Assisting clients in reworking irrational thoughts - PowerPoint Presentation

Assisting clients in reworking irrational thoughts Michele D. Aluoch, LPCC2018

Depressive episodes 5 or more in 2 week periodChange from previous functioning Either: depressed mood or loss of pleasure significant weight loss when not dieting or weight decrease or increase in appetite nearly every day insomnia or hypersomnia nearly every day psychomotor agitation or retardation fatigue or loss of energy nearly every day worthlessness or excessive or inappropriate diminished ability to think or concentrate, or indecisiveness recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation, or a suicide attempt or a specific

Depressive episodes SpecifiersFrequency: Single or recurrent Types : mild, moderate, severe Chronic - full criteria for depressive episode met continuously for at least 2 years- either depression or Bipolar Catatonic - motor immobility/stupor, excessive motor activity (purposeless), extreme negativism, rigid posture or mutism , grimmacing , echolalia or echopraxia Melancholic - lack of pleasure in activities, lack of reactivity to usually pleasurable activities and 3 or more: depressed mood, depression worse in am, marked psychomotor agitation or retardation, anorexia, excessive or inappropriate guilt

Persistent Depressive Disorder (Dysthymia) Symptoms recently renamed in the updated DSM-5 (2013). at least 2 years (at least 1 year for children and adolescents)chronicthere has never been a manic episode, a mixed episode, or a hypomanic episode in the first 2 years, and criteria have never been met for cyclothymia .

New DSM-5: Depressive and Bipolar Disorders DSM-5:  Bipolar and Related DisordersIn DSM-IV, Criterion A for Manic Episode included elevated, expansive and irritable moo. In addition to elevated mood, DSM-5 added changes in energy and activity levels- more readily observed and reported. Specifiers : A new specifier has been added, with mixed features -no longer requires the full criteria for both depressive and manic episodes A new anxious distress specifier has been added- poorer prognosis across a variety of disorders. The Grief/Bereavement exclusion for depression has been removed!  

DISRUPTIVE MOOD DYSREGULATION DISORDER extreme, explosive ragesbeyond describing temperamental children to those with a severe impairment severe and recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situationa persistently irritable or angry mood most of the day nearly every day, at least two settings (at home, at school, or with peers) for 12 or more months Not three or more consecutive months without symptoms

Depression Paradise, L. V., & Kirby, P.C. (Winter 2005).Roughly 10% to 25% of the population experiences some form of depression. Depression is the number one cause of disability worldwide. One third to more than 60% of mental health professionals had reported a significant episode of depression within the previous year. Depression is 10 times as prevalent now as it was in 1960! While every objective indicator of well-being in the U.S. has been increasing, every indicator of subjective well-being is decreasing.

Related Feelings To Look For Pessimism Feeling trappedHopelessness angerDespair feeling hurtResentment easily offendedMoodiness overburdenedIrritabilityLow Self Esteem Discouragement Chronic grief

Male and female differences Physiology factors:Brain anatomy and functionSex hormonesReproductive hormonesEffects of aging on perception and metabolism

Male and female differences Social factors:Different ways to be socialized about depression, anxiety, and angerSignificance and meaning behind relational bonds

Male and female differences Employment/ses:Employed- less depressedHigher Ses across cultures tend to be less depressed-more options and More control

Depression and social supportsDalgard,O.S ., Dowrik, C., Lehtine n, V., Vazquez- barquero , J.L., Casey, P., Wilkinson, G., ayuso-mateos , J. L., Page, H., dunn , G., 2008 Women report more life events and stressors relate to social situations women are more vulnerable to issues related to social supports-> depression 58.9% of women report “lots of help” versus 41.1% of men. men- work and legal while women- social network limitations

Male and female differencescoping strategies Kelly, M. A. R., Sereika, S. M., Battista, D. R., & brown, c. (2007)Different styles among the sexes Five significant components : 1. the way the person labels the problem 2. the beliefs about the cause of the illness (depression) 3. beliefs about the timeline and duration of depression 4. consequences- beliefs about the long term outcome and impact of depression 5. resiliency and ability to effect change

Male and female differencescoping strategies Kelly, M. A. R., Sereika, S. M., Battista, D. R., & brown, c. (2007)Women: emotionally focused coping crying, emotional expression Dwelling and rumination Men: problem focused coping Medical and pharmacological methods Compulsive work Video games and escapism

Coping strategiesSimon, R.W., & Lively, K., 2010 Talked to the person .34 .39Talked to someone else .51 .64 Yelled or hit something .09 .08Thought about the situation .36 .33Took a drink or pill .08 .05 Tried to forget .34 .29 Tried to change the situation .26 .27

Coping strategiesSimon, R.W., & Lively, K., 2010 Prayed for help from god .20 .34Fantasized about a magical solution .07 .07Exercised .13 .14Waited for the feelings to pass .29 .29Tried to accept the situation .45 .47 Left the situation .15 .16 Thought bout how to get revenge .06 .07 Planned how to end the relationship .08 .11 Did something else .04 .05

Male and female differencessuicide and death SuicideMore common among the unemployed, unmarried, those with physical illness, those with drug and alcohol abuseIncreasingly similar statistics in violent deaths among men and womenAbout 1/3 of suicide attempts involve alcohol (alcohol generally historically a bigger factor for men) Deaths among the elderly and older adult nearly always linked to chronic pain and health issues Men and the elderly tend to use medicinal self poisioning more and often are not detected.

Male and female differencessuicide and death Men who used firearms were more likely to be married and shoot self at homeHangings: unmarried men more than married men but unmarried women more than married womenSubstance abuse: a bigger factor for men then women in suicide type. Men with Sa more likely to involve substances in suicide

Male and female differencessuicide and death Place of death (Frequencies):HomeOutdoor settingsHotelsVehiclesRailway tracks No significant differences between sexes

Male and female differences Though women are twice as likely to be diagnosed depressed Women are much more likely to seek help for depressionMuch greater mortality risk in men with depressionMen report more frequent difficulty expressing feelings including: 1. inexpressive,2. hypoemotional, 3. unable to identify or describe their feelings (alexithymia) Women: tendency to express depression through crying, emotionality, ruminating, helplessness, and changes in food intake Men- greater risk taking and antisocial behaviors associated with depression- drinking, sexual encounters, gambling, road rage, drunk driving, impulsive suicidality Widowers tend to report significantly higher levels of depression than widows Women encouraged t internalize while men encouraged to externalize

Male and female differences Borooah, V. K., 2010Two factors that are significant:1) exposure2)responsePrimary differences between males and females are related to response to stressors. Exposure rates are similar.

Depression, anger, and sex differences Women: more, expressive with tears, sadness, comm9unicating needs but not anger- depression as anger turned inward- are women really more angry or does the anger look different?Men- less emotionally expressive with the exception of anger, anger as masculine emotion whereas “depression” seen as a feminine emotionAnger rating scales suggest comparable rates but depression rating suggest more inward anger in females

Men and shame Self protection mode to avoid feeling shameCertain life events= “I’m not a man” or I’m inadequate.” Treatment that works:Person-centered relational therapy b/c therapist is not expert- how do you feel about that? Becomes safe Acknowledging difficulties expressing things Behavioral techniques for shame regulation- exercise, meditation, compassionate self talk, mindfulness, building tolerance, exposure to feelings Building male pride in healthy ways Group work for modeling safe ways to express and process feelings and decisions

women and emotion-work vs. emotion-play Fullagar, S., 2008CriticalGuilt riddenSupposed to take care of everyone elseBe superwoman and juggle it all Complexities of being a woman Grief over not being assertive Grief over balancing work and family

Efficacy of treatment Cbt equally effective with males and females and treatment of choicemen tend to utilize more pharmacological methods then women and women tend to be quicker and more ready to utilize talk therapy

Depression and levels of spousal support High level spousal support had a greater protective effect against depression in older adults than support from friends and adult children while low level spouse support regardless of gender had a significant worse effect on depressive symptoms than the absence of spousal supportMore positive interactions with a spouse lower depressive symptoms Negative interactions or discord more depression

Depression and gender equality factors Depression has a higher in low gender equality countriesThe gender difference is highest in high gender equality countries with women exhibiting more depression related to multiple rolesIn no country were men significantly more depressedThe most depressed people were women who were young in low gender equality countries followed by young women in high gender equality countries- significance of young age for female depression Those who were employed in low gender countries rarely had depression

Depression and cultural factors Depressed Latinas and african American were significantly less likely than whites to obtain mental health care

Depression and activity limitations Men tended to be more limited in terms of leisure activities when depressed than women

Depression and mattering Who am i?Where do I belong?Am I important to others?An issue for all clientsEspecially important for teens and girlsMattering linked to levels of anxiety and depression and life satisfaction

Bipolar disorder in men and women (Curtis, V., 2005)Greater tendency for women to have higher frequency of Bipolar IIGreater tendency for women to have depressive episodes as more recent versus men listed as manic more recentGreater tendency for women to be labeled rapid cycling Hormonal changes with child rearing and monthly cycles also noted with bipolar diagnosis in women

Exercise: Men Vs. Women How do you think each might deal with:Just let go from job and has family to supportPerson you were engaged to suddenly ended relationshipA sudden health diagnosisAn ailing parent Your child being bullied Someone taking bad about the most important person in your life

Depression and teens Teen girls suffered more interpersonally as a result of depression:1. decline in reciprocal friendships2. poorer quality friendshipsBoth depressed teen girls and boys experienced declines in peer acceptance.

What made me feel better Men more often cited antidepressants or some combination of antidepressants and therapy than women who were more likely to use talk therapy(52% males to 36% females)- [Hansson, M., Chotai, J., & Bodlund, O., 2012]

Defining HopeThe New Integrative Hope Scale No hope without stress, loss, possibility of things getting worseRelated to locus of controlBeing open to surprisesFinding the scared in despair Fostering resiliency and possibly wholeness or even post traumatic growth Ability to consider positive possibilities Future orientation Persistently seeking Seeing what is not yet realizable Reaching inward and outward Reinforcing what is the most important or valuable to them

Defining HopeThe New Integrative Hope Scale Belief that there is a way out of circumstancesInternal locus of control in spite of external stressorsAffirmation that it is okay to have and process feelingsAffirmation that it is okay to proactively do something about stations in life Applying meaningful strengths to what feels like weakness Making a small plan for change ( use scaling)

Defining HopeThe New Integrative Hope Scale Trust and Confidence:“ I have deep inner strength.”“ I believe that each day has potential.” “I have a sense of direction.” “Even when others get discouraged, I know I can find a way to solve the problem.” “I feel my life has value and worth.” “I can see possibilities in the midst of difficulties.” “My past experiences prepared me well for the future.” “I have bene pretty successful in life.” “I have faith that gives me comfort.”

Defining HopeThe New Integrative Hope Scale Lack of Perspective“It is hard for me to keep up my interest in activities I used to enjoy.”“It seems as though all my support has been withdrawn.”“I am bothered by troubles that prevent my planning for the future.” “I am hopeless about some parts of my life.” “I feel trapped pinned down.” “I fid myself becoming uninvolved with most things in life.”

Defining HopeThe New Integrative Hope Scale Positive Future Orientation“There are things I want to d in my life.”“ I look forward to things I enjoy.”“ I make plans for my on future.”“ I am hopeless about some parts of my life.” “I feel trapped, pinned down,” “I find myself becoming uninvolved with most things in life.”

Defining HopeThe New Integrative Hope Scale Social Relations and Personal Value:“I feel loved.”“ I have someone who shared my concerns.”“I am needed by others.”“I am valued for who I am.”

