DBT: Psychotherapy for People with Personality Disorders PDF

DBT: Psychotherapy for People with Personality Disorders Personality Disorders in the DSM-5 There are three clusters of PDs from the DSM-5 ○ Cluster A: odd, eccentric (e.g. paranoid, schizoid, schizotypal) rare ○ Cluster B: dramatic, emotional,...

DBT: Psychotherapy for People with Personality Disorders Personality Disorders in the DSM-5 There are three clusters of PDs from the DSM-5 ○ Cluster A: odd, eccentric (e.g. paranoid, schizoid, schizotypal) rare ○ Cluster B: dramatic, emotional, erratic (e.g. Borderline, narcissistic, antisocail) ○ Cluster C: anxious, fearful (e.g. avoidant, dependent, obsessive-compulsive) What makes personality disorders challenging to treat? There is not enough research on different types of personality disorders There is a lot of work to be done The patient not motivated to do therapy Ensure that the patient is on board with changing and moving forward, even if they don’t know why they need to change yet. Dialectical behavioral therapy Increasing insight into why he feels the way he feels Emotional regulation strategies Anger issues, aggression Therapy involves finding/revealing things about yourself that you don’t like It will be painful to realize Need to be motivated to change or to accept something they are refusing to accept History and Presenting Evidence Developed by Marsha Linehan after determining that traditional CBT is not effective for BPD, chronic suicidality A third wave of therapy, multimodel intervention incorporating aspects of CBT, Psychodynamic psychotherapy, ACT, Zen Buddhism, Catholicism, and more! The key component - the dialectical balance between acceptance and change Studies show that it’s more effective than CBT and other interventions in treating BPD and suicidal behaviors The Dialectic Acceptance and Change Acceptance: in DBT, clients begin to learn how to accept who they are and how they feel, think and act Change: in DBT, clients begin to learn new skills and ways of relating with others and themselves Important to consider both sides Components of DBT Treatment Skills Group Individual therapy ○ Serves the function of helping the patient/client apply the skills that they go through in their day-to-day life Phone Coaching ○ Helping the client apply some of the skills to get through the toughest moment in their life ○ If they can’t get through the situation on their own, it’s the role of the phone coach to offer some in-the-moment help (the specific situation right now, directive advice to cope with the situation right now) DBT Consultation Team ○ Think about what we could’ve done differently ○ Team members offer advice to help the therapist navigate different situations DBT's goal isn’t to prevent them from suicide but to help them find a life that is worth living. Priorities to discuss: ○ Suicidal behaviors ○ Therapy preventing behaviors ○ Quality of life behaviors DBT skills 1. Mindfulness (core skill) a. Focusing on the present moment, not letting the mind wander to the past or future, which can interfere with what you’re engaging in right now b. *Awareness that arises through paying attention, on purpose, to the present moment,, non-judgementally c. Emotional mind + reasonable mind = wise mind 2. Emotional regulation: improving the ability to flexibly respond to emotions a. Check the facts: check whether your emotional reactions fit the facts of the situation. Changing your beliefs and assumptions to fit the facts can help you change your emotional reactions to situations b. Opposite Action: when your emotions do not fit the facts, or when acting on your emotions is not effective, acting opposite (all the way) will change your emotional reactions i. Acting the opposite of your urge, acting the opposite of your anger, helps you pull back to the reality of the situation c. Problem solving: when the facts themselves are the problem, solving the problem will reduce the frequency of negative emotions i. Focusing on solving the problem will distract you from the negative automatic thoughts and reduce negative emotions by solving what you can control 3. Distress tolerance: learn that distressing emotions are tolerable a. Survive crisis situations: without making them worse  b. Accept reality: replace suffering and being “Stuck” with ordinary pain and the possibility of moving forward c. Become free: of having to satisfy the demands of your own desires, urges, and intense emotions 4. Interpersonal effectiveness: improve relationships, manage conflict Radical Acceptance Worksheet Incorporates distress tolerance and mindfulness skills If you have trouble accepting the reality to life Distress Tolerance Skills STOP skill Stop: Do not just react. STOP! Freeze! Do not move a muscle! Your emotions may try to make you act wihtout thinking! Stay in control! Take a step back: Take a step back from the situation. Take a break, let go. Take a deep breath. Do not let your feelings make you act impulsively Observe: Notice what is going on inside and outside. What is the situation? What are your thoughts and feelings? Proceed mindfully: Act with awareness, in deciding what to do. Consider tour thoughts and feelings, the situation, and other people’s thoughts and feelings, teh situation and other people’s thoughts and feelings. Think about your goals TIP Tip the temperature (cold/ice bath) Intense exercise Paced Interpersonal Effectiveness DEAR MAN ○ Describe the situation, expres yourself, assert yourself, reinforce, (stay) mindful, appear confident, negotiate GIVE ○ (Be) Gentle, (act) Interested, Validate, (Use an) Easy Manner FAST ○ (Be) Fair, (No) Apologies, Stick to values, (Be) Truthful Somatic Symptom Disorders Revisedin the DSM 5 - making it easier to differentially diagnose patients… The emphasis on the extent to which the thoughts, feelings and behaviors related to the illness are excessive or out of proportion Somatic Symptom Disorder  The fear and anxiery is disproportionate to what’s actually going on Emphasizes that Dx is made based on the presence of disrressing symptoms + abnormal thoughts, feelings and behaviors in response to them.. They do have symptoms but their *REACTION/FEAR* is disproportionate to their actual symptoms DSM-5 Diagnostic Criterioa (table) The emotions and psychological response that is preventing them from functioning High levels of anxiety Excessive amount of time focusing on the symptoms ○ Doing research on google, looking up the symptoms Persistent state of being symptomatic (more than 6 months) Excessive