Northumberland, Tyne and Wear NHS Foundation Trust

Foundation in Cognitive Behaviour Therapy

Newcastle Cognitive and Behavioural Therapies Centre Dr. Sally Standart MRCPsych 2011 1

Aims of the Course

• To ask - What is CBT?

– This is an introduction to CBT; we won’t be covering all aspects of treatment using CBT – Is CBT for me?” How well does it fit my needs, aspirations etc?

• To get to know the model by reflecting on our own reactions in thoughts, feelings, behaviour • To get a taster of the basics of CBT theory • What kind of conversation goes on in CBT?

– An introduction to Socratic dialogue.

• How to socialise the client to the session structure 2

Your objectives for the course…

• What would you like to get out of the next 2 afternoons?

• Are there any particular questions you would like us to try and address?

– Let’s see if we can collaboratively address them… 3

What is CBT?

• It may be more accurate & helpful to think of “the C & B T’s” – No one single set of interventions; A family of theories and practices – A mixed marriage of two fundamentally different theory sets: • Behaviourism – theory built on observable environment–organism interactions • “Cognitivism” – theory built on the understanding that people perpetually interpret their environment & feel & act accordingly – This workshop is going to major on this second side of the “family” – group members going on in CBT training should become well acquainted with Behavioural theory and practice 4

The basic theory

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What is CBT?

“We are what we think. All that we are arises with our thoughts. With our thoughts we make the world.”

GAUTAMA BUDDHA,

Dhammapada

Agree? Disagree? What did he mean?

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Exercise • Spotting our own automatic thoughts:

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Exercise……..

• What was going through your mind when you knew what the exercise was?

– Words… – Pictures… – Sounds… – Memories… • How did you feel physically?

• Did you do anything to prepare for the noise?

• Take some time and write down your responses-there is no right or wrong answer 8

Discussion…………..

• What were you focussing on most? • Did you have any urges to act?

– leave the room, – move away – Interrupt the exercise – Laugh it off • If yes, what were you trying to achieve (e.g. Were you concerned about how you might react in front of the group?) • Did the

way

you were your thinking change?

– Speed up?

– Get less clear?

– Go round in circles?

– Shift to the future?

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Observations

• In response to being told the balloon would pop – we reacted • Our immediate thoughts were

instant

– not

thought out

or

considered

• We experienced physical changes • Emotions altered • We had the urge to do something • Our or the rest of the group • Our attention memory was focussed on the balloon, or ourselves, accessed previous similar experiences 10

Emotions and Actions

• When we feel a certain way we tend to act accordingly.

• E.g. - It’s been a long, tiring, stressful week. We might put off going out with friends and stay home on our own with a few drinks instead • We tend to notice our emotions and what we do before our thoughts 11

Exercise 2

• Think about a time recently when you felt a bit down, stressed or tired.

• Can you recall: – What you did as a result?

– What you were thinking at the time?

• Is one easier to recall than the other?

• When you pause to reflect now, does anything come to mind more clearly?

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How does this relate to CBT?

• The way we think can affect how we feel emotionally, physically and what we do.

• When distressed our thinking tends to change. • Thoughts can become extreme, worsening how we feel. • We may then behave in a way that prolongs their distress • Psychological ailments can be understood as persistent stuck patterns of thinking, feeling and acting that obstruct an individual’s need to change 13

So what does CBT

do?

• …helps clients recognise their own thoughts, feelings and ways of coping with everyday situations that have become problematic • …helps clients understand the

links

feelings and reactions between thoughts, • …helps clients

find

and

test out

new, more helpful ways of thinking and doing for themselves 14

“models” in CBT

• Because CBT seeks to treat a range of different problems, there are many disorder-specific models.

– Depression – Panic, Social Anxiety, OCD, GAD, PTSD – Eating Disorders – Delusions – Voices – Personality disorders • In this workshop we’re focussing on the generic model underpinning these, derived from the work of Aaron T. Beck 15

What do we mean by “Cognitive”?

situation What I notice How I

Cognition

What I think What I How I think about it remember remember about it How I react

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An illustration of the Cognitive Behavioural Model

situation “thinking” Behaviour emotions Physical reactions

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An illustration of the Cognitive Behavioural Model Balloon Exercise “What if I make a fool of myself”?

Heart rate changes, get a bit hot… nervous Hunch shoulders, hold breath 18

Automatic Thoughts: What do we mean?

• Raw, immediate, “the first thing that comes into my mind” “gut reactions”, “hot” thoughts • Emotion-laden • Behaviour-driving • More limited in scope than assumptions and beliefs • So how does a CBTist help a client get hold of this stuff?

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Exercise 3

• Think of someone you’ve been working with recently • Think of particular instance of raised emotion or unhelpful behaviour • Get specific – think about minutes rather than days • Can you put it together as per the previous slides?