Two Key Components Agency-Ongoing motivation to do something about lifePathways- Strategies and plans for reaching goals

Cultivating Hope in Counseling How did you manage in spite of___________ ?3 good things- finding exceptionsDiscovering strengths- personality characteristics that help people endureBuilding on strengths you already haveFocusing on positive memories

Comparison Threat bias Faces problemsNegative Perceptions Considers possibilitiesWhat’s wrong What could be rightPoor coping skills Healthy options and choices

Cognitive Behavioral Cycle Using proven REBT- Rational Emotive Behavior Therapy (Albert Ellis) but incorporating client belief systems and spiritual worldviewCompared to baseline

Dealing With the Feelings

Cognitive Behavioral Principles Early life experiencesMaintained throughout timeMaintained by behaviors that may not be usefulMaintained by looking for thoughts and behaviors that keep the cycle going

Cognitive Behavioral Principles Continuing to elicit negative thoughts and record more helpful ways of thinking about situations, self and others to influence emotion positively.Reviewing thoughts, particularly expectations for self and ‘shoulds’ rather than ‘wants’. Identifying rules for living and examining their helpfulness. Identifying unhelpful thinking styles that lower mood. Encouraging the client to analyze thoughts and then step back from them. Reviewing alternative explanations for negative automatic thoughts. Conducting behavioral experiments to help increase believability of alternative thoughts. Listing goals with an emphasis on own needs and expectations.

Thinking Error Types 1) Awfulizing/Catastrophizing- Predicting only negative outcomes for the future: “ ____ is awful, terrible, catastrophic or as bad as it could possibly be”, “If ___ happens my life is over.” 2) Disqualifying/Discounting - Overlooking the positive and only seeing the negative, believing that good things don’t count: “I am sure even when my family complimented me they had to because they are my relatives. They had to be nice.” 3) All or nothing - Viewing the situation on one end of extremes: “If my boss corrects me I must be the worst employee”, “If my child does something wrong I failed as a parent”, “If I didn’t pass one exam I am an unsuccessful student.” 4 Low Frustration Tolerance - Belief that things should not be inconvenient: “I can’t stand _____” ; “_____ is too much and is intolerable or unbearable.”

Thinking Error Types 5) Self Downing- Self deprecating thoughts: “I am no good, worthless, useless, and utter failure, beyond hope or help, devoid of value.” 6) Other downing - Derogatory beliefs about others: “You are no good, worthless, useless, an utter failure, beyond hope, of no value.” 7) Emotional reasoning - Letting emotions totally overrule facts to the contrary: “I feel as if everyone is talking about me.” 8) Labeling - Giving a label or stereotype without testing beliefs out:” All of them are like that.” 9) Mind reading - Trying to predict things based on limited aspects of a situation: “ I know they will think I’m poor because I can’t afford the latest clothes.”

Thinking Error Types 10) Overgeneralization- Making broad conclusions about an event based on limited information: “My husband doesn’t love me because he is always busy when I am around.”11) Personalization - Assuming that others behaviors are all about you: “My wife is quiet. Something must be on her mind.” 12) Shoulds /musts - Having an absolute concrete standard about how things ought to be: “ Successful people in life only get As in school.”

Cognitions Related To Anxiety Cognitions Supporting Worry:(Dugas & Koerner , 2005) “Worrying is helpful.” “Worrying, thinking about possible outcomes can help me deter or change events.” “Worry can prevent negative outcomes. “Worry is a sign of a caring concerned person.” “Worrying is a positive personality trait.” “Worrying aids in problem solving and helps me plan.” “Worrying motivates me.”

Cognitions Related To Anxiety “I am losing control.”“I cannot handle this anymore.”“My life is falling apart.”“Everyone knows how socially inept I am.”“I can’t deal with this stress anymore. It is absolutely overwhelming and immobilizing.” “I know I will absolutely fail.” “This is bound to happen again.”

Cognitions Related To Anxiety “Something bad is going to happen to me.”“I must be having a heart attack or other serious health issue if I am having these symptoms. Next thing I know I’ll die.”

Anxiety Versus Depression- Self Statements(Safren, Heimberg, Lerner, Henin, Warman, Kendall, 2000) Inability to cope I can’t take it anymore. I can’t stand it. I wish I could escape. I don’t want to feel this way. I cant cope. I can’t get through this Something has to change.

Anxiety Versus Depression- Self Statements(Safren, Heimberg, Lerner, Henin, Warman, Kendall, 2000) Uncertainty About the Future How will I handle myself? Can I overcome the uncertainties? What will happen to me? Will I make it? Can I make it? Am I going to make it? What am I going to do with my life? I want to fight back but I’m afraid to do so.

Anxiety Versus Depression- Self Statements (Safren, Heimberg, Lerner, Henin, Warman, Kendall, 2000) I don’t feel good. No one understands me. I don’t feel very happy. I don’t think I can go on. I am not safe, comfortable. I wish I could die. I am not sure that I can I’m worthless/a failure. accomplish this. I’ll never make it. I don’t feel so good about I hate myself. Myself/my life. I’m against the world. I feel like a loser. I’m no good. Something is wrong with me.. I can’t get started.

Cognitions Related To Depression Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)Relationships, Entitlements, Achievements If people criticize me, I am not a worthwhile person. Other people’s approval is very important to me. I can make everyone like me if I just try hard enough. The most important thing in the world to me is to be accepted by other people. I find it impossible to go against other people’s wishes. Unless I get constant praise I feel that I am not worthwhile.

Cognitions Related To Depression Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)LOVE Life is unbearable unless I am loved by my family. If I am not loved it is because I am unlovable. If I love somebody who doesn’t love me, I must be inadequate. I need to be constantly told I’m loved to feel secure. If I were a better person then somebody would love me. In order to be happy, I need someone to really love me.

Cognitions Related To Depression Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)InfluenceI can prevent people being upset by thinking about what they might need. If I have a fight with my friends, it must be my fault. I should be able to please everybody. I am responsible for other people’s happiness. If people are uncomfortable around me it is my fault. If the people around me are upset, I usually worry that I have upset them.

Cognitions Related To Depression Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)SuccessI can’t feel equal to others unless I’m really good at something. I only feel valued if I achieve my goals. My success in life defines my goals. I need to be successful in all areas that are important to me. Life is pointless if I don’t have goals to chase. Without success in life, it is impossible to be happy.

Cognitions Related To Depression Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)Perfection I see no point in doing anything unless it can be done perfectly. There are no second prizes in life. Things must be done to certain standards, otherwise there is no point in doing them. If I make mistakes then others will think less of me. If I don’t do something perfectly then I don’t like myself very much. I never seem to be able to reach my own high standards.

Cognitions Related To Depression Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)ExternalI can only be happy if I have the good things in life. Unless I have expensive possessions, people won’t approve of me. If I were rewarded for the goals I achieve, know I could be happy. If my friends are unhappy, then I cannot be happy. Everything has to be going well in order for me to be happy. My happiness depends on others.

Cognitions Related To Depression Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)Rights If obstacles are placed in my path, it is natural that I would get angry. Things should always go right for me. If I do the right things people should acknowledge it. If I feel that I deserve something, I should get it. If I go out of my way to help others, they should do the same for me when I need it. I shouldn’t have to work so hard to get the things I want.

Behaviors Related To Anxiety Attending to the disturbing stimulus to the neglect of additional environmental informationIntolerance of uncertainty- the tendency to react negatively on an emotional, cognitive, and behavioral level to uncertain situations and eventsMaladaptive schemas related to earlier life: disconnection and rejection, impaired performance, impaired limits, etc.

Overcoming Depression and Anxiety “You can look at what happened to you; it was truly horrible, but it is not unthinkable or unfaceable. You do not have to run from it day and night, and you do not need to totally curtail your life for fear of a recurrence. You can live in a world where this once happened and where there is a remote chance that it could happen again. Moreover, you MUST look at it. You must face it down, because what is happening now is what happens when you don’t.” (Bergner, 2009)

Essential Elements Cognitive Restructuring(Hope, Burns, Hayes, Herbert, Warner, 2010)Identify and change dysfunctional cognitive beliefs/automatic thoughts Replace anxiety producing thoughts with more socially adaptable ones Through Socratic questioning Challenge the voracity of assumptions regarding social situations Living in new attitudes about self and others by applying new rational rebuttals to the irrational beliefs and behaviors Targets 3 areas: 1. experiencing anxiety, 2. negative self evaluation, 3. fear of negative evaluation Use a hierarchy of thoughts- surface to core (keep asking “what would that mean?” until 4-6 th = core) Exposure Reducing disabling behaviors Finding exceptions Systematically facing feared situations in context they feared Redirecting attention

Essential Elements Social Reappraisal Therapy(Hoffman & Scepkowski, 2006) Factors which influence formation=social apprehension, high social standards and goals, increased self attention (50-60%), high estimated social cost, perceived poor social skills, low perceived control, post event rumination Create at least one social mishap per week Switch focus on environment rather than inwardly- see the genuine observer’s perspective rather than the client’s own perspective Realistically appraise the social cost Reframe to increase sense of emotional control

Essential Elements Cognitive-Behavioral Treatment: Key Aspects(Lamplugh, Bele Milicevic , & Starcevic , 2008) Understanding anxiety and the flight or fight response Understanding the role of hypervigilence Promoting a sense of ‘riding out the wave’ of anxiety in an accepting manner instead of trying to control symptoms Realistic appraisal of body sensations Acknowledgment of physical feelings rather than distraction away from those feelings Rating the intensity of physical feelings rather than anticipating the worst Abandoning anxiety Acknowledgement that catastrophic misinterpretations of physical feelings are problematic, not the physical feelings themselves Cessation of maladaptive behaviors that maintain the problem

Essential Elements Collaboration, cooperation between therapist and clientClinician skills in CBTAbility to psychoeducational foundation regarding thoughts, feelings, and behaviors Ability of client to have insight and awareness Desire of client to modify thoughts and behaviors Homework and exercises for applications for client outside of session 4-6, 6-8 sessions

Essential Elements Forsyth, D.M., Poppe, K., Nash, V., Alarcon, R.D., & Kung, S(October 2010)Gains in positivity are more closely related to emotional healing from depression and anxiety than loss of negativity.

Who Might Benefit? AnxietyDepressionAssertiveness BuildingDiet and Health IssuesSocial IsolationMedical concerns Grief Alcohol Dependence PTSD Divorce Life stressors

Video Clips: Cognitions and Behaviors Identify the thought patterns and toxic behavior choices in the video clips.

Problem Orientation positive problem orientation a protective factor that facilitates the initiation of proactive problem-solution skills to manage or minimize early signs or symptoms of psychological distressnegative problem orientation- a serious threat to their well-being, respond with strong negative emotions (e.g., anxiety and/or depression), and avoid or postpone dealing with a problem

Transdiagnostic Approach(Clark, 2009; McManus, Shafran, & Cooper, 2010) Moving away from diagnosis specific treatments Symptoms overlap between similar disorders “A therapy that is made available to individuals with a wide rage of diagnoses, and does not rely on knowledge of thee diagnoses to operate effectively.” Assumptions : General cognitive-behavioral processes which are shared Absence of diagnostic assessment Adoption of a convergent or integrative scientific approach Commonalities : 1) Altering incorrect or faulty appraisals based on emotions about self or other 2) Prevention of avoidance 3) Psychoeducation 4)Behavior modification

Challenging Thought Patterns Shoulds“Why?”“if only ____, then _____” Have tos _____ “enough” Absolutes : always/never Right/wrong Good/bad _____

Challenging Thought Patterns Cognitive distortions- the different types of distorted cognitive processes that produce automatic negative thoughts, which in turn, evoke or strengthen early symptoms of psychological distress and emotional and/or behavioral disorders

Cognitive Reframing Instead of “if he/she would…….”Use:“If I could just get a grip on _____ then we’d finally be happy.” Watch where you put your BUTs: __________ BUT __________.

Who Does Cognitive-Behavioral Therapy Work For? Strong Motivation To ChangeTime CommitmentCognitive Functioning/Educational LevelObservant People Insightful People Those who will do work outside of session

Conceptualizing The Problem AntecedentsWhat happened before?Something triggered thisNot Out of The Blue(e.g. Boy throwing cars around the room- Is it a behavior issue really?)

Conceptualizing The Problem

Conceptualizing The Problem Antecedents:What happened right before that? (Affective)What happens to you physically before this happens? Do you feel sick? (Somatic) How do you normally act right before this happens? (Behavioral) What thoughts go through your head before this happens? (Cognitive) Where and when does this usually happen? (Contextual) Do you do this with everyone or just when you are around certain people? (Relational)

Conceptualizing The Problem BehaviorsWhat the client does in responseExamples:I avoiding going out of the house. I stomped off my job. I yelled at the kids. I cried and staying in my room.

