Knowing What Does and Doesn't Work in CBT: Lessons for Counselors

Hey there everybody, and welcome to this video on a guide to Cognitive Behavioral Therapy for counselors. What works, what doesn't, and why. I'm your host, Dr. Donnelly Snipes. Now, I know in the beginning I said this is for counselors, but this is really for anybody who's interested in cbt. People tend to either love CBT or hate it. And I'm hoping, believe it or not, that I get a lot more of the haters giving this video a chance to see why CBT may not be working for them and what they can do to address it. So we're going to start out by talking about what cognitive behavioral therapy is. The effects of CBT done correctly. Then we'll move on to what doesn't work, what does work, and the ABCDEs of CBT. So cognitive behavioral therapy, the underlying principle at your ego is that your thoughts, feelings and behaviors all interact. When you do something that is good for you, it affects the way you think about yourself and the way you think about that activity. And it generally affects your feelings when you do something that is problematic or harmful. And then you may feel guilty about it and you may have anger, angry thoughts towards yourself. So it's important to help people recognize the connection. Whether they're presenting for a behavioral issue or an emotion based issue, it's important to help them recognize how all three of these things interact. The Role of Cognitive Schema Processing and Behaviors now, cognitions are our thoughts in the moment, how we're thinking. Schema are shortcuts that our brain develops based on prior experiences, and it's educated by thoughts that help us predict what may happen in the future. Unfortunately, schema may not always be accurate. A lot of times people form schema that were accurate at one time in one context, but in this context at this time, they may not be accurate. So it's important to explore those things. As people start becoming more aware of what schema are and the need to periodically check them out based on the context, then we may start seeing changes in brain structure and functioning. As people start to feel safer and more empowered and start understanding where their emotional reaction may be coming from, they start to feel more empowered. The benefit is then our amygdala is able to kind of wind down a little bit and people are able to more easily de escalate and get into their wise mind so they can process what's going on. If the brain is in fight or flight, then the person is not able to effectively cognitively process what's going on. When people are regularly stressed out when they are regularly feeling unsafe and disempowered. It impacts the nervous system, the vagus nerve, which is the nerve that we tend to think of as our relaxation nerve. It becomes a lot less effective in its ability to help people down regulate. We call it poor vagal tone or a weak vagal response. And that's partly because the strength of the stress response has just become so overpowering that the vagus nerve just doesn't have a freaking chance. The vagus nerve is impacted not only by the person's thoughts and the situation, but also by changes that happen within the body. When people are stressed, distressed, they have a surge of stress hormones, cortisol, adrenaline, norepinephrine that prepare them to fight or flee. When their brain is bathed in these chemicals persistently or frequently and in really high doses, it causes changes in the nervous system. It actually causes shrinkage in certain areas of the brain and growth in other fear processing areas of the brain. So it's important to recognize that stress does cause brain changes. But, but cognitive behavioral therapy can be a tool to help people basically rewire their brain and heal those brain changes. Another issue that comes up is circadian rhythms. When people are frequently distressed, that means they are frequently in that fight or flight state, which often means that they are not getting adequate quality sleep, which is going to impact their energy levels. It may impact their circadian rhythms when the circadian rhythms start to get out of whack. And for most people, this happens because they are not getting that good quality sleep. But when circadian rhythms get out of whack, it throws everything else out of whack. Your cortisol levels, your gonadal hormones. And you know, I could go on, and I have in other videos, but suffice it to say that people who are distressed, people who are feeling unsafe and disempowered because they believe they're having thoughts that they're unsafe and disempowered, are going to have a hard time getting good sleep and having the energy to engage in behaviors that can minimize some of those vulnerabilities. So let's talk about what doesn't work. Because I have a lot of people that come up to me and they say, doc snipes, I hear you talk about cbt, but that just doesn't work. Or I would never engage in CBT because it is too harsh and impersonal. Well, that's cbt. That's done incorrectly. So what doesn't work? Jumping into cognitive processing before establishing rapport, safety and empowerment, getting Ready to ask a person to make themselves vulnerable by processing information, by talking about things, by being willing to hear what you have to say. So you need to help them believe, have the thoughts that they are safe in that current environment in order to promote