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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 5 to 29 of 93. Go back in thread:
Posted by gardenergirl on December 26, 2003, at 11:55:23
In reply to Re: Therapist Orientation? CBT or psychodynamic? » mattdds, posted by Dinah on December 26, 2003, at 9:49:25
Hi,
I'm somewhat new to this board but I have been following some of the threads. I see a psyhcologoist who is a pretty pure psychodynamic practitioner. I, too find that CBT and a more experiential therapy seem to self-select both the therapist and the type of client when it is a good fit. As I am more of an introspective, feeling-oriented person, this therapy works for me. I think that CBT would feel too practical and intellectual to help me.That being said, I am also in my fourth year of training as a clinical psychologist. I have used CBT techniques with clients who are more outwardly focused, with specific problems. There is definitely a place for it in psychotherapy, and my supervisor is CBT oriented. In general from what I have observed, she is less emotionally-focused and less introspective than I am. It seems that her choice to practice CBT fits her personality and that my preference for process-experiential and dynamic therapy fits my personality better.
If CBT is working for you, that's great! I often incorporate aspects of it when appropriate even with the clients I treat with a more experiential approach.
Happy new year, everyone!
Posted by Medusa on December 26, 2003, at 13:28:16
In reply to Therapist Orientation? CBT or psychodynamic?, posted by mattdds on December 26, 2003, at 1:52:24
Matt, how would you categorize family systems therapy? Based on therapy duration and session structure, I'd place it more in the behavioral camp, but it probably depends on the practitioner. Then again, a lot of the theories, such as differentiation of self, have root in psychoanalytic thinking.
I went through years of psychodynamic therapy, and it didn't get me what I wanted. (Nor did I get to experience the thrills of transference/countertransference, so I must have been doing something wrong.)
I've found a lot of help and insight and relief in writings by Michael Kerr and Murray Bowen - here's a link to a description of Bowen theory:
http://www.georgetownfamilycenter.org/pages/theory.html
I'd be really interested in discussing this more (as well as more about CBT/DBT) - I've felt discouraged, a real outsider, by the slant of this board, but I don't know of other discussion boards.
Posted by DaisyM on December 26, 2003, at 13:43:22
In reply to Therapist Orientation? CBT or psychodynamic?, posted by mattdds on December 26, 2003, at 1:52:24
Matt,
I agree with Dinah. I think some of the negativity you've observed is more about the Therapist and their actions/reactions to the client -- not their orientation.
I have experience with both in very different ways: my son (12) had pretty severe anxiety attacks and he started seeing a Therapist who is primarily CBT oriented. They worked on many types of coping techniques AND they worked on "admitting" which means figuring out what you are really worried about and dealing with it. It has worked really well for him. 14 months later he is ready (though I am nervous) to terminate.
For me, when I finally admitted that I was increasingly overwhelmed and stressed out, I wanted a Therapist with whom I could "just" talk to. Someone who didn't have a preconceived notion of how competent I was, especially since my main coping strategy is always to look at the options for solving the problem, choose one and move on. That isn't to say that I still didn't (ok, do) ask for intellectual explanations of "what is happening to me/!" :) I think if I was working with a Therapist who was CBT oriented I would have mastered the techniques, said thank you very much and left therapy, probably feeling better about the depression but with a likeliood of it coming back.
Why? Because after 3 or 4 months I finally realized that what I needed to do was talk about a trauma that I had never ever talked about before. My Therapist, who is psychodynamically oriented, uses some of the CBT techniques like reality testing or corrective thinking, but he is really pretty interested in how I feel about stuff, especially him. I think he really believes that therapy is the "corrective emotional experience" needed to heal. (I say fix, he says heal) I can't imagine going through all of this without someone who can just be there for me sometimes and yet push me others.
So, again, Dinah is right. I think what works for one person may not for the next and depends on the issue(s) you are dealing with.
What do you think about the efficacy studies of one vs. the other?
Posted by mattdds on December 26, 2003, at 15:58:24
In reply to Cognitive vs Behaviorists » mattdds, posted by Kalamatianos on December 26, 2003, at 2:15:14
Thanks for posting, I didn't think I'd get a response!
>>I see no overlap between cognitive and behaviorists. Behaviorists are "you are what you do", and cognitive is overcoming faulty thinking. Albert Ellis and Aaron Beck see a distinction between "who you are" and "what you do".I'm not really sure what you mean here. I'm aware of the distinction between pure behavioral therapy and cognitive therapy. But most CBT is a blend of the two. CBT is also somewhat of a successor to behavioral therapy. I think most CBT therapists still employ behavioral techniques (e.g. exposure), but also use cognitive restructuring-like techniques as the "core" treatment.
Best,
Matt
Posted by mattdds on December 26, 2003, at 16:25:42
In reply to Re: Therapist Orientation? CBT or psychodynamic? » mattdds, posted by Dinah on December 26, 2003, at 9:49:25
Dinah,
You make some good points here.
I agree that a lot of CBT purists do not express enough empathy and are somewhat mechanical in their therapy. It's as if they're rewiring some soulless electronic device. Albert Ellis, and the REBT types are more this way.
You might be interested to read a study done by none other than David Burns (Stanford) and Diane Spangler (Brigham Young Univeristy), that showed CBT success was greatly enhanced by the patient's feeling that the therpist was empathetic.
I agree that there has to be some show of empathy, or the patient is likely to resist or not be receptive to it. But I think that empathy alone is not enough, as evidenced by people who never get better even with all the empathy in the world from their families, friends, etc. I think there has to be a change in thinking patterns to have real success. I'm not saying that this can't happen in other types of psychotherapy, it certainly does. It's just that CBT was "made" to do this, while the others might do it in a more roundabout way.
