Cognitive Behavioral Therapy for PTSD, Chronic Conditions & Anxiety

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox you I'd like to welcome everybody to today's presentation on cognitive processing therapy. And we're really going to talk about how to use CPT tools not only with ptsd, but also how we can use it with anxiety and chronic conditions that our clients may experience. We'll learn the goals of cpt, discuss how it can be applied to people with chronic conditions, anxiety or trauma issues, and identify some of the common tools used in CPT which can be helpful with many clients. So cpt, or cognitive processing therapy, is based on social cognitive theory, which focuses on how the event or symptoms are construed and coped with by a person who's trying to regain a sense of mastery and control in his or her life. So when we think about ptsd, you know, that one seems obvious. They're going along, their schema for this just world is, you know, what they have, and then all of a sudden something very unfortunate happens to them and their schemas and their perception of what is happening and what can be trusted is turned upside down. So they want to get a sense of control back. When we think of our PTSD symptoms, you know, the flashbacks, the emotional numbing, all of, all of the symptoms that you may typically encounter with ptsd, you can see how the body is trying to protect the person and how they're trying to sort of integrate what happened into their view of the world and people and life in general. We can also see similar things if somebody's diagnosed, for example, with a chronic illness, because prior to that diagnosis, they were going along and they've envisioned their life to be one thing, and then all of a sudden they're diagnosed with a chronic illness, whatever that is, which may or may not be life threatening, but it does alter what they expected their life to be. So there is a trauma there, there is a loss, there is some grief to be dealt with. With people with generalized anxiety, for example, they may also experience a loss of a sense of control in their life. They may be worried about things constantly and feel like they are disempowered, unable, what's going on in their lives, which exacerbates their anxiety, which, you know, goes down this downward spiral. So cognitive processing therapy takes what's going on or the symptoms that the person is experiencing, and it says, okay, you've got these right now. Radical acceptance. How are you coping with them? What types of things are you telling yourself? And are those approaches helping you or. Or are they making things worse? Emotions such as fear, anger, or sadness may emanate directly from the trauma or condition. And in cpt, they call these primary emotions. In act acceptance and commitment therapy, they call this clean discomfort. These are feelings that happen. They're natural emotions. They're your body's way of saying you need to protect yourself or there was something important that you lost. And those are natural, and they will go away if they're not fed. If they continue to be fed, the person may get stuck. And CPT really helps people look at those stuck points. We're not saying that they shouldn't be, shouldn't feel out of control. We're not saying that they shouldn't feel angry or sad or whatever they're feeling. What we're looking at is the duration of that emotional reaction and what's keeping them stuck there. Secondary or manufactured emotions or an act they call this dirty discomfort may also result from faulty interpretations made by the person. So if they interpret that it they should have been able to do something, or this shouldn't be happening to them. Those shoulda, coulda, wouldas often come in there. There's also a lot of other feelings that compound the initial feeling of fear and anger, like guilt at feeling angry or guilt at feeling sadness. So there are a lot of layers that we're dealing with. What we want people, again to realize is the initial emotions are very natural and they're there to protect them. Social cognitive theories focus more on the content of the thoughts and the effect that distorted cognitions have on emotional responses to behavior. So it's really looking at what are you thinking and how is that affecting you now? How is that affecting you emotionally? And what can we do to help you feel emotionally better? In order to reconcile the information about the current situation with prior schemas, people tend to do one of three assimilate, accommodate, or over accommodate. And if you remember back to Piaget, you might be thinking, I've heard those words before. Assimilation is altering information to match prior beliefs. So you're remembering whatever happened in a way that you can fit it into your prior schema. So if you believe that your parents are supposed to be good people and they, and they punish you, then it's important to take a look at. What, how you might be changing those thoughts. Accommodation is altering beliefs in order to incorporate the new information. So you have this schema that your parents are good people, but then they are abusive so do you hold on to this schema? Do you hold on to this idea that your parents are good people? Or do you start to change that? So either way, you're trying to basically work this new piece of information into your narrative. Over accommodation is altering your beliefs about oneself and the world to the extreme in order to feel safer and more in control. And this is when you get into those cognitive distortions, the all or nothing thinking and the I can never ever do this again. Obviously, anything that deals with cognitive. We're probably going to talk about cognitive distortions and we will get there. But it's important to understand how assimilation and accommodation, we do this every day. It's when it's done to the extreme or when it's done