Cognitive Therapy Basics

Cognitive Behavioural Therapy, or CBT, is an effective psychological treatment for psychological and emotional problems. As a psychiatrist in Edinburgh I use CBT techniques a great deal, and I see a lot of clients who feel low and unhappy. They often ask me if I think they’re depressed, and what has caused them to feel like this. These questions have prompted me to write this short account.

The term “depression” means different things to different people. To psychiatrists, “depression” is synonymous with “clinical depression”, a mental illness with a set of (numerous and rather loosely drawn) symptoms and it’s own clinical course and prognosis. To most of the rest of us, “depression” simply means feeling very low.

Depression, in either sense of the term, is common. Statistics vary as to just how common it is, but a figure in the range of 50% for “life-long” risk of clinical depression is common. This means that most of us have a 1 in 2 chance of experiencing clinical depression in our lifetimes. Similarly, at any one time, between 10% and 20% of the adult population fulfil the criteria for clinical depression. These figures have been rising for many years now, and it is expected that they will continue to increase in the future. It can seem as if the world (particularly the industrialised part of it) is suffering an epidemic of depression.

The causes of such widespread and increasing frequency of depression are unclear and depend to a great extent on who you ask! What follows is a very brief summary of the main contenders.

Many psychiatrists (and the pharmaceutical companies) focus on genetic and biochemical factors in depression – they emphasise the apparent hereditary nature of depression and the response of depression to antidepressants and Electro-Convulsive Therapy (ECT). They see depression as a physical disease of the brain.

Finally , Cognitive Behavioural Therapy (or CBT) focuses on the individuals thinking as a potential cause of depression. The theory is that people prone to depression tend to habitually think in particular “depressive” ways, and when these people experience adverse events (or even simply believe that something bad has happened), then they are at great risk of becoming depressed. An example of a “depressive” thinking habit is “negative filtering”, where a person will “see” or “count” only the unpleasant or bad things she experiences, and discount the good ones. A CBT therapist would call this pattern of thinking a “Thinking Error”. Thinking in this way can make the world will seem threatening and yourself seem persecuted – and it’s a small step from here to feeling depressed. A CBT therapist aims to help the person identify and change their “depressive” thinking habits.

As noted previously, the causes of depression are not known – we have some good hypotheses, but psychological and emotional problems are notoriously difficult to research and reach a definitive conclusion. And there are many more hypotheses out there – ranging from viral theories of depression to sunlight deprivation to dietary deficiencies.

Suffice to say that, given our current level of knowledge, it seems wise to accept that there are likely to be many causes of depression, either working alone or in tandem. Indeed, most Mental Health Practitioners use a “multi-factorial” model of mental illness that has room for physical, environmental (social) and psychological factors. The treatments offered for depression should (but, unfortunately, frequently don’t) reflect this complexity. In particular, there remains a paucity of psychological treatments available on the NHS. Many clients that I see privately as a psychiatrist in Edinburgh have been unwilling to wait months before getting help.

Dr Steve Last is a Psychiatrist who uses CBT techniques. He is based in Edinburgh. Please visit http://www.drstevelast.co.uk for more information about psychological problems and CBT.



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Teen suicides are on the rise and they are related to myriad reasons. Depression is the most common cause that leads many healthy teenagers taking to anti-depressants and attempting suicides at the prime of their lives. Either they suffer from some mental and severe personality disorder and take to drugs or alcohol and kill themselves knowingly or while driving too fast while living life in the fast lane. It is not easy to tackle depression related problems of teens and all parents know about the arduous task of parenting them. Even though a few years back the FDA made it mandatory to print warnings on the labels of anti-depressants, the suicide rate hasn’t gone down.

But is seen that suicide rates are down in countries where the drug Prozac is used with cognitive behavior therapy. It has managed to improve the skills of coping remarkably. As CBT aims at the thinking process and the mapping of the thought process to reorient it to more positive domains, the drug taking teenager prone to suicidal tendencies can see hope. In the US, research on suicidal teenagers revealed that the combination of the drug Prozac and CBT was the best cure available. It enhanced the skills of coping among teenagers.

The worst case scenario during depression is to leave it as it is and not do anything about it. Dr. John March, professor at Duke University, the leader of the study conducted a few years ago maintained that the combination treatment to battle teenage suicide was the best possible available. He felt it was the most effective way to tackle those teenagers with heightened levels of suicidal tendencies. If your child is suffering from this tendency, then instead of stopping the depressant right away, it is better to try out CBT with an experienced therapist.

The best approach is to watch your child while he or she is under medication and when the therapy has started. Usually for CBT to be successful, it has to be a hands-on treatment where the therapist is in close consultation with the patient. Your child should not be made to feel alone and lonely during the critical stages of the treatment. To be successful, the CBT has to be regular and the therapist knows the regularity and the intensity.

Just last year a national review was again conducted for adolescents who are depressed and in the age group of 13 to 17. It gave major focus and attention to the high incidence of suicides in that age group. It was found that the use of CBT was the best cure available and highly effective. Among the youth, the remission rate was far higher at 60% than in any other forms of cure like family therapy or support from other sources. The great benefit of the CBT is to reorient from the negative angle to the positive.

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There has been a growing interest in Online Therapy using email, correspondence and live video conferencing using Skype or similar free services. The convenience of this approach for the client is very apparent: The client can take control of the process, paying only for the time that he or she wants to pay for. The client can have his session at a time that is convenient to him, and can take the time to compose his email questions and feedback at his leisure, instead of feeling pressured to perform during a traditional session. Of course, not having to take time off work to drive to a therapist’s office is always a plus. Generally the cost for online sessions is much lower too since the therapist doesn’t have to pay for office space. Generally, it is well recognized that if you make therapy more accessible and more convenient, then people will be more likely to stick with it, and this is always a major factor in the successful outcome of psychotherapy.

What about effectiveness?

Well, in a clinical study published in the Lancet in August, 2009, Online Therapy, via instant messaging, resulted in a significant recovery rate for patients suffering from depression. The treatment method used was Online Cognitive Behavioral Therapy (CBT).

In general online therapy works best when clients are offered specific strategies with which they can experiment at home. Techniques such as CBT, Neuro-Linguistic Programming (NLP), Mindfulness-based Psychotherapy (http://www.mindfulnessmeditationtherapy.com) are particularly appropriate.

The very process of writing down your thoughts in an email is an immensely powerful tool for helping you develop a more objective relationship with emotions, which can be very abstract and difficult to verbalize. This is why journaling has long been encouraged in many schools of psychotherapy. Then taking the bold step of sharing this with another person is also very empowering for most people. Some people are good at doing this face-to-face, but many actually feel intimidated and need more time to formulate the right words, without a therapist pressing them for content.

The online approach can also be good for the therapist, because he or she can take time to design the right strategies to offer the client and not feel pressured to provide a solution on the spot.

Is Online Therapy a substitute for face-to-face sessions?

No, probably not, but it is clearly an excellent addition, and provides an alternative for those who don’t feel comfortable with traditional therapy sessions, or are unable to attend such sessions. It may be particularly useful for those suffering from social anxiety or agoraphobia. One thing is for certain: the internet has become a major part of most people’s lives, and we should develop the extraordinary potential of the World Wide Web for bringing people together to promote healing.

