cognitive-behavioral counseling : foundations and applications

Cognitive-Behavioral Counseling:

Foundations and Applications

Michele D. Aluoch, PCCRiver of Life Professional

Counseling LLCc. 2013

Depressive Disorders- DSM IV-TRDepressive Episode 5 or more in 2 week period Change from previous functioning Either: depressed mood or loss of pleasure

At least 5 out of 9: Depressed mood most of the day nearly every day, as indicated by

subjective report (e.g feel sad or empty) or observation made by others (e.g. appears tearful). NOTE: In children or teens can be irritable)

Markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day as indicated by either subjective account or observation made by others)

Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day

Insomnia or hypersomnia nearly every day

Depressive Disorders- DSM IV-TR Psychomotor agitation nor retardation nearly every day

(observable by others, not merely subjective feelings of restlessness or being slowed down)

Fatigue or loss of energy nearly every day Feelings of worthless or excessive and inappropriate guilt

(which may be delusional) nearly every day Diminished ability to think or concentrate or

indecisiveness nearly every day (either by subjective account or as observed by others)

Recurrent thoughts of death (not just ear of dying), recurrent suicidal ideation without a plan, or a specific plan for committing suicide

Impairment in social , occupational or other areas of functioning

Depressive Disorders- DSM IV-TRSpecifiers Frequency: Single or recurrent Types: mild, moderate, severe Chronic- full criteria for depressive episode met

continuously for at least 2 years- either depression or Bipolar

Catatonic- motor immobility/stupor, excessive motor activity (purposeless), extreme negativism, rigid posture or mutism, grimmacing, echolalia or echopraxia

Melancholic- lack of pleasure in activities, lack of reactivity to usually pleasurable activities and 3 or more: depressed mood, depression worse in am, marked psychomotor agitation or retardation, anorexia, excessive or inappropriate guilt

Depressive Disorders- DSM IV-TRDysthymic Disorder

Depressed mood most of the day for more days than not as indicated either by subjective account or observation of others for at least 2 years. (Note: Children/teens- irritability for at least 1 year)

At least 2 of 6: 1) poor appetite or overeating 2) insomnia or hypersomnia 3) low energy or fatigue 4) low self esteem 5) poor concentration of difficulty making decisions 6) feelings of hopelessness

Depressive Disorders- DSM IV-TR

Depressive Disorder NOSCatch all for depression that does not

meet criteria for other depression dx.

DepressionParadise, L. V., & Kirby, P.C. (Winter 2005).

Roughly 10% to 25% of the population experiences some form of depression.

Depression is the number one cause of disability worldwide.

One third to more than 60% of mental health professionals had reported a significant episode of depression within the previous year.

Depression is 10 times as prevalent now as it was in 1960!

While every objective indicator of well-being in the U.S. has been increasing, every indicator of subjective well-being is decreasing.

Anxiety Disorders- DSM IV-TRPanic Attack: A discrete period of intense fear or discomfort in which 4 or more of the

following symptoms developed abruptly and reached a peak within 10 minutes

palpitations sweating trembling or shaking sensations of shortness of breath or smothering feeling of choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady,. Lighthearted, or faint de-realization (unreality) or de-personalization (detached from oneself) fear of losing control or going crazy fear of dying paresthesias (numbness or tingling sensations) chills or hot flashes

Anxiety Disorders- DSM IV-TR

Agoraphobia- Anxiety about being in places from which escape may not be possible (being outside home alone, in a crowd, on a bridge, on a bus, in a line in the store, etc.), breeds avoidance

Panic Disorder:Panic attacks1 or more: concern regarding additional attacks, worry

about implications of additional attacks (heart attacks, going crazy), change in behaviors following attacks

With or without agoraphobia

Anxiety Disorders- DSM IV-TR

Specific Phobias: Marked, persistent fearsSituationally bound panic attacksRealizes that they are excessive and

unreasonableStimuli produce marked anxiety/distressAvoidance

Anxiety Disorders- DSM IV-TRSocial Phobia: Marked and persistent fear of one or more social or

performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears he or she will act in a way where the anxiety will be humiliating or embarrassing.

Exposure to the feared social situation almost invariably provokes anxiety which may take the form of a situationally bound or situationally predisposed panic attack

The person realizes that the fear is excessive or unreasonable

The fear interferes with daily functioning

Anxiety Disorders- DSM IV-TRObsessive Compulsive Disorder (OCD): Either obsessions or compulsions”:

Obsessions: Recurrent and persistent thoughts, impulses or images that are

experienced at some time during the disturbance as intrusive and inappropriate and that cause some marked anxiety or distress

The thoughts, impulses, or images, are not simply excessive worries about real life problems

The person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize theme with some other thought or action

The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as thought insertion)

Anxiety Disorders- DSM IV-TRCompulsions:repetitive behaviors that the person feels driven to

perform in response to an obsession that must be applied rigidly

2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are deigned to neutralize or prevent or are clearly excessive

