Transcript Concepts, theories and models

Cheryl Jordan
Lecturer KCL.
►
► What
is your current
understanding/training/experience with CBT?
►
What do you see as being a key concept in
CBT practice?





Introduction to concepts, theories and
models underpinning CBT practice
Assessment and formulation within CBT
practice
The course of therapy
Overview of cognitive behavioural techniques
The therapeutic relationship in CBT
“Man is not affected by events but by the views
he takes of them” ( Epictetus)
“There is nothing good or bad but thinking
makes it so” ( Hamlet, Shakespeare)

Interacting systems

Cognitive principle
Emotional reactions are strongly
influenced by cognitions
Behavioural principle
What we do is crucial in
maintaining or in changing
psychological states
Fear of a particular
situation /object
No change to fear beliefs
Client does not learn coping
Strategies or expose beliefs
to disconfirmation
Escape/avoidance
Depression
Loss of positive rewards
Negative thoughts
( activity is seen as pointless)
Reduced activity
The continuum principle
Emotional problems arise from
exaggerated versions of
Normal process

Here and now
Focus on what’s happening in
the present and what
processes are maintaining it.

Characteristic cognitions in different
problems

Depression: themes of loss and failure

Anxiety: themes of threat and danger

Anger ?
Cognitive
consequences
Un/healthy negative
emotion
Anger
Behaviour
( action
Tendencies)
Hit, shout, sulk,
Recruits allies against others
Seek revenge
Overestimates
Extent to which other
person acted
Deliberately.
See’s malicious
intent in action of othe
Self right other wrong
Unable to see
others point of view
Plots to exact revenge
Cognitive
consequences
Un/healthy negative
emotion
Envy
Behaviour
( action
Tendencies)
Avoid, Denigrate the object/person
Destroy object/person
Its unfair that they
have it and I do
not.
It means I am not
as good as them.
Critical of them or
object, pretend its
not what I want.
Give up.
They don’t deserve
it.


Albert Ellis
1913-2007
considered as the second
most influential
psychotherapist
in history ( USA,Canada)
Carl Rogers ranked first
Sigmund Freud was
ranked third

A
Activating event
Rational belief
Irrational Belief
Flexible
Self/other accepting
High frustration tolerance
Rigid
Self/other downing
Low frustration tolerance
Consequences
Consequences
healthy negative emotion
helpful behaviour
Adaptive Cognitions
Unhealthy negative emotions
Unhelpful behaviour
Biased cognitions
A
Completing assignment
Rational belief
Irrational Belief
I prefer to pass but it is
possible I may not, if I do
it proves I am a fallible
Human and I can
tolerate it
I want to pass therefore this
must happen, If i don’t it’s
Proof I am a total failure
I can’t stand it
Consequences
Consequences
concerned
Focus on task at hand
Giving it my best
anxiety
Procrastinate
I going to fail, I’ ll never cope


Please read the chapter
Fit the information given into the ABC model
A
No current partner
Rational belief
I would prefer to be in a
relationship, I can accept
myself if i am not.
Irrational Belief
I want to be in a relationship, therefore
I absolutely should be. The fact I am
not is proof I am defective.
Consequences
Consequences
Sad
Seek out reinforcements
Depression
no one wants me
There is something wrong with me
Think about past failed relationships
withdraw


Watch the clip
Keep the ABC model in mind, see if you can
identify the problem......
Cognitive
consequences
Un/healthy negative
emotion
Behaviour
( action
Tendencies)
Trained as a psychoanalytic
analyst at the Philadelphia
Psychoanalytic Institute.

(1921-….)
Early
Experience
Core Beliefs
Rules and
Assumptions
Self, world, others
If ……. Then……..
I must………
Critical
Incident
Emotion
physiology
thinking
Behaviour
Early
Experience
Core Beliefs
Rules and
Assumptions
Critical
Incident
Emotion
Low energy
Somatics
Withdraw
ruminates
I am defective
If I am in a relationship then ....
in a relationship
if I am not then it proves I am …………
Relationship not working out
Seeing others in relationships
depression
thinking
Behaviour
What am I doing wrong
Think about past
Relationships ,
no one wants me.
Negative automatic thoughts
Assumptions
Core Schema
Trigger: critical incident
Thoughts
Mood
Physical
Behaviour


Consider what you think about the basic
principles of CBT. Do they make sense to
you?
What do you think of the theory underpinning
CBT? does it make sense ? Does it fit with
your experience?
1) Therapeutic relationship: engage and facilitate collaborative
working process
2) Comprehensive assessment: Detailed picture of problem
within context of person’s life experiences and history
3) Problems & Goals: agree on a ‘CB’ definition of problem, set
goals
4)Clinical Ratings: baseline ratings symptoms distress disability
progress evaluated set time frame and target
5) Formulation; Develop shared understanding of problem and
it’s maintenance.
6) Treatment rationale: explanations of how and why CBT could work
with the problem
7) Interventions: aims reduce symptoms, increase coping
8) Evaluation: Of interventions for effectiveness
9) Relapse prevention: Maintain gains prevent relapse
10) Discharge.
11) Follow-up: further reflection on practice learnt . Set new long term
goals



Watch the clip
Analyse the information elicited by the
therapist, use CBT theory to understand what
the problem is and what might be
maintaining it.
Take note of the questions the therapist asks
to elicit the information and how the CBT
approach is introduced.