Internet Psychotherapy and Counseling provides a vehicle that will allow many more people to connect and find wise counsel for working with their emotional issues than is possible through in-person sessions alone.

In my work in online counselling, mostly by email, I am always pleased to see how clients become more empowered through the process. Recently, I helped a person in South Africa, who was struggling with anxiety following a recent personal trauma. It was a joy to see his emails in the morning and then take the time to suggest the next exercise to practice to help him resolve his inner pain. We never met in person and probably never will, but nevertheless, I have been able to help heal his inner trauma, and that is immensely satisfying to me as an online therapist as it was to him as an online client.

Peter Strong, PhD is a scientist and Psychotherapist, based in Boulder, Colorado, who specializes in Mindfulness Meditation Therapy and NLP to treat anxiety, depression, phobias, grief, and post-traumatic stress. He specializes in Online Psychotherapy and teaches individuals and couples strategies for overcoming emotional problems. Visit

http://www.mindfulnessmeditationtherapy.com

Email enquiries welcome.



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Cognitive-behavioral therapy is currently receiving a significant degree of attention as the treatment of choice for individuals needing assistance with a variety of psychological disorders.  It is a structured, pragmatic approach to dealing with problems and is appealing to those seeking therapeutic treatment.  People in need of counseling are seeking out clinicians who have specialized training in CBT.  Understanding the reason for this current trend in popularity of cognitive-behavioral therapy can be found in the unique characteristics which are pivotal to this modality of treatment.  There is a simplicity and yet effectiveness in the model which characterizes the concepts of CBT. 

 

Cognitive-behavioral therapy facilitates a collaborative relationship between the patient and therapist.  Together, patient and counselor develop a trusting relationship and mutually discuss the presenting problems to be prioritized and explored in therapy.  In CBT, the most pressing issue troubling the patient typically becomes the initial focus of treatment.  As a result, the patient tends to feel relieved and encouraged that the primary problem that brought him to therapy is immediately being acknowledged and addressed.

 

Problems are tackled head-on in a very practical manner.  The patient is coached on the ABC’s of cognitive-behavioral therapy.  The therapist explains the connection between thoughts and beliefs and their impact on behavior.  How the patient thinks about problems determines the way in which the individual responds to various issues.  It’s the manner of thinking about life’s issues that steers the patient’s way of behaving.

 

Let’s assume that you work in an office and for an entire week a co-worker has walked past you without acknowledging your presence.  Each day you go back to your cubicle and wonder why this colleague is treating you so unjustly.  You build up thoughts about her being condescending and snobbish and begin questioning what you might be doing to annoy her.  Anger begins to emerge and your start thinking, “How dare she treat me this way!”  Eventually, you settle down and start to rationally consider the problem.  You think, “This is stupid, why don’t I go visit her at her office and see what’s going on in her life that might be affecting this situation.  You enter her office and begin starting a conversation.  In the midst of your discussion, she reveals that her son is suffering from depression and needs to see a counselor.  Your colleague is disturbed about the situation and confides in you that she has been on edge with everyone at the office.  She asks you if you know of a qualified therapist.  You give her some ideas and before you leave, she gets up from her chair and gives you a firm hug.  This incident demonstrates how our thinking can be faulty and can be based upon some erroneous assumptions.

 

CBT is effective because it teaches the patient to modify patterns of thinking which affect behavior.  CBT is a straight-forward therapy which is designed to alert the patient to self-defeating ways of thinking.  Locating distorted or maladaptive thinking is accomplished through an exploratory process which is dependent upon a solid patient/counselor therapeutic alliance. 

 

Cognitive-behavioral therapy focuses on the patient’s negative self-talk, and offers practical suggestions on how to untwist one’s thinking to make it more adaptive.  The CBT therapist assists the client in thinking more rationally by examining the individual’s spontaneous thoughts, observing ways in which they may distort reality, and ferreting out underlying assumptions or beliefs that affect ways of thinking and behaving.

 

Spontaneous thoughts are the nonsensical things that we tell ourselves when we are under stress – “I’ll never get a date, who would ever want me!”  Cognitive distortions are the lenses out of which we perceive reality – “You always make me feel like a loser” (either or thinking).  Underlying assumptions are the “hot buttons” which crystallize as a way of coping and getting our needs met during childhood – “I must avoid conflict at all costs; I hate disapproval and getting my feelings hurt.”

 

Cognitive-behavioral therapy seeks to refute the nonsensical things we tell ourselves and assists us in developing more rational ways of responding to our maladaptive thought processes.  Since homework is an integral part of therapy, patients will be encouraged to complete exercises designed to change negative thinking.  One concrete procedure helps the client to identify current troubling events, negative self-talk, and ways of rationally responding to situations sited.  The individual logs difficult situations, identifies self-defeating thinking and refutes the negative thought processes with more rationally, adaptive way of responding to events.  During each therapy session, the log sheet is reviewed for patient progress. 

 

With CBT, clients are in control of their own progress.  They are aware of the process that is necessary for change, and diligently work at modifying faulty thought patterns.  Therapeutic progress is easily monitored through self-inventories and patient feedback.  Time is always left at the end of sessions to review the benefits or pitfalls of the counseling sessions.  Clients are asked to assess the effectiveness of their counselor’s treatment process. 

 

Patients often ask, “How long will this counseling treatment take?”  Although each case is unique, six to eight sessions are generally sufficient to teach clients strategies for reshaping their thinking.  CBT is a time-limited, user-friendly, practical process for helping individuals to assess their negative thinking and making needed transformation in the way they respond to themselves and others.  Individuals with anxiety, addictive patterns and depressive disorders are particularly well suited to benefiting from this from of treatment.  The good news is that many behavioral health disorders can be treated successfully through cognitive-behavioral therapy.  NACBT or The National Association of Cognitive-Behavioral Therapy is a good resource for locating counselors who are sufficiently trained, certified, and specialize in this treatment approach. 

 

 



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Dyadic Developmental Psychotherapy (DDP) is an evidence-based and effective form of treatment for children with trauma and disorders of attachment[1]. It is an evidence-based treatment, meaning that there has been empirical research published in peer-reviewed journals. Craven & Lee (2006) determined that DDP is a supported and acceptable treatment (category 3 in a six level system). However, their review only included results from a partial preliminary presentation of an ongoing follow-up study, which was subsequently completed and published in 2006. This initial study compared the results of Dyadic Developmental Psychotherapy with other forms of treatment, ‘usual care’, 1 year after treatment ended. It is important to note that over 80% of the children in the study had had over three prior episodes of treatment, but without any improvement in their symptoms and behavior. Episodes of treatment mean a course of therapy with other mental health providers at other clinics, consisting of at least five sessions. A second study extended these results out to 4 years after treatment ended. Based on the Craven & Lee classifications (Saunders et al. 2004), inclusion of those studies would have resulted in Dyadic Developmental Psychotherapy being classified as an evidence-based category 2, ‘Supported and probably efficacious’. There have been two related empirical studies comparing treatment outcomes of Dyadic Developmental Psychotherapy with a control group. This is the basis for the rating of category two. The criteria are:

* 1. The treatment has a sound theoretical basis in generally accepted psychological principles.

Dyadic Developmental Psychotherapy is based in Attachment Theory (see texts cited below

* 2. A substantial clinical, anecdotal literature exists indicating the treatment’s efficacy with at-risk children and foster children.

