Self-therapy using CBT

'What lies at the bottom of the ocean and shakes all over?’ A nervous wreck! Yes, that was me confronted with fear of public speaking. This is a common phobia among my contacts and reportedly the no.1 fear in the American society. Whenever we are thrown into the situation to speak up, very few of us are brave enough to do so. Although my work does not require me to address a large group but I am expected to lead in a small group from time to time.

When I was younger, I used to tremble whenever I spoke in a large setting. I am more composed now but I am still plagued by internal discord just before I open my mouth to speak. My thoughts would also become jumbled somewhat. The CBT specialization has helped me address the fear. I think I am worried about making mistakes. I want to give a perfect speech or deliver a perfect performance. I may have even harbored a mistaken thought that I have to get everyone in the audience to approve of me.


But I think I am wrong. I realize now as I type, my audience doesn’t expect perfection. I think they want something of value. If they walk away feeling better about themselves or feeling happy or entertained, they will consider their time worthwhile. The operative word is GIVE not GET. (Not to get respect, approval, fame, client… but to give of myself.) The truth is also someone in the audience is going to disapprove of either me or my argument. I need to recognize that in a large group, there will always be a diversity of opinions, judgments, and reactions. I have learnt that the best way to succeed is to give myself permission to be myself in front of other people. And that includes being silly or do anything else that feels natural in the moment. The key is to be humble and if possible, humorous too.

Growing Families International (GFI)

330 delegates congregated at the Queenstown Baptist Church for the GFI conference.
GFI runs the GKGW (Growing Kids God’s Way) and Reaching the Hearts of Teens in some churches in Singapore. I attended the Teens course earlier this year to learn of the spiritual dimension that parents turn to when all else fail to work. I was encouraged when reminded that I am HOPE for within me dwell HIM who is HOPE.

As a parent of the post-modern age, what I say and how I say it matters. The impact of post modernism is chaos and confusion somewhat. It is like playing different types of games on a common field. There are many rules and different realities. Nothing is absolute. How do I communicate the absolute truth when the young person before me ‘sees everything at once’? The diverse choices available to him/her make decision-making a more complex process. How do I adapt to social/technological changes in order to tune into the senses of the children of the new age.

How do I manage the WHY and the problem of HOW?

(B + g) = W + H = S to satisfy N.

B – Beliefs g - goals W – Why H - How S – Solution N – Need

‘g’ must have reasons to exist. Without beliefs there will be no goals. ‘W’ is why we do what we do. It represents the constant beliefs in our hierarchy of values forming our beliefs and goals.

The next symbol of the equation is where the rubber meets the road in parenting. It is taking the WHY behind what we are doing based on our BELIEFS and GOALS and translating it into HOW we accomplish our WHYS. HOW represents the many options and variables of application.

HOW and WHY compete when HOW tries to take over WHY. One of the most unrecognized causes of frustration in the management of the home appears when HOW takes over WHY. We mistakenly and unintentionally assign value to how something is done that supersede the VALUE of WHY (Primary). Sometimes the HOWS of life stop us cold. In our frustration, we begin to examine why our METHOD (HOW) does not work and we miss moving forward in life because we are stuck trying to fix a broken HOW.


The secondary HOW then begins to dominate our thinking and time. We end up worried and more focused on fixing the broken HOW than returning to the original WHY to consider other means to satisfy it. In fact, we often become spellbound by FEAR that if our HOW does not get fixed, our goals will never be achieved. In parenting, the greatest values are not on HOW you accomplish our goals, but the WHYS that govern our goals.

The Ezzos touched on the childhood transitions based on Structured Function Principles.
Transitions take on a progression. Expectations on the 1st born are higher and tend to frustrate the child as he/she may find it difficult to keep up. The parents can’t wait to move on to the next stage of transition and may impose certain training prematurely.
Wrong assumptions too may lead to fixing of the wrong things.

1. Nature Vs Will

Before age 3, the NATURE of a child is all ‘me, myself and I’. 3 different theories describe a child below age 3.

a. The child is morally good and has no desire to do wrong.
b. The child is morally neutral.
c. The child has the propensity for self-serving acts that may hurt others.
(i.e. The child sins with no knowledge of it.)

The WILL is a cognitive choice – sinning with knowledge.

2. Training Vs Education

Training takes place before a child is ready to be educated.
Training is the substitute for understanding as the child is not old enough.

When a child does something with the RIGHT motive but WRONG action, EDUCATION is necessary.

When a child does something with the WRONG motive and WRONG action, then CORRECTION is necessary.

Training progresses to education and the process should be positive, speaking ‘LIFE’ and not ‘DEATH’ into the child.

3. Boundaries Vs Freedom

No structure is more stressful as the fear for the unknown is real. Ideal parenting should be restriction leading to freedom and not the other way round. Children may not be able to make moral decisions. They are confronted with too many choices too. First 3 years of the child’s life, parents are the ‘bosses’ as the child is not capable of obeying.


4. Compliance Vs Obedience

When the parents believe that OBEDIENCE is important, the goal will be to train the child to obey. A child may comply outwardly without genuinely want to obey in his/her heart. Compliance is a mind over heart issue that shows outwardly. When a child remains compliant way beyond 3 years of age, problems may arise.

5. External Vs Internal

Children are externally influenced by what they see in their parents (self-control, wisdom.. etc) There are also internal (intrinsic) values which the children possess.

6. Authority Vs Influence

Authority is God-given where parents exercise to achieve goals. A child is ready to make his own choices WHEN he is ready to accept NO option. Parents only exercise relational influence for relational goals.

Attitudes that are not Beatitudes:

Positive attitude starts with the virtue of GRATITUDE. Negative attitudes start with a single vice of ungodly judgments. Attitudes are expressed in facial expressions (rolling of the eyes), body language (shrugging the shoulders) or through speech (yelling). Attitudes do not truly develop until after the child’s conscience begins to interact with moral understanding. Bad attitudes can not be out-grown. Parents correct both the wrong actions and bad attitudes.

Children 6 years and above can be made to reflect on bad attitudes and make it right.

CBT Specialization II (Schema Therapy)

Dr Theiler placed strong emphasis on therapist-client relationship. Concepts in CBT are good for Axis 1 e.g. anxiety, phobias but long-standing issues such as Personality Disorders (Axis 2), CBT alone are not helpful. People with PDs are more rigid in relation to cognitions and emotions. Relationships are often more critical to PDs.
Some people are not able to express and that result in inaccessibility of some cognitions.
Cognitive theories often neglect early childhood.

