comorbid with each other.So if you have one, you probably have some of its buddies.It’s also comorbid with depression.Bipolar PTSD, prolonged grief, obsessive-compulsive disorder, obsessive-compulsive personality disorder, somatic symptom, related disorders, so any of your physical symptom disorders, anti-social personality, specifically social anxiety, common commonly may co, occur with anti-social, oppositional, defiant disorder and substance use disorders.Physically autoimmune diseases may increase the risk of psychiatric disorders partially due to thyroid dysfunction when that hpa axis goes offline.It also affects the functioning of the thyroid cardiovascular issues like supraventricular tachycardia can also be misdiagnosed and is often misdiagnosed for panic disorder. Hormone level fluctuations, especially extreme hormone fluctuations, can contribute to anxiety, related symptoms, high levels of estrogen or testosterone, nutrient deficiencies, or toxicities.So too, much or too little of certain vitamins and minerals can also cause anxiety-like symptoms.Environmentally poverty is a high risk factor for the development of anxiety disorders, for obvious reasons and socially adverse childhood experiences that include abuse, neglect, abandonment, or mental illness in the household.Are all risk factors for the development of anxiety disorders later in life? Anxiety disorders represent an anxiety response that is developmentally culturally and contextually excessive it’s persistent or recurrent, and causes clinically significant distress, so that differentiates it from people’s run-of-the-mill anxiety.If you will multiple anxiety disorders are common.This presentation covered some of the more common anxiety disorders but did not cover selective mutism substance-induced anxiety or other specified and unspecified anxiety disorders.Finally, it is important to rule out or diagnose comorbidly any physiological causes of anxiety.Symptoms include cardiovascular issues, pots, or diabetes.
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Cognitive Behavioral Therapy (CBT) Skills and Counseling Techniques with Dr. Dawn-Elise “Doc” Snipes

 CEUs are available for this presentation at AllCEUs.com/CBT-CEU Hi everybody and welcome to today’s presentation on cognitive behavioral therapy skills. Like the other The presentation we did on assert not assertive community treatment acceptance and commitment therapy, which is also based on providing information about skills that can be used not providing an evidence-based practice We couldn’t cover that in a full hour or just an hour so over the next hour we’re going to define cognitive behavioral therapy and its basic principles a lot of us are familiar with this but it’s going to be a good review and it also may highlight some nuances that you didn’t know about will identify factors impacting people’s choice of behaviors explore causes and impact of thinking errors and identify common thinking errors and their relationships to cognitive distortions so why do we care well as therapists we want to help people figure out the best way to live a happy healthy meaningful goals-driven life for some people that’s going to mean using some cognitive behavioral interventions that can be in addition to mindfulness that can be in addition to a lot of other things but it’s important to help people understand that the way we believe things to be the way we interpret things is going to affect our reactions so for example think about a situation you know you’ve walked into and maybe you walked into it with a small child and it was a different situation it was a new situation but you know it was no big deal you walked in it was not a threatening situation to you because you were like hey I got this the little kid walks in and goes oh wow there are a lot of people walking around here, this is really scary same situation as two different perceptions you probably didn’t have much of a stress reaction going on whereas the little child probably had this fight-or-flight thing going on grabbing onto your hand like please don’t let go Atlanta Airport is a perfect example if you’ve ever taken a little kid through Atlanta Airport it gives you an idea about how People can perceive things differently and when you enact that fight-or-flight reaction you’re going to have all those stress hormones you’re going to have all either anxiety or anger or whatever that goes with it it may serve to exhaust the person and leave them feeling hopeless and helpless so what we want to do is help people see that but we also want to help them see that when They’re depressed when they’re tired when they’re sick things are going to seem a lot worse a lot of times because they don’t have the energy to perceive it differently I mean when you’re sick it’s overwhelming to think of going through Atlanta Airport so this is what we want to help people start understanding is it’s two sides of the same coin they interact if one is you know kind of going wonky is going to affect the other one the good thing is If one’s going really well the other one’s going to go well if you’re Having positive thoughts you’re probably going to feel pretty good there’s an activity and I think we’re going to talk about it later it’s called the coin flip activity and I asked client clients to flip a coin in the morning and in the morning if it turns heads then they have to be the most positive Pollyanna all day long look for the silver lining and everything smile walk with their head up hold those nonverbals up and see how they feel at the end of the day besides a little sore because there are muscles they’re using they haven’t been used in a while if it lands on tails they can just be their normal selves which generally if they’re seeing me means that they are depressed anxious stressed out angry about something in the negative realm then we Talk about how things seemed different on the days when you were feeling better when you were walking taller when you were smiling even our nonverbals it doesn’t even have to be sickness it can be our nonverbals that can make us feel or make our body feel heavy and tired and make it seem like it’s a whole lot harder to deal with life as a person who perceives the world generally good and believe they can deal with challenges as they arise that good old self-efficacy will be able to allow their stress response system to function normally so if they’re like you know what I can deal with whatever life throws at me I’ve got it and maybe I need help with it maybe I’ll need to ask for support but I’ve got it it’s not going to completely overwhelm me with people who see the world as hostile unsafe and unpredictable You know for a variety of reasons whatever happened to make their scheme as such that they don’t believe that people or the world is trustworthy are predictable They are always on guard they’re always kind of like a hamster in a cage that has Have you ever had a hamster hamsters doesn’t recognize you and goes Hey that’s my own Or human contact score hamsters go run under their little house And you just kind of open the cage and stick your hand in there and flip over their house and you’re like come here and give me cuddles and you’re like you know 200 times bigger than they are so the little hamster is like freaking out this is what it’s like for people and obviously, I’m exaggerating but this is what it’s like for people who have a negative perspective a negative view or a hostile view of the world so kind of keep that little hamster in your mind cognitive behavioral therapy we have core beliefs those things that are in our hearts when I talk with my clients about honesty step one and that’s what they’ve got to do to start recovery is get honest with themselves first and then other people we talk about head heart and gut honesty do you think it’s right does it seem like the right thing to do does it feel right in your heart you know does it make you happy it doesn’t make you feel good and then the Spidey senses is your gut saying and or Is your gut fine if one of those is saying this might not be the right choice and we need to think about what’s going on so we have those core beliefs and I put them in the heart just because that’s the middle of the head heart and gut but you have core beliefs about yourself whether you’re good with You’re bad whether you’re effective at certain things yadda You have core beliefs about other people same thing good bad effective predictable and you have core beliefs about the future and a lot of that goes with locus of control but also your past experiences if the world in the past is seemed unfriendly and uncontrollable and you’ve perceived it that way then you’re going to expect the future to be uncontrollable so what we want to do is help people look at their schemas and their core beliefs about themselves others in the future and figure out kind of what they want it to look like these schemas are going to affect your behavior your thoughts and your feelings and you know you can pick wherever you want to start it doesn’t matter because all three interfaces with one another so if you haven’t let’s Start with negative thoughts If you have negative thoughts then you might feel anxious angry stressed dysphoric which will affect the behavior you’re going to do different things than if you have positive thoughts about something you feel excited and energized you’re going to have different behavior the best thing example I can give you is if you’ve ever done public speaking or had to present something Some people detest public speaking it’s just terrifying for them to get up in front of a group of people so their thoughts are I’m going to trip up I’m going to forget what I’m going to say I’m going to make a fool of myself I’m going to you know it can go on forever that when you get on a roll you can get on a negative roll and go on forever or positive hopefully get on that roll with those thoughts you start holding onto Those thoughts remember as we talked about in a CT the other day when you hold those thoughts and you kind of mush them around in your mind and you come to believe them that you’re going to make a fool of yourself and it’s going to be awful you’re going to start feeling terrified which is going to likely affect your behavior if you go out on the stage and you’re terrified You’re going to probably stutter you’re probably going to get foggy-headed You’re going to have that fight-or-flight reaction so there’s an adrenaline rush and you start sweating and you can’t focus and you can’t concentrate you want to away as opposed to somebody like me who loves public speaking and I’m just like cool I get to go out there and try to engage however many people are in the audience it’s a game for me because when I can see your faces I enjoy trying to figure out and make eye contact with people and figure out what it is that they’re there for what is it that’s going to make them tick what resonates with them so my behavior as You can kind of see right now when I go out there I’m excited and I want to engage people and it’s a fun experience for me again just like the airport the same experience for two different people and two very different interpretations and reactions to it so what effects I don’t like the term rational but when We’re talking about CBT irrationally comes up a lot I like to replace it with helpful because every behavior in its weird sort of way is or probably was rational at one time that being said we’re going to get back to that stress affects our behavioral choices if we’re under stress we can have negative emotions negative emotions will affect our thoughts if we’re feeling sad we’re probably going to look at the dark side if we feel sad we’re going to look at the bottom falling out if we’re happy we’re probably going to look for that silver lining physical factors if you’re in pain sick sleep-deprived poorly nourished so your body can’t produce the neurotransmitters it needs to or heaven forbid intoxicated you’re probably not going to make the same decisions as you would if you were comfortable healthy well-rested nourished and not Intoxicated any of those things can impact how you perceive a situation or how you react in a situation, especially the intoxication whereas in your intoxicated State in your sober state, you may think that you want to do something but then you’ve got that filter that does not not a good idea in an intoxicated State or even in a manic state if you’re you know if you have somebody with bipolar that filter kind of goes away so the behaviors that someone may normally not do because they have a rational filter That goes you know punching this guy out is probably not the best idea right Now the filter goes away when you’re sleep-deprived you’re less generally People are less patient generally people don’t have as much of a filter thing about watching your children if you have children or your grandchildren or even yourself I know myself when I’m sleepy I am giddy as all get-out and things I wouldn’t normally say because they’re you know stupid I’ll just come out and say anyway and my kids just roll their eyes or the mom you’re overtired could go to bed, uh but that’s okay You know I’m okay with that In that situation now if I acted that way at work it would be a worse thing environmentally if you’re introduced to a new or unique situation and you perceive it as stressful because the unknown we know can be stressful then you may not make as rational of a choice or as helpful of a choice because you Maybe trying to escape the same thing as exposure to UNPROFOR bellowing for a word here but UNPROFOR ball is the best I could come up with we all prefer certain situations some people like I said would rather do just about anything then get up in front of a lecture hall of a hundred and fifty people and talk but if they have to do it then they’re going to be under stress which may affect how they do things so we want people to understand that their perception and their feelings are affected by a lot of other things not Just you know an emotion here or a particular memory there’s a lot that goes into it and social if peers your family convey irrational thoughts as necessary very standards for social acceptance people may tend to cling more to it to those unhelpful thoughts and unhelpful behaviors you know in CBT they say irrational because quote nobody wants to associate with those people you know who are those people and why can’t we associate with them there are a lot of things if you think back think high School you know high school is pretty rough if we’re going to talk about having irrational thoughts and cognitions if you have to be part of this particular group to be accepted you have to do this you have to do that but do you do you do those kinds of all-or-nothing statements are cognitive distortions and while they may have served a purpose in some way shape or form in the past we need to encourage our clients to take a look at them now and go are they still helpful ways of thinking is it still helpful for me to think that I am only successful if I live in a million-dollar house in a gated community and do this that and the other or can I be can I define success as a different way or do I define success differently and lack supportive peers to buffer stress so we had those peers who caused stress by talking about the half dues and categorizing and lots of attributions but then there’s Also not having somebody to go you know does this make any sense because sometimes we are our own worst enemies and if we go to a friend and we go you know this is what I’m thinking and I think I have to do this in order to be acceptable to be loved or you know whatever the case may be Most people are not going to use those exact phrases A good friend is probably going to listen and go yeah you’re right or no that’s way off so supportive peers are essential to reminding us to consciously regularly check in with our cognitions to make sure that they are hopeful and rational so a note about irrationality and this is mine this is not from CBT the origins of most beliefs for rational and helpful given the information the person had at the time and their cognitive development their ability to process that information so concepts schemas and core beliefs that people formed when they were five are probably going to be very egocentric you know the person is going to feel like everybody sees it my way because this is how I see it you know just like A five-year-old does A five-year-old doesn’t think Well you know let me take Johnny’s perspective is no he assumes that Johnny sees it the same way so it’s going to be egocentric It’s probably going to be focused on only one aspect of the situation because small children can’t focus on multiple aspects and it’s probably going to be dichotomous it’s all-or-nothing Mommy loves me mommy hates me and it could be personalized you know Everything a lot of kids think that everything has to do with them so if something happens something bad happens many times Children will take it personally or be afraid it’s going to happen to them Again you know if Hurricane Katrina hurricane Andrew those sorts of things you know we saw a lot of trauma in children and they developed very real fears about thunderstorms and hurricane season And if you’ve watched Florida hasn’t had a notable hurricane in years now but There’s a lot of stuff that goes into that but young people During some of those really bad hurricane seasons perceive those situations differently okay so we need to help people understand that if we especially if we use the term irrational those thoughts you form when you are knee-high to a grasshopper and they made perfect sense to you back then but now that you’re an adult you’ve got more experience and you’re able to take different perspectives your brain is more developed Let’s take a look at it and see if you can look at different perspectives and Come up with something a little more helpful maybe a different way of perceiving this situation the irrational irrationality or unhelpful Nosov Fox comes when those beliefs are perpetuated without examination so something a the belief that you formed when you’re five you’re still holding when you’re 35 and you’ve never questioned it you’ve never gone you know does this make sense is This is helpful to getting me toward where I want to be Most of us don’t know We form these attitudes and beliefs when we’re you know growing up when we’re in elementary school middle school high school from watching TV to being around our peers from being around our family in our community and we get all This input of the way things should be and a lot of times people don’t stop to question and go and go Well does this make me happy Is this really what I want and they can be irrational if they continue to be held despite causing harm to the person so the person continues to hold this belief even though it is causing them general emotional cognitive harm is making them miserable we need to look at what’s motivating them to hold on to that belief why is that belief so important and how can we make it so they can live a happy values-driven life with an emphasis on the harness and how can we make it less harmful sometimes it’s more productive for clients to think of these thoughts as unhelpful or helpful instead of irrational sometimes when I say irrational to clients and you know I’m the same way if somebody says you’re being irrational I’m like oh I’m not it elicits this instantaneous defensive reaction it’s like when you tell them they’re being resistant they’re like I am NOT resistant so helpful or unhelpful and then we talk about why it is unhelpful in getting them toward their goals basic principles of cognitive behavioral therapy we teach or help clients learn to distinguish between thoughts and feelings I can think something is scary I’ll probably feel it but if I have an automatic you know feeling I walk into Atlanta Airport and I see yeah I went to an airport in New York I can’t even remember which one it was because my plane was diverted and I got off and I walked out there and I have never seen so many people packed in his place like sardines before in my life I was just completely overwhelmed that was kind of an automatic feeling now that was a feeling based on you know who knows it was overwhelming to be surrounded by that many people so then I had to separate the thoughts and go Okay what am I thinking that’s making me feel so overwhelmed and at that point you know I didn’t know how to get to my gate and all that other sort of stuff with traveling I don’t travel well but encouraging clients to stop and go okay why am I feeling this way what are my What thoughts am I having that are contributing to these dysphoric feelings CBT helps people become aware of how thoughts can influence feelings in ways that are sometimes not helpful We have hecklers in our gallery the automatic tapes that we plaything memories that we have whatever you want to call them when you try something When you are just going through daily life you hear these voices in the back of your head and not real voices but that is saying you’re never going to make this or if you would have just blah blah blah then you’d be a better person helping clients become aware of those thoughts and how they’re Negatively influencing their feelings and keeping them kind of stuck is a huge part of CBT we help them learn about thoughts that seem to occur automatically without even realizing how they may affect emotions again those thoughts from the they’re saying you’re not good enough You’re not smart enough and nobody’s going to like you Where did that come from and do you believe it you know maybe it came from somebody When you were in high school so was that a valid was that a valid source Maybe it came from somebody yesterday on Facebook was that a valid source taking in those thoughts and then figuring out is something I’m going to hold because it makes me happy or is this something that I’ve got to deal with because I’m having a negative reaction constructively evaluate whether these automatic thoughts and assumptions are accurate or perhaps biased the other thing to remember is a lot of our clients not all of them but a lot of them hold themselves to a standard there’s like up here and they hold everybody else to a standard that’s down here so they are a failure if they don’t achieve this but Everybody else is successful as long as they achieve this so encouraging them to take a look at how accurate and biased or unbiased are the thoughts and like I said they may be their thoughts they may be telling themselves these things evaluate whether the current reactions are helpful and a good use of energy or unhelpful and a waste of energy that could be used to move toward those people and things important not impotent important to the person road-rage you’re In the car you’re driving somebody cuts you off Okay natural reaction fight or flight reaction you’re just like slam on the brakes and do whatever you got to do aversive maneuvers you’re good so you could let it go at that point ago got Lucky on that one and keep driving most people not all but most found that 80% of drivers have reported incidences of road rage which is a high number but most people will start getting all fired up and irritated and grumpy and we and just rageful and so my question would be I hear that and I hear that it made you angry In retrospect did screaming at the person as you pass them at sixty miles An hour in your car with the windows rolled up does any good Did it Did any good at all what else could you have done with that energy if you wouldn’t have expended it all yesterday we had to wait for the vet to come by and my daughter just completely wore herself out worrying about when the vet was going to get there what he was going to say about her donkeys and was beside herself so by the time it got to evening and it was time for her to go to her martial arts class she didn’t have the energy to go she’s like um wiped out I just want to go to bed in retrospect we’re looking back and saying okay now Tell me what it was that you were so stressed out about and let’s talk about whether that was a