Trial-Based Cognitive Therapy (TBCT) is a three-level, three-phase, case formulation approach developed by Dr. Irismar Reis De Oliveira at the Federal University of Bahia, Brazil in 2011. TBCT’s foundation is in Cognitive Therapy.
Like CBT, TBCT is an active approach to treatment that helps clients to recognize situationally based thoughts and unhelpful beliefs that exacerbate emotional distress. One of the main goals of both approaches is to help clients modify the so-called core beliefs (CBs) which are those global, rigid, and over-generalized perceptions about themselves, and accepted as absolutely true to the point that they do not question them. However, TBCT has a unique approach to conceptualization and techniques that make it a distinct intervention in modifying clients’ CBs.
- One of the main techniques used in TBCT is the Trial-Based Thought Record (TBTR or Trial I), a structured strategy that is presented as an analogy with Law, in which the therapist engages the client in a simulation of the judicial process. Inspiration for this technique came from the surreal novel by Franz Kafka, The Trial; in the book, the character Joseph K., for reasons never revealed, is arrested and ultimately convicted without even knowing the crime of which he was accused. The TBCT therapist uses a creative and stimulating process to make clients aware of their core beliefs about themselves (self-accusations) and, differently from Joseph K’s process, engages them in a constructive trial to develop more positive and functional beliefs.
Emotional Support Animal Prescription Letter
Are you anxious? depressed?
Have panic attacks? Fear flying?
You may be eligible for an Emotional Support Animal Prescription Letter to allow your dog or cat access to “no pet” residences and airplanes.
To schedule an assessment, contact NYC Cognitive Therapy at 347-470-8870 or email firstname.lastname@example.org.
What is an Emotional Support Animal?
- An emotional support animal is not a pet. It is a companion dog or cat that provides therapeutic benefit to an individual with a mental or psychiatric disability.
- Any size or breed of dog or cat can be an emotional support animal. They do not have to be professionally trained to perform any task, but must be trained to behave appropriately in a public setting.
- Emotional support animals are protected under the Fair Housing Amendments Act (FHAA) and the Air Carrier Access Act (ACAA),
- The FHAA prevents landlord and homeowner associations from restricting your emotional support animal from living with you–even when there is a no pet policy in place. These associations are also not allowed to assess special pet fees on you because of your companion animal.
- The ACAA protects individuals by allowing an emotional support animal to fly with them in the cabin of an airplane, without having to pay any additional fees.
- While emotional support animals are often used as part of a medical treatment plan, they are not considered service animals under the Americans with Disabilities Act.
This is a post from 2015 on how we can be more rational in responding to our fears of terrorism.
Key points were clarified and fascinating information was shared at an incredibly insightful presentation I attended with Noah Clyman, LCSW-R and colleagues from NYC Cognitive Therapy earlier this month, Imagined Ugliness: Understanding and Treating body Dysmorphic Disorder, given by Sabine Wilhelm, Ph. D.
Body dysmorphic disorder (BDD), can be briefly defined as having a preoccupation with one or more perceived defects or flaws in physical appearance that is not observable or appear slight to others (Diagnostic and Statistical Manual of Mental Disorders, DSM-5). BDD usually begins during adolescence, but can occur earlier in childhood and presents almost evenly among genders.
Common physical appearance obsessions:
- Body or facial hair
- Thinning hair on head
- Scars or markings on skin
- Coloring of skin complexion
- Facial Asymmetry
- Shape or size of facial features, various body parts, or muscles
Maladaptive behaviors include: mirror checking, excessive grooming, skin picking or mental acts of comparing appearance to that of others. Many patients also exhibit avoidance behavior. They may avoid places that are very appearance focused (e.g. weddings), brightly lit places and mirrors. This can lead to problems with friends, family or work (calling out, arriving late due to rituals, etc). Preoccupations cause significant distress or impairment in social, occupational or other important areas of functioning. The preoccupations are not attributable to other medical conditions or better accounted for by concerns with body fat or weight in an eating disorder. Muscle dysmorphia–a psychological disorder marked by a negative body image and an obsessive desire to have a muscular physique—is a subtype of BDD.