Schema Therapy (Jeffery Young) is a wholistic and integrative theory (combines CBT with other psychotherapies) with treatment designed to help many long-term (originating from childhood and adolescence) emotional difficulties. Early maladaptive Schemas develop when specific; core childhood needs are not met. Such as safety, a stable and predictable home life – loving, nurturing and attention-giving. There is a lack of acceptance, praise, empathy, guidance and protection. Feelings and needs are not validated.

The broad goal of Schema Therapy is to help clients adapt through changing maladaptive schemas and dysfunctional coping responses by getting their core needs met. The Early Maladaptive Schema (EMS) is defined as a pervasive theme comprised of memories, bodily sensations, emotions and cognitions regarding oneself and one’s relationships with others that are developed from birth throughout one’s lifetime (Client’s perception of reality). And they are dysfunctional to a significant degree. (Young, 1999)

The EMS is more than a belief; it is a theme in life. E.g. Abandonment, Mistrust & Abuse, Emotional Deprivation (due to Cold Parents), Enmeshment, Vulnerability, Defectiveness (due to Critical Parental Style), Social Isolation, Approval-seeking, Failure, Entitlement (Indulgent Parents), Dependence (Overprotective Parents), Subjugation (Controlling Parents) etc.

Schemas originated from negative childhood & adolescent experiences, innate temperament and cultural influences (religion, social economic status, etc). Schemas formed as a result of severe frustration of needs, traumatization, ‘too much of a good thing’, over-identification with significant other, etc.

Coping Styles in relation to Schemas – The ways in which a child copes with a dysfunctional childhood environment:
Schema surrender - --- (freeze)
Schema avoidance ------ (flight)
Schema overcompensation ---- (fight)
As such, we can go into any of the following schema modes through-out our life –

* Vulnerable Child
* Angry Child
* Detached Protector (avoidance & no emotion)
* Punitive, Critical Parent
* Overcompensator
* Spontaneous Child (may be irresponsible)
* Healthy Adult (to strengthen)

Applications of Schema Therapy

Initial Evaluation:
Suitability of Client – psychotic, drug-abuse, or when problem is situational.
What are the main presenting problems and therapy goals?

Pattern Identification:
Presenting problem
Cognitions
Symptoms
Relationships
Life & Family history
Genogram

σ Young’s Schema Questionnaire YSQ
σ Four early memories (client’s memories from childhood)
σ Parenting Inventory YPI

 Link presenting problems to life pattern
 Find emotional links

Schema psycho-education:

 Assign reading of ‘Reinventing Your Life’ by Jeff Young, Ph.D. and Janet Klosko, Ph.D. on chapters for schemas that client scored high on.
 Discuss YSQ and YPI. Look for discrepancies between the two.

Experiential Techniques for Assessment:

 For triggers, get upsetting childhood images of mother or father
 Set up imagery or dialogues with significant people for empowerment
 Ask clients what they need in the image
 Link emotions from childhood images with current life circumstances – Client vents anger and asserts rights when appropriate; client grieves for losses

Case Conceptualisation

• Background information
• Relevant Schemas
• Current Problems
• Schema triggers
• Temperament or biological factors
• Developmental origins
• Early Memories
• Core cognitive distortions
• Surrender behaviours
• Avoidance Behaviours
• Over compensatory behaviours
• Relavant schema modes
• Therapy relationship

Summary of Conceptualization presented to client for feedback and conceptualization is fine-tuned. Client and therapist agree on important problem to work on first in the Change Phase.

 Test the validity of each schema, using evidence from all periods of life
 Try to discredit evidence
 Set up dialogues between Schema Side and Healthy Adult (note positive aspects and feedback to client)

Cognitive Techniques: Self-help Assignments

 Therapist dictates flashcards (to write positive statements) using template
 Write separate flashcards for all recurring life situations/schemas
 Assign Schema Diary in later therapy

Therapy Relationship for Schema Change:

Point out when client’s schemas seem to be activated in a session
Ask client for trigger event, emotions and cognitions
Test validity of client’s reaction: distinguish accurate perceptions from schema-driven overreactions.
Therapist is aware when own schemas are being activated and obtains supervision when necessary.
Concept of Limited Re-parenting – Client internalizes therapist’s Healthy Adult mode
Therapist fulfills needs that were never adequately met, within appropriate boundaries of therapy relationship

Assign and rehearse behavioral and interpersonal changes related to presenting problem to break dysfunctional behavioural pattern.

CBT Specialization IIb

Underlying Schemas

Schemas are clusters of knowledge in a given area that are associated with emotions and behavioural scripts. This tacit knowledge occurs first in the course of development and relates to attachment experiences. It is a non-verbal, implicit view of the self. Tacit knowledge is the source of automatic and unconscious reactions to emotionally meaningful stimuli.

Cognitive Restructuring (from Dr Theiler’s perspective)

Stage 1 – Developing self-awareness

During this stage, the therapist attempts to help the client to identify their evaluative negative ATs, the associated processes of cognitive distortion and their underlying schemas.

Strategies for developing self-awareness:

- Revisit the specific episodes (the ABC model) using Form 2.1 to assess client’s cognition – the distorted automatic thoughts, the underlying maladaptive assumptions, the underlying negative schema; the behavior as well as interpersonal relationship of client with others.

- Explore shifts in affect (inside and outside the session)

- Free association (ask what AT comes to mind?)

- Using imagery/Role-plays

- Symptom induction using Hot Seat technique to bring in the emotions

- Discussion of the worst case scenario (how likely?)

- Look for thoughts that might explain feelings

- Dysfunctional Thought Records (DTR)

- Homework
Stage 2 - Identifying Contrasts in Thinking

The client needs to know thoughts can be different. The variations in the thoughts are determined by the schema one holds. Thoughts can be replaced and that can change feelings/mood.

Stage 3 - Evaluating and Challenging Thoughts

Terms are being defined using Semantic Technique, such as, ‘success’ in the client’s understanding and belief. (How would you define ‘success’? What is 100%, 50%, 0% success?) Therapist will conduct Cost Benefit Analysis, ie., the cost to having such assumption as well as the benefit. Examining the evidence will further help evaluate the value of holding such thought. Both therapist and client will also explore alternative explanations or other way of looking at things. Subsequently actual consequences are evaluated – So what if it happens?