feelings of calm so they can get into their wise mind and engage in those behaviors. Cognitive behavioral therapy, just like any other type of therapy, has to start with rapport development. That's not a step you can skip. Okay. It's also important that you continue throughout the process checking in with your clients and making sure that they feel safe and empowered, making sure that they feel heard. Heard. That is one of the most common things I hear when I'm talking to people who've tried CBT and it hasn't seemed to work. They're like, my therapist just didn't hear me. They just kept barking orders at me or telling me that I was incorrect. Oh my gosh. Okay. Aggressive confrontation of beliefs and behaviors. That doesn't work. Most people, not all, but most people's mood disorders or mental health issues develop as a result of feeling unsafe and disempowered. It results from trauma of some sort, and that can be grief, that can be victimization. It can be a variety of different things. But if the therapist is aggressively confronting beliefs and behaviors, that's a boundary violation, and that just creates an environment where the person feels unsafe and powerless. So we're not going to aggressively confront behaviors. We're going to explore with curiosity. Failing to address all three points of the triangle is another thing that doesn't work. You can't just go in and say, hey, we're not going to talk about those pesky old feelings or behaviors and vulnerabilities. Nah, we're not going to do that. We're or only going to address how you're thinking. Well, that's like having a stool with only one leg and, you know, not being bolted down. You can't address one without recognizing the impact on the other three because it has an impact. If you are feeling anxious, then your brain is automatically going to start scanning for threats, and your feelings are going to impact the way you perceive the environment and the way you react to the environment. If you are feeling safe and content, it impacts what your brain pays. Attend attention to how you perceive it and how you react. We know that these three things are inextricably interconnected. Telling instead of exploring, telling somebody how they should feel. Oh my gosh, there's that should word. Telling somebody what's actually going on, telling them that they're safe. That doesn't work. Because if they don't feel safe, if they don't believe that they're safe, no matter how many times you tell them they're safe, especially if they don't trust you, it's not going to work. So we want to explore are you safe? What helps you feel safe? We want to explore what has worked for you. Instead of just hearing somebody come in and say, hey doc, I've got anxiety and throwing a bunch of worksheets and handouts at them and deciding what's going to work for them. Person comes in says, hey doc, I've got anxiety. We sit down and we say, okay, well, tell me a little bit more about that. What seems to make it worse? What seems to make it better? What have you tried that's worked? What have you tried that hasn't? Because we don't want to keep doing something that hasn't worked in the past, expecting it to suddenly start working. Mechanistic plug and chug application is another one. And it kind of goes along with telling instead of exploring thinking that and this is just one example. The ABCs work for everybody where somebody identifies their when they start having a feeling, they identify the activating event, what happened, the consequences they're feeling, and then they start exploring all their automatic beliefs about the event. Now that can be really, really helpful for some people, but that doesn't work for everybody. So it's important to examine. It's also important to remember that you don't have to start with cognitions. Sometimes we need to start with feelings and helping people develop distress tolerance skills so they can get into their wise mind and explore those cognitions. Sometimes we need to address behaviors like substance use or not sleeping or other things that create vulnerabilities and help them develop behaviors that can help them feel safe and empowered, that can help them start resting and recharging so then they can start addressing thoughts and feelings. You don't want to start with confronting cognitions. And I know I've said that a bunch of times, but that is the biggest mistake that a lot of therapists make when they try to use cognitive behavioral therapy. Instead of developing rapport, instead of considering whether we need to address the behaviors, the feelings or the thoughts first, they just jump right in there to those irrational thoughts or cognitive distortions. Another thing that doesn't work is trying to force people to adopt a new set of beliefs or schema. And self esteem is one of these areas. That's a perfect example because a lot of times in cognitive Behavioral therapy. One of the things that people are told to do is to regularly engage in positive affirmations. Well, if they don't believe that they're worthy, if they don't believe that they're lovable, then sitting there telling themselves, I'm worthy and lovable, that ain't going to go nowhere. If they don't believe it, it's not going to help. So we need to identify the schema that may be causing the problematic feelings that may be causing the problematic behaviors, and then explore those schema and identify ways to restructure it that