REBT Treatment of Anxiety Disorders

Hello everybody. I am Dr. Steve Johnson, and welcome to this webinar in which I will be covering the REBT treatment of anxiety disorders.

Uh, just wanted to announce that this is one of the, one of the last three webinars that I will be doing. I've created an opportunity for individuals who are interested in monthly webinars and, uh, weekly videos on, uh, psychotherapy related topics. They can become members of my, uh, of my channel. But there will be more of an announcement about that, uh, on the, uh, YouTube, uh, channel, Psychotherapy Education and Training.

But for now, let's jump into, um, the presentation for today, again, which is REBT treatment of anxiety disorders. Let me just cover quickly what I will be, um, talking about. Um, not each of these will get equal treatment. I will very, very briefly look at evolutionary origins of anxiety and, of course, the neuro-psych, uh, uh, origins of anxiety. I think we often neglect that in present REBT presentations, but it's tremendously important because they also give us, uh, the basis for additional REBT kind of treatment plan. So I will be looking at that. Look at typical anxiety symptoms and discuss when anxiety becomes problematical, when we call it a disorder, particularly according to the DSM-5.

But more importantly today, the main part will be on the REBT conceptualization of anxiety. How does REBT look at anxiety? And then, based upon that conceptualization and the components of that conceptualization of anxiety, what form do we have in terms of cognitive and behavioral interventions? Cognitive restructuring and then also behavioral interventions. And then I'm going to look at, and this is based upon some of that evolutionary neuro-psych origins of, uh, anxiety, what we can do visa connection with others and how would that help or not help in the treatment of anxiety. And of course, I will leave time for Q&A. If at any time during the [Music] um, during the, um, U presentation, you have questions, feel free to, um, feel free to, uh, just, uh, message me, make the comments, and then I will get to them as I, uh, as I can. This will be recorded and, um, posted, um, on my YouTube channel, um, sometime after, um, after the presentation.

Okay, so, um, let me move into it. If we look at the evolutionary neuro-psych origins of anxiety, as I often talk about the brain, the brain has a primary function, and that is survival. And and that's based upon perceiving two things within the environment: the perception of threat, especially some kind of overwhelming threat to the self, and perception of resource and opportunity. Threats may harm us, resources keep us alive. So when we, when the brain perceives, uh, what it takes to be threat within the environment, we see a cascade progression of activation that occurs, you know, within the body. And I'm not going to go into that cascade progression. In recent, um, videos that I posted on the, my YouTube channel, I've covered that. But I want to look specifically at one, and that is the HPA axis. The HPA HBAA axis is involved in the production of cortisol. When the brain perceives an environmental threat, what does it do? It gets us ready to address the, uh, threat. And, um, and that's good. We want the production of cortisol to get the body in a state of readiness to take on the threat, or depending upon our species and specific characteristics, um, how we will take that on, whether we attack, whether we retreat, whether we play dead, as some animals do. Um, so the initial production of cortisol is tremendously, tremendously important.

The trouble is when there are high levels of cortisol within the body over a long period of time, and that creates some problems for us because those high levels of cortisol over a long period of time increase the, um, blood pressure, that contributes to cardiac problems, you know, stroke, etc., heart attacks, um, increases the incidence of diabetes, and then also increase incidence of dysfunctional emotion such as anxiety and depression, etc. And suppresses the immune system. Initially, um, there's an up-regulation of the immune system, but over time, it, the cortisol can suppress the immune system and increase inflammatory response that causes all kinds of autoimmune diseases, etc. So, initially fine, the cortisol production, but high levels over time, uh, problematical and may, may contribute to the development of dysfunctional emotions.

Now, if we look at anxiety, what are the symptoms of it? And, you know, uh, there are a huge number of symptoms for, uh, for anxieties, uh, cognitive symptoms, physiological symptoms, and even behavioral symptoms. But just some of them I listed here, and some of them are really obvious, you know, restlessness, feeling panicky, fear. I do want to say something of throughout this presentation, and most of my presentations, I don't distinguish anxiety and fear. I know Freud made a distinction, and there are many individuals who see anxiety as kind of inwardly of focus, whereas fear is outwardly focused. Um, I don't, um, make that distinction. I really look at how we can treat whatever it is, um, whatever the symptoms are that, that, that come up, no matter what the word is for it. Um, it can be, it can cause uneasiness, nausea, CR, and really important is sleep-related problems, um, that can take many different forms, either excessive sleep or sleeplessness, etc. You know, many of you, um, you know, if you've had anxiety, your clients have anxiety, they may complain of cold or sweaty hands, maybe numbness in the hands or the feet, difficulty breathing, shortness of breath, heart rate may go up, chest pains, dry mouth, um, trembling, dizziness.

And then behaviorally, which we will look at today because we want to look at the treatment of the behavioral, uh, response to anxiety, is, uh, the avoidance of situations that we perceive as the cause of our fear. In REBT, we wouldn't say it actually causes the fear, but it is certainly relevant to the, um, produ, you know, to the, a, avoidance that we experience. So, um, avoidance would be a very, very common kind of behavioral response when one is experiencing anxiety, and that can even take in exaggerated forms, obsessions and compulsions. Remember that OCD used to be, um, listed as an anxiety disorder by the, um, DSM. It no longer is. U, that doesn't mean that OCD has lost its anxiety. It's just that OCD now has kind of its own category, and but it still has a large degree of anxiety associated with that. So these are some of the typical, I mean, typical anxiety symptoms.

