# Motivation and emotion/Book/2021/Cognitive behaviour therapy for emotional abuse

* Multimedia presentation (3 min)

## Overview

Emotional abuse is often abusive behaviour that is not physical in nature, but effects a person’s emotions, thoughts, feelings and behaviour. Emotional abuse may include verbal aggression, humiliation, intimidation, and manipulation; these actions are often exacerbated over time and can become a pattern of behaviour which alters or weakens the victim’s sense of identity, dignity and self-worth. Emotional abuse often results in the victim becoming anxious, depressed, isolated, and can become so extreme it brings on suicidal thoughts or post-traumatic stress disorder. One tool to help process the distressing and negative feelings and emotions brought on emotional abuse is cognitive behaviour therapy (CBT).
CBT centres around our cognition, emotion and behaviour, and how these three aspects interact. To expand on this, cognition refers to how we think, emotions refer to how we feel and behaviour refers to how we act. A person’s thoughts determine their feelings and behaviour; thus, if a person has negative and unrealistic thoughts, this may cause distress to the individual and cause further problems, or poor emotion regulation. Cognitive behaviour therapy is not intended to be a lifelong treatment for an individual, however, it does aim to provide strategies for clients to use to self-manage negative or intrusive thoughts and feelings as they arise.
CBT assists with reframing thoughts, feelings and emotions, which are key areas of concern when treating a patient who has experienced emotional abuse. CBT provides long-term, self manageable strategies for the victims to use when needed. The therapy educates victims to recognise abusive behaviour and understand the way it changes, or controls, thought processes and self-esteem; this enables the victim to feel more empowered, in control and able to identify abusive behaviour in future.
* Focus questions:
* Why is CBT a helpful tool for victim's of emotional abuse?
* What CBT techniques are useful for emotional abuse?
* How does CBT differ when treating adults and children who have experienced emotional abuse?

## Why is CBT helpful for victim's of emotional abuse?

CBT is a psychosocial intervention which intentionally targets, modifies, and changes unhelpful thoughts, beliefs attitudes and behaviours. By changing these cognitions in the direction of more rational, realistic, and balanced thoughts, the individual’s symptoms can be relieved, and the patient may develop increased adaptability and functionality (Antonio Gonzalez Prendes, 2012). The key principal of CBT treatment is to help patients attain safety in relationships, and in their thoughts, behaviour and emotions, which effectively reduces their trauma. It can be delivered in group and individual formats for both adults and children who have experienced emotional abuse (Ramirez de Arellano et al., 2014).
A victim of emotional abuse commonly loses their self-worth, sense of identity, and feel trapped in their situation[factual?]. Victims become susceptible to developing cognitive distortion and cognitive dissonance (Nicholson & Lutz, 2017; Weismoore & Esposito-Smythers, 2010). The manipulating behaviours and emotionally distressing environments may result in the victim suffering from irrational, unrealistic thought processes (Smullens, n.d.). Victims become emotionally triggered by events and/or peoples[grammar?] actions, as it can draw frightening memories, insecurities, or expectations to the surface. These triggering moments bring the victim back to a state of vulnerability and emotional distress. CBT has been found as an effective tool in managing these irrational reactions (Wills, 2012), using techniques such as cognitive restructuring, journaling and guided discovery. Restructuring these irrational and unrealistic thoughts is one of the key functions of CBT (Leahy & Rego, 2012). Cognitive restructuring is a therapeutic technique that helps to make patients aware of negative thoughts and helps to change negative thinking patterns. The purpose of restructuring these thoughts is to aid the patient with managing their emotional responses, as they arise, limiting the impact the thoughts have on the patients[grammar?] relationship with themselves, intimate relationships, work relations and relationships with family and friends.
CBT therapists aim to understand why a patient may appraise an event in a certain manner, and why it makes them feel a particular way. People have idiosyncratic ways of evaluating events because of cognitions, perceptions, beliefs and schema, which have been formed by events and experiences (Wills 2012). CBT is a form of therapy, for emotional abuse, where the patient and therapist identify issues the patient is having and build coping mechanisms to address and manage them. The therapist and patient apply strategies and activities, which patients can also do at home, to control, reframe/restructure and self-manage episode of triggering thoughts, feelings and emotions (Wills 2012). It is a suitable and effective strategy for emotional abuse victims, as it solidifies a victim’s sense of control, independence and creates a set of coping strategies for ongoing use. (Ramirez de Arellano et al., 2014)

