Introduction to Cognitive Behaviour Therapy

1. Introduction to Cognitive Behaviour Therapy Dr Sue Waite Psychiatrist TQEH 23/8/12

2. Cognitive Theory • Emotions are experienced as a result of the way events are interpreted, rather than the events themselves Aaron (Tim) Beck 1921-

3. Cognitive Model A -------------------> B --------------------> C Antecedents Beliefs Consequences (Mood, Behaviour)

4. The First Wave of Cognitive Therapy • Classical Behaviour Therapy • Focus on changing problematic behaviour and emotions themselves

5. Behaviour Therapy

6. The Second Wave of Cognitive Therapy • Cognitive Behaviour Therapy • Focus on changing content of dysfunctional thoughts assumed to mediate problematic emotions and behaviour

7. The Third Wave of Cognitive Therapy • ‘Thinking about thinking’ • Mindfulness and metacognitive processing • Focus on process rather than content of thinking (e.g. rumination, worry) • Leads to a non-judgemental acceptance of events (thoughts, body sensations, emotions) rather than a change in their content or frequency

8. The Third Wave of Cognitive Therapy • Acceptance and Commitment Therapy (Hayes) • Dialectical Behavioural Therapy (Linehan) • Mindfulness-Based Cognitive Therapy (Williams, Teasdale, Segal) • Metacognitive Therapy (Wells)

9. Cognitive Theory • Depressed and people have continuous negative thoughts • With each negative thought the depressed feeling increases • BUT, the thoughts are only interpretations of some of the facts and not truths in themselves • SO, they may make a person feel depressed when there may be no objective reason to feel that way

10. Stance Of The Cognitive Therapist • Socratic Questioning- art of asking questions to encourage people to think for themselves to arrive at the objective truth • Socrates (470-399 BC)- Greek philosopher who believed the best method of understanding an issue or concept was to help students think through the matter critically. Questions aroused curiosity and led to more questions. New realisations were more powerfully believed as they came from within rather than being imparted by someone else.

11. Socratic Questioning and Guided Discovery Asking informational questions • What do you mean by____? • Can you give me an example? • What makes you think this is true? Empathic listening and reflection

12. Socratic Questioning and Guided Discovery Frequent summaries (To organise information and help patient remember what has been discussed) Synthesising/analytical questions that require the patient to apply the new information • What do you make of this? • How do you put it all together? • What is an alternative way of looking at it?

13. What is CBT? • Brief (10-20 sessions) • Time limited • Goal oriented • Structured (clear agenda each session with homework between sessions) • Here and now • Symptom relieving

14. CBT Components • Behavioural activation • Practical problem solving • Behavioural experiments (To test thoughts) • Exposure to feared situations or bodily sensations • Cognitive restructuring (Examining the evidence for thoughts)

16. Rationale for Behavioural Activation • Distracts mind from painful thoughts • Restores sense of control • Increases self esteem • May lead to re-experience of pleasure • Reduces lethargy and fatigue • Enhances motivation

17. Daily Activity Monitoring • Monitor activities hourly • Rate Pleasure (P) and Mastery (M) • Allows development of awareness of variations in mood, activity levels and associated thoughts • Informs subsequent structuring of helpful activities

18. Daily Activity Scheduling • Plan each day in advance at set time • Aim for balance of ‘fun’ activities and ‘work’ activities • Start day with a ‘no lose’ activity • Reward after difficult activity • Record what is done • Review at end of day and trouble shoot

19. Practical Problem Solving • Identify problem • Brainstorm possible solutions • Assess pros and cons of each solution • Choose best option and devise step by step plan to implement it • Assess outcome

20. Behavioural Experiments • Planned experiments intended to test validity of patient’s beliefs • Observational expts- patient is observer or data gatherer. Useful if direct action too anxiety-provoking or more information is required. Includes direct observation of therapist, surveys, internet search etc. • Active expts- patient deliberately acts in a different way in a problem situation and notes outcome.

