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INTRODUCTION TO CBT WESTMINSTER ROUGH SLEEPING SERVICES
JANUARY 2016
BRETT GRELLIER
AGENDA & WELCOME
• What is CBT
• Historical development
• Behavioural and Cognitive theory
• CBT for Panic
• Behavioural model and interventions
• CBT for Depression
• Cognitive model and interventions
COGNITIVE BEHAVIOURAL THERAPY (CBT)
• Cognitive – thoughts, perception, memory systems
• Behaviour – what we do & what we avoid doing
• Therapy – making helpful cognitive and behavioural
changes to improve well-being and reduce distress
• CBT is a formulation driven, collaborative and goal
directed approach
• Focus on identifying and changing maintenance factors
• Many tools and techniques used
DEVELOPMENT OF CBT
• 1st wave – Behaviourism: classical (Watson) & operant conditioning (Skinner), observational learning (Bandura)
• 2nd wave – Cognitive: Rational Emotive Behaviour Therapy (Ellis), Cognitive Behavioural Therapy (Beck)
• 3rd wave – Mindfulness Based Approaches: Mindfulness Based Cognitive Therapy (Segal, Williams & Teasdale), Compassion Focused Therapy (Gilbert), Acceptance and Commitment Therapy (Hayes)
BEHAVIOURISM
• Behaviourism is a theory of animal and human
learning that only focuses on objectively
observable behaviours and discounts mental
activities.
• Developed by John B. Watson (1913) who was
influenced by Ivan Pavlov.
• Developed further by B.F Skinner and Albert
Bandura
• A reaction to the prevailing Psychoanalytic
Theory at the time
CLASSICAL CONDITIONING
• A neutral stimulus can produce a
conditioned response through this
learning process initially demonstrated
by Pavlov’s dog experiments.
• John B. Watson demonstrated that this
also applied in humans in the Little
Albert experiment.
• This is commonly reported by drug
users, e.g. items associated with drugs,
such as injecting equipment or foil, can
trigger a desire to use.
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OPERANT CONDITIONING
• B.F Skinner, in his rat experiments, demonstrated that behaviour is affected by external forces that impinge on it
• Positive reinforcement is when there is an increase in behaviour by receiving anything that is pleasant
• Negative reinforcement is when there is an increase in behaviour by avoiding something unpleasant
• Punishment is when there is a decrease in behaviour by anything that is unpleasant
SOCIAL LEARNING THEORY
• Albert Bandura showed that behaviour does
not have to be classically or operantly
conditioned but can be learned through
modelling and observation
• Change in behaviour can be facilitated
through:
• The observation of role models (e.g. peers,
parents)
• Hearing descriptions and explanations of a
behaviour.
• Observing real or fictional characters displaying
behaviours in books, films, television programs,
or online media.
• Person’s sense of self-efficacy and personal
control are seen as important determinants of
behaviour change
ANGER FOR EXAMPLE
• Raised voice of other stimulates
anger response (classical
conditioning)
• Aggression keeps away danger
(negative reinforcement)
• Aggressive behaviours learnt
through observation of parents
(social learning theory)
HOW DOES THIS APPLY?
• In small groups think of a recent
workplace incident.
• Can you highlight any of learning
theories at play?
• How could you use learning
theories to achieve a more
desirable outcome?
COGNITIVE THEORY
• Both Albert Ellis and Aaron Beck proposed that behaviourism alone was not enough to explain all aspects of mental distress.
• They proposed that the way information is processed by the brain is key in development and maintenance of mental health difficulties.
• The term cognition encompasses all activities in the mind
• Encoding data (visually and auditory)-allows for entry into our cognitive system
• Can be stored in working memory (limited capacity-needs to be rehearsed/repeated) before we can go on to store in long-term memory
• Our long-term memory s a complex and dynamic system.
BASIC ELEMENTS OF COGNITIVE THEORY
• We rely heavily on our memory to
engage in any form of cognitive
processing (perceiving, problem solving,
making inferences, remembering, language etc.)