Exercise: Responses to The Antecedent Antecedent Behavior Reaction Feeling Reaction I was playing with my child but had to leave to get the laundry. I expected to get the job but found out it was offered to someone else. I had a flashback of a trauma from my childhood. I discovered my boyfriend was cheating.

Exercise: Responses to The Antecedent Antecedent Behavioral Response Feelings Response The doctor told me I have cancer. I got a pay cut. My child failed school. I do not look the way I want.

What Could the Antecedent Be? Antecedent Behavioral Response Feelings Response My son threw his crayons across the room My son cried and kicked. I covered my eyes and shook. I stayed in bed all day. I felt disappointed in myself, unhappy with my life.

What Could The Antecedent Be? Antecedent Behavioral Response Feelings Response I slammed the phone down. The teenager put the music on as loud as possible. My spouse drove away. I left the busy concert.

What Could The Antecedent Be? Antecedent Behavioral response Feelings response I felt like throwing up as my heart raced and I experienced panic. I resolved not to try anything again because “nothing ever works for me.” I tried again – “next time could be better.”

Challenging Attributions 1) Am I ascribing something like “This situation happened because ______?”2)Am I making a judgment about another person’s personality because of this event? What am I telling myself about what this means? (Because this happened, it means---) 3) Am I using adjectives to describe the other person’s personality, intentions rather than simply describing the behavior? (e.g. “You are always so lazy. You never care about our house.” versus “I am concerned about the amount of cleaning we still have to do. I realize we have busy tiring jobs but I am wondering how we plan to get the dishes done and get our things set up for tomorrow plus help the kids to finish their homework. How do we plan to get to divide these things up- any ideas?”)

Challenging Attributions 4) Is the way I’m thinking about this definitely 100% a fact?5) Is there any other way of looking at the situation? Come up with at least three exceptions. 6) Have I assumed that because something is (perceived by me to be) such and such way that I am powerless over it?

Attributions Exercises 1) My spouse came home late two days this week. His clothes were a little disheveled looking- he must be having an affair.2) My wife was supposed to meet me for the romantic dinner. She was ½ hour late and did not call me. When I saw her I had to yell at her because I knew she did not make our dinner a priority.3) My coworker left a pile of unfinished work on her desk. It must be that she is lazy and planned to have me do all her dirty work.

Attributions Exercise 4) The group of popular people looked at me and smiled. I knew they were talking behind my back badly about me.5) When I walked by they got quiet. I am sure they noticed my hand me down clothes compared to their name brand outfits.6) Every time my mother comes over she helps me clean the house. I knew she always thought I was a slob and couldn’t do anything right.

Setting Behavioral Goals ConcreteSpecificManageableAchievable With accountability for follow through

Goal Setting Process

Setting Goals Exercises Broad Goal Specific Step Outcome Desired Feel less depressed Get out of bed and get set for the day Be bathed, dressed and get out of the house for at least one hour per day Stop fearing everyone’s reaction of me Go to a public place three times per week for at least ½ hour and find out that the worst doesn’t happen. Learn to talk to strangers without automatic belief and avoidance because I assume that everyone’s out to get me.

Setting Behavioral Goals Broad Goal Specific Goal Desired Outcome Feel more self confident Have a better self concept, believe I have self worth Try new things without fear of rejection

Tips For Goal Setting Tell what you want to happen rather than what you don’t want to happen.State observations- what would you/others see?What would be the benefits of such an action?Use 1-100 scaling to identify priorities. Behavioral outcomes should be inconsistent with the depression and anxiety symptoms

Tips For Goal Setting Reintroduce prior successesReintroduce pleasant activitiesChoose active helping (e.g. taking some proactive behavior action to relieve a stressor)Don’t avoid.

Solution Focused Approaches

Facts About Solution Focused Therapy Average length of sessions= 5-8 sessions for SFTAverage length of sessions for SFBT is 1-3 sessionsMax benefits of treatment are usually achieved win 6-8 sessions for 75% or more of patients.Graduate students in research studies endorsed and had the most successes with solution-focused approaches compared to other treatment approaches: saw real transformation and maintained changes in clients, ease of use

Facts About Solution Focused Therapy With 80% of patients in a 2005 study having 4 sessions or fewer still 77% maintained symptom reduction at 9 month follow up (Rothwell, N., 2005)

Why Do People Have Problems? They do things that don’t work.They don’t have an expectation of changeLack of insight/awarenessNot doing the right thing enoughUnwillingness to do something different

What Keeps People Stuck Don’t listen to anybody.Listen to everybody.Endlessly analyze and never change anything.Blame others.Blame yourself. Keep doing what does not work.

What Keeps People Stuck Keep focusing on the same things when that does not help.Keep thinking the same thoughts that doesn’t help.Keep putting yourself in unhelpful environments.Keep relating to unhelpful people.

Basic Tenants of the Solution-Focused Approach What works in spite of what doesn’t workLooking for exceptionsPlanning experiments and testsThere is some good even in bad or unpleasant circumstances. Nothing stays awful forever. If you have done something that works one time before you can do it again- twice, ten times, etc. If you have done something for a small length of time you can do it a little longer until it becomes a new habit.

Basic Tenants of the Solution-Focused Approach Clients want things to be different to where they are not so problem bound.Clients would not come to us if they did not believe things could be better.Clients are capable of self evaluating.Clients are the experts on their own lives. Treatment does not need to be scripted to be successful and effective.

What Works in Spite Of What Doesn’t Work Focus on client strengthsA success driven modelSolution buildingFocus on the desired outcomeUses success language: How have your managed?... All clients have resource already.

Exercise: reframing 1) A mother comes in stating that her daughter is nothing but strong willed, defiant, and opinionated. She wants her to be more happy and cooperative. She wants her daughter to have treatment for behavior issues.2) A husband says his wife’s Bipolar “just plain gets to him.” He comments, “can’t she just be more self controlled and stop the mood swings?” He admits that on the other hand he would not want to lose her passion and enthusiasm as this is one of the things that drew him to her.

Exercise: reframing 3) A family comes in stating that “no one ever agrees on anything.” The presenting problem is that the house has become increasingly chaotic all the time. The whole family agrees that things are out of hand with how they relate to each other. You ask if there was a time when things were different. They state “before we moved here. Life was consistent and predictable. We had the schools, friends, and jobs we had for over 10 years. This place is a world of difference and the only people we know are each other.”

Exercise: reframing 4) A young adult is in trouble and is being referred by his company for counseling. The referral states that they are concerned that he is defensive, always gives input even when not asked, likes to do things his own way.” The client states that he “sees himself as made for so much more than just this current job.”

Exercise: reframing ) Allison was molested throughout childhood by her foster parents. Kids bullied her in school, Now here house was recently broken into, Her car also broke down and she has no money to pay for repairs. She feels like “bad things keep happening to her.” She is having flashbacks , sleep problems, and anxiety, and wondering if the problems will ever end. She says she has always been the victim in life and can’t handle it any more. She does consult with an older woman friend for emotional support and also periodically goes to “Victims of Crime” meetings in the community. She mentors other young women who have blamed themselves for being raped.

Things Will Change Planning for change vs. avoiding changeInevitable and constantPlanting as seed in the client’s mind that things always eventually turn aroundTherapist amplify change

Looking For Exceptions Even in the stressor or presenting problem when does it not occur?Are there parts of the situation or reactions which are useful?No problem happens all the time.Solutions are there already but just aren’t implemented enough. 1) When you do not have the problem? 2) When the situation is “less bad?”

Relaxation Tension ReductionPerceived control over stressProgressive muscle relaxation- one by one relaxing and tensing various muscle groups

Imagery Imagining yourself as successful in identifying what that would take.Involve as many senses as possible.Strengths based- what would you like to see happen? When has this happened? How would you act if the new improved situation, feeling, behavior was going on?Set aside time to ponder this. Schedule a thinking time.

Typical Session Outline

Questions For Ongoing CBT What points did we come to since last session?Anything you learned as you thought over things?Anything you were uncomfortable with?Things better or worse?Treatment agenda- where are we? What to focus on today? What to amend? Completed or not completed homework?

Setting Homework Done collaborativelyDon’t assume follow up- ask. (e/g. couple I counseled re. communication interchanges)Affirm the value of outside practices.Highlight attempts and successes- build onStart by modeling and practicing in session. Inquire re. homework. Anticipate problems.

Other Ways of Presenting Homework BibliotherapyProgressTasksExperimentsObservationsExercises Not about doing things “right”

Moving Away From “Why?”

Solution Focused Therapeutic Conversations Problem focus Solution FocusedHow long have you been What would it be like if you depressed? were not depressed?What happens when you are anxious? When your relationship problems are worse between you and your parents how do you act? Tell me about the nights when you cry yourself to sleep. Everywhere you go there seems to be pain and grief.

Changing Narratives What happens when others do not view the person as mentally ill, crazy, incompetent, depressed etc.Are there other people who managed through similar situations?Restorative narrativesNormalizing things people face

Changing Narratives Using the narrative to provide insight into self, beliefs, values, goalsIdentify choices.Considering various endings to the story.

The ACCEPT Framework Acknowledge, validate, and value.- attending to client’s perceptions, normalizing experienceClarifying concerns- discovering what would be a successful outcome for the clientChanging or challenging what is being attended to and how it is done E valuating progress- are the beliefs and actions helpful?

The ACCEPT Framework Planning next steps- Set up experiments. What is progress? Try more of what works, less of what doesn’t work. Modify as needed in small steps.Terminating treatment- Once client is implementing viable solutions and has understanding of the possibility, solution focused applications allow them to take responsibility for applying the framework in other areas of their life

When Thoughts are Hard to Determine Observe behaviorsObserve body languageObserve positioning, tone, facial expressions, hand gestures.Observe what emphasized more or less .

Mindfulness Approaches Use decentering to switch from a judgmental problem focus which promotes negativity to a present here and now nonjudmental stanceExamples: What did you notice in your thinking, emotions, or sensations? Did you notice the sense of tightening or tension in any particular place in your body? So, these difficult thoughts and emotions were present in your awareness.?

Mindfulness Approaches Key Components:Begin in the initial assessment session. The participant is provided an opportunity to describe his or her experience of depression. Together, the therapist and participant explore ways in which MBCT may effectively reduce relapse risk.The therapist enhances a sense of mutuality and connection with participants. The process of inquiry should be a genuine exchange during which the therapist uses questions to help the participant deepen awareness of his or her practice, while also embodying the present-focused, open, and warm attitudes of mindfulness.

Mindfulness Choosing to control our focus of attentionExample: Washing dishes: instead of thinking of the stresses of the day and how much more to do- “Listen to the bubbles. They are fun!”Just observeAccepting things as they are rather than trying to always change them. Stop thinking too much. Just let it be.

Cognitive Behavioral Overview Increase insight and awareness then elicit more health positive outcomesNote negative thoughts and record more helpful ways of thinking about situations, self and others to influence emotion positively.Review thoughts, particularly expectations for self and ‘ shoulds ’ rather than ‘wants’. Identifying rules for living and examining their helpfulness. Self monitor. Identify unhelpful thinking styles that lower mood. Encouraging the client to analyze her thoughts and then step back from them. Consider alternative explanations to negative automatic thoughts or behaviors.

Cognitive Behavioral Overview Conducting behavioral experiments to help increase believability of alternative thoughts.Analyze self-criticisms with focus on undoing negative automatic thoughts and behaviors.List goals with an emphasis on own needs and expectations.

