The Issues as to why women do not engage in therapeutic CBT groups


 


The issue as to why women do not engage in therapeutic CBT groups determines the issues of learning styles, gender issues, communication issues and other possible factors as to why CBT groups may collapse even though there are advantages of treating women such health care setting as women who require inpatient treatment have a history of abuse and trauma, often of a physical or sexual nature that could trigger the situation as to why these women don’t engage in CBT groups and as an outcome such anxiety support groups may collapsed because of the fact that the client may have conflicted emotions regarding such therapy actions and be reluctant to talk openly or be emotionally vulnerable in front of the CBT groups. Thus, these women tend to internalize their difficulties in the form of depression and sense certain anger and are unwilling to be open and tend to withdraw in the presence of these groups. Women also do well such groups because of the commonality of their experiences. They are conditioned toward cooperation rather than competition, sometimes leading them to take on the responsibility of peace within relationships, often through codependency. They are influenced by society and the media regarding the importance of personal appearance and weight which factors into eating disorders which the vast majority of men do not experience. Society tells them to be competitive in the workplace while many religions and cultures still tell them to be submissive and passive.


 


 


 


 


Women still bear the majority of the responsibility for raising children and housekeeping duties while many are employed outside the home as their conflicts and issues are quite not the same as those of CBT groups. Women who have suffered trauma often tend to view themselves as helpless victims who are incapable of fighting back or standing up for themselves. They may react to their emotional difficulties by developing addictions, whether to chemical substances, food and or relationships and their reactions to their addictions differ from those of men. Moreover, in these days of hospital stays and insurance company mandates to treat them and street them,” it is incumbent upon us as therapists to maximize the benefit the women clients receive from inpatient and outpatient treatment. There could be distinct advantages to treating female clients in a women-only setting, based upon such factors as differences in other women’s history, diagnoses and symptoms and women’s commonality of issues with diagnoses and affects how women react to CBT treatment and the treatment setting as these clients have conflicted emotions regarding men. They have difficulty with mistrust and often feel responsibility, guilt and shame for what has happened to them.


 


 


 


 


Thus, women are unenthusiastic to talk openly or be emotionally vulnerable in front of therapeutic CBT groups, often viewing them as potential perpetrators. In addition, when women are forthcoming in a group setting, other women offer support and understanding while men frequently exhibit no response. Whatever the reason for their silence, the woman frequently believes the men either don’t care. Paradoxically, should a man offer any expression of empathy, the woman still distrusts his sentiment and motivation and hesitates to repeat her openness. Alternatively, some women’s symptoms tend to the opposite extreme. Their long-standing need for intimacy and/or compulsion to recapitulate the traumatic incidents leads them to form inappropriate relationships with male clients. Additionally, within the crucible of an inpatient setting, when denied access to their accustomed numbing behaviors, some women turn to relationships to distract themselves from their emotional distress. Women tend to internalize their difficulties in the form of depression. While women exhibit their depression through sadness, men react with anger and antisocial behavior. Women sense this anger and are reluctant to be open in front of them, tending to withdraw in the presence of the groups, who frequently remind them of prior abusers and whom they view as being unable or unwilling to cooperate and fully become a member of the group.


 


 


 


 


Women who have suffered trauma often tend to view themselves as helpless victims who are incapable of fighting back or standing up for themselves. When attempting to express their anger, their behaviors differ from those of men. Rather than becoming outwardly aggressive or exhibiting antisocial behavior, they turn their anger on themselves, engaging in self-sabotage, self-abuse, or even self-mutilation. Women react to their emotional difficulties by developing addictions, whether to chemical substances, food, work, or relationships, in order to alleviate the pain and distress associated with their symptoms. Research indicates that up to 70 percent of drug abusing women report histories of physical and sexual abuse. Women who do drink heavily are at greater risk than men for developing alcohol-related problems. They develop dependency with a lower incidence of exposure and less consumption than do men. In addition to their histories of abuse, women are influenced by society and the media regarding the importance of personal appearance and weight. Shame is significantly associated with the attitudinal features of eating disorders, primarily regarding weight concern in women. Research has also indicated that there is an addictive component to eating disorders. Support for this idea comes from evidence that anxiety and depression are frequent premorbid characteristics both of addicts and of patients with eating disorders.


