CBT Interventions and Group Activities Live Interactive Webinar

I don't want to be blue. I'd like to welcome everybody to today's presentation. We're going to be talking about cognitive behavioral interventions and how to use those and teach those in group. So we're going to explore ways to teach cognitive behavioral interventions in group. Because cbt, since it is, tends to be somewhat cognitive, it can be really easy to fall into the trap of lecturing and just doing a straight discussion. And there are some ways that you can make it a little bit more fun. And I find, number one, that we have experiential learners, kinesthetic learners, that do better if they're actually working with material. And people tend to enjoy group and remember it more if they are having fun. The way our brains are wired, for whatever reason, when we're doing something enjoyable, we tend to remember that information more than if you're sitting there kind of drooling on yourself while somebody lectures at you. Do remember when you're providing this in group? Because we're, you know, especially if you go over multiple techniques in group to provide handouts and worksheets for people to use and practice over the week, because this isn't something they're going to hear once and go, okay, I can do that. No problem. And it's ingrained in what they do. So we want to make sure that they have the material they can go back and look at. One thing that I've done in the past which seems to have worked well, is teaching people a cognitive behavioral skill at the beginning of each group. So instead of teaching them 10 in one group, and they're just kind of, like, overwhelmed with all that, it's kind of like going into Home depot and getting 10 new tools and going home and going, gosh, where do I start? It provides them one tool per week that they can work with and manipulate. You can use that tool in order to help them work through whatever you're talking about in group. So if you teach it at the beginning of group, then when things come up in group, you can say, okay, let's use this new tool and see how it works. So those are just a couple tips for CBT groups. So, as we know, the basis of cognitive behavioral therapy is that thoughts, feelings, and behaviors are all connected in that triad. So I start out by explaining that the fact that when you change your thoughts, it can have a direct impact on your physiological reactions, which may impact your urges and behaviors. And I give the example of, you know, if a bee lands on your arm, you know, if your thought is, it's going to sting me. Then you're going to want to get it off. You're going to feel scared, you know, so you're going to have an unpleasant emotional reaction. And your urge, your behavior, is going to be to swat it, which unfortunately probably increases the chances you're going to get stung. Another example I give, because I'm a real big sissy when it comes to needles and bee stings, is shots. If you are thinking to yourself while the nurse is coming at you, this is going to hurt, then guess what? When they give you a shot, you're probably going to be more likely to tense up, and it hurts a whole lot more. And there's anxiety associated with anticipating pain. So one of the things that we can do is change our thoughts, which is the basis of cognitive. We can also change our behaviors because changing our behaviors has a direct response on our thoughts and emotional reactions. When we are, for example, getting ready to get a shot, we can force ourselves to relax. Now, if you're having stressful thoughts, you're not going to be able to relax. So if you're having thoughts about relaxation, if you're actively focusing on relaxation, guess what? That's going to change your behavioral reaction when. When the nurse comes at you with that needle. At its core, cognitive behavioral therapy has the principles of noticing, understanding, and addressing thoughts, feelings, and behaviors. So again, I really want people to wrap their heads around the fact that intervening in any one of these three areas actually can have a positive effect on the other two areas. So I do something called the triad activity. And with that activity, With that activity, I have people and I have little placards that they can wear, and they're not fancy, they're just laminated sheets. But I will have two people. One is the positive thought person and the other is the negative thought person. One is the positive feeling person, and the other is the unpleasant feeling person. And then the helpful behaviors and unhelpful behaviors. So we have six people. And if you don't have a really big group, you can adjust that a little bit and have one person play both roles. But generally you have a group that's big enough that you can have six people. So, anyway, so I start out, and I have all three negatives or unpleasants or whatever you want to say in there. The unpleasant behavior, the unpleasant thoughts, and the unpleasant feeling. So let's start with a first date, you know, and I put them in there, and I say, okay, thought person, tell me what you're thinking. What are the stressful thoughts that you're having right now. And that thought person starts talking about what thoughts they might be having that make this situation seem stressful or anxiety provoking. And then I let them go for a second and I say, okay, so behavior person, what are you wanting to do right now? And generally the behavior person says, I'm not wanting to go on that date, or I'm wanting to go to the bathroom and crawl out through the window, whatever. And I'm like, okay, so your stressful thoughts lead to the behaviors of wanting to escape or wanting to avoid it. All right, that's good. You know, okay, then we have the feeling person, and you can address it in any order. And I say, okay, feeling person, how are you feeling right now? And they usually look at me like, well, duh, I'm feeling really anxious. Okay, so then I put the take the negative thought person out and I put the positive thought person in. And I say, okay, positive thought person, you're getting ready to go on a first date. What are all the positive thoughts you can have? And then again, we go through and I say, all right, behavior person, how are you feeling? What are your urges right now? And generally it's like, let's see how it goes. And feelings person, how are you feeling with these positive thoughts? And it might be optimistic or curious or whatever, excited. So that's wonderful. All right, see where we're going here? So then the next person, I usually go around and I do behaviors next, and I say, all right, you're getting ready to go on a first date. And what behaviors might you be doing that increase your anxiety? So what behaviors can you do? Drinking a lot of caffeine, drinking alcohol, because we know as it starts to wear off, anxiety goes up. Changing clothes 16 different times, whatever the person is doing. And then I say, okay, you know, so