Tag Archives: Cognitive therapy

When the Yellow Grows into Gold and Happy Breaks Out

Lower Grove Creek 7 14 17This morning the clock said 3:51am. My lungs felt refreshed. Then a memory from last night bubbled up. You know how they do.

Rita and I discovered mold in our garden. It was yellow and green and it shared its spores with my lungs before we recognized or best option: retreat inside to formulate our battle plan in response  to the attack of the multicolored mold.

Google was waiting. All the postings were about White mold or Black mold, or even yellow dog-vomit mold. Nothing fit our mold. I read with great and trepidiacal interest of a U.K. man who died from inhaling compost mold; my lungs were burning. Not good.

But sleep came.

Then 3:51am came.

And then the thoughts came.

At 3:52am it seemed odd that I could hear my pulse in my ear on the pillow. It seemed fast. That U.K. man had a rapid pulse. I could either choose to lift my head and take my pulse and while waiting for the digital clock to move to the next minute, or I could look at my fit bit. But my fit bit is charging. But I decide, anyway, to roll over and grab it and attach it to my wrist and look at the pulse rate. It flashes, 113. Not good. I check again, 112. Not good. Not normal. I compulsively check again, 111. The fit bit is probably still adjusting, now it’s 109. Stop checking, the voice in my head says. Let it be. Let it settle. Thirty seconds later, it’s 55. I am normal again.

At 3:54am, I find another troubling thought. Today is July 14, 2017. My Theories text revision is due in 31 days. I have five more chapters to revise. That’s six days per chapter. Plus references. Plus table of contents and preface and . . . . Not good. I’m a bad author.

At 4:12am, I’m up, turning on the computer. I’m a bad author and a bad husband and a bad father and a bad friend. All I do is write meaningless drivel that maybe 12 people a year will read and then immediately forget. Forgettable, I am. Even my own students can’t answer my pop theories quiz questions when they drop by my office. I wonder why they don’t stop in so much anymore.

Good thing I’m revising CBT today. God and Albert Ellis know, I sure as Hell need it.

One of today’s content areas is called, Thinking in Shades of Gray. It’s a description of a cognitive technique to help people get out of destructive, irrational, and maladaptive black-white (aka polarized) thinking. It’s boring. Of course it’s boring. Shades of gray? It’s a technique to help with depressive thoughts. I can hear the Albert Ellis voice in my head. WTF? You work with depressed people and you teach them how to think in shades of gray. What the Holy Hell are YOU thinking?

Later this morning, as I ride through Lower Grove Creek with yellow flowers and the Beartooth Mountains looming, I stop for a photo. There are no cars, no deer, and not even a trace of fungal spores. Just me and my breath and my bike and the yellow flowers and shades of gray, black, and white rising above. Why are there no colors in the shades of gray activity? There’s more to our thinking (and our client’s) thinking than black, white, and gray. Today, with the wind in my face and Tippet Rise to my starboard, I want to be an art therapist. “Let’s put a little yellow there,” I say. And the yellow grows into gold and happy breaks out.

But sooner or later, you and I know. We. Know. The yellow will catch dust and lose its sparkle and turn to mold, until a future morning at 3:51am, when a red seed of awareness gets planted among the anxiety bushes and purple flowers bloom, replacing the moldy browned-up yellow, and then we will remember. We have been here before. And it was wondrous and terrible and everything in between.

At that point, it’s not a bad idea to find your fit bit, take your pulse, and embrace the ever disintegrating now that is morning. You have your next 31 days and I have mine. Let’s meet somewhere in the middle and celebrate the next disintegrating now with all the passion and monotony we can muster. You know we can. We’ve done it before.

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How to Use the Six Column CBT Technique

A Description of the Six Column CBT Technique

In contrast to popular belief, CBT requires counselors to be warm and compassionate. Also, the focus of CBT is on experiential psychoeducation. Aaron Beck emphasized collaborative empiricism. Never forget that term. Collaborative empiricism is the bedrock of good CBT. It emphasizes the process of counselors and clients working together to test the accuracy and usefulness of specific thoughts and behaviors. As a therapeutic process, collaborative empiricism is also central to Person-Centered and Motivational Interviewing approaches. Remember: We want the client to have a central role in determining the usefulness and dysfunctionality of his or her cognitions and behaviors.

The six column technique is simply a procedure that helps clients and counselors organize, explore, and discover how situations, thoughts/beliefs, emotions, behaviors, and emotional/interpersonal/psychological outcomes are inter-related. This is my own particular version of the six column technique. It’s derived from the work of Aaron Beck, Albert Ellis, Judith Beck, and other cognitive behavioral therapists. You can see a short clip of me using this technique at: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118402537.html

Here’s a description of the six columns:

Column #1: The Situation

BE THINKING ABOUT LINKING EMOTIONS TO SPECIFIC SITUATIONS

It may be that you’ll begin with whatever emotional distress the client is experiencing or reporting. Or you may begin with thoughts and beliefs that are clearly linked to specific client emotions and behaviors. Or you may begin with the situation or “trigger” for the cognitions and subsequent emotions.