will help the person, not just give them canned responses looking in the mirror and saying, I'm good enough, I'm smart enough, and gosh darn it, people like me. Well, if they don't believe that, that's just going to be a waste of their time. So let's move on to what does work, because I am a firm believer in CBT. I have work, used CBT for 20 some odd years, and I think it is a wonderful tool to have in your toolbox. So what does work? We want to educate people about the connection between their feelings, thoughts and behaviors. If somebody comes into my office and says, you know, I was feeling really anxious this week, all right, I'm going to validate how you were feeling. Now tell me what thoughts were contributing to that anxiety and what behaviors did you engage in that may have either made it worse or contributed to it? For example, drinking too much caffeine, not getting enough sleep, being in environments that were highly anxiety provoking for you, what were you doing that may have contributed to it? Now they may not be able to avoid some of those environments that are really stressful for them. Okay, so then we'll talk about what behaviors, what tools they may be able to use to feel safer and believe that they're safer. So we want to always bring it back to the TFB triangle and make sure people are understanding that there are multiple ways to address it if you're feeling anxious. Well, we can address the cognitions, sure. We also may be able to address behaviors instead. What can you do that will help you feel safer? Like bring a friend with you. We want to help people see behaviors and thoughts and feelings as communication. When somebody feels anxious, that's telling me that they're saying, I don't feel safe right now. If somebody is engaging in addictive behavior, for example, that is telling me that they are feeling a need to escape. Or maybe they started out feeling a need to escape, and now when they start to Withdraw. The pain is overwhelming. So then they need to escape that pain. That's oversimplifying it. Don't just assume that any behavior has one meaning. But we want to get curious. Why is little Johnny throwing a temper tantrum after school? I know my son used to come home from school and you know, he's always been kind of a high strung child, a high energy child. And that's great. When he's on, he's wide open and then when he's sleeping, he's sacked out. And I noticed that when we would come home from school, a lot of times he would just kind of be bouncing off the walls and doing things that I found to be annoying, making a lot of noise, those sorts of things. But he wasn't trying to be bad. He had held it together so long all day at school. He needed an outlet for all that stuff that he had kept bottled up while he was behaving in school. What did I do? I changed our behaviors. And after school we would go to the park for 30 minutes so he would have a chance to get out some of that energy. His behavior was not saying I want to be disrespectful or whatever one might interpret it as. His behavior was saying, I don't know what to do with all this energy. So in that particular case, addressing the behavior with an alternate behavior was helpful. We want to validate people's thoughts, feelings and behaviors in the moment. If somebody grew up in a dysfunctional household and they developed the belief that they were unsafe and they were unloved, or that their, their parent hated them, whatever beliefs they developed, okay, those were your beliefs. Let's look at it through the perspective through the eyes of a six year old. I can certainly see how you develop those beliefs. I can certainly see how you felt unsafe as a result of those beliefs. I can certainly understand your behaviors whether they were withdrawing or acting out as a way of trying to communicate to others that you felt unsafe, or as a way of trying to help you stay safe. Thoughts, feelings, behaviors. For a six year old, that was totally understandable. Looking back at it as a 26 year old, you may think that those reactions were inaccurate. And maybe they were. When you're looking at it from with adult knowledge, but that child with the knowledge, skills and resources they had at that time, that child's reaction was spot on. Now you may be able to change your perception. If your caregiver abandoned the family because they had addiction issues or mental health issues, for example, the child may believe that the parent left because they didn't love me. Okay. We want to validate that for that child and how that must have felt looking back as a 26 year old. We can help the person explore what are the facts for and against the belief. Now, with more information and more knowledge and more tools, what are your facts for and against the belief that your parent didn't love you versus they left for some other reason? So we can explore it. And whatever the person comes up with is what they believe. It is not for me to tell them, well, I'm sure your parent loved you and it was the addiction just made them incapable of staying around. That's my belief, but that may not be my client's belief and their belief is their belief. And then we can look at how does holding on to this belief continue to impact you in the present and in what ways is the schema that you formed about others being untrustworthy or about yourself being unlovable? How accurate is that in the present? In the current