The debate about Positive Core beliefs

My colleague and I presented the information from the Padesy workshop I recently described to one of our therapy teams.

The debate was electric.  People were intrigued by the integration of different ideas in CBT.  It came to a raucous debate surrounding Padesky’s emphasis on clients to develop positive core beliefs; the “new system”.

We are so used to asking clients to think of realistic alternative thoughts that we almost frown on positive thoughts.  One colleague that introducing the possibility of building new positive beliefs was dangerous as it would definitely disappoint clients the world is not “safe” all the time- why would we encourage someone to think that?  He felt this was just as dangerous or more than negative beliefs; in fact I got the sense that the negative beliefs seemed safer to him. 

It got me thinking on my bike ride home regarding the role of “positive schemas”.  When we are working with those in distress we do not ask them to think of a “so so” place for a “safe place”- the place they invoke is usually one full of positive feeling.  This is an internal positive image that they begin to build inside them; in some sense it is a new internal model they can draw on- it is not the real world. 

When we are motivating people to change our goal must be something worthwhile- something worth striving for.  What the positive core belief is an alternative to the negative belief on an internal level that can stand in competition with the old belief that judges every situation, regardless of whether or not it applies (an overdeveloped strategy).  It is not a representation of the world as it is- if that makes sense. The core belief is an ideal that can find a home in someone’s mind.  Her theory is that strong experiential affect (negative and positive) make a considerable mark ; they are hotter than a hot thought.  Realistic thoughts don’t necessarily have that edge to carry someone into something new.  To give someone the courage to try an underdeveloped strategy in a new situation the hope is that positive affect and memory associated with the new system will do that.

Padesky’s behavioural experiments and new strategies allow someone to carry this into the world with them to access to begin to explore the possibility of something new and promising even if it is just a few moments of the world.  I’m not sure this makes total sense. I’m still grappling with that.  It’s a fascinating topic to contemplate.

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CBT for Personality Part 2: From a Christian Perspective

After reflecting further on my original post on CBT for personality, the New Paradigm for CBT I noticed some interesting parallels between my Christian faith and this therapy that may be relevant for both therapists and people seeking help for personality disorders that are also Christian.

In her new paradigm what I noted is that she explains old behaviour and beliefs that were held/used for “good reasons”.  Instead of challenging the old system she introduced a “new paradigm” in a very experiential manner.

It made me think of how Jesus taught about being born again to Nicodemus and how he offers the gift of eternal life to the woman at Jacob’s well.  He does not challenge the old system of sin, but acknowledged it openly and assumed that a person is already understood how the old system did not work and instead they are looking and seeking a new paradigm, this living water, or spirit life that is not based in place or a set of laws but “in spirit and in truth ” (John 4: 24).  Jesus is continuously offering images, and stories to activate the imagination of people to create a “new paradigm” to enter the kingdom of God that is “here but not yet” (common term from Kingdom theology).

Some of the people Jesus encounters, like those with personality disorders have been suffering for many years, like the woman with continuous bleeding.  Those with these physical ailments were also consequently excluded from relationships and the acceptance of society which is similar to the interpersonal difficulties and invalidation that those who have personality disorders experience.

However, unlike CBT personality that reconceptualizes  the world Jesus challenges us to imagine a new kingdom of God that is loving, beautiful, and a place for the broken.  This kingdom of God is not the world- the world is fallen- whereas the kingdom of God is good and allows people to live fully in love.  Paul for example would likely not approve of imagining the world as a good and loving place, but challenges followers to “not conform any longer to the pattern of this world, but be transformed by the renewing of your mind.”.(Romans 12:2).

Jesus does not want us to idealize ourselves in positive terms but to hold a dialectic together of both sinner and a new creation in Christ.  Loved deeply by God, though rejected by others.

We have an initial belief or experience as followers of Christ but that does not always mean that our old beliefs and habits die completely.  We struggle between paradigms slowly through steps of faith and in acting out our faith in obedience (behavioural experiments of sorts) we learn to walk in this new way. 

Ultimately what anchors us in this new life are not just the word and promises of the bible on a page (the challenging of our old system of belief through words and reason) but the discipline of living out faithfully this new life.

In this new system- or more accurately through a God that is who loves us, who is greater than ourselves – we gain the strength and new resources to cope in a new way with the struggles we face in this world.  Our old ways are no longer necessary as we live more deeply into the new way of Christ.

So if I was to use the new paradigm for CBT for personality from a Christian perspective I might initially focus the old as she does on the view of self, others and the world but conceptualize the new through replacing a focus on the world to the Kingdom of God as the new realm to live in.  This new kingdom paradigm could also be anchored through visualization, and experiential elements- encouraging one to actively enter God’s presence using imagery.

Then introducing interpersonal difficulties into this new kingdom/paradigm makes total sense because you are inviting someone to little by little start living in the kingdom of God (“let your kingdom come on earth as it is in Heaven”). For example you could say “If you are living in this new kingdom of God where God loves you, you are forgiven, you have joy, and are special…what happens when someone insults you…?” .

