cbt lewis.pptx

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COGNITIVE ANDBEHAVIORAL

THERAPIESAnne Cristine D. Guevarra, MD

Child Psychiatry Rotator

Lewis’s Child and Adolescent Psychiatry:

A Comprehensive Textbook 4th edition



Objectives

• To introduce cognitive-behavioraltherapy as a modality for treatment ofpsychiatric disorders especially inchildren and adolescents

• To review basic concepts that formthe basis for CBT

• To discuss specic disorders whereinCBT may be eective



Cognitive Therapy

Foundations• it is not events, but people's interpretations of events, thatcause psychological disturbance

• focuses on identifying and changing people's cognitions asa way of changing their feelings and reducing psychological

distress

• behavioral changes are thought to inuence thoughts and

feelings• etting concrete goals and measuring specic behaviors

• !"#CT$%#& ()*()CT$+) !unctional &ssessment )valuation

&ntecedents B).&+$%* Conse/uences

Behavior Therapy Foundations



Classical Conditioning

Establishes the connection of

an existing response to a new stimulus



Classical Conditioning &

Phobias



Classical Conditioning & CBT

The subsequent avoidance behavior does not allowextinction to occur, such that the phobia is maintained



Classical Conditioning & CBT

• )motional responses, addictions, andpsychosomatic disorders

• Therapy techni/ues0• Counterconditioning

• ystematic desensiti1ation

• Covert sensiti1ation

• )2posure and response prevention



Classical Conditioning



Operant Conditioning



Operant Conditioning:Schedules of Reinforceent

• Continuous schedule 3 initially teaching a newbehavior

• Thinning 3 to decrease the ratio of reinforcers to

responses• $ntermittent

45 2ed interval

65 variable interval

75 2ed ratio85 variable ratioThe variable ratio schedule is the

most effective schedule when trying

to maintain a behavior because it

creates relatively high steady rates of

responding.



Initial Behavir Res!nse "re#uen$%

Rein&r$e'ent

Re've(

E)tin$tin

Burst

S!ntaneus

Re$ver%

O$$urs

E)tin$tin

!"tinction #raph



Operant Conditioning & CBT

• &pplied behavior analysis 9&B&5

• (arent management training 9(:T5

• (roblem solving s;ills training 9(T5



Coon Therapy Techni$ues %ssociatedith

Principles Of Operant ConditioningRein&r$e'ent t In$rease Behavir

T%!e an( Te$hni#ue Des$ri!tin

T*ene$n'%

Reinorcin! tar!et behavior with tokens "stickers# points# poker chips$ that can then be traded in or reinorcers once m%ltiple tokenshave been earned

DRO+Di&&erential

Rein&r$e'ent& Other Behavir

Reinorcin! speciic appropriate behaviors while i!norin! inappropriate behaviors that serve

the same %nction

Sha!in- Reinorcin! !rad%al approximations o a behavior

Punish'ent t De$rease Behavirs

Over$rre$tin Applied conse&%ence that involves en!a!in! in a series o retrib%tionsteps that are related to the inappropriate behavior "washin! soiled clothes ater toiletin! accident$

Res!nse $st Removal o previo%sly earned reinorcers as conse&%ence o ne!ative behavior' (sed especially incon)%nction with token economy when tokens are removed

Ti'e ut Removin! all so%rces o reinorcement or allotted period o time' Typically involves placin! the individ%alin a location where access to reinorcin! activities# incl%din! social attention# is not available

E)tin$tin t De$rease Behavirs

Removin! previo%sly available reinorcement rom an inappropriate behavior to decrease theprobability that the behavior will occ%r in the %t%re



Cognitive'Behavior TherapyFoundations

*ehavior

Tho%!hts

+eelin!s



Cognitive'Behavioral (odel

• Escape or Avoidance Conditioning• why negative thoughts and beliefs persist

• why behavioral cycles do not get bro;en over time

• avoidance, escape and safety-see;ing behaviors

• individuals erroneously believe they prevented the feared situation

from occurring by engaging in certain behaviors

• Attention-related Factors• electively attend to cues that conrm or e2acerbate their condition

• Cognitive images• $mages are interpreted as signs of danger li;elihood that

distressing events will occur

• Memor !rocesses• *ecall of instances that conrm an2iety

• *umination 3 thin;ing of the li;elihood of the event occurring• :a;es the event more abstract and threatening vs< constructive processing



