Monday, 18 June 2012

Guest Post - Focus on Personal Strengths by Donald Robertson



Positive Psychology and Resilience Building

Build your ResilienceCopyright Donald Robertson, 2011.  All rights reserved. 
[This chapter was originally intended for my book Build your Resilience (2012) but was later replaced by a different approach.  It assumes that Martin Seligman’s work on Positive Psychology and resilience-building programmes like the Penn Resilience Program (PRP) have been briefly introduced in introductory parts of the book, along with some references to CBT approaches to resilience training.It was originally published at http://londoncognitive.com/2012/06/09/personal-strengths-resilience-building/and is reprinted here with permission of the author]]
In this chapter you will learn:
  • What personal “signature strengths” are and their role in building emotional resilience
  • How to reliably identify and assess your own signature strengths
  • How to systematically evaluate your strengths and weaknesses
  • How to make better use of your strengths in daily life and in overcoming adversity
  • How to build your strengths and overcome your weaknesses
  • How to integrate a “strengths focus” with the other aspects of resilience-building you’re learning
The greatest good for man is to talk every day about virtue and the other things about which you hear me talking and examining myself and others… the unexamined life is not worth living. – Socrates

The Importance of Personal Strengths

Have you examined your own strengths and virtues? What character traits have seen you through problems in the past? What personal qualities might you need to fall back on in times of great adversity to come? What inner resources might contribute to your emotional resilience? The goal of this chapter is to help you assess and make better use of your personal strengths as a way of enhancing resilience, something that will stand you in good stead when you begin to use the techniques in subsequent chapters. Knowing your own strengths from the outset will help you to make better use of every other resilience-building technique.
In recent years, increasing emphasis has been placed on the importance of identifying and making better use of personal character strengths, particularly by researchers involved in the “Positive Psychology” movement, whose work we’ve encountered in previous chapters. One of the pioneers of Positive Psychology, Professor Martin Seligman, is also a leading expert on emotional resilience training. So it’s no surprise that this “strengths focus” has become part of modern approaches to resilience-building, although it was not so prominent in the past. Popular wisdom tells us that we should “play to our strengths” and that philosophy has indeed been found to serve well as a basis for building psychological fitness and coping with adversity.
The strengths and virtues […] function to buffer against misfortune, and against the psychological disorders, and they may be the key to building resilience. (Seligman M. E., 2002, p. xiv)
Seligman’s research has provided evidence that the “signature strengths exercise”, employed in Positive Psychology was one of the most effective methods of lowering depression and increasing rating of happiness, and that the effects typically lasted at least six months, especially when the techniques were used repeatedly over time (Seligman, 2011, p. 38). You’ll learn similar concepts and techniques in this chapter as a means of enhancing your emotional resilience. Although psychologists have increasingly emphasised the value of focusing onstrengths rather than weaknesses, evaluation of weaknesses and how they can be improved may come later. By first focusing upon and developing your core strengths, you will subsequently be in a better (stronger) position to tackle your weaknesses and making creative use of your strengths may help you to do so.

‘Key idea’: Strengths Focus

Recent decades have seen a shift toward greater focus among psychologists upon personal strengths, positive character traits, and resources, referred to as the “Positive Psychology” movement. Spending time focusing your attention on particular aspects of experience tends to shape things in certain directions. Focusing on your personal flaws or weaknesses can be helpful in some cases, if you learn to change them, but it can also be depressing if it continues for too long. Focusing on strengths and positive qualities tends to be immediately rewarding, it makes you feel good. When those good feelings are linked to constructive action, attempts to make better use of your strengths in life, you may begin to flourish as a result and achieve longer-term improvements in your quality of life and ability to cope resiliently with setbacks.
There’s a growing consensus that focusing on personal strengths can contribute to building emotional resilience. The Master Resilience Training (MRT) programme developed by Seligman and others for the US military, follows training in basic “emotional toughness” (resilience) skills with training in identifying personal character strengths (Seligman, 2011, p. 171). Some cognitive therapists, such as Christine Padesky, whose work we’ve encountered in previous chapters, have likewise placed the concept of personal strengths at the heart of their approach to resilience-building: “Resilience describes how people use their strengths to negotiate adversity” (Kuyken, Padesky, & Dudley, 2009). In the absence of immediate problems, moreover, focusing on building strengths may seem a more natural goal than spotting weaknesses or preparing to cope with hypothetical adversities in the future, although these are all important aspects of resilience-building.

‘Remember this’: Start by Building Strengths

A good way to begin building resilience is to by focusing initially on your psychological strengths and resources. You need to prepare your weapons and armour before going into battle. It’s quite enjoyable to study your positive qualities and how they could be put to better use. Keep an eye out for evidence of your strengths in action at all times though because doing so will help you to gain self-confidence, grow stronger, and learn how to make better use of your most important qualities.

