Introduction toIntroduction to

Cognitive Behaviour Cognitive Behaviour

TherapyTherapy

Carol Vivyan 2007

Epictetus 55 - 135 ADEpictetus 55 - 135 AD

•Men are disturbed, not by Men are disturbed, not by things, but by the things, but by the principles and notions principles and notions which they form which they form concerning thingsconcerning things

• Roman (Greek-born) slave & Stoic philosopherRoman (Greek-born) slave & Stoic philosopher

•Cognitive Therapy is a system Cognitive Therapy is a system of psychotherapy that of psychotherapy that attempts to reduce excessive attempts to reduce excessive emotional reactions and self-emotional reactions and self-defeating behaviour, by defeating behaviour, by modifying the faulty or modifying the faulty or erroneous thinking and erroneous thinking and maladaptive beliefs that maladaptive beliefs that underlie these reactionsunderlie these reactions

• Beck et al 1976, 1979, 1993Beck et al 1976, 1979, 1993

The approach is:The approach is:

•Collaborative (builds trust)Collaborative (builds trust)

•ActiveActive

•Based on open-ended Based on open-ended questioningquestioning

•Highly structured and focusedHighly structured and focused

Event

Event

Emotion

EmotionMeaning we give the event

‘Common Sense’ Model

Cognitive Model

You’re walking down the You’re walking down the High Street, and someone High Street, and someone you know walks by without you know walks by without acknowledging you…acknowledging you…

4 interpretations – 4 4 interpretations – 4 emotionsemotions• I don’t want her to see me, I won’t I don’t want her to see me, I won’t

know what to say – she’ll think I’m know what to say – she’ll think I’m stupid & boringstupid & boring

•Nobody wants to talk to me, no-one likes meNobody wants to talk to me, no-one likes me

•She’s got a nerve being so snooty!She’s got a nerve being so snooty!

•She’s probably still hung over from She’s probably still hung over from that party last night!that party last night!

•Cognitive principle – it is Cognitive principle – it is interpretations of events, not interpretations of events, not events themselves, which are events themselves, which are crucial.crucial.

•Behavioural principle – what we Behavioural principle – what we do has a powerful influence on do has a powerful influence on our thoughts and emotionsour thoughts and emotions

•The continuum principle – mental The continuum principle – mental health problems are best health problems are best conceptualised as exaggerations conceptualised as exaggerations of normal processesof normal processes

• ‘‘Here and now’ principle – it is usually Here and now’ principle – it is usually more fruitful to focus on current more fruitful to focus on current processes rather than the pastprocesses rather than the past

• Interacting systems principle – it is Interacting systems principle – it is helpful to look at problems as helpful to look at problems as interactions between thoughts, interactions between thoughts, emotions, behaviour and physiology emotions, behaviour and physiology and the environment in which the and the environment in which the person operatesperson operates

Padesky’s 5 Aspects ModelPadesky’s 5 Aspects Model (1986)(1986)

ENVIRONMENT

THOUGHTS

BIOLOGY MOOD / FEELINGS

BEHAVIOUR

ENVIRONMENTOn Plane

Turbulence

THOUGHTSWe might crash

BIOLOGYHeart racingPalpitations

Rapid breathingDifficult to breathe – choking sensation

MOOD / FEELINGSAnxious 90%

BEHAVIOURReassurance

seeking

Feelings & commonly associated Feelings & commonly associated thoughtsthoughts

GroupsGroups• Think of a recent situation or event Think of a recent situation or event

which resulted in a negative mood which resulted in a negative mood shiftshift– AnxietyAnxiety– SadnessSadness– AngerAnger

• Groups: therapist / client / observerGroups: therapist / client / observer– Identify: Identify:

•thoughts / feelings / behavioursthoughts / feelings / behaviours

• Identify a recent significant shift in Identify a recent significant shift in mood (emotion)mood (emotion)

• What was the situation?What was the situation?

• How did you feel? How did you feel? (emotion/physiology)(emotion/physiology)

• What was going through your mind What was going through your mind at the time? (thoughts)at the time? (thoughts)

• What did you do? (behaviours)What did you do? (behaviours)

• What were the consequences?What were the consequences?

Internal / External Trigger

Turbulent flight

Perceived ThreatWe might crashI’m going to die

Anxiety / Panic 90%

Physical / Cognitive Symptoms

Heart racingBreathless

Difficulty breathing – choking sensation

ShakingSweating

Catastrophic Interpretation of

Symptoms

I’ll suffocate and dieAvoidance & Safety Behaviours

Reassurance seeking:Ask companion

Look at faces of other travellersAsk cabin crew

Avoid flying!

