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Structure and Techniques of Cognitive Behavioural Therapy (CBT). 23 December 2007. Underlying assumptions: Cognitive Behavioral Therapy. How an individual interprets life events plays a role in determining how he or she responds to those events (Beck, 1991).

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structure and techniques of cognitive behavioural therapy cbt

Structure and Techniques of Cognitive BehaviouralTherapy(CBT)

23 December 2007

underlying assumptions cognitive behavioral therapy
Underlying assumptions:Cognitive Behavioral Therapy
  • How an individual interprets life events plays a role in determining how he or she responds to those events (Beck, 1991).
  • Patients are seen as being excessively negative in their beliefs and suffering from the use of maladaptive information processing strategies.
  • Seeks to teach patients to identify their maladaptive beliefs and processing tendencies and to systematically test the accuracy of those beliefs and tendencies.
  • Encourages examining the accuracy of their beliefs, and engaging in a series of “experiments” in which behaviors are systematically varied in order to test the accuracy of those beliefs.
overarching goals of cbt
Overarching goals of CBT
  • Provide patients with clear and credible rationale for understanding their disorder and mechanisms of therapeutic change
  • Offer highly structured sessions and a viable course of action for addressing their concerns
  • Be active and problem-focused
  • Encourage self-monitoring and the assessment of progress
overview of cbt
Overview of CBT
  • Short term, time-limited psychotherapy
    • 20 sessions over 10 – 15 weeks
  • Collaborative, empirical approach to identify and resolve problems
  • Comparable to scientific investigation:
    • Collecting data (events, thoughts, feelings)
    • Formulating hypotheses based on data
    • Testing and revising hypotheses (i.e. thinking patterns) based on new information
overview of cognitive therapy
Overview of Cognitive Therapy
  • Homework assignments (“experiments”) are critical to treatment
    • Designed to help patient:
      • Develop objectivity about situations
      • Identify underlying assumptions
      • Develop and test alternative conceptualization and assumptions
structure of typical cbt session
Structure of Typical CBT Session
  • Assess mood (subjective and objective reports) and review recent events
  • Collaboratively set an agenda for the session
  • Review homework from the previous session; reinforce progress
  • Discuss “issues and incidents” on the agenda
  • Introduce or review specific skill or “module” to address these concerns
  • Formulate a homework task, identify factors that may interfere with successful completion
  • Help patient to summarize main points and conclusions
  • Discuss thoughts and feelings about the session
slide7

Choosing an Intervention Strategy

Assess risk, develop safety plan, reduce hopelessness, consider an evaluation for medication.

Begin with behavioural interventions, pleasant activity scheduling, social skills training, simple problem solving techniques.

Teach skills in identifying thoughts and feelings, teach connection between thoughts and feelings, introduce thought diaries, begin self-instruction.

Is the person free from suicidal ideation and hopelessness?

Is the person’s level of distress low or mild?

Is the person cognitively and emotionally ready for rational analysis skills?

Use test of evidence, reattribution, and hypothesis testing techniques

No

Yes

No

Yes

No

Yes

slide8

Choosing an Intervention Strategy

Is the person free from suicidal ideation and hopelessness?

Is the person’s level of distress low or mild?

Assess risk, develop safety plan, reduce hopelessness, consider an evaluation for medication.

Begin with behavioural interventions, pleasant activity scheduling, social skills training, simple problem solving techniques.

