Contextual Cognitive Behavioral Therapy | CBT The Importance oc Context

I'd like to welcome everybody to today's presentation on mindfulness and acceptance of behaviors using contextual cognitive behavioral therapy. I am your host, Dr. Donnelly Snipes. We're going to define and review the concepts of contextual CBT and explore the impact of context on people's phenomenological reality. What may be scary in one situation may not be scary in another. What. What may be an appropriate reaction in one situation may not be an appropriate reaction in another. And we really want to look at that not only for our own behaviors, but also for children as well as our staff. If you supervise staff, in what way does context influence their behaviors? We'll talk later. Explore how addiction and mental health issues can be influenced by context. And explore how acceptance, awareness, mindfulness, and psychological flexibility can be used transdiagnostically. These are tools. Once we understand how a person is perceiving that situation in that context, their phenomenological reality, their construction of reality, then we can use a variety of different tools to help them make choices that are going to be more in line with helping them achieve their goals. Why do we focus on context? Well, addiction and mental health issues and behavioral issues are often intergenerational. They are strongly correlated with each other. We look at people who have behavioral issues, they don't have emotional dysregulation, they have difficulty coping, and those issues may be related to behavioral issues, and they may be related to substance use or addictive behaviors. Addiction and mental health issues are also correlated with adverse childhood experiences and impaired occupational and social functioning and health problems. So we really want to understand why is this person behaving this way at this point in time, Understanding that we choose our behaviors as they are most beneficial in that particular time. Now, if you think back to acceptance and commitment therapy, there is that moment of mindfulness, the acceptance part, and then choosing whether how to use your energy in order to work toward whatever your goals are. Contextual approaches encourage mindfulness in the present moment. When we want people to take a breath. That's the hard part. Probably one of the hardest parts of any of these contextual based or even cognitive based approaches is getting people to get out of their emotional mind and into their wise mind, taking that time to stop. We want to encourage mindfulness in the present moment, except each person's truth is constructed from their schema and the resulting interpretation of the current moment. Now, what does that mean? That means if I walk into a situation and I see people that are talking with big hands and they are being loud and boisterous, Based on my history coming from a family that tends to use big gestures and be loud and boisterous, I might not think twice about it. Not threatening to me. I'm not going to trigger that fight or flight response. I'm like, you know, whatever. Another day. People who have experienced violence or whose families didn't use that type of communication, except for in adversarial situations, may walk into that same environment and have their trauma triggered. And it's important to recognize how they are reacting to that situation. Let's take one that's a little bit more personal, if you will, to clinicians. If you have a client, if you have a history of working with clients who have had suicidal ideation, attempted suicide, or heaven forbid, committed suicide, that is a prior learning experience, you are probably going to have a different phenomenological reality or when somebody comes into your clinic and has suicidal ideation than a clinician who's never worked with that before. You may be more confident or less confident. You know, that depends on how you dealt with that and what your schema is around clients with suicidal ideations. But it's important to recognize that your phenomenological reality, how you perceive that situation, how dangerous you perceive it, how much stress it causes you, is probably going to be very different than other people's perception and reaction to that situation. The goal is to consider the context and function of the past and present issue and empower the person to make a conscious choice toward their valued goals. If they were in a situation that was abusive before or dysfunctional in some way, and they walk into a current situation and it triggers those memories, part of contextual is encouraging them to stop and be mindful and ask themselves, basically, is this happening again? Is this the same situation as happened before? So I'm in a bad place, or is this just reminding me of this situation and I'm reacting out of the past, am I holding the person in the present hostage for things that happened to me in the past or things that people. People did to me in the past is another way to say it. Remember that the prefix re means to do it again. We repeat something over and over again. We redo it. If you don't do it right the first time, or maybe you just want to do it multiple times, we regress, we go back to doing things the way that we did when we were at a younger place, we relapse, we go back to doing behaviors the same way we did before, whatever that looks like, and we have a reaction. Typically, reactions are again, behaviors and actions that are based on schema that we've experienced in the past. So we're reacting out of our knowledge. If we don't have any knowledge of it, then you might more appropriately call it an action instead of a reaction. But whatever we are being triggered. The family context can be a preventative or a risk factor for the development of contextual issues. Children develop schema about themselves, others and the world through these early interactions. In later life, people continue to develop schema influenced by their past learning. If you grew up in a family in which there was a person who had a substance abuse issue or an anger management issue, and that person, we'll call them, the identified patient, came home, then that would be a trigger for behaving a