cognitive-behavior-therapy

Dialectical Behavioral Therapy

Self-Encouragement: Reality Statements for Interpersonal Effectiveness 

  1. It is OK to want or need something from someone else.  
  2. I have a choice to ask someone for what I want or need. 
  3. I can stand it if I don’t get what I want or need. 
  4. The fact that someone says no to my request doesn’t mean I should not have asked in the first place.
  5. If I didn’t get my objectives, that doesn’t meant I didn’t go about it in a skillful way. 
  6. Standing up for myself over “small” things can be just as important as “big” things are to others. 
  7. I can insist upon my rights and still be a good person. 
  8. I sometimes have a right to assert myself, even though I may inconvenience others. 
  9. The fact that other people might not be assertive doesn’t mean that I shouldn’t be. 
  10. I can understand and validate another person, and still ask for what I want. 
  11. There is no law that says other people’s opinions are more valid than mine.
  12. I may want to please people I care about, but I don’t have to please them all the time. 
  13. Giving, giving, giving is not the be-all of life. I am an important person in this world, too.  
  14. If I refuse to do a favor for people, that doesn’t mean I don’t like them. They will probably understand that, too. 
  15. I am under no obligation to say yes to people simply because they ask a favor of me. 
  16. The fact that I say no to someone does not make me a selfish person. 
  17. If I say no to people and they get angry, that does not mean that I should have said yes. 
  18. I can still feel good about myself, even though someone else is annoyed with me. 

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DBT Resources Masterpost

As promised, a masterpost of DBT resources. I’ve starred the ones I think are most helpful.

Information about DBT

DBT Skills Training

Handouts, Worksheets, Downloads, etc.

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Compulsive lying or pathological lying is not in the DSM anymore (was in the DSM 3) and therefore cannot be diagnosed on it’s own. Due to this change, there are many beliefs and arguments about compulsive lying, what it is, and how to treat it.

Here are some of the things I found:
The person who struggles with compulsive lying tells lies that are just believable enough. They may be amazing stories or things they did that made them heroic, but you can’t completely say for sure they are lying. It is also important to note that these lies are not due to a delusion. They know they are lying and upon confrontation they will admit that that they were lying. Also, there urge to lie doesn’t come from any external force. They feel that they need to lie because their life isn’t exciting enough. Lastly, all of the lies or stories they tell will place them in a favorable light.

As for treatment many argue that compulsive lying is part of other personality disorders and should be treated as such. The people who believe it should be it’s own diagnosis; CBT or Behavioral Therapy tends to be best. This can help them recognize when the thoughts and urges to lie build up and how to stop them from acting out on that. I hope you found this helpful!

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Are you depressed, dealing with anxiety, PTSD an Eating Disorder or some other mental health issue? You probably are wondering what type of therapy works best for you. In my practice in Santa Monica, I use dialectical behavior therapy, cognitive behavioral therapy and talk therapy. Of course there are others many others (probably somewhere in the neighborhood of 300). The most common other types of therapy you’ll hear about are: Psychodynamic therapy, Psychoanalysis, Interpersonal therapy, Experiential therapy. 

I’d love to know what therapy methods you have experienced (negative and positive). Let’s talk about it in the comments!

 

 

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Everyone deserves to feel good about themselves.

Did you know that by changing your thoughts, you can ultimately change your behavior? Feeling truly good about yourself means loving the person you are, inside and out.

Start with identifying the thoughts, emotions, and behaviors that might block you from feeling good about yourself. After that, you can work on creating a lifestyle that makes you feel valuable, loved, and fulfilled.

Growing Self-Love

  1. Embrace your individuality. 
  2. Develop your confidence. 
  3. Take pride in your strengths.
  4. Expect to have bad days.
  5. Work on developing a positive attitude. 
  6. Know that you have a lot to offer.
  7. Make a list of all of the things you’re thankful for.
  8. Focus less on your appearance.
  9. Pay less attention to what others think.

Addressing Insecurities

  1. Understand where the insecurity comes from.
  2. Learn about Cognitive Behavioral Therapy.
  3. Identify your thought patterns.
  4. Start a journal.
  5. Accept your thoughts as valid.
  6. Change your thoughts.
  7. Learn coping skills. 
  8. Practice.

More on taking action, making it stick, and details of the above steps in the full article!

Centipeetle has PTSD

Gem corruption seems a lot like PTSD. It’s not a physical trauma, it’s a mental one. She doesn’t remember anything from her past until Steven starts to trigger her repressed memories.

However, as in the case of real people with repressed memories, it can be dangerous and terrifying to recover them. Steven tries to be careful using triggering words like “corrupted” but when she is clearly in distress over the corrupting light/sound he gets carried away and keeps asking for more information.