Clinical Considerations )n *se of CBT+ith Children and %dolescents

• Collaborative empiricism• (atient-therapist relationship= team

• .igh degree of collaboration and scientic attitude towardtesting the validity and accuracy of the patient>s cognitionsand behaviors

• developing hypotheses about thoughts and behaviors,collecting data on those thoughts and behaviors,

e2amining patterns, and generating alternative, moreadaptive, ways of thin;ing and behaving



,evelopental Perspective

• The child's level of autonomy and independencemust be ta;en into consideration

• Consider what other individuals or systems andhow they are involved in the child's life and whattheir role should be in therapy

• (arent, teacher, and other adult-focused training isoften necessary in addition to individual therapysessions

• &dapting treatment concepts to children'sdevelopmental level

• Cognitive-behavioral play therapy 9CB(T5 in veryyoung children



Faily'Related Factors

• The Role of Families and OtherSystems in Cognitions and Behaviors• %ther people in the child's life are ma;ing

accommodations that support and maintain,rather than discourage, the maladaptivebehaviors

• Parent/Family Involvement in Therapy

• family conte2t, and parental cognitions,emotions, and behaviors

• family routines, dynamics, and disciplinepractices



#enerali-ation and

(aintenance• &cross settings

• &cross functional domains 9behavior, cognitions5

• %ver time 9maintenance5

"r su$$ess&ul $han-e, the !atient 'ust use the te$hni#ues learne( insessin a$rss settin-s, learn t a!!l% the' t a variet% & ('ains, an(

$ntinue t use the' ver ti'e &r as ln- as ne$essar%.



Strategies for prooting generali-ationand aintenance of iproveents in

functioning ./endall and 0ochan 1• *ewarding behavior change using attainable goalsthat are applied across an increasing number ofsettings over time

• Treatment length is an important consideration inprogramming for maintenance of changes made 9?months or longer5= intensity may be an importantfactor as well

• "se of behavioral rehearsal 9role-playing5

• (roblem solving processes that apply to multiplebehaviors and situations



Course of Therapy

General Characteristics of CBT TreatmentPlans

45 The patient will be an active participant in trying newstrategies

65 the patient will be e2pected to complete homewor;75 therapy outcomes will be measured via data collection,and techni/ues will be modied if they are unsuccessful

85 therapy will focus on symptoms and daily functioning

@5 therapy will be time limited

?5 maintenance of treatment gains and relapse preventionwill depend on generali1ation of techni/ues into everydaylife



Three Phases of Treatent

,nitial Active +inal



Fre$uency and ,uration ofTreatent• 7- to ?-month period

• once or twice per wee; in an outpatient setting

• Booster session

• Tapering the therapy



(.&) %! T*)&T:)#T



Phases of Treatent

• %ssessent for Treatent Planning

• Psychoeducation

• (iddle Phase of Treatent

•Terination and Relapse Prevention



%ssessent for TreatentPlanning• To develop a cognitive behavioral model of the presentingproblem that can be used to guide treatment

• Aescriptions of when the symptoms occur

• Cognitions that accompany each symptom

• Behaviors that accompany each symptom

• )motions that occur with each symptom• $f cognitions and behaviors relieve symptoms, detailed description of

how this occurs

• $nformation about factors that help or e2acerbate the symptoms

• :aintaining variables0 avoidance, escape, safety behaviors,

attentionfocus, dysfunctionalfaulty beliefs, automatic thoughts

• %verall beliefs 9cognitive schemas5 that lead to cognitions, behavior,and feelings

• (revious treatment and treatment outcome

• %nset0 including any possible causal factors that are not maintainingfactors 9e<g<, traumatic event in (TA, negative situation paired with

stimuli in specic phobias5



ays of !liciting

• &s; patient to describe a recent event in detail,while as;ing pointed and specic /uestions, suchas0• hat were you thin;ing when that happenedDE or

• .ow did your body feel at that momentDE

• .omewor;• )2plicit information from children

• elf-monitoring



Psychoeducation

• Techni/ues utili1ed in CBT are driven by theoreticalor empirical underpinnings that, when understood,allow the patient to better grasp wh suchtechni/ues are being used and how change will

occur, thus increasing motivation and followthrough

• )2plained or demonstrated• (hysiological

• Cognition• Connection between thoughts and events



(iddle Phase of Treatent

• %ngoing active participation in therapy

• .omewor;

"oals and content of therap sessions during this phase will var widel depending on the chiefcomplaint#