certain way, maybe walking on eggshells, being really quiet, whatever it was not to irritate that person. That context of the home may be transferred to future life. And when you are, when the person is starting their new life with their new significant other or whatever, when that person comes home and is in a bad mood, it may trigger their memories of how it was when their parent or caregiver came home and was in a bad mood. So they may start feeling edgy and nervous and anxious even though their current partner is not a threat at all. They just had a bad day at work. And it's important for us to help people again to stop, take a breath and figure out, am I reacting to the past or the present? Caregiver requirements for secure attachment and healthy development if we want people to have healthy schema from which to react, then we need to help them develop healthy experiences as they're growing up. They need to have consistent, age appropriate responsiveness for from their caregivers initially. Remember Erickson's stages? Initially the caregiver has to do just about everything because Junior can't even crawl, you know, let alone make his own dinner. So there has to be an element of trust. That caregiver is going to respond to my cries and is going to keep me safe, warm, fed, you know, comfortable, all that kind of stuff. And you know, we talk about trusting the caregiver a lot, but we also, in that interaction, the child is learning to trust themselves. If they are crying because they are hungry and they get fed, then they figure out, oh, I can trust people to meet my needs and I can trust my instincts or whatever. I can trust that I can have an effect on the world. How cool is that? Now an infant really isn't going to think about that that much. The. Next stage is autonomy Making sure that the child has the ability to make choices and to try to do things and take chances. Step out of that comfort zone a little bit and assert again some more power on the world then industry and identity. As youth start developing their own idea of who they want to be, they still need to have a consistent, responsive, empathetic place to come back to. Safe place that they can come back to if things don't go so well or if they're not sure how things went. They need to have that safe space. We need to make sure that caregivers are providing empathy, compassion, teaching and developing effective communication skills and providing unconditional positive. Regardless which you've heard me say it before and I'll say it again. There's a difference between a bad boy and a bad behavior that a boy did. And it's really important in our semantics that we make sure that we are saying I love you but I really don't like it when you throw your shoe at the dog or whatever it is that they did. That's really important to pay attention to. Why are we talking about this with context again? We want to create a healthy context for children to grow up. In that way their schema are strengths based and empowered. Think about what it's like for a child growing up in a house in which one or both parents has an addiction or a mental health issue. Let's just go with bipolar disorder. You know, if one of the caregivers has bipolar disorder, there are the times when caregiver is clinically depressed and may not be able to be emotionally or even physically available. They can't get out of bed because their depression is so oppressive. Children remember they're dichotomous and egocentric. They don't understand that this is a sickness causing cancer. Caregiver to stay in bed or not be available or not want to play with them. They see it as the caregiver doesn't like them. Or you know, worse yet, if caregiver, you know, attempts non suicidal self injury or even suicide, you know that is going to greatly impact the child and that's going to be filed back in those memory banks. When somebody starts acting depressed, this is what to expect. When somebody starts acting depressed, it's my fault. That is what the child learns. And unless the child checks those schema, checks those beliefs, then when they grow up they still may believe that they are responsible for how everybody else feels. And I think we've all, well, not all. A lot of us have probably seen grown ups, adults who come to us for counseling. Or maybe they're just our friends, whatever, who still believe that it is their responsibility to make other people happy. Common characteristics of a person growing up in an addicted household, for example, And I want you to think what it's like for an infant, a toddler, a school kid, and an adolescent. Just pick one. Difficulty dealing with life on life's terms. The person with the addiction is overwhelmed right now. They have difficulty dealing with anything. So they're putting one foot in front of the other, hopefully. And if anything gets in their way, a parent teacher conference or problems at school, or the child needs something, that caregiver may not be able to respond appropriately. They may not have the tools or the energy or both. Difficulty dealing with distress, impulsivity, lack of patience, neglectfulness. Not saying that a person with an addiction intentionally is neglectful. A lot of times they're neglectful of themselves. And they certainly aren't able to provide adequate emotional and physical attention to a small child, which the child often perceives as a personal failure. You know, mommy doesn't want to play with me. Or, you know, mommy's angry at me all the time. Hostility, defensiveness, blaming. It gets even worse if the person with the addiction turns it around and it says, if you would just clean up after yourself, if you weren't such a bad child, if you blah, then I wouldn't have to get upset. You know, that's pretty typical verbal abuse, in my opinion. Manipulation, withdrawal from others, justification, minimization, and denial of their behaviors. I drink because I have to. If you had four kids, you would drink too. Those are the kinds of justifications we hear. And if the child hears this, if the child, which they hear a lot more than we think they do, when those children hear these things, then they may feel rejected. They may feel like it's their fault. And there are also