Cognitive Therapy Basics

People with generalized anxiety disorder (GAD) go through the day filled with exaggerated worry and tension, even though there is little or nothing to provoke it. They anticipate disaster and are overly concerned about health issues, money, family problems, or difficulties at work.
People with GAD cannot get rid of their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. They are unable relax, startle easily and have difficulty concentrating.
Physical symptoms that often accompany the anxiety include, but are not limited to, fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, having to go to the bathroom frequently, feeling out of breath and hot flashes.
GAD affects about 6.8 million Americans and about twice as many women as men. It comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age.
It is diagnosed when someone spends at least 6 months worrying excessively about a number of everyday problems. There is evidence that genes play a modest role in GAD.
Other anxiety disorders, depression, or substance abuse often accompany GAD, which rarely occurs alone. It is commonly treated with medication an/or cognitive-behavioral therapy.
Treatment of Anxiety Disorders
Anxiety disorders are typically treated with medication, specific types of psychotherapy, or both. Treatment choices depend on the problem and the persons preference.
Before treatment, a doctor must conduct a careful diagnostic evaluation to determine whether the symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder must be identified, as well as any coexisting conditions, such as depression or substance abuse.
Sometimes alcoholism, depression or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.
People with anxiety disorders who have already received treatment should tell their current doctor about that treatment.
If they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether it was ever increased or decreased, what side effects occurred and whether the treatment helped them significantly. If they received psychotherapy, they should describe the type of therapy, how often they attended sessions and how much the therapy helped.
Often people believe that they have failed at treatment or that the treatment did not work for them when, in fact, it was not given for an adequate length of time or was administered incorrectly. Sometimes people must try several different treatments or combinations before they find the one that works for them.
Medications
Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy, often from a psychologist. The principal medications used to treat anxiety disorders are antidepressants, anti-anxiety drugs and beta-blockers which control some of the physical symptoms.
With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.
Antidepressants
Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.
SSRIs
Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.
Fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil) and citalopram (Celexa) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. These drugs are also used to treat panic disorder when it occurs in combination with OCD, social phobia or depression.
Venlafaxine (Effexor), a drug closely related to the SSRIs, is also used to treat GAD. These medications are started at low doses and gradually increased until they cause side effects or produce a beneficial effect.
SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time, however.
Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another medication.
Tricyclics
Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased.
They sometimes cause dizziness, drowsiness, dry mouth and weight gain, which can usually be corrected by changing the dosage or switching to another medication.
Tricyclics include imipramine (Tofranil), which is prescribed for panic disorder and GAD and clomipramine (Anafranil), which is the only tricyclic antidepressant useful for treating OCD.
MAOIs
Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications and the ones most commonly prescribed for anxiety are phenelzine (Nardil), followed by tranylcypromine (Parnate) and isocarboxazid (Marplan), which are useful in treating panic disorder and social phobia.
People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil, Motrin and Tylenol, cold and allergy medications and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure.
MAOIs can also react with SSRIs to produce a serious condition called serotonin syndrome, which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm and other potentially life-threatening conditions.
Anti-Anxiety Drugs
High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can develop a tolerance to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol or who become dependent on medication easily.
One exception to this rule, however, is people with panic disorder, who can take benzodiazepines for up to a year without harm. Clonazepam (Klonopin) is used for social phobia and GAD, lorazepam (Ativan) is helpful for panic disorder and alprazolam (Xanax) is useful for both panic disorder and GAD.
Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.
Buspirone (Buspar), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.
Psychotherapy
Psychotherapy involves talking with a trained mental health professional, such as a psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.
Cognitive-Behavioral Therapy
Cognitive-Behavioral Therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears and the behavioral part helps people change the way they react to anxiety-provoking situations.
For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.
People with OCD who fear dirt and germs are encouraged to get their hands dirty and wait increasing amounts of time before washing them. The therapist helps the person cope with the anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety diminishes.
People with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee and to make small social blunders and observe how people respond to them. Since the response is usually far less harsh than the person fears, these anxieties are lessened.
People with PTSD may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep breathing and other types of exercises to relieve anxiety and encourage relaxation.
Exposure-based behavioral therapy has been used for many years to treat specific phobias. The person gradually encounters the object or situation that is feared, perhaps at first only through pictures or tapes, then later face-to-face.
Group therapy is particularly effective for social phobia. Often homework is assigned for participants to complete between sessions.
There is some evidence that the benefits of CBT last longer than those of medication for people with panic disorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time.
Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.
Taking Medications
Before taking medication for an anxiety disorder:
1. Ask your doctor to tell you about the effects and side effects of the drug.
2. Tell your doctor about any alternative therapies or over-the-counter medications you are using.
3. Ask your doctor when and how the medication should be stopped. Some drugs cannot be stopped abruptly but must be tapered off slowly under a doctors supervision.
4. Work with your doctor to determine which medication is right for you and what dosage is best.
5. Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.
How to Get Help for Anxiety Disorders
If you think you have an anxiety disorder, the first person you should see is a psychologist, psychiatrist or your family doctor. It must be determined whether the symptoms that alarm you are due to an anxiety disorder, another medical condition or both.
If an anxiety disorder is diagnosed, the next step is usually contracting with a mental health professional to provide treatment. The practitioners who are most helpful with anxiety disorders are psychologists and therapists who have training in cognitive-behavioral therapy and/or behavioral therapy and who are open to using medication if it is needed.
You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere.
Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder.
Remember that once you start on medication, it is important not to stop taking it abruptly.
Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it.
If you are having trouble with side effects, it is possible that they can be eliminated by adjusting how much medication you take and when you take it.
Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out.
If you do not have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.
Ways to Make Treatment More Effective
Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common.
Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a psychologist or other mental health professional. Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of their therapy.
There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs and even some over-the-counter cold medications can aggravate anxiety disorders, they should be avoided.
Check with your physician or pharmacist before taking any additional medications. Also, the family is very important in ones recovery. Ideally, the family should be supportive and should not trivialize the disorder or demand improvement without treatment.

