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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.

What research is Dr. Beck presently involved in? (Students Ask Dr. Beck – Part SEVEN)

This is the seventh question from the Q&A portion of Beck Institute’s 3-Day CBT Workshop on Depression and Anxiety for students and post-doctoral fellows, held on August 15 – 17, 2011. In this video Dr. Aaron Beck discusses research he is presently involved in and/or leading at the University of Pennsylvania. Dr. Beck explains the work being done by three different teams within his unit; including clinical trials with suicidal patients, groundbreaking research on CBT treatment for schizophrenia, and a community mental health center project involving dissemination of cognitive behavior therapy.

Note taking in Session

judith-beck_1024w.jpgRecently, there’s been an interesting discussion on the Academy of Cognitive Therapy listserv about the therapy notes patients take home with them to review. Here’s how I make sure a patient is able to remember important ideas we discussed in treatment, specifically the changes a patient makes in his thinking:

Generally, when I ascertain that the patient has modified his thinking during a session (e.g., following Socratic questioning, behavioral experiments, roleplaying, etc.), I’ll ask the patient for a summary. I might say:

• Can you summarize what we just talked about?
• What do you think it would be important for you to remember this week?
• What do you think the main message is?

If the patient comes up with a good summary, I positively reinforce him and ask whether he wants to write it down or if he would like me to do so. If his summary is not quite on point, I usually offer a revised version and ask the patient whether he thinks it might be helpful to remember it this latter way. If he agrees, he or I will write the summary down. At that point or later on in the session, I will ask the patient how likely it is that he will read these important therapy notes every day at home. If he’s not highly likely, I’ll ask him about what might get in the way.

I’ve found that most patients just don’t learn the skill of writing cogent summaries. They rarely write down complete ideas and they usually add in extraneous or less important material which dilutes what is really important; that’s why I’m nicely directive about what is written down. I want to be certain the patient has good notes to read this week and ten years from now, if a similar problem arises.

Beliefs Can Interfere with Treatment Adherence

judith-beck_1024w.jpgI recently read an interesting case description on a professional listserv about a “difficult” client who was not fully adherent with treatment. Apparently he argued with his therapist and did little homework outside of the session. It was apparent to me that the therapist had made a mistake. She was continuing to try to deliver “standard” CBT treatment, without attending to the therapeutic relationship sufficiently. I hypothesized that the client had an interfering belief:

“If I refrain from arguing with my therapist and comply fully with treatment……[something bad will happen or it will mean something bad about me.” ].

I don’t have enough details about the case to understand how the client would finish this assumption, but some clients might answer:

“I’ll feel so distressed that I won’t be able to stand it,” or “it will mean she’s in control, and I’m not.”

Until such interfering beliefs are elicited, evaluated, and effectively responded to, this client is unlikely to make much progress.

–Posted by Judith S. Beck, Ph.D., Director, Beck Institute

When patients get angry in session

Judith S. Beck writes in:

Some therapists are quite concerned about their patients becoming angry at them. Yet when therapists respond sensitively, they can help patients learn important lessons.

The first thing I do when a patient becomes angry is to elicit their automatic thoughts and positively reinforce them, in a genuine way. “I’m so glad you told me that.” And I am glad. If there’s a problem, I want to know about it, so I can fix it.

Next, I conceptualize the problem in order to decide what to do. If I think the patient is correct, I’ll apologize – and in so doing, become a good role model. For example, a patient might be annoyed because he felt I was interrupting him too much. If he had that reaction, he’s right. I overestimated his tolerance for interruptions, so I can – again genuinely – say, “You know, I think you’re right. I did interrupt you too much. I’m sorry.”

If I don’t think I made a mistake, I can still genuinely say, “I’m sorry you’re feeling distressed,” because I truly am sorry if something I’ve said or done (or not said or done) made the patient feel worse. Then I try to figure out how to solve the problem, which might involve helping the patient evaluate his negative ideas about me or suggesting we change what we’re doing in the session.

Demonstrating to patients that interpersonal problems can be solved is sometimes one of the greatest benefits of therapy.

Setting the Agenda in session

A frequent question I’m asked by clinicians who are not cognitive therapists is why we set agendas toward the beginning of sessions with patients. They often think that doing so will result in their missing out on important information. I tell them that we’ve found the opposite to be generally true.


We ask patients, “What problems do you want my help in solving today?” and guide them into naming the problems (as opposed to giving us a full description at that moment). Then we ask them to prioritize the problems and let us know roughly about how much of the session they’d like to devote to each one. When clinicians don’t set agendas, they deprive the patient of the opportunity to think through what is most important to them to spend time on in session.

-Judith S. Beck, Ph.D.

Recalling Recent Experiences in Session

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I do many things at the beginning of therapy sessions, one of which is to ask patients about their experiences since I last saw them. Depressed patients routinely report only negative incidents. I then ask them what positive things happened, or what was going on during the better parts of their week. One reason I do this is to collect data that may be contrary to their globally negative thinking. (“No one likes me.” “It isn’t worth doing anything.” “Everything is terrible.”)


Another reason I do this is to allow the session to be a little more conversational, a little lighter in tone. I also find that having patients recall positive experience lightens their mood and makes it easier for them to take a more realistic (less negative) view of their problems. A recent study confirms the importance of doing so. When people are depressed, their thinking is more rigid and ruminative when stimuli are negative, which translates into greater difficulty in solving problems.  

-Judith S. Beck, Ph.D.