So when do those symptoms become a disorder? Now, this is according to the DSM, and I am generalizing what the DSM actually, uh, has to say about this. The, um, when the anxiety disorder becomes excessive, you know, it's really intensive and it lasts, um, at least six months, uh, in length. So there's a time period criterion. The ability to control, if the individual has great difficulty controlling that anxiety, then it, it becomes a disorder. And if there are associated symptoms, the anxiety and worry, according to the DSM-5, need to be accompanied by at least three other, uh, symptoms, and those can be cognitive, behavioral, or some combination thereof. And then, then of course, the level of distress or impairment. For it to be a disorder, for anxiety to be a disorder, there needs to be significant distress, or the anxiety needs to impair our social or occupational functioning. In REBT, we would say that it gets in the way of us, uh, achieving our desired life goals. That's exactly the kind of impairment that raises anxiety from the level of just normal anxiety to problematical anxiety, at least according to the DSM-5. Our clients are going to be terribly interested in that distinction. Um, they just know that they often just don't want that anxiety. That it's getting in the way of them achieving, uh, what they want in life, and even, uh, experiencing the life that they want.

So let's move into the REBT conceptualization of anxiety. So when we do this, one of the things that we do initially is, if a client comes in and they are saying that they're experiencing anxiety, we would want to assess the reality of the anxiety, not the word anxiety. And a lot of people do this. I have my, my graduate students, sometimes the client will say that they're anxious, they will assume that from the REBT perspective that it is indeed anxiety, and they will see it as problematical and dysfunctional. We don't react to the word. We react to the reality to which the word is pointing. And sometimes the word is pointing to something that we would not call anxiety with an REBT or according to the DSM-5. It may be really pointing, what they're calling anxiety may actually be depression or whatever. We take seriously what they have to say, but we want to assess whether the word they're using corresponds to what we would need to understand about whatever the phenomenon is, so we would know how to better help that client. Um, and so within REBT, in the conceptualization, we would want to determine whether whatever the word is that the client uses, that the reality impairs or inhibits the attainment of their desired life goals in one or more of the domains of, uh, domains of life.

We, and then the other, other, other parts of the conceptualization of anxiety is, we want to identify relevant cognitions that the client has, relevant forms of thinking. And the two forms of thinking that we zero in on when in REBT would be inferences, um, and beliefs. What's the difference? Um, inferences are thoughts or cognitions that attribute meaning to a situation. So, um, the inference of a client would be the meaning that they're given, giving to a situation, event, or to be more general, a state of affairs. Another way to say that is, um, an inference is the interpretation the client makes of the event or situation. Now, that is in distinction to, uh, beliefs. The other form of cognitions that we look at very carefully within REBT, beliefs are cognitions, they're forms of thought, but they don't evaluate the meaning of a situation or event. They, um, they evaluate the meaning that is a, uh, attributed to the event or situation. So they're evaluating the situation, not giving meaning to it. Okay.

So in the conceptualization, we want to make sure that what the client means when they're talking about that particular word, and anxiety, we want to make sure that that anxiety is dysfunctional in the sense that it impairs or inhibits the attainment of the desired life goals of the client. We also want to know what the relevant cognitions are that the client has, and I'm going to go into those in a little bit more detail in just a few minutes. And then the third thing that we want to look at is what we would call the behavioral potential or the, uh, action potential associated with anxiety. Okay. So these are the three things that we want to look at as we get ready to understand the emotion and get ready to, uh, form a treatment. Okay.

Um, and, and of course, you know, just keep in mind that all of this is for educational purposes. Or certainly not, um, you know, sub, you know, talking about an actual treatment that we need to give a client. We're not talking about specific clients. If individuals have anxiety, you or someone you know, then it's very important that they go to a licensed mental health, uh, professional. But these, this is just, uh, for educational purposes.

Now, what is the importance of the conceptualization of anxiety in the treatment of anxiety? Well, it's going to give us, if we do the conceptualization well, it's going to give us some vital information. It will identify the inferences and beliefs that warrant that we do cognitive restructuring. I'll cover cognitive restructuring in a few minutes. It will help us to identify the behavioral symptoms that may warrant behavioral interventions, as well as cognitive interventions. It will help us actually create a provisional treatment plan, and it will give us some objective measures for the progress of therapy. We always need some objective measures. Okay. Um, subjectively, we always ask the client how they're doing, but it's very important that we have objective measures for the progress of therapy, in part because research shows that often therapists, um, overestimate the progress of the therapy. So we need some objective measures to ground our assessment of the progress of, of therapy. And again, any questions whatsoever, feel free to just message me, make a comment, and I will address that as I can.

Now, I want to go into those cognitions because they're going to be very important in the treatment of anxiety disorders, and I already said that, uh, and I'm going to zero in on inferences. And I've already said that inferences are cognitions or thoughts that give meaning to a situation or event, or they can be thought of as the client's interpretation of a situation, event. REBT conceptualization of emotions holds that each emotion has a particular inference. This is tremendously important. REBT theory says that the conceptualization of emotion holds that each emotion has a particular inference. So anxiety has a particular inference, depression has a particular inference, anger has a particular inference, same with guilt and shame and remorse and jealousy, etc. All of them have a particular inference associated with them. There may be multiple inferences, but there's at least one very particular inference. The inference for anxiety is that there is a presence of threat to the client. There's an environmental presence of threat to the client. Now, sometimes the presence of threat is internal to the client, but generally, it's going to be external, that there is, um, a perception that there is in the environment, external environment, a threat to the client. They may be right, may be wrong, but that's their perception, and perception has emotional and behavioral consequences. So we take that perception very, very seriously. There's no argument with the client about whether the threat is actually there or not. I mean, that may be what friends do with each other, no, there's no, no threat. But we don't do that within therapy. We will take the perception of threat of the client very, very seriously.

And this, um, inference of the presence of threat is in large part due to, remember the brain's primary activity of perceiving threat or resources within the environment. The brain perceives threat in the environment to keep us alive. That's the main, the one of the main goals, or to perceive a resource. In anxiety, the brain is perceiving threat. The brain, but, and, and let me say this because this is tremendously important, the brain frequently perceives threat when there is no real threat. Why? Because the brain doesn't perceive a bunch of details of what's in the environment. It perceives a pattern. It perceives pattern. Why does it see patterns instead of particularity? Because it, the, uh, brain would need to prepare the body to react to the perceived threat quickly and doesn't have time to sift through all the detail of that. But because the brain perceives patterns of threat rather than particularities, the brain often makes mistakes. So what? Well, one, it's a really good. So what is it keeps us alive? The downside of that is that we may experience anxiety or fear, uh, needlessly, right? And that's unpleasant. Let me give an example. Let's say I'm, don't, you know, take care of my club at the end of the day and I just throw it on the back of the chair or something. Wake up in the middle of the night, I look over and I see, I perceive there's somebody sitting in the chair, and then I have this immediate reaction until I get myself, um, you know, calm down and I realize I just do the, um, my clothes on the chair. But if there were a real person in the room, then that excited, uh, state would be important for me to be ready to take, uh, action. So the brain prepared me to get ready when it was just me being, you know, uh, very casual in the way that I tossed my clothes onto onto the chair. Okay.