Here’s an example of a situation as reported by a client:

“My in laws are staying in my home     .”

“They’re messy and lazy and I have to pick up after them”

Column #2: Automatic Thoughts and Automatic Behaviors

HELP CLIENTS SEE THAT AUTOMATIC THOUGHTS ARE OFTEN THE BRIDGE BETWEEN SITUATIONS AND EMOTIONS

Here are some examples of the automatic thoughts the clients thinks when she faces the previously described situation:

“They’re old enough to pick up after themselves.”

“Sometimes I stand in front of the television they’re watching to block their view as I pick their stuff up.”

Sometimes if “she” says she’ll do the dishes, I say, “No thanks. I want them to get done in the next two weeks.”

REMEMBER THAT AN EXPLORATION OF YOUR CLIENTS AUTOMATIC THOUGHTS AND BEHAVIORS OFTEN WILL SHED LIGHT ON DEEPER CORE BELIEFS ABOUT THE SELF, THE WORLD, AND THE FUTURE.

Column #3: Emotions and Sensations

SOMETIMES IT IS VERY NATURAL TO START HERE BECAUSE YOUR CLIENT’S EMOTIONS AND SENSATIONS MAY BE A WAY THAT THE MIND AND BODY ARE VOICING HIS OR HER DISTRESS (or you may find the best entry point into the six column technique is somewhere else)

Here are the ratings and descriptions the client provided for column #3:

Anger = 75 (on a 0-100 scale with 0 = totally mellow and 100 = explosive distress)

Discomfort = 75

EMOTIONS AND SENSATIONS MAY BE WHAT IS MOST TROUBLING TO CLIENTS AND THAT’S WHY THEY’RE TYPICALLY RE-EXAMINED IN COLUMN #6: NEW OUTCOMES

Column #4: Helpful Thoughts

HELPFUL THOUGHTS ARE ALSO SOMETIMES REFERRED TO AS “COOL THOUGHTS.” THIS IS ESPECIALLY TRUE WHEN WORKING WITH ANGER AND AGGRESSION BECAUSE COOL THOUGHTS HELP CALM OR COOL OFF THE ANGER AND REDUCE THE POTENTIAL FOR AGGRESSION.

Here are some thoughts that the client identified as helpful. Helpful thoughts are often seen as adaptive or more accurate or more “rational” (which is an Albert Ellis term).

“This is important for my husband.”

“I can see this as a challenge for me to become more direct and assertive.”

“They mean well.”

A WAY OF ASKING ABOUT HELPFUL THOUGHTS IS TO JUST ASK DIRECTLY: WHAT ARE SOME THOUGHTS OR BELIEFS THAT YOU THINK WOULD BE HELPFUL TO YOU IN THIS SITUATION? YOU MAY NEED TO HELP CLIENTS WITH THIS BY PROVIDING EXAMPLES . . . BUT NOT BY TELLING THEM WHAT THEY SHOULD THINK. ENCOURAGE THEM TO FIND THEIR OWN WORDS.

Column #5: Helpful Behaviors

SIMILAR TO THE PRECEDING COLUMN, WE CAN THINK OF BEHAVIORS AS “HOT” OR “COOL” BEHAVIORS. HOT BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS WORSE; COOL BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS BETTER.

Here are some behaviors the clients said she thought might be helpful:

“I could sit down and talk with them about picking up their messes at a regular time.”

“I could ask my husband to talk with them.”

“I could go to a Yoga class two nights a week.”

WHEN IT COMES TO BOTH HELPFUL THOUGHTS AND HELPFUL BEHAVIORS, IT’S USEFUL TO THINK OF THEM AS OCCURRING (A) BEFORE, (B) DURING, OR (c) AFTER THE SITUATION ARISES. SOME BEHAVIORS (E.G., GETTING ENOUGH SLEEP) HELP THE SITUATION AS A PROACTIVE OR PREVENTATIVE ACTION. OTHER BEHAVIORS (E.G., DEEP BREATHING) MAY BE CRUCIAL DURING THE SITUATION. STILL OTHER BEHAVIORS (E.G., VENTING TO A FRIEND OR PROVIDING SELF-REINFORCEMENT) MAY BE HELPFUL AFTER THE SITUATION IS OVER.