context, we want to help people develop emotional intelligence. And this is another thing. Remember I said a lot of times when people. Counselors try to do cognitive behavioral therapy, well, feelings aren't anywhere in the title, so why should we address them? Oh, because they're part of the triad. Triad. If you've studied cognitive behavioral therapy, you know they're important. Feelings are automatic reactions that we have based on our schema. It's our body's, you know, shortcut to help us stay safe, to help us anticipate what might be happening. So when people have anxiety or anger, that's a threat reaction. Flee or fight. Okay, that's fine. They what does anxiety look like for you? What does it feel like for you? What triggers it for you? What are your behaviors in response to anxiety? For example, this past week we've been dealing with some pretty serious health issues. In one of my cats, and I love my cats dearly. I noticed that I was engaging in a lot of emotional eating. I wasn't really being mindful of how I was feeling. I knew I was feeling anxious, but I was just kind of ignoring that. Then I noticed that one of my behaviors was emotional eating. And I took a step back and I said, this is not how I want to deal with this situation. This is not a helpful response for me. So it's important to help people recognize the purpose of the feeling, the symptoms, the what that feeling looks like for them, and not be afraid of the feeling, not feel overpowered by the feeling, but understand the feeling as a form of communication. And it is your automatic response based on prior learning experiences, based on thoughts and schema you formed in the past. When the smoke alarm goes off, it doesn't mean there is a fire. It means that it's been programmed to notice things that generally occur when there's a fire and let you know, hey, the conditions might be right for this, but the smoke alarm's not saying there's definitely a fire. We want to explore and alter behaviors that create vulnerabilities. And I know I've brought up sleep several times already, but sleep and nutrition are two of the foundations, physical foundations that can greatly increase or decrease anxiety in people. Nutrition, if the. Well, we. Not, it's not. If the body makes our neurotransmitters based on and other things based on what we eat, the food we're giving it, those are the raw materials. If the body has crappy raw materials, then the output is probably not going to be great. So good nutrition is really important. Likewise, if you're ingesting a lot of caffeine, that's going to have effects on you. So nutrition definitely plays a part in helping people feel their best. When the body is nutrient deprived, it recognizes that and it triggers the stress response. So if somebody's dealing with anxiety and they've got nutrient deficiencies, then the body's saying, well, I'm already stressed out and oh my gosh, I don't have the building blocks to make what I need. What am I going to do? So anxiety increases as that stress response is intensified. Sleep. Sleep deprivation again is registered by the brain as a stressor to the body. So it kicks off the body stress response and releases extra cortisol, extra adrenaline. The body says, hey, you don't want to be sleepy when that hungry lion comes along. You want to be alert. So I'm going to give you some more energy to try to help wake you up. We know that sleep deprivation or poor quality sleep, even if you're in bed for a long time, is associated with increased ruminations, increased intrusive thoughts, increased anxiety. So those are two behaviors that can create vulnerabilities. I have several other videos that talk about all the different types of vulnerabilities because you have vulnerabilities in every aspect of your life, including your environment and your relationships. But it's important to explore these things. And that's part of the behavioral interventions for people with presenting issues. And we'll talk about different presenting issues in a few minutes. We want to help people explore their schema and their expectations to Understand their emotional and behavioral reactions. Schema were formed based on that experience, based on that person's understanding of that situation at that time. Children don't have the wealth of knowledge to understand a lot of stuff. Children think very concretely. They can't think, well, you know, maybe, maybe mom's mad today because she's just not feeling well. They think mom's mad today because I must have done something to tick her off. So it's important that we understand when those schema were formed, how they might have been the best that you could have come up with in that context based on your age and environment and everything else, and explore them in the present. How is this situation similar to and different from that one? And how are you similar and different to that prior situation? A six year old, they can't take care of themselves. So if their caregiver is not dependable, yeah, that's really freaking threatening. A 26 year old can take care of themselves if their caregiver is not being responsive. Yeah, it hurts. And there's a lot of cognitions that go along with that. However, they are not in a position where they may be in a life threatening situation. So we want to explore people's schema and help them explore them themselves. To identify in the present context, with me as I am, the skills and