DBT Therapy and Mental Health Services in Lloydminster

COGNITIVE BEHAVIOURAL THERAPY (CBT)

Other kinds of therapy can be excellent at keeping the ‘walking wounded walking’, but cognitive therapy can actually get you better and keep you better. It can be used for depression, anxiety, obsessive compulsive disorder, bipolar disorders, and even schizophrenia and personality disorders. It can and often is combined with medication. While not the only kind of counselling to show long term benefit, cognitive therapy gives you ”a bang for the buck”. Differences happen fairly early in therapy – six sessions are usually enough to see a significant difference.

Some therapists think of cognitive therapy as simply one type of tool in a chest full of tools, applying the various tools as needed. Some argue that really depressed patients don’t have the mental function to “do” cognitive therapy. There is some validity to this, but some concrete, achievable steps early on often lead to significant improvements. Cognitive therapists would argue that ‘a little of this type of cognitive therapy a little of that’ means that none of the techniques are likely to be used to the point of effectiveness. I would recommend cognitive therapy for a particular patient because I would feel the time and the patient are right for it. For someone in a crisis, I might recommend strategies to tolerate the situation and cope better before embarking on formal cognitive therapy.

HOW IT BEGINS

Cognitive therapy has the patient start noting events that cause stress, even minor stress. It might be being 5 minutes late for an appointment and being caught in traffic. It could be the boss being mildly critical of some aspect of your work. It could be an argument with a loved one. It might be nothing more than your car breaking down or your computer not working for you.

The premise of Cognitive Therapy is that events generate thoughts, and it is those thoughts that make us feel an array of feelings. Of course, clinical depression itself causes negative thoughts, so it’s a bit of the chicken and the egg. Regardless, I find it easy to imagine that there are all sorts of factors influencing the level of serotonin in the brain. Things like friends and exercise and the feeling of a job well done all raise serotonin, as does medication. Factors like being overly sensitive and putting oneself down and worrying all lower serotonin. It doesn’t matter that low levels of serotonin tend to make you worry – the act of continuing to worry lowers serotonin by itself. Every time you catch yourself having a distorted thought, a thought not by the situation and the evidence, and you come up with a more appropriate thought, instead of running with that negative thought, that’s one less factor pushing down the serotonin, thus giving medication, time and other positive influences a chance to raise the serotonin and thus prevent further worrying.

The counselor acts as a coach, helping you identify and record successful events. They teach you to note the thoughts that the event generated and identify the feeling that followed. They show you how to come up with realistic alternative thoughts that you might have had in response to the event and what kind of “thought distortion” you used in the first place to end up feeling bad.

A simple example is as follows.

You are a secretary and your boss steps out of his office, comments on your lousy spelling, and disappears inside, slamming his door on the way. This was the event. Your thoughts in response to this event might be any one or more of the following.

• He doesn’t like the work I do
• I’m not a good secretary
• This is a hint he’s going to fire me
• I’m not a likable person, after all, if I were, he wouldn’t criticize me
• My, he’s having a bad day
• So, I can’t spell, neither can he – so there!
• I’m not a great speller, but I have many other endearing/valuable characteristics
• He knew I couldn’t spell when he hired me and told me it wasn’t a problem; that wasn’t what he was hiring me for
• I know I’m not a good speller, and I’m going to start working on that immediately – I’m going to …

The first four responses are likely to involve thought distortions. Two commonly used thought distortions are generalization and looking at things as black or white. You took a mild criticism on one occasion about one part of your work and generalized it to your whole job all of the time. Or you exaggerated – he made a mildly critical remark, but you react as if he had spent 30 minutes criticizing everything about you, or you perhaps used the black and white thought distortion. You figure either you are a terrific secretary, or you are a terrible secretary. You KNOW you’re not a terrific secretary because he just criticized you, so you must be a terrible secretary – so now it’s realistic that you fear for your job? Reality is, of course, that none of us is perfect; we muddle along doing the best job we can with the resources we have. All of us could do a better job, but it might involve increased stress, more fatigue, or compromising other parts of our lives. And if we can’t accept our imperfections and compromises, we are doomed to be miserable.

Recognizing that we have generalized, we can rethink the event and come up with a more realistic thought about the event. “My spelling is not great, but the boss has been overreacting to everyone all week.” “He has praised other aspects of my work often enough that I have no valid reason to feel threatened over this one area.” ‘Heck, I might go into his office, apologize about the spelling errors and comment on mood this week and ask if there is anything I can do to help”.

With practice, the time between the event and the corrected thought becomes shorter and shorter until it becomes automatic to think the right way – even though initially it feels very awkward and artificial and is hard to do.