you're doing all these things. You are in a tizzy. You are doing all these, you know, frantic behaviors. So what are your thoughts that are going along with that? And I have the thought person talk. And again, we're back to the negative thought person here. And the negative thought person says, yeah, you know, when he's acting like that, I'm not. I'm thinking that it's going to be kind of catastrophic. And they start talking about the thoughts they're having. Like when the one of the behaviors is changing clothes 17 times. Well, what are your thoughts that are making you do that? Well, I don't look good in this outfit. I need to be approved of whatever the thoughts are. And then the feelings person is still hanging out there. And I'm like, well, how are you doing? And the feelings person is going, my anxiety is creeping up. Okay, so then we swap out again, I put the positive behaviors in there. What positive behavioral things can you do to get ready for this first date that will help you feel calm, confident, all that kind of stuff? And then that person talks about what they're doing. Then I asked the thought person, all right, what are your thoughts? You know, if that person has called their friend and they're talking about what they're going to do, and, you know, they went out and worked out that morning, and whatever it is that helps them get grounded, the thought person, hopefully, is having calmer thoughts. I mean, there's still a little trepidation for a first date. And then the feelings person. So I just swap out, you know, each one of those six people. But the goal is to see that how when you increase positive thoughts, positive behaviors or helpful behaviors, or even positive feelings, that it affects the other two areas. So that can be a fun way to do it. Functional analysis. I do a timeline, and, you know, since I have a whiteboard, that's what I use, because I already use way too much paper. Draw along the whiteboard, and in the middle is whatever the issue is, and then leading up to it are the causes and triggers. And then after it is the aftermath of whatever the behavior was. So, you know, Sally was at work, and she spilled her coffee on all of her notes that she'd been working on for three hours, and she just lost it, started screaming, slamming things, whatever. All right, it happens. So we want to look at what were the antecedents, what led up to that may have caused Sally to be more likely to freak the freak out, as my kids say, when the coffee spilled on her notes. You know, one of the things I'm hearing is, well, if she'd been working on notes for two hours, that means she was way behind in her notes, and she probably doesn't like doing them anyway, and now she's got to redo them, so that's frustrating. So, you know, looking at the antecedents leading up to that, and it could have been a really good cup of coffee, and that always is irritating when you spill that. So we look at what led up to it and ways that could have been prevented. You know, maybe doing your notes right after each session, figuring out a way to do notes in session, like I've suggested to y' all before, whatever the case may be, maybe she also got up late or. Or she just wasn't feeling it that day. So what could she have done to improve her mood before she started on those notes? One of the things I'll do, if I'm having to do something that I really am not excited about doing, I will put something on the tv because I just like having that background noise. And that makes me feel more calm. I don't know why, but it does. But we talk about ways you can mitigate those vulnerabilities. Then we want to look at the impact after she lost her mind and started throwing things and yelling and screaming and thought that the sky was falling. What were the consequences of that? Well, it didn't get the notes done any faster. It used a whole lot of emotional and physical energy. It got her into a negative mental space. Socially. People around, you know, in her office were going, oh, yeah, we want to steer clear of Sally for a little while. And environmentally, you know, her office is a mess. Now you can look at those however it's impacting the person, but you can do a functional analysis, timeline. Another technique that we can use is unhooking and diffusion. So separating yourself from your thoughts and fears. And this is kind of, when we get to it, a gestalt activity a little bit. So fears keep us stuck. Fears hold on to our anxiety and keep us stuck in that fight or flight place. Fusion, meaning we feel we are one with our thoughts and feelings. Excessive goals can keep us stuck. If our goals are too big or we lack the skills or resources, we can feel really overwhelmed and encumbered. A stands for avoidance of discomfort. Because sometimes when you're stepping outside of your safe zone, you're getting outside that box, however you want to say it. It's uncomfortable. You know, there's a little bit of anxiety going, er, can I do this? If you're not willing to make room for that discomfort and you want to avoid it, then you may not step out of that comfort zone and grow and take on challenges that you want to. And R stands for remoteness from values. If you're doing things that are not in line with your values in order to avoid the discomfort or deal with this fusion with your fears, then it can keep you stuck even more. So the antidote to fear is DARE diffusion. And this is where the activities come in. Because, you know, I don't necessarily want to get people fusing. I want to get them to diffuse. So diffusion. Feelings, thoughts and behaviors are not who we are. Feelings are something we have, thoughts are something we have, and behaviors are something we do, but they are not who we are. And I want to separate that. When little Johnny makes a mistake, he's not a bad boy. He is a good boy that made a bad choice. And there is a strong, huge, large, you know, big difference between those two things. I don't want Johnny thinking he's a bad boy because then that makes him feel ashamed of who he is instead of ashamed of what he did in the moment. We can fix things that we did, or we can make amends, but we sometimes we can't fix who we are. So there are different activities you can do for diffusion. The first one, I am having feelings of. So if somebody is having really strong feelings of, let's start with addiction. Really strong craving feelings and feelings of being overwhelmed and not being able to cope without having that drug. All right, so one of the activities that I'll do with people is tell them, let's have a dialogue dyad. And I put two chairs. This is where the gestalt sort of thing comes in. Two chairs out there, and the first chair is their unpleasant feeling. And they're going to have a discussion with that unpleasant feeling. Why are they feeling that way and accepting that that's how they feel, but recognizing that that feeling is out there and that feeling can get up and walk away at any