Adult Therapy Exam 2

Elemental realism (third-wave CBT)

Also called the mechanism or methodological behaviorism. Assumes the behavioral phenomenon of interest consists of critical elements interacting with one another. Stresses operationalism in defining components that together form reality and aim to create an accurate model of the reality. Emphasizes nomothetic research methods over idiographic research methods.

Functional contextualism (third-wave CBT)

A phenomenon of interest is the manifestation of behavior-environment interactions as a whole (i.e., the act of a whole person in context). Assumes that knowledge is constructed and justified for a stated purpose and aim

Third-wave CBT views on psychopathology

• Characterized by the narrowness, rigidity, and imbalance in behavioral repertoires, characterized by behavioral deficits in centered, open, or engaged response styles, along with behavioral excesses of repertoires referred to as experiential avoidance, emotion dysregulation, and rumination

• Uses DSM and ICD as an entry point but relies more on assessment, conceptualization of the case, and treatment (not bound by DSM)

• Mindlessness, impulsivity, rumination, and lack of awareness

Aware and centered response style (third-wave CBT)

Behavioral skills including being aware of what one is experiencing in the moment; shifting, focusing, or expanding one’s intentional awareness and focus; experiencing the self as the context in which all perceptual experience unfolds

Related terms - present-moment awareness, self-as-context, and being mode of mind

Open response style (third-wave CBT)

The extent to which one is experiencing the present moment fully and openly as it is, without reacting to it or acting on it

Related terms - acceptance, detachment, metacognitive awareness, decentering, defusion, emotion regulation

Engaged response style

Making connections in life and engaging in activities that align with our values 

How is psychological health defined in third-wave CBT?

The extent to which an individual is flexibly and openly centered and oriented to whatever they are experiencing in a given moment, and chooses behaviors in service of their values when a situation affords doing so

Mindfulness-Based Cognitive Therapy (MBCT)

• 8 week, 2 hour per week group program, one-time joining so all participants join at same time, therapist must have 1 year of meditation practice and have gone through MBCT themself

• Has mindfulness meditation with cognitive therapy to target relapse vulnerability among formerly depressed people

• Theory - those who formerly had depression are vulnerable to relapse, particularly during dysphoric mood states that were present during previous episodes of depression

• Sessions 1-4 are to learn the basis of mindfulness

• Sessions 5-8 focus is to learn how to handle mood shifts

Dialectical Behavior Therapy (DBT)

• Originally for chronic suicidal behavior then for those with BPD and now for those with chronic emotional dysregulation

• Emphasizes the interaction between biological predisposition and environment

• Primary dialectical principle is acceptance and change

• A goal is to increase dialectical thinking in clients and to see the tensions in their own thinking and look for a middle path

• Commitment for treatment of about 6-12 months

DBT stage 1

DBT stage where therapist and client build a life worth living by decreasing life-threatening behavior (suicidal, homicidal, and self-injurious behaviors), decreasing therapy-interfering behavior, decreasing significant quality of life interfering behaviors (substance use, eating disorder behaviors) and increasing behavioral skills (mindfulness, interpersonal effectiveness, emotion regulation)

DBT stage 2

DBT stage where therapist and client decrease misery and increasing capacity to experience full range of emotional experiences, emphasized exposure and acceptance

DBT stage 3

DBT stage where therapist and client move to attaining “ordinary” happiness by obtaining life skills in key life domains (employment, education, interpersonal relationships)

DBT stage 4

DBT stage where therapist and client increase capacity for joy, generally through mindfulness

Acceptance and Commitment Therapy (ACT)

• More experiential of a therapy, less confrontation and directive forms of verbal interactions (use metaphors, paradoxes, and experiential exercises) to loosen entanglement of thoughts and self-narrative

• Focuses on readily changeable domains like overt behavior and life situations rather than personal history or private events

• Experiencing and feeling are accepted and valued

• Goal - establish a therapeutic context as a form of therapeutic relationship in which client and therapist pursue a mutually agreed upon treatment goal with shared expectation in therapy

• Derived from philosophy of functional contextualism and relational frame theory

Relational frame theory (textbook definition)

Core insight includes that cognitions and verbally labeled emotions, memories, bodily sensations, and other private events achieve their potency (behavior regulatory function) not by their form but by the historical and situational context for which they occur. Basically - these functions of private events are learned phenomena.

