CCPX 4037: Introduction to Cognitive Behavior Therapy (CBT) Midterm

The mid-term will focus on information from the first half of the semester (CBT for depression). It will also consist of multiple choice, short answer, and essay.

CBT is comprised of

Cognitive Therapy & Behavioral Therapy

Cognitive Restructuring Techniques

• Thought Records

• Socratic Questioning

• De-catastrophizing

• Identifying Cognitive Distortions

• Behavioral Experiments

Best treatment associated with the best evidence for depression

Cognitive Therapy (CT) - change thoughts, change mood, change behavior

Behavioral Obstacles

Actions that serve to maintain depression

Precipitating Factors

Factors that influence perceptions at onset of depression

Developmental Events

Events in childhood &/or adolescence that predispose client to depression

Enduring Patterns of Interpretation

The continuous and prolonged interpretation one has with circumstances around them

Cognitive Model

People’s emotions, behaviors, and physiology are influenced by their perception of events

Behavioral Therapy

Study of how behaviors are learned and reinforced, focusing on modifying maladaptive behaviors to improve emotional well-being

“Third Wave” CBT

Focus on changing FUNCTION of psychological events rather than content of thoughts (e.g. Acceptance & Commitment Therapy, Cognitive Diffusion, Mindfulness-Based Cognitive Therapy)

Classical Conditioning

A learning process that occurs through associations between an environmental stimulus and a naturally occurring stimulus, leading to new behavior responses; Ivan Pavlov

Operant Conditioning

A learning process where behaviors are reinforced through rewards and punishments, influencing the likelihood of the behavior being repeated; Burrhus Skninner

Behavioral Concepts

Systematic desensitization; Aversion Therapy; Flooding

Systematic Desensitization

• Based on Graduated Exposure Theory

• Associates pleasant relaxed state with gradually increasing anxiety-triggering stimuli until anxiety to stimuli is eliminated;

• 3 steps:

1. Relaxation Training

2. Hierarchy construction

3. Systematic Desensitization Proper

Aversion Therapy

• Pairing pleasant stimulus with unpleasant response so pleasant stimulus becomes unpleasant by association

Flooding

• Usually for phobias and anxiety disorder

• Patient directly exposed to phobic stimulus for prolonged duration and escape made impossible

• Therapist’s guidance, encouragement, and modelling important to decrease anxiety around phobia

• Can lead to extinction of fear

Reinforcement

Concept used to increase the likelihood of a behavior being repeated

Positive Reinforcement

Involves addition of a certain stimulus/item to increase a response

Negative Reinforcement

Involves removal of a certain stimulus/item to increase a response

Punishment

Given when undesired response occurs in order to decrease said response

Time Out

Reinforcement is withdrawn for some time

Modelling

Patient learns new behavior by imitation, primarily by observation

Psychodynamic Theory

Posits that unconscious psychological processes determine thoughts, feelings, and behavior

Cognitive Therapy

Focuses on identifying, evaluating, and modifying negative automatic thoughts and core beliefs (schemas)

• Developed by Aaron Beck in early 1960’s

• Thoughts affect mood, affect behavior

• Identified that negative cognitions are primary feature of depression and developed a short-term treatment that allows patients to test reality of depressed thinking

How long to CBT sessions last?

• 45-55 minutes; 12-16 sessions

• By session 8, most of the change as already been done for the patient

Structure of CBT Session

1. Check mood during session, during past week , during situation, after reframing situation (mood score 0-10), other symptoms (use scales), monitor medication adherence