Patient Self Guided CBT Ridgway, N., & Williams, C. (December 2011)General principles taughtResources tailored to clientAudios, videos, workbooks Bibliotherapy May be computerized Emphasis on homework As effective with mild to moderate depression and anxiety as face to face therapist guided CBT

Patient Self Guided CBT Ridgway, N., & Williams, C. (December 2011). Strengths Many people like to read As effective as in person CBT Can teach key information and skills Uses a clear structure Paper-based tasks and records Ability to personalize what is read Low cost and can be copied Can incorporate many modalities, e.g. reading, listening, video, etc. Interactive learning Automated alerts can be used if deterioration or risk is recorded Online forums can provide added support

Patient Self Guided CBT Ridgway, N., & Williams, C. (December 2011) Weaknesses Text used can be difficult to understand if foundations not properly laid Licensing may make copying expensive Need online access or to travel to a fixed unit Needs flash and adobe reader plus adequate bandwidth and access to soundcard/speakers Making sure the client has proper equipment – E.g. Newer delivery mechanisms use MP3 or certain video formats Audios or videos are fun to many people Documentary style may make people feel as if they are not alone May watch but not learn or apply Needs ways of helping people implement what they are learning

Evaluation Questions Situational Questions Feelings Questions Thought Questions What happened? What were you doing? Who was there? Who were you speaking to? When was this? What time of day was it? Where were you? How were you feeling before this happened? How did you feel while this was happening? What mood were you in after this happened? Rate your mood: 1-100. What was going through your mind before you started to feel this way? What thoughts bothered you? What are you afraid might happen? What if what you think is true? Are there other ways of thinking about things?

Thought Log Event Thought Consequence Alternate Response

Anxiety Ladder Rate 0-100, Systematically challenge one by one, pair with relaxation

Cognitive Debating Strategies Is this a fact/strong opinion?What evidence is there for this? Any evidence against this?Alternative explanations that are more reasonable/possible?Is there another way of feeling or thinking? What would someone else make of this situation? What advice would I give someone else? Is this a type of unhelpful thinking habits? Is this an automatic thought?

Cognitive Debating Strategies What am I actually reacting to?Am I getting anything out of proportion?What harm has actually been done?Am I overestimating the bad? The danger?Am I underestimating my ability to cope? Am I going to a negative automatic place? How is pressuring myself or others helping me get through this? Just because I feel bad is it really bad? Are things really totally black or white- as clear cut as I am making them? Can there be more than one solution to this problem?

Cognitive Debating Strategies Is believing this life giving or death producing?How important is this really?How will things be in 1 week? 1 month? 6 months? 1 year? If I continue thinking or behaving this way?What would happen if I tried to see this situation as an outside observer? How would things look? Would things have a different meaning? What is the bigger picture?

Dealing With Grief

Stages of Grief ShockDisorganizationSearching BehaviorEmotional ComponentsDespair Guilt-real or imagined, what if? What could I have done? I wish I could have done more. Anger- at person for their sickness/death, anger with yourself for being about your own business

Stages of Grief Anxiety-what now?, feeling of loss of control over your emotionsJealousy- of others who don’t have to go through loss Shame-don’t want to admit true feelings of loss – what it means Aggression/Protest- doctors & nurses, family members who did not help, God for “letting it happen” Letting Go - final goodbye, not searching, acceptance of new reality Reintegration - reassigning meaning to symbolic experiences

The Six Needs of MourningWolfelt, 2004 Accept the reality of the death.Let yourself feel the pain of the loss.Remember the person who died. Develop a new self identity. Search for meaning. Let others help you- now and always.

What Clients Said Was Helpful Cognitive strategies to help they be optimistic, increase positive self-talk, compartmentalize rather than generalize things, and healthy avoidanceSpiritual resources- beliefs, Bible verses, prayerListening and empathy Assistance with practical resources Assistance with verbal expressions Physical exercise Some alone time

What Clients Said Was Helpful Freedom to talk about and reintegrate their relationship with the deceasedAssistance with decision making- information, options, referralsAnxiety reduction techniques to deal with stimuli that serve as reminders Strengths based approach regarding what client has already successfully used Thought restructuring Behavioral approaches- goal setting from here

Who Can Help? Use the law of thirds principleGoal What that Would Who Look Like Can Help

The Helicopter View What can I see in this situation as I look higher and higher?

Helping Kids What is making you scared? Sad?What are you expecting will happen?Are you in a thinking trap?Are you 100% sure this will happen?Could there be any other ending to the story?

STOP S Signs of anxiety or depressionT Thoughts of anxiety or depressionO Other better ways of thinking or feeling? P Praise for new plan for next time

Hindsight Bias A type of memory distortion“ I knew it all along phenomenon”Needs to be confronted just like other distortionsThinking that we knew more or could predict more than we could

Old Versus New Systems I am… People are… The world is… I am… People are… The world is… Old Rules that Protect Me: New Rules that Protect Me…

Positive Self Talk I can be anxious/angry/sad and still deal with this.I have done this before so I can do it again.I don’t have to feel happy all the time to get through what I need to do in life.These are just feelings. They won’t last forever. I don’t need to rush. I can take things one by one. I have gotten through things before. I will get through them again.

Generalizing Skills Outside Sessions Ongoing homeworkPlanning for reassessing thoughts and behaviors oftenPlanning for alternatives to depression and anxiety: if/when ___ happens I will do ___.Booster sessions

Modified ABC Model Activating EventBeliefsConsequences D isputations of Beliefs E ffective New Beliefs

Key: Making Allowances for Pain Room for stresses in lifeFreedom in scheduleRealistic ExpectationsHealthy, open communicationAvoiding absolutes: good, right, strong, perfect Stop the “if____, then _____” thinking Cultivating happiness within rather than without Self monitoring regarding personal triggers

Summary: Depression & Anxiety Physical Thought Behs . Feelings Anxious Tense, shaky, worried, energized, HR increase, can’t concentrate I’m in danger, Have to get out, I can’t cope Avoid, Fidget, Escape, Ruminate Nervous, edgy, apprehensive, panicked, terrified Depressed Tired, lethargic, withdrawn, eating or sleeping changes, loss of interest in hobbies, restlessness, poor ADLs I’m worthless, Life’s awful, Bad things happen to me, It’s hopeless Do less, talk less or quieter voice, Eat or sleep less or more, isolate Sad, gloomy, unhappy, despairing, hopeless

Summary: Depression & Anxiety New Thoughts New Behaviors Depression Even if I feel sad I will get through, If I do something I will feel better, This is just my habitual gloomy way of thinking. Do things anyway, Get out, talk to someone, Get dressed, Do an activity I used to enjoy, Relax, Focus attention elsewhere Anxiety Is this really a threat? I could be overestimating the threat, I have gotten through before even when I was worried or panicked. Problem solve, Don’t avoid or you’ll never find out that the worst doesn’t happen.

Changing Distortions Type of thinking Neg. impact Replacement All or nothing Discouragement, no middle ground Continuum thinking Overgeneralization Makes all problems last forever Focus on the here and now Negativity Make the positive impossible Appreciate the positives Discounting positive Eliminates real joy in the present Purposely find and enjoy the positives

Changing Distortions Jumping to Conclusions Anger, anxiety, depression Consider all possibilities Predictions Dread, disaster, panic Stay in present Mind Reading Anxiety, sadness, anger, assumptions Clear communication Magnification Treating people unfairly See strengths in self and others Emotional reasoning Upsetting judgments made without evidence Listen to your head and heart

Changing Distortions Shoulds Discouragement at self, Anger at others Bring expectations in line with reality Labeling Discouragement at self, Anger at others Stick to specific circumstances Blame Discouragement at self, Anger at others Stick to specific circumstances

Religious Coping as Strength Preoperative rates produce less depression and distressPeople also benefit when others are praying for themA transcendent being outside self – support system

Five Religious Coping Functions (Folkman, S., & Moskowitz, J.T., 2004)1) Finding meaning in the face of suffering and baffling life experiences 2) Providing an avenue to achieve mastery and control 3) Finding comfort and reducing apprehension 4) Fostering social solidarity and identity 5) Assisting people to give up old objects of value and find new sources of significance

Assessing Suicidality: Suicide= the intentional ending one’s lifePassive suicidal ideationActive planAccess to meansMotives/rationale and likelihood of follow through

Protective Factors Social supportsReligiosity/spiritualityInner strengthsWillingness to seek and comply with outpatient treatmentTreatment compliance

Suicide Assessment( Bjorkdahl, A., Nyberg, U., Runeson, B., and Omerov, P., 2011) Hopelessness, despair 100 Suicide pans of preparations 100 Self harm, suicide attempt 100 Death, death wish or thoughts 97 Impulsivity, impulsive acts 94 Sudden mood variation 94 Seeping 94 Commanding, imperative voices 92 Withdrawn distant isolated 92 Distorted concept of reality, psychotic 92 Worried, anxious 91

Suicide Assessment( Bjorkdahl, A., Nyberg, U., Runeson, B., and Omerov, P., 2011) Aggressive, hostile 86 Sad, depressed 85 Guilty . shameful 84 Motor restlessness 77 Psychache , psychological pain 77 Suspicious 72 Activity outside of room 69 Confused 69 Angry, irritated 69 Mixed mood 69 Hopeful planning for the future 61 Eating or drinking 60

Suicide Assessment( Bjorkdahl, A., Nyberg, U., Runeson, B., and Omerov, P., 2011) Calm 58 Closure of practical or personal issues 58 Conflict with staff or others 54 Taking care of personal hygiene 54 Physical complaints or pain 53 Medication intake 49 Good relations to staff or others 44 Contact with relatives 44 Excited 42

Suicide Assessment(Bjorkdahl , A., Nyberg, U., Runeson, B., and Omerov, P., 2011)Receiving visit, using the phone 37Visiting toilet, bathroom 34 Sociable 25 Complaints about care or treatment20 Trustful 17

Suicide Assessment: How often do you have thoughts? 1-10 ratingWhen first started? Degree of frequency/intensity?Plan(s)? Steps toward completion?Steps towards death?Communication of suicide thoughts or plan to others? What being dead or alive represents? Future orientation or hopelessness? Hope? What one thing would help him or her no longer be suicidal?

Suicide Assessment: Most professionals were confident in risk assessment but few knew what to do to then counsel people or what to do in ongoing care/referral

Four Key Factors: Press- the perception of outside demands on an individual, social stressorsPerturbation- the degree of urgency to get reliefHopelessness- the idea that there will someday be an end to the painSelf hate/self loathing - failure focus

Suicide Warning Signs Talks about committing suicideHs difficulty eating or sleepingExhibits drastic changes in behaviorWithdraws from friends or social activitiesLoses interest in school, work, or hobbiesPrepares for death by writing a will and making final arrangements Gives away prized possessions Has attempted suicide previously

Suicide Warning Signs Risk taking behaviorsRecent and serious lossesPreoccupation with death and dyingLoss of interest in activities and hobbies used to enjoyDecrease in concern about taking care of personal appearanceIncreased drug or alcohol use

Suicide Contracts Little proof for efficacy of thisNo legal and ethical immunityActually harmful because not necessarily in context of long term trusting relationshipOverused and undereffectiveDoesn’t address the amount of constant supervision really needed to prevent suicide

What’s Wrong With Risk Assessment? Insurance based concept, not clinical conceptDiverts attention from others clients who need services just as muchNot related to the actual treatment needs of clientsA statistical concept to predict and identify but does not tell you what to do clinically Sorting patients not necessarily predictive of clinical needs Multiple clinical sources and collateral info. Better Detailed comprehensive history more important High risk categories may put people into categories that may actually cause harm rather than good Deprives “low risk” patients of suitable care

Depression and Forensic Settings Women have less criminal history than menWomen’s crimes are usually related to reacting to a very specific offense done by someone they know Sexual and physical trauma often related to women’s crimesMental health issues like depression and anxiety more significant in women criminals as opposed to more antisocial personality in males More environmental rationales by women than men- more stressor or situation specific Suggests need for gender related treatments

Rise of Teen Suicide Leading causes of death for teens13-20% contemplating at a given time’13% with specific plans8% attempt at some pointTend to be most honest re. suicide risk assessment Most often by OD but most successful by guns Girls more impulsive but boys more successful Hx of MH dx significant Self mutilation is a strong predictor Bullying is a strong predictor Risk of copycat suicides

ACT Acknowledge signs of suicideCare about the suicidal personTell a responsible adult

IS PATH WARM IdeationSubstance Abuse P urposelessness A nxiety T rapped H opelessness W ithdrawal A nger R ecklessness M ood change

Resilience “More than education, more than experience, more than training, a person’s resilience will determine who succeeds and who fails.”

Videos: Doing Treatment Watch the videos and see how the irrational cognitions and unhealthy behavior choices are addressed.