realistic and helpful line of thought to perseverate on all day long and what could you have done differently because she didn’t bother to mention any of that to me yesterday and then developed the skills to notice interrupt and correct these biased thoughts independently causes of these thinking errors information processing shortcuts when we form schemas and we encounter a situation that reminds us of something in the past like when I go to my grandmother’s house I have a schema I have a belief system I have you know stuff that I know about my grandmother’s house so when I go to my grandmother’s house it’s kind of a shortcut to knowing what to expect when I walk in and how to behave how to do different things and it helps me plan and predict if you’re Using outdated or dichotomous all-or-nothing schemas may cause thinking errors because you may be now incorrectly processing current events mental noise some of us have it a lot of us have it Not everybody thinks about trying to focus and study for a final exam in the middle of a really busy sports bar okay this is a cause of thinking or you’re going to miss important things you’re not going to be able to focus you’re not going to necessarily attend to the correct things because there’s just so much else going on your attention is drawn in 17 different directions and or the brain’s limited information processing capacity due to age we talked about that before young kids think all or nothing they think dichotomously egocentric ly middle school-aged kids and older start developing the ability for abstract thinking, by the time we get older, you know as adults theoretically We’re able to you know think pretty well and think pretty clinically about different events but if we’re in crisis when someone is in crisis it could be like what we think of clinically as a crisis or it could be they’re just completely overwhelmed and burned out and have been burning the candle at both ends for three months they’re not going to process information quite as well They’re not going to take in all this stuff because they’re just like shell-shocked have you ever seen teachers in the hallway of like an elementary school Oh at the end of the second nine weeks they just kind of stand there with this blank look on their face they’re not processing as much as they were the first day of school and you know God loved them they have a lot to deal with but we need to help our clients understand that there are some times that they are going to have to really stop and focus write things down so they can remember or they can make decisions A little more my guess is most of us have times in our lives when we’ve been able to think through complex problems but then there are other times where you just can’t keep it all in your head and you’ve got to put it on a Whiteboard maybe that’s just me but we want clients to understand that they are not broken they’re not faulty they’re doing the best they can with the tools they have and the knowledge they have and our job is to help them see where some of this might have gone a little awry other causes of thinking errors and emotional motivations I feel bad therefore whatever I’m thinking must be bad if I’m scared that means whatever it’s coming on the other end of the phone is bad news moral motivations I did it because it was the right thing to do and that can be an excuse for doing wrong behaviors as well it can also be you know you can argue on The moral one social influence well everyone else is doing it so it must not be bad set that again a lot of times and this is where the frames approaching the Motivational interviewing is helpful It stands for feedback about the reality of what’s going on is everybody doing it let’s look at statistics you know not subjective information let’s look at objective information so the impact of these thinking errors makes people want to fight or flee when they get upset and we use upset as a kind of this all-encompassing garbage term emotionally they get depressed or anxious we don’t want to feel that way Anxiety and anger are flee or fight fight or flee it’s our body saying there’s a threat you got to do something depression is your body going I give up I just don’t I don’t even have the energy to do it anymore behaviorally some people withdraw because they Shut down We all know people get frustrated when they get overwhelmed When they start feeling hopeless or helpless they just kind of withdraw from Everything and everyone’s addictions numb that out so they don’t have to feel the dysphoria sleeping problem and changes when we start being on that constant fight-or-flight hyper-vigilant sort of thing going on in the body is always sort of turned on which means you’re not going to sleep as well then The circadian rhythms get messed up which starts causing exhaustion and lethargy and then everything seems harder because you’re sleep-deprived and then you start thinking more negatively and more hopelessly you see where this is going it’s a downward spiral and eating changes some people eat a lot more because they’re eating comfort foods some people eat a lot less because Their stomach is so torn up from the stress they can’t even think about holding anything down physical stress-related illnesses fibromyalgia gastrointestinal problems headaches neck aches backaches you know the whole the gamut of it when you start feeling bad when you start hurting generally it gets frustrating after a while and that frustration makes it kind of raises the bar brings you up a little bit so you’re That thatch closer to kind of just kind of being overwhelmed as you do You have as much of a cushion as you would if you were happy healthy well nourished not in pain and socially a lot of times we will get irritable or impatient with other people or withdrawal when we’re having these negative cognitions these thinking errors that are keeping us in a dysphoric state these effects of thinking errors contribute to fatigue a sense of hopelessness and helplessness which intensifies thinking errors This is an important concept that I want my clients to understand and I want to drive home in this presentation so thinking errors what are they emotional reasoning feelings are not facts and we want to help people learn to identify feelings and separate them from facts so if somebody says I’m terrified okay that is a feeling what are the facts supporting that feeling why are you are terrified what is the evidence that you are in some sort of danger Right now you know that danger may not be the right word for your client at that a particular point in time but what’s the evidence that there’s a threat in what ways is this similar to other situations maybe it’s triggering something from the past that was scary or you know you were too little to be able to handle it but you can handle it now and how if you dealt with similar situations Like in the past, we wanted people to just step back and get some distance between their feelings and their thoughts and try to figure out you know which thoughts are helpful and productive and even if a sought makes people anxious or angry it can be helpful it may be telling them hey dude you need to get your butt up and get out of there if it’s helpful it means it’s moving them toward where they want to be happy healthy safe and values-driven life so happy and helpful developed a stress tolerance skills when people use emotional reasoning they feel emotions which then they start attributing finding the facts to support those emotions instead of looking at all the facts we want to help them learn to tolerate their distress so they can kind of let that subside for a second they can accept their feeling they can name them They say I’m scared I’m stressed I’m angry and whatever but they don’t have to act on it right then they can tolerate the distress for a minute without having to try to make it go away and emotional regulation skills they can feel a feeling without having to make it go from zero to 120 You know if they feel sad they go I feel kind of sad instead of grabbing onto it and going I wonder what I feel sad about I must feel sad about all these sad things now I’m going to be sad and devastated so we want to help people learn how to regulate their emotions identify them accept them Whatever word you want to use tolerate them because feelings are there for a reason they’re there to tell you your brain thinks something’s going now thankfully we have that higher-order cognition stuff going on so We can contradict our brain and we can go you know maybe that’s not true in this situation cognitive bias negativity mental filter whatever you want to call it people who focus on the negative they walk in they get up in the morning and They look outside and it’s partly cloudy They get to work and they say instead of saying there was it was very light traffic they said there was a fair amount of traffic everything is always the flip side of what somebody who’s optimistic would say so asking them what’s the benefit to focusing on the negative in what ways is this helpful to you know some people say Well it keeps me from getting disappointed because I know It’s going to end up negative anyway so we can trap challenges that know that whatever it is they think they know and see if there have been exceptions when It hasn’t turned out that way What are the positives to this situation I give the example a lot of you know I wash my car or it rains and maybe I wanted to go out on a run that day but I can perceive it I can look at the positives you know the rain washed my car for me so I don’t have to do it now score it watered my garden all the better it knocked down some of the pollen out of there even better I can find and I can encourage people to find positives in a situation yes there are negatives there are negatives to every situation if you want to find them you’re going to find them but if you want to find the positives you can too which takes us down to what are all the facts there’s the positive and the negative and the neutral I told you Earlier about the coin toss activity having people toss a coin on the heads days they act like it is just the greatest day to be alive and see how Things are different when they do their journal because you know I have my clients do I’m sort of a mindfulness check-in in the morning and in the evening and preferably at lunchtime how are they feeling what’s their emotional state what’s their energy level on the happy days a lot of times it can be less and sometimes they need a little coaching throughout because some of those old patterns kick in but I want them to start challenging some of their automatic thoughts that we’re going to talk about in a minute disqualifying or minimizing the positive most of us can probably say we’ve had a bunch of clients that do this they are more than happy to tell you about all the things that they mess up but then when they do something right they minimize it encouraging people to hold themselves to the same standard they would hold everyone else to and I know I talked about that earlier ask them things like would it minimum would you minimize this.If it was your best friend’s experience your best friend came to you and said I just got into such-and-such college would you say awesome or would you say anybody can get in there how would that go ask them what is scary about accepting these positive things that you might have had an accomplishment for some people it means that it might mean other people expect more of them for other people they just don’t know how to accept the positive They don’t know how to accept compliments they don’t know how to be the center of attention and they don’t like it and then we want to look at why that is sometimes we disqualify the positive because it fails to meet someone else’s standards so as people might that be true here you know I know When I was growing up and going through college and going through school and everything got my doctorate but I will always not being not a real doctor because a Ph.D. is not an MD and I’m like really So is it somebody else’s standards or can I feel good about having a Ph.D. egocentrism My perspective is the only perspective I’ll being egocentric but it doesn’t work most of the time so encouraging people to take alternate perspectives Maybe you’re texting with someone and they say something that is not what you interpret as not the nicest thing and this happens in text messages a lot and they get upset now an egocentric thinking error would say that purse is just grumpy today Someone who’s taking other perspectives would stop and go back and read the text and go I wonder if maybe this could have been taken some other another you know obvious reaction is not what I intended So egocentrism if you hold on to that I don’t understand anybody else because You know I don’t see a problem with anything personalizing and mind-reading This is when you assume that everybody’s frowning because of something you did your boss walks down the hallway and looks at you and grimaces and continues to walk on oh I must have done something wrong No maybe he just got out of his senior management meeting that was five hours long and he’s got to go to the bathroom you know there could be a hundred different explanations for why that happened so encourage clients to ask themselves what some alternate explanations for this event that are doesn’t involve me you know why this might have happened if they hold on to that, I must have done something wrong but as soon as their boss calls them up and goes hey can you come to my office for a second you know where their thoughts are going to go I’m getting fired I’m going to get laid off I don’t know what it was that I did wrong but he walked by me two weeks ago in the hallway and grimaced and I’m just I’m the worst person in the whole world But where did that come from so encouraging people to not necessarily assume they know what’s going on in someone else’s mind and not automatically attributing every person’s negative behavior to something they did How often and then ask them how often has it been about you now think about the last 10 times you’ve taken something personally how many of Those 10 times has it been about something you did versus something with the other person then the availability heuristic remembering what’s most prominent in your mind so asking clients what the facts ah the most obvious One that we talk about is plane crashes You know it is very dangerous to fly on a plane because you hear about all those plane crashes well yeah you hear about the airlines crashes but don’t hear about the 20,000 every day that land safely so you remember it and it seems more dangerous because that’s what is in your mind that’s what is available to you that’s what you’ve based your thought processes on because maybe you didn’t know that 20,000 planes or more fly and land just perfectly every day this can also be true with people remembering what’s most prominent in your mind sometimes and this can be very very true in domestically violent relationships if somebody falls in love with someone and that person is just the greatest person since sliced bread for the first four months and then the cycle starts and there’s this little tiny a sliver of the honeymoon period after the battering cycle and the person’s like That’s the person I fell in love with that’s what I remember and they try to focus on that that’s most prominent in their mind and they ignore the rest of the stuff so we need to encourage people to look objectively at the facts magnifying high and low probability outcomes what are the chances that this is going to happen how Many clients have worked with have gone to the doctor and gotten into a physical or get a test run and then the doctor had to call them back and This could be true for you too and the doctor had to call them back two or Three days later when the tests came back from the lab and that whole three days they were just in a panic because they were afraid they were going to get some terminal diagnosis so thinking about high and low probability outcomes another instance or example of magnification is somebody that thinks this is the end of the world whatever it I think I’ve told you before my little story about um tripping when I was walking down the hall at work and falling and yeah it was embarrassing my folders went everywhere and yeah but in that big scheme of things will it matter That much from now you know are people going to think Oh she is such a clutch she must be a ditz too no I mean they may have thought that at that time I don’t know but you know in six months nobody’s going to remember and then ask them in the past when something like this has happened when you’ve had to get a test done and you’ve had to wait on results or if you’ve done something that was embarrassing and you didn’t think you thought everybody was going to remember it forever how did you tolerate it how did you learn to deal with it building on those strengths that they already have all-or-nothing thinking errors These are things like love versus hate I love them or I hate them it’s all or Nothing she does this all the time or she never does it if I’m going to do it I’m going to do it perfectly or I’m not going to do it at all thank you all good intentions or all bad intentions you know sometimes we do things with good intentions that have some bad repercussions so did we do it with all Bad intentions are all good intentions and the answer is neither most of the time life is kind of in that middle-ground gray area encouraging clients to Look and find examples where something hasn’t been one of the polls when have they done something that they’re proud of that wasn’t perfect or when again When has somebody else done something that they were proud of that wasn’t perfect remembering that with availability heuristic remembering how often something happens and how long it’s been since you’ve seen that behavior and remember that sometimes good times are amazing but how frequent are they compared with the bad times another thinking error is a belief in a just world or a fallacy of fairness I just asked clients to identify for good people you know who’ve had bad things happen and in in reality we all have bad things happen good people do bad people do in between people do attributional errors and this is a pet of mine you know labeling yourself is not a behavior so global versus specific and I am stupid versus I’m stupid at math I don’t have good math skills it’s not about me it’s about the skills I can change skills stable I am and I always will be versus it’s something I can change it’s something I can learn internally It’s about me as a person versus it’s about a skill deficit or something I could learn or change and there’s you know lots of information on attributions out there on the internet if you need a refresher on it but we find that a lot of people who have dysphoria have negative global stable internal attributions so questions for clients remember the beliefs equal thoughts and facts plus personal interpretation another way of saying it is reality is 10% perception is 10% reality and 90% interpretation so what are the facts for and against my belief is the belief based on facts or Feelings Does the belief focus on one aspect or the whole situation Does the belief seem to use any thinking errors what are alternate explanations what Would you tell your child or best friend if they had this belief how would you want someone to tell what would you want someone to tell you about this belief so If you’re telling somebody about this what are you hoping they’re going to say in return and finally, how is this belief moving you toward what and who is important to you or moving you away from what or who is important to you now they can do a worksheet and have all of these or you can pick one or two of these questions that are most salient for your clients but they can have kind of at their fingertips so as they’re going through the day and something happens They can ask themselves ok what’s an alternate explanation Or you know Whatever it is this salient for that client’s irrational thoughts how do these thoughts impact the client’s emotions health relationships and perceptions of the world you know this is what we want to ask them How is this thought impacting you globally how may this thought have been helpful in the past Where did it come from How does it make sense from when you formed it in the past when you’re dealing with it ask the person if the thought is bringing you closer to those that are important Are there any examples of this thought or belief not being true and how can the statement be made less global less all-encompassing so it’s about a specific incident a specific situation less stable which means you can change it and less internal which means it’s not about who you are as a person but maybe something that you do or a skill that you have so we’re going to go through some of these thoughts real Quickly here mistakes are never acceptable and if I make one it means that I’m incompetent well never is kind of stable and I am incompetent is kind of global, that’s also that extreme all-or-nothing thinking so you can see where these cognitive distortions end up leading to unhelpful beliefs When somebody disagrees with me it’s a personal attack Well there’s Personalization If I ever heard it before maybe it’s not about you may be They’re having a bad day and you just happen to be the unlucky target or maybe they’re disagreeing with you because they have a different point of view and It’s not a personal attack it’s just their point of view If someone criticizes or rejects me there must be something wrong with me personalization all-or-nothing thinking global stable and internal something wrong with me as a person to feel good about myself others must approve of me Now this is one we’ve talked about external validation before and we can’t control other people to feel good about yourself how can you do that Besides necessarily requiring other people to approve of you to be content in life I must be liked by all people Wow I’ve never met anybody who’s liked by all people I’ve never even met anybody who’s been hated by all people but it’s important to help clients see how this is dramatic to say all people and for them to be content everybody has to like them I mean I like to be liked but if everybody doesn’t like me you know That’s pretty understandable My true value as an individual depends on what others think of me I would challenge this one this is all you know Also very personally I would challenge people to look at and say it so your child’s value as an individual depends on what other people think of Most people would say no but the perspective thing nothing ever turns out the way you want it to okay all-or-nothing thinking and probably availability heuristic if something bad just happened then they may be focusing on that which causes them to focus on all the other bad things in the past that have happened not to focus on that is okay you know bad thing happen but look at all these good things I won’t try anything new unless I will be good at it this fear of failure fear of rejection It just really paralyzes a lot of people when they get stuck with that thinking the area that they have to be perfect I am in total control of anything bad that happens is my fault well that’s egocentric and personal if They think they’re in total control that’s their perception of how the world Do they think if they’ve got everybody on marionette strings anything bad in the world that happens is their fault how powerful are they I feel happy about uh if I feel happy about life something will go wrong It happens sometimes but let’s look at times when you’ve been happy that something hasn’t gone wrong you know let’s get rid of that all-or-nothing thinking it’s not my fault my life didn’t go the way I wanted could be true but it seems like that’s making you unhappy so what do we do about that if I’m not in an intimate relationship I’m alone No, again that’s pretty extreme I’m either in an intimate relationship or I am alone and a loner and you know it’s just me and my 17 cats which follows with there’s no gray area so encouraging people to look at what these beliefs are saying important thoughts impact behaviors and emotional and Physical reactions emotional and physical reactions impact thoughts and interpretations of events so if you do something and it’s pleasurable and you have a great physical reaction you know let’s take bungee jumping or Skydiving if you go out there and it’s scary but you do it and you’re just like Whoa what a rush Your interpretation of that is probably going to be good which means you’ll probably do it again if you go out there and it’s just the most horrible experience you’ve ever had you’re probably not going to do it again and your interpretation of it is going to be not good which is going to make it hard to understand why other people would do it irrational thinking patterns are often caused by cognitive distortions so let’s just look back at some of those because there are a lot fewer cognitive distortions or general ways of thinking about the world then there are thinking errors because There are lots and lots of thinking errors Cognitive distortions are often schemas which were formed based on faulty inaccurate or immature knowledge or understanding and by identifying the thoughts of the hecklers you know the automatic tapes that maintain our unhappiness the person can choose whether to accept those thoughts or change them.As found on YouTubeNatural Synergy $47.⁰⁰ 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Cognitive Behavioral Therapy (CBT) Skills and Counseling Techniques with Dr. Dawn-Elise “Doc” Snipes