Interfere with daily functioning

Anxiety Disorders- DSM IV-TRPTSD:

Exposed to a traumatic event in which both of the following were present: The person witnessed, experienced, or was confronted with an event or events

that involved actual or perceived death, threat or serious injury or a threat to the physical integrity of others

The person’s response involved intense fear, helplessness or horror (NOTE: in children may=agitation)

The event is re-experienced persistently in one of the following ways: Recurrent and intrusive distressing recollections of the event including images or

perceptions Recurrent distressing dreams of the event Acting or feeling as if the traumatic event were occurring Intense psychological distress at exposure to internal or external cues that

symbolize or represent an aspect of the traumatic event Physiological reactivity on exposure to internal or external cues that symbolize

or resemble an aspect of the traumatic event

Anxiety Disorders- DSM IV-TRPersistent avoidance of stimuli associated with the trauma and a numbing or general responsiveness (not present before the trauma), as indicated by 3 or more of the following: Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid activities, places or people that arouse recollections of the trauma Inability to recall an important aspect of the trauma Markedly diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect Sense of a foreshortened future

Persistent feelings of increased arousal (not present before the trauma), as indicated by 2 or more: Difficulty falling sleep or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response Causes distress and impairment in daily functioning

Anxiety Disorders- DSM IV-TRAcute Stress Disorder:Differences with PTSD: minimum, of 2

days-4 weeksWithin 4 weeks of the traumatic event

Anxiety Disorders- DSM IV-TRGeneralized Anxiety Disorder: Excessive anxiety and worry about a number of events or

activities for at least 6 months Difficulty controlling the worry 3 or more (1 for children): Restlessness or being keyed up and on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance Causes impairment in daily functioning

Generalized Anxiety

5-6% of Americans at some point in their lives First in young adulthood throughout 50s

Areas To Assess (Shear, Belnap, Mazumdar, Houck,& Rollman, 2006):

1) Frequency of Worries◦ How often do you worry about things? Do you worry every day? On average how much of your time per day is

occupied with worries?

2) Distress Due To Worrying◦ How much distress does worrying cause you? How upset or uncomfortable do you feel when worrying?

3) Frequency of Associated Symptoms (restlessness, feeling keyed up or on edge, irritability, muscle tension, difficulty concentrating, mind going blank, fatigue, sleep disturbance)◦ How often do you have these symptoms? Every day? How much of the day?

4) Severity and distress due to associated symptoms◦ During the past week, when you had these symptoms, how intense were they? How much distress did they

cause you? How upset or uncomfortable were you when you had them?

Generalized Anxiety

5. Impairment/Interference in work functioning◦ How much do the symptoms we have been discussing

interfere with your ability to work and/or carry out responsibilities at home- our ability to get things done as quickly and effectively? Are there things you are not doing because of your anxiety? Does anxiety ever cause you to take short cuts or request assistance to get things done?

6. Impairment/interference in social functioning◦ How much do the symptoms we have been discussing

interfere with your social life? Are you spending less time with friends and relatives than you use to? Do you turn down requests of opportunities to socialize? Are there certain restrictions in your social life about where or how long you will socialize?

Generalized Anxiety DisorderThe “Looming Cognitive Style” (Riskind & Williams,

2005) Mental scenarios and appraisals of events

1) Anxiety and depression2)Worry

3)Attempts at Though Suppression

Threat Appraisals:1. Likelihood Estimations

2. Lack of Control3. Imminence

Generalized Anxiety DisorderAnxiety and Depression

Attending to the “negative” or unpleasantStimuli viewed as negative, dangerous,

impendingSelf viewed as helpless or hopeless Sense of stimuli gaining velocity and

gathering momentum (unfolding, changing, advancing)

Self protective

Generalized Anxiety DisorderWorry

A chain of thoughts and anticipatory processes A repetitive habitual means of verbal thoughts regarding

potential or possible threatening events Paradoxical: actually lessens autonomic system arousal,

reduces the somatic component Helps avoid aversive imagery

Believed (by the client) to be a coping mechanism Beliefs regarding thoroughly considering all the possible

outcomes and being able to mentally manipulate circumstances

Fears are all-encompassing network and even include “neutral” stimuli

GAD versus OCD (Fergus, Wu, 2010)

Intolerance of Uncertainty (can’t deal w/ambiguity) GAD-worry, OCD- compulsionsPerfectionism OCD-a way to decrease anxiety about the uncertainty of

the futureNegative Problem Orientation GAD-Higher negative problem orientation (attentional

bias)Responsibility and Threat Estimation Related to anxiety in generalImportance of and Control of Thoughts Central to OCD

