Cognitive Behavior Therapy Basics Gordon G Cappelletty Ph

Cognitive Behavior Therapy Basics Gordon G. Cappelletty, Ph. D. Family NET of Catawba County 1 12/3/2020

Outline of Day Overview of CBT l Basic Theory l Common Approaches l Lunch (12: 00 – 1: 30) l Treatment Approaches l CBT Structure l Resources l 2 12/3/2020

What is C-B-T? relatively short-term (3 to 6 months) l focused on current thinking, behaving, and communicating l de-emphasizes past experiences l action-oriented l practical l rational l structured l 3 12/3/2020

C-B-T is effective with … Depression l Anxiety Disorders & Phobias l Borderline Personality Disorder l Victims of trauma l Perpetrators of trauma l Substance abuse & dependence l 4 12/3/2020

CBT Outcome Studies l l l l Adults Depression Anxiety Bipolar disorder Eating disorders Substance Abuse Marital Discord Anger Medically-related disorders Family therapy Separation and divorce Low self-esteem Stress Aging Relationship difficulties Etc. l l l Children & Adolescents Depression Anxiety (separation, avoidant disorder, overanxious disorder, OCD, phobias, PTSD) Conduct disorder Oppositional Defiant Disorder Recurrent abdominal pain Physical complaints not explained by medical conditions Separation and divorce Low self-esteem Stress Grief and loss Etc.

When CBT is not effective … Reason #1: No coherent system l Reason #2: Accurate empathy not established l Reason #3: Irrational thoughts not recognized l Reason #4: Individual does not develop a new rational replacement thought l Reason #5: CBT practiced superficially l

But first … some theory 7 12/3/2020

Suppose you overheard the following conversation … Joe: Did you order it? l Bob: Yeah, it will be here in about 45 minutes. l Joe: Oh … well, I’ve got to leave before then. But, save me a couple of slices, okay? And a beer or two to wash them down with? l 8 12/3/2020

What is a “Schema”? Hypothetical mental structure for representing generic concepts stored in memory l It is a set of rules for organizing information l It is like a framework, plan or script l 9 12/3/2020

Schema (plural: Schemata) Memories of experiences are stored and configured into structures called schemata. l Schemata serve as filters for ongoing experience, allowing us to come to conclusions about events automatically. l Each person has a unique store of memories l The conclusions made about events will vary from person to person l 10 12/3/2020

How are schemata formed? We know more about how schemata are used than how they are formed. l Created through experience with people, objects and events l When we encounter something repeatedly, we begin to generalize across other experiences l 11 12/3/2020

Features of Schemata Composed of generic or abstract knowledge l Used to guide encoding, organization and retrieval of information l Reflect prototypical properties of experiences encountered by a person l Are formed and used without the individual’s conscious awareness l 12 12/3/2020

Dimensions of Schemata Core versus superficial l Dormant versus active l Pervasive versus specific l Rigid versus flexible l 13 12/3/2020

Types of Schemata Person schema – attributes of particular individuals or groups of individuals l Event schema – processes, practices or ways in which tasks are typically approached l Role schema – role expectations for self and others l Self schema – generalizations about the self (i. e. , one’s self concept) l 14 12/3/2020

Sources of schemata Cultural schema l Familial schema l Generational schema l Professional schema l Idiosyncratic schema l Biological schema l 15 12/3/2020

Modification of Schemata Accretion: new information is remembered in the context of an existing schema l Tuning: if new information cannot be fully accommodated under an existing schema, the schema will evolve to become consistent with the new data l Restructuring: when information cannot be fit into an existing schema, a new schema will be formed l 16 12/3/2020

Schematic distortion l When a schema is: – – l l core rigid pervasive active then new information which conflicts with the schema will be distorted to fit the schema This is the root cause of many types of emotional and interpersonal distress 17 12/3/2020

Schema = Belief Dysfunctional Schema : a schema that habitually results in adverse consequences for the individual l Ellis: Irrational belief l Beck: Cognitive distortion l 18 12/3/2020

Dysfunctional Schema l The best opportunity for weakening a dysfunctional schema is when: – the schema is activated – the person is experiencing severe negative affect l At these times, the person is most receptive to alteration of the dysfunctional schema and development of more adaptive ways of thinking 19 12/3/2020

Basic A-B-C’s of C-B-T 20 12/3/2020

Structural Model of C-B-T 21 12/3/2020

Example of Irrational Thinking 22 12/3/2020

REBT Insight #1 It is not what happens to us, alone, that determines our feelings but it is our thinking, our beliefs, about what happens which also contributes to our feelings. 23 12/3/2020