 CEUs are available for this presentation at AllCEUs.com/CBT-CEU Hi everybody and welcome to today’s presentation on cognitive behavioral therapy skills. Like the other the presentation we did on assert not assertive community treatment acceptance and commitment therapy, which is also based on just providing information about skills that can be used not providing an evidence-based practice we couldn’t cover that in a full hour or just an hour so over the next hour we’re going to define cognitive behavioral therapy and its basic principles a lot of us are familiar with this but it’s going to be a good review and it also may highlight some nuances that you didn’t know about will identify factors impacting people’s choice of behaviors explore causes and impact of thinking errors and identify common thinking errors and their relationships to cognitive distortions so why do we care well as therapists we want to help people figure out the best way to live a happy healthy meaningful goals-driven life for some people that’s going to mean using some cognitive behavioral interventions that can be in addition to mindfulness that can be in addition to a lot of other things but it’s important to help people understand that the way we believe things to be the way we interpret things is going to affect our reactions so for example think about a situation you know you’ve walked into and maybe you walked into it with a small child and it was a different situation it was a new situation but you know it was no big deal you walked in it was not a threatening situation to you because you were like hey I got this the little kid walks in and goes oh wow there are a lot of people walking around here, this is the really scary same situation as two different perceptions you probably didn’t have much of a stress reaction going on whereas the little child probably had this fight-or-flight thing going on grabbing onto your hand like please don’t let go Atlanta Airport is a perfect example if you’ve ever taken a little kid through Atlanta Airport it gives you an idea about how people can perceive things differently and when you enact that fight-or-flight reaction you’re going to have all those stress hormones you’re going to have all either anxiety or anger or whatever that goes with it it may serve to exhaust the person and leave them feeling hopeless and helpless so what we want to do is help people see that but we also want to help them see that when they’re depressed when they’re tired when they’re sick things are going to seem a lot worse a lot of times because they don’t have the energy to perceive it differently I mean when you’re sick it’s overwhelming to think of going through Atlanta Airport so this is what we want to help people start understanding is it’s two sides of the same coin they interact if one is you know kind of going wonky is going to affect the other one the good thing is if one’s going really good the other one’s going to go good if you’re having positive thoughts you’re probably going to feel pretty good there’s an activity and I think we’re going to talk about it later it’s called the coin flip activity and I asked client clients to flip a coin in the morning and in the morning if it turns heads then they have to be the most positive Pollyanna all day long look for the silver lining and everything smile walk with their head up hold those nonverbals up and see how they feel at the end of the day besides a little sore because there are muscles they’re using they haven’t been used in a while if it lands on tails they can just be their normal selves which generally if they’re seeing me means that they are depressed anxious stressed out angry about something in the negative realm then we talk about how did things seem different on the days when you were feeling better when you were walking taller when you were smiling even our nonverbals it doesn’t even have to be sickness it can be our nonverbals that can make us feel or make our body feel heavy and tired and make it seem like it’s a whole lot harder to deal with life as a person who perceives the world generally good and believes they can deal with challenges as they arise that good old self-efficacy will be able to allow their stress response system to function normally so if they’re like you know what I can deal with whatever life throws at me I’ve got it and maybe I need help with it maybe I’ll need to ask for support but I’ve got it it’s not going to completely overwhelm me with people who see the world as hostile unsafe and unpredictable you know for a variety of reasons whatever happened to make their scheme as such that they don’t believe that people or the world is trustworthy are predictable they are always on guard they’re always kind of like a hamster in a cage that has Have you ever had a hamster hamsters don’t recognize you and go hey that’s my own or human contact score hamsters go run under their little house and you just kind of open the cage and stick your hand in there and flip over their house and you’re like come here and give me cuddles and you’re like you know 200 times bigger than they are so the little hamster is like freaking out this is what it’s like for people and obviously, I’m exaggerating but this is what it’s like for people who have a negative perspective a negative view or a hostile view of the world so kind of keep that little hamster in your mind cognitive behavioral therapy we have core beliefs those things that are in our hearts when I talk with my clients about honesty step one and that’s what they’ve got to do to start recovery is get honest with themselves first and then other people we talk about head heart and gut honesty do you think it’s right does it seem like the right thing to do does it feel right in your heart you know does it make you happy it doesn’t make you feel good and then the spidey senses is your gut saying and or is your gut fine if one of those is saying this might not be the right choice and we need to think about what’s going on so we have those core beliefs and I put them in the heart just because that’s the middle of the head heart and gut but you have core beliefs about yourself whether you’re good with you’re bad whether you’re effective at certain things yada yada you have core beliefs about other people same thing good bad effective predictable and you have core beliefs about the future and a lot of that goes with the locus of control but also your past experiences if the world in the past is seemed unfriendly and uncontrollable and you’ve perceived it that way then you’re going to expect the future to be uncontrollable so what we want to do is help people look at their schemas and their core beliefs about themselves others in the future and figure out kind of what they want it to look like these schemas are going to affect your behavior and your thoughts and your feelings and you know you can pick wherever you want to start it doesn’t matter because all three inter interface with one another so if you haven’t let’s start with negative thoughts if you have negative thoughts then you might feel anxious angry stressed dysphoric which will affect the behavior you’re going to do different things than if you have positive thoughts about something you feel excited and energized you’re going to have different behavior the best thing example I can give you is if you’ve ever done public speaking or had to present something some people detest public speaking it’s just terrifying for them to get up in front of a group of people so their thoughts am I going to trip up I going to forget what I’m going to say I’m going to make a fool of myself I’m going to you know it can go on forever that when you get on a roll you can get on a negative roll and go on forever or positive hopefully get on that roll with those thoughts you start holding onto those thoughts remember as we talked about in a CT the other day when you hold those thoughts and you kind of mush them around in your mind and you come to believe them that you’re going to make a fool of yourself and it’s going to be awful you’re going to start feeling terrified likely which is going to likely affect your behavior if you go out on the stage and you’re terrified you’re going to probably stutter you’re probably going to get foggy-headed you’re going to have that fight-or-flight reaction so there’s an the adrenaline rush and you start sweating and you can’t focus and you can’t concentrate you want to away as opposed to somebody like me who loves public speaking and I’m just like cool I get to go out there and try to engage however many people are in the audience it’s a game for me because when I can see your faces I enjoy trying to figure out and make eye contact with people and figure out what it is that they’re there for what is it that’s going to make them tick what resonates with them so my behavior as you can kind of see right now when I go out there I’m excited and I want to engage people and it’s a fun experience for me again just like the airport the same experience for two different people and two very different interpretations and reactions to it so what effects I don’t like the term rational but when we’re talking about CBT irrationally comes up a lot I like to replace it with helpful because every behavior in its weird sort of way is or probably was rational at one time that being said we’re going to get back to that stress affects our behavioral choices if we’re under stress we can have negative emotions negative emotions will affect our thoughts if we’re feeling sad we’re probably going to look at the dark side if we feel sad we’re going to look at the bottom falling out if we’re happy we’re probably going to look for that silver lining physical factors if you’re in pain sick sleep-deprived poorly nourished so your body can’t produce the neurotransmitters it needs to or heaven forbid intoxicated you’re probably not going to make the same decisions as you would if you were comfortable healthy well-rested nourished and not intoxicated any of those things can go impact how you perceive a situation or how you react in a situation, especially the intoxication whereas in your non intoxicated State in your sober state, you may think that you want to do something but then you’ve got that filter that goes not not a good idea in an intoxicated State or even in a manic state if you’re you know if you have somebody with bipolar that filter kind of goes away so the behaviors that someone may normally not do because they have a rational filter that goes you know punching this guy outs probably not the best idea right now the filter goes away when you’re sleep-deprived you’re less generally people are less patient generally people don’t have as much of a filter thing about watching your children if you have children or your grandchildren or even yourself I know myself when I’m sleepy I am giddy as all get-out and things I wouldn’t normally say because they’re you know stupid I’ll just come out and say anyway and my kids just roll their eyes or the mom you’re overtired could go to bed, uh but that’s okay you know I’m okay with that in that situation now if I acted that way at work it would be a worse thing environmentally if you’re introduced to a new or unique situation and you perceive it as stressful because the unknown we know can be stressful then you may not make as rational of a choice or as helpful of a choice because you maybe trying to escape the same thing as exposure to UNPROFOR bellowing for a the word here but UNPROFOR ball is the best I could come up with we all prefer certain situations some people as I said would rather do just about anything then get up in front of a lecture hall of a hundred and fifty people and talk but if they have to do it then they’re going to be under stress which may affect how they do things so we want people to understand that their perception and their feelings are affected by a lot of other things not just you know an emotion here or a particular memory there’s a lot that goes into it and social if peers your family convey irrational thoughts as necessary very standards for social acceptance people may tend to cling more to it to those unhelpful thoughts and unhelpful behaviors you know in CBT they say irrational because quote nobody wants to associate with those people you know who are those people and why can’t we associate with them there are a lot of things if you think back think high school you know high school is pretty rough if we’re going to talk about having irrational thoughts and cognitions if you have to be part of this particular group to be accepted you have to do this you have to do that but do you do those kinds of all-or-nothing statements are cognitive distortions and while they may have served a purpose in some way shape or form in the past we need to encourage our clients to take a look at them now and go are they still helpful ways of thinking is it still helpful for me to think that I am only successful if I live in a million-dollar house in a gated community and do this that and the other or can I be can I define success a different way or do I define success differently and lack supportive peers to buffer stress so we had those peers that caused stress by talking about the half dues and categorizing and lots of attributions but then there’s also not having somebody to go you know does this make any sense because sometimes we are our own worst enemies and if we go to a friend and we go you know this is what I’m thinking and I think I have to do this in order to be acceptable to be loved or you know whatever the case may be most people are not going to use those exact phrases a good friend is probably going to listen and go yeah you’re right or no no that’s way off so supportive peers are essential to reminding us to consciously regularly check in with our cognitions to make sure that they are hopeful and rational so a note about irrationality and this is mine this is not from CBT the origins of most beliefs for rational and helpful given the information, the person had at the time and their cognitive development their ability to process that information so concepts and schemas and core beliefs that people formed when they were five are probably going to be very egocentric you know the person is going to feel like everybody sees it my way because this is how I see it you know just like a five-year-old does a five-year-old doesn’t think well you know let me take Johnny’s perspective is no he assumes that Johnny sees it the same way so it’s going to be egocentric it’s probably going to be focused on only one aspect of the situation because small children can’t focus on multiple aspects and it’s probably going to be dichotomous it’s all-or-nothing Mommy loves me mommy hates me and it could be personalized you know everything a lot of kids think that everything has to do with them so if something happens something bad happens many times children will take it personally or be afraid it’s going to happen to them again you know if hurricane katrina hurricane Andrew those sorts of things you know we saw a lot of trauma in children and they developed very real fears about thunderstorms and hurricane season and if you’ve watched Florida hasn’t had a notable hurricane in years now but there’s a lot of stuff that goes into that but young people during some of those really bad hurricane seasons perceive those situations differently okay so we need to help people understand that if we especially if we use the term irrational those thoughts you formed when you are knee-high to a grasshopper and they made perfect sense to you back then but now that you’re an adult you’ve got more experience and you’re able to take different perspectives your brain is more developed let’s take a look at it and see if you can look at different perspectives and come up with something a little more helpful maybe a different way of perceiving this situation the irrational irrationality or unhelpful Nosov Fox comes when those beliefs are perpetuated without examination so something a belief that you formed when you’re five you’re still holding when you’re 35 and you’ve never questioned it you’ve never gone you know does this make sense is this is helpful to get me to where I want to be most of us don’t know we form these attitudes and beliefs when we’re you know growing up when we’re in elementary school middle school high school from watching TV to being around our peers from being around our family in our community and we get all this input of the way things should be and a lot of times people don’t stop to question and go and go well does this make me happy is this really what I want and they can be irrational if they continue to be held despite causing harm to the person so the person continues to hold this belief even though it is causing them general emotional cognitive harm is making them miserable we need to look at why what’s motivating them to hold on to that belief why is that belief so important and how can we make it so they can live a happy values-driven life emphasis on the happy how can we make it less harmful sometimes it’s more productive for clients to think of these thoughts as unhelpful or helpful instead of irrational sometimes when I say irrational to clients and you know I’m the same way if somebody says you’re being irrational I’m like oh I’m not it elicits this instantaneous defensive reaction it’s like when you tell them they’re being resistant they’re like I am NOT rien resistant so helpful or unhelpful and then we talk about why it is unhelpful in getting them toward their goals basic principles of cognitive behavioral therapy we teach or help clients learn to distinguish between thoughts and feelings I can think something is scary I’ll probably feel it but if I have an automatic you know feeling I walk into Atlanta Airport and I see yeah I went to an airport in New York I can’t even remember which one it was because my plane was diverted and I got off and I walked out there and I have never seen so many people packed in his place like sardines before in my life I was just completely overwhelmed that was kind of an automatic feeling now that was a feeling based on you know who knows it was overwhelming to be surrounded by that many people so then I had to separate the thoughts and go okay what am I thinking that’s making me feel so overwhelmed and at that point you know I didn’t know how to get to my gate and all that other sort of stuff with traveling I don’t travel well but encouraging clients to stop and go okay why am I feeling this way what are my what thoughts am I having that are contributing to these dysphoric feelings CBT helps people become aware of how thoughts can influence feelings in ways that are sometimes not helpful we have hecklers in our gallery the automatic tapes that we plaything memories that we have whatever you want to call them that when you try something when you are just going through daily life you hear these voices in the back of your head and not real voices but that is saying you’re never going to make this or if you would have just blah blah blah then you’d be a the better person helping clients become aware of those thoughts and how they’re negatively influencing their feelings and keeping them kind of stuck is a huge part of CBT we help them learn about thoughts that seem to occur automatically without even realizing how they may affect emotions again those thoughts from they’re saying you’re not good enough you’re not smart enough and nobody’s gonna like you where did that come from and do you believe it you know maybe it came from somebody when you were in high school so was that a valid source maybe it came from somebody yesterday on Facebook was that a valid source taking in those thoughts and then figuring out is this something I’m going to hold because it makes me happy or is this something that I’ve got to deal with because I’m having a negative reaction constructively evaluate whether these automatic thoughts and assumptions are accurate or perhaps biased the other thing to remember is a lot of our clients not all of them but a lot of them hold themselves to a standard there’s like up here and they hold everybody else to a standard that’s down here so they are a failure if they don’t achieve this but everybody else is successful as long as they achieve this so encouraging them to take a look at how accurate and biased or unbiased are the thoughts and like I said they may be their thoughts they may be telling themselves these things evaluate whether the current reactions are a helpful and good use of energy or unhelpful and a waste of energy that could be used to move toward those people and things important not impotent important to the person road-rage you’re in the car you’re driving somebody cuts you off okay natural reaction fight or flight reaction you’re just like slam on the brakes and do whatever you got to do aversive maneuvers you’re good so you could let it go at that point ago got Lucky on that one and keep driving most people not all but most they found that 80% of drivers have reported incidences of road rage which is a high number but most people will start getting all fired up and irritated and grumpy and we and just rageful and so my question would be I hear that and I hear that it made you angry in retrospect did screaming at the person as you pass them at sixty miles an hour in your car with the windows rolled up does any good did it do any good at all what else could you have done with that energy if you wouldn’t have expended it all yesterday we had to wait for the vet to come by and my daughter just completely wore herself out worrying about when the vet was going to get there what he was going to say about her donkeys and was beside herself so by the time it got to evening and it was time for her to go to her martial arts class she didn’t have the energy to go she’s like um wiped out I just want to go to bed in retrospect we’re looking back and saying okay now tell me what it was that you were so stressed out about and let’s talk about whether that was a realistic and helpful line of thought to perseverate on all day long and what could you have done differently because she didn’t bother to mention any of that to me yesterday and then developed the skills to notice interrupt and correct these biased thoughts independently causes of these thinking errors information processing shortcuts when we form schemas and we encounter a situation that reminds us of something in the past like when I go to my grandmother’s house I have a schema I have a belief system I have you know stuff that I know about my grandmother’s house so when