based on faulty information that it can start causing problems. So five major dimensions that may be disrupted by traumatic events. Safety. If you don't feel safe in your, in your own skin, if you don't feel safe in your home. Trust. Not only your ability to trust other people, but your ability to trust yourself. Power and control. What amount of self efficacy do you have in certain situations? What can you control? And remember, remember that over accommodation sometimes people go to one of two extremes. They either start trying to control everything so they never have to feel out of control again, or they give up and they're like, I can't affect change on anything, so I might as well just, you know, sit back and watch the world go by. Either aspect of over accommodation is going to be problematic. Esteem how they feel about themselves in terms of how they handle the situation and in terms of how they're proceeding in their life henceforth and forevermore. What does this event, what does this diagnosis, what does this thing say about them and intimacy or their ability to be able to be close to other people, trust other people. Now all five of these are not necessarily disrupted for every single person. It depends on the incident, the situation, the trauma, the diagnosis. But it is important to look at each one of these and see where people might have started altering their, their schema or over accommodating. Do they feel like they can never be safe again? That they can never trust themselves again? Do they feel like they have no power? Do they feel like their esteem, you know, took a nosedive? Do they feel like it's not safe to be intimate with anyone anymore? Obviously that's one set of extremes. So those are things we're going to look at and those are things we often look at in a assessment anyway. But paying attention to those and hearing the disruption that may be caused by whatever the trauma is. So CPT itself is a 12 session protocol and in your class there is. There are links to the CPT manual and there's also a great free course put on by the University of South Carolina Med School. I believe that is also linked in your course if you want to get in depth in working with CPT. But for now, the 12 session protocol starts out with an introduction. This is what CPT is. Then we move on to talking about what is the meaning of this event for you? So we have people start writing an impact statement. What happened in the event? Not necessarily in great detail, but what happened and how has it impacted you, your feelings, your relationships, the way you interact with others, etc. They move on to identification of thoughts and feelings about the event. Because now that we see how you assign meaning to the event, what you've basically come to understand the event as. Now we have to look at those underlying thoughts and feelings and try to figure out what's feeding that schema going back to remembering the event. So looking in more clear detail and looking at some cognitive errors that people may make in the midst of trauma or extreme distress and start identifying stuck points. And these are those unhelpful thoughts that often come up and keep people stuck, telling them they should have done something differently. Then we introduce the Challenging Questions worksheet, which you all know is one of my favorites, and start helping people identify problematic thinking in cbt. It's called problematic thinking. These are your cognitive distortions. Safety. How do you feel safe? How do you start feeling safe in your own skin? How do you start feeling safe in the world now that this thing has happened and it can't unhappen? How do you start learning to trust yourself and others? What do you and don't you have power and control over? Then we work on building self esteem and intimacy and finish up wrapping it up by re examining the meaning of the event in this person's life once they've had a chance to really look at it through a few different lenses. So it's important to really emphasize to clients that there are two kinds of emotions that follow traumatic events. The natural or universal. Those are the things that are going to happen no matter who you are or where you are. Fear if there's danger. Anger if there's a threat and you could be intentionally harmed. Joy or happiness with positive events and sadness with losses. Natural emotions have a course and they won't continue on forever. And this is one of those things we hear in a Lot of different approaches. We hear it in dbt, we hear it in act, that emotions will come and go. We can let them come, and we don't have to latch onto them. We can unhook from our emotions. So that's something that is underscored in a lot of different approaches to helping people deal with traumatic events and situations. Manufactured feelings result not directly from in response to the event, but based on how you interpret it. So if you're in a car crash and somebody else is at fault, or you interpret somebody else is at fault, how is that going to affect you differently than if you're in the same car crash and you interpret yourself at fault? And, you know, I'm not going to go into the gory details of, you know, what happened, but people are going to respond differently emotionally and cognitively based on how they interpret an event. If they interpret something happening as punishment from their higher power, they're going to interpret it differently than if they interpret it as karma or just a random event. So we want to help them understand how they're interpreting this event. And it's not for us to say whether it's right or wrong, but I want them to look at it with their eyes wide open and get all the facts. Because a lot of times when people are in distress, you know, whether they've been diagnosed with a chronic illness or they've been victimized or something has happened, they've