No

Yes

No

Yes

pleasant event activity scheduling
Pleasant Event/Activity Scheduling
  • Scheduling is used to increase the level of positive reinforcement in person’s daily routine as well as to activate an inactive person
  • Pleasant event scheduling makes use of a schedule that resembles a daily planner
  • Large body of evidence demonstrating mood improvement
relaxation training
Relaxation Training
  • Targeted for children, adolescents and adults who are “stressed out”
  • Skills include:
    • Controlled Breathing
    • Guided Imagery
    • Muscle Relaxation
    • Adaptive Self-Statements
social skills training
Social Skills Training
  • Teaching social skills follows a characteristic cognitive-behavioral process
    • Mood influences social behaviour and social behaviour influences mood
    • Rejection and mood are transactional
  • Direct instruction
  • Graduated practice and rehearsal
  • Real-world experimentation and positive reinforcement
basic problem solving intervention
Basic Problem-Solving Intervention
  • Disorders may stem from deficits in problem solving
  • Steps to improving problem solving:
    • Relax
    • Identify the Problem
    • Brainstorm Possible Solutions
    • Evaluate their strengths and weaknesses
    • Say ‘Yes’ to One (or Two)
    • Encourage yourself for success
affect regulation
Affect Regulation
  • Inability to effectively regulate moods
    • Emotionally labile, moody, volcanic
  • Emotion Thermometer
    • Describe feelings when you are

“about to lose it…your feelings are

out of control.”

  • Anchors
    • Identify cues that mood is beginning

to escalate.

    • Identify what needs to be done to

prevent outburst.

slide14

Choosing an Intervention Strategy

Assess risk, develop safety plan, reduce hopelessness, consider an evaluation for medication.

Begin with behavioural interventions, pleasant activity scheduling, social skills training, simple problem solving techniques.

Teach skills in identifying thoughts and feelings, teach connection between thoughts and feelings, introduce thought diaries, begin self-instruction.

Is the person free from suicidal ideation and hopelessness?

Is the person’s level of distress low or mild?

Is the person cognitively and emotionally ready for rational analysis skills?

No

Yes

No

Yes

No

Yes

identifying feelings
Identifying Feelings
  • Adopting simple classification strategy for emotions
  • Feeling Faces
  • Then taught to rate intensity

None Kind of A lot

1 3 5

identifying thoughts
Identifying Thoughts
  • Automatic thoughts are often based on legitimate concerns but conclusions and meanings drawn from experiences are not reasonable
    • “Valid but not useful” (Beck, 1995)
  • Introduce the concept of an internal dialogue
  • Have the person think of a recent example when something went wrong
  • Ask person what they were thinking when that happened
cognitive errors
Cognitive Errors

ABRITRARY INFERENCE

  • Drawing a conclusion that is not supported by evidence
    • “Jumping to conclusions”

SELECTIVE ABSTRACTION

  • Focusing on a detail taken out of context, ignoring other more salient features, and conceptualizing whole experience based on this element
    • “Blowing it out of proportion”
      • “One person has been saying negative things about me so why would anyone like me.”
cognitive errors1
Cognitive Errors

OVERGENERALIZATION

  • Drawing general conclusion based on single incident
    • “I felt nervous with others at the party; I don’t think I have what it takes to make friends.”

MAGNIFICATION / MINIMIZATION

  • Error in evaluation based on over- or underemphasizing selected aspects of situations
    • “Doing poorly shows how inadequate I am”
    • “Getting good grades doesn’t mean I’m smart.”
cognitive errors2
Cognitive Errors
  • PERSONALIZATION
    • Inappropriately relating external events to oneself without an obvious basis for making such connections
      • “She didn’t say hello to me because I must have done something wrong.”
  • DICHOTOMOUS THINKING
    • View a situation in only two categories instead of on a continuum
      • “All or none thinking”; “Black or white”
        • “If I’m not a total success, I’m a failure”
cognitive errors3
Cognitive Errors
  • CATASTROPHIZING
    • Predict the future negatively without considering other, more likely outcomes
      • “Fortune telling”
        • “I’ll be so upset, I won’t be able to function at all.”
  • DISQUALIFICATION / DISCOUNTING
    • Unreasonably disregard positive experiences or qualities as without value
      • “I did well on the project not because I’m good - I got lucky.”
  • MIND READING
    • Belief that one knows what others are thinking, and failure to consider other, more likely possibilities
      • “He’s thinking I’m a failure”
cognitive errors4
Cognitive Errors
  • LABELING
    • Place a fixed, global label on oneself and others without considering evidence that leads to a less disastrous conclusion
      • “I’m a loser” ; “I’m no good.”
  • EMOTIONAL REASONING
    • Think that something must be true because one “feels” it strongly, ignoring contrary evidence
      • “I know I did okay, but I still feel like a failure.”
connecting thoughts to feelings
Connecting Thoughts to Feelings
  • ABC Model