I go to my grandmother’s house it’s kind of a shortcut to knowing what to expect when I walk in and how to behave how to do different things and it helps me plan and predict if you’re using outdated or dichotomous all-or-nothing schemas it may cause thinking errors because you may be now incorrectly processing current events mental noise some of us have it a lot of us have it not everybody thinks about trying to focus and study for a final exam in the middle of a really busy sports bar okay this is a cause of thinking or you’re going to miss important things you’re not going to be able to focus you’re not going to necessarily attend to the correct things because there’s just so much else going on your attention is drawn in 17 different directions and or the brain’s limited information processing capacity due to age we talked about that before young kids think all or nothing they think dichotomously egocentric ly middle school-aged kids and older start developing the ability for abstract thinking, by the time we get older, you know as adults theoretically we’re able to you know think pretty well and think pretty clinically about different events but if we’re in crisis when someone is in crisis and it could be like what we think of clinically as a crisis or it could be they’re just completely overwhelmed and burned out and have been burning the candle at both ends for three months they’re not going to process information quite as well they’re not going to take in all this stuff because they’re just like shell-shocked have you ever seen teachers in the hallway of like an elementary school Oh at the end of the second nine weeks they just kind of stand there with this blank look on their face they’re not processing as much as they were the first day of school and you know God loved them they have a lot to deal with but we need to help our clients understand that there are some times that they are going to have to really stop and focus write things down so they can remember or they can make decisions a little more my guess is most of us have times in our life when we’ve been able to think through complex problems but then there are other times where you just can’t keep it all in your head and you’ve got to put it on a whiteboard maybe that’s just me but we want clients to understand that they are not broken they’re not faulty they’re doing the best they can with the tools they have and the knowledge they have and our job is to help them see where some of this might have gone a little awry other causes of thinking errors and emotional motivations I feel bad therefore whatever I’m thinking must be bad if I’m scared that means whatever it’s coming on the other end of the phone is bad news moral motivations I did it because it was the right thing to do and that can be an excuse for doing wrong behaviors as well it can also be you know you can argue on the moral one social influence well everyone else is doing it so it must not be bad set that again a lot of times and this is where the frames approaching the motivational interviewing is helpful f stands for feedback about the reality of what’s going on is everybody doing it let’s look at statistics you know not subjective information let’s look at objective information so the impact of these thinking errors makes people want to fight or flee when they get upset and we use upset as a kind of this all-encompassing garbage term emotionally they get depressed or anxious we don’t want to feel that way anxiety and anger are flee or fight fight or flee it’s our body saying there’s a threat you got to do something depression is your body going I give up I just don’t I don’t even have the energy to do it anymore behaviorally some people withdraw because they shut down we all know people who get frustrated when they get overwhelmed when they start feeling hopeless or helpless they just kind of withdraw from everything and everyone’s addictions numb that out so they don’t have to feel the dysphoria sleeping problem and changes when we start being on that constant fight-or-flight hyper-vigilant sort of thing going on in the body is always sort of turned on which means you’re not going to sleep as well then the circadian rhythms get messed up which starts causing exhaustion and lethargy and then everything seems harder because you’re sleep-deprived and then you start thinking more negatively and more hopelessly you see where this is going it’s a downward spiral and eating changes some people eat a lot more because they’re eating comfort foods some people eat a lot less because their stomach is so torn up from the stress they can’t even think about holding anything down physical stress-related illnesses fibromyalgia gastrointestinal problems headaches neck aches backache you know the whole the gamut of it when you start feeling bad when you start hurting generally it gets frustrating after a while and that frustration makes it kind of raises the the bar brings you up a little bit so you’re that is much closer to kind of just kind of being overwhelmed you don’t have as much of a cushion as you would if you were happy healthy well nourished not in pain and socially a lot of times we will get irritable or impatient with other people or withdrawal when we’re having these negative cognitions these thinking errors that are keeping us in a dysphoric state these effects of thinking errors contribute to fatigue and a sense of hopelessness and helplessness which intensifies thinking errors this is an important concept that I want my clients to understand and I want to drive home in this presentation so thinking errors what are they emotional reasoning feelings are not facts and we want to help people to learn to effectively identify feelings and separate them from facts so if somebody says I’m terrified okay that is a feeling what are the facts supporting that feeling why are you are terrified what is the evidence that you are in some sort of danger right now you know and danger may not be the right word for your client at that a particular point in time but what’s the evidence that there’s a threat in what ways is this similar to other situations maybe it’s triggering something from the past that was scary or you know you were too little to be able to handle it but you can handle it now and how if you dealt with similar situations like this, in the past, we want to help people just step back and get some distance between their feelings and their thoughts and try to figure out you know which thoughts are helpful and productive and even if a sought makes people anxious or angry it can be helpful it may be telling them hey dude you need to get your butt up and get out of there if it’s helpful it means it’s moving them toward where they want to be happy healthy safe and values-driven life so happy and helpful developed a stress tolerance skills when people use emotional reasoning they feel emotions which then they start attributing finding the facts to support those emotions instead of looking at all the facts we want to help them learn to tolerate their distress so they can kind of let that subside for a second they can accept their feeling they can name they can say I’m scared I’m stressed I’m angry and whatever but they don’t have to act on it right then they can tolerate the distress for a minute without having to try to make it go away and emotional regulation skills they can feel a feeling without having to make it go from zero to 120 you know if they feel sad they go I feel kind of sad instead of grabbing onto it and going I wonder what I feel sad about I must feel sad about all these sad things now I’m going to be sad and devastated so we want to help people learn how to regulate their emotions identify them accept them whatever word you want to use and tolerate them because feelings are there for a reason they’re there to tell you your brain thinks something’s going now thankfully we have that higher-order cognition stuff going on so we can contradict our brain and we can go you know maybe that’s not true in this situation cognitive bias negativity mental filter whatever you want to call it people who focus on the negative they walk in they get up in the morning and they look outside and it’s partly cloudy they get to work and they said instead of saying there was it was very light traffic they said there was a fair amount of traffic everything is always the flip side of what somebody who’s optimistic would say so asking them what’s the benefit to focusing on the negative in what ways is this helpful to you you know some people say well it keeps me from getting disappointed because I know it’s going to end up negative anyway so we can trap challenges that know that whatever it is they think they know and see if there have been exceptions when it hasn’t turned out that way what are the positives to this situation I give the example a lot of you know I wash my car or it rains and maybe I wanted to go out on a run that day but I can perceive it I can look at the positives you know the rain washed my car for me so I don’t have to do it now score it watered my garden all the better it knocked down some of the pollen out of there even better I can find and I can encourage people to find positives in a situation yes there are negatives there are negatives to every situation if you want to find them you’re going to find them but if you want to find the positives you can too which takes us down to what are all the facts there’s the positive and the negative and the neutral I told you earlier about the coin toss activity having people toss a coin on the heads days they act like it is just the greatest day to be alive and see how things are different when they do their journal because you know I have my clients do I’m sort of a mindfulness check-in in the morning and in the evening and preferably at lunchtime how are they feeling what’s their emotional state what’s their energy level on the happy days a lot of times it can be less and sometimes they need a little coaching throughout because some of those old patterns kick in but I want them to start challenging some of their automatic thoughts that we’re going to talk about in a minute disqualifying or minimizing the positive most of us can probably say we’ve had a bunch of clients that do this they are more than happy to tell you about all the things that they mess up but then when they do something right they minimize it encouraging people to hold themselves to the same standard they would hold everyone else to and I know I talked about that earlier ask them things like would it minimum would you minimize this if it was your best friend’s experience your best friend came to you and said I just got into such-and-such college would you say awesome or would you say anybody can get in there how would that go ask them what is scary about accepting these positive things that you might have had an accomplishment for some people it means that it might mean other people expect more of them for other people they just don’t know how to accept the positive they don’t know how to accept compliments they don’t know how to be the center of attention and they don’t like it and then we want to look at why that is sometimes we disqualify the positive because it fails to meet someone else’s standards so as people might that be true here you know I know when I was growing up and going through college and going through school and everything got my doctorate but I will always be ever and always being not a real doctor because a Ph.D. is not an MD and I’m like really so is it somebody else’s standards or can I feel good about having a Ph.D. egocentrism my perspective is the only perspective I’ll being egocentric but it doesn’t work most of the time so encouraging people to take alternate perspectives maybe you’re texting with someone and they say something that is not that you interpret as not the nicest thing and this happens in text messages a lot and they get upset now an egocentric thinking error would say that purse is just grumpy today someone that’s taking other perspectives would stop and go back and read the text and go I wonder if maybe this could have been taken some another way you know cuz their reaction is not what I intended so egocentrism if you hold on to that I don’t understand anybody else because you know I don’t see a problem with anything personalizing and mind-reading this is when you assume that everybody’s frowning because of something you did your boss walks down the hallway and looks at you and grimaces and continues to walk on oh I must have done something wrong no maybe he just got out of his senior management meeting that was five hours long and he’s got to go to the bathroom you know there could be a hundred different explanations for why that happened so encourage clients to ask themselves what are some alternate explanations for this event that doesn’t involve me you know why might this have happened if they hold on to that, I must have done something wrong but as soon as their boss calls them up and goes hey can you come to my office for a second you know where their thoughts are going to go I’m getting fired I’m going to get laid off I don’t know what it was that I did wrong but he walked by me two weeks ago in the hallway and grimaced and I’m just I’m the worst person in the whole world but where did that come from so encouraging people to not necessarily assume they know what’s going on in someone else’s mind and not automatically attributing every person’s negative behavior to something they did how often and then ask them how often has it been about you now think about the last 10 times you’ve taken something personally how many of those 10 times has it been about something you did versus something with the other person then the availability heuristic remembering what’s most prominent in your mind so asking clients what are the facts ah the most obvious one that we talk about is plane crashes you know it is way dangerous to fly on a plane because you hear about all those plane crashes well yeah you hear about A few planes crash but you don’t hear about the 20,000 every day that land safely so you remember it and it seems more dangerous because that’s what is in your mind that’s what is available to you that’s what you’ve based your thought processes on because maybe you didn’t know that 20,000 planes or more fly and land just perfectly every day this can also be true with people remembering what’s most prominent in your mind sometimes and this can be very very true in domestically violent relationships if somebody falls in love with someone and that person is just the greatest person since sliced bread for the first four months and then the cycle starts and there’s this little tiny a sliver of the honeymoon period after the battering cycle and the person’s like that’s the person I fell in love with that’s what I remember and they try to focus on that that’s most prominent in their mind and they ignore the rest of the stuff so we need to encourage people to look objectively at the facts magnification are you confusing high and low probability outcomes what are the chances that this is going to happen how many clients have we worked with that have gone to the doctor and gotten in a physical or get a test run and then the doctor had to call them back and this could be true for you too and the doctor had to call them back two or three days later when the tests came back from the lab and that whole three days they were just in a panic because they were afraid they were going to get some terminal diagnosis so thinking about high and low probability outcomes another instance or example of magnification is somebody that thinks this is the end of the world whatever it I think I’ve told you before my little story about um tripping when I was walking down the hall at work and falling and yeah it was embarrassing my folders went everywhere and yeah but in that big scheme of things will it matter that much from now you know are people gonna think oh she is such a clutch she must be a ditz too no I mean they may have thought that at that time I don’t know but you know in six months nobody’s going to remember and then ask them in the past when something like this has happened when you’ve had to get a test done and you’ve had to wait on results or if you’ve done something that was embarrassing and you didn’t think you thought everybody was going to remember it forever.

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How did you tolerate it how did you learn to deal with it building on those strengths that they already have all-or-nothing thinking errors these are things like love versus hate I love them or I hate them it’s all or nothing she does this all the time or she never does it if I’m going to do it I’m going to do it perfectly or I’m not going to do it at all thank you all good intentions or all bad intentions you know sometimes we do things with good intentions that have some bad repercussions so did we do it with all bad intentions are all good intentions and the answer is neither most of the time life is kind of in that middle-ground gray area encouraging clients to look and find examples where something hasn’t been one of the polls when having they do something that they’re proud of that wasn’t perfect or when again when has somebody else do something that they were proud of that wasn’t perfect remembering that with availability heuristic remembering how often something happens and how long it’s been since you’ve seen that behavior and remember that sometimes good times are amazing but how frequent are they compared with the bad times another thinking error is a belief in a just world or a fallacy of fairness I just asked clients to identify for good people you know who’ve had bad things happen and in reality we all have bad things happen good people do bad people do in between people do attributional errors and this is a pet of mine you know labeling yourself is not a behavior so global versus specific and I am stupid versus I’m stupid at math I don’t have good math skills it’s not about me it’s about the skills I can change skills stable I am and I always will be versus it’s something I can change it’s something I can learn internally it’s about me as a person versus it’s about a skill deficit or something I could learn or change and there’s you know lots of information on attributions out there on the internet if you need a refresher on it but we find that a lot of people who have dysphoria have negative global stable internal attributions so questions for clients remember the beliefs equal thoughts and facts plus personal interpretation another way of saying it is reality is 10% perception is 10% reality and 90% interpretation so what are the facts for and against my belief is the belief based on facts or feelings does the belief focus on one aspect or the whole situation does the belief seem to use any thinking errors what are alternate explanations what would you tell your child or best friend if they had this belief how would you want someone to tell what would you want someone to tell you about this belief so if you’re telling somebody about this what are you hoping they’re going to say in return and finally, how is this belief moving you toward what and who is important to you or moving you away from what or who is important to you now they can do a worksheet and have all of these or you can pick one or two of these questions that are most salient for your clients but they can have kind of at their fingertips so as they’re going through the day and something happens they can ask themselves ok what’s an alternate explanation or you know whatever it is this is salient for that client’s irrational thoughts about how to do these thoughts impact the client’s emotions health relationships and perceptions of the world you know this is what we want to ask them how is this thought impacting you globally how may this thought have been helpful in the past where did it come from how does it make sense from when you formed it in the past when you’re dealing with it ask the person if the thought is bringing you closer to those that are important are there any examples of this thought or belief not being true and how can the statement be made less global less all-encompassing so it’s about a specific incident a specific situation less stable which means you can change it and less internal which means it’s not about who you are as a person but maybe something that you do or a skill that you have so we’re going to go through some of these thoughts real quickly here mistakes are never acceptable and if I make one it means that I’m incompetent well never is kind of stable and I am incompetent is kind of global, that’s also that extreme all-or-nothing thinking so you can see where these cognitive distortions end up leading to unhelpful beliefs when somebody disagrees with me it’s a personal attack well there’s personalization if I ever heard it before maybe it’s not about you may be they’re having a bad day and you just happen to be the unlucky target or maybe they’re disagreeing with you because they have a different point of view and it’s not a personal attack it’s just their point of view if someone criticizes or rejects me there must be something wrong with me personalization all-or-nothing thinking global stable and internal something wrong with me as a person to feel good about myself others must approve of me now this is one we’ve talked about external validation before and we can’t control other people to feel good about yourself how can you do that besides necessarily requiring other people to approve of you to be content in life I must be liked by all people Wow I’ve never met anybody who’s liked by all people I’ve never even met anybody who’s been hated by all people but it’s important to help clients see how this is dramatic to say all people and for them to be content then everybody has to like them I mean I like to be liked but if everybody doesn’t like me you know that’s pretty understandable my true value as an individual depends on what others think of me I would challenge this one this is all you know also, very personally internally I would challenge people to look at and say it so your child’s value as an individual depends on what other people think of he or most people would say no but the perspective thing nothing ever turns out the way you want it to okay all-or-nothing thinking and probably availability heuristic if something bad just happened then they may be focusing on that which causes them to focus on all the other bad things in the past that have happened not to focus on that is okay you know bad thing happen but look at all these good things I won’t try anything new unless I will be good at it this fear of failure fear of rejection it just really paralyzes a lot of people when they get stuck with that thinking the area that they have to be perfect I am in total control of anything bad that happens is my fault well that’s egocentric and personal if they think they’re in total control that’s their perception of how the world are they think if they’ve got everybody on marionette strings anything bad in the world that happens is their fault how powerful are they I feel happy about uh if I feel happy about life something will go wrong it happens sometimes but let’s look at times when you’ve been happy that something hasn’t gone wrong you know let’s get rid of that all-or-nothing thinking it’s not my fault my life didn’t go the way I wanted could be true but it seems like that’s making you unhappy so what do we do about that if I’m not in an intimate relationship I’m alone no, again that’s pretty extreme I’m either in an intimate relationship, or I am alone and a loner and you know it’s just me and my 17 cats which follows with there’s no gray area so encouraging people to look at what these beliefs are saying important thoughts impact behaviors and emotional and physical reactions emotional and physical reactions impact thoughts and interpretations of events so if you do something and it’s pleasurable and you have a great physical reaction you know let’s take bungee jumping or skydiving if you go out there and it’s scary but you do it and you’re just like whoa what a rush your interpretation of that is probably going to be good which means you’ll probably do it again if you go out there and it’s just the most horrible experience you’ve ever had you’re probably not going to do it again and your interpretation of it is going to be not good which is going to make it hard to understand why other people would do it irrational thinking patterns are often caused by cognitive distortions so let’s just look back at some of those because there are a lot fewer cognitive distortions or general ways of thinking about the world then there are thinking errors because there are lots and lots of thinking errors cognitive distortions are often schemas which were formed based on faulty inaccurate or immature knowledge or understanding and by identifying the thoughts of the hecklers you know the automatic tapes that are maintaining our unhappiness the person can choose whether to accept those thoughts or change them As found on YouTubeThe Destroy Depression ꆛ System-Cure Depression Naturally YOUR DEPRESSION HAS BEEN IN CONTROL LONG ENOUGH. It’s Time to Fight Back ☂🗯 “Depression Sufferer Of Over 20 Years Reveals His Simple 7-Step System That Gives You The Power To Destroy Your Depression, End Your Feelings Of Sadness And Hopelessness, And Get Your Life Back.” “This didn’t just change my life, it saved my life.“