Assessing your Personal Signature Strengths

What traits do you most value in yourself and others? If you were to draw a list of the five most important qualities that a human being can possess, what would they be? Of course, people have thought about this quite a lot already! The English word “virtue” comes from the Latin word (virtus) for “strength” or “manliness” and originally alluded to those positive qualities thought to make a man (or woman) excel in their essential nature, i.e., character strengths. In ancient Greek and Roman culture there was a well-known list of four “cardinal virtues”: “courage”, “temperance” (or self-discipline), “justice” (or integrity), and “wisdom.” Thousands of years later the same cardinal virtues are incorporated into the main questionnaire used in Positive Psychology and evidence-based resilience training programmes (see below). However, these are just generalisations and guidelines; it’s ultimately down to every individual to decide what they consider to be important character strengths based on their own personal values.

The VIA Questionnaire

In Seligman’s approach, strengths are evaluated using the Values in Action (VIA) Signature Strengths questionnaire, designed by Professor Chris Peterson at the University of Michigan. The VIA questionnaire is a particularly valuable assessment tool, having been used extensively in research on Positive Psychology and resilience-building. It has been made available online, free-of-charge as a “public service”, at Seligman’s Authentic Happiness website: www.authentichappiness.org. You should register on the site and complete the questionnaire right now if possible. It provides an excellent, well-established, starting point for the evaluation of personal signature strengths. Once you’ve answered the questions online, you’ll be provided with a printable set of results, ranking the “strengths” in the order which your responses suggest they apply to you. There’s also an abbreviated version of the questions in the appendix of Seligman’s recent book, Flourish (2011).

‘Remember this’: Review your List

There’s no value in assessing your personal strengths only to forget about them. Once you have an initial list, keep reviewing it periodically. Doing so will help you both to memorise it and refine it. Using the other questions and techniques to evaluate your strengths, monitoring them in action, and making time to put them into practice in new ways, will help you to become more and more familiar with them. The goal is to know your own strengths like the back of your hand and to make the best of them.

Questions from Cognitive Therapy

There are actually many useful ways to start assessing your own strengths. Even if you don’t have access to the VIA questionnaire or choose not to use this method, there are plenty of other ways to help identify your personal signature strengths. It’s been found to help if you make a point of considering even qualities that might seem small or trivial to you, as these often provide important clues to hidden strengths. Likewise, your greatest strengths might be qualities you’re simply taking for granted. The following list of questions is adapted from two well-known cognitive therapy approaches from Melanie Fennell’s Overcoming Low Self-Esteem (1999, p. 127) and Judith Beck’s Cognitive Therapy: Basics & Beyond (1995, p. 181).

‘Try it now’: Questions about Personal Strengths

Try to answer as many of the questions below as you can, in as much detail as possible, to help paint an initial picture of your key personal strengths and positive qualities. Don’t worry if you find you’re repeating yourself, just skip to the next question.
  1. What personal strengths or positive qualities do you possess?
  2. What do you like or value about yourself, however small?
  3. What have you achieved in your life, however small?
  4. What challenges or problems have you overcome and how did you manage to do it?
  5. What gifts or talents do you have, however modest?
  6. What skills have you acquired during the course of your life?
  7. What do other people like or value about you?
  8. What qualities that you value in other people do you share?
  9. What positive qualities do you value and try to possess, regardless of whether you think you’ve sufficiently achieved them?
  10. What aspects of yourself or your actions would you appreciate if they were qualities of another person?
  11. What small positive characteristics could you possibly be discounting or overlooking in yourself?
  12. What bad things are you not? What flaws, vices, or weaknesses do you not have? How are you different from someone who has those flaws?
  13. How might another person who cared about you describe your best qualities?
  14. When your self-esteem is at its strongest, what is going on? What are you like when feeling self-confident and functioning at your best?
Finish by trying to write a brief list summarising your core strengths, drawing on your responses to the questions above.

Learning from Past Experience

Another way to identify your personal strengths is to analyse specific situations from your past in more detail, perhaps your proudest moments or greatest achievements. Write an account of a specific challenging situation, telling the story of how your personal strengths have helped you to cope with adversity or solve a problem. The questions below are designed to help you evaluate your problem-solving retrospectively and identify the personal strengths that contributed to your resilience in the past.

‘Try it now’: Questions about Previous Situations

Answer the questions below in relation to a past situation where you successfully overcame a significant challenge and exhibited personal resilience,
  1. What specifically was the problem and why was it a problem?
  2. What was your goal, what were you trying to achieve? What was the actual outcome?
  3. What obstacles, challenges, or setbacks did you have to overcome?
  4. What specifically did you do, in terms of your behaviour, to overcome these things and achieve your goal?
  5. What specific thoughts and attitudes helped you to succeed?
  6. How would you rate your resilience in that situation from 0-100%?
  7. Why wasn’t it 0%? What strengths and personal qualities helped you?
  8. If it wasn’t 100%, how could your resilience be improved during similar situations in the future?
If you want, repeat these questions for several situations and build up a cumulative picture of the strengths employed by you to overcome different problems.