What are the key processes of change in third-wave CBT?

Awareness/centered, open, and engaged response styles

Awareness and centered response style

Allows us to see difficult thoughts and feelings as mental events distinguished from the self.

Example intervention - MBCT breathing space - mindfulness exercise where we practice awareness of our body and our mind, acknowledge the thoughts rather than push them away, and then allow awareness to expand of the body as a whole

Open response style

Generalize aware and centered response style to emotional dysregulation and experiential avoidance

Example intervention - Teach an open response style - observer exercise, client encouraged to experience their difficult self-narrative and feelings, create a self that is aware of the content but not defined by the content. Therapist helps by giving dialogue to notice body and then to client’s thoughts.

Engaged response style

Promotion of adaptive behaviors that are value-consistent in major life domains like communication skills and self-care

Example intervention - Sitting inside Significant Questions - construct personal values in major life domains. Ask questions - What does it mean for you to be a daughter, a sister? What does family mean to you? - Listen and let yourself settle into them, noticing what shows up. Then they write about what showed up for them and why they were important or meaningful.

Therapeutic relationship in third-wave CBT

• Therapeutic relationship considered central for successful therapy

• Therapist serves as a contextual factor for behavior change

• Third-wave CBT encourages therapists to attend to behavioral processes like self-disclosure, countertransference, and rupture in alliance 

Curative factors or mechanism of change in third-wave CBT

• Awareness/centered, open, and engaged response styles

• Insight and understanding

  • The way we perceive, think, and feel about the world, ourselves, and our problems

  • Learn to view and understand presenting concerns functionally and contextually in the context of learning the centered response style

• Interpersonal skills

  • Our core values often reside in the context of interpersonal relationships such as being honest, kind, and caring

  • Personal struggles are also often here - loneliness, conflict with loved ones

MBTC is recommended for….

Those who were formerly depressed with cognitive vulnerabilities (repertoires of depressive thinking and rumination)

DBT is recommended for…

Those with pervasive behavioral pattern of emotional dysregulation

ACT is recommended for…

Those with chronic pain, substance use problems, and a wide range of anxiety-related issues

Third-wave CBT ethical considerations

• Clients must be informed of nature and expected course of therapy, confidentiality, rules of payment and cancellation, etc

• Some third-wave therapies have specific rules for participants to stay in therapy

• Boundaries of competence

• Third-wave models and interventions can be easily misused and misunderstood

How is third-wave CBT different from traditional CBT?

• Traditional sees humans as naturally psychologically healthy so psychological pain is abnormal and needs to be fixed.

• Third-wave believes that it is normal for us to psychologically suffer at some point in time. Our suffering comes from language, our relationship to our thoughts, and our attempts to control our internal experiences.

How is third-wave CBT similar to traditional CBT?

• A focus on changing behavioral patterns

• Highly directive and structured

• Time-limited

• Recognition of thoughts influence on behaviors

Who are notable ACT figures?

• Steven Hayes is the creator

• Russ Harris has a large training presence and wrote The Happiness Trap book

What is the goal of ACT?

• Live a more meaningful and valued life

• Doesn’t seek to change symptoms or reduce them, instead try to live a more meaningful life - despite this not being a goal, there is still symptom reduction in ACT treatment

Relational frame theory (lecture definition)

• Human language and thoughts have a set of “relational frames” or linked concepts. Words become representations for the things they are meant to be communicating

• Development of frames in early childhood

  • Barking = dog

  • We put labels on things to understand what they represent

  • We might have thoughts come to mind and they are arbitrary, it doesn't mean the thought is true or helpful

• The words and thoughts we use have a connection to our actions

• The more we try to control our inner world or thoughts, it will be frustrating and we will keep having negative thoughts - that is part of life

