frenz another arrow for your quiver 2017-1101...another arrow for your quiver rebt for sud marrch...

AnotherArrowforYourQuiver

REBTforSUD

MARRCHAnnualConference|1November2017

DavidA.Frenz,M.D.Diplomate,AmericanBoardofAddictionMedicineDiplomate,AmericanBoardofFamilyMedicine

Disclosures

• I’maphysicianinprivatepractice• Iwaspreviouslyemployedby– HealthEastCareSystem(medicaldirector)– NorthMemorialHealth(vicepresident)

• I’monfacultyattheUniversityofMinnesota– Evidence-basedmedicine

• Idon’thaveanyfinancialrelationshipswiththepharmaceuticalormedicaldeviceindustries

• Idon’tintendtodiscussinvestigationaldrugsorthe“offlabel”useofmedications

SessionObjectives

1. TheaudiencewillunderstandREBT’sA-B-Cmodelforconceptualizingunhealthynegativeemotionsandself-defeatingbehaviors

2. Theaudienceappreciatehowirrationalbeliefsdriveunhealthynegativeemotionsandself-defeatingbehaviors,includingaddiction

3. Theaudiencewilllearnvariouswaystodisputetheirclients’irrationalbeliefsconcerningsubstancecravingsandsubstanceuse

Preliminaries

WhyILikeREBT

• Simplemodel• Efficient• Effective• ConnectswellwithSMARTRecovery– www.smartrecovery.org

• Generalizestootherareasoflife

CounselingToday

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CERTIFIES THAT

DAVID A. FRENZ,M.D.T{AS COMPLETED A PRIMARY TRAINING CO{.]RSE

IN RATIONAL-EMOTIVE & COGNITIVE.BEHAVIORAL TI{EORY AND TECHMQUES

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DIRECTOR OF PROFESSIONAL EDUCATION

AlbertEllisInstitute

ThinkingAboutThinking

EvanSiegle |packers.com

Epictetus

“ Itisn’tthethingsthemselvesthatdisturbpeople,butthejudgementsthattheyformaboutthem.”

Handbook

Shakespeare

“ Forthereisnothingeithergoodorbad,butthinkingmakesitso.”

Hamlet

JohnMilton

“ Themindisitsownplace,andinitselfCanmakeaHeav'nofHell,aHellofHeav'n.”

ParadiseLost

MarcusAureliusAntonius

“ Itispossibletoformnoopiniononthismatterandnotbetroubledinone’smind;forthingsthemselvesarenotofsuchanaturethattheycancreatejudgementswithinus.”

Meditations

RaymondA.DiGiuseppe,etal.APractitioner’sGuidetoRationalEmotiveBehaviorTherapy,3ded.NewYork:OxfordUniversityPress,2014,p.352

REBT Self-help Form

Examples:- A can be internal or external, real or imagined- A can be an event in the past, present, or future

• Situation: “My wife and I disagreed about something”• Critical A: “She criticized me badly”

Bs (Beliefs): Irrational (Unhelpful/Dysfunctional) Beliefs

Ds (Disputation): Debate Your Irrational (Unhelpful/Dysfunctional) Beliefs

Es (Eff ective): Rational (Helpful/Functional) Beliefs

Fs (Functional): Major Functional/Healthy Emotion and Adaptive/Helpful Behaviors

(Goal): New Functional/Healthy Negative Emotion:

(Goals): New Adaptive/Helpful Behaviors:

Maladaptive Behaviors include:- Social avoidance- Not taking care of yourself GOALS(e.g. not exercising, not resting)- Being aggressive

Dysfunctional Negative Emotions include:- Anxiety/fear - Problematic jealousy- Shame/embarrassment - Problematic envy- Rage/anger - Hurt- Guilt- Depression (depressed mood)

To Th ink More Rationally, Strive For:1) Flexible Preferences

(e.g. I want to do well, but I don’t have to do so.)2) Anti-Awfulizing

(e.g. It may be bad or unfortunate, but it is not awful, and I can still enjoy some things.)