differences, like Candace points out, Depending on the birth order. You may have an older child, you know, maybe 4 years old, and baby brother comes home. And parents remember, both men and women can develop postpartum depression. Caregivers, whatever you want to call them, develop postpartum depression. And they are having difficulty just dealing with this new baby that doesn't ever sleep. Little junior has a hard time understanding. Mommy and daddy are just really tired. We are not getting enough sleep. All junior sees is this little new baby is getting all the attention, and mommy and daddy don't seem to want. Want me around anymore. I seem to be a burden. Think of it through a child's eyes where they're trying to understand why something changed and the only information they have is what they see with their eyes and what they've experienced. They, especially children under the age of about nine, have a lot of difficulty conceptualizing alternate explanations like, you know, postpartum depression, you know, what kid's going to come up with that? It's really important that caregivers are able to try to explain it on a level that's appropriate to that child as an infant. You know, the infant is in that trust mistrust stage. If the infant is crying a lot, they're colicky, it happens, they are, and they're not getting their needs met because the person is not able to, you know, meet their needs, then they're going to start developing a distrust of the world very, very early on. Additionally, if the caregiver has an addiction or a mental health issue. Regardless, we know that children are extraordinarily perceptive of non verbals and you might call them micro emotions children perceive when you're stressed. When you're stressed, kids get stressed. When kids get stressed, they start getting scared. When they get scared, they act out. That's the context. So Johnny, Little Johnny, maybe 6 years old, and he's going to the doctor's office to get a checkup. No shots, no nothing. If he goes with a caregiver who is stressed out and angry and frustrated to have to be there and irritable, how is Johnny's behavior and experience likely going to be different and perception of the situation likely going to be different as opposed to if he goes to the doctor's appointment with his caregiver, other caregiver who is affable and sits in the lobby and plays games and says, you know what, this is going to be no big deal. You're just going to go and the doctor's going to listen to your heart and look in your ears and you know, not a big deal. Two completely different reactions and perceptions of the situation based on the context. Not you're going to the same waiting room, going to the same doctor's office, but the context is different based on the caregiver that is there. In mental health issues, we see pretty much a lot of the same issues. You know, difficulty dealing with life on life's terms, difficulty dealing with distress. When somebody is highly anxious, clinically depressed, struggling with some stuff, grief, whatever it is, they may have difficulty dealing with anything else. They are maxed out at their coping resources. They may be impulsive, lack patience, neglectful. How many times have you worked with patients who have been in the throes of a major depressive episode who haven't taken a bath or a shower for a week. You know, that's self neglect, hostility, irritability, withdrawal, low self esteem, guilt and shame. And I should have put that one on addiction too, because a lot of people with addictions also are just drenched in, in guilt and shame. They recognize what they're doing is not healthy when they sober up, but they don't know what to do about it. And a lot of times they numb that again with the addictive behavior, fatigue and a sense of hopelessness or helplessness. Thinking about a caregiver who has two older children at home and has an infinite home and is exhausted, experiencing clinical depression. Maybe it's not postpartum, maybe it's just regular old, straight up clinical depression has difficulty. When people are clinically depressed, they're apathetic. It's hard to sit down and play pretend. It's hard to even fake taking an interest in what kids are doing a lot of times in a way that they don't pick up on it. So children, even if the caregivers are trying their best to fake it, a lot of times children pick up on it and don't understand why you don't like playing with them. They don't understand what's going on. And they may start to become sensitive to cues that that caregiver is getting ready to go into a depressive episode or a manic episode or whatever it is. Those cues are going to be carried forth henceforth and forevermore until they check them, they're going to remember those cues. When somebody starts acting this way, it could mean, and that may trigger those past memories. When somebody drinks alcohol, if they come from a family where there's an alcoholic, when somebody drinks alcohol, then I can expect, based on my prior learning, that they will act this way. So I need to react in a certain way to protect myself. Now, we know that people all over the world drink alcohol, and there are a lot of people who drink alcohol and don't have a problem with it. However, that prior learning experience shapes people's future expectations of what may happen and it may stress them out when their new significant others, you know, whoever they hang out with, whether it's relationship or friendships or whatever, when those people drink, it may stress them out because it triggers those prior memories and, and contextual cognitive behavioral therapy encourages them to take a breath and say, okay, let's recognize what happened back then and that was awful. No doubt. Now let's recognize what your thoughts are and your expectations are about this situation. Let's make a list of them. I like making lists. Now let's examine the facts for and against this happening. You know, that happened with your primary caregiver. Now your new significant other likes to drink beer. Okay, let's call him Jim Bob. Jim Bob likes to drink beer. Now what evidence do you have that Jim Bob is going to react the same way that Uncle Sam did back when you were a kid? You know, what's