Cognitive Behavioral Therapy (CBT) Skills and Counseling Techniques with Dr. Dawn-Elise “Doc” Snipes

 CEUs are available for this presentation at AllCEUs.com/CBT-CEU Hi everybody and welcome to today’s presentation on cognitive behavioral therapy skills. Like the other the presentation we did on assert not assertive community treatment acceptance and commitment therapy, which is also based on just providing information about skills that can be used not providing an evidence-based practice we couldn’t cover that in a full hour or just an hour so over the next hour we’re going to define cognitive behavioral therapy and its basic principles a lot of us are familiar with this but it’s going to be a good review and it also may highlight some nuances that you didn’t know about will identify factors impacting people’s choice of behaviors explore causes and impact of thinking errors and identify common thinking errors and their relationships to cognitive distortions so why do we care well as therapists we want to help people figure out the best way to live a happy healthy meaningful goals-driven life for some people that’s going to mean using some cognitive behavioral interventions that can be in addition to mindfulness that can be in addition to a lot of other things but it’s important to help people understand that the way we believe things to be the way we interpret things is going to affect our reactions so for example think about a situation you know you’ve walked into and maybe you walked into it with a small child and it was a different situation it was a new situation but you know it was no big deal you walked in it was not a threatening situation to you because you were like hey I got this the little kid walks in and goes oh wow there are a lot of people walking around here, this is the really scary same situation as two different perceptions you probably didn’t have much of a stress reaction going on whereas the little child probably had this fight-or-flight thing going on grabbing onto your hand like please don’t let go Atlanta Airport is a perfect example if you’ve ever taken a little kid through Atlanta Airport gives you an idea about how people can perceive things differently and when you enact that fight-or-flight the reaction you’re going to have all those stress hormones you’re going to have all either anxiety or anger or whatever that goes with it it may serve to exhaust the person and leave them feeling hopeless and helpless so what we want to do is help people see that but we also want to help them see that when they’re depressed when they’re tired when they’re sick things are going to seem a lot worse a lot of times because they don’t have the energy to perceive it differently I mean when you’re sick it’s overwhelming to think of going through Atlanta Airport so this is what we want to help people start understanding is it’s two sides of the same coin they interact if one is you know kind of going wonky is going to affect the other one the good thing is if one’s going well the other one’s going to go well if you’re having positive thoughts you’re probably going to feel pretty good there’s an activity and I think we’re going to talk about it later it’s called the coin flip activity and I asked client clients to flip a coin in the morning and in the morning if it turns heads then they have to be the most positive Pollyanna all day long look for the silver lining and everything smile walk with their head up hold those nonverbals up and see how they feel at the end of the day besides a little sore because there are muscles they’re using they haven’t used in a while if it lands on tails they can just be their normal selves which generally if they’re seeing me means that they are depressed anxious stressed out angry about something in the negative realm then we talk about how did things seem different on the days when you were feeling better when you were walking taller when you were smiling even our nonverbals it doesn’t even have to be sickness it can be our nonverbals that can make us feel or make our body feel heavy and tired and make it seem like it’s a whole lot harder to deal with life as a person who perceives the world generally good and believes they can deal with challenges as they arise that good old self-efficacy will be able to allow their stress response system to function normally so if they’re like you know what I can deal with whatever life throws at me I’ve got it and maybe I need help with it maybe I’ll need to ask for support but I’ve got it it’s not going to completely overwhelm me with people who see the world as hostile unsafe and unpredictable you know for a variety of reasons whatever happened to make their scheme as such that they don’t believe that people or the world is trustworthy are predictable they are always on guard they’re always kind of like a hamster in a cage that has Have you ever had hamster hamsters don’t recognize you and go hey that’s my own or human contact score hamsters go run under their little house and you just kind of open the cage and stick your hand in there and flip over their house and you’re like come here and give me cuddles and you’re like you know 200 times bigger than they are so the little hamster is like freaking out this is what it’s like for people and obviously, I’m exaggerating but this is what it’s like for people who have a negative perspective a negative view or a hostile view of the world so kind of keep that little hamster in your mind cognitive behavioral therapy we have core beliefs those things that are in our hearts when I talk with my clients about honesty step one and that’s what they’ve got to do to start recovery is get honest with themselves first and then other people we talk about head heart and gut honesty do you think it’s right does it seem like the right thing to do does it feel right in your heart you know does it make you happy it doesn’t make you feel good and then the spidey senses is your gut saying and or is your gut fine if one of those is saying this might not be the right choice and we need to think about what’s going on so we have those core beliefs and I put them in the heart just because that’s the middle of the head heart and gut but you have core beliefs about yourself whether you’re good with you’re bad whether you’re effective at certain things ya ya you have core beliefs about other people same thing good bad effective predictable and you have core beliefs about the future and a lot of that goes with the locus of control but also your past experiences if the world in the past is seemed unfriendly and uncontrollable and you’ve perceived it that way then you’re going to expect the future to be uncontrollable so what we want to do is help people look at their schemas and their core beliefs about themselves others in the future and figure out kind of what they want it to look like these schemas are going to affect your behavior and your thoughts and your feelings and you know you can pick wherever you want to start it doesn’t matter because all three inter interface with one another so if you haven’t let’s start with negative thoughts if you have negative thoughts then you might feel anxious angry stressed dysphoric which will affect the behavior you’re going to do different things than if you have positive thoughts about something you feel excited and energized you’re going to have different behavior the best thing example I can give you is if you’ve ever done public speaking or had to present something some people detest public speaking it’s just terrifying for them to get up in front of a group of people so their thoughts am I going to trip up I going to forget what I’m going to say I’m going to make a fool of myself I’m going to you know it can go on forever that when you get on a roll you can get on a negative roll and go on forever or positive hopefully get on that roll with those thoughts you start holding onto those thoughts remember as we talked about in a CT the other day when you hold those thoughts and you kind of mush them around in your mind and you come to believe them that you’re going to make a fool of yourself and it’s going to be awful you’re going to start feeling terrified likely which is going to likely affect your behavior if you go out on the stage and you’re terrified you’re going to probably stutter you’re probably going to get foggy-headed you’re going to have that fight-or-flight reaction so there’s an the adrenaline rush and you start sweating and you can’t focus and you can’t concentrate you want to away as opposed to somebody like me who loves public speaking and I’m just like cool I get to go out there and try to engage however many people are in the audience it’s a game for me because when I can see your faces I enjoy trying to figure out and make eye contact with people and figure out what it is that they’re there for what is it that’s going to make them tick what resonates with them so my behavior as you can kind of see right now when I go out there I’m excited and I want to engage people and it’s a fun experience for me again just like the airport the same experience for two different people and two very different interpretations and reactions to it so what effects I don’t like the term rational but when we’re talking about CBT irrationally comes up a lot I like to replace it with helpful because every behavior in its weird sort of way is or probably was rational at one time that being said we’re going to get back to that stress affects our behavioral choices if we’re under stress we can have negative emotions negative emotions will affect our thoughts if we’re feeling sad we’re probably going to look at the dark side if we feel sad we’re going to look at the bottom falling out if we’re happy we’re probably going to look for that silver lining physical factors if you’re in pain sick sleep-deprived poorly nourished so your body can’t produce the neurotransmitters it needs to or heaven forbid intoxicated you’re probably not going to make the same decisions as you would if you were comfortable healthy well-rested nourished and not intoxicated any of those things can go impact how you perceive a situation or how you react in a situation, especially the intoxication whereas in your non intoxicated State in your sober state, you may think that you want to do something but then you’ve got that filter that goes not not a good idea in an intoxicated State or even in a manic state if you’re you know if you have somebody with bipolar that filter kind of goes away so the behaviors that someone may normally not do because they have a rational filter that goes you know punching this guy outs probably not the best idea right now the filter goes away when you’re sleep-deprived you’re less generally people are less patient generally people don’t have as much of a filter thing about watching your children if you have children or your grandchildren or even yourself I know myself when I’m sleepy I am giddy as all get-out and things I wouldn’t normally say because they’re you know stupid I’ll just come out and say anyway and my kids just roll their eyes or mom you’re overtired could go to bed, uh but that’s okay you know I’m okay with that in that situation now if I acted that way at work it would be a worse thing environmentally if you’re introduced to a new or unique situation and you perceive it as stressful because the unknown we know can be stressful then you may not make as rational of a choice or as helpful of a choice because you maybe trying to escape the same thing as exposure to UNPROFOR bellowing for a the word here but UNPROFOR ball is the best I could come up with we all prefer certain situations some people as I said would rather do just about anything then get up in front of a lecture hall of a hundred and fifty people and talk but if they have to do it then they’re going to be under stress which may affect how they do things so we want people to understand that their perception and their feelings are affected by a lot of other things not just you know an emotion here or a particular memory there’s a lot that goes into it and social if peers your family convey irrational thoughts as necessary very standards for social acceptance people may tend to cling more to it to those unhelpful thoughts and unhelpful behaviors you know in CBT they say irrational because quote nobody wants to associate with those people you know who are those people and why can’t we associate with them there are a lot of things if you think back think high the school you know high school is pretty rough if we’re going to talk about having irrational thoughts and cognitions if you have to be part of this particular group to be accepted you have to do this you have to do that but do you really so those kinds of all-or-nothing statements are cognitive distortions and while they may have served a purpose in some way shape or form in the past we need to encourage our clients to take a look at them now and go are they still helpful ways of thinking is it still helpful for me to think that I am only successful if I live in a million-dollar house in a gated community and do this that and the other or can I be can I define success a different way or do I define success differently and lack supportive peers to buffer stress so we had those peers that caused stress by talking about the half dues and categorizing and lots of attributions but then there’s also not having somebody to go you know does this make any sense because sometimes we are our own worst enemies and if we go to a friend and we go you know this is what I’m thinking and I think I have to do this in order to be acceptable to be loved or you know whatever the case may be most people are not going to use those exact phrases a good friend is probably going to listen and go yeah you’re right or no no that’s way off so supportive peers are essential to reminding us to consciously regularly check in with our cognitions to make sure that they are hopeful and rational so a note about irrationality and this is mine this is not from CBT the origins of most beliefs for rational and helpful given the information the person had at the time and their cognitive development their ability to process that information so concepts and schemas and core beliefs that people formed when they were five are probably going to be very egocentric you know the person is going to feel like everybody sees it my way because this is how I see it you know just like a five-year-old does a five-year-old doesn’t think well you know let me take Johnny’s perspective is no he assumes that Johnny sees it the same way so it’s going to be egocentric it’s probably going to be focused on only one aspect of the situation because small children can’t focus on multiple aspects and it’s probably going to be dichotomous it’s all-or-nothing mommy loves me mommy hates me and it could be personalized you know everything a lot of kids think that everything has to do with them so if something happens something bad happens many times children will take it personally or be afraid it’s going to happen to them again you know if hurricane Katrina hurricane Andrew those sorts of things you know we saw a lot of trauma in children and they developed very real fears about thunderstorms and hurricane season and if you’ve watched Florida hasn’t had a notable hurricane in years now but there’s a lot of stuff that goes into that but young people during some of those really bad hurricane seasons perceive those situations differently okay so we need to help people understand that if we especially if we use the term irrational those thoughts you formed when you are knee-high to a grasshopper and they made perfect sense to you back then but now that you’re an adult you’ve got more experience and you’re able to take different perspectives your brain is more developed let’s take a look at it and see if you can look at different perspectives and come up with something a little more helpful maybe a different way of perceiving this situation the irrational irrationality or unhelpful Nosov Fox comes when those beliefs are perpetuated without an examination so something a the belief that you formed when you’re five you’re still holding when you’re 35 and you’ve never questioned it you’ve never gone you know does this make sense is this is helpful to get me to where I want to be most of us don’t know we form these attitudes and beliefs when we’re you know growing up when we’re in elementary school middle school high school from watching TV to being around our peers from being around our family in our community and we get all this input of the way things should be and a lot of times people don’t stop to question and go and go well does this make me happy is this really what I want and they can be irrational if they continue to be held despite causing harm to the person so the person continues to hold this belief even though it is causing them general emotional cognitive harm is making them miserable we need to look at why what’s motivating them to hold on to that belief why is that belief so important and how can we make it so they can live a happy values-driven life emphasis on the happy how can we make it less harmful sometimes it’s more productive for clients to think of these thoughts as unhelpful or helpful instead of irrational sometimes when I say irrational to clients and you know I’m the same way if somebody says you’re being irrational I’m like oh I’m not it elicits this instantaneous defensive the reaction’s like when you tell them they’re being resistant they’re like I am NOT being resistant so helpful or unhelpful and then we talk about why it is unhelpful in getting them toward their goals basic principles of cognitive behavioral therapy we teach or help clients learn to distinguish between thoughts and feelings I can think something is scary I’ll probably feel it but if I have an automatic you know feeling I walk into Atlanta Airport and I see yeah I went to an airport in New York I can’t even remember which one it was because my plane was diverted and I got off and I walked out there and I have never seen so many people packed in his place like sardines before in my life I was just completely overwhelmed that was kind of an automatic feeling now that was a feeling based on you know who knows it was overwhelming to be surrounded by that many people so then I had to separate the thoughts and go okay what am I thinking that’s making me feel so overwhelmed and at that point you know I didn’t know how to get to my gate and all that other sort of stuff with traveling I don’t travel well but encouraging clients to stop and go okay why am I feeling this way what are my what thoughts am I having that are contributing to these dysphoric feelings CBT helps people become aware of how thoughts can influence feelings in ways that are sometimes not helpful we have hecklers in our gallery the automatic tapes that we plaything memories that we have whatever you want to call them that when you try something when you are just going through daily life you hear these voices in the back of your head and not real voices but that is saying you’re never going to make this or if you would have just blah blah blah then you’d be a the better person helping clients become aware of those thoughts and how they’re negatively influencing their feelings and keeping them kind of stuck is a huge part of CBT we help them learn about thoughts that seem to occur automatically without even realizing how they may affect emotions again those thoughts from they’re saying you’re not good enough you’re not smart enough and nobody’s gonna like you where did that come from and do you believe it you know maybe it came from somebody when you were in high school so was that a valid source maybe it came from somebody yesterday on Facebook was that a valid source taking in those thoughts and then figuring out is this something I’m going to hold because it makes me happy or is this something that I’ve got to deal with because I’m having a negative reaction constructively evaluate whether these automatic thoughts and assumptions are accurate or perhaps biased the other thing to remember is a lot of our clients not all of them but a lot of them hold themselves to a standard there’s like up here and they hold everybody else to a standard that’s down here so they are a failure if they don’t achieve this but everybody else is successful as long as they achieve this so encouraging them to take a look at how accurate and biased or unbiased are the thoughts and like I said they may be their thoughts they may be telling themselves these things evaluate whether the current reactions are a helpful and good use of energy or unhelpful and a waste of energy that could be used to move toward those people and things important not impotent important to the person road-rage you’re in the car, you’re driving somebody cuts you off okay natural reaction fight or flight reaction you’re just like slam on the brakes and do whatever you got to do aversive maneuvers you’re good so you could let it go at that point ago got lucky on that one and keep driving most people not all but most they found that 80% of drivers have reported incidences of road rage which is a high number but most people will start getting all fired up and irritated and grumpy and we and just rageful and so my question would be I hear that and I hear that it made you angry in retrospect did screaming at the person as you pass them at sixty miles an hour in your car with the windows rolled up does any good did it do any good at all what else could you have done with that energy if you wouldn’t have expended it all yesterday we had to wait for the vet to come by and my daughter just completely wore herself out worrying about when the vet was going to get there what he was going to say about her donkeys and was beside herself so by the time it got to evening and it was time for her to go to her martial arts class she didn’t have the energy to go she’s like um wiped out I just want to go to bed in retrospect we’re looking back and saying okay now tell me what it was that you were so stressed out about and let’s talk about whether that was a realistic and helpful line of thought to perseverate on all day long and what could you have done differently because she didn’t bother to mention any of that to me yesterday and then developed the skills to notice interrupt and correct these biased thoughts independently causes of these thinking errors information processing shortcuts when we form schemas and we encounter a situation that reminds us of something in the past like when I go to my grandmother’s house I have a schema I have a belief system I have you know stuff that I know about my grandmother’s house so when I go to my grandmother’s house it’s kind of a shortcut to knowing what to expect when I