thoughts, feelings and behaviors that are disproportionate to their actual symptoms ○ Taking their mind away from things they need to deal with What is illness anxiety? defined by excessive worry about having or developing a serious disease/illness that has not been diagnosed Persistent anxiety, internet searching, misinterpretation of physical symptoms/bodily sensations Preoccupations with bodily functions ○ Interpret normal bodily sensations as something being seriously wrong Death anxiety ○ Anxiety about death Have normal everyday symptoms, or none at all, but they will demand tests from doctors Illness anxiety disorder (the focus is on having the illness even without any actual symptoms) DSM 5: illness anxiety disorder Somatic sumptoims are not present or if present are only mild in intensity People with IAD may be uncomfortable experiencing normal bodily sensations, and they may label the subtle bodily changes as psychological (table) Short Health anxiety Inventory (HAI-18) How much time the patient takes worrying about their health Hypochondria (always worrying abou their health) Risk Factors Having a serious childhood illness Experiencing a significant health scare Close family member or friend with a serious illness or death Fear and anxiety manifesting as i am going to die, I have an illness Anxiety disorder diagnosis in the past  Family history of anxiety disorders Case study (illness anxiety disorder) : patient comes to the doctor saying they have pancreatic cancer, takes tests, nothing is wrong. Patient is always hyperfocused on pancreatic cancer, convinced with no medical diagnosis to confirm that they are ill, so they take a lot of time creating videos and letters for their daughter. stressful. Her marriage has been deterioration for some time Financial issues have left her worried about losing her home She is not interested in her husband romantically Her children are not doing well in adult life Husband has a “Fantasy football” addiciton that drained their bank accoutn without her knowledge What is her diagnosis? How owuld we apply the different psychotherapy approaches? ○ Psychodynamic conceptualizations Unconscious conflicts underlie the disorder Unconscious aggresive feelings manifest as physical complaints Undealt with traumatic or frustration during childhood manifest in adult life as symptoms Angry and disappointed in children Frustrated towards husband, guilty for not loving husband/being proud of husband Suppressing these emotions ^ Defense used to avoid attendance to actual problems that are too difficult to face ○ Psychodynamic Affect phobia - keeping real emotions about real situations at bay People will harm themselves to get attention from doctors and people around them. They will infect wounds, eat things that will cause intestinal issues, something in them needs nurturing (that they didn’t get early on) Explore areas of unconscious trauma Explore areas of anxiety and or underlying conflicts Therapist help with these wounds Does the patient feel trapped Trauma (remembered in the trauma) Feelings of anger/hostility Feelings of being “trapped” in a situation Loss of control? ○ Resolve on a conscious level Object relations: attatment transferred to phsycial symptoms? ○ Be there for the patient and form a theraputic relationship Psychodynamic Negative therapeutic reactions… Just listen to the patient and answer them empathically while exploring the other things in the patient’s life becuase it is the other things that  Deeper understanding of the patient that helps them get better Cognitive-behavioral appraoch Core beliefs Remember: congnitive theory of psychopathology, disorders are reso=ult of maladaptive core beliefs about themselves and the world Not concerned about past events or unconscious conflicts Cognitive distortions Application to illness anxiety (slide) Challenging maladaptive patterns of thought ○ Core belief: good health means no physical symptoms or physical symptoms lead to death → is this a cognitive distortion? All or nothning? Catastrophizing? You can be in good health and have symptoms Functional Neurological Disorder (FND) Conversion disorder DSM4 (used to be called that) Features nervous system Neurological symptoms that can’t be explained by neurological disease or other medical conditon ○ However, the symptoms are real and cause significant distress or problems functioning Tells the doctor they can’t feel anything in their hand, but nothing wrong with the nerves A neurological condition caused by changes in how brain networks work, rather than changes in the structure of the brain itself, as seen in many other neurological disorders Common symptons ○ Psychogenic non-epileptic seizures (PNES) ○ Psychogenic dystopia (movement disorder) ○ Sensory disruptions: eharing, seeings, numbness of a limb ○ Paralysis ○ Tremors and ticks Having a neurological disorder due to a psychological problem Physological change after thinking about something (like a midterm or fight) ○ Cascade of physiological effects in our body just from thinking ○ Stress effects the immune system CBT for Psychogenic Dystonia (Psychogenic Movement disorder) -type of FND When there is muscle movements that are ambnormal ○ Nothing going on in their biological health, no physcial problem ○ Needs psychological examination Case study ○ Body buckle ups ○ They get angry with themselves or frustrated with themselves when they bottle things up. Doesn’t allow herself to get angry. (affect phobia) ○ Doctor used CBT to help the patient  16 weeks post-treatment: symptom free Fucntioning properly Predisposing Factors A history of childhood trauma Comorbid mental health disorders, especially depression or anxiety A recent stressful or traumatic event A recent health condition Cognitive Behavioral Model for the Developnnent of FND (image) traumatic/adverse event →symptoms occur → catastrophizing thoughts → stress-intensified symptom → serious functioning difficulties Cognitive Restructuring – Bottom up to top down Access the thoughts and take control of them Bottom up processing is a primitive automatic implicit and preconsicous information processing system that is activated by the salient features of relevant stimuli or situations ad associated schemas Studies of emotional evalluation using fMRI have associated bottom up processing (implicit and automatic) with the amygdala Top down processing is a slower, deliberate (explicit) Mass Psychogenic Illness A number of cases of FND within a certain area There is increasing recognition this is