the evidence that Jim Bob is going to get violent or get angry or go on a three day bender where you don't see him and he's just out getting drunk? Encouraging people to examine the evidence of the situation in the present, the current context, and compare and contrast it with prior experiences, The end product. People's reactions to things are based on prior learning combined with the present moment. What I learned in the past gives me shortcut for expectations of what to expect in the present. So when there's something in the present that triggers, makes me feel like I'm back there again. You can say flashback if you want to. It's not exactly accurate. Then I may react the way I did back then. Bridges, for example, if you've been in my classes, you know, I have a irrational fear of bridges. Hate them. And that's because when I was in third grade, my grandfather thought he would be funny. And he wasn't trying to be mean, you know, he had the sweetest heart, but he thought he'd be funny. And we were on this bridge, one of those ones that opens up to let the ships through in Clearwater. And we were on the place, you know, where it was, the metal grateful. And he looks at his watch and we're stuck in traffic and he goes, oh, it's almost 3 o'. Clock. And I'm like, what's, what's up with 3 o'? Clock? He goes, 3 o', clock, the bridge opens. Hope you can swim. I started freaking out, you know, because little third grader me thought he was serious and thought I was fixing to have to swim in order to get home. So now, for whatever reason, whenever I go over a bridge, especially one of those that opens up, there's some part in the back of my head that goes, you are not safe, you're going to have to swim. And it's not something that extinguishes easily, it's something that is always there and we need to help people understand that. It's not just as easy as, okay, drive over a bridge a few times when people are afraid of Something, it takes a while to help them get into that context. Now when I go for a bridge, I can rationalize. I can say, okay, you know, emotional mind gets triggered, move into the logical mind. I can say, I know this isn't going to open, I know I'm safe, I know, yada yada yada, but there's still that little third grader in the back of my head going, are you sure? Contextual cognitive behavioral therapy helps people understand that that was one learning experience they had. And they can choose to continue to get upset in the present, or they can choose to acknowledge that it's reminding them of something from the past and then develop positive self talk to help them get through the present core concepts. Mindfulness improves people's ability to be present in the present. Go figure. You shift from automatically reacting to thoughts and feelings based on your prior schema to being aware of all experiences in the present to provide more flexibility. We're not ignoring the past, we're not ignoring our prior experiences. You know, all my prior experiences evidently are stored in the back of my head because that's where I always go to. But we know those exist, but we are accepting those as prior experiences that we've had, while also exploring the present moment as it is and trying to be objective about that as we can with general awareness. We want people to ask themselves, what am I feeling physically, what am I feeling emotionally, what am I thinking and what are my urges? Those are pretty simple mindfulness things to go through. And I encourage people to do that on a regular basis. But especially if they are getting ready to do something stressful or feeling some sort of distress, encourage them to do a body scan and figure out what it is they want to do. And then we need to figure out why. Which moves us over to the contextual application. Remember, we only do things that are the most beneficial. All right, so I know what I'm thinking and I know what my urges are. How has this been protective or helpful in the past? How have these urges to run or to cry or to be on edge or to be hypervigilant? How has that been protective in the past? In similar situations? What is similar in this situation to the past? You know, in that example I gave earlier, it may just be that somebody that they loved has been drinking alcohol. Okay, well that if that is the extent of it, then we need to look at the other things that are different. Because there's a lot that's different and the person is different. That six year old who endured the angry alcoholic coming Home and throwing things and doing whatever that six year old couldn't extricate themselves from that situation. They were dependent on their parents. As a 26 year old or a 46 year old, they are able to say, you know what? Nope, I ain't going to be around this. I'm not going to tolerate this kind of behavior. Get their car keys and leave. Ostensibly. So it's important for them to understand the difference in the context between what their abilities and skills are and what's different about the situation itself and what is, you know, what is the same as the past and what is different in the past. And encouraging people to compare and contrast is really important to help them understand A their reactions, but B what the next best step is. If they're comparing the two situations and they're pretty daggom similar, then that's going to be a different reaction to protect themselves than if they are comparing the situations and there are only a few similarities and in this situation they're a lot safer or they feel a lot safer. Encourage acceptance of internal experiences, accepting thoughts, feelings and sensations without having to act on them. Remember my analogy of the bee, assuming that you are not deathly allergic to bees. Urges are like bees. Well, triggers I guess are like bees. When a bee lands on your arm, a lot of people, their initial urge is to swat it off. It's like, get off of me, I don't want you to hurt me. Well, unfortunately when we do that, a lot of times that makes the bee sting us, which the bee doesn't want to do. Because when it's a lot of bees, when they sting you, they die. And that's not real good for their survival. However, if you just let the bee sit on your arm, despite your