### Techniques used in CBT for emotional abuse

Although these techniques have been found useful in helping with some psychological disorders and symptoms brought on by emotional abuse, studies have found that CBT may not be effective in reducing symptoms of PTSD (Cloitre et al., 2002; Foa et al., 1999; Habigzang et al., 2018; Vickerman & Margolin, 2009). Therefore, CBT may not be an effective treatment alone for some patients, depending on their diagnosis, and additional psychotherapy treatment may be required to further treat PTSD symptoms.

#### Cognitive restructuring

Cognitive restructuring is a technique used during CBT, to help identify negative thought processes and develop strategies to reframe or reshape those thoughts; it has also been found effective on cognitive distortion (Ramezani, 2016). Cognitive distortion is described as a distorted and unhealthy view of reality.
Examples of cognitive distortions are:
* Polarised thinking
* Overgeneralising
* Catastrophising
* Personalisation
Studies show a high correlation between emotional abuse and cognitive distortion (Weismoore & Esposito-Smythers, 2010). Thus, making cognitive restructuring a useful technique during CBT treatment for emotional abuse victims[grammar?].

#### Journaling

Journaling is a useful tool for victims where they write down their moods and thoughts as they arise. People are encouraged to note down the time of the mood/thought, the event or trigger, the intensity, and their reaction. This process helps with identifying thought patterns and emotional tendencies, and enables the person to describe the experience, and change, adapt, or cope with it more effectively (Utley & Garza, 2011). Journaling allows the person to reflect on a situation after the emotional response has passed, with a more clear perception of reality, and assess why they may have reacted in that way and how they can challenge those intrusive and unhelpful thoughts in future.

#### Guided Discovery

Guided discovery is a technique where the therapist will ask their client questions in order to have them respond or reflect on their thinking processes. This technique can make client more self aware and provide alternative thought process, and supports the client in changing their perceptions and behaviours. Guided discovery can aid in changing thought processes which have been developed throughout a persons[grammar?] life, as well as those that arise from the persons[grammar?] immediate mood state.
* Case studyAn example of cognitive behaviour therapy techniques in use
* Jessica has recently left am emotionally abuse relationship and has begun therapy, as she does not feel herself. Jessica wants coping strategies for when she feels she cannot control her emotions and is triggered into an irrational and anxious state.
* Jessica's therapist suggests she write in a journal during, and/or after, she is distressed, and asks Jessica to bring this journal to their sessions. This enables the therapist to more clearly understand the distorted thoughts and provide appropriate strategies to manage these.
* In their next session the therapist asks Jessica to read reactions and reflect on her emotions toward the reaction. This is helpful as Jessica is removed from the triggering situation and can more accurately assess whether her reaction was irrational or not. The therapist then suggests Jessica ask herself these questions when she is in a state of panic as this is a technique used for cognitive restructure and helps to rationalise the situation as it happens.
* Is this reaction an emotionally irrational response to a triggering situation?
* Are my thoughts and feelings based on emotion or facts?
* What evidence is there that this is true?
* What evidence is there that this is not true?

## Using CBT to treat children and families who have experienced emotional abuse

Children are especially vulnerable to emotional abuse (Doyle, 1997). Children may be exposed to emotional abuse by their parents or other family/friends, they can also experience emotional abuse in school settings. Emotional abuse is extremely dangerous for children and will likely affect their self-esteem and emotional well-being (Liu et al., 2018). Abusive behaviour, from adult to child, has a lasting effect on a child’s development and well-being. Children who have experienced emotional abuse may suffer from emotional, psychological and physical problems as a result.
A number of evidence-based CBT treatment designs have been found effective in supporting children who have experienced emotional abuse, and their caregivers (Kolko, 2011).

