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.