A Brief Overview of Cognitive Behavioral Therapy CBT

A Brief Overview of Cognitive Behavioral Therapy (CBT) Vesna Antičević, Ph. D. , cognitive behavioral therapist Clinical Medical Hospital and School of Medicine, Split Department of Psychiatry

Outline What is Cognitive Behavior Therapy (CBT)? Understanding the Theory behind CBT What are the basic principles of treatment?

What is CBT? Psychological treatment that addresses the interactions between how we think, feel and behave; Short-term focused treatment (10 -20 sessions); Focuses on current problems and follows a structured style of intervention; Strong empirical support with randomized clinical trials.

Human mental procesess

It is impossible to change emotions directly. But we can change what we think (cognitions) and what we do (behavior). By changing our cognitions and behavior, we can influence on emotions.

CBT is a process of teaching, exercising and reinforcing realistic/positive behaviors. It helps people to identify cognitive patterns of thoughts and emotions that are linked with behaviors.

Understanding the Theory Behind CBT is an integration of two originally separate theoretical approaches to understanding and treating psychological and psychiatric disorders: -The behavioral approach focuses on observable, measurable, “overt” behavior; -The cognitive approach focuses on the role of mind, specifically on cognitions as determinants of feelings and behaviors.

The Behavioral Approach: classical and operant conditioning J. B. Watson-”father of behaviorism” Classical conditioningkey elements: -Unconditioned stimulus (US) and response (UR) -Conditioned stimulus (CS) -Conditioned response (CR)

An example. . . Baby. . . US (food) – UR (salivation) CS (light) - CR (salivation) Experiments: little Albert, Peter Most of the behaviors, healthy and pathological, have been learned via classical conditioning and can be changed in the process of Behavior Therapy.

The second way of learning. . . Operant conditioning by B. F. Skinner When the organism is rewarded for a particular response, the response is more likely to occur again.

An example A child who cries before school. . . Four possible consequences of behavior: -positive reinforcement (salary) -negative reinforcement (smoking) -punishment (critics) -ignoring (crying child)

The cognitive Approach A. T. Beck –. . . it is not events themselves that affect our behavior, but rather how we perceive events.

The Cognitive Approach Based on criticism of behavioral (too simple) and psychoanalytic (lack of scientific evidence) approaches CT is a focused form of psychotherapy based on a model stipulating that psychiatric disorders involve dysfunctional thinking. Dysfunctional/distorted thinking arises from both biological and psychological influences Individuals’ emotional, behavioral, and physiological reactions are influenced by the way they structure their environment. J. Beck, 1995

Mediation hypothesis A event B cognition C behavior cognitions (thoughts) mediate between events and behavior- the way we interpreted events

An example Jane. . .

The cognitive model Core belief (I am unlucky person. ) Intermediate belief (Bad things will happen to people I am close to. ) Situation Automatic thoughts Emotions (My friend was in accident. ) Behaviors Physiology

Explaining the terms Core beliefs (CB): about oneself, others and the world Automatic thoughts (AT): “actual words or images that go through a person`s mind” and which are situation specific”. In between CB and AT are intermediary beliefs which are “attitudes, rules and assumptions”.

Cognitive Distortions in patients Patients tend to make consistent errors in their thinking Often, there is a systematic negative bias in the cognitive processing of patients suffering from psychiatric disorders Help patient identify the cognitive errors s/he is most likely to make

Types of Cognitive Distortions –Emotional reasoning Feelings are facts –Anticipating negative outcomes The worst will happen –All-or-nothing thinking All good or all bad –Mind-reading Knowing what others are thinking –Personalization Excess responsibility –Mental filter Ignoring the positive

In Cognitive Therapy Modifying dysfunctional thinking and behavior leads to improvement in symptoms. Modifying dysfunctional beliefs which underlie dysfunctional thinking leads to more durable improvement

How does CBT works? Cognitive-behavioral integration

Course of Treatment 1. Assessment 2. Provide rationale 3. Training in self-monitoring 4. Behavioral strategies 1. Monitor relationship between situation/action and mood. 2. Applying new coping strategies to larger issues. 5. Identifying beliefs and biases 6. Evaluating and changing beliefs 7. Core beliefs and assumptions 8. Relapse prevention and termination

Behavioral Interventions Breathing retraining Relaxation Behavioral activation Interpersonal effectiveness training Problem-solving skills Exposure and response prevention Social skills training

Cognitive Interventions Monitor automatic thoughts Teach imagery techniques Promote cognitive restructuring Examine alternative evidence Modify core beliefs Generate rational alternatives

Basic Principles Change mood states by using cognitive and behavioral strategies: –Identifying/modifying automatic thoughts & core beliefs, –Regulating routine, and –Minimizing avoidance. Emphasis on ‘here and now’ Preference for concrete examples –Start with specific situation (complete thought log) Reliance on Socratic questioning –Ask open-ended questions Empirical approach to test beliefs –Challenge thoughts not based on evidence –Cognitive restructuring Promote rapid symptom change

Applications of CBT Mood Disorders –Unipolar Depression (1979) –Bipolar Disorder (1996) –Dysthymia and Chronic MDD (2000) Anxiety Disorders –GAD (1985) –Social Phobia (1985) –Panic Disorder (1986) –OCD (1988) –PTSD (1991) Emotional Disorders (2006)

Applications of CBT (Continued…) Eating Disorders (1981) Marital Problems Behavioral Medicine –Headaches (1985) –Insomnia (1987) –Chronic Pain (1988) –Smoking Cessation –Hypochondriasis –Body Dysmorphic Disorder

Conclusions System of psychotherapies Unified theory of psychopathology Short-term treatment Objective assessment and monitoring Strong empirical support As effective as pharmacotherapy

Questions?