2. Review Presenting problem/homework/Action Plan

3. Set agenda for session

4. Discuss items on the agenda (apply old and new CBT techniques)

5. Assign homework/Action Plan

6. From time to time, review goals, summarize progress, BOTH client and therapist give feedback and review direction

Structure of CBT Treatment

1. Assessment

2. Psychoeducation

3. Looking at patient’s problem

Basic Principles of CBT

1. Individualized conceptualization of each patient

2. Requires a therapeutic alliance

3. Emphasizes collaboration and active participation

4. Therapy process is goal-oriented and problem focused

5. The present is emphasized

6. Teach patient to be own therapist

7. Time-limited

8. therapy session structured

9. Teach patients to evaluate and respond to their dysfunctional thoughts and behaviors

Tripatite Model/Think-Feel-Do Cycle

• Emotions hardest to change

• Easier to change thoughts and behaviors

• Teach clients to identify their thoughts and behaviors

• Changing thoughts and behaviors improves mood

DSM-V Major Depressive Episode Diagnosis

• Often based on self-report

• Comes in episodes

• Person must have at least 5 of following symptoms listed below

• Each symptom must have been present for at least 2 weeks, nearly everyday

• Symptoms 1 & 2 or both must be present for most of the day

• Symptoms result in impairment or distress

1. Sadness

2. Loss of Interest/Pleasure

3. Appetite/Weight Problems (e.g. eating too much or too little)

4. Sleep problems (e.g. sleeping too much or too little/Hypersomnia or Insomnia)

5. Tiredness/Lack of energy

6. Poor concentration (difficulty in thinking or decision making)

7. Movement (e.g. moving too slow or fast as seem=n by others)

8. Worthlessness and/or guilt

9. Suicidality (person thinks life isn’t worth living; has a plan for/tried to kill themselves)

Depression Triggering Events

• Loss

• Rejection

• Failure

• Stress

• Isolation

Depression Emotional Responses

• Sadness

• Hopelessness

• Shame

• Guilt

• Anxiety

Psychoeducation

• Conduct assessment (e.g. PHQ, HDRS, Suicidality Questionnaire) and share diagnosis with patient

• Take blame away from having depression

• Instill hope about symptom relief

• Potential triggers of symptoms

• Identify support system

• Explain the CBT treatment model and rationale

Pleasurable Behaviors

Behaviors that make someone feel good

Mastery Behaviors

Behaviors that make feel accomplished

Passive Suicidal Ideation

Wish to go to sleep and not wake up

Active Nonspecific Suicidal Ideation

No method, intent, or plan

Active Suicidal Ideation (Method)

Method but no intent or plan

• Need safety plan

Active Suicidal Ideation (Method, & Intent)

Method, intent, but no plan

• Need safety plan

Active Suicidal Ideation (Method, Intent, and Plan)

Method, intent, and plan

• Need safety plan

Completed Suicide

Self-injurious behavior that resulted in fatality and was associated with at least some intent to die as a result of an act

Intent does not have to be explicit. For example, a patient denies intent to die, but thought that the behavior could be lethal. Intent can be inferred.

Suicide Attempt

A self-injurious act committed with at least some intent to die

Intent does not have to be explicit. For example, a patient denies intent to die, but thought that the behavior could be lethal. Intent can be inferred.

Interrupted Attempt

Individual is stopped by an outside circumstance from starting the self-injurious act (e.g. just didn’t work due to external factors or someone stepped in to stop it)

Aborted Attempt

Individual take steps towards a suicide attempts but stop themselves h=before engaging in any potentially self-destructive behavior/completed suicide

Presence of Intent to Die

Differentiates suicidal acts from self-injury

Management of Suicidality

• Assess warning signs (e.g. verbal, behavior, mood)

• Assess ideation, intent, and plan

• Develop a safety plan

• Discuss options for reducing availability of suicide methods

Safety Plan

• A collaboratively developed plan (NOT a traditional contract ) that builds on a detailed analysis of the specific circumstances and emotional reactions leading to suicidal behavior or to a past attempt.

• Its aim is to prevent tension from building to uncontrollable levels and providing alternative, nondestructive means of dealing with anger, frustration, or loss

• Developed by the clinician who obtains information of events occurring of events occurring before, during, and after most recent suicidal crisis

• Using a problem-solving approach, patient and clinician sit side-by-side and collaborate to develop

• Original document given to patient, and copy is kept in the medical record

  once he/she indicates willingness to use the plan

Should be:

• Brief and use the patient’s own words

• Easy to read

• Review periodically

Suicidality Risk Factors

• History of attempts (family history as well)