Obsessive-Compulsive Disorder

Obsessions & Compulsions Obsessions- Upsetting thoughts, images, or urges that intrude, unbidden into the

person’s stream of consciousness Compulsions- behaviors or mental acts that the person feels compelled to perform,

usually with a desire to resist; are connected to what they are intended to prevent (e.g. checking, washing, hoarding, ordering or memory compulsions, cognitive restructuring, neutralizing rituals, themed rituals- religious, sexual, aggressive)

Dysfunctional Beliefs(Taylor, Coles, Abramowitz, Wu, Olatunji, Timpano, McKay, Kim, Cramin, & Tolin, 2010):

1) Inflated personal responsibility- belief that the client has the power to cause, and the duty to prevent, negative outcomes

2) Over-estimation of threat (negative events are likely to occur and their occurrence would be terrible)

3) Over-importance of thoughts (belief that control over one’s thoughts is entirely possible)

4)Perfectionism- belief that mistakes and imperfection are unacceptable 5) intolerance of uncertainty- belief that it is necessary and plausible to be

completely certain that negative outcomes will not occur

Obsessive-Compulsive Disorder

Three Aspects of Perfectionism(Ashby, Rice, & Martin, 2006):

Self-oriented- high standards for selfSocially Prescribed Perfectionism- belief

that others set high standards for youOther-oriented Perfectionism- setting high

standards for others

Post-Traumatic Stress Disorder

Witnessing an event perceived as traumatic Traumatic to self or other Event causing distress Could be either: a) Restrictions experiencing

emotion/emotional responsivity (emotional numbing) OR b) intense arousal

Belief that risk of bodily injury or death Horror Re-experiencing (nightmares, intrusive memories, flashbacks) Hyperarousal (disturbed sleep, irritability, being easily

startled) Hypoarousal (avoidance) The past invading the present, short term stuck in long term

memory: moved to limbic system of the brain

PTSD (Cont.)

More numbing predicts worse outcomes.More emotional “outbursts” predict better

prognosis.

PTSD (cont.)Proposed domains to address

Biology (developmental problems, increased medical problems) Cognitive- difficulties in attention, information processing,

learning Dissociation- depersonalization, derealization, impaired

memory Affect regulation- poor emotional self-regulation, difficulty

labeling emotions Attachment- social isolation, difficulty with perspective taking Behavioral control- poor impulse control, aggression,

oppositional behavior Self-concept- low self-esteem shame and guilt, lack of sense of

self

Social PhobiaMarked and persistent fear of social

situationsConcerns about possible scrutiny by othersPresumptions of judgment and rejectionAnticipating incompetence on part of selfAvoidance behaviorsIgnoring social cues which may be helpfulCognitive Biases (e.g “I will mess up.”,

“They will see how bad I am at this.”)

Panic Disorder Negative interpretations limited to self- different

explanations regarding such symptoms in others Interpretation bias Cognitive errors: double messages- self and others- note

inconsistencies A number of people with panic disorder were found to have

strongly influencing and significant life events which predisposed them to panic (loss separation, bereavement, health related concerns starting in childhood or young adulthood, major separation from significant caregivers

Associated and correlated with neuroticism- low perception of pleasantness, perceived control, goal achievement and higher sense of moral violation

Cognitive Behavioral Cycle Using proven REBT- Rational Emotive Behavior Therapy (Albert

Ellis) but incorporating client belief systems and spiritual worldview

Compared to baseline

A- Activating event

B- Belief about A

C- Consequenc

e

Dealing With the Feelings

Situation

Thought

Feelings,Emotions

Cognitive Behavioral Principles

Early life experiencesMaintained throughout timeMaintained by behaviors that may not be

usefulMaintained by looking for thoughts and

behaviors that keep the cycle going

Cognitive Behavioral Principles

Continuing to elicit negative thoughts and record more helpful ways of thinking about situations, self and others to influence emotion positively.

Reviewing thoughts, particularly expectations for self and ‘shoulds’ rather than ‘wants’.

Identifying rules for living and examining their helpfulness. Identifying unhelpful thinking styles that lower mood.

Encouraging the client to analyze thoughts and then step back from them.

Reviewing alternative explanations for negative automatic thoughts.

Conducting behavioral experiments to help increase believability of alternative thoughts.

Listing goals with an emphasis on own needs and expectations.

Thinking Error Types1) Awfulizing/Catastrophizing- Predicting only negative outcomes for the future: “ ____ is awful, terrible, catastrophic or as bad as it could possibly be”, “If ___ happens my life is over.”2) Disqualifying/Discounting- Overlooking the positive and only seeing the negative, believing that good things don’t count: “I am sure even when my family complimented me they had to because they are my relatives. They had to be nice.”3) All or nothing- Viewing the situation on one end of extremes: “If my boss corrects me I must be the worst employee”, “If my child does something wrong I failed as a parent”, “If I didn’t pass one exam I am an unsuccessful student.”4 Low Frustration Tolerance- Belief that things should not be inconvenient: “I can’t stand _____” ; “_____ is too much and is intolerable or unbearable.”