See reference list.

* 3. The treatment is generally accepted in clinical practice for at risk children and foster children.

As demonstrated by the large number of practitioners of Dyadic Developmental Psychotherapy and it’s presentation as numerous international and national conferences over the last ten or fifteen years.

* 4. There is no clinical or empirical evidence or theoretical basis indicating – that the treatment constitutes a substantial risk of harm to those receiving it, compared to its likely benefits.

* 5. The treatment has a manual that clearly specifies the components and administration characteristics of the treatment that allows for implementation.

Creating Capacity for Attachment, Building the Bonds of Attachment, and Attachment Focused Family Therapy constitute such material.

* 6. At least two studies utilizing some form of control without randomization (e.g., wait list, untreated group, placebo group) have established the treatment’s efficacy over the passage of time, efficacy over placebo, or found it to be comparable to or better than an already established treatment.

See ref. list

* 7. If multiple treatment outcome studies have been conducted, the overall weight of evidence supported the efficacy of the treatment.

These studies support several of O’Connor & Zeanah’s[2] conclusions and recommendations concerning treatment. They state (p. 241), “treatments for children with attachment disorders should be promoted only when they are evidence-based.”

Dyadic Developmental Psychotherapy, as with any specialized treatment, must be provided by a competent, well-trained, licensed professional. Dyadic Developmental Psychotherapy is a family-focused treatment[3].

Dyadic Developmental Psychotherapy is the name for an approach and a set of principals that have proven to be effective in helping children with trauma and attachment disorders heal; that is, develop healthy, trusting, and secure relationships with caregivers. Treatment is based on five central principals.

At the core of Reactive Attachment Disorder is trauma caused by significant and substantial experiences of neglect, abuse, or prolonged and unresolved pain in the first few years of life. These experiences disrupt the normal attachment process so that the child’s capacity to form a healthy and secure attachment with a caregiver is distorted or absent. The child lacks a sense trust, safety, and security. The child develops a negative working model of the world in which:

Ø Adults are experienced as inconsistent or hurtful.

Ø The world is viewed as chaotic.

Ø The child experiences no effective influence on the world.

Ø The child attempts to rely only on him/her self.

Ø The child feels an overwhelming sense of shame, the child feels defective, bad, unlovable, and evil.

Reactive Attachment Disorder is a severe developmental disorder caused by a chronic history of maltreatment during the first couple of years of life. Reactive Attachment Disorder is frequently misdiagnosed by mental health professionals who do not have the appropriate training and experience evaluating and treating such children and adults. Often, children in the child welfare system have a variety of previous diagnoses. The behaviors and symptoms that are the basis for these previous diagnoses are better conceptualized as resulting from disordered attachment. Oppositional Defiant Disorder behaviors are subsumed under Reactive Attachment Disorder. Post Traumatic Stress Disorder symptoms are the result of a significant history of abuse and neglect and are another dimension of attachment disorder. Attention problems and even Psychotic Disorder symptoms are often seen in children with disorganized attachment[4].

Approximately 2% of the population is adopted, and between 50% and 80% of such children have attachment disorder symptoms[5]. Many of these children are violent[6] and aggressive[7] and as adults are at risk of developing a variety of psychological problems[8] and personality disorders, including antisocial personality disorder[9], narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder[10]. Neglected children are at risk of social withdrawal, social rejection, and pervasive feelings of incompetence[11]. Children who have histories of abuse and neglect are at significant risk of developing Post Traumatic Stress Disorder as adults[12]. Children who have been sexually abused are at significant risk of developing anxiety disorders (2.0 times the average), major depressive disorders (3.4 times average), alcohol abuse (2.5 times average), drug abuse (3.8 times average), and antisocial behavior (4.3 times average)[13] (MacMillian, 2001). The effective treatment of such children is a public health concern (Walker, Goodwin, & Warren, 1992).

Left untreated, children who have been abused and neglected and who have an attachment disorder become adults whose ability to develop and maintain healthy relationships is deeply damaged. Without placement in an appropriate permanent home and effective treatment, the condition will worsen. Many children with attachment disorders develop borderline personality disorder or anti-social personality disorder as adults[14].

FIRST PRINCIPAL. Therapy must be experiential. Since the roots of disorders of attachment occur pre-verbally, therapy must create experiences that are healing. Experiences, not words, are one “active ingredient” in the healing process.

For example, one eight year old boy who had Reactive Attachment Disorder, Bipolar Disorder, and a variety of sensory-integration disorders wrote about his past therapy and attachment therapy this way (More details of this story can be found in the book Creating Capacity for Attachment, edited by Arthur Becker-Weidman & Deborah Shell):

My first therapy was with Dr.Steve. The therapy was FUN!!!! We ate lots of snacks. I had a bottle. We played lots of cool games like thumb wrestling, pillow rides, giant walk, Superman rides, guess the goodies, eye blinking contests, hide and go seek goodies. I had to follow the rules and play the games just like Dr. Steve said.

Dr. Steve taught me how to play and have fun with my Mom. But I still didn’t know how to love. I would still get real mad and try to hurt Mom and break things. Inside I still thought I was a bad boy. I was still afraid Mom and Dad would get rid of me. I had lots of tantrums at home. Sometimes I would still get out of control and break things and try to hurt Mom. I was getting even worse when I got mad.

Stuff Dr. Art Taught Me

I learned about my feeling well. Sometimes I stuff too many feelings like mad, scared and sad into my feeling well. Then the well will overflow and I could explode with behaviors. But I can stop that by expressing my feelings. Then the well can’t overflow because I let some of the feelings out.

I also made pictures of my heart. I was born with a nice heart but then when I went into the orphanage I got cracks in my heart. My heart cracked because they couldn’t take good care of me. I was a baby and I needed someone to hold me and rock me. But they couldn’t because there were too many babies. Then I put 16 bricks around my heart. I was protecting my heart so it wouldn’t get hurt anymore. But the bricks kept the love out too. I wouldn’t let Mom’s love in. I had lots of mad in my heart.

My hard work in therapy got rid of all the bricks. Then Mom’s love got in. The love made the cracks heal. Now I have a bright red heart with no cracks.

I really liked Dr. Art now and am proud that I am strong. I still don’t need therapy. I still let Mom’s love into my heart!!!!!! Sometimes I send e-mail’s to Dr. Art. I tell him how good I’m doing.

I started missing Dr. Art and told Mom. Mom was confused and thought I wanted more therapy. I told Mom “I don’t need therapy. I just want to have lunch with Dr. Art.” So I sent Dr. Art an email to let him know that I wanted to have lunch with him. Then one day we had lunch together.

Sometimes it’s still hard. I still get mad and sometimes I don’t express my feelings well. Sometimes when Mom helps me ? I can express my feelings and say “I don’t want to pick up my toys. It makes me mad that I have to ? but I will”. When I say that it doesn’t make me feel mad anymore. It helps me to listen to Mom. But sometimes when I get mad I pout and stomp my feet and run to my room if I forget to express my feelings. But now I let Mom help me so that I can talk about my feelings and do what she says

It’s been a really longtime since I tried to hurt Mom or break things when I’m mad. I feel good about love now. I know that my Mom and Dad love me. I know that I love Mom and Dad. I don’t feel like I’m a bad boy anymore.

