Tips, Ideas & Recommendations in CBT Treatment

How do you define competence? Your answer to this seemingly simple question can have a large impact on how you interpret your academic and professional achievements and how satisfied you feel about them. Some views of competence can be particularly detrimental to your emotional well-being, so it’s worth watching out for them.
 
Dr. Valerie Young has described five unhelpful “competence types”: views of what defines aptitude and proficiency that actually hold us back. They are:
 
1-The Perfectionist: in this view, competence is defined by “how” things are done. If they are 100% correct, 100% of the time, then you’re competent. Any small deviation from that equals total defeat. And since it’s impossible to get everything right all of the time, you are often aware of your misses and the distress that accompanies them in the form of self-doubt, worry, or shame.

2-The Natural Genius: here, competence is defined by “when” things are done right. For the Natural Geniuses out there, being competent means getting it right the first time, and doing it naturally, effortlessly, and immediately. This is the view that talent is congenital and you either have it or not. If you don’t get it right on the first time or struggle to master a skill or project, then you’re actually not that competent. That’s a huge disappointment.

3-The Soloist:  This is the “who” view of competence, in which it equals the ability to perform tasks independently at all times. If you need help, you are incompetent, so you might as well take on immense mountains of work to do all by yourself. When you struggle or get stuck, feelings of failure, shame or defeat follow.

4-The Expert: The focus of competence for the Expert is in “what”. If you are competent in this definition, then you know everything there is to know about a task, challenge, or project even before you start. You fear being exposed as ignorant or inexperienced, so you spend inordinate amounts of time getting better educated, more informed, and more deeply acquainted with whatever topic is at hands; often times, at the expense of actually getting stuff done.

5-The Superhuman: For this type, competence is measured in throughput. It parallels how many roles you can juggle, how many projects you can deliver, how often you volunteer, or how much time you spend on turbocharge, doing more than everyone else around you. This overload can lead to many short-term accomplishments, at the cost of long-term stress and burn out.
 
Do you see yourself in any of the types above? If so, how has this definition of competence served you over time? If the answer is not that well, then you can start working on changing it. You can do that with the help of a CBT therapist by first understanding your current belief system, then challenging assumptions that are unhelpful, and finally building new ones that are more realistic, take into account several viewpoints, are more complete, and help you truly succeed in the long-term.

Many mothers - both those staying-at-home with the kids as well as those working out of the house - often struggle with "mom guilt." Those are nagging feelings of guilt, shame, sadness, anger and despair that may be temporary or pretty pervasive. They are difficult and unpleasant. Older parents will tell you to let go, to enjoy the journey as time flies: "they grow up so fast." And yet, day to day those pesky feelings pop up, sometimes on cue and many times unannounced. 

Cognitive theory will tell you that those unwelcome emotions stem from your thoughts, the stories that you tell yourself in your head. It can be a thought that you may not be doing enough, a notion that you are not sacrificing enough, or just a belief that you are not getting things right while everyone else has it together. In terms of concrete thoughts, they might span the range from "I should be playing with the kids right now (as opposed to doing something else I also enjoy!)", "they are watching too much TV", "I shouldn't loose my cool", "I actually want to complete this work assignment but feel I should be spending more time with the kids." 

If you can't change your reality short-term, how can you deal with these thoughts and feelings more effectively? First, if I offer you a magic button that would make all of those beliefs and reactions go away, consider whether you'd press the magic button. It sounds like a good deal, right? Yet, these negative thoughts and feelings tell us a lot of beautiful things about you...They show you care, you want to do what is right by your children, that you are willing to look at your choices critically, and that you have really high standards and goals for yourself. All of those things are good!

Rather than pressing the magic button and make the "mom guilt" disappear altogether, how about figuring out how to modulate it? You can find a way to hold on to some of the healthy aspects of the guilt - after all, wanting to be the best mom you can be is an awesome goal! - but it is not so high that takes away from your chance to enjoy your children and your limited time with them. That is very doable with CBT.

To get to this lower level of distress, you will need to revisit the stories that you are telling yourself in your head. In CBT, we embrace the idea that your thoughts drive your emotions. Change your thoughts, change your emotions. There are a myriad techniques to re-write the automatic thoughts and ideas in your head around your parenting choices. You can learn about them in CBT-driven books such as Dr. David Burns' new Feeling Great book. Or you can work with a CBT therapist who can guide you in understanding and applying these techniques to the specific circumstances in your life. Your family will thank you!

Dr. David Burns is a world renowned psychiatrist and one of the pioneers in the development of Cognitive Behavioral Therapy. In the past decades, Dr. Burns has been focusing on advancing the clinical applications of CBT through a new therapeutic approach that he calls TEAM-CBT. You can read more about the elements of TEAM-CBT in one of my early blog posts or on Dr. Burns website.

