Cognitive-Behavioral Counseling: Therapeutic considerations and Applications

1. Cognitive-Behavioral Counseling: Therapeutic considerations and Applications Michele D. Aluoch, LPCC c. 2017

2. Depressive Disorders Depressive Episode • 5 or more in 2 week period • Change from previous functioning • Either: depressed mood or loss of pleasure At least 5 out of 9: • Depressed mood most of the day nearly every day, as indicated by subjective report (e.g feel sad or empty) or observation made by others (e.g. appears tearful). NOTE: In children or teens can be irritable) • Markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day as indicated by either subjective account or observation made by others) • Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day • Insomnia or hypersomnia nearly every day

3. Depressive Disorders • Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) • Fatigue or loss of energy nearly every day • Feelings of worthless or excessive and inappropriate guilt (which may be delusional) nearly every day • Diminished ability to think or concentrate or indecisiveness nearly every day (either by subjective account or as observed by others) • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a plan, or a specific plan for committing suicide • Impairment in social, occupational or other areas of functioning

4. Depressive Disorders- DSM IV-TR Specifiers • Frequency: Single or recurrent • Types: mild, moderate, severe • Chronic- full criteria for depressive episode met continuously for at least 2 years- either depression or Bipolar • Catatonic- motor immobility/stupor, excessive motor activity (purposeless), extreme negativism, rigid posture or mutism, grimmacing, echolalia or echopraxia • Melancholic- lack of pleasure in activities, lack of reactivity to usually pleasurable activities and 3 or more: depressed mood, depression worse in am, marked psychomotor agitation or retardation, anorexia, excessive or inappropriate guilt

5. Depressive Disorders- DSM IV-TR Dysthymic Disorder • Depressed mood most of the day for more days than not as indicated either by subjective account or observation of others for at least 2 years. (Note: Children/teens- irritability for at least 1 year) • At least 2 of 6: 1) poor appetite or overeating • 2) insomnia or hypersomnia • 3) low energy or fatigue • 4) low self esteem • 5) poor concentration of difficulty making decisions • 6) feelings of hopelessness

6. Depressive Disorders- DSM IV-TR Depressive Disorder NOS • Catch all for depression that does not meet criteria for other depression dx.

7. DepressionParadise, L. V., & Kirby, P.C. (Winter 2005). • Roughly 10% to 25% of the population experiences some form of depression. • Depression is the number one cause of disability worldwide. • One third to more than 60% of mental health professionals had reported a significant episode of depression within the previous year. • Depression is 10 times as prevalent now as it was in 1960! • While every objective indicator of well-being in the U.S. has been increasing, every indicator of subjective well-being is decreasing.

8. Anxiety Disorders Panic Attack: • A discrete period of intense fear or discomfort in which 4 or more of the following symptoms developed abruptly and reached a peak within 10 minutes • palpitations • sweating • trembling or shaking • sensations of shortness of breath or smothering • feeling of choking • chest pain or discomfort • nausea or abdominal distress • feeling dizzy, unsteady, lighthearted, or faint • de-realization (unreality) or de-personalization (detached from oneself) • fear of losing control or going crazy • fear of dying • paresthesias (numbness or tingling sensations) • chills or hot flashes

9. Anxiety Disorders Agoraphobia- Anxiety about being in places from which escape may not be possible (being outside home alone, in a crowd, on a bridge, on a bus, in a line in the store, etc.), breeds avoidance Panic Disorder: • Panic attacks • 1 or more: concern regarding additional attacks, worry about implications of additional attacks (heart attacks, going crazy), change in behaviors following attacks • With or without agoraphobia

10. Anxiety Disorders- DSM IV-TR Specific Phobias: • Marked, persistent fears • Situationally bound panic attacks • Realizes that they are excessive and unreasonable • Stimuli produce marked anxiety/distress • Avoidance

11. Anxiety Disorders- DSM IV-TR Social Phobia: • Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears he or she will act in a way where the anxiety will be humiliating or embarrassing. • Exposure to the feared social situation almost invariably provokes anxiety which may take the form of a situationally bound or situationally predisposed panic attack • The person realizes that the fear is excessive or unreasonable • The fear interferes with daily functioning

