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.

CBT reduces fear and restores function for patients after cardiac defibrillator implantation

A recent article in Current Psychiatry reviews the negative effects on quality of life for people who receive an implantable cardioverter defibrillator (ICD) for irregular heart rhythms. These effects are particularly severe after the first experience of a “shock”—or ICD discharge. Though life-saving, these high-energy electrical discharges (shocks) are typically painful, and many patients experience anxiety, anger, and a sense of helplessness.

After a shock, patients instinctively begin to analyze the events or behaviors leading to the shock—which are often routine and not truly associated with the discharge event—so that they can avoid or even eliminate them from their lives. The fear of another shock and the fear of anything that could precipitate one can result in a “fear of fear” cycle. Patients may then start limiting their lifestyles so dramatically that depression ensues.

The authors suggest that this scenario can be avoided by routine cognitive-behavioral assessments during follow-up visits after the ICD implantation. Ideally, treatment consists of a combination of medication, psychotherapy, and support. With CBT, patients are guided to see how their thoughts about the device might be erroneous. Daily logs of ICD-related thoughts and cognitive re-structuring are useful CBT strategies.

In an example referenced in this article, eight sessions of CBT, which included exposure therapy and relaxation training, allowed a patient to resume most of his activities, and had a beneficial effect on his personal relationships and quality of life.

Study authors: D. P. Gibson, K. K. Kuntz