REBT Insight #2 Although our beliefs may have been formed in the past, we continue to reindoctrinate ourselves with them now in the present. 24 12/3/2020

REBT Insight #3 It is only through hard work and practice that we can overcome self defeating beliefs and replace them with more helpful beliefs. 25 12/3/2020

Two Basic Human Tendencies Ellis (1979) l Humans have a strong biological tendency to think irrationally. l Humans also have a biologically innate ability to think about their thinking, and the ability to exercise their power to choose to work towards changing their irrational thinking. l 26 12/3/2020

Event Cognitive Appraisal Behavior Emotion Basic Cognitive. Behavioral Model

Cognitive-behavioral model l Working model simplified to direct attention to the relationships among thoughts, emotions, and behaviors and to guide treatment interventions l Recognizes that there are complex interactions among biological processes, environmental and interpersonal influences, and cognitive-behavioral elements in the genesis and treatment of psychiatric disorders l Research findings: CBT and biological interventions (e. g. , pharmacotherapy) have resulted in significant improvement in multiple psychiatric disorders

Cognitive Model (adapted from Beck) CORE BELIEFS INTERMEDIATE BELIEF SITUATIONS/ EVENTS AUTOMATIC THOUGHTS • EMOTIONS • BEHAVIORS • PHYSIOLOGICAL RESPONSES

Beck’s model l l Core beliefs: (a) about self, others and the world which are formed during childhood based on experiences as we grow up; (b) so deep that they are regarded as absolute truths; and (c) apply to situations in general Automatic thoughts: (a) words or images that instantaneously go through a person’s mind related to specific situations; (b) influence our reactions to situations Intermediate beliefs: attitudes, rules and assumptions which occur between core beliefs and automatic thoughts Events may trigger a variety of responses/reactions as a result of the way a person interpret a situation. Responses may be emotional, behavioral, and/or physiological. On the most basic level, CBT works to change parts of the chain of events of the situation-interpretation-reaction; helps a person understand different ways of interpreting and responding to an event

INTERMISSION 31 12/3/2020

Phases of C-B-T Treatment Assessment : Aim is to identify dysfunctional schemas l Alteration of Dysfunctional Schemas l Maintenance: Need to continue to practice skills l Relapse Prevention: Use of “booster sessions” as needed l 32 12/3/2020

Phase I: Assessment Determine the nature of the dysfunctional schemas l Irrational Beliefs: REBT l Automatic Thoughts: Cognitive Therapy l 33 12/3/2020

Types of Irrational Beliefs l The heart of psychological disturbance rests in absolutistic evaluations of the perceived events in life – Must, should, have to, got to, ought The philosophy of “musturbation” l Awfulizing l I-can’t-stand-it-it is l Damnation l 34 12/3/2020

Distortions Due to IB’s All-or-none thinking l Jumping to conclusions l Fortune telling l Focusing on the negative l Disqualifying the positive l Allness and neverness l Minimization l 35 12/3/2020

Distortions Due to IB’s Emotional Reasoning l Labeling and overgeneralization l Personalizing l Phonyism l Perfectionism l 36 12/3/2020

Appropriate Negative Emotions Concern versus Anxiety l Sadness versus Depression l Regret versus Guilt l Disappointment versus Shame l Annoyance versus Anger l 37 12/3/2020

Automatic Thoughts Beck, Rush, Shaw & Emery (1979) l Focus on the cognitive content of one’s reaction to upsetting events l Emphasis on the relatively easily accessed (preconscious or conscious) mental events that clients can be trained to report l Cognitive Triad: clients views of self, the future, the world (others, things) l 38 12/3/2020

Types of Dysfunctional Automatic Thoughts Arbitrary inference l Selective abstraction l Overgeneralization l Magnification and minimization l Personalization l Dichotomous Thinking l 39 12/3/2020

Assessment Forms Beck Depression Inventory l Beck Anxiety Scale l REBT Personality Data Form l Various schema check sheets l 40 12/3/2020

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Phase II: Changing Schemata Key Components of Change Schema change requires repetition l People slightly weaken their dysfunctional schemata each time they think and behave functionally while experiencing a dysfunctional emotion l It is necessary to have a clear understanding of the emotion and the associated cognitive components of the schema l 42 12/3/2020

Theory of Therapeutic Change 1. 2. 3. To a large degree, people create their own psychological disturbance While environmental conditions can contribute to problems, they are of a secondary importance People have the ability to significantly alter these disturbances 43 12/3/2020