walk in and how to behave how to do different things and it helps me plan and predict if you’re using outdated or dichotomous all-or-nothing schemas it may cause thinking errors because you may be now incorrectly processing current events mental noise some of us have it a lot of us have it not everybody thinks about trying to focus and study for a final exam in the middle of a really busy sports bar, okay this is a cause of thinking or you’re going to miss important things you’re not going to be able to focus you’re not going to necessarily attend to the correct things because there’s just so much else going on your attention is drawn in 17 different directions and or the brain’s limited information processing capacity due to age we talked about that before young kids think all or nothing they think dichotomously egocentric ly middle school-aged kids and older start developing the ability for abstract thinking by the time we get older, you know as adults theoretically we’re able to you know think pretty well and think pretty clinically about different events but if we’re in crisis when someone is in crisis and it could be like what we think of clinically as a crisis or it could be they’re just completely overwhelmed and burned out and have been burning the candle at both ends for three months they’re not going to process information quite as well they’re not going to take in all this stuff because they’re just like shell-shocked have you ever seen teachers in the hallway of like an elementary school Oh at the end of the second nine weeks they just kind of stand there with this blank look on their face they’re not processing as much as they were the first day of school and you know God loved them they have a lot to deal with but we need to help our clients understand that there are some times that they are going to have to really stop and focus write things down so they can remember or they can make decisions a little more my guess is most of us have times in our life when we’ve been able to think through complex problems but then there are other times where you just can’t keep it all in your head and you’ve got to put it on a whiteboard maybe that’s just me but we want clients to understand that they are not broken they’re not faulty they’re doing the best they can with the tools they have and the knowledge they have and our job is to help them see where some of this might have gone a little awry other causes of thinking errors and emotional motivations I feel bad therefore whatever I’m thinking must be bad if I’m scared that means whatever it’s coming on the other end of the phone is bad news moral motivations I did it because it was the right thing to do and that can be an excuse for doing wrong behaviors as well it can also be you know you can argue on the moral one social influence well everyone else is doing it so it must not be bad set that again a lot of times and this is where the frames approaching the motivational interviewing is helpful f stands for feedback about the reality of what’s going on is everybody doing it let’s look at statistics you know not subjective information let’s look at objective information so the impact of these thinking errors makes people want to fight or flee when they get upset and we use upset as a kind of this all-encompassing garbage term emotionally they get depressed or anxious we don’t want to feel that way anxiety and anger are flee or fight fight or flee it’s our body saying there’s a threat you got to do something depression is your body going I give up I just don’t I don’t even have the energy to do it anymore behaviorally some people withdraw they shut down we all know people who get frustrated when they get overwhelmed when they start feeling hopeless or helpless they just kind of withdraw from everything and everyone’s addictions numb that out so they don’t have to feel the dysphoria sleeping problem and changes when we start being on that constant fight-or-flight hyper-vigilant sort of thing going on in the body is always sort of turned on which means you’re not going to sleep as well then the circadian rhythms get messed up which starts causing exhaustion and lethargy and then everything seems harder because you’re sleep-deprived and then you start thinking more negatively and more hopelessly you see where this is going it’s a downward spiral and eating changes some people eat a lot more because they’re eating comfort foods some people eat a lot less because their stomach is so torn up from the stress they can’t even think about holding anything down physical stress-related illnesses fibromyalgia gastrointestinal problems headaches neck aches backaches you know the whole the gamut of it when you start feeling bad when you start hurting generally it gets frustrating after a while and that frustration makes it kind of raises the the bar brings you up a little bit so you’re that is much closer to kind of just kind of being overwhelmed you don’t have as much of a cushion as you would if you were happy healthy well nourished not in pain and socially a lot of times we will get irritable or impatient with other people or withdrawal when we’re having these negative cognitions these thinking errors that are keeping us in a dysphoric state these effects of thinking errors contribute to fatigue and a sense of hopelessness and helplessness which intensifies thinking errors this is an important concept that I want my clients to understand and I want to drive home in this presentation so thinking errors what are they emotional reasoning feelings are not facts and we want to help people to learn to effectively identify feelings and separate them from facts so if somebody says I’m terrified okay that is a feeling what are the facts supporting that feeling why are you are terrified what is the evidence that you are in some sort of danger right now you know and danger may not be the right word for your client at that a particular point in time but what’s the evidence that there’s a threat in what ways are this similar to other situations maybe it’s triggering something from the scary past or you know you were too little to be able to handle it but you can handle it now and how if you dealt with similar situations like this, in the past, we want to help people just step back and get some distance between their feelings and their thoughts and try to figure out you know which thoughts are helpful and productive and even if a sought makes people anxious or angry it can be helpful it may be telling them hey dude you need to get your butt up and get out of there if it’s helpful it means it’s moving them toward where they want to be happy healthy safe and values-driven life so happy and helpful developed a stress tolerance skills when people use emotional reasoning they feel emotions which then they start attributing finding the facts to support those emotions instead of looking at all the facts we want to help them learn to tolerate their distress so they can kind of let that subside for a second they can accept their feeling they can name they can say I’m scared I’m stressed I’m angry and whatever but they don’t have to act on it right then they can tolerate the distress for a minute without having to try to make it go away and emotional regulation skills they can feel a feeling without having to make it go from zero to 120 you know if they feel sad they go I feel kind of sad instead of grabbing onto it and going I wonder what I feel sad about I must feel sad about all these sad things now I’m going to be sad and devastated so we want to help people learn how to regulate their emotions identify them accept them whatever word you want to use and tolerate them because feelings are there for a reason, they’re to tell you your brain thinks something’s going now thankfully we have that higher-order cognition stuff going on so we can contradict our brain and we can go you know maybe that’s not true in this situation cognitive bias negativity mental filter whatever you want to call it people who focus on the negative they walk in they get up in the morning and they look outside and it’s partly cloudy they get to work and they said instead of saying there was it was very light traffic they said there was a fair amount of traffic everything is always the flip side of what somebody who’s optimistic would say so asking them what’s the benefit to focusing on the negative in what ways is this helpful to you you know some people say well it keeps me from getting disappointed because I know it’s going to end up negative anyway so we can trap challenges that know that whatever it is they think they know and see if there have been exceptions when it hasn’t turned out that way what are the positives to this situation I give the example a lot of you know I wash my car or it rains and maybe I wanted to go out on a run that day but I can perceive it I can look at the positives you know the rain washed my car for me so I don’t have to do it now score it watered my garden all the better it knocked down some of the pollen out of there even better I can find and I can encourage people to find positives in a situation yes there are negatives to every situation if you want to find them you’re going to find them but if you want to find the positives you can too which takes us down to what are all the facts there’s the positive and the negative and the neutral I told you earlier about the coin toss activity having people toss a coin on the heads days they act like it is just the greatest day to be alive and see how things are different when they do their journal because you know I have my clients do I’m sort of a mindfulness check-in in the morning and in the evening and preferably at lunchtime how are they feeling what’s their emotional state what’s their energy level on the happy days a lot of times it can be less and sometimes they need a little coaching throughout because some of those old patterns kick in but I want them to start challenging some of their automatic thoughts that we’re going to talk about in a minute disqualifying or minimizing the positive most of us can probably say we’ve had a bunch of clients that do this they are more than happy to tell you about all the things that they mess up but then when they do something right they minimize it encouraging people to hold themselves to the same standard they would hold everyone else to and I know I talked about that earlier ask them things like would it minimum would you minimize this if it was your best friend’s experience your best friend came to you and said I just got into such-and-such college would you say awesome or would you say anybody can get in there how would that go ask them what is scary about accepting these positive things that you might have had an accomplishment for some people it means that it might mean other people expect more of them for other people they just don’t know how to accept the positive they don’t know how to accept compliments they don’t know how to be the center of attention and they don’t like it and then we want to look at why that is sometimes we disqualify the positive because it fails to meet someone else’s standards so as people might that be true here you know I know when I was growing up and going through college and going through school and everything got my doctorate but I will always be ever and always being not a real doctor because a Ph.D. is not an MD and I’m like really so is it somebody else’s standards or can I feel good about having a Ph.D. egocentrism my perspective is the only perspective I’ll being egocentric but it doesn’t work most of the time so encouraging people to take alternate perspectives maybe you’re texting with someone and they say something that is not that you interpret as not the nicest thing and this happens in a text messages a lot and they get upset now an egocentric thinking error would say that purse is just grumpy today someone that’s taking other perspectives would stop and go back and read the text and go I wonder if maybe this could have been taken some another way you know cuz their reaction is not what I intended so egocentrism if you hold on to that I don’t understand anybody else because you know I don’t see a problem with anything personalizing and mind-reading this is when you assume that everybody’s frowning because of something you did your boss walks down the hallway and looks at you and grimaces and continues to walk on oh I must have done something wrong no maybe he just got out of his senior management meeting that was five hours long and he’s got to go to the bathroom you know there could be a hundred different explanations for why that happened so encourage clients to ask themselves what are some alternate explanations for this event that doesn’t involve me you know why might this have happened if they hold on to that, I must have done something wrong but as soon as their boss calls them up and goes hey can you come to my office for a second you know where their thoughts are going to go I’m getting fired I’m going to get laid off I don’t know what it was that I did wrong but he walked by me two weeks ago in the hallway and grimaced and I’m just I’m the worst person in the whole world but where did that come from so encouraging people to not necessarily assume they know what’s going on in someone else’s mind and not automatically attributing every person’s negative behavior to something they did how often and then ask them how often has it been about you now think about the last 10 times you’ve taken something personally how many of those 10 times has it been about something you did versus something with the other person then the availability heuristic remembering what’s most prominent in your mind so asking clients what are the facts ah the most obvious one that we talk about is plane crashes you know it is way dangerous to fly on a plane because you hear about all those plane crashes well yeah you hear about A few planes crash but you don’t hear about the 20,000 every day that land safely so you remember it and it seems more dangerous because that’s what is in your mind that’s what is available to you that’s what you’ve based your thought processes on because maybe you didn’t know that 20,000 planes or more fly and land just perfectly every day this can also be true with people remembering what’s most prominent in your mind sometimes and this can be very very true in domestically violent relationships if somebody falls in love with someone and that person is just the greatest person since sliced bread for the first four months and then the cycle starts and there’s this little tiny a sliver of the honeymoon period after the battering cycle and the person’s like that’s the person I fell in love with that’s what I remember and they try to focus on what’s most prominent in their mind and they ignore the rest of the stuff so we need to encourage people to look objectively at the facts magnification are you confusing high and low probability outcomes what are the chances that this is going to happen how many clients have we worked with that have gone to the doctor and gotten in a physical or get a test run and then the doctor had to call them back and this could be true for you too and the doctor had to call them back two or three days later when the tests came back from the lab and that whole three days they were just in a panic because they were afraid they were going to get some terminal diagnosis so thinking about high and low probability outcomes another instance or example of magnification is somebody that thinks this is the end of the world whatever it I think I’ve told you before my little story about um tripping when I was walking down the hall at work and falling and yeah it was embarrassing my folders went everywhere and yeah but in that big scheme of things will it matter that much from now you know are people gonna think oh she is such a clutch she must be a ditz too no I mean they may have thought that at that time I don’t know but you know in six months nobody’s going to remember and then ask them in the past when something like this has happened when you’ve had to get a test done and you’ve had to wait on results or if you’ve done something that was embarrassing and you didn’t think you thought everybody was going to remember it forever how did you tolerate it how did you learn to deal with it building on those strengths that they already have all-or-nothing thinking errors these are things like love versus hate I love them or I hate them it’s all or nothing she does this all the time or she never does it if I’m going to do it I’m going to do it perfectly or I’m not going to do it at all thank you all good intentions or all bad intentions you know sometimes we do things with good intentions that have some bad repercussions so did we do it with all bad intentions are all good intentions and the answer is neither most of the time life is kind of in that middle-ground gray area encouraging clients to look and find examples where something hasn’t been one of the polls when having they do something that they’re proud of that wasn’t perfect or when again when has somebody else done something that they were proud of that wasn’t perfect remembering that with availability heuristic remembering how often something really happens and how long it’s been since you’ve seen that behavior and remember that sometimes good times are amazing but how frequent are they compared with the bad times another thinking error is a belief in a just world or a fallacy of fairness I just asked clients to identify for good people you know who’ve had bad things happen and in reality we all have bad things happen good people do bad people do in between people do attributional errors and this is a pet of mine you know labeling yourself is not a behavior so global versus specific and I am stupid versus I’m stupid at math I don’t have good math skills it’s not about me it’s about the skills I can change skills stable I am and I always will be versus it’s something I can change it’s something I can learn internally it’s about me as a person versus it’s about a skill deficit or something I could learn or change and there’s you know lots of information on attributions out there on the internet if you need a refresher on it but we find that a lot of people who have dysphoria have negative global stable internal attributions so questions for clients remember the beliefs equal thoughts and facts plus personal interpretation another way of saying it is reality is 10% perception is 10% reality and 90% interpretation so what are the facts for and against my belief is the belief based on facts or feelings do the belief focus on one aspect or the whole situation does the belief seem to use any thinking errors what are alternate explanations what would you tell your child or best friend if they had this belief how would you want someone to tell what would you want someone to tell you about this belief so if you’re telling somebody about this what are you hoping they’re going to say in return and finally, how is this belief moving you toward what and who is important to you or moving you away from what or who is important to you now they can do a worksheet and have all of these or you can pick one or two of these questions that are most salient for your clients but they can have kind of at their fingertips so as they’re going through the day and something happens they can ask themselves ok what’s an alternate explanation or you know whatever it is this is salient for that client’s irrational thoughts about how to do these thoughts impact the client’s emotions health relationships and perceptions of the world you know this is what we want to ask them how is this thought impacting you globally how may this thought has been helpful in the past where did it come from how does it make sense from when you formed it in the past when you’re dealing with it ask the person if the thought is bringing you closer to those that are important are there any examples of this thought or belief not being true and how can the statement be made less global less all-encompassing so it’s about a specific incident a specific situation less stable which means you can change it and less internal which means it’s not about who you are as a person but maybe something that you do or a skill that you have so we’re going to go through some of these thoughts real quickly here mistakes are never acceptable and if I make one it means that I’m incompetent well never is kind of stable and I am incompetent is kind of global that’s also that extreme all-or-nothing thinking so you can see where these cognitive distortions end up leading to unhelpful beliefs when somebody disagrees with me it’s a personal attack well there’s personalization if I ever heard it before maybe it’s not about you may be they’re having a bad day and you just happen to be the unlucky target or maybe they’re disagreeing with you because they have a different point of view and it’s not a personal attack it’s just their point of view if someone criticizes or rejects me there must be something wrong with me personalization all-or-nothing thinking global stable and internal something wrong with me as a person to feel good about myself others must approve of me now this is one we’ve talked about external validation before and we can’t control other people to feel good about yourself how can you do that besides necessarily requiring other people to approve of you to be content in the life I must be liked by all people Wow I’ve never met anybody who’s liked by all people I’ve never even met anybody who’s been hated by all people but it’s important to help clients see how this is dramatic to say all people and for them to be content then everybody has to like them I mean I like to be liked but if everybody doesn’t like me you know that’s pretty understandable my true value as an individual depends on what others think of me I would challenge this one this is all you know also, very personal internal I would challenge people to look at and say it so your child’s value as an individual depends on what other people think of he or most people would say no but the perspective thing nothing ever turns out the way, you want it to okay all-or-nothing thinking and probably the availability heuristic if something bad just happened then they may be focusing on that which causes them to focus on all the other bad things in the past that have happened not to focus on that is okay you know bad thing happen but look at all these good things I won’t try anything new unless I will be good at it this fear of failure fear of rejection it just really paralyzes a lot of people when they get stuck with that thinking the area that they have to be perfect I am in total control of anything bad that happens is my fault well that’s egocentric and personal if they think they’re in total control that’s their perception of how the world are they think if they’ve got everybody on marionette strings anything bad in the world that happens is their fault how powerful are they I feel happy about uh if I feel happy about life something will go wrong it happens sometimes but let’s look at times when you’ve been happy that something hasn’t gone wrong you know let’s get rid of that all-or-nothing thinking it’s not my fault my life didn’t go the way I wanted could be true but it seems like that’s making you unhappy so what do we do about that if I’m not in an intimate relationship I’m alone no, again that’s pretty extreme I’m either in an intimate relationship, or I am alone and a loner and you know it’s just me and my 17 cats which follows with there’s no gray area so encouraging people to look at what these beliefs are saying important thoughts impacts behaviors and emotional and physical reactions emotional and physical reactions impact thoughts and interpretations of events so if you do something and it’s pleasurable and you have a great physical reaction you know let’s take bungee jumping or skydiving if you go out there and it’s scary but you do it and you’re just like whoa what a rush your interpretation of that is probably going to be good which means you’ll probably do it again if you go out there and it’s just the most horrible experience you’ve ever had you’re probably not going to do it again and your interpretation of it is going to be not good which is going to make it hard to understand why other people would do it irrational thinking patterns are often caused by cognitive distortions so let’s just look back at some of those because there are a lot fewer cognitive distortions or general ways of thinking about the world then there are thinking errors because there are lots and lots of thinking errors cognitive distortions are often schemas which were formed based on faulty inaccurate or immature knowledge or understanding and by identifying the thoughts of the hecklers you know the automatic tapes that are maintaining our unhappiness the person 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Group Counseling Modules 1 & 2 Based on SAMHSA TIP 41