Thinking Error Types5) Self Downing- Self deprecating thoughts: “I am no good, worthless, useless, and utter failure, beyond hope or help, devoid of value.”6) Other downing- Derogatory beliefs about others: “You are no good, worthless, useless, an utter failure, beyond hope, of no value7) Emotional reasoning- Letting emotions totally overrule facts to the contrary: “I feel as if everyone is talking about me.”8) Labeling- Giving a label or stereotype without testing beliefs out:” All of them are like that.”9) Mind reading- Trying to predict things based on limited aspects of a situation: “ I know they will think I’m poor because I can’t afford the latest clothes.”

Thinking Error Types10) Overgeneralization- Making broad

conclusions about an event based on limited information: “My husband doesn’t love me because he is always busy when I am around.”

11) Personalization- Assuming that others behaviors are all about you: “My wife is quiet. Something must be on her mind.”

12) Shoulds/musts- Having an absolute concrete standard about how things ought to be: “ Successful people in life only get As in school.”

Cognitions Related To AnxietyCognitions Supporting Worry:

(Dugas & Koerner, 2005)“Worrying is helpful.”“Worrying, thinking about possible outcomes can

help me deter or change events.”“Worry can prevent negative outcomes.“Worry is a sign of a caring concerned person.”“Worrying is a positive personality trait.”“Worrying aids in problem solving and helps me

plan.”“Worrying motivates me.”

Cognitions Related To Anxiety“I am losing control.”“I cannot handle this anymore.”“My life is falling apart.”“Everyone knows how socially inept I am.”“I can’t deal with this stress anymore. It is

absolutely overwhelming and immobilizing.”

“I know I will absolutely fail.”“This is bound to happen again.”

Cognitions Related To Anxiety“Something bad is going to happen to

me.”“I must be having a heart attack or other

serious heath issue if I am having these symptoms. Next thing I know I’ll die.”

Anxiety Versus Depression- Self Statements(Safren, Heimberg, Lerner, Henin, Warman, Kendall,

2000)Inability to cope I can’t take it anymore. I can’t stand it. I wish I could escape. I don’t want to feel this way. I cant cope. I can’t get through this Something has to change.Uncertainty About the Future How will I handle myself? Can I overcome the uncertainties? What will happen to me? Will I make it? Cam I make it? Am I going to make it? What am I going to do with my life? I want to fight back but I’m afraid to do so.

Anxiety Versus Depression- Self Statements(Safren, Heimberg, Lerner, Henin, Warman, Kendall,

2000) I don’t feel good. I don’t feel very happy. I am not safe warm, comfortable. I am not sure that I can accomplish this. I don’t feel so good about myself/my life. I hate myself. I feel like a loser. I’m worthless/a failure. Something is wrong with me. No one understands me. I don’t think I can go on. I wish I could die. I’m against the world. I can’t get started. I’ll never make it. I’m no good.

Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)

Relationships, Entitlements, Achievements

If people criticize me, I am not a worthwhile person. Other people’s approval is very important to me. I can make everyone like me if I just try hard enough. The most important thing in the world to me is to be accepted by other people. I find it impossible to go against other people’s

wishes. Unless I get constant praise I feel that I am not

worthwhile.


LOVE

Life is unbearable unless I am loved by my family. If I am not loved it is because I am unlovable. If I love somebody who doesn’t love me, I must be inadequate. I need to be constantly told I’m loved to feel secure. If I were a better person then somebody would love

me. In order to be happy, I need someone to really love

me.


InfluenceI can prevent people being upset by thinking about

what they might need.If I have a fight with my friends, it must be my fault. I should be able to please everybody.I am responsible for other people’s happiness. If people are uncomfortable around me it is my

fault. If the people around me are upset, I usually worry

thatI have upset them.


SuccessI can’t feel equal to others unless I’m really

good at something.I only feel valued if I achieve my goals. My success in life defines my goals. I need to be successful in all areas that are

important to me.Life is pointless if I don’t have goals to chase. Without success in life, it is impossible to be

happy.


Perfection I see no point in doing anything unless it can be

done perfectly. There are no second prizes in life. Things must be done to certain standards, otherwise there is no point in doing them. If I make mistakes then others will think less of me. If I don’t do something perfectly then I don’t like

myself very much. I never seem to be able to reach my own high

standards.


ExternalI can only be happy if I have the good things in life. Unless I have expensive possessions,people won’t approve of me.If I were rewarded for the goals I achieve, know I

could be happy.If my friends are unhappy, then I cannot be happy.

Everything has to be going well in order for me to be happy.

My happiness depends on others.


Rights

If obstacles are placed in my path, it is natural that I would get angry.

Things should always go right for me. If I do the right things people should acknowledge it. If I feel that I deserve something, I should get it. If I go out of my way to help others, they should do

the same for me when I need it. I shouldn’t have to work so hard to get the things I

want.