12. Anxiety Disorders- DSM IV-TR Obsessive Compulsive Disorder (OCD): • Either obsessions or compulsions”: Obsessions: • Recurrent and persistent thoughts, impulses or images that are experienced at some time during the disturbance as intrusive and inappropriate and that cause some marked anxiety or distress • The thoughts, impulses, or images, are not simply excessive worries about real life problems • The person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize theme with some other thought or action • The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as thought insertion)

13. Anxiety Disorders- DSM IV-TR Compulsions: • repetitive behaviors that the person feels driven to perform in response to an obsession that must be applied rigidly • 2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive • Interfere with daily functioning

14. Anxiety Disorders- DSM IV-TR PTSD: • Exposed to a traumatic event in which both of the following were present: • The person witnessed, experienced, or was confronted with an event or events that involved actual or perceived death, threat or serious injury or a threat to the physical integrity of others • The person’s response involved intense fear, helplessness or horror (NOTE: in children may=agitation) • The event is re-experienced persistently in one of the following ways: • Recurrent and intrusive distressing recollections of the event including images or perceptions • Recurrent distressing dreams of the event • Acting or feeling as if the traumatic event were occurring • Intense psychological distress at exposure to internal or external cues that symbolize or represent an aspect of the traumatic event • Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

15. Anxiety Disorders- DSM IV-TR Persistent avoidance of stimuli associated with the trauma and a numbing or general responsiveness (not present before the trauma), as indicated by 3 or more of the following: • Efforts to avoid thoughts, feelings, or conversations associated with the trauma • Efforts to avoid activities, places or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma • Markedly diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affect • Sense of a foreshortened future Persistent feelings of increased arousal (not present before the trauma), as indicated by 2 or more: • Difficulty falling sleep or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response • Causes distress and impairment in daily functioning

16. Anxiety Disorders- DSM IV-TR Acute Stress Disorder: • Differences with PTSD: minimum, of 2 days-4 weeks • Within 4 weeks of the traumatic event

17. Anxiety Disorders- DSM IV-TR Generalized Anxiety Disorder: • Excessive anxiety and worry about a number of events or activities for at least 6 months • Difficulty controlling the worry • 3 or more (1 for children): • Restlessness or being keyed up and on edge • Being easily fatigued • Difficulty concentrating or mind going blank • Irritability • Muscle tension • Sleep disturbance • Causes impairment in daily functioning

18. Generalized Anxiety • 5-6% of Americans at some point in their lives • First in young adulthood throughout 50s Areas To Assess (Shear, Belnap, Mazumdar, Houck,& Rollman, 2006): 1) Frequency of Worries • How often do you worry about things? Do you worry every day? On average how much of your time per day is occupied with worries? 2) Distress Due To Worrying • How much distress does worrying cause you? How upset or uncomfortable do you feel when worrying? 3) Frequency of Associated Symptoms (restlessness, feeling keyed up or on edge, irritability, muscle tension, difficulty concentrating, mind going blank, fatigue, sleep disturbance) • How often do you have these symptoms? Every day? How much of the day? 4) Severity and distress due to associated symptoms • During the past week, when you had these symptoms, how intense were they? How much distress did they cause you? How upset or uncomfortable were you when you had them?

19. Generalized Anxiety 5. Impairment/Interference in work functioning • How much do the symptoms we have been discussing interfere with your ability to work and/or carry out responsibilities at home- our ability to get things done as quickly and effectively? Are there things you are not doing because of your anxiety? Does anxiety ever cause you to take short cuts or request assistance to get things done? 6. Impairment/interference in social functioning • How much do the symptoms we have been discussing interfere with your social life? Are you spending less time with friends and relatives than you use to? Do you turn down requests of opportunities to socialize? Are there certain restrictions in your social life about where or how long you will socialize?