>>I have always said that CBT or DBT should be required for everyone - maybe taught at school. They give you a very good set of coping skills and a way to do some reality testing
Wow, couldn't agree more. I think I could have avoided the bulk of my crises if I had gotten some elementary school training in CBT, or if I had gone to CBT school instead of Sunday school and learning about Jesus (not meant to be sacreligious). I didn't even learn about CBT until I was about 22.
>>So CBT therapists who do any but the briefest therapies should have some training in how to effectively and sensitively deal with the feelings that arise in the client. Otherwise they can do a fair amount of damage. They don't need to encourage transference, but they shouldn't be appalled or at a loss if it crops up. It's part of their business and they should be trained.
Agreed, I think sometimes CBT types can have knee-jerk reactions to anything old-school, like transference issues. They just tend to ignore them or get flustered. I'm not saying transference doesn't occur or shouldn't be dealt with. I'm just not convinced it is as significant or meaningful as the psychodynamic ideology makes it out to be. I also wonder if so much time should be spent trying to "work it out". I'm not so sure it can be, and I'm not that convinced it's such a huge problem. My idea would be to acknowledge it, accept it as normal, and move the hell on!
>>>When he first started with me, he was almost purely CBT with a lot of it straight from the "Anxiety and Phobia Workbook" complete with homework assignments.
Wonderful book, IMO. A must read for everyone with anxiety issues.
>>>...for those clients with the temperament to respond to it ideally.
Yes, there are many personality types that "clash" with CB therapy. But I think that if these differences can be negociated (and this is where the good CBT therapists are distint from the not-so good - managing these differences in personality), almost *anyone* could get at least *some* benefit from it.
>>>DBT should be required for everyone
I'm not familiary with DBT, other than it's purported to be similar to CBT but with an emphasis on personality disorders, like BPD? Am I right here?
Thanks for your thoughtful post, Dinah.
Matt
Posted by mattdds on December 26, 2003, at 17:59:34
In reply to Re: Therapist Orientation? CBT or psychodynamic?, posted by gardenergirl on December 26, 2003, at 11:55:23
Hello,
Thanks for your thoughtful comments, it's interesting to hear it from the perspective of someone who actually practices psychodynamic therapy.
>>As I am more of an introspective, feeling-oriented person, this therapy works for me. I think that CBT would feel too practical and intellectual to help me.
I just had a question about that statement. I was unclear about a couple of things. How does being "introspective" relate to the type of therapy that will work? Also...introspective as opposed to what? Shallow? That might seem to imply that psychodynamic therapy selects out the "introspective" people. I'm not sure there is any evidence for this. Perhaps there is, though, but would this translate into better outcome?
Also, what do you mean by "feeling-oriented"?
I used to consider myself very introspective, and when I was severely depressed I was even more so. Actually, one of the aims of my therapy was to cut down on introspection. I used to use (abuse?) introspection as a means of "getting to the bottom" of my problems, as if there were some evil core that I had to break through to. In short, what I used to call introspection, I now call rumination.
I started feeling better when I learned to stop doing this. I learned to stop wondering about the "origin" of my problems, and started working on defining specific problems and making specific solutions. Dealing on an abstract, vague level has never worked for me.
I'm not saying healthy introspection and self awareness are not healthy and desirable attributes, I'm just wondering how that relates to selection of therapeutic style. I'm also wondering if all that introspection really solves anything. My experience is the opposite, but we're all different.
>> I think that CBT would feel too practical and intellectual...
Again, we're all so different :). My newer view is that practicality is all there really is in life, everything else is a mirage, in my view. If my symptoms are relieved and my relationships are healthy, I don't really care what lurks in the deep dark rancid corners of my subconscious.
Anyway, thank you for your exchange and your input. And best of luck in your studies.
Best,
Matt
Posted by mattdds on December 26, 2003, at 18:25:13
In reply to question » mattdds, posted by Medusa on December 26, 2003, at 13:28:16
>>>Matt, how would you categorize family systems therapy?
Actually, I'm not familiar with that type of therapy, so I wouldn't know how to categorize it.
>>>Based on therapy duration and session structure, I'd place it more in the behavioral camp, but it probably depends on the practitioner. Then again, a lot of the theories, such as differentiation of self, have root in psychoanalytic thinking.
Sounds like a "blend" of the two?
>>>I went through years of psychodynamic therapy, and it didn't get me what I wanted.
>>>(Nor did I get to experience the thrills of transference/countertransference, so I must have been doing something wrong.)
I bet this experience (transference) is overrated ;).
I hear this all the time - people doing years of psychodynamic therapy and not getting any measurable symptomatic relief. I'm a big believer in measuring progress of symptoms, with charting and stuff, to make sure it's working. Otherwise, why bother with something if it's not working? Often people waste so much time and money in therapy with no measurable success. I think therapists should be held accountable for this!
Of course people have different goals. Some psychodynamic (especially the "old-school", Freudian type therapists) will freely admit that it may take years for symptoms to go away, if at all. For me, this would be unacceptable, especially when meanwhile there are therapies available (namely, CBT and interpersonal therapy) that have been shown in studies to rapidly alleviate symptoms - no aimless subconscious groping of ones traumatic childhood necessary!
In medicine (and CBT) the chief complaint is addressed first. Specific problems are identified, and a treatment plan is generated to specifically target the problems. Why is it so different with psychotherapy? Why so much time wasted in techniques that aren't working to solve the chief complaint?
>>>I'd be really interested in discussing this more (as well as more about CBT/DBT) - I've felt discouraged, a real outsider, by the slant of this board, but I don't know of other discussion boards.
