Cognitive Behavioral Therapy, A Brief Primer Part 1: Automatic Thoughts, Assumptions and Personal Schemas

Cognitive Behavioral Therapy (CBT) is one of the most popular forms of therapy used in the Western world. The premise behind CBT is that stressful states such as depression, anxiety and anger are often maintain or exacerbated by exaggerated or biased ways of thinking. The role of the therapist is to help the patient recognize his or her idiosyncratic style of thinking and modify it through the application of evidence and logic.

One of the key components of CBT is getting the person to start recognizing their automatic thoughts which usually serve to maintain their undesired state.

Automatic thoughts come spontaneously, so much so that we often give no thought to them, and they appear to be true even when distorted, which often lead to problematic behaviors and disturbing emotions.

Some forms of automatic thoughts include fortune tellingdichotomous (all or nothing thinking), catastrophizing, personalizing, mind-reading and labeling.

Automatic thoughts could be true or false. For example, someone may have the mind-reading thought that “My boss doesn’t like me” and that could be true. However, the problem is that without sufficient evidence, we usually believe our automatic thoughts to be totally accurate, even when they aren’t. Combine this with the other underlying assumptions and rules that we all have, which tend to be rigid, over-inclusive, almost impossible to attain and ascribe vulnerability into the future, and we have a recipe for repeated disappointment, anger, depression, anxiety and a host of other unhealthy feelings and thoughts (Leah, 2003).

For example, if the person who has the automatic thought “My boss doesn’t like me”, also has the underlying rule that “Everyone must like me or I am a bad person”, will be deeply upset over the thought that his/her boss doesn’t like them. The same is true with rejection which partially explains why some people do not take rejection as well as others. One person can ask someone out on a date and if that person politely says “no”, that person goes on with their day, giving little thought to the rejection. But if another person has the rule and automatic thought “If she rejects me, that means I am undesirable to all women and will spend the rest of my life alone”, they will handle the rejection totally differently.

Underlying assumptions are deeply linked to personal schemas. Personal schemas are basically the core beliefs of what we belief about ourselves. We all have personal schemas, some positive and some negative, which influence the way we interpret information filtered through our automatic thoughts.

Back to our example. If someone has the personal schemas, “I am undesirable”, “I am worthless”, “I am unattractive”, they will have selective attention and memory as they look to validate their core beliefs about themselves and thus their automatic thoughts will also work to validate their core beliefs. So if the person already has the personal schema “I am undesirable”, and the automatic thought “this person will probably reject me” (mind reading), if they get rejected it will validate their personal schema and thus send them into a tail spin of self-pity, depression and anxiety, building on the strength of their erroneous thinking, assumptions, and schema.

(The ego always wants to be in balance with you and wants to make you happy. “The ego’s mission is to take the beliefs of the self and turn them into the experiences of the self.” – Falco, 2010)

This person, like many people with depression or anxiety, will filter out any information that contradicts their negative personal schemas and assumptions. For example, they may not notice the cute guy that flirts with them, but will fall to pieces at the person who makes a disapproving comment about her hair or her dress.

The goal of a CBT therapist would be to get the person to start recognizing all of these erroneous patterns of thinking, unravel them and replace them with more accurate forms of thinking.

We will discuss in a later post how thoughts create feelings.

Gabrielle “Gabby” Douglas and A.N.T.S.

Recently I watched as Gabrielle “Gabby” Douglas won two gold metals in the Olympics and made history by becoming not only the first African-American woman, but also the first woman of color to win the individual-all around in gymnastics. Remarkable feats for anyone, let alone a 16 year old. Being an African-American I was so proud of her, so you can imagine my shock when I was told that much of the talk about Gabby within the African-American community online wasn’t about her gold metals or her history making accomplishment, but about her hair. Her hair? Are you kidding me?

I took some time reading different blogs and websites and was shocked to see that a lot of people were more concerned about the texture, style and condition of her hair than about what this 4’11” exceptional athlete was doing in London. The more I read, the more I found myself enraged at the ignorance of those who expressed that Gabby was representing all African-American women “and her hair should look good” while she was doing it. This is so ridiculous. She is representing African-American women, showing that if you are dedicated, focused, work hard, refuse to take no for an answer and never give up on yourself, you can accomplish all of your dreams. Instead, many people are worried about the superficial and that got me to thinking.

There are so many places I could go with this. I could talk about the psychology of racism, self-hate, the European standard of beauty, stereotypes, the psychodynamic value (or devaluation) of African-American hair, post traumatic slave syndrome, images in the media that make many African-American’s consciously or sub-consciously reject their own images as attractive, self esteem, and the list could go on and on. However, I decided to try to stay as true to this blog as possible, and discuss something I think everyone could benefit from and that is understanding automatic negative thoughts, or ANTS.

