CBT: Family Stress: Divorce and Loss

Authors: 

Soledad Apodaco

Veronica Bustos

Shekenna Chapman

Joanna Fye

Jennifer Greene

 Assessment and Intervention Techniques

Cognitive behavioral therapy is most closely allied with the scientist–practitioner model. This model emphasis changing someones dysfunctional thinking and their patterns of behavior for attainment of their personal goals. Typically those who are wishing to undergo therapy using the cognitive-behavioral approach would meet face-to-face with a therapist for a total of 10-20 sessions between 45 minutes to an hour each. These sessions would take place normally 1 time a week, at the beginning and then move to every other week.  Afterwards a client might continue to come in for "booster sessions" after the therapy has been ended for one month and then again at the third month. Another useful approach, although not commonly used, are computer sessions. This could be achieved by using several applications such as Skype that allow for real time communication between the therapist and patient. Cognitive behavioral therapy holds an emphasis on measuring changes in both the cognition and behavior of an individual. It obtains these goals by  a variety of methods including  "homework" or practice exercise's.  These assignments/exercises are crafted together for the client to bring to the next session. They should include a short list of the clients broad goals that are put into order of importance that the client wants to work toward. Incorporate these goals into planning the homework assignments.  These assignments are a necessary part of CBT because it shows the clients willingness to change and set outside their comfort zone or normal way of handling a situation. A homework assignment for someone suffering with depression or anxiety might be something as simple as attending a social event, documenting daily activities to striking up a conversation with someone new. What is important in this process is the collaboration of the homework assignment between client and therapist and the dedication on the clients part to complete it. The completion or lack thereof allows the therapist to gauge what treatment steps are most logically needed based upon the patients compliance. This compliance is linked to the therapeutic alliance between therapist and the person seeking help and/or assistance.  Method of Evaluation: The first couple of sessions are spent making sure that CBT is the right therapy for your situation and to make sure you comfortable with the process. The therapist will ask questions about your life and background to gather information about your situation, automatic thoughts, and emotions. You will also be asked about any therapy you have previously received and your experiences.  For example, if you say you are depressed or suffer from anxiety you may be asked if this interferes with your work, family and/or social life.  This process is used to assess the patients concerns and also to discover the best initial treatment plan including clients goals.   Goal setting could include items such as behavioral activation, identifying maladaptive thoughts/beliefs, or challenging maladaptive thoughts/beliefs.  Around the 3-4th treatment session your therapist may start assigning homework assignments. Homework is an essential part of CBT therapy showing the working relationship between therapist and client along with the clients devotion to change.  The client might also start to notice a trend in therapy services around this time that might look something like this: check mood, introduce new activities, review homework,  set new homework, use of tracking sheets for completed activities, receive client feedback. Sessions should begin and end with checking the clients mood and receiving client feedback. You will also notice each session consist of intervention techniques and re-assessing goals and treatment plan as therapy progresses. By the 7th session the therapist will start discussing ending treatment and preparing for maintaining changes. Method of Termination: When terminating a client is important for the client to understand the process. CBT is not a long term therapy. Normally a client will have between 10-20 sessions, with the average being 16. It is important for the client to understand this upfront and to realize that they are working toward an end goal. Bringing termination up early will help clients understand the length of therapy and not be taken by surprise. Another useful technique to terminating CBT is to pick after the first few sessions pick a final session date. This provides a framework to work toward goal completion. Before terminating a therapist also needs to be asking questions to determine if the client is ready for termination or if therapy should be extended by a few weeks. CBT should be terminated in a face-to-face final session so the therapist can answer any questions the person seeking assistance might have. It is also important to make sure your client knows termination is not the end. You are always there should they need follow up care and further assistance. Theoretical Underpinnings are a set of ideas, motives, or devices that justify or form the basis for something. Cognitive-behavioral therapist believe in frequent re-evaluation of of theories and treatment as often as possible for several reasons: 1. Scientifically, so we are using sound, well established theories that are advancing in research and empirical evidence. 2. Ethically, so we can have confidence in the effectiveness of the treatment we are offering. 3. Economically, to ensure the best use of mental health resources and benefits.