tools I have right now, Are my beliefs and feelings accurate and helpful or not? And if they are, if I determine as the client, if I determine my beliefs are inaccurate, what is more accurate? If I as the client determine that my beliefs are still accurate. Okay, so your feelings in response to those beliefs may be very accurate. This increased anxiety. All right, behaviors, let's look at addressing those. What is the best response for those behaviors? If you truly believe that you are in a threatening situation, what is a helpful response for addressing that anxiety and maybe reducing or preventing it in the future? We want to help people develop tools to tolerate distress. Address inaccurate or unhelpful beliefs in the current context while validating the beliefs as they were formed. You know, this is how you felt back then. Your feelings, your thoughts are your feelings and your thoughts and they aren't right or wrong, they just are in that context. And now you can look back with more information with fresh eyes. We always say hindsight is 2020 for a reason. We want to help people develop tools to maintain motivation and prevent or mitigate vulnerabilities. We want to enhance motivation for behaviors and cognitive restructuring between sessions. Now, a lot of times therapists will refer to this as homework. Unfortunately for A lot of us homework has a really negative connotation, so I encourage you to find a different word for it between session activities or real life practice. Whatever you want to say. But in order to strengthen the connection to new beliefs or new behaviors, we need to repeat them and repeat them on a daily basis. Doesn't mean you have to be perfect. The person's probably not going to be perfect, but we want to see improvement, we want to see strengthening. So the new thoughts, the new behaviors become more prominent, become more readily available to the person when they're in a fight or flight state. So a lot of people also talk about how CBT can only be used with a few things. Well, that's not true. Now, CBT is not going to fix or cure adhd, for example, or schizophrenia, but it can be used to help address some of the issues that people with ADHD or schizophrenia, for example, may present with. And this is, these are just a few little examples that I pulled out to help you see how CBT can be part of a treatment program with people with adhd. CBT can be used to develop behaviors, to mediate attention deficits. So people can start creating lists, they can create a routine, they can have push notifications. What's important is to identify where they're having difficulties in life and help them identify behaviors that they can use to overcome those challenges that may be ever present for them. Many people with ADHD have experienced a lot of rejection, a lot of criticism over their life, prior to their diagnosis and even after their diagnosis. So they may have a lot of negative self referential beliefs, low self esteem, and a lot of schema that are related to rejection and criticism. So there's a lot of anxiety in a lot of people and sometimes depression in, in people with ADHD because they have not been neurotypical. Because they have not flourished in the typical environment, they've received a lot of criticism. So we want to again start addressing some of those schema and help them understand. Yeah, I can totally see how it would be difficult for you to do this based on your wiring. And there are tools that can help you function more effectively in a neurotypical environment. And here are some communication skills and some things that might help to educate your employers, your significant others, etc. To create a more welcoming and supportive environment. So those are some behaviors that we can engage in and, and then we're going to continue to explore those schema. We want to help them start developing schema of someone who is safe, some who, someone who is lovable. Someone who is capable, someone who is empowered. Now, that may not help. That may not happen overnight. Actually, it won't happen overnight. And we don't want to jump from someone who feels completely incapable to, to saying, all right, well, you know, let's develop schema about yourself as being totally capable. No small steps. Help them, for example, if they have difficulty with organization, help them start feeling more capable in their ability to organize themselves and explore that on, at your appointments and have them explore that on a daily basis, maybe with their, with their charting, so they can start to see, hey, I am capable of organizing myself. All right, well, what else do they feel incapable at? And you can start addressing those things one at a time. You're not going to change a global schema instantly. You know, we've got to look at what goes into that. Mood disorders. We're going to help people develop behaviors to address vulnerabilities for anxiety and depression. What is it that makes you more vulnerable? Is it the holidays? Is it short days? Is it lack of sunlight? Is it not exercising? What behaviors may contribute to you having a mood episode and what can you do to address some of those issues? They may not be ready or willing to address all of them. Maybe they're not willing to change their diet. Okie dokie. We may want to periodically check in and see if they're making the, the connection between their caffeine intake and their anxiety, for