Transcript Introduction to Cognitive Behavioural Therapy (CBT)

Introduction to Cognitive
Behavioural Therapy (CBT)
November 2010
Dr Helen Barlow
Clinical Psychologist, CPFT
Overview
 Characteristics of CBT
 - The CBT model
 - Different levels of the model
 - The CBT approach & techniques
 - CBT-style assessment
 - Introduction to formulation
 What do you think might make CBT different to
other therapies?
NICE Guidelines 1
 Clinical guidelines are based on best available evidence
 Panic disorder or Generalised anxiety- 1)CBT 2)SSRI
3)CBT-based self-help
 Mild to moderate depression – CBT-based guided self
help; computerised CBT; structured group activity
 Moderate or severe depression – Combination antidepressants and CBT or IPT
 Mild OCD- Brief or group CBT including ERP/ SSRI or
CBT
 Moderate OCD – SSRI or CBT
 BDD – moderate – SSRI or CBT
NICE Guidelines 2
 Bipolar – meds +psychological support
 PTSD – 1-3 months after, trauma focused CBT.
More than 3 months after trauma, traumafocussed CBT or EMDR (Eye movement
desensitising reprocessing)
 Eating disorders – A.N CAT, CBT, IPT, family
interventions/ B.N – self-help then CBT
 Schizophrenia – CBT to all + family intervention
if family close by +anti-psychotics
 BPD - DBT
Basic CBT Approach 1
To understand problems, we need to
understand the interactions between
thoughts, physiology, and the environment
Cognitive: Interpretations are crucial
Behavioural: Changing what you do is
often a powerful way of changing other
systems
The basic cognitive idea
Usual way of understanding
Event
Emotion
e.g. Loss of job
Anger or depression
Cognitive Model
Event
Interpretation Emotion
Loss of job
(cognition)
Anger or depression
Example of interpretation
-you fail an exam
Possible thought
Possible emotion
I’m a failure- they made
a mistake to accept me
on this course
Depression
I can’t cope with the work
Anxiety
How dare they fail me!
Anger
I can learn from this, and will
do better next time
Upset but positive
Discussion
With the person next to you, try to give an
example of an event that has happened to
you (not too upsetting), then name what
emotion you felt, and what your thoughts
were at the time that made you feel like
that. Discuss how another person might
have felt if they had thought about the
same situation in a different way.
Then swap.
Implications of the Cognitive Model
It is not events themselves that matter but
the meaning of these events to the person
The ‘same’ event can have different
emotional consequences depending on
the interpretation
When an emotional reaction seems out of
proportion, the idiosyncratic meaning
explains the reaction i.e “if I had those
thoughts would I feel that bad?”
Beck’s Cognitive Therapy
 “An active, directive, time-limited
approach…based on an underlying rationale
that an individual’s affect and behaviour are
largely determined by the way in which (they)
see the world”
 A.T. Beck et al.(1979). Cognitive Therapy of
Depression.
Implications of the Cognitive Therapy
Model
To understand people’s distress, we have
to understand their cognitions i.e. their
way of perceiving the world
We can reduce their distress by helping
people change the way they think about
things
Thus ‘cognitive’ therapy
The cognitive model of emotional disorder

Affect

Thinking
Behaviour
Physical Symptoms
Example
 Thought
 Something really bad will happen
 I need someone with me all the time
Feelings
Behaviour
Anxious
Frightened
Call GP/ Go to A & E/
Never go anywhere alone
 ENVT
 Physiology
 Racing heart, dizzy, sweats
Discussion
Go back to the example you discussed in
your pairs earlier. Having identified the
thoughts and emotions last time, try to
identify now the physical sensations you
felt at the time, how you behaved, and
what was going on in that environment at
the time.
Negative Automatic Thoughts
An automatic stream of thoughts about
events / interpretations
- Can become conscious
- But habitual so often outside of awareness
- Often taken as true, especially when
emotions are strong
- May be suppressed or avoided
- May be words or images
Dysfunctional Assumptions
 Rules of Living; rules that guide daily actions
and expectations
 Develop from core beliefs about self, others and
the world
 Negative Automatic Thoughts (NATs) stem from
Dysfunctional Assumptions
- Not as obvious as NATs, often have to infer them
from behaviours
- Usually conditional: “If…, then…”/ “I should/must
please others otherwise I’ll be rejected”
Core Beliefs
 Absolute statements
e.g. I am unlovable
I am defective/bad
-Usually learned early in life but may develop
later as result of trauma
 Worked on later in therapy
Levels of Cognition
 Core Beliefs (also called schemas)
 I am unlovable / I am defective
 Dysfunctional Assumptions (Rules for Living)
 If I don’t let people get to know me then they won’t find out how rubbish I am
and reject me
 If I try to be perfect all of the time, my flaws will remain hidden
 Negative Automatic Thoughts
 I am being boring/ I can’t think of anything worthwhile to say / They don’t
like me/ I am a failure
CBT Model in full
 Early experience (high achieving family, praise contingent on success)
 Core beliefs (I am incompetent)
 Dysfunctional assumptions/rules for living
 (If I don’t fully understand then I am stupid)
 Critical incident (Not understanding a lecture)
 Thoughts