What do you think the differences might be
when undertaking a cognitive behavioural
assessment ?
Gather Information
Analyse info using CBT theory
Decide what further
Info will help test
hypotheses
Develop hypotheses about important processes
initial ideas about formulation
Modify formulation
Discuss with client and modify as necessary
Agreed working formulation
Treatment plans
Note further info acquired
During treatment





Helps client and therapist understand the
problem
Bridge between CBT theory about problem
development and maintenance and clients
experience
Shared rationale and guide for therapy
Opens up new ways of thinking
Helps therapist understand/predict
difficulties in therapy or therapeutic
relationship
What’s the problem?
Ask for a recent example
What?
Where?
When?
With Whom?
Critical
Incident
What does it mean to you?
What’s going through your mind
when you feel……..?
Thoughts
Affect
physical
What do you feel most ….
about ?
How frequent? how intense?
Duration?
Behaviour
Do you notice anything
happening in your body ?
What do you do or feel like doing when you feel..?
What’s the consequences of doing this?
Fear of a particular
situation /object
No change to fear beliefs
Client does not learn coping
Strategies or expose beliefs
to disconfirmation
Escape/avoidance
Depression
Loss of positive rewards
Negative thoughts
( activity is seen as pointless)
Reduced activity
Problem: I feel X ( emotion) about X
( situation) and this leads to X
( behaviour)

Overall goal:
I would like to feel X ( emotion) about X
( situation) and this would lead to X
( behaviour)

Smart goals : set week to week
( Dryden W, 2001)












Divide into groups of 4
Cheryl to play patient
Plan your questions to elicit info on the following:
Thoughts
Emotions/physical sensation
Behaviour
Situation
Patients goals for therapy
1 person from each group to ask the questions
Others observe
Carry out assessment. In your small groups begin to
construct a formulation, need anymore info?

Art or science?
Do different therapists agree the exact
same formulation for the same client?
(Beiling & Kuyken 2003)

Is treatment based on formulation more
effective ? (Schulte et al 1992) ( Ghaderi,
2006)

Think about one of your own fears and
consider to what extent they are maintained
by the way you think about them and behave
in relation to them.

Two main methods
◦ Questioning unhelpful beliefs
◦ Devising behavioural tests




Evidence for questions
Evidence against questions
Alternative view questions
consequences of questions
Principles :
 Ask a series of questions to uncover relevant
information outside of the client’s awareness
 Tease out :
 false assumptions,
 inconsistencies in belief,
 contradictory views
 Double standards
 Faulty conclusions
 Develop a way forward

Behavioural Experiments
 Involve testing predictions about physical, social or
psychological danger or gathering information
 Focus is on belief change through experience
 Experiment must have a clear hypothesis from client,
followed by a task that tests out that belief in an
appropriate setting


The client has the ability to answer or work
out an answer
The answer reveals new perspectives
‘People are generally better persuaded by the
reasons which they themselves discovered,
than by those which have come into the
minds of others.’
(Pascal 17th Century French Philosopher)


Exercise:
Socrates in action

Clinical application

 What did you like about the therapists style?
 What’s the aim of this session?
 What’s thoughts/beliefs are tested?
 Are any behavioural experiments proposed?
 In your groups:
 Thinking back to the role play and your formulation
 What beliefs might it be useful to check out? What
questions could you ask to help with this?
 Can you identify 2 behavioural experiments that it
might be useful to carry out?











Survey by Wright and Davis(1994), found that clients wanted
their therapists to:
Offer physically safe, private, confidential setting free from
distractions
Be respectful
Treat concerns seriously
Prioritise client interests over own
Be competent
Share information
Permit client to make own choices
Be flexible not assume the client fits a theory
Review progress
Pace , not rush or keep changing appointments
What works in Therapy? –
Traditional view
Techniques, 15%
Therapeutic
Relationship, 30%
Expectancy (Placebo
effects) , 15%
Adapted from
Lambert (1992)
Extratherapeutic
change, 40%










Phobic disorders
Anxiety disorders (GAD panic disorder)
Obsessive compulsive disorder
Mild-moderate depression
Post-traumatic stress disorder
Eating disorder
Substance abuse (alcohol, cocaine)
Sexual dysfunction
Habit & impulse control disorders
Psychosis





Bipolar disorders
Delusional disorders
Personality disorders
Severe depression
Depression and anxiety associated with long
term chronic health problems




Branch R, Dryden W 2008, The cognitive
behaviour counselling Primer. Athenoeum
Press, UK.
Dryden W, 2001 10 steps to positive living.
Sage. London
Hawton K, Salkovskis P, Kirk J, Clark D,
1993, Cognitive behaviour therapy for
psychiatric Problems. Oxford University
Press.Oxford.
Beck A T, The current state of Cognitive
Behaviour Therapy.Archive of Gen Psy
2005;629-539