Hexaflex of psychological rigidity

• Absent or confused values

• Inactivity, avoidance, and impulsivity

• Attachment to conceptualized self

• Cognitive fusion

• Experiential avoidance

  • Dominance of conceptualized past and feared future

Absent or confused values

• Assess avoidance of meaningful life activities and overreliance on what others or society promoted as important 

• Going “away” or “towards” our values

Inactivity, avoidance, and impulsivity

• Actions are only pursued under acceptable conditions, procrastination might be evident committed action is not seen as a free choice

• Avoidance of behavior in the real world

Attachment to conceptualized self

• Similar to narrative about who we are, who we are and what are capable of - then relates to avoidance

• How people see themselves as no more than the sum of verbal descriptions and memories. There is an inability to contact self as a perspective

Cognitive fusion

• Assesses the strength of attachment to internalized beliefs, there might be difficulty recognizing thoughts as the product of the mind

• Being trapped and spiraling into the thoughts we have

Experiential avoidance

• Avoidance of the internal world

• Assess for avoidance of internal content such as emotions or thoughts, the individual might be strongly invested in acquiring avoidance strategies

Dominance of conceptualized past and feared future

• Continuous worry, rumination, and planning

Hexaflex of psychological flexibility

• Values

• Committed action

• Self as context

• Defusion

• Acceptance

• Contact with present moment

Values

• Not goals, but how we want to live life, what we want it to be about

Committed action

• Moving toward what’s most important

• What actions are consistent with our values

Self as context

• Transcendent sense of self - here and now

• We are not our thoughts, feelings, images

Defusion

• See our thoughts for what they are - products of the mind

• Content remains but is no longer controlling behavior

• Notice thoughts and accept that we have negative emotions, sensations, etc. without trying to change them

Acceptance

• Active openness to experiences without defense or judgment

Contact with present moment

• Engaged in the moment, the here and now, mindfulness

Psychological flexibility triangle

• We want to open up (acceptance and defusion)

• So we can be present (contact with present moment and self-as-context)

• So we can do what matters (committed action and values)

ACT vs CBT dragon example

• Think of negative thoughts as a dragon

• CBT - We need to slay the dragon

• ACT - The dragon can follow me around but I will keep doing what I am doing

Goals versus values in ACT

• Goals and values are interconnected

• Goals - I read the chapter - checked off on the list

• Value - Learning or kindness or creativity. These are more continuous.

What is the main objective of ACT?

Increase psychological flexibility

“Creative hopelessness”

• Understanding the cost of experiential avoidance

• The happiness trap or trying to control our inner world. Control over inner world is the problem, not the solution.

• In psychoeducation, what have clients tried, how has it worked, and what has it cost them

  • Video - alcohol and self-help books, has helped in short-term but not long-term, and it has cost the client time with his family

  • This strategy is not workable, avoidance and suppression in the long-term are not effective. 

Fusion psychoeducation metaphors

• Help the client understand the problem of fusion to help learn defusion

• Index card exercise - hold card with thoughts in front of their face

• Demons a boat - demon say scary things behind the person

• Unwanted houseguest - having a party and an obnoxious guest. We escort the guest out of the party but then we are missing the party.

Cognitive defusion metaphors and activities

• “I’m having the thought that…”

  • I’m having the thought that I am a loser.

• Repetition of the word (lemon, lemon, lemon)

• Computer screen animations

• Thanks mind

• Leaves on a stream

• 3 Ns - Notice, Name, and Neutralize

Mindfulness awareness

• What am I experiencing and being present in the immediate context

• 5-5-5 technique - 5 things I hear, see, feel

• Drop Anchor - Acknowledge inner experience, come back to body, engage with the world

• Urge surfing - want to have a specific behavioral pattern but are doing something else, notice urge and thoughts, the wave will crest

Acceptance

• Being in the observer self and noticing

• Misconception is it is tolerating the thought, it means leaning into it (polar plunge)

• Nonjudgmental embracing of the experience, feeling the feeling

• “Thanks mind.”