So, um, the brain's perception of threat when there is no real threat keeps us alive. That's a really good thing. But many times, we're just going to experience need anxiety or fear, whatever. So let me give some examples of inferences that are associated with anxiety, fear, for example, um, and, and again, it's not even these sentences. We have to look at what the client means by these sentences. We don't take words overly seriously, and we don't take sentences overly seriously. We look more at how embedded they are, what's the context, and so talk to the client about the context and what they really mean. So, for example, one would be, "Tom hates me and he's going to hurt me." Okay, that's the attribution of threat. Or, "The people in the audience are judging me and thinking that I'm stupid." We don't know, but that is the meaning that the individual is attributing to whatever they see. Okay. "This diagnosis could cause my, uh, death." Okay, so that's the meaning they're giving to a medical diagnosis. Or, "Driving on this highway isn't safe." See what I mean? So, um, these are attributions of meaning or interpretations of something that the individual, uh, perceives. Now, really important here, inferences are either true or false. However, the possibility that something is true or false is quite different than whether we actually grasp the truth, because sometimes we don't have enough data to know whether it's true or false. But an inference, hypothetically, has to be able to be either true or false. There must be a way to falsify the inference by appealing to data.

Okay, let's move on. Now that we've looked at inferences, which are going to be a tremendously important part of the development of an anxiety disorder, a client has to have this inference that is attributing a threat to the environment. Beliefs are a different kind of cognition. They're not an attribution of meaning. They are an evaluation of the content of the inference. So this is very straightforward within REBT, and it's, um, it's one of the things that I love about the model is that, um, there, there's not a long list of beliefs that you really have to consider. There are only four types or categories of beliefs, and then they can take many, many different forms. But once you know the categories of beliefs, these are categories of dysfunctional beliefs. Once we know those categories, then it makes us, uh, much more capable of navigating through what the client is saying about the threat that they're perceiving in the environment. One, and we call this the core, uh, disturbance produced, uh, belief is demandingness. Demandingness is going to be present in every form of, um, anxiety, okay, in every case of anxiety. Demandingness, and I'm, of course, I'm speaking in English here, so I don't know all those other languages. But in English, there are certain words that kind of signal, uh, a demand. They may signal it, they may not signal it, but if they're there, we want to follow up to see whether the client actually was making a demand or not. And those words in English take the form of should, ought, must, have to, or need. So we hear those kinds of words, we want to follow up to see whether there is a demand. We don't become rigid in word police. Okay, we don't jump on those words and assume that they're making a demand. We always have to talk to the client to see whether, uh, the client has some form of demandingness. So the presence of the word does not indicate a demand, but how the word is being used by the client. Therefore, the therapist should always assess the meaning of the word as used by the client. Again, don't react to words, react to the reality behind that word, and we only know that by talking to the client. We cannot know that a priori.

The second category, uh, of these, so demandingness is the core, and then the next three are what we call derivative. They are, you know, more or less added to the demandingness. Sometimes there's just demandingness, sometimes there would be one or more of the following derivatives. And one derivative is what we call alizing, or what our friends in, uh, CBT called catastrophizing. And alizing or catastrophizing is a particular kind of belief that the, the situation or the event is as bad as that, as it could possibly be, in the sense that it has the potential, perhaps, to destroy any meaning, purpose, or potential happiness in my life. Now, um, if we're alizing, that's usually going to be exaggeration, right? So that's why we would call it dysfunctional. We can alize it. Now, however, if somebody says, "Oh, oh my gosh, this is awful," they may not mean that it's awful. I mean, like in New York, I might go, "Oh, the subway, it's awful down here, right? The heat down here." Well, it's, you know, it's not going to destroy my meaning, purpose, or potential happiness. I'm going to get off, and even I'm, I'm there. What's the worst I'm going to be? I'm going to be perspiring and soaking through one of my shirts or whatever.

This is another form of derivative: frustration intolerance. This is when we believe that a situation is utterly unbearable, that we absolutely can't stand it. Now, I want to come back to that because that one's a very important one, and it's almost always present with anxiety, not, not invariably, but almost always. And then the third derivative is what we call global negative rating of, what? Global negative rating of the self, of others, life, world, or Wendy Dryden talks about, um, the global negative rating of our own psychological processes. We may have a global negative rating of the way that we're thinking. We may have a global negative rating of our emotions, right? I mean, people who grew up thinking that it's horrible to be sad may have a global negative rating of their sadness, when sadness might be quite functional. So you see what I mean? Global negative rating of self, others, life, and world. This means, um, it's global and it is negative. Okay. So we want to look at how pervasive and how bad is the perception of those elements. Now, could you have global negative rating of more than one of those? Absolutely. Absolutely. And sometimes clients do have a global negative rating of, of, of several of these. And so we would want to know about the presence of any or all of them.

Now, when we are doing a conceptualization of emotion, we want to check the presence of all of these, uh, beliefs, whether or not they're, they're there, and, um, and whether there are multiple. So, for example, um, if you're talking to a client and they're very demanding about a situation that it must not happen, etc., do they also have other forms of demands? Because we're going to have to deal with each one of the forms of demand that the client has. We don't just deal with one, we deal with all of them, not all at once, we deal with them sequentially. Um, we want to see, same thing with alizing. Maybe they're authorizing about a number of things that are contributing to the anxiety. Well, what is it that they're authorizing about? Now, um, and the same thing with frustration intolerance, and the same thing with global negative. We try, you know, in philosophy, we say it needs to be exclusive and exhaustive. We need to see, we want to exclude whether there are some forms of dysfunctional beliefs that are not there, but we do want to be exhaustive in the number that, um, of, of dysfunctional beliefs that are there.