Characteristics of “Signature Strengths”

Some strengths may be more important or central to your character than others. Once you’ve identified an initial list of your strengths using the VIA questionnaire or the other methods above, you should consider which ones most closely fit the following criteria for being a personal “signature strength” (Seligman, 2011, pp. 38-39),
  • It feels authentic, part of the “real you”
  • You feel enthusiasm and excitement about using it, especially if you’re not used to doing so
  • Learning quickly accrues from using the strength as you tap into something that feels right
  • You experience a desire to find creative new ways to use your strength
  • You feel a sense of “inevitability” as if you are bound to do what comes naturally in using your strength
  • You feel energised by using the strength rather than exhausted
  • You create personal goals based upon it
  • You experience an abundance of positive, energising sensations and emotions when using your signature strength fully
Your signature strengths are those, according to Seligman, which should initially receive the most attention as they’re likely to be your most powerful psychological assets and may generate a momentum of their own once you begin to become more aware of them and make more extensive use of them.

‘Key idea’: Signature Strengths

Everyone has positive qualities and strengths. However, some of your personal strengths are particularly important because they may be central to your personality and have an “authentic” quality to them, which makes you feel like you’re being true to yourself when you’re using them to the best of your ability. These “signature strengths” may coincide with your core values in life and you may even feel you’re fulfilling your destiny or answering your calling in life by using them more fully.

Evaluating your Strengths

Reflecting on your own Strengths

Once you’ve developed an initial list of your key strengths and identified which ones are most important, possible “signature strengths”, it can be useful to reflect on your strengths in more detail. Your initial list is probably just a rough draft and awareness of your strengths may become clearer over time as you make an effort to focus on them and observe them in action in your daily life.

‘Try it now’: Reflecting on Personal Strengths

Try to answer the questions below by reflecting on the work you’ve done so far to assess your personal strengths.
  1. What have you learned from about your strengths from the questions and exercises above?
  2. How did you actually acquire these strengths?
  3. How do you typically use your strengths to deal with problems?
  4. How do your strengths influence your relationships with other people?
  5. Does using these strengths too much ever cause problems? How can you prevent or minimise this?
  6. How could you make better use of your strengths in daily life?
  7. What would happen if you made more use of your key strengths? What impact might it have on your life in general?

The Positive Data Log: Raising Awareness of Strengths in Action

So far you’ve been considering resilience from a general perspective but now it’s time to begin looking more closely at specific examples of your strengths in action, on a daily basis. A common technique in cognitive therapy, called the “Positive Data Log”, involves keeping a running log of specific events that provide cumulative evidence supporting a positive belief the client is trying to adopt (Padesky, 1994). Sometimes a similar method is used to record any evidence of positive qualities or personal strengths, in general, to help build self-esteem (Fennell, 1999). Part of the reason for doing this is that when people are depressed they appear to automatically overlook or forget about positive events and to pay more attention to negative experiences. Keeping a Positive Data Log entails making a conscious and systematic effort to pay more attention to evidence of positive qualities, no matter how small or apparently insignificant. The underlying purpose is to retrain the mind to automatically pay more attention to these events and remember them and to overcome negative biases in thinking, memory, and attention, where these are responsible for problems with low mood or self-esteem. The Positive Data Log can be used by anyone though and provides another way of monitoring and increasing awareness of personal strengths.

‘Key idea’: Focus of Attention

People tend to automatically focus attention in ways that are influenced by their existing beliefs and assumptions. For example, someone who is anxious and believes they are vulnerable to harm will tend to, automatically and perhaps without realising they are doing so, focus their attention on possible signs of danger in their environment, noticing even the slightest cause for worry, that other people might overlook. Someone who suffers from hypochondria and believes he is ill will scan his body looking for unusual sensations, symptoms, and notice even the faintest twinge of pain, which wouldn’t catch the attention of another person. Keeping a written log recording specific events on a daily basis is an excellent way to train your mind to notice and remember things that it may have previously overlooked. In this chapter, we’re interested in how keeping a log could be used to enhance awareness of personal strengths and the evidence of them in action on a day-by-day basis.
The Positive Data Log usually contains an ongoing record of specific events which can provide evidence for general strengths or positive qualities, noted in a second column. For example, a couple of entries from a running log, spanning two days, might look as follows, containing specific events in one column and the general strengths they provide evidence of in the other,
Positive Data Log
Specific Events
General Strengths / Positive Qualities
Saturday 9th July 2011
1. Completed essay well before deadline for university.
2. Made up with boyfriend after argument.
1. Patience, self-discipline, good organisation
2. Forgiveness, assertiveness
Sunday 10th July 2011
1. Cleaned out the garage finally.
1. Patience, perseverance, self-discipline
This record should be maintained for several weeks, at least, and events should ideally be noted down as soon as they happen, in case they’re forgotten. The more it’s used, the more automatically you should begin to notice evidence of personal strengths and store them in your memory. Having an initial list of personal strengths, from the VIA or the cognitive therapy questions above, will help you know what sort of events to be on the lookout for. However, as you record events, you’ll probably begin to recognise that you have other strengths, or to define your strengths more clearly. Having the patience to write things down will pay dividends as the process of writing requires more attention and is believed to help your brain become more attuned to further evidence in the future, which might otherwise have been overlooked.