moment. The other chair are positive feelings or hopeful feelings or efficacious feelings, if you will. But I have them talk to each one and say, I could feel this way by. But I'm feeling this way now because, okay, that's how you're feeling. It is what it is. An unrelated activity that I'll do sometimes, and I call it squirrel, mainly because of the movie up. And when we are unhappy, when we are going through a stressful time, anxiety, anger, depression, whatever it is. Very rarely do we feel that way all the time. 100% no change. There are milliseconds there sometimes where we can feel a moment of peace. It may not be exhilaration, but it may be like, okay, I remember when my daddy was in hospice, when he was at the hospice facility. You know, that was devastating. It was devastating to see him that way. And, you know, I was overwhelmed, and I. I was having a lot of feelings of helplessness and hopelessness and yada, yada. Which one will when. During the grief process. But while he was there, we would sit on the. On the sofa in his hospice room, and he had a sliding glass door, and there was this little squirrel that would come up to the sliding glass door and scratch on the sliding glass door because daddy had fed him french fries one time, and this smart little squirrel learned that daddy would feed him french fries every time he came to the door and scratched. So, yes, I was in the middle of this devastating thing, but that little squirrel came up and scratched on the door. And I had this moment of, oh, that's so sweet. And then I went back to, you know, the unhappiness, but recognizing that you are not your feelings. And feelings will come and go, and we need to make room for the happy feelings, too. You know, thinking of feelings as commodities, you know, kind of like filling up your grocery basket. You know, you're going to have all those healthy foods in there that you're supposed to eat, but you may put in some chips and some other things. And for me, the squirrel was like the junk food, you know, that was my junk food of happiness for the moment. So encouraging people to recognize that they are not their feeling and that feeling does not consume them. To make room for others, you can also do. I'm having the thought that. And this is an interesting one to do. During the dialogue dyad, you can make notes of thoughts people have, both positive and negative. You know, you want to write down both of them and write them down on slips of paper. And, yes, I know, more paper, lots of composting anyhow. But then you have people walk by, and this person is, you know, struggling with addiction, for example, and they've already talked about the unpleasant feelings that they're having. But then there are other feelings of empowerment and remembering when they've been clean and sober for a while, or remembering when they've been happy and been proud of themselves. So we take all those feelings, all of those thoughts, and I start out with sort of a litany of the unpleasant ones, because that's where they're at. And sometimes people just need to get their thoughts out to get them out, validate them, go, okay, that's how I feel. It is what. What it is. And then they can let it go. They just need to get it out. Otherwise, it knocks around in their brain until it can get out. So let's let them get it out. It doesn't mean they have to hold on to it. So they have this feeling. And people hold the slips of paper and walk past the person who is unpleasant having this unpleasant experience. And the person reads the feeling statement, I don't feel like I can tolerate this. I'm going to relapse. I can't take this anymore. I'm miserable without my drug, whatever it is. I. But as soon as the person reads it, the thought person in the thought line walks past them and that thought is gone. They said it, they acknowledged it, it's gone. After you get through a few negative thoughts, then I start interspersing some of the ones that came when they were talking to the positive thought chair. Because once we start getting that negative out, because worry, if we don't feed it, if we don't dwell on it, worry should only last five or 10 minutes probably. And then we start having the problem solving thoughts, you know, that anxiety and adrenaline starts bleeding off and we get more in our wise mind and we start having more problem solving thoughts. So then the problem solving thoughts start coming in and they walk by too. You know, the person doesn't have to hold on to any of the thoughts that go by, but if they choose, then they can grab, not physically, but tell somebody from the thought line, you come here, I want to hold on to this thought for a minute. And we see what thoughts that they hold on to. The key is to provide them a visual of the fact that thoughts, you want to get them out, acknowledge them and let them walk away. And if they can get that vision in their head, sometimes it can help them when they start having those thoughts, they can actually envision those thoughts being typed out on a piece of paper and flying away. The other thing is, my behaviors are sometimes behaviors are not the healthiest, but they're behaviors. So again, let's go back to addiction. Person can feel overwhelmed, they can feel frustrated that they can't use. They can feel cravings, they can have thoughts that they are powerless. They can have thoughts that they have to have that drug or use that thing right now or they're going to die. Those are all feelings they can have. Those are all thoughts they can have. Their behaviors, you know, if they end up using, you know, okay, their behavior was that they used to, that was probably not the most helpful behavior, but it helped them survive. Their behaviors are not who they are. They are not failures, they are not relapsers. They are people who chose a behavior and encouraging them to see behaviors. You know, again, Johnny's not a bad boy. Johnny made a bad choice. So encouraging people to see behaviors separate from themselves. All right, so once we see that feelings, thoughts and behaviors are not who we are, we are good people, we have good hearts and good intentions. We just sometimes, you know, go a little bit off the, off the helpful path. Acceptance of discomfort. This is the next thing. And this is where distress tolerance skills come in really handy. Because anytime we do something. I mean, if an occurrence happens like you're in a relationship and you know, it breaks up. So you start having these feelings of super anxiety, thoughts that you're going to be alone forever, fears that you're going to be abandoned forever. Behaviors may be somewhat erratic in order to try to plug that hole that the person has in their heart. Okay, you know, when abandonment occurs, one of the steps is acknowledging how you feel and what your thoughts are and then accepting the discomfort, going, okay, this really sucks right now. Making room for it and going, it's okay, it is what it