People who suffer from panic attacks experience symptoms such as heart palpitations, sweating, loss of control, feelings of impending doom, disorientation, and feeling trapped. Although those who suffer from this disorder feel debilitated, it is one of the most manageable syndromes to treat through the use of cognitive-behavioral therapy.

When people first come for cognitive-behavioral therapy, they may indicate that they have received prior counseling, have made innumerable visits to doctors, and have been treated in emergency rooms for symptoms associated with their anxiety. Patients are usually desperate for answers to alleviate their on-going struggle with panic. Patients are relieved to know that their symptoms are treatable through the use of cognitive-behavioral therapy. Often, patients feel that they are going crazy, although they need to be reassured that having “crazy” feelings is a cognitive distortion and is vastly different from those who might be considered clinically crazy.

Most individuals know the time-frame when they first started experiencing panic attacks. There may have been triggering events that fostered the emergence of panic. The patient may be unable to make an association between the panic and a painful triggering experience. Factors such as a significant illness, job stress, family abuse/ trauma, losing a loved one, and lacking emotional expressiveness may create conditions ripe for panic. Once a panic attack erupts, further attacks usually follow if an individual is not aware of the cycle of self-defeating thinking and behavior which sustains the panic process.

The key to curtailing panic is to help people understand that it’s the secondary symptoms that keep the panic alive. In other words, it’s the “panic over the panic” that sustains the panic pattern. With cognitive-behavioral therapy, recovery involves educating the sufferer on ways to respond to their self-defeating thought processes during the onset of their attack. For example, let’s say that you are taking a mid-term exam during college. You open up the test booklet and immediately react by saying, “Oh my God, none of this material looks familiar; there’s no way that I can pass this test; if I flunk this test, I might fail this course for the semester; if my parents find out, there’s going to be hell to pay!” In contrast, you can learn to respond rationally by saying, “Wow, some of this stuff doesn’t look familiar; just take some deep breaths and relax; I guess I better survey the whole test, answer the questions that I can and then go back and work on the other one’s; I can tackle this test, I just need to relax and be patient!”

How one responds to panic determines whether it subsides. Those who fight with their panic by “awfulizing” about their symptoms, intensify their panic. They may say, “Oh my God, here come those unbearable feelings again – I feel like I’m going to die!” However those who accept their panic and respond rationally with thoughts like, “Here comes that panic again – just calm down and take those deep breaths and it will eventually subside. These feelings won’t last forever, they are time-limited – they’ll be gone soon.”

