Cognitive Therapy Basics

Helen Keller has said that “the only way to get to the other side is to go through the door.”  This is certainly true in the work of transforming grief into healing and growth. This process involves allowing ourselves to feel the intense emotions of grief – sadness, anger, despair and other difficult emotions, as well as tapping into our internal strengths and external sources of support and ultimately finding new ways to stay connected to our departed loved ones. Narrative therapy and has been used with a wide variety of difficulties and issues, including grief reactions.  The role of the narrative therapist is as collaborator or co-author with the client.  As such, the narrative therapist partners with the client to explore the stories that give meaning to the client’s life (White, 1995).  Carr (1998) describes the context of narrative therapy as follows:Within a narrative frame, human problems are viewed as arising from and being maintained by oppressive stories which dominate the person’s life….Developing therapeutic solutions to problems, within the narrative frame, involves opening space for the authoring of alternative stories, the possibility of which have previously been marginalized by the dominant oppressive narrative which maintains the problem (p. 468).Narrative therapy is thus an empowering vehicle for “re-authoring lives” (Carr, 1998, p. 468; White, 1995), in which the therapist takes the role of a partner or collaborator with the client, rather than an authority figure (Angell, Dennis & Dumain, 1999).. The narrative therapist partners with the client to create a safe place to feel the emotions of grief, and to explore the stories that give meaning to the client’s life. The use of narrative or story is a useful vehicle for making meaning and sense of difficult experiences in our lives, by allowing us to access alternative cognitions and gain self-knowledge…  A narrative therapy tool that is often used in grief work is the use of written expression, such as journaling and letter writing.  This can be a powerful vehicle for expressing the emotions of grief and accessing the individual’s unique internal resources and strength, as well as a means of enforcing continuing bonds with the deceased and keeping him or her in the bereaved person’s life as an internalized source of strength and guidance.  Accessing Spiritual Beliefs and Strengths through Narrative TherapyThe collaborative approach of the narrative therapist can be useful for accessing the client’s spiritual strengths by respectful inquiry into the client’s worldviews, including his or her beliefs before the loss, and how they may have changed since the loss, and discussing spiritual and existential issues that arise in this context. (Calhoun & Tedeschi, 2000, p. 167). As one gets in touch on a deep level with his or her own suffering and resiliency in the face of that suffering, he or she can begin to get a panoramic view of the human condition and tap into his or her spiritual strength. Religious and spiritual beliefs have been observed to be one way in which individuals create meaning and a sense of order and purpose to the human condition, life and death, as well as creating an ongoing relationship with the deceased (Golsworthy & Coyne, 1999; Calhoun & Tedeschi 2000). My Theoretical PerspectiveThe strength-based and holistic approach I use with my grieving clients, through the use of techniques of narrative and solution-focused therapy, is informed by my Buddhist practice.  In particular, I come to each session with my clients with the ground that each human being possesses inherent wisdom, or Buddha Nature, and that this wisdom can be called upon to access the individual’s strengths and resilience in times of suffering.  As Stephen Levine (1982) notes, grief fully experienced allows us to “plumb the depths” of our souls and to “touch something essential in [our] being….[W]hat is often called tragedy holds the seeds of grace” (pp. 85-86). Those “seeds of grace” are the basic goodness and inherent wisdom possessed by all, and it is my job as a collaborator or partner in the journey of grief to support my clients to get in touch with the strengths that they possess, but which may be obscured by the intensity of their feelings of helplessness and loss.  Through narrative therapy, including the use of literary and other creative forms of expression, clients are able to create some space around that intensity, which in turn gives them some perspective and hope for change and transformation.  The broader perspective that can be reached through narrative therapy techniques can put the client in touch with both the uniqueness of his or her own loss, and the universality of grief and suffering.  Paradoxically, contemplating the universal truth of suffering can open us to acceptance and peace.  As His Holiness the Dalai Lama (1998) observes, “if we can transform our attitude towards suffering, adopt an attitude that allows us greater tolerance of it, then this can do much to help counteract feelings of mental unhappiness, dissatisfaction, and discontent” (p. 140). Through allowing ourselves to experience and express our suffering, we can find a meaningful way to grow, transforming hopelessness into hope and possibility.  The use of journaling and other narrative therapy techniques can foster the realization that grief is an integral component of the human condition.  Through experiencing our own unique grief, we can tap into its universality, lessening our hopelessness and isolation, and deepening our connection with others and the human condition.  