is. I'm not going to judge myself for how I feel. Once you're not fighting with those feelings and trying to suppress them and ignore them and push them away, then you can focus on fact based thoughts, you know, and that ABCDE that we'll get to in a little bit and setting realistic goals. It's like, okay, so I'm having these feelings and I'm having these thoughts and they're unpleasant. I want to feel better. So what's a realistic goal to improve the next moment in this situation? What's the first step I need to take to change the situation or change my reaction to this situation? And then finally, embracing values, living authentically increases happy feelings, positive thoughts and behaviors. So, you know, if I am, well go back to addiction again. If I'm struggling with that, I'm, you know, in this really relapse prone mental place right now and maybe even behaviorally not doing the things I need to do in order to maintain my recovery lifestyle. If I accept discomfort, I go, okay, recovery is not always, you know, roses. It sometimes is discomfort which is uncomfortable, but I'm going to accept that. So what goals can I set to help me feel better in the moment without using and what are the fact based thoughts? Because likely I'm not going to die if I don't use again. So what are the fact based thoughts? Thoughts that support my goals and how do these goals and these thoughts help me embrace the things that are important to me like recovery and doing things so I can be closer to my family. Going back to abandonment, you know, having the feelings of anxiety and despair, having the thought that I'll be alone forever. My behaviors are unhelpful because, you know, I've texted him 72 times in the past 24 hours. Okay, I can see how that behavior is not helpful. Does it make me a bad person? No, it's just not a helpful behavior. So let me accept the discomfort I'm feeling and set realistic Goals and focus on, you know, disputing those thoughts that I'm having and figuring out which ones are actually based in fact and what do I need to do to start feeling better, embracing those values and cancer, you know, again, you find out that you've got cancer or a loved one has cancer. That can feel awful, extremely disempowering. You can feel terrified. You can have all kinds of, you know, catastrophic. Thoughts and behaviors vary. Some people ignore it, Some people become very depressed. Some people, you know, frantically try to figure out how to make it go away. A lot of times that's not helpful. So diffusing. So you're not just reacting. You want to be able to act purposefully. So diffusing. So you can choose purposeful action. You can choose. The logical next step means saying, okay, these are the thoughts and feelings I'm having. I accept that this is really terrifying and uncomfortable right now. So what are the facts here and what is the next thing I need to do in order to keep moving towards what's important to me? Continuing to live and have a healthy life or, you know, celebrating and enjoying the time I have left with this person or whatever it is. So problem identification and solving is another technique, and I couldn't figure out a good acronym that fit everything, so it's cited E. Go figure. So stop. Identify the problem. Develop alternative solutions. Explore the short and long term consequences and outcomes of solutions. Decide on a response and evaluate the outcome. Okay, well, one of the things that's hardest for people is, is the stop. Once they get into their wise mind, it's a lot easier. But stop is difficult. So I love music, and generally if I get a song stuck in my head, it's stuck there for the rest of the day, if not the rest of the week. And I apologize if this does that to some of you right now. But when people get upset, if I can have them that unpleasant feeling trigger in their minds a song like, I think it was the Supremes singing Stop in the name of love Stop in the name of love before you break my heart Think it over. You know, that's them telling you to stop. Bobby McFerrin, don't worry, be happy. You know, sometimes that's a mantra. There's a song called the Middle by Joni Eats World that we'll talk about at the end of the presentation that has a lot of really uplifting words in it or just the Serenity Prayer. And when my kids were little, I shortened it, and instead of the whole thing, I would just say, God grant Me, patience. And I would turn it over at that point, but you know, that that was me. So identification of the problem. You know, once you've stopped and you're able to think, and sometimes these songs will even make you happy because you'll start going around like stop and singing and bless the people in my heart or in my office because I get a little goofy sometimes, but you can feel a little bit happier. But at least it helps you stop. Then identify the problem. Who's causing the problem? What part of the problem is being caused by you? There's multiple who's in every problem? Where is the problem occurring? What exactly is happening and why is it a problem? Then develop alternative solutions. Explore the short and long term outcomes of those solutions, decide on the response and evaluate the outcome. So again, addictions and cravings, abandonment, cancer, we'll go through those really quick. So if somebody's having cravings, one of the first things we want them to do is stop, you know, stop doing what they're doing and focus on the moment. Become mindful. Identify who's involved, where they are, what's triggering their cravings, why they don't want to use, and what the next step could be. With abandonment, you know, again, stop identifying the problem. Whose involved, you know, where did this happen? What happened? And part of what happened is really examining those thoughts about whether somebody's using an external or internal locus of control, doing a lot of blaming, etc. And why is this happening? So they're figuring out what's going on. Develop alternative solutions. Okay, you know, this person broke up with me, left, whatever. I can't get them back. Texting them 72 times or whatever probably isn't going to help. So what are some alternative solutions I can do to help myself feel better, to help myself deal with this situation? And with cancer. And Christina points out that, yeah, cancer, there is less that you can do about it, but there are things you can do. Like my mom, when she was diagnosed with cancer, it was devastating and she could have crawled into a bottle of whiskey and cigarettes and whatever, but instead she said, okay, I'm going to go to the doctor and I'm going to follow the treatment protocols that they've got set out right now. And I'm going to do the research to recognize that people do look at the facts to realize that people do recover from this kind of cancer. She identified the problem. She knew what was going on, why it happened, hard to say. But she did also identify some things that she could do in order to help