Behaviors Related To AnxietyAttending to the disturbing stimulus to the

neglect of additional environmental information

Intolerance of uncertainty- the tendency to react negatively on an emotional, cognitive, and behavioral level to uncertain situations

and eventsMaladaptive schemas related to earlier life:

disconnection and rejection, impaired performance, impaired limits, etc.

Overcoming Depression and Anxiety

“You can look at what happened to you; it was truly horrible, but it is not unthinkable or unfaceable. You do not have to run from it day and night, and you do not need to totally curtail your life for fear of a recurrence. You can live in a world where this once happened and where there is a remote chance that it could happen again. Moreover, you MUST look at it. You must face it down, because what is happening now is what happens when you don’t.”(Bergner, 2009)

Essential ElementsCognitive Restructuring

(Hope, Burns, Hayes, Herbert, Warner, 2010) Identify and change dysfunctional cognitive beliefs/automatic thoughts Replace anxiety producing thoughts with more socially adaptable ones Through Socratic questioning Challenge the voracity of assumptions regarding social situations Living in new attitudes about self and others by applying new rational

rebuttals to the irrational beliefs and behaviors Targets 3 areas: 1. experiencing anxiety, 2. negative self evaluation, 3.

fear of negative evaluation Use a hierarchy of thoughts- surface to core (keep asking “what would

that mean?” until 4-6th= core)Exposure

Reducing disabling behaviors Finding exceptions Systematically facing feared situations in context they feared Redirecting attention

Essential Elements

Social Reappraisal Therapy(Hoffman & Scepkowski, 2006)

Factors which influence formation=social apprehension, high social standards and goals, increased self attention

(50-60%), high estimated social cost, perceived poor social skills, low perceived control, post event rumination

Create at least one social mishap per weekSwitch focus on environment rather than inwardly- see

the genuine observer’s perspective rather than the client’s own perspective

Realistically appraise the social costReframe to increase sense of emotional control

Essential Elements

Cognitive-Behavioral Treatment: Key Aspects(Lamplugh, Bele Milicevic, & Starcevic, 2008)

Understanding anxiety and the flight or fight response Understanding the role of hypervigilence Promoting a sense of ‘riding out the wave’ of anxiety in an

accepting manner instead of trying to control symptoms Realistic appraisal of body sensations Acknowledgment of physical feelings rather than distraction away

from those feelings Rating the intensity of physical feelings rather than anticipating

the worst Abandoning anxiety Acknowledgement that catastrophic misinterpretations of

physical feelings are problematic, not the physical feelings themselves

Cessation of maladaptive behaviors that maintain the problem

Essential ElementsCollaboration, cooperation between therapist

and clientClinician skills in CBTAbility to psychoeducational foundation

regarding thoughts, feelings, and behaviorsAbility of client to have insight and awarenessDesire of client to modify thoughts and behaviorsHomework and exercises for applications for

client outside of session4-6, 6-8 sessions

Essential ElementsForsyth, D.M., Poppe, K., Nash, V., Alarcon, R.D., &

Kung, S(October 2010)

Gains in positivity are more closely related to emotional healing from depression and anxiety than loss of negativity.

Who Might Benefit?AnxietyDepressionAssertiveness BuildingDiet and Health IssuesSocial IsolationMedical concernsGriefAlcohol DependencePTSDDivorceLife stressors

Video Clips: Cognitions and Behaviors

Identify the thought patterns and toxic behavior choices in the video clips.

Problem Orientationpositive problem orientation a protective

factor that facilitates the initiation of proactive problem-solution skills to manage or minimize early signs or symptoms of psychological distress

negative problem orientation- a serious threat to their well-being, respond with strong negative emotions (e.g., anxiety and/or depression), and avoid or postpone dealing with a problem

Depression and Anxiety

Transdiagnostic Approach(Clark, 2009; McManus, Shafran, & Cooper, 2010)

Moving away from diagnosis specific treatments

Symptoms overlap between similar disorders

“A therapy that is made available to individuals with a wide rage of diagnoses, and does not rely on knowledge of thee diagnoses to operate effectively.”

Assumptions: General cognitive-behavioral processes which are shared

Absence of diagnostic assessment Adoption of a convergent or integrative scientific approach

Commonalities:1) Altering incorrect or faulty appraisals based on emotions about self or other

2) Prevention of avoidance3) Psychoeducation

4)Behavior modification

Challenging Thought PatternsShoulds“Why?”“if only ____, then _____”Have tos_____ “enough”Absolutes: always/neverRight/wrongGood/bad _____

Challenging Thought PatternsCognitive distortions- the different

types of distorted cognitive processes that produce automatic negative thoughts, which in turn, evoke or strengthen early symptoms of psychological distress and emotional and/or behavioral disorders

Cognitive ReframingInstead of “if he/she would…….”

Use:“If I could just get a grip on _____ then

we’d finally be happy.”Watch where you put your BUTs:__________ BUT __________.