Column #6: New Outcomes

AFTER IMPLEMENTING THE HELPFUL COGNITIONS AND HELPFUL BEHAVIORS, IT’S A GOOD IDEA TO RE-EVALUATE THE CLIENT’S EMOTIONS AND SENSATIONS (OR DISTRESS).

In this case, the client provided the following ratings:

Anger = 40

Discomfort = 40

ONE OF THE GOALS OF CBT IS TO REDUCE DISTRESS AND REDUCE SYMPTOMS AND MAKE LIFE A LITTLE BETTER. YOU MAY NOT CREATE VAST IMPROVEMENTS, BUT IMPROVEMENTS ARE IMPROVEMENTS. THIS IS ALSO JUST THE BEGINNING OF CBT (OR WHATEVER APPROACH YOU’RE USING) BECAUSE THE WHOLE POINT IS THAT LIFE IS AN EXPERIMENT AND THAT WE COLLABORATIVELY AND INTERACTIVELY ARE HELPING CLIENTS TRY OUT NEW THOUGHTS AND BEHAVIORS THAT MAY (OR MAY NOT) LEAD TO IMPROVEMENT. AND IF THE IMPROVEMENT ISN’T OPTIMAL . . . THE CBT WAY IS TO GO BACK TO THE BEGINNING AND REWORK THE PROCESS TO SEE IF FURTHER IMPROVEMENTS CAN OCCUR.

CBT Tips

Here are a few tips on how to integrate CBT in your work.

Some counselors or mental health professionals resist using CBT and complain that it’s too sterile or too educational or not focused enough on feelings. Basically, I think this is a cop-out similar to CBT folks who say that person-centered therapy is ineffective. My belief (and I think it’s rational and so it must be (smiley face) is that when mental health professionals don’t understand how to implement a particular approach, they blame the approach rather than admitting their lack of knowledge or skill. Instead, I encourage you to try this six column CBT model, but use it with whatever other model you prefer. In other words, you can be a person-centered CBT person or an existential CBT person . . . especially if you just use this six column technique as a means for exploring and understanding different dimensions of your client’s personal experience.

Goal-setting is essential to counseling. From the CBT perspective, goal-setting is initiated by generating a problem list. However, your IR clients may not have a problem listJ. That’s why you may need to use your excellent active listening skills to help your clients focus in on a distressing emotion. Then you can begin with the distressing or disturbing emotion and build the six columns from there.

Good CBT involves adopting an experimental mindset (never forget collaborative empiricism). All you’re doing is helping your client look at his/her daily experiences and identify patterns. It helps to organize the client’s experience into Situation, Automatic Thoughts/Behaviors, Emotions and Sensations, Helpful (Cool) Thoughts, Helpful (Cool) Behaviors, and New Outcomes. You can explore these common dimensions of human experience collaboratively.

It’s very important to know and remember that giving behavioral assignments can be disastrous. This is part of why a good CBT counselor is better than a technician. If you’re brainstorming possible helpful behaviors, your client (and you) may zero in on a behavior that, if enacted, has a strong possibility of a negative outcome. New behaviors expose clients to risk. The risk may be worth it; but there also may be too much risk.

Avoid asking questions like: “Have you thought about talking directly to your in-laws?” This sort of question implies that your client should talk directly to the in-laws. It’s better to step back and brainstorm behavioral options with your client. Then, emphasize that behavioral goals must always be in the client’s control. Then, after your nice list of behavioral options has been generated, you can look at the different options and engage in “consequential thinking.” In other words, you ask your client to explore the possibilities of what is likely to happen if: “You (the client) directly confront the in-laws about their messy behaviors? “ (See sample six column worksheet).

There are many ways you can get to your client’s underlying core beliefs or cognitive dynamics. For example, you could ask: “What stops you from telling them to pick up after themselves?” The client might respond with a different emotion and new content (e.g., I’m afraid of getting into a conflict). You can pursue this further: “What is it about being in conflict makes it scary?” She might say, “I’m afraid my husband will side with them and leave me.” As a consequence, this conflict is viewed as something she needs to manage independently and gets at a deeper schema: “I must keep the peace and deal with everything or bad things (e.g., abandonment) will happen.” There are two problems with this: (a) If she overfunctions she feels angry and acts passive-aggressively; and (b) there may be truth to this schema/belief. This is why we can’t just push her into being assertive. We must always keep the corrective emotional experience rule in mind. New behavioral opportunities need to be free from the likelihood of re-traumatization.

A Quick Look at the Collaborative Cognitive Therapy Process

Cognitive-behavioral therapy is arguably the most evidence-based of all counseling and psychotherapy approaches. With roots in Adlerian therapy and substantial influences from Albert Ellis, Aaron Beck, and others, the cognitive component of CBT involves therapists working with clients to help develop awareness of automatic thoughts — thoughts that have an adverse or maladaptive affect on client emotions and behaviors. Once clients have awareness of their automatic and maladaptive thinking, cognitive therapists work collaboratively with clients to question the usefulness of the thoughts, possibly even actively disputing them, and eventually revising or replacing them with more adaptive or helpful thoughts.