Another technique is Distinguishing Behaviors from People, for e.g., if you do some things that are worthwhile, then how can you be worthless?

Double-Standard Technique is used to highlight client’s tendency to apply a different standard to self from another.

Examining evidence For and Against the assumption – What is the quality of the evidence?

Logical Analysis – E.g., How does someone’s not liking you make you worthless? If one person likes you and another doesn’t, are you worthless or worthwhile?

Challenging the ‘should’ statement and identifying the conditional rules will help client to progress in life although the therapeutic outcome may not be perfect.

Below is an example of a vertical arrow for identifying schemas:-

What if I sing the wrong key? (NAT)


People will notice


They might laugh at me


They’ll think I’m not good enough


I think I’m not good enough
Assumption: If I sing off key, people will think I’m not good enough (it means I’m not good enough)

Belief: I’m not good enough


A General Model of Cognitive Theory

Learning experience

Dysfunctional Schema formed

Critical incident

Schema activated

Negative automatic thoughts and cognitive biases

Anxiety and other affective responses
Behavioural responses


The Standard CBT approach to Depression


Assessment & formulation: Involves behavioural (e.g. withdrawal from others, rumination and social skill deficits), cognitive and interpersonal factors; suicidal risk and medical review

Socialization to treatment

Establishment of goals

Behavioural activation & other behavioural interventions (crucial first step in depression)

Cognitive interventions

Inoculation against future depressive episodes

Phasing out therapy






Developing a Cognitive-Behavioural Formulation

1. Create an all-inclusive problem list that includes major symptoms and problems in functioning

2. Propose an underlying theme that might underlie all the problems
(Client’s belief) What are the antecedents and consequences of the behaviour?

3. Hypothesize how the underlying theme might cause the problems

4. Explore the precipitants for the current problem

5. Look for the origin of the problem in the client’s early life

6. Predict obstacles in treatment based on the formulation

CBT Specialization IIa

Depression affects the whole being of a person – negative (thoughts) about self, (emotional) pains and loss of pleasure (behaviours) with most things.
The fact is people inherit a vulnerability to depression but they do not inherit depression itself and that explains why depression is episodic. All depressions are biochemical events. Medication and the label attached to this illness may help combat shame. Stressful life events (e.g. breakup) are strongly related to onset. They are psychosocial causes of depression.

Anger has a role to play in depression but it is not the sole cause. Depression almost always has more than one cause. Low self-esteem and fear of expressing anger are risk factors for depression. Each painful depressive episode has the potential for personal growth. The depressed person may need to ‘think about what they are thinking about’ – psychological-minded or aware of self. He needs to instill change in himself. The goal is to progress or move forward while retaining the good. The best approach to battling depression is to use multiple approaches to change such as behavioural, cognitive, and interpersonal.

The key symptoms of Major Depressive Episode (MDE) can be clustered into 5 areas:

Behaviour - Inactivity due to loss of interests, poor self-care, self-defeating behaviour, restlessness (do lots but achieve little), light and noise avoidance, alcohol and drug use, crying & inability to cry (in itself does not worsen depression), self-harming behaviours.

Emotional - Depressed mood, loss of interest or pleasure, guilt and shame, anxiety, anger and despair. (Emotional bankruptcy).

Thoughts – Poor concentration, poor memory, difficulty making decisions, negative beliefs about self, the world and the future. Biased memory of the past, ruminations, being easily overwhelmed, racing thoughts, acute sensitivity to rejection, a belief of being punished, paranoia, delusions and hallucinations and thoughts of death.

Physiological - Weight loss, weight gain, insomnia, hypersomnia, agitation, psychomotor slowing, fatigue, reduced sex drive, pre-occupation with bodily symptoms.

Social - Isolation, decreased assertiveness, irritability, disconnection, difficulty tracking conversations, friends asking what’s wrong and friends drift away.


Dr Theiler presented two Personality Subtypes of Depression – The Socially Autonomous style (Type A) and the Socially Dependent type.

I was reminded of my client Grace who fell into the latter type. She has a strong desire for help and always comes to session with a plethora of material. The trouble is she often saves the most important problem to the end and thereby extends the length of the session. She wants the therapist to solve problems and I expect her to return even when she can handle the problems. From her sharing of presenting issues, it was clear she has been over-dependent on her spouse. She expects her spouse to make nearly all decisions by giving up control to spouse. Her spouse finds her too intimidating as she overreacts to crises and wants to share all her feelings with him.

It was interesting to note too some spouses or family members who were called to the session upon requests of clients fell into the Autonomous Type. They were indifferent to therapy and believed they should solve own problems. They too showed lack of trust for the clients’ ability to control and tend to make decisions on their own by covering up their reactions to crises. Some of my teenage clients fall into this category too.

Treatment of Depression

Pharmacology (AntiDepressants Medications – work for approx 50%)
ECT (ElectroConvulsive Therapy) – benefit 50% of those not responding to ADM
Both ADM and ECT may be required for severe MDD

Psychological treatment for mood disorders –

Psychodynamic Long-term and Brief
Cognitive-Behavioural Therapy (Beck et al.) which is evidence-based.


In CBT, the automatic thoughts are being examined. Such thoughts are short, specific and idiosyncratic. They seem to occur reflexively and involuntarily. People’s thoughts are negative most of the time. They involve evaluative distortions of reality. (Even highly intellectual people are not spared.)

Some patterns of distorted cognitive processes (it is refreshing to go through them again):

Filtering (out of positive) by magnifying the negative details.

Polarised thinking – Things are either good or bad. There is no middle ground.

Overgeneralisation - Come to a general conclusion based on a single piece of evidence.

Mind-reading – Without others saying so, I know what people are feeling and why they behave the way they do.

Catastrophising - ‘What if it happens to me?’
Personalisation - Thinking that everything people do or say is some kind of reaction to me.
Control fallacies - If I feel externally controlled, I see myself as helpless, a victim of fate. The fallacy of internal control makes me feel responsible for the pain and happiness of everyone around me.

Blaming - I hold other people responsible for my pain or blame myself for every problem.

Shoulds - I hold a list of ironclad rules about how I and other people should act. People who break the rules anger me and I feel guilty if I violate the rules.