I feel like an outsider too! I check this board very often, but I just can't relate to issues of transference, countertransference, the unconscious, exploring childhood trauma, etc. That's why I suggested splitting the board, but this is not going to happen for the sheer lack of people interested in CBT.
I hold out hope for more talk of CBT here, and sometimes even try to start threads, but they usually wind up fizzling out quickly or people just argue about whether it works or not, rather than working on solutions or giving each other suggestions. However, I have had some good exhanges here, especially with Dinah and Larry.
I've searched far and wide for a board that deals with CBT exclusively, but I don't believe there is one :(. I agree, the board is heavily slanted in terms of orientation.
Thanks for listening to my rambling :).
Take care,
Matt
Posted by mattdds on December 26, 2003, at 18:26:23
In reply to Re: question, posted by mattdds on December 26, 2003, at 18:25:13
Posted by Dinah on December 26, 2003, at 18:32:44
In reply to Re: Therapist Orientation? CBT or psychodynamic? » Dinah, posted by mattdds on December 26, 2003, at 16:25:42
Since my therapist has done both CBT and more psycho-dynamic therapy with me, I think I might post an issue, and how he might approach it from either side. And how I'm not sure there is that much difference in effect.
I'll look through my workbook and see if something pops into mind.
Maybe some other folks with a bit of familiarity with both could do the same thing, with their therapists' different approaches. I'll bet that we find out there are more similarities than differences.
I'm not familiar with all of the outcome studies. But I do remember reading recently that the therapist/client relationship as viewed by the client accounted for most of the therapy satisfaction rating. I'm not sure satisfaction is identical with success though. I also remember the grand rounds presentation on CBT outcome studies (linked from here) that showed that the outcome was better for people with some types of personality than others.
You might have to factor in other things as well. For example, I had excellent results with CBT for my OCD. I still have the occasional panic attack (one last night even), but I handle them much better. But when the OCD got under control, my mood disorder worsened. And it doesn't seem as amenable to CBT.
The brain is so darn complicated.
Dinah
P.S. Matt. Though you might hear me complain about pure CBT sometimes, you'd equally hear me complain about pure Freudian psychoanalysis. Most of the books I own that I want to ditch are classic psychoanalytic books. I always read a few pages and my eyes glaze over when they're not rolling. And I did a consultation with a psychiatrist once who thought perfectly normal interpersonal feelings had to be transference - it made me as crazy as CBT biofeedback guy did. But that's just me. :) I'm sure they've helped plenty of people.
Posted by mattdds on December 26, 2003, at 20:01:24
In reply to Re: You know what might be interesting? » mattdds, posted by Dinah on December 26, 2003, at 18:32:44
> Since my therapist has done both CBT and more psycho-dynamic therapy with me, I think I might post an issue, and how he might approach it from either side. And how I'm not sure there is that much difference in effect.
>I think that would be very interesting indeed. I'm not married to the idea that CBT is the *only* way. I think there's something deeper to therapeutic success, that I'm sure psychoanalytic therapy can attain. Part of the problem that I have with psychoanalytic therapy may in part be a misunderstanding. Perhaps I don't fully understand what "psychodynamic" means in the first place. I have it lumped together with classic "couch therapy", free association, psychoanalysis, sexual connotations for everything, dream analysis (which I think is pure bunk), oedipal conflicts, etc, etc. I'm sure psychodynamic therapy has come a long way since its Freudian roots. I'm also pretty sure it does not embody one "doctrine", but is highly variable depending on the school of thought.
>I'll bet that we find out there are more similarities than differences.
I bet you'd be right. But I would also bet it also all boils down to something similar to cognitive restructuring, the shifting of some paradigm, or a change in a core belief.
> I'm not familiar with all of the outcome studies. But I do remember reading recently that the therapist/client relationship as viewed by the client accounted for most of the therapy satisfaction rating. I'm not sure satisfaction is identical with success though. I also remember the grand rounds presentation on CBT outcome studies (linked from here) that showed that the outcome was better for people with some types of personality than others.
>Again, you're probably right here. Take me for example. I "happened" to choose dentistry as a career path, where there is a specific procedure for every problem. A patient comes in with a cavity, and you fill it. Missing tooth? Do a 3-unit bridge, or an implant. Simple. Remind you of CBT? Is it any wonder why I chose CBT as my therapy?
Unfortunately, we understand far less about psychiatric illness than we do about dental / periodontal disease (which we pretty much have figured out). But I still like the idea of working out tangible, practical soluble problems, and kind of not worrying about the rest.
> You might have to factor in other things as well. For example, I had excellent results with CBT for my OCD. I still have the occasional panic attack (one last night even), but I handle them much better. But when the OCD got under control, my mood disorder worsened. And it doesn't seem as amenable to CBT.
>What is your mood disorder? If it's bipolar, you probably won't have much luck with CBT without a mood stabilizer. I don't have OCD, but my experience was the same with panic disorder. I still get panic attacks (which I believe to be some sort of neurological glitch), but they occur much less frequently, and I don't have panic *disorder* now, with anticipatory anxiety about the panic attacks, or agoraphobia. Isolated panic attacks (the immutable part, IMO), did not cause me to break down mentally. Most of the suffering was from anticipatory anxiety and catastrophizing about the attacks, and was amenable to CBT. Actually, Klonopin killed all the residual panic symptoms that CBT didn't. Now I don't get ANY panic.
I've never heard of OCD "translating" into a mood disorder. Are you sure this isn't a post hoc, ergo propter hoc thing? There is no way to prove or disprove that your OCD improvement caused your mood disorder, but I can see how a belief that it did might set up a self fulfilling prophecy.
