Cognitive-Behavioral Therapy Flashcards

Cognitive-Behavioural Therapy

Introduction

• Cognitive-Behavioural Therapy (CBT) is characterized by short sessions, ideally 15-20 minutes, making it efficient and cost-effective.

• CBT is collaborative and empirical in its approach.

Underlying Assumptions of CBT

• Emotional outcomes are primarily determined by interpretations of events.

• When an emotion seems disproportionate, examine the interpretation of the event.

• Emotional and behavioral changes can be achieved by modifying cognitions associated with events.

• CBT challenges patients' assumptions and cognitions, encouraging actions that test their accuracy.

• Patients are encouraged to examine the accuracy of their beliefs through systematic behavioral experiments.

• Cognitions and behaviors are targeted first because they are more accessible than emotions.

Goals of CBT

1. Identify and change maladaptive thought processes.

2. Change maladaptive behaviors.

3. Improve emotional regulation.

4. Develop coping skills and problem-solving abilities.

5. Increase self-awareness and insight.

6. Increase autonomy and prevent relapse through self-monitoring.

7. Promote activity and increase self-efficacy.

Benefits of CBT

• Structured and goal-oriented approach facilitates progress tracking and re-evaluation.

• Skills-based approach enhances client self-efficacy, enabling independent application of skills outside of treatment.

• Evidence-based and applicable to a wide range of disorders.

• Collaborative and flexible.

• Focuses on the present while acknowledging the past.

• Transparent; techniques and rationale are clearly explained to the client.

Limitations of CBT

• May be too structured, leading clients to feel restricted; Dialectical Behavior Therapy (DBT) addresses trauma-related issues.

• May not adequately explore developmental roots of issues.

• May not suit clients who are not verbal or cognitively oriented.

• Time-limited nature may be a constraint.

• Can feel invalidating if clients perceive a need to be 'fixed'.

• High dropout risk if clients don't engage with homework or see quick results.

History and Evolution of CBT

• Rooted in the Behavioural School:

  • The 'mind' is considered too vague for testing.

  • Focuses on changing behavior, prioritizing factors maintaining the issue over its origin.

  • Assessment focuses on observable, operationalized, and measurable aspects.

  • Scientific origin based on systematic empirical research.

• Limitations of Behaviorism Led to the Inclusion of Cognitions:

  • Behavioral therapy was effective for phobias and anxiety but less so for internal issues like depression.

• Cognitive Therapy:

  • Based in psychoanalysis and rational emotive therapy.

  • Provided the introspective element lacking in behavioral therapy.

Cognitive Therapy Principles

• Problems arise not from experiences themselves but from the individual's interpretation, filtered through core beliefs.

• Personal appraisal is essential.

• Beck and Ellis demonstrated that affective symptoms arise from distorted thinking.

Reasons for CBT's Popularity

1. Based within the scientific model, making it easily testable and conducive to empirical study.

2. Outcomes are positive when the assumptions resonate with patients.

3. Cost-effective and easily systematized and distributed.

4. Patients gain a sense of control and self-efficacy due to the model's focus on their actions and the collaborative therapeutic relationship.

Assessments in CBT

• Assessments must include:

  • Presenting problem across different contexts.

  • Disorder criteria met, if any.

  • Maintaining factors (social, environmental, behavioral).

  • Body states and sensations.

  • Emotion states and moods.

  • Thoughts and beliefs.

• Assessments are ongoing and collaborative, with an initial assessment to describe the patient's issues.

• Assessment differs from diagnosis; diagnosis may mask specificities of the individual, such as maintenance behaviors.

Aims of Assessment

1. Establish a therapeutic relationship (trust, rapport).

2. Establish suitability for CBT interventions.

3. Gather relevant information to formulate and create a treatment plan.

4. Psychoeducation about CBT to establish informed consent and increase faith in treatment.

Outputs of Assessment

• Problem list structured by priority.

• Possible diagnosis.

• Detailed description of issues across different contexts with specific examples.

Modes of Assessment

1. Clinical Interview.

2. Self-Report Measures:

   • Beck Anxiety Inventory (BAI).

   • Beck Depression Inventory (BDI).

   • GAD-7 (Generalized Anxiety Disorder).

   • PHQ-9 (Depression).

3. Disorder-Specific Measures:

   • Depression: BDI, PHQ-9, Reynolds Adolescent Depression Scale.

   • Anxiety: Penn State Worry Questionnaire, PHQ-9, GAD-7.

   • OCD: Obsessive Compulsive Inventory.

   • Social Phobia: Social Phobia Inventory (SPIN).

   • PTSD: Impact of Events Scale.

   • Health Anxiety: Health Anxiety Inventory (HAI).

4. Behavioural Assessments:

   • ABC (Antecedent-Behaviour-Consequence) Model.