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Building our understanding

• Thus far we’ve only considered what happens in the here-and-now • But what do these here-and-now thoughts rest on?

• In the examples from the previous, what is your understanding of the background to the specific episode? 21

Purely here-and-now

Working on essay Go back & re-write Miserable, anxious It’s no good. I’ll fail 22

A little background…

Working on essay Go back & re-write “It’s no good. I’ll fail” Remember the essays I messed up Only attend to Worry about mistakes failing Miserable, anxious 23

Balanced thinking & helpful action…

doing something new Working on essay Limit re writing Remember a range I’ll fail” of ok & poor essays “It’s no good. Check mistakes Worry about & good failing points A bit miserable, somewhat anxious 24

But if we have deeper-set ways of thinking … Working on essay Activates assumption Go back & re-write I should do everything well. Less than 100% = failure Appraises performance according to rule It’s no good. I’ll fail Miserable, anxious 25

& if we have yet

deeper

set ways of thinking… Working on essay Fits with memory of emotionally abusive upbringing Activates assumption Re-write? Give up?

“People are vicious” I must do everything perfectly or else Appraises performance according to belief I’ll fail & get punished Miserable, anxious 26

Layers of cognition

• Automatic thoughts … tend to rest on assumptions & rules … which tend to rest on our beliefs • We tend not to notice our thoughts as readily as we notice our emotions and actions • Our rules, assumptions & beliefs tend to operate implicitly rather than being explicitly voiced • ATs are easier to access than underpinning assumptions and beliefs • CBT therefore typically deals with Behaviour and ATs before deeper-set cognition 27

Exercise 4

• Back to the previous example • Can you suggest (you may know or need to hypothesize) the rules, assumptions, beliefs underpinning the ATs?

• What do you know about the person’s life experience via which these may have been learned? 28

The basics of practice

CBT & Socratic Dialogue 29

Role play demonstration

• Role play to demonstrate links between thoughts, emotions, physical reactions and behaviour. • Look out for all of the above • Does the information help make sense of the client’s experience?

• What do you observe about the way the therapist communicates?

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How the therapist helped the client focus on ATs

• In the moment unhelpful behaviours are switching on – E.g., “what were you thinking as you began to run away”?

• In the moment that you notice emotion rising – E.g. “ What went through your mind in the moments you began to feel scared”?

• In the moment of marked distressing physiological changes – E.g. “What were you most concerned about when you felt your heart pounding”?

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The style of the dialogue

• What do you observe about the way the therapist communicated?

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What are Socratic Questions?

• Semi open (generally not “yes or no” responses but directed to some extent) • What was happening just then?

• What went through your mind?

• What did that mean to you?

• How did you feel?

• What emotional impact did that have?

• What physical symptoms did you have?

• What did you do when you felt really upset?

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Questioning and Summaries • CBT has a very distinctive style:

– An active, enquiring therapist – Socratic questions.

– Frequent Summaries.

– Giving & getting Feedback.

– Building summaries into formulations as dialogue progresses 34

Feedback & Summaries

• • Giving feedback… – It sounds to me that….. – Let me see if I have got this right….

– Have I understood this correctly?...

Getting Feedback… – Have I missed anything important?

– How would you put that in your own words?

– Could you feed back your own understanding of what we’ve been discussing?

– What things stand out as most important in our discussion so far?

– I’m not putting you on the spot, but I want to check that

I’ve

explained things clearly, so could you summarise what’s been said so far? • Putting it together – Itt looks like things link up this way… 35

Socratic questions

• Ask questions that the person is capable of answering – Avoid “Why?” questions – Ask sequences of simple questions rather than single complex questions • Summarise regularly (give

and

invite feedback) – The longer the chain, the easier to get lost – Don’t assume that client assent to

your

summary indicates understanding • Client should not feel interrogated by the therapist – Take responsibility for the question your client can’t answer – Remember your basic counselling & communication skills – Focus on the problems you agree to tackle 36

What’s useful about this style?

• Collaborative • Specific • Promotes client-owned learning • Testing of hypotheses rather than presuming you know • Accesses theory without “fitting the patient into boxes” • Engages client, promotes shared understanding 37

Helping the client change

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Learning and Change

• CBT doesn’t simply seek understanding, but to change – To open up stuck patterns of thought, feeling & behaviour – To bring about new learning – But people’s stuck patterns serve purposes (e.g. maintain a sesne of sefety) so change can be anxiety provoking • Goal orientation is therefore a key foundation to the process • Get your goals wrong & therapy has no sound foundation 39

Goals and Change

• Goals can be – short-term (for this session), – mid-term (for this course of sessions, this month…) – Long-term (life) • For therapy have a tangible, measured impact on the client’s life goals need to be tangible, measurable & achievable • Well-set goals can – Guide learning – inspire hope – Build confidence – Establish teamwork 40

Goal Setting

• Specific and achievable • Designed to have a positive, consistent impact on a client’s life • Prepares the client for change through consideration • Allows for discussion of fears (often predictive and testable) • Informs a collaborative approach 41

Role Play

• Observe therapist and client elicit, formulate and set goals • Discussion 42

In Pairs

• Consider one or two specific goals that you would like to set yourselves over the next week – Avoid life-changers at this stage – we’re simply trying to get at the way goals work – Use previous slides as guide – Phrase positively –i.e. what you want to achieve – Can you come up with time settings?