Who Does Cognitive-Behavioral Therapy Work For?

Strong Motivation To ChangeTime Commitment

Cognitive Functioning/Educational LevelObservant PeopleInsightful People

Those who will do work outside of session

Conceptualizing The ProblemAntecedents

What happened before?Something triggered thisNot Out of The Blue(e.g. Boy throwing cars around the room-

Is it a behavior issue really?)

Conceptualizing The Problem

Antecdents

Affective

Somatic

Behavioral

Cognitive

Contextual

Relational

Conceptualizing The ProblemAntecedents:What happened right before that? (Affective)What happens to you physically before this happens? Do

you feel sick? (Somatic)How do you normally act right before this happens?

(Behavioral)What thoughts go through your head before this

happens? (Cognitive)Where and when does this usually happen? (Contextual)Do you do this with everyone or just when you are

around certain people? (Relational)

Conceptualizing The ProblemBehaviorsWhat the client does in response

Examples:I avoiding going out of the house.I stomped off my job.I yelled at the kids.I cried and staying in my room.

Exercise: Responses to The Antecedent

Antecedent Behavior Reaction Feeling ReactionI was playing with my child but had to leave to get the laundry.I expected to get the job but found out it was offered to someone else.I had a flashback of a trauma from my childhood.I discovered my boyfriend was cheating.

Exercise: Responses to The Antecedent

Antecedent Behavioral Response

Feelings Response

The doctor told me I have cancer.I got a pay cut.My child failed school.I do not look the way I want.

What Could the Antecedent Be?Antecedent Behavioral

ResponseFeelings Response

My son threw his crayons across the room

My son cried and kicked.

I covered my eyes and shook.I stayed in bed all day.

I felt disappointed in myself, unhappy with my life.

What Could The Antecedent Be?

Antecedent Behavioral Response

Feelings Response

I slammed the phone down.The teenager put the music on as loud as possible.My spouse drove away.I left the busy concert.

What Could The Antecedent Be?

Antecedent Behavioral response

Feelings response

I felt like throwing up as my heart raced and I experienced panic.

I resolved not to try anything again because “nothing ever works for me.”I tried again – “next time could be better.”

Challenging Attributions

1) Am I ascribing something like “This situation happened because ______?”

2)Am I making a judgment about another person’s personality because of this event? What am I telling myself about what this means? (Because this happened, it means---)

3) Am I using adjectives to describe the other person’s personality, intentions rather than simply describing the behavior? (e.g. “You are always so lazy. You never care about our house.” versus “I am concerned about the amount of cleaning we still have to do. I realize we have busy tiring jobs but I am wondering how we plan to get the dishes done and get our things set up for tomorrow plus help the kids to finish their homework. How do we plan to get to divide these things up- any ideas?”)

Challenging Attributions4) Is the way I’m thinking about this

definitely 100% a fact?5) Is there any other way of looking at the

situation? Come up with at least three exceptions.

6) Have I assumed that because something is (perceive by me to be) such and such way that I am powerless over it?

Attributions Exercises1) My spouse came home late two days this week.

His clothes were a little disheveled looking- he must be having an affair.

2) My wife was supposed to meet me for the romantic dinner. She was ½ hour late and did not call me. When I saw her I had to yell at her because I knew she did not make our dinner a priority.

3) My coworker left a pile of unfinished work on her desk. It must be that she is lazy and panned to have me do all her dirty work.

Attributions Exercise4) The group of popular people looked at me

and smiled. I knew they were talking behind my back badly about me.

5) When I walked by they got quiet. I am sure they noticed my hand me down clothes compared to their name brand outfits.

6) Every time my mother comes over she helps me clean the house. I knew she always thought I was a slob and couldn’t do anything right.

Setting Behavioral GoalsConcreteSpecificManageableAchievableWith accountability for follow through

Goal Setting Process

Broad Goal

Small Steps

Application

Setting Goals ExercisesBroad Goal Specific Step Outcome DesiredFeel less depressed Get out of bed and

get set for the dayBe bathed, dressed and get out of the house for at least one hour per day

Stop fearing everyone’s reaction of me

Go to a public place three times per week for at eats ½ hour and find out that the worst doesn’t happen.

Learn to talk to strangers without automatic belief and avoidance because I assume that everyone’s out to get me.

Setting Behavioral GoalsBroad Goal Specific Goal Desired OutcomeFeel more self confidentHave a better self concept, believe I have self worthTry new things without fear of rejection

Tips For Goal SettingTell what you want to happen rather than

what you don’t want to happen.State observations- what would you/others

see?What would be the benefits of such an

action?Use 1-100 scaling to identify priorities.Behavioral outcomes should be inconsistent

with the depression and anxiety symptoms

Tips For Goal SettingReintroduce prior successesReintroduce pleasant activitiesChoose active helping (e.g. taking some

proactive behavior action to relieve a stressor)

Don’t avoid.