Vignettes For discussion

No One Loves Me Anymore A 83 year old female, Rhonda, is referred to you for counseling because she seems to have worsening depression after becoming a widow when her husband of 53 years died one year ago. She has been making more comments lately that she just wants to die and go to be with her husband and that she has already lived her best days. Additionally her nursing home facility has reported increasing forgetfulness and moments where she just does not seem to fully understand or remember who she is, where she is and be in the present moment. While collateral sources say she is generally a pleasant lady with nice stories of life memories with regards to her husband and grown children there are moments the health aides who work with her report that she acts entirely different. During these other times she is suddenly agitated and defensive and may even refuse to take meds or bathe or do day to day tasks even around the health care nurses who she normally enjoys. She does have someone stop by daily to help her with meds and check in on her. She tends to really dwell on and share many stories about the past fond memories with her husband before he dies and about her family life when the kids were growing up. However, she has a tendency to forget more recent things quite a bit lately.

No One Loves Me Anymore rhoda reports having had many more support systems in the years raising her children. She says that soon thereafter her husband’s death her kids came around shortly after the funeral but that they “have all left me alone now” to deal with life by herself. She says that after retiring from her job teaching, people have seemed to forget about her. She has beeN involved in a church for twenty years but says since her health problems have gotten a little worse she cannot go as she’d like. She describes the church as large in size and that they do not reach out to people with life issues like hers as they used to. She cries and gets choked up stating “no one loves me anymore.” She proceeds to tell you how her kids have forsaken her, no one else has the time to listen to her stories, and she is just living her final moments alone. Specifically she says, “I wish death would come quick. I don’t know what more that’s left for me on this earth anyway. My best days are gone. Oh the fond memories I have of them. I’d rather just keep it that way and e happy now. Between the health problems, no one being there and the loneliness I can’t handle things anymore.”

“Where Do We Go From Here?”: A wealthy couple comes in with a presenting problem of trying to learn how to deal with decisions about their life and retirement years from here. Both of them have had a great deal of money and assets , they each own their own companies that have bene extremely successful. They have several jets and had many opportunities to fly a multitude of places for personal and business interests through the years. They are in their mid fifties and are bored.” They state that they are seeking counseling to assist them with this place of indecision. Both remark that they have done everything there is to do and are facing retirement age or decisions about the future of life and companies but don’t know where to go from here. The typical tasks of the retirement ages are things they believe they have already not only done but mastered.

“Where Do We Go From Here?”: There is nowhere left to travel and nothing left to acquire. They actually cannot imagine not doing what they are already doing with heading their companies and managing things. Each has a sense that there has got to be something more but is not sure how to decide what that something is from there.

“But They Won’t Accept The Man I Love”: A 30 year old Japanese woman comes in for grief counseling through her EAP. She states that she believes she has found “the one” in her current boyfriend who is 15 years her senior and is divorced. She describes him in highly positive terms and is quick to remark about his attributes. She states that it has been nearly two years that she has been dating him, going on trips with him, and serious with him but that she has told her family from Japan about him in the last 6 months. She speaks about the traditional values of her extended Japanese family who all live with her at her parent’s household. They are 100 % against divorce and consider him a low life and a lesser person because he has been divorced. She also states that they feel I have settles and gone for someone beneath me not only because he is divorced but because he is not Japanese and is not from the right type of job and socioeconomic status they would like.

“But They Won’t Accept The Man I Love”: She would like the backing of her family but is to a point that she is tired of keeping lies from them about how much she is into him. She also comments that he has a 10 year old daughter and would have to learn to be a mom if they ended up getting married. This is something she is working on as she is spending increasing amounts of time around his daughter. However, when her family found out that he has a daughter it is only another strike against him. She loves her family but is frustrated that they do not give her the same freedom they have given her baby sister who is in her mid twenties: “she got pregnant to a loser guy and was allowed to live on her own in her own place but I am not allowed to have my own choices at all.” She expresses fear that something as simple as choosing to find her own apartment would devastate that family because she is the oldest and the one who is “supposed to uphold the family’s wishes and interest.”

“But They Won’t Accept The Man I Love”: Her cries and she speaks about how her family refuses for her to even talk about her boyfriend or to consider meeting him. She also feels trapped because the boyfriend “does not want to force his way into her family and is going too slow” because she does not want to disrespect her family’s values. She would like to be engaged to him by now but feels as if everything is at a standstill because the family won’t move to accept him and he won’t move to initiate more commitment. She wants help with deciding if she should just move out to her own place and start her own life as a sign to her family that she has opinions about making decisions in her life. However, she is afraid that the family may essentially disown her and she may lose them and maybe also the boyfriend in the process.

“Maybe they’ll let me off” Bill a 40 year old gentlemen is in trouble with the law and is facing jail time for stolen property and drug possession. His girlfriend calls in stating that if he can come in to your program and show something that he is learning to deal with his drug use and manage his anger better than maybe the courts will let him off easier at his next court date. He regularly drinks up to a gallon of vodka nearly daily for at least the past year and had two DUIs in the past ten years as a result. He also binges on crack cocaine from time to time. He sells and uses marijuana daily because “it is the only thing that relaxes his mood.”

“Maybe they’ll let me off” He did come in to assessment scheduled by his girlfriend though throughout assessment girlfriend spoke often for him trying to explain how motivated he is for treatment. He says he “has just had a hard life and did not grow up with both parents in the home. He often moved from home to home from ages 2-10 until a distant relatives was able to get him. But then, a lot of people have issues growing up.”

“Maybe they’ll let me off” Bill reports a history of impulsivity in many areas from substance use, overall quick decision making, spending money he doesn’t have, jumping from one relationship to another. He had had run ins with the law for theft, forgery and assault since he was a preteen. He has never been inpatient and when referred to therapists she states that he never clicks with them because “they all have agendas.” He expresses a great deal of anger toward the system which put him in multiple foster placements growing up and makes him do programs just to get more insurance money out of him. He considers himself to be strong willed and determined. He does not really see anything wrong with his life: “people do the stuff I do all the time. It is just that they are more secretive about it and able to not get in trouble. I just got caught.”

“Maybe they’ll let me off” Bill states that he has not been to doctors in ages because “they too are part of the messed up system of outsiders that tries to run his life. They put him in residential homes and made him take meds he feels he did not need.” As he has aged he has developed some chronic pain issues from a bike accident and injury at work. Over time the pain became so bad that even the system was worthless and could do nothing but prescribe pain killers. He became addicted to pain killers and now routinely uses more than prescribed because “that is the only thing the system did that even helped at all.” He has two grown children from a past marriage and one young child with his current girlfriend. The two grown children live in their own places and the young child with his girlfriend was removed from the home due to neighbors and relatives reporting him for abuse when he was angry and went overboard with discipline. He states he only disciplined his kids and again the system can tell him nothing about the best way to raise a child.

“Maybe they’ll let me off” Bill does not appear to have many future goals related to his mental health accept to “get the system off my back.” He is more motivated by a desire to make his relationship with his girlfriend work out and to do what she suggests if it involves some sort of treatment. He appears to take her opinions seriously and considers her and a few drinking buddies his supports. Except for pain meds for his physical aches and pains Bill is adamant about “not being drugged up on that prescription stuff.” He is unsure about how much he wants his moods “managed” as it has been his survival tool through the years. He says that “just takes after his dad” and that all the guys on that side of the family were hotheads at times.”

My Family’s Cursing My Butter Michael, a middle aged Haitian man, is in distress saying that he “can’t even feel safe to eat at home because his mother and brother have cursed his butter and food in his refrigerator. Some agencies have already branded him psychotic for saying this. He describes a life of having meals outside the home because he does not know which foods the family members have cursed and what may happen if he eats them. When asked about his family of origin he describes coming to US a few years ago from Haiti and how spiritual his family was growing up. The spirituality of Haiti incorporated a mix of traditional Catholicism with voodoo and native folklore and curses/blessings of tribal leaders.

My Family’s Cursing My Butter He states that his mother and brother do in fact have keys to his apartment and have been angry at him for some time now because they think he has favor and prosperity in arriving in the US compared to their struggles and they want him to be cursed for this. During a more thorough clinical diagnostic interview he describes comments they have made about potions and things. Later in the diagnostic interview he reports getting sick on bread, butter, and some soup which he thinks the relatives may have cursed. He does not appear to be hearing any voices, seeing any visual hallucinations or having other psychosis symptoms. Prior to his coming to US he was never treated for psychosis. However a referring agency believes him to be psychotic regarding the food poisoning and paranoid towards his family members. What do you think? How would you process in therapy with him?

“I’m not as happy as you think I am” Lisa’s husband owns several franchises of a major restaurant throughout the state. Years ago it was thrilling when they managed the businesses together. They traveled. They administrated things. They each had a role and part. Lately, however, he wants to run everything. While they get to go on many trips she usually ends up at the each house or cabin or resort alone in the room reading books and magazines and drinking the day away. They have more associates and attend more social events then she can count but she experiences an inner emptiness. “He is more focused and driven for others and gives his best to outside people rather than me,” she sys. She cannot go even for part of a day without drinking much less on day or one even week. She has been drinking at this rate for years now. “When I drink I momentarily don’t have to think about how lonely I am. The alcohol keeps me company.”

“I’m not as happy as you think I am” Lisa has management skills and good leadership and organizational skills but has not used them since her husband has taken over the operations of the businesses. She has been in four marriages prior and she has always ended up doing some type of codependent caretaking of either of her exes or of their children. She has been a people pleaser. Now it has grown to the point at which she is diving deeper into despair as she wonders if anyone will desire to please her at all. She has internal bouts of resentment as she feels that others do not exhibit the level of caretaking she does towards them. She is now at the point of daily contemplating suicide by drinking herself to death. Lisa mentions, for example, “No one would know the difference after all. They know I drink already. What would it be to drink a little more than usual?”

“I’m not as happy as you think I am” She still lives with her husband and travels with him all the time. By outsider’s views they appear happy. They don’t fight or have discord but they also don’t have the time or quality of a one on one relationship she wishes they had. Recently things have gotten so bad that she has set an appointment with a psychiatrist to explore options of getting on an antidepressant. She remarks, “I have learned to hurt in private. People tell me I have everything in the world a person could want and others envy my lifestyle but how can they envy the loneliness, the pain, the sadness? They only see the cars and trips the fake friends, the outward.”

“I’m not as happy as you think I am” Finally, Lisa remarks, “I have tried to not drink but it’s not possible. I have been through two attempts at detoxing. My husband even paid for me to go out of state but after seizing and shaking and discomfort without the alcohol I signed myself out both times within days. I am to the point I don’t think I can do detox or treatment but I know I will die of drinking myself to death if I don’t. What is the option?”

“I am all alone” Francine has been a single mom of 5 children. All the children’s dads are for the most part unavailable. She has had to pick up three different jobs just to make ends meet and even then there are times she and the kids are lacking. She tried a counselor before who attempted to use cognitive-behavioral therapy on her to get her to change her thinking and choices but she states that did not go over too well because the therapist really did not understand her personal issues and challenges.

“I am all alone” She is quick to explain how she has been stuck in an inexpensive small apartment that is not in the safest of neighborhoods. She was born in this neighborhood and multiple generations of her relatives have lived here. She grew up knowing that multiple people die young due to gangs and violence. Trying to raise a family and have any level of optimism to do better is rather challenging.

Disabling flashbacks A 63 year old man named Harvey comes in distraught because his marriage is worsening as wife cannot understand why he is behaving as he has. He is ready to end the marriage because he is so anxious and preoccupied. He also believes “everything sets (him) off.” He admits, “I know I can be irritable but I feel like I can’t help it because of the intrusive memories are a problem.” For example, he begins, “my wife and I live near an airport and every time airplanes fly low overhead it reminds me of planes overhead during the war. My nephew gets into video games regarding war combat and I get angry and stressed because it is no game that I lost several buddies to wars.”