Terination and RelapsePrevention• (rogramming for generali1ation and maintenance

• Thinning of schedule of therapy sessions

• *elapse prevention• Cognitive framewor; for thin;ing about brief relapses

• $dentifying antecedents to relapse behaviors

• Booster sessions



CBT T!C23)4*!S



CBT Techni$ues

• Cognitive Restructuring• $dentifying &utomatic Thoughts

• imagerey F role-playing, thought recording

• ocratic Guestioning)2amining the )vidence• eliciting automatic thoughts and calling their validity into

/uestion

• Thoughts are considered hypotheses determine andevaluate evidences for and against them

• Can be combined with self monitoring

• Correct :isinterpretations



Cognitive !rrorsCOGNITIVE ERROR DESCRIPTION EAMPLE

Catastr!hi/in- Placin! %nrealistic importance on tho%!hts andeventsand ass%min! terrible ne!ative o%tcomes willocc%r as a res%lt

, !ot a C on my report card# so , will never !etinto colle!e and , will ail in lie'

Ma-ni&%in-0Mini'i/in- Placin! an inacc%rate amo%nt o importance ontho%!hts# eelin!s# -vents "either too m%ch or toolittle$

*elievin! !ettin! ca%!ht doin! dr%!s is notimportant beca%se the ,mplications o havin!a dr%! problem are too anxiety provokin!

"minimi.in!$

A1slutis' All events and experiences are tho%!ht o inextremecate!ories# rather than moderately

, will never lose any wei!ht beca%se , )%st atea cookie'

Persnali/atin Attrib%tin! responsibility or external events to thesel with no basis or the attrib%tion

,t is my a%lt that my parents are !ettin!divorced'

Sele$tive A1stra$tin Takin! inormation o%t o context and i!norin!relevant details

/y soccer coach hates me when s0he did notplay yo% in spite o the act that yo% havestarted the last three !ames

Ar1itrar% in&eren$e /akin! arbitrary concl%sions contrary to orwitho%t evidence

*elievin! homework is too hard when in actthe child completed the same work that dayin class

I-nrin- evi(en$e Leavin! o%t important inormation when ormin!tho%!hts abo%t events

*elievin! that werewolves are a dan!er atni!ht in spite o the act that m%ltiple ad%ltshave told the child they do not exist# and allthe doors in the ho%se are locked'

Atten(in- t ne-ative

&eatures & events

Placin! !reater co!nitive importance on ne!ativeeat%res o events and i!norin! positive eat%res

+oc%sin! on one poor !rade when all otherswere !ood



CBT Techni$ues

• Behavioral)2periments

• :odication of$magery

• &ltering Core Beliefs

• (hysiological Techni/ues

• *egulated Breathing

• *ela2ation Training

• )2posure Techni/ues

• &ctivity cheduling

• &pplied Behavior&nalysis 9&B&5 Behavioral:odication

• Counterconditioning

• ystematicAesensiti1ation

• &versive

Counterconditioning• Covert ensiti1ation

• .abit *eversal



CBT Techni$ues

• Behavioral !"perients• Auring psychoeducation= e2ercises that patient can complete in

a session= demonstrates error in thin;ing in a concrete manner

• Thought suppression increased fre/uency of a thought 9e<g<pin; elephants5

• $nstead of supressing thoughts observe thoughts as theycome F go

reduction of intrusive thoughts

• (odi5cation of )agery•

$dentify e2aggerated aspects of the imagery associated withtraumatic event

• %ften stops at the height of crisis help patient continueimage to a positive resolution

• (assing out !alling to the ground getting embarrassed standing up



CBT Techni$ues

• %ltering Core Beliefs• "nderlying belief cognitive schemas automatic thought

• 9tupid ;ids are unlovable5 9$ am stupid5 $f $ don>t write that sentenceeveryone will ;now $ am stupid Therefore, no one loves me

• :aladaptive &daptive

• Physiological Techni$ues• &n2iety= catastrophi1ing physical symptoms

• Regulated Breathing• Counteracts hyperventilation, reduces physical tension, decreases

physical sensations associated with an2iety

• "ncovering the patient>s understanding of the physiology decreases fears

• Rela"ation Training• (rogressive tensing and rela2ation of muscles= target large muscle groups

• )ective for sleep-onset insomnia, anger management, impulsive children



CBT Techni$ues

• !"posure Techni$ues• Based on &voidance afety Behaviors

• Hraded series of e2posures

• .abituation 9Classical Conditioning5 3 an2iety e2tinguish over time

• &n2iety, phobia

• %CA 3 compulsive behavior 9safety behavior5

• !looding 3 not graded= begins by eliciting a full-blown fear response=needs good self-control to prevent avoidanceescape