This past spring and summer, Rita and I produced a DVD with demonstrations of 11 different theory-based counseling and psychotherapy approaches. Our publisher, John Wiley & Sons, recently posted a clip (or teaser) of this cognitive therapy video. In the clip I’m demonstrating the five column technique popularized by Albert Ellis. What I think is most interesting about this clip is the how the five column technique is used as a platform for exploring the client’s anxiety . . . while at the same time, a unique, spontaneous, and collaborative relationship between therapist and client is developing.

If you like, you can watch this video clip at: http://www.youtube.com/watch?v=LQ8hNDHoyDU&list=UUDoXxitLiq5PMruS7AbBJbA&index=1&feature=plcp

 

Positive Thinking is Not (Necessarily) Rational Thinking

This past Saturday I got a phone call from a former Counseling student (who will remain unnamed). He said that he and another student were heading to the University of Montana gym to play basketball at 1pm and wondered if I’d like to join them.

I should have recognized I was in trouble when I somehow decided NOT to tell my wife that my sudden reason for going to the gym was to play basketball. She would have reminded me that the odds of injuring my back while playing basketball are better than any odds you can get in Vegas. But I didn’t want her to rain on my positive thinking fantasy world. Do you know what I mean? Have you ever had a time when a part of you knew better and so you decided not to tell any other rational human being what you were planning?

I also should have recognized a few other obvious flaws in my positive thinking: (a) my age is approximately the sum of the two young men with whom I planned to play; (b) I quickly began developing a handicapping system through which I could compete with them; (c) for a few minutes I was visualizing myself leaping into the air without hurting myself.

In his book, The Elements of Counseling, Scott Meier, an old friend of mine and professor at SUNY-Buffalo, wrote that positive thinking is not rational thinking. This is a great point . . . and one that’s easy to forget. Despite the many cultural messages that we get about having “no limits” or being “able to accomplish whatever we can imagine,” it’s not really true. No matter how much visualizing (and personal training) I do, I’ll never be able to keep up with any professional . . . or college . . .  or high school . . . or middle school basketball player. I can practice “the secret” ( a visualizing strategy) all I want, but Obama will not ask me to replace Joe Biden on his 2012 campaign. These are limitations; they are SIMPLY NOT HAPPENING.

Typically, when positive thinking fails, many of us begin rationalizing away because we want to jump back on the positive thinking horse. This is a form of denial that even happens to cult members who are planning for the end of the world. When the end doesn’t come they develop a reason why . . . and often set a new date.

In my case, as I limped and slumped home in humiliation, I was already rationalizing my glorious return. And this is my second point: Rationalizing is generally irrational. What this means is that when we catch ourselves excusing our behavior or re-writing history, we’re probably fooling ourselves. In this case, I quickly began telling myself that the main reason I hurt myself was because I just wasn’t in good enough shape to play on this particular day . . . but that if I rehabbed and worked on my conditioning (for the next year!), I could return to the court and teach those young whipper-snappers a lesson they wouldn’t soon forget. Of course, I forgot to factor in (a) I’m already in pretty good shape; (b) in a year, I’ll be a year older (duh!); (c) I can’t reasonably spend all day rehabbing; and (d) there aren’t many bionic body parts for sale at the local hardware store.

Positive thinking and rationalizing are, quite naturally, at the heart of most of our temptations. For some, the temptation is alcohol, drugs, sex, or chocolate. We may tell ourselves we can have one drink, one bowl, one sexual indiscretion, or one bite and then find ourselves suffering the consequences. This doesn’t mean we shouldn’t engage in positive thinking. It’s just that we need to balance or moderate it with real rational thinking. And one way to get a dose of rational thinking — even if we don’t want to admit it — is to ask someone who really loves us and cares about us if we’re sounding reasonable or not. Another way is to engage in honest self-scrutiny.

Personally, I plan to remain a positive thinker, but in the future I will moderate it with spousal consultation and honest personal reflection. This isn’t nearly as fun as pretending I’m younger and more capable than I really am . . . but right now the pain, ibuprophen, ice, and physical therapy are inspiring me to think more rationally and live more mindfully. I share this story as a reminder to myself and others of what Norman Vincent Peale referred to as the power of positive thinking. In fact, positive thinking is so powerful that it’s actually one more good way for us to get ourselves in trouble. Really, it may seem depressing, but it’s perfectly okay to know our limits and live within them. In the spirit of reality therapy, that’s my new plan . . . and I’m sticking with it.