TEAM-CBT is a framework for delivering evidence-based interventions in psychotherapy (and evidence-based here means techniques that have been corroborated as effective by rigorous scientific research). It combines Routine Outcome Monitoring, Motivational Enhancement, and CBT Methods with a strong focus on empathy and rapport building to deliver meaningful symptom reduction in fast periods of time. Indeed, in his current clinical work, which revolves mostly around training of therapists and professional workshops, Dr. Burns has, on many occasions, observed that individuals who had been struggling with depression or anxiety for years can experience near complete recovery in just a few hours.

To explain how that can happen, and provide more background and perspective on the TEAM-CBT approach, Dr. Burns was interviewed by one of our colleagues, Lisa Kelley. The transcript of the interview is an excellent primer to learn more about this powerful new modality. Here it is:

As a Level 5 Certified TEAM-CBT trainer and Master Therapist, I would be delighted to help you learn more about these tools to to enhance your life or, if you are a health care provider, to revolutionize your clinical practice!

TEAM-CBT is a framework for providing evidence based psychotherapy. It was developed by Dr. David Burns, MD, Adjunct Emeritus Professor at Stanford School of Medicine. 

What is Evidence-Based Practice in Psychotherapy?
Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences.  It leverages evidence-based treatments. This designation describes specific clinical interventions that have been validated as efficacious for certain mental health conditions under rigorous academic research. Many cognitive and behavioral interventions (e.g., thought re-structuring, exposure therapy) are recognized by the American Psychological Association as evidence-based treatments.

What is CBT?
​Cognitive Behavioral Therapy is a type of evidence-based treament. It examines our thoughts processes - our idiosyncratic way of seeing the world around us -, our typical behaviors or actions, and our emotions in defined moments in our lives. It then providers actionable, well-defined, and simple ways of modifying thoughts and behaviors, with the ultimate goal of changing our feelings - for the better. It is focused on the here and now and aims to deliver symptom reduction in a fast but sustainable way.

What is TEAM-CBT?
TEAM, as mentioned above, is a framework for compiling cognitive and behavioral therapy interventions and delivering them through powerful, results-driven psychotherapy. TEAM stands for four key elements in this therapeutic approach:

T = Testing
In this type of therapy, clients are asked to gauge their level of distress and life satisfaction on a regular basis. Looking at metrics over time, the client and therapist can then determine whether their work together is helping the patient objectively improve their well-being.

E = Empathy
Before the more active part of the therapy begins, it is imperative that the therapist and the client be on the same page. TEAM-CBT offers specific techniques for increasing openness, authenticity, and vulnerability in the therapy sessions.

A = Agenda Setting
This is where TEAM combines evidence-based practices of traditional CBT with elements of Motivational Interviewing, a therapeutic method that works on facilitating and enhancing intrinsic motivation within the client in order to change behavior. The client and the therapist develop a shared agenda for the overall work and for each session where the client is effectively arguing for change - and thus melting away the psychological resistance to upset the status quo. 

M = Methods
TEAM brings together over 50 cognitive and behavioral methods for change, from traditional thought analysis and behavior experiments to innovative role playing techniques, compassion-based techniques, communication training, and much more. For each angle of unhelpful thought processes, TEAM has a number of powerful techniques that can help the client find more constructive alternatives.

The goal of TEAM therapy is to help the client, over time, become their own therapist. For individuals motivated to change their lives, it can lead to meaningful gains in happiness, peace, fulfillment, and contentment in short periods of time. 

To lear more about TEAM therapy, visit Dr. Burns's Feeling Good website or call me for a free phone consultation. 

Cognitive behavioral therapy (CBT) tends to operate within a much more short-term, focused model of psychological intervention that aims to reduce current symptoms, address specific problems, and build skills that the client can take with him/her after treatment ends. Hence, treatment length is usually measured in weeks or months, rather than years or decades.

​Indeed, there is ample research evidence that response to psychotherapy follows a 'negatively accelerated' curve where more and more effort is required to achieve smaller and smaller changes (that is called a log-normal curve for the math geeks out there). Dr. Ken Howard was the first to analyze this correlation and posit markers for response to psychotherapy according to dosage. Here is his original article.

The original dose-effect study was run in 1986, based on psychodynamic or interpersonal treatment only, with the following findings:
* About 15% of patients improve before the first session of therapy 
* 50% of patients typically improve at 8 sessions
* 75% of patients typically improve at 26 sessions
* 85% of patients typically improve at 52 sessions

It is possible that modern psychological techniques have accelerated that theoretical curve in the past 30 years. In practice, however, there are many factors influencing the right dose of psychotherapy for each client, including diagnosis, acuity, readiness to change, social circumstances, and frequency of treatment (more regular treatment is  shown to be more effective).  But what we can glean from the data above is that longer and longer treatment periods may indeed offer diminishing gains at increasing levels of effort. 

With CBT, you and your therapist will have powerful tools for change readily available. The specific length of psychotherapy treatment will vary for each person and each presenting problem. But with commitment and focus in the context of a true partnership, CBT can lead to fast and meaningful change.