got a certain amount of tunnel vision. And when they start to try to remember it and make sense of it and put the pieces together and fit it into their schema, things get altered a little bit. Think about fish stories. When people tell fish stories, you know, that fish gets a little bit bigger each time. The same sort of thing happens when we go back to memories. They get adjusted just a little bit each time to make them fit better into our. Into our schema sometimes. So what are our goals? We want to help clients recognize and modify what they're saying to themselves. These are their stuck points. If they're saying that they didn't deserve to survive, well, that's probably going to keep them stuck in a pretty dark place. If they say to themselves, on the other hand, I did the best I could and I acted justifiably, they're probably going to be able to move further. So it takes, you know, over the course of, you know, 12 weeks or so, and it really depends on the client, but you're going to continue to identify certain stuck points. And there are some clues in here that we'll Talk about. About how to identify stuck points. We want to help clients identify how the condition, you know, their chronic condition or diagnosis or the event, if they were traumatized, impacted their views of themselves, other people and the world. Why do they think it happened to them? And how has it changed or strengthened their views about themselves or other people and the world in general? Now, remember, we're going to come back to these same questions at the end of the 12 sessions and have people look at this again and say, do I still feel the same way? We want to help people address the content of the meaning derived from the traumatic memory and help them accommodate or accept the traumatic event or condition happened. You know, this is reality, and discover ways to successfully integrate it into their life narrative. So if they're diagnosed with ms, if they are diagnosed with generalized anxiety that they can't seem to get a hold, hold on, if they are, if they experience a trauma, whatever it is, it is. So we want to kind of infuse a little radical acceptance here and say, all right, now, how do you improve the next moment? How do you move forward? Will help them determine the impact of the traumatic event or condition on beliefs about themselves and others and begin to normalize the grief process and differentiate it from ptsd, anxiety, or depressive symptoms. A lot of people will experience very, very similar emotions after a trauma or a significant loss or something. It's not necessarily going to develop into ptsd. Some people will have this rush of emotions and be completely overwhelmed, but they will. It will normalize out and they will be able to deal with it. What we recognize is certain people end up developing stuck points from the. From their interpretation of what's going on, which can keep them in this negative spiral. We want to begin to assist them in viewing their relationship with the person who died or whatever the event was that caused the PTSD symptoms or their relationship with themselves if they were diagnosed with a chronic illness or something. And they're not ever going to be the same person they were 30 minutes ago before they got the diagnosis. We need to help them look at the relationship is different now, but it's not necessarily finished. We'll help them label thoughts and emotions in response to events and introduce the idea that changing thoughts can change the intensity or type of emotions that are experienced. We'll begin challenging self blame and guilt with regard to the symptoms or event through Socratic questioning. Now, Socratic questioning is when we really use basically our best motivational interviewing techniques to help people look at objectively at what they're saying and See if what they're saying kind of jives with what they're feeling. And we're going to assign clients to write a detailed account of the trauma or the course of the symptoms and precipitating events. Help me understand how we got here. A lot of us do that. If we have clients write an autobiography, but, you know, it is a technique you can use. We will start discussing 2020 hindsight, because when things happen, you know, if somebody, for example, developed a drinking problem and they look back and they said, well, I shouldn't have, I should have seen it coming. I should have seen all these things happening. Well, in 2020 hindsight, probably, but we want to pay attention to the fact that you didn't and we're here and you can't change the past. So we want to look at assigning blame or responsibility, but we want to encourage people not to beat themselves up over things that they probably wouldn't have seen anyway. We want to help them contextualize the event, whatever happened. And look at not only just that little narrow swath of what they're remembering, but who else else was there? What else was going on? What else could be, could have contributed to this situation and get a broader picture of what's going on. Educate the patient about the distinction between blame and responsibility. Responsibility relates to one's actions in a situation that contribute to a certain outcome. You're driving a car, you run through a stoplight, you crash into somebody. Are you responsible? Sure. Blame in CPT world is a combination of responsibility and intentionality. Did you intend to crash into somebody? And that's, you know, a tricky one to work out, but it is something to give people a something to chew on. It's kind of like talking about the difference between forgiveness and acceptance. So Socratic questions help people start looking at the logic of what they're thinking and their beliefs. Clarification questions help patients examine beliefs by requesting more information. So if somebody was at a. If somebody's a rape victim