 


 


 


Women tend to do well in women’s only groups because of the support they receive from others who have a commonality of experiences. Women have issues and difficulties not faced, nor understood, by most male clients. They are conditioned toward cooperation rather than competition, sometimes leading them to take on the responsibility of peace within relationships, often through codependency. Yet society tells them to be competitive in the workplace while many religions and cultures continue to tell them to be submissive and passive. Women still bear the majority of the responsibility for raising children and housekeeping duties while many are also employed outside the home. A woman has been led to believe that unless she can balance being a mother, adequate sexual partner, being gainfully employed and competitive, and being the perfect helpmeet at home while deferring to her partner, she has somehow failed as a woman. Furthermore, single mothers in inpatient treatment not only worry about the welfare of their children, they often fear the loss of their children simply because they now have a psychiatric hospitalization. Knowing others live with the same demands and pressures leads to more trust and therefore more openness within the group setting.


 


 


 


 


 


 


The depression experienced of depressed women may have had a greater determined component, which may be less responsive to psychosocial interventions which similarly could have rendered these youths less responsive to group CBT. (1999) confirms that youths who had a depressed parent had poorer outcomes. Similar poor outcomes for depressed youths with depressed parents have been reported in other CBT trials (1998). Due in part to a productive interplay between research and clinical practice ( 1999), many clinical researchers believe that cognitive-behavioral therapy (CBT) administered within an evidence-based, multidisciplinary practice model is the psychotherapeutic treatment of choice for youth with internalizing disorders (1997;  2003). Henceforth, behavioral psychotherapists work with patients to change behaviors and to reduce distressing thoughts and feelings. Although CBT is often referred to as a unitary treatment, it is actually a diverse collection of complex and subtle interventions that must each be mastered and understood from the social learning perspective. Subsequently, a cognitive-behavioral case formulation guides the therapist in administering treatment techniques in a flexible manner for the patient presenting with any one disorder or comorbid presentation of mental disorders (2003).


 


 


For example, using cognitive restructuring and exposure-based interventions, CBT for anxiety disorders encourages cognitions and behaviors designed to promote habituation or extinction of inappropriate fears. Likewise, CBT for depression directly confronts maladaptive depressogenic cognitions, including helplessness, hopelessness, and hostility, and aims behaviorally to reconstitute pleasant relationships, be they intrapsychic, interpersonal, school, or spiritual. As evidence-based therapies, each is supported by a more or less robust research literature, and manuals are usually available to guide practitioners in using CBT for specific problems. Thus, CBT fits nicely into the current medical practice environment that appropriately values empirically supported, brief, problem-focused treatments. In CBT, the task of the mental health practitioner is to understand the presenting symptoms in the context of child-specific constraints to normal development and to devise a tailored treatment program that eliminates those constraints so that the youngster can resume a normal developmental trajectory insofar as is possible ( 1997;  2000). Valid and reliable assessment is essential to the skillful application and evaluation of cognitive-behavioral treatments ( 1991) and is strength of the cited studies taken as a whole identifying women as having an anxiety disorder as well as documenting diagnostic comorbidities and assessing treatment outcomes. ( 1996).