• Bottom up processing – taking
information directly from the environment
• Top down processing - using our schemas (mental maps) to interpret new
experiences
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IMAGINAL EXERCISE
Close your eyes and imagine that
you are walking along the street…
5-AREA MODEL (PADESKY & MOONEY, 1990)
Thoughts
Moods
Biology
Behaviours
Environment
Thoughts
Moods
Biology
Behaviours
Thoughts
Moods
Physiology
Behaviours
IDENTIFYING BELIEFS: ABC MODEL
Activating Event Belief Consequences
Friend walks past you on street with out saying hello
“She’s ignoring me because she is angry about something I
have done.”
Behavioural: Go back indoors, cry.
Emotional: Sadness, guilt.
KEY MESSAGE
“It is not the event that gives rise
to the emotional reaction but the
meaning that attribute to the
event”
CBT FOR PANIC
• Trigger in the environment or internal
• Perceived threat
• Fight or flight response activated.
• Cognitive and physical symptoms
• Misinterpretation of those symptoms creates a further trigger completing the
cycle.
• The role of avoidance and safety seeking behaviours
PANIC MODEL (CLARK, 1986)
https://www.youtube.com/watch?v=32K-rEIbBgE
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TIME TO PRACTICE
• In triads practice working through the panic
model.
• Client: Either use a feared situation of your
own or role play a client.
• Worker: Using the blank model guide the
client through each of the stages, eliciting the
triggers, cognitive and physical symptoms,
misinterpretation of symptoms and the
avoidance and safety seeking strategies.
• Observer: What worked well and what worked
less well in the interaction?
1. Validate
2. Normalise
3. Non-judgemental
4. Warm
5. Empathy
6. Compassion
OVERCOMING PANIC
• Triggers – don’t be concerned if you can’t identify the trigger, much of the
brains operation happens without conscious awareness.
• Physical – Slow rhythmic breathing
• Cognitive – Remind yourself that there is not a real threat, e.g. develop a
mantra. “Thanks for the warning brain, but there is no tiger in the room”.
• Drop safety seeking and avoidance – these only reinforce the idea that there
is a real threat to be avoided.
CREATING A HIERARCHY
• Idea is to create a list of feared
situations from least to most feared.
• Exposure to each situation until fear
subsides (habituation).
• The association between sensation
of fear and avoided object/situation
is broken.
HABITUATION
CREATING A HIERARCHY - PRACTICE
• Create a hierarchy of seven stages
to overcome one of following fears:
• Going to hospital appointments
• Going to a day centre.
• Going on a bus.
• Your own example
• Start with pictures.
• With or without someone
accompanying.
• Use your creativity
TRAUMA-FOCUSED CBT
• Formal training in CBT is required in order to
carry out a full treatment for PTSD or complex
trauma, however it is possible to help a person
understand and even reduce some symptoms.
• Psycho-education, e.g. linen cupboard or
factory conveyer belt metaphors.
• Overcoming panic.
• Grounding techniques for managing
flashbacks.
• Using imagination to create a secure or safe
place.
• Understanding PTSD can help normalise and
validate distressing symptoms.
• It can also increase motivation for treatment
• There are plenty of free psycho-education and
self-help materials on the web – CCI,
Psychology Tools and Get Self Help are all
good sources
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BEHAVIOURAL MODEL OF DEPRESSION
Increase activity
Mood improves
Do less Feel
worse
BEHAVIOURAL ACTIVATION
• Schedule activities for both
pleasure and achievement.
• Pick previously enjoyed activity
and/or link to values.
• Rate mood before and after activity.
• Remember behaviour – affect lag,
i.e. it takes a few attempts before
mood begins to improve.