example. But don't keep hammering that if that's not something that they're willing to look at. All right, let's look at some other things. Because none of us is perfect, let's face it, none of us is perfect. So we want to empower them to address the behaviors that they are motivated to address that they see as useful and worth the energy. We want to help them develop distress tolerance. Let's face it, distress sucks. And people who have major depressive disorder, postpartum depression, anxiety, anger issues, when they experience distress, it can feel very overwhelming. So we want to help them develop distress tolerance skills. If they are feeling overwhelmed, if they are feeling overpowered, there's no way they're going to effectively get into their wise mind to be able to explore their beliefs and the validity of their beliefs in the moment. So distress tolerance skills are important, and distress tolerance skills differ for every individual. We don't want to just say, you're going to do this. Breathing, for example, we know that square breathing, where you breathe in for four, hold for four, exhale for four, hold for four. We know that can trigger the Vagus nerve. We know that that can help with distress tolerance. We also know that for people who've experienced trauma, it may actually trigger dissociation. So that may not be the best recommendation we want to explore with people. Be curious when you get upset, when you dysregulate, whatever word they're using, what helps you calm down, what helps you down regulate and what doesn't. Most people can tell you right off the bat what doesn't help them. And sometimes they have some tools that do sometimes help. Okay, let's build on those. Let's look at those for distress tolerance skills. And then again, we want to. Once they're able to feel less overwhelmed and overpowered by their emotions, once they've started addressing some of the behaviors that may be creating the vulnerabilities, then they may have the energy and the desire to explore some of the beliefs that are triggering those emotions, that are impairing their sleep and keeping them revved up and exhausted all the time in addiction. There's a lot of physical healing that needs to happen in addiction. And we can help people develop an awareness of themselves in the moment, start developing mindfulness, their thoughts, wants and needs, and their feelings. A lot of times people who have been engaging in addictive behaviors haven't felt much for a long time. One of the things they say in early recovery. So one of the greatest things about recovery is feeling feelings again. And one of the worst things about recovery is feeling feelings again. Because it's so new and so overwhelming and it brings up so many feelings, thoughts and memories and schema and stuff. Okay. Just becoming aware of those is the first step. Identifying behaviors to reduce those vulnerabilities. For example, not taking the same way to work that you used to take where that triggers cravings in you. Cognitive exploration and restructuring. Most people don't develop addictions through simple recreational use. They may have been using recreationally and then something happened and it triggered an intensification of use, which triggered tolerance and all the other stuff in their addiction. They also developed thoughts about themselves and others that may or may not be accurate. So we need to explore those because ultimately we need to help people develop thoughts about themselves and the world that help them feel safe and empowered, that can help them promote or reduce feelings of anxiety and anger and depression and can help them be motivated to engage in recovery oriented behaviors. And then there's those distress tolerance skills again. Since emotions are often what triggers people to start using heavily, whatever that use looks like, it's going to be important to help them develop Skills to tolerate distress without having to or behaviors, if you will, to tolerate distress without having to engage or feel like they have to engage in the add behaviors. Personality disorders. Now, a lot of people say you can't use CBT with personality disorders. Well, Linan was one of the first people to say, excuse me. Yes you can. Thank you very much. Many personality disorders, not going to say all, but many personality disorders develop as a result of adverse childhood experiences, early, early trauma and attachment trauma. So personality disorders are behaviors, you think of your triangle. Behaviors that developed as a result of the child feeling unsafe, the child feeling terrified, and the thoughts that they had in order to try to understand the situation in their concrete thinking mind. Children think differently than adults. So we need to understand personality disorders by exploring the thoughts underlying the behaviors. When somebody emotional emotionally dysregulates, we know part of that is neurochemical and it happens because of changes in the nervous system as a result of persistent stress. But when they dysregulate, when they're triggered and they go from 0 to 250, what thoughts did they have that said, you're unsafe, you need to get the heck out of here or you need to jump to and defend yourself? Splitting is another behavior we see in personality disorders where somebody is all good or all bad, they're safe or they're unsafe. What are the thoughts underlying that behavior? What are the