Learning through cognitive-behavioral therapy to go “down stream” with panic is important to its eradication. Those who “catastrophize” about their symptoms intensify panic attacks. Learning to rationally respond to panic diminishes its effect. Trying to figure out what caused an individual’s panic is not necessary to treat it. What is essential is teaching those who suffer from panic to respond with positive self-talk.

People who experience panic attacks tend to feel ashamed of their problem. It is important for sufferers to understand that they are not alone – anxiety is apart of the human condition. Anxiety and panic is not unusual and those who experience it need to learn to be more open and expressive with all of their feelings. Sharing a wide range of emotions with those you can trust is essential to the healing process. Those who hide panic as a shame-based pattern set themselves up to repeat it. When those we trust are aware of our authentic self, which includes our vulnerability, our anxiety problems tend to fade in significance.

Paradoxical interventions can be helpful in dealing with panic disorder. Having a patient schedule a panic time and encouraging them to perseverate can bring humor and assist in breaking the panic cycle. A ruminating patient might be asked to conduct cardiovascular exercises during panic-related chest tightness to try to lighten the moment and break the cycle of suffering. Cognitive-behavioral therapy is a structured, pragmatic approach which assists people in addressing the symptoms of panic by learning to respond to the disorder with a positive approach to their thinking.

Both NLP ( Neuro Linguistic Programming ) and CBT ( Cognitive Behaviour Therapy ) are effective techniques for treating people who are suffering from panic attacks. At my practice in Hertfordshire I have treated many clients for panic attacks. Panic attacks can be more serious then people imagine. Some severe cases can cause the person to experience physical pain to such an extent they feel they are having a heart attack. Also in some severe cases people go on to develop Agoraphobia which can affect their daily life. I use both NLP and CBT techniques at my practice in Hertfordshire to treat clients suffering from panic disorder. I use both techniques as it really depends on the client. Some clients respond better to NLP and others respond better to CBT.

 Cognitive Behaviour Therapy works by looking at the relationship between what people think, do and feel. It is based upon the principle that what you are thinking will affect what you feel and what you do, and what you are doing will have an effect on what you are thinking. Within CBT Herts, people learn to change the way they are thinking and feeling. Part of the CBT therapy I offer in Hertfordshire involves helping clients overcome their fear of panic attacks by going through whatever gives them a panic attack, for example a train ride or being in a lift. CBT, Herts, encourages you to challenge your fears, however, this does not mean forcing the person to go into that situation. This will come at a later date and really will depend on the individual. It is about working with the client and asking them questions so that they can devise their own programme to overcome panic attacks.

Nuero Linguistic Programming Herts is different from CBT as it looks at the language people use in their own mind. NLP Herts is about finding out what’s going on in a person’s head to allow panic attacks and then teaching them new ways of conquering panic attacks. An NLP Practitioner will ask clients to describe what happens before a panic attack comes on. This would involve asking a client if they see, feel, hear anything just before the attack takes over. The practitioner can put the client in a deep state of relaxation by using hypnotic techniques to try to combat the fear. At my practice in Hertfordshire I find it helpful to teach clients ways of calming their mind by teaching them relaxation techniques such as breathing techniques.

Ultimately the test will be asking the client to go back into the situation that causes them to experience panic attacks such as getting in a lift, being in a large crowd of people etc……….

At my practice in Hertfordshire I would assess a client to see which therapy NLP or CBT would be most effective for them. Sometimes it is good to use a mixture of both therapies in order to create the desired solution.