OTHER BEHAVIOURAL TECHNIQUES
• Activity monitoring and
scheduling
• Problem solving
• Assertiveness training
• Sleep hygiene
ASSERTIVENESS TRAINING
• Educate the client about the difference between passive,
assertive and aggressive behaviours
• Evaluate the client’s assertiveness across a range of activities
(e.g. with partner, in a restaurant, at work)
• Create a hierarchy of least to most difficult situations for
assertion and practice these skills in behavioural rehearsal in the
session and as homework tasks outside the session
SLEEP HYGIENE
• Develop regular sleep times • Use your bed only for sleep and sex
• Avoid drinks several hours before sleep to avoid being interrupted by urinary urgency
• Do not try to fall asleep • If you are lying awake for more than fifteen minutes, get up and go to
another room. • Write down your worries on a piece of paper and leave them in the other
room
• Mindfulness
• Try systematic relaxation and breathing techniques • Do not expect immediate results
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COGNITIVE MODEL OF DEPRESSION
• The model describes the negative thinking that is characteristic of depression
• They tend to focus on the cognitive triad - negative beliefs about:
• The self -“I’m defective or inadequate”
• The world - “is full of overwhelming difficulties”
• The future - “things will never change, there is no hope for the future”
COGNITIVE TRIAD OF DEPRESSION
THE ROLE OF AVOIDANCE
• Avoidant coping strategies that were functional in childhood to
deal with unpleasant events, thoughts and feelings are often
continued in adult life and help maintain depression
• Continual avoidance prevents development of problem solving
skills, limits personal development and does not allow client to
collect any evidence that counters negative view of self, world
and others
AVOIDANCE
BEHAVIOURAL AVOIDANCE
• Not leaving the house or lying in
bed all day
• Keeping busy with work related
tasks but not attending to own
needs
• Tidying up and getting drinks
during social interactions
COGNITIVE AVOIDANCE
• Reluctance to discuss problems or irritability with personal questioning
• Active thought suppression of unwanted thoughts or memories (Try not thinking of a pink elephant!)
• Use of substances to block out thoughts and feelings
SOCIALISATION TO THE MODEL
• Use a model like the vicious flower or five area to introduce people to
the CBT model.
• Use analogies or an example of the clients to illustrate the link
between thoughts, feelings and behaviour.
• Important to understand that a thought is not a fact.
• Focus is on here and now and symptom reduction rather than an
extended exploration of the causes of the depression.
VICIOUS FLOWER MODEL (MOOREY, 2010)
Depression mode: negative
view of self, world & future
Automatic negative thinking
Ruminations and self-attacking
Mood/ emotion
Withdrawal and
avoidance
Unhelpful behaviours
Motivation and physical symptoms
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5-AREA MODEL (PADESKY & MOONEY, 1990)
Thoughts
Moods
Biology
Behaviours
Environment
Thoughts
Moods
Biology
Behaviours
Thoughts
Moods
Physiology
Behaviours
PRACTICE – SOCIALISING TO MODEL
• In triads practice using either the
five area or vicious flower model.
• Goals – to understand links
between the different areas and
understand how that maintains the
problem.
• Role play a client you are currently
or recently worked with.
COGNITIVE TECHNIQUES
• Working to modify negative biases in the client’s thinking
• The client is taught to identify negative thoughts, potential thinking traps and to assess their validity
• Reducing the degree of belief in negative thoughts and considering plausible alternatives can directly lift mood
• Socratic questioning
• Thought records
• Behavioural experiments
• Positive data log
THINKING TRAPS
• The Beck model also holds that the negative thinking is the result of typical biases or distortions in the way that a person attends to and processes information from their environments.
• These biases are sometimes called, ‘thinking errors’.
• Common biases include: black and white thinking, personalisation, emotional reasoning and catastrophising (see handout for complete list)
AUTOMATIC THOUGHTS
• Can be words, an image, a memory, a physical sensation, an imagined sound, or
based on ‘intuition’ – a sense of just ‘knowing’
• Believable – we tend to automatically believe our thoughts, usually not stopping to
question their validity.
• Are automatic. They just happen, popping into your head and you often won’t even
notice them.
• Our thoughts are ours – they can be quite specific to us, perhaps because of our
present or past experience, knowledge, values and culture, or just for no good
reason at all.
• Habitual and persistent – our thoughts seem to repeat over and over, and the more
they repeat, the more believable they seem, then they set off a whole chain of new
related thoughts that lead us to feel worse and worse
NEGATIVE AUTOMATIC THOUGHTS (NATS)
• Identify NATs when they occur during interactions with clients.
• Notice changes in affect when the client is talking or thinking.
• Capturing these ‘hot thoughts’ are useful ways of eliciting negative cognitions. “What is going through your mind right now?”
• Ask the client to describe a specific, recent situation when they have felt depressed and ask “What was going through your mind when you were sitting at home…”
• If the client is still unable to access their negative beliefs, you can also ask the client to imagine the specific event and describe it as if it were happening now.