herself Feel better and enjoy the. Enjoy her life, you know, however much of it she has left, whether it ends up being terminal or it goes into remission instead of focusing on, you know, six months from now, if I'll be alive, it's, well, I woke up this morning and it's a good day. And so she's changed her. Her perspective a little bit. So one of the things you can do, and this typically does better as just a group discussion, when you experience the problem, how can you remember to practice the pause? How can you remember to stop? What techniques can you use to get through the initial adrenaline rush? What are your distress tolerance techniques? Some people deep breathe, some people go on a walk, some people put on loud music, splash cold water on your face. There are a variety of techniques, but I want people to figure out what works for them. Describe a time you got upset and effectively managed it. So I want people to recognize that they have managed distress before. Given a time when you. An example of a time when you got upset and did not effectively manage it, and what was the difference? So you have managed distress before, but then sometimes you don't manage it so well, so what's the difference? And sometimes it can be vulnerabilities leading up to it, they're not getting enough sleep, whatever. But other times it can be very specific issues coming up. Maybe issues of rejection trigger a much stronger reaction than issues of loss of control. Practice identifying the problem. Remember to think broadly about who's involved. You know, you're finding out that, you know, this relationship ended okay, well, it's not just about you. It's about that person as well. And maybe other people, you know, maybe that other person's family didn't want them in a relationship with you, so they were contributing. You know, there could be a lot of other people involved in the situation. What happened, explored objectively in relationships. You know, you want to look at, you know, there was that final fight or disagreement or whatever it was, but what happened broadly? Let's look at the relationship and how many, how often was it conflictual and problematic? When did it take place in the chain of events? You know, when did this breakup take place? Was it after the very first fight you ever had, or was it after the 21st fight that you'd had that month? Why did it happen? You know, why did, why did this breakup happen? And again, if you have looked back at this other stuff about when it took place, where it took place, who's involved, you're going to get an idea about why you guys, you Know might not have meshed, and why the relationship may have ended, and then why did it bother you? And, you know, obviously when relationships end, it hurts. But figuring out specifically why this situation bothers you this much at this time is important, you know, and it could be thoughts that you're having, it could be. It triggers memories from past traumas of abandonment. There are a lot of reasons, but it's important to understand. So when the situation happens again, whether it's getting into a fight with your best friend or breaking up with a romantic relationship, you understand a little bit better what prompts your reactions. Identify alternatives to your immediate response. You know, the immediate response may be to yell, scream, you know, cry, withdraw, drink, you know, whatever it is for that person. Okay, what are the benefits and drawbacks to that? And whatever people choose generally has the benefit of making the pain stop in some way, shape or form, or give them a sense of control in some way, shape or form, at least briefly. But what are the drawbacks to that immediate response? And generally, that means looking 30 minutes or three days down the road. What are the drawbacks to that response? Drained your energy, did no good, alienated other friends, whatever it is. So, okay, so what are some alternate responses that you could choose, and what are the benefits and drawbacks to those? And I'll tell you, one of the drawbacks to a lot of the alternate responses is it doesn't numb the pain quite as well immediately. You know, instead of being, you know, lidocaine or something, it's, you know, more like just triple antibiotic ointment. You know, it doesn't. It doesn't do a lot to stop the pain right away, but it does start to help it heal and then choose and implement the response contracting. Encouraging people to identify problem behaviors. The function of the problem behavior. So maybe you have little Tommy, and little Tommy throws a tantrum every night before it's time to take a bath. And this is a problem behavior. So what's the benefit of the behavior? What's the function? He doesn't want to get into the bath. He's delaying the time to get into the bath. Why is he delaying that? Is it because he's got some sensitivities and when this water hits his skin, it hurts? It can happen. Is it because once he takes his bath, he knows he's got to go to bed and he doesn't want to go to bed yet? What's the function? Identify a new behavior to replace it. So, okay, Tommy, you don't want to take a bath, right? Now, we don't want to reward that behavior, but instead of throwing a temper tantrum, because that's not going to get you what you need. What are other things that you could do? Maybe helping Tommy find the words to say I don't want to go to bed yet, or I want to read one more story. If you can figure out why Tommy is doing this behavior. You know, again, let's say he, he doesn't want to go to bed yet. He wants to read another story because maybe dad or mom just got home from work. Okay. Or maybe siblings are staying up and Johnny wants to be. Or Tommy wants to be big like his siblings. Okay, that's fine. So how about since you don't want to go to bed yet, you know, what if you take a shower now anyway and then you can stay up and read a book or watch a show with the family or whatever it is. Yes. That means you got to make the shower time come a little earlier because we don't want Tommy going to bed at 10 o'. Clock. But contracting with Tommy a little bit to figure out what to do. Identify rewards for the new behavior and drawbacks to the old behavior. So if you get into the shower now, how can I reward that behavior? And what are the drawbacks to you throwing a temper tantrum? If Tommy is 4, this is not going to be a productive discussion very much. But even if Tommy's four, as an adult, as a parent, we can look at the benefits and the drawbacks to the old behavior. We also want to address drawbacks to the new behavior. So if he says, I don't want to go to bed yet, and we say, okay, but you have to go to bed, then that might punish him. Articulating what he wants anyway. Write a contract and monitor the behavior. Contracting can also be used for emotional eating. You know, just about anything that you want to change. Target behaviors. And you can do this on flip charts. I do put them around the room. One