and they said, well, I should have fought back harder or I should have done more, I should have done something differently, a clarification question might be, well, what do you think you could have done? Or what else could you have done in that situation? And, you know, there's probably not a lot more that they could have done. But if they come up with things, then we want to look at how realistic it was that that could have happened. Probing assumptions challenge the patient's unquestioned beliefs that underlie their stuck poor points. It's my fault so, okay, it's your fault. Help me understand how all of this is your fault. What exactly happened? What did you do where you. You are responsible for this happening? Probing reasons and evidence help patients examine the actual evidence supporting their beliefs. So we start looking at, you know what, when you tell me what happened, I see this chain of events. I see, you know, maybe you were walking home in the dark or what. Whatever happened. So let's look at the actual evidence supporting the beliefs that it's your fault. And, you know, should you be able to walk home or walk through the parking garage in the dark? And the person's probably going to say, well, yeah. Questioning viewpoints and perspectives encourages patients to come up with alternate perspectives. And this is the whole, turn it around. If this were your. If your best friend were in your situation, would you be blaming her or him for being. For being victimized or for being in this situation? And a lot of times when you turn the tables and get them to step outside of themselves, the answer's not so clear. Or maybe it is. A lot of times the client will go, of course not. I wouldn't blame them. So then we start saying, well, what would you be telling them to help them look at their specific thought patterns, their cognitions that surround, well, if this happened to somebody else, it wouldn't be their fault. It would. And all. All the other positive things that can help them get unstuck. And then we can take those thoughts and juxtapose them with what they're telling themselves and say, well, if. If it's not your friend's fault, then why do you think it's your fault? Analyzing implications helps patients examine the unpleasant outcomes that logically hold from. Logically flow from holding maladaptive beliefs. So we want to look at, okay, you firmly believe it's your fault. What are the implications of that? How is that impacting your life? What is the benefit of. To holding on to this belief that it's your fault? How is it going to benefit you henceforth and forevermore? Is this how you want to live? And generally, if they're in our office, the answer to that question is no. So we can say, all right, what do we need to do next? And questions about questions place the focus back on the patient when potentially inappropriate questions get asked of the therapist. So if the therapist client says, well, what would you have done? Or do you think that this should happen? When. If X happens, why should happen? Asking us to judge, asking us to formulate ideas isn't necessarily in the best interest of the client. And it's going to depend on the client and the relationship you have with the client. Obviously, how you answer which questions about your personal views on things. But questions about questions. Turn it back around. Why is it important for you to know what my feelings are about this situation? So stuck points are often the most difficult parts to revisit. So if the person is telling you this story about what happened and they get choked up, they get stuck telling the story, or they suddenly jump over from one event to another without transition, we might want to, you know, back up a little bit and help me understand how we got from point A to point B. If the person avoids the full details, and we may not know what the full details are, but we can stop if it seems like it's a stuck point and get a little bit more information about who else was there, what was motivating this particular action that the person was taking. If it's something they can't write about, every time they try to write, they just stop. Or if they can read it to you but it sounds numb or intellectualized, they're just kind of reading like they're reading this five o' clock news or they're suddenly flooded with emotions. Those are all important parts to take a look at. I worked with one person who was a law enforcement officer. He responded to a traffic crash on the interstate. The truck driver was pinned inside his vehicle and the officer was trying to get him out. Long story short, officer wasn't able to get him out before the truck exploded. So the officer had to back off and watch this man alive get perish in the truck. So there were periods when he was telling his story where he would jump from. I was doing this, then it was over. And there's a lot between when he was trying to get the seatbelt unbuckled to, quote, when it was over. So we needed to go back and take a look at, you know, what happened, what were you thinking? Who else was there? What responsibility did you have in this? And, you know, how do you feel about what's going on? A stuck point also can happen when there's a conflict between your old beliefs and the reality of the situation. In his particular situation, he was. He became a cop so he could help people. And in this particular situation, he wasn't able to save someone, he wasn't able to help someone, so there's a conflict. So he's looking for what he could have done differently, what he should have done differently, and trying to make meaning and sense out of something that was just didn't make sense. Stuck points can also happen if there's an experience that confirms a prior negative belief that somebody had about themselves. So if, you know, in the case of domestic violence, for example, if someone