Cognitive Behavioral Therapy

When was the first wave of cognitive behavioral therapy?

-Began in 1950s and 1960s by Joseph Wolpe

-Started out as Behaviorism or Behavior Therapy

-Systemic Desensitization

-Utilizes the learning theory

How did cognitive behavioral therapy begin developing?

-Beck noticed that depression patients tended to have a more negative and distorted thought process about themselves

-Examples: Pts tend to see themselves as failures, worthless, and unlovable

-Pt's don't notice their negative thought processes and beck decided that we should bring awareness to these thought processes to patients to help change their mindset

When did the second wave of cognitive behavioral therapy begin?

-Began in the 1960s-1970s by Aaron Beck

-Began looking at thought, interpretations, and beliefs

-Effective treatment for depression as an antidepressant medication

What was the third wave of cognitive behavioral therapy?

-Various therapies including: Acceptance and Commitment Therapy (ACT), Mindfulness Based Cognitive Therapy (MBCT), Dialectical Behavior Therapy (DBT)

-Started in 1970's

- Mindfulness, acceptance, dialectics, relationships, values, spirituality: Primacy of engaging emotional process, behavioral change, and attentional control

-Dealing with not only what we think but how we think

What is the philosophy of CBT?

-All psychological problems involve problems in thinking

-The thinking is not the "cause" of psychological problems, per se

-Once a person has a psychological problem (such as depression or anxiety) - a problem in thinking is operating

What examples of the thought process of a depressed patient?

-When someone is depressed, their thinking style may be to ruminate on the negative aspects of their experience

-"I'm such a failure"

-"I can't do anything right"

-"Things will never get better"

What examples of the thought process of a anxiety patient?

-When someone is anxious, their thinking style may be to ruminate on the feared aspects of their experience (often fears around future outcomes)

-"I won't be able to handle this"

-"Something terrible is going to happen"

-"This is awful"

What are core beliefs of a person?

-Core beliefs are a person's most fundamental beliefs about themselves, other people, and their worlds

-These beliefs develop in childhood as the child interacts with significant others and encounters a series of situations.

What are characteristics of negative core beliefs of a person?

-Negative core beliefs tend to be more global, overgeneralized, and absolute

-People tend to always find evidence to support these negative core beliefs but ignore ways to refute it/prove it wrong

What are automatic thoughts of a person?

-Automatic thoughts are not deliberate or reflective

-They "pop up" spontaneously in situations

-They are usually very brief and often outside of our awareness

-They can be in verbal form, images, or both

-With practice we can begin to build awareness of them and evaluate them to see if they are useful or valid

What are negative automatic thoughts?

-Stems from self-doubt where some people have more than others causing low self esteem and confidence in one self to be successful in their goals/career

-More resilient people tend to be bolstered by more positive views of theirselves causing them to be able to overcome their self doubt in stressful situations

-Ppl with psychological disorders have crippling self doubt that affects their ability to do tasks confidently

What is an example of negative automatic thoughts?

-Case: A person becomes depressed after having heart surgery

Reasons:

-Depressed because they feel useless being off from work (may reflect doubts about competence)

-Depressed because they feel lonely (may reflect doubts about lovability)

What are the 3 types of negative automatic thoughts?

1. Distorted in some way, and occurs despite objective evidence to the contrary

-"I'm such an idiot" [distorted]

2. The thought is accurate, but the conclusion drawn is distorted

-"I didn't follow through on my homework/physical therapy exercises" [accurate] "I am worthless" [distorted]

3. The thought is accurate, but dwelling on it is dysfunctional when it causes distress

-"I am so overweight, it will take me years to reach my goals" [accurate]

-Look at utility of this thought, "It's true it will take me years to reach my overarching goals, but I can set smaller goals along the way that will keep me moving forward"

What are rules/compensatory strategies that help us live with core beliefs?

-Developing conditions that help us live with core beliefs

-IF I do/don't[engage in the compensatory strategy] ...