• Compassionate hands - place hand over heart

Values

• You are 80 years old looking back on today. I spent too much time worrying about…

• Values list or card sort, bullseye exercise, or ACT matrix

Committed action

• Toward vs away moves

• Link values to our actions

• Set SMART goals and take steps

• Carrot (link actions to values) vs stick (harsh judgment)

• Structured exercises - flavor and savor, action plan

Who is the founder of DBT?

Marsha Linehan

Dialectical

Two seemingly opposing strategies of acceptance and change, humanism and behaviorism, and validate emotions and also encourage change

DBT origin of symptoms

• Biosocial theory

  • Biological - genetics, brain

  • Social - Invalidating emotions and/or poor modeling and poor environmental fit with temperament

• Emotional responses

  • Vulnerability of cues, internal and external cues, appraisal and interpretation

What are the four consequences of emotion dysregulation?

• Dysregulation of self

• Interpersonal difficulties

• Difficulty recognizing emotions

• Behavioral dysregulation

What are the two modules for acceptance?

• Mindfulness

• Distress tolerance

What are the two modules for change?

• Emotion regulation

• Interpersonal effectiveness

What are the four stages of DBT?

• Behavior stabilization

• Trauma-focused work

• Problems in living

• Incompleteness

Behavior stabilization (DBT stage 1)

Work on decreasing life-threatening and therapy-interfering behaviors. This stage is easily a year or more in length.

Trauma-focused work (DBT stage 2)

Work on PTSD, emotional trauma, residual mental health concerns. Move from “quiet desperation” to “emotional experiencing” Must have emotional regulation skills before this stage.

Problems in living (DBT stage 3)

Help client live their best life, learn to trust themself, and reach their goals

Incompleteness (DBT stage 4)

Help client go from feelings of emptiness to deepening meaning and transcending

Full DBT

• Group therapy

• Individual therapy

• DBT phone coaching for crisis calls

• Therapist consultation team

Diary cards (DBT)

Monitor client behaviors to try to decrease behaviors, track skills, bring into session to see what has been going on.

Chain behavior analysis

• Asking a series of questions in individual therapy, what factors led to a particular episode of problematic behavior they had recently - functional analysis

• Vulnerability -> prompting event -> links of attributions -> problem behavior -> consequences

Clinician mindset for DBT

• Nonpejorative stance - no shaming or judgment

• Compassionate

• Validating

• Radically genuine -

• Irreverance - say something to have a shock value to shake the person out of the pattern

Mindfulness skills

• Wise mind

  • Rational mind and emotional mind

    • Wise mind is a combo of the two

    • There’s wisdom on both sides and wise mind is aware of both

• “What” skills

  • Observing, describing, participating

• “How” skills

  • Nonjudgmental, one-mindfully, effectively

• Other perspectives

  • Spiritual, balancing, walking the middle path

Distress tolerance skills - crisis skills

• STOP - stop, take a step back, observe, proceed mindfully

• Pros and cons

• TIPP skills - temperature, intense exercise, PMR, paced breathing

• ACCEPTS - distraction strategies

• Self-soothing

TIPP Skills

• T - Temperature, hold something cold

• I - Intense exercise, get the energy out

• P - PMR

• P - Paced breathing, deep breathing

Distress tolerance skills - radical acceptance skills

• Radical acceptance

  • Doesn’t mean we condone or the situation is hopeless. It is about accepting what is or what has been

  • Ex - stuck in traffic, can be really angry the whole time, besides calling ahead and saying you will be late you can’t really do anything -> accept that you are in traffic

• Turning the mind

  • Observing, making an inner commitment. Instead of the “why me” find something to commit to in the moment.

• Willingness/Willfulness

  • Willfulness - back into the fight

  • Willingness - accepting this is the situation

• Half-smiling and willing hands

  • Trying to have a body hack to get into a more peaceful and open state.

  • If you are angry, you tense up, your open up your hands

  • Social psych pen - people with the more smiling face had a more positive view on things

Interpersonal effectiveness skills

Obtaining objective while maintaining relationships and self-respect. For building relationships and ending destructive relationships. Walking the middle paths for needs - our needs and someone elses.