Assessing the Strengths of Others

Strengths and weaknesses don’t only apply to individuals. In some contexts, of course, these ideas and techniques can be applied to groups, teams, organisations, etc., perhaps even couples in relationships. For example, an organisation may find it lacks creativity, although a particular individual within the group may have that strength, which could be better utilised by the others.
Try developing what Seligman calls a “family tree” of strengths by encouraging your friends and family to discuss personal strengths. If you’re able, try asking other people to summarise your key personal strengths and do the same for them. Note how your own self-appraisal may differ from other people’s perception of you. Obtaining information from others in this way can help to correct gaps or biases in your own perception of your strengths. Understanding other people’s strengths and weaknesses may help you to interact with each other more constructively. However, assessing the strengths of others can also be used for “modelling” or imitation. Indeed one of the best ways to develop your own strengths is by contemplating the strengths of others.

‘Remember this’: Learn from Others

Focus on strengths isn’t just about your own virtues. There are many benefits to be obtained by carefully contemplating the strengths of other people. Most importantly, by putting into words what it is that you admire about other people’s resilience it makes it easier for you to remember and imitate their positive qualities yourself.

Role-Models & Contemplation of the Sage

Try assessing the strengths of your heroes or role-models, real or fictional individuals. Think of someone you admire or a character who exhibits emotional resilience in the face of adversity. If it helps, begin by writing a short description or story highlighting their positive qualities. Then try to extract the essence of their strengths by summarising them in one or more short sentences. This could be a description of the key strength or a statement of the belief or philosophical principle that they seem to be following. For example,
In ancient philosophy, it was common practice to write about, discuss and contemplate the qualities of the ideal “Sage” or wise man and how he might act in different situations or overcome specific problems. The historical figure of Socrates was most often used as a living example of the ideal Sage – serving as a kind of “role-model” for ancient philosophers. The last days of Socrates, his trial and execution, were famously described in the “Dialogues” of his student Plato. If the philosopher Socrates were taken as an example, we might say he exhibited wisdom, of course, and great courage and equanimity, or temperance, in the face of adversity.

‘Try it now’: Learning from the Strengths of Others

Think of a specific person whom you consider to be particularly resilient. This could be a real person that you know in life or even a fictional or historical character. Describe the key strengths that make them resilient.
  1. How do you know they are resilient? What problem did they overcome and why was it a problem?
  2. What goals were they trying to achieve? What was the actual outcome?
  3. What obstacles, setbacks, or challenges did they have to overcome?
  4. What specifically did they do, in terms of their behaviour, to overcome those things and achieve their goal?
  5. What specific thoughts or attitudes do you suppose helped them?
  6. How would you rate their resilience overall in that situation from 0-100%?
  7. Why wasn’t it 0%? What strengths and personal qualities helped them?
  8. If it wasn’t 100%, how could their resilience have been better?
  9. What do you learn by considering their example? How might you put this into practice in your own life?
Repeat this exercise several times with different “role-model”, whether real people or fictional characters.

Using your Signature Strengths

Set aside time within the next week or so to put one of your signature strengths into practice to the best of your ability, scheduling somespecific event or activity that allows you to experiment with changing your behaviour. Try to think of creative ways to do this, going beyond the ways in which you already use your strengths to find new opportunities for them to be brought forward. It’s as if you’re asking yourself: “If this is what I’m good at doing then how can I make better use of it?” For example, if one of your signature strengths is that you have a strong “love of learning” then you might set aside time one evening to read in detail about a subject you’re interested in, if that’s not something you’d typically do with your time. On the other hand, if “appreciation of beauty” is one of your signature strengths, and you haven’t done so for a while, you might go out of your way to create an opportunity to visit the theatre or an art gallery and perhaps to share the experience with other people.

‘Try it now’: Experiment with Using Your Signature Strengths

Write down a record of your experiment, noting how you felt before, during, what you learned from the experience and what you plan to do next.
  1. Where and when are you planning to carry out the experiment?
  2. What signature strengths are you planning to use?
  3. How specifically do you plan to use them?
  4. What exactly do you predict will happen?
  5. (Now do the experiment, using your signature strength!)
  6. What actually happened?
  7. Rate how much pleasure you experienced by using your signature strengths (0-100%)?
  8. Rate how much you experienced a sense of achievement by using your signature strengths (0-100%)?
  9. What have you learned by using your signature strength in this way? How could you get more out of it next time?
  10. (If you’re keeping a Positive Data Log, use it to record any relevant information from this experiment, including evidence of any additional strengths.)
Try to schedule opportunities to use your signature strengths as frequently as possible as doing so will tend to help develop them further and benefit your mood and general sense of resilience. If you don’t use your strengths then you’re potentially wasting opportunities for growth and personal improvement. Make a deliberate effort to create time in your schedule to experiment with new ways to use your core strengths creatively.