Historical Foundations

Cognitive Therapy (CT), or Cognitive Behavior Therapy (CBT) was pioneered by Dr. Aaron T. Beck in the 1960s, while he was a psychiatrist at the University of Pennsylvania. Having studied and practiced psychoanalysis, Dr. Beck designed and carried out several experiments to test psychoanalytic concepts of depression. As a result of his findings, Dr. Beck began to look for other ways of conceptualizing depression. He found that depressed patients experienced streams of negative thoughts that seemed to arise spontaneously. He called these cognitions “automatic thoughts.” He found that the patients’ automatic thoughts fell into three categories. The patients had negative ideas about themselves, the world and/or the future. He found that by doing so, patients were able to think more realistically. As a result, they felt better emotionally and were able to behave more functionally. When patients changed their underlying beliefs about themselves, their world and other people, therapy resulted in long-lasting change. Dr. Beck called this approach “cognitive therapy.” It has also become known as “cognitive behavior therapy.”

In hundreds of clinical trials, CBT has been demonstrated to be an effective treatment for a wide variety of disorders. To name just a few, it has been found useful for:

·         psychiatric disorders such as depression, the full range of anxiety disorders, eating disorders, substance abuse, personality disorders, and (along with medication) bipolar disorder and schizophrenia;

·         medical disorders with a psychological component, including several conditions involving chronic or acute pain,  chronic fatigue syndrome, pre-menstrual syndrome, colitis, sleep disorders, obesity, Gulf War syndrome, and somatoform disorders; and

·         psychological problems such as anger, relationship difficulties, and compulsive gambling.

CBT is also used to address stress, low self-esteem, grief and loss, work-related problems and problems associated with aging.

The information above was taken from: Beck Institute for Cognitive Behavior Therapy http://www.beckinstitute.org/cognitive-behavioral-therapy/

Social Work Implications

Cognitive CBT is well established in working with vulnerable people and serves as a valuable approach for social work practice. Families and children experiencing divorce are vulnerable in the circumstance. Key concepts of CBT theory include: cognitive schema, automatic thoughts, connection between assumptions, thoughts, feelings, and behavior (Miller, 2005). All people have cognitive schemas that shape views of self, others, and the world. Cognitive schemas are formed around individual unique experiences. A life experience such as divorce is an experience that would influence cognitive schemata. Social workers understanding this theoretical concept are able to assist in the helping process by understanding the deeper meaning behind individual’s perspectives and therefore behaviors as well. Social workers can obtain understanding of a person’s perceptual framework by encouraging them to share their experiences and stories and then listening carefully to identify themes and patterns. Automatic thoughts are immediate and habitual, rooted in cognitive schemas and direct the choices people make. Automatic thoughts can create unhelpful assumptions and feelings, a social worker will look to challenge these underlying ideas and explore alternative views. An assumption for a child in response to divorce may be “it’s my fault”, which would be unhelpful and untrue. Redirecting unhealthy thoughts enables space for improvement on feelings and behaviors. CBT is applicable to individuals or groups of all ages experiencing a wide range of challenges such as; anxiety, stress, anger, depression, and PTSD (Miller, 2005).  

Policy:

Social policy plays a leading role in people’s mental health. Social policy includes the rules and regulations of societal functioning in areas like healthcare, education, and economics, all in which influence one another. CBT is recognized as a safe and effective treatment in the mental health community and therefore commonly applied by professionals. CBT is noted in managed care guidelines as a preferred approach to treatment and intervention in managed care organizations, MCO’s (Henderson, 2011). It is important that CBT be approved and recognized in healthcare and the mental health community to equally enable accessibility to all people in need. Counselor accountability to client and MCO are high, cost is reasonable, treatment is relatively short, treatment is versatile, client problems are addressed, client’s report derived benefits, and success rates are high, all making CBT compatible with managed healthcare guidelines (Henderson, 2011). Further, social policy and CBT have a common intention, enhancing the human condition. Social policy involves the study of human wellbeing, the social relations necessary for wellbeing, and the systems by which it may be promoted (What is Social Policy?, 2015).  

Family Stress caused by loss and divorce

Everyone hears that stress typically affects the individual but there are studies that demonstrate that entire family units also suffer from stress. Stress is caused by many factors but in this site, we will be looking into two of the chief causes of stress, which are divorce, and of loss. In situations where the absence of a loved one occurs by either divorce or death the managing of stress is extremely difficult for those family members left behind. More so when there are children involved.