 


 


Without encouragement, women often find it difficult to remain in the presence of anxiety-arousing stimuli for a sufficient length of time to allow habituation to occur in the natural environment. In fact, in some cases, the process of negative reinforcement maintains the anxiety response. By escaping or avoiding the situation, such as through complaints of feeling ill and needing to leave class or the behavior of school avoidance/refusal, the individual feels immediate relief from the anxiety. This is the process of negative reinforcement. The escape behavior is reinforced by the relief and sets the stage for cycles of anxiety arousal followed by escape or avoidance and relief. Hence, it is of critical importance to note that study is supportive for problem-specific psychotherapies in CBT groups (1996; 1996). In particular, several trials have demonstrated that group administered cognitive-behavioral psychotherapy is an effective treatment for depressed women (1997;  1994) as there considers the CBT to be the treatment of choice for anxiety disorder ( 1998) and suggesting that future studies will be needed to evaluate the exportability of protocol-driven CBT treatment packages to divergent patient populations. Women don’t engage in such groups as the role of the CBT groups are to establish a collaborative working relationship with the adolescent and to help the adolescent learn new ways of behaving and thinking, which in turn reduces depressive severity and risk of relapse.


 


 


Moreover, evidence is beginning to emerge that combined child and parent treatment may be more effective than treatment directed at the teenager alone ( 1990). In addition to teaching contingency management procedures, parents are provided with alternative, effective methods for parenting and creating a more positive family environment. Furthermore, family interactions are targeted directly to shape and reinforce effective communication and to increase pleasant activities and positive affect. Helping women parents make rapid and difficult behavior change over short time intervals requires considerable expertise and training. CBT is taught from manuals that are mostly used to conduct outpatient care ( 2004). In a crisis-based inpatient service, because of time limitations, it is necessary to focus on basic concepts in cognitive restructuring as the teaching must use simple examples to show the power and control gained by using thoughts to modify feelings and actions. Communication is necessary to integrate CBT concepts into crisis inpatient treatment. Communication should begin as an admission is planned. It involves the referral source, the family, and the patient. Information is collected by intake staff about the goals of the various parties for diagnosis and treatment. Although data collection is part of any good treatment program, unique to this program is the way in which it is filtered and redefined through a CBT perspective, which permits treatment to begin with everyone on the same page.


 


 


For example, when a patient is referred for wanting to kill him- or herself, clinical information is organized into a paradigm that reviews how the feelings of wanting to die led to a specific suicide plan; other alternative thoughts that were entertained, such as running away; which options were not considered, such as confiding distress to friends; and which feeling, thought, and action alternatives might be preventive in the future. In most cases, a referring professional looks to a hospital to make diagnoses, change medication, and stop dangerous behavior. A parent seeks ways to keep his or her child alive and safe. A patient may seek a physical refuge from his or her situation yet wish to avoid dealing with the emotional decisions that precipitated admission. Although these positions seem to run at cross-purposes to one another, they are consistent in considering hospital treatment as a procedure, like an appendectomy, in which the patient is mainly the recipient of care. A CBT perspective offers an opportunity for the patient to be a more active agent. It integrates information about feelings from a variety of sources, from personal experience to psychiatric data and exposes it to thought management exercises. Inpatient hospital programs that emphasize medication management may also require active participation to promote compliance. When a patient can say that he or she uses thoughts to change his or her feelings and can give examples of how this would have prevented poor choices, such as self-injury or assault, then assume comprehension skills are developing.


 


The strategies are used to deal with peer problems such as teenagers, whose admissions are triggered by crises in their love life, are helped to work through the details of their troubled relationships in discussions centered on gender-specific dating workbooks. The goals are to help modify dating expectations so that social relationships will be more satisfying. During discharge, all patients are expected to present a safety plan to the therapist and their caretakers. It outlines specific CBT strategies that help a teenager manage conflicts and reduce stress. Once underlying psychiatric conditions are identified, patients can learn their affective control components. For example, CBT skills can assist in managing bipolar illness irritability (2003;  2004; 2004). It has been difficult to offer treatment approaches other than CBT because much of therapy is carried out in groups. Those who do not find CBT ideas useful feel excluded, so their treatment is limited to individual and family therapy and psychiatric and psychopharmacologic management. Despite issues and drawbacks, a CBT focus appears to provide a productive approach for treating patients in a crisis inpatient setting. Determining the presence of social and communication difficulties requires a thorough interview with the client that may go beyond the typical five-axis diagnostic criteria. This sense of inadequacy, desire to please and simultaneous fearfulness and lack of initiative in social interactions can converge to create loneliness. Some researchers have found that loneliness is a strong factor in predicting and maintaining depression in young people (1993, 1994).


