156 -Cognitive Processing Therapy with Anxiety, PTSD and Chronic Illness
Counselor Toolbox

 
 
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Cognitive Processing Therapy with Anxiety, Trauma and Chronic Conditions
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs.com Counselor Continuing Education
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery

Counseling CEUs can be earned for this presentation at https://www.allceus.com/member/cart/index/product/id/336/c/
Objectives
~ Learn the goals of CPT
~ Discuss how CPT can be applied to people with chronic conditions, anxiety or trauma issues
~ Identify some of the common tools used in CPT which can be helpful with many clients
Introduction
~ CPT is based on a social cognitive theory that focuses on how the event or symptoms are construed and coped with by a person who is trying to regain a sense of mastery and control in his/her life (chronic illness dx, trauma, GAD)
~ Emotions such as fear, anger, or sadness may emanate directly from the trauma or condition (primary emotions), because the situation is interpreted as dangerous, and/or resulting in losses.
~ Secondary, or manufactured, emotions also result from faulty interpretations made by the patient.
Social-Cognitive Theory
~ Social-cognitive theories focus more on the content of cognitions and the effect that distorted cognitions have upon emotional responses and behavior.
~ In order to reconcile the information about the current situation with prior schemas, people tend to do one or more of 3 things:
~ Assimilation is altering the information to match prior beliefs (“Because a bad thing happened to me, I must deserve punishment”).
~ Accommodation is altering beliefs enough to incorporate the new information (“Although I didn’t use good judgment in that situation, most of the time I make good decisions”).
~ Over-accommodation is altering ones beliefs about oneself and the world to the extreme in order to feel safer and more in control (“I can’t ever trust my judgment again”).
Dimensions of Disruption
~ 5 major dimensions that may be disrupted by traumatic events:
~ Safety
~ Trust
~ Power and Control
~ Esteem
~ Intimacy
12-Session Protocol
~ Introduction
~ Meaning of the event
~ Identification of Thoughts and Feelings
~ Remembering the Event
~ Identifying “Stuck” Points
~ Challenging Questions
~ Problematic Thinking
~ Safety
~ Trust
~ Power and Control
~ Esteem
~ Intimacy and Meaning

Natural and Manufactured Feelings
~ 2 kinds of emotions that follow traumatic events.
~ Natural/universal: fear when in real danger, anger when being intentionally harmed, joy or happiness with positive events, or sadness with losses.
~ Natural emotions have a natural course. They will not continue on forever unless there is something that you do to feed them
~ Manufactured feelings, result not directly in response to the event, but based on how you interpret the event.
Goals
~ Help clients recognize and modify what they are saying to themselves “stuck points”
~ Help clients identify:
~ How the condition or event impacted on your views of yourself, other people, and the world.
~ Why this event happened to you
~ How has it changed or strengthened your views about yourself, other people and the world in general?
~ Address the content of the meaning derived from the traumatic memory.
~ Help clients accommodate, or accept that the traumatic event occurred and discovering ways to successfully integrate the experience into the one’s life
Goals cont…
~ Determine the impact of the traumatic event or condition on beliefs about self and others
~ Begin to normalize the grief process and differentiate it from PTSD, anxiety or depressive symptoms
~ Identify stuck points that may interfere with the normal course of bereavement
~ Begin to assist patients in viewing their relationship with the person who died or themselves as altered, but not finished.
More Goals
~ Assist patients in labeling thoughts and emotions in response to events
~ Introduce the idea that changing thoughts can change the intensity or type of emotions that are experienced
~ Begin challenging self-blame and guilt with regard to the symptoms or event through socratic questions
~ Assign clients to write a detailed account of the trauma or the course of the symptoms and precipitating events.
More Goals
~ Begin challenging self-blame and other assimilation with Socratic question
~ Discuss 20/20 hindsight (hindsight bias) and how easy it is to say how you should have behaved after something occurs.
~ Help the patient contextualize the traumatic event.
~ Educate the patient about the distinction between blame and responsibility.
~ Responsibility relates to one’s actions in a situation that contributes to a certain outcome.
~ A combination of responsibility and intentionality is what determines blame.
6 main types of Socratic questions
~ Clarification Questions help patients examine beliefs by requesting more information.
~ Probing Assumptions challenges the patient's unquestioned beliefs that underlie their stuck points.
~ Probing Reasons and Evidence helps patients examine the actual evidence supporting their beliefs
~ Questioning Viewpoints and Perspectives encourages patients to come up with alternative perspectives.

6 main types of Socratic questions
~ Analyzing Implications helps patients examine the unpleasant outcomes that logically flow from holding maladaptive beliefs.
~ Questions about Questions place the focus back on the patient when potentially inappropriate questions get asked of the therapist.
Identifying Stuck Points
~ “Stuck Points” the most difficult parts to re-visit.
~ Look for these parts of the story:
~ Where you jump from one event to another, without any transition.
~ Where you avoid the full details.
~ That you can’t write about.
~ You can read, but sound numb/intellectualized
~ You are suddenly flooded with emotions.

Identifying Stuck Points
~ A stuck point happens wherever
~ There is a conflict between your old beliefs (or what you want to believe), and the reality of the situation.
~ Your experiences seem to confirm a prior negative belief you have had about yourself.

