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Explain at least two challenges PMHNPs might encounter when using CBT in one of these settings.

Explain at least two challenges PMHNPs might encounter when using CBT in one of these settings.

Explain at least two challenges PMHNPs might encounter when using CBT in one of these settings.
QUESTION

Explain at least two challenges PMHNPs might encounter when using CBT in one of these settings.
Explain at least two challenges PMHNPs might encounter when using CBT in one of these settings.

ANSWER
Therapeutic Issues Diagnosis
Clinicians must also determine which therapeutic factors are contributing to the difficulties. Dr. Beck addressed two possibilities: (1) external factors influencing therapy and (2) therapist error. External factors include receiving the appropriate amount of treatment, receiving therapy in the appropriate format, medication issues, and whether the patient requires adjunctive treatment.

While it can be difficult for therapists to recognize their own errors, Dr. Beck has provided them with eight questions to ask themselves:

Is there a strong therapeutic alliance between me and the patient?
Did we establish concrete, attainable behavioral goals that the patient can control and that he or she genuinely wants to achieve?
Is the patient truly in agreement with all aspects of the cognitive model?
Have I changed the treatment based on the cognitive fomulation of the patient’s disorder?
Do I have a valid conceptualization of the patient, and do I base treatment on it?
Is the session properly structured?
Did I adequately socialize the patient to therapy?
Is my technique being used effectively?
Fundamental Beliefs
According to Dr. Beck, patients with personality disorders may have three core beliefs about themselves: (1) helplessness, (2) being unlovable, and (3) worthlessness. “Knowing patients’ core beliefs allows clinicians to collaborate with patients to decide which problems and cognitions to focus on in treatment,” she said.

“When patients have a core belief of helplessness, they believe they are incompetent, vulnerable, and/or inferior; they do not measure up to others.” Patients who believe they are unlovable may use a variety of descriptors, according to Dr. Beck, such as “I’m unlikeable, there’s something wrong with me (so no one will love me), I’m ugly, I have nothing to offer other people, and so on.”

“They may or may not have helpless beliefs; rather, they are very concerned that they will never receive or maintain love and intimacy from others.” When patients have worthless beliefs, they believe they are immoral sinners.”

Cognitive Visualization
Dr. Beck also talked about how he uses cognitive conceptualization with patients, illustrating it with the Cognitive Conceptualization Diagram. Her 2005 book Cognitive Therapy for Challenging Problems: What to Do When the Basics Don’t Work described the approach.

“The Cognitive Conceptualization Diagram assists the clinician in taking a large amount of information about a patient, looking for patterns in trigger situations, cognitions, emotional and behavioral responses, and identifying the patient’s key cognitions and behavioral coping strategies,” she said.

“The recurring themes in their thoughts always make sense once we understand their core beliefs: the fundamental way they see themselves, others, and the world,” Dr. Beck continues. “Once we realize they are coping with negative core beliefs, their dysfunctional patterns of behavior always make sense.”

Behavioral Strategies of Patients
According to Dr. Beck, patients with personality disorders employ a wide range of dysfunctional strategies both during and between sessions. These include being excessively aggressive or withdrawn, criticizing others, abusing substances, and self-harm.

“It’s helpful to ask patients what was going through their minds just before they displayed the problematic behavior when they use a coping strategy in session,” she said. “Their thoughts are frequently distorted, and if this is the case, they may benefit from an assessment of the validity and utility of their thoughts.”

Dr. Beck also discussed how specific personality disorders can obstruct therapy. Patients suffering from avoidant personality disorder, for example, may believe: “I will be hurt if I trust my therapist;” “I will feel too overwhelmed if I focus on problems in therapy,” and “I will be rejected if I try to work toward achieving interpersonal goals.” These patients may also engage in therapy-interfering behaviors such as putting on a false front, changing the subject when distressed, and discussing problems and cognitions on a surface level.

Important Takeaways
Dr. Beck concluded her presentation by emphasizing actionable takeaways for clinicians to use with patients. She emphasized the importance of clinicians forming therapeutic alliances with all patients and provided the following pointers:

Be a good human being to all of your patients. Treat each patient as you would like to be treated as a patient. • Take steps to make your patients feel safe.
Use Rogerian counseling techniques.
Maintain reasonable expectations for your patients; after all, they are supposed to be difficult, which is why they are called patients.
Maintain realistic expectations for yourself; you will not be able to fully assist every patient who walks through the door, but you should strive to develop a good therapeutic alliance with them so they will be more willing to see another provider if you are unable to assist them sufficiently.
“It’s critical to pay attention to patients’ emotions during sessions.” “Ask patients what was going through their minds when you notice them looking more distressed,” Dr. Beck advised. “Regardless of what they say, clinicians must positively reinforce them: ‘It’s good you told me that.’ If they provide negative feedback that you believe is correct, model apologizing and problem solving to avoid making the same mistake in the future.”

“If they make incorrect assumptions about you, you may place their cognition in the context of the cognitive model and engage in Socratic questioning,” she added. “As soon as they correct their perception of you, ask if they have the same perception of other people.” If so, assist them in applying what they’ve learned to these other relationships.”

“Recognize that the therapeutic relationship improves when patients realize they’ve had a sudden gain in treatment—they’re feeling better and working to solve their problems,” Dr. Beck advised clinicians. “As a result, it’s critical to get right to work on the difficulties patients will face when they leave your office,” she says.

Clinicians must also be aware of their own negative reactions to clients with personality disorders and address them appropriately. She suggested that clinicians look at the patients they’re scheduled to see each day and ask themselves, “Who do I wish didn’t come in today?”

“Initially, most patients with personality disorders do not feel safe in treatment.” They have negative beliefs about other people and, unless strongly demonstrated otherwise, apply these beliefs to the therapist,” Dr. Beck said. “Clinicians’ negative reactions to patients are unavoidably transmitted.”

Dr. Beck advised clinicians to use basic CBT techniques on themselves to avoid negative reactions, particularly modifying their own relevant core beliefs. They should also seek supervision or consultation, work to improve their abilities, and practice self-care.

Dr. Beck stated, “I’m hoping they can see their patients in a less pejorative way, realizing that due to genetic and epigenetic influences interacting with childhood experiences, these patients have developed very negative dysfunctional core beliefs, which they cope with in dysfunctional ways.”

“It’s not their fault that they have the problems they do,” she says. “It’s only reasonable to expect that they will bring their dysfunctional way of viewing others to the therapy situation, and that they will undoubtedly use dysfunctional coping strategies in and between sessions.”

“I’m also hoping that clinicians will be able to better identify patients’ beliefs and problematic patterns of behavior, and that I’ve provided them with some tools to help them be more effective,” Dr. Beck added. “Finally, I hope I inspired the audience to learn more about CBT for personality disorders.”

Explain at least two challenges PMHNPs might encounter when using CBT in one of these settings.

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