is persistent worrying, one is not getting out of bed. One is anger outbursts, smoking, stress, eating and caving, or being overly passive. So then I have people go around the room the first time, identify the vulnerabilities for each. What makes you more likely to engage in persistent worrying, to not want to get out of bed, to have anger outbursts, you know, etc. Then they go back around the room and they identify the benefits and drawbacks of each. You know, what are the benefits to persistent worrying? Well, it keeps you from being caught unawares, that's for sure. One of the drawbacks though is it is exhausting and it keeps you from feeling happy because you're stressed out all the time. So they go around the room and do that. Identify alternate ways of meeting the same need. So you know, the benefit of persistent worrying is it keeps you from being surprised or being caught unaware. So what's an alternate way to keep yourself from being surprised? Thinking about what that is. If the person is worrying about particular things like their kid getting injured or getting in a car crash, you know, how can you address that so you're not persistently worried every time Junior takes the car out and worried until he comes home six hours later every single night. It's exhausting. So what are some other ways that you can feel more confident and calm and identify ways to address that target behavior? Schedule in the Positive and I do this on our Friday roundup. On Fridays when I do group, when I do group therapy, we have, we go over the treatment plan. Everybody goes over their treatment plan, identifies the progress that they made, goals that they have for the upcoming week so data they can share and support one another in their progress. But then we also talk about scheduling in the positive for the weekend and the upcoming week. What health related activities are you going to do? And you know, for some people it's going to the gym every day and that doesn't really change. But sometimes people may say, oh, on Wednesday I'm going to go hiking, blah, blah, cool, what are you going to do for fun? And I want them to schedule in fun for the next week. I want them to schedule in rest and relaxation for the next week and I want them to schedule in socialization for the next week. And if they are all sharing how they are going to do that in theory, then there is a little bit more peer pressure, there is a little bit more support for doing these positive activities. And then the next Friday when we go over the treatment plan and everything, we also go over all of these activities from the prior week. You know, I've made notes, you know, you said you were going to go hiking last Wednesday. How did that go? So you know, it reinforces the fact that taking care of themselves and doing positive things are important. Because if we increase our positive activities and are happy that the number of minutes per day that we're happy, that's a fewer number of minutes per day that we are unhappy. Chunking and successive approximations Chunking means breaking overwhelming tasks into smaller ones. Recovery for example, when people go through substance abuse recovery in our IOP program, we have it chunked where there are certain tasks that they are supposed to accomplish and treatment plans do the same thing. Certain tasks they were supposed to accomplish every week. You know, we're not worried about this big goal over here that's overwhelming. There's a lot of stuff to do to get there. We're worried about what you need to do today, what you need to do this week. Spring cleaning can be chunked. You know, when I do spring cleaning, I don't do the whole house in one day. I pick a room and that's the room that I do that day or two, if it's a easy room, like the bathroom or something. But I chunk it that way I don't feel overwhelmed and lose, you know, three solid days to cleaning the house. Getting kids back is another one. Following that Department of Children and Families case plan. That can feel overwhelming because you get it and it's 20 pages long. So helping people chunk it and go, okay, what are you going to do today? What are you going to do this week? Successive approximations. Gradually working towards a harder goal. One of the most common ones that we think of is fears and phobias. So if you are using successive approximations or systematic desensitization, you're getting closer to being able to be exposed to whatever that fear provoking thing is without it causing you anxiety. So snakes, for example, you know, first you want to be able to think about snakes and get to the point where you can calm yourself down without being overwhelmed. Then you want to get to the point where you can look at pictures of snakes and not shudder. Then you want to get to the point where you can watch that Indiana Jones where he fell into the pit that had all the snakes and not have your skin crawl. Working gradually towards being able to get to the point where you can be in the same room with a snake and go, hey, not a big deal. Smoking cessation, another example, you know, people will gradually cut down on their cigarettes and they will provide themselves rewards for that. So smoking cessation, maybe they cut down one cigarette less each day, you know, so they're not smoking their final cigarette in the night for a week, and then the next week they're not smoking that cigarette, but they're also not smoking their first cigarette of the day and then the next week they eliminate another one. Running a marathon, you know, you don't generally get go from being a couch potato to a marathon runner overnight. So what can you do to run that marathon? You know, first you've got to be able to walk a mile, then you got to be able to jog a mile, then you got to be able to run a mile, then you got to be able to walk three miles. You see where we're going here? So just gradually increasing the difficulty of the goal that you're working towards. So cognitive distortions, activity. This is a fun one. And since we're running short on time, I'm not going to really explain a lot with each one, but I call it the be and become activity. And I give each person in the group a particular cognitive distortion, personalization, exaggeration, all or nothing, thinking, whatever, and then I will announce a situation that typically causes people anxiety or distress, and they are supposed to react as strongly as they can with that distortion. So if a friend canceled plans, how you know the personalization person is going to say, you know, that my friend doesn't like me anymore. They're not going to be my friend anymore. I must have offended them, yada yada, you know, I want them to be as catastrophic as they can be. To highlight these cognitive distortions, and each person explains why whatever this problem is happened and why it's upsetting them in terms of their cognitive distortion. So it can be fun because since you're taking it to such an