urge to swat it off, in short order it will fly away because it gets bored, doesn't find the sugar or salt or whatever it was looking for and it will fly away. We need to help people explore how to conceptualize their urges. Are they going to think of them like bees? Are they going to think of them like clouds that float through the sky or like a train that that is just barreling past them? Whatever metaphor they want to use is really important for them to understand that their thoughts, feelings and sensations are there and they will be gone in a few minutes if they don't feed them and nurture them and whatever. We want to encourage them to use radical acceptance. And the best way I explain this to my clients is just to say it is what it is. I may not like it. I Don't have to like is what it is. I'm angry, I'm depressed, I'm scared. That's ok. Feelings are natural feelings. We're programmed to have them to protect us. So accepting those is really important. Unhooking from those feelings. Feelings taking a step back and saying, okay, I'm a fly on the wall. What am I seeing? In acceptance and commitment therapy, he talks about inserting the phrase, I'm having the thought that whatever's happening, I am sorry. I'm having the thought that I'm in danger. I'm having the thought that this is my fault. That helps unhook from it. And then you can say, let's look at that thought. It's easier to do that than if we say I am. Just helps us separate from it a little bit and encourage people to embrace dialectics. I can be a good person and be divorced. Some people aren't raised in a culture where that's okay or they feel a lot of guilt about getting divorced, and that may be something that they're struggling with is in their life. I can be happy and grieving at the same time. Does that make sense? Well, yes, it does. We can be grieving. We can be very sad about something. After my mother passed, I was very sad and continued for. Well, it's still continuing to grieve the process. But there are also things in my life that I'm very happy about. I love my job. I'm very happy about the people I meet. I'm very happy about my children. So I can be happy and still grieve. It doesn't take away from my grieving. It just means I'm not choosing to allow the grief to consume me. We want to encourage people to accept thoughts, feelings and sensations using distress tolerance. And if you go back to Linehan's distress tolerance mnemonics, acronyms, I've never figured out whether this is a mnemonic or an acronym, but whatever. If you know the difference, let me know. Anyway, accept. Encourage people to engage in activities. Sometimes when we're feeling something and we can't change it and it's distressful, like waiting for results from the doctor and, you know, they take your blood or whatever and they're like, we'll get back to you in a week. What? You know what I want to know, like in 30 minutes, what's going on, not in a week from now. So that week could be a really long week, depending on what those tests were. What can you do during that week in order to tolerate those Internal experiences. So engaging in activities that distract you or make you happy can be one of them. Contribute, you know, volunteer. Do something that makes you feel good inside. Make comparisons between where you're at right now and people who are doing less. Well, you know, I'm really stressed about this. Or make comparisons between where you are right now and how strong you're being compared to times when you haven't been as strong. Do things that trigger the opposite emotion, things that make you happy. What do you do? And I encourage clients. You know, one of the first things we generally do in any of my. With any of my clients is they make a list of things that they can do for each one of these. What are five activities? What are five things you can do to contribute that usually is harder? What are five comparisons? That tends to be a little hard. What are five ways you can engage the opposite emotion? So if it is fear and engage courage. If it is depression, engage happiness or just focus on happiness. You don't have to get quite that specific. But we want to get away from distress, to eustress. Teach them how to push away. You know, what can you do to push away thoughts when they start coming up? You can talk to them. You can sing loudly. What are five? I like the number threes and five. What are some thoughts that you can have that will help you cope with this situation? What are some positive thoughts? And when all else fails, what sensations can help get you out of that emotional mind? Holding ice cubes, Taking a cold or hot shower. Not so cold or hot that it causes damage of any sort. You know, you don't want to hurt yourself. Splashing cold water on your face sometimes that'll jar you out of that emotional mind for a second, and then you can get moved more into that logical mind. Help the person define a rich and meaningful life and make choices based on that versus eliminating a problem. When I am in pain, I want it to go away. But a lot of times the things I choose to make it go away are just temporary. They're escape behaviors. They're not using my energy to get towards anything that makes me happy. So depression, encouraging people to think. What do we do to eliminate depression? You know, we can have people change their thoughts. Well, they're changing them. They're adding positive thoughts. We're not just eliminating negative thoughts. If we do. If all we do is eliminate thoughts and eliminate behaviors and eliminate feelings, what's the person left with when it's not there anymore? We need to help them put something in its place and it's also hard to prove the absence of anything. So I will be less depressed as evidenced by, you know, that would be the absence of something. I am happier as evidenced by addiction. What do we do when we eliminate addiction? What does the person do? And this is one of my battle cries, I guess, in early recovery and relapse prevention is the addiction served a purpose. People need to understand in their reality what, what purpose, what function that addiction filled and identify alternate behaviors. Because if you don't, you are just, you know, half a step