-THEN my [negative core belief/"true self"] will/won't be exposed.

-These compensatory strategies are used by all of us at times, but people with mood and anxiety disorders overuse these strategies at the expense of more functional strategies

What is cognitive distortion?

A term used to describe a pattern of thinking, or "self-talk", that consistently shifts life events into a negative framework.

-Distorted thinking

-Thinking errors

-Logical Fallacies

-Stinking thinking

What is the error of all or nothing thinking/thought processes?

-All-or-nothing thinking (Black-and-white): You view a situation in only two categories instead of on a continuum.

-Example: "If I'm not a total success, I'm a failure."

What is the error of catastrophizing thinking/thought processes?

-You predict the future negatively without considering other, more likely outcomes.

-Example: "I'll be so upset, I won't be able to function at all

What is the error of disqualifying or discounting the positives of something thinking/thought processes?

-You unreasonably tell yourself that positive experiences, deeds, or qualities do not count.

-Example: "I did that project well, but that doesn't mean I'm competent; I just got lucky."

What is the error of emotional thinking/thought processes?

-You think something must be true because you "feel" (actually believe) it so strongly ignoring or discounting evidence to the contrary.

-Example: "I know I do a lot of things okay at work, but I still feel like a failure."

What is the error of labeling thinking/thought processes?

-You put a fixed, global label on yourself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion.

-Example: "I'm a loser. He's no good."

What is the error of Magnification/minimization thinking/thought processes?

-When you evaluate yourself, another person, or a situation, you unreasonably magnify the negative and/or minimize the positive.

-Example: "Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn't mean I'm smart."

What is the error of mental filter thinking/thought processes?

-You pay undue attention to one negative detail instead of seeing the whole picture.

-Example: "Because I got one low rating on my evaluation [which also contained several high ratings] it means I'm doing a lousy job."

What is the error of mind reading thinking/thought processes?

-You believe you know what others are thinking, failing to consider other, more likely possibilities.

-Example: "He's thinking that I don't know the first thing about this project."

What is the error of overgeneralization thinking/thought processes?

-You make a sweeping negative conclusion that goes far beyond the current situation.

-Example: "[Because I felt uncomfortable at the meeting]I don't have what it takes to make friends."

What is the error of personalization thinking/thought processes?

-You believe others are behaving negatively because of you, without considering more plausible explanations for their behavior.

-Example: "The repairman was curt to me because I did something wrong."

What is the error of "should" and "must" thinking/thought processes?

-You have a precise, fixed idea of how you or others should behave and you overestimate how bad it is that these expectations are not met.

-Example: "It's terrible that I made a mistake. I should always do my best."

What is the error of tunnel vision thinking/thought processes?

-You can only see the negative aspects of a situation.

-Example: "My son's teacher can't do anything right. He's critical and insensitive and lousy at teaching."

How can we educate patients using CBT who experience negative automatic thoughts?

-Educate her about the connection between her thoughts, feelings, and behavior

-Educate her about the difference between "thoughts" and "facts"

-Assign the ABCDE thought challenges to do along with physical therapy exercises to look for themes together

-Observe together the impact of typical automatic thinking and its connection with ineffective coping responses

What is the thought process/questions we can give patients to perceive their negative thoughts and help them break out of their negative thought processes?

1. What is the evidence?

-What is the evidence that supports this idea?

-What is the evidence against this idea?

2. Is there an alternative explanation?

-What is the worst that could happen?

-Could I live through it?

-What is the best that could happen?

3. What is the effect of my believing the automatic thought?

4. What could be the effect of changing my thinking?

5. What could I do about it?

6. What would I tell ___________ (a friend) if he or she were in the same situation?

What does this thought process of a patient re-interpreting their negative thoughts?

