mardi 3 février 2009

Seventeen cognitive therapy techniques

Again, this is based on an un-attributed handout I got in therapy.

The idea behind most of these techniques is to have a conversation with yourself about the distorted cognition. You might feel critical of this notion, but it does work. I know, because I was very critical of CBT when I was working with the Fired Therapist, but now that I'm on my own and I do it my way, it works. My personal experience of it is that over time it's created a separation in my mind between two (or more) "voices." No, I don't have "voices in my head." I just have various aspects of me who I hold responsible for various kinds of cognitions. For our purposes the important ones are The Brain, which is the voice of mental illness and distorted cognitions, and the Dog Training Voice, which challenges the distorted cognition. It's called the Dog Training Voice because it does sound like my dog training voice. Or horse training voice. Or Girl Guides training voice. The voice that makes it clear to whoever you're talking to that your patience just ran out and now would be a good time to smarten up.

I don't like either The Brain or the Dog Training Voice. They're not friendly people. But that's not the point. The Brain is here to stay, and the Dog Training Voice is here as long as The Brain needs someone to keep it in line. There's nothing that says you have to enjoy Cognitive Therapy when you're doing it, but it's like brushing your teeth. You do it whether you like it or not, or else you live with the consequences of choosing not to do it.

Having said that, on to the CT techniques.

  1. Questioning what you really mean
    This is useful when you're indulging in the "labeling" distorted cognition. Say you're thinking to yourself, "self, I'm a loser." The Dog Training Voice would then ask "Brain, what do you mean by that?" Then you'd think about it and you might say "I don't have any friends." Or whatever it is you're thinking. By itself this exercise doesn't do much, but it then allows you to have something specific to work on with the next technique:

  2. Questioning the evidence
    You review the evidence that supports your cognition, and then challenge it. So say you're thinking "I don't have any friends." What's the evidence for that? Say, for example, "I'm never invited to anything." Well, for one, that has "never" in it so we question whether it's an exaggeration. Are you really never invited to anything, if you stop feeling maudlin and really, honestly, review whether you've been invited to anything or not? Just because you didn't go, doesn't mean you weren't invited.

    The trick here is that at first you will think all the evidence backs your cognition. But this is a distorted cognition of type "filtering": you're actually (probably) ignoring any evidence that's contrary to your cognition, and choosing to remember only what backs you up. So the challenge is to admit to yourself that indeed there is contrary evidence that you've been discarding.

  3. Reattribution
    This is useful when you think a problem is either entirely your fault, or entirely not your fault. Say you're having a conflict with someone and you're thinking "OMFG she is such a skank, this is all her fault." Well, really... Let go of the "it's all her fault," and look at it again. Perhaps using techniques #1 and #2. What do you mean by "it", and does the evidence really support the notion that "it" is all her fault, if you stop discarding the pieces that make you look like you had something to do with it? Did you escalate the situation? Did you react to something based on a distorted cognition? Really? Honestly?

    Conversely if you're thinking "this is all my fault," then go through #1 and #2 honestly, stop discarding the parts where someone else contributed to the problem, and look at it in a realistic light. Again, at first you will be convinced that you're right and that the evidence backs you up, so the trick is to be willing to admit that you're not always right, and look for the "other" cognitions, the ones that you're refusing to look at because they disagree with how you choose to think.

  4. Examining options and alternatives
    This is fairly self-explanatory. Basically it's just problem-solving. Thinking you have no options is a distorted cognition, because there are always things you can do and choices you can make. One reason you might think otherwise, is because you haven't brainstormed the options, and the other reason is, you refuse to consider some of the options. This is very common among the blogs I read, I find, when someone thinks they "can't" do something, most of the time it's because they're refusing to make the choices that go along with it. For practice, start by looking at previous decisions where you figured you had no choice or no options, and consider honestly, what options were available. Including the ones that are unpalatable or difficult. Just because you didn't like an option, doesn't mean it didn't exist. Once you get the hang of it looking at the past, you can apply it to current situations.

  5. Decatastrophizing
    Catastrophizing is when you think something will have catastrophic consequences. The reality is, in most people's lives, nothing you can do has the potential for catastrophic consequences. Clearly this isn't the case if you're, say, the guy who filed work permits on Piper Alpha, but are you? No you're not. In fact, when you look at your own personal life and stop making a big deal out of everything, you start to realize that there is very little you can do that has any consequences at all. Granted, you might have more or less money depending on the choices you make. You might have to move. You might have to change jobs. You might break up with your partner. Is any of this the end of the world? Actually, no. It's a bump in the road, that's all. Nothing horrible will happen along with any of the above, if you're honest with yourself about it.

    Now on the other hand, if you discover that there is indeed in all honesty a possibility for catastrophe, then you need to act accordingly. For example, there is a real possibility for catastrophe if you have a baby in a car with no car seat. So don't. But that's something we'll come to later.

  6. Examining expected consequences
    This is much the same as decatastrophizing, except looking at all the consequences and not just the catastrophic ones. What consequences, both good and bad, do you expect from something? Now honestly, are these expectations realistic? Really? Seriously? Fine. So if a negative outcome has a high possibility of happening, what can you do to prevent it, or what can you do to deal with it? Example: "if I swear at my boss, I will lose my job." Well, that's a pretty high possibility all right. So... Can you prevent it? Well yes, you could choose not to swear at your boss. Or, can you deal with the consequences? Well yes, you could get a new job. So, should you swear at your boss, or not? Depends. Which sounds more appealing: biting your tongue, or looking for a new job? It's all a matter of choice.

  7. Listing advantages and disadvantages
    This is similar to the last three techniques, but again, slightly different. In this one, you ask yourself what are the advantages and disadvantages of engaging in a certain behaviour. For example, you take things personally. What are the advantages? Well, myself I can't think of any, but some people do it, so clearly they find advantages in it. What are the disadvantages? You're constantly being offended. People don't want to talk to you because they can't speak freely around you. You sound like a crazy person. You feel persecuted. In fact, you might even be persecuted, because when people get fed up with you and your schema, they're gonna start doing things on purpose to trigger you. (No, seriously.) So, is it to your advantage to be taking things personally? Realistically, no. However if you do come up with the answer that yes, it is to your advantage to take things personally, that tells me you're abusive and somebody's been enabling you. Because what's happening here is that you take something personally, you get mad, someone caters to your anger with apologies and changing of their behaviour. Ok, yeah, it worked out to your advantage in that you demonstrated control over someone. Bully for you!

  8. Turning adversity to advantage
    This is pretty self-explanatory and is another form of problem-solving so I won't go on at length about it. It's really simple: something bad happen, you make the best of it. Or, life gives you lemons, and you make lemonade.

  9. Labeling distortions
    We've been over this before. Identify distorted cognitions by comparing them with the categories. "Oh look, a distorted cognition of type 'catastrophizing'!" It becomes a game. How about getting a bunch of coloured stars and sticking one on the calendar every time you spot a certain type of cognition? This is an actual CBT technique that I've seen used with foster kids: you keep track of the number of occurences of a behaviour, and reward decreases in the frequency of occurences. No reason it can't work on you, too.

  10. Guided association and discovery
    This is harder to do on your own, given the "guided" part. I've been known to apply it to the douchebags in my life, though. If you remember the argument with Darcy, he had a whole bunch of irrelevant angry cognitions regarding my opinion, and my answer to all of them was "and?" He didn't answer me on that, but that's the idea anyway. Follow up on your distorted cognitions. "You're a bitch": distorted cognition of type "labeling". Possible follow-up questions: a) "and?" b) "what do you mean by that?" c) "what makes you say that?" Answer: "your opinion offends me." Possible follow-up questions: a) "how does my opinion offend you?" b) "why does that make you angry?" Stuff like that. Definitely easier to do with a therapist that you get along with.

  11. Using paradox and exaggeration
    Make your distorted cognitions even more distorted. Make them so distorted they sound ridiculous even to you. Then you come to realize, they were distorted even before you blew them out of proportion. Distorted cognition: "I'm fat." Even more distorted cognition: "I'm so fat, I have to back into the stalls in public washrooms." Of course this only works if "I'm fat" was a distorted cognition. Because when I lived in dorms I really did know a woman so large, she had to back into the bathroom stalls, and then she couldn't turn around to flush, either, in which case, "I'm fat" is a pretty realistic cognition. But if you can turn yourself into a "yo mama" joke, it helps point out the distortedness of your distorted cognitions.

  12. Scaling
    This is for people who have black-and-white thinking. Distorted cognition: "she's evil." Fine. On a scale of 0 to 100, where 0 is a newborn lamb and 100 is the most evil psychopath you can think of, how evil is she really? Probably she's not 100. If she a 95 on the evil scale? As evil as, say, Dahmer? No? Not that evil? How about 85? As evil as Mussolini? Not even? How about 70? Is she as evil as... Hmmm... Eva Peron? And so on. Maybe she turns out to be only a 21 on the evil scale, which is actually rather on the non-evil side, yes? Or maybe she's like, 54, which is more evil than not, but still only average evil compared to everybody else.

  13. Replacement imagery
    Hmmmm... This one is complicated and I don't think I use it. If I think of something later I'll write about it.

  14. Cognitive rehearsal
    That's pretty much what the name entails. You rehearse things in your mind. Say you have to be job-tested later in the day... You just rehearse in your mind how it's gonna go and the specific things you need to do to have a successful outcome, like say, remember to wear your safety glasses even though in real life you never do. Practice in your mind until you can visualize yourself doing all the right things and having a successful outcome. It reduces anxiety and depressed feelings.

  15. Self-instruction or coaching
    This is where the Dog Training Voice really shines. It's good for learning impulse control. Say you're trying to lose weight and you're about to eat a cookie. You say to yourself in your Dog Training Voice "no!" or in my case "leave it!" (which is what I say to my dog when she's about to eat something off the ground). At first you say these things to yourself out loud. This makes you look crazy, so you quickly learn to do it in your head instead. Conversely, you can cue yourself to do something, rather than not do something. Have you ever had a moment in sports where you suddenly hear your coach's voice in your head telling you... whatever it is he's been telling you in practice all along? And you do it and everything works out? Right. So be your own coach. Cue yourself every time. Personally, I don't like to brush my teeth, so twice a day I have to tell myself "go brush your teeth." Seriously. If I don't order myself to go brush my teeth, I don't do it. Luckily the Dog Training Voice isn't the one who hates brushing teeth, so it has no problem ordering me to go brush my teeth.

  16. Thought stopping
    My favourite. Instead of all the above, when a distorted cognition comes up, you just stop it. The self-instruction technique helps here, too. I always tell myself "leave it!" when I'm gnawing at a distorted cognition. The trick here is, you might have to do it thousands of times a day, especially at first. So don't quit because you did it ten times and the distorted cognition didn't go away. The distorted cognition might not ever go away, but if you stop it every time it comes up, it won't get you into a mood cycle. Seriously.

  17. Focusing
    That's pretty simple. Focus on doing something other than having distorted cognitions. Your mind can only do so many things at once. If you're focused on something, there won't be room in your mind for the distorted cognitions. This is why I crochet. Because at one time in my life, I needed to be constantly focused on something, and so I started to crochet. Constantly. Every waking moment, except when walking the dog. Now I do because I enjoy it, but it all started as just something to prevent me thinking about distorted cognitions. Like putting a cone on a dog.
Well, that's them. Hopefully some of these will be useful to some of youse. (I sure hope so, considering how long it took to type it out.)

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