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How do we learn? Exercise…

• Consider some recent or pivotal learning in your own experience 44

Kolb’s Experiential Learning Theory

Concrete experience Planning Reflection Conceptualisation Concrete Experience: doing/”hands-on” experience Reflection: standing back, observing, reviewing the experience Conceptualisation: making coherent sense of, coming to conclusions from the experience Planning: Trying a new/different way of doing or thinking Back to the next phase… 45

What kinds of learning happen in CBT?

• How current patterns are maintained, e.g.

– Via Safety-seeking behaviours that prevent us from checking out the real level of risk – Via mental behaviours (e.g. rumination) which take up vast amounts of time & prevent us from getting new info into our system – Via depressive withdrawal & anxious avoidance – Via reassurance-seeking rather than information-getting – Via drugs alcohol etc 46

What kinds of learning happen in CBT?

• How

current

thinking, feeling & acting is affected by

past

experiences.

– Formulating to make sense – Building client understanding & therapist empathy – Helping to show how the present & the future can be different 47

What kinds of learning happen in CBT?

• How to recognise what I am thinking • How to recognise

how

I’m thinking – Overgeneralising – Catastrophising – Personalising – Ruminating – Worrying 48

What kinds of learning happen in CBT? • How to generate and use new thoughts and beliefs – Thought diaries – Data logs – Re-evaluation methods • How to work out new

ways

of thinking – If I can spot rumination & worry, what alternatives can I employ?

– There I am personalising again, what’s a less personalised way of looking at this?

• How to generate and practice new ways of behaving – Reaction X doesn’t help; let’s try Y… 49

Applying the theory in our work…

• Back to the examples we’ve used in our formulation exercises… • Based on the way we have formulated the person’s problems what do they need to learn – Re thoughts… – Re behaviour… • Try to frame their learning need as a goal • Now consider the learning cycles they will need to go through… 50

Summary…

• CBT proposes that psychologically “stuck” states (illnesses, PD, unhelpful habits, overly limited lifestyles, poor ways of managing relationships…) can be understood in terms of enclosed cycles of thinking, acting and feeling • Depending on the severity, chronicity, complexity & breadth of these states, the problem may be adequately explained in here-and-now terms, or need a more “longitudinal” formulation 51

Summary…

• Therapy works by – Forming an alliance based on shared goals – Exploring the client’s experience in Socratic terms – formulating the stuck state – Promoting learning that breaks unhelpful cycles and opens the client to new learning 52

How we organise therapy

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Structure

• Structure of both the sessions and the overall length of treatment is informed by – Our goals – The learning methods we need to use – The learning speed of the client – The setting of therapy – The format of therapy • If we forget that structure therapy

follows

from the things we’re trying to achieve, we’ll become rigid and rule-bound in • Good structure can’t alone make good therapy, but bad structure is a sure-fire way of ending up with bad therapy 54

Structure Exercise

• Observe the setting up of the discussion: – How does the therapist get things started?

– How does this compare with how you tend to work at present?

– What’s required of the client?

– What gets agreed? 55

Structure -considerations

• Be clear about… – what are you and the client trying to achieve (be realistic!) – how long you have to work on it – what you’ll talk about – what you’ll do – the most important from the less important issues – (if you need to) allotting times for different items (to make sure you work through things steadily) • An agenda is not set in stone, so… – Adjust as you need to & be clear about changes 56

Structure continued….

• Session content is agreed

collaboratively

junctures a ccording to – the needs & wishes of the client – your goals in therapy • Areas discussed will be likely to include – a review of the week, – mood check, and will have discrete – your own professional know-how as a therapist – homework review and new homework negotiation – items that will follow naturally from the formulation • Consider: how this might be used in your own service/role 57

Conclusion

• How well have we done in achieving our goals?

• What have we learned about CBT?

• About its application in your own work?

• What attracts you to it (or not)?

• Where you might go next… 58

To consider…

• How has this helped inform you knowledge about CBT?

• Would you like to take this curiosity further?

• Has this aided your clinical work by exploring processes?

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References

• Beck, Rush, Shaw, & Emery (1979) Cognitive Therapy of Depression • Kolb, D. A. (1984)

Experiential Learning

, Englewood Cliffs, NJ.: Prentice Hall. 60