believes that they are deserving to be beaten and deserving to be treated that way, then they may get stuck there and have difficulty moving past it. Common stuck points. I have no right to feel happiness or take a break, give myself a mental break from being angry and feeling despair. Looking a little bit survivor guilt here. I could have prevented this if only, you know, and again, we've been talking a lot about traumas, but if we're looking at things that happen to a person, chronic illnesses, they may be looking back over their life and said, well, if I wouldn't have smoked for 20 years, I could have prevented this. If I had this fill in the blank, this wouldn't have happened. This can't be happening. It's just a bad dream. Which, you know, I can see people trying to distance themselves going, this isn't real. But then it also keeps them from working through it. So we need to talk about what reality is. My life is over and I am broken or faulty. So these are all common things that we hear, all common stuck points that we hear in people who've experienced trauma or gotten diagnosed with some sort of chronic physical or mental health illness. So when these things happen, there is a loss. Now, it can be a loss because of a death. You know, obviously in PTSD there are often deaths, not always, but there are also losses. If, like I said, you are going along and you're living a healthy lifestyle and all of a sudden you have a stroke and you lose function of half of your body, there's going to be some loss and grieving there. So it's important for us to help people understand that there are a lot of misconceptions about mourning and losses. Number one, we grieve things that are not only death. We grieve things that represent losses of a part of our self or our self esteem. Grief and mourning decline in a steadily decreasing fashion over time. This is not true. Yes, over time it can get easier, but that's not true for everybody. If they get stuck, it may not decline. So if they're just expecting they're going to sit there and have the same thoughts and do the same things that are keeping them stuck and their grief and mourning is going to go down, they're probably mistaken. All losses prompt the same type of mourning. No, you know, think about, you know, losses that you've had, there's been deaths, there's been expected deaths, there's been unexpected deaths, there's been job losses, there's been all kinds of things. Did you mourn the same way for each one? The answer is probably no. Some are going to be more intense, some are going to be more devastating, some are going to hit you in different ways. To be healthy after a loss, the mourner must put it out of mind. And some people will tell clients this. I don't think that's healthy. My personal thought and CPT agrees the mourner needs to make sense of it and integrate it into their narrative. Now there's a time and a place, distress tolerance and all, to be able to take a mental vacation from it and say, you know what, I'm not going to think about that right now. But it's also important that the mourner able to eventually take that information and integrate it into the narrative. Grief will affect the mourner psychologically but will not interfere in other ways. Well, I think we can all find that laughable because when someone is depressed, anxious, angry, you know, all the stages of grief, denial, anger, bargaining, depression and acceptance. Well, anger and depression affect a lot of things. It affects your work performance, it affects your relationships, it affects your self esteem. So we need to understand that grief is a whole person influencing thing. The intensity and length of mourning are a testimony to the importance of the loss. And this is something that some people feel guilty if they don't feel like they mourn for, quote, long enough. And what we really want to look at is whether the person made sense of what happened. And the intensity and length of mourning is going to be different for each person, partly based on their coping skills, their social support, and, you know, whether they get stuck or whether they're able to move forward. When one mourns a death, one mourns only the loss of that person and nothing else. Well, no, that's not true. You know, there are a lot of things that you probably envisioned that you are going to do with that person. So your, your life is changed when someone important to you is gone. Losing something unexpectedly is the same as losing something you anticipated. No. And in the presentation on complicated grief, we talked about the fact that when something unanticipated happens, it really shakes up a person's sense of control of the world, which can throw them into a tailspin. Because when something's anticipated, they can get closure on it. If it's unanticipated, it's like they're Always, henceforth and forevermore feeling like they've got to wait for the other shoe to drop. Morning is over in a year, no, now. For a lot of people, it gets easier after a year, but it often takes going through certain anniversaries and things. Now, not everybody needs the whole year. So again, I don't want people to feel like they have to be stuck in this mourning phase for a prescribed period of time. And finally, the last myth of mourning is time heals all wounds. And most people when they're mourning, really want to grit their teeth when somebody says this, because it hurts right now. And in time, yes, you can probably move forward. But again, if they get stuck, it's not going to. Which is why we want to help them look at how to integrate this new plot twist, if you will, into the narrative of their life. So we start looking at ABC worksheets. You know, they've given us their general overview of what happened, how it's impacting them, how they make meaning out of it. Then we want to give them ABC worksheets so they can start becoming