Emotional reasoning - I believe that what I feel must be true – automatically. Eg. If I feel stupid and boring, then I must be stupid and boring.

Fallacy of change - I expect other people will change to suit me if I just pressure or cajole them enough. I need to change people because my hopes for happiness seem to depend entirely on them.

Global labeling - I generalize one or two qualities into a negative global judgment.

Being right - I am continually on trial to prove that my opinions and actions are correct. Being wrong is unthinkable and I will go to any lengths to demonstrate my rightness.

Heaven’s reward - I expect all my sacrifice and self-denial to pay off, as if there were someone keeping score. I feel bitter when the reward does not come.

BasPsychopathology & Classification of Mental Disorders

Classification of Mental Disorders
Wherever we try to mark out the frontier between mental health and disease, we find a neutral territory, in which the imperceptible change from the realm of normal life to that of obvious derangement takes place.’ – Kraepelin (1917)

There is no consensus definition of Abnormal Behaviour. The elements (changes as society changes) of abnormality include:

Distress (suffering)
Dysfunction (maladaptiveness)
Deviancy (statistical deviance)
Deviancy (social deviance – violation of the standards of society)
Discomfort (social)
Dangerousness (irrationality and unpredictability)

Mental disorders are classified so as to provide:

A nomenclature (to structure information helpfully)
An effective ‘language’
Social and political implication (legal etc)
Natural history of disorder defined (prognosis)
Effective specific treatments
Aetiology and pathophysiology
Genetgics (phenotype vs genotype )

Stigmas, Labelling and the Downside to Classfication:

Loss of information
Absence of context
Stereotyping -
Labeling - What happens if fail to label correctly? Diagnoses can be self-fulfilling prophecy for patient. How long does the label apply?
Sigma – Is it ever removed?

DSM classification of mental disorders:

- Patient’s subjective description of a physical or mental disorder
- Objective observation of a patient’s physical or mental disorder by a diagnostician.
Basic Psychopathology - The study of abnormal states of mind

Disorders of Perceptions:

Perception is a process of becoming aware of what is presented to the sensory organs. An illusion is a misinterpretation of a normal perception (normal phenomenon). E.g. saw a shadow and perceived the tenant had come home. Hallucination is a sensory perception without an external stimulus. Hallucinations may occur in any sensory modality—visual, auditory, olfactory, gustatory, tactile, proprioceptive, equilibrioceptive, nociceptive, thermoceptive.

Hypnagogic hallucinations and hypnopompic hallucinations are considered normal phenomena. Hypnagogic hallucinations can occur as one is falling asleep and hypnopompic hallucinations occur when one is waking up. Hallucinations may also be associated with drug use (particularly hallucinogenic drugs), sleep deprivation, psychosis or neurological illness.

Disorders of Thinking:

In psychiatry, thought disorder is a term used to describe a pattern of disordered language use that is presumed to reflect disordered thinking. It describes a persistent underlying disturbance to conscious thought and is classified largely by its effects on speech and writing. Disorders of thinking may affect the stream of thought. Affected persons may show pressure of speech (speaking incessantly and quickly), derailment or flight of ideas (switching topic mid-sentence or inappropriately), thought blocking, rhyming, punning, or 'word salad' when individual words may be intact but speech is incoherent.

Eugen Bleuler, who named schizophrenia, held that its defining characteristic was a disorder of the thinking process. It is important to note however that the delusions and hallucinations of psychosis could also be considered as disorders of thoughts in its content. Delusion is a belief that is unshakeable, untrue and unshared. It can be persecutory (paranoid), grandiose (expansive), jealous, love, hypochondriacal (the belief and fear of serious illness which lasts for six months, beyond and despite medical reassurance), nihilistic (severe depression) and guilt.

Disorders of form of thought is persistent and inappropriate repetition of a response, eg dementia - Perseveration. Rapid shifting on one topic to another, eg mania - Flight of ideas. Clang Association is based on similarity of sound without regard for differences, eg. Schizophrenia.

Disorders of Emotion:

Affect is a subjective feeling at a point in time while mood is a prolonged emotional state. Changes in the nature of emotion come in the form of anxiety, depression, elation, anger, fear and panic. Abnormal fluctuations of affect refer to blunted, flattened, labile and incongruity of affect.
Disorders of Consciousness:

This is a state of drowsiness resulting in incomplete reactivity to external stimuli. Stupor is a state in which patient is mute, immobile and unresponsive yet fully conscious.

Disorders of Memory:

Memory processing involves registration, retention, recognition and recall of datas.
Left brain is for verbal memory. Right brain is for visor-spatial memory. Amnesia is failure of memory.

Disorders of Motor:

There are many types of Motor Disorders. Tics refer to irregular repeated movements of a group of muscles. Echopraxia attempts to imitate movements of others.

Other disorders:

Depersonalization - change of self-awareness, a feeling of unreal, of being detached and unable to feel emotion.

Derealization – objects and environment seem unreal and lifeless.

Déjà vu – recognition of events that are in fact novel/new

Jamais vu – failure to recognize events encountered before

Confabulation – fabrication of stories in response to questions about situations or events that are not recalled

CBT Specialization Ic

CBT is a collaborative empirical approach looking for evidence. It is to be presented as one useful perspective and non-cognitive determinants of distress are not to be ignored. The focus is on trialling the new perspective in order to decrease the emotional commitment to the old. It is about asking ‘what’s useful?’ ‘what’s not useful?’

In order to develop a Cognitive Behavior Formulation, I have to assess client’s suitability for CBT in terms of accessibility of ATs, awareness of differentiation of emotions, acceptance of personal responsibility for change and compatible cognitive rationale of ‘beliefs may be given up if found to be invalid and self-defeating.’ Client must have the potential for alliance. Chronic issues may be harder to treat as compared with an acute issue.

Having considered the above, I will first create an all-inclusive problem list that includes major symptoms and problems in functioning. Then I will look for the underlying (or overaching) theme that might underlie all the problems (e.g. low self-esteem) and then hypothesize how the underlying theme might cause the problems. Explore the precipitants for the current problem. Look for the origin of the problem in the client’s early life. Predict obstacles in treatment based on the formulation.

The 3 stages of Cognitive Restructuring:

Stage 1 - Developing self-awareness

Help the client to identify their evaluative negative ATs, the associated processes of cognitive distortion and their underlying schemas. When client ‘floods’ the therapist with his story, one way to slow him down will be to write down key words to slow down the process. Client may do so in an attempt to reduce anxiety by not going in-depth.