Now, let's be quite honest, um, we may not get all of those in the first session, in the, you know, in the intake. We may not get those. The client may reveal those over time, and sometimes the most difficult of them, they reveal over time because they are now comfortable with us, they trust us, and so they may reveal those that they may, especially kind of global negative rating, etc., right? So, um, you know, give it time. We're not going to just, it's not a once and for all this kind of assessment. May be going on throughout, um, throughout therapy as we uncover, uh, more information, or the client comes in and they have many different, you know, new events that they're, that they're talking about.

Now, let me give some examples of these typical beliefs that are associated with anxiety and fear. Demandingness, for example, "I absolutely must not get sick." Um, and so, "absolutely must not" may be equivalent to "can't." "I can't get sick." "I cannot get sick." That's, uh, so be, be flexible about this. And, and this is why I don't want us to, you know, us to react only to the words should, ought, must, have to, or need, becomes because sometimes the client is, um, you know, exhibiting demandingness, but they're not using those words. So, for ex, this is an example of that. "I can't me, I must not get sick." "My spouse ought never to look at someone else who is attractive." Or, "I have to get an A on this exam." All forms of demandingness, after we talk to the client, right, to see what the context is of this, and if they're really being demanding.

Alizing or catastrophizing. Some examples that may be examples of alizing, catastrophizing are, "It would be awful if I got kicked out of the psych department." Right? They just say, "Ah, no, not a good enough student for the PhD, and I get kicked out." "It would be the end of my life if my spouse left me." Or, "If the Cookie Monster gets elected president, it would lead to the destruction of democracy within the United States and perhaps the world." Right? This is awfulizing or catastrophizing. Again, if the person means it. If they're just talking and they're exaggerating, that's a different thing. That's a speech act. But this is whether the reality is that they're alizing or catastrophizing, and you're going to discern that.

Frustration intolerance. "I can't stand it when my kids don't listen to me." Or, "I can't stand it when people drive under the speed limit." Right? "Can't stand people who lie to me." If they really mean this, these would be examples of frustration intolerance.

And then global negative rating. "I am a total loser." Notice the global nature of that and the negativity of that. "People who don't vote are horrible people." "My life has no meaning now that I lost my job." "The world's a terrible place, filled with nothing, nothing but suffering, um, a valley of the shadow." "My thoughts recently have been utterly negative and horrible." Notice this is a global negative rating of a psychological process, the process being thinking. Okay. So it's not just self, others, and life world, but also potentially global negative rating of psychological process, believing or thinking.

Now, what do we do with this? So let's say we have, uh, identified all of the dysfunctional beliefs. We don't just stop there. This, that's when we begin to, um, do a cognitive restructuring. Uh, and so we've identified all the relevant beliefs held by the client about what? Well, about in the ABC model, we would say the activating event, or more specifically, the critical activating event. And if you're wondering what we mean by critical activating event, because maybe you studied REBT long before we actually began talking about a critical activating event, critical activating event is really simple. Don't make it something complicated. The critical activating event is just that part of the precipitating event, that part of the activating event, that part of the adversity, right, that is most relevant to the dysfunctional emotion, behavior. Uh, an example I often give is, um, if the person, um, uh, is, you know, angry because they just got fired, and we go, uh, we don't just assume that getting fired is what is causing the anger. We would say, what part of that? What part of getting fired? And the client may surprise us in terms of what part of getting fired was most relevant to their anger. They might say, "It was the condescending way in which the boss fired me." Waited. Oh, or they might say, "They waited till, um, I finished a big project and then they fired you know, they were manipulative, etc." So that part is going to be what the critical activating event is. And why is that important? Because when we talk about that critical activating event, we have more access to the actual beliefs and the emotions that the client has.

Now, uh, if you have, if you come from a model where a lot of work is on early childhood stuff, um, let me just say one thing, and that is in REBT, we do believe that early childhood events, you know, all the things that are measured by ACES, are are relevant. It is that place where we've formed that the way that we look at the world, the meaning we attribute to relationships, and all kinds of things. We don't ignore that, but we believe that often that's that kind of, um, uh, history, uh, becomes present as we're working in the moment, because those beliefs that were formed in early childhood or even later, um, come up in therapy today in the present activating event. So we don't, so, um, what we wouldn't say is, let's say that person's angry, we wouldn't say, "Oh, it's because the mother or the father was condescending." That may be a reality. Now, and if the client is thinking about that early memory, right, having that memory, and that's what they're focusing on, then that memory is the critical activating event. If they're not focusing on it, it may be operative, but that's not what they're focusing on right now. So is the critical activating event is what they're focusing on right now. Now, understanding why that is there may be related to the event that happened in the past, but we deal with their reaction to things that, that were due to the past, based upon what they present in the present. Okay. So we don't do an archaeological dig. We will certainly be discussing the past and how it's relevant, but, um, the critical activating event is going to be in the, in the present.

REBT theory holds that every dysfunctional emotion or behavior is directly caused by demandingness. I already said that when I said that the demandingness is the core belief, and that there may or may not be some of the derivative beliefs. Remember, those are alizing, frustration intolerance, and global negative rating, self, others, life, world, and psychological processes. Okay.