Drums are one of the few, perhaps the only, musical instruments to earn a very unique distinction in human culture. Not only are they utilized for the traditional purpose of music, but they have been put to other uses as well. One of the most interesting of these alternative uses is that of music therapy. Music therapy is an approach that uses music to address the physical, emotional, cognitive and social needs of individuals. The American Music Therapy Association defines this type of therapy as “the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship.” There are claims that music therapy can promote wellness, manage stress, alleviate pain, express feelings, enhance memory, improve communication and promote physical rehabilitation.
Although many might assume that drum therapy is a fairly recent advent, this is not necessarily the case. Some proponents advocate that drum therapy is an ancient technique and evidence of its history may be found in both Asia and Africa, where some of the world’s oldest civilizations reside. While it may be true that drum therapy has been around for thousands of years, it is also true that in the 20th and 21st centuries, science has been used in an attempt to verify the therapeutic effects of drum therapy and its rhythm techniques. Much to the delight of drummers everywhere, some studies indeed show that drumming accelerates physical healing, boosts the immune system, produces feelings of wellbeing and even has a calming effect on people suffering from Autism, Alzheimer’s and various traumatic experiences.
Drums, especially those played with the bare hand, are often used in music therapy for two reasons. One, they are exceptionally tactile in nature and two, they are easy to use. This combination makes them ideal for therapeutic situations. The act of drumming is believed to help people express and address emotional issues that may be otherwise difficult to face. It allows the drummer to create an external and almost physical manifestation of whatever frustration they may feel inside.
Drum circles are a popular form of music therapy. In such a situation, each person is able to express themselves through their individual instrument while simultaneously participating as part of a larger whole. Such groups can range from just a few people to literally thousands of individuals. Drum circles have no beginning or end, no top or bottom. Such a construction places every participant on equal footing, another important component in a therapeutic situation. Drum circles may be facilitated, meaning that they are, to some degree, guided by a facilitator who encourages the participants. The circles may also be anarchic, possessing no formal leadership or moderation.
Drum circles may also have a spiritual focus, which for some is an important component of therapy. The practices most commonly associated with drum circles are Neo-Paganism, sometimes referred to as Wicca, and those of the Native American people. The drum circles of Neo-Pagans can also involve changing, singing, poetry and spoken artistry and are generally anarchic. Those of the Native Americans are usually facilitated by a shaman who uses the music of the circle to enter a trance or go on a spiritual journey.

The most obvious dysfunctional behaviors you will be helped to eliminate are panicking at the first sign of trouble, indulging a pessimism that seems to have a life of its own, using irrational stubborn behavior and having a mindset of HAVING to be right!
Some other defense mechanisms to avoid include blaming others, losing your temper, talking more than listening and using mind-altering substances to reduce anxiety.
It will take work and deliberate effort to remove them from your life but if you do not work on changing these behaviors now you will be prolonging your treatment time.
If you would like more rapidly successful therapy, develop a chart to monitor your progress in reducing these behaviors and work it seriously. Counseling and therapy are often associated with a person who is troubled but intelligent and desirous of enhancing his or her quality of life.
The IQs of those entering therapy are sometimes much higher than those who do not. Similarly, counseling for adults can be easier than for teens; the latter have dysfunctional ways of coping of which they are unaware and sometimes their ability to reflect on their emotions is limited or seems overwhelming.
In some serious cases, patients have to take anti-depressant or anti-anxiety medication along with their counseling and psychotherapy. The most popular kind of counseling today is called cognitive-behavioral.
This type of therapy can sometimes achieve positive results in 3 to 6 months. Patients are taught to become aware of their subconscious thoughts that cause painful feelings or behavioral symptoms.
Also, reviewing your familys history of problems can speed things up by helping you to become even more aware of thoughts and behaviors that have been passed down from generation to generation in your family. Some of your resulting insights will be startling.
How about a technique that could help you replace the family symptoms with more constructive behavior? Sound good? Well, cognitive re-structuring will help you with that.
This technique inventories the subconscious thought patterns you received inadvertently from your family that cause your rage, depression and anxiety to rear their ugly heads. The therapist helps you to discover these unhealthy thought patterns and helps you to almost magically transform them so that your rage, anxiety and depression are eliminated.
This counseling technique is also safe, because it is drug-free and when used by a professional counselor, it virtually has no side effects. Writing your thoughts down two or three times a day, then discussing them with your counselor or psychologist can help minimize and re-shape, if not eliminate, these unhealthy thinking patterns and the anxiety that is caused by them.
Also, practicing time-tested relaxation exercises can help if you are having serious anxiety problems, such as panic attacks or irrational fears. It is likely that genes can play a not insignificant role in the development of your vulnerability to episodes of anxiety or depression.
Some researchers believe that there are certain genes that affect a persons likelihood of developing emotional problems. Some believe that the connection is how certain people metabolize various chemicals and hormones that are related to emotional reactivity; rates and efficiency of their metabolism may be impaired in these people, causing more emotional discomfort.
Stress is clearly related to anxiety and is something that cannot be avoided. It is an everyday circumstance and may arise in any given situation.
Though the link between severe stress and heart attack is established, other dysfunctional behaviors have recently been linked to it: chronic rage and anger.
Although the relationship is somewhat hazy, researchers are learning more about it.
One theory is that anger causes the bodys nervous and circulatory systems to prepare to fight danger, causing blood vessels to constrict, blood pressure to increase and the heart to work harder. This might cause cardiac stress which would be sufficient to lead to a heart attack.