There are many causes of BDD:
- environmental factors (teasing, childhood neglect/abuse, socio cultural pressures)
- psychological factors and personality traits (perfectionist, rejection sensitivity)
- interpretation biases and information processing abnormalities (detail oriented, self-focused, misperception of neutral facial expressions or situation as threatening)
- biological theories (involvement of frontal-striata/amygdala brain circuitry, family history).
Associated problems include depression and/or anxiety. Alarmingly, the suicide rate for BDD patients is approximately 45 times higher than the general population.
Effective vs. Ineffective treatments
A few treatments are considered by BDD patients. Non-psychiatric treatments are often sought out, such as dermatologist or plastic surgeons. These are usually ineffective and often the patient consequently feels worse after. They can be disappointed when the desired social result is not achieved (e.g., belief that surgery will lead to having friendships, feeling confident, and so on). A significant amount (27%) of BDD patients obtain cosmetic surgery or dental procedures. Medications that are best studied are antidepressants (SRI’s: fluvoxamine and clomipramine). However, all the SRI’s appear to be effective. Typically patients who suffer from BDD require dosages at the higher end of the therapeutic range for SRI’s. Cognitive behavioral therapy, time-limited psychotherapy that modifies maladaptive thoughts, beliefs and behaviors has been proven effective.
Tips to help a friend or loved one overcome barriers to treatment:
- Don’t argue with loved one over the existence of the perceived flaw (or agree).
- Focus on the excessive preoccupation and how it may be impairing their daily lives. In regards to discussions about surgery or dermatological treatments, start a cost/benefits conversation of strategies (consider CBT and/or medication).
- If friend or loved one wants to drop out of CBT to get cosmetic treatment, have them consider postponing the surgery. The surgery can always be an option later, see if they are willing to try a certain number of sessions first.
- Embarrassment about being seen in the waiting room – think of a plan to manage anxiety (arrange appointment time with practitioner so there is no waiting time with other patients).
Tips to enhance motivation for loved one or friend:
- Look forward by asking loved one a question such as: What do you want life to look like in 5 years (what would it look like with or without CBT)? Also think of extreme scenarios (what is the best/worst case) and encourage change talk.
- Start at the end by asking questions like: What do you want people to say about you when you aren’t here? When you look back on your life? What memories do you want to have?
Results of a recent study (24 treatment completers): BDD Severity of sample decreased and results were sustained post treatment. The mean BDD YBOCS score (questionnaire used to measure BDD severity) was 32.5 pre treatment, 15 post treatment (week 24) and 13.5 at the 6 month follow up.
About the author:
Kaley Montgomery is a second year MSW student at New York University Silver School of Social Work. Making a career change after seven years in the fashion industry, she revisited her long standing passion to help people improve functioning in their lives and relationships. Having worked in corporate offices with a variety of companies in New York City, she understands the stress and pressure that can accompany juggling the many demands of city life. She takes a joint approach while working with clients and is an avid believer of CBT, mindfulness and meditation. To book an appointment with Kaley, visit www.nyccognitivetherapy.com.
Mark*, a 27 year-old married graduate student, presented to my office years ago when I first started my practice. He described chronic anxiety, low mood, and trouble sleeping for the past two years. He had been struggling with “keeping up with it all”. This included his schoolwork, relationship, a part-time job, and his one year old baby. He experienced similar symptoms throughout school, especially as the course load became more challenging.
In the past, he had been diagnosed with anxiety disorders and depression and his doctor tried him on two antidepressants that both caused intolerable side effects. When I met with him, his top complaints were feeling overwhelmed and discouraged due to struggling in most areas of his life.
After an extensive evaluation, I diagnosed him with ADHD, inattentive type. He did not have depression or an anxiety disorder. He responded extremely well to medication and his mood and anxiety improved as he became more organized and competent in his life.
However, despite ADHD treatment with medications and therapy, he continued to exert significant energy “just to keep up”. This is often true with adults with ADHD. In addition to focus, procrastination, and distractibility, ADHD affects a set of cognitive skills known as executive functions. Executive functions include long-term planning, follow through, prioritizing, strategizing, time-management and other complex thinking skills. Deficits in executive function often persist despite ADHD medication treatment and require both extra effort and specific coping strategies.
Therefore, people with ADHD often experience difficulty maintaining their energy. Here are some tips to energize your life as you cope with ADHD. I hope they help you on your journey to success.