### Treatment design approaches for children and caregivers

[Provide more detail]

#### Trauma-focused cognitive behavioural therapy (TF-CBT)

TF-CBT is an evidence-based treatment (EBT) design which is successful in helping children and caregivers overcome trauma and issues associated with emotional abuse (Kolko, 2011). TF-CBT uses techniques originally developed for treatment of anxiety, depression and fear in adults (Beck, 1976; Wolpe, 1969) and have since been used when approaching therapy for excessive fear and anxiety in children (Beidel & Turner, 1998). Researchers have applied TF-CBT in studies which look at the efficacy of the treatment in cross cultural and diverse socioeconomic settings. In one study, researchers found no difference in retention of participants and no difference in outcomes of treatment. Thus,[grammar?] confirming TF-CBT is effective in reducing symptoms and improving behaviours, and is a cross-culturally applicable treatment option (Weiner, 2009).
Research shows that TF-CBT helps children to process traumatic memories, overcome problematic thoughts and behaviours, and supports the development of coping and interpersonal skills (Cohen & Mannarino 2008). The aim is for the therapist, caregiver and child to work collaboratively to identify common goals and attain them. The treatment design involves both the child and caregiver, with joint and individual components. Individual sessions are intended to build a safe and therapeutic relationship with the therapist, educate the participants, and create a safe environment to address and process the traumatic memories, feelings and thoughts. The joint sessions aim to create a space where the caregiver and child can practice the skills they have learnt in the individual sessions, and also fosters better parent-child communication.
The goals of TF-CBT are to:
* reduce negative emotional and behavioural responses to trauma
* evaluate, understand and amend maladaptive beliefs related to traumatic events and memories
* provide education and support to both the child and caregiver, so they are both equipped with skills to more effectively manage their emotional distress.
Elements/modules of TF-CBT design - referred to as “PRACTICE”[factual?] :
| PRACTICE | Description of module focus |
| Psychoeducation and parenting skills | Discussion and education about emotional abuse and emotional and behavioural reactions to abuse; educating parents in child behaviour management strategies and effective communication. |
| Relaxation techniques | Providing tools and strategies for relaxation, some include focused breathing, progressive muscle relaxation, and visual imagery. |
| Affective expression and regulation | Management of emotional reactions to triggers and events which remind the child and caregiver of the abuse, improvement in identifying and expressing emotions, and implement self-soothing techniques. |
| Cognitive coping and processing | Education and understanding of the connection between thoughts, feelings, and behaviours; identifying and amending erroneous attributions related to regular events. |
| Trauma narrative and processing | Exposure exercises (gradual), such as written, verbal, or symbolic recounting of abusive events and memories, and working through inaccurate and unhelpful thoughts, feelings and emotions relating to the abuse. |
| In vivo exposure | Exposure exercises (gradual) involving reminders of the trauma or traumatic environment to the child, for example it might be a bedroom, darkness or confined spaces. This allows the child to learn to control their emotional reactions. |
| Conjoint parent/child sessions | Joint sessions where communication enhancement is the focus, as well as encouraging safe and therapeutic discussions about the abuse between the child and caregiver. |
| Enhancing personal safety and future growth | Education and training in safety skills and interpersonal relationships, and skill implementation for managing future triggers and trauma reminders. |