understudiesd, unerrecognized, under-reported and is cause for significant social and health concerns Two Types Anxiety hyteria ○ Mostly seen in western countires ○ Triggered by intense, acute stress within a close group of people ○ Typically, not always, someone will report an odd odor and coice concern it is a harmful toxin ○ Symptoms are transient, do not pose a health threat → dizziness, headache, passing out and hyperventilating ○ Most recover within 24-48 hours ○ There is an absence of pre-exissting tension within the group of people ○ Motor hysteria ○ Caused by long term anxiety and features motor agitation ○ Sumptoms include twtiching, tremors, unsteady gait, uncontrollable laughing, crying, communication difficultites and being ina trance  ○ onset is slow and takes weeks or months to subside…. Mass Psychogenic Illness Someone who has some type of connection In october 2011 several adolescent girls at a high school in the town of Leroy, NY spontaneously developed facial tics, muscle twitching and a garbled speech. By early january 2012, it was revealed they were diagnosed with conversion disorder. Traditionally there is a stressor that provoke a physical reaction in the body. It is unconscious, the stress has to come out of its body in some way shape or form. What elements from DBT could we bring in to the therapy? Mindfulness, stress managements skills Hunanistic (person-centered)? Treating patient with unconditional positive regard, help the patient overcome illness Working With Difficult Patients Last Class Somatic symptom disorder- emphasizes that the Dx is made based on the presense of distressing symptoms and abnormal thoughts, feelings, and behaviors in response to them. Thinking, researching, worrying… Not just the absence of a medical explanation for symtoms Behavioral Therapy for Illness Anxiety Exposure to the fear by using words ○ Cancer, stroke, multiple sclerosis, heart attack Don’t let the illness take control of them Strong therapeutic alliance “What would it look like if you had cancer, what would that mean?” (make them confront the fear) ○ Figure out waht they’re really afraid of. (i.e. passing away, death) ○ Asking if someone in ther life has passed away Functional Neurological Disorder (FND) Symptoms that can’t be explained by a neurological disease or other medical condiiton However the symptoms are real and casue significant distress or problems functioninng Resolve the actual issue, will see that the symptoms will resolve Working with difficult patients Difficult behaviors Counter-transference Rupture and repair Difficult behaviors Resistance: a process of avoiding or diminishing the self-disclosing communication requested by the interviewer because of its capacity to make the interviewee uncomfortable or anxious. ○ Happens when you approach something that is uncomfortable for the patient ○ Theories: Psychodynamic view - defense mechanism Behaviorist view - they don’t have faith int he therapy process or themselves regarding the skills to change their behavior Social interaction theory - what the therapist is doing is creating the resistance to the aptinet (pushing them too quickly, not aware of where they are in the change, timing) ○ Types of resistance Response quantity: not responding a lot, giving you bits and pieces, not going you enough conversation/inforomation, changing the subject Response content: diverting the subject, patient is gaurded Response style: they’re deflecting, joking, or just saying what the therapist wants to hear (want to move past this), start telling a story about something that is not appropriate to respond to what the therapist is trying to get at Logistic management: Talking to you through behavior, showing you something. (they are late, they don’t show up, not truthful with you, not paying on time) Saying that something is wrong and they’re not dedicated. Passive aggressive way to push the therapist back. Therapist needs to approach it in therapy. I noticed this..what’s wrong, are you not happy with the goals? Might need to change the approach or build a therapeutic alliance before going into deeper issues lack of commitment ○ Type of resistance: mandated patients, spouse or family member pushed then into treatment cultural factors influence views of psychology and therapy Therapeutic alliance anger/disregualtion ○ Therapist shouldn’t push further if the patient isn’t ready ○ What could therapist have done differently? She’s talking about his mom and pathologizing her The guy was very upset but she didn’t know and approached it wrong ○ Acknowledge the anger - very important in the deescalating process Repeat what they are telling you, deescalate the pateint ○ Show understanding - how can we work on this? Tell me more ○ Once they’ve calmed down: is this a pattern that interferes with their relationships? ○ Do they have a distorted perception ○ Emotion regulation skills  Do they have emotion regulation problems? demaning/entitled/boundary breaching ○ Longer sesion - more frequent sessions ○ Social interactions Intsert themselves in the same social setting as them ○ Proving you care about them ○ Set clear boundaries! Do not blur the boundaries between the therapist and patient ○ Explore if this behavior has interfered in other relationships They just be doing this in other relationships, is this causing them problems ○ These are seen as a great deal on BPD Break boundaries and test the therapist Common patient factors Shame Evading responsibility Chaging issue means changing, who they are in a familhy system or the world ○ How they see themselves, how they’re functioning, excuses ○ Scared to change Scared ○ Change is scary even if its positive change ○ We are comfortable with what we know, we know how to navigate it, steppig out of it brings a lot of new things that we can be scared of Common Therapis Factors Weak connection Lack of understanding regarding patient abilities ○ You think they are able to do this stuff, and think in a complex way but they can’t. Unrealistic expectaios Poor skills/knowledge Advice giving ○ We shouldn’t be giving advice (i.e. “Here’s what I think you need to do” DON’T DO THIS) ○ Therapists should process potential outcomes Patient makes the decision of change “If you do this what would happen, I know research suggests that this would happen, what do you think is best for you and what do you think would happen” Therapist needs to know that’s dangerous, they’re putting them in a situation if they suggest them to leave or do somehting Patient’s social/family environment This is