Indeed, there is evidence that poor social and communication skills are often a precursor to depression and other emotional problems. Inadequate interpersonal skills combined with stressful life events can lead to major emotional difficulties because the client has been unable to use in developing and maintaining a supportive social milieu ( 2000) and a review of literature indicates that women who are depressed often have unhealthy patterns of communication affecting their approach to the CBT group as it construct of interpersonal interaction ( 2000). The importance of the social milieu and relationships to the individual’s mental health, whether in the family, workplace and community, is an ongoing area of research. Studies focusing on women and on older persons have identified poor interpersonal relationships as preceding and then co-occurring with depression (2003; 2003). In particular, the CBT therapist seeks to help the client express the general tone of the relationship, what each person’s expectations were and whether these were met, what was good and bad about the relationship, and the changes the client would like to see (p. 61). The CBT group does not downplay the client’s presenting complaint of depression but instead helps the client to see the depression in terms of its connection to unsatisfying relationships and interactions. Examining underlying assumptions, being clear in communication, and learning to use healthy styles of communication to have needs met in relationships are pillars of CBT ( 1993).


 


Motivation is an important first step toward any action or change in behavior. Sayings such as “You can lead a horse to water, but you can’t make it drink” reflect the fact that people generally will not perform desired behaviors unless or until they are motivated to do so. Researchers have outlined a series of stages of change to describe the process that a person goes through when making a behavioral change. Those stages–pre-contemplation, contemplation, action and maintenance offer a new perspective on motivation and the process of behavior change (1998; 1992). Recognizing that patients vary in their motivation or readiness to change, researchers have designed interventions and treatments to enhance motivation (1992; 1993; 1991;1992;  1993). External influences and pressures, as well as internal thoughts and feelings, contribute to a persons motivation both to consider and implment a change in behavior (1994). Evaluating a person’s motivation requires assessment of the persons attitudes and intentions, confidence and commitment, and decisionmaking ability (1998). Researchers have attempted to measure motivation in several different ways, including querying patients about their intentions and plans to change and asking multiple questions reflecting the different stages of change (1998; 1989;  1996;  1992). Motivation appears to be a critical dimension in influencing patients to seek, comply with, and complete treatment as well as to make successful long-term changes in their drinking (1997). Studies among substance-abusing patients have demonstrated the importance of motivation for treatment in predicting treatment participation and recovery (1997;  1993). Motivation for changing problem behaviors like drinking, however, is not synonymous with motivation for participating in treatment. Motivation, a key element in treatment and recovery, influences a patient’s progression through the stages of change- from considering change, to making the decision to change, to following the planned action into sustained recovery. Current research and treatment initiatives reflect the increased focus on the role of motivation in alcoholism treatment ( 1993). In general, motivated patients enter and attend treatment at higher rates than do less motivated patients. Both the type and intensity of the patient’s motivation for change are important potential moderators of treatment participation and recovery success. A number of issues would benefit from further research, such as the best way to measure motivation and whether primary care physicians can use motivational techniques to effectively treat patients with alcohol dependence as well as patients with less problems. An important area of exploration is whether and how motivational techniques can be used with patients dually diagnosed with alcohol abuse or dependence and an additional psychiatric disorder.