A = ADVERSITY (Any negative event)

B = BELIEFS (Beliefs and Interpretations about A)

C = Consequences (Behavior and Feelings following A)

abc model
ABC MODEL

C

Consequences

A

Adversity

B

Beliefs

A

Adversity

C

Consequences

daily thought record dtr
Daily Thought Record (DTR)
  • DTR contains three columns:(1) Situation, (2) Feeling, (3) Thoughts
  • Situation – Objective description of what is happening
  • Feelings – Feeling word and Intensity
  • Thoughts – “What is going through my mind?” (Cardinal question)
slide26

Choosing an Intervention Strategy

Assess risk, develop safety plan, reduce hopelessness, consider an evaluation for medication.

Begin with behavioural interventions, pleasant activity scheduling, social skills training, simple problem solving techniques.

Teach skills in identifying thoughts and feelings, teach connection between thoughts and feelings, introduce thought diaries, begin self-instruction.

Is the person free from suicidal ideation and hopelessness?

Is the person’s level of distress low or mild?

Is the person cognitively and emotionally ready for rational analysis skills?

Use test of evidence, reattribution, and hypothesis testing techniques

No

Yes

No

Yes

No

Yes

the daily mood log
The Daily Mood Log

STEP ONE:Describe the upsetting event _________________________ __________________________________________________________

STEP TWO:Record your negative feelings and reach each one from 0 (the least) to 100 (the most). Use words like sad, anxious, angry, guilty, hopeless, frustrated, etc.

STEP THREE: The Triple-Column Technique

identifying distortions
Identifying Distortions
  • All-or-nothing thinking
  • Overgeneralization
  • Mental Filter
  • Discounting the Positives
  • Jumping to Conclusions
  • Magnification or Minimization
  • Emotional Reasoning
  • “Should Statements”
  • Labeling
  • Personalization and blame
ten ways to untwist your thinking1
Ten Ways to Untwist Your Thinking
  • Identify Distortion
  • Examine the Evidence
test of evidence
Test of Evidence
  • Instead of assuming that your negative thought is true, examine the actual evidence for it.
  • Useful strategy to test overgeneralizations, faulty conclusions, and ill-founded inferences
test of evidence1
Test of Evidence
  • Reasons for conclusions“What convinces you 100% that your thought is true?”
  • Search for contrary evidence“What facts make you less certain about your conclusion?”
  • Alternative explanations“What is another way of looking at ________other than your conclusion?”
  • Derive conclusion based on facts and plausible alternative explanations
ten ways to untwist your thinking2
Ten Ways to Untwist Your Thinking
  • Identify Distortion
  • Examine Evidence
  • The Double-Standard Method
the double standard method
The Double-Standard Method
  • Instead of putting yourself down in a harsh, condemning way, talk to yourself in the same compassionate way you would talk to a friend with a similar problem.
    • “Would you say the same things to your friend in a similar situation?”
ten ways to untwist your thinking3
Ten Ways to Untwist Your Thinking
  • Identify Distortion
  • Examine Evidence
  • The Double-Standard Method
  • The Experimental Technique
the experimental technique
The Experimental Technique
  • Do an experiment to test the validity of your negative thought.
    • Ex: “I am about to die of a heart attack!”