This new Christian interpretation of Padesky’s paradigm doesn’t just apply to those with personality disorders but I can see how it would be useful for each one of us to conceptualize in our imagination what it is like to live more fully in the kingdom of God.  It might also be helpful for those who struggle with deep shame, despite intellectually accepting that “God loves me” or “I am deeply loved”.

Kind of exciting!

Questions? Comments?

CBT for Personality Disorders Workshop

I recently attended a workshop by Christine P., a well-known CBT therapist who has authored  Mind over Mood.

The workshop I attended was about her “New Paradigm for CBT” for personality disorder treatment.

CBT focuses on the relationships between thoughts, feelings and behaviours and specifically targets changing thoughts and behaviours as dysfunctional thinking is thought to be at the core of problems such as depression.  Automatic thoughts are challenged through thought logs and behavioral experiments to test core beliefs or “schemas”.  Behaviour is challenged through behavioral activation, skill building (assertiveness, for example) The premise is that as behavior and thinking are changed so mood will also change as a result.

This is the standard protocol treatment for most conditions as there is a lot of evidence backing up its use with many different issues (anxiety, depression, etc.).  However for personality disorders research shows therapy take a lot longer to treat, and are treated most effectively by a variety of therapies.  For example according to research, Borderline Personalty disorder is best treated by mentalization-based therapy, transference-focused therapy, dialectical behavioral therapy, and schema-focused therapy.  Classic CBT was not listed among those in a review in 2009 by Zanarini although the last two therapies are in the CBT tradition and the first two are psychodynamic in their roots.

Her new Paradigm, is meant to treat those with personality disorders after they have already addressed Axis I issues (depression, bulimia, etc.) using evidence-based methods.

It departs from traditional CBT in a couple of ways.

1. It does not challenge core beliefs  eg.”I am unlovable”.  This is because she had come to the conclusion that in those with personality disorders lack positive core beliefs to fall back on. Instead of challenging old beliefs the majority of time is spent on building a new system, a new set of beliefs is imagined and dreamed that are tested out through behavioral experiments.  

Core beliefs are notoriously difficult to challenge and VERY hard to dislodge in most people.  I question the need or even ability to fully challenge in general in CBT. I do not agree that those with personality disorders do not have positive schemas- I believe they do but to enact them would be feel threatening and “unsafe”, and is likely something that has not been done for a long time without getting hurt badly. 

2. Similar to attachment theory, which many people say is a major factor in personality issues, she affirms the adaptive nature of people’s strategies to get through earlier struggles and uses the phrase people do things “for good reason” .  This is fantastic and really does well to not pathologize people who are labelled and judged greatly by the psychiatric/medical system.

3. Christine P. ventures into right brain territory by capitalizing on the power of positive affect (see Diane Fosha AEDP) to encourage smiling and warmth when imagining a new “system” for new beliefs and strategies. She also uses imagery to activate the “experiential” mind (see Epstein, 1998) (rather than just the rational mind that traditional CBT focuses on) to allow a person to construct a new system.  She asks people to imagine a scene, be aware of the body sensations, a memory from the past, and a metaphor/song/image as “anchors” to engage this new system.  This is completely new territory for traditional CBT.  It seems to be crossing boundaries with a lot of experiential therapies (and EMDR) that focus on the emotional experience to create and instill change.  I love the integration myself and have been wanting to focus more of the experiential but wondering how to fit it in to my theoretical framework.  This workshop gave me an opportunity to continue ot integrate ideas together that previously appeared very separated.

4. To test out these new beliefs and strategies she uses behavioral experiments- this is not new.  But the rationale is different: to continue ot create safety and protection in this “new system”.  This really fits well with the idea of defenses in traditional psychodynamic theory; defenses are constructive for protection although they may seem extremely counterproductive on the outside; just getting rid of defenses will be futile.  I think what Padesky has conceptualized is important in that she focuses energy on building new defenses so the other ones aren’t necessary.  Like CBT in general it does not focuses on the past but on the “here and now” and immediate future.

As you can tell, I quite loved the workshop and how it seemed to breathe new life into my understanding of CBT and different theories and practices that I’m using.  Padesky’s workshop gave some solid reasons and some evidence to use some practices that I have started to use outside the usual CBT box, but that seem to work well for people along with some of the classic CBT strategies.

CBT Thought Record Challenge Follow-Up

So it’s been over a week after I began this CBT challenge and I thought I should give an update.  I did the thought record a total of three times using situations of high emotion.  That is kind of a miserable number of times considering I am a therapist with no clinical depression or anxiety.

Nonetheless I will share my experiences.  Like most clients I dreaded doing it.  I begrudgingly scribbled in my journal a couple times.  During the experience I found it fairly easy, to put the words down but like others in my group who have done it did feel kind of hallow/fake.  I wasn’t sure what difference it did make.