 This episode was pre-recorded as part of a live continuing education webinar on demand. Ceus are still available for this presentation through all CEUs registered at all, CEUs comm slash counselor toolbox. I’d like to welcome everybody to group therapy, which is a product of treatment improvement. Protocol 41. Today we’re going to be going over chapters 1 and 2 tips 41. They did make it into an in-service, which is what I loosely based. The next set of presentations on and we’re, going to talk about some of the different ways you can use group and make it beneficial and hopefully easier than some other ways of approaching treatment. So, in the first part of today’s presentation, the goal is to provide an overview of group therapy which is used in substance, abuse, and mental health treatment, and, as I said, I’m, loosely basing it on it, but a lot of times the groups That we’re doing in substance abuse are the same ones. We’re doing in mental health. We’re going to discuss the uses of group therapy in treatment, define five therapy models, explain the advantages of group therapy and modify group therapy to treat and address substance abuse issues. So group therapy is awesome because it supports members in times of pain and trouble. It’s something that we can make available to the community mental health center that I worked at before and if you’ve worked in community mental health or even private mental health. Maybe a lot of times. There are waiting lists to get into IOP to get into PHP to get into residential to get into detox. So one of the things that we started instituting was an intervention-level psycho-educational group, so we were able to sort of keep a tab on people who are on our waiting list. They got on the waiting list and they started coming to these groups that provided them with tools provided them skills. We weren’t treating any particular issue. We were focusing more on life skills, distress, tolerance, emotion, regulation, and all that other DPP kind of stuff. Helping them get through, was also enabling us to provide them with some hope and keep their motivation going. Group therapy can enrich members with insight and guidance. I found, and one of the reasons I love doing group so much is because you can ask a question to a group of 10 people and get 8 or 10 different answers to it, and the cool thing about that is that each person has their blind spots, so what they might not have thought about before might still be germane to them, and somebody else puts it out there. So when you start putting asking questions and putting the answers on the board or using the flip chart papers and having stations around the room that people go and contribute to the group process, you start getting a lot more feedback from individuals and they’re going To come up with ideas and suggestions and thoughts that not only each other had never had so they’re going to enrich each other’s lives, but they teach me something every single time. So I loved doing and still do love doing group and it’s. A natural ally with addiction, treatment or treatment in general group therapy enables us to provide a basic framework of information to people in a cost, effective manner. You know there are a lot of things like emotion, regulation, distress, tolerance, self, esteem, skills, effective interpersonal communication relationship skills, and self-esteem. I may have already said that we give to all of our clients whether it’s substance, abuse or mental health, and everybody who’s coming through the program. Has this curriculum? If you will go through now, it’s going to apply a little bit differently to each one and they’re going to take the stuff they get from those groups and they’re going to be able to take it back to their Therapists and say this is what I learned in group. If it is just a group process, then they’re going to be able to talk among each other and come up with their ideas, but IOP, PHP, and residential all have individual accounts. One component, if you’re doing an intervention level group 0 05 on the ACM. If you will, you may not have that individual therapy component. So you want to make sure that when you provide members with information – and you help them start gaining insight you tie it up in a nice little bow at the end and help them apply it. So what did you get out of today?’s group that could have been helpful last week and how could you have used it then go back around the room and say from whatever you got from today:’s group or what’s a morsel you got from today,’s, group that You’re going to use next week, and how do you expect to do that? So I encourage them to take one or two morsels and figure out how they can use that in their particular life. A little bit of a slide track here. In support groups, if somebody is going to celebrate recovery or 12 step group, or even a depression or anxiety management group, I encourage them when they walk out of the group to be able to answer the question. What was in that group for me? What can I take away from that now? It may be, I know what I don’t want to do, or it may be. That was a great idea that so and so had, but I want them to answer that question every time, not just walk out of a group and go well. That was a good group. Why? Why was it a good group? What did you get out of it? Group therapy, as opposed to self-help groups and support groups, if you will have trained leaders, so you do have a lot more ability to facilitate what’s going on and kind of point people in directions that you want them to go. Where support groups may have facilitators, but they don’t have the training that clinicians do and group therapy produces healing and recovery from substance abuse and mental health issues. You see a lot of people gain. Hope you see a lot of people gain optimism. You see a lot of people learn tools from one another and nobody can comic con. If you will – and I had to figure out a way to say that a little bit nicer than the way I usually do. But when people are in recovery and you can even think about it with your teenagers, if you’ve been around known more if you have them, teenagers hear what their parents say and they’re like yeah, okay, whatever old, fuddy-duddy, but when their Parents or when their peers say it, it carries a lot more weight, so sometimes the hope and faith and tools and stuff that they hear from their cohort has more impact than what we say. If we’ve created a good supportive, healthy, nurturing environment, group therapy has a lot of power to it because it’s basically like having a bunch of code therapists and the ability to control it a little bit more than in group therapy. You can address factors associated with addiction or these factors by themselves, such as depression, anxiety, anger, shame, temporary cognitive impairment, character, pathology, ie, personality disorders, medication management, and pain management. So let’s go through these a little bit. Depression groups are wonderful. Now we’re going to talk about different types of groups and there’s everything from the traditional therapy group where people are sitting in a circle and or however, usually in a circle and sharing what’s going on in their particular situation. To psycho-educational and skills groups, where we’re, providing them the tools to understand what’s going on and the tools to deal with what they’re experiencing, and you know with depression. One of the groups I’m, going to do is depression. Well, any of these is to talk about what is it. What causes it? Where did it come from? How is it impacting you to have people start figuring out what that means to them, then we’re going to start talking, probably in the next group, about what are some ways we can start addressing this and what has worked for you. What what has worked in the past and what things might you want to do? Try? Temporary cognitive impairment can be addressed in the group in the sense that we can provide some life skills coaching. We can provide for early recovery and substance abuse. For example, a lot of people come to our groups, or at least where I used to work. They would get out of detox and they weren’t fully detoxed. Yet they had two days under them and the drug was out of their system. For the most part, you know, except for like marijuana or benzos, but they were still not on their game so getting them to just get there on time, be prepared, pay attention, and process what’s going on was huge. We didn’t expect to make huge therapeutic gains, but what I wanted was somebody to be able to dress up and show up. If you will character, pathology can be addressed in groups, one of the basic reasons that Marsha Linehan created dialectically. Behavior therapy was to address borderline personality disorder and DBT is very strong in skills groups. Now it has individual components and coaching components as well, but she uses the skills groups to help people with character, pathologies, and borderline personality disorder, among other things, start learning about what are these symptoms. What do they mean? What does it look like and how can I deal with them and then they personalize it in their sessions? Medication management is huge for me, whether it’s, somebody who’s on antidepressants or somebody who’s on methadone. I don’t care, but I think it’s really important for people when they start taking medication, especially psychotropic medication, whether it’s, addiction or mental depression, or anxiety to be able to go into a group and talk with others who’ve Been on similar medications understand the side effects understand that gets better understand what they’ve done, that helped them deal with the side effects. For example, a lot of my clients used to be on Seroquel and Seroquel is extremely sedating, so a lot of them found that they needed to take it at night. But I had a small group of people who, when they took it at night, you know they would go to sleep at like 11, 00 get up at 6 30 and they were still groggy. As I’ll get out from the Seroquel and among themselves, they started talking about okay, so I need to take it at 7, 00 every night for it to be out of my system. So I can function the next morning they worked it out by talking about how long before it starts sedating you and how long the sedating effects last, but it helped clients stay more compliant with their medication because a lot of times and not knock Psychiatrists or doctors, but the ones that I’ve had experience with. For the most part, I’ve had a couple of awesome: attendings they don’t have the patients they don’t have time in their schedule to hear all of the issues and help the client brainstorm, and a lot of times they don’t think to share with the patient. These are the most common side effects that people tell me they experience. Yes, they get the handout from the pharmacist. There are like six pages, long and in eight-point font of all the potential side effects. But what do people feel like when they start taking it? This Zoloft is another one. You know that’s, what one is commonly prescribed and a lot of patients feel kind of like they’ve got the flu. They feel dizzy for the first two-to-three days and then that wears off, if they understand that, if they have a place where they can go and talk about the side effects and talk about how to deal with some of the side effects, it helps. And this is also a place where they can talk about things like weight, gain and fatigue, and lethargy. And how do you deal with this when you’re on this Giller medication, it doesn’t have to be facilitated by a nurse or a doctor. That’s more helpful if it’s facilitated by a clinician. What we want to do is encourage patients to become aware of what their potential obstacles are to be maintained to remain med, compliant, and identify some ways to address them. Some intervention that might be effective and then go talk to their doctor, so they are armed with knowledge when they go see their psychiatrist and say I’m having these problems, it also gives them a chance to talk to other people and understand what it looks like if the medication is working for them and gives them hope if they have to change two three four times to find the right medication, so medication management obviously, is a group that I think is important. If you’ve got clients that are medicated on pain, management,’s, pain can cause depression and anxiety. Your body perceives pain as a stressor, so anybody who has pain may experience negative affect, especially if it goes on for a while, so helping them figure out ways to deal with the pain and ways to deal with breakthrough pain. If you’re dealing with somebody who’s in recovery, then you’re also dealing with the issue of pain management without narcotics, so pain management groups can help teach stress management skills, progressive muscular relaxation, and sharing nonpharmacological interventions that they can discuss with their doctor, such as massage physical therapy, acupuncture yay, it also is a place that people get hope again. This is going to keep coming up with group therapy hope because they hear other people’s stories and yeah. I hear that after John’s accident, he was in agony for six months and he was able to get through it, so they can share and support one another. Another group provides positive peer support for abstinence from substances or addictive behaviors. Remember we want to check our clients, and assess our clients to make sure they’re, not engaging in addictive behaviors like internet gaming, pornography, gambling, food-ish food, and eating addiction. Anything like that, but it also provides positive peer support for positive action in any direction. So if it’s growth goals, if it’s depression goals, the group is there to cheer you on. They’re also there to notice when you’re starting to lose your motivation and point it out and help you increase that motivation groups reduce isolation. So if you’re dealing with someone who’s got empty nest syndrome, someone who’s got depression, someone who’s got it up an addiction. It helps them understand that they’re, not the only one dealing with that and they can share and support, enabling the members to witness the recovery or transformation of their fellow group members and see how other people deal with similar problems, because we all I mean There’s what twelve people in class today. So if I throw out any problem, I’m probably going to get at least eight or nine different suggestions for how to deal with it and that’s cool, but that’s. The awesome part about group two because they can share. What do you do when you can’t get to sleep at night? What do you do when the anxiety is so oppressive that you feel like you can’t breathe, rich, and provide information to clients who are new to the recovery process? So they know what to expect they’re not going to be giddy as all get out. Twenty-four hours, seven days a week, 365 days a year, probably ever that’s not reality, but it helps them learn what the recovery trajectory looks like helps. They accept the fact that they’re going to be bad days and it helps them see how they can be empowered in the process. It provides feedback on group members, values, and abilities. They’re going to hone in on their values, and you know I encourage them in my groups and obviously from a multicultural perspective. I think it’s vital that we encourage members to explore their values and accept or reject them as they are and do not meet them. For me to say whether your values are right or wrong, I want you to know what your values are and make sure that they’re. Yours, not something that came from the media or something that just kind of popped into your head. You don’t know where it came from that you, don’t agree with, and sometimes that will come up, especially as it pertains to medication, use or controlled drinking, or anything like that. But it also provides feedback on their abilities, and this is where I focus more than values. What is it that you have done already? What are your strengths if you went three hours yesterday without being depressed and crying that is awesome? What did you do? How did you do it? How are you able to do that, I want to highlight that ability, so we can build on it. We want to highlight the exceptions to the problems and offer the sort of family-like experience where people get a sense of belonging and support when groups are run well, even if their skills are psycho-educational groups when a group member leaves drops out relapses, whatever happens, They just if they suddenly leave. It affects the entire group. When you’ve got a well-run group and a group member graduates or completes treatment, there’s still a whole process and sort of a grieving process, as that person leaves the family and launches out of the nest. Whatever you want to say, we the way I’ve always run groups and what the way I was taught was. We always celebrate that at the end of somebody,’s treatment, or experience after the last group that that person attends we have a little bit of a little pizza party or something to celebrate. Let people say their goodbyes and have a good sense of closure. A lot of our clients did not have good family experiences, so we want them to have the experience of being supported, being able to have different opinions and disagree with others, but being respected and being able to care about groups encouraged coach support and reinforce What they’re doing? Well, we don’t have to focus on what they’re doing wrong. You know, we can talk about that. An individual – or you know it may become germane to the group, but what we want to do is reinforce what they’re doing. Right from a management perspective groups allows a single treatment professional to help several clients. At the same time, as I said, there are a core set of groups – educational modules, if you will that, I think all clients need to be exposed to so group is a great way to do it instead of saying the same thing six times a day to Each one of your clients having a group available with the advent of media and Internet, just like we’re doing right now. Web chat web groups. You can do some skills-based groups, you know if they’re, not treatment. You don’t have as many issues with confidentiality, but you can also have videos online that you have them watch, learn from complete a worksheet and then come and participate in a one-hour group, instead of maybe having to sit through the whole lesson, which is An hour or so and then participate in the group, so there are a lot of different things that you can do using group techniques to reach a bunch of people in with one treatment provider. In the same hour. Groups add needed structure and discipline because, generally the group leader has a certain goal for the group or has a certain style of managing the group, so it can help sort of add a rhythm. If you will to the group process. Now we’re talking about traditional therapy groups. You’re going to be sort of like the parent that controls the rhythm of the family. If you’re talking skills or psycho, read groups, you’re going to be setting more of a tone like a teacher and creating a learning experience, but it adds structure, so people feel safe. They know what they can share, what they’re. What’s too much sharing or what’s inappropriate sharing and it helps people also learn to bite their tongue, wait their turn all those other things that can be helpful in life. They instill hope in a sense that, if that person can make it so can I so they see people doing a little bit better yeah. They also see some people doing a little bit worse, sometimes, but that’s an opportunity for them to be able to reach out and provide support, and that helps the person providing support as much as it helps the person receiving it. I truly believe that most people get a sense of contentment if you will, by being able and being able to reach out and help someone that they are concerned about, it provides support and encouragement to one another outside the group setting now this gets a little dicey Depending on your groups and your agency philosophy in reality, in substance abuse groups, the people that are in your group are probably going to be going to the same support group meetings so telling them not to ever contact each other outside of the group is unrealistic. They’re going to see each other in the community, so it’s important to help them understand how to set boundaries and what’s? Okay, behavior, and what’s? Not okay, behavior between group members, other groups, other facilities are less stringent on that and encourage the clients to reach out to one another outside of the group setting. So, depending on the group, the issue, your agency, all that kind of stuff there’s going to be more or less sharing. What I want to see, especially, is, if you have, for example, in IOPS three hours here and have three groups with breaks. I want to see people talking outside a group. I want to see people sharing, not just all sitting in there going when do we get out of here? I want them to develop relationships and learn how to effectively communicate so group therapy is not individual therapy done with an audience. It is not a mutual support group. It’s designed to help people develop and practice knowledge and skills in a microcosm. You’re, creating a mini family or a mini-community. It aids patients in learning how to develop healthy, supportive relationships and also how to terminate relationships, because sometimes when people graduate they move on it, which doesn’t necessarily mean that they’re going to continue to interact with the clients in the group. Alright. So the second half of this class, we’re, going to look at the group therapy models used in treatment, explain the stages of change, and discuss three specialized group therapy modules that may be used for the stages of change. I’ve gone over this before for new people. I’ll go over it again, real quick think about getting into a pool in the summer. It’s hot it’s like 90 degrees. You are sweating bullets, pre-contemplation, and you’re still laying on the lawn chair going. I ain’t hot. Yet no, I’m not anywhere near hot enough to go near that pool contemplation you’re starting to get hot and sweaty, and you’re looking at the pool going. You know that might be a nice change in preparation. You move to the side of the pool and you’re dangling your feet in the water trying to figure out. If you’re ready to take the plunge because it’s cold, I mean compared to the 90 92 5 degrees C is outside and you know your 98 6 body temperature water is cold, so you’re preparing action is when you jump in you. ‘re, like I, can’t take it anymore. I’m too hot to jump in the pool. Now, if that pool is too cold, if it’s too painful to stay in there because you’re just like a ho ho, you may jump back out again and back into preparation or further back. If you get in there and get moving – and you know, get your body temperature back up that’s – sort of basically like treatment – and you’re getting the swing of things, then you just want to maintain. So you don’t get cold again and recurrence is when you get out you get hot again and go through this process again so pre-contemplation, I ain’t got a problem. Contemplation yeah, I’m a little uncomfortable, but I’m not ready to do anything yet preparation. I’m starting to get ready to make a change because this is uncomfortable, but I’m not