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HOW TO FACILITATE AUTOMATIC THOUGHT CHANGE
• Using the essence of Socratic Questioning, also known as Guided Discovery, the client can be asked a series of questions to assess the validity of the NATs
• The intensity of the negative feeling and degree of belief in the negative thoughts are often rated before and after the questioning process. These ratings help to show any change
• The structure of the questioning can also become an important modelling exercise as the therapist teaches the client how to objectively evaluate his or her own belief system
SOCRATES
• Classical Greek Athenian Philosopher, C.
469 BC – 399 BC.
• Developed the Socratic Method in which a
series of questions are asked not to draw
individual answers but to encourage
fundamental insight into the issue at hand.
• Socratic questioning is the glue that holds
CBT interventions together.
SOCRATIC QUESTIONING INVOLVES ASKING QUESTIONS THAT:
a) The client has the knowledge to answer
b) Draw the client’s attention to information which is relevant to the issue being discussed but which may be outside the client’s current focus
c) Generally move from the concrete to the more abstract so that
d) The client can, in the end, apply the new information to either re-evaluate a previous conclusion or construct a new idea
(Padesky, 1993)
EXAMPLES OF GOOD SOCRATIC QUESTIONS
• Have you ever been in similar circumstances before?
• What did you do?
• How did that turn out?
• What do you know now that you didn’t know then?
• What would you advise a friend who told you something similar?
STAGES OF SOCRATIC QUESTIONING
1. Asking informational
questions
2. Listening
3. Summarising
4. Synthesising or Analytical
Questions
ASKING INFORMATIONAL QUESTIONS • The client will know the answers
• They will bring into awareness relevant and potentially helpful information
• They will strive to make the client’s concerns concrete and understandable to both client and keyworker
• E.g. “I’ve screwed up”: What do you mean by screwed up? What led you think you screwed up? What exactly did you screw up?
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LISTENING
• It is critical that the key worker does not just ask questions. She or her must LISTEN well to the answers
• The key worker must be open to discovering the unexpected even if he she or he anticipates a specific answer
• Listen for idiosyncratic words and emotional experiences
• Listen to your client’s metaphors and recreate in your own mind their images
• Listen for a word that seems oddly placed in a sentence
• Listening for these unexpected parts of your client’s story and reflecting these back instead of the expected parts will often intensify affect and create faster inroads to life themes
SUMMARISING
• Summarise every few minutes
• When a summary is particularly relevant he or she should write it down for later review
• It is a chance for key worker and client to discover if they are understanding things in a similar way
• Provides a chance for the client to look at all of the information as a whole which sometimes has a greater impact than considering each bit of data as a single piece
SYNTHESISING OR ANALYTICAL QUESTIONS
• This helps the client tie the answers together in a meaningful way at
the end
• Provides one last chance to discover something unexpected
• Put simply the question might be, “How does all this information fit
with the idea that you screwed up?”
LIVE DEMONSTRATION
• Listen to the interaction
• Make a note of questions asked
• When were summaries made?
• Did the summarising question help the client to come to a novel conclusion?
THOUGHT RECORD Mood: What were you
feeling? Rate your
mood(s) on a scale of 0-100
Situation: What, where,
when, who with? What
actually happened? What was
the trigger?
Thoughts: What thoughts
or images were going
through your mind?
Thinking Trap? Does this
thought fit in to any of
the thinking traps?
Evidence that supports
the thought
Evidence that doe not fit with
the thought
Alternative and more balanced
thinking.
CHALLENGING UNHELPFUL THINKING Evidence for the thought (belief) Evidence against the thought (belief)
• “What makes you think this is true?” • “What’s the evidence for this belief?”
• “What led you to believe it?”
• “Where did you get this idea from?”
• “Is it possible that this thought contains any of the thinking traps from the list?
• “If this thought was a charge against you,
would it stand up in court?”
• “Is there any evidence that does not fit your belief?”
• “What things have happened to you that
don’t fit with this?” • “Have you always thought like this?”
• “What would a friend say to you about this belief?”
• “If a friend was in this situation what would
you say to them?” • “Is this a thought or a fact?”
• “Is there another way of looking at this?” • “What is a more balanced/helpful way of
thinking?”
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DEVELOPING A RATIONAL ALTERNATIVE THOUGHT
• Having elicited all the evidence FOR and AGAINST the next step is to enable the client to summarise both of these columns
• Does the client still strongly believe the original thought or has their been a change in perspective, a less negative interpretation of the event?