“am I doomed to life as a single man?” A 50 year old gentlemen, Robert, comes in because his life “just isn’t what it is supposed to be.” For so long he has wanted to meet the “right” woman. He said he always thought by his 30s or latest 40 he would have been settled down with her and have a family. Now he is 50 and has never been married so he wonders if true love exists. He questions whether or not anyone would ever like someone like him. He is hard working on his job but feels like “the right doors have ever opened for him.” Because of this he believes a woman will probably not think he can take care of her. He does not have a ton of relationship experience. He does not even know how to approach a girl he is interested in. Robert feels inadequate about everything pertaining to women. And he is unsure whether someone would even find him a good catch because he has some imperfections and inadequacies he is hung up on.

am I doomed to life as a single man?” He grew up the only child of his parents and at a young age was raised by his mom. When his mom because sickly he ended up as a young man having to forego any advanced college degree and be her caregiver at home. He feels like as a result he has skipped a lot of the developmental milestones of a normal young man. He wonders “am I even normal?” and “will I ever even be able to win over a woman I desire?” He has come to the point he reports at times to looking at internet porn and being preoccupied with fantasies about a woman he likes at work but doubts whether or not he could ever have a relationship with her.

“I’m lost since my wife died” Guido, a 75 year old man, comes in teary eyed with a downcast look on his face. “I cant do anything without her,” he states in reference to thinking about 1 year anniversary of the passing of his wife. He says “I still feel lost. I eat out all the time. I can’t even manage the stove to boil water for food. The house is so disorganized.” “The reason I was referred to an inpatient facility lately was because a buddy who came to visit came over and found my gun closet unlocked and with a loaded gun in my hand. I told him, ‘I’m not really living if it’s without her. That’s no life at all. I miss her so much I think I hear her voice at times and I imagine seeing her there then realize it’s all an illusion.’”

“I’m lost since my wife died” He adds, “I’ve stopped playing cards with my buddies or going out on senior trips because that was what we used to do. I can’t bear another person asking, how it is since Margie’s gone. I feel like telling them ‘good for you. You still have everyone in your life. How do you think it is going?’ ”Guido then becomes silent and looks down as a single tear falls from his eye: “I get very easily irritated when guy friends tell me about lonely widows I could talk to in the seniors group. I’m nothing without my Margie. She was my everything.”

Out of place and rejected all my life A young lady, Olivia, comes in distrustful and suspicious about whether you can help her. She comments, “I never met a person who ever accepted me for me.” She described a life of being out of place for years- made fun of in young elementary school, high school, and throughout life- “people called me a boy, said I lesbian, said I’m a he-she. I’ll never fit in with anyone. Girls said I wasn’t girly enough and wasn’t all sensitive emotionally like them. I played more with guy friends but I wasn’t a guy. There was nowhere for me with anyone.”

Out of place and rejected all my life She adds, “I tried to find a place to fit in/excel and never did. I have always wondered why is it so hard to just be me? Why is it so important for everyone to try and label what they don’t understand?” Olivia described having bouts of irritation because though she does well academically, works hard on her job, and has admirable life goals but she thinks people look at her punk hair, different sense of fashion and atypical ways of approaching things. “I guess you’d call me eccentric,” Olivia says . “I have been told that on my skills I could get certain jobs but not on my looks, my punk style hair, and colored hair would have to go and I could not wear my piercings. The story of my life is one way after another of people screaming ‘not okay, unacceptable, rejected outcast, look at the freak coming.’”

Perfectionism at it’s best Darlene has had several significant achievements in the past 6 months or less. In spite of this she remarks that she “should have done better.” She looks at her master’s degree in education while working full time at a local school. She and her fiance got married. She gave birth to her first child. During the assessment her husband verbalizes appreciation and admiration for the way she has juggled many significant life events. Others such as her best friend who also attends the assessment have additionally repeatedly complemented her as well. However, to her she “should have done better.” She looks at what she’s done and is self critical regarding wishing she had done things better, achieved more, and achieved goals faster throughout her assessment.

Perfectionism at it’s best You hear her talk a lot about “not being good enough” and minimize her effort and accomplishments. She has begun to have bad panic attacks and anxiety in response to internal pressure to do more quicker, better, and more perfectly than before. She has a lot of “if only” thinking, believing that if she only was “good, right, strong, and perfect she could handle the layers of multi-tasking without feeling stressed out. She was hesitant to admit just how things had gotten as she sees this as a personal failure, herself and her failure in her ability to handle things.

Perfectionism at it’s best Her husband brought her in for this assessment out of a concern for her brought up that she has bene having increasing SI in the past 3 months with a major escalation in the frequency and intensity of suicidal thoughts in the past two weeks. Finally, through tears and a number of self deprecating comments. Darlene admits to having a few specific plans including overdosing on antidepressant meds, driving a car into something. She has never been inpatient before and sees it as a shameful thing that with all her education and ability she can’t just talk herself out of her slump. She cannot contract for safety tonight and is at a point that’s she doesn’t believe that if she goes home with her husband he and the kids will even be a protective factor anymore.

Leaving For The Big City Beyond: Erica, a 17 year old is in the second half of her senior year of high school. She is excited about graduating high school and considering her life options for after high school. Her family and her live in southern Ohio and believe that she should, like other generations past, just be satisfied with the high school education, meet someone, and have kids and stay home but not go to college. Relatives had made it clear per her report that she would be forsaking the whole family if she leaves them and goes to the big city. They have spoken with her about the “evils” that lie in the big city versus what they believe to be the protected and familiar area they live in. They also are trying to convince her that she will remain around extensive support systems if she remains in southern Ohio but if she leaves to go to the big city she will be prone to outside influences without the shelter of her extended family. Mary believes she can, by going to the big city, possibly do “better” or at least have career, financial, and other options. She would like to do something possibly with nursing or with children. She even has thought that in the long run she can help her family more then.

Too much stress Maria has gotten to the point where she cries at the drop of a hat. Now it is daily and throughout every day. She feels there is no way out of all the pain she has had in her life. A few of her best friends recently died and the aunt who raised her is now dying of cancer. She went through a painful divorce last year. She is struggling financially and may have to file bankruptcy with the possibility of losing the house she has grown to love. She is not sure life is worth fighting for anymore. Though she says that she can’t actively kill herself because of her religious beliefs she admits to thinking about death all the time. It was her outpatient therapist who suggested that she get an assessment to see if she should have a higher level of care such as inpatient or PHP.

Too much stress Maria reports loss of interest and pleasure in nearly all the things she used to enjoy. It has been worsening for the past 6-9 months and escalated the most this past week to a point of hopelessness. She is socially withdrawing because she feels like the more she is around people the more bad news she is likely to find out. She sleeps all the time meaning as much as 12-16 hours per day to avoid thinking about her stressors. She does not feel like eating and has lost a significant amount of weight in the past 6 months. Though she reports depression and tearfulness, profound grief, and sadness she smiles and sometimes jokes or laughs even throughout the assessment.

Too much stress She is employed and tries to stay busy to not think about things. As a single mom she had limited social supports and her treatment goal is to “learn to be strong again for the kids.” She is on a few antidepressants and some medication for sleep. She says it is her faith and work ethic on her job that keep her going through. But anymore she is having a hard time hanging onto anything.

The rape never goes away Barry, a middle-aged single male is having flashbacks of horrible sexual abuse he went through in his childhood by his uncle and by his mother’s prostitution clients. He only recently came to fully feel the anger and sheer sense of violation as this was the norm for him. He thought the abuses he went through were “love.” Now he is at the point though where intrusive flashbacks invade his life. He cannot concentrate on daily activities well as he’d like because sounds, smells, certain buzz words, and memories flood in. He is hypervigilant especially when he feels someone is standing too close behind him. He, every now and then, senses shadows around him though he is not sure if these are hallucinations or not.

The rape never goes away His family does not understand PTSD at all and tells him how crazy the abusers were. They encourage him to just move on and not give the memories of the abusers the time of day. Since the memories are so intrusive he believes he no longer has a life. He has several suicide plans and backups if certain ones do not work. He will start with thinking so his guard will be down and he will be less likely to resist. Then he will try to OD on some meds. He will walk in front of a train or heavy traffic, jump off a bridge or shoot himself with one of the guns in his gun collection. He already has injuries from where he jumped off a high structure years ago. He has a maimed arm which was shot when he had intended to blow his brains out in the past.

The rape never goes away His psychiatrist and other medical doctors have tried various combinations of medications but he reports that his anxiety is simply out of control. He gets panic attacks that he feel “all consuming.” Finally, as his anger worsens he contemplates ways of hurting the people who raped him back. He states that “they just go on with their lives. They need to feel what it was like to have your life, your innocence, your happiness robbed away.”

“It’s not my fault they ticked me off” Paul is known to have a short fuse at times. To him it is other people ticking him off. When asked about a history of behavior problems he says, “only if people piss me off.” He claims he never initiates anger outbursts . However there are others who might say differently. His employer referred him for evaluation because he is routinely argumentative with the supervisors over little things. He expects special treatment and says he is beyond rules other people have to adhere to.

“It’s not my fault they ticked me off” Paul’s history includes several Bipolar relatives on his dad’s side. He has never been identified formally as Bipolar or any diagnosis to this point. However, he endorses impulsivity in the areas of impulsive spending what he does not have, intense and multiple relationships, and sporadic binge drug use less than 10 times per year. He admits to bursts of energy and productivity stating this should not be a problem because it is what makes him effective and productive to this point.

“It’s not my fault they ticked me off” He lives alone because his ex wife who accompanied him to the assessment believes he is just too hard to be around and too unpredictable. He goes for days without sleeping and then crashes when the lack of sleep hits him. He does not believe he has any metal health issues that require treatment as he is productive, does his daily activities, holds down a job, has multiple relationships with significant others. To him all the employers, exes, and other companies are just in the wrong and out to get him.

“just considering all my options” John a 50 year old man is accompanied by his sister for an assessment. Their stories are vastly different. While he reports a little stress he is able to offer specifics as to how he redirects himself. His sister gives a different story. According to her John is extremely depressed and even suicidal. She saw him looking on the internet at ways to kill yourself. He went to a gun store and talked with a buddy of his about his gun collection. He also bought a rope and some supplies which she claims she found in his car. John minimizes saying that thinking about suicide and asking questions doesn’t mean anything. He is “just exploring his options in case he may want to exercise them someday.” He says that he eats and sleeps fine and keeps his job with excellent ratings so he really doesn’t see what the concern is.

“just considering all my options” His sister is the person he has lived with since he has been single all his adult life. The sister and her husband and children are in the home with John. She is concerned because she says that even her husband and kids think John is seeming different and more somber lately, stays in his room more, and is overall more negative about life.

A hopeless living arrangement Daniel learned that in life all one could do is barely survive. Self protection is where it is at. Most kids in his neighborhood, knew as he did that there was little chance of growing up to be a 30, 40, or 50 year old man. Life was a series of dodging bullets (literally), taking care of yourself, and being on guard. No one’s words can be taken seriously and everyone needs to be watched. You must watch your back. In his neighborhood he learned that as soon as you let someone into your heart and life they hurt you. If they gain access it is to rob you, steal your food, acquire the little scraps that you have. And there’s no real hope for getting out of the place. People live and die here. The rest of the world goes on without one thought of his crime ridden neighborhood.

A hopeless living arrangement That was until one day when he met Bog Bob- a local shopkeeper- and a few other role models who pulled together an after school mentoring program. He likes that he could just shoot hoops, run, and talk crap with Big Bob. No fakeness, no false promises. Bob is from the neighborhood and made the neighborhood work for him. In fact, Big Bob even let Daniel help in his shop some days after school. Eventually Daniel saw that there was an exception to the fact that everyone lives and dies here. Something about the community actually was okay. Eventually Daniel began working with Big Bob to establish a nonprofit for people in the community.

“My World is falling apart” A 15 year old girl named Ashley began counseling because she feels her world is falling apart. Though she is captain of a swim team and active in multiple sports, has many friends, and makes honors in school she reports not fitting in with others. She likes a boy who has a serious crush on another girl. She struggles with acne. She believes she “is a loser” because 1 of the 10 colleges she applied to did not accept her. Ashley struggles with low self esteem and self deprecating thoughts regarding not being good enough, likeable enough, pretty enough, talented enough. She has a lot of beliefs that if only maybe she looked, talked, behaved, thought, and was different her life would be better. She has started to withdraw and stay in her room more on the weekends, stopped returning phone calls from friends, and has started starving herself and exercising compulsively. She finds it difficult to tell the assessor any positive qualities about herself. Even if family/friends say positive things to her it is easy for her to disregard them because she believes they “have to say nice things even if they don’t mean them.”