Experiment: Jog or run up and down several flights of stairs – Physiological similarities to anxiety shows that person is not dying and can manage the symptoms.

ten ways to untwist your thinking4
Ten Ways to Untwist Your Thinking
  • Identify Distortion
  • Examine Evidence
  • The Double-Standard Method
  • The Experimental Technique
  • Thinking in Shades of Gray
thinking in shades of gray
Thinking in Shades of Gray
  • Instead of thinking about your problems in all-or-nothing extremes, evaluate things on a range from 0 to 100.
    • When things do not work out as well as you hoped, think about the experience as a partial success rather than a complete failure.
    • See what you can learn from the situation.
ten ways to untwist your thinking5
Ten Ways to Untwist Your Thinking
  • Identify Distortion
  • Examine Evidence
  • The Double-Standard Method
  • The Experimental Technique
  • Thinking in Shades of Gray
  • The Survey Method
the survey method
The Survey Method
  • Ask people questions to find out if your thoughts and attitudes are realistic.
    • Ex: If you believe that public speaking anxiety is abnormal and shameful,

ask several friends if they ever felt that way before a talk.

ten ways to untwist your thinking6
Ten Ways to Untwist Your Thinking
  • Identify Distortion
  • Examine Evidence
  • The Double-Standard Method
  • The Experimental Technique
  • Thinking in Shades of Gray
  • The Survey Method
  • Define Terms
define terms
Define Terms
  • When you label yourself as “stupid” or “inferior” or “a loser,” ask what is the definition of “stupid.”
    • Apply definition universally
ten ways to untwist your thinking7
Ten Ways to Untwist Your Thinking
  • Identify Distortion
  • Examine Evidence
  • The Double-Standard Method
  • The Experimental Technique
  • Thinking in Shades of Gray
  • The Survey Method
  • Define Terms
  • The Semantic Method
the semantic method
The Semantic Method
  • Simply substitute language that is less colorful and emotionally loaded.
  • This method is helpful for “should statements.”
    • Ex: “I shouldn’t have made that mistake!”

“It would have been better if I hadn’t made that mistake.”

ten ways to untwist your thinking8
Ten Ways to Untwist Your Thinking
  • Identify Distortion
  • Examine Evidence
  • The Double-Standard Method
  • The Experimental Technique
  • Thinking in Shades of Gray
  • The Survey Method
  • Define Terms
  • The Semantic Method
  • Re-Attribution
re attribution
Re-attribution
  • Instead of automatically assuming that you are “bad” and blaming yourself entirely for a problem, think about the many factors that may have contributed to it.
  • Responsibility pie
    • List all possible reasons for event
    • Allocate portion of pie to each cause
responsibility pie
ResponsibilityPie
  • Event: Parents getting separated
ten ways to untwist your thinking9
Ten Ways to Untwist Your Thinking
  • Identify Distortion
  • Examine Evidence – Test of Evidence
  • The Double-Standard Method
  • The Experimental Technique
  • Thinking in Shades of Gray
  • The Survey Method
  • Define Terms
  • The Semantic Method
  • Re-Attribution
  • Cost-Benefit Analysis
cost benefit analysis
Cost-Benefit Analysis

The attitude or belief I want to change: I want all people to like me

Advantages of Believing This

Disadvantages of Believing This

  • It will feel good when people approve of me.
  • I’ll work hard to make people like me.
  • I’ll be very sensitive to other people’s feelings
  • I’ll feel lousy when people don’t like me or approve of me.
  • Other people will control my self-esteem.
  • People will not respect me in the long run if I don’t stand up from what I believe in.
  • I may be less sensitive to other people because I’ll be so worried about criticism or conflict.

35

65

Revised Attitude: It can be great to have people like me and approve of what I do. When people are more critical of me, I can understand their point of view.

cbt case example

CBT:Case Example

Curry, J.F. & Reinecke, M.A. (2007)

background
Background
  • 16 year old female
  • Referred by mother for CBT because:
    • Mood
    • Low self-esteem
    • Academic difficulties
  • “little will to do well” ; “no interest in anything” ; “seems sad”
  • Intelligence - normal range
  • Low socioeconomic status
presenting problems
Depressed

Irritable

Anhedonic

Lack of reactivity to positive stimuli

Insomnia

Hypersomnia

Fatigue

Low self-esteem

Concentration difficulty

Hopelessness

Suicidal ideation (no plan)