RelaxationTension ReductionPerceived control lover stressProgressive muscle relation- one by one

relaxing and tensing various muscle groups

ImageryImagining yourself as successful in

identifying what that would take.Involve as many senses as possible.Strengths based- what would you like to

see happen? When has this happened? How would you act if the new improved situation, feeling, behavior was going on?

Set aside time to ponder this.Schedule a thinking time.

Typical Session Outline

5• Briefly review patient’s mood and/or physical

functioning.

5• Bridge discussion from previous session with the

current session.

5• Set the agenda for the current session and prioritize

the items.

5-10• Review and homework given in the previous

session.

20-25• Discuss agenda items and set up homework.

5• Summarize the current session and exchange

feedback.

Questions For Ongoing CBTWhat points did we come to since last

session?Anything you learned as you thought over

things?‘Anything you were uncomfortable with?Things better or worse?Treatment agenda- where are we? What

to focus on today? What to amend?Completed or not completed homework?

Setting HomeworkDone collaborativelyDon’t assume follow up- ask. (e/g. couple I

counseled re. communication interchanges)Affirm the value of outside practices.Highlight attempts and successes- build onStart by modeling and practicing in session.Inquire re. homework.Anticipate problems.

Other Ways of Presenting Homework

BibliotherapyProgressTasksExperimentsObservationsExercisesNot about doing things “right”

When Thoughts are Hard to Determine

Observe behaviorsObserve body languageObserve positioning, tone, facial

expressions, hand gestures.Observe what emphasized more or less.

Mindfulness Approaches Use decentering to switch from a judgmental problem focus which

promotes negativity to a present here and now nonjudmental stance Examples:

◦ What did you notice in your thinking, emotions, or sensations?◦ Did you notice the sense of tightening or tension in any particular place in your

body?◦ So, these difficult thoughts and emotions were present in your awareness.?

Key Components: Begin in the initial assessment session. The participant is provided an

opportunity to describe his or her experience of depression. Together, the therapist and participant explore ways in which MBCT may effectively reduce relapse risk.

The therapist enhances a sense of mutuality and connection with participants.

The process of inquiry should be a genuine exchange during which the therapist uses questions to help the participant deepen awareness of his or her practice, while also embodying the present-focused, open, and warm attitudes of mindfulness.

MindfulnessChoosing to control our focus of attentionExample: Washing dishes: instead of

thinking of the stresses of the day and how much more to do- “Listen to the bubbles. They are fun!”

Juts osberve1Accepting things as they are rather than

trying to always change them.Stop thinking too much. Just let it be.

Cognitive Behavioral Overview Increase insight and awareness then elicit more health positive

outcomes

Note negative thoughts and record more helpful ways of thinking about situations, self and others to influence emotion positively.

Review thoughts, particularly expectations for self and ‘shoulds’ rather than ‘wants’. Identifying rules for living and examining their helpfulness.

Self monitor. Identify unhelpful thinking styles that lower mood. Encouraging the client to analyze her thoughts and then step back from them.

Consider alternative explanations to negative automatic thoughts or behaviors.

Cognitive Behavioral OverviewConducting behavioral experiments to help

increase believability of alternative thoughts.

Analyze self-criticisms with focus on undoing negative automatic thoughts and behaviors.

List goals with an emphasis on own needs and expectations.

Patient Self Guided CBTRidgway, N., & Williams, C. (December 2011)

General principles taught Resources tailored to client. Audios, videos, workbooks Bibliotherapy May be computerized Emphasis on homework As effective with mild to moderate depression and anxiety

as face to face therapist guided CBT

Patient Self Guided CBTRidgway, N., & Williams, C. (December 2011).

Strengths Many people like to read As effective as in person CBT Can teach key information and skills Uses a clear structure Paper-based tasks and records Ability to personalize what is read Low cost and can be copied Can incorporate many modalities, e.g. reading, listening,

video, etc. Interactive learning Automated alerts can be used if deterioration or risk is

recorded Online forums can provide added support

Patient Self Guided CBTRidgway, N., & Williams, C. (December 2011)

Weaknesses Text used can be difficult to understand if foundations not properly

laid Licensing may make copying expensive Need online access or to travel to a fixed unit Needs flash and adobe reader plus adequate bandwidth and access

to soundcard/speakers Making sure the client has proper equipment – E.g. Newer delivery

mechanisms use MP3 or certain video formats Audios or videos are fun to many people Documentary style may make people feel as if they are not alone May watch but not learn or apply Needs ways of helping people implement what they are learning

Evaluation QuestionsSituational Questions

Feelings Questions Thought mQuestions

• What happened? What were you doing?

• Who was there?• Who were you

speaking to?• When was this?• What time of day

was it?• Where were you?

• How were you feeling before this happened?

• How did you feel while this was happening?

• What mood were you in after this happened?

• Rate your mood: 1-100.