Often, how we feel is driven by a series of incorrect assumptions we make about other people, how they feel, what they think, and how they will react to a given situation. A man driving home wants to tell his wife he’s going away for a golfing weekend with his buddies. He’s rehearsing in his mind how the conversation will go. He assumes that she will tell him, “we can’t afford it”, “you need to spend more time with the kids”, ” I had plans for this weekend…” He gets more and more upset over how he assumes she is going to react. As a result, he’s looking for a fight as he comes in the door, and with an attitude like that, it’s not surprising he often gets one. I find that patients who make assumptions about how others will act, overreact, and are wrong more often than they are right and that they spend an inordinate amount of time stewing about these assumptions. Cognitive therapy teaches you to challenge these assumptions, to test them, to recognize when you are making assumptions so you can stop reacting to thoughts that they never had, or might not have.

Cognitive therapy provides you with tools to come up with better ways to look at events. These tools include things like charting, worst-case scenario, experiments, making lists, etc. A patient might feel that they cannot lean on a friend, for fear of losing them, even though they themselves have “been there for the friend on many occasions. The counselor shows that this fear may be unrealistic and has the patient challenge that belief with an experiment, opening up a little to the end and observing their reaction – did it meet the pessimistic expectations and fears of the patient? In a different situation, the patient might express incredible fear of a bad outcome – If I ask for a raise, or ask for help, or say no to more overtime, I risk losing my job”. This logic is used to justify continuing to work 12 – 14 hour days to the frustration of both patient and employer. The counselor might tackle this fear of losing the job with a question, “What would actually happen if you lost your job?” Often when presented with questions like that, the patient describes an outcome that is nothing like as bleak as they feared – they realize that they could find other work, they do have talents, they’d actually enjoy some time off, they wouldn’t mind selling an expensive house and living within their means for a while, they’d actually cope. The counselor might have them evaluate the actual likelihood of losing the job. What evidence is there that if you said no, you’d be fired?

The same might be said of losing a loved one, that they actually end up pushing that person away. A counselor might help the patient evaluate what the important things in their life are. Is this relationship they fear losing equal to 100 percent of what they due in life, or are their kids, their job, and their friends worth something too? So, despite saying that this person is everything to them, it isn’t true and shouldn’t be thought of in those terms – it isn’t healthy or realistic.

Recognizing thought distortions alone often helps patients feel better but is just the beginning. The therapist goes on to help you correct some of the core beliefs about yourself and your world. This involves some understanding of the past but does not dwell on it. For example, the daughter of a dominating father and a timid mother becomes very timid herself and lets people run all over her, especially her husband. The counselor doesn’t need to go into great detail of how and when every hurt happened, just enough to recognize that there is a pattern in how you deal with the world, that there is a reason for it, and now that you recognize it’s a pattern, there are some things you can do about it. The counselor shows you how to recognize these patterns and helps you take the first steps to change some of these patterns. It may be that you were genetically predisposed to be timid, but lacking examples of how to assert yourself effectively, you are doomed never to change, unless you acquire the right tools.

Patterns of behavior include things like pushing people away, letting others control you, being domineering yourself for fear of losing control, relying on alcohol to help you cope, avoiding conflict to the degree that it only lets things fester. Anxiety makes us avoid doing things that are hard for us – if I do this I might get hurt – so I won’t, but often anxiety can build to the point you can’t leave home and can’t go shopping or can’t make a decision (what if it’s the wrong one).

It’s at least possible to do cognitive therapy on your own -the books are certainly our there – David Burns, “Feeling Good, The New Mood Therapy” is a classic and there are many others, but cognitive therapy is a bit like learning to play an instrument -it really helps to have a teacher show you the right way – they can’t do the playing for you, but they point out the right strategies. Depression, in particular, can make it very difficult to do something like this on your own because of the reduced concentration, lack of motivation and interest, and the general pessimism with which depression is usually associated. The counselor plays both coach and cheerleader.

It’s easy to be skeptical – how is it possible to change the way you feel just by keeping some lists. There is new scientific evidence that when you think differently long enough, the brain actually makes new connections and severs old ones -you literally change the wiring in your brain. You don’t have to tell yourself to feel better – you just have to do the homework, and you will automatically start to feel better. The brain works by associations. How many of us can’t help but think of the Lone Ranger on hearing the William Tell Overture – cognitive therapists take advantage of the way the brain works to create new associations and new pathways to change you, possibly forever.

Depression is felt to be a combination of stresses, genetics, personality, and belief systems. Each individual with depression has differing ratios of these to add up to depression. So it is that the roles of counselling and medication vary in importance from person to person. Someone who has been fine all their life till losing their job may only need a six month prescription of an antidepressant and never looks back. Someone else with long-standing depression may well get more from counselling than from medication, while others won’t get better with either on its own, they need both.

Cognitive therapy works, it doesn’t take a lifetime of sessions, results can be seen within weeks, and it may just change your life. While most of us don’t have full medical coverage, and it is expensive, a financial investment in your future mental health may pay many times over.