CBT Exam #2

Addressing non-compliance

• Psychoeducation

• Prepare for difficulty of treatment ahead of time

• Reduce difficulty of exposures

• Problem-solve expected difficulties ahead of time

• Enlist at-home support

• Increase therapist contact

• Identify barriers to compliance

• Openly discuss possibility of termination/referrals

• Use acceptance-based bx (ABBT) strategies to improve distress tolerance/clarify values

Why do you like ACT over CBT?

• Use of metaphors and vivid imagery - helps make it stick

• Defusion as a method of having contact with the present moment (leaves on a stream) - mindfulness

• Values-based decision making - serves as guidance for personal achievement, meaningful way of life that drives sustainable committed action

Generalized Anxiety Disorder exposures

• Worry exposure is a specific variant of imaginal exposure

  • Worry = a chain of catastrophizing thoughts that are predominantly verbal

• Maladaptive worry generates a repetitive range of negative outcomes in which the individual attempts to generate coping solutions until some internal goal is achieved (e.g., “a sense of control”)

• Threatening mental images and their corresponding unpleasant emotional arousal are avoided by worrying in words and sentences

  • Exposure = sustained imaginal exposures of actual worse case scenarios ripe with imagery and emotional content

Common OCD therapist mistakes

• Not encouraging patients to go far enough

• Choosing wrong form of exposure (in vivo v imaginal)

• Encouraging distraction

• Providing reassurance

• Treating peripheral and not core fear

• Infeffectively handling mental compulsions

Research on CBT vs. antidepressants

• CBT = medication short term

• CBT > medication long term (6-12 mos.)

• CBT + medication > medication alone

• CBT + medication = CBT alone

Cognitive triad for depression

What is behavioral activation?

• Structured, brief psychosocial approach

• Based on premise that limited rewarding experiences and reduced ability to experience positive reward from the environment maintain depression

• Aims to systematically increase activation such that patients may experience greater contact with sources of reward in their lives and solve life problems that allow them to lead a more rewarding life

• Focuses directly on activation and on processes that inhibit activation, such as escape and avoidance behaviors and ruminative thinking

Key elements of behavioral activation

• Behavioral case conceptualization

• Activity monitoring and scheduling

• Identification and elimination of avoidance patterns

• Establishment of healthy routines

• Behavioral strategies for targeting worry or rumination

• Goals are specific to the individual

Targets of behavioral activation

• Avoidance behavior

• Chaotic routines

• Engagement in pleasant or valued activities

  • Pleasant events

  • Healthy habits

  • Mastery of tasks

  • Values guided activities

Individualizing activation targets

• What are you doing more or less of since you became depressed?

• What would make your life feel more fulfilling/rewarding?

• What is the relationship between specific activities/life contexts/problems and mood?

• Conduct detailed examination of what is getting in the way of acting differently or feeling better

Activation chart as a central tool in behavioral activation

• Baseline assessment of activity and relationship with mood

• Schedule activation

• Ongoing monitoring of activity and mood

• Evaluation of progress

Practical strategies to maximize activation

• plan specific strategy for implementation (what, when, where, etc.)

• Write it down

• Monitor progress, highlight consequences

• Adopt a scientific/experimental attitude

• Break tasks into manageable components

• Aim for activities that have a high likelihood of natural reinforcement

• Consider help from significant others

• Identify and block cues for avoidance

Routine regulation

• Sleeping

• Eating

• Exercise

• Basic self-care (e.g., showering, brushing teeth, doing laundry)

• Work/school

• Chores/other responsibilities

Blocking avoidance

• Orient patient to avoidance (how it impacts short-term and long-term)

• Identify behaviors that function as avoidance

• Help patient engage in alternative behaviors

Termination and relapse prevention

• Have a plan for termination from the first session (time-limited, goal-focused)

• Taper session frequency (weekly → biweekly → monthly); offer booster sessions

• Review progress: which skills helped most? → client becomes their own therapist