20. Generalized Anxiety Disorder The “Looming Cognitive Style” (Riskind & Williams, 2005) • Mental scenarios and appraisals of events 1) Anxiety and depression 2)Worry 3)Attempts at Thought Suppression Threat Appraisals: 1. Likelihood Estimations 2. Lack of Control 3. Imminence

21. Generalized Anxiety Disorder Anxiety and Depression • Attending to the “negative” or unpleasant • Stimuli viewed as negative, dangerous, impending • Self viewed as helpless or hopeless • Sense of stimuli gaining velocity and gathering momentum (unfolding, changing, advancing) • Self protective

22. Generalized Anxiety Disorder Worry • A chain of thoughts and anticipatory processes • A repetitive habitual means of verbal thoughts regarding potential or possible threatening events • Paradoxical: actually lessens autonomic system arousal, reduces the somatic component • Helps avoid aversive imagery • Believed (by the client) to be a coping mechanism • Beliefs regarding thoroughly considering all the possible outcomes and being able to mentally manipulate circumstances • Fears are all-encompassing network and even include “neutral” stimuli

23. GAD versus OCD(Fergus, Wu, 2010) Intolerance of Uncertainty (can’t deal w/ambiguity) • GAD-worry, OCD- compulsions Perfectionism • OCD-a way to decrease anxiety about the uncertainty of the future Negative Problem Orientation • GAD-Higher negative problem orientation (attentional bias) Responsibility and Threat Estimation • Related to anxiety in general Importance of and Control of Thoughts • Central to OCD

24. Obsessive-Compulsive Disorder • Obsessions & Compulsions • Obsessions- Upsetting thoughts, images, or urges that intrude, unbidden into the person’s stream of consciousness • Compulsions- behaviors or mental acts that the person feels compelled to perform, usually with a desire to resist; are connected to what they are intended to prevent (e.g. checking, washing, hoarding, ordering or memory compulsions, cognitive restructuring, neutralizing rituals, themed rituals- religious, sexual, aggressive) Dysfunctional Beliefs (Taylor, Coles, Abramowitz, Wu, Olatunji, Timpano, McKay, Kim, Cramin, & Tolin, 2010): • 1) Inflated personal responsibility- belief that the client has the power to cause, and the duty to prevent, negative outcomes • 2) Over-estimation of threat (negative events are likely to occur and their occurrence would be terrible) • 3) Over-importance of thoughts (belief that control over one’s thoughts is entirely possible) • 4)Perfectionism- belief that mistakes and imperfection are unacceptable • 5) intolerance of uncertainty- belief that it is necessary and plausible to be completely certain that negative outcomes will not occur

25. Obsessive-Compulsive Disorder Three Aspects of Perfectionism (Ashby, Rice, & Martin, 2006): • Self-oriented- high standards for self • Socially Prescribed Perfectionism- belief that others set high standards for you • Other-oriented Perfectionism- setting high standards for others

26. Post-Traumatic Stress Disorder • Witnessing an event perceived as traumatic • Traumatic to self or other • Event causing distress • Could be either: a) Restrictions experiencing emotion/emotional responsivity (emotional numbing) OR b) intense arousal • Belief that risk of bodily injury or death • Horror • Re-experiencing (nightmares, intrusive memories, flashbacks) • Hyperarousal (disturbed sleep, irritability, being easily startled) • Hypoarousal (avoidance) • The past invading the present, short term stuck in long term memory: moved to limbic system of the brain

27. PTSD (Cont.) • More numbing predicts worse outcomes. • More emotional “outbursts” predict better prognosis.

28. PTSD (cont.) Proposed domains to address • Biology (developmental problems, increased medical problems) • Cognitive- difficulties in attention, information processing, learning • Dissociation- depersonalization, derealization, impaired memory • Affect regulation- poor emotional self-regulation, difficulty labeling emotions • Attachment- social isolation, difficulty with perspective taking • Behavioral control- poor impulse control, aggression, oppositional behavior • Self-concept- low self-esteem shame and guilt, lack of sense of self

29. Social Phobia • Marked and persistent fear of social situations • Concerns about possible scrutiny by others • Presumptions of judgment and rejection • Anticipating incompetence on part of self • Avoidance behaviors • Ignoring social cues which may be helpful • Cognitive Biases (e.g “I will mess up.”, “They will see how bad I am at this.”)

