Transcript Slide 1

SOWK6190/SOWK6127
Cognitive Behavioural Therapy and Cognitive Behavioural Intervention
Week 3 - Cognitive conceptualization and Structure of the
first therapy session
Dr. Paul Wong, D.Psyc.(Clinical)
A recap (and additional
information) of the last two
classes
Seven Basic Assumptions
Beck (1979) provides a list of general assumptions that
underlie the theory (from p.8 in Beck, A. T., Rush, J. A.,
Shaw, B. F., & Emery, G. (1979). Cognitive therapy of
depression. New York: The Guilford Press]
Seven Basic Assumptions
Beck (1979) provides a list of general assumptions that underlie the theory.
CBT is based on the following:
1. Perception and experiencing in general are active processes which involve
both inspective and introspective data.
2. The patient's cognitions represent a synthesis of internal and external
stimuli.
3. How a person appraises a situation is generally evident in his cognitions
(thoughts and visual images).
4. These cognitions constitute the person's “stream of consciousness” or
phenomenal field, which reflects the person's configuration of himself, his
world, his past and future.
5. Alterations in the content of the person's underlying cognitive structures
affect his or her affective state and behavioral pattern.
6. Through psychological therapy a patient can become aware of his cognitive
distortions.
7. Correction of these faulty dysfunctional constructs can lead to clinical
improvement. (p. 8)
Basic Concepts
CT is based on the role information processing plays in
survival
The theory behind cognitive therapy asserts that altering
thoughts influences feelings, motivations and
behaviors
The theory states cognition, behavior, affect, and
motivation are intertwined and co-occurring
Therapeutic intervention focuses on the primacy of
cognition
Basic Concepts
Cognitive Schema – a structure containing self-perceptions;
thoughts about others and the world; our memories, goals,
fantasies; and everything we’ve learned. Structures that
contain an individual's core beliefs and assumptions are
labeled Cognitive Schemas) Cognitive Theory states that an
individual's fundamental beliefs and assumptions are
contained in structures termed cognitive schemas.)
Cognitive Shift – a systematic bias in information processing
Cognitive Vulnerabilities – specific attitudes predisposing the
interpretation of experiences
Cognitive Distortion - refers to a systematic error in reasoning
Basic Concepts
Mode
– Networks of cognitive, affective, motivational, and behavioral
schemas
– Primal modes are universal and related to survival
– They include primal thinking which is rigid, absolute, automatic
and bias
– Dysfunctional modes are treated by deactivating them,
altering their structure and content and developing more
adaptive modes
CT’s Cognitive Triad
Pattern that triggers depression:
1. Client holds negative view of themselves and blames
themselves (self)
2. Selective abstraction: Client has tendency to interpret
experiences in a negative manner (others)
3. Client has a gloomy vision and projections about the
future (world)
Basic Characteristics of CT
• Practical
• Symptom focused
• Empirically derived techniques
• Collaboration
• Acknowledges underlying precursors of symptoms while
remaining in present
• Case conceptualization drives treatment
Primary Roles of the CT Therapist
Conceptualizing the patient in cognitive terms
Structuring the sessions
Using collaborative empiricism and guided
discovery to specify problems and set goals
The Cognitive Model
Behaviors
Situation
Automatic
Thoughts
Emotions
Underlying
Beliefs
Physiological
Response
The Cognitive Model
Automatic thoughts influence not only one’s emotional
response, but also one’s behavioral, motivational, and
physiological responses.
The relationship is bi-directional (all systems act together
as a mode) therefore simultaneously biology, emotions,
behavior (and motivation) influence thoughts
Subsequently, biological treatments can change thoughts
and CBT can change biological processes.
The Cognitive Model
We all have cognitive vulnerabilities (i.e., core beliefs)
which predispose us to interpret information a certain
way.
These vulnerabilities are developed early
When these beliefs are rigid, negative, and ingrained we
are predisposed to pathology
These core beliefs give rise to conditional assumptions,
i.e., rules for living, as we mature
In psychopathology there are systematic biases toward
selectively interpreting information in a certain manner
which are disorder specific.