away from relapse. That addiction served a purpose. So what can you do instead? We need to add things, not just take away. And encourage people to accept their feelings, thoughts and reactions and change their relationship with them. Instead of when they feel anxious, instead of being afraid of being anxious and feeling like they're going to lose control, developing a different relationship with that anxiety that is more positive, that says, okay, thank you, Bodi, for telling me that there may be a threat out here or that I need to prepare now. How can we work together? You alerted me. Awesome. I've got it from here. Increase awareness. Have people in each of the following areas identify what things are important in their rich and meaningful life, what that looks like now and what they want it to look like. Having them identify which intimate relationships are important, which family relationships, other than their intimate relationships, important in terms of parenting, if they do it, you know, not everybody has all of these. If they're parents, what's important, if anything, about parenting to them, their friends in social life, what parts of that are important? What parts of that are deserving of energy? If they envision a rich and meaningful life, where does that fit in work, education, spirituality, recreation, physical health, their community life, the environment and arts and creativity? People are going to look at some of these and go, yeah, you know, I don't really care one way or another about that, and cross it off. And that's cool. What I want to know is their rich and meaningful life. When they look at it and they go, this would be good. I would be content. I would be maybe even happy. That's what I want them to envision. Because then when they start looking at their behavioral options and their cognitive reactions, they can choose. Is my choice here helping me use my energy to move towards things that are important? Radically Accept feelings, thoughts and urges like road signs. You can take them under advisement and decide what to do. Think of a speed limit sign, like anger. You know, you see that speed limit sign and you can choose whether you're going to Blow right past it or you are going to go the speed limit. Construction zones. Like giving up. No, passing like addiction. And a rest stop would be like depression. These signs are just telling you, or these emotions, or in the case of addiction, your urges just telling you that something is amiss, something is going on. What do you need to do in order to not stay stuck here? How can you improve the next moment? Motivational enhancement. In contextual cognitive behavioral therapy, we want to look at what is functional. We need to understand that motivation for change, as well as not to change is dependent on the person's idea of a rich and meaningful life. We want to mitigate these. We want to reduce their impact, the benefits to staying the same and the function of the behavior. So addiction, the benefit to continuing to use. There are benefits to it. And we need to help people identify what those are and, and figure out how to meet those needs in a different way. If addiction is not leading them down the path they want. Depression. Sometimes people choose to stay depressed because they have or give up on trying to change because they've tried before and it's failed and they feel like it's hopeless and helpless. So the benefit to staying the same is they know what to expect. We need to examine that with them and figure out how can we mitigate these, how can we make this less motivating to stay the same? And we need to look at the drawbacks to change. Sometimes people look at change and they go, oh, that looks really painful or really uncomfortable or I don't want to give up xyz. Okay, well, how can we make it less painful, more comfortable? And maybe, depending on what it is, avoid completely giving up xyz. Like when people try to change their nutrition, they don't necessarily have to give up chocolate and gluten forever unless the doctor says so, but they may want to reduce it and minimize it. The drawback to change, when they thought about it initially, was making this huge change and cutting food groups out of their life left and right. And that looked pretty dull and depressing. But when they start thinking about it from a different perspective, where they can, you know, compromise, okay, well, maybe that's doable. And we want to enhance the benefits to change. Help people see the benefits to addressing their depression and getting happier. The benefits to getting sober. And we want to look at the drawbacks to staying the same, which often are what brought them to our office in the first place. They don't want to be depressed anymore because fill in the blank. They don't want to be Addicted anymore, because we want to help highlight those. And this is your typical motivational interviewing, decisional balance exercise. But we need to help them turn up the volume, so to speak, on the intensity of the motivation. Use a broad functional approach. There are common mechanisms underlying a lot of different diagnoses and presenting issues such as shoulds and shouldn'ts. How many clients have we worked with that say I should feel or I shouldn't feel or I should be or I shouldn't be? You know, the shoulds and shouldn'ts, it contributes to depression, anxiety, low self esteem, and potentially addiction. We need to help them look towards acceptance of what is. You know, I shouldn't feel this way. Well, I do. So I feel this way. I'm radically accepting it. Then I'm going to make a choice to improve the next moment. Lack of awareness of needs and wants contributes to most diagnoses. If we're living on autopilot all the time, we're often not getting our body, our mind and our spirit the attention and resources that it needs. We want to help people be mindful of vulnerabilities, things that make it more difficult to deal with life on life's terms, because that can prevent and even mitigate some of the mental health issues. Autopilot or rigid thinking. We can help them develop psychological flexibility which enables them to have a willingness to accept all aspects of all aspects of their