Effective therapy uses experiences to help a child experience safety, security, acceptance, empathy, and emotional attunement within the family. A number of techniques and methods are used including psychodrama, interventions congruent with Theraplay, and other exercises.

SECOND PRINCIPAL. Therapy must be family-focused. Therapy helps the child address the underlying trauma in a supportive, safe, secure environment in “titrated” and manageable doses so that what the parents have to offer can get in and heal the child. It is the parents’ capacity to create a safe and nurturing home that provides a healing environment. Being able to have empathy for the child, accept the child, love the child, be curious about the child, and be playful are all part of the “attitude[15]” that heals. Parents are actively involved in treatment.

THIRD PRINCIPAL. The trauma must be directly addressed. Therapy helps healing by providing the safety and security so that the child can re-experience the painful and shameful emotions that surround the child’s trauma. Revisiting the trauma is essential if the child is to begin to revise the child’s personal narrative and world-view. It is by revisiting the trauma and sharing the anger and shame with an accepting, empathetic person that the child can integrate the trauma into a coherent self.

FOURTH PRINCIPAL. A comprehensive milieu of safety and security must be created. Traumatized children are often hyper-vigilant, insecure, and deeply distrusting. A consistent environment that is safe and secure is essential to creating the experiences necessary for the child to heal. This milieu must be present at home and in therapy. Good communication and coordination among home, school, and therapy is another important element of effective treatment. “Compression-wraps,” invasive and intrusive stimulation designed to evoke rage, “re-birthing,” and other provocative techniques are not part of Dyadic Developmental Psychotherapy. These intrusive and invasive techniques are not therapy, not therapeutic, and have no place in a reputable treatment program.

Fifth Principal. Therapy is consensual and not coercive. At our center we are very clear that physical restraint is not treatment and is not used in treatment in any manner. Treatment is provided in a manner consisted with the Association for the treatment and Training of Children’s White Paper on Coercion in treatment.

DETAILED DESCRIPTION OF TREATMENT

Dyadic Developmental Psychotherapy is a treatment developed by Daniel Hughes, Ph.D., (Hughes, 2008, Hughes, 2006, Hughes, 2003,). Its basic principals are described by Hughes and summarized as follows:



A focus on both the caregivers and therapists own attachment strategies. Previous research (Dozier, 2001, Tyrell 1999) has shown the importance of the caregivers and therapists state of mind for the success of interventions.

Therapist and caregiver are attuned to the child’s subjective experience and reflect this back to the child. In the process of maintaining an intersubjective attuned connection with the child, the therapist and caregiver help the child regulate affect and construct a coherent autobiographical narrative.

Sharing of subjective experiences.

Use of PACE and PLACE are essential to healing.

Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships.

Caregivers use attachment-facilitating interventions.

Use of a variety of interventions, including cognitive-behavioral strategies.



Dyadic Developmental Psychotherapy interventions flow from several theoretical and empirical lines. Attachment theory (Bowlby, 1980, Bowlby, 1988) provides the theoretical foundation for Dyadic Developmental Psychotherapy. Early trauma disrupts the normally developing attachment system by creating distorted internal working models of self, others, and caregivers. This is one rationale for treatment in addition to the necessity for sensitive care-giving. As O’Connor & Zeanah (2003, p. 235) have stated, “A more puzzling case is that of an adoptive/foster caregiver who is ‘adequately’ sensitive but the child exhibits attachment disorder behavior; it would seem unlikely that improving parental sensitive responsiveness (in already sensitive parent) would yield positive changes in the parent-child relationship.” Treatment is necessary to directly address the rigid and dysfunctional internalized working models that traumatized children with attachment disorders have developed.

Current thinking and research on the neurobiology of interpersonal behavior (Siegel, 1999, Siegel, 2000, Siegel, 2002, Schore, 2001) is another part of the foundation on which Dyadic Developmental Psychotherapy rests.

The primary approach is to create a secure base in treatment (using techniques that fit with maintaining a healing PACE (Playful, Accepting, Curious, and Empathic) and at home using principals that provide safe structure and a healing PLACE (Playful, Loving, Acceptance, Curious, and Empathic). Developing and sustaining an attuned relationship within which contingent collaborative communication occurs helps the child heal. Coercive interventions such as rib-stimulation, holding-restraining a child in anger or to provoke an emotional response, shaming a child, using fear to elicit compliance, and interventions based on power/control and submission, etc., are never used and are inconsistent with a treatment rooted in attachment theory and current knowledge about the neurobiology of interpersonal behavior.

The usual structure of a session involves three components. First, the therapist meets with the caregivers in one office while the child is seated in the treatment room. During this part of treatment, the caregiver is instructed in attachment parenting methods (Becker-Weidman & Shell (2005) Hughes, 2006). The caregiver’s own issues that may create difficulties with developing affective attunement with their child may also be explored and resolved. Effective parenting methods for children with trauma-attachment disorders require a high degree of structure and consistency, along with an affective milieu that demonstrates playfulness, love, acceptance, curiosity, and empathy (PLACE). During this part of the treatment, caregivers receive support and are given the same level of attuned responsiveness that we wish the child to experience. Quite often caregivers feel blamed, devalued, incompetent, depleted, and angry. Parent-support is an important dimension of treatment to help caregivers be more able to maintain an attuned connecting relationship with their child. Second, the therapist with the caregivers meets with the child in the treatment room. This generally takes one to one and a half hours. Third, the therapist meets with the caregivers without the child. Broadly speaking, the treatment with the child uses three categories of interventions: affective attunement, cognitive restructuring, and psychodramatic reenactments. Treatment with the caregivers uses two categories of interventions: first, teaching effective parenting methods and helping the caregivers avoid power struggles and, second, maintaining the proper PLACE or attitude.

Treatment of the child has a significant non-verbal dimension since much of the trauma took place at a pre-verbal stage and is often dissociated from explicit memory. As a result, childhood maltreatment and resultant trauma create barriers to successful engagement and treatment of these children. Treatment interventions are designed to create experiences of safety and affective attunement so that the child is affectively engaged and can explore and resolve past trauma. This affective attunement is the same process used for non-verbal communication between a caregiver and child during attachment facilitating interactions (Hughes, 2003, Siegel, 2001). The therapist and caregivers’ attunement results in co-regulation of the child’s affect so that is it manageable. Cognitive restructuring interventions are designed to help the child develop secondary mental representations of traumatic events, which allow the child to integrate these events and develop a coherent autobiographical narrative. Treatment involves multiple repetitions of the fundamental caregiver-child attachment cycle. The cycle begins with shared affective experiences, is followed by a breach in the relationship (a separation or discontinuity), and ends with a reattunement of affective states. Non-verbal communication, involving eye contact, tone of voice, touch, and movement, are essential elements to creating affective attunement.