their identity in the family system Fear of making problems in the family Family menbers sabotage - consciously or unconsciously (dissuade the patient from going to therapy) How do therapists address this behavioir Eduicating the patinet about resistance Socratic questioning Discuss pros and cons of addressing issues Empathy Giving the patient choices and dial back directive approaches Being aware of countetransference The therapist’s projections that shape how they perceive, feel about and react to the patient Rupture and Repair The alliance is probably the quintessential integrative variable behcaiuse its importance does not lie within the specifications of one school of thought Ruptures: co;llaboration is interrupted and there is acomporomise in the therapeutic alliance ○ Disagreement of goals lack of collaboration with interventions ○ Strain in the relationship ○ Can occur across all different types of psychotherapy.. Withdrawal rupture markers: denial, menial presonse, abstract communciaition, avoidant storytellinga dnor shifting the topic, differential and appeasing, content/affect split, self criticism and or hopelessness Controngtation rupture markers: complaints and concerns about the therapist, patient rejects therapist intervention, complaints converns about eh activities of therapy, complaints about the parameters of therapy, compaints or concerns about the process… Predicts droput UNLESS RESOLVED - then greater retention across theoretical orientations This can hep with patients with interpersonal skill difficultires such as emotion regulation, anger, etc ○ Is a model, showing then that ruptures are going tohappen in a relationship but you can repair tit Resolution process: process to repair rupture ○ Address it! ○ Validate ○ refine/shift therapeutic approach if necessary (it’s not always the patient’s faiult) ○ Explore the bhavior ○ If its confrontation, be empathetic and reaffrim commitment to help ○ Reinstate connection EMDR EMDR - Eye Movement Desensitization and Reporcessing Procedures designed to stimulate bilateral brain activity ○ Side to side movement of the eyes (using finger, lightbar, etc)  ○ Alternating sounds ○ Alternating tapping ○ Main focus is on the memory and how it is stored in the brain ○ Distracting the brain and relaxing the body Ongoing PTSD by using the brain’s ability to heal itself 8 phase approach to resolve symptoms ○ History and treatment plan ○ Prepare and explain process ○ Activate the memory to be processed ○ Memory desensitization ○ Bilateral stimulation to install the desired way of thinking of the traumatic event ○ Identifying and processing residual physical disturbances related to teh target memory ○ Bring session to a close ○ Re-assess the patient and their memories to ensure progression throughout treatment and staying on track to meet goals Eye Movement Desensitization and Reprocessing (EMDR) therapy Developed in 1987 originally for (PTSD) and is guided by the Adaptive Information Processing Model AIP - symptoms of PTSD and other disorders (unless physcially or chemically based) result from past disturbing experiences that continue to cause distress because the memory was not adequeately processed ○ Focuses on how memories are stored Unprocessed memories are understood ot contain the emotions, thoughts, beliefs, and physical sensations that occurred at the time of the event When the memories are triggered, these storied disturbing elements are experienced and cause the symptoms of PTSD or other disorders ○ The memroy stressors trigger PTSD, physical/bodily symptoms Symptoms of PTSD: flashbacks, anxiety attacks, dissociation, dissociative identity disorder (byproduct of experiencing trauma that hasn’t been processed properly) Bilateral Stimulation (BLS) accelerates the learning process by engaging both hemispheres of the brain ○ Eye movements, tones, taps, light, while the patient focuses on a selected target memory, picked during the assessment phase ○ Focusing on a target, identify the target by going through the steps of EMDR One to two times per week for 6 to 12 sessions Taxing working memory theory EMDR suggests that the process of engaging in bilateral stimulation (BLS) while recalling traumatic memories can help reduce the emotional intensity of those memories by taxing the brain’s working memory capacity ○ Working memory limitations: working memory has a limited for processing information at any given time  The patient focuses on a distressing memory while simultaneously engaging in BLS - their wroking memory becomes overloaded Reduced emotional recall, attenuating the emotional salience of the target memory ○ Reduced emotional recall: this cognitive overlaoad makes it more dicficult for the patitnet to fully engage with the emotional aspects of the traumatic emmory, attenuating the emotional salience of the meory ○ Facilitating reprocessing: by reducing the emotional intensity pateints can process the emomory more efficiently Think of the memory with less emotion attached to it Eight-Step protocol History Taking - we are gathering information, including traumatic experiences, distressing symptoms, goals to help identify targets for processing. This can take an entire session Preparation - preparing the patient by explaining the process, Assessing the copig skills and gounding techniques the patient already uses, if any, if not, teaching them ○ Conduct a test set of bilateral stimulation ○ Is the tapping helping, is this better? → mmove forward in treatment Assessment: the patient identifies specific memories to work on a discusses associated negative belifs, emotions, and physical sensations ○ This helps establish baseline measures for distress and positive beliefs. How do we access these mrories to target Float back technique Float Back Technique During the assessment and desnesitization phases Assess earliest, related traumatic memories ○ Identifying triggers- encourages then to “float back” to earlier memories that might be connected to the current symptoms ○ Accesses earlier memories: the patient is guide to recall earlier incidents that may contributed to the developent of their current beliefs or emotional responses. This can reveal patterns or roote causes of their distress ○ Processing new targets: once these earlier memories are identified, they can be processed usiong the EMDR protocol This allows for a deeper exploration and healing of the underlying issues The float back techniwue helps patients uncover and address foundational experiences that may be influencing their current trauma symptoms, leading to more effective healing Therapist’s Guide “When you bring this memory to your awareness, there is an image that represents the most distressing part of this target?” Negative cognition about yourself related to this image (i am a failure, i am not good enough) Positive referee “what would you like to believe instead?”  