Transcript History, Assumptions, and Overview of CBT

Theory and Practice of
Cognitive Behavioral Therapy
Shona N. Vas, Ph.D.
Department of Psychiatry & Behavioral
Neuroscience
Cognitive-Behavior Therapy Program
MS-3 Clerkship 2008-2009
Outline
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What is Cognitive Behavior Therapy (CBT)?
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What are the basic principles of treatment?
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What is the course of treatment?
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What are some examples of interventions?
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Who is appropriate for CBT?
What is CBT?
Set of ‘talk’ psychotherapies that treat
psychiatric conditions.
 Short-term focused treatment.
 Strong empirical support with
randomized clinical trials.
 As effective as psychiatric medications.
 Recommended as critical component of
treatment, particularly when
medications are contraindicated or
ineffective.
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Why So Popular?
Clear treatment approach for patients
 Assumptions make sense to patients
 Based on patient’s experience
 Encourages practice and compliance
 Patients have a sense of control
 CBT works!
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Definition of Cognitive Therapy
CT is a focused form of psychotherapy based on
a model stipulating that psychiatric disorders
involve dysfunctional thinking.
 Dysfunctional/distorted thinking arises from both
biological and psychological influences
 Individuals’ emotional, behavioral, and
physiological reactions are influenced by the way
they structure their environment.
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J. Beck, 1995
Definition of CT (continued…)
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Modifying dysfunctional thinking and
behavior leads to improvement in
symptoms.
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Modifying dysfunctional beliefs which
underlie dysfunctional thinking leads to
more durable improvement
Definition of CT (continued…)
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Cognitive therapy is defined by a cognitive
formulation of the disorder and a cognitive
conceptualization of the particular patient.
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Cognitive therapy is not defined by the use of
exclusively cognitive techniques. Techniques
from many modalities are used.
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CT also often referred to as Cognitive-Behavior
Therapy (CBT).
Rationale for CBT
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Negative emotions are elicited by cognitive processes
developed through influences of learning and
temperament.
Adverse life events elicit automatic processing, which
is viewed as the causal factor.
Cognitive triad: Negative automatic thoughts center
around our understanding of:
– Ourselves
– Others (the world)
– Future
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Focus on examination of cognitive beliefs and
developing rational responses to negative automatic
thoughts.
Beck et al., 1979
Cognitive Specificity Hypothesis
Distorted appraisals follow themes relevant to
the specific psychiatric condition.
 Psychological disorders are characterized by a
different psychological profile.
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– Depression: Negative view of self, others, and
future. Core beliefs associated with helplessness,
failure, incompetence, and unlovability.
– Anxiety: Overestimation of physical and
psychological threats. Core beliefs linked with risk,
dangerousness, and uncontrollability.
Cognitive Specificity
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Negative Triad Associated with Depression
– Self
“I am incompetent/unlovable”
– Others “People do not care about me”
– Future “The future is bleak”
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Negative Triad Associated with Anxiety
– Self
“I am unable to protect myself”
– Others “People will humiliate me”
– Future “It’s a matter of time before I am
embarrassed”
Targeted Cognitions for Different
Disorders
OCD: appraisals of obsessive cognitions
 Anorexia: control, worth, perfection
 Panic: catastrophic misinterpretation of
physical sensations
 Paranoia: trust, vulnerability
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Working Model of CBT
Event
Appraisal
Maladaptive
Behavior
Behavioral
Inclination
Affective and
Biological Arousal
Thase et al., 1998
Cognitive Model
Triggering Event
Bill goes to collection
Behavior
Appraisal
“I can never do
anything right…”
Avoidance; withdrawal
Behavioral Inclination
“I don’t want to deal with it”
“It’s too stressful to think
about it”
Bodily Sensations
Low energy, disruption of
sleep, increased fatigue
Thase et al., 1998
What are Automatic Thoughts?
What was going through your mind?
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Happen spontaneously in response to situation
Occur in shorthand: words or images
Do not arise from reasoning
No logical sequence
Hard to turn off
May be hard to articulate
Stressful
Situation
Negative
Automatic Thoughts
Emotions
Cognitive Distortions
Patients tend to make consistent errors in
their thinking
 Often, there is a systematic negative bias
in the cognitive processing of patients
suffering from psychiatric disorders
 Help patient identify the cognitive errors
s/he is most likely to make
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Types of Cognitive Distortions
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Emotional reasoning
Feelings are facts
Anticipating negative outcomes
The worst will happen
All-or-nothing thinking
All good or all bad
Mind-reading
Knowing what others are thinking
Personalization
Excess responsibility
Mental filter
Ignoring the positive
Examples
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Cognitive Distortions
– Emotional Reasoning: “I feel incompetent, so I
know I’ll fail”
– Catastrophizing: “It is going to be terrible”
– Personalization: “It’s always my fault”
– Black or white thinking: “If it isn’t perfect, it’s
no good at all.”
Core Beliefs
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Core beliefs underlie and produce
automatic thoughts.
These assumptions influence information
processing and organize understanding
about ourselves, others, and the future.
These core beliefs remain dormant until
activated by stress or negative life events.
Categories of core beliefs (helpless,
worthless, unlovable)
Core Beliefs
Automatic Thoughts
Examples of Core Beliefs
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Helpless core beliefs
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I am inadequate, ineffective, incompetent, can’t cope
I am powerless, out of control, trapped
I am vulnerable, weak, needy, a victim, likely to be hurt
I am inferior, a failure, a loser, defective, not good enough, don’t
measure up
Unlovable core beliefs
– I am unlikable, unwanted, will be rejected or abandoned, always be
alone
– I am undesirable, ugly, unattractive, boring, have nothing to offer
– I am different, flawed, defective, not good enough to be loved by
others
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Worthless core beliefs
– I am worthless, unacceptable, bad, crazy, broken, nothing, a waste
– I am hurtful, dangerous, toxic, evil
– I don’t deserve to live
Cognitive Conceptualization
Physiology
Current
Situation
Automatic Thoughts
About self, world
And others
Feelings
Behavior
Childhood
And Early
Life Events
Underlying Assumptions
and Core Beliefs
Compensatory
Strategies
Example 1
Situation
Partner says:
“I need time to
be with my friends”
Automatic Thoughts
Automatic response:
“Oh no, he’s losing interest
and is going to break up
with me….”
