Introduction to Cognitive Behaviour Therapy

1
Introduction toCognitive Behaviour Therapy
Carol Vivyan 2007
2
Epictetus 55 - 135 AD

• Men are disturbed, not by things, but by the
  principles and notions which they form concerning
  things
• Roman (Greek-born) slave Stoic philosopher

3

• Cognitive Therapy is a system of psychotherapy
  that attempts to reduce excessive emotional
  reactions and self-defeating behaviour, by
  modifying the faulty or erroneous thinking and
  maladaptive beliefs that underlie these reactions
• Beck et al 1976, 1979, 1993

4
The approach is

• Collaborative (builds trust)
• Active
• Based on open-ended questioning
• Highly structured and focused

5
Common Sense Model
Event
Emotion
Cognitive Model
Meaning we give the event
Event
Emotion
6
Youre walking down the High Street, and someone
you know walks by without acknowledging you
7
4 interpretations 4 emotions

• I dont want her to see me, I wont know what to
  say shell think Im stupid boring

• Nobody wants to talk to me, no-one likes me

• Shes got a nerve being so snooty!

• Shes probably still hung over from that party
  last night!

8
(No Transcript)
9

• Cognitive principle it is interpretations of
  events, not events themselves, which are crucial.
• Behavioural principle what we do has a powerful
  influence on our thoughts and emotions
• The continuum principle mental health problems
  are best conceptualised as exaggerations of
  normal processes

10

• Here and now principle it is usually more
  fruitful to focus on current processes rather
  than the past
• Interacting systems principle it is helpful to
  look at problems as interactions between
  thoughts, emotions, behaviour and physiology and
  the environment in which the person operates

11
(No Transcript)
12
(No Transcript)
13
Padeskys 5 Aspects Model (1986)
ENVIRONMENT
THOUGHTS
BIOLOGY
MOOD / FEELINGS
BEHAVIOUR
14
ENVIRONMENT On Plane Turbulence
THOUGHTS We might crash
BIOLOGY Heart racing Palpitations Rapid
breathing Difficult to breathe choking
sensation
MOOD / FEELINGS Anxious 90
BEHAVIOUR Reassurance seeking
15
Feelings commonly associated thoughts
16
Groups

• Think of a recent situation or event which
  resulted in a negative mood shift
• Anxiety
• Sadness
• Anger
• Groups therapist / client / observer
• Identify
• thoughts / feelings / behaviours

17

• Identify a recent significant shift in mood
  (emotion)
• What was the situation?
• How did you feel? (emotion/physiology)
• What was going through your mind at the time?
  (thoughts)
• What did you do? (behaviours)
• What were the consequences?

18
Cognitive Model of Panic      
Internal / External Trigger Turbulent flight
             
Perceived Threat We might crash Im going to die
Anxiety / Panic 90
Physical / Cognitive Symptoms Heart
racing Breathless Difficulty breathing choking
sensation Shaking Sweating
Catastrophic Interpretation of Symptoms Ill
suffocate and die
Avoidance Safety Behaviours Reassurance
seeking Ask companion Look at faces of other
travellers Ask cabin crew Avoid flying!
19
Cognitive Model of Depression
Early Experiences
Core Beliefs Assumptions
     
                                           

• Beck (1979)

Critical Incident
Negative Automatic Thoughts (NATS)
Behaviour
Feelings
20
Negative Automatic Thoughts
Assumptions
Core beliefs
21
Negative Automatic Thoughts

• Stream of thoughts that we can notice if we try
  to pay attention to them (automatic)
• Negatively tinged appraisals or interpretations
  meanings we take from what happens around us or
  within us
• Specific thoughts about specific events or
  situations
• Brief, frequent, habitual often not heard
• Plausible and taken as obviously true, especially
  when emotions are strong

22
Identifying NATs

• Shifts in Affect
• Distinguish between thoughts and emotion and
  behaviour
• Check for images

23
Cognitive Model of Depression

• Negative cognitive triad
• Biased views of
• Oneself
• I am bad, useless, unlovable, worthless, a
  failure
• The world in general
• Nothing good happens, life is just a series of
  trials
• The future
• It will always be like this, nothing I can do
  will make any difference, whats the point of
  anything?
• Negative filter
• Remembering events
• Interpreting current events / situations
• Overgeneralising from small negative event to
  broad negative conclusion

24
Goals of therapy

• Help the client counteract negative cognitive
  biases, and develop more balanced view of
  herself, the world, and the future
• Restore activity levels especially those that
  give sense of pleasure or achievement
• Increase active engagement and problem solving

25
Course of treatment

• Identify specific problem list ( prioritise)
• Eg. Poor sleep, relationship difficulties etc
• Introduce cognitive model how it might apply to
  client
• Goals (SMART)
• Reduce symptoms through behavioural or simple
  cognitive strategies
• Identify and challenge NATs
• Relapse prevention

26
Overview of a typical course of therapy

• Referral
• Assessment suitability, therapeutic
  relationship
• Assessment (ongoing) problem analysis, wider
  picture, measures
• Problem list prioritise
• Goals for therapy (SMART)
• Formulation (ongoing) Sharing model,
  maintaining factors, predisposing factors,
  rationale for treatment

27
Overview of a typical course of therapy

• Assessment, Formulation
• Treatment start with symptom focused
  intervention
• Review every six sessions, repeat measures
• Discharge repeat measures, relapse prevention
• Follow up / booster sessions
• 1,3,6,12 month ?