Don't get me wrong, I fully believe you have a mood disorder that does not respond to CBT, but are you sure it was *caused* by CBT?
> The brain is so darn complicated.
I think we can all agree on that.
>
> Dinah
>
> P.S. Matt. Though you might hear me complain about pure CBT sometimes, you'd equally hear me complain about pure Freudian psychoanalysis. Most of the books I own that I want to ditch are classic psychoanalytic books. I always read a few pages and my eyes glaze over when they're not rolling. And I did a consultation with a psychiatrist once who thought perfectly normal interpersonal feelings had to be transference - it made me as crazy as CBT biofeedback guy did. But that's just me. :) I'm sure they've helped plenty of people.I can't even read psychoanalytic stuff without laughing or rolling my eyes. In my mind it is nothing but colorful and imaginative conjecture that has been intellectualized for far too long.
Best,
Matt
Posted by tabitha on December 26, 2003, at 20:49:09
In reply to Re: You know what might be interesting? » Dinah, posted by mattdds on December 26, 2003, at 20:01:24
Hi Matt. I don't think anyone does that Freudian stuff anymore. There was one thread here about someone having classic psychoanalysis, but it was the exception. My therapist uses a whole mixture of techniques. I see influences from cognitive, interpersonal, transactional analysis, gestalt therapy, EMDR, client-centered, re-parenting techniques, and I don't know what all else. Maybe it's a regional thing-- Southern California eclectic.
Posted by mattdds on December 26, 2003, at 21:25:33
In reply to Re: You know what might be interesting? » mattdds, posted by tabitha on December 26, 2003, at 20:49:09
> Hi Matt. I don't think anyone does that Freudian stuff anymore. There was one thread here about someone having classic psychoanalysis, but it was the exception. My therapist uses a whole mixture of techniques. I see influences from cognitive, interpersonal, transactional analysis, gestalt therapy, EMDR, client-centered, re-parenting techniques, and I don't know what all else. Maybe it's a regional thing-- Southern California eclectic.
You may be right, could be a regional thing. Here in the Northeast (well, at least NYC), I have noticed there is much more CBT influence than when I lived out West.
Best,
Matt
P.S. As an aside, I personally don't think EMDR is much more than CBT with a pseudoscientific gimmick added on. I read some stuff that showed that the eye movements + CBT had no additional benefit over CBT alone. I'll post an abstract below, from www.quackwatch.com:
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR is promoted for the treatment of post-traumatic stress, phobias, learning disorders, and many other mental and emotional problems. The method involves asking the client to recall the traumatic event as vividly as possible and rate certain feelings before and after visually tracking the therapist's finger as it is moved back and forth in front of the client's eyes [6]. EMDR's developer and leading proponent, Francine Shapiro, Ph.D., received her nonaccredited doctoral degree in 1988 and established the EMDR Institute to train mental health professionals. She and her associates have trained more than 22,000 clinicians worldwide in workshops that in 1997 cost $385 [7]. EMDR resembles various traditional behavioral therapies for reducing fears in that it requires clients to imagine traumatic events in a gradual fashion in the presence of a supportive therapist. However, controlled research has shown that EMDR's most distinctive feature (visual tracking) is unnecessary and is irrelevant to whatever benefits the patient may receive [8]. Recent reviews have concluded that the data claimed to support EMDR derive mostly from uncontrolled case reports and poorly designed controlled experiments and that the theory of EMDR clashes with scientific knowledge of the role of eye movements [9,10].
Posted by Dinah on December 26, 2003, at 23:01:56
In reply to Re: You know what might be interesting? » Dinah, posted by mattdds on December 26, 2003, at 20:01:24
Ok, let me try one. Mind you, my therapist is by no means a analyst, Freudian or otherwise. He's not at all a blank slate. Perhaps someone with a more classically trained analyst could provide some examples there.
Scenario 1 (using the relationship between therapist and client): My therapist and I are having a disagreement. I'm upset that we are angry with each other. From a cognitive behavior standpoint, there's plenty of ground that could be covered. I'm quite probably filtering and overgeneralizing, possibly catastrophizing. I might be assuming that if my therapist is angry with me right now, he'll always be angry with me, and if he is angry he doesn't like me, and if he doesn't like me I must be a miserable wretch of a human being. I might be thinking I "shouldn't" ever be angry with someone I care about, or they shouldn't be angry with me. A CBT therapist might go over my irrational thoughts with me, carefully countering each one, perhaps with a whiteboard for emphasis (sorry, Bell, but I like that whiteboard image). He might assign me homework to see other instances in my life where I might have the same sort of thoughts. He might also teach me some behavioral steps that can keep my arousal level down.
My therapist would more likely take a different approach. He would probably admit to being frustrated or maybe even angry, while telling me he also still cared for me. He would tell me it's ok for me to be angry with him. That our relationship was strong enough to withstand some anger. He might ask me about how my parents felt about anger directed towards them, or how I felt about anger from my parents. He might ask me about other relationships in my life and whether or not they had withstood anger. Perhaps he finds that when I get angry with people in my life, the relationship doesn't survive. Maybe he finds that anger is so painful to me that I disengage. Now he can talk about what I lose in life by not accepting anger as a part of a relationship. I might have told him stories that could have gotten to this point, but the immediacy of the therapeutic relationship gives an example that is still emotionally charged and that he can use to greater effect.