I am powerful/smart/good enough Image, cognition associated with it, reframed goal Validity of Cognition (VOC) scale Thinking of that image, how true is the reframe (positive cognition) Subjective Unites of Disturbance (SUD) scale Rate distress 1-10 with image and negative cognition Desensitization: the patient fociuses on teh traumatic memory while engaging in bilateral stimulation Be aware of the image and how it connects to the bodily sensations What are they noticing now? “Go with that” phrase Repeat stimulation (BLS) This phase aims to reduce the enomtional intensity of the memory and facilitate its processing Invite a pause How are they feeling? More relaxed. Reinforce →”go with that” Continue Check back in with target. How? Let’s go back to the original target image and rate your distress on the same scale” Installation (positive cognition) the therapist encourages teh client to focus on a positive belief related to teh memory and reinforces this belief through BLS helping to strengthen adaptive thinking Askt he aotient if the initial reframe is still a good fit (“ i am powerful/smart enough) Ask for rating on VOC scale If they aren’t at a 7 during next bilateral stim, ask them to focus on why it’s not a 10, what is blocking this? Then ask for another T/F rating. “In this moment, looking back, I am smart enough, how true is this? Installation statement: ask the patient to hold and pari the true statement with the original trauatic image. And another set of bilateral stimulation. Future Template Focus shifts to reinforcing positive beliefs and preparing the patient for future situations that may evoke negative feelings By incorporating the future tempalte during installation, strengthen their ability to cope effectively in future scenarios ○ Identify future scenarios: think about specific cuture events or situations where they anticipate feeling uncomfortable or anxious due to past trauma ○ Creating positive beliefs: develop a positive belief or coping statetnet they wish to embody in those situations, such as “I can handle this” or “I am capable” ○ Bilatera stimulation: while focusing on the future scenario and the psitive belief, patient engages in bialteral stimulation (BLS) reinforces the new positve belief ○ Visualization: clients visiualize themselves successfully navigating the future event, experiencing confidence and resilience Body Scan: the client scans their body for any residual tension or discomfort associated with the memory. Teh therapist addresses any lintgering physical sensations through additional BLS Body scan statement (body scan + statement) Future templating (pictute a future scenario, how true is the positive statement now) Closure: the session concludes by helping the patient return to a state of equilibrium Must ensure the feels grounded and stable before leaving the session How? 5-4-3-2-1 technique Diaphragmatic breathing Reevaluation: in subsequent sessions, the therapistchecks in on the patient’s progress, assesses the effectiveness of previoius work, and identiifies any new targets for processing Does it work? EMDR is recommended as the first-line treatment for PTSD by the APA and the Department of Veterans Affairs Effective for treating trauma in children, and adolescents, with significant reductions in PTSD symptoms Shown lasitng effects in reducing PTSD symptoms, with follow-up studies indicating sustained improvement over tine Shown efficacy in treating other conditions related to trauma, such as anxiety disorders and depression Anger Management Therapy Anger: unpleasant emotion, mood, or temperament with cognitive and motivational components Mood: episodic or discrete onset and offset. Varies in intensity from annoyance to rage Emotion: tonic or porlonged. Less intense than the angry emotion. Iriritability, easily frustrated Temperament: Recurrent, frequent, proneness. This disposition is often referred to as hostility. Recurrent and pervasive anger. ○ A hostile individual is not just momentarily angry or just in an angry mood, but one whose anger is recurrent and pervasive Anger and Hostiliy Anger: characterized by antagoninsm toward someone or something you feel has “done you wrong” ○ Can be a result of frustration (not always, learned helplessness) Hostility: mistrust, and negative beliefs and attributions concerning others (that motivate aggressive behavior) Adverse Effects Interpersonal conflict: fear vs respect. Realtionships should be from respect Increased risk taking ○ Risk taking during driving increases uinder condiitions of induced anger  ○ Executive funtionis impaired ○ Reverse relationship between the activitry of amygdala and frontal cortext, the more active your amygdala is (anger) the less your frontal cortex is active (in making rational decisions)** Impaired judgment: cognitive difficultires ○ Anger induced in undergraduate students reduces their performance on maths exams regret/guild Negative perceptions - filtering out positive and seeing negative Depression Violence - breaking things, tear up or break sentimental objects, criminal charges/prison They usually have a parent or caregiver who was hurtful to them and had these outbreaks, so they create these personas who have overactive amygdala, angry/cynical disposition, hypervigilant What makes YOU angry? We have schemas or core beliefs about situations, and we may perceive them as a threat based on prior experiences Trauma - sense of safety is compromised Abandonment Leads to inaccurate and maladaptive schemas from past Amygdala (HPA-Axis) Reactions are disproportionate to the emotion (cognitive distortions) They are hypervigilant, on edge. Those people need to change the ways that they think about situations and their core beleifs. You want them to have insights. Difficult patients (i.e. mandated patients) you need to have that therapeutic connection Angers Role in Aggression and Violence The terms anger, aggression, violence are often used interchangeably because they occur together Someone can be angry not aggressive, and aggressive and not angry Someone can be violent, without anger (psychopaths enjoying hurting people) Aggression, behavior (physical or verbal) that is intended to hurt Violence