Now let's move into the cognitive restructuring. What do we do? Well, we have disputed each of the dysfunctional beliefs that we have identified. Remember I said we try to get as many of those, we try to be as exhaustive as possible, but we may not be able to get to all of those in one setting and in one sitting. So we identified each of the dysfunctional beliefs, we've disputed them one by one, right? By the way, we dispute them one by one, and we fully dispute and replace the dysfunctional belief with a functional belief before we move on to the next, next dysfunctional belief. We don't dispute all of the dysfunctional beliefs and then begin to sequentially replace them. You dispute a dysfunctional belief and then replace that with the functional belief. But you don't try to replace it. So I've seen a lot of students said, as soon as they get the dysfunctional belief, they just want to replace it. They said, "Well, might you might, what if you set thought this rather than that?" And they just supply them with that. There's a problem with doing that. Is it horrible? It may not be actually horrible. However, the problem with that is the client may not yet be convinced that their belief is actually dysfunctional. And if they don't believe it's dysfunctional, why would they want to replace it? So part of dis, what the reason for going through the disputation of the dysfunctional belief is to help the client see that it is not helpful. And once they realize it isn't helpful, then they'll be much more motivated to replace it or even experiment replacing it with a potentially more functional, uh, belief. Okay, that's the function of the dispute.

And there are, um, types of disputes, right? And I want to just, um, I've covered these in other webinars, and if you go and look at those webinars on my YouTube channel, Psychotherapy Education and Training, you'll find these in great, great detail in, in different, uh, different videos. But I've tried to list the typical, um, types of disputes in order of most effectiveness. This is generally, don't take this as the, this for any given client is going to be the order of effectiveness for that particular client. This is generally okay. So, and so often when I'm working on helping the client learn how to dispute their beliefs, I proceed in this kind of order, not always, but generally.

The first kind of dispute is what we call the pragmatic or functional one. Typically for most clients, this is the most effective and it's very easy. Um, we don't make it into something complicated. We, we're asking, how is holding that dysfunctional belief helpful to the client? So we already looked at some examples of, of, um, the dysfunctional beliefs, right? And we've given categories of those. And so whichever ones the client has, if we're going to do a pragmatic or functional dispute, we simply ask them, "How is holding that belief helping you?" And sometimes after we've done that, we go, "Okay, and how is it not helping you?" Okay. So once we've gotten them to recognize that, "Wow, you know what, um, it's not helping me." Now you go, "Isn't that obvious to a client?" Not always. Sometimes they have, they haven't thought of that before. They've just held it because it's habitual, it's habituated. So we ask, "How was holding that belief, um, dysfunctional? How it's getting in the way of them attaining, you know, happiness and desired life goals?" Um, and once we do that, then we might say, "Well, if it's not helping you, is it hurting you anyway?" And so we get more buy-in there.

The empirical dispute. The next typically most effective is where we ask the client, "Where's the evidence that supports the dysfunctional belief, or where is that belief written?" Okay. Now, sometimes a client will say, "Here's the evidence," and the evidence they give us is not showing that, um, you know, is not showing us that the belief is, um, uh, bad, etc. It may be that it shows, there, it's evidence that, yeah, it's not desirable, but it may not be evidence for it's horrible, or that they can't stand it. Okay. So, um, we have to help them see what they think is evidence for the belief is not really evidence for the belief. It would be evidence for not wanting that situation to occur.

The friendship dispute is tremendously important. In general, we don't use this friendship dispute when we're dealing with a client that has anger or rage, but in anxiety, yeah, we may use it. And this is where we ask the client, um, what they would say to a friend who held the dysfunctional belief that the client is holding. So, let me give an example. If the client held the belief that they were a loser, ask what they would say to a friend who held the belief that, you know, that they were a loser. And I often will sometimes use a little bit of humor and say, "Hey, would you say to your friend, 'Yeah, I've been meaning to tell you that you are a total loser'?" And they just smile and go, "Of course not." I go, "Why not?" "Well, it wouldn't be help, it would, you know, it would hurt them." And I'm like, "So why are you saying it to yourself? You know, if you wouldn't say that to a friend, why wouldn't we be a friend to the self and not say that stuff to us?" Okay.

And then the logical dispute, which often is the least helpful, but having said that, I have clients who absolutely love the logical disputation and find that to be the most helpful. This brings up an important issue, and that is, uh, we want to try all of these, uh, especially in the early sessions, because we never know a priori which one is going to be, you know, which one's going to be most helpful for the client. So try them all, and then the client will tell you which one seems to be most helpful for them. The logical dispute is, we ask, "How does it logically follow that because they want something to be the particular way that it must be that way, right?" Or some similar statement that, "How does it logically follow that because they want something? How does it logically follow that because you want your spouse to listen to you when you talk about something important, that they absolutely have to do it? That they have to do it?" They don't. They have free will. They don't have to listen if they don't want to. So the logical dispute may be, you know, uh, helpful for a good number of, a good number of clients. So use them all, especially in early sessions, and then try to find out which, from the client, they'll let you know which ones, uh, which one or which ones work better than the others.

Now, those are the types, and then there are styles, um, and when it comes to the dis, styles of the disputation or the disputes, we usually begin with the Socratic. And what does that mean? You know, Socrates, if you ever, um, you know, in college, you read or high school, you read the dialogues of Socrates, he would ask, he would pose these questions, you know, he was like setting people up and asking particular questions, uh, and, and that was the example that I gave already. If I said, "How is holding this belief helping you?" then I'm using a Socratic style. Okay. Now, this is usually the best one to begin with because it gets more engagement of the client. The client has to begin to think about that. However, some clients, um, don't respond well to that. They have trouble with the Socratic one. You know, no problem. We're all different. There. So sometimes we kick into the didactic style of disputing. What does didactic mean? It means teaching or informing. Let me give an example. Some people might, we might say to them, "Some people might find holding that belief has been unhelpful to them. For example, the belief that makes them feel defeated or unmotivated. When they hold the belief that you're talking about, then they feel defeated or unmotivated. Do you find that true for yourself?" Ah, okay. I get that. So we're didactically teaching about that disputation, right? And we were doing a little teaching, a little informing. But for many clients, that's where they begin, and then maybe they learn how to approach it more Socratic, um, later, um, later on.