 


 


 


 


 


 


Women who experience depression and other comorbid illnesses such as anxiety, substance abuse or eating disorders, displayed poorer play interactions with their 4-month-old infants than mothers with depression only or mothers who had no psychological problems. These same infants with comorbid mothers at 14-months-old were at higher risk for attachment insecurity. The infant-parent dyad may be able to buffer long term effects on the family if depression is the sole risk factor. When combined with depression, social conditions such as poverty, single parenting, family conflict and dangerous environments may interfere with developmental progress. Racial and ethnic disparities may exist with respect to treatment need as well as access to, appropriateness, and quality of care. Whether access to treatment is more compromised for minority clients than for Whites is a matter of debate. It is clear, however, that ethnic disparities in the quality and appropriateness of alcohol services are ubiquitous. Despite these disparities, treatment often appears to be as successful for minority patients as for Whites. More in-depth investigations are needed to understand why outcomes often are similar despite disparities in treatment. Evidence suggests that minorities may receive care that is less appropriate to their needs. For example, research on outcomes reveals that minority patients are less likely to receive specialty treatment and multiple episodes of care even though they often have different needs like higher unemployment rates and more legal problems than Whites (2003).


 


Treatment approaches will need to be as varied as the individuals presenting with co-morbid mental health and substance misuse problems. There is therefore no specific treatment approach, as each person will need to be assessed individually and the treatment approach will need to be tailored to the individual needs of each client. Key elements in treatment will include: (  2002).


Ø      engagement of clients into services


Ø      retaining clients in active treatment


Ø      providing interventions which facilitate motivation to change


Ø      addressing the relapsing nature of a chronic condition through relapse prevention work


Ø      facilitating re-integration into the community with appropriate support


 


 


 


 


 


 


 


The question is not the size of one’s brain used in developing any person’s intelligence and potentials. In fact, people can learn anything and can be adept in any field as long as they are taught in a way that agrees with their personal learning style. Learning styles are individual ways in which a person begins to digest, understand and retain new and often difficult information. Learning styles vary from person to person. Even members of the same family may have different learning styles among themselves. Some people may need to pace back and forth while memorizing for a big test. Some people need music or television, something to nibble on while studying or a piece of paper to ‘doodle’ on. In a working group with members that come from varying cultural backgrounds that may have an effect on their learning styles, for example, it is often difficult for a leader to create an atmosphere that caters to all cultures. In this given situation, it would be helpful to know what kind of leadership style would be helpful in dealing with such cultural differences and different learning styles of the work force. Real life is about desperate women who take the abuse, scared to testify against their partners. Who have to leave the family home and live in a shelter because some idiot can’t keep his pathetic low self-esteem under control and cheers himself up by slapping the missus around (1988; 1981; 1991). Learning styles are cognitive, affective, and psychological indicators of the manners by which students perceive, interact with and respond to the learning environment (1979).


 


According to  (1981, 1984), a person’s learning style develops because of hereditary factors, life experiences, and the demands of the present environment. Although learning style is stable, qualitative changes result from maturation and environmental stimuli (1983). (1990) argues that style of thinking and style of learning, which differ widely among and within individuals, are as important as levels of ability and that institutions should reward all styles equally throughout their organizational and delivery systems. According to, learning style is characterized by the degree to which the learner emphasizes abstractness over concreteness in perceiving information and the degree to which he or she emphasizes action over reflection in processing information in a learning situation. According to  (1979), learning styles consist of “distinctive and observable behaviors that provide clues about the mediation abilities of individuals” (p. 19). A learning style is defined as “the way each person absorbs and retains information and/or skills” (1984). Cognitive therapy has been defined as a structured therapy that is both time limited and directive, with emphasis on changing thoughts and belief systems ( 1967/1972; 1979).  (1999) stated that “the goals of cognitive-behavioral therapy are to change thoughts, improve skills, and modify emotional states that contribute to psychopathology”


 


 


CBT is indicated to treat clients who present with persistent distorted perceptions and beliefs that lead them to see themselves as deficient, incapable, or unlovable; to see their current environment as unsupportive and overpowering; and to see their future as hopeless ( 1976). The goal of CBT therapists is to help their client examine and modify negative thoughts, excessive self-criticism, lack of motivation, and the client’s tendency to view problems as insurmountable. Some techniques used in CBT include challenging irrational or self-destructive thoughts, changing the way in which individuals process information, self-monitoring exercises, communication skills, problem-solving initiatives, increasing positive self-statements and experiences, and countering mistaken belief systems ( 2002;  2001). The intended effect of this therapy is to alleviate depression by developing reinforcing and rewarding experiences and perceptions (2000). Overly controlling and overprotective parenting has been linked consistently to increased anxiety, whereas two studies have shown that authoritative/democratic parenting is associated with less anxiety. Interestingly, studies of negative family factors such as minimal positive affect, rejection, criticism have yielded mixed results. The most unique family risk factor for anxiety disorders is parental modeling, or reinforcing, of anxious or avoidant behaviors. For example,  (1996b) found that, compared with families of nonanxious children, children diagnosed with anxiety disorders and their parents perceived more threats and generated more avoidant responses in ambiguous situations (1996).


