CBT for C-PTSD

[Mark]

So now after completing the recommended amount of sessions I still feel I have a long way to go. What does a person do next? Is it more CBT or a different style of therapy required to try and keep moving forward?

Great question!

I think Allan has a good point, that sometimes a therapist is not so good at communicating what needs to be learned in order for CBT to be maximally effective. So one way to think about the answer to the question is to try again with a different and hopefully better therapist. The core ideas of CBT are easy enough to communicate. It is helping people to figure out what beliefs they need to dispute and how to dispute them best that is tricky.

The first stage in CBT is to become aware of the Automatic Thoughts, which is the stream of thoughts that people have, often there without their being all that aware of it. It is the stream of consciousness. The next task, once you're aware of the stream of consciousness, is to distill out from all the creative ways that the thoughts can occur, what are the important themes that each thought is an instance of. The "root" of the thoughts as it were are the "core beliefs", and it is the core beliefs and not the surface manaifestations of those beliefs which need to be addressed and disputed. It is hard to do this distilation. Hard for therapists and hard for clients.

The disputing process is not about being positive. This is not a whitewashing process at all. It is a critical process. You are learning to critically examine the assumptions that form the foundation of the core beliefs and the automatic thoughts that stem from those core beliefs. You are trying to knock out faulty foundations of those beliefs so that they become less stable. You might think of yourself as weilding a sledge hammer and giving each belief a series of wacks to see where they might be sitting on something that is fragile, faulty, inaccurate or wrong. Your job is to root out anything that is wrong or inaccurate. You are trying to get to the objective truth, meaning the truth about the beliefs and thoughts beyond how you feel about them. You are not trying to be positive here, as that would just be another way to build on a faulty foundation that won't hold up to wacking. You are instead trying to build on the most solid stuff you can find - that stuff which is still around after you have criticized the hell out of your thoughts and cannot find any fault with what is left over. If you've done your job well, this process will probably result in your feeling better not becuase you've brainwashed yourself into thinking that you feel better, but becuase you've knocked out a bunch of mistakes and wrong impression and untruths that felt right but weren't, and the result is more accurate beliefs, which just happen to be less depressing in nature.

To switch gears back to the question of "what next", I think that CBT is easier for some people than others, and this can be true regardless of the skill level of your therapist. If you think that you aren't getting results from your therapist, you might consider trying a different therapist (but the same approach), or a different therapist with a different approach. CBT is one of the "empirically validated" forms of psychotherapy, meaning that it is one of the forms of therapy that has been rigorously subjected to research study and found to be useful. However, there are other forms of therapy that are known to work as well. Interpersonal Therapy is one of them too (for depression). And there are other forms that I think highly of as well such as Acceptance and Committment therapy and Schema Therapy . And, even if you go into therapy with a therapist who practices a form of therapy that has not been shown to work for a specific type of problem, if the therapist is good and more to the point, if you form a good working rapport with the therapist, you may end up with good results simply becuase technique only takes you so far and the rest requires a good therapy relationship.

Edited January 21, 2009 by Mark

[confused12]

Thanks Allan, Cynthia and Mark for sticking with me in this thread.

Confused12

Edited March 27, 2010 by confused12

[Guest ASchwartz]

Hi Confused,

Another example of one of your automatic thoughts:

some of the deeply rooted thinking has modified my personality. I am now someone that I don't really know myself. So how is someone able to work with me

Now, really, your trauma is so very deep that no one can understand you???

How realistic is that? It is not.

First: thinking does not modify personality. Thinking is simply thinking!

Second: You are no more confused than lots of other people and therapists can and do understand you.

Third: To feel better, I do not need to change my personality. I need to change how I think. This therapist is not helping me to change how I think because he has confused me.

Fourth: I need a new therapist.

In a comment to me in an early part of your post, you state that it is easier to blame yourself than to blame the therapist. Mark had pointed out that the therapist may have failed to explain how CBT works. I agree with him.