“A narrative or story is anything told or recounted; more narrowly, something told or recounted in the form of a causally-linked set of events; account; tale, the telling of a happening or connected series of happenings, whether true or fictitious” (Denning, 2006).

Your life is a narrative, counted and recounted from many different perspectives, and by diverse people. There are settings, themes, characters and plots – just like in any movie, book, historical account or legendary fable.

In this article we review the approach of Narrative Therapy and how it can be effectively used by counsellors to assist individuals improve their lives.Fundamentals of Narrative Therapy

The Narrative Therapy is an approach to counselling that centres people as the experts in their own lives. This therapy intends to view problems as separate entities to people, assuming that the individual’s set of skills, experience and mindset will assist him/her reduce the influence of problems throughout life. This therapeutic approach intends to place the individual in both the protagonist and author roles: switching the view from a narrow perspective to a systemic and more flexible stance.

Systemic and flexible stance? Yes. The aim is to help clients realise what forces are influencing their lives and to focus on the positive aspects of the ‘play’. In many events of our lives, we tend to focus on particular things and ignore others. Analysing our lives as a play, or a system, helps us understand the different forces and roles that are influencing our behaviour. This in turn gives us flexibility to invoke the necessary changes for improvement.

“The products of our narrative schemes are ubiquitous in our lives: they fill our cultural and social environment. We create narrative descriptions for ourselves and for others about our own past actions, and we develop storied accounts that give sense to the behavior of others. We also use the narrative scheme to inform our decisions by constructing imaginative “what if” scenarios. On the receiving end, we are constantly confronted with stories during our conversations and encounters with the written and visual media. We are told fairy tales as children, and read and discuss stories at school.” (Polkinghorne, 1988)

Merging a familiar set of events (one’s life) to a familiar structure (a narrative story) is a useful strategy. The emotional, cognitive and spiritual perspectives of a person are usually combined in order to derive meaning to an event. In many instances, one or two perspectives will prevail over the other(s), and this will depend upon the particular scenario and the individual’s personality traits.

As an example, we can compare the perspective of two people who have different levels of emotional intelligence. According to Coleman (1998) “intellectual and emotional intelligence express the activity of different parts of the brain. The intellect is based solely on the workings of the neocortex, the more recently evolved layers at the top of the brain. The emotional centers are lower in the brain, in the more ancient subcortex.” Thus, individuals that are more ‘emotionally intelligent’ will draw different conclusions, and behave differently in certain situations.

This is only an example of possible disparities in perception and decision-making. It is the protagonist responding to the setting, the characters, the theme and plot.Techniques and Objectives

“The techniques that narrative therapists use have to do with the telling of the story. They may examine the story and look for other ways to tell it differently or to understand it in other ways. In doing so, they find it helpful to put the problem outside of the individual, thus externalizing it. They look for unique outcomes: positive events that are in contrast to a problem-saturated story.” (Sharf, 2004)

Externalising the Problem

In Narrative Therapy the problem becomes the antagonist of the story. Certain behaviours are based on particular ‘unhealthy’ or ‘undesired’ characteristics – such as lack of patience, aggressiveness, etc. Thus, they are approached as not a part of the client but as an opposing force which needs to be ‘defeated’. An example would be a child that has a very bad temperament and tends to be aggressive to other kids at school and his parents. The child might feel guilty for his temperament and blame it on himself (“I don’t know… it is the way I am…”). The counsellor will work with him towards isolating that undesired trait (aggressiveness) and placing it as an external trait – not a characteristic of the individual.

This strategy helps clients re-construct their own stories in a way which will reduce the incidence of the problem in order to eliminate negative outcomes and reinforce personal development and achievement. The protagonist becomes the author and re-writes the story constructively.