• Identify high-risk situations and early warning signs

• Write a relapse prevention plan

• Normalize setbacks; lapse is not relapse

Problem solving therapy

• Premise: distress is maintained by ineffective coping with life problems

• Problem orientation: positive vs. negative

• Problem-solving style: rational vs. impulsive, careless, or avoidant

• Effective for depression and comparable to other psychotherapies

Core steps

1. Define problem and set realistic goals

2. Brainstorm solutions (quantity, defer judgement)

3. Weigh pros and cons and decide a solution

4. Implement, evaluate, and revise

Contingency management

• Grounded in operant conditioning: reinforce behavior with tangible rewards

• Target behavior must be objectively verified (urine screen, attendance)

• Reinforce immediately and consistently

• Escalating rewards for consecutive successes; reset after a miss

  • Strongest evidence for substance use disorders, especially stimulants

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Definitions of theoretical models

• Specifies theory of etiology

• Intervention technology

• Mechanisms of action

• Optimal health/functioning (end goal)

Acceptance and commitment therapy (ACT)

• Action-oriented approach related to CBT

• Focus on present and future, improving current functioning and encouraging patients to try out new ways of behaving in the future

• Clients learn to stop avoiding, denying, and struggling with their inner emotions

  • Instead learn to accept these feelings

• Developed in the 1980s by Steven Hayes, PhD

ACT hexaflex model

Acceptance and mindfulness processes:

• Contact with the present moment

• Acceptance

• Defusion

• Self as context

Commitment and behavior change processes:

• Contact with the present moment

• Values

• Committed action

• Self as context

Psychological flexibility of:

1. Acceptance: are you willing to have that stuff, fully and without defense? →

2. Defusion: as this thing is, and not as what it says it is? →

3. Self as context: given a distinction between you and the stuff you are struggling with and trying to change →

4. Committed action: AND doing what takes you in the direction of →

5. Values YOUR chosen values

6. Contact with the present moment: at this time, in this situation?

Hexaflex in practice

Psychological flexibility of:

1. Acceptance: are you willing to have that stuff, fully and without defense? →

2. Defusion: as this thing is, and not as what it says it is? →

3. Self as context: given a distinction between you and the stuff you are struggling with and trying to change →

4. Committed action: AND doing what takes you in the direction of →

5. Values YOUR chosen values

6. Contact with the present moment: at this time, in this situation?

Experiential avoidance

The unwillingness to remain in contact with distressing internal experiences along with the attempts to control or avoid distressing internal experiences

• Has been associated with a range of psychopathological symptoms across a range of clinical presentations of anxiety and fear

Creative hopelessness

• You’ve tried just about everything to feel better, get rid of negative emotions; “gold medal” effort

• Could simply “try harder,” but how likely is that to work?

• What if your experience is valid? What if it won’t work because it CAN’T?

  • Man in the hole metaphor

• Control strategies are limiting and unlikely to be effective

Man in the hole metaphor

A man is doing fine, experiences a catastrophic fall into a deep crisis (the hole), and then uses his own resilience, wit, or outside help to climb back out (his shovel)

• Using the only thing he has (his shovel), he tries to get out of the hole; yet, the hole gets deeper and the problem gets worse

Why do we keep trying to dig our way out of holes?

• The shovel works elsewhere

• It seems to work for others

• You are told it should work for you

• It often does work in the short run and in some types of situations

Acceptance as the alternative to control

Are you willing?

• Not because you want or like it

• Not because you’ve given up hope it will get any better

• But instead, to openly allow the momentary pain to end the long-term suffering?

The hidden choices

• Give up “direct control” of your thoughts and emotions to gain control of your life

• Allow yourself to experience all emotions so you can also experience “good” emotions

Metaphors showing acceptance as an alternative to control

Chocolate cake metaphor:

• Trying to push away an unwanted thought will almost always backfire

• Deliberately try NOT to think about chocolate cake

Polygraph metaphor:

• Told you MUST stay relaxed when hooked up to a polygraph…and then having a weapon held to your head. Impossible to relax.