So, what about the idea that:

1. The therapist has not explained CBT to me.

2. That makes what has happened his fault and not mine.

3. I need to find a better CBT therapist.

What do you think???

Allan;)

[Mark]

You're assuming that personality is something that is supposed to be one way and which can become "corrupted" in some fashion such that recovery is fundamentally impossible, recovery being some return to an initial uncorrupted state. If this is how you are thinking, that sounds rather like the story of the Fall of Man from the Bible, and not necessarily how things actually work.

IMHO, personality is best thought of as the sum of two major inputs. First, your brain and body come with some parameters set on them out of the box as it were. This is called "temperament" and this is the genetic/biological part of personality. This stuff tends to stay stable over time. Then there is the contribution of experience and maturity, both of which make it possible for people to change over time and alter their personality. Personality at any given moment is a sort of state vector - the working average of all the inputs at any given moment. But those inputs change and so personality can change too.

Time goes one-way: forward. There is no return to innocence possible and neither is that desirable. The closest we humans come to a return to innocence is not thought desirable (dementia!). instead, we move forward relentlessly, and our only option is to become something new that better fits the ideas we wish for ourselves to fit.

Which leads to a major point, which is that ideas like "pure" and "ideal" are not humanly achievable things; we are always imperfect; there is always some distance between our best effort and what we can imagine perfection looks like. So people who demand perfection/purity/idealness are always disappointed. This is why the cultivation of a healthy self-acceptance, flaws and all is so important. You have to be able to be happy knowing you are not perfect and neither is the world, because there just isn't any other good alternative.

As Allan has expressed, it is highly unlikely that you are so unique that other people who've been around the block can't relate. What is more likely the case is that you haven't extensively talked to other people and so in your isolation, have reached the erroneous conclusion that your case is special/unique. It's natural and normal to be a little grandiose like this, but that is what this sort of belief is, however; a little grandiose.

This is not to trivialize your issues, which I do not doubt are painful and will be difficult to alter or work around. However, giving creedence to the idea that you have endured something that is so unique that no one has any good ideas for how to deal with it is unlikely to be helpful to your progress.

If you need to; fire your therapist and find a new one. But don't stop the work (since you are saying that you are continuing to be in pain).

Mark

[finding my way]

Mark and Allen, you guys might shoot me for this, but I have to ask.... is CBT a bit overly left brained? The thinking function is an awesome tool, believe me, I appreciate that. It's just that there are other dimensions to us too. Do therapists ever blend CBT with other approaches, or once CBT is begun, does that need to be the exclusive path?

I would think that if the relationship was good between therapist and client, that would take care of the problems of being overly cognitive... and that's what's been missing for Confused. Sorry to butt in, Confused! I hope you find what you need in a therapist soon!

Edited January 24, 2009 by finding my way
adding

[confused12]

Thanks Allan, Mark and Finding my way,

Edited March 27, 2010 by confused12

[finding my way]

Confused, 02-09 has a suggestion for ohsosad in another thread:

"Well, OSS, I think writing stuff down before your therapy sessions is a great idea. I remember that really helping me. Number one, it helped me think. Two, it allowed me to say things I was way too shy to speak out loud. How things have changed, though. Today, I would have absolutely no problem saying I "loathed" my Dad, but I can remember a therapy sessions years ago in which the only way I could communicate that was to write it down. One pointer, though, for what it's worth: if a positive thought comes along while you're writing, don't resist it...write it down too."

I used to do that too. I even wrote little papers and dropped them off for my therapist to read prior to a session.

[Guest ASchwartz]

Hi Confused,

I agree with Finding that writing things down might help you when you enter your therapy sessions.

By the way, what is the "stuff" you mention? Can you tell us. That might help you to talk about it in therapy.

Allan:)

[confused12]

Thank you finding my way I will have a look at the thread.

Edited March 27, 2010 by confused12

[Guest ASchwartz]

Hi Confused12,

As for the 'stuff' Allan I wish I could share and feel guilty that I don't. I did try to share when I first joined this site but I deleted most of it as I was scared of it being here. Scared of I don't know what.