Unique Outcomes

If a story is full of problems and negative events, the counsellor will attempt to identify the exceptional positive outcomes. When exploring unique positive outcomes in the story, the counsellor will assist the client in redeveloping the narrative with a focus on those unique outcomes. This assists the client in empowering him/herself by creating a notion that those unique outcomes can prevail over the problems. Think about this analogy: you are a novel writer. You were given a novel to review and publish the way you prefer. You have read it and found it generally poor, but there were some interesting ideas which you liked. You selected these ideas, and re-write the novel around them. You can make a flawed story become a bestseller.

Alternative Narratives

The focus of Narrative Therapy is to explore the strengths and positive aspects of an individual through his or her narrative. Therefore, the main objective of this therapeutic approach is to improve the person’s perspective internally (reflective) and externally (towards the world and others). Alternative narratives are a simple way to relate to this concept. This technique works in combination with unique outcomes. How? The individual will reconstruct a personal story using unique outcomes, therefore, focusing on the positive aspects of a previous story in order to achieve a desired outcome. This process is based on the premise that any person can continually and actively re-author their own life.

By creating alternative perspectives on a narrative (or event within the narrative) the counsellor is able to assist the client in bringing about a new narrative which will help combat the ‘problems’. This is similar to Cognitive Behavioural Therapy as it aims to create a positive perspective of an event.Boundaries of Narrative Therapy

Despite being a widely used approach, particularly when combined with other therapeutic approaches, Narrative Therapy has certain boundaries or limitations. In many occasions, diverse clients may expect the therapist to act as the expert, instead of having to ‘conduct’ the conversation themselves. For this reason, Narrative Therapy can be challenging when the individual is not articulate. Lack of confidence, intellectual capacity and other issues could also undermine the expression of the individual through a narrative.

Another common boundary of Narrative Therapy is the lack of recipe, agenda or formula. This approach is grounded in a philosophical framework, and sometimes can become a particularly subjective or widely interpretative process.The Leading Role

The most important aspect of Narrative Therapy is to empower the client. Placing the client as an expert, and understanding his/her story instead of attempting to predict it, indicates the therapist’s mindset. The idea is to emphasise the therapeutic relationship, in particular the therapist’s attitudes. This standpoint encompasses many of the important aspects of good interpersonal communication, such as: demonstration of care, interest, respectful curiosity, openness, empathy, and fascination.

Once this collaborative relationship has been established, the counsellor and the client can move forward and work on how to improve the outcomes of the narrative:

“Once upon a time… there was an optimistic, content and productive person…”

References:

Coleman, D. (1998). Working with Emotional Intelligence. (1st Ed.). London: Bloomsbury Publishing.

Denning, S. (2004). Steve Denning: The website for business and organizational storytelling. (www.stevedenning.com/What_story.html)

Polkinghorne, D. (1988). Narrative Knowing and the Human Sciences. Albany N.Y.: State University of New York Press

Sharf, R. (2004). Theories of Psychotherapy & Counselling. (3rd Ed.). Pacific Grove, CA: Thomson Learning.Subscribe to our FREE eZine.

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.

Play Levels Of Social Interaction In Speech And Language Therapy There are different levels of play used in the assessment of children’s speech and language. These levels are used to measure children’s play skills. However, there are also play levels of social interaction that can give a general overview of the child’s play skills. In general, there are six play levels of social interaction that children go through respectively. Each level becomes more complex than the previous one, and requires more communication and language skills than the other. Unoccupied Play The first level of play is unoccupied play. In this kind of play, the child may seem like he is simply sitting quietly in one corner but actually is finding simple things that he sees around him to be rather amusing. A typical adult may not notice that what the child is doing is already considered to be play, unless they observe meticulously. The child may just be standing and fidgeting at times, but this could already be unoccupied play at work. Onlooker Play The second level is onlooker play. In this level, the child watches other children play but doesn’t engage in play himself. This is when children learn to observe others. Such play level can show a child’s attention and awareness skills. Solitary Play The third level is solitary play where the child plays by himself and doesn’t intend to play with anyone else. This level shows an outright manifestation that the child do have play skills, only that it is still at a level that no interaction is required. A child can be at this level when he is already able to play functionally with an object, can play by himself up to fifteen minutes, and is able to follow simple play routines. Parallel Play The fourth one is parallel play. This level characterizes children who play side by side but don’t communicate with each other. Neither do they share toys. It is said to serve as a transition from solitary play to group play and is at its peak around the age of four years. A child is said to be in this stage when he is able to play alone, but the activity he is doing is similar with the play activity that other children beside him are engaging in. The child also doesn’t try to modify or influence the play of other children around him. Here, the child is playing ‘beside’ rather than ‘with’ the other kids in the area. Associative Play Next is the associative play. This is where the children still don’t play with each other but are already sharing the toys that they are playing with. This level shows the child’s awareness of other children, although there is no direct communication between them, other than the sharing of toys and the occasional asking of questions. Their play session doesn’t involve role taking and has no organizational structure yet. The child still carries on the way he wants to play, regardless of what the other children around him are doing. Cooperative Play The last level is cooperative play. This is the final stage wherein the children are already playing together, sharing toys and communicating with each other. This level usually happens at about the age of five or six, where children engage into group games and other highly structured play activities. These levels can be utilized by the therapist as a guide when it comes to the interactions that he wishes to have with the child through play activities.