aware of, of what they're telling themselves on a day to day basis, about their goodness, about their safety, about whether their intuition is trustworthy, about what other people are trustworthy, et cetera. So we all know these. The activating event, something happens, the belief is what they tell themselves about the event, which leads to the emotional reaction and behavioral urges. So having them go through these and have them dispute beliefs, looking for realism, identifying more alternate helpful thoughts that they could tell themselves in the future. So in office, we're probably going to look at some thoughts that they have about the traumatic situation. But outside, you know, between sessions, I also want them to use these worksheets dealing with other thoughts that cause them distress. Because a lot of times those same themes of loss of trust, loss of safety, loss of esteem are going to permeate other areas of their life and other thought patterns. So helping them see how this negativity and this negative or this stuck interpretation, if you will, of the trauma is negatively impacting them in the present, in all areas of their life is going to be important. And then we have them evaluate their reactions, determine if there are more helpful ways of responding to the emotion and urges. So something happens, they get upset. That's one of those natural emotions there. Okay, sure. Now your reactions. Continuing to beat yourself up for it, continuing to lash yourself with a wet noodle, is that helpful? What other helpful ways could help you move past this and respond to the emotion and urges In a way that moves you towards things that are important and meaningful in your life. Reviewing the ABC sheets for themes, like I said, it permeates throughout what they tell themselves at work, when they're driving, in their parenting, in their relationships. So I want to look for themes of anger and guilt and their emotions. If somebody feels like they should have, maybe they were driving a car and they got into a car wreck and their wife was terribly, terribly injured, so that person henceforth and forevermore feels angry at themselves and guilty for causing their wife to get so terribly injured that whenever that person wants something, the husband responds with, of course I will. And the husband is miserable. The husband is stuck with anger and guilt for something that happened 10 years ago. So we want to look at what's going on here. Faulty schemas, global, internal, stable and negative. So looking for things that say, I am a bad person, I can never trust the world again. You know, all those all or none. Thinking and identify emotions and reactions that flow logically from expressed thoughts. So if somebody says, you know, I'm worthless, I deserve. I don't deserve to be happy, well, then we want to talk about what logically flows from that. If you tell yourself you don't deserve to be happy, then what's going to happen? And what is it that you are wanting your. What's your goal? What is you. What are you wanting your future to look like? We want to encourage patients to use I feel or my reaction to this is for feelings. Instead of getting too caught up in descriptions, we can also have them use the phrase my belief is or I think for thoughts, so help them separate thoughts and feelings. Now, I don't get too stuck on this because some people, especially if you go back to Myers Briggs, the thinkers tend to not like to use the feeling word so much. We focus on reactions and beliefs, but those can get a little bit muddy. And I don't want to henpeck people at this point, but that's my personal choice, to let them kind of figure out what they're feeling or reacting and what they're believing. So the challenging questions worksheet. Remember I said when people get bad news when they're experiencing trauma, they tend to get tunnel vision. They only see certain parts and remember certain parts. Now, your brain does that to kind of help you sometimes, too. So it's important to think back to the HPA axis and all the things that your brain does to protect you. But in retrospect, you know, they're in our office now, so let's look at this belief, if you believe that it's all my fault and I don't ever deserve to be happy, so you ask them what's the evidence for and against this? So it's all my fault and have the person list the evidence. Is this belief based on habit or based on facts? If somebody starts telling themselves that an event that happened was all their fault, a lot of times that way of thinking and interpreting will carry on to other things that they do. So everything becomes all their fault and then they're carrying the weight of the world on their shoulders. So is your belief based on the habit of just assuming that everything's all your fault or is it based on facts? Was it all your fault? Are your interpretations of the situation too far removed from reality to be accurate? Sometimes people have rethought the situation so many different times that and you know, they believe that they should have been able to go in and just magically make something happen differently. Well, that's. Is there any way in reality that this could have happened? Are you thinking in all or none terms? Are you using words or phrases that are extreme or exaggerated like always, forever, never need, should, must, can't, and every time, are you taking the situation out of context and only focusing on one aspect of the event? So let's go back to the car crash. If this person's driving and they, they're driving along, it's raining, it's storming, it's dark, they're on a two lane road, they're coming over a hill and they get into a car crash. Now it sounds to me like there were some other things contributing to this car crash besides, you know, it wasn't a sunny day at noon and they were, you know, driving on a four lane road. So we want to look