   • Exposure hierarchies (for phobias).

5. Cognitive Assessments:

   • Thought records/diaries.

   • Socratic questioning.

   • Automatic Thoughts Questionnaire.

6. Functional and Risk Assessments.

7. Direct Observation (during sessions, roleplay, behavioural experiments).

8. Observation by Others:

   • Two-way glass, supervision.

   • Accounts by family members.

Assessing Suitability for CBT

1. Client needs self-awareness and ability to differentiate emotions.

2. Access to thoughts/images.

3. Problems must be clearly defined and bounded.

4. Person must be motivated to do homework and improve their situation.

5. Person must be able and willing to sustain a working therapeutic alliance.

6. Rationale and CBT proceedings must make sense to the client.

Clients Not Suitable for CBT

• Low insight/motivation (e.g., severe depression; consider medication first).

• Cognitive/intellectual limitations.

• Undergoing severe life changes/instability.

• High emotional dysregulation/severe presentations (e.g., BPD, C-PTSD, suicidal risk; consider medication and trauma-informed therapies like DBT).

• Extreme rigidity/self-righteousness in beliefs.

• Clients from different cultures/belief systems (discuss expected outcomes during assessment).

Formulations/Case Conceptualizations

• Specific application of general theory to the case.

Aim of Formulation

1. Understanding and conceptualizing the patient's case.

2. Provides a rationale and backbone for designing treatments.

3. Helps manage and predict issues in therapy.

A Formulation Contains

1. A detailed description of the presenting issue (thoughts, emotions, sensations, behaviors).

2. Ideas about the development of the issue.

3. Ideas about the maintenance processes.

Formulation Models

• Hot Cross Bun (Padesky & Mooney).

• 5 Ps (Dudley & Kuyken, 2006):

  1. Presenting Issues

  2. Precipitating Factors

  3. Perpetuating Factors

  4. Predisposing Factors

  5. Protective Factors

Cross-Sectional Perspective (Problem Oriented)

• Assess for current issues (ABC model).

  • Recent and well-defined examples.

  • Cognitions, Sensations, Emotions.

  • Environmental Factors.

  • Maintenance/Safety behaviors (prevent issues from resolving).

  • Maintaining Factors:

    • Core beliefs.

    • Cognitive Distortions.

    • Safety behaviors (e.g., OCD compulsions).

  • Context & Modulating Factors:

    • Internal triggers.

    • External triggers.

    • Factors influencing severity (use a rating scale).

  • Consequences:

    • Effects on self.

    • Effects on others.

    • Material consequences (e.g., job, home life).

    • Coping behaviors.

  • Adaptive behaviors and resilience factors:

    • Coping skills.

    • Support networks.

    • Character traits.

    • Important relationships.

    • Valued roles.

Longitudinal Perspective (Time Oriented)

• Assess for problem development, vulnerabilities, and predisposing factors.

  • Onset.

  • Precipitating events.

  • Problem development:

    • Time-Event Chart.

    • How the issue got worse/better.

  • Vulnerabilities & Predisposing Factors:

    • Genetic.

    • Environmental/Social.

Intervention Strategies & Techniques

• Target behaviors and cognitions.

1. A clear formulation is necessary; update or tweak the formulation as needed.

2. Strategy must match the presenting issue:

   • Generalized Anxiety: Worry tree, cognitive restructuring, behavioral experiments.

   • Panic Disorder: Interoceptive exposure, breathing retraining, experiments involving re-attribution of panic symptoms.

   • Depression: Behavioral activation, problem-solving, self-compassion work, pleasant activity scheduling.

   • OCD: Exposure & Response Prevention (ERP), cognitive reappraisal.

   • Social Anxiety: Video feedback, behavioral experiments, roleplay.

   • PTSD: Imagery rescripting, trauma-focused exposure, grounding and relaxation techniques.

3. Patient details must be taken into account:

   • Suicidal ideation & hopelessness:

     • Risk assessment, safety plan, gentle techniques.

     • Consider medication and psychiatric intervention.

   • Level of distress:

     • Behavioral interventions, pleasant activity scheduling, relaxation & grounding techniques, social skills training, problem-solving.

   • Cognitive and emotional readiness:

     • Assess curiosity and engagement.

     • Willingness to consider evidence, reattribution, and hypothesis-testing.

Psychoeducation

• If resistance or distress occurs provide psychoeducation.

Daily Thought Record

• Situation, Feeling, Thought.

Daily Mood Log

• Emotion & Rating.

• Triple Column Technique: Automatic thoughts, Distortions, and Rationale.

Double-Standard Method

• Encourage patient to relate to themselves as if they were a close friend.

Evidence Testing

• Reasons for and against a statement, alternative explanations.