And again, what's the whole purpose of disputing? The main goal of disputing a dysfunctional belief is to help the client realize in what ways holding that belief is really negatively impacting them. Impacting them about what? Impacting what? How they reach or don't reach their desired life goals. Does holding that belief help you reach a desired life goal? Okay, fine, hold it. If that belief is not helping you do that, if it's getting in the way of you attaining what you would like to attain in life, then let's consider, um, the ways that it's not helpful, and then maybe replace that. Okay. So in some ways, we're helping the client realize it, and it may be more motivational for them.

So once that disputation is completed, and initially this entails using all the different types of disputes, right? We're going to begin to replace the dysfunctional belief with the functional alternative belief. So let's look at that. So here's what we do. I've given you kind of the categorization of this, um, and, um, we've, we've had the dysfunctional beliefs, we've already identified them, we've helped the client, we've identified with the client, we've helped the client, um, through disputation, realize that it's not helpful for them. Now we're at the point where we want to dis, replace the dysfunctional belief with a functional alternative. So instead of demandingness, you know, the shoulds, the oughts, the wants, the have to, and the needs, what we want to do is replace it with preferential ones: "Oh, I wish, I want, I hope, I desire." Because if we have a wish or a want, and it doesn't happen, we may be disappointed or feel a bit down. But if we have a demand, and it doesn't happen, then we may be much more, uh, disturbed or disturbed about about that.

What about alizing and catastrophizing? What would we want to put in place of the alizing or catastrophizing? We want, we would like to have them, um, believe that the situation is, yeah, it's negative, it's bad. We're not going to play games and say, "Oh, no, it's a blessing in disguise." It may not be, right? Or it might be. But better that we just say, "Okay, let's acknowledge, you know, the badness or the negativity of that situation. Let's do that, but realize that it is not negating all meaning, purpose, and potential happiness in life." If we move that down, right, to accepting the situation. Acceptance is a huge first step, absolutely huge first step for them to make significant changes that will help them mentally and emotionally and behaviorally.

What about frustration intolerance? The "I can't stand it-itis." We want to replace that with, "Accept the situation as really undesirable." I often say, "Yeah, I wouldn't wish that on my worst enemy, but you're standing it, right?" So often, just pointing out that, yeah, it's not, who would want to go through this? It's not desirable, it's not likable. You know what? You're standing it. No one's had to dial 911 and do mouth, you know, mouth-to-mouth resuscitation on you. You were standing it. It does feel bad. It does feel bad. So you, so we're showing empathy, but we're helping them bring down the magnification, um, of that that they're engaging in. You know, our CBT, uh, friends would use magnification as one of those, um, dysfunctional beliefs.

And then what do we do with the global negative rating? That's simple, but it always requires some, um, explanation to clients because there's always confusion here. Instead of global negative rating of self, others, life, world, or as Wendy Dryden says, psychological processes, we want, we hope that we can help them to develop unconditional acceptance of the self, unconditional acceptance of others, or life. Now, they're going to say, "What do you mean unconditional? You mean I should like the bad things I did, or the bad things that others have done?" No, no, no. Acceptance is just accepting that it happened. We're not saying that it's good at all. Under no circumstance are we saying that it is good. We're just accepting it. Because if you globally negative rate it rather than accept that it's there, you know, William James said, you know, more than a century ago, that healing begins with acceptance. And so true. Accept the reality of something, and then, um, rather than globally rate it. Now, instead of globally rated, you know, may come in above in terms of accepting, "Yeah, there, you know, this aspect of me. Sometimes I'm judgmental." I'll accept that I'm judgmental. Doesn't mean I like it. It doesn't mean that I'm not going to work to try to change my judgmentalism. I may really do that. But, you know what? Change in is in essence much more, you know, doable. It's easier if we accept it rather than fight against it and keep putting the self down. If I accept that this is a part that I would like to change, not that I must, but that I would like to change, why? Because it would help me in life, it would help others, etc., then it goes better. So help them understand. And it's takes time to do that because a lot of people think, "I, you're asking me to accept something really, really bad." No, I'm not asking you to, to do that. In, in that, that you're, we're not saying that you have to see the bad as good. We're just saying acknowledge it. So I often use the word acknowledge that it's there rather than judge it. Okay. Sorry that that took a little bit long, but it is really important that we kind of explain that to clients because that can be confusing.

Now, let me give some examples of replacement of beliefs, and these are ones that I gave earlier. Let's say I have a dysfunctional belief: "My spouse ought never to look at someone else who is attractive." A functional replacement, a functional alternative belief would be, you know, "I hope my spouse doesn't look at someone who is attractive, but if they do, it isn't the end of the world. It doesn't mean that they don't, you know, they don't think I'm attractive, or it doesn't mean that that's going to be a threat to the relationship." See what I mean? So we come up with a functional alternative to that dysfunctional belief.

"It would be awful if I got kicked out of the psych department." Functional: "I wouldn't like it if I got kicked out of the psych department, but it wouldn't mean that I would never get over it, and that I, you know, I could do something else enjoyable in life." Right?

"You know, it's really interesting. They, research actually on this. They did research on individuals who were working on a PhD, and they studied those who attained the PhD and those who did not attain."

The PhD. And they thought that those who did not attain their doctorate were going to be less happy than those who did. There was no correlation there. Um, many of the people who didn't attain it were actually doing some things in life that they found quite, quite fulfilling. Initially, that may not have been the case. You know, we have the disappointment and all of that stuff, stuff, and regrouping and trying to come up with new strategies and new ways that we could act into the world. But, um, and then they also found that those who attained the PhD weren't necessarily happy. You know, it's really interesting because when they met, you know, Emmons did some research and it found that what contributes more to happiness than anything else is that we strive for a desired goal. But it is the, the strive, it's the striving that actually contributes much more happiness than the attainment of it. Because, and we now know why, because the striving for a goal actually raises dopamine more than actual attainment of that goal. Or so, um, that's my reading of the, uh, of the research.

Another one, um, dysfunctional: "I can't stand it when people lie to me." A functional alternative: "I really dislike it when people lie to me, and I might not be real happy about it, but I can deal with it and move on." See what I mean? It's much more adaptive, not so rigid. That is a major distinction here. Dysfunctional beliefs tend to be very rigid and somewhat extreme. Functional alternatives tend to be more flexible and not, not as extreme. Okay, hope that's, uh, that's [Music] helpful.

