Introduction to Cognitive Behaviour Therapy Carol Vivyan 2007

Epictetus 55 - 135 AD • Men are disturbed, not by things, but by the principles and notions which they form concerning things • Roman (Greek-born) slave & Stoic philosopher

• Cognitive Therapy is a system of psychotherapy that attempts to reduce excessive emotional reactions and self-defeating behaviour, by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions • Beck et al 1976, 1979, 1993

The approach is: • Collaborative (builds trust) • Active • Based on open-ended questioning • Highly structured and focused

‘Common Sense’ Model Event Emotion Cognitive Model Event Meaning we give the event Emotion

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

4 interpretations – 4 emotions • I don’t want her to see me, I won’t know what to say – she’ll think I’m stupid & boring • Nobody wants to talk to me, no-one likes me • She’s got a nerve being so snooty! • She’s probably still hung over from that party last night!

• Cognitive principle – it is interpretations of events, not events themselves, which are crucial. • Behavioural principle – what we do has a powerful influence on our thoughts and emotions • The continuum principle – mental health problems are best conceptualised as exaggerations of normal processes

• ‘Here and now’ principle – it is usually more fruitful to focus on current processes rather than the past • Interacting systems principle – it is helpful to look at problems as interactions between thoughts, emotions, behaviour and physiology and the environment in which the person operates

Padesky’s 5 Aspects Model (1986) ENVIRONMENT THOUGHTS MOOD / FEELINGS BIOLOGY BEHAVIOUR

ENVIRONMENT On Plane Turbulence THOUGHTS We might crash BIOLOGY Heart racing Palpitations Rapid breathing Difficult to breathe – choking sensation MOOD / FEELINGS Anxious 90% BEHAVIOUR Reassurance seeking

Feelings & commonly associated thoughts

Groups • Think of a recent situation or event which resulted in a negative mood shift – Anxiety – Sadness – Anger • Groups: therapist / client / observer – Identify: • thoughts / feelings / behaviours

• Identify a recent significant shift in mood (emotion) • What was the situation? • How did you feel? (emotion/physiology) • What was going through your mind at the time? (thoughts) • What did you do? (behaviours) • What were the consequences?

Cognitive Model of Panic Internal / External Trigger Turbulent flight Perceived Threat We might crash I’m going to die Anxiety / Panic 90% Catastrophic Interpretation of Symptoms I’ll suffocate and die Avoidance & Safety Behaviours Reassurance seeking: Ask companion Look at faces of other travellers Ask cabin crew Avoid flying! Physical / Cognitive Symptoms Heart racing Breathless Difficulty breathing – choking sensation Shaking Sweating

Cognitive Model of Depression Early Experiences Core Beliefs & Assumptions Beck (1979) Critical Incident Negative Automatic Thoughts (NATS) Behaviour Feelings

Negative Automatic Thoughts Assumptions Core beliefs

Negative Automatic Thoughts • Stream of thoughts that we can notice if we try • • to pay attention to them (automatic) Negatively tinged appraisals or interpretations – meanings we take from what happens around us or within us Specific thoughts about specific events or situations Brief, frequent, habitual – often not heard Plausible and taken as obviously true, especially when emotions are strong

Identifying NATs • Shifts in Affect • Distinguish between thoughts and emotion and behaviour • Check for images

Cognitive Model of Depression • Negative cognitive triad – Biased views of • Oneself – I am bad, useless, unlovable, worthless, a failure • The world in general – Nothing good happens, life is just a series of trials • The future – It will always be like this, nothing I can do will make any difference, what’s the point of anything? • Negative filter – – – Remembering events Interpreting current events / situations Overgeneralising from small negative event to broad negative conclusion

Goals of therapy • Help the client counteract negative cognitive • • biases, and develop more balanced view of herself, the world, and the future Restore activity levels – especially those that give sense of pleasure or achievement Increase active engagement and problem solving

Course of treatment • Identify specific problem list (& prioritise) – Eg. Poor sleep, relationship difficulties etc • Introduce cognitive model – how it might apply • • to client Goals (SMART) Reduce symptoms through behavioural or simple cognitive strategies Identify and challenge NATs Relapse prevention

Overview of a typical course of therapy • Referral • Assessment: suitability, therapeutic • • relationship Assessment (ongoing): problem analysis, wider picture, measures Problem list & prioritise Goals for therapy (SMART) Formulation (ongoing): Sharing model, maintaining factors, predisposing factors, rationale for treatment

Overview of a typical course of therapy • Assessment, Formulation • Treatment: start with symptom focused intervention • Review: every six sessions, repeat measures • Discharge: repeat measures, relapse prevention • Follow up / booster sessions: • 1, 3, 6, 12 month ?