is behavior that intentionallyu brings about actual physical injury or material damage Angers role in aggression and violence Aggression: observable behavioir intended to harm another person who is motivated to avoid harm ○ Aggressive conditions (e.g. hostile attitudes, beliefs, thoughts, or desires) are important precursors of aggressive behavior Violence: exrtreme aggression with a goal of severe physical harm ○ Attempting to injure someone with a weapon, is still considered a violent act even if they miss their target Both are best conceptualized as a being on a continuum of severity All acts of violence include aggression Put in the context of behaviorism, a response that far out - weighs the stimulus is likely to be an overreaction  Also it is possible to underreact to provocation )the response falls short of the stimulus) Behavioral theory suggests a disorder can take the form of an excess or deficit in a behavior Explosive or repressed anger ○ Passive aggression, issue is not resolved ○ Can become explosive Factors of the behavior can be represneted in a functional behavioral analysis (FBA) Amygdala Responds when we are frightened Also generate aggressive behavior Their brain adapts as they’re developing so that they are ready to battle and protect themselves Response to stimuli si influenced by context, past trauma, or learned behaviors can affect how an individual responds to perceived threats Lesions or removal create decreased or an absence of aggression ○ Court ordered amygdalectomy Stereotaxic apparatus used for clinical amygdalotomy Defense mechanism, a protective response Brain changes as a result of EBT and mediation (graph) The aggression cycle Buildup, explosion, outburst, aftermath What causes aggression We have this circuitry that developed similar to wild animals, same chemicals, same circuitry, it’s a part of the brain that’s 100 million years old threaten a human (threaten a monkey, and they are likely to become aggressive) We can make ourselves angry, our cognition, we can be angry over beliefs There is a difference, chimps will murder each other, use of weapons- just like up, nut no chimps or babooon has evr killed another over ideology, or belief system Thoughts - this is why cognitive therapy is sued for anger management Violence in long term psychiatric patients Impulsive - most common Predatory - instrumental - psychopathy, antisocial personality disorder Psychotically driven (least common) Predatory Violence Instrumental - person looks to gain something from being violent. Obtain protperty, dominate others Psychopathy antisocial personality disorder Underactive amygdala (flat effect) Low autonomic arousal. Children at 6 years old with low arousal. 75% became violent crimials.Most of the others became prosocial enforcement  Difficult time with emotional empathy Can show cognitive empathy Impulsive violence Impulsive violence - driven by anger/reactive Impusle generation (VTS) and the failure of the PFC to inhibit the behavior Failure of the VMPFC to fucntion and top-down inhibition is impaired “Leaping before you look” Frontal temporal dementia Personality disorders tumors TBI Taking out the amygdala if they’re overly anger Outpatient Anger and Violence Targets for treatment ○ Impulse control ○ Faulty cognition Anger: cognitive -motivational model Emotions consist of two components: ○ Cognitive appraisal: how individuals interpret situations ○ Action tendency: the motivation to respond to those interpretations Anger: ○ Involved an appraisal of perceived wrongdoing ○ Leads to a tendency or motivation ot address or counter that wrongdoing Subjectivity: ○ The appraisal of wrongdoing is subjective and varies among individuals Response ranges: ○ Active retaliation ○ Passive resistance Anger: cognitive Model Our emotions comprise cognitive appraisals and an action tendencies Appraisal or perception ○ Subjective, based on current mood and pase experiences and individual differences Action tendency ○ Motivation to act and counter wrongdoing ○ Autonomic response - biologoical response Action response ○ ranges/differs (depends on what they experienced that day, if they have eaten, steroids in body? Before your period in famales, levels of hormones  ○ Active retaliation Example: Road Rage Maladaptive anger while driving is best conceptualized as a syndrome ○ Being in a car, anonymous Emotional experience (feelings of fury and rage) Physiological arousal (elevated heart rate, blood pressure, tense shoulders, upset stomach) Cognitive processes (malicious attributions, obscene ascriptions, self-centered demands, catastrophic interpretations, thoughts and images of revenge and retaliation) Behavior (e.g. verbal, physical, or vehicular aggression; speeding and reckless driving; impulsive hitting or kicking of the vehicle) Core beliefs→ how they process the situation Understanding your patient’s anger and aggression How are they viewing the world Events that person perceives as aversive Blocked from acheiving a goal and or does not receive an anticipated reward Perceived threat to socail status and iterprets other people’s motives as malevolent This is why treatment must begin with and continue to exam situation in which your patient becomes angry, the level of anger in reported situations CBT Session one: education and evaluation8 Provide psychoeducation ○ Why people have anger problems ○ How they can create difficulties Anger could be measured in terms of five key parameters (also applicable to other emotions) ○ Frequency (how often one gets angry) ○ Duration (how long the anger lasts) ○ Intensity (how strong the anger is) ○ Latency (how quick to anger) ○ Threshold (how sensitive to provocation) Session one: Motivation and Quick Skills Ask: how is theanger affecting you? sleep , concentration, mood More education Define your rich and meaningful life (good life model for offenders) End with quick skills to use immediately while working through sessions ○ Slow the physiological response ○ Square breathig ○ Adaptive sublimation  ○ Mantra “this will pass” blocks out other thoughts → getting out of emotional mind and getting into wise mind ○ Unhooking - from ACT, this feeling isn’t part of you - envision it as something separate from you (hot coal) ○ Homework Session Two: habits, strengths Review homework ○ What was the highest number the patient reached ○ What triggered the anger ○ How long did it ilast ○ What strategies did they use Learn about habits ○ Ask: have you ever had any other habits? How did you break them? ○ Is this a habitual