‘Key idea’: Using Signature Strengths

Using your signature strengths should be inherently rewarding, which is important because it means the more you do it, the more you want to do it again. That makes change potentially “self-reinforcing”, which is gold dust for therapy because change is usually bothersome and requires repeated effort to maintain. By using your signature strengths more fully you give yourself the opportunity to flourish and develop emotional resilience in ways that can seem completely natural and effortless, although some courage, patience, and effort may be required to begin with.

Focus Points (Summary)

The main points to remember from this chapter are,
  • Focus on personal strengths is a valuable way of enhancing resilience
  • You can learn to focus on your strengths, identify them, evaluate them, and make better use of them
  • Once you’ve identified an initial list of strengths you can use the Positive Data Log to monitor evidence of these and other strengths in action
  • You can develop your strengths further and improve your relationships by learning to identify and model the strengths of others
  • Scheduling opportunities to actually use your signature strengths in creative new ways will help them develop and tends to be inherently rewarding

Works Cited

Fennell, M. J. (1999). Overcoming Low Self-Esteem: A Self-Help Guide Using Cognitive Behavioral Techniques. London: Robinson.
Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative Case Conceptualization: Working Effectively with Clients in Cognitive-Behavioral Therapy. New York: Guilford.
Padesky, C. A. (1994). Schema change processes in cognitive therapy. Clinical Psychology and Psychotherapy, 1(5), 267-278.
Seligman, M. E. (2002). Authentic Happiness: Using the New Positive Psychology to Realize your Potential for Lasting Fulfilment. New York: Simon & Schuster.
Seligman, M. E. (2011). Flourish: A New Understanding of Happiness and Well-being. Nicholas Brealey: London.
Copyright Donald Robertson, 2011.  All rights reserved. 

Sunday, 17 June 2012

How Not to Do CBT - Part 2


In part 1 of this series I showed one way that CBT can go wrong. In this post I will illustrate that there is more than one road to a therapy train crash! Here is a reminder of the client.
John comes to CBT because of his depression.  He is a 40 year old who has recently been made redundant. He is worried about getting a job again and his redundancy has also  caused tension in his marriage. When questioned about how he spends his time now, he says he gets up late, intends to look for jobs but ends up doing very little. He feels demotivated, discouraged and, at times, hopeless.  He is having trouble sleeping and hints that he may be using drinking to cope with his difficulties.  At times, he says, he wonders if he will ever get a job again.  He sees his redundancy as meaning that he is a failure.  He talks in  a flat, slow monotone. As he talks, he is becoming more sad and more hopeless.
How NOT to do CBT: Counsellor / Therapist  B with John

B1: (In a business-like tone) Welcome back  John, This is session 3 and today we are going to look at how being more active can help you be less depressed.  Have you got your homework with you?
J1: Yes (Gets sheet out of pocket) – here it is.
B2: Right, so let’s see. Good, so on Wednesday you were more active and felt better. On Thursday you didn’t do much and felt worse. This supports what we know to be true in general, which is that when we are active we feel better and when we are less active we feel worse. Make sense?
J2: I guess so.
B3: There’s what we call a vicious cycle of depression (Shows John handout  “Vicious Circle of depression” ). I’d like you to read this sheet as part of your homework, OK?
J3: Yes.
B4: So what we need to do is work out how we can get you more active in the next week.  Do you ever go jogging?
J4: Not much.
B5: Swimming?
J5: No
B6: How about talking to friends?
J6: Well to be honest I haven’t felt much like doing those things much.
B6: Well, as homework for this week I’m going to suggest you commit to one activity each day. What are you going to do today?
J7: (Smiles)
B7: I’m glad to see you smiling. Are you thinking of something enjoyable you are planning to do?
J8; No, I was thinking of that old Sinead O’Connor song, “Nothing Compares to you”. Remember the line “went to the doctor …he said girl you better try to have fun no matter what you do
but he's a fool.”
B8 (a bit annoyed) It’s not foolish to ask you to do more – there’s a lot of evidence that backs it up!
J9: (smiling again) And does everyone get better when given a dose of your CBT medicine?
B9: No, of course not, not everybody, there are exceptions …
J10:  The hopeless cases, right. Well look at me  - old, unemployable, broken marriage –ready  for the scrapheap of life. Best save your medicine for a less hopeless case, don’t you think, doc?

Can you see what is wrong with counsellor B's approach?

What tips would you give him or her?

Sunday, 10 June 2012

How Not to do CBT - part 1

It's far from true to say that CBT is just about applying a few techniques. In fact, good CBT requires a lot of knowledge and a lot of skills, including the ability to put these all together when in the company of a client.
In this article series I will be sharing some ideas about how to do CBT - and first, how not to do CBT, with a hypothetical client, "John".  Hopefully it will be useful.