1. OBSERVE RUMINATION
Rumination is thinking about the same thing over and over. It can sap your energy and take the “wind out of your sails”. People with Adult ADHD may be more prone to rumination due to difficulty shifting gears.
Attempting to stop the thoughts can often make them persist. Instead, label them as “ruminating thoughts” and turn your focus to another activity. One technique that you may find helping is saying, “Oh…there is obsessing”, or “Oh…there is worry”. Just observe what happens when you name the thought. Research has shown that this can lower the intensity and duration.
2. INCREASE STRUCTURE
People with ADHD often struggle with a cluster of cognitive skills called executive function such as time management, initiating tasks, organization, follow through, and prioritizing. Challenges in executive function can lead to anxiety and feeling exhausted.
Having a schedule or “game plan”, can help one feel calmer. Using a calendar, either paper or digital, can help structure tasks and time. This can help with productivity and organization.
Many people with Adult ADHD often feel they never are going to catch up or achieve their goals. This may be due to painful experiences in the past. You may recognize some of the self-talk:
●”I am always screwing things up”.
●”I will never be good enough”.
●”This will never work for me”.
This type of self-talk is often called the inner critic and can sap energy similar to rumination. Often, I encourage my patients to do the following:
●Notice the inner critic.
●As above, label it. “Oh….There is the inner critic.”
●Remind yourself: “I am a work in progress”.
This may just sound like positive talk or unrealistic, but thousands of studies for many decades have shown that how we talk to ourselves affects how we feel and behave.
4. IMPROVE SLEEP
There has been more attention over the past decade on sleep and the impact of sleep deprivation. Restorative and adequate sleep is important not only for energy but also for cognitive functioning. Sometimes, ADHD symptoms may worsen during periods of interrupted sleep, insomnia, or sleep deprivation.
Some tips to improve intermittent sleeping difficulties include:
●Avoiding electronic devices for three to four hours prior to bedtime.
●Establishing a consistent, evening routine.
●Creating a calm, uncluttered sleeping environment.
●Using earplugs or a white noise machine if needed.
●Exercising during the day and not within three hours of bedtime.
If you suffer from significant low energy during the day or chronic insomnia, it is important to seek treatment from your doctor about potential underlying medical causes of fatigue.
Often, people with ADHD feel so overwhelmed or without enough time that fun or pleasurable activities are ignored. People may say, “I don’t have time to relax or have fun” or “I don’t deserve to do that”. However, fun can energize you and help you have a better outlook and be more productive. Fun can involve watching a comedy, playing with your dog, visiting friends, or pursuing an artistic passion.
6. SET GOALS
Just like a map, having specific goals can help you stay on track. As you make progress in your goals, it can provide momentum and guidance on your journey. I would recommend that you set several create both short-term (e.g. one month) and long-term (e.g. one year) goals.
Effective goals usually have specific outcomes (e.g. increased sales by $10,000 or eating meals with the family three times a week), a game plan or strategy, and most importantly, a means to measure the outcome (e.g. a chart or checklist).
7. CARDIOVASCULAR EXERCISE
Cardiovascular exercise such as biking, running, dancing, swimming and other activities are good for our overall health. In addition, cardiovascular exercise can improve our sense of well-being and energy.
There are many hypotheses why cardiovascular exercise has this benefit including releasing endorphins and increasing a “motivational transmitter” called dopamine.
Adult ADHD can be very challenging as you pursue success in your personal and professional life. However, I hope these seven ideas help to provide you the stamina and energy to achieve your potential.
If you would like to learn more about Adult ADHD and coping strategies, please visit my website at www.scottshapiromd.com.
*Disclaimer: Details of cases have been altered to protect the confidentiality of any and all individuals.
|About Scott Shapiro, MD, Helping Adults with ADHD
Scott Shapiro, MD, specializes in helping adults with ADHD. He is a psychiatrist in private practice who sees patients struggling with depression, anxiety, bipolar disorder and attention deficit and hyperactivity disorder (ADHD). He enjoys working closely with other high quality and personable specialists in providing comprehensive care. He uses evidenced based treatments including psychopharmacology, cognitive behavioral therapy (CBT), and schema therapy.