You see, we all have automatic thoughts which are thoughts that just pop into our head without us giving much thought about them. We will discuss this more in detail next week. We all at times even have ANTS (automatic negative thoughts), but some people seem to be infested with ANTS and when reading those disparaging remarks about Gabby, I realized that those people were infested. Instead of looking at a beautiful, successful, incredible young woman, they quickly pointed out the negative and decided to focus on that for whatever reason (in the African-American community, the word “crabbing” is often used to describe when other African-American’s complain about more successful African-Americans, often in attempts to make the other person feel bad while also making the person complaining feel better about themselves). Those ANTS keep them from being able to truly see or recognize the beauty right in front of them.

People with ANTS, if you take them to a beautiful beach will complain that it’s too hot, the waves are too loud, it smells too salty or that the sand is getting between their toes.  If you take them on a beautiful midnight stroll they will complain that the moon is too bright or that their feet hurt. Or, if you show them a beautiful teenager making Olympic history, will complain that her hair isn’t done nicely. They will never be happy unless they are complaining about something. They are so used to being miserable that they are only happy when complaining. These people usually don’t even know that they have a problem because they have lived with the ANTS for so long that they are part of them.

Are there people in your life who have ANTS? People who always seem to rain on your parade, point out the negative in every situation or seem to only be somewhat content when they are complaining about how miserable they are or pointing out flaws and imperfections in other people? If so, recognizing that they are infested with ANTS helps keep you from making their issue, your issue, and allows you to detach from them either physically or emotionally. Maybe you recognize that you have an infestation of ANTS. Start paying attention to your automatic thoughts, especially those ANTS and next week we’ll start working on getting rid of them.

The Relationship Between Anger, Control and Fear

A lot of times when I am working with people with anger problems, I realize that two of the main sources of their anger come from either the need to control other people and fear.

Anger and fear are part of our natural flight or flight responses. The problem is, we are genetically geared to survive real threats that our ancestors who had to deal with threats to their lives on a daily basis were designed for. Today we don’t have to constantly worry about getting attacked by a leopard or the tribe across the river attacking us, and so our mind often generates fear and anger even when it is unnecessary or the threat is just imagined.

Anger in it’s self is not a bad emotion and can actually motivate people to make changes for themselves and their environment. The Civil Rights leaders in our recent history were angry and so they marched, protested and boycotted to make changes. Anger can make you write a letter voicing your disappointment in a company’s costumer service department or make you search for a new job instead of taking the abuse from a harsh boss. It can make you leave a bad situation, stand up for something you believe or protest against something you don’t.

However, anger can be destructive if it’s not dealt with in a healthy way which is when people run into problems.

Most of my clients with anger problems, once they get to the point where they can verbalize and dissect where their anger is coming from, are actually afraid. They are afraid of losing control, being taken advantage of, being ignored, etc. Take a client of mine who got into a fight while standing in line at a burger joint when he felt someone had blatantly skipped him. Does it make since for a grown man to get in a fight over a $5 hamburger because he had to wait an extra two minutes? Was it worth him going to jail and having to take anger management classes? Of course not, but to him at the time it was. He was eventually able to tell me that the reason he got so angry so quickly is because when he got skipped it made him afraid that he was invisible, that he would be seen as weak, and that he wouldn’t be respected. His fear is what made him so angry and caused him to act in an irrational way. At the same time, his need to be respected caused him to want to control the situation by making the other other person respect him and beating him up until he did.

Often times clients tell me, “She ignored me so I hit her”, “He came home late so I burnt his favorite shirt”, “He didn’t say excuse me when he brushed my shoulder so I had to push him”. All of these statements show both fear and control. Fear of being ignored, fear of being cheated on or left by a spouse and fear of being disrespected. They also show the desire to control the other person, to make them pay attention, come home on time and say “excuse me.” The problem is, we can’t control other people, just ourselves. The desire to control other people will always end up stressing us out, making us angry and causing us to act in irrational ways.

Another example is the constant wars that are waged across the world. People are afraid of losing their religion or xenophobia (the fear of people different from you), and will fight and kill out of that fear and the desire to control other people by either making them convert, conform or leave a region.