John comes to CBT because of his depression.  He is a 40 year old who has recently been made redundant. He is worried about getting a job again and his redundancy has also  caused tension in his marriage. When questioned about how he spends his time now, he says he gets up late, intends to look for jobs but ends up doing very little. He feels demotivated, discouraged and, at times, hopeless.  He is having trouble sleeping and hints that he may be using drinking to cope with his difficulties.  At times, he says, he wonders if he will ever get a job again.  He sees his redundancy as meaning that he is a failure.  He talks in  a flat, slow monotone. As he talks, he is becoming more sad and more hopeless.

How NOT to do CBT:   Counsellor/Therapist  A with "John"

A1: (In a very empathic tone). Good to see you again, John , how has your week been?
J1: Well, up and down.
A2: (Sits in silence, waiting for more)
J2: I still haven’t got a job. I still waste most of my time.  I still think I’m a waste of space ….
A3: Sounds like it’s been a tough week.
J3: To be honest, I’m not sure if this counselling is helping.  I wasn’t sure whether to come, but my wife insisted. (Sits in silence)
A4: So you weren’t sure whether it was worth you coming or not?
J4: Well, I’m not better yet, am I?
A5:  I’m really sorry that you aren’t feeling much better. What’s the main thing that’s been on your mind?
J5: I don’t see any prospects of getting work. I’m not getting any younger, the economy is getting worse. Be honest, would you employ a sick 40 year old if you could take on a healthy, cheaper 30 year old?  My mate Dave said “treat it like a holiday” but I’m telling you, it’s no holiday.  Or if it is, it’s a holiday from hell. My wife hardly talks to me, except to make digs at me.  I just don’t see any future.
A6: (increasingly feeling engulfed in John’s depressed mood) I can see why you do feel hopeless.
Silence
A7 (Remembering they are meant to be doing CBT not general counselling) I can see it is all looking hopeless now, but sometimes when people are depressed they think in rather extreme and unhelpful ways. It’s like putting on a pair of glasses that filters out all the good things. Do you think that might be happening to you?
J6: I suppose so.
A8: So, what would it be like for us right now to try on a pair of more rose-tinted spectacles and see what your life might look like?
J7: Right, like in those self-help books – “think yourself to happiness!” (Smiles ironically). No thanks, tried that.  I’m afraid with me the situation really is bleak it’s not just my thinking.  Maybe I was right after all in thinking that this approach isn’t going to help me.

Can you see what is wrong with counsellor A's approach?

What tips would you give him or her?

Sunday, 20 May 2012

10 things I learnt from Judith Beck workshop on CBT for Personality Disorders

I attended an excellent workshop given by Judith Beck on CBT for Personality Disorders in London last week. It was a really engaging workshop, with a good mix of lecture, videos and demonstration. The group was large but not overwhelmingly so, meaning that there was a reasonable amount of time for questions. Despite her eminence (Judith is the daughter of Aaron T. Beck and the author of several books including the classic Cognitive Therapy: Basics and Beyond) she came across as humble and approachable as well as extremely knowledgable.

I'm writing this blog entry to share 10 things I learnt or was reminded of in the workshop.

1) How to set an agenda in CBT
Agenda setting is very important in CBT. Like in a meeting at work, having a clear idea of what you want to talk about helps you prioritise and focus collaboratively. However, some therapists find that asking formulaic questions such as "What shall we talk about today?" or "What agenda items do you have?" is either too vague or too formal. Beck shared with us that she no longer tends to ask "What shall we put on the agenda?" but asks the more concrete "What problem or problems would you like my help in solving today?" or "What can we look at today that will help you in the next week?". I like those questions, and have already added them to my set of  standard agenda-setting questions with a positive result.

2) There are three main areas of core beliefs one can have about oneself, relating to helplessness, unloveability and worthlessness. I think this this is a useful set of categories. Less direct ways clients might express this are, respectively "I can't cope", "If people knew the real me they wouldn't care for me" and "I am nothing".Being aware of these three categories can help you be aware of a particualr clients main vulnerability. Of course, the three areas are not completely exhaustive (for example where do you put the client who says "I am broken"?) and Jeffrey Young's idea of lifetraps in Reinventing Your Life contains a  longer list of areas of concern, which also go beyond core beliefs or schemas about onself.

3) Judith Beck's template for formulation or case conceptualisation is a useful tool to use for clients with personality disorders.  It differs from  some other CBT case conceptualisation templates in that it includes compensatory strategies and has room for an example of how it plays out in a situation with automatic thoughts and  their meaning (often a core belief) and reaction (often a behaviour).Here is an example in Word format.

4) The idea of a compensatory strategy is that people understably behaviour people carry out to get round their core beliefs and assumptions. For example, someone who believes that other people are hostile might have a compensatory strategy of avoiding them or of being a people-pleaser. For those familiar with Melanie Fennell's model of low self-esteem, it's quite similar to her  notion of "unhelpful behaviours".

5) A normalising and compassionate way of helping those with personality disorders to understand their compensatory strategies  is in terms of overdeveloped and underdeveloped strategies. For example, someone with Obsessive Compulsive  Personality Disorder may have overdeveloped responsibility and systematisation (Christine Padesky calls this "too much of a good thing") and undeveloped spontaneity and impulsivity.