Typical CBT treatment session • Set collaborative agenda • Review time since last session • Feedback on last session • Review homework • Focus on major topics for the session • Set homework • Potential problems with completing homework • Feedback on session

Therapy Skills • Engagement • Warmth and empathy • Collaboration • Guided discovery – socratic questioning • Feedback and summarising • Agenda setting – structure and focus • Open and closed questioning

Aims of Assessment • Initiate & develop therapeutic relationship • Establish suitability for CBT • Gather specific information re current • • difficulties Elicit maintaining factors Initial formulation Socialise to CBT model Establish joint understanding of the presenting problem

Suitability for short term CBT • • • Ability to identify & describe negative thoughts Awareness & differentiation of emotion Compatibility with CBT rationale Acceptance of personal responsibility for change Alliance potential Chronicity of problem Security operations Focality Optimism/pessimism regarding therapy

Homework • Identify a recent significant shift in mood • What was the situation? • How did you feel? • What was going through your mind at the time? • What did you do? • What were the consequences?

Measures • The concept of measures is central to the CBT • approach, as it enables both client and practitioner to evaluate the impact of interventions (Grant et al 2004) They are important in the process of assessment and aid the practitioner to develop a credible formulation for the client, so that appropriate cognitive and behavioural interventions can be used

Why Measures? • Assessment – to provide information • Baseline – subsequent measures will show extent of change • Effectiveness – helps to (objectively) demonstrate effectiveness of therapy, and allow modification of treatment • Feedback • Knowledge - data collection & suggests areas for future research

What measures? • Standardised – developed for particular populations and problems – – – Eg. Beck Depression Inventory Beck Anxiety Inventory Agoraphobic Cognitions Questionnaire • Individualised – allow for more specific information for assessment and formulation. – Eg. Problem definition, Targets of therapy, Diaries, % Belief Ratings, Ratings of specific emotions

Cognitive Interventions • Restructuring thoughts and beliefs – Guided discovery – Thought diaries – Challenging NATs (looking at evidence) – Addressing thinking errors – Responsibility Pie – Cost/Benefit Analysis – Downward Arrow technique

Cognitive Interventions • Education Eg. Written information on thinking errors, disorder specific info • Continuous use of formulation • Imagery techniques • Role play & role reversal • Action Plan • Education in Body systems (symptoms)

Behavioural Interventions • Very powerful method of bringing about change • Key component of CBT intervention • Borrowed and adapted from Behaviour Therapy • Incorporate different methodological approaches

Behavioural Experiments • Similar in BT / CBT, but fundamentally different • In BT, it is the end product, in CBT, a means to an end ie. Cognitive change • In BT – graduated, repeated and prolonged exposure • In CBT - New ideas are put to the test. Means of testing the validity thoughts, perceptions, beliefs.

Examples • Hyperventilation to simulate panic • Activity monitoring and scheduling • Metaphors – South American tribe? • Consider experiment for client with OCD, believes something terrible will happen to family if he doesn’t neutralise his thought by doing rituals for up to an hour

Problem solving • Identify problem to be worked on • Think of as many solutions as possible • Consider each solution – pros & cons • Pick solution that appears best • Small steps • Action & review

Relapse Prevention • What have I learned? • What was most useful? • What can I continue to do? • When will I be at risk of this happening again? • What are the signs? • What could I do to avoid losing control? • What could I do if I did lose control?

Coping with Relapse • How can I make sense of this lapse? • What have I learnt from it? • With hindsight, what would I do differently?

Introduction to CBT • This presentation gives you an introduction to the rationale of CBT • It does not enable you to perform CBT • Using Cognitive Behavioural interventions may be helpful for your clients • CBT - Guided self-help?

Summary • No formulation No CBT • Use CB techniques – – Bibliotherapy: e. g. Mind Over Mood Challenge negative thoughts • Court Case • Evidence • More balanced/alternative thought • Downward arrow – Behavioural experiments / exposure – Activity Diaries – Relaxation?

More information & resources • www. get. gg – Self help – Workbooks – online CBT programmes – printable forms etc – Online • Professional links – CBT organisations – Therapist manuals online – Books

Bibliography • Certificate in Cognitive Behaviour Therapy. – Salford Cognitive Therapy Training Centre. 2006 • An introduction to Cognitive Behaviour Therapy: Skills & Applications. – Westbrook, Kennerley, Kirk, 2007. Sage. • Treatment Plans & Interventions for Depression & Anxiety Disorders. – Leahy. 2000. Guilford. • Cognitive Therapy of Anxiety Disorders. – Wells. 1997. Wiley. • Mind Over Mood. – Greenberger, Padesky. 1995. Guilford.