In effect, his interaction isn't that much different than a CBT therapist in outcome. He's shown me that he can be angry with me while he still cares about me (overgeneralizing and filtering). He reminds me that our relationship has withstood anger in the past and can withstand it now (catastrophic thinking). By admitting that I was perceiving his feelings correctly, he validates my reality, but in talking to me about what the feelings mean, he points out to me that while my perceptions are correct, my assumptions might not be. He not only gives me permission to feel angry (shoulds) but he also places my original should thought in context. In the past feeling angry has led to this or that, so I got the idea that I shouldn't be angry, but that feeling angry doesn't have to lead to this or that. That here is a relationship where it hasn't, that there could be other relationships where it wouldn't.
He doesn't tell me these things, but he gets me to realize them through experiencing the moment. It's not a didactic experience, it's an experiential one. And it takes longer, yes, because at the beginning of our therapeutic relationship he couldn't have used our relationship as an example. I wouldn't have *felt* that what he was saying was true because I wouldn't have yet experienced it.
But to some of us, the felt experience has a far greater effect than the rational understanding that a thought or idea isn't true.
Posted by Dinah on December 26, 2003, at 23:28:44
In reply to Re: You know what might be interesting? » Dinah, posted by mattdds on December 26, 2003, at 20:01:24
Ok, here's another one. This one doesn't use the relationship.
I report that I have been upset this week because I discovered my dog is dying. I break my thoughts down with my CBT therapist and, while they contain a certain amount of realistic grief, there are also some dysfunctional thoughts. My dog is dying. I will be bereft and suicidal when he dies. I won't be able to stand the pain. I will never again know the love that I have known with this dog. It's not fair! He shouldn't be dying! I'm fortunetelling, catastrophizing, overgeneralizing, guilty of emotional reasoning, and believing that the world should always be fair. My CBT therapist could pull out his blackboard again, point out the myriad flaws in my thinking, have me question each thought, and come up with counterthoughts for each of them.
Now at this point, I'd probably be ready to break the whiteboard in two and storm out. And my therapist (if he were a particularly unwise CBT therapist) might be asking me if I want to keep feeling this way, what is my secondary gain. And then I would storm out. But that's just me. :)
My therapist would reflect that my dog obviously meant a lot to me. And I might tell him funny stories from his life, and how he makes me feel. He might guide me to point out the needs I have met by the dog. I might tell him about previous grieving experiences I had, where I did feel the things I was now afraid of feeling. We might talk about how we could spend our remaining time together. He'd guide the conversation to the points he wanted to make, while not rushing it.
Again, the presentation would be less didactic, more experiential. But the result would be the same. I would come to a more reasoned view of what was happening and how I would react. Yes, it would hurt, but yes, I could live through it. I had lived through grief in the past, however much it hurt. He might let me remain angry that the world wasn't fair, even as I accepted the truth of it.
You might say that this isn't a general enough tool. That I wasn't taught the wider concept of challenging all my thoughts, not just this one. I wasn't sent home with a split journal to write the dysfunctional thoughts of the week and my counterthoughts. And that's true enough. And for those who do well with the teaching approach of CBT, it would certainly save time to start with the global and apply it to the specific. But you get to the same end starting with the specific too. After you've gone through the process enough times, you start to internalize it (or so the theory goes, and I have noticed it to be true). You begin to have an internalized therapist, who guides you through the steps that your real therapist would have.
Posted by Dinah on December 26, 2003, at 23:45:19
In reply to Re: You know what might be interesting? » Dinah, posted by mattdds on December 26, 2003, at 20:01:24
If you aren't sick enough of me already...
My much disliked biofeedback therapist told me at the first (and best) of our three sessions that there were three parts we would be dealing with - thoughts, feelings, and body. He said that the biofeedback portion would work on changing my body reactions and that doing so would change my feelings and thoughts. He said that the CBT portion of his therapy would work on changing my thoughts, and in doing so change my feelings and body reactions.
What he failed to say was that you can also work on changing your feelings, and that that would change your thoughts and your body reactions. The more traditional therapies work on changing your feelings. So in the first example I gave, I felt my anger and I also felt my therapist's caring stance towards me. I could remember the feelings of other fights and also the continued safe relationship. The current feelings and remembered feelings changed my body sensations by relaxing me, and changed my thoughts. Hey!!! You can be angry while you still have a caring relationship! I know this! I can feel it!
I've heard that there are different ways that people have to learn. That some learn better visually, some kinetically, some through hearing. Perhaps therapy is the same way. Some learn better through their body (behavior therapy?), some through their thoughts (cognitive therapy), some through their emotions (the other therapies). And perhaps most of us learn best with all three modes used optimally.
Posted by Speaker on December 27, 2003, at 0:04:49
In reply to Therapist Orientation? CBT or psychodynamic?, posted by mattdds on December 26, 2003, at 1:52:24
This board has been very informative for me! I had no clue how many types of therapy there were when I started I just knew I needed help! I have been in therapy for several years and CBT has worked well for me. I now have to find a new T and am finding how different they all are and seeing the different styles of therapy...I really just want my old T back :). I have been to a T about six weeks now and he has 3 PH.D's (how boring and expensive) so he does a little of everything and I find myself caught off guard...probably good for me but I don't like the fact I don't always know where he is going or what the RIGHT answer is :). Thanks to all of you who keep this type thread going as I learn so much and it is much more cost effective!!!
Posted by DaisyM on December 27, 2003, at 0:36:42
In reply to Re: You know what might be interesting? » mattdds, posted by Dinah on December 26, 2003, at 23:28:44
We could make it even harder:
My husband is essentially dying. We don't know whether we have 2 years, or 5 or maybe, even 10. What we do know is that it is going to be a slow, ugy, up and down process. We have kids to raise and we need to keep life as normal as possible for them.