This is the transpersonal and transformative work of healing grief.Clinical Application and Discussion“Peggy”:  A Story of Abuse and Resilience“Peggy” came to therapy to deal with her conflicting feelings after the recent death of her mother.  Peggy had been her mother’s caregiver in the last months of her mother’s life.  In our first session, Peggy recounted that her mother was an alcoholic, and that she has a history of alcohol abuse as well.  She also told me of the emotional abuse she experienced at the hands of her father, and her mother’s failure to protect her from that abuse. In addition, Peggy was experiencing distress about her conflicted relationship with her siblings – which is often exacerbated and magnified by the death of a key family member.During our next session, I encouraged Peggy to tell me the story of her relationship with her mother, and how that relationship transformed from one of recrimination over her mother’s failure to protect Peggy from her father’s abuse to one of forgiveness and intimacy.  I was able to get Peggy in touch with the knowledge that her mother’s death does not mean she is no longer a source of support and strength for her. Peggy agreed with my suggestion, as her therapeutic partner, to write a letter to her mother to reinforce her continued attachment to her mother as a source of spiritual strength.The process of writing the letter to her mother yielded some unexpected rewards for Peggy.  She surprised herself by her ability to not only acknowledge her continued love for her mother, but also to finally express anger toward her mother for her mother’s role in perpetuating the alcohol-fueled dysfunction in her family, and thus to let go of her family role of being the “good girl”.  Peggy was empowered by this newfound ability to express herself more authentically.  A key narrative therapy intervention is to affirm the availability of the client’s social network to support his or her grief work.  Part of this process is learning who is a source of support, and who is not.  Peggy has excellent support from friends at her church who share her spirituality, and she realized that it would be far better to turn to them for support at this time, rather than to her family.  At the same time, I acknowledged and validated that giving up the hope that her family can be a source of support at this time was a secondary loss resulting in another experience of grief.  My acknowledgement of this fact was reassuring to Peggy and helped normalize her process.   In addition, I worked with Peggy to link her use of this strength and self-awareness in the past to her current circumstances.  She was thus able to see that she is not a victim of her family of origin, but rather, has some control over the course of her life and the process of her grief.Peggy now has some tools for healing.  She knows on a core level the strengths she has to move forward.  She feels empowered by her mother’s continued supportive presence in her life and has a renewed faith in her spiritual strength and resiliency.  Considerations for the use of Narrative TherapyDespite my successful experience with the use of narrative therapy in accessing continued attachment as a source of strength in grief, other interventions may first need to be used before certain clients have the ability to fully experience the feelings of grief and transform them into healing and growth.    My work with “Frank”, an eighty year old widower, is illustrative.  Frank’s wife “Paula” died after a long bout with dementia.  Frank reported that, despite a long and loving marriage, a byproduct of Paula’s dementia was extreme anger toward him. I attempted to do a life review with Frank to see if he could gain some perspective, but in telling the story of his life with Paula, he consistently berated himself.   I realized that a narrative therapy life review would have been counterproductive at that point, and that narrative therapy interventions would only be useful with Frank if he were able to let go of some of his distress and internalized self-blame.  I therefore used Gestalt techniques to work with Frank to release the power of his wife’s anger, and cognitive behavioral approaches to foster Frank’s self-care and self-esteem and to help him realize that he did not have to hold on to the blame and shame his wife had instilled in him.  I also helped Frank access other avenues of support, such as emotional support from his son, social support at the local senior center and a grief support group.    As a result of continued work with Frank’s feelings of blame and shame and Frank’s availing himself of his sources of support, Frank became less distressed about feeling Paula’s presence.  He found that he was now able to tell the story of his life with Paula without internalizing her anger.  It was only after the use of other interventions that Frank was able to re-author his story, and he came to feel Paula’s presence in his life as his guardian angel.ConclusionNarrative therapy can be an effective tool for working with the emotions and grief and finding new meaning in one’s life.  The process of expression literally takes deep feelings out of the body, externalizing them so that they become workable. Through this process, grieving clients are able to see that they have some control over their lives, and can tap into their strengths and their inherent wisdom.  With my guidance as a partner on the path of healing grief, my clients can discover their unique strengths, resources and resiliency, deepen their spiritual beliefs, and enhance the meaning of their lives in the context of the human condition.

