Transcript Cognitive Behaviour Therapy

Introduction to
Cognitive Behaviour Therapy
Carol Vivyan 2007
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
• 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
The approach is:
• Collaborative (builds trust)
• Active
• Based on open-ended questioning
• Highly structured and focused
‘Common Sense’ Model
Event
Emotion
Cognitive Model
Event
Meaning
we give
the event
Emotion
You’re walking down the High
Street, and someone you know
walks by without acknowledging
you…
4 interpretations – 4 emotions
• I don’t want her to see me, I won’t know
what to say – she’ll think I’m stupid &
boring
•Nobody wants to talk to me, no-one likes me
•She’s got a nerve being so snooty!
•She’s probably still hung over from that
party last night!
• 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
• ‘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
Padesky’s 5 Aspects Model
(1986)
ENVIRONMENT
THOUGHTS
MOOD /
FEELINGS
BIOLOGY
BEHAVIOUR
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
Feelings & commonly associated thoughts
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
• 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?
Cognitive
Model of
Panic
Internal / External Trigger
Turbulent flight
Perceived Threat
We might crash
I’m going to die
Anxiety / Panic 90%
Catastrophic
Interpretation of
Symptoms
I’ll suffocate and die
Avoidance & Safety Behaviours
Reassurance seeking:
Ask companion
Look at faces of other travellers
Ask cabin crew
Avoid flying!
Physical / Cognitive
Symptoms
Heart racing
Breathless
Difficulty breathing –
choking sensation
Shaking
Sweating
Cognitive
Model of
Depression
Early Experiences
Core Beliefs &
Assumptions
Beck (1979)
Critical Incident
Negative Automatic
Thoughts (NATS)
Behaviour
Feelings
Negative Automatic Thoughts
Assumptions
Core
beliefs
Negative Automatic Thoughts
• Stream of thoughts that we can notice if we try
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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
Identifying NATs
• Shifts in Affect
• Distinguish between thoughts and
emotion and behaviour
• Check for images
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, what’s the point of anything?
• Negative filter
– Remembering events
– Interpreting current events / situations
– Overgeneralising from small negative event to broad negative
conclusion
Goals of therapy
• Help the client counteract negative cognitive
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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
Course of treatment
• Identify specific problem list (& prioritise)
– Eg. Poor sleep, relationship difficulties etc
• Introduce cognitive model – how it might apply
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to client
Goals (SMART)
Reduce symptoms through behavioural or simple
cognitive strategies
Identify and challenge NATs
Relapse prevention
Overview of a typical
course of therapy
• Referral
• Assessment: suitability, therapeutic
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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
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 ?
Typical CBT treatment session
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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
Therapy Skills
• Engagement
• Warmth and empathy
• Collaboration
• Guided discovery – socratic questioning
• Feedback and summarising
• Agenda setting – structure and focus
• Open and closed questioning
Aims of Assessment
• Initiate & develop therapeutic relationship
• Establish suitability for CBT
• Gather specific information re current
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difficulties
Elicit maintaining factors
Initial formulation
Socialise to CBT model
Establish joint understanding of the
presenting problem
Suitability for short term
CBT
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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
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?
Measures
• The concept of measures is central to the
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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
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
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
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
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)
Behavioural Interventions
• Very powerful method of bringing about
change
• Key component of CBT intervention
• Borrowed and adapted from Behaviour
Therapy
• Incorporate different methodological
approaches
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.
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 doesn’t neutralise
his thought by doing rituals for up to an
hour
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
Relapse Prevention
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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?
Coping with Relapse
• How can I make sense of this lapse?
• What have I learnt from it?
• With hindsight, what would I do
differently?
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?
Summary
• No formulation
• Use CB techniques
No CBT
– Bibliotherapy: e.g. Mind Over Mood
– Challenge negative thoughts
• Court Case
• Evidence
• More balanced/alternative thought
• Downward arrow
– Behavioural experiments / exposure
– Activity Diaries
– Relaxation?
More information & resources
• www.get.gg
– Self help
– Workbooks
– online CBT programmes – printable forms etc
– Online
• Professional links
– CBT organisations
– Therapist manuals online
– Books
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.