Importance Of Play In Speech TherapyPlay has a very important role in speech therapy. It is actually one way that speech therapy can be conveyed, especially if the one undergoing therapy is a child.What’s Play Got To Do With It?Play isn’t just used during the therapy proper. In fact, play is already used during the initial phases of assessment. Kids can be very choosy with people that they interact with, so seeing a therapist for the first time doesn’t promise an instant click. Rapport has to be established first, and this is usually done through play.Benefits Of PlayOther than using it as a tool to establish rapport, play also gives a lot of benefits. First off, it gives an over view of the child’s skills, whether it be their abilities or limitations. Then, therapy wise, play can be used to make a child cooperate with whatever exercises a therapist has lined up for him/her. Since play doesn’t put much pressure on a child, he/she would likely cooperate to do the exercises and not know that what he/she is doing is already called therapy.When the child is more relaxed, he can be at a more natural state. If a child is at his more natural state, then his skills could show more naturally. Thus, this would be a benefit on the therapist’s part, since the therapist could get a more comprehensive assessment of the child’s skills. Play could also make therapy more fun and less scary. Since play is an activity to be enjoyed, the child would not get bored with monotonous therapy activities that seem like chores, rather than activities. Play As A SkillIn fact, play is considered to be a skill itself, because it is a natural activity that children do. If a child doesn’t play, then there must be something wrong with him, most probably with his Inner Language skills. This is because; play is a representation of a child’s inner language. This is just one of the many reasons why play is important. It actually has a domino effect, if you look at the bigger picture. Play is needed to have Inner language, which is in turn needed to have Receptive language that is a prerequisite of Expressive language. Thus, if a child has no play abilities, then his whole language system may be affected.Play And CognitionPlay is also a basis of a child’s cognition skills. The more developed a child’s play skills are, the higher the probability that his cognition skills would be at a fair state. However, play and condition are not the same. Play is more likely a prerequisite or a co-requisite of cognition.What Parents Have To SayUnfortunately, most parents may have a negative impression when they see the therapist playing with their child. Initially, parents get surprised and shocked that they paid a very valuable amount for therapy, only to find out that their child would only be playing.That’s why it is very important for therapists to explain the procedures that they are going to do with the child to the parents. To make the session more interesting, the therapist could also include the parent/s in the play session with the child. In this way, the child would definitely think that it is a play session. Additionally, the parent can also do the play activity at home with the child. Doing this, could serve to be practice of the targeted skill of the play activity.

Steve Cownley

http://www.health.comyr.comhttp://www.allsortsofbits.comoj.com

People who suffer from panic attacks experience symptoms such as heart palpitations, sweating, loss of control, feelings of impending doom, disorientation, and feeling trapped. Although those who suffer from this disorder feel debilitated, it is one of the most manageable syndromes to treat through the use of cognitive-behavioral therapy.

When people first come for cognitive-behavioral therapy, they may indicate that they have received prior counseling, have made innumerable visits to doctors, and have been treated in emergency rooms for symptoms associated with their anxiety. Patients are usually desperate for answers to alleviate their on-going struggle with panic. Patients are relieved to know that their symptoms are treatable through the use of cognitive-behavioral therapy. Often, patients feel that they are going crazy, although they need to be reassured that having “crazy” feelings is a cognitive distortion and is vastly different from those who might be considered clinically crazy.

