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Guest Blogger Dr. Judith Beck: Helplessness

I recently presented a Master’s Clinician Class at the Anxiety and Depression Association of America. My topic was cognitive conceptualization of personality disorders. I asked for a volunteer to describe a case so as a group, we could conceptualize the client, using the Cognitive Conceptualization Diagram (Beck, 2005).ADAA 2015 Registration I have changed certain details to protect the client but his difficulties are fairly typical of someone with avoidant personality disorder.

Joe is a 52 year old man who developed PTSD 32 years before, following a series of traumatic incidents. For a long time, he lived with his family and led a fairly reclusive life. He then moved into subsidized housing which he dislikes.

Joe has been in and out of therapy for many years with many therapists. Although he no longer displays symptoms of PTSD, and hasn’t for a long time, he suffers from dysthymia. His anxiety is fairly low as he avoids situations that could lead to distress. He hasn’t had a job since he developed PTSD and has made only half-hearted attempts to secure one. He does have a few friends, “drinking buddies,” but isn’t particularly close to any of them. His relationships with his family are somewhat strained.

When the therapist listed Joe’s automatic thoughts in situationsADAA 2015 with Cindy Aaronson, PhD where he either felt some (mild) distress or acted in a dysfunctional way (using avoiding something), it became clear that Joe has very strong core beliefs of helplessness. Many patients have a belief in one of the three subcategories of helplessness; Joe seems to have core beliefs of being ineffective in all three.

When Joe discusses his future, he says, “My crummy apartment is preventing me from living my life.” When he considers doing his therapy homework, he thinks, “I won’t be able to do it right.” This represents the subcategory of believing one is ineffective in getting things done.

When Joe imagines going to session without having done his homework, he thinks, “She [his therapist] will be mad if I don’t do it.” When they discuss fixing up his apartment, he thinks, “I don’t want to talk about this. It will be too upsetting.” This represents the subcategory of believing one is ineffective in being able to protect oneself, in this case, in being emotionally vulnerable.

When Joe discusses his past, he thinks, “I’ve wasted so many opportunities. I’m a loser.” When Joe fails to protest a teasing insult from his buddy, he thinks, “I should have said something. I’m a wimp.” This represents the subcategory of being ineffective as compared to others.

Joe’s sense of helplessness has led to extensive behavioral avoidance. He procrastinates, avoids doing homework or cleaning up his apartment. It has led to extensive social avoidance. He avoids intimacy in relationships. And it has led to extensive cognitive and emotional avoidance. He over-intellectualizes, changes the subject in therapy, and avoids even thinking about upsetting topics. And he fails to take responsibility for improving his life, blaming his mother, PTSD, and his living situation for holding him back.

Clients’ emotional and behavioral reactions always make sense once we understand what they are thinking. And the patterns or themes in their thinking always make sense once we understand the fundamental ways they view themselves, other people, and their worlds.

 

Beck, J. S. (2005). Cognitive therapy for challenging problems: What to do when the basics don’t work. New York: Guilford Press.

Older Veterans with Post-traumatic Stress Disorder Helped by CBT

NewStudy-Graphic-72x72_edited-3Medscape: According to a pilot study presented at the Anxiety Disorders Association of America 2009 Annual Conference, older veterans suffering from post-traumatic stress disorder (PTSD) and related symptoms of depression and anxiety – which can persist for decades – may benefit from prolonged exposure therapy (a form of cognitive behavioral therapy). Twelve sessions included “in vivo experience, in which patients are exposed to fears out in the world, and imaginary exposure.”

Measures of efficacy included a Clinician-Administered PTSD Scale (CAPS); after treatment, patients showed a significant reduction in mean CAPS score and 75% no longer met PTSD criteria. Patients showed clinical improvement in most PTSD symptoms along with individual symptoms of avoidance and hyperarousal. Additionally, Beck Depression Inventory (BDI) and other measures showed “clinically significant improvement in both depression and anxiety.” The study author noted that after the treatment, the men were able to “do things they hadn’t done in years.”

These findings are particularly promising because they call into question the “dogma” that older adults cannot tolerate or could be harmed by exposure therapy.

According to the study author, “There are lots of people with PTSD who fought in prior wars or who have the condition for other reasons, who have pushed it aside and coped pretty well throughout their lives. Then a spouse dies, they retire or become medically ill, and their PTSD is something they no longer can put aside, and they need help. We need to know how to treat these people.”

The author is planning a randomized clinical trial in 100 older adults with PTSD.

Study author: S. R. Thorp