3) High Frustration Tolerance(e.g. I don’t like it, but I can stand it, and I can still enjoy many things.)

4) Self-Acceptance, Other-Acceptance, Life-Acceptance (e.g. I can accept myself as a fallible human being.)

Functional/Healthy Negative Emotions include:

x� Concernx� Disappointmentx� Healthy anger/annoyancex� Remorse/regretx� Sadnessx� Healthy concern for relationshipx� Healthy envyx� Sorrow

Adaptive/Helpful Behaviors include:x� Meeting friends or seeking supportx� Exercisingx� Assertive behaviors

To Identify Irrational Beliefs, Look For:

1) Demands (musts/absolute shoulds/oughts)2) Awfulizing/Catastrophizing

(It’s awful, terrible, horrible!)3) Frustration Intolerance

(I can’t stand it!)4) Self-Downing, Other-Downing, or Life-

Downing (I’m bad or worthless, He/she is bad or worthless, or Life is not worthwhile)

© Windy Dryden and Jane Walker, 1992. Revised by Albert Ellis, 1996. Revised by Windy Dryden and Daniel David, 2009.

To Change Irrational Beliefs, Ask Yourself:■ Where is holding this belief getting me?

Is it helpful or getting me into trouble? ■ Where is the evidence to support my

irrational belief?º Is it really awful (as bad as it could be)?º Can I really not stand it?º Am I really a totally bad person?

■ Is it logical? Does it follow from mypreferences?

■ Use metaphorical disputation (e.g. metaphors, stories, humor)

Major Dysfunctional/Unhealthy Negative Emotion (Feeling):

Maladaptive/Unhelpful Behaviors (and/or Action Tendencies):

Briefl y Summarize the Situation as Objectively as Possible:

Critical A (What I Was Most Disturbed About):

A (Activating Events or Adversities) C (Consequences)

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IrrationalBeliefs

B—S

“ Everytimeahumanbeinggetsupset—exceptwhenshe’sinphysicalpain—shehasalwaystoldherselfsomebullshit thesecondbeforeshegetsupset.”

AlbertEllis.GrowthThroughReason.PaloAlto:ScienceandBehaviorBooks,1971,p.228

Love&Approval

“ Theideathatitisadirenecessityforanadulthumanbeingtobelovedorapprovedbyvirtuallyeverysignificantotherpersoninhiscommunity.”

AlbertEllis.ReasonandEmotioninPsychotherapy.NewYork:LyleStuart,1962,p.61

Competence

“ Theideathatoneshouldbethoroughlycompetent,adequate,andachievinginallpossiblerespectsifoneittoconsideroneselfworthwhile.”


Condemnation

“ Theideathatcertainpeoplearebad,wicked,orvillainousandthattheyshouldbeseverelyblamedandpunishedfortheirvillainy.”


Awfulizing

“ Theideathatitisawfulandcatastrophicwhenthingsarenotthewayonewouldverymuchlikethemtobe.”


Victimization

“ Theideathathumanunhappinessisexternallycausedandthatpeoplehavelittleornoabilitytocontroltheirsorrowsanddisturbances.”


Rumination

“ Theideathatifsomethingisormaybedangerousorfearsomeoneshouldbeterriblyconcernedaboutitandshouldkeepdwellingonthepossibilityofitsoccurring.”


Avoidance

“ Theideathatitiseasiertoavoidthantofacecertainlifedifficultiesandself-responsibilities.”


Dependence

“ Theideathatoneshouldbedependentonotherandneedssomeonestrongerthanoneselfonwhomtorely.”


Determinism

“ Theideathatone’spasthistoryisanall-importantdeterminerofone’spresentbehaviorandthatbecausesomethingoncestronglyaffectedone’slife,itshouldindefinitelyhaveasimilareffect.”


Reactivity

“ Theideathatoneshouldbecomequiteupsetoverotherpeople’sproblemsanddisturbances.”


Perfectionism

“ Theideathatthereisinvariablyaright,precise,andperfectsolutiontohumanproblemsandthatitiscatastrophicifthisperfectsolutionisnotfound.”