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Emotional stress is someth ing that we all experience when we have to cope with the many demands and responsibilities of home and work. Stress can be defined as an intense emotional and physiological reaction to a situation or the mental representation of a situation as a memory or anticipation. Chronic stress is produced when stress reactions do not resolve themselves and become habitual. The sustained physiological effects of chronic stress can have a serious effect on the body and lead to an increased risk of disease. The psychological effects of chronic stress produce fatigue, poor concentration and an impaired ability to perform tasks, which leads to more stress. Stress produces a general feeling of helplessness and negativity, both of which reinforce the stress reactions. This produces a lack of vitality, enthusiasm and creativity and many people describe chronic stress as a heavy blackness that covers everything and in its severe form, chronic stress leads to depression. Chronic stress can result in an increased chance of accidents as well as reducing work performance. Chronic stress also reduces our listening and learning skills and this reduces the quality of communication in our personal relationships and family.

It is well recognized that stress reactions are learned and originate from the influence of our own mental outlook and from belief patterns acquired from our parents, family and culture. Stress always contains both an objective component and a subjective component and in most situations, it is the habitual subjective emotional reactivity that generates the emotional tension and physiological characteristics of stress. There is pain and there is suffering. Pain is the objective component that is often inevitable or unavoidable, but suffering is a subjective reaction that we generate and add to the pain. The Buddha described this subjective suffering as dukkha and not surprisingly, mindfulness, which is one of the central teachings of the Buddha, was and continues to be very relevant for working with and resolving emotional stress.

The other major source of stress comes from unresolved traumas that result from physical injury, assault, domestic abuse and violence. In general this kind of trauma-related stress results from experiences and associated emotional reactions that we cannot process, because they are outside of our normal range of experience. These unresolved wounds become repressed and submerge into the subconscious mind where they continue to simmer and generate a generalized anxiety. This is described as post-traumatic stress disorder (PTSD). Occasionally, in severe cases of PTSD resulting from war or other intense situations, the stress reactions will erupt as nightmares and flashbacks in which the individual re-lives the trauma.

Whatever the source of the stress reactions, it is important to understand that each reaction has an internal structure in the form of negative thoughts and beliefs and associated emotional energy that gives power to these thoughts. It is often very helpful to examine these negative thoughts and try to change them. This is the approach taken in Cognitive Behavioral Therapy. Another approach is to change the emotional energy that empowers the thoughts and beliefs, because without this compulsive charge, the beliefs will have no power to generate stress. This is the approach taken in MMT. Through careful attention and investigation of the emotion through mindfulness, we can uncover the internal structure of the emotion and discover what needs to change. As the structure changes, so does the emotion. Resolve this and you will neutralize the stress reactions.

OVERCOMING STRESS REACTIONS: THE FOUR Rs

Stress is generated by habitual emotional reactions to external events and internal beliefs. These patterns of negative thinking can be changed by the application of the four Rs, which are the primary focus of MMT. These are: RECOGNITION, REFRAMING, RELATIONSHIP, RESOLUTION.

RECOGNITION

All habitual emotional reactions rely on two key elements: ignorance and emotional energy. The first task in MMT is to learn to recognize our stress reactions as they arise in stressful situations. We train ourselves to watch very carefully for any impulse to react. This counteracts the automatic and mechanical part of what makes reactions habitual. The maxim of MMT is that all change begins with mindfulness and mindful-recognition is the first and most important step. You know what pushes your buttons. It might be in your personal relationships with your partner or with your children or perhaps with your parents. One of the most important steps you can take on the path of self-transformation is to take the initiative to examine what stressors cause you to react and to learn to recognize your impulse to react. This is very empowering and changes your attitude from being a victim to being a warrior. For most of the time, most of us react out of habit and have no awareness of what is happening while it is happening. We are simply seduced into the same automatic patterns of reactive thinking over and over again. Clearly, the first step is to break this pattern of ignorance and know what is happening as it happens. This is the fundamental first part of mindfulness. Mindfulness means to be present for experience as it is unfolding.