extreme, it tends to be a little bit humorous. You can also have a beach ball with the different distortions written on it. Toss it around to people, and when they catch the ball, they look down. Whatever's up, they've got to give an example of when they use that distortion. You can discuss why each distortion may develop. What's the function of personalization? Explore the benefits and drawbacks of each distortion. How is personalization beneficial if it's ingrained in us for some reason? It was reinforced at some period of time? In what way was this beneficial? It could be that that was the safe thing to do in the environment that you grew up in, and then identify ways to address each distortion. Again, you can put the distortions around the room and have people go around and put their suggestions for how to address it. Or you can do the beach ball activity, whatever you want. I do a lot of the same activities. But again, at least it usually keeps people moving. We've gone over the ABCs a lot. The activating event, the consequences of that event, the automatic beliefs that led to the consequences or people's emotional reaction. Go back and dispute those automatic beliefs. Eliminate any that were inaccurate, moderate any that were extreme, and keep the rest. You know, sometimes it's a bad situation and your feelings and thoughts are pretty daggum accurate. And if they are okay, then you evaluate the effectiveness of your reactions. So if this was a bad situation and your automatic beliefs are really intense, but that's accurate. Okay, so, so was your reaction to crumple up in a ball, was that effective? Or how could you have better used your energy in that situation? So the activity that we do, I have people identify three things that trigger anxiety for them and you know, bridges, authority figures, tests, relatives coming to visit, three things that trigger anger, tailgating, lying, computer problems, laziness, whatever it is for them. Get some things and have them go through and apply the ABCDEs. Cognitive restructuring or taking the middle path means literally changing your thoughts. So finding meaning in the current event and this can be hard, especially with things like cancer, it can be really hard to find meaning and understanding you can challenge the interpretation. So if you find out that you've got a cancer diagnosis, your initial interpretation may be this is a death sentence. But if you challenge that interpretation, you may realize that cancer research is getting better literally every single day. So it may not be and what are your chances? And develop a both and perspective. You know, yes, this is devastating and I am going to fight it and try to get it into remission. Examples of restructuring. So when people get stressed, instead of viewing something as a threat, how can they view it as a challenge? So public speaking, some people hate it. So instead of viewing it as a threat and worrying that you're going to trip over your own tongue or you're going to pee on yourself or whatever, how can you view it as a challenge? How can you view it as a growth experience? Failure. You know, we can see things as failure and again, remember, we're seeing things as failures, not ourselves as a failure. But how can you see failure as a learning experience? Now you learn one way not to do it again, loss versus opportunity. So maybe you lose a job and that can be devastating. However, maybe it's an opportunity to find a different job that you'll be happier in and powerless versus empowered. So sometimes we feel powerless. Helping people focus on yeah, there are a lot of things about this situation you're powerless over. But what do you have the power to, to address in this situation and in your life right now? Have people identify three common triggers for anxiety and anger. They find the meaning in the current event, interpret the event as a challenge instead of a threat, and develop a both and perspective. So, you know, again, we talk about it and then I have them apply it. Examples can be applying it to a significant, significant other, not responding To a text, not getting a promotion or a first date. Systematic desensitization. We talked about earlier learning to effectively use coping skills to reduce distress through gradual exposure. Level one, imagining and describing the distressing event. Level two, and sometimes there are levels in between here, but the middle level, exposing yourself at a safe distance to the distressing event. And level three is experiencing the distressing event. So going back to snakes, you know, the other day I brought in sweet potatoes or sweet potato vines because the greens are really good if you bake them. But I digress and, you know, I fix the vines and whatever and I put them back out in the garden, the remnants. And the next morning I got up and I started making my coffee, and my daughter looks at me. She's like, you brought another pet in? And I'm looking at her and I'm like, what are you talking about? Well, apparently in the sweet potato vines that I had brought in, I had brought in two snakes, and they had presented themselves that morning for her to see when she first got up. Oops. So, you know, thankfully she's not real freaky about snakes. But, you know, if somebody would have been, that would have been overwhelming. So first you want to imagine yourself walking into the living room and seeing a snake, and then maybe walking into the living room and seeing a snake in a terrarium, and then eventually walking into the living room and seeing a snake on the floor. But during each, at each level, people. People need to get themselves to a place where they can rate their distress, but they can calm their distress down. And they get to the point where they can see it and it doesn't upset them. They can see it and go, all right, that's a picture of a snake. Distressing events that I can do or I have done systematic desensitization for include public speaking, a first date airplane ride, and then, you know, some other personal example snakes. That's one for people. Cognitive processing therapy. Using analytical questions to help identify cognitive errors so people can make more effective choices. This helps them address over generalization and emotional reasoning. I have people put these questions on a card and carry it with them. It's their emergency card when they get upset. What is the evidence for and against this situation? And I want facts, I don't want hypotheses, I don't want assumptions. I want facts. What are the facts? Is my feeling based on facts or feelings? So just because I'm scared doesn't mean it's necessarily scary, you know, going on a roller coaster. I'm terrified of roller coasters. And does it mean they're unsafe? No. Statistics say they're pretty safe, but I'm terrified of them. So my reaction is based on feelings, not facts. Are all aspects of the situation being considered? We'll stay with my roller coasters for a