30. Panic Disorder • Negative interpretations limited to self- different explanations regarding such symptoms in others • Interpretation bias • Cognitive errors: double messages- self and others- note inconsistencies • A number of people with panic disorder were found to have strongly influencing and significant life events which predisposed them to panic (loss separation, bereavement, health related concerns starting in childhood or young adulthood, major separation from significant caregivers) • Associated and correlated with neuroticism- low perception of pleasantness, perceived control, goal achievement and higher sense of moral violation

31. Cognitive Behavioral Cycle • Using proven REBT- Rational Emotive Behavior Therapy (Albert Ellis) but incorporating client belief systems and spiritual worldview • Compared to baseline

32. Dealing With the Feelings

33. Cognitive Behavioral Principles • Early life experiences • Maintained throughout time • Maintained by behaviors that may not be useful • Maintained by looking for thoughts and behaviors that keep the cycle going

34. Cognitive Behavioral Principles • Continuing to elicit negative thoughts and record more helpful ways of thinking about situations, self and others to influence emotion positively. • Reviewing thoughts, particularly expectations for self and ‘shoulds’ rather than ‘wants’. • Identifying rules for living and examining their helpfulness. • Identifying unhelpful thinking styles that lower mood. Encouraging the client to analyze thoughts and then step back from them. • Reviewing alternative explanations for negative automatic thoughts. • Conducting behavioral experiments to help increase believability of alternative thoughts. • Listing goals with an emphasis on own needs and expectations.

35. Thinking Error Types 1) Awfulizing/Catastrophizing- Predicting only negative outcomes for the future: “ ____ is awful, terrible, catastrophic or as bad as it could possibly be”, “If ___ happens my life is over.” 2) Disqualifying/Discounting- Overlooking the positive and only seeing the negative, believing that good things don’t count: “I am sure even when my family complimented me they had to because they are my relatives. They had to be nice.” 3) All or nothing- Viewing the situation on one end of extremes: “If my boss corrects me I must be the worst employee”, “If my child does something wrong I failed as a parent”, “If I didn’t pass one exam I am an unsuccessful student.” 4 Low Frustration Tolerance- Belief that things should not be inconvenient: “I can’t stand _____” ; “_____ is too much and is intolerable or unbearable.”

36. Thinking Error Types 5) Self Downing- Self deprecating thoughts: “I am no good, worthless, useless, and utter failure, beyond hope or help, devoid of value.” 6) Other downing- Derogatory beliefs about others: “You are no good, worthless, useless, an utter failure, beyond hope, of no value.” 7) Emotional reasoning- Letting emotions totally overrule facts to the contrary: “I feel as if everyone is talking about me.” 8) Labeling- Giving a label or stereotype without testing beliefs out:” All of them are like that.” 9) Mind reading- Trying to predict things based on limited aspects of a situation: “ I know they will think I’m poor because I can’t afford the latest clothes.”

37. Thinking Error Types • 10) Overgeneralization- Making broad conclusions about an event based on limited information: “My husband doesn’t love me because he is always busy when I am around.” • 11) Personalization- Assuming that others behaviors are all about you: “My wife is quiet. Something must be on her mind.” • 12) Shoulds/musts- Having an absolute concrete standard about how things ought to be: “ Successful people in life only get As in school.”

38. Cognitions Related To Anxiety Cognitions Supporting Worry: (Dugas & Koerner, 2005) • “Worrying is helpful.” • “Worrying, thinking about possible outcomes can help me deter or change events.” • “Worry can prevent negative outcomes. • “Worry is a sign of a caring concerned person.” • “Worrying is a positive personality trait.” • “Worrying aids in problem solving and helps me plan.” • “Worrying motivates me.”