very it action I’m on it, and maintenance is keeping your gains and maintaining a steady state, so variable factors for groups, the group leader group or Leader of focus, so if you’re focusing on a part of it, is your training. You know if you are more Rogerian client-centered in your training versus cognitive, behavioral versus DBT versus AC T, whatever your theoretical underpinnings are and what you choose to focus on. In that particular group, there’s a lot of stuff. We can focus on whether it’s cognitive, physical, or emotional. We want to another thing that affects it is the specificity of the group agenda. If you’re going to have a group and it’s on self-esteem, well that’s not specific, so we could go sixteen different ways till Sunday if you’re looking at self-esteem and disarming the internal critic. Now that’s much more specific for that group, so that’s going to affect what that group looks like for that session or that says sessions how similar or different your group members are. If they have a lot of different experiences, you’re going to have a different experience as a group leader. Then, if you have a lot of people who have the same experiences, open, ended or determinant duration of treatment, if you’ve got a group that somebody can join and if they want to stay for 104 weeks, they can stay for 104 weeks. That’s up to them versus a group that is 16 weeks long that’s also going to affect how your group goes. What do you cover, how connected do group members become? I use 104 weeks just to sort of overemphasize. I hope nobody stays in the group for 104 weeks, but the level of leader activity is. I have seen groups where its leaders will throw out a discussion and are like okay topic for today is what do you think about it, and let the group facilitator with a little bit of nudging here and there versus other groups where the leader is very involved In goes around goes okay, Sam.What do you think about this sally? What do you think about it and that affect how people react and what they expect it? Doesn’t necessarily affect what they get out of it, but these are variables that could affect how someone meshes with the group. Not everybody is going to like a real open, ended, a loosey-goosey group I don’t. You know I’m structured. So I prefer to be in groups where I know what the agenda is, and what we’re going to do. In my groups, start with a review from the last group that’s the first five minutes, and check in with everybody. Next, in five minutes we do a 15 to 20-minute psycho, ed piece, and then the last. You know 30 minutes of group. I spend going around the room and having people tell me, what is it that you got out of this? What do you think you could use this next week etc and apply it to what they know that’s how my groups go, so they’re, really very structured. You’ve got to be able to drop back and punt. If a client is in crisis or something strikes a nerve with them, you know you might have to change up a little bit. But overall you’re sort of setting the tone for what’s going to happen in the group, the duration of treatment, and the length of each session. You’re going to cover a lot more in a 3 hour of IOP session. That and treatment is five days. A week for 12 weeks, then you’re going to cover in a treatment program that’s one hour a week for eight weeks, just knowing what you’re going to try to cover will affect the depth or the breadth of what you go through. The arrangement of the room also affects how the people interact. If you have them set up in theatre, style, or classroom style. People interact differently than if they’re all sitting around in a circle, and if you ever want to experiment with that, it is interesting to notice how much differently people interact and how much more they seem to participate when they’re sitting sort of in A circle versus when they’re in theater style and I feel like they can hide and the characteristics of the individuals. Sometimes you’re, going to have people who are enthusiastic and chatting. Sometimes you’re going to have people who are not, and it could be for a whole host of reasons. It could be a bad fit, it could be their involuntary, or it could be they just got out of detox. It could be that they’re. All are just at that level of clinical depression that they’re having a hard time staying with the group and it’s up to us to adjust to try to meet the needs of as many people in a group as possible. Now, while I’m saying this, they didn’t say to size of the group. Here, the recommended size of the group is 8 to 12 people. If you’re dealing with adolescents or people with severe and assistant Mental Illness, it’s more along the lines of 812. For your average group 15 for psycho-educational and skills groups any more than 15. You’re doing a class and not a group. Psycho-egg groups assist individuals in every stage of change, pre-contemplation contemplation, yay. It helps clients, learn about their disorders, their treatment or intervention options, and other resources that might be available to them, such as assistance with prescriptions or physical therapy, or whatever other wraparound services. We often call it might be available. They can also be used to provide family members with an understanding of the person in recovery, so family egg groups can be awesome because then you get to understand and hear what the family thinks is going on and expects is going to happen in treatment and What they’re seeing and hearing, and you can normalize for them what’s going on with the client, so somebody recovering from clinical depression or somebody with bipolar disorder. You know this is what recovery looks like this is what living with the disorder looks like. This is what being on this medication looks like, I, ‘ve had a lot of patients because I deal with mainly co-occurring. I’ve had a lot of patients who have bipolar disorder, and you know some sort of substance abuse issue. They start taking. Seroquel, because that seemed to be the drug of choice for our prescribing at that particular time and they would start acting all groggy and family would freak out going you’re using again, and so Family Education groups were a great time for us to educate. Not only about the disorder but also about treatment, medication, side effects, and how to interact with the loved one to be as most supportive as possible. So ad groups educate about a disorder or teach a skill or tool and work to engage the clients in the discussion. I don’t want to stand up there in the lecture. I want them to be able to throw out ideas. So if I say you know what is it that you do when you’re struggling with somebody, because they just great on your every last nerve, what are some things you do to solve that problem or to deal with it? I don’t want to just tell them everything I want to do something more Socratic and encourage them to tell me how they work with it, and if they come up with something that’s, not quite on point. As far as being the most effective or healthiest approach, then we’ll talk about it and we’ll say well. I’m sure that’s worked for you. I’m wondering you know if there’s a kinder gentler way to do it, or you know you kind of massage it a little bit to morph it into something useful. We want to prompt clients to relate what they learn to their issues, including their disorders. You know how you, how this relates to your depression, but also your goals, your challenges, and your successes? Psycho-ed groups are highly structured and follow a manual or curriculum, and it doesn’t have to be a manualized curriculum that you buy from somewhere. You can create your curriculum, but you teach the same thing and it’s sequential and it follows a teach, apply practice method. So you teach a skill, you have them talk about how they would apply it, how that might apply to them, and then you have them practice it in role plays or imagine how they might use it. Next week, basic teaching skills are required for psycho-ed groups, though, which requires that you understand the basic components of learning, and I call these the three C’s capture, which is how you get the knowledge I mean you got to get it into your brain. Somehow I am a visual kinesthetic learner. I learned virtually nothing from sitting in lecture classes. I’m off in la la land in about 30 seconds. I know this about myself, so I need to have material that I and see, which is why I do powerpoints here some of y’all may not might not even be looking at the screen. You may be often doing something else and listening to me more power to you. However, you get the information in your brain is great. Global and sequential. Some people are global. They need the big picture when they’re doing a puzzle. They want to see the box first to do the frame and then fit all the pieces in sequential people. Don’t want the box that’s cheating they look for pieces and put them together and then try to figure out how all the pieces go together to make a hole and then their wall out as a whole. To appeal to both of those at the beginning of the group give an overview of what you’re going to cover in the group, and if you can sort of a written agenda it’s, not always practical. I always tried to put it up on the whiteboard. We always had issues with how many copies we were allowed to make and stuff. So in the interest of saving trees, try to give them some sort of an agenda, so they know what the progress is or what they can expect from group talk about it, so people can hear it and apply it through role plays having them apply it to themselves. Make them manipulate that information in their mind and provide visual representations like bullet points of what you’re going over. If you can’t, if copies again are an issue, have them bring a notebook and write on a whiteboard, so they can see it. So you’re presenting information in as many ways as possible. Conceptualization is relating the information to building blocks. So if you’re teaching a unit on cognitive distortions, then you’re going to talk about maybe using extreme words or nothing talk. So I might say tell me about a time that you’ve said something like you always do this and then what we’re going to talk about, how to change that and how you know. Thinking about things that way might be contributing to some of their distress and then caring. This is the biggest one which is again why I have clients when they leave a group, ask themselves: what could I get out of that? Why was that important to me if they’re not motivated to remember it, they’re not going to think back to high school biology or college humanities archaeology? 101. For me, I learned what I needed to learn for as long as I need to learn. It’s to pass the test, and then I forgot it all because I didn’t care about it, so we want them to care or they’re not going to remember so get it in their heads and help them relate it to something they know and make Them care about it, make them figure out why it’s important to them, foster an environment, to support participation, encourage participants to take responsibility for their learning, use a variety of learning methods that require sensory experiences, which means talking about it. You know talking about it listening to it and maybe drawing art therapy try to incorporate as many senses as possible. I always find that role plays are a big hit. You can also break up concepts and have to break up your group into smaller groups and have each of the smaller groups reteach a concept to make sure that they understand it and be mindful of cognitive impairments. So if you’ve got someone who is impaired in some way, make sure that you have some sort of method to ensure that that person is keeping up with the rest of the group. If it’s a diverse group skills development cultivates the necessary skills to prevent a relapse, depression, anxiety, and addiction and achieve an acceptable quality of life. Part of the skills groups assumes that the clients lack needed skills such as coping skills, interpersonal skills, and communication skills, hence the term skills group. So we want to allow clients to practice skills in groups. Psycho-ed groups provide the knowledge and, if you remember basic treatment, planning, and knowledge skills and abilities, so you know it, you learn how to use the skill and then the ability is a put those skills into practice. So we want them to be able to practice. These skills in a safe microcosm, you want to focus on skills, directly related to recovery and those to thrive in general. Think about Maslow’s hierarchy. They need to get those biological needs met, they need food, shelter, medication, pain management, health, safety and safety from themselves and love and belonging. So we want to help them make sure they’re getting those not just focusing specifically on depression or anxiety skills development groups have a limited number of sessions and a limited number of participants. So everybody can practice. We don’t want a big auditorium. We want that 8 to 15 number ideally, and there used to strengthen behavioral and cognitive resources. Skills groups focus on developing an information base on which decisions can be made and actions can be taken. So when they’re thinking when they practice the pause and they’re trying to decide okay, what is the best reaction to this current situation that’s when skills kick in and they’ve got a menu of skills to choose from cognitive, behavioral Groups, conceptualize dependence on substances as a learned, behavior that subjects to modifications through various interventions, which is a bunch of garbage garbled a for CBT groups, really look at using as a triggered behavior in response to pain. You want the pain to go away and your drug of choice does that. The same is true for self-injury or a variety of other symptoms that we see in our patients. So we want to look at what’s triggering those and how can we. What are they trying to meet? What need are they trying to meet with that behavior and how can we help them meet that? Otherwise, sorry, my nose is itchy today, work to change, my learned, behavior by changing my thinking, patterns, beliefs, and perceptions and include psychological elements like thoughts, beliefs, decisions, opinions, and assumptions. Cbt groups develop social networks that support abstinence, so the person with dependence becomes aware of behaviors that may lead to relapse and develop strategies to continue in recovery. Now that’s for addictions, groups for anxiety and depression, the same is true. We want them to have social networks with other people who experience the same diagnosis. If you will so, they can become aware of relapse. Warning signs when are starting to become impatient. They’re not sleeping as much, whatever their relapse warning signs are for their condition, disorder, whatever you want to call it, so they can develop. Strategies to stay, happy and healthy educational devices are used in CBT groups including worksheets role plays, and videos that encompass a variety of proof, and approaches that focus on changing the way we think and the behavior that flows from it. I cannot stand feeling this way can be changed too. I don’t like feeling this way, but I know it will change. In the next moment. Cbt techniques teach group members about self-destructive, behavior and thinking that lead to maladaptive behavior. We look at those unhelpful, cognitions and their effects of them. How does that impact you in your relationships? The way you perceive the world and your general sense of empowerment and happiness? They focus on problem-solving and short and long-term goal-setting which a lot of people don’t know how to do. Imagine how much better people and more empowered people feel when they figure out hey. I know how to do that. I know how to see a problem, develop a plan and solve the problem and they help clients, monitor feelings and behavior, particularly those associated with their diagnosis. Support groups are useful for apprehensive clients who are looking for a safe environment and they boast remembers efforts to develop and strengthen their ability to manage thinking and emotions and interpersonal skills support groups. Don’t have a trained facilitator necessarily, so they’re. Not necessarily. How do I want to say this? They’re only as effective as the effectiveness of the group leader and the health of the group leader, support groups, address pragmatic concerns, and generally improve members, self-esteem and self-confidence they’re. Often open-ended with changing members, encourage discussion about members, current situations, and recent problems. So we’re less focused on education and skill building and more focused on what’s going on with you today, and they provide peer feedback and require members are accountable to one. Other support groups vary with group goals and member needs and include facilitating desilting discussion among members while maintaining appropriate group boundaries, which can be a little difficult, especially with untrained if there are no trained facilitators there. These groups can help the group the whole group work through obstacles and conflicts. So if you’ve got people that are arguing within the group remember, this is a microcosm. This is a little family, whether it’s a support group or any other kind of group. These people meet every week and there are going to be conflicts, so we want to help people work through these and develop acceptance and regard for one another support groups ensure that interpersonal struggles among group members do not hinder group development. So if you’ve got a relationship budding between two people, not unheard of, or if you’ve, got a huge conflict, getting ready to happen between two people. You want to make sure that doesn’t interfere with the group process, so you may need to handle that outside of the group, or you know, figure out how to address it. Interpersonal process groups recognized conflicting forces in the mind, some of which may be outside of one’s. Awareness determines a person’s behavior, whether it’s helpful or unhelpful. So interpersonal process groups help people identify the developmental influences and other things that have gotten them to where they are, that influence, how they act and react the way they do currently, and bring a lot of stuff into awareness. Oh, that makes sense that I react that way because that’s how my mom used to react or when I did that when I was a kid I got in trouble for it whatever the case may be interpersonal process groups delve into major developmental issues. Searching for patterns that contribute to the problem or interfere with recovery abandonment issues is one that comes up a lot looking at the family of origin and their coping skills. We want to learn. What did you learn when you were growing up that is? You are using now and how effective is that for you, these groups use psycho dynamics or the way people function psychologically to promote change and healing and rely on the here-and-now interactions of members. So we’re focusing on all this stuff. That made you who you are and gave you the tools that you have right now, how’s that working for you? So there are multiple types of groups that are available to assist clients in achieving their goals. We view current coping skills as creative adaptations to what they’ve learned and ways to get their needs met. They may not be the healthiest coping skills, but they are serving a purpose. So we want to look at the way. Clients are coping acting interacting. Just look at their behaviors and ask ourselves what’s the benefit to that? What’s motivating is that, because we always choose the behavior. That seems – and I emphasize the word seems to have the most reward to it, based on reward and effort groups, help strengthen the healthy skills, but they also help point out some of the unhealthy ones, and again a lot of times it has more to it. If it comes from a peer, as opposed to, if it comes from a therapist skills required to facilitate groups, overlap significantly a lot of my psycho, groups are also kind of skills groups. I kind of do a psycho, ed skills blend when I do groups that are, my style though, and the group facilitator needs to figure out his or her style because you’re going to set the tone for your group. Not everybody is going to thrive in your group. Just like not everybody is going to mesh with you as an individual therapist, knowing your style and being confident is one of the first steps to having a really strong group experience. Types of groups include psychoeducational, which provides your knowledge, and classroom-type format. Skills development provides takes the information that knowledge and helps people translate it into skills. Okay. Now I know what an unhelpful thought or a cognitive distortion is. What do I do about it? Skills group is the: what do I do about it and let’s practice it. So when I have this thought, what can I do? Cognitive behavioral groups kind of integrate those but focus strongly on what’s going on with the individual and the thoughts if you think, of the ABCs, the automatic beliefs that may be perpetuating or maintaining the unpleasant consequences and support groups are those groups that Are not facilitated by a trained facilitator or by a clinical facilitator. In some groups like smart recovery, the facilitators are trained, but they’re, not necessarily clinicians and group members are accountable to one another more so than accountable to a group leader who starts the group by telling people what they’re going to learn and do and why it’s useful to them make them care, give them that global perspective of what’s going to happen and then go through the information step by step or sequentially. So all of your learners are getting as much as possible provide an overview of what you’re talking about have written material like I said, if copies are a big issue where you come from it’s, not unheard of, or if you just don’t like making lots of Xerox copies, write it on a whiteboard and encourage clients to bring a notebook and write it down. Clients will remember things better if they have to write them down because they’re going. To paraphrase it, which is a form of kinesthetic learning before they write it down most likely because they want to write down as little as possible, discuss the material and apply it ask for their input. How do you deal with this? What do you think about this option? How could you use this? How could you have used this last week and what do you think you might? How do you think you might use it next week and give me an example of what that would look like for you? Can also have them roleplay, maybe they’re having somebody in the group having a particular issue with a supervisor or roommate. You may choose to roleplay that in a group and have them apply a skill that you’re talking about. Have each group member close by identifying one thing they got at a group and how they are going to use it in their recovery plan. Again, it brings it back to caring, has the kind of tie it up into a neat bow, and is able to walk out with one tool. Yep give them two too many tools in one group and they’re going to walk out, and none of them are going to get used. You give them one tool and they walk out. They may try to use it throughout the week and then next week in the group, you can ask them how’d it go. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube, you can attend and participate in our life. Webinars with doctor Snipes by subscribing at all CEUs comm, slash counselor toolbox. This episode has been brought to you in part by all CEUs com providing 24 7 multimedia, continuing education, and pre-certification; training to counselors therapists, and nurses, since 2006 use the coupon code consular toolbox to get a 20 discount off your order. This month,As found on YouTubeHi, My name is James Gordon 👻🗯 I’m going to share with you the system I used to permanently cure the depression that I struggled with for over 20 years. My approach is going to teach you how to get to the root of your struggle with depression, with NO drugs and NO expensive and endless therapy sessions. If you’re ready to get on the path to finally overcome your depression, I invite you to keep reading…