She becomes so distraught that she throws up (acid spit), falls to the floor weeping, and begins losing control over her physical form. I would argue that her frantic attempt to return to her ship and crew is a part of the flashback Steven triggered. It’s what she was doing when she was corrupted.

Seeing the ship causes another loss of control. It’s nearly destroyed, and inaccessible without help from Steven (she seems genuinely shocked that Steven can open the door, but that’s off topic, so…).

Once she’s inside she finds that her crew stayed behind for her. She’s with gems who are familiar. She’s in a place that feels safe. She can finally relax, but she’s still a creature molded by trauma.

It’s like she went from being enraged and violent, externalizing her pain (way back in Gem Glow) to being sedated and trapped in her own mind (bubbled) to an institutional setting with a support group (her ship and crew), and though Steven’s healing powers were able to begin helping her (like a pharmaceutical, the physical component of healing from an emotional trauma), he’ll need to use his empathetic ability to share her thoughts (talk therapy) to finish helping her.

I’m not crying, you’re crying.

Don’t be mean to people who majored in psychology.

There’s a tendency for people to assume that anyone who majors in psych just doesn’t know what else to do with their lives - that they’re going to college because their parents want them to have a degree, so they might as well do something “easy.”

Let me explain you a thing: psychology is NOT easy. We work just as hard, do the same amount of internships and senior thesis research. Increasingly, psychology is being approached as an entirely scientific field (as opposed to the humanities label it previously labored under); as such, most of us are learning a lot of biology and chemistry, sometimes on our own just to keep up. We’re not resting on our laurels and quoting Freud.

(We fucking hate Freud).

So do us all a favor. The next time someone tells you that their major is psychology, don’t roll your eyes. Instead, ask them why. Ask them about something interesting they’ve learned. Ask them if their focus is cognitive psychology, or social psychology, or school psychology, or behavioral neuroscience. Ask them if they want to research and teach, or if they want to be a practitioner. 

Trust me when I say that they’ll be delighted to relieve you of your prejudices.

9 Responses to Criticisms of Cognitive Behavioral Therapy

1. CBT only treats the surface level, part 1

The most common criticism I hear about CBT is that it only treats the so-called “surface level” and never gets to the “root issue.” Usually people who make this criticism are comparing CBT to psychoanalysis or psychodynamic approaches.

This criticism is a profound misunderstanding of what CBT is. CBT is not merely about “surface level” issues (although- see #2). CBT is about understanding the thought patterns, behavioral patterns, and emotional patterns in a person’s life, often over years, and how they interact with each other in context. Therapists identify core beliefs that lead to dysfunctional patterns and distress. These beliefs are generally very emotionally laden, rooted in long term beliefs about the self, and often difficult for the client to identify alone.

For example, I have worked with clients to identify that their paranoia comes from a belief that they did not do enough to protect their child from domestic violence (core belief might be, “I cannot fail my child again,”) or that their depression comes from the belief that because their parent rejected them, they will never be loved or accepted (core belief might be, “I am unloveable.”) The idea that this is not “deep work” and does not get to the root issue is false. CBT identifies the core of how a person understands themselves and the world around them, and works to help that person recalibrate beliefs that are causing them distress and harm.

2. CBT only treats the surface level, part 2
Even if this were true, why is “surface level” a bad thing? It’s a fallacy that therapy has to treat the deepest, darkest, most hidden parts of a person in order to be effective. It comes from our initial beliefs about psychoanalysis- that in order to help someone, you have to understand and treat their subconscious. But this just isn’t the case. Many people are in therapy because of so-called “surface level” things- like difficulty interacting with others, difficulty with organization, problems self-motivating, financial issues, etc. These problems are real and palpable and have long lasting effects on those people’s lives. They are worthy of treatment. I find all of the “therapy must be focus on “deep” issues or it is bad” to be ultimately short-sighted and elitist because it ignores the real world problems that people come to therapy with. CBT is one of many therapies that can meet people where they are and help them with the problems they have. This is a credit to CBT, not a weakness.

3. Anyone can be a CBT therapist, part 1
One of the other major criticisms of CBT is that it’s easy to be a CBT therapist. I think the idea is that all you do as a CBT therapist is like, tell the client do more stuff and think positive thoughts and give out a homework sheet, right? Anyone can do that! Well, sure, if that’s what CBT was (it’s not, see #1 and #5 for a starter).

CBT is way more complicated than “think positively” and it’s not easy to do at all. The research backs this up. For example, when therapists are properly trained, the success rate for treating panic disorder with CBT increases from 10% to 60%. The impact of therapist experience on outcomes for cognitive therapy for personality disorders has a medium effect size (cohen’s d = .73). Not everyone can competently do CBT. The therapists that can see much greater results.