response? ○ Implement mindfulness ○ BETA… Did they have an angry episode? ○ Discuss the strategies they used Did they work? If not,why? Help them envision the situation occurring again with a different strategy and positive outcome Ask the patient to describe how the situation would have gone differently if they used an adaptive skill Teach and rehearse skill Session Three What was their highest score of anger? Strategies Change in frequency, intensity, duration? Beginning to identify specific trigger themes, core beliefs, and cognitive distortions Do these bring up memories from childhood? ○ Fear of failure ○ Rejection sensitivity ○ Loss of control ○ Loss Process and reframe Identify different adaptive ways to think and respond Continue to log with additional column for specific trigger thees Practice skills Session Four: Identifying signs of Escalation Physical - heartrate, tense muscles, flushed face Behavioral - raising voice/ get very quiet, clench fists, grind teeth, pace, slamming cabinets Emotional - feeling disrespected, hurt, jealous, scared Cognitive Session Four: identifying anger-engendering cognitions Hostile appraisals and blame Aggressive beliefs and blame (he did that on purpose) Catastrophizing feelings (i can’t stand this) Labelig others in inflammatory, derogatory ways Anger and aggression supportive beliefs and expectancies (people like that ought to be run over) rigid demands (slow drivers should get the hell out of the way) Thoughts and images of revenge (nobody can do that to me and get away with it) and the like (patient pictured torturing coworker who took him to court over assault) Session Four: addressing cognitions as important Pejorative labeling/verbally aggressive thinking associated with higher with verbal aggression and expression of anger Revengeful/retaliatory thinking more with using the vehicle to express anger revengeful/retaliatory and physically aggressive thinking associated with violent tendencies Coping self-instruction, leads to more adaptive/contructive expression of anger Changing their thinking changes their behavior Session Five: identifying vulnerabilities and themes Review homework What were the escalation signs that the patient identified? Physical, cognitive? Behavioral? Emotional? What was the highest level of anger on the log? What strategies did you implement? What themes are becoming apparent? (failure, rejection, loss of control, lossP) Session Five: Identifying vulnerabilities and themes Create more of a likelihood the patient will respond with anger ○ Affective: stress, more than one trigger, time of year (for loss) ○ Physical: sleep deprivation, caffeine, sick, pain, blood sugar, alcohol ○ Cognitive: negative expecations, pessimism ○ Environment: loud, stressful environment, lack of privacy ○ relationallly : people, groups, that trigger anger Session Six: Anger Control Plan Homework review: ○ Anger level/strategies ○ themes/vulnerabilities that contributed to the patient’s anger ACP: must contatin immediate and preventative stratregies Immediate strategies: ○ Walk away: discuss when this will be helpful and how they will do this ○ Distract with positive activity Mindfulness Music Guided imagery, meditation ○ Thought stoppingL interrupting angry thoughts with pleasant ones Not as effective with OCD Develop thought stopping statements with patient Have them accessible ○ Mindfulness - 3’s ○ Radically acceptance (i guess i’ll jsut have to accpet it instead of getting angry) Preventative - discuss minimizing vulnerabilities ○ Emotional - ex: doing activities that promote happiness ○ Mental - gratitude list ○ Social - boundaries, decrease social media ○ Physical - sleep, health exercise’ Homework: continue… Session Seven: idnetifying cognitive distoritions Personlaization: believing another person’s statements or actions are directed, about or attacking you ○ Ask the patient to produce 3 reasons a situation may not be about them Mental filter minimization of the positive: focusing on what the person has done to upset you while ignoritn ht person’s good intentions and the positive things the person ahas done for you (angry attributaitonal style) ○ Ask the patient to discuss what good things are associated with the person or sutaiton (partner, job, friend group) ○ Think about the positive things about the person, and not just the negative things Catastrophizing - exaggerating the negative and peotntail negative consequences ○ How likely is this outcome? ○ You’ll work through it, it’s not as bad as you think ○ Your brain is making up the scenario Control fallacy: thinking someone should be within their control ○ Why is this? What is the fear? Is this rational? ○ Feel like they need to be in control, ask them why. Emotional reasoning ○ I feel angry so there must be something making me angry  ○ Could be a memory being triggered by something in the environment ○ Trauma is remembered as a reaction or emotion Session seven: applying ABC (DE) model Activating event Belief about A (event) ○ It is not the event, its our belief about it that creates C Consequence - reaction Dispute if necessary ○ Identify distortions, maladaptive patterns of thoughts and reframe Evaluate your response ○ Choose a response that will benefit your goals of healthy relationships and a peaceful and productive life Homeowrk: anger log, add cogtnitive distortions, reframing column ○ (identify cognitive distortion first, then reframe their thoughts to something more rational) Session 8: assertiveness education and skills Ask patient: what message does someone send you when they are being aggressive? Is this helpful or harmful in a relationship ○ aggression The only important feelings are min What you believe isnt important Your needs aren’t as important as mine ○ Assertiveness Both of our feelings are important Validate Two things can exist (dialectivs) Aggree to disagree It’s okay to not always have things your way You feel the way you feel, and you can’t change that so it’s impotant how you respond to those feelings Session 9: conflict resolution model Be objective (not emotional) Identify the problem Identify your believes about the situation Weigh facts against your beliefs Be committed to resolve the conflict How? ○ validate ○ Communicate ○ Determine how to move forward Homework: log and apply this model in a situation. Apply this model in a situation. Apply this in a new situation. Practice using past situations Session 9: familial patterns of anger Help patient gain insight into their anger with regard to their parents