• Challenge core beliefs Cognitive *esponse (revention• Behaving inconsistently with pathological belief

• Ao homewor; with some imperfections 9a couple of mista;es do not ma;eme stupid5

• %ctivity Scheduling• Bec;>s cognitive triad negative 9thin;ing, evaluations of self, world,

future5

• *einforcing daily activities



CBT Techni$ues

• Self'(onitoring 6 Self'(anageent• &utomatic thoughts, habits, evaluation plan

• %pplied Behavior %nalysis .%B%1 6 Behavioral(odi5cation• $ncrease desirable decrease undesirable• Contingent reinforcers reinforcement is applied to a

positive behavior increases the fre/uency of that

behavior occurring

• Counterconditioning• olpe 3 $f a response antagonistic to an2iety can be made

to occur in the presence of an2iety-provo;ing stimuli so that

it is accompanied by a complete or partial suppression ofthe an2iety responses, the bond between these stimuli andthe an2iety response will be wea;ened<E



CBT Techni$ues

• Systeatic ,esensiti-ation• :ost commonly used counterconditioning techni/ue= subclinical fears

• *ela2ation training

• Constructing an2iety heirarchy

• Aesensiti1ation in imagination

• $n vivo Aesensiti1ation• $maginal or in vivo e2posure heirarchy paired with progressive

muscle rela2ation to reduce fearan2iety

• +isuali1ation in vivo training

• %versive Counterconditioning• &ddictions, se2ual fetishes

• Target behavior or conditioned stimulus paired with unconditionedstimulus that naturally elicits an unpleasant response maladaptivebehavior is avoided

• Aisulram I alcohol consumption physical ilness reducedrin;ing behavior



CBT Techni$ues

• Covert Sensiti-ation• $magining an aversive condition while imagining engaging

in maladaptive behavior

• 2abit Reversal

• Trichotillomania, Tourette>s syndrome, Tic disorders• &wareness training

• Training in an incompatible competing response

• ocial support



C%H#$T$+) B).&+$%*&

:%A) &#A T*)&T:)#T!%* )&C. A$%*A)*



Cognitive Behavioral (odel Treatent• overestimation of the dangerassociated with certainsituations, bodily sensations,or even thoughts

45 the li;elihood of an event

65 the severity of an event

75 one's coping s;ills and theavailability of help, support, or escape

• interpret events from anegative and therefore

inaccurate perspective• two-factor learning theory

• (hysiological symptoms,especially ongoing somaticcomplaints, are often the mostcommon an2iety symptoms inchildren

• (hysiologicaltreatment strategies

• Behavioral Treatmentstrategies

• Cognitive strategies

• Combined trategies

ANIET2



Cognitive Behavioral (odel Treatent

• $ntrusive anddistressing thoughts,impulses, or images

about possible harmcoming to oneself orothers

• counterthoughts or

behaviors to preventharm or negativeconse/uences fromoccurring

• )2posure andresponse prevention9)*(5 has substantial

• based on models ofclassical e2tinction

• CBT alone was founde/ually eJcacious as

CBT I *$ - (ediatric%CA Treatment tudy9(%T5

OCD




• two-factor learningtheory

• brea;ing the operantconditioning cycle andteaching the individualthat the fearedsituation is unli;ely to

occur again even whenit is not avoided

• Hraded e2posure

• ystematicdesensiti1ation

• *ela2ation training

PHOBIAS




• fear of impendingdisaster, which isconrmed by

physiological andcognitive symptoms misinterpret theirsymptoms asconrmation that their

an2iety represents realdanger :%*) &#K$)TL

• precipitating factor in theattac; is a fear of havingone, rather than a fear ofa specic stimulus

• cognitive andphysiologicalstrategies

• e2posure therapy

PANIC DISORDER




• $nability to cope withintrusive, unwanteddistressing thoughts

and memories after atraumatic event

• )2posure

• Cognitiverestructuring

• *ela2ation

• &n2iety managementtraining

PTSD



%lternative set of diagnostic criteria forpreschool'agedtraua victis .Scheeringa145 the individual does not have to be able to report the an2ietyreaction, as many young children are incapable of doing so

65 recurrent recollection of the event may manifest in repetitivetrauma-related play themes

75 recurrent distressing dreams do not have to include trauma-related

content, but must be distressing85 ashbac;s may be behavioral in nature, with no accompanyingverbal description