28
Typical CBT treatment session

• Set collaborative agenda
• Review time since last session
• Feedback on last session
• Review homework
• Focus on major topics for the session
• Set homework
• Potential problems with completing homework
• Feedback on session

29
Therapy Skills

• Engagement
• Warmth and empathy
• Collaboration
• Guided discovery socratic questioning
• Feedback and summarising
• Agenda setting structure and focus
• Open and closed questioning

30
Aims of Assessment

• Initiate develop therapeutic relationship
• Establish suitability for CBT
• Gather specific information re current
  difficulties
• Elicit maintaining factors
• Initial formulation
• Socialise to CBT model
• Establish joint understanding of the presenting
  problem

31
Suitability for short term CBT

• Ability to identify describe negative thoughts
• Awareness differentiation of emotion
• Compatibility with CBT rationale
• Acceptance of personal responsibility for change
• Alliance potential
• Chronicity of problem
• Security operations
• Focality
• Optimism/pessimism regarding therapy

32
Homework

• Identify a recent significant shift in mood
• What was the situation?
• How did you feel?
• What was going through your mind at the time?
• What did you do?
• What were the consequences?

33
Measures

• The concept of measures is central to the CBT
  approach, as it enables both client and
  practitioner to evaluate the impact of
  interventions (Grant et al 2004)
• They are important in the process of assessment
  and aid the practitioner to develop a credible
  formulation for the client, so that appropriate
  cognitive and behavioural interventions can be
  used

34
Why Measures?

• Assessment to provide information
• Baseline subsequent measures will show extent
  of change
• Effectiveness helps to (objectively)
  demonstrate effectiveness of therapy, and allow
  modification of treatment
• Feedback
• Knowledge - data collection suggests areas for
  future research

35
What measures?

• Standardised developed for particular
  populations and problems
• Eg. Beck Depression Inventory
• Beck Anxiety Inventory
• Agoraphobic Cognitions Questionnaire

• Individualised allow for more specific
  information for assessment and formulation.
• Eg. Problem definition, Targets of therapy,
  Diaries, Belief Ratings, Ratings of specific
  emotions

36
Cognitive Interventions

• Restructuring thoughts and beliefs
• Guided discovery
• Thought diaries
• Challenging NATs (looking at evidence)
• Addressing thinking errors
• Responsibility Pie
• Cost/Benefit Analysis
• Downward Arrow technique

37
Cognitive Interventions

• Education Eg. Written information on thinking
  errors, disorder specific info
• Continuous use of formulation
• Imagery techniques
• Role play role reversal
• Action Plan
• Education in Body systems (symptoms)

38
Behavioural Interventions

• Very powerful method of bringing about change
• Key component of CBT intervention
• Borrowed and adapted from Behaviour Therapy
• Incorporate different methodological approaches

39
Behavioural Experiments

• Similar in BT / CBT, but fundamentally different
• In BT, it is the end product, in CBT, a means to
  an end ie. Cognitive change
• In BT graduated, repeated and prolonged
  exposure
• In CBT - New ideas are put to the test. Means of
  testing the validity thoughts, perceptions,
  beliefs.

40
Examples

• Hyperventilation to simulate panic
• Activity monitoring and scheduling
• Metaphors South American tribe?
• Consider experiment for client with OCD, believes
  something terrible will happen to family if he
  doesnt neutralise his thought by doing rituals
  for up to an hour

41
Problem solving

• Identify problem to be worked on
• Think of as many solutions as possible
• Consider each solution pros cons
• Pick solution that appears best
• Small steps
• Action review

42
Relapse Prevention

• What have I learned?
• What was most useful?
• What can I continue to do?
• When will I be at risk of this happening again?
• What are the signs?
• What could I do to avoid losing control?
• What could I do if I did lose control?

43
Coping with Relapse

• How can I make sense of this lapse?
• What have I learnt from it?
• With hindsight, what would I do differently?

44
Introduction to CBT

• This presentation gives you an introduction to
  the rationale of CBT
• It does not enable you to perform CBT
• Using Cognitive Behavioural interventions may be
  helpful for your clients
• CBT - Guided self-help?

45
(No Transcript)
46
(No Transcript)
47
Summary

• No formulation No CBT
• Use CB techniques
• Bibliotherapy e.g. Mind Over Mood
• Challenge negative thoughts
• Court Case
• Evidence
• More balanced/alternative thought
• Downward arrow
• Behavioural experiments / exposure
• Activity Diaries
• Relaxation?

48
More information resources

• www.get.gg
• Self help
• Workbooks
• online CBT programmes printable forms etc
• Online
• Professional links
• CBT organisations
• Therapist manuals online
• Books

49
Bibliography

• Certificate in Cognitive Behaviour Therapy.
• Salford Cognitive Therapy Training Centre. 2006
• An introduction to Cognitive Behaviour Therapy
  Skills Applications.
• Westbrook, Kennerley, Kirk, 2007. Sage.
• Treatment Plans Interventions for Depression
  Anxiety Disorders.
• Leahy. 2000. Guilford.
• Cognitive Therapy of Anxiety Disorders.
• Wells. 1997. Wiley.
• Mind Over Mood.
• Greenberger, Padesky. 1995. Guilford.