Presenting Problems
  • Meets DSM IV-TR criteria for major depression (MDD)
presenting problems1
Presenting problems
  • Family:
    • Mother and father in “unhappy, loveless” marriage
      • Girl is aware
    • Mother has advanced diabetes and is physically unwell
      • Girl is anxious about mother’s condition
    • Mother and daughter have strained relationship
  • School:
    • Previously did well in school subjects
    • Poor performance attributed to lack of effort and care
  • Friends
    • Declines invitations to go out with friends
      • Stays home in her bedroom and listens to music
    • Feels self-conscious around friends
  • No history of illnesses, accidents, or injuries
initial assessment
Initial Assessment
  • Findings from self-report questionnaires:
    • BDI / Reynolds Adolescent Depression Scale/ BAI:
      • Severe feelings of depression, anxiety and pessimism at time of referral
    • Hopelessness Scale:
      • Significant
    • Automatic Thoughts Questionnaire:
      • Large number of negative thoughts about herself, her world, her relationships with others, and her future
case formulation
Case Formulation
  • Consider cognitive, social, behavioural, and environmental factors that contribute to difficulties
  • ENVIRONMENT / SOCIAL:
    • Neighborhood chaotic, dangerous, stressful
    • Home environ full of criticism, arguing, financial stress
    • Few stable friendships and sensitive to criticism and rejection
    • Tendency to withdraw exacerbates feelings of frustration and isolation

= LIMITED SOCIAL SUPPORT

case formulation1
Case Formulation
  • COGNITIVE:
    • Negative cognitive triad
    • Self-critical
    • Cognitive distortions
      • Overgeneralization
      • Selective Attention
      • Magnification
    • Limited self-efficacy (easily discouraged, gives up - both academically and socially)
    • Poor self-concept = maladaptive schemas
      • Social undesirability
        • Dull, poor conversationalist, loss for words in social situations
case formulation2
Case Formulation
  • AFFECTIVE:
    • Delayed affective regulation skills
      • Lack of effective modeling from parents with regards to mood regulation
      • No adaptive problem solving role models
  • STRENGTHS:
    • Motivated to improve psychological well-being and overcome social and academic difficulties
course of treatment
Course of Treatment
  • Developing goals
  • Mood and event monitoring
  • Pleasant activities
  • Social activities
  • Parent / Family sessions
  • Behavioural problem solving
  • Identifying maladaptive thoughts
  • Realistic counterthoughts
  • Relapse prevention
session 1 psychoeducation
Session 1 - Psychoeducation
  • Provide information about:
    • Nature of clinical depression
      • Sadness, dysphoria, irritability are not volitional, intentional
    • Factors that have been found contribute to depression
      • Social withdrawal, reduced activity, rumination, negativistic beliefs exacerbate anxiety and depression
    • Skills that may be helpful in managing these feelings
    • Rationale for CBT
session 1 developing goals
Session 1 - Developing goals
  • Patient:
    • Not feel as depressed
    • Have more energy
    • Get a more positive attitude
    • Work out problems with mother
  • If possible, collaborate with parent(s) or family
    • Builds trust and shows understanding of distress
  • Mother’s goals for daughter
    • Develop confidence
    • Make better life decisions
    • Be happy
session 1 mood and event monitoring
Session 1+: Mood and event monitoring
  • Monitor moods
  • Identify situations that trigger negative affect
  • Identify associated automatic thoughts

Technique:

Introduce Daily Mood Log or Dysfunctional Thought Record (DTR)