Bibliography Ashby, J.S., Rive, KG., & Martin, J.L. (Spring 2006). Perfectionism, shame, and depressive symptoms. Journal of Counseling & Development, 84 , 148-156.   Alexander, S., Shilts , L.,. Liscio , M., & Rambo, A. (2008). Return to sender: Letter writing to bring hope to both client and team. Journal Systemic Therapies, 27(1), 59-66 Almedon , A. M. (2005). Resilience, hardiness, sense of coherence, and posttraumatic growth: All paths leading to “light at the end of the tunnel?” Journal of Loss and Trauma, 10, 253-265. Anicha , C.L., Ode, S., Moeller, S.K., & Robinson, M.D. (April 2012). Toward a cognitive view of trait mindfulness: Distinct cognitive skills predict is observing and nonreactivity facets. Journal of Personality, 80(2) , 255-285. Bergner, R.M. (2009). Trauma, exposure, and world reconstruction. American Journal of Psychotherapy, 63(3) , 267- 282.   Beck, J.S. (2995). Cognitive therapy: Basics and beyond. New York: Guilford Press. Belus , J. M., Brown-Bowers, A., & Monson, C. M. (2012) . Thinking about your thoughts: Investigating different cognitive change strategies. Current Psychology, 31 , 423-432. Bennett, K. M., Smith, P. T., & Hughes, G. M. (July 2005). Coping, depressive feelings and gender differences in late life widowhood. Aging and Mental Health, 9(4) , 348-353.

Bibliography Boelen , P.A. (2006). Cognitive-behavioral therapy for complicated grief: Theoretical underpinnings and case descriptions. Journal of Loss and Trauma, 11 , 1-30. Bolden, L.A. (2007). A review of “Grief and grieving: Finding the Meaning of Grief Through the Five Stages of Loss.” Counseling and Values, 51, 235-237. Bond, F.W., & Dryden, W. (2002). Handbook or brief cognitive behaviour therapy. San Francisco: Wiley. Borooah , V. K. (2010). Gender differences in the incidence of depression and anxiety: Economic evidence from the USA. Journal of Happiness Studies, 11 , 663-682. Breslin , F. C., Gnam , W., Franche , R., Mustard, C., & Lin, E. (2006). Social Psychiatry, 41 , 648-655. Brinker, J. K., & Dozois , D. J. A. (2009). Ruminative thought style and depressed mood. Journal of Clinical Psychology, 65 , 1–19.  

Bibliography Broeren , S., Muris , P., Bouwmeester , S., Van der Heijden , K.B., Abee , A. (May 26, 2010). The role of repetitive negative thoughts in the vulnerability for emotional problems in non-clinical children. Journal of Child and Family Studies .   Bruininks , P., & Malle , B.F. (2005). Distinguishing hope from optimism and related affective states. Motivation and Emotion, 29(4) , 327-355. Burton, L.A., & Tarlos-Benka , J. (1997). Grief-driven ethical decision- making. Journal of Religion and Health, 36(4) , 333-343. Burwell, R., & Chen, C.P. (June 2006). Applying the principles and techniques of solution-focused therapy to career counselling. Counselling Psychology Quarterly, 19(2) , 189-203. Callanan , V. J., & Davis, M. S. (2012). Gender differences in suicide methods. Social Psychiatry, 47, 857-869. Calmes , C., A., Roberts, J., E. . (March 17, 2012).Erratum to: Repetitive thought and emotional distress: Rumination and worry as prospective predictors of depressive and anxious symptomatology, Cognitive Therapy & Research, 36 . Carman, R. (2004). Helping kids heal: 75 activities to help children recover from trauma and loss . The Bureau for At-Risk Youth. Carverhill , P.A. (2002). Qualitative research in thanatology. Death Studies, 26 , 195-207.

Bibliography Cheavens , J.S., Feldman, D.B., Wodward , J.T., & Snyder, C.R. (2006). Hope in cognitive psychotherapies: On working with client strengths . Journal of Cognitive Psychotherapy: An International Quarterly, 20(2) , 135-145. Cheng, C., Kogan , A., & Chio , J. H. (July-September 2012). The effectiveness of a new, coping flexibility intervention as compared with a cognitive-behavioral intervention in managing stress. Work and Stress, 26(3) , 272-288. Choi, N. G., & Ha, J. (April 2011). Relationship between spouse/partner support and depressive symptoms in older adults: Gender difference. Aging and Mental Health, 15(3) , 307-317. Chu, B.C., & Jendall , P.C. (2009). Therapist responsiveness to child engagement: Flexibility within manual-based CBT for anxious youth. Journal of Clinical Psychology, 65(7), 736-754. Clark, D.A. (2009). Cognitive behavioral therapy for anxiety and depression: Possibilities and limitations of a transdiagnostic perspective. Cognitive Behavioral Therapy, 38(S1), 29-34.   Coleman, D., Cole, D., & Wuest , L. (2010). Cognitive and psychodynamic mechanisms of change in treated and untreated depression. Journal of Clinical Psychology, 66 , 215–228.   Corr , C.A. (1993). Coping with dying: Lessons that we should and should not learn from the work of Elizabeth Kubler -Ross. Death Studies, 17 , 69-83. Costa, B.M., Hall, L., Stewart, J. (2007). Qualitative exploration of the nature of grief-related beliefs and expectations . Omega, 55(1), 27-56.

Bibliography Cully, J. A., & Teten , A.L. (2008). A therapist’s guide to brief cognitive behavioral therapy. Department of Veteran’s Affairs South Central MIRECC. Houston. Curtis, V. (2005). Women are not the same as men: Specific clinical issue for female patients with bipolar disorder. Bipolar Disorders, 7(1), 16-24. Cutcliffe , J. R. (2004). The inspiration of hope in bereavement counseling. Issues in Mental Health Counseling, 25 , 165 -190. Cutcliffe , J. R. (2006). The principles and processes of inspiring hope in bereavement counseling: A modified grounded theory study- part one. Journal of Psychiatric and Mental Health Nursing, 13 , 598-603. Dalgard , O.S., Dowrick , C., Lehtinen , V., Vasquez- Barquero , J. L., Casey, P., Wlikison , G., Ayuso-Mateos , J. L., Page, H., Dunn, G. (2006). Negative life events, social support and gender difference in depression. Social Psychiatry, 41 , 444-451. Davis, C.G, Wortman , C.B., Lehman, D.R., & Silver, R.C. (2000). Searching for meaning in loss: Are clinical assumptions correct? Death Studies, 24 , 497-540. DeMillan , S.G., & Millan, S. (2004). Hidden meaning of an early loss: The common ground of attachment and social character assessments and their clinical applications. Forum Psychoanal , 13 , 157-163. Dopheide , J., A. (February 1, 2006). Recognizing and treating depression in children and adolescents. Am erican Journal Health- Syst Pharmacology, 63 .  

Bibliography Dennis, M.R. (2008). The grief account: Dimensions of a contemporary bereavement genre. Death Studies, 32 , 801-836. DiFlorio , A., & Jones, I. (October 2010). Is sex important? Gender differences in bipolar disorder. International Review of Psychiatry, 22(5), 437-452. Dixon, A. L., Sheidegger , C., & McWhirter , J.J. (Summer 2009). The adolescent mattering experience” Gender variations in perceived mattering, anxiety, and depression. Journal of Counseling & Development, 87 , 302-310. Dubose, J.T. (1997). The phenomenology of bereavement, grief, and mourning. Journal of Religion and Health, 36(4) , 367-374. Dugas , M.J., & Koerner , N. (2005). Cognitive-behavioral treatment for generalized anxiety disorder: Current status and future directions. Journal of Cognitive Psychotherapy: An International Quarterly, 19(1 ), 61-81.   Duggleby , W.,Hicks , D., Nekolaichuk , C., Holtslander , L., Williams, A., Chambers, T., & Eby , J. (2012). Hope, older adult, and chronic illness: A metasynthesis of qualitative research. Journal of Advanced Nursing, 28, 1211-1223. Duggleby , W., Williams, A., Wright, K., & Bollinger, S. (2009). Renewing everyday hope: The hope experience of family caregivers of persons with dementia. Journal of Mental Health Nursing, 30 , 514-521. Dunn, D.S., & Civitello , T. (2009). Grief is many things: Current perspectives on bereavement . Journal of Social and Clinical Psychology, 28(7), 937-941. Ebersbah , M., & Hagedorn , H. (2011). The role of cognitive flexibility in the spatial representation of children’s drawings. Journal of Cognition and Development, 12(1), 32-55. Enea , V., & Dafinoiu , I. (September 2009). Motivational solution focused intervention for reducing school truancy among adolescents. Journal of Cognitive and Behavioral Psychotherapies, 9(2), 185-198 Fairweather -Schmidt, A. K., Antsey , K.J., & Mackinnon, A. J. (October 2008). Is suicidality distinguishable from depression? Evidence from a community based sample. Australian and New Zealand Journal of Psychiatry, 43 , 208-215. Felder, J.N., Dimidjian , S., and Segal, Z. (2012). Collaboration in Mindfulness-Based Cognitive Therapy. Journal of Clinical Psyhcology : In Session, 68 , 179-186.   Fergus, T.A., & Wu, K. (2010). Do symptoms of generalized anxiety and obsessive disorder share cognitive processes? Cognitive Therapy Research, 34 , 168-176.

Bibliography Field, N.P. (2006). Unresolved grief and continuing bonds: an attachment perspective. Death Studies, 30 , 739-756. Field, N.P., & Horowitz, M.J. (1998). Applying an empty-chair monologue paradigm to examine unresolved grief. Psychiatry, 61(4), 279-287. Forsyth, D.M., Poppe , K., Nash, V., Alarcon, R.D., & Kung, S. (October 2010). Measuring change in negative and positive thinking in patients with depression . Perspectives in Psychiatric Care, 46(4). Freeman, M. P., & Gelenberg , A. J. (2005). Bipolar disorder in women: reproductive event and treatment considerations. Acta Pscyhiatrica Scandinavica , 112 , 88-96. Fukui, S.., Starnino , V.R., Susana. Davidson, L.D., Cook, K., Rapp, C.A., & Gowdy , E.A. (2011). Effect of wellness recovery active plan (WRAP) participation on psychiatric symptoms sense of hope, recovery. Psychiatric Rehabilitation Journal, 34(3), 214-222. Fullagar , S. (2008). Leisure practices as counter-depressants: Emotion-work and emotion-play within women’s recovery from depression. Leisure Sciences, 30 , 35-52. Gilbert, K.R. (2002). Taking a narrative approach to grief research: Finding meaning in stories. Death Studies, 26 , 223-239. Hansson, M., Chotai , J., & Bodlund , O. (2012). What made me feel better? Patients’ own explanations for the improvement of their depression. Psychiatry, 66(4), 290-296. Hodge, D.R. (April 2006). Spiritually modified cognitive therapy: A review of the literature. Social Work .   Hoffman, S.G., & Scepkowski , L.A. (2006). Social; self-reappraisal therapy for social phobia: Preliminary findings. Journal of Cognitive Psychotherapy: An International Quarterly, 20(1), 45-57.

Bibliography Hopcroft , R. L. & Bradley, D. B. (June 2007). The sex difference in depression across 29 countries. Forces, 85(4), 1483-1507. Hope, D.A., Burns, J.A., Hayes, S.A., Herbert, J.D., & Warner, M.D. (2010). Automatic thoughts and cognitive restructuring in cognitive behavioral group therapy for social anxiety disorder. Cognitive Therapy Research, 34 , 1-12. Hopko , Lejuez , Ruggiero, et. Al. (2003). Contemporary behavioral activation treatments for depression: procedures, principles, and prognosis. Clinical Psychological Review, 23(5), 699-717. Hughes, R.B. (1988). Grief counseling: Facilitating the healing process. Journal of Counseling and Development, 67, 77. Jacobs, S., Ptrigerson , H. (2000). Psychotherapy of traumatic grief: A review of evidence for psychotherapeutic treatments. Death Studies, 24 , 479-495. James , I. A., Reichelt , F. K., Carlsonn , P., & McAnaney , A.,(2008). Cognitive behavior therapy and executive functioning in depression. Journal of Cognitive Psychotherapy: An International Quarterly, 22(3). Jordan, J.R. (2001). Is suicide bereavement different? A reassessment of the literature. Suicide and Life-Threatening Behavior, 31(1), 91-102. Jordan, J.R. (2008). Bereavement after suicide. Psychiatric Annals, 38(1), 679-685. Jordan, J. R., & Neimeyer , R.A. (2003). Does grief counseling work? Death Studies, 27, 763-786. Judd, F., Jackson, H., Komiti , A., Bell, R., & Fraser, C. (2012). The profile of suicide: Changing or changeable? Social Psychiatry and Psychiatric Epidemiology, 47 , 1-9. Kinghorn , W. (Fall 2013). “Hope that is seen is no hope at all”: Theological constructions of hope in psychotherapy. The Menninger Foundation, 77(4), 369-394.