The treatment provided often adhered to a structure with several dimensions. It is pictured in Figure 1, below. First, behavior is identified and explored. The behavior may have occurred in the immediate interaction or have occurred at some time in the past. Using curiosity and acceptance the behavior is explored. Second, using curiosity and acceptance the behavior is explore and the meaning to the child begins to emerge. Third, empathy is used to reduce the child’s sense of shame and increase the child’s sense of being accepted and understood. Forth, the child’s behavior is then normalized. In other words, once the meaning of the behavior and its basis in past trauma is identified, it becomes understandable that the symptom is present. An example of such an interaction is the following:

Wow, I see how you got so angry when your Mom asked you to pick up your toys. You thought she was being mean and didn’t want you to have fun or love you. You thought she was going to take everything away and leave you like your first Mom did, like when your first Mom took your toys and then left you alone in the apartment that time. Oh, I can really understand now how hard that must be for you when Mom said to clean up. You really felt mad and scared. That must be so hard for you.

 

Fifth, the child communicates this understanding to the caregiver.

Sixth, finally, a new meaning for the behavior is found and the child’s actions are integrated into a coherent autobiographical narrative by communicating the new experience and meaning to the caregiver.

Past traumas are revisited by reading documents and through psychodramatic reenactments. These interventions, which occur within a safe attuned relationship, allow the child to integrate the past traumas and to understand the past and present experiences that create the feelings and thoughts associated with the child’s behavioral disturbances. The child develops secondary representations of these events, feelings and thoughts that result in greater affect regulation and a more integrated autobiographical narrative.

As described by Hughes (2006, 2003), the therapy is an active, affect modulated experience that involves acceptance, curiosity, empathy, and playfulness. By co-regulating the child’s emerging affective states and developing secondary representations of thoughts and feelings, the child’s capacity to affectively engage in a trusting relationship is enhanced. The caregivers enact these same principals. If the caregivers have difficulty engaging with their child in this manner, then treatment of the caregiver is indicated.

Children who have experienced chronic maltreatment and resulting complex trauma are at significant risk for a variety of other behavioral, neuropsychological, cognitive, emotional, interpersonal, and psychobiological disorders (Cook, A., et. al., 2005; van der Kolk, B., 2005). Children and adolescents with complex trauma require an approach to treatment that focuses on several dimensions of impairment (Cook, et. al., 2005). Chronic maltreatment and the resulting complex trauma cause impairment in a variety of vital domains including the following:

Ø Self-regulation

Ø Interpersonal relating including the capacity to trust and secure comfort

Ø Attachment

Ø Biology, resulting in somatization

Ø Affect regulation

Ø Increased use of defensive mechanisms, such as dissociation

Ø Behavioral control

Ø Cognitive functions, including the regulation of attention, interests, and other executive functions.

Ø Self-concept.

Dyadic Developmental Psychotherapy addresses these domains of impairment. Dyadic Developmental Psychotherapy shares many important elements with optimal, sound social casework and clinical practice. For example, attention to the dignity of the client, respect for the client’s experiences, and starting where the client is, are all time-honored principles of clinical practice and all are also central elements of Dyadic Developmental Psychotherapy

In summary, therapy for traumatized children who have disordered attachments must be experiential, consensual, and provide an environment of security, acceptance, safety, empathy, and playfulness.

[1] Becker-Weidman, A., (2006) “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 23 #2, April 2006, 147-171.

Becker-Weidman, A., (2006). “Dyadic Developmental Psychotherapy: A multi-year Follow-up,” in, New Developments In Child Abuse Research, Stanley M. Sturt, Ph.D. (Ed.) Nova Science Publishers, NY, pp. 43 — 61.

Becker-Weidman, A., (2007) “Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy,” http://www.center4familydevelop.com/research.pdf

Becker-Weidman, A., & Hughes, D., (2008) “Dyadic Developmental Psychotherapy: An evidence-based treatment for children with complex trauma and disorders of attachment,” Child & Adolescent Social Work, 13, pp.329-337.

Craven, P. & Lee, R. (2006) Therapeutic interventions for foster children: a systematic research synthesis. Research on Social Work Practice, 16, 287–304.

[2] O’Connor, T., & Zeanah, C., (2003) Attachment Disorders: Assessment strategies and treatment approaches. Attachment & Human Development, 5, 223-245.

[3] Hughes, D., (2008) Attachment-focused Family Therapy. NY: Norton.

[4] Lyons-Ruth, K., & Jacobvitz, D., Attachment disorganization: unresolved loss, relational violence and lapses in behavioral and attentional strategies. In Cassidy, J. & Shaver, P., (Eds.) Handbook of Attachment. pp 520-554, NY: Guilford Press, 1999.

Solomon, J. & George, C. (Eds.). Attachment Disorganization. NY: Guilford Press, 1999.

Main, M. & Hesse, E. Parents’ Unresolved Traumatic Experiences are related to infant disorganized attachment status. In Greenberg, M.T., Ciccehetti, D., & Cummings, E.M. (Eds.) Attachment in the Preschool Years: Theory, Research, and Intervention, pp.161-182, Chicago: University of Chicago Press, 1990.

Carlson, E.A. (1988). A prospective longitudinal study of disorganized/disoriented attachment. Child Development 69, 1107-1128.

[5] Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1995). Finding order in disorganization: Lessons from research on maltreated infants’ attachments to their caregivers. In D. Cicchetti & V. Carlson (Eds), Child Maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 135-157). NY: Cambridge University Press.

Cicchetti, D., Cummings, E.M., Greenberg, M.T., & Marvin, R.S. (1990). An organizational perspective on attachment beyond infancy. In M. Greenberg, D. Cicchetti, & M. Cummings (Eds), Attachment in the Preschool Years (pp. 3-50). Chicago: University of Chicago Press.

[6] Robins, L.N. (1978) Longitudinal studies: Sturdy childhood predictors of adult antisocial behavior. Psychological Medicine,. 8, 611-622.

[7] Prino, C.T. & Peyrot, M. (1994) The effect of child physical abuse and neglect on aggressive withdrawn, and prosocial behavior. Child Abuse and Neglect, 18, 871-884.

[8] Schreiber, R. & Lyddon, W. J. (1998) Parental bonding and Current Psychological Functioning Among Childhood Sexual Abuse Survivors. Journal of Counseling Psychology, 45, 358-362.

 

[9] Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000). Attachment Styles in Maltreated Children: A Comparative Study. Child Development and Human Development, 31, 113-128.

[10] Dozier, M., Stovall, K.C., & Albus, K. (1999) Attachment and Psychopathology in Adulthood. In J. Cassidy & P. Shaver (Eds.). Handbook of Attachment (pp. 497-519). NY: Guilford Press.

[11] Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000). Attachment Styles in Maltreated Children: A Comparative Study. Child Development and Human Development, 31, 113-128.

 

[12] Allan, J. (2001). Traumatic Relationships and Serious Mental Disorders. NY: John Wiley.

Andrews, B., Varewin, C.R., Rose, S., & Kirk (2000). Predicting PTSD symptoms in Victims of Violent Crime. Journal of Abnormal Psychology, 109, 69-73.

 

[13] MacMillian, H.L. (2001). Childhood Abuse and Lifetime Psychopathology in a Community Sample. American Journal of Psychiatry, 158, 1878-1883.

 

[14] Allan, J. Traumatic Relationships and Serious Mental Disorders, NY: Wiley, 2001.

Andrews, B., Varewin, C.R., Rose, S. & Kirk. Predicting PTSD symptoms in Victims of Violent Crime. Journal of Abnormal Psychology, vol. 109, 69-73, 2000.