AlbertEllis.ReasonandEmotioninPsychotherapy.NewYork:LyleStuart,1962,p.86–87

Characteristics

1. Itisabsolute,dichotomous,rigid,andunbending;2. Itisnotlogical;3. Itisnotconsistentwithreality;4. Itdoesnothelptoachieveone’sgoals;5. Itleadstounhealthy/dysfunctionalemotions


Demandingness

“ Anunrealisticandabsoluteexpectationofeventsorindividualsbeingthewayapersondesiresthemtobe.”


Awfulizing

“ Anexaggerationofthenegativeconsequencesofasituationtoanextremedegree,sothatanunfortunateoccurrencebecomes‘terrible.’”


FrustrationIntolerance

“ Demandsforeaseandcomfort”


GlobalEvaluationsofHumanWorth

“ [Theideathat]humanbeingscanberated,andthatsomepeopleareworthless,oratleastlessvaluablethanothers. ”


BeliefContent

• Socialrelationships– Demands,awfulizing,frustrationintolerance,globalevaluations

• Achievement• Comfort• Fairness


AddictioniBs

• Icannotstandavoidingadrink• Icannotfunctionwithoutadrink• Iamnotstrongenoughtoresistalcohol• Icannotstandthedeprivationofmydesireforadrink• IamahorriblydeprivedpersonifIcannothaveadrink• LifeistoohardsoIamentitledtohaveadrink• Tomakeupformydifficultlife,Imusthaveadrink

AlbertEllis,etal.Rational-EmotiveTherapywithAlcoholicsandSubstanceAbusers.NewYork:Pergamon Press,1988,p.25

AddictioniBs

• ImusthaveadrinkorIcan’tgoon• Imustnotabstainwhenit’ssoenjoyabletoimbibe• Imustnotabstainwhenitissopainfultodoso

AlbertEllis,etal.Rational-EmotiveTherapywithAlcoholicsandSubstanceAbusers.NewYork:Pergamon Press,1988,p.25

Consequences

• Unhealthynegativeemotions– Anxiety– Depression– Clinicalanger– Guilt– Shame– Hurt

• Unhealthymaladaptivebehaviors– Socialavoidance– Poorself-care– Aggression– Chemicalcoping

Consequences

RaymondA.DiGiuseppe,etal.APractitioner’sGuidetoRationalEmotiveBehaviorTherapy,3ded.NewYork:OxfordUniversityPress,2014,p.113,352


REBT Self-help Form





































Disputation

T—S

“ ThetwowordsIusuallyrecommendare:“Toughshit!’Ifyoureallybelievethesewordsandthebasicphilosophyforwhichtheystand,youwillinstantlystarttoloseyourextremefeelingsofanxiety,depression,andshameandbecomeemotionallyunblocked.”

AlbertEllis.ExecutiveLeadership:ARationalApproach.Secaucus,NJ:CitadelPress,p.154–155

Logical

• Whydoesithavetobeso,justbecauseyouwantit?• Howdoyougetfromwantingthemtorespectyoutothe

beliefthattheymustrespectyou?• Ifyouheardsomeoneelseclaimingitwastheworstthing

ever,wouldyoubeconvinced?• Youmightnotlikebeingdisrespected,butdoesitlogically

followthatyoucan’tstandit?• Howdoyoubecomeworthlessiftheydon’trespectyou?


Empirical/Reality-Testing

• Whereistheevidencethattheymustrespectyou?• Whereisitwrittenthattheymustrespectyou?• Howwillyourworldbedestroyediftheydon’trespectyou?• You’vebeendisrespectedbeforeandsurvived.Where’sthe

proofthatyoucan’tstandit?• Assumetheydisrespectyou.Doesanyoneelseintheworld

valueyou?


Pragmatic/Functional

• So,youthinkit’sterriblethattheydon’trespectyou.Howisthatthoughtworkingforyou?

• Whenyouthinkthatway,howdoyoufeel?Isthatfeelinghelpful?