Support Systems: CBT (Cognitive Behavior Therapy)

Cognitive Behavior Therapy is a form of intervention known to help families overcome or decrease stress during times of crises. Younger members within the family model their behaviors with those of the adults, including those related to managing stress. Adults reacting to stress in ways that are unhealthy, increase the risk passing those same behaviors on to the younger members of the family. On the other hand, those adults that handle stress in healthy ways may not only foster better adjustment and happiness for themselves, but also encourage the development of very critical and valuable habits and skills in those family members in need of guidance and support (APA, 2015).

Studies on cognitive behavioral therapy (CBT) have demonstrated that it can be as successful in treating some mental health problems as medication (NHS, 2014).


 ·         strengths/limitations 

Ø  The advantages are that it can be completed within a short period of time,  it can be provided in various formats to fit the need, the skills learned can be incorporated into a family’s/individual daily life, and can be helpful in cases where medication does not.

Ø  The disadvantages are that it takes commitment and time such as extra work between sessions, could experience periods of increase stress when confronting emotions and anxieties during the initial phase. 

LOSS

Losing a loved one or someone who one cares for deeply can be very devastating and painful. Individuals have different emotions and grief with it differently. This depends on Individuals personality and coping- styles and sometimes our faith can help faith cope with the loss a little better. There are five stages of grief: 1) Denial, 2) Anger, 3) Bargaining, 4) Depression and 5) Acceptance, which all individual go through; although not in any specific order or experience all during the loss. Grief can have a yo-yo effect due to its ups-and-downs. It is important to get support during the grieving process whether it is professional, friends/family, religious support group.  Sometimes grief does not go away and symptoms may become complicated. The individual may experience intrusive thoughts/images of the love one, avoid things/places/or anything that reminds them of the loved one, feeling empty or extreme anger. At times, the grieving process can lead to depression, which can include suicidal ideations, inability to function, guilt feelings, and hopelessness. 

Untreated and complicated grief and depression may also lead to significant emotional damage and life threatening problems (1-Helpguide, n.d). Although grief is mainly associated with the loss of a loved one there are other things that can cause grief such as the loss of a job, loss of a pet, a miscarriage, moving to a different home or state, retirement and divorce.

DIVORCE

Divorce is another difficult event for all family members and sometimes it affects relatives and friends. The world may seem like it is upside down and the individual may experience all sorts of painful and emotional feelings and thoughts such as grieving. Although the relationship may have not been working for quite some time, it ends up hurting a lot. Here we can see how divorce is considered a loss for the individual and family. You may ask, “A loss of what?” Well, a loss of shared dreams, shared adventures, time spent together, and the pain and loss due to separation when children are involved. Actually, divorce brings along some of the same stages as loss (denial, anger, bargaining, acceptance, and depression).



STATSTICS

Various studies have shown that there are certain populations that are more prone to loss and divorce thereby increasing the risk of stress and its related maladies. “Marriage, divorce, and widowhood are important events in the lives of many adults in the United States” (Elliott & Simmons, 2011).

For example, data gathered by the U.S. Census Bureau show 2009 statistics concerning divorce and loss within the populations of the United States. There is a tendency to reject depressive symptoms as something socially and culturally acceptable, whereas significant distress associated with divorce and loss could be forerunners of psychiatric illness often-requiring medical attention or otherwise (NAMI, 2015).

Media
Professional Resources: Basics of Cognitive Behavioral Therapy. – Available at https://youtu. be/QRwAuWsoKms

Cognitive Behavioral Tools – Available at https://youtu.be/IEsYiCDoJks
 
The Grieving Process: Coping with Death – Available at https://youtu.be/gsYL4PC0hyk

 

How to Manage Friends and Family During Divorce – Available at https://youtu.be/L1KXiznsO_k 

 The SOCIAL WORKERS SKILLS, KNOWLEDGE AND ROLE

• Aging

Social workers (SW) offer counseling to the elderly and their families covering loss and bereavement, brief therapy, stress management, adjustment or addiction. The SW focuses on strengths and views the person as unique and promote resilience. Elderly persons coping skills can be improved by allowing informed decision-making and by aiding individuals to view their circumstances from diverse viewpoints (Special Interest Group on Ageing, IASW, 2011).

•  Children and Family

Many studies have been conducted that have shown the importance and usefulness of family intervention, family participation in therapy, display of positive control over the child by the parent’s, and decreased stress levels within the family. By working with both the parents and the child(ren) to identify negative ideas and behaviors that promote depression of both, and attempts to change those negative ideas and behaviors into a positive influence in order to modify those conditions. They are taught to recognize the symptoms, how best to approach and help a child that is depressed. They are provided information about mood disorders, interpersonal skills, decreasing stress, medication and their side effects (Sokolova, 2003).