 

[15] Hughes, D., (2007) Building the Bonds of Attachment, 2nd. Edition, NY: Guilford Press.



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One of the most perspective methods of psychotherapy today is distant internet psychotherapy or “psychotherapy in letters”. In spite of its simplicity it is a very effective and accessible way to help people who need psychotherapy.

The more so there are a lot of Internet means that allow to get in touch with psychotherapist very soon, e-mail is the most suitable for this purpose: massages comes for seconds! And a psychotherapist virtually is always near to a client, so he or she always is able to give her or his professional advice and competent opinion.

A lot of difficulties we experience during our lifetime and this is quite a normal thing. All of us time after time turn out in the face of different material and spiritual problems: radical changements in life order, loss of job or significant relationships, depression, family difficulties, anxiety for future and so on.  But all these things do not imply mental disorder, you are just stressed. This thing is quite usual one, but not always we have a possibility to master these difficulties ourselves.

A psychotherapist has got special education and experience to help you in this case. And PSYCHOTHERAPY IN LETTERS, or INTERNET-PSYCHOTHERAPY is the best alternative and very good source of help in cases when traditional psychotherapy is not accessible. It is really effective. For some people this is the only method to get help in conditions when they have no opportunity to meet with psychotherapist personally.

 INTERNET-PSYCHOTHERAPY is that very comfortable  and optimal way of consultations that  allows you to save as time as petrol.

Another point why the method of internet psychotherapy is attractive is that the process can be absolutely ANONIMOUS and all the problems even the most delicate and intimate ones can be discussed freely.

DOCTOR DOBRYNIN, the member of Russian Psychotherapy League,    psychotherapist with much  work experience uses the most modern Russian achievements in the field of psychotherapy, offer you this kind of services FREELY.



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The Dyadic Developmental Psychotherapy Institute (DDPI) has been formed to allow therapist to become appropriately trained and certified as practitioners and/or consultants of Dyadic Developmental Psychotherapy(DDP). The DDPI has a certification process to become a certified practitioner of DDP and to become a certified consultant of DDP.

Dyadic Developmental Psychotherapy, which is an effective and evidence-based treatment (Becker-Weidman & Hughes, 2008) has been developing for over a decade now. The purpose of the Institute and its certification program is to ensure that practitioners of the model adhere to its basic principles and to maintain integrity of the model. Dyadic Developmental Psychotherpay, Dyadic Developmental Psychotherapy Institute, Certified Dyadic Developmental Psychotherapy Psychotherapist, Certified Dyadic Developmenal Psychotherapy Consultant, Certified Dyadic Developmental Psychotherapy Trainers, DDP, DDPI, CDDPP, CDDPC, and CDDPT are all registered service marks/trademarks of the DDPI and may only be used with its permission.

Dyadic Developmental Psycotherapy has been shown to be an effective and evidence-based treatment for a variety of issues and concerns.  The Institute’s focus will be to maintain integrity of the model and to facillitate the ongoing development, refining, and research on this model of treatment.

DDPI will provide a certification process for those clinicians who are utilizing the DDP model of treatment and who wish to become certified in having demonstrated their knowledge of its core principles and their competence in its implementation in their practice. To be certified clinicians will have completed a minimum number of hours both in DDP course participation as well as in receiving consultation of their utilization of DDP in their treatment (through video review). Clinicians will also be certified to be DDP consultants, who are responsible for the providing consultation to those applying to become DDP certified therapists.

REFERENCES

Becker-Weidman, A. (2006a). Treatment for children with trauma-attachment disorders: Dyadic Developmental Psychotherapy. Child and Adolescent Social Work Journal, March, 2006.

Becker-Weidman, A. (2006b). Dyadic Developmental Psychotherapy: a multi-year follow-up. In New Developments in Child Abuse Research S.M. Sturt, Ed. Nova Science Publishers.

Becker-Weidman, A., (2007) “Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy,”

http://www.center4familydevelop.com/research.pdf

Becker-Weidman, A., & Hughes, D., (2008) “Dyadic Developmental Psychotherapy: An evidence-based treatment for children with complex trauma and disorders of attachment,” Child & Adolescent Social Work, 13, pp.329-337.

Becker-Weidman, A. & Shell, D. Eds. (2005, 2nd Printing 2008). Creating Capacity for . Oklahoma City OK: Wood ‘N’ Barnes, Williamsville, NY: Center For Family Development

Bowlby, J., (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. NY: Basic.

Holmes, J., (1993). John Bowlby Attachment Theory. London: Routledge.

Hughes, D. (1997). Facilitating Developmental Attachment: The Road to Emotional

Recovery and Behavioral Change in Foster and Adopted Children (1997).

Northvale, NJ: Jason Aronson.

Hughes, D. (1998). Building the Bonds of Attachment: Awakening Love in Deeply

Troubled Children. Northvale, NJ: Jason Aronson.

Hughes, D. (2003). Psychological Interventions for the Spectrum of Attachment

Disorders and Intrafamilial Trauma. Attachment and Human Development, 5,

271-277.

Hughes, D. (2004). An Attachment-Based Treatment for Maltreated Children and Youth.

Attachment and Human Development, 6, 263-278.

Hughes, D. (2006). Building the Bonds of Attachment: Awakening Love in Deeply

Troubled Children.2nd Edition. Northvale, NJ: Jason Aronson.

Hughes, D. (2007). Attachment-focused family therapy. New York: WW Norton.



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Dyadic Developmental Psychotherapy is an effective form of treatment for trauma-attachment disordered children. It is an “evidence-based” treatment, meaning that there has been research published in peer-reviewed journals (Becker-Weidman, A., (2006) “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 23 #2, April 2006, 147-171. Becker-Weidman, A., (2006). “Dyadic Developmental Psychotherapy: A multi-year Follow-up,” in, New Developments In Child Abuse Research, Stanley M. Sturt, Ph.D. (Ed.) Nova Science Publishers, NY, pp. 43 — 61. Becker-Weidman, A., (2006) “Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy,” Child and Adolescent Mental Health. Published article online: 21-Nov-2006 doi: 10.1111/j.1475-3588.2006.00428.x). One empirical study from a professional peer-reviewed journal found that 1.1 years after treatment ended, there were statistically and clinically significant reductions in aggressive, delinquent, avoidant, and other symptoms( Becker-Weidman, A., (2006) “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 23 #2, April 2006, 147-171. All children in the study who had RADQ scores above 65 had scores reduced below the cut-off for Reactive Attachment Disorder. Average score before treatment was 65 average post treatment score was 20. Scores on the Child Behavior Checklist on the Withdrawn, Anxious/Depressed, Social Problems, Thought Disorder, Attention Problems, Rule-breaking, and Aggressive subscales were reduced from the “clinical level” to the “normal level.” These reductions were clinically and statistically significant.). It is important to note that over 80% of the children in the study had had over three prior episodes of treatment, but without any improvement in their symptoms and behavior. Episodes of treatment means a course of therapy with other mental health providers at other clinics, consisting of at least five sessions. Dyadic Developmental Psychotherapy is primarily an experiential-based treatment, designed to facilitate experiences of safety and security so that a secure attachment may grow. Dyadic Developmental Psychotherapy, as with any specialized treatment, must be provided by a competent, well-trained, licensed professional. Dyadic Developmental Psychotherapy is a family-focused treatment.