39. Cognitions Related To Anxiety • “I am losing control.” • “I cannot handle this anymore.” • “My life is falling apart.” • “Everyone knows how socially inept I am.” • “I can’t deal with this stress anymore. It is absolutely overwhelming and immobilizing.” • “I know I will absolutely fail.” • “This is bound to happen again.”

40. Cognitions Related To Anxiety • “Something bad is going to happen to me.” • “I must be having a heart attack or other serious health issue if I am having these symptoms. Next thing I know I’ll die.”

41. Anxiety Versus Depression- Self Statements(Safren, Heimberg, Lerner, Henin, Warman, Kendall, 2000) Inability to cope • I can’t take it anymore. • I can’t stand it. • I wish I could escape. • I don’t want to feel this way. • I cant cope. • I can’t get through this • Something has to change. Uncertainty About the Future • How will I handle myself? • Can I overcome the uncertainties? • What will happen to me? • Will I make it? • Can I make it? • Am I going to make it? • What am I going to do with my life? • I want to fight back but I’m afraid to do so.

42. Anxiety Versus Depression- Self Statements(Safren, Heimberg, Lerner, Henin, Warman, Kendall, 2000) • I don’t feel good. • I don’t feel very happy. • I am not safe warm, comfortable. • I am not sure that I can accomplish this. • I don’t feel so good about myself/my life. • I hate myself. • I feel like a loser. • I’m worthless/a failure. • Something is wrong with me. • No one understands me. • I don’t think I can go on. • I wish I could die. • I’m against the world. • I can’t get started. • I’ll never make it. • I’m no good.

43. Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005) Relationships, Entitlements, Achievements • If people criticize me, I am not a worthwhile person. • Other people’s approval is very important to me. • I can make everyone like me if I just try hard enough. • The most important thing in the world to me is to be accepted by other people. • I find it impossible to go against other people’s wishes. • Unless I get constant praise I feel that I am notworthwhile.

44. Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005) LOVE • Life is unbearable unless I am loved by my family. • If I am not loved it is because I am unlovable. • If I love somebody who doesn’t love me, I must be • inadequate. • I need to be constantly told I’m loved to feel secure. • If I were a better person then somebody would love me. • In order to be happy, I need someone to really love me.

45. Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005) Influence • I can prevent people being upset by thinking about what they might need. • If I have a fight with my friends, it must be my fault. • I should be able to please everybody. • I am responsible for other people’s happiness. • If people are uncomfortable around me it is my fault. • If the people around me are upset, I usually worry that I have upset them.

46. Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005) Success • I can’t feel equal to others unless I’m really good at something. • I only feel valued if I achieve my goals. • My success in life defines my goals. • I need to be successful in all areas that are important to me. • Life is pointless if I don’t have goals to chase. • Without success in life, it is impossible to be happy.

47. Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005) Perfection • I see no point in doing anything unless it can be done perfectly. • There are no second prizes in life. • Things must be done to certain standards, otherwise there is no point in doing them. • If I make mistakes then others will think less of me. • If I don’t do something perfectly then I don’t like myself very much. • I never seem to be able to reach my own high standards.

48. Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005) External • I can only be happy if I have the good things in life. • Unless I have expensive possessions, • people won’t approve of me. • If I were rewarded for the goals I achieve, know I could be happy. • If my friends are unhappy, then I cannot be happy. Everything has to be going well in order for me to be happy. • My happiness depends on others.

49. Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005) Rights • If obstacles are placed in my path, it is natural that I would get angry. • Things should always go right for me. • If I do the right things people should acknowledge it. • If I feel that I deserve something, I should get it. • If I go out of my way to help others, they should do the same for me when I need it. • I shouldn’t have to work so hard to get the things I want.

50. Behaviors Related To Anxiety • Attending to the disturbing stimulus to the neglect of additional environmental information • Intolerance of uncertainty- the tendency to react negatively on an emotional, cognitive, and behavioral level to uncertain situations and events • Maladaptive schemas related to earlier life: disconnection and rejection, impaired performance, impaired limits, etc.