4. Anyone can be a CBT therapist, part 2
Similarly to #2- why does it have to be hard to be a CBT therapist in order for CBT to have value? This is such an odd criticism to me. Is the implication that CBT therapists are lazy, and are picking CBT because it is easy rather than because it is effective? If so- conducting competent CBT is difficult (see #3). What is more difficult is staying on task with a person’s goals despite all of the interesting distractions in therapy. The task of a good, quality therapist is to go with what is useful, helpful, and effective, in both the short- and long-term for the client. This means evidence based-practice, and that often (not always) means CBT. It’s not relevant whether conducting CBT is the hardest road for the therapist. It’s relevant whether it is the best road for the client.

5. CBT doesn’t focus enough on people’s emotional experiences
Like #3, I think this comes from a fundamental misunderstanding of what CBT is. Think about exposure therapy. Exposure therapy- a cognitive behavioral therapy process –is about ending avoidance of distressing emotional experiences. Through exposure to distressing emotion, clients find that triggers to panic, anxiety, and other emotions no longer have such an overwhelming hold on them. Or, consider cognitive restructuring. Cognitive restructuring- paramount to the cognitive behavioral therapy process –is about understanding the cause and context of distressing emotions and discovering other ways to interpret that context. Through full discovery, clients find that they can have greater understanding and flexibility over their emotional experience. CBT is all about emotions, it just takes a different path. Because that path is more structured and thoughtful, it makes sure that any experiencing and processing a client must do in therapy is useful and not making them go through pain for no reason. Emotional experience and emotional processing is a fundamental mechanism of the success of CBT.

6. CBT isn’t really more effective than other therapies, it’s really just easier to research
This one is odd, because there are several other effective therapies with a range of research available on them. See for example, Acceptance and Commitment Therapy, Dialectical Behavioral Therapy, Social Skills Training, Interpersonal Therapy, and Motivational Interviewing.  Even large program-level interventions like Assertive Community Treatment and Contingency Management have had a number of studies conducted on their effectiveness.  CBT may have the most research conducted on it in the most areas of these interventions, but that’s primarily because it has been around the longest (or close to) and its creators were very focused on testing efficacy early on. 

The fact remains- therapies and other treatments of various kinds, including the complex and dynamic, can be tested for efficacy and effectiveness. This argument is merely an attempt by proponents of psychoanalytic and psychodynamic approaches to argue that their interventions are so special that they cannot be tested. This is fallacious and harmful.

7. CBT is becoming less effective over time
CBT is effective, and current trials still find it to be effective. The finding here is  that the effect size for CBT for depression in randomized trials is getting smaller over time. However, average effect sizes for recent studies are still large, around Hodge’s g = 1.00 or greater, so there is no indication that CBT is not effective. It’s a question of going from really big effective sizes to big effect sizes.

There are multiple theories about why studies have found decreased effect sizes. One of them is that this usually happens- that is, effect sizes tend to fall. Effective novel interventions often find really big effect sizes initially, and then with further testing, the effect size stabilizes. So what is happening to CBT is normal and not evidence that it is ineffective.

The other explanation has to do with #3- although many things are called “CBT” or “CT” these days, but many clinicians are not actually trained in CBT or CT. Training matters, and untrained clinicians are unlikely to actually implementing CBT with fidelity, and are therefore unlikely to be making the impact intended. So if a study is being conducted using therapists who are not well trained in CBT or with a protocol that is not truly CBT, the therapy is likely to be less helpful.

8. CBT doesn’t lead to lasting change
There are at least dozens, possibly hundreds, of quality research articles that have found long term positive outcomes for participants of CBT. This includes people with chronic painpanic disorder, insomniaPTSD, eating disorders, and depression, among others.

9. CBT didn’t work for me
Maybe not. That happens. Maybe CBT wasn’t applied correctly, or you and your therapist didn’t have a good relationship. There are a lot of reasons why goals might not be met during therapy. One of them certainly is that the treatment chosen was the wrong one, but it’s not the only reason.

CBT is not meant to be the One True Path. CBT researchers and clinicians don’t argue that all people’s difficulties and distress will be fixed by CBT. It is one method, that has a significant amount of evidence behind it, for a number of issues. It works for many people. That doesn’t make it one sizes fit all people. It may not be right for you. There are a number of other effective therapies and interventions that might work better. That doesn’t mean there’s something wrong with you, or CBT. That’s the way evidence-based practice is supposed to be- finding the right fit between you and the treatment(s) chosen so you get what you need.