Dyadic Developmental Psychotherapy is the name for an approach and a set of principals that have proven to be effective in helping trauma-attachment disordered children heal; that is, develop healthy, trusting, and secure relationships with caregivers. Treatment is based on five central principals. These principals are based on the causes and courses of disorders of attachment.

At the core of Reactive Attachment Disorder is trauma caused by significant and substantial experiences of neglect, abuse, or prolonged and unresolved pain in the first two years to three years of life. These experiences disrupt the normal attachment process so that the child’s capacity to form a secure attachment with a caregiver is distorted or absent. The child lacks trust, safety, and security. The child develops a negative working model of the world in which:

Ø Adults are experienced as inconsistent or hurtful.

Ø The world is viewed as chaotic.

Ø The child experiences no effective influence on the world.

Ø The child attempts to rely only on him/her self.

Ø The child feels an overwhelming sense of shame, the child feels defective, bad, unlovable, and evil.

FIRST PRINCIPAL. Therapy must be experiential. Since the roots of disorders of attachment occur pre-verbally, therapy must create experiences that are healing. Experiences, not words, are the “active ingredient” in the healing process. Traumatized children who are unable to trust do not respond to traditional forms of treatment such as play therapy, residential treatment, or talk therapies, since these therapies require and work through a relationship between the therapist and client.

For example, one eight year old boy who had Reactive Attachment Disorder, Bipolar Disorder, and a variety of sensory-integration disorders wrote about his past therapy and attachment therapy this way:

My first therapy was with Dr.Steve. The therapy was FUN!!!! We ate lots of snacks. I had a bottle. We played lots of cool games like thumb wrestling, pillow rides, giant walk, Superman rides, guess the goodies, eye blinking contests, hide and go seek goodies. I had to follow the rules and play the games just like Dr. Steve said.

Dr. Steve taught me how to play and have fun with my Mom. But I still didn’t know how to love. I would still get real mad and try to hurt Mom and break things. Inside I still thought I was a bad boy. I was still afraid Mom and Dad would get rid of me. I had lots of tantrums at home. Sometimes I would still get out of control and break things and try to hurt Mom. I was getting even worse when I got mad.

Stuff Dr. Art Taught Me

I learned about my feeling well. Sometimes I stuff too many feelings like mad, scared and sad into my feeling well. Then the well will overflow and I could explode with behaviors. But I can stop that by expressing my feelings. Then the well can’t overflow because I let some of the feelings out.

I also made pictures of my heart. I was born with a nice heart but then when I went into the orphanage I got cracks in my heart. My heart cracked because they couldn’t take good care of me. I was a baby and I needed someone to hold me and rock me. But they couldn’t because there were too many babies. Then I put 16 bricks around my heart. I was protecting my heart so it wouldn’t get hurt anymore. But the bricks kept the love out too. I wouldn’t let Mom’s love in. I had lots of mad in my heart.

My hard work in therapy got rid of all the bricks. Then Mom’s love got in. The love made the cracks heal. Now I have a bright red heart with no cracks.

I really liked Dr. Art now and am proud that I am strong. I still don’t need therapy. I still let Mom’s love into my heart!!!!!! Sometimes I send e-mail’s to Dr. Art. I tell him how good I’m doing.

I started missing Dr. Art and told Mom. Mom was confused and thought I wanted more therapy. I told Mom “I don’t need therapy. I just want to have lunch with Dr. Art.” So I sent Dr. Art an email to let him know that I wanted to have lunch with him. Then one day we had lunch together.

Sometimes it’s still hard. I still get mad and sometimes I don’t express my feelings well. Sometimes when Mom helps me ? I can express my feelings and say “I don’t want to pick up my toys. It makes me mad that I have to ? but I will”. When I say that it doesn’t make me feel mad anymore. It helps me to listen to Mom. But sometimes when I get mad I pout and stomp my feet and run to my room if I forget to express my feelings. But now I let Mom help me so that I can talk about my feelings and do what she says

It’s been a really longtime since I tried to hurt Mom or break things when I’m mad. I feel good about love now. I know that my Mom and Dad love me. I know that I love Mom and Dad. I don’t feel like I’m a bad boy anymore.

Effective therapy uses experiences to help a child experience safety, security, acceptance, empathy, and emotional attunement. A number of techniques and methods are used including psychodrama, interventions congruent with Theraplay, and other exercises.

SECOND PRINCIPAL. Therapy must be family-focused. Therapy helps the child address the underlying trauma in a supportive, safe, secure environment in “titrated” and manageable doses so that what the parents have to offer can get in and heal the child. It is the parents’ capacity to create a safe and nurturing home that provides a healing environment. Being able to have empathy for the child, accept the child, love the child, be curious about the child, and be playful are all part of the “attitude  (Hughes, D., (2007) Building the Bonds of Attachment, 2nd. Edition, NY: Guilford Press.)” that heals. Parents are actively involved in treatment.

THIRD PRINCIPAL. The trauma must be directly addressed. Therapy helps healing by providing the safety and security so that the child can re-experience the painful and shameful emotions that surround the child’s trauma. Revisiting the trauma is essential if the child is to begin to revise the child’s personal narrative and world-view. It is by revisiting the trauma and sharing the anger and shame with an accepting, empathetic person that the child can integrate the trauma into a coherent self.

FOURTH PRINCIPAL. A comprehensive milieu of safety and security must be created. Traumatized children are often hyper-vigilant, insecure, and deeply distrusting. A consistent environment that is safe and secure is essential to creating the experiences necessary for the child to heal. This milieu must be present at home and in therapy. Good communication and coordination among home, school, and therapy is another important element of effective treatment. “Compression-wraps,” invasive and intrusive stimulation designed to evoke rage, “re-birthing,” and other provocative techniques are not part of Dyadic Developmental Psychotherapy. These intrusive and invasive techniques are not therapy, not therapeutic, and have no place in a reputable treatment program.

Fifth Principal. Therapy is consensual and not coercive. At our center we are very clear that physical restraint is not treatment.

The therapist must be well trained, licensed, and have significant experience in treating trauma-attachment disordered children. A good resource to locate such therapists is the Association for the Treatment and Training in the Attachment of Children, ATTACh.  In selecting a therapist you should look for the following:

Ø Significant training from a recognized training program. Ask where the therapist was trained, how long ago, and for how long.

Ø Ongoing training. Ask when was the last training event the therapist attended and how long was the event.

Ø Licensure in the state in a recognized mental health discipline.

Ø Membership in ATTACh.

Ø A comprehensive informed consent document and appropriate releases.

Ø An initial assessment to develop a differential diagnosis and treatment plan.

In summary, therapy for traumatized children who have disordered attachments must be experiential, consensual, and provide an environment of security, acceptance, safety, empathy, and playfulness. Only an experienced and trained therapist can provide attachment therapy.



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Cognitive-Behavioral Therapy (CBT) is often used to teach Fibromyalgia and other chronic pain sufferers how to cope with their illnesses.  It is said to help treat many conditions and diseases like FM, back pain, rheumatoid arthritis and cancer.  It helps determine how well a patient manages their pain and teaches them how to take control of it.  Depression plays a key role in the inability to be proactive in our treatment.  So, our state of mind is very important when it comes to getting better.

