COGNITVE BEHAVIOR THERAPY

8/10/2019 COGNITVE