• DEARMAN

• GIVE

  • Gentle

  • Interested

  • Validate

  • Easy Manner

• FAST

  • Fair

  • Apologies

  • Stick to values

  • Trustful

DEARMAN

• Describe

• Express

• Assert

• Reinforce

• Mindful

• Appear confident

• Negotiate

Emotion regulation skills

• Understand and name emotions

• Change unwanted emotions - turn slap to hug

• Reduce vulnerability of the emotion mind

• PLEASE

• Manage extreme emotions

PLEASE

• Physical illness - treat

• Eating well

• Avoid mood-altering substance

• Sleep is balanced

• Exercise daily

Who is a big figure for Mindful self-compassion?

Dr. Kristin Neff

What are the four aspects of mindful self-compassion?

• Mindfulness

• Common humanity

• Self-kindness

• Plan

Mindfulness (Mindful self-compassion)

Slowing down, understanding this is a moment and moments are transient. Feelings can feel big in the moment and that they will last forever.

Common humanity (mindful self-compassion)

You are reminding yourself that you aren’t alone, universality like Yalom. We are all works in progress and experience hardships and make mistakes. Pain is a human experience.

Self-kindness (mindful self-compassion)

Self-soothing, what would we say to a friend, reassurance, affectionate words to ourself, appreciations and compliments, self-hug. 

Plan (mindful self-compassion)

What are the next steps, what am I needing, what are the next steps

What are the three characteristics of a person after successful therapy? (Rogers reading)

1. Openness to experience

2. Live in an existential fashion

3. Organism as trustworthy and using this guide for satisfying behavior

Openness to experience (Rogers)

• To fully live the experiences of the organisms rather than shutting them out of awareness

• Example where client listens to their body when they feel tired and believe they feel tired rather than criticizing themself that they feel tired

• There are no barriers that prevent the fully experiencing

Live in an existential fashion (Rogers)

• Self and personality emerge from experience rather than experience being translated and twisted to fit a preconceived self-structure

• You are a participant in and an observer of the experience rather than the one in control of it

• Living in the moment with an absence of rigidity and tight organization, having maximum adaptability

Organism as trustworthy and using this guide for satisfying behavior (Rogers)

• They would do what “felt right” in the moment and use this as a trustworthy guide of behavior

• Computer example where the computer is fed all of the data over time and then computes a course of action - for behavior of our client

  • Need all data to be available and accurate (not in distorted forms)

What is a fully functioning person? (Rogers)

Combines the three characteristics of a person after successful therapy - openness, existential life, and trustworthy and satisfying behaviors.

Implication of the fully functioning person (Rogers)

• Concepts relate to positive therapeutic outcomes already in literature

• Leads toward operational hypotheses

• Explains perplexing contradictions - Roscharch difference between clinician and diagnostician

• Creativity of people

• Trustworthiness of human nature

• Behaviors are dependable but not predictable

• Relates freedom and determinism

Humanistic psychotherapies

• Holistic

• Nondirective

• Experiential

• Open-ended

• Client Autonomy

The goal of client-centered therapy is…

self-actualization or striving to be your true and authentic self

How do client-centered therapies view client resistance?

There is a miss of empathy or something the therapist missed. We need to go back and listen again to the client.

When do we mean when we say client-driven in client-centered therapy?

The client heals themself and create the change.

Organismic valuing process (OVP)

• Organisms know what is needed for survival and growth

• People function best when they are aware of it and can take into account the wisdom of their own organism

• Example - an infant cries when it is unhappy

Conditions of worth (COW)

• Signs others give us of I will love and accept you if…

• Your worth is dependent on x, y, and z

The real/actual self is like _____ and the idealized self is like ______.

organismic valuing process, conditions of worth

The dilemma in client-centered therapy is ________ between the real/actual and idealized self, which creates anxiety.

incongruence

What are criticisms of client-centered therapy?

• Overly optimistic

• Individual focused

• Ignored biological, unconscious, or social factors

What are the facilitative conditions in client-centered therapy?

• Unconditional positive regard

• Empathy

• Congruence