experience without avoidance. You know, they just accept how they feel, what they're thinking, what their urges are and their physiological reactions in the moment. And they may say, all right, this really sucks right now. I hate needles. And you know, radical acceptance of being in the doctor's office when I've got to get my flu shot. You know, I acknowledge what's going on, what I'm thinking, what I'm feeling, and, you know, my heart's generally racing, but I know as soon as I get out of there, once I get the shot, it'll be all over and I'll feel fine. But I need to be willing to accept it. And the ability to ponder multiple possible actions and thoughts and consciously choose. So when I'm getting a shot, when I'm getting that flu shot, I can ponder walking out of the doctor's office. I can ponder getting all tens. I can ponder relaxing my muscles and stopping my thoughts and using some distress tolerance skills. So when I get that shot, it doesn't end up bruising my arm and causing me pain for a week. You know, I can choose, and generally I choose to try to relax and use thought Stopping because I'm getting the shot and I don't want to feel it for a week. That helps me move towards what's important in my life because when my arm hurts, then I don't like lift and when I don't like to lift, I get cranky. So all, you know, plays into what's important in my life. Difficulty with self esteem or self efficacy may also cause or maintain problems. When people don't feel like they are good enough or like they have the power, the ability to affect change, then it can maintain problems. They still feel like they are that person that's stuck back in the problem. The self as content in contextual cognitive behavioral therapy is the narrative about oneself and our attributes. Self as content is my idea of who I am, what strengths I have, and what weaknesses I have. Being overly attached to this conceptualization can prohibit flexibility. If I see myself as weak and powerless and I'm attached to that, then it's going to be really hard to see myself in a position of power and courage. Other examples, being a good worker in a bad job. You know, somebody may see themselves and they may be unhappy and not thriving at their job, and they may see themselves as a bad worker. And in actuality, it's not them. They have a lot of skills and tools, but it's a bad fit for them. It's the job, it's not their ability as an employee. It's just a bad fit. Or being a good daughter. But getting a divorce, you know, with people who are not culturally accepting of divorce, it's hard for people to hold on to some of those things. You know, they may think, if I get a divorce, then I have shamed my family and I'm a bad daughter and this, that and the other. And in the context of that one behavior, maybe that's true. However, can you be a good daughter in other behaviors? Caring for your family and being responsive and all that kind of stuff? That is a choice that person's got to make. I can't say how they are going to rectify that. It's important, though, to recognize being a. In that particular situation, being a good daughter, you know, there's more to it than whether or not you stay married. There's a lot of different things that go into being a good daughter and being obviously culturally responsive. When examining that phenomenological reality with that person addressing self as content, ask people, who do you want to be? And explain to me why each of these characteristics is important. In what ways does the current situation prevent you from Being who you want to be, if at all. You know, they may say, there's really nothing preventing me from doing well, all right, let's figure out how to make it happen then. What areas in your life are going as you want them to? And this is really important because a lot of times people come to our office and they say, you know, life sucks. Nothing. I can't ever get a break. Nothing goes the way I want it to. Encouraging them to address those global attributions that all or none talk and identify things that are going at least reasonably well as they want them to. I have yet to find anybody who couldn't identify at least one or two things that were going, okay. Are there other ways to achieve or conceptualize the same end? You know, things that they want to be? If somebody says, I want to be a size three because they think that will make them attractive and lovable, well, then we may want to look at what it is that actually makes people attractive and lovable. Is being a size three going to make you more lovable or not? Is being a doctor going to. The only way to demonstrate you're successful is being loyal and dependable, regardless of the situation. The only way to demonstrate that you're not a quitter. Sometimes situations, you know, you're in a job or we'll stick with a job and the job is just wearing on. All other aspects or most other aspects of your rich and meaningful life, it is detracting from those, yes, you can be loyal, but at a certain point, you've got to decide to whom you're loyal. Are you loyal to yourself and your family and your friends, or are you more loyal to your job? Loyalty can go a lot of different ways. Encouraging people to step away instead of saying, I am disloyal if I quit, stepping back and going, all right, maybe I am. Maybe I am being disloyal to this organization if I quit this job. But by making that decision, I am being loyal to and help them differentiate that you can be. There are different explanations for loyalty. Self as process also relates to awareness of one's internal experience. Many people have difficulty attending to their internal experiences in a flexible way. Handling urges and feelings and identifying those thoughts, feelings, urges and sensations. Our society, our culture, really encourages people to be mindless in their behaviors. We want to encourage people to start to be mindful and to learn the skills to deal with their thoughts, feelings and urges so they're not afraid of them. They're not afraid of their anger. They're not afraid. It's going to overwhelm them. They're not afraid of their fear or their depression or whatever it is. They can accept it. You know, sometimes after you break up