Recounting specific episodes (the ABC model) by asking client to relate the most recent or most important event through free association, imagery or role-plays. Explore and interpret shifts in affect when discuss about the worst case scenario. Look for thoughts that might explain feelings. Distinguish thoughts from facts. Categorize the distorted thinking. Encourage the client to keep a Dysfunctional Thought Records as homework.





Using the Vertical Arrow technique to identify schemas:

What if I babble? (NAT)…. that will be distressing because..
People will notice…………… that will be distressing because..
They might laugh at me……. that will be distressing because..
They won’t take me seriously… that will be distressing because..
They will think I’m stupid.. that will be distressing because..
I’ll think I’m stupid and… that will be most devastating!
(Auto-pilot thinking)

Assumption: If I babble, or am incoherent, people will think I’m stupid (or it means I’m stupid).

Belief: I’m stupid.

Some ways to deal with problems of arousal (Symptom Induction):

1. Use of controlled breathing to reduce anxiety (client feels threatened and can’t cope)

2. Self-soothing (mindfulness)

> Appreciate positive things:

visually (nature; be in the pleasurable moment)
hearing (music)
smell (perfume)
taste (yummy food)
touch (spa; massage)
kinestic (rocking chair)

3. Distraction techniques: [Marshall Linehan – Alternative Process]

ACCEPTS

A – Activities (child throws tantrum at home, take child outdoor)
C - Contributing (talk to someone)
C - Comparisons (others are anxious too)
E - Emotions (alternative)
P - Push away (leave)
T - Thoughts (distracting thoughts)
S - Sensations (alternative eg when having thoughts of self-mutilation, put cold water on chest)


Stage 2 – Identifying CONTRASTS in thinking

Bring to client’s awareness that thoughts or evaluations CAN be different. Rate client’s emotions and beliefs. Help client to identify CONTRASTS in other people that people can behave differently in same situation. Ask client, ‘if you were to think this other way, what might you feel or behave?’ (Thought Insertion). Client experiences personal contrasts in thinking too as in they hold meaningful perspectives at different times/events.

Stage 3 – Evaluating and Challenging Thoughts

- Define terms such as ‘I am a failure.’ Objectively (useless good for nothing) and subjectively. (What does that mean to you? – ‘I didn’t get a HD for this paper.’)

- Cost-benefit analysis (Advantages and disadvantages)

‘I’ll get rejected if I go to the party.’

Costs: I won’t enjoy even if I go. I will the chance for being accepted.

Benefits: I avoid some anxieties of going. I don’t have to make any effort. (Avoidance)


- What is the evidence?

- Is there any other way of looking at this? (alternative explanations)

- So what if it happens? (evaluating actual consequences)

- Using behaviour to resolve the negative thought (eg using ‘shame attack’)

- Double standard technique (Others can do anyhow but I must give a flawless presentation.)

- Challenging the ‘should’ statement (absolute).

- Identify conditional rules (‘If I perform 100% at work, I’ll be ok.’

- Help client to distinguish PROGRESS from PERFECTION.
(Do not need the BEST outcome. Do not have to be perfect.)

CBT Specialization Ib

When client comes in with his problem (e.g. ‘feeling anxious when looking up newspapers for job opportunity’), CBT framework will be used to conduct an initial assessment of the presenting issues. The client will describe problems with regards to:

1. Situations where problem occurs

- Have people noticed or commented on your anxiety? What have they said?

2. Duration

- How long have you experienced this problem?
- When did you first notice that you were feeling anxious?
- Did something happen before you start to feel anxious?
- Have you experienced any major traumatic events in the last 6 months?

3. Frequency

- Do you notice that the problem happens every time you check out on job opportunities?
- Does it happen more on some days compared to others? Why/Why not?

4. Intensity

- On a scale from 1 to 10 where 10 is really bad and 1 is not bad at all, where would you rate your level of anxiety? (i.e. SUDS scale)

- Is it always that bad? Can you think of other situations where the rating would change?

5. Course of problem

- Has there been a time in the last 1 month you have not felt anxious?
- Does it come and go?
- What has brought you to see me now?

6. Predisposing factors

- Are you aware of anyone else in your family who experiences anxiety? If yes, has he sought help for the problem? - Hospitalization, medication, etc.
- Do you have any medical health problem?

- Have you noticed frequent changes in your mood state?

Behavioral Analysis of the Problem:

Situational triggers - ‘Have you noticed that you feel more anxious when you are checking out the job advertisement with people around you?’

Behaviour triggers – ‘Have you noticed that you feel more anxious when you need to call the prospective employer for appointment?’

Cognitions – ‘Can you tell me exactly what was going through your mind when that happened?’

Affect/emotional factors – ‘Can you tell me whether there are any other moods that influence the anxiety?’

Social factors –
‘Does it make any difference whether you are interviewed by just one interviewer or a few?’
‘How would you normally respond to no reply from job application?’
‘What does your husband think about the problem?’

Physiological triggers – ‘What do you notice about your body before you experience the anxiety?’

Maintaining factors –

‘You said that you are tired of working, is this something that you would try to avoid?’
‘What would need to happen for you to let go of this problem?’
‘What have you stopped doing because of this problem?’
‘How has your life changed since having this problem?’

Coping (Environmental) Resources/Personal Strengths

‘I wonder what you do to help manage this problem.’
‘What about other times in your life when you have felt anxious – how did you get through these times – do you remember what you did?’

Client’s views of the problem & expectations of change

‘How hopeful are you that the problem will go away?’
‘What are you expecting from the treatment process?’

CBT Specialization Ia

AP Glen Bates arrived with flu but there was no sign of jetlag. I recalled how I benefited from him when he was here in June. I had a PTSD client then and the equipping was timely enough for me to ‘unload’ whatever that was relevant from AP G Bates on to my client. Lo and behold, the client recovered after two sessions. 

As the final Assessment Tasks were designed (and to be marked) by AP G Bates, the whole cohort seemed unusually motivated to engage and elicit whatever tips and ‘extra’ information necessary to churn out a satisfactory piece of work.

One of the major assumptions of the CB approach is that people have a natural tendency to negate the cognitive processes which results in psychological distress. Cognitive processes are the key proximal (‘at the time’) determinant of stress and behavioral dysfunction.