and familites during childhood/adolescence How as anger expressed in the family? How do these past interactions influence your current thoughts, feelings, and behaviors? How do they influence “how you interact with other people?” ho w were other emotions such as happiness and sadness expressed in yout family? Were warm emotions expressed or was emotional expression typically anger and frustration? How were you disciplined? Were you hit? ○ Living in a family where anger and punishment was a daily thing Painful memories are usually shared Connections are made to current behavior ○ Did they live in a situation here instrumental anger or instrumental anger was normal? Dad was violent towards mother and mother was submissive Is anger a way to get what you want? Learned through observation Senstiiev topics requires humanistic approach What messages did you receive regarding anger? Instrumental? Unresolved anger… Session 10:wrap up Review anger log for the week ○ Where they able to identify triggers, distortions, implement conflict resolution or control plans ○ Provide encouragement, praise, and support What have you learned about managing your anger? ○ Conflict resolution, what specifically triggers me What strategies are you most comfortable with to better manage your anger? ○ E.g. step away, square breathing What ways can you continue to improve your anger management skills? Psychotherapy for Sex Offenders Assessment and treatment Sex Offender Profile Different levels of sex offesnses Typically see complex trauma history Criiminal diversity and recidivism (more likelty to commit crimes again) are correlated, beginning in childhood Early attatchment issues  Interpersonal connections are problematic Trust issues with adults No specific demographic of sex offenders ○ What they experienced during developmental years ○ Genetics Risk Assessments When an incarcerated offender is set to be released into the community, the Board of Examinders of SEx offenders will evaluate the case and provide a risk level recommendation to the court The court will hold a risk level hearing and assign a level to the offender prior to release The risk level determines how much information can be provided to the community Risk Evaluation The most prominent risk management model is the risk-need-responsivity (RNR) Model ○ The RNR is a valid and reliable risk assessment of static risk and dynamic factors (risk principle) ○ Static risk factors are factors in the person’s history that precidc recidivism Parents are criminals History of crime Childhood experience ○ Dynamic risk factors are potential changeable factors, such as substance abuse, negative peer assocaitions Peers, cognitive distortions Risk Factors for Recidivsim in Adults Higher rates of sexual re-offending is seen if: ○ Deviant sexual arousal Measuring arousal of looking at something that is deviant They don’t like it, it arouses them (biollogically) even if they don’t want to be ○ Prior convicted sexual offenses ○ Multiple victims ○ Social isolation ○ Incomplete sexual offender treatmnt ○ Problematic patient-child relationships ○ Attitudes supportive of sexually abusive behavior Static 99 Acturarial Risk Assessment - Statistical method for estimating the risk of a sexual offender commiting another offence More accurate than clinical judgement alone The most widely used sex offender risk assesment instrument in theh world, and is extensievly used int he US, canada, the united kingdom, australia, and many european countries  ITem #1: age at release from indexed sex offense ○ Most studies have found that older sex offenders are lower risk to reoffend than youner sex offenders ITem #2: … Deviant Arousal Beyond the static and the dynamic factors two otoher factors are conclusively associated with higher risk of sexual reoffending ○ Psychopathy Whether or not they are a psychopath ○ Deviant sexual arousal Both are predictive of increased risk for sexual reoffending, especially in combination Scoring high on both→very high risk of sexual reoffending MMPI Answering quesitons, looking for patterns Assessing for introversion and extroversion (if they are withdrawn and psychopathic deviant, they will be more likely to reoffend) Virtual Reality (VR) Virtual reality (VR) is an “advanced form of human-computer interface, that allows the user to interact with and become immersed in a computer-generated environment. To evaluate whether or not they are at a high risk Some risk management approaches provide frameworks for the construction of relevant future risk situations Due to ethical reasons, it is not possible to evalujate the validity of constructed risk situations in reality They can’t control their microexpressions and heart rate and breathing, you note that Treatment There are approximately 2500, psychotherapists in the US that provide court mandated treatment to sex offenders Psychotherapy is also offered through prisons and other government institutions Judges referthe offenders to psychologists or clinical social workers whoa re authorized by states In some cases, the government subsidizes the cost of treatment Private therapists can refuse to see certain patients at their discreiton Medications used to treat sex offenders act by decreasing desire ○ Two kinds Agents that work by suppressing testoserone Agents that reduce sexual drive by other mechanisms ○ Mediaction for ADHD  Reduce impulsiveness Psychothrapeutic Approach Cognitive behavioral therapy (CBT) is the preferred mode of treamtne for sex offedenders according to the association for the treatment of sexual abusers The primary goals of these interventison are to reduce the risk of reoffending by cognitive restructuring Feel uncomfortable out in public Why is Risk assessment and TX important? The majority do not spend a long time in prison They are back int he community Apprx 250,000 people righ tnow are in contact with the penal system for sex offense Aprox 60% are in teh comubnity udner superviison witha treatment team and parole or probation officer 3.5-5 years for contact or violent crime Cognitive distortions: distorted perceptions THEY think the victim is enjoying it or consented to it Goals of CBT with SO’s Decrease recidivism Address cognitive distortions Build self worth-particulary with young offenders Improve social skills Empathy training Emotion regulation Address anger management and deviant sexual arousal Impulsivity, stress, minimizing the crime, distancing himself emotionally from what he actually did, rationalizing why he did it, not owning the behavior