6)CBT can help those with personality disorders but CBT will tend to take longer and more attention needs to be given to developing and maintaining the therapeutic alliance and to developing alternative more helpful core beliefs.

7) To help maintain a good therapeutic alliance, Judith Beck's tips include
  • asking for feedback (e.g. on a scale of 1 to 10 how empathic was I, what would have made it one point higher?), 
  • helping with solving problems relevant to client (see 1 above), l
  • looking out for signs of emotional distress in session and bring them to attention of client, 
  • giving a  rationale for your treatment, 
  • using your formulation 

8) Be on the lookout for your own negative reactions to clients with personality disorders, and deal with them, for example by
  • looking at your own core beliefs being activated and looking after yourself (Beck said that she herself finds mindfulness helpful) and 
  • using supervisions (of course!). 
  • Above all, expect interpersonal issues to arise - that's why there here - and use the therapy room as a laboratory for helping the client resolve them.

9. "We don’t see things as they are, we see things as we are." Strongly held core beliefs or schemas filter out our experience in a certain way. For example,  if you think you are unloveable, you will look out for things which support this view and either fail to notice or discount examples where you appear to be lovable. Oxford-based therapists Fennell, Butler and Hackmann  refer to this process as the "mental crusher." In Judith Beck's version of this idea , you might draw a diagram showing the client's mind with space for a circle, representing an  existing core belief. Contradictory core beliefs are then shown as  squares or triangles. You can then ask the client "what do you think will happen when you come across an idea that doesn't fit?".  This can help clients be prepared for how difficult it may be for them to change their core beliefs but also that they could benefit from being more flexible in how they see themselves and the world. This sets the scene for numerous ways to modify unhelpful core beliefs.

10. There are a number of ways to modify core beliefs. I have written elsewhere about many of these. Beck adds to my list of 10 ways to change core beliefs by adding
  •   using metaphors and stories (e.g. Cinderalla story for how someone can overcome abuse) and
  •  restructuring the meaning of early experiences through imagery,
All in all it was very refreshing to hear how you could deal with more complex cases in CBT without departing too much from standard CBT practice. Whilst approaches such as Schema Therapy and  Dialectical Behaviour Therapy may seem very attractive to those who have tried CBT for those with personality disorders without success, Beck's approach suggests that such a radical change in approach may not always be necessary.

I hope this list of 10 things I learnt from the workshop gives some flavour of how CBT can help with Personality Disorders and more generally with working with more complex clients. Of course, there was much more in the workshop than is summarised above, and I thoroughly recommend you go to one of Judith Beck's workshops if you get the chance.

Further resources
Beck Institute  Website
Interview with Judith Beck
Judith Beck video on You Tube

Saturday, 18 February 2012

CBT for Depression - a brief overview of treatment with free resources

According to the NICE Guidelines, CBT is one of the most evidence-based treatments of choice for (unipolar) depression.  In this short article I will describe how a CBT therapist might treat depression in  a course of therapy, giving links to free off-site depression resources.

In an assessment, the therapist will screen for depression, possibly using the PHQ-9 amongst other measures to assess the level of depression and assess risk. The clinician will explain the rationale and basics of CBT for depression, often giving a handout on CBT for depression for the client to read as homework. The might also recommend self-help books to read about depression.

In the first session the therapist will start by setting an agenda, which will include reviewing the homework and starting a simple formulation of the client's depression. This may well include helping the client see if they are in a vicious cycle of depression, where low mood leads  low energy and fatigue,  leading to decreased activity and neglect of duties, feelings of guilt and hopelessness and increased depression ... The first intervention may well be activity monitoring and activity scheduling.  This will allow the therapist and client to see how active or inactive they have become and also to identify possible activities that will give them either some pleasure or sense of achievement that will lift their mood and start moving them into a virtuous cycle.
Later sessions will include cognitive restructuring, challenging negative automatic thoughts using a thought record.
Other inteventions may include problem-solving and behavioural experiments. 
For example, a behavioural experiment may test out some dysfunctional assumptions that are maintaining the clients depression - e.g. "if I go out, I won't enjoy myself" or "if I call a friend, they won't wont to speak to me.".  In some cases, it may be necessary to try to help unhelpful schemas and negative core beliefs.