@5 diminished interest in signicant activities may present asconstriction of play

?5 a feeling of detachment or estrangement may manifest aswithdrawal

M5 loss of developmental s;ills may occur

N5 increased arousal may manifest as tantrums and fussiness<



%dditional Cluster OfSyptos• 45 new separation an2iety

• 65 new onset of aggression

• 75 new fears 9e<g<, fear of the dar;5 withoutobvious lin;s to the trauma



,S('7 Criteria for PTS, inChildren



Cognitive Behavioral (odel Treatent• intrusive negative thoughts

9e<g<, selective ruminationsabout past unpleasant

events, hopelessness aboutthe future, andhelplessness aboutimproving their situation5

• overgenerali1ation,

catastrophi1ing, ta;ingresponsibility for negativeoutcomes, and attending tonegative features of events

• restricted behavioralrepertoires

• Cognitiverestructuring

• elf control strategies

• ;ills training

• &dolescent Copingwith AepressionCourse 9CA-&5

DEPRESSION



Cognitive Behavioral (odel Treatent• lac; of motivation and

learned helplessness• &pplied Behavior&nalysis 9&B&5

• discrete trial training

• pivotal response training• incidental teaching

• Techni/ues

• (rompting

• !ading

• haping• Tas; &nalysis

• Bac;wards Chaining

• Behavior plans

• %vercorrection

A3TISM 4 PERVASIVE DEV5T DISORDERS



Cognitive Behavioral (odel Treatent• Coercive interactions

• $nformation (rocessing:odel

• !our types oftherapeutic change

• )cological

• %perant methods• :edication

• Behavioral parenttraining

• (erspective ta;ing and

social problem solving• (arent managementtraining 9(:T5

• (roblem solving s;ills

training 9(T5

EMOTIONAL 4 BEHAVIORAL DIST3RBANCE



Cognitive Behavioral (odel Treatent• $nattention, hyperactive,

impulsive symptoms

• poor self-monitoring and

self-evaluation s;ills, mayhave diJculty withreceptive and e2pressivelanguage, and suer fromassociated e2ecutivefunctioning decits

• (harmacological andbehavioral treatments

• (rogramming at home

• chool intervention• ong-term goal in &A.A

treatment is gradually tofade the adult control tochild-driven self-

management

ADHD



Cognitive Behavioral (odel Treatent• Cognitive distortions

• mista;en view thatcompensatory behaviors

9vomiting, la2ative use,diuretics, overe2ercising5are eective means ofweight control

• binge-purge cycle is also

associated with theantecedent of negativeaect

• tages 9!airborn5• Teaching the patient self-

monitoring of eating andrelated behaviors

• )ducating the patient abouteating and weight 9physicaleects of binge eating,information about weightuctuation, ineectivenessof compensatory strategies,

eects of dieting5• (rescribing a regularpattern of eating 9regular,planned meals and snac;s5

• Aeveloping a plan toaddress post-meal vomitingwhen this behavior is partof the illness<

B3LIMIA



Cognitive Behavioral (odel Treatent• Cognitive distortions

• do not believe they have aproblem

• they believe that they arefat and truly need to loseweight

• !irst goal 3 weight gain

• &ddress the lac; ofmotivation of the

patient• tages 9Harner, +itouse;, and (i;e5

• tabili1ation of thepatient's physical healthand building a therapeutic

alliance

• Continued emphasis on

weight gain and normaleating

• (rogress is summari1ed

and emphasi1ed

ANOREIA



Cognitive Behavioral (odel Treatent• role of negative

reinforcement 9dissipationof the urge upon

performance of the tic5 as acontributing factor in theshaping and maintenanceof tic e2pression

• .abit reversalprocedures

• &ssessment phase

• &wareness training

• Competing responsetraining

• ocial support

TO3RETTE S2NDROME



Cognitive Behavioral (odel Treatent• hair pulling behaviors are

maintained by a negativereinforcement paradigm

similar to %CA and ticdisorders, as tension isreduced when thehairpulling behavior occurs

• .abit reversalprocedures

• &ssessment phase

• &wareness training

• Competing responsetraining

• ocial support

TRICHOTILLOMANIA



Other Probles

• )nuresis 3 night alarm

• )ncopresis - la2ative prescription, dietary changes,and behavioral methods

• elective mutism - behavioral methods0 shaping,

fading 9situational F individual5• tuttering 3 rela2ation training

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