Common Stuck Points
~ I have no right to feel happiness/take a break
~ I could have prevented this if only…
~ If only I had ____, this wouldn’t have happened
~ This can’t be happening. It is just a bad dream.
~ My life is over
~ I am broken/faulty

Myths of Mourning
~ Grief and mourning decline in a steadily decreasing fashion over time.
~ All losses prompt the same type of mourning.
~ To be healthy after a loss, the mourner must put it out of mind.
~ Grief will affect the mourner psychologically but will not interfere in other ways.
~ Intensity and length of mourning are a testimony to importance of the loss.
~ When one mourns a death, one mourns only the loss of that person and nothing else.
~ Losing something unexpectedly is the same as losing something you anticipated.
~ Mourning is over in a year.
~ Time heals all wounds.
ABC Worksheet
~ Activating Event – Something Happens
~ Belief – What I tell myself about the event
~ Consequence – My emotional reaction and behavioral urges
~ Dispute the beliefs looking for realism. Identify alternate, more helpful thoughts you could tell yourself in the future
~ Evaluate your reactions to determine if there are more helpful ways of responding to the emotion and urges
ABC Worksheets
~ Review A-B-C sheets for themes
~ Emotions (i.e. anger, guilt)
~ Faulty schemas (global, internal, stable)
~ Identify if emotions/reactions follow logically from expressed thoughts
~ Encourage patients to use
~ I feel or my reaction to this is… for feelings
~ My believe or I think … for thoughts
Challenging Questions Worksheet
~ Belief: _______________________________________________________
~ What is the evidence for and against this idea? FOR: AGAINST:
~ Is your belief a habit or based on facts?
~ Are your interpretations of the situation too far removed from reality to be accurate?
~ Are you thinking in all-or-none terms?
~ Are you using words or phrases that are extreme or exaggerated? (i.e., always, forever, never, need, should, must, can’t and every time)
~ Are you taking the situation out of context and only focusing on one aspect of the event?
~ Is the source of information reliable?
~ Are you confusing a low probability with a high probability?
~ Are your judgments based on feelings rather than facts?
~ Are you focused on irrelevant factors?
Patterns of Problematic Thinking
~ Problematic thinking patterns that are seen frequently with this population.
~ Self-Blame
~ Mind-reading
~ Emotional reasoning
~ Over-generalizing from a single incident
~ All or Nothing
~ Even if they do not believe it completely to begin with, convincing patients to modify language use can have an immediate effect on the severity of secondary (manufactured) emotions
Patterns of Problematic Thinking
~ Jumping to conclusions when the evidence is lacking or even contradictory.
~ Exaggerating or minimizing a situation (blowing things way out of proportion or shrinking their importance inappropriately).
~ Disregarding important aspects of a situation.
~ Oversimplifying things as good/bad or right/wrong.
~ Over-generalizing from a single incident (a negative event is seen as a never-ending pattern).
~ Mind reading (you assume people are thinking negatively of you when there is no definite evidence for this).
~ Emotional reasoning (you have a feeling and assume there must be a reason).

Challenging Beliefs (Similar to ABCs)
~ Describe the situation
~ Identify the thoughts related to the situation
~ Use the challenging questions worksheet to examine automatic thoughts
~ Use the problematic thinking patterns sheet to identify any of your problematic thinking patterns
~ Identify alternate self-talk and interpretations
Patient Stuck Points
~ Stuck points may be conflicts between prior beliefs and current beliefs that create unpleasant emotions and problematic or unhealthy behavior.
~ Stuck points may also be formed if prior negative beliefs are confirmed or reinforced by the event
Self-Trust
~ When old and new beliefs are in conflict, people often develop an amount of self-distrust
~ Self-distrust may even generalize to other areas of functioning and the patient may have difficulty making everyday decisions.
~ Trust becomes an either/or concept in which people (and self) tend not to be trusted unless there is overwhelming evidence to the contrary. As a result, they tend to avoid becoming involved in, or withdraw from relationships
Self-Efficacy
~ Self power (self-efficacy) refers to a person's expectations that she can solve problems and meet new challenges.
~ Identify what challenges the person has and can solve.
~ Because the event was out of their control, traumatized people often:
~ Attempt complete control over other situations and their emotions. (ABCs)
~ Adopt the unrealistic belief that they must control everything or they will be completely out of control. (Challenging Questions)
~ Conversely, if someone overgeneralizes and believes she has no control over anything, she may refuse to make any decisions or be proactive believing that nothing will work out anyway.
Self-Efficacy Goals
~ Moderate Locus of control
~ Learn adaptive balanced beliefs about ability to control people and events
~ Develop assertive communication skills

Self-Concept Beliefs (Challenging Questions)
~ Beliefs Related to Self – The belief/expectation that you can solve problems and meet challenges.
~ Negative beliefs are manifested as unrealistically high or unrealistically low expectancies for personal power.
~ The belief that one must be in control of oneself, one's emotions, and one’s actions at all times and that any sign of vulnerability represents a sign of weakness and powerlessness.
~ The belief that one is helpless to control forces both within and outside of the self.
~ What is in your control
~ If negative helpless beliefs become fixed, the person is vulnerable to future exploitation or victimization.
Summary
~ Chronic conditions, losses and traumas can all provoke “stuck points” which can prevent people from accepting life on life’s terms
~ CPT techniques can help clients examine self-defeating thoughts which are keeping them stuck and negatively impacting multiple areas of life.
~ The goals are to help clients:
~ Understand cognitive distortions
~ Identify unhelpful self-talk (ABCs)
~ Dispute stuck points (Cognitive Processing)
~ Accommodate the event or condition into their current schema