       

Cognitive Cognitive Model of Model of PanicPanic   

Cognitive Cognitive Model of Model of DepressionDepression

Beck (1979)Beck (1979)

Early Experiences

Core Beliefs & Assumptions

Critical Incident

Negative Automatic Thoughts (NATS)

Behaviour Feelings

                         

Negative Automatic Thoughts

Assumptions

Core beliefs

Negative Automatic Negative Automatic ThoughtsThoughts• Stream of thoughts that we can notice if Stream of thoughts that we can notice if

we try to pay attention to them we try to pay attention to them (automatic)(automatic)

• Negatively tinged appraisals or Negatively tinged appraisals or interpretations – meanings we take from interpretations – meanings we take from what happens around us or within uswhat happens around us or within us

• Specific thoughts about specific events or Specific thoughts about specific events or situationssituations

• Brief, frequent, habitual – often not heardBrief, frequent, habitual – often not heard• Plausible and taken as obviously true, Plausible and taken as obviously true,

especially when emotions are strongespecially when emotions are strong

Identifying NATsIdentifying NATs

• Shifts in AffectShifts in Affect

• Distinguish between thoughts and Distinguish between thoughts and emotion and behaviouremotion and behaviour

• Check for imagesCheck for images

Cognitive Model of DepressionCognitive Model of Depression• Negative cognitive triadNegative cognitive triad

– Biased views of Biased views of • OneselfOneself

– I am bad, useless, unlovable, worthless, a failureI am bad, useless, unlovable, worthless, a failure

• The world in generalThe world in general– Nothing good happens, life is just a series of trialsNothing good happens, life is just a series of trials

• The futureThe future– It will always be like this, nothing I can do will It will always be like this, nothing I can do will

make any difference, what’s the point of make any difference, what’s the point of anything?anything?

• Negative filterNegative filter– Remembering eventsRemembering events– Interpreting current events / situationsInterpreting current events / situations– Overgeneralising from small negative event to broad Overgeneralising from small negative event to broad

negative conclusionnegative conclusion

Goals of therapyGoals of therapy

• Help the client counteract negative Help the client counteract negative cognitive biases, and develop more cognitive biases, and develop more balanced view of herself, the world, and balanced view of herself, the world, and the futurethe future

• Restore activity levels – especially those Restore activity levels – especially those that give sense of pleasure or that give sense of pleasure or achievementachievement

• Increase active engagement and problem Increase active engagement and problem solvingsolving

Course of treatmentCourse of treatment• Identify specific problem list (& prioritise)Identify specific problem list (& prioritise)

– Eg. Poor sleep, relationship difficulties etcEg. Poor sleep, relationship difficulties etc

• Introduce cognitive model – how it might Introduce cognitive model – how it might apply to clientapply to client

• Goals (SMART)Goals (SMART)

• Reduce symptoms through behavioural or Reduce symptoms through behavioural or simple cognitive strategiessimple cognitive strategies

• Identify and challenge NATsIdentify and challenge NATs

• Relapse preventionRelapse prevention

Overview of a typical Overview of a typical course of therapycourse of therapy• ReferralReferral

• Assessment: suitability, therapeutic Assessment: suitability, therapeutic relationshiprelationship

• Assessment (ongoing): problem analysis, Assessment (ongoing): problem analysis, wider picture, measureswider picture, measures

• Problem list & prioritiseProblem list & prioritise

• Goals for therapy (SMART)Goals for therapy (SMART)

• Formulation (ongoing): Sharing model, Formulation (ongoing): Sharing model, maintaining factors, predisposing factors, maintaining factors, predisposing factors, rationale for treatmentrationale for treatment

Overview of a typical Overview of a typical course of therapycourse of therapy• Assessment, FormulationAssessment, Formulation

• Treatment: start with symptom focused Treatment: start with symptom focused interventionintervention

• Review: every six sessions, repeat Review: every six sessions, repeat measuresmeasures

• Discharge: repeat measures, relapse Discharge: repeat measures, relapse preventionprevention

• Follow up / booster sessions: Follow up / booster sessions: •1,3,6,12 month ?1,3,6,12 month ?