at all the contributing factors to this. I think a lot of us have been driving, we just had a gully washer here a couple weeks ago and I was driving my kids to martial arts. And the entire street, not just the size, the entire street had like an inch of water on it in places. And you'd hit that inch and your car would want to pull really hard to one side or the other. It's a little bit scary. So that's one of those things that you need to help people remember. What were all the factors going in there? Is the source of the information reliable? You know, do you have concrete information or are you just kind of spitballing what you think happened? Do you have the police report? Do you remember what happened or are you Just relying on what people told you. Are you confusing low probability with a high probability? So if their belief is that they will never, it's never safe to drive and if they go out, they're going to get into a car wreck, well, is that low probability or high probability? And that's one of those tricky ones if you really want to look at statistics. It could get dicey, but likely. You know, most people drive every day and don't get into car wrecks, or at least not into devastating car wrecks. So let's look at the validity of some of these assumptions you're making. Are your judgments based on feelings rather than facts? If it feels scary to get into that car again, which it would after a devastating car wreck, does that mean that driving is terrifyingly dangerous? Or are you basing your judgment or your thought on feelings? Are you focused on irrelevant factors? And you know, people could be looking at, I can't even think of an irrelevant factor right now. But a lot of times people, when they're trying to make sense of something, they're grasping for straws and they're trying to find some evidence to support what they're thinking, whether it's a stuck point, think thinking or helpful thinking. I love the Challenging Questions worksheet because it really encourages people to look more broadly at the situation. When people, when law enforcement officers go to crime scenes, I mean, think about it, they interview four different witnesses and they will get four different accounts of what happened because each one of those witnesses was paying attention to something slightly different. So very rarely do people have the entire picture of what happened. And those four witnesses may have different interpretations of the event and place blame on different people. Same thing for this person. We need to help them figure out what their interpretation is. But I want them to get a more three dimensional view of what happened, if you will. Problematic thinking patterns that are seen frequently with people who have been traumatized or experienced a significant devastating loss. Self blame, mind reading, emotional reasoning, overgeneralizing from a single incident and all or nothing. So all of these are really addressed in the Challenging Questions worksheet. Looking at, you know, was it your fault? You know, what other factors are playing into it? Are you using emotional reasoning or facts? How likely is this to happen again? Are you assuming everything's dangerous because of one thing that happened? Even if they don't believe it completely to begin with? If we can convince patients to modify their language, it will often have an immediate effect on the severity of their secondary emotions. So take out all of those. All or Nothing. Words take out all of those shoulda coulda words. Encourage them to look at some of those unhelpful ways of self talk that they use that they can adjust, tweak just a little bit. People often jump to conclusions when the evidence is lacking or even contradictory because we want to make sense of it. We want to gain control of something that left us feeling completely out of control, which can freak them out, it can keep them stuck, or it can lead them down the wrong, lead them to an incorrect conclusion. Some people will exaggerate or minimize a situation. A lot of times they may exaggerate how much control they had and minimize the good stuff they did. They can disregard important aspects of the situation. For example, in a wartime situation if somebody was acting on orders, you know, that could be an important aspect of the situation. Oversimplifying things as either good or bad or right or wrong. Most of us know, which is why we have all those classes on ethics we have to take. There's a lot of gray area in here. Very Rarely is something 100% good or 100% right. So we need to help them walk the middle path and look at what happened. Overgeneralizing from a single incident. Mind reading and emotional reasoning so the Challenging Beliefs worksheet which is also in that manual is very very similar to the ABCs. It has people describe the situation, identify their thoughts related to the situation, use the Challenging Questions worksheet to examine their automatic thoughts. Each one of them use the problematic thinking pattern sheet to go back and identify any cognitive distortions and then figure out how can we alter the cognitive distortions to create more healthy and helpful self talk and interpretations. Stuck points may be conflicts between prior beliefs and current beliefs that create unpleasant emotions and problematic or unhealthy behavior. When an old and new belief are in conflict, people often develop a certain amount of self doubt distrust. So the law enforcement officer I talked about, he got into this because he believed he was a good person and he wanted to help people, yet he stepped back and was unable to help this person. Now initially he saw that as a weakness and you know, he didn't take into the into account the fact that there was no way to get this guy out and if he would have died he would have left his children and wife without a father and husband and all the