Lastly, a client of mine and her teenage daughter got into a very big fight after she found her daughters diary and read it. She didn’t like what she read in her daughter’s diary and decided to confront and punish her for the contents of her diary. Now nothing in that diary was life threatening or even “bad”, they were just her daughter expressing how she really felt about her mother and some of the things her mother did. I felt it was wrong 1) for the mother to have read the diary and 2) for her to try to punish her daughter for her private thoughts. Eventually the mother expressed to me that she felt like she had little control over anything in her life except her daughter, and she was terrified of losing control over her daughter. That need for control was actually pushing her daughter further away as well as causing the mother all kinds of anxiety and anger issues.

We have to understand that the only people we can control is ourselves and that if we can’t change a situation, we have to change the way we think about it. Wasting our time trying to change other people or change a situation instead of changing the way we think about it or removing ourselves from it, will only cause us to develop angry feelings as we try to control what we cant.

What is a Co-morbid Psychiatric Disorder?

ImageA co-morbid psychiatric disorder is any disorder that co-occurs with another psychiatric disorder. Often times we see people as having one issue, when often the truth is they have more than one problem which complicates treatment and recovery.

Recently I started seeing a young man who has both attention deficit/hyperactivity disorder and oppositional defiant disorder. This complicates treatment slightly because both issues have to be taken into consideration at all times sincetotally ignoring one while focusing on the other is seldom successful.

When I worked in the adult unit of a psychiatric hospital, it wasn’t uncommon to see people with depression and alcoholism, or schizophrenia and chronic marijuana use. Often these people use drugs to try to self-medicate and lessen the symptoms of their psychiatric disorders and other times the substances help create or amplify the psychiatric disorder. As a matter of fact, substance abuse and mental health disorders often co-occur in individuals and it’s often hard to tell what came first. Did the alcoholic become depressed the more the disease took over him, or did the depression drive him to drink?People with anxiety disorders for example often turn to illegal substances or prescription pills in attempts to relieve their anxiety. One of my clients who became depressed after losing her baby quickly became addicted to the Xanax given to her by her doctor to help cope with her depression and anxiety.

Definitely some disorders are more likely to co-occur with other disorders. As an example, people with bi-polar disorder are highly susceptible to substance abuse, ADHD, obesity and anxiety disorders.

In the high school setting I generally see teenagers who have depression and an eating disorder, so I work with them to solve both, usually paying more attention to what problem seems to be the most present and severe. With the 15 year old I recently started seeing, he is already receiving medication for his ADHD and while I definitely believe that his ADHD plays a role in his oppositional defiant behavior, I’ll focus on that later since the main reason he was referred for counseling is because of his bad attitude, refusing to follow simple rules, and anger towards his parents and teachers.

Often times teachers and parents are only aware of what condition is rearing it’s ugly head the most and aren’t aware that their are other factors contributing to the behavior. Teenagers rarely drink and smoke just because. Sure there are many who do, but usually once I sit down with them there is more to their substance abuse than peer pressure, usually if it’s not problems at home or self-esteem issues there are signs of a psychiatric disorder such as depression, anxiety or bipolar disorder.

That’s what makes treating and dealing with co-morbidity so difficult. If a patient goes to his family doctor complaining of not being able to sleep at night, he may be prescribed a sleep aid. If he doesn’t tell his doctor that the reason he can’t sleep at night is because he’s worried about his job, the economy, his elderly mother, his doctor in college, etc., then his anxiety will not go away and worse yet, he may become dependent on sleep aids.

It’s isn’t to ignore co-morbidity by focusing on just the problem that we see, but it’s important that we ask, what else may be going on. This will not only help us understand the people we care about, people that we deal with on a regular basis, but also ourselves.

I know all too well the importance of healthy eating on children’s behaviors. So many of the “problem” behaviors I work with could be diminished by healthier eating habits and proper nutrition. Excellent post and great reminder for all of us.

help4yourfamily

Written by, Kate Oliver, MSW, LCSW-C

It’s the middle of the summer.  Schedules are out of whack and ever-changing.  We have vacations and might be spending more meals on the go or out at restaurants.  Summer can be brutal to a healthy diet, especially if we take the old approach of telling ourselves what not to eat, instead of focusing on what to eat.  It might not seem like a big difference, but focusing on what to eat over what not to eat can make a big difference.  Think of it as looking for abundance rather than deprivation.  Which sounds better to you?  Try this affirmation for the week to see about getting your health back on track or keeping it healthy.

I nourish myself by joyfully eating healthy foods and sharing them with my family.

What does this have to do with parenting?  Two major things happen as…

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help4yourfamily

Written by Kate Oliver, LCSW-C

English: Children at play in the 'Cottage Home...

Boundaries are tough for a lot of people, especially if they were not always honored for you while you were growing up in your family of origin.  They are also ever- changing.  The boundaries you have with your two-year old will be very different from those you have with your teenager.  Extenuating family circumstances and developmental issues can also play a major role in the boundaries we set with our children.