I feel sad, angry and overwhelmed. I don't know how I will cope.
I know I am: fortunetelling, catastrophizing, overgeneralizing, guilty of emotional reasoning, and believing that the world should always be fair. I am also minimizing a great deal of the time because it isn't "actually happening to me. I'm not the one who is sick."
Instead of corrective thinking, my Therapist helps me recognize my own sadness and anger, allows it and offers support. Reality testing is helpful for the guilt. As one who strugges with thinking that she should do it all on her own, learning to accept support is a huge part of all of this.
It seems to me that any effective approach must be individualized, both for the situation and the individual.
Posted by Kalamatianos on December 27, 2003, at 1:17:27
In reply to Re: Cognitive vs Behaviorists » Kalamatianos, posted by mattdds on December 26, 2003, at 15:58:24
I feel I was out of line to post what I posted. Thanx for being patient with me and my naivete'.
Posted by tabitha on December 27, 2003, at 1:30:38
In reply to Re: You know what might be interesting?, posted by mattdds on December 26, 2003, at 21:25:33
I read that Quackwatch article after my therapist started wanting to use EMDR. I have the same hunch that the eye movement probably isn't the magical brain-integrating thing they claim it is. It does provide a little focal point or distraction though. Maybe it just helps focus concentration? Anyway my therapist is convinced it's useful. I go along with some skepticism-- I think it's the thought process and the talking that's important, not the gimmicky eye thing.
Posted by mattdds on December 27, 2003, at 2:19:20
In reply to Or to put it another way..... » mattdds, posted by Dinah on December 26, 2003, at 23:45:19
> If you aren't sick enough of me already...
Haha, nope. I think your posts are really thoughtful actually. I'm using this thread as a challenge to not get defensive or treat this as an "argument". I'm enjoying the exchange.
>
> My much disliked biofeedback therapist told me at the first (and best) of our three sessions that there were three parts we would be dealing with - thoughts, feelings, and body. He said that the biofeedback portion would work on changing my body reactions and that doing so would change my feelings and thoughts. He said that the CBT portion of his therapy would work on changing my thoughts, and in doing so change my feelings and body reactions.
>
> What he failed to say was that you can also work on changing your feelings, and that that would change your thoughts and your body reactions. The more traditional therapies work on changing your feelings. So in the first example I gave, I felt my anger and I also felt my therapist's caring stance towards me. I could remember the feelings of other fights and also the continued safe relationship. The current feelings and remembered feelings changed my body sensations by relaxing me, and changed my thoughts. Hey!!! You can be angry while you still have a caring relationship! I know this! I can feel it!
>To me, this does not seem like your emotion changed first, but your *cognitions* surrounding the emotion changed, then a subsequent change in emotion. Did I get this right? You realized that you can be angry and still have a caring relationship. No?
> I've heard that there are different ways that people have to learn. That some learn better visually, some kinetically, some through hearing. Perhaps therapy is the same way. Some learn better through their body (behavior therapy?), some through their thoughts (cognitive therapy), some through their emotions (the other therapies). And perhaps most of us learn best with all three modes used optimally.
This is so true. If you're feeling a certain way, you are more likely to think certain thoughts. Same is true if you are behaving a certain way, you are likely to feel and think certain ways that would correspond with the behavior. Emotion-cognition-behavior is a complex interplay, not a one way street. Any honest CBT-ist will admit that. It's kind of like one big equilibrium problem in chemistry. The equation can go back and forth. The problem is that we really only have *direct* control over a couple of variables - behavior (most obvious) and cognition.
I find it really hard to change feelings directly. I've tried relaxation, yoga, acupuncture, etc, all to no avail. The only form of emotional control that I know of is the control of my metacognitions surrounding my mood state. But this is still indirectly controlling emotion, and it follows a change in cognition, in my view.
If you know of any reliable methods of directly changing emotions, please let me know. I'm not being sarcastic here, I'm serious! This would be the missing link for me. Because in the end, we all just want to *feel* good. Period.
But this is the reason I sought treatment...I can't directly control my emotions. I can accept them, and not catastrophize about them. I can control the metacognitions that appear surrounding them (acceptance paradox, not magnifying). I can even pry my butt out of bed after 2 hours of sleep that was interrupted with panic attacks and attend a pharmacology exam (behavioral activation), despite my horrible mood.
But for me at least, there is no knob or button to control my emotions. That's the whole problem!!
This thread is getting good, thanks for the exchange, Dinah!
Best,
Matt
Posted by mattdds on December 27, 2003, at 2:43:05
In reply to Re: You know what might be interesting? » mattdds, posted by Dinah on December 26, 2003, at 23:28:44
> Ok, here's another one. This one doesn't use the relationship.
Good, because I can think of a number of potential problems with depending on your relationship with your therapist for experiential-emotional change.
>
> I report that I have been upset this week because I discovered my dog is dying. I break my thoughts down with my CBT therapist and, while they contain a certain amount of realistic grief, there are also some dysfunctional thoughts. My dog is dying. I will be bereft and suicidal when he dies. I won't be able to stand the pain. I will never again know the love that I have known with this dog. It's not fair! He shouldn't be dying! I'm fortunetelling, catastrophizing, overgeneralizing, guilty of emotional reasoning, and believing that the world should always be fair. My CBT therapist could pull out his blackboard again, point out the myriad flaws in my thinking, have me question each thought, and come up with counterthoughts for each of them.
>This really (I hope) is a straw-man CBT therapist, and does not represent how they really are in general. This really is not all there is to CBT, and the chalkboard thing you keep bringing up is really oversimplifying it. For example, David Burns suggests attacking the problem from 15 or so different approaches. The negative thought - counterthought method is only *one* CBT technique! There are myriads, literally. If this was all the treatment you got, you were done a disservice!