You really are very hard on yourself. You feel guilty that you do not share and feel scared of what people will think if you do share, at least, that is my take on it. Do you think yourself a "terrible person?"

Allan:)

[Mark]

I do wish I could be a little more open though

Don't think of this as something solid and fixed. This is a process - something that is continually becoming. Not something that "is". So if you are not comfortable opening yourself now, this may change in the future. You have already talked about how much positive change you've experienced in the past year, so there is no reason to think that this cannot continue to be the case in the gradual sort of way that personal changes tends to come.

[Mark]

Mark and Allen, you guys might shoot me for this, but I have to ask.... is CBT a bit overly left brained? The thinking function is an awesome tool, believe me, I appreciate that. It's just that there are other dimensions to us too. Do therapists ever blend CBT with other approaches, or once CBT is begun, does that need to be the exclusive path?

This is a common criticism of cognitive approaches (e.g., that they ignore emotions too much). Another way of saying it is that they are over-reliant on technique at the expense of the relationship. And yes, this can be the case sometimes, with a therapist who for whatever reason has selected this particular style of therapy because of some motivation to not get too close to a patient (for whatever reason), or with a therapist who doesn't understand that there is more to therapy than the techniques. I don't think it has to be the case, however. A good therapist will always pay attention to the relationship, and CBT properly done is about emotions - it just gets there via the cognitive functions rather than diving right into them directly.

Many of the more modern incarnations of CBT (what I have called the post-cognitive therapies) are now going beyond the straight cognitive restructuring stuff and incorporating lots of relational stuff. The heavy hitters are dialectical behavioral therapy (DBT), acceptance and committment therapy (ACT) and schema therapy. Schema therapy is a merger of object relational psychodynamic insights that focus on relationships and emotions with cognitive technqiues. The other two are about merging mindfulness and emotional distancing techniques with cognitive techniques. The young cutting edge energy is taking cognitive stuff in a more relational direction for sure.

If I hammer on the virtues of CBT it is becuase it is one of the few "empirically supported' therapies, which has actualy been researched and found to be effective. Not all therapy is like this, and it is entirely possible that you go to see a therapist and you work with that therapist for years, and you emerge from the process just as messed up as you were when you started. Look at woody allen and you know this is true. CBT is not about fixing deep problems; it is about addressing moods, worries, false perceptions, etc. and producing measurable improvements that insurance companies are willing to fund.

Lastly (for now), keep in mind that it's important to fit the therapy to the patient. Some patients are not terribly verbal and CBT isn't likely to be all that useful for them. Etc.

Probably a way to think about it is that if you have a focused concern (like "depressed mood" or "speach anxiety", CBT is the way to go provided you are a verbal person. If you have deep seated issues such as a personality disorder, cbt can still be very useful, but it needs to be extended/modified with relational stuff and self-soothing stuff in order to work best. The more deepseated/chronic/characterological a problem is, the more it will require a more extended therapy focused on relational emotional concerns, such as a psychodynamic, or humanistic, or objectrelational approach. On the far side of this, if your problems are very minor, you might get by with just emotional support and coaching and pep talks.

Mark

[finding my way]

Mark, thanks for the thorough reply, I feel & think more positively about CBT now!

Have you ever worked with/studied internal family systems therapy?

[confused12]

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Edited March 27, 2010 by confused12

[confused12]

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Edited March 27, 2010 by confused12

[finding my way]

Confused, may I say bravo? I just want to acknowledge that you are doing it, you are telling us how you feel! I can relate to being super self conscious. It is an utterly miserable feeling. It gets better with more experiences expressing yourself with people who accept what you say.

[Guest ASchwartz]

Hi Confused,

You stated that the CBT treatment is ending. I think that you need to understand the reason why it is ending. It is ending because your insurance company will only pay for 20 sessions per year and only just a few years. Once the twenty sessions are used up they will pay no more, finished or not, at least not until the next year. You and your therapist can try to appeal for more sessions.