• Health Care

Social workers work closely with patients and their families to assist them in comprehending, navigating and coping with sickness and with the larger health care system. They offer understanding, listening, intervention, and support to patients and families. Social workers play an important role in psychosocial evaluation, distress screening, simplified decision-making, care coordination, navigation and understanding the patient and family needs within their cultural and social context (UT Inter-Professional Education, n.d.).

• Mental Health

The social worker helps in building family relationships, resource and resilience. Identifies the wide variety of risks to children and aids in management of those risks. The social worker makes sure that proportionate intervention, assess theory and research results are applicable. Shows knowledgeable use in the practice of: age related physical, mental, social, emotional and behavioral development. Understand and interpret the influence of cultural and social elements on child development that may promote mental and physical ill health, substance misuse, domestic violence, and disability that may have an impact on family functioning and social circumstances (Department of Education, 2014).

 COPING WITH STRESS: Additional Reading and Help

Anxiety and Depression Association of America (2015). Therapy, [website] Available at http://www.adaa.org/finding-help/treatment/therapy
Dyer, K.A., (2005). Living Through and Surviving Traumatic Events, Vol. 2, No. 2, Medical Wellness Archives, Available at http://www.medicalwellnessassociation.com/articles/traumatic_events.htm
MAYO Clinic, (2015). Cognitive behavioral therapy, [website] Available at http://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/basics/definition/prc-20013594
PsychGuides, (2015). Crisis Symptoms, Causes and Effects. [website] Available at http://www.psychguides.com/guides/crisis-symptoms-causes-and-effects/
Ruffin, N.J., (2009). Children and Stress: Caring Strategies to Guide Children [website] Publications, Educational Resources, Virginia Polytechnic Institute, and State University Available at https://pubs.ext.vt.edu/350/350-054/350-054.html
The American Institute of Stress, (2015). Families, Site offers suggestions to learning resources Available at http://www.stress.org/families/
Unity Point Health, (2015). Counseling and Psychiatry, Treatment Services, [website] Available at https://www.unitypoint.org/desmoines/services-grief-and-loss-issues.aspx

Useful Websites

Author/Topic: Bruner, Jerome, (Main Concepts)

Address: http://mercury.sfsu.edu/∼ching/personal/Learning/theorists/Bruner.html
Accessed 2015
Description: An overview of Bruner’s theory of discovery learning with a home link to many other relevant theorists and their studies along with a section of quizzes to test your own knowledge and understanding

Author/Topic: Gagńe, Robert, M. (Conditions of Learning)

Address:  http://www.educationau.edu.au/archives/cp/04d.htm
Accessed: 2015
Description: An overview of Gagnes conditions of learning theory and how it relates to the process of instructional design

Author/Topic: Kelly, Curtis (David Kolb: The Theory of Experiential Learning)

Address: http://reviewing.co.uk/research/experiential.learning.htm
Accessed: 2015
Description: A critique of Kolb’s experiential learning style model, making reference to other experiential learning models along with many other relevant references

Author/Topic: Mayer, John, Salovey, Peter (The Intelligence of Emotional Intelligence)

Address: http://trochim.human.cornell.edu/gallery/young/emotion.htm
Accessed: 2015
Description: Details on emotional intelligence with many links to other related websites on brain theory and neuroscience.

Source: Jordan (2003:96–100) (adapted)

Implications for Social Work Practice

It Provides Hope to Distressed Clients
Resiliency provides many implications for social work practice. Firstly, it is an important strategy and coping mechanism to teach to clients. It presents an approach to the helping process that enables client’s to actively seek how their talents, abilities, and strengths help them cope and survive hard times. Those who seek social work help are usually going through a trial or feel disadvantaged to the point that it effects their wellbeing and place in society. Feelings of marginalization, trauma, and hopelessness make it difficult for clients to see the possibility of improving their situation. It can also cause emotional distress, physical illness, and reduce self-esteem and self-worth. It is easy for clients to feel overwhelmed in their problem and feel that they have no power (Kapoulitsas & Corcoran, 2015). Utilizing resiliency in the social worker-client setting provides a useful lense through which clients can look at their situation and see a glimmer of hope. Discussing how they have shown resiliency in their circumstance can open up an entire new perspective that clients already possess strength and resources to combat the negative things going on in their lives. Teaching clients about resiliency and discussing how they've demonstrated it thus far can also open them up to the other parts of the helping process, contributing even more to possible change.