• Whathappenstoyouwhenyouthinkthatthought?• Whydoyouholdontoabeliefthatcausesyousomuch

trouble?• Howhasthatbeliefhelpedyouaccomplishyourgoals?

RaymondA.DiGiuseppe,etal.APractitioner’sGuidetoRationalEmotiveBehaviorTherapy,3ded.NewYork:OxfordUniversityPress,2014,p.167–168

DisputingStyles

• Didactic• Socratic• Humorous• Metaphoric• Creative• Vicariousmodeling

RaymondA.DiGiuseppe,etal.APractitioner’sGuidetoRationalEmotiveBehaviorTherapy,3ded.NewYork:OxfordUniversityPress,2014,p.170–178


REBT Self-help Form





































EffectiveRationalBeliefs

EffectiveRationalBeliefs

• Flexiblepreferences– Iwanttodowell,butIdon’thaveto

• Anti-awfulizing– Itmaybebadorunfortunate,butit’snotawful,andIcanstillenjoysomethings

• Highfrustrationtolerance– Idon’tlikeitbutIcanstandit,andIcanstillenjoymanythings

• Acceptance– Icanacceptmyselfasafalliblehumanbeing


BecomingTheirOwnTherapist

• Clientsneedtocontinuously,vigorouslypracticecopingstatements– TurniBs intoEs– Es transformCsintohealthy negativeemotionsandadaptive behaviors


REBT Self-help Form





































FunctionalEmotions&Behaviors

HealthyNegativeEmotions

Unhealthy&Dysfunctional Healthy&Functional

Anxiety Concern

Depression Sadness

Clinicalanger Annoyance

Guilt Remorse

Shame Regret

Hurt Disappointment


HealthyAdaptiveBehaviors

Maladaptive&Dysfunctional Adaptive&Functional

Socialavoidance Meeting friends,seekingsupport

Poor self-care Bathing,exercising

Aggression Assertive behaviors

Chemical coping Healthy copingbehaviors



REBT Self-help Form





































ClinicalExample

Client

• Femalepatientsubjecttorandomurinetoxicologyperthechildprotectionsystem

A&C

A ColorwheelC Anxiety abouthercolorcomingup

Anger andoutbursts whenhercolorcameup

iBs

• Imust havetimetomyself.CPSshouldnot disruptmyday• Itwouldbeterrible ifmycolorcameupbecauseitwould

ruinmyday• Icouldn’tstandit ifmycolorcameup.Ican’thandle the

inconvenienceofrunningdowntoHCMC• MyCPSworkeristotallyevil

D

• IsitlogicalthatjustbecauseIdon’twantmycolortocomeupthatitshouldn’t?

• Whereisitwrittenthatmycolorcan’tcomeup?Istherealawofphysicsthatsaysitcan’t?

• Wheredoesanxietyandangergetme?Dotheyhelpmereachmygoals?(lessemotionaldisturbance,gettingoffofCPS)

E

• I’dreallylikemycolortonotcomeupbutthere’snoreasonwhyitshouldn’t

• Itwouldbeinconvenientifmycolorcameup,butitwouldn’tbeterribleorhorribleifitdid

• Idon’tlikeitwhenmycolorcomesup,butIcanhandleit• MyCPSworkerinconveniencesmebutthatdoesn’tmean

she’scompletelyrotten

F

• Anxietybecameconcern• Angerbecameannoyance• Outburstsbecamecooperative,respectfulbehavior

Resources

StartHere

London:SAGEPublications,2011

DeeperDive

• BishopFM.ManagingAddictions:Cognitive,Emotive,andBehavioralTechniques.Northvale,NJ:JasonAronson,2001

• EllisA.ReasonandEmotioninPsychotherapy.NewYork:LyleStuart,1962

• EllisA,etal.Rational-EmotiveTherapywithAlcoholicsandSubstanceAbusers.NewYork:Pergamon Press,1988

• DiGiuseppe RA,etal.Practitioner’sGuidetoRationalEmotiveBehaviorTherapy,3ded.NewYork:OxfordUniversityPress,2014

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