In the final sessions, a blueprint will be created to manage relapse


Recommended Links - free resouces for CBT of Depression


Very Good self-help guide from MoodJuice

Excellent handout on Vicious Cycle of Depression

NICE guidelines on depression (2009 64 page PDF)
NICE quick reference guide on depression

WORD version of Activity Scheduling - grid and tips

Thought Record for Depression

Simple explanation of CBT for depression

PHQ-9 - Free Patient Health Questionnaire frequently used in NHS as quick and easy way to measure depression

First Chapter of "Depression for Dummies"

The evidence base for cognitive–behavioural therapy in depression: delivery in busy clinical settings - full 2003 article

2007 review of evidence for CBT for depression








Useful CBT/REBT manual for clinicians for depression
Short article expalining CBT for depression

Short handout for clients on CBT for depression

Good article on problem-solving therapy which has been shown to be effective for depression

Sunday, 5 February 2012

CBT and Behavioural Experiments

According to the bible of Behavioural Experiments,  the Oxford Guide to Behavioural Experiments in Cognitive Therapy 
"Behavioural experiments are amongst the most powerful methods for bringing change in cognitive therapy".  
In this article I will 
-  Answer the question "What is a behavioural experiment?"
-  Explain why and when to use behavioural experiments
- Give an example of a good behavioural experiment
- Advise on  some Dos and Don'ts for setting up effective behavioural experiments
- Provide further resources on behavioural experiments in CBT, including handouts and record sheets.

What is a Behavioural Experiment?


Behavioural Experiments are planned activities , based on experimentation or observation,  undertaken by clients in session or between sessions. They test existing beliefs  and/or help  test more adaptive beliefs. Their design is derived from the formulation. 
Put most simply
A behavioural experiment is when the client gets to  test something out.


Why   Why use Behavioural Experiments?
Inece
WO      Many novice  practitioners associate CBT with thought records , with just about trying to help clients think about things differently. Whilst its true that the thought record can be a powerful method, it's rarely sufficient on its own. The thought record allows the client to become more aware of their thinking and patterns of behaviour, and even to come up with alternatives. But they still may not be fully convinced that the alternatives are true. This is where behavioural experiments come in. Behavioural experiments can

          Test client’s old, negative and unhelpful existing beliefs
          Test client's ne  and more helpful beliefs 
          Enable experiential learning - "learning by doing" 
          Increase the chances that clients will say they "feel it in my heart" as well as "know it in my head"

            An example of a good behavioural experiment

For example, let's consider Julie, who has come for CBT because of difficulties with social anxiety, especially with making  presentations which she has to do at work. She has already done a thought record where she has identified the following belief
When I give a presentation it is obvious I am very nervous and everybody thinks I am a terrible presenter 
Julie believes this is true with a certainty of 90%.
A thought record gives her the alternative perspective  that this may be mind-reading and extreme thinking.
She constructs an alternative belief

               Although I am very nervous it may be that not everyone notices this and maybe some people think this I am an OK presenter

After consideration she says she believes this 25% and the original belief goes down to 75%. As a result her anxiety is somewhat reduced.Whilst this represents some progress, notice that Julie still doesn't really believe the second belief very strongly.

Julie needs to test out which belief is true - she needs to do a behavioural experiment.
Her therapist and her design the following behavioural experiment. Julie will design a survey to give to colleagues after she does her next presentation. The survey asks for two questions to be answered  honestly
1. On a scale of 0-10 (10 very nervous)  how nervous do I look when presenting?
2. On a scale of 0-10 (10 very good) how good am I at presenting?

Julie predicts she will score 9 out of 10 for nervousness and 2 out of 10 for being good at presenting.

She is amazed when she gets the feedback forms back from her survey and discovers she scores 4 out of 10 for nervousness and 6 out of 10 for being good at presenting. Notice that her colleagues don't say that she is completely nerveless or that she is a fantastic presenter - but they say enough to disprove her extreme thinking.

When asked to re-rate her original beliefs she now says rerates the positive belief at 75% and the more negative belief only 25%

As if often the case, a behavioural experiment has made a much greater impact that thethought record.

Some Dos and Don'ts for setting up effective behavioural experiments

*         Plan experiments thoroughly don't just say "why don't you try it out"?
*      Find out what beliefs are being tested, and how much the client believes them now
*      Be specific about what the client will do, where and when
*      Think about what problems are likely to be encountered and how to deal with them
*       Set up experiments to be  “no-lose” – we learn whatever happens
*          After the experiment, explore the outcome – what happened, which beliefs were vindicated, what the client has learnt – how much their beliefs have changed
*      Be enthusiastic and positive about the clients efforts and stay curious 
*      Finish by asking "what's the next step?"


More good free resources on Behavioural Experiments in Cognitive Therapy
Introductory chapter (Historical and conceptual underpinnings) from Bennett-Levy, Butler, Fennell, Hackmann, Mueller  & Westbrook  Oxford Guide to Behavioural Experiments in Cognitive Therapy


Chapter on Behavioural Experiments for Depression by Fennell, Bennett-Levy & Westbrook from their book  Oxford Guide to Behavioural Experiments in Cognitive Therapy (Chapter 10)

Good handout on behavioural experiments to give to clients

Good powerpoint presentation on Behavioural Experiments

Behavioural Experiment Worksheet

Another behavioural experiment worksheet from Good Medicine (recommended site)

Good  Behavioural Experiments   FAQ

Video demonstration of  setting up a behavioural experiment

Manual including behavioural experiments for Chronic Fatigue Syndrome (CFS) and ME

Systematic review suggesting some evidence that behavioural experiments may be more effective than exposure alone