Modifying Core Beliefs creates the
most significant change in a
dysfunctional mode for a client
Hierarchy of Beliefs
(Adapted from Judith Beck’s Cognitive Therapy: Basics and Beyond)
Core
Beliefs
Assumptio
ns
Strategies
Automatic
Thoughts
& Images
Hierarchy of Beliefs
(Adapted from Judith Beck’s Cognitive Therapy: Basics and Beyond)
Situation
Automatic
Thoughts
Intermediate Beliefs
Core Beliefs
Emotion
Strategies of Cognitive Therapy
• Collaborative Empiricism
• Guided Discovery (Guided discovery refers to
the process by which a therapist serves as a
guide to clarify problem behaviors and thoughts)
• Deactivation of Dysfunctional Modes
– Techniques which directly deactivate them
– Modifying their content and structure
– Constructing more adaptive modes to neutralize them
CT’s View of Personality
Thinking is Problematic or Distorted when it is very ...
Extreme
Broad
Catastrophic
Negative
Unscientific
Idealistic
Demanding
Judgmental
Comfort Seeking
Obsessive
Confusing
Cognitive Distortions
1. Arbitrary Inference: Drawing a conclusion
without evidence or in the face of contradictory
evidence. Example - a young woman with
anorexia nervosa believes that she is fat
although she is dying of starvation
2. Selective Abstraction: Dwelling on a single
negative detail taken out of context. Example –
While on a date you say one thing you wish
you could have said differently and now see
the entire evening as a disaster.
Cognitive Distortions
3. Overgeneralization: A single negative event is viewed
as a never-ending pattern of defeat. Example - Following
a job interview an accountant does not receive the job.
She/he begins thinking that they will never find a job
despite their qualifications
4. Magnification and/or Minimization: The binocular trick.
Things seem bigger or smaller than they truly are
(depending on which lens you are looking through).
Example: An employee believes that a minor mistake will
lead to being fire vs. an alcoholic who believes he/she
doesn’t have a problem.
Cognitive Distortions
5. Personalization: Assuming personal responsibility for something for
which you are not responsible. (Attributing external events to oneself
without evidence supporting a causal connection is termed
Personalization.) Example – sometimes seen in patients who have
been sexually or physically abused.
6. Dichotomous Thinking: Is All or Nothing Thinking - Things are seen
as black or white, there is no gray (middle ground). Example 1 –
Things are wonderful or awful, good or bad, perfect or a failure.
Example 2 - Kate has anorexia nervosa and when she gains one
pound she believes she is fat. If she loses one pound she can
perceive herself as thin. Kate's thought process reflects
Dichotomous Thinking. Example 3 - A patient with anorexia nervosa
believes that she is thin when she exercises, but fat if she eats. This
would be an example of the all or nothing thinking cognitive
distortion
Cognitive Distortions
7. Mind Reading: Assuming you know the motives,
thoughts, intentions of others. Example – If your friend is
in a bad mood you assume it’s your fault and don’t asked
what is wrong.
8. Fortune Teller Error: Creating a negative self fulfilling
prophesy. Example: You believe you will fail an
important exam so you do not study and fail.
Cognitive Distortions
9. Emotional Reasoning: You assume your negative
feelings result from the fact that things are negative.
Example – If you feel bad, then that means that the
world or situation is bad. You don’t consider that your
feelings are a misrepresentation of the facts.
10. Should Statements: The use of words like should,
ought, must rather than “it would be preferred” to guilt
self. Example: “I should be perfect”.
11. Labeling and Mislabeling: Labeling yourself or others
in a demeaning way. Example: Name calling “I am
worthless” or “He’s a total failure”.
Process of CBT
Process of Psychotherapy in CT
Early in treatment a cognitive therapist may rely
more on behavioral techniques whereas later in
treatment the focus shifts towards cognitive
techniques
Through the process of guided discovery
cognitive therapy patients create homework
assignments for themselves called "behavioral
experiments" with input from their therapist.
Process of Psychotherapy in CT
Structure of a CBT Session
6.
1. Mood check
2. Setting the Agenda
3. Bridging from last session
4. Today’s agenda items
5. Homework assignment
Summarizing throughout and at the end
7. Feedback from patient
General Principles of CT
Goal is to correct dysfunctional thinking and
help patients modify erroneous
assumptions
Patient is taught to be a scientist who
generate and tests hypotheses
Relationship between patient and therapist
is collaborative
Fundamental Concepts
Collaborative Empiricism – goal is to demystify
therapy
Socratic Dialogue – form of questioning used to
help patients come to their own conclusions
about their thoughts and behaviors
Guided Discovery – therapist collaborates with
patient to develop behavioral experiments to test
hypothesis
Process of Therapy
1.