-Assists with breaking down the day into more manageable pieces

-Helps with reality checking

-Helps patient and therapist look for more effective ways to use the day or validate current schedule

What relaxation techniques can be used to help with lessening negative thoughts and perceptions of oneself?

Deep Breathing

-The way you breathe affects your whole body. Breathing exercises are a good way to relax, reduce tension, and relieve stress.

-Progressive Muscle Relaxation

-Patients can try different exercises to see which work best for them.

What are behavioral experiments that can be done in CBT to help patients move past their automatic negative thoughts?

-Life "experiments" set up to test the validity of the patient's thoughts or assumptions

-Example: "I am not qualified to get any new job"

-Experiment: Bring job listings to session so we can evaluate credentials needed

-Example: "I don't know how to confront my boss about passing me over for a promotion"

-Experiment: Do role play in session

-Example: "If I move my knee more, it will hurt too much"

=Experiment: Gradual movements in physical therapy

What is the ABCDE thought challenge to help patients fight their negative automatic thoughts?

-Activating Event

-Belief

-Consequence (emotional, behavioral, physical)

-Disputes

-Effects or Emotional Recovery

How has CBT been used in Physical Therapy research?

-Complex regional pain syndromes

-Chronic pain

-Somatization

-Prevention of long-term disability

-The roles of psychological factors in tx outcomes:

-Attributions of change

-Self-efficacy

-Acceptance

What does a physical therapist look for to use CBT in physical therapy?

-"Raw data" is collected from the patient

-Attempt to understand the patient's worldview

-Therapist notices how the patient responds across situations to look for patterns and themes

-Assesses what compensatory strategies the patient using to avoid the pain of their core beliefs

How is CBT used in physical therapy?

-Thoughts lead to Feelings and Behaviors

-What you think influences how you feel.

-Sometimes your thinking is not right or just partially right

-Example - if you think you that your physical therapy will never help you feel better, you might feel sad, and then not consistently do your exercises

-Example - if you believe the pain of doing physical therapy is "unbearable" then you feel afraid or anxious and may not do the treatment plan needed to regain mobility

What is the process of using CBT in physical therapy with patients?

-Together we will:

1. Identify your automatic thoughts

2. Evaluate and respond to your automatic thoughts

3. Problem-solve if the thoughts are true

4. Find more effective ways to respond if not true or only partially true

How can physical therapist incorporate CBT in real time during a treatment session with a patient?

-Think of integrating CBT into "real time" of PT sessions vs. adding time to sessions

-Begin sessions by checking in about mood and motivation

-"How did your exercises go this week?"

-"Did you notice any thoughts, feelings, or bodily sensations that got in the way of your exercises?"

-"Would you be open to looking at these with me as part of our work together/treatment plan?"

-Teach/model identifying automatic thoughts during the session "Are you noticing any reactions to the exercises we are doing right now?

What are breathing techniques that incorporated with CBT?

-Teach/model deep breathing esp. during exercises that are painful or more difficult

-"Let's make sure to breathe during this series. I will count in for 4 and out for 4.

-What did you notice while breathing?

-Would you be open to trying this type of breathing during your homework exercises?"

What are CBT questions you can ask at the end of sessions to gauge changes in a patient's feelings?

-Elicit feedback at end of sessions around feelings of pleasure and mastery (rate 0 - 10)

-Help patients connect that action results in an improved sense of well-being and competency (improved emotions)

-"Do you notice a difference in how you feel now vs. how you felt when we started the session?"

What is overall takeaways of CBT in physical therapy and how we can educate and give it to patients?

-Augment PT with CBT!

-Educate about types of "thinking errors"

-Encourage Behavioral Experiments to "test out" hopeless automatic thoughts

-With client like this, use in session experiences as much as possible

-Assign Activity Chart (leave some time at end of session to specifically find a time of day to schedule physical therapy exercises)

-Follow-up with homework at each session

-Help patient identify "automatic thoughts" that may have gotten in the way of her doing the homework

-Consider assigning ABC's to further support this