Rationale for CBT (integration of cognitive and behavior therapy) Negative emotions are elicited by cognitive processes developed through influences of learning and temperament. Adverse life events elicit automatic processing, which is viewed as the causal factor. Cognitive triad: Negative automatic thoughts center around our understanding of: –Ourselves –Others (the world) –Future Focus on examination of cognitive beliefs and developing rational responses to negative automatic thoughts. Beck et al. , 1979

Cognitive Specificity Hypothesis Distorted appraisals follow themes relevant to the specific psychiatric condition. Psychological disorders are characterized by a different psychological profile. –Depression: Negative view of self, others, and future. Core beliefs associated with helplessness, failure, incompetence, and unlovability. –Anxiety: Overestimation of physical and psychological threats. Core beliefs linked with risk, dangerousness, and uncontrollability.

Cognitive Specificity Negative Triad Associated with Depression –Self “I am incompetent/unlovable” –Others “People do not care about me” –Future “The future is bleak” Negative Triad Associated with Anxiety –Self “I am unable to protect myself” –Others “People will humiliate me” –Future “It’s a matter of time before I am embarrassed”

Examples Cognitive Distortions –Emotional Reasoning: “I feel incompetent, so I know I’ll fail” –Catastrophizing: “It is going to be terrible” –Personalization: “It’s always my fault” –Black or white thinking: “If it isn’t perfect, it’s no good at all. ”

Core Beliefs Core beliefs underlie and produce automatic thoughts. These assumptions influence information processing and organize understanding about ourselves, others, and the future. These core beliefs remain dormant until activated by stress or negative life events. Categories of core beliefs (helpless, worthless, unlovable) Core Beliefs Automatic Thoughts

Examples of Core Beliefs Helpless core beliefs –I am inadequate, ineffective, incompetent, can’t cope –I am powerless, out of control, trapped –I am vulnerable, weak, needy, a victim, likely to be hurt –I am inferior, a failure, a loser, defective, not good enough, don’t measure up Unlovable core beliefs –I am unlikable, unwanted, will be rejected or abandoned, always be alone –I am undesirable, ugly, unattractive, boring, have nothing to offer –I am different, flawed, defective, not good enough to be loved by others Worthless core beliefs –I am worthless, unacceptable, bad, crazy, broken, nothing, a waste –I am hurtful, dangerous, toxic, evil –I don’t deserve to live

Cognitive Conceptualization Current Situation Automatic Thoughts About self, world And others Physiology Feelings Behavior Childhood And Early Life Events Underlying Assumptions and Core Beliefs Compensatory Strategies

Example 1 Situation Partner says: “I need time to be with my friends” Automatic Thoughts Automatic response: “Oh no, he’s losing interest and is going to break up with me…. ” Physiology Heart racing Lump in throat Feelings Sadness Worry Anger Behavior Seek reassurance Withdraw Cry Childhood Experiences Parental neglect and criticism Underlying Assumptions & Core Beliefs “I’m flawed in numerous ways, which means I’m not worthy of consistent attention and care. People only care when they want something. ” Compensatory Strategies Be independent and you’ll be safe. Watch out – people are careless with you.

Example 2 Automatic Thoughts Situation Disappointing exam result “I am not going to get through this program I’m not as smart as everyone else. People will discover this and I will be humiliated. ” Physiology Pit in stomach Dry mouth Feelings Worry, shame, Disappointment Humiliation. Behavior Use alcohol, Procrastinate with homework Childhood Adversities Parental standards reinforce academic achievement Underlying Assumptions “If I don’t excel in school, I’m a total failure” Compensatory Strategies Work extra hard to offset incompetence.

Responding to Negative Thoughts Define Situation Clarify meaning of cognitive appraisal –What was going through your mind just then? –What did the situation mean for you? Evaluate interpretation –Evidence: For and against this belief? –Alternatives: Any other explanation(s)? –Implications: So what…. ?

Evaluating Negative Thoughts What is the effect of telling myself this thought? What could be the effect of changing my thinking? What would I tell ___ (a friend/family member) if s/he viewed this situation in this way? What can I do now?

Sample Thought Log

Common Components of CBT Establish good therapeutic relationship Educate patients - model, disorder, therapy Assess illness objectively, set goals Use evidence to guide treatment decisions Structure treatment sessions with agenda Limit treatment length Issue and review homework to generalize learning

Efficacy Cognitive and behavioral approaches are effective Supported by over 325 controlled outcome studies State-of-the-art therapy, manualized

Controlled Outcome Studies on CBT Unipolar Depression (~30) Eating Disorders –Anorexia (~5) –Bulimia (~15) Generalized Anxiety Disorder (~12) Social Phobia (~14) Panic Disorder (~10) Borderline P. D. (2) Schizophrenia (~45) C/A Depression (8) Chronic Depression (1)

Questions? Comments? Dr. Shona Vas (773) 702 -1517 Psychiatry Department Office: A-312 svas@yoda. bsd. uchicago. edu