Psych 3501 Exam 3: Cognitive Behavior Therapy

Cognitive behavior therapy (CBT)

Structured: every session of CBT generally follows the same format

Time-limited: 12-20 session in general

Present-focused: targeting on current thought patterns/behaviors

CBT Goals

Develop strategies to modify dysfunctional thinking patterns or cognitions ("C")

Develop strategies to modify maladaptive emotions and behaviors ("B")

CBT Skills

help the client develop a new set of skills to reduce symptoms and to maintain in the long-run through collaboration

Increase awareness of thoughts and emotions

Identify how situations, thoughts, and behaviors influence emotions

Improve emotions by changing thoughts and behaviors

- Collaboration is important

- What sets CBT apart: teaching skills & homework to reinforce skills learned

- Focused on skill acquisition

General session structure

Symptom check

Bridge from previous session: linking today to what you did last time

Agenda setting: what we are going to do today

Homework review

Agenda items: go through

Assign homework

Session summary and feedback

Symptom check

Brief assessment: the level of symptom severity the client is presenting today

Goals:

Track progress over time

Make progress explicit to client: the client can see symptom decrease

Alerts therapist to symptoms that require immediate attention

Bridge from previous session

Identify negative reactions

Make sure goals are met

Identify agenda items to put on the current session

Agenda setting

Collaborative process to identify topics for session

- “What do you want to discuss/accomplish today?”

Models a systematic approach to problems

- Good problem-solving model to clients

Provides structure to session

Use agenda items to meet treatment goals and facilitate skill development

Homework review

Reinforce importance of between-session practice

- Always check in to show client that it’s important

Assess skill acquisition

- What did you learn from the homework? What impact?

- Opportunity to reinforce the CBT principles

May be brief or take most of the session

Dealing with noncompliance

- Identify barriers: too challenging? Too time-consuming?

Agenda items

Address in order of importance agreed upon by client and therapist

Therapist identifies CBT principles underlying each problem

Uses problems to teach CBT skills

Assign homework

Essential component of CBT

Reinforce in-session learning

Practice skills in real life

Collaboration fosters compliance

- The client comes up with ideas for homework

- Also test for their understanding of the session

Good homework assignments set clients up for success

- E.g., thought record: did it one time in session so the client understands how to do it

- Realistic, plausible

Concrete goals

Break down to exactly what you are asking them to do

Session summary and feedback

goal: knowledge check, address misunderstandings

Summary initially by therapist, later by client

What was the most helpful thing that we discussed in today's session?

What will you take away from this session?

Unaddressed agenda items

Feedback from the client

CBT application and efficacy

Efficacious for almost every disorder that has been assessed

For all different disorders, good response rates for CBT, better than controls

CBT: the "gold-standard" for psychotherapy

1. CBT is most researched psychotherapy

2. No other psychotherapy shown to be systematically superior to CBT

- May be not significantly different, but no evidence of "better"

3. CBT theoretical models/mechanisms of change most researched, consistent with current neuroscience paradigms of human mind and behavior

- E.g., information processing; learning and memory

Cognitive Processing Therapy (CPT)

Specific CBT psychotherapy for PTSD

Impact statement

Write down what your traumatic experience means to you. Why do you think it occurred? How did it impact your thoughts, perceptions and beliefs about yourself, others, and the world in general?

Goal: to understand the meaning of the trauma to the client without getting into details yet

Use the impact statement to identify stuck points

Stuck points

Unhelpful, maladaptive thoughts that keep the client “stuck” from recovering

Thoughts about why the trauma happened

Thoughts about self, others, the world have changed because of the trauma

Often an “if…then…” structure

- E.g., if I had been paying attention, no one would have died

Often have extreme language

- E.g., I am damaged forever because of the assault

Challenging stuck points

Evidence for and against?

Is the stuck point missing information?

Does the stuck point include black/white thinking?

Does the stuck point originate from a reliable information source?

Does the stuck point conflate possible with likely?

A-B-C analysis

Similar to thought record

A: activating event

B: belief/stuck point

C: consequence

Written trauma account

Around session 3-4, not directly jump in

Full written account of the trauma with sensory details

Read account daily (homework)

Read account in session with emotion expression

- Reliving experience

Rewrite with more detail

- The first draft is usually thin on details

- As exposure increases, they are able to increase more details, making the exposure more robust

Goal: engage with the fear stimulus, anxiety goes up, and learn that you can tolerate it, so it goes back down, eventually for the client to be able to discuss the event without the impact

Efficacy of CPT for PTSD

Comparing CPT to waitlist control/placebo: large effect size

Comparing CPT to another evidence-based psychotherapy for trauma: small significant difference better than the other psychotherapy

Conclusion: efficacious as treatment for PTSD

Is the exposure piece needed?

There is no significant difference in CPT outcomes with or without the written exposure

Significantly lower symptom reduction in military compared to non-military

Rates of dropout from CPT

CPT comparing to other treatments for PTSD

Relatively higher than other treatment, but not dramatically so

Dropout higher for military compared to non-military clients

Predictors of dropout

Factors in-session that are predictive of dropout:

Physiological distress: higher distress associated to lower dropout

Avoidance: higher avoidance associated to higher dropout

Cognitive emotional processing: higher processing associated to lower dropout

Engaging -> getting a desired effect

Summary