Tug -of-war with a monster metaphor:

• If you lose the tug-of-war, you will fall into a pit and be destroyed. So you keep pulling as hard as you can but you are also getting closer to the pit. The most rational solution is to let go

Acceptance of difficult content

Giving up the control agenda means:

1. Accepting the inevitability of distress; and

2. Willingness to experience that distress in the service of living a valued life

Psychological acceptance

• Ability and willingness to endure/tolerate aversive internal experiences

• Learning to accept the presence of uncomfortable internal experiences

• Engaging in behaviors even when they produce internal discomfort

What does willingness look like?

• A choice

  • Not a feeling

  • Not a belief

• An action

  • Doing, not trying

  • Jump, not a step

• Always in the serve of our goals/values and recovery

  • Not a resignation

  • Not touching the stove for the sake of touching the stove

Two scales metaphor:Not trying to control anxiety by bringing it down to zero, but by increasing your willingness. When willingness increases, the weight (distress) of the anxiety becomes less relevant because there is no longer a power struggle.

• letting go of the need to control discomfort restores your ability to act on your personal values

Can willingness alter the frequency/intensity of internal experiences?

• Short answer, yes

  • In long term, in an average kind of way

  • “Rogue waves” and life happens; inability to ever take away ALL negative feelings

• We can tell clients this directly but they have to stop trying to pick up the rope

Distress tolerance

• Psychological acceptance

• Uncoupling

• Willingness

• Pattern smashing

• Dealing with dirty distress

Uncoupling

Converting “but” language into “and” language

• I would eat all my meals and snacks today but I am afraid of gaining weight → I will eat all my meals and snacks today and I am afraid of gaining weight

Willingness

Transforming “only if” statements into “even if” statements

• I will get go to the social event only if I don’t feel too tired or depressed → I will get go to the social event even if I feel tired and depressed.

Dirty distress

Additional feelings ABOUT your distressing feelings

• “I shouldn’t feel sad — I should just get on with it.”

Cognitive defusion

• Recognizing that an internal experience is an internal experience-

  • e.g. labeling and describing thoughts as thoughts, emotions as emotions, etc.

• Learning to look at internal experiences, rather than from internal experiences

  • Automaticity and ease of programming (everyone says “lamb” after, “Mary had a little”) → applied to “I am…” statements

Cognitive fusion and defusion model

Cognitive fusion → believing literal contents of the mind, one becomes fused with their thoughts

• Goal of defusion is to disentangle people from their minds

Cognitive defusion exercises

1. Observe

2. Describe

3. Balance

• Learning to get distance from and label thoughts, feelings, and physical sensations

• Balancing inner and outer wisdom

Cognitive defusion

• the act of focusing the mind in the present moment

• the ability to bring one’s complete attention to present experiences

• the ability to observe and experience rather than evaluate and change internal experiences (thoughts, emotions, urges, hunger, fullness)

Example: leaves on a stream exercise

• muck and debris are thoughts, sensations, events, feelings, and that river/stream is our distress as we drift helplessly downstream. But we can stand on the riverbank, watching as those thoughts, events, sensations, feelings go by. You might watch individual items as they pass – perhaps a thought floating on a leaf.

Present moment awareness

Nonjudgmental awareness of the present moment

• What it is: A state of full, open, and non-judgmental awareness of your current experience—both internal (thoughts, feelings) and external (sights, sounds, sensations)

• The goal: To be fully engaged in what is happening right now, rather than being lost in rumination about the past or worry about the future

  • Focus on shifting attention back to the present moment when worries about the future or ruminations about the past emerge

Present moment awareness vs. defusion

How they work together:

• By using defusion techniques, you create the mental space to make "contact with the present moment" more fully.