Typical CBT treatment Typical CBT treatment sessionsession

• Set collaborative agendaSet collaborative agenda

• Review time since last sessionReview time since last session

• Feedback on last sessionFeedback on last session

• Review homeworkReview homework

• Focus on major topics for the sessionFocus on major topics for the session

• Set homeworkSet homework

• Potential problems with completing Potential problems with completing homeworkhomework

• Feedback on sessionFeedback on session

Therapy SkillsTherapy Skills

• EngagementEngagement

• Warmth and empathyWarmth and empathy

• CollaborationCollaboration

• Guided discovery – socratic Guided discovery – socratic questioningquestioning

• Feedback and summarisingFeedback and summarising

• Agenda setting – structure and focusAgenda setting – structure and focus

• Open and closed questioningOpen and closed questioning

Aims of AssessmentAims of Assessment

• Initiate & develop therapeutic relationshipInitiate & develop therapeutic relationship

• Establish suitability for CBTEstablish suitability for CBT

• Gather specific information re current Gather specific information re current difficultiesdifficulties

• Elicit maintaining factorsElicit maintaining factors

• Initial formulationInitial formulation

• Socialise to CBT modelSocialise to CBT model

• Establish joint understanding of the Establish joint understanding of the presenting problempresenting problem

Suitability for short Suitability for short term CBTterm CBT• Ability to identify & describe negative thoughtsAbility to identify & describe negative thoughts

• Awareness & differentiation of emotionAwareness & differentiation of emotion

• Compatibility with CBT rationaleCompatibility with CBT rationale

• Acceptance of personal responsibility for Acceptance of personal responsibility for changechange

• Alliance potentialAlliance potential

• Chronicity of problemChronicity of problem

• Security operationsSecurity operations

• FocalityFocality

• Optimism/pessimism regarding therapyOptimism/pessimism regarding therapy

HomeworkHomework

• Identify a recent significant shift in Identify a recent significant shift in moodmood

• What was the situation?What was the situation?

• How did you feel?How did you feel?

• What was going through your mind at What was going through your mind at the time?the time?

• What did you do?What did you do?

• What were the consequences?What were the consequences?

MeasuresMeasures

• The concept of measures is central to the The concept of measures is central to the CBT approach, as it enables both client CBT approach, as it enables both client and practitioner to evaluate the impact of and practitioner to evaluate the impact of interventions (Grant et al 2004)interventions (Grant et al 2004)

• They are important in the process of They are important in the process of assessment and aid the practitioner to assessment and aid the practitioner to develop a credible formulation for the develop a credible formulation for the client, so that appropriate cognitive and client, so that appropriate cognitive and behavioural interventions can be usedbehavioural interventions can be used

Why Measures?Why Measures?

• Assessment – to provide informationAssessment – to provide information

• Baseline – subsequent measures will show Baseline – subsequent measures will show extent of changeextent of change

• Effectiveness – helps to (objectively) Effectiveness – helps to (objectively) demonstrate effectiveness of therapy, and demonstrate effectiveness of therapy, and allow modification of treatmentallow modification of treatment

• Feedback Feedback

• Knowledge - data collection & suggests Knowledge - data collection & suggests areas for future researchareas for future research

What measures?What measures?• Standardised – developed for particular Standardised – developed for particular

populations and problemspopulations and problems– Eg. Beck Depression InventoryEg. Beck Depression Inventory– Beck Anxiety InventoryBeck Anxiety Inventory– Agoraphobic Cognitions QuestionnaireAgoraphobic Cognitions Questionnaire

• Individualised – allow for more specific Individualised – allow for more specific information for assessment and information for assessment and formulation. formulation. – Eg. Problem definition, Targets of therapy, Eg. Problem definition, Targets of therapy,

Diaries, % Belief Ratings, Ratings of specific Diaries, % Belief Ratings, Ratings of specific emotionsemotions

Cognitive InterventionsCognitive Interventions

• Restructuring thoughts and beliefsRestructuring thoughts and beliefs– Guided discoveryGuided discovery– Thought diariesThought diaries– Challenging NATs (looking at evidence)Challenging NATs (looking at evidence)– Addressing thinking errorsAddressing thinking errors– Responsibility PieResponsibility Pie– Cost/Benefit AnalysisCost/Benefit Analysis– Downward Arrow techniqueDownward Arrow technique

Cognitive InterventionsCognitive Interventions

• Education Eg. Written information on Education Eg. Written information on thinking errors, disorder specific infothinking errors, disorder specific info

• Continuous use of formulationContinuous use of formulation

• Imagery techniquesImagery techniques

• Role play & role reversalRole play & role reversal

• Action PlanAction Plan

• Education in Body systems Education in Body systems (symptoms)(symptoms)

Behavioural Behavioural InterventionsInterventions• Very powerful method of bringing Very powerful method of bringing

about changeabout change

• Key component of CBT interventionKey component of CBT intervention

• Borrowed and adapted from Borrowed and adapted from Behaviour TherapyBehaviour Therapy