What I would like for each parent to take a moment to do this week is to really think about how your child will have many, many adults go in and out of their lives, but very few parents.  Your role is so special and unique for your child.  They look to you to show them the way to be in the world.  They want you to guide them and teach them how…

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Do You Suffer from an iDisorder?

I first heard of the word iDisorder when I came across Larry D. Rosen’s book iDisorder: Understanding Our Obsession With Technology and Overcoming it’s Hold on Us.

While iDisorder is a fairly new term, the idea that our constant and immediate availability to technology causes signs and symptoms that mirror those of some psychological disorders, isn’t.

Most of us have almost immediate and continuous access to either email, our smart phones, our computers or our tablets and often at the same time, using one device to do multiple things like answering phone calls, sending emails, receiving text messages and surfing the web. The thing is, while we use these devices in attempts to control our environment by making everything in immediate access, we also began to become dependent on them.

How many of us have our smart phone with us all the time? Even while on a date or at the dinner table with family we have it next to us, often without thinking, checking text messages or emails instead of being present and engaging with the people right in front of us? Some people find it rude if you are staring at your screen and tapping away instead of making eye contact with them, but it happens so often that I dare to say it is becoming almost socially acceptable.

I remember one time at a restaurant I was people watching as I often do and I saw a couple that looked like they were out on a date, maybe a first date, but instead of sitting across from each other talking, they were both tapping away on their phones and didn’t speak to each other for at least twenty minutes as they waited for their food to be served. At that same restaurant I observed four young ladies all out to dinner together, none of them talking to each other, but all four focused in their smart phones.

There is no doubt that our devices makes it easier for us to get and stay connected with people we might only otherwise communicate with sparingly, but what about the present and those around us. Are we missing out on real life by being too focused on virtual lives?

I have friends who would rather play games on their devices than actually play games with and be around real people. Recently I was co-presenting with another counselor and when I went to turn the presentation over to her I was shocked to see she was texting on her phone. I had to stall until she came back to the here and now. I later asked her what was going on and she laughed it off, saying that it was a text message from one of her kids, nothing was wrong, but she was so used to reading and responding to their text messages that she didn’t think about it even when we were standing in front of hundreds of people.

We get so used to our phones buzzing with phone calls, text messages, emails and other notifications that even when they aren’t going off, our mind is anticipating them going off so much that it triggers our mind and body to think that we feel our phone buzzing in our pockets. These are called phantom vibrations. It’s crazy, I’ve experienced them before and I am sure most of you who are frequent cellphone users have as well.

How many of us are so dependent on our devices that we feel lost without them? Ever leave your house and accidentally left your cell phone? How did you make it through the day or did you turn back around and get it? How many accidents are caused because people are driving and texting. It’s as if that text message has to be read and answered despite the fact we are already engaged in the dangerous activity of driving. Ever watch people who’s smart phone battery is about to die and thy don’t have access to a power source? It’s like watching a drug addicted desperately searching for a fix.

I see kids all the time getting in trouble in school for having their smart phones out, even when they know they aren’t supposed to. And trying to take the phone from them? You’d think you were trying to take a kidney. They throw tantrums, even at times become hostile and risk suspension or worse over a simple device. Can we say addiction?

In his book, Larry Rosen goes on and on connecting our access to technology to things like depression, narcissism, ADHD, hypochondria, voyeurism, eating disorders, anti-social behaviors and a host of other psychological disorders.

On top of that, in teenagers I think it retards their spelling and writing abilities. I’ve seen in teenagers writing that some of them have become so used to short hand text messaging that their spelling suffers and they don’t know when they are writing papers that you can’t just put IMHO when you mean in my humble opinion or txt when you mean text. It’s crazy, but true, so many of the teenagers I work with don’t seem to know when it is and isn’t appropriate to use that type of short hand. One of my teenagers, a very intelligent junior, once wrote me a personal letter I had to decipher. If I didn’t know her I would think she couldn’t read, spell or speak proper for that matter.

The thing is, you can become addicted to anything used in excess and one of the hallmarks of addiction is denial.

As a side note, if you ever have a house party or get together, you may want to thank about banning smart phones as people tend to pull out their phones, start texting, playing games and surfing the internet instead of actually engaging in conversation and activities with people around them. 

It is a good idea for us to unplug every now and then, even if it’s just for a few hours. Put away the cell phone, the tablets, the computers and connect with real people and be present. That would be some thing great for a family to do together although your kids may throw a tantrum at the thought. I think it will help keep us grounded and appreciative of who and what we have surrounding us.