Graded Thinking

• Evaluate problems on a scale of 0-100.

Re-Attribution

• Responsibility Pie.

Cost-Benefit Analysis

• Pros and cons list for the attitude or belief.

Positive Data Logs

• Encourages gratitude.

Survey Method

• Behavioral experiment for social anxiety.

Semantic Method

• Rephrasing statements to be more neutral.

Counterthinking/Cognitive Restructuring

• Challenge and reframe thoughts, identify cognitive errors.

Relapse Prevention

1. Reviewing skills and gains.

2. Identifying warning signs.

3. Planning for setbacks.

4. Develop an action plan.

5. Strengthen autonomy.

Psychoeducation (Types)

1. Identifying feelings (emotion chart/wheel, feeling faces).

2. Thought-feeling mapping.

3. Identifying Automatic Thoughts & Distortions (Thought Record).

4. Mood log.

5. Learning about cognitive distortions.

Emotion Thermometer

Behavioural Experiments/Homework

• Essential for:

  1. Test the validity of the patients’ existing beliefs

  2. Construct/test new more adaptive beliefs

  3. Contribute to the development and verification of the cognitive formulation

  4. Build the collaborative therapeutic relationship

• Formula for testing: if this theory is true, then in these defined circumstances X will happen.

• EXPERIENTIAL information is coded multimodally using different sensory systems.

Types of Experiments

• Pure/Active Experiments – the patient manipulates their environment from their behaviour;
  *Real;
  *Simulated/Role-play;

• Observational Experiments – patients set out to observe and gather evidence relevant to their specific thoughts/beliefs

Experiment Types

1) Hypothesis-Testing:
*Testing the validity of a current unhelpful cognition;
*Comparing and contrasting an unhelpful cognition with a new more helpful one;
*Directing patient attention to situations likely to provide evidence for a new perspective;

2) Discovery

Steps for Behavioural Experiments

1. Identify the cognition(s) to be tested (0–100%).

2. Identify an alternative (0–100%).

3. Devise an experiment.

4. Identify likely problems.

5. Outcome: What happened?

6. What have you learned? New belief (0–100%)?

7. What next?

Pleasant Event/Activity Scheduling/Behavioural Activation

• Useful for depression.

1. Psychoeducation: thought-feeling linking.

2. Activity brainstorming:

   • Pleasure

   • Mastery

   • Values-based

Relaxation Training & Mindfulness

1. Mindfulness

2. Breathing training

3. Progressive Muscle Relaxation

4. Adaptive Self-Statements

5. Guided Imagery & Meditation

Social Skills Training (SST)

• Assess lacking skills.

• Create clear goals.

• Instruction → Modelling → Role-play → Feedback → Homework.

Problem Solving Training

1. Relaxation Techniques Training.

2. Teach identification of problem.

3. Teach brainstorming techniques.

4. Evaluate strengths and weaknesses.

5. Say yes to one/two of the proposed solutions.

6. Homework: trying out the problem-solving technique irl.

Psychodrama techniques/Roleplay

• Teaching a socially anxious person to speak up within a safe setting

Affect Regulation

• Teach identification of emotions and the buildup when it is occurring
  *WHAT is the emotion
  *STRENGTH of the emotion
  *HOW the emotion feels (rating)

Cognition

1) Process: flexibility in switching between different ways of processing
2) Content: appraisals of ourselves, others and the world + interpretations of events

Levels of Cognition:

1) Automatic thoughts – automatic, involuntary thoughts
2) Underlying assumptions – operating principles/rules
3) Core beliefs – enduring, global beliefs
4) Schemas – deep, enduring cognitive structures
5) Metacognitive beliefs – theories and beliefs held about their own cognitions

The Learning Circle (Lewin & Kolb)

Plan → Experience → Observe → Reflect

Cognitive Distortions & Errors

Overgeneralisation

Drawing a conclusion from a single incident

Mental Filter

The person ‘filters out’ positive experiences and focuses exclusively on the negative

Discounting/Disqualification

Discarding/downplaying evidence of positive experiences

Jumping to Conclusions

Thoughts would not be supported by evidence

Blowing out of Proportion

Focusing on a detail taken out of context

Magnification/Minimization

Errors in evaluating based on over/underemphasising certain aspects of situations

Emotional Reasoning

Thinking something is true, despite evidence of the contrary, just because it elicits strong emotions

‘Should’ Statements

Using ‘I should have/be_ ’

Labelling

Placing of a global label on oneself & others

Personalisation

Thinking everything is about ‘you’

Dichotomous Thinking (All-or-Nothing/Black-and-white)

everything is either good or bad

Catastrophizing/Fortune-telling

Predicting the future excessively negatively

Mind Reading

The belief that one knows what other people are thinking