REFRAMING

Now you are learning to recognize anger reactions, disappointment and frustration reactions, fear and anxiety reactions as they arise in real-time. This new awareness can be very transformational by itself by simply making you conscious of what you are doing. It is a truth that what you don’t see is what has the greatest power over you. Awakening to what is happening is therefore the first step to change.

The next step that paves the way for transformi ng the emotional energy that powers stress reactivity is to change your relationship to the emotion. Our usual response is to say I am angry or I am afraid or I am upset and we literally become the emotion. Contrast this to saying I notice anger/fear/upset in me. Now the emotion becomes reduced to an object, not me, that I can relate to with mindfulness. This simple reframing of how we perceive an emotional reaction – as me or as an object that has arisen in me is itself transformational.

RELATIONSHIP

However, what keeps a reaction alive is the associated emotional charge, without which the reaction would have no power to cause stress. MMT teaches us how to form a non-reactive relationship, the Mindfulness Based Relationship, with this underlying emotional energy that compels us to react. This is the RELATIONSHIP phase of MMT.

The mindfulness relationship is very important. This is where we allow ourselves to open our awareness and investigate the emotional energy, which is quite different to our usual reactions of ignorance, avoidance or aversion. We choose to be fully present with the inner feelings behind the stress reactions, rather than getting sucked into the content and story line. Just as in personal relationships, it is the quality of our PRESENCE, our ability to listen with an open mind and heart that is most important. Now we are learning to cultivate this same presence for our inner emotional stress. The nature of the mind is such that if you allow things to change, they inevitably will. If you allow things to change and unfold into this safe spaciousness of the mindfulness-based relationship, things will change in a beneficial direction that will transform and resolve the inner conflict and pain. It is the habitual reactivity that stops this natural healing and as we learn to disengage from the patterns of reactivity we create the right conditions in which emotional tension will resolve itself.

RESOLUTION

Mindfulness creates a therapeutic space that allows the emotion to unfold and undergo transformation. If you give it space it will change. This is one of the great discoveries made by the Buddha, 2500 years ago and which we are rediscovering today. It is not what we do that matters as much as how we relate to our emotional stress. When this relationship is based on the receptivity and openness of mindfulness, then we create the best possible conditions in which emotional tension can resolve itself.

Resolution can be understood as the process in which a stress producing emotion like anger or anxiety or disappointment undergoes a process of unfolding and differentiation. When we investigate anger with mindfulness, we begin to see that the anger is actually an assembly of more subtle content – the inner structure – in the form of feelings, memories, sensations and often some form of inner imagery that pulls all these parts together into the form of an emotion. The anger differentiates into feelings of sadness, emptiness, fear. With intense stress reactions resulting from trauma, we will likely notice vivid inner imagery. It is by uncovering the internal structure of the emotions and associated imagery that change becomes possible and mindfulness provides one of the best ways of cultivating a safe relationship with painful content by teaching you how to stay present and avoid becoming reactive to what you are uncovering.

Through becoming conscious of the inner structure of the emotions that power our stress reactions, the emotional energy will change and resolve. Without this emotional power, there is nothing to sustain the emotional reactions and life-long patterns of stress producing reactivity begin to dissolve, leaving you free from their compulsive grip. Like the petals of a lotus bud that were previously held and constrained so tightly, the mind begins to explore a new freedom with all its possibilities and choices. This is the freedom that the Buddha talked about and that is possible for all of us to discover through the practice of mindfulness. MMT teaches you how to apply mindfulness to resolve your patterns of habitual reactivity so that you can realize your full potential and enjoy your life and relationships to the full.

Peter Strong, PhD is a scientist and Buddhist psychotherapist who specializes in the study of mindfulness and its application in Mindfulness Meditation Therapy. Peter teaches mindfulness meditation (vipassana) and works with individuals and couples using Mindfulness Meditation Therapy for resolving difficult emotional problems including anxiety, depression, phobias, grief and trauma and the management of anger and stress. Besides face-to-face work, Peter also works with individuals and couples online via email and web conferencing. To learn more visit http://www.mindfulnessmeditationtherapy.com/

Email enquiries welcome.