Also, I do not see how the CBT can be causing you to explode or feel worse except for one thing, and that is that it is not working.

Confused, I believe we discussed this before but it is always worth revisiting: The success of any type of psychotherapy depends upon more than the technique being used. There needs to be a good match between therapist and patient. If not, it will not succeed. A patient can be very angry at their therapist about something but it can still be a good match. Also, each patient needs to feel motivated, you know, really wanting to get better.

Do you feel a good match with your therapist? Do you trust him and his abilities?

Are you motivated and how much? Do you believe?

Even when someone goes for surgery a lot of the outcome depends on how much faith they have in their doctor and in the notion that they want to get better and that they will get better. What about you?

Allan

[confused12]

Thank you finding my way. It is uncomfortable to state feelings but I am working on it.

Edited March 27, 2010 by confused12

[Guest ASchwartz]

Hi Confused,

Well, your therapist has explained where he is coming from: he does not do long term therapy and he has taught you all he knows. I am sorry but I have my doubts about this therapist. If he has taught you all he knows in 20 sessions then he does not know much.

It seems to me that you need a good therapist who will work with you long term. Therapists do that whether they are of the cognitive behavioral type or the psychodynamic type. Long term therapy is especially good with the personality disorders because they take a long time to change. Besides, I tend to believe in long term therapy.

What I mean by "do you believe" is do you believe that therapy, the therapist and yourself will fix you? Of course, we all tend to have doubts but having faith that things will get better due to the therapy, etc should out weigh the doubts.

Allan:)

[confused12]

Cheers Allan,

Yes I do believe

Confused12

[Cynthia]

I am surprised how much has been written here since my last visit. So much to comment on but so little time (sorry). I will say a lot of good discourse here and I like what Allan has been saying a lot. First thing that my cbt group leader would have said if I said I was a terrible person if to define what a terrible person is and once I did, then point out all of the thinking errors/irrational thoughts encompassed in applying a term like that to anyone not just you.

The other point I want to make is that most of the work and progress I experienced with cbt came between sessions doing the thought countering and exposures not during the actual sessions themselves. My understanding of cbt is that one of the things that sets it apart from other forms of therapy is that it empowers you to help yourself get better so when the sessions are done you have the tools necessary to help you help yourself forever. I still counter my thoughts in my TEA forms almost every day and that makes the new ways of thinking that reduce my anxiety become stronger and stronger.

I hope this makes sense as I am typing as fast as I can because I have to get going:confused:

[Lisa11]

I have lots of questions about Therapy at the moment.

I would like to know if CBT can be successful when a person has not verbalized all their trauma's with their therapist.

Lisa11

[Guest ASchwartz]

Hi Lisa and Cynthia,

In many ways, Cynthia has given you a nice picture of what CBT is like. And, so, Lisa, my answer to you question is YES, CBT can help you even if you have not verbalized all your traumas to your therapist. You see, CBT centers around the present more than the past. The past is only important when it comes to play upon your thinking and feeling right now but the focus is much more on right now.

Cynthia, how are you doint these days??

Allan

[Cynthia]

Hi Allan,

So good to hear from you

Sorry I have not posted recently and didn't realize it had been so long since my last visit? I am doing very well, thanks for asking. How are you doing?

I enjoy reading your posts and hope our cbt advice is getting through to others so they can experience the results I have gotten from it too:)

[karai]

Hi confused12,

Thank you for posting your question. And thank you Allen, Mark and everyone else who replied to your post. Now I know what to expect from therapy. I finally got up the nerve to call the psychologist's office but he wasn't in; he will be calling me tomorrow to set up an appointment with me. At least I think I will be able to have a positive and productive experience because of all the stuff I've learned here. I will be re-reading all of the replies again before my appointment because I'm still a bit confused. But now I do have one worry though: will my insurance cover all the therapy I need?!?

Thanks everybody....

Edited April 7, 2009 by karai