• Defusion helps you stop being swept away by your thoughts, and contact with the present is the result—a direct, sensory experience of the here and now

Mindful decision-making

Awareness of immediate experiences

• Internal : thoughts, feelings, desires, hunger, cravings

• “External”: sounds, sights, smells

• STOP, THINK

Self-as-context

The Story of Me

• Organized into cognitive networks coherent across time and situations

  • Well-elaborated

  • Multi-layered

• Once we have a story, we don’t like how it feels to be “wrong” about our story: e.g. cognitive dissonance

• We work to construct our worlds in a way that confirms the truth of our self-labels.

This approach involves understanding that one's identity is distinct from thoughts and feelings, fostering a stable sense of self amidst changing internal experiences. This perspective helps individuals maintain a consistent sense of self-identity, even as their thoughts and emotions fluctuate

Common treatment-interfering conceptualized selves

Over-attachment to:

• Illness as part of identity

• Victimhood

• Likability

• Everyone else is the problem, not me

• Busyness as a virtue

• Caretaker roles

• Success/things come easy to me

What is the alternative? Self-as-context

The sense of self as perspective

• You are a person separate from your story

• Your story can and should grow and change over time

Not threatened by aversive content

• Facilitates willingness, compassion, intimacy

Self-as-context - chessboard metaphor

• The Chess Pieces (Content): These represent your transient thoughts, feelings, memories, physical sensations, and judgments. "Good" or pleasant experiences act like one side of the board, while "bad" or distressing experiences (like anxiety, sadness, or self-doubt) act like the opposing side.

• The Chessboard (Context): This represents your observing self—your stable, unchanging consciousness that holds and contains these experiences without being harmed, defined, or altered by them.

ACT teaches you to stop identifying as a chess piece trying to win a war. Instead, you shift your perspective to being the chessboard: a chessboard can hold both black and white pieces simultaneously without caring who wins or loses.

Values

Freely chosen, verbally constructed consequences of ongoing dynamic, evolving patterns of activity, which establish predominant reinforcers for that activity that are intrinsic in engagement in the valued behavioral pattern itself

Values-based decision making skills

• Values clarity

• Building a valued life

• Values-based decision making

• Values awareness

• Up votes and down votes

• Using values to address negative mood

• Addressing competing values

Values-based decision making

Behaviors as choices

• Consider options

• Consider values and goals

• Engage in behavior congruent with values

Up/down vote for values

Recognize that every decision you make is a vote up or down for your values

• Every small action you take—even when your mind is screaming at you with anxiety or self-doubt—acts like an "upvote" for the kind of person you want to be

Using values to address negative feelings/distress

• Unpleasant feelings can be an important signal that we are about to make a decision about how to behave or act.

• In this way, unpleasant feelings are an important cue that we should use a values-based decision-making skill.

Values conflict/barriers to living a valued life

1. Clarifying disorder - specific “values”

2. Values integration

3. Values prioritization

Values integration

• Even though it may feel like our values are incompatible with each other, there are always ways to integrate multiple values into one activity.

  • In other words, we don’t always have to choose one value over the other – we can live by both.

Values prioritization

• Sometimes hard/impossible to make choice that is consistent with 2 values at the same time.

• Consider which value is most important to act on (at the moment); prioritize that value

  • Don’t always default to same value!

Committed action

• Encourages taking concrete steps toward goals that are consistent with one’s values, promoting perseverance and adaptability

• Involves setting specific, values-driven goals and pursuing them despite obstacles, thereby enhancing overall life satisfaction and achievement

• Means living in line with our values even when we have difficult thoughts and feelings

• Unlike values, which are constantly instantiated but never achieved as an object, concrete goals that are values consistent can be achieved and ACT protocols almost always involve therapy work and homework linked to short, medium, and long-term behavior change goals.

• Behavior change efforts in turn lead to contact with psychological barriers that are addressed through other ACT processes (acceptance, defusion, and so on)

Homework

• Use worksheet to identify your values

• Identify areas where values are seemingly in conflict

• Practice values integration and/or values prioritization strategies