Physiology
Heart racing
Lump in throat
Feelings
Sadness
Worry
Anger
Behavior
Seek reassurance
Withdraw
Cry
Childhood
Experiences
Parental neglect
and criticism
Underlying Assumptions &
Core Beliefs
“I’m flawed in numerous ways,
which means I’m not worthy of
consistent attention and care.
People only care when they want
something.”
Compensatory
Strategies
Be independent and
you’ll be safe.
Watch out – people
are careless with you.
Example 2
Automatic Thoughts
Situation
Disappointing
exam result
“I am not going to get
through this program I’m not as smart
as everyone else.
People will
discover this and I
will be humiliated.”
Physiology
Pit in stomach
Dry mouth
Feelings
Worry, shame,
Disappointment
Humiliation.
Behavior
Use alcohol,
Procrastinate
with homework
Childhood
Adversities
Parental standards
reinforce academic
achievement
Underlying Assumptions
“If I don’t excel in school, I’m a
total failure”
Compensatory
Strategies
Work extra hard
to offset
incompetence.
Responding to Negative Thoughts
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Define Situation
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Clarify meaning of cognitive appraisal
– What was going through your mind just then?
– What did the situation mean for you?
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Evaluate interpretation
– Evidence: For and against this belief?
– Alternatives: Any other explanation(s)?
– Implications: So what….?
Evaluating Negative Thoughts
What is the effect of telling myself this
thought?
 What could be the effect of changing my
thinking?
 What would I tell ___ (a friend/family
member) if s/he viewed this situation in
this way?
 What can I do now?
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Sample Thought Log
Situation
Thoughts
Emotions
Rational
Response
Outcome
Going on
vacation—Ask a
colleague to do
some work for
me
She’ll say no…
I’m not doing a
good job
The boss thinks I
take too much time
off
Anxiety
(70%)
Guilt (40%)
Sadness
(20%)
I haven’t taken
a day off in 6
months. We
work as a team,
so it’s also her
job to track the
samples.
Anxiety (10%)
Guilt (0%)
Relief (40%)
Cognitive
Distortions:
All/nothing
Mindreading
FortuneTelling
Overgeneralization
Common Components of CBT
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Establish good therapeutic relationship
Educate patients - model, disorder, therapy
Assess illness objectively, set goals
Use evidence to guide treatment decisions
Structure treatment sessions with agenda
Limit treatment length
Issue and review homework to generalize
learning
Course of Treatment
1.
2.
3.
4.
Assessment
Provide rationale
Training in self-monitoring
Behavioral strategies
1.
2.
5.
6.
7.
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Monitor relationship between situation/action and mood.
Applying new coping strategies to larger issues.
Identifying beliefs and biases
Evaluating and changing beliefs
Core beliefs and assumptions
Relapse prevention and termination
Basic Principles
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Change mood states by using cognitive and
behavioral strategies:
– Identifying/modifying automatic thoughts & core beliefs,
– Regulating routine, and
– Minimizing avoidance.
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Emphasis on ‘here and now’
Preference for concrete examples
– Start with specific situation (complete thought log)
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Reliance on Socratic questioning
– Ask open-ended questions
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Empirical approach to test beliefs
– Challenge thoughts not based on evidence
– Cognitive restructuring
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Promote rapid symptom change
Behavioral Interventions
Breathing retraining
 Relaxation
 Behavioral activation
 Interpersonal effectiveness training
 Problem-solving skills
 Exposure and response prevention
 Social skills training
 Graded task assignment
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Cognitive Interventions
 Monitor
automatic thoughts
 Teach imagery techniques
 Promote cognitive restructuring
 Examine alternative evidence
 Modify core beliefs
 Generate rational alternatives
Efficacy
 Cognitive
and behavioral approaches
are effective
 Supported
by over 325 controlled
outcome studies
 State-of-the-art
therapy, manualized
Applications of CBT
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Mood Disorders
– Unipolar Depression (1979)
– Bipolar Disorder (1996)
– Dysthymia and Chronic MDD (2000)
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Anxiety Disorders
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GAD (1985)
Social Phobia (1985)
Panic Disorder (1986)
OCD (1988)
PTSD (1991)
Emotional Disorders (2006)
Applications of CBT (Continued…)
Eating Disorders (1981)
 Marital Problems
 Behavioral Medicine
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Headaches (1985)
Insomnia (1987)
Chronic Pain (1988)
Smoking Cessation
Hypochondriasis
Body Dysmorphic Disorder
Controlled Outcome Studies on
CBT
Unipolar Depression
(~30)
 Eating Disorders
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– Anorexia (~5)
– Bulimia (~15)
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Generalized Anxiety
Disorder (~12)
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Social Phobia (~14)
Panic Disorder (~10)
Borderline P.D. (2)
Schizophrenia (~45)
C/A Depression (8)
Chronic Depression (1)
Conclusions
 System
of psychotherapies
 Unified theory of psychopathology
 Short-term treatment
 Objective assessment and monitoring
 Strong empirical support
 As effective as pharmacotherapy
Questions? Comments?
Dr. Shona Vas
(773) 702-1517
Psychiatry Department Office: A-312
[email protected]