Most individuals know the time-frame when they first started experiencing panic attacks. There may have been triggering events that fostered the emergence of panic. The patient may be unable to make an association between the panic and a painful triggering experience. Factors such as a significant illness, job stress, family abuse/ trauma, losing a loved one, and lacking emotional expressiveness may create conditions ripe for panic. Once a panic attack erupts, further attacks usually follow if an individual is not aware of the cycle of self-defeating thinking and behavior which sustains the panic process.

The key to curtailing panic is to help people understand that it’s the secondary symptoms that keep the panic alive. In other words, it’s the “panic over the panic” that sustains the panic pattern. With cognitive-behavioral therapy, recovery involves educating the sufferer on ways to respond to their self-defeating thought processes during the onset of their attack. For example, let’s say that you are taking a mid-term exam during college. You open up the test booklet and immediately react by saying, “Oh my God, none of this material looks familiar; there’s no way that I can pass this test; if I flunk this test, I might fail this course for the semester; if my parents find out, there’s going to be hell to pay!” In contrast, you can learn to respond rationally by saying, “Wow, some of this stuff doesn’t look familiar; just take some deep breaths and relax; I guess I better survey the whole test, answer the questions that I can and then go back and work on the other one’s; I can tackle this test, I just need to relax and be patient!”

How one responds to panic determines whether it subsides. Those who fight with their panic by “awfulizing” about their symptoms, intensify their panic. They may say, “Oh my God, here come those unbearable feelings again – I feel like I’m going to die!” However those who accept their panic and respond rationally with thoughts like, “Here comes that panic again – just calm down and take those deep breaths and it will eventually subside. These feelings won’t last forever, they are time-limited – they’ll be gone soon.”

Learning through cognitive-behavioral therapy to go “down stream” with panic is important to its eradication. Those who “catastrophize” about their symptoms intensify panic attacks. Learning to rationally respond to panic diminishes its effect. Trying to figure out what caused an individual’s panic is not necessary to treat it. What is essential is teaching those who suffer from panic to respond with positive self-talk.

People who experience panic attacks tend to feel ashamed of their problem. It is important for sufferers to understand that they are not alone – anxiety is apart of the human condition. Anxiety and panic is not unusual and those who experience it need to learn to be more open and expressive with all of their feelings. Sharing a wide range of emotions with those you can trust is essential to the healing process. Those who hide panic as a shame-based pattern set themselves up to repeat it. When those we trust are aware of our authentic self, which includes our vulnerability, our anxiety problems tend to fade in significance.

Paradoxical interventions can be helpful in dealing with panic disorder. Having a patient schedule a panic time and encouraging them to perseverate can bring humor and assist in breaking the panic cycle. A ruminating patient might be asked to conduct cardiovascular exercises during panic-related chest tightness to try to lighten the moment and break the cycle of suffering. Cognitive-behavioral therapy is a structured, pragmatic approach which assists people in addressing the symptoms of panic by learning to respond to the disorder with a positive approach to their thinking.

Exposures involve voluntarily bringing on a mild to moderate level of anxiety In other words, exposures show you ways to face the demon, challenge him head on, and kill him once and for all.

There are two keys to exposures:

1. They have to be voluntary (which means that you can’t do them all the time, because you won’t always be in the mood)

2. If you imagine your anxiety from a 0-8 (with 0 being calm and 8 being a panic attack), you want to hit a 4 during any given exposure (because if you go above a 4, the anxiety might get ahead of you and no longer be voluntary and under your control).

Exposures are used to gain mastery over any phobia. They work for panic disorder because the core of panic disorder is usually phobia as well: A phobia to certain physical sensations. Whether it’s a racing heart, dizziness, nausea, a choking sensation, or a certain pain, every panic disorder patient has at least one or two physical symptoms that trigger their panic cycle. Exposures show you how to experience these sensations in such a way that you finally stop being triggered by them. After 1-2 months of exposures, most patients find that coping techniques begin to be effective (i.e. the shield actually starts working). Once patients are good at exposures, they can often use them to actually stop a panic attack that is coming on. In other words, once the demon appears, they can turn the tables on the demon, challenge it, and get it to run scared with it’s tail between it’s legs. After several months of exposures, most of my patients become completely panic free (and can usually be taken off on any panic-related medications they have started).

Exposures are at the heart of Cognitive Behavioral Therapy, and they are by far the most useful techniques for killing the Demon and gaining mastery over panic once and for all.