21. Designing Behavioural Experiments • Identify target cognition and rate belief intensity • Identify any alternative perspectives • Determine which variables are to be manipulated so thought can be challenged- often involves safety behaviours • Make a testable prediction

22. Designing Behavioural Experiments • Anticipate possible problems • Determine what is to be observed (thoughts, feelings, sensations, behavior of self and others, environment) and how (e.g. video) • Record outcome and re-rate beliefs • Plan follow up expts to reduce degree of target cognitions further

23. Behavioural Experiment- Example • Survey for social phobia

24. Behavioural Experiment- Example • Behavioural experiment for procrastination

25. Behavioural Experiment - PTSD • Target Cognition- If I allow myself to think about the accident, I’ll lose the plot. • (Avoids talking about accident, engages in thought suppression and avoidance of reminders)

26. Behavioural Experiment- Bipolar Disorder • Target Cognition- My friends don’t like me unless I’m the life of the party. • (Tries to be vivacious, fills in gaps in conversation, exaggerates recent events to sound more interesting)

27. Behavioural Experiment- Panic Disorder • Target Cognition- If my heart races, I must rest otherwise I will pass out. • (Avoids exercise, takes pulse, sits down if notices increase in HR)

28. Behavioural Experiment- Social Phobia • Target Cognition- I can’t let people see me blush. They'll think I’m weak and reject me. • (Hides face with hair and hat, avoids eye contact, rarely socialises)

29. Behavioural Experiment- Depression • Target Cognition- There’s no point doing anything until I feel better. It will just make me feel worse. • (Makes excuses not to attend social gatherings, rarely engages in conversation, spends lots of time in bed)

30. Behavioural Experiment- Psychosis • Target Cognition- I can’t disobey my voices or they will destroy me. • (Responds immediately to command hallucinations, denies symptoms when questioned by doctors or friends)

31. Exposure • Graded exposure to feared situations or sensations leads to a reduction in anxiety (habituation) • Exposure must be repeated (3/week), prolonged (stay in situation until anxiety halves) and focused • Hierarchy of least feared to most feared situation • Mainly used for OCD, simple phobias and in panic disorder (for feared sensations)

33. Thought Records Monitoring thoughts and questioning the evidence with thought records. Identifying unhelpful thinking styles. • What is the evidence to suggest this belief may not be true? • What is another way of looking at the problem? • What would your best friend say if they knew you were thinking this way? • What advice would you give your best friend if you knew they were thinking this way • When you weren’t so depressed/anxious how might you view this?

34. Thought Records • In 5 years time will this still be important? • Even if your worst fears come true, can you cope? • What is a more compassionate way to think about this? • Is it helpful to think this way?

35. Being a Good Coach • Work together as a team on the problem • Help the person remain focussed on the task at hand (NB distraction and avoidance) • Provide emotional support (e.g. “ I can see how hard this is for you”) • Show empathy • Ask open-ended questions (e.g. “How are you feeling right now?”, “What is going through your mind?”) • Summarise your understanding of their thoughts and feelings

36. Being a Good Coach • Don’t argue. When you notice yourself directing, persuading or telling your patient what to do, you are essentially putting them in the position not to change. Take time out. • Help the person make decisions but don’t make decisions for them (e.g. “Is this helpful in getting over your problem?”) Look at pros and cons of changing versus not changing. • Predict into the future (e.g. “In 5 years time if you still have this problem, what will things be like?”, “If you no longer have this problem, what will things be like?”) • Be a cheerleader. Remind client of task, tell them you believe they can do it, congratulate them for their achievements.

37. Reading List • Beck J. (1995). Cognitive Therapy: Basics and Beyond. New York: Guilford Press. • Beck AT, Rush A. et al. (1979). Cognitive Therapy of Depression. New York: Guilford Press. • Burns D. (1990, revised 1999). The Feeling Good Handbook. London: Plume. • Greenberger D. & Padesky C. (1995). Mind Over Mood. London:Guilford Books. • Overcoming self help book series- www.overcoming.co.uk/

38. Internet Sites www.cci.health.wa.gov.au resources- consumers (detailed), medical practitioners (brief) www.moodgym.anu.edu.au thiswayup.org.au/clinic www.blackdoginstitute.org.au www.beyondblue.org.au