Initial Sessions – essential to build rapport, focus on
problem definition, goal setting, and symptom relief,
psychoeducation, behavior interventions. (Symptom
relief is a primary goal in the initial cognitive therapy
interview)
2.
Middle Sessions – emphasis shifts from
symptom/behaviors to patterns of thinking
3.
Termination – Expectation that therapy is time-limited.
First session
• Goals:
1. Establishing trust and rapport
2. Educate the patient about CBT, her
presenting problems/disorders/the cognitive
model/process of therapy
3. Eliciting (and correcting, if necessary) the
patient’s expectations for therapy.
4. Gathering additional information about the
patient's expectations for therapy.
5. Using this information to develop a goal list
Structure
1. Setting the agenda
2. Doing a mood check
3. Briefly reviewing the presenting problem and
obtaining an update
4. Identifying problems and setting goals
5. Educating the patient about the cognitive
model
6. Eliciting the patient’s expectations for therapy
7. Educating the patient about her disorder
8. Setting homework
9. Eliciting feedback
Caution!!
Check is the patient is taking
medication
If patient is suicidal, forget about the
structure, do CRISIS
INTERVENTION
Setting the agenda
Key statements (pp.28):
“I’d like to start off our session by setting the agenda…. We
will do this at the beginning of every session so we make
sure we have time to cover the most important things”.
“This first session is a little different from other sessions
because we have a lot of ground to cover and we need
to know each other better…”
“We will be doing these…… today”. “Is there anything you
want to add to the agenda today”.
Mood Check
USE Beck Depression Inventory, Beck Anxiety
Inventory, and Beck Hopelessness Scale
If no, then spend some time to teach the patient to
provide a rating of her mood on a 0-100 scale
Key statement:
“If it’s okay with you, I’d like you to come to every
session a few minutes early so you can fill out
these three forms”.
Review of presenting problem, problem
identification, and goal setting
Key statements:
“(summarized what you have just talked about)…. (then briefly review what you know
about the patient)… Is that right?”
“Can you tell me SPECIFICALLY what problems you’ve been having?”
“Helping the patient to focus and to break down the problems into a more manageable
size) Okay, it sounds like you have two major problems right now…..”.
“What would you like to accomplish in therapy?”
“If you were happier (a term that the client used), what would you be doing?”
“Do you want to write down a goal list?””
“Okay, before we finish, let me quickly summarize what we have done so far.”
Educating the patient about the cognitive model
“Can you tell me what you know about cognitive behavioural therapy?”
“First, I’d like to find out how your thinking affects how you feel. Can
you think of a moment that you have a sudden mood change?”
“Do you remember what was going through your mind?”
Show client the model if necessary
“Can you tell me in your own words about the connection between
thoughts and feelings?”
Set homework for the client to write down events using the cognitive
model
“… what we’ll be doing together is identifying these thoughts which
seem to be upsetting you.Then we will examine those thoughts and
see how accurate they are. Lots of times I think we will find that
these thoughts are not completely accurate.”
KEY : make sure the patient can explain the relationship between
thoughts and mood in his/her own words.
Expectations for therapy
Key: Check what the patient expect to do with and get from you
“some patients have the idea that a therapist will cure them. Some
expects to do some work with the therapist o make themselves
better.”
“I’ll help you learn some tools to get over depression and you will be
able to use these tools for the rest of your life when you are sad or
unhappy before you become depressed again”.
“It’s hard to predict now how long you should be in therapy. My best
guess is somewhere around 8 to 14 sessions.”
Educating the patient about her disorder
Key – do some preparations before hand,
and please do make sure the information
is updated and accurate/evidence-based
End-of-session summary and setting of homework
“Let me summarize, we set the agenda, checked your mood, set some goals
and explained how your thoughts influence your feelings, how therapy will
go. We are going to be doing two major things: working on your problems
and goals and changing your thinking when you find it’s not accurate. Now
let’s see what you’ve written for homework.”
Key: mood check using cognitive model, think about what to talk about next
time, do some relaxation exercises.
Feedback
Asking for feedback further strengths rapport,
providing the message that the therapist
cares about what the patient thinks.
Verbal or written form (pp.42 – therapy
report).
In –class activity
Please from a group of two, then one acts
as a client, and one as a therapist. Role play
session1.
After that, if we have time, we can have
some discussion.
Homework
Please do follow the guidelines
from the text and pretend that
your are the client, and finish
the homework as set by the
therapist.