Studies show that when FM patients effectively deal with the particular symptoms and over-lapping conditions of their illness and of their lives, they feel better. Cognitive-behavioral therapy (CBT) increases a patients’ belief in their own power to cope with the things they face and helps them develop ways for dealing with depression and stressful situations.

The goal of CBT is to make patients aware of self-defeating behaviors and emotions so that they can be changed consciously. Healthy, positive thoughts and emotions supersede the negative, resulting in a powerful influence on your life and lessening your pain.  Over time, the idea that you are helpless against the pain goes away and, instead, you learn that you can manage the pain.  Many studies show an improved quality of life and overall reduction in average pain scores.

Cognitive behavioral therapy has shown to be as beneficial as anti-depressant medications for patients with depression.  In one large study there were considerably higher results of reaction and remission from depression when cognitive behavior therapy was used in addition to anti-depressant medications than when either method was used alone.  CBT is used to change the patients negative feelings and social withdrawal.

Cognitive therapy is very helpful in defining and setting limits (something I know I have a problem with) and is vitally important for FM patients. Many “Fibromytes” live their lives in extremes. We push ourselves too far and suddenly we break-down. This reverses the way we view ourselves, we become demoralized, feel worthless, and give up our power to cope with the simplest tasks. One important goal of cognitive therapy is to help us find a middle ground. Patients learn to prioritize their responsibilities, and drop some of the less important tasks or delegate them to others. My biggest problem is just saying “NO”.  I want to please everyone and prove to them and myself that I can do whatever is asked of me.  When I reach my limits and cannot complete a task, I tend to go through a period of self-loathing.  Learning to say “NO” and other coping skills can ultimately lead to a more manageable life. We can learn to view ourselves and others in a better light.

CBT is also a useful treatment for anxiety disorders, including phobias, panic attacks, and obsessive-compulsive disorders. In CBT, patients learn to be aware of and change negative thinking patterns. It is a way to gain conscious control over unwanted thoughts or feelings which are, as a rule, connected to anxiety.  Those of us who suffer from panic attacks learn our bodies’ negative responses and actions during an attack and CBT helps us find ways to counteract the reason for the attacks.  CBT can also help improve quality of sleep so we can hopefully reduce some of our medications.

Cognitive therapy requires approximately six to twenty sessions that last one hour.  The cognitive therapy program may involve keeping a diary to look at all aspects of your daily activities, coping skills and mind-set.  This helps you learn what changes need to be made, limits that need to be set and a way to organize and prioritize activities.  Many of these things contribute to stress and can make your pain better or worse.  Setting limits keeps us from getting discouraged and helps us learn to take each task one step at a time.  CBT also helps us confront negative thoughts and emotions and we are taught how to reverse them.  It all boils down to self-perception:  self-loathing, worthlessness, helplessness, hopelessness, negative self-talk, believing that other people view us the same way.  CBT helps us reverse those thought processes so we can pick ourselves up and keep going.  Patients will learn to find things we once enjoyed doing and make the time to do them with the help of learning how to schedule activities without being overwhelmed.

As we know accomplishing too much too soon can often cause a relapse of symptoms. We should respect these relapses and slow down. We should not consider them a sign of failure.  That’s just how Fibromyalgia works. Don’t be so hard on yourself!

 

 



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Cognitive Behavioural Therapy (CBT) is an effective psychotherapy for a wide range of emotional and psychological problems. The basic tenet of CBT is that our emotions are affected by our cognitions. To put it another way – the way we think affects the way we feel.

A CBT therapist aims to help people suffering from emotional problems by helping them to identify the ways in which their thinking may be causing their problem. A first step in CBT is therefore the identification of “Negative Automatic Thoughts” (or “NATs” for short) – these are the thoughts that accompany unpleasant or unhelpful emotions such as depression or anxiety.

A closely related aim of the CBT therapist is the identification of so-called “Thinking Errors”. These are habitual (and unhelpful) ways a person has of thinking about themselves, others, and the world around them. These thinking errors will often twist or distort experiences, acting to make the person seem a failure, others as hostile, and the world as dangerous or unpleasant.

The identification of NATs and related Thinking Errors is half the battle in CBT – once a person is aware of their unhelpful thoughts and mental habits they can then choose to think in more rational, healthy ways. A CBT therapist can guide them through this (fairly straightforward) process.

As a Psychiatrist and therapist working in Edinburgh I use CBT techniques extensively. Some of my clients are quite happy with the results they get from simply challenging their NATs and Thinking Errors – they feel much better and have no desire to delve further. However, the majority of clients are keen to “get to the bottom” of why they had their emotional problems in the first place. I tend to encourage this further work as it helps to reinforce the progress made to date and, in my opinion, helps to prevent the client from relapsing at some future date.

This further work involves a search for “Negative Core Beliefs” (or “NCBs”). These are the unhelpful beliefs that a person has had throughout their later childhood and adult life. They are core components of the person’s personality and they are the root cause of the person’s Thinking Errors and ultimately their NATs. If a CBT therapist can help a person to change their Negative Core Beliefs (or, more realistically, find more rational and healthier alternatives), then the person’s Thinking Errors and NATs will diminish, and their emotional problems will lessen (usually!).

A difficulty with NCBs is that a person is rarely aware of them. Even when someone is competent at identifying NATs and Thinking Errors, the cause of these problems may be hidden. But we can use NATs and Thinking Errors as clues.

In my experience as a Psychiatrist in Edinburgh I have found two techniques of most benefit in the search for the NCBs of my clients.

Firstly, there is the method of “Repeated Questioning”. I ask the client what a particular NAT he has identified means to him – he will give an answer, and I then ask him what that answer means to him. He will give a second answer, and I then ask him what that second answer means to him, and so on. Within a short space of time, the client ends up with a global statement that can’t be taken any further. This is a Negative Core Belief. It’s probably best demonstrated with an example:

Client:                                    “There’s loads of litter around Edinburgh” (He’s angry)

CBT Therapist:            “What does that mean?”

Client:                                    “That I’m the only one who cares about it”

CBT Therapist:            “What does it mean if you’re the only one who cares about it?”

Client:            “People don’t care about things that aren’t their personal property”

CBT Therapist:            “And what does it mean if people only care about their own stuff?”

Client:                                    “People are only out for themselves”

(”People are only out for themselves”. This is the client’s Negative Core Belief – a global statement that is uncompromising and will clearly influence the way he views and interacts with others in other areas of life, not simply littering!)

A second method of identifying Negative Core Beliefs is to look for the “themes” that run throughout a persons many NATs and Thinking Errors. Such themes may be “I’m a failure” or “There’s no point to life” (very common in depression), or perhaps “The world’s a dangerous place to live” (common in anxiety conditions).

Once a client’s Negative Core Beliefs have been identified, the CBT therapist will (along with the client) try and explore alternative and more rational ways of thinking about the self, others, and the world in general. This is where real, sustained recovery from emotional problems is made and I will discuss this in a follow-up article entitled “Cognitive Behavioural Therapy (CBT) and Negative Core Beliefs (NCBs) – Treatment”.

Dr Steve Last is a Psychiatrist and Therapist in Edinburgh. He makes extensive use of CBT techniques to treat problems such as depression, anxiety, and OCD. Please visit http://www.drstevelast.co.uk for further information about psychological problems and CBT.



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