mood and event monitoring
Mood and event monitoring
  • Additional techniques:
    • Before bed each night, write down the best and worst events of the day
      • Note feelings at the time of the events
      • Rate feelings on scale of 0-100
      • Note thoughts at the time of the events
    • Focus on positive events, emotions, cognitions
      • Helps challenge the frequency and intensity of negative self-referential cognitions of cognitive triad
session 2 3 pleasant activities
Session 2-3:Pleasant activities
  • Develop list of activities that are active, “inexpensive”, available, and not harmful
    • In our case, avoid most solitary activities
  • Determine a baseline of how many of these activities she had participated in in the past week
    • Rate feelings while engaged in activity
  • Create schedule of pleasurable activities
    • Select 5 or so activities that can be reasonably accomplished
  • Girl adhered to the list and noticed improvement in mood after each time
session 3 4 social activities
Session 3-4:Social activities
  • Focus on developing positive social relationships
    • Address social withdrawal issues
  • Identify instances where friends had been supportive
  • Advance notion of perception
    • Perception of rejection by friends may influence her reaction to them
  • Role play in session
    • Model, rehearse, practice potential social interactions
  • Continue to monitor social interactions
    • Note both positive and negative interactions
example social skills training
Example:Social Skills Training
  • Active engagement of concerns with others:
    • Approach friend after failing another exam
  • Direct communication of thoughts and feelings
    • Girl: “I failed another exam and I’m embarrassed.”
    • Friend: “Don’t worry about”
  • Attend to others’ responses
    • Girl: “So it doesn’t make you think I’m stupid if I fail.”
    • Friend: “No…if you need help with math, let me know.”
  • Identify shared goals and express appreciation
    • “It would mean a lot if you helped me study.”
example problem solving skills
Example:Problem solving skills
  • University entrance exam:
    • Efforts to prepare are greatly impacted by depression and academic difficulties (reduced self-efficacy, anxiety, fear, hopelessness, amotivated)
  • Apply techniques
    • Identify problem and consider how past attempts have failed
    • Brainstorm solutions (tutor, get extra books, ask another student for help, give up)
    • Examine short and long-term costs and benefits
    • Select course of action
initial result and response
Initial result and response
  • Girl does not initiate any of the solutions and fails to follow through with plan
    • “I would be embarrassed if friends found I used a tutor”
  • Examine this negative belief and determine if this belief is well-founded
    • Ultimately, none of her peers comment
  • Agree to reward (reasonable item/activity) if solutions are enacted before next session
identifying maladaptive thoughts
Identifying maladaptive thoughts
  • Recurrent throughout all sessions
    • Review upsetting events that occurred during the week
    • Note shifts in affect during therapy session
  • “What was going through your mind right then?”
    • Identify thoughts associated with mood
realistic counterthoughts
Realistic counterthoughts
  • Become adept at developing adaptive ways of thinking about problematic situations
    • Work towards cognitive restructuring and rational responses
  • Provide with 5 questions when reflecting on events:
    • What is the specific thought that is upsetting me?
    • What is the evidence for and against this?
    • Is there another more reasonable way of looking at this?
    • Is it really a big deal? (decatastrophize)
    • What can I do about it? What’s the solution?
  • Regular practice on vignettes using personal and others’ experiences
  • Keeps things in perspective
example counterthoughts
Example:Counterthoughts
  • Girl fails a math exam and is worried that her friends will think she is “stupid”:
    • “I have a hard time with math, like many others. So I shouldn’t be embarrassed.”
    • “I can be persistent. I am good at other things and with practice and effort, I can feel more confident about my math ability.”
  • Note drop in ratings of distressed feelings when she adopts these thoughts regularly.
relapse prevention
Relapse prevention
  • Review with patient the skills found to be helpful
    • “Keep it in perspective” and “Don’t catastrophize” most useful
    • Social / pleasant activities beneficial
  • Discuss how these can be applied if depression arises again
    • Maintain level of activity after therapy and persist with counterthinking and problem solving techniques
  • Identify potentially problematic situations
    • Effects of failing exam
    • Social withdrawal
  • Develop plans to manage these potential situations
    • Problem solve before exam to effectively study
    • Address concerns with friends before negative thoughts
relapse expectation
Relapse expectation
  • Discuss relapse with patient
    • Mood can wax and wane, so anticipate sad, depressed or anxious feelings
    • Relapses should be expected
    • Through use of techniques and skills, it is reasonable to believe that relapses can controlled
    • Assess self-efficacy
booster sessions
Booster sessions
  • Schedule during first 3 months after termination
    • Every other week or once a month
  • Offer additional “as needed” sessions for the following year
  • Objectively and subjectively assess mood and compare with initial and subsequent scores on self-report measures
    • Clinical Global Assessment Score (CGAS)
    • Clinical Global Impression (CGI)