thoughts or the schema? What experiences have you had that have taught you that people are either totally safe or totally unsafe? Manipulation. It's another behavior, very common. What are the thoughts underlying this behavior? Well, the thought is if to get my needs met, I need to manipulate this other person. They're not going to voluntarily meet my needs. Distrust of others. Again, where did this belief. Where did these behaviors that exemplify distrust of others, like avoidance and withdrawal, where did this come from? What experiences did you have and what beliefs do you have as a result of those experiences that contribute to your anxiety about trusting others? The need to be the center of attention or get praise all the time. The need to be controlling other people a lot of the time. How did you develop that in codependency? The need to be in control all the time is a behavior that develops because as a child or in a dysfunctional relationship, the person learned that if they weren't trying to control everything all the time, other people weren't going to step up and things would go to hell in a handbasket. Engaging in unlawful or socially unacceptable behaviors. Now, this can be something that somebody learned because their caregivers or their peers engaged in unlawful or socially unacceptable behaviors, and they believe that this is the way it's supposed to be. Or they may have kind of turned off that empathy volume because nobody was ever there for them. And they learned that the only way to survive was to figure out how to get their needs met on their own. And that's kind of spiraled out of control, if you will. Now, one thing that's important to recognize Is that for a lot of people, personality disordered behavior is what we call egocentonic. They don't see that they have a problem. It seems like the rest of the world has the problem. And if they are in this situation, then cognitive behavioral therapy is going to be much harder, if not impossible. But we can address some of the problematic behaviors. For example, stealing, if that is one of the behaviors, we can say, okay, let's look at this behavior and see what makes you think it's okay, and see how it fits in your vision of a rich and meaningful life. How does this help you be the person that you want to be? How do you believe this behavior helps you be the person you want to be? And we want to help people identify and address problematic thoughts or behaviors Instead of going in and tell. Telling them how they should think, how they should act, how they should feel, okay, that's aggressive. That's invading their boundaries. Instead of doing that, we want to say, all right, what issues are causing you a problem right now? What do you see as a problem? And let's talk about how I might be able to help. And then schizophrenia. Now, a lot of people are kind of scratching their head. Schizophrenia cannot be cured with cbt, don't get me wrong. And psychotic episodes cannot necessarily be prevented with cbt. However, we do know that stress tends to increase the breakthrough symptoms of people who are on medication. We also know that dehydration and in particular, is also a behavior that can trigger psychotic episodes. So in terms of preventing or minimizing the symptom, breakthroughs, or the relapses that the person has, There are a lot of behaviors that we can look at. If somebody is in an active psychotic episode, telling them that they're wrong, that their belief about people spying on them or whatever their belief is telling them that that's. That's wrong, that doesn't fit with their reality. You have to recognize when somebody's in a psychotic episode, Their reality is their reality, and it's like they're on a completely different plane in space and time than you are. So you need to join them in their reality and then explore the thoughts, feelings, and behaviors. What is it that you can do now to help you feel safe? There was one person that I worked with many, many years ago that believed that the word the was very offensive and very aggressive. And that particular word meant somebody was damning that person to hell. And that was terrifying for that person. Now think about how often you use the article the in your speech. Oh, my gosh. Therefore, it was extremely threatening to him when he was in a psychotic episode to hear anything on the radio, to see anything on tv, because inevitably somebody would use the word. The word the. We had to talk about ways that he could protect himself from that, like not watching TV when he was feeling like those things were happening. If he noticed that people were being aggressive towards him, that he could turn off the tv, turn off the radio, that would keep them from being able to curse him. And yes, it's not an ideal situation, but if he doesn't feel safe, then he's not going to get out of that threat spiral. So it was important to help him to start feeling safe and to recognize that when he started feeling that way, another thing that was helpful was to talk to his psychiatrist or his case manager and they were going to help him stay safe. You know, it. It worked for in that particular case. So joining them in their reality and helping them figure out what thoughts, feelings, and behaviors are accurate, inaccurate, and helpful and unhelpful and what can we do instead? And trauma. Trauma focused. CBT is a process that was developed to use with children