• What was going through your mind before you started to feel this way?

• What thoughts bothered you?

• What are you afraid might happen?

• What if what you think is true?

• Are there other ways of thinking about things?

Thought LogEvent Thought Consequence Alternate Response

Anxiety Ladder

Rate 0-100, Systematically challenge one by one, pair with relaxation

Cognitive Debating StrategiesIs this a fact/strong opinion?What evidence is there for this? Any evidence

against this?Alternative explanations that are more

reasonable/possible?Is there another way of feeling or thinking?

What would someone else make of this situation?What advice would I give someone else?Is this a type of unhelpful thinking habits?Is this an automatic thought?

Cognitive Debating Strategies What am I actually reacting to? Am I getting anything out of proportion? What harm ahs actually been done? Am I overestimating the bad? The danger? Am I underestimating my ability to cope? Am I going to a negative automatic place? How is pressuring myself or others helping me get

through this? Juts because I feel bad is it really bad? Are things really totally black or white- as clear cut as I

am making them? Can there be more than one solution to this problem?

Cognitive Debating StrategiesIs believing this life giving or death producing?How important is this really?How will things be in 1 week? 1 month? 6

months? 1 year? If I continue thinking or behaving this way?

What would happen if I tried to see this situation as an outside observer? How would things look? Would things have a different meaning?

What is the bigger picture?

The Helicopter ViewWhat can I see in this situation as I look

higher and higher?

Helping KidsWhat is making you scared? Sad?What are you expecting will happen?Are you in a thinking trap?Are you 100% sure this will happen?Could there be any other ending to the

story?

STOP S Signs of anxiety or

depressionT Thoughts of anxiety or

depressionO Other better ways of

thinking or feeling?P Praise for new plan for

next time

Hindsight BiasA type of memory distortion“ I knew it all along” phenomenon”Needs to be confronted just like other

distortionsThinking that we knew more or could

predict more than we could

Old Versus New Systems

I am… People are… The world is…

I am… People are… The world is…

Old Rules that Protect Me:

New Rules that Protect Me…

Positive Self TalkI can be anxious/angry/sad and still deal with

this.I have done this before so I can d it again.I don’t have to feel happy all the time to get

through what I need to do in life.These are just feelings. They won’t last forever.I don’t need to rush. I can take things one by

one.I have gotten through things before. I will get

through them again.

Generalizing Skills Outside Sessions

Ongoing homeworkPlanning for reassessing thoughts and

behaviors oftenPlanning for alternatives to depression

and anxiety: if/when ___ happens I will do ___.

Booster sessions

Modified ABC Model

Activating EventBeliefsConsequencesDisputations of BeliefsEffective New Beliefs

Summary: Depression & AnxietyPhysical Thought Behs. Feelings

Anxious Tense, shaky, worried, energized, HR increase, can’t concentrate

I’m in danger, Have to get out, I can’t cope

Avoid, Fidget, Escape, Ruminate

Nervous, edgy, apprehensive, panicked, terrified

Depressed Tired, lethargic, withdrawn, eating or sleeping changes, loss of interest in hobbies, restlessness, poor ADLs

I’m worthless, Life’s awful, Bad things happen to me, It’s hopeless

Do less, talk less or quieter voice, Eat or sleep less or more, isolate

Ad, gloomy, unhappy, despairing, hopeless

Summary: Depression & AnxietyNew Thoughts New Behaviors

Depression Even if I feel sad I will get through, If I do something I will feel better, This is just my habitual gloomy way of thinking.

Do things anyway, Get out, talk to someone, Get dressed, Do an activity I used to enjoy, Relax, Focus attention elsewhere

Anxiety Is this really a threat? I could be overestimating the threat, I have gotten through before even when I was worried or panicked.

Problem solve, Don’t avoid or you’ll never find out that the worst doesn’t happen.

Changing DistortionsType of thinking Neg. impact ReplacementAll or nothing Discouragement, no

middle groundContinuum thinking

Overgeneralization Makes all problems last forever

Focus on the here and now

Negativity Make the positive impossible

Appreciate the positives

Discounting positive Eliminates real joy in the present

Purposely find and enjoy the positives

Changing DistortionsJumping to Conclusions

Anger, anxiety, depression

Consider all possibilities

Predictions Dread, disaster, panic Stay in presentMind Reading Anxiety, sadness,

anger, assumptionsClear communication

Magnification Treating people unfairly

See strengths in self and others

Emotional reasoning Upsetting judgments made without evidence

Listen to your head and heart

Changing Distortions

Shoulds Discouragement at self, Anger at others

Bring expectations in line with reality

Labeling Discouragement at self, Anger at others

Stick to specific circumstances

Blame Discouragement at self, Anger at others

Stick to specific circumstances

Videos: Doing Treatment

Watch the videos and see how the irrational cognitions and unhealthy

behavior choices are addressed.

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cognitive-behavioral counseling : foundations and applications

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