Feelings
Behaviour
 Physiology
Basic CBT Approach 2
Focus on ‘here and now’ (past only focus
of Tx when necessary e.g. complex probs)
Start at hot cross bun level
Cognitive change is done to enable mood
change
Collaboration – shared goals, knowledge,
tailored to client’s needs
Brief (15 sessions)
Technique: Guided discovery
Thoughts are to be tested, not taken as
facts
Explore and question to examine
evidence, generate new perspectives, and
gather new evidence to come to valid
conclusions
‘Socratic questioning’ - reach their own
conclusions, hypothesis testing
Homework
Therapy is structured and active
Homework between sessions
Most change occurs outside of sessions
Encourages self-help
Links sessions to client’s world
Related to outcome of therapy
CBT- Style Assessment: Aims of
Assessment
Establish a detailed description of problem
(s) and impact on client’s life
Develop a ‘list’ of problems and associated
goals
Explain the vicious cycle (‘hot cross bun’)
Impart the message that they can do
something about how they feel
Give a task at end
e.g. reading/mood monitoring
CBT-Style Assessment: Funnel
General description of main problem,
especially asking about common
thoughts/feelings/behaviours
Ask for examples
Ask about different parts of the problem
and if they interact, how
Try to pick up on maintaining factors
Assess motivation – are they ready to
change?
General points about assessment
Give reassurance, don’t fire questions
Be compassionate and accepting
Listen
Reflect what they’ve told you to check
you’ve understood
Summarise every so often
Don’t assume- ask curiously for more info
Assessment process
Gather information
Use CBT theory to analyse info
Generate tentative hypotheses
Ask more info
Produce a formulation
Plan for treatment
Ongoing assessment
Assessment 1
What are the problems?
-Thoughts (might be hard to verbalise)
-Feelings/ moods
-Physical sensations
-Behaviours/responses
Maintaining processes e.g vicious cycles
Assessment 2
 Triggers/modifiers: In what situations do the
problems occur?
What factors affect the problem’s severity when it
occurs? What helps?
 Consequences: What has happened as a result
of the problem?
 - Effects on client’s life
 - Reactions from others
 - How usually copes
 - Why seeking help now?
Role Play
 Establish a general description of your client’s
problems
 - identify how their thoughts, feelings, physical
symptoms and behaviours are related (ask them
to give you a recent example)
 What are the triggers?
 What are the modifiers? (i.e. make the problem
better/worse)
 What ways do they try to cope?
Assessing Problem Development
 Predisposing factors





-loss
-separation
-family attitudes/beliefs
-sense of responsibility
-family history of similar problems
 Precipitating events
 -life events
 -accumulation of stressors
 Modifying factors
 -relationships
 -responsibilities
 -role transitions
Formulation
Holds theory and practice together
Structures the way of working
Makes a whole host of problems more
understandable and manageable
CBT has problem-specific models
Assessment-> hypothesis/formulation
-> plan treatment & how to evaluate
outcome
Take home message re: CBT
Its about identifying the links between
thoughts, feelings and behaviours and
helping make sense of why they feel the
way they do, so that we can then change
this
The goal is to increase ability to deal with
emotions
Practice between sessions (and beyond)
Role play
Explain the cognitive model to ‘John’
Include info about vicious cycles
Give the message that he can do
something about how he feels
Debrief- how was that for
client/practitioner? What was helpful/less
helpful?
NICE Guidelines 1
 Clinical guidelines are based on best available evidence
 Panic disorder or Generalised anxiety- 1)CBT 2)SSRI
3)CBT-based self-help
 Mild to moderate depression – CBT-based guided self
help; computerised CBT; structured group activity
 Moderate or severe depression – Combination antidepressants and CBT or IPT
 Mild OCD- Brief or group CBT including ERP/ SSRI or
CBT
 Moderate OCD – SSRI or CBT
 BDD – moderate – SSRI or CBT
NICE Guidelines 2
 Bipolar – meds +psychological support
 PTSD – 1-3 months after, trauma focused CBT.
More than 3 months after trauma, traumafocussed CBT or EMDR (Eye movement
desensitising reprocessing)
 Eating disorders – A.N CAT, CBT, IPT, family
interventions/ B.N – self-help then CBT
 Schizophrenia – CBT to all + family intervention
if family close by +anti-psychotics
 BPD - DBT
Recommended Reading
Greenberger, D., & Padesky, C. (1995) A
Clinicians Guide to Mind Over Mood.
Beck, J. (1995) Cognitive Therapy: Basics
and Beyond.
NICE www.nice.org