Primitive Thinking Mature Thinking
Non-dimensional and global
‘I am rotten.’ ‘I’m rotten in everything
I do.’ Multidimensional
- multiple selves (roles/styles)
Absolutistic and moralistic
- Fear of making mistakes, must have approval
all the time Relativistic and non-judgmental

Invariant Variable
Character diagnosis (Who we are) Behavioural diagnosis
(What we do)
Irreversible Reversible

AP Glen Bates touched on Ellis’ REBT on sources of well-being namely, approval from others (ego/sense of self), successful performance/achievements (ego/sense of self) and comfort (absence of distress).

In REBT, the Core Irrational Beliefs are:

- Demands (Unless that happens….)
- Awfulising (A distress state of internal rumination.)
- Low Frustration Tolerance (LFT)
- Global evaluations of self-worth (ingrained view of self)

Whereas Beck’s Cognitive theory consists of:

- Automatic thoughts :

Short, specific and idiosyncratic (personally relevant)
Occur extremely involuntarily and rapidly, immediately after the event
Do not occur in sentences or logical order
Often ATs have the same themes (e.g. approval)
ATs involve evaluative distortions of sense of self. (e.g. I am stupid.)
Seem plausible at the time

- Distorted cognitive processes (unconscious) :

• Filtering – ‘Anyone can do it.’ ‘Most times I can’t do it well.’
• Polarised thinking – ‘I must pass with HD, otherwise I can’t face my family.’
• Overgeneralization - ‘He is out to get me all the time.’
• Mind reading - ‘He thinks I’m unattractive.’
• Catastrophising – ‘I will faint if I go on stage.’
• Personalization – ‘They are looking at my direction. They must be talking about me.’
• Control fallacies - Externally controlled: ‘He always says I am useless and bad. I must be bad.’ Internally controlled: ‘My company goes into bankruptcy because of my poor performance.’
• Fallacy of fairness – ‘They always think I am biased in my judgment.’
• Blaming – ‘He always makes me feel awful.’
• Shoulds – ‘He should address me properly instead of calling me by my first name.’
• Emotional reasoning – ‘I must be stupid and boring coz I feel stupid and boring.’
• Fallacy of change – ‘My husband must start buying me flowers on Valentine’s Day.’
• Global labeling – ‘The whole school will shun him for being tardy.’
• Being right – ‘I know the only right way to go about doing it.’
• Heaven’s reward – ‘I have sacrificed so much for the family but no one is grateful.’

- Underlying schemas (how people interpret events)

σ They are clusters of knowledge occurs largely out of awareness (associated with emotions and behavioral scripts)
σ Tacit knowledge occurs first in the course of development and relates to attachment experiences
σ It is non-verbal, creates an implicit view of the self.
σ It is the source of automatic and unconscious reactions to emotionally meaningful stimuli


A General Model of Cognitive Theory:

Attachment Theory:

Attachment theory asserts that there is a vital initial stage early in life that lays the foundation for the development of healthy relationships. An attachment bond is a specific form of relationship that is characterized by feelings of comfort when near the other person and a desire to remain close when distressed or when this person is inaccessible. The need for attachment bonds is believed to be inborn and is satisfied initially by the presence of responsive, dependable, and available caregivers who provide sustenance and comfort and actively intervene when problems are beyond the child's capacities. Attachment figures provide a secure base from which the child can explore the world and return for comfort, safety, or help when necessary due to distress, fatigue, or other problems.

In order to establish healthy adult attachment patterns, the child must have experienced with caregivers some level of safety, consistency, responsiveness, and comfort that creates a "secure base." If established, this secure base allows the child to actively explore his or her external and internal worlds and successfully develop new relationships. Through these early interactions, each person develops "working models" or internalized views of self and others that influence how each person anticipates and perceives later interpersonal relationships as well as the methods for and ability to elicit appropriate caretaking behaviors from others. As such, the attachment process and attachment styles of people are mediated by the quality of early caregiving, which ultimately influences future relationships.

Securely attached individuals are better able to explore and experience their internal and external worlds relatively effectively and confidently. Anxiously or insecurely attached (avoidant, detached, enmeshed, or ambivalent) individuals have more difficulty exploring and experiencing their worlds and have particular difficulty getting their interpersonal needs met appropriately. A pattern of insecure attachments is believed to be related to a variety of psychological difficulties.

Bartholomew, K. (1990). Avoidance of intimacy: An attachment perspective. Journal of Social and Personal Relationships, 7, 147-178.

SOS Suicide Prevention II

Being the Executive Director, Mrs Tan is very well-versed with the SOS Suicide Model.
As it was right after lunch, I noticed a couple of sleeping eyes. I was glad I did not take a full lunch and got interested in how to ‘ask suicide questions’. Posing the question will not make the situation worse if the ideation is already there. I was relieved to learn it may even be a relief for the client to know someone cares enough to want to know about it. Asking the question outright at the right timing with the right amount of empathy instead of skirting around it nervously will be perceived more professional and confident, I reckon. Open-ended questions invite the client to open up slowly as most times the latter is in a state of ambivalence.

Who do we pose the question to? Clients from any age group and the mentally ill included. Elderly persons fall under the high risk bracket of suicide cases. Even those aged 10 and below know what suicide is about basically although the depth of their knowledge varies. The young persons are impulsive and they fall under suicide copy-cats. Those who are mentally ill form 1/3 of completed suicide cases. I must not miss the opportunity to pose the question. It is safer to err on the side of caution.

In my risk assessment for suicide ideation, I examine client’s feelings, motives and expressions. Some empathetic statements I can use before popping the suicide question are:

1. I hear you say ‘life is not worth living’, I wonder if you have ever thought of ending it?

2. I sense you feel intense hopelessness, I wonder if you ever consider ending it all?

3. You seem devastated and overwhelmed by the challenges you are facing presently. You talked about ‘no way out’, I wonder if you have thought of ending it all?

The Los Angeles Suicide Prevention Centre identified 7 basic factors which can be used for judging a person-at-risk’s potential for completing suicide.