• Incorporate different Incorporate different methodological approachesmethodological approaches

Behavioural Behavioural ExperimentsExperiments• Similar in BT / CBT, but fundamentally Similar in BT / CBT, but fundamentally

differentdifferent

• In BT, it is the end product, in CBT, a In BT, it is the end product, in CBT, a means to an end ie. Cognitive changemeans to an end ie. Cognitive change

• In BT – graduated, repeated and In BT – graduated, repeated and prolonged exposureprolonged exposure

• In CBT - New ideas are put to the test. In CBT - New ideas are put to the test. Means of testing the validity thoughts, Means of testing the validity thoughts, perceptions, beliefs.perceptions, beliefs.

ExamplesExamples

• Hyperventilation to simulate panicHyperventilation to simulate panic

• Activity monitoring and schedulingActivity monitoring and scheduling

• Metaphors – South American tribe?Metaphors – South American tribe?

• Consider experiment for client with Consider experiment for client with OCD, believes something terrible OCD, believes something terrible will happen to family if he doesn’t will happen to family if he doesn’t neutralise his thought by doing neutralise his thought by doing rituals for up to an hourrituals for up to an hour

Problem solvingProblem solving

• Identify problem to be worked onIdentify problem to be worked on

• Think of as many solutions as Think of as many solutions as possiblepossible

• Consider each solution – pros & consConsider each solution – pros & cons

• Pick solution that appears bestPick solution that appears best

• Small stepsSmall steps

• Action & reviewAction & review

Relapse PreventionRelapse Prevention

• What have I learned?What have I learned?

• What was most useful?What was most useful?

• What can I continue to do?What can I continue to do?

• When will I be at risk of this happening When will I be at risk of this happening again?again?

• What are the signs?What are the signs?

• What could I do to avoid losing control?What could I do to avoid losing control?

• What could I do if I did lose control?What could I do if I did lose control?

Coping with RelapseCoping with Relapse

• How can I make sense of this lapse?How can I make sense of this lapse?

• What have I learnt from it?What have I learnt from it?

• With hindsight, what would I do With hindsight, what would I do differently?differently?

Introduction to CBTIntroduction to CBT

• This presentation gives you an This presentation gives you an introduction to the rationale of CBTintroduction to the rationale of CBT

• It does not enable you to perform It does not enable you to perform CBTCBT

• Using Cognitive Behavioural Using Cognitive Behavioural interventions may be helpful for interventions may be helpful for your clientsyour clients

• CBT - Guided self-help?CBT - Guided self-help?

SummarySummary

• No formulation No CBTNo formulation No CBT• Use CB techniquesUse CB techniques

– Bibliotherapy: e.g. Mind Over MoodBibliotherapy: e.g. Mind Over Mood– Challenge negative thoughtsChallenge negative thoughts

• Court CaseCourt Case• EvidenceEvidence• More balanced/alternative thoughtMore balanced/alternative thought• Downward arrowDownward arrow

– Behavioural experiments / exposureBehavioural experiments / exposure– Activity DiariesActivity Diaries– Relaxation?Relaxation?

More information & More information & resourcesresources• www.get.ggwww.get.gg

– Self helpSelf help– WorkbooksWorkbooks– online CBT programmes – printable forms etconline CBT programmes – printable forms etc– Online Online

•Professional linksProfessional links– CBT organisationsCBT organisations– Therapist manuals onlineTherapist manuals online– BooksBooks

BibliographyBibliography

• Certificate in Cognitive Behaviour Therapy. Certificate in Cognitive Behaviour Therapy. – Salford Cognitive Therapy Training Centre. 2006Salford Cognitive Therapy Training Centre. 2006

• An introduction to Cognitive Behaviour An introduction to Cognitive Behaviour Therapy: Skills & Applications. Therapy: Skills & Applications. – Westbrook, Kennerley, Kirk, 2007. Sage.Westbrook, Kennerley, Kirk, 2007. Sage.

• Treatment Plans & Interventions for Treatment Plans & Interventions for Depression & Anxiety Disorders.Depression & Anxiety Disorders.– Leahy. 2000. Guilford.Leahy. 2000. Guilford.

• Cognitive Therapy of Anxiety Disorders.Cognitive Therapy of Anxiety Disorders.– Wells. 1997. Wiley.Wells. 1997. Wiley.

• Mind Over Mood.Mind Over Mood.– Greenberger, Padesky. 1995. Guilford.Greenberger, Padesky. 1995. Guilford.