> Now at this point, I'd probably be ready to break the whiteboard in two and storm out. And my therapist (if he were a particularly unwise CBT therapist) might be asking me if I want to keep feeling this way, what is my secondary gain. And then I would storm out. But that's just me. :)
>
> My therapist would reflect that my dog obviously meant a lot to me. And I might tell him funny stories from his life, and how he makes me feel. He might guide me to point out the needs I have met by the dog. I might tell him about previous grieving experiences I had, where I did feel the things I was now afraid of feeling. We might talk about how we could spend our remaining time together. He'd guide the conversation to the points he wanted to make, while not rushing it.
>
> Again, the presentation would be less didactic, more experiential.Again, there is much more to CBT than just didactics. As I mentioned before, therapeutic empathy also predicts success with CBT. But what your therapist (the good one) did sounded like it *was* CBT, but wrapped in a very warm, empathetic package.
>
> You might say that this isn't a general enough tool.Actually, I would *not* say that. The emotional brain does not do well with abstract concepts. That's why it's best to work with specific, real life problems, rather than on a vague, abstract level.
>>And that's true enough. And for those who do well with the teaching approach of CBT, it would certainly save time to start with the global and apply it to the specific. But you get to the same end starting with the specific too.
Burns refuses to talk to patients on abstract, global levels, he encourages specific, real, definable problems. Actually, what you are describing, *is* CBT.
>>After you've gone through the process enough times, you start to internalize it (or so the theory goes, and I have noticed it to be true). You begin to have an internalized therapist, who guides you through the steps that your real therapist would have.
Yes, exactly. It is developing coping strategies that become second nature over time. I definitely agree that using specific problems helps to drive it home emotionally much better than didactic education. I think the didactics just provided me with a framework, but you really must use specific examples. Also, this is why most good CBT therapists prescribe behavioral experiments as well as didactic. It is another modality to access the problem.
Great analogy about the inner therapist. I have mine, which is better some times than others, but his (her?) skills are improving over time.
Best,
Matt
Posted by mattdds on December 27, 2003, at 2:45:29
In reply to Re: Cognitive vs Behaviorists » mattdds, posted by Kalamatianos on December 27, 2003, at 1:17:27
> I feel I was out of line to post what I posted. Thanx for being patient with me and my naivete'.
>I wasn't offended or put off, but thanks for being concerned. I appreciate it! I don't consider you or your post to be naive in the least.
Regards,
Matt
Posted by Dinah on December 27, 2003, at 9:29:31
In reply to Re: You know what might be interesting? » Dinah, posted by mattdds on December 27, 2003, at 2:43:05
> Good, because I can think of a number of potential problems with depending on your relationship with your therapist for experiential-emotional change.
>
Yes, there are. But there are also a heck of a lot of benefits. No other relationship or situation is quite so open for work as that one, because first of all there is emotional immediacy, and second the therapist is more familiar with what really happened, unfiltered by a secondary reporting. That's why the much maligned transference is important in therapy, because it is a microcosm of the rest of our lives. Many of our irrational thoughts and dysfunctional coping mechanisms crop up in that one relationship, especially if it is highly charged emotionally on our parts.All this is assuming that a therapist is aware of and in some control of his own behavior. Biofeedback guy considered himself direct (he called my therapist a narcissist after two sentences from me, and told me I liked to be annoying to gain control). While he considered me hostile. He'd have a lousy time trying to use the therapeutic relationship, because he didn't own his role in it.
> This really (I hope) is a straw-man CBT therapist, and does not represent how they really are in general. This really is not all there is to CBT, and the chalkboard thing you keep bringing up is really oversimplifying it. For example, David Burns suggests attacking the problem from 15 or so different approaches. The negative thought - counterthought method is only *one* CBT technique! There are myriads, literally. If this was all the treatment you got, you were done a disservice!
>
I know. And I was oversimplifying for the purpose of pointing out the basic similarities of the two approaches, for which I apologize. I know how much, for example, lifestyle changes and a myriad of other things come together for anxiety disorders, right down to skipping the caffiene.And the whiteboard was just a technique that Bell mentioned that my therapist hadn't thought of, but I wish he had. It really tickled my fancy. My therapist used his worksheets and handouts.
>
> Again, there is much more to CBT than just didactics. As I mentioned before, therapeutic empathy also predicts success with CBT. But what your therapist (the good one) did sounded like it *was* CBT, but wrapped in a very warm, empathetic package.
>Well, there is a problem I have with CBT, or at least CBT as it was practiced with me. Perhaps since it's often short term, the therapist wasn't always wise in choosing teachable moments and ended up angering by mentioning technical terms for thought distortions when I was too emotionally aroused to take them kindly, or worse yet (and this made steam rise from my ears) mentioned lack of motivation or secondary gain.
> >
> > You might say that this isn't a general enough tool.
>
> Actually, I would *not* say that. The emotional brain does not do well with abstract concepts. That's why it's best to work with specific, real life problems, rather than on a vague, abstract level.Well, again I'm overgeneralizing and getting through the process rather quickly. The specifics of my irrational thoughts wouldn't be mentioned or countered directly. None of the CBT words for ways of thinking would be mentioned. The conclusions would appear on the surface to mine, although if I were thinking about it, I'd realize that my therapist was guiding me to it.
> Burns refuses to talk to patients on abstract, global levels, he encourages specific, real, definable problems. Actually, what you are describing, *is* CBT.