from a relationship, you may be sad, you may be grieving the loss of that relationship, and you may choose, for example, to say, all right, it's okay for me to be depressed today. I am going to take today and I am going to allow myself to feel my feelings. And then tomorrow I am going to start using my energy to improve the next moment. Giving people permission to be compassionate with themselves and feel their feelings. It's okay to feel distress. It's okay to experience that. It rarely, you know, I have never seen it, like, completely destroy somebody when they, when they allowed themselves to feel something. It can feel terrifying sometimes, especially if you're not used to feeling feelings. We want to help people before we open that Pandora's box. We want to make sure that they have the skills and tools to handle urges and feelings. And then encourage them to start becoming aware on a daily basis of how they're feeling, because then they can make minor changes here and there instead of waiting until it's a big deal and, you know, life seems like it's falling apart and there's so much more to fix. Mindfulness journals and logs are really helpful. Not everybody wants to write in a journal. I hate writing in journals. But I will do a log. I will complete a worksheet. That's fine. Whatever helps the person, whatever encourages them to do it. Encourage them to think about doing it when they wake up. Before breakfast, before lunch, before dinner, and before bed. And that's five times. But it doesn't take long to check in. How am I feeling? What are my thoughts? What are my urges? What do I feel like I want right now? Encourage meditation to increase awareness. And there are videos on our YouTube channel that go through dozens of different types of meditation. Not all meditation is going to work for every person. It's important for them to find a form of meditation that is comfortable for them, that allows them to increase awareness of themselves in the world. You can use cognitive behavioral activities that involve exposure and noticing, such as anger. When they have a thought, when they feel angry, they notice it. They can also practice thinking about things that make them angry and de escalating themselves so they get familiar with with the feeling of anger, and they get a sense of mastery over that feeling so they're not afraid of it when it happens. It's important for them to develop relapse prevention plans to handle internal processes it's not just addiction. It's also depression and anxiety and cravings and whatever else. Relapse prevention. Relapse remembers, remember, means going back to an old way of being. So a mental health relapse. For somebody who's got major depressive disorder, maybe having that depression, those depression symptoms come back up. We want to look at how to prevent that for that person. We want to help them figure out these internal processes. It's not just thoughts, it's not just emotions. It's also physiological sensations. When people start feeling run down and exhausted, that can contribute to them feeling getting their circadian rhythms out of whack, which can lead to a cascade of effects that can trigger depression or anxiety or contribute to impulsive behaviors. Have people make a committed action worksheet for each thing that is important to them. So if getting healthy is important to your client, they will make a committed action worksheet for it. They are going to identify all the reasons they want to get healthy, all their anticipated obstacles and ways to deal with those, and strategies for achieving that goal. Health may be two years down the road. What are they going to do this week? What are they going to do this month? What are they going to do over the next three months? We want to encourage people to adopt the perspective of the self. In the past, present, and future. Who you were, who you are right now, and who you want to be, you may have been a very depressed, powerless child. Who are you now? And compared to who you are now, who do you want to be? Encourage them to develop the past, present, and future. We want to encourage people to have the ability to take the perspective of others. What would your best friend say about you? How would she describe you or he describe you? How would he envision this situation? What would his perspective of this situation be? I know things come up at work a lot. My husband and I work together and I'll get, you know, flustered about it. And he just kind of looks at me. He's like, really? It's not that big of a deal. And from his perspective, it's not rigid. Selfish context or inability to take other people's perspectives may prevent effective problem solving. If we want to hold on to this idea that I am and always will be a failure, then it's going to be more difficult. We need to examine the reasons the person is so afraid or so unwilling to let go of that conceptualization. Encourage people to look at their definition of a rich and meaningful life and think about what does your past self tell you about your current situation? What might your future self tell you about your current situation? Your past self may say, this is dangerous. Get out of there. You're never going to succeed. Your future self may have a very different edict for you to follow. What might you tell someone else in a similar situation? And how do your current thoughts, feelings, and behaviors help you move toward what's important to you? Contextual CBT involves understanding people's phenomenological truth, their personal perception of reality. Problems can arise when people think or feel that they are not who they should be or things are not as they should be. Hate that word should Are unaware of their internal feelings, thoughts, and urges. So they're operating on autopilot. Are unaware of the motivation in that particular context for their feelings, thoughts, and urges. You know, why am I feeling this way right now? And use rigid problem solving and conceptualization without considering context or perspective. Contextual CBT uses awareness, mindfulness, radical acceptance, and psychological flexibility activities to help people move toward a rich and meaningful life instead of trying to escape.