Key Points for Social Workers to Discuss With Clients (Fraser, Richman & Galinsky, 1999, p.136)

• Overcoming odds
• Sustaining competence under pressure
• Recovering from trauma

It Creates a Focus on Strengths
A second implication for social work is that utilizing resiliency emphasizes a focus on strengths-based perspective rather than needs-based. A strengths perspective is becoming increasingly more common in the social work realm because of the active role it places on the client. The Social Work Policy Institute . Clients who are stuck focusing on the negative aspects of their situation and why they are unable to change it often forget what they have already been able to overcome. Social workers can use resiliency to focus on personal attributes, motivations, and experiences to help clients feel empowered. All problems have the ability to bring out strengths and capacities that can contribute to solutions (McCashen, 2005). This switches the focus from what clients are lacking to what they possess. If they are able to look beyond the pain of their situation and focus on their strengths and grow as a person, then they will be more equipped to endure future trials. Rather than feeling inadequate and worthless, resiliency helps clients feel more motivated and likely to succeed in making positive change in their lives.

It Helps Prevent Compassion Fatigue
Resiliency is also a strategy that is useful for social workers to integrate into their own professional lives, as it is a key factor in preventing compassion fatigue and burnout in social workers (Kapoulitsas & Corcoran, 2015). To combat against time constraints, large caseloads, and emotionally/physically distressed clients that so often accompany social worker’s lives, it is important for social workers to reflect on their own resiliency in the midst of these stressful factors. This is especially important for those working as trauma responders or cases of physical and sexual abuse, as social workers take on secondary trauma resulting from interaction and reliving the event with the client (Naturale, 2007). It would be advisable for social work agencies that work with trauma victims implement a resiliency training for employees, as well as supervisors regularly check in with employees about how they are handing the job’s demands and encourage resiliency to continue guarding against burnout.

Click here to take the Compassion Fatigue Assessment

Implications for Research

Resiliency poses implications for social work research as well. It is important that studies continue to research resiliency because this helps find gaps and aspects of resiliency that should be further studied. It would be beneficial for more research to be completed on the specific factors that contribute to one’s resiliency. This would allow social workers to ask more specific questions during the assessment phase to get a more well rounded view of the client’s current level and understanding of resiliency. In addition, research about whether resiliency is an innate quality or a psychosocial process that can be learned and increase or decrease would assist social workers in educating their clients about resiliency. Why do some children develop severe mental and emotional disorders when others seem unaffected by the same stressor? ("Resiliency," 2004).

Fraiser et al. (1999) indicates the difference between resiliency and survival. Those focusing on simply being survivors of their situation can get caught up in victimization but those who focus on resiliency become empowered by their strengths and adaptations in high risk situations. Further research should investigate what contributes to survivors’ feeling as if they are just surviving or feeling resilient following a trial or traumatic experience. Knowing these factors can help social workers tailor their interviews and assessments, as well as know which aspects of their clients’ lives to specifically address to increase feelings and recognition of resiliency. An increase in longitudinal studies would be valuable, as this would take into account external factors in a person's life that may contribute to or prevent resiliency. 

Implications for Policy

Resiliency is an important concept within social work policy. Research has shown that resiliency goes hand in hand with child development ("Resiliency," 2004). Children and teens who have experienced substantially challenging and traumatic life experiences develop a gap in their development and often need extra support to make up for their delays. Thus, policy regarding community efforts to create programs and support for children and teens in low income areas or for those who have experienced traumatic events would be worth further advocacy.
The NASW Code of Ethics does not make any references to resiliency. However, given the impact that it can add to the helping process, the way it can shape the client's way of viewing their situation, and provide motivation, resiliency should be given a place in social work policy. Incorporating the use of resiliency in direct practice, especially with trauma victims, would only benefit the social work profession.

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Wiki Details

Wiki Group 2 Resiliency

• Getting Started
• Appropriateness/Applications
• Concepts
• Evidence-based knowledge
• Historical Foundations
• Implications for SW Practice
• References
• Wiki page- Resiliency

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Resiliency model: