464 - Contextual Cognitive Behavioral Therapy

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Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director: AllCEUs Counselor Education Host: Counselor Toolbox Podcast Objectives • Define and review the concepts of contextual cognitive behavioral therapy • Explore the impact of context on people’s phenomenological reality • Explore how addiction and mental health issues can be influenced by context • Explore how acceptance, awareness, mindfulness and psychological flexibility can be used transdiagnostically.

Why Contextual • Addiction and mental health issues are often intergenerational • Addiction and Mental Health issues are strongly correlated with: • Each other • Adverse childhood experiences (history of and children with) • Impaired occupational and social functioning • Health problems Contextual Approaches • Encourage mindfulness in the present moment • Accept each person’s “truth” is constructed from their schema and the resulting interpretation of the current moment • The goal is to consider the context and function of the past and present issue and empower the person to make a conscious choice toward their valued goals • Remember that the prefix RE means to do again • REpeat • REdo • REgress • RElapse • REaction

Childhood Context and Development • The family context can be a preventative or risk factor for the development of issues • Children develop schema about themselves, others and the world through these early interactions • In later life people continue to develop schema influenced by their past learning.

Caregiver Requirements for Secure Attachment and Healthy Development • Consistent Age-Appropriate Responsiveness • Trust • Autonomy • Industry • Identity • Empathy • Compassion • Effective Communication Skills • Unconditional Love

Think About It • What is it like for a child growing up in a house in which one or both parents has: • An addiction • A mental health issue Common Addicted Characteristics • Difficulty dealing with life on life’s terms • Difficulty dealing with distress (poor coping) • Impulsivity / lack of patience and distress tolerance • Neglectfulness • Hostility • Defensiveness • Blaming • Manipulation • Withdrawal • From others/disconnected • No pleasure in other activities • Justification/minimization/denial • Low self-esteem • Guilt and shame

Common Characteristics in People with Mental Health Issues • Difficulty dealing with life on life’s terms • Difficulty dealing with distress (poor coping) • Impulsivity / lack of patience and distress tolerance • Neglectfulness • Hostility • Irritability

• Withdrawal • From others/disconnected • Apathy • Low self-esteem • Guilt and shame • Fatigue • Sense of hopelessness or helplessness

The End Product • People’s REactions to things are based on prior learning + present moment. • Bridges • Stress • Depression • Self-esteem

Core Concepts in Contextual CBT Mindfulness • Improves people’s ability to be present in the present • Shift from automatically reacting to thoughts and feelings based on schema to being aware of ALL experiences in the present to provide more flexibility

Encouraging Acceptance of Internal Experiences • Accepting thoughts, feelings, sensations without having to act on them • Radical Acceptance • Unhooking • Dialectics • I can be a good person AND be divorced • I can be happy AND grieving • I can stay sober AND be stressed Acceptance of Internal Experiences • Accepting thoughts, feelings, sensations without having to act on them • Distress Tolerance • ACCEPTS • Activities • Contributing • Comparisons • Emotions (opposite) • Push Away • Thoughts • Sensations Focus on Adding vs. Eliminating • Help the person define a rich and meaningful life and make choices based on that vs. eliminating a problem • Depression • What do we do to eliminate depression? • What are we left with when we eliminate depression? • How do you prove the absence of depression? • Addiction • What do we do to eliminate addiction? • What are we left with when we eliminate addiction? • How do you prove the absence of addiction? • Accepting feelings thoughts and reactions and changing your relationship with them

Creating a Rich and Meaningful Life • Increasing Awareness • For each of the following areas identify which are important in your RML and what that looks like now and what you want it to look like

Changing Your Relationship • Radically accept feelings, thoughts and urges • Think of them like road signs • You can take them under advisement and decide what to do. • Speed limit/Anger • Construction/Giving up • No passing/Addiction • Rest stop/Depression Motivational Enhancement (Functional) • Understanding motivation for change as well as no change in the context of the person’s RML in order to motivate purposeful action

Use a Broad Functional Approach • Transdiagnostic • Common mechanisms underlying an array of difficulties: Depression, Low Self-Esteem, Addiction • Shoulds and Shouldn’ts (Acceptance) • I should feel • I shouldn’t think • I should be • Lack of Awareness of Needs/Wants (Mindfulness) • Vulnerabilities • Autopilot or Rigid Thinking (Psychological Flexibility) • A willingness to accept all aspects of ones experience without unnecessary avoidance—Emotional, Cognitive, Behavioral, Physical • The ability to ponder multiple possible actions and thoughts and consciously choose Difficulties with Self-Processes • Difficulty with self esteem or self efficacy may cause or maintain problems • Self-as-content – Narrative about one’s self and attributes • Being overly attached to the conceptualized self can prohibit flexibility • Ex. Being a good worker in a bad job • Ex. Being a good daughter but getting a divorce

Addressing Self as Content • Who do you want to be? • Explain why each of those is important? • In what ways does the current situation prevent you from being who you want to be? • What areas in your life are going as you want them to? (addressing global attributions) • Are there other ways to achieve or conceptualize the same end? • Examples • A size 3 (attractive/lovable) • A doctor (successful) • Not divorced (not a failure) • Loyal/dependable (not a quitter)

Difficulties with Self-Processes cont… • Difficulty with self esteem or self efficacy may cause or maintain problems • Self-as-process • Awareness of internal experience • Many people have difficulty attending to their internal experience in a flexible way • Handling urges, feelings • Identifying thoughts, feelings, urges, sensations etc. Addressing Self-As-Process • Mindfulness journals/logs • Meditation to increase awareness • CBT Exposure-Noticing / In-Vivo Logs • Anger • Fear • Craving • Relapse prevention plans to handle internal processes • Make a committed action worksheet for each thing that is important to you.

Difficulties with Self-Processes • Difficulty with self esteem or self efficacy may cause or maintain problems • Self-as-context • Adopting the perspective of the self in the past, present and future—Who you were-are-want to be • Ability to take the perspective of others • Rigid self as context—or inability to take perspective may inhibit effective problem solving. • I am and always will be a failure/an addict/depressed Addressing Self-As-Context • Increasing Perspective • Looking at your definition of a RML, what does your… • Past self tell you about your current situation? (schema) • What might your future self tell you about your current situation? (Flexibility) • What might you tell someone else in a similar situation? • How do your current thoughts, feelings, behaviors help you move toward what is important to you?

Summary • Contextual CBT involves understanding people’s phenomenological truth • Problems can arise when people • Thinks/feels that they are not who they should be or things are not as they should be • Are unaware of their internal feelings, thoughts, urges • Are unaware of the motivation (in context) of their feelings, thoughts, urges • Use rigid problem solving and conceptualization without considering context or perspective • Contextual CBT uses awareness, mindfulness, radical acceptance and psychological flexibility activities to help people move toward a rich and meaningful life instead of trying to escape or avoid discomfort.