Skills in Cognitive Behaviour Counselling

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Skills in Cognitive Behaviour Counselling
Psychotherapy

• CHAPTER 6 Skills for working with emotions in CBT

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The nature and functions of emotion(In as far as
we have any real understanding of it whatsoever!)

• Emotion is a form of information about what is
  happening to us. It tells us that something in or
  around us may need attention. It often has
  evolutionary survival value.
• Emotions often seem to help us identify what we
  really need.
• Although emotions are often experienced as pure
  feelings, it is hard to make sense of them
  without attributing some element of cognitive
  appraisal and evaluation within them.
• There are slow-track and fast-track ways of
  processing emotions. There can be conflicts
  between the need for speed of processing and the
  need for accuracy in processing (e.g., I am not
  quite sure if it is a lion or a tiger but Im
  going to run anyway!).

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Strategies for handling emotions in therapy

• Suppression of negative emotions often produces a
  rebound effect.
• Therapeutically it is usually necessary to allow
  expression and encourage acceptance of emotions.
• It is helpful to distinguish between
• primary and secondary emotions
• healthy and unhealthy emotions
• instrumental and other emotions

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Primary and secondary emotions

• There are a few primary emotions, such as
  sadness, anger, fear and shame, that appear
  regularly as main issues in therapy.
• Secondary emotions may appear as emotions that
  mask the primary emotions.
• A classic example is hurt and anger anger may be
  a secondary emotion, the expression of which acts
  as a way of drawing attention away from the
  primary hurt.

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Healthy and unhealthy emotions

• HEALTHY EMOTIONS may be negative but tend to have
  a sense of freshness and newness. They are less
  related to stuff and seem to be clearly
  expressed and to push the client in a certain
  direction. They do not interfere with the client
  getting help.
• UNHEALTHY EMOTIONS are negative but they are old
  and familiar. They feel stuck and are often
  hazily expressed. They show destructive effects,
  including inhibiting the client from getting
  proper help.
• INSTRUMENTAL EMOTIONS often function in an
  unhealthy way in that they be used in a covert
  way e.g., crying as a way of eliciting sympathy.

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A process map for working with emotions in CBT

• IDENTIFYING the type of emotion.
• HEALTHY EMOTIONS the therapist can encourage the
  client to accept these emotions and allow them to
  be processed with fairly minimal intervention
  e.g., the AWARE strategy.
• PRIMARY UNHEALTHY EMOTIONS consider emotional
  regulation, cognitive restructuring or changing
  emotion with emotion (Greenberg, 2002).
• SECONDARY OR INSTRUMENTAL EMOTIONS the main
  strategy is to try to bring to the surface the
  primary emotion and deal with that. Other
  strategies include trying to find out what need
  is met by the secondary or instrumental emotion,
  and to help the client find another way of
  meeting that need e.g., appropriate ways to seek
  peoples sympathy and time.

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Focusing as a way of processing healthy emotions
(Gendlin, 1998)

• 1. Finding a still place.
• 2. Scanning the body for tension and signs of
  bodily held emotions.
• 3. Focusing on the emotions and allowing them to
  speak.
• 4. Seeking to get a verbal handle on the emotion.
• 5. Allowing self to flow between feeling and
  verbal label, enabling emotions and meaning to
  unfold.

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Cognitive-emotional processing

• A variety of similar methods has been developed
  to allow for the more active processing or
  reprocessing of more negative emotions,
  especially those linked with PTSD. It is possible
  to see a generic form of cognitive-emotional
  processing that runs through all these methods.
• CBT treatment of PTSD typically consists of some
  element of reprocessing the trauma story with
  appropriate emotions (Foa Kozak (1986) on the
  fear network) plus other interventions to
  tackle other symptom areas such as avoidance and
  resultant phobias.

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Steps in cognitive-emotional processing

• Identify the negative emotion.
• Encourage the client to hold the emotion in open
  awareness.
• Allow the client to process the feeling and
  observe what new forms of feeling and meaning
  arise.
• Reflect on the shift in feeling and meaning.
• Stay with the shifts in feeling and meaning until
  they have fixed into a new meaning gestalt.

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How trauma processing works (1)

• Historical precedents with the work of Dr Rivers
  in the First World War (Barker, 1992).
• There is always the possibility of a new and more
  benign meaning emerging the war after all is
  over, the accident is in the past.
• Has to be the right blend of new meaning and
  actual feeling too intense emotion and/or
  post-accident pain can block processing and lead
  to looping of the same trauma story/experience.

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How trauma processing works (2)

• Processing can clear channels of negative
  meaning (similar to Freuds and Breuers chimney
  sweeping (Breuer et al., 1982)).
• Trauma memories are typically hazy processing
  may regain lost details that help to shift the
  meaning of the trauma.
• There may be layers of trauma processing can
  help to feel them back may uncover nested
  previous traumas. (Can sometimes catch client
  and/or therapist unawares.)

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Imagery reprocessing

• Clients may retain sharp and disturbing images of
  early shameful experience that can re-emerge
  during periods of stress and trauma.
• It can be helpful to revisit the scenes of
  earlier trauma using imagery re-scripting.
• The client can be relaxed and taken back to the
  scene and encouraged to describe it in
  first-person, present-tense language (usually
  intensifies the memory and the feeling associated
  with it and thus allows some processing).
• Re-scripting can be used to a greater or lesser
  extent (according to client preference). New
  outcomes can be scripted or new elements can be
  introduced these frequently result in positive
  meaning shifts and defusing of negative emotion.

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Self-soothing

• Sometimes emotions can be simply too intense to
  work through, process or focus on.
• We all at times need the capacity to soothe
  ourselves in the face of emotions that simply
  cannot be put aside or, for the moment, healed.
• Some psychoanalytic theorists, such as Kohut
  (1977), have suggested that we learn to soothe
  ourselves by seeing how we could be soothed by
  our parents or other significant people. Some
  people, however, sadly lack a soothing model and
  have to learn how to do it from scratch.

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Self-soothing and borderline personality

• Clients with borderline symptoms often have
  backgrounds of abuse and therefore usually do
  lack internal models of appropriate
  self-soothing.
• Self-soothing is a prime strategy, along with
  validation, in the treatment of borderline
  features using dialectic behaviour therapy (DBT,
  Linehan, 1993).
• Self-soothing in DBT is heavily dependent on
  mobilizing comforting sensory soothing using a
  predetermined client list of appropriate and
  favourite sensory modes that have worked for the
  client in the past.