Introduction to CBT - Behavioral Activation & Cognitive Model

Blood Injection Injury Phobia

• Uniqueness of blood pressure drop, associated with fainting

• Applied tension paired with exposure

  • Tense body parts to increase blood pressure so that during exposure when the blood pressure drops, it doesn’t drop to the point that could cause fainting.

• Need to be in contact with medical provider when conducting exposures.

Generalized Anxiety Disorder (GAD)

• Worry exposure is a specific variant of imaginal exposure

• Worry = a chain of catastrophising 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.

• Worry diary:

  • What would happen/feel like if the worry happens

  • How would the worry be handled

  • Likelihood of it happening. 

Addressing Non-Compliance

• Psychoeducation

• Prep clients ahead of time for the difficulty of tx

• Reduce difficulty of exposures

• Problem solve expected difficulties with compliance ahead of time

• Enlist at home support

• Increase the frequency of therapist contact

• Make sure to identify the real barriers to compliance

• Openly discussing the possibility of termination/referrals

• Use ABBT strategies to improve distress tolerance/values clarity

CBT for Depression

• Large literature establishing efficacy and effectiveness

• Antidepressants = CBT = Interpersonal therapy (IPT), at post & 18-month follow ups

• General conclusion: 30-50% response rate, regardless of treatment

• Ideally, antidepressant medication is taken in combination with CBT

• For severe depression CBT = medication

• 1 year relapse rates

  • CBT: 12-20%

  • Medication: 60-80%

Behavioral Activation (BA)

• Structured, brief psychosocial approach

• Behavioral component of CBT

• 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

Efficacy of Behavioral Activation

• BA by increasing pleasant events for the treatment of depression

• BA as the behavioral component of cognitive therapy treatment for depression

• BA as an independently effective intervention for depression 

• BA as a stand-alone behavioral treatment for Major Depressive Disorder.

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

BA Case Conceptualization for Depression

• Life events

• Less rewarding life

• Sad, tired, worthless, indifferent, etc

• Stay home, stay in bed, watch TV, withdraw, ruminate, etc.

• Loss of friendships, conflict with supervisor at work, financial stress, poor health, etc.

Targets of Behavioral Activation

• Avoidance behaviors (inertia, withdrawal, isolation, ruminating, etc.)

• Chaotic routines

• Engagement in pleasant or valued activities

  • Pleasant events

  • Healthy habits

  • Mastery tasks

  • Values guided activities

Ways to Individualize 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.

Activity Chart

• Central took in BA

• Baseline assessment of activity and relationship with mood

• Schedule activation (e.g., hourly week schedule)

• On-going monitoring of activity and mood

• Evaluate 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

Important Factors when doing BA

• Work with patient to develop regular routine for basic life activities

  • Sleeping

  • Eating

  • Exercise

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

  • Work/School

  • Chores/Other Responsibilities

• Orient patient to avoidance (how it works in short run and long run)

• Identify behaviors that function as avoidance

• Help patient engage in alternative behaviors

Targeting Rumination

• Important part of CBT

• Can function as avoidance

• Can maintain depression

• Focus on context and consequences, not content

Cognitive Triad and Depression (Aaron Beck)

• Negative views about the world

• Negative views about the future

• Negative views about oneself

Clinical Implementation of Cognitive Therapy

• Protocols typically 12-25 weekly sessions (2X weekly initially for severe depressives)

• Model: cognitive triad (self, environment, & future)

• Importance of nonspecifics (warmth, genuineness, accurate empathy)

  • Essential for the success of the therapy

• Focus: rational, linear thinking

• Highly directive

• Collaborative relationship

Cognitive Therapy Strategies for Depression

• Intro to cognitive model (e.g., cognitive triad)

• Eliciting and recording automatic thoughts

• Testing and/or questioning automatic thoughts

  • Use of Socratic questioning very important in cognitive therapy

• Identifying and adopting alternative/adaptive thoughts

  • “Act as if (this thought was true)”

  • “Try on for size”

• Core belief work (sometimes)

• A focus on the content of thinking

• A focus on the context and consequences of thinking

Cognitive Model

A situation provokes a thought (e.g., core belief, cognitive distortion) that leads to an emotion which leads to a behavior. 

• If two people have the same situations but different emotions and behaviors, the thought each one had about the situation was different.

Though Record

A CBT therapeutic tool

• Situation

• Automatic thoughts

• Emotions

• In more advance charts: alternative response, future steps