 


Thus, women are not worth as much as men in the labor market because notions of traditional gender roles continue to result in the prescriptive assignment of responsibility for children and home to women even if it may be true that more women than men would prefer to care for home and family, even in the absence of cultural pressure, not all women desire such a role. It is equally true that not all men would eschew primary caretaking roles. Although it is currently possible for an individual to rise above cultural pressures and claim a role different from that encouraged for their gender, the mere fact that a hurdle can be cleared does not justify its existence. The strong influence of issues of gender is an unnecessary hurdle barring individual choice and a major factor in gender inequities not involving in therapeutic CBT groups. Gender issues seems to be a controversial issue as of today’s society and that men are considered to exercise higher status over women in terms of handling business firms and organizations and that because of gender inequality it is true that more women do not engage in group management because of the fact that the emphasis on the individual women are in partnership with others and the fact that women are to be associated with the nature of the process implying that management is not for women within the gender perspective. The social conditions that reinforce gender inequalities may impinge on her personal life at several levels (1992).


 


 


Thus, underlying the gender issues as women is not treated fairly at work and has been effectively reduced to a reflection of gender relations in the family and needs to invoke not only the family and care, but also to the CBT groups application as women in joining groups are much qualified even if they are into child care. The population comprised individuals with a variety of special needs including mild intellectual functioning, severe literacy problems, significant communication difficulties and other important deficits and special needs. It should be noted that some of these special needs individuals would not meet the diagnostic criteria for intellectual disability and the groups aimed at the broader group inclusive of a number of special needs. Therapeutic adaptations have been guided by current research and practice and may have some utility for mainstream anxiety management programs. Moreover, women who do not engage in such therapeutic CBT groups may also have tendencies of being a social phobia which implies a form of anxiety disorder characterized by heightened fear and avoidance of group social or performance situations such as public speaking, meeting new people and attending social gatherings.


 


 


 


 


 


 


Thus, women with social phobia are typically anxious about the possibility that others will evaluate them negatively and/or notice symptoms of their anxiety. Social phobia affects up to 13 percent of individuals at some time in their lives and is usually associated with at least moderate functional impairment. Research on the nature and treatment of social phobia has increased dramatically over the past decade. As with many of the anxiety disorders, sensitive assessment instruments and effective treatments now exist for people suffering from heightened social anxiety. Treatments with demonstrated efficacy for social phobia include pharmacotherapy and cognitive behavior therapy (CBT) Over the past decade, understanding of the nature and treatment of social phobia has increased in CBT therapies for social phobia have been demonstrated to be effective for avoiding barriers of CBT groups engagement and some process condition and if combined treatments do prove to be effective, the issue of treatment sequencing will need to be addressed There needs enough research should be conducted on predictors of outcome for various treatment modalities with minimal therapist and may be helpful for social phobia. Despite the fact that most patients respond well to CBT and medications, many individuals continue to have significant anxiety following treatment as continued research may help to improve existing treatments so that more patients achieve greater benefit.


 


 


 


Similarly, such individuals tend not to be distressed by their lack of social activity and are not particularly interested in socializing. In contrast, individuals with avoidant personality disorder tend to avoid socializing because they fear criticism from others. In fact, people with severe, generalized social phobia often meet diagnostic criteria for avoidant personality disorder as well.


 


 


 


 


 


 


 


 


 


 


 


 


 


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