What I did notice is that my high emotions tend to centre around embarrassment or shame.  This was helpful as it exposed a sore spot for me.  A negative core belief that still nags me that “I always make mistakes/fail”. I have a tendency to believe or fear that people think that worst of me.  This seems to be connected to feeling exposed when I err or make mistakes, so in response I may become defensive or fearful in those situations.

The advantage to doing this exercise more than once is that you can begin to see some dominant emotions and thought patterns that reoccur.  This is something I had never thought to mention to my clients or ask.

One drawback to doing this thought record is that there is little cathartic emotional release in thinking rationally about the situation.  It doesn’t have that same feeling as when you journal about pain or hurt or anger.  The analytic nature just wasn’t that much of an enjoyable experience; perhaps that’s why we tend to think more emotionally than logically and we end up with distorted beliefs.

I don’t think the lesson of this exercise would sink in without emotionally processing (which I’m doing right now and one would hope would happen within the context of individual therapy).

In this way I think more emotional expression through art or otherwise would be a complementary activity to this one.

So all in all, this exercise gave me some perspective, helped me enter into the experience and let me see the limitations as well as some unexpected advantages to doing this.

So reader: what experiences have you had with CBT personally (and in particular thought records) that you would add?

CBT “Thought Record” Challenge

I have been mulling over Cognitive Behavioral Therapy techniques and what it is like for clients to engage in this therapy.  If you are in healthcare as a therapist this is a mainstay of therapy.  One of the cornerstones of this techniques is the assignment of  “thought log” or “though record” or “thinking report” as homework assignments.  In these exercises you ask clients to identify a trigger (situation), an emotion (and intensity level), actions, and the automatic thoughts that are experienced.  After these “hot thoughts” are identified you ask people to find alternative realistic thoughts and/or behaviors.

When used these can be very effective.  When is the operative word.  Like any homework given to a depressed or anxious person they often are not completed and trigger a whole wave of feelings and avoidance.  Some therapists choose to discard this type of homework all together as it creates “resistance” that they deem unnecessary.  Others embrace this not doing homework and ask clients to examine this action using a thought log in session, or do a chain analysis to understand this behavior.

I have been thinking about these two views.  Mostly I have attempted to use these logs, examined the not doing them, and sometimes concluded after discussing with the client that they just do not work for the client at this time.

To gain a new perspective I want to delve into this experience personally.  I want to commit to doing a daily thought log for the next week and see how it goes.  How effective is it?  How much do I want to avoid it?  What will I learn about what a client goes through.  Granted I will not have the same experience as I’m not dealing with a dyadic therapeutic relationship, but I bet you I will still feel some guilt and pressure to doing it just by making this post here and knowing that a few lone souls will check back and see if I actually did what I endeavored to do.

Wish me luck!

Suffering and Trauma

A few days ago I picked up Trauma and Recovery by Judith Herman a book that has been recommended by various people I’ve met in the field of trauma.  Herman uses a feminist narrative to understand the history of trauma, responses to trauma, and recovery.  Right now I’m entrenched into the gory details of human suffering.  As I read the descriptives of what people have suffered in concentration camps, through rape, kidnapping, and child abuse I begin to feel that I cannot bear taking in any more stories of such pain.  It is at these moments that I feel the weight of working in the profession that I do.

In reading this book and hearing the reams of horrible nightmare-like events that people survive I’m drawn back to Job.  How in the world did he manage to cling to his faith in God during that time?  Herman in her book claims that only the smallest minority can survive intense war/kidnapping/abuse without experiencing symptoms of trauma.  She develops a hypothesis that for all there is a breaking point although that is different for some than others.

I was speaking to a colleague today and I challenged her to find a client with a significant persistent mental health issue who has not suffered family neglect/abuse or some sort of trauma inflicted by others.

It is interesting that the line of treatment for mental health issues is cognitive behavioral therapy something which is aimed at understanding and restructuring thoughts and negative core beliefs, but does not centre on pain and suffering as a central part of its framework.  However, for the severely traumatized/mentally ill most clinicians likely agree that this is rarely adequate or enough.  Many cases we file away as hopeless, at least within the bounds of a brief therapy/managed care setting.

I tend to hope that even a short-term therapy interaction that can provide a person a sense of safety, a holding place to process their emotions and begin to understand their thoughts and feelings could be helpful.  I believe this because I have faith that most of the change in people’s life happens outside of the therapy session, through the community, extended family, and social engagement.  However this change may not be initiated or engaged when a person continues to be captive to the negative and false beliefs about themselves that were necessitated by an oppressor (especially one who they loved).  How can we give the fit of beginning on the path to change and healing without falling off that path all together?

For many we do not do enough and some will leave the opposite feeling disappointed and abandonned again, by us as mental health professionals.

Some, however, I hope (with God’s grace and care) are carried onward by a significant experience of care and understanding in therapy.  For this these individual are able to begin to acknowledge their pain, sit with it, process it, and then through re-imagine the world based on new experiences  and then regain a realistic trust in the world and see themselves as worthy and lovable human beings.