1. Age - Risk of suicide increases with age.
2. Sex - Men die by suicide more often than women. (Apparently the methods they used are more fatalistic.) Women attempt suicide more often than men.
3. Stress - A loss/change (current or anticipated) that is perceived as substantially diminishing the value of life.
4. Symptoms - Changes in behaviour, physical condition, thoughts or feelings (hopelessness/helplessness).
5. Current Suicide Plan - A specific, detailed plan consisting of method, venue and date and time of how to kill oneself and the means to carry it out.
6. Prior suicidal behaviour - Prior attempt or history of suicide in the family. Is it active and intense? (Happened recently? Frequency? Method?)
7. Resources - Supportive, preserving factors - Family, friends, career (external) and faith (internal).

In my assessment of risk, my focus will be on item 5, 6 and 7.

If there is no concrete suicide plan (+), no prior suicidal attempt record (+) and there is resource for client to fall back on (+), the risk is LOW.

If there is suicide plan (-), no prior suicidal attempt record (+) and there is resource for client to fall back on (+), the risk is LOW – MEDIUM

If there is suicide plan (-), there is prior suicidal attempt record (-) and there is resource for client to fall back on (+), the risk is MEDIUM

If there is suicide plan (-), there is prior suicidal attempt record (-) and there is no resource for client to fall back on (-), the risk is HIGH.

The protocol for SOS counsellor to do will then be:

1. Identify risks (using empathetic statements and suicide question)
2. Inquire plans
3. Assess risks (CPR)

Personally, I find clients’ ambivalence usually lies between wanting to die for someone and at the same time to live for another. By helping client to focus on the one(s) he would live for seems to help to a great extent.

Response to Child Psychotherapy

Ms Leong: “I see that working with Children and working with Adolescents as being
vastly different, and I certainly believe that it requires very different
skills, as well as specific knowledge to working with adult clients. I think
in any statements on this position we need to draw a clear distinction
between the two, and recognize them as linked, but slightly different
specialisms.

I feel that therapists working with these 2 groups must constantly use a
'mental check list' to see if we have sufficient skills and knowledge to do
the job competently. If in doubt we should seek supervision and get into
working support groups.

We should also encourage ourselves if we are working with children to invest
in books, conferences and workshops to strengthen ourselves with an
underpinning theoretical framework and that our therapy is also supported by
professional literature.”

A belated reflection after reading Toh Hwee Boon’s input :

In my practicum experience, I had only come across 3 children (aged 9 to 15). From the outset, I chose to abide by the formal training received from ECTA with regards to confidentiality and boundary. For both groups of children (in primary and secondary), I would assure that whatever they shared would be kept in confidence unless they had intent to self-harm or hurt others. (Informed Consent form applies.) As for the parents, I would make it clear that permission would be sought from their children before I divulge any info. As such, I didn't have an issue with enmeshing the two parties. I agree with Jessica’s subsequent comment in a later email that very often the parents themselves are overwhelmed by their own personal and interpersonal issues to be able to handle their kids. I believed the relational tensions experienced by the kids at home had caused the kids to play out their frustrations in school. In the cases above, therapy was extended to the parents concurrently so that with improved relationships they could role-model their kids better.

I agree with H Boon that children can be very 'lonely' in spite of intense care of their well-being by parents and school. Their 'facade' (fueled by their rackety feelings) seems to work for them for some time but you and I know we need to help them to address the repressed feelings when they find it difficult to cope any longer. In therapy, often than not children react well to 'friendly chats' which leads to deep sharing if the therapeutic alliance is well-established. For children who enjoy drawing, I used their drawings to find 'openings' to enter their inner worlds. Some stories are great materials to inculcate good values indirectly. In this IT age, an IT-enhanced therapy may be more appealing and meaningful (?) to the computer savvy ones who are more attuned with the technology. For older children, I find topics on hobbies, games, friendship etc good avenues to explore and venture into the young minds.

I have yet to meet any parent who is resistant to therapy. The parents in my contact are mostly concerned & overly concerned ones with a couple of spouses who prefer to pursue their own happiness than addressing the needs of a kid. By and large, they want to co-operate with the therapist to reach out to their children (away from the limelight in school). This may take on a different meaning and implication in a school setting as the school authoritative figures are also involved in the helping (open) process. Some times the parents who are called in to meet the school counselor have different sets of expectations to comply - the school’s expectation of the child, the counselor’s expectation of the parents and child, and the parents’ own expectation of the child. Whose value systems should prevail in this case?

I will be seeing a Primary 6 child next month. She is ‘misbehaving’ according to her mother. The negative behavior came about after being locked up in the house together with her mother and siblings by their father on two occasions. She became hysterical during one of the lock-ups and threatened to jump out of the window. Knowing her unique background information, I cannot think of a straightforward approach to addressing her as she may be 12 years of age, but having witnessed and experienced family violence growing up has developed in her the fighter’s spirit.

Every child and adolescent has their own unique encounter in life. I agree with Jessica in that our approaches towards children and adolescents may have to be creatively varied to meet the special needs of the young person willingly or unwillingly enter our therapeutic zone. 

SOS Suicide Prevention

Mrs Tan briefed us on the types of services provided by SOS at the outset of workshop:

- Email befriending (targeting the young people mainly)
- Face to face counselling sessions
- Hospital and police referrals
- Emergency squads (2 volunteers on standby)
- Local outreach to suicide survivors/bereaved (LOSS)
- Healing bridge
- Community education (suicide prevention)

Trained counsellors man the 24 hr hot line – 1800 2214444 and types of crises intervened include accidental (sudden and unexpected ) or situational (retrenchment) crises, developmental or maturational crises (unwanted pregnancy, loss of health), disasters (mass destruction). When a person’s coping mechanism is overpowered by disequilibrium, it is not a pathological state; it may occur to anyone at any stage in a life span. (Golan 1978) It is possible to overcome the crisis if the problems are clearly defined and the significant persons re involved in the resolution.

The six stages of a crisis:

1. Hazardous build-up (stress/pressure/tension evaluated from Client’s point of view.)
2. Precipitating event (coping mechanism stretched as a result of direct/indirect events; experience loss of some sorts.)
3. Disorganization (can’t think properly; turn to secondary resources – eg social worker)
4. Breaking Point (pinnacle/unbearable. Reach out to anyone/anything even to an active suicide attempt.)
5. Re-organization (exhausted emotions, rediscovery of strength and options.)
6. Restoration (renewed confidence in self. able to make choice and take action.)

While handling a crisis situation:

1. Remain calm and attend to the feelings by putting judgement aside. Reflect client’s feelings (say ‘I sense you feel…’ ‘I hear you say….’)