Bibliography Kwan, S.S.M. (2010). Interrogating “hope”: The pastoral theology of hope and positive psychology. The International Journal of Practical Theology, 14, 47-67. Lamplugh , C., Berle , D., Millicevic , D., & Starcevic , V. (2008). A pilot study of cognitive behavior therapy for panic disorder augmented by panic surfing. Clinical Psychology & Psychotherapy, 15 , 440-445. Lang, T., J., Blackwell, S. E., Harmer, C. J., Davison, P., & Holmes, E., A. (2012). Cognitive bias modification using mental imagery for depression: Developing a novel computerized intervention to change negative thinking styles. European Journal of Personality, 26 : 145–157. Larsen, D. J., & Stege , R. (January 2012). Client account of hope in early counseling sessions: A qualitative study. Journal of Counseling and Development, 90 , 45-54. Leach, L.S., Christensen, H., Mackinnon, A.J., Windsor, T.D., Butterworth, P. (2008). Gender differences in depression and anxiety across the adult lifespan: The role of psychosocial mediators. Social Psychiatry, 43 , 983-998.

Bibliography Lee, J. H., Name, S. K., Kim, A., Kim, B., Lee, M. Y., 7 Lee, S. M. (July 2013). Resilience: a meta-analytic approach. Journal of Counseling and Development, 91, 269-279. Lemma, A. (2010). The power of relationship: A study of key working as an intervention with traumatized young people. Journal of Social Work Practice, 24(4), 409-427. Lo, C.S. , Ho, S.M., & Hollon , S. D. (February 3, 2009). The effects of rumination and depressive symptoms on the prediction of negative attributional style among college students. Cognitive Therapy & Research . McGlinchey , J. B., Zimmerman, M., & Atkins, D. C. (January/February 2008). Clinical significance and remission in treating major depressive disorder: Parallels between related outcome constructs. Harvard Review of Psychiatry .   McManus, F., Shafran , & Cooper, Z. (2010). What does a ‘ transdiagnostic ’ approach have to offer the treatment of anxiety disorders? British Journal of Clinical Psychology, 49, 491-505. Miller, J.H. (September 2010). Does teaching a solution-focused model of counselling work? A follow up of graduates. Counseling and Psychotherapy Research, 10(3) , 173-182.

Bibliography Muller, E.D., & Thompson, C.L. (2003). The experience of grief after bereavement: A phenomenological study with implications for mental health counseling. Journal of Mental Health Counseling, 25(3 ), 183-203. Murphy, J. M., Gilman, S.E., Lesage, A., Horton, N. J., Rasic , D., Trinh, N., Alamiri , B., Sobol , A. M., Fava, M., & Smoller , J. W. (December 2010). Time trends in mortality associated with depression: Findings from the Stirling County study. The Canada Review of Psychiatry, 55(12) , 776-783. Nakashima, M. (2003). Beyond coping and adaptation: Promoting a holistic perspective on dying. Families in Society, 84(3), 367-376. Neimeyer , R.A., (1999). Narrative strategies in grief therapy. Journal of Constructivist Psychology, 12 , 65-85. Neimeyer , R.A., (2000). Searching for the meaning of meaning: Grief therapy and the process of reconstruction. Death Studies, 24 , 541-558.. Neimeyer , R.A., Prigerson , H.G., & Davies, B. (2002). Mourning and meaning. The American Behavioral Scientist, 46(2), 235-250. Neimeyer , R.A. (2005-2006). Complicated grief and the quest for meaning: A constructivist contribution. Omega, 52(1), 37-52. Newman, J. L., Fuqua, D. R., Gray, E. A., & Simpson, D. B. (Spring 2006). Gender differences in the relationship of anger and depression in a clinical sample. Journal of Counseling and Development, 84, 157-162. Nolan, S. (2011). Hope beyond (redundant) hope: How chaplains explain work with dying patients. Journal of Pallative Medicine, 25(1), 21-25.

Bibliography O’Hara, D. J. (2011). Psychotherapy and the dialectics of hope and despair. Counselling Psychology Quarterly, 24(4) , 323-329. Ojeda V. D., & McGuire, T. G. (2006). Gender and racial/ethnic differences in use of outpatient mental health ad substance use services by depressed adults. Psychiatric Quarterly, 77 , 211-222.   Panayiotou , G., & Papageorgiou , M. (2007). Depressed mood: The role of negative thoughts, self- consciousness, and sex role stereotypes. International Journal of Psychology, 42(5) , 289-296. Paradise, L. V., & Kirby, P.C. (Winter 2005). The treatment and prevention of depression: Implications for counseling and counselor training. Journal of Counseling & Development, 83(117). Park, C.L., & Cohen, L.H. (1993). Religious and nonreligious coping with the death of a friend. Cognitive Therapy and Research, 17, 561-577. Parslow , R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005). The warpy thoughts scale: A new 20-item instrument to measure dysfunctional attitudes. The New Zealand Journal of Psychology . Powers, L.E., & Wampold , B.E. (1994). Cognitive-behavioral factors in adjustment to adult bereavement. Death Studies, 18, 1-24. Price, J. (June 2012). Cognitive behaviour therapy: A case study. Mental Health Practice, 15(9). Proyer , R. T., Ruch , W., & Bushor , C. (2013). Testing strengths- based interventions: A preliminary study on the effectiveness of a program targeting curiosity, gratitude, hope, humor, and zest for enhancing life satisfaction. Journal of Happiness Studies, 14 , 275-292.

Bibliography Rhodes, A.E., Bethell , J., Spence, J., Links, P.S., Syreiner , D.l ., & Jakkimainen , R. L. (2008). Age- sex differences in medical self poisonings. Ridgway, N., & Williams, C. (December 2011). Cognitive behavioural therapy self-help for depression: An overview. Journal of Mental Health, 20(6) : 593–603. Ripley, J.S., & Worthington, E.L. (Fall 2002). Hope-focused and forgiveness-based group interventions to promote marital enrichment. Journal of Counseling and Development, 80 , 452-463. Riskind , J.H., & Williams, N.L. (February 2005). The looming cognitive style and generalized anxiety disorder: Distinctive danger schemas and cognitive phenomenology. Cognitive Therapy and Research, 29(1) , 7-27.   Rubinstein, G. (2004). Locus on control and helplessness: Gender differences among bereaved parents. Death Studies, 28 , 211-223. Rudolph, K. D., Ladd, G., & Dinella , L. (2007). Gender differences in the interpersonal consequences of early-onset depressive symptoms. Merrill-Palmer Quarterly, 53(3) , 461-488. Safren , S.A., Heimberg , R.G., Lerner, J., Henin , A., Warman, M., & Kendall, P.C. (2000). Differentiating anxious and depressive self-statements: Combined factor structure of the anxious self-statements questionaire and the automatic thoughts questionnaire-revised. Cognitive Therapy and Research, 24(3), 327-344. Sakinofsky , I. (2007). The aftermath of suicide: Managing survivors’ bereavement. Canadian Journal of Psychiatry, 52 , 129-136.

Bibliography Saleehey, D. (1994). Culture, theory, and narrative: the intersection of meanings in practice. Social Work, 39 , 351-359. Sava, F.A., Yates, B.T., & Lupu , V. Szentagotai , A., & David, D. (2009). Fluoxetine (Prozac) in treating depression: A randomized clinical trial. Journal of Clinical Psychology, 65(1), 36-52.   Servaty-Seib , H.L. (2004). Connections between counseling theories and current theories of grief and mourning. Journal of Mental Health Counseling, 26(2), 125-145. Shear, K., Belnap , B.H., Mazumdar , S., Houck, P., & Rollman , B.L. (2006). Generalized anxiety disorder severity scale (GADSS): A preliminary validation study. Depression and Anxiety, 23 , 77-82. Simm , J., & Kendal, R. (March 2008). Collaborative action research to develop the use of solution-focused approaches. Educational Psychology in Practice, 24(1), 43-53. Simon, R. W., & Lively, K. (June 2010). Sex, anger, and depression. Social Forces, 88(4), 1543-1568. Smith, B. W., Dalen, J., Wiggins, K., Tooley , E., Christopher, P., & Bernard, J. (2008), The brief resilience scale: Assessing the ability to bounce back. International Journal of Behavioral Medicine, 15 , 194-200.

Bibliography Smith, S.C. (1999). The forgotten mourners: Guidelines for working with bereaved children . (2nd ed.). Jessica Kingsley Publishers Ltd.: Philadelphia, PA. Strong, T., & Pyle, N.R. (2009). Constructing a conversational “miracle”: Examining the “miracle question” as it is used in therapeutic dialogue. Journal of Constructivist Psychology, 22, 328-353 Taylor, S., Coles, M.E., Abramowitz, J.S., Wu, K.D., Olatunji , B.O., Timpano , K.R., McKay, D., Kim, S., Carmin , C., & Tolin , D.F. (2010). How are dysfunctional beliefs related to obsessive-compulsive symptoms? Journal of Cognitive Psychotherapy: An International Quarterly, 24(3), 165-176.   Thomas, M. L. (2006). The contributing factors of change in a therapeutic process. Contemporary Family Therapy, 23, 201-210. TWatson , H. J., & Nathan, P. R. (2008). Role of gender in depressive disorder outcome for individual and group cognitive-behavioral treatment. Journal of Clinical Psychology, 64(12) , 1323-1337. Watts, S., Mackenzie, A., Thomas, C., Griskaitis,A ., Mewton , L., Williams, A., & Andrews, G. (2013). CBT for depression: a pilot RCT comparing mobile phone vs. computer. BMC Psychiatry, 13(49).   Wegener, I., Alfter , S., Geiser , F., Liedtke , R., & Conrad, R. (Spring 2013). Schema change without schema therapy: The role of early maladaptive schemata for a successful treatment of major depression. Psychiatry, 76(1) .

Bibliography Wilhelm, K., Parker, G., Geerlings, L., Wedgwood, L. (2008). Women and depression: a 30 year learning curve. Australian and New Zealand Journal of Psychiatry, 42, 3-12. Wilson, C. J., Bushnell, J. A., Rickwood , D. A., Caputi , D., & Thomas, S.J. (October 2011). The role of problem orientation and cognitive distortions in depression and anxiety interventions for young adults. Advances in Mental Health, 10(1), 52-61. Wilson, M. & Turneil , A. (1993). Introduction to Solution Focused Brief Therapy. Centrecare Brief Therapy Service. Wolfelt , A.D. (2001). Healing your grieving heart: 100 practical ideas . Companion Press: Fort Collins, CO. Wolfelt , A.D. (2001). Healing your grieving heart for teens: 100 practical ideas . Companion Press: Fort Collins, CO. Wolfelt , A.D. (2001). Healing your traumatized heart: 100 practical ideas after someone you love dies a sudden, violent death . Companion Press: Fort Collins, CO. Wolfelt , A.D. (2004). Understanding your grief: Ten essential touchtones for finding hope and healing your heart. Companion Press: For Collins, CO. Wolfelt , A.D. (2004). The understanding your grief support group guide: Starting and leading a bereavement support group. Companion Press: For Collins, CO. Zalta , A. K., & Chambless , D. L. (2008). Exploring sex differences in worry with a cognitive vulnerability model. Psychology of Women Quarterly, 32 , 469-482.