who have experienced trauma. But there are a lot of trauma informed cognitive behavioral tools that can be used. For example, educating the person to normalize their thoughts, feelings, and behaviors as they relate to the trauma. Yeah, I can see why you're scared staying home alone at night now because the break in happened when you were home alone at night, makes sense to me that that would feel threatening. Okay. And in this context, at this time, are your thoughts accurate that you are unsafe? If so, if you still believe that you're unsafe when you're home alone at night, okay. What behaviors can you do in order to believe that you're safe so you can reduce your anxiety distress tolerance skills after a trauma? Trauma makes people feel unsafe and powerless, therefore they tend to experience more distress. Helping them feel like they can be safe from being overwhelmed by those feelings can also go a long way. Exploring and addressing thoughts and schema related to the trauma. So we're going to normalize their feelings and thoughts and behaviors. Okay. That Makes sense. And we're going to help them explore and address their thoughts and schemas in the current context as they relate to the trauma. This reminds you of that time. As. As I said earlier, how is this context, this situation, similar to and different from, and how are you similar to and different from from the person you were then? And explore and address behaviors related to the feelings, thoughts, and schema. So splitting, for example, that is a behavior that people do in order to feel safe. You're all good or you're all bad. Dissociating, that is a behavior that people engage in in order to feel safe. I'm going to check out of my body. And dysregulation is another behavior. It's kind of the emotional version of splitting, going from flat to furious in order to. To help them feel safe in order to communicate something. So we want to explore these things and then identify alternate behaviors or thoughts or feelings in order to cope when these things start happening or to prevent them. One client I worked with would frequently dissociate when she was cooking because a lot of her abuse memories actually took place in the kitchen. And she would make noise and her mother would beat her with a spoon. So you know that that's not okay. And now as an adult, when she would go into the kitchen, she would start having flashbacks to those sorts of things. So her survival response was to start dissociating. You can understand how dissociating while you're cooking, probably not a good thing. We started working on mindfulness and grounding exercises when she was cooking. She would narrate what she was doing. I'm going to get the eggs out. I am going to start heating the stuff in the pan. And that was a tool that helped her stay grounded and helped her stay present. Sometimes she would call a friend if she was feeling particularly out of sorts or particularly vulnerable, and she would talk to her friend while she was doing the cooking. And that helped a lot. It didn't do everything, but it certainly helped a lot. So we want to explore the behaviors with curiosity, recognize that they have a purpose. They're trying to help the person stay safe in one way or another and help them identify behaviors and thoughts that can help them feel safer in henceforth and forevermore. So I said we'd sum it up with the ABCDEs of CBT. A stands for awareness of the thoughts, feelings, and behaviors and what they are communicating for the person. I'm not going to tell them what it's communicating. I am going to ask them, what do you think that means now? If they want to banter about it, sure. But I am not going to tell them what what they should be thinking or feeling. B stands for behaviors to reduce vulnerabilities and increase a sense of safety and empowerment. C stands for cognitive or cognition and schema exploration and restructuring. We want to look at the schema when they were formed, understand them and consider yes, they were accurate based on that child's experiences as a 6 year old. However, as a 26 year old, can I understand that situation from a different point of view? That child needs to be comforted. But as a 26 year old, do I still agree with the way or believe the same beliefs that that child had and then explore cognitions and schema in the current context. What are the facts for for and against your beliefs in the current context at the current time? Distress tolerance skills is D E stands for explore, don't direct. We don't want to tell people what to think or how to feel. We want to explore what's worked for you, what hasn't, what helps, what doesn't. What do you think this means and what do you think it's communicating? We don't want to tell them those things. And S stands for safety and empowerment or developing rapport. Obviously these are not in the order that you do them, but these are some of the key features of cognitive behavioral therapy and most of them are features that often get overlooked. People trying to do CBT just jump right into the sea and and forget all the rest of it. Cognitive behavioral therapy is often done incorrectly. Rapport, that is Developing safety and empowerment is a crucial first and ongoing step to help the person believe that they are safe and be willing to engage in the behaviors that may make them feel vulnerable. Like exploring some of those past traumas. Just because.