minute. No, I'm considering going downhill at a bazillion miles an hour and that's not safe. But I'm not considering that I'm strapped in that it's been inspected. All of those other things and how many millions and millions of rides happen every day with no problems? Am I thinking in all or nothing terms, Am I confusing high and low probability events? Well, yeah, I'm thinking if I get on there, I'm going to die. That's kind of an all or nothing thought. And I'm confusing high and low probability because there is an extraordinarily low probability anything is going to happen if I ride a roller coaster. So what's the most logical course of action? Well, for me it's to avoid roller coasters because there's just no reason to expose myself to that. But sometimes there are other choices that you can make. Identify three things you're worried about right now. Not being good enough. Failure, being alone forever. Have your people put in things that work for them. These three things come up a lot for people. Have them go through the questions and like I said, have them create an emergency card. Psychological flexibility means accepting reality as it is and committing to choosing thoughts and behaviors which will move you toward a rich and meaningful life. You know, sometimes you can't fix this situation, but you've got 18 other things in your life that are really important and really awesome. So you can devote your energy to those. If this is unchangeable. Commitment means determination to improve the next moment and realization that there are multiple aspects to commit to in your rich and meaningful life. There's your job, your kids, your health, your house, whatever it is that makes you happy. So have people define a rich and meaningful life because it's going to be different for everybody. Have them identify what their top five values are. You know, what are the top five characteristics they want to be remembered for? Which people are important in your life? And I include two and four legged creatures. And what things, hobbies and activities are important in your life. So if you have this rich and meaningful life, all of these things are going to be there and you're going to be acting in accord with whatever those values are. So once they know what their destination is, that's over here, then they can figure Out. Okay, I'm unhappy right now. This is unpleasant. First thing, is this worth my energy? Is addressing this issue even and devoting energy to it going to do anything to move me closer to my goals? And a lot of times the answer is no. You know, yelling at the person that cuts you off in traffic, that's just a waste of your energy. So figuring out, is this worth my energy? And then if it is, saying, okay, what things can I do and thoughts can I have that will help me address this situation in a way that moves me closer to my goals. So if you get passed over for a promotion, you know, you could get angry and badmouth your boss and yada yada, or you could say, okay, so one of the things I can do is learn why I got passed over, develop some skills, have some positive self talk, reminding myself that I'm a good person, maybe I wasn't a good fit for this, yada yada, and reminding myself of why I'm coming to work each day. Maybe it's to keep a roof over your head. So focusing on that use of energy, where you are is where you are. It is what it is. You feel how you feel. But what can you do to use your energy right now? The energy you have to move you back or start you moving again towards what's important in your life. So think of it like you all of a sudden get stuck in a traffic jam. What do you need to do? What detours do you need to take, if any, to get you back on the road towards your rich and meaningful life? So there are a variety of ways to help people explore and address the thoughts which may be keeping them stuck. Some techniques will work better in certain situations since cognition. Since our thoughts are based on prior experiences, teaching it in group can help clients explore alternate interpretations and information in similar situations. So they may think, you know, I never thought about it that way before. That's great, they're doing your work for you. By developing a broader understanding of situations, people can explore the effectiveness of their thinking in terms of how it impacts their ability to live a rich and meaningful life. Okay, so if you have any questions, you can start thinking of them now. If you are ready to go, you can go. This is that song the Middle from Jimmy Eat World. I really like it. It's basically talking about sounds like a teenager who feels down, feels dejected and he's saying, don't worry about what other people say. It's about how you feel. And you know, yeah, it sucks right now. It feels really awful when you come out the other side, you know, you can keep going. You are strong. So anyway, I like this song a lot. Other songs, Kelly Clarkson's Stronger, Demi Lovato, Skyscraper, Toby Mack. Start somewhere. There are tons of songs out there. So it's important to, you know, encourage clients who like music to find music that supports a positive outlook. Yeah, we can have our moments where we're listening to, you know, death metal, but we also want to have those playlists that are uplifting and encouraging. Okay. And yes, Pat, I agree there are apps that can be developed. There are some CBT apps out there. You know, I think there's definitely room to add more CBT apps to the Play Store, but. And a lot of adolescent clients and even some of your adult clients will have songs that they really love. So, you know, I bring three or four to the table saying, these are ones that I really like. What do you like? And have them share that. And if they don't have any, then it's an assignment before the next group so we can create a group playlist. Alrighty, everybody. I know we went through a ton of activities. Remember, you can go into the classroom, download the PDF so you can look over some of these and if there are any that you want to try and, you know, hopefully it will add a little bit of spice to your CBT groups. Have a great night, day, whatever it is. Now, tomorrow, same time at 12:00 CST, 1:00 clock EST, we have the discussion group and it's on attachment and trauma this week. So I kind of went a little bit overboard. I think there were like 34 articles or something. Oops. I shouldn't ever be turned loose on PubMed. But I digress. But we will be talking about the effect of parent attachment style on children, the effect of people's attachment style when they are children on their reaction to trauma and development of mental health symptoms, and the effect of adult attachment style on dealing with adversity and trauma. So there are three different attachment style phases, if you will, that we'll be looking at. And then Thursday we'll be talking about something else. I can't remember. Sorry. So I will see you all hopefully tomorrow or Thursday.