2. Explore the problem NOW, not the root cause. Examine triggers/meaning/impact.

3. Periodically paraphrase/recap to the client to ensure common understanding of key terms.
4. Define the focus - WHAT is causing the client great pain? Allow focused area to change.

5. Explore available resources - What has Client tried so far? What would the client wish to do about the situation? What is client afraid to do? Who would he like to talk to if he could?

6. Establish open line of communication for client to re-contact if client’s choice of action plan fails.

On the continuum of suicidal behaviour, the following take place:

1. Client harbours and exhibits risk-taking thoughts and behaviours respectively.
2. Suicidal ideation – (at thinking level) either fleeting or intense
3. Suicide threat (e.g. sitting on the window ledge)
4. Suicide attempt (any form) – High intent to die but survive attempt
5. Suicide (death is the outcome) - High intent to die.

6. Low intent to die and end in death – classified as accidental suicide if no foul play (misadventure, accident)
7. Low intent to die and survive – para-suicide

Facts:

- Suicidal people don’t want to die.
- A suicidal crisis is generally of short duration.

Myths:

- People who talk about suicide won’t do it.
- Suicide occurs without warning.
- Asking someone if he is feeling suicidal will put the idea into his head.
- Suicidal people do not seek medical help.
- Terminally ill people often die by suicide.

A suicidal person is more likely to be thinking about ending their pain, rather than ending their lives.

Acknowledge and reflect their strong feelings of suicide AMBIVALANCE.

Counseling Research Methods & Processes

Dr Lim is soft-spoken, very humble and warm. We were asked to write a paragraph about self in 2 minutes, draw a line, write another paragraph about self in 2 minutes, and then draw another line and another paragraph about self in 2 minutes….

The 3 paragraphs of mine are ‘I am God’s child, seeking to understand how to impact people’s way of life through therapeutic intervention. One way is to sharpen my intuitive and interpretative skills.’ ‘I think I care enough to want to listen to another’s views or perspectives. I care enough to offer alternatives/options. I learn to leave the decision to change to the client (and to God if client is powerless to do so). I am only an agent for change.’ ‘I’m capable of change myself. I am changed by my interactions with people around me. I need to consciously be aware of not allowing my professional self to interfere with my personal interaction with loved ones. I need to consciously step back and look at the bigger picture.’

Counseling is more than having a good heart. It is about professionalizing the profession. Dr Lim talked about using the 3rd ear to listen for hidden fear, hurt and be less literal. My assessment of the client has to be continual, systematic and not rigid. Clients may come to me as a ‘customer’ (or visitor to shop for a doctor) or (complainer who appears committed but with motive to change others and not himself). Functionally, who is the identified patient? He is the one who cares most to change the situation because he is suffering the most ‘pain’ and is motivated to change.

As client goes through different levels of honesty with the therapist, the latter has to repeatedly gather information, forming hypothesis, test it and conduct therapy. In presenting a problem to the therapist, client uses his own language to describe his problems. Although the therapist has the professional vocabulary to collapse problems into meaningful category (efficient but not personal), it will appear more personal for the client if the therapist uses client’s words. The idea is for the client to verbalize his goals. The way to collect past data will be to ask, ‘why now?’ ‘What was helpful? What was not? What’s made it intolerable now? What kind of resources were there previously?’

I find the encapsulated assessment guide a very organized way to do a Focused History which is self-explanatory (sample on next page) of presenting problems. It serves as a guide which means while collecting data, I will do ‘trial therapy’ based on guesswork and clinical judgment.

Personal Life experience (intuition) Clinical experience

Factual Treatment
CONCEPTUALIZATION
Data Plan

Empirical Research (eg DSM IV) Theoretical
Biological (Behavioral) models

While conceptualizing or formulating symptoms, I may use Psychodynamic psychotherapy (PP) to hypothesize , CBT to understand (a compounded issue) as well as PP to make sense of and Existentialism Theory to examine .

Conceptualization Explanatory Concepts

1. Psychodynamic Conflicts (Internal)
(Internal forces) Developmental arrest (stuck at a certain age)
(TA – Reparenting)

2. Behavioral Contigency (sequence of events)
Keep repeating/reinforce
(e.g. What was the last quarrel like?)
A > B > C

3. Cognitive Cognitive distortions (specific incident)

-competency (not good enough)
-affiliation (nobody loves me)
-safety (people are out to get me)

4. Systemic Interpersonal functions of symptoms. [Problem is
serving a function.]


Treatment Plan:

Goal (Client’s) Intervention (Therapist’s) Review date

1. Client will be sleeping an ave of at least
six hrs each night (Frequency)

Instruct him on sleep
Hygience and
Diaphragmatic breathing
30/12/07

2. Client will report a general depressed mood of no more than 6 (1-10 scale). (Intensity)
Motivate him to identity and exercise his strength
(eg meditation) 30/10/07

Before we were dismissed, Dr Lim went through with us a long list of defense mechanism definitions. He explained each one of the following painstakingly and we benefited from it a great deal. 

DENIAL - No, I am not having cancer (after having diagnosed positively.)
RATIONALIZATION (Prove one’s action.)
INTELLECTUALIZATION (logic-tight comparisons)
DISPLACEMENT (scolded by boss, go home and kick the dog.)
PROJECTION (Husband wishes to have girl friend, blame wife for having EMA.)

REACTION FORMATION (act out opposite to how one feels)
UNDOING (husband comes home with a bunch of flowers to reduce guilt after seeing gf)

WITHDRAWAL (numbing self emotionally)
INTROJECTION (‘I think I should at least pass.) – don’t really believe.
FANTASY (too painful, boring.) - daydreaming, imaginary solutions

REPRESSION (unconsciously block out painful thoughts)
IDENTIFICATION (Feel more important by associating with someone with higher value)
ACTING OUT (Repeatedly doing actions to keep from being uptight without weighing the possible results of those actions)

COMPENSATION (hiding weakness, stress on strength)
REGRESSION (In face of PSLE, wet the bed.)
RETROFRACTION (‘I really want to do it to somebody else, but I can’t, so I do it to myself.)
SUBLIMATION RETROFRACTION (I want to beat you but I choose to change it to humor and direct it to myself.)

The defense mechanism in bold are the ones I associate with from time to time. 