#### Alternatives for families: a cognitive behavioural therapy

Alternatives for families cognitive behavioural therapy (AF–CBT) has been developed as a comprehensive EBT approach to reduce or prevent the effects and risks associated with exposure to physical or emotional abuse. AF-CBT helps families to recover from the effects of exposure to abusive environments. This treatment aims to teach both caregivers and children intrapersonal and interpersonal skills which can increase self-control, promote positive relationships and reduce abusive behaviour (Brown & Kolko, 2019). AF-CBT develops skills for the family in anger management, social skills, effective coping strategies, challenging misattributions, and better communication and problem-solving skills.
AF-CBT involves four assessment tools which look at clinical targets. These assessment tools include:
* The Alabama parenting questionnaire – short form (APQ-SF)
* The brief child abuse potential inventory (B-CAP)
* The child PTSD symptom scale (CPSS)
* The strengths and difficulties questionnaire (SDQ)
AF-CBT includes techniques which target three cognition (thinking), affect (feelings and physiological reactivity), and behaviour (doing) [grammar?] and includes educating the participants in psychological skills in each of these areas. This process is similar to treatment techniques for adults harnessing CBT. AF-CBT is designed largely for use in patients aged 5 to 17, therefore, [grammar?] a more appropriate treatment design for youth rather than adults.
AF-CBT treatment is delivered in three phases: engagement and psychoeducation, individual skill building, and family applications and routines. Each phase has topics of focus and is designed to be flexible, meaning topics can be adapted, condensed or repeated as necessary, depending on the participant progress and treatment needs. Typically, both phase one and two are administered in individual sessions to the parent/caregiver and the child, and phase three is administered to both parent/caregiver and child, in joint session[grammar?].
Elements/modules of AF–CBT design [factual?] :
| Phase description | Description of phase topics |
| Phase one: engagement and psychoeducation This first phase focusses on teaching the child intrapersonal skills, which centres around cognitive change. | Topic 1: orientation–caregiver and child Topic 2: alliance building and engagement–caregiver Topic 3: learning about feelings and family experiences–child Topic 4: talking about family experiences and psychoeducation–caregiver |
| Phase two: individual skill-building (skills training) The second phase moves onto teaching more interpersonal skills, such as behavioural and social skills. | Topic 5: emotion regulation–caregiver Topic 6: emotion regulation–child Topic 7: restructuring thoughts–caregiver Topic 8: restructuring thoughts–child Topic 9: noticing positive behaviour–caregiver Topic 10: assertiveness and social skills–child Topic 11: techniques for managing behaviour–caregiver Optional topic 12: imaginal exposure–child Topic 13: preparation for clarification–caregiver |
| Phase three: family applications Joint phase | Topic 14: verbalizing healthy communication–caregiver and child Topic 15: enhancing safety through clarification–caregiver and child Topic 16: solving family problems–caregiver –caregiver and child |
Both of these models (TF-CBT and AF–CBT) incorporate various CBT techniques, such as emotion regulation, restructuring thoughts, coping strategy development and use of exposure therapy.

## Breaking the cycle

Victims of emotional abuse, both children and adults, often engage in emotionally abusive relationships throughout their life. Some reasons for re-engagement in unhealthy relationships are feelings of familiarity, desire to regain control and feelings of inadequacy. CBT tools and techniques have been found effective in supporting abuse victims in regaining control and developing strategies that challenge those feelings of inadequacy, as they arise (Maier & Seligman, 2016). This therapy teaches cognitive tools which reduce destructive, distressing, negative thoughts and emotions. Patients are taught that they can do something - which promotes sense of control. These findings [factual?] demonstrate a clear correlation between CBT and reduction in probability of re-engaging in abusive relationships.
Looking at this from a psychological theory lens, Walker (1970, 1999) developed a theory of cyclic abuse, based off both the social cycle theory and learned helplessness. This theory suggests that abusive behaviours become predictable repetitious patterns of abuse and prolonged periods of time in this cyclic abusive environment may lead the victim to learned helplessness. A recent study found CBT to be effective in treating patients presenting with learned helplessness (Maier & Seligman, 2016) and further found CBT useful in reappraisal of situations victims see as 'catastrophic'.
There are various elements which factor into cycles of abuse, each with their own complexities. CBT is a diverse tool, which applies various techniques which stimulate different, more beneficial thought processes in patients, and is highly effective in reducing a wide range of symptoms associated with abuse and the possibility of reengaging in abusive relationships.

## Conclusion

CBT is an effective therapeutic choice of treatment for both adults and children who have experienced emotional abuse. There are different strategies that may be applied, and different treatment designs may be chosen depending on the persons[grammar?] age and experiences. Therapy techniques used in CBT are effective in reducing and self-managing symptoms associated with emotional abuse and provides skills, strategies and coping mechanisms, which allow a victim to actively manage these episodes as they arise and control their emotional response more effectively. The key techniques used in emotional abuse treatment are cognitive restructure[grammar?], journaling and guided discovery,[grammar?] these techniques enable patients to develop an ability to reframe negative thought process, and reflect on their reactions. CBT also helps to manage symptoms associated [grammar?] anxiety and depression. However, depending on the severity of the symptoms and diagnosis of the psychiatric disorders, additional treatment may be useful in conjunction with CBT, as research found it lacked effectiveness for symptoms associated with PTSD.
There are two key treatment designs used for children who have experienced emotional abuse, TF–CBT and AF–CBT. Both of these approaches incorporate a structured plan, where both children and caregivers are provided treatment. These treatment designs are effective for emotional abuse suffered by children, as they provide both the child and caregiver with skills to manage their trauma, communicate more effectively, and develop strategies to reframe and restructure negative and distressing thoughts as they arise.