• Next step is to ask the client to use the summaries to construct a new more realistic thought that better fits the evidence
• Finally ask the client to rate their belief in the new thought and re-rate the original thought
DOWNWARD ARROW TECHNIQUE
• Uses a series of questions to
uncover the underlying belief.
• It would be unhelpful to do a
cognitive challenge of, for example,
“I forgot to go to the G.P” because
that might be true.
• An underlying belief of, “I always
mess things up”, would be a more
helpful place to start.
PRACTICE – THOUGHT DIARIES
• In triads role play a client or use an example
of your own.
• Work through the thought diary identifying
the mood, situation, thoughts and any
thinking traps.
• Use the Socratic questioning method and the
challenging unhelpful thinking guide to help
the client come up with a more balanced
alternative thought.
BEHAVIOURAL EXPERIMENTS
• Challenging thoughts in sessions is often not sufficient to effect lasting change. Changes in behaviour are essential to embed belief changes
• Behavioural experiments offer practical opportunities to directly test the validity of a client’s depressed thoughts and develop or strengthen more adaptive beliefs
• Usually occur outside in real-life settings
• The goal is to allow the client to discover what will really happen in the situation, which is often not the same as their negative prediction
• Often given as homework tasks to complement in-session work.
• Preferably developed collaboratively within the session rather than as an add on at the end
• For an excellent guide on behavioural experiments see Bennett-Levy et al (2004)
BEHAVIOURAL EXPERIMENTS - GUIDE
1. With your client, write down a specific thought to be tested
2. Identify ways to test the thought out
3. Get the client to predict what s/he thinks will happen and write it down
4. Identify any obstacles that might prevent him/her carrying out the experiment
5. Get the client to record the outcome when s/he has carried out the experiment
6. To ensure the thought is fully tested identify a number of behavioural experiments s/he could try
7. Ask the client what s/he was learned from this
TEMPLATE FOR DESIGNING BEHAVIOURAL EXPERIMENTS
Situation
Prediction What do you think will happen
? How would you know ? Rate
belief (0-100)
Experiment "What did you do to test the
prediction?
Outcome What actually happened ? Was
the prediction correct ?
What was learned Balanced view?
(Rate belief 0-100) How likely is
what you predicted to happen in the
future (Rate 0-100)
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STAGE I – PREDICTIONS
Situation
Prediction Experiment Outcome What was learned
Going to friends party
• Need to drink alcohol to get though this evening
without feeling overwhelmed (90%)
• I will not be able to enjoy myself if I don't drink (90%)
• Other people will not find me interesting
or fun if i don't have a drink (100%)
• I will constantly be
worrying about how I'm being if i don't
have a drink (90%)
STAGE II – TESTING IT OUT
Situation
Prediction Experiment Outcome What was learned
Going to friends party
• Need to drink alcohol to get though this evening without
feeling overwhelmed (90%)
• I will not be able to enjoy myself if I don't drink (90%)
• Other people will not find me interesting or
fun if I don't have a drink (100%)
• I will constantly be
worrying about how I'm being if I don't
have a drink (90%)
Go to party and don't drink any
alcohol. See what
happens?
Went to party without drinking and felt very
nervous. Stuck close to my friend
for support. Soon involved in a group conversation and
met a very interesting woman
who had very similar experiences to me. Forgot
about worries for a time and still did
not take a drink.
Felt overwhelmed at first but this eventually calmed.
Also enjoyed myself when involved in
interesting conversation. Person seemed to
enjoy conversation. All this without a
drink. Can enjoy a social occasion without a
drink (80%) but need friend's
support
POSITIVE DATA LOG
• When people are depressed they tend to interpret
events from a negative perspective.
• Furthermore they attend to information in the
environment that confirms their negative view of the
self, world and future.
• A positive log book is to things that have gone well.
• It also encourages positive self-appraisal by asking
what the positive event means about the person.
POSITIVE DATA LOG
Date and time Positive things that happened today (however small)
What does this say or mean about me?
e.g. Monday 7th 10am e.g. Managed to get up and eat even though I felt tired.
e.g. I am able to take care of myself.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
POSITIVE DATA LOG PRACTICE
• Think about the last week and add
in something positive that has
happened on two or three of the
days.
• Make a note of it and ask what it
says about you.
• How does it feel focusing on the
positives?
END
Questions and comments