Well, after all my therapist is CBT oriented. :) He just discovered that a textbook presentation of it wasn't the best method with me. But again, I probably summarized a bit too much in the example. In session, it would look more like a discussion with an empathetic listener of my grief and fears.
>
>
> Yes, exactly. It is developing coping strategies that become second nature over time. I definitely agree that using specific problems helps to drive it home emotionally much better than didactic education. I think the didactics just provided me with a framework, but you really must use specific examples.Exactly! And my theory is that non-CBT therapy is not that different in the end result than CBT therapy, but without the teaching component and without the homework assignments. It works with what comes up in therapy. And it does explore the past more, helping us understand why we do the things we do, and validating our experiences and our resulting reactions while still gently pulling us towards change.
> Great analogy about the inner therapist. I have mine, which is better some times than others, but his (her?) skills are improving over time.
>
:) I still have an absolutely rotten problem with internalizing my therapist. That's why I've been in therapy so long. But I may be doing myself a disservice there.I really didn't like this example as much as the other one, and in both I collapsed the process perhaps a bit too much to point out the similarities.
Daisy's post gives a much better example, I think, of learning by feeling.
I'm enjoying our discussion too, and hope people keep it going. Discussing theory of psychology is fascinating to me.
Posted by Dinah on December 27, 2003, at 9:30:26
In reply to Re: You know what might be interesting?, posted by Dinah on December 27, 2003, at 9:29:31
Posted by Dinah on December 27, 2003, at 9:58:34
In reply to Re: Or to put it another way..... » Dinah, posted by mattdds on December 27, 2003, at 2:19:20
>
> To me, this does not seem like your emotion changed first, but your *cognitions* surrounding the emotion changed, then a subsequent change in emotion. Did I get this right? You realized that you can be angry and still have a caring relationship. No?No, not exactly. First I felt the anger, and felt the caring. Not until I was able to feel both at once, and recognize that I was feeling both at once did I entertain the cognition that I *could* feel both at once. The feelings came first, recognition of the feelings brought about a change in my thoughts. No one could have convinced me that I could feel any differently (changed my cognition on a fundamental level) until I *had* actually felt differently.
Now, I suppose you could say that that resulted from behavior therapy, except that I hadn't done anything really differently than usual. I hadn't forced myself to behave differently. I just got a different response to the behavior I normally exhibit. And that different response allowed me to feel differently. And feeling differently allowed me to think and behave differently in the future.
That can happen in other places than therapy. For example, when I switched to a new high school, I didn't behave differently, but I found that the students were more accepting. So my feelings about school changed first, then my thoughts, and then my behaviors. But in therapy, it isn't happy coincidence, it's a planned endeavor.
>
> This is so true. If you're feeling a certain way, you are more likely to think certain thoughts. Same is true if you are behaving a certain way, you are likely to feel and think certain ways that would correspond with the behavior. Emotion-cognition-behavior is a complex interplay, not a one way street. Any honest CBT-ist will admit that. It's kind of like one big equilibrium problem in chemistry. The equation can go back and forth. The problem is that we really only have *direct* control over a couple of variables - behavior (most obvious) and cognition.
>
> I find it really hard to change feelings directly. I've tried relaxation, yoga, acupuncture, etc, all to no avail. The only form of emotional control that I know of is the control of my metacognitions surrounding my mood state. But this is still indirectly controlling emotion, and it follows a change in cognition, in my view.
>
Well, in my humble opinion, relaxation, yoga and acupuncture probably work on the body part, not the feelings part, just like biofeedback.> If you know of any reliable methods of directly changing emotions, please let me know. I'm not being sarcastic here, I'm serious! This would be the missing link for me. Because in the end, we all just want to *feel* good. Period.
>
I don't think therapy works quite that directly. My therapist would be the first to admit that I can't decide to wake up feeling happy and excited tomorrow. But therapy does provide a controlled environment designed to change your feelings. Not global ones, cerntainly. But in small increments.> But this is the reason I sought treatment...I can't directly control my emotions. I can accept them, and not catastrophize about them. I can control the metacognitions that appear surrounding them (acceptance paradox, not magnifying). I can even pry my butt out of bed after 2 hours of sleep that was interrupted with panic attacks and attend a pharmacology exam (behavioral activation), despite my horrible mood.
>
Yes, and all those things are wonderful, and very helpful. That's why I think CBT should be required for everyone.
> But for me at least, there is no knob or button to control my emotions. That's the whole problem!!
>
No, there's not. And I certainly can't say my therapist can help me control my emotions directly. But there are reasons for many of our emotions. Some are purely cognitive, but others come from our life experiences. And sometimes the emotions that come from our life experiences are best changed by having new, different, life experiences. Admitting something that we have always been ashamed of and feeling the person with us exuding acceptance can help us let go of the shame. Growing up in a household where it was necessary to perform to receive attention and "love" leave us feeling that we are what we do. Feeling someone accept us without the necessary performance first can help us feel differently about our worth. The therapist is providing us with new experiences and helping us feel differently. Once we start to feel differently it affects our thoughts and our bodies.Oh, by the way, I wanted to clear up something I said in another post. I don't in any way think that having my OCD brought under control by CBT caused my mood disorder. I do think that OCD masked, diverted, and drained the energy from a previously unknown mood instability. Not completely true. My mood instability was obvious in my early teens but was rigorously under control after that point. The OCD was possibly a side effect of that control? Or a mechanism that helped the control? At any rate, I was too out of touch with my feelings to recognize the mood instability. And ironically, one of the things CBT for anxiety disorders does is try to get you in touch with your feelings. :)
Ok, can some others with better examples or who might be better at explaining the processes jump in here?
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