• Substance use

• Hopelessness

• Guilt/shame

• Lack of social support

• Level of impulsivity

• Financial and other stressors/trauma

• Access to means

• Agitation

• High anxiety

• Psychosis

• Exposure to other suicides

Negative Affect

The tendency to experience high levels of distress, such as anxiety, anger, guilt, and fear

• Threat/Loss System

• Amygdala

• Insula

• Stress Response System

• Detects danger and loss

Low Positive Affect

The absence of joy, enthusiasm, energy, and interest in pleasurable activities (anhedonia)

Traits:

• Reward Approach system

• Ventral Striatum/Nucleus Accumbens

• Dopamine Pathways

• Reward Learning Systems

• Detects reward and opportunity

CBT Goal Setting

• Long-term and short-term goals

• Break a big goal into small manageable goals

Example Questions:

• What would you like to be different?

• What would you like to get out of this program?

• If say “be happy, better”, ask “If you felt ____, what would you be doing?”

• What changes do you want to see in yourself?

• How do you want things to be in 6 months? 5 years?

CBT Techniques & Skills to Decrease Negative Mood/Affect and Depression

• Emotional Thermometer (0 = “Best I’ve ever felt” and 10 = “Worst I’ve ever felt”)

• Daily Mood Monitoring

• Behavior Activation (BA)

• Problem-Solving Skills

• Cognitive Restructuring

Behavior Activation (BA)

Change behavior to improve emotions; Increase pleasurable and mastery activities which results in increasing amount of positive reinforcement and productive behavior

• How: reward planning, activity scheduling

• Behavior Activation Table

Rewards can be internal and external

• Increasing rewards improves mood

• Leads to more productive behavior

• Decrease negative thoughts/rumination by focusing on direct experience

Problem-Solving Skills

• Identify the problem

• Cost-benefit analysis of solving problem

• Gather information and determine resources

• Generate many solutions (w/o evaluating them)

• Rank order solutions (most to least desirable)

• Create a plan of action based on above

• Identify each necessary step to take/resources

Cognition Levels

• Automatic Thoughts

• Intermediate Beliefs

• Core Beliefs

Automatic Thoughts

• Automatic, situation specific thoughts

• Closest to mood and behavior

• Usually unaware, but can become accessible with training

• One of the focuses of CBT

Intermediate Beliefs

• Overall rule, expectations, values (“If…, then…”)

• Not as accessible

• One of the focuses of CBT

Core Beliefs

• Core beliefs about self and others

• Often based on previous experience

• Shape how people perceive situations

• Very emotionally charged, rigid, unaware

• Not focus of CBT

Questioning Automatic Thoughts

Ask:

• How much do you believe that this is accurate? 100%? 50%?

• Where is the evidence that your automatic thoughts are accurate? Evidence that supports it? Evidence against it?

• If it’s accurate, what does it mean about you as a whole person? What can you do about it?

• What’s the worst that could possibly happen?

• What is the best that could possibly happen?

• What is the most realistic?

• What will happen if I keep believing in your automatic thought?

• What could happen if you change your thoughts?

• What would you tell a friend thinking the same thoughts in this situation?

Cognitive Distortions

• All-or-nothing thinking: black or white, no gray area

• Overgeneralization: making overarching conclusions (always/never)

• Mental filter: focus on one detail, miss big picture

• Discounting the positive: good things don’t count

• Mind reading: assume know what others think

• Catastrophizing/Fortune telling: exaggerate how bad things are/will be

Relapse Prevention

• Evaluate clinical progress

• Evaluate progress on CBT themes

• What tools were helpful?

• What are the future anticipated stressors? What

• CBT tools could help in those circumstances?

• When and how will patient get in touch with therapist? Conduct a relapse drill: “how will you know you are getting depressed again”? How can you reach me?

Safety Plan Components

1. Recognize warning signs of a suicidal crisis about to happen

2. Identify and employ internal coping strategies without needing to contact another person

3. Utilize settings and contacts with people as a means of distraction from suicidal thoughts and urges

4. Contact family members or friends who may help to resolve a crisis and with whom suicidality can be discussed

5. Contact mental health professionals or agencies

6. Reduce potential use of lethal mean

Socratic Questioning

Asking many questions to help patients see themselves