other stuff that folded in on it. So he was very distrustful of himself and of his own self image. He wasn't sure who he was anymore. This can generalize to other areas of functioning and the person may have difficulty making everyday decisions. So if they don't feel like they can affect change, if they don't know who they are, if they don't feel like they have any control in the world, they may not be able to effectively make decisions. And trust becomes an either or concept in which people tend to not be trusted, including themselves, unless there's an overwhelming evidence to the contrary. So they don't trust themselves, they withdraw. They're just like, I can't, I can't put myself out there, I can't trust my own judgment and I certainly can't trust other people. Power and self efficacy needs to be encouraged because a lot of times people feel like they can't change what's going on. They're stuck in this unhappiness, they're stuck in this situation and they weren't able to change whatever that horrible situation was. So we want to help people identify what challenges they have right now and what can they solve? What do they have control over? We want to help them use the ABCs and the challenging questions worksheet to address over accommodation so they don't try to have complete control over everything or abdicate control over everything. We want to help them have a moderate locus of control, understanding that there are certain things you can change and certain things you've got to accept because you can't change them. We'll help them learn adaptive balanced beliefs about the ability to control people and events, develop assertive communication skills. Self concept beliefs are really important for us to help people work on towards the end. We've really worked through the trauma, but they still are not feeling great about themselves. They're not trusting themselves. They're trying to figure out who they are now that whatever this is has happened. So we want to help them develop the expectation that, that they can meet challenges. We want to help them identify negative beliefs and alter them to find the positive. Sometimes they have the belief that they have to be in control all the time and that any sign of vulnerability represents a sign of weakness and powerlessness. Well, this is when that Socratic questioning comes in and you can say really? So tell me about other people in your life who are completely invulnerable. They're not going to have any. So we want to talk about their expectations for other people. We want to, if they have kids we can talk about how do you feel when they express vulnerability to you and what do you do to help them? Chronic conditions, losses and traumas can all provoke stuck points which can prevent people from accepting life on life's terms. So for example, you know, we've been talking a lot about trauma, but if somebody has generalized anxiety and they are with panic and they have these panic attacks frequently, they're starting to get a little agoraphobic maybe. Well, the more they focus on the panic attacks, the more likely they are to trigger a panic attack. The more likely they are to get scared to go out into the world and become more agoraphobic. So we want to help people relook at this situation, relook at the anxiety and understand it, work it into their self talk instead of telling themselves that no matter what I do, no matter where I go, I'm going to have a panic attack and I'm going to look stupid. What else could they tell themselves? We want to help them examine self defeating thoughts which are keeping them stuck and negatively impacting multiple areas of life. So thinking again about anxiety with panic and agoraphobia, if they tell themselves that they're no good to anybody and that it's not safe to go out in the world, well, how are these thoughts keeping you stuck? You know, if you tell yourself it's not safe to go out in the world, then you have to go out in the world, is that going to likely increase your anxiety and possibly trigger a panic attack? It may. Now they may not be able to control all of their panic attacks, probably won't be able to. But if we help them see how their cognitions can increase their anxiety and set them up, then we can also help them see how their cognitions can decrease their anxiety and buffer them from the potential negative outcomes. The goals are to help clients understand cognitive distortions. Learn how to identify unhelpful self talk, not only around the event or the condition, but also in their life, how it permeates other areas of their life. Learn to dispute stuck points using cognitive processing, using the challenging questions worksheet to look for the facts. You know, if they're having a panic attack and they're like, oh my gosh, I'm going to die, I feel like I'm going to die. What's the evidence for and against this? Are you basing your current reactions on feelings or facts? Some of this just helps them get through the distress tolerance period. So for their heart rate to go down or whatever. Obviously we don't want to minimize, you know, in case they're having a heart attack. But working with their care team, working with the client, helping them identify what they tell themselves, that can ramp them up and cause more problems. And we want to help them accommodate the event or condition into their current schema. Which is a really gibberish way of saying we want to help them take this plot twist and figure out how to write it into the script of their life, because it's happened. So where is this character going to go from here? If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com counselortoolbox this episode has been brought to you in part by allce.com, providing 24. 7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. Use coupon code counselortoolbox to get a 20% discount off your order this month.