Now let's move to that last aspect of the conceptualization of emotion. Remember I said that each of the emotions we check out, you know, what the nature of that emotion is, we look at the cognitions, the inferences, and the beliefs, and then we look at the, um, the behavioral potential or the action potential associated with that emotion. And the typical behavioral potential for anxiety is avoidance. Think about it. Um, if those things that you really make yourself anxious about, um, you tend to want to, um, you tend to want to avoid, right? So that's normal. It's natural. And I say that to my clients, "Look, you're not abnormal. You want to avoid something that you get anxious about." Yeah, of course. Who wouldn't? It's just typically not real helpful to do that. The trouble is, avoidance pays off in the short term. Sometimes you feel better. That's like procrastination, right? Procrastination is a form of avoidance. Sometimes when you pro-procrastinate, like for you, procrastinate studying an ex-for an exam, ah, it's nice. You go enjoy yourself. You have a party, whatever. But, um, in the long term, you have still have those things that you need to do, and it builds up, and you're putting more pressure on your on yourself. Okay. So avoidance, you know, is rewarded in the short term, but it contributes to bigger problems later on.

What are some examples of avoidance that we often see in anxiety? And I'm sure you'll have your own, right? Because you're all, you know, competent therapists or you're working on that, um, maybe you're a grad student or whatever. Um, examples of avoidance may be: "I won't go to a theater anymore because that's where a shooting took place." "I only drive on back roads and avoid highways because many wrecks occurred on on highways." Let me give an example of that one that's very, very personal. When I was young, I was a hit-and-run victim, and it occurred on a really windy road where, you know, a car hit and made and so for a long time, even when I first started driving, I would get highly anxious and on edge when I would drive on roads that were winding. And so often I would go on major highways, um, so that I didn't have those windy country roads, whatever. So, um, that was a form of avoidance. But sometimes I needed to go on those, um, those roads. And so I really worked hard. It took a, it took a while, and I had to change my beliefs, but also change my behavior in some ways. To the one way that helped was to begin to drive on winding roads, and I worked that out.

Another one: "I can't even think about the possibility that I might have cancer." I've had clients that get diagnosed with cancer and they go, "I can't even think about this. I cannot think about it." And yet they had an aggressive form of cancer. And so we had to talk about avoiding that may actually complicate that. And I understand the avoidance. Who wants to have to sit around and think about having cancer, making decisions about the treatment that you want, etcetera? Right? But not doing it is, maybe you don't think about it, you may not have options later on. Or, "I won't go to a dentist because those procedures are very, very, very painful." Etc. I tell my clients, all of these are normal. Nothing is abnormal about this. But often this avoidance is not helpful in the long run. Okay.

And then we've also worked on this cognitively, in addition to being behaviorally. So what do we do with this? I'm sorry for the title. I don't know what happened here, but it says "Behavioral Intervention: Exposure." So one thing about exposure is we, it's to be conducted within a safe location. We, you know, if they're, if they're, you know, anxious about being in front of people who are holding guns pointed at them, we're not going to say, "Well, you, that's what you need to do." No, absolutely not. Right? We do that, we conduct that within a safe location. And exposure therapy has been found to be helpful for a number of, a number of conditions. And this is not exhaustive. And even these, um, for some clients, it doesn't mean that they're going to respond well to the exposure. But phobias, or panic disorder, social anxiety, which is probably the most common of the anxiety ones, OCD, PTSD, GAD, generalized anxiety disorder, um, all of the have, you know, a high level of anxiety associated with them. And so, um, uh, often, not invariably, they will respond to exposure.

Now, when we say exposure, that's kind of a catch-all word because there are different kinds of exposures here. There are different formats, like in vivo. Right? Um, you take the individual to the, um, live plays. Uh, let me give an example. And a, um, young client who was years and years ago, who was afraid to go out in public, to restaurants, and all kinds of things. And he was a, he was wanting to begin to date, and it was really difficult if he wouldn't go out to places, right? And so I just took him to a place. And, um, he was very, very nervous at first. We had practiced this. We practiced, you know, disputing the beliefs that he had about what would might happen in that situation. We'd covered all of those and role-played and that. And it came time for him to go there, and he goes, "I don't know if I can do it." And we got there, and he, he paused about ordering, um, you know, from the person because he was afraid he wouldn't say the right thing. And so he, he eventually said it. He got a large H soda, and he was on the way back of, you know, the booth where we were going to sit, and the soda fell over and spilled right in his lap. And he looked at me with terror. And he saw me smiling. And so he jumped up and he got, um, you know, some paper towels and was wiping, you know, his lap off. And then he acted like, um, you know, a young teenager and started walking like a robot. And everybody started applauding for him. And so he was so happy with that experience that he always wanted me to take him back to the rest. I said, "No, we have to move on in other ways."

Imaginal. We could have done the same thing using the imagination. Or virtual reality. There are virtual, the military has been fantastic with virtual reality situations, you know, computerized for the treatment of P, of the anxiety associated with PTSD. Or interoceptive, right? Where we have the individual experience of a symptom, maybe the dizziness. One of the ways I used to do that was to put them on a on a chair and spin them around a little bit, um, and so we discharge the negativity of the dizziness somewhat. Pacing. There may, we may look at how we pace the exposure. Do we grade it? And, you know, kind of like a subjective unit of distress, um, kind of starting with things that would be less bothersome to more bothersome and just go up. So we pace that. Or flooding. Just dump them into the, dump them into the situation. Some individuals, I know a lot of therapists are worried about re-traumatizing an individual with flooding. If, um, if the exposure is done well, research has shown that, um, it tends not to be re-traumatization. But if there is concern about that, then, um, you know, talk it through with a client and maybe you have them do graded, you know, graded exposure rather than flooding initially. That helps you with your own anxiety, even with working with the client. Or systematic desensitization. The difference between systematic desensitization and graded is that with systematic desensitization, you are, you know, you're exposing, but you're practicing the relaxation techniques in the present presence of the, uh, exposure. Okay.