Theory of Therapeutic Change 4. 5. Emotional and behavioral disturbances stem largely from irrational, absolutistic dogmatic beliefs Detect dysfunctional schemas and discriminate between them and their functional (rational) counterparts 44 12/3/2020

Theory of Therapeutic Change 6. 7. Work toward internalization of functional schemas by employing cognitive, behavioral and emotive methods of change. Continue this process of challenging dysfunctional schemas and using multimodal methods of change for the rest of their lives. 45 12/3/2020

Levels of Intervention l Superficial – Schema camouflage – Schema reinterpretation ---------------------– Schema modification – Schema reconstruction l Deep 46 12/3/2020

Structure of a C-B-T Session Check-In & Review l Assessment activity l Develop agenda l Work through agenda l Summarize l Assign homework l (5 minutes) (< 5 min. ) (25– 35 min. ) (5 minutes) (2– 3 min. ) 47 12/3/2020

Check-In & Review Check-In on events since last session l Review of previous session l – What helped from that session? – What did not help? l Examine homework from previous session – How much completed? – Barriers to completion? – Effectiveness of assignment. 48 12/3/2020

Assessment Activity Assess client’s current level of functioning l Where are they at in their goals? l Use inventories, if appropriate l – Beck Depression Inventory – Zung Depression Scale – Beck Anxiety Scale – Etc. , etc. … 49 12/3/2020

Developing Agenda Collaborative activity l What do we need to work on today? l You cannot accomplish everything on the agenda: l – Set priorities for the session – Examine what can be done out of session 50 12/3/2020

Working through the agenda l Using – Cognitive (changing thinking) – Behavioral (changing doing) – Emotive (changing feeling) l strategies of change 51 12/3/2020

Summarize Session What did we accomplish today? l Are we on target? l – Is this helping you? – What else could we do? l What do we have left to do? 52 12/3/2020

Assign Homework l Start out: – Small – Simple – Easy Progress to more complex assignments when client begins to gain mastery over symptoms l Always write it down! l 53 12/3/2020

Change Techniques l Behavioral l Cognitive l Emotive l Occurs within the context of an empathic relationship 54 12/3/2020

Behavioral Methods Used to increase mastery, pleasure and activity l Self monitoring l Scheduling activities l Graded tasks (success therapy) l Breaking down complex tasks (chunking) l Differential reinforcement l 55 12/3/2020

Cognitive Methods Daily Record of Dysfunctional Thoughts l Three questions l – What is the evidence for/against the belief? – What are alternative interpretations of the event? – What are the real implications if the belief is correct? 56 12/3/2020

Cognitive Methods Downward arrow: What would it mean if it were true that X? l Recognizing automatic thoughts l Identifying schemata l Active disputing of dysfunctional thoughts l 57 12/3/2020

Emotive Methods Use of humor l Stories, mottos, witticisms, poems, aphorisms l Anything that helps the client gain mastery over their feelings l 58 12/3/2020

POUND, POUND (sung to the tune of Jingle Bells) If you get release and let your anger out Disrupt the blasted peace and scream and yell and shout Just go to any length to show you can’t be still And you’ll display enormous strength – until the time you’re killed. 59 12/3/2020

POUND, POUND Pound, pound, pound! Pound your enemies! Oh what fun it is to stun anyone who does not please you! Sock, Sock! Knock, knock! Howl and wine and cry! And everyone from you will run and hate you till you die! 60 12/3/2020

POUND, POUND Pout, pout! Shout, shout! When things are a mess! Rip, rip! Slip, slip into profound depression! Think, think! Drink, drink only of cruel fate! Keep your mind preoccupied with everyone you hate! 61 12/3/2020

Homework Assignments An essential component of C-B-T l Bibliotherapy l – Books – Pamphlets – Articles Simple activities l Self-monitoring l 62 12/3/2020

C-B-T Web Sites l http: //www. rebt. org l http: //beckinstitute. org l http: //www. cognitivetherapynyc. com 63 12/3/2020

C-B-T Resources The REBT Resource Book for Practitioners from Albert Ellis Institute l Cognitive Therapy Worksheet Packet by Judith S. Beck l Cognitive Therapy of Depression by Aaron T. Beck, A. John Rush, Brian F. Shaw & Gary Emery l 64 12/3/2020

C-B-T Resources What To Do When He Has a Headache by Janet L. Wolfe l Love is Never Enough by Aaron T. Beck l Cognitive Therapy for Personality Disorders: A Schema-Focused Approach by Jeffrey E. Young l 65 12/3/2020

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