29/01/2016

1

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.

29/01/2016

2

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

29/01/2016

3

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

29/01/2016

4

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

29/01/2016

5

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

29/01/2016

6

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

29/01/2016

7

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.

29/01/2016

8

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?

29/01/2016

9

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?”

29/01/2016

10

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)

29/01/2016

11

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