So, um, think about the best delivery form for the exposure. I want to kind of look at now that we've gone through the conceptualization of emotion, what some of the treatments, treatment developing the treatment plan. We will have cognitive restructuring. We may have particular kinds of exposures. Um, and again, this is all educational. We're not talking about, um, what we do in a particular with a particular client. That always needs to, um, uh, you know, be done by a licensed mental health professional.

What about connection with others? There's tremendous research that shows that connection with others, rather than isolation, helps with the issue that we're talking about. And this goes back to evolution. If we think about the evolutionary mechanism, uh, that was often used with reducing threat, perceived threat in the environment, whether it was real or not, but evolutionarily, you know, our ancestors, um, formed communities. We formed tribes. We were tribal and then developed bigger and bigger, um, bigger and bigger communities. And they developed types of community, uh, supports, not only just being together, but ways that tied them together. So, for example, if we, if you've watched movies, you've seen how they may have used, uh, they may have created stories or epic stories of coming together and fighting and against great odds. One of my favorite books was Homer's Odyssey, and it is about I, right, who, um, was trying to get back to Ithaca, um, and to do that, he had to go through a lot of different trials and seeming threats. But he did it with a group of, um, men on a ship. They were together. They were connected. And so these epic stories are stories really about the triumph of community and heroes who were, you know, um, working in, uh, in community and for, um, and for community. There's dance. There's even our ethical systems. The issue of forgiveness. Forgiveness is one way that we handle, um, potential threat. If we forgive, then perhaps the other individual who that we may need to rely upon to help us feel safe, to actually create safety, we increase the likelihood of that happening if we, uh, if we forgive. Okay. So we have an ethical system that's grounded in, uh, community and the value of community and connectivity. So there is, um, there is that.

Also, there are experiments and findings that show the value, the mental, emotional, behavioral, and also physical health conditions, medical conditions, um, that can be helped as a result of, um, good connection with others. One is, um, a great study in which they had, uh, two groups in the study. Um, both of them are looking at pictures of a mountain. But one group, there was one person in isolation that was looking at the picture. The other one, there were two people, you know, associates looking at the mountain. The task was to judge the the steepness of the mountain. Same picture. The individuals who were alone perceived the mountain as having, as being more steep and more treacherous than those that did looked at it together. You would say, "But the, the mountain's the same." The mountain is the same, but they are perceived differently. And if you perceive less threat, you are more likely to take measured risks, to actually do it. So getting together lowered the perception of threat. Amazing. Utterly amazing.

There's also, um, what's called the Roseto effect. Roseto, uh, was it is, um, a town in Pennsylvania that was populated by immigrants from Italy, and they from the same community in Italy. And so in the early 20th century, maybe closer to mid, but early mid, they noticed that, um, L, the citizens of Roseto had far less health problems, particularly cardiovascular problems such as stroke, etcetera, than those who are not from that area. And so they thought, "Well, maybe it's because the diet is different." No, the diet wasn't different. They had high fat, high carb diets with lots of alcohol and and yet they were healthy. Um, they, um, then thought, "Well, maybe it was due to safety on the trop." No, they worked in stone quarries where they could breathe, they were breathing, you know, um, unsafe dust and all kinds of things, but still they were healthier than surrounding. So what was the contributing factor? They found that the contributing factor was, um, being connected. They shared values. The roles of everybody in the community were valued roles. Grandparents were just as valuable as children, as etcetera. Um, and they, they shared shared values. They shared religious values too, moral values. So that created a connectivity and, um, that actually most likely reduced prolonged cortisol, high cortisol levels. So they ended up not having some of the problems. However, by the second and third generations, as that greater disconnectivity occurred, then we saw the increase in, uh, un-problematic medical conditions.

What about loneliness? Um, the CDC, Center for Disease Control here in the United States, has reported loneliness as one of the major health hazards that we have in the country today. And it is equivalent to smoking two pack packs of cigarettes a day, um, experiencing obesity, unhealthy obesity, um, and, um, all, you know, just all kinds of all kinds of the things. And so, um, it's a problem. It's a problem. So research was done to discover how we can get them connected because being lonely is a threat. So we want connection. The question was, how do we bring about the connection? So fortunately, a research was done there, and they found there were like three major ways to try to bring about connection. One was, um, you know, physicians, mental health professionals would recommend to the client who was isolated, "Here are some groups that you might consider getting connected with." Another one was, they assumed that people who were not connected maybe had poor social skills, so they wanted to give them social skills training. And the third is that they looked at dysfunctional cognitions that contributed to, uh, loneliness and the maintenance of loneliness. They found that while recommending that they get into a group or social skills training, um, didn't, I mean, it helped, but it didn't help that much. And in fact, the social skills training, they found that most people had the social skills, they just didn't use them. And, um, recommending that they go to a group, good idea, but a lot of them didn't. Why? They found that what helped the most was working with them on the dysfunctional cognitions they had that contributed to alone, disconnection of with others, or not connecting with others, etcetera. So they might have thoughts like, "Oh, it's not going to help. I'm always the one that's going to be the one that's reaching out. Nobody really cares. People aren't care." Those kinds of cognitions, inferences, and beliefs tended to cause and maintain their loneliness and the associated deleterious health hazards.

There's another one that I've been very interested in. It has to do with the mid-anterior cingulate cortex, and that is, um, part of the function of that part of the brain is that, um, is to, you know, development of empathy, understanding, and emotional regulation. And we've been talking about emotional regulation. And one of the things that increased blood flow to or activation of the anterior cingulate cortex was being connected to others. Also, some exercise, um, a particular kind of exercise. There was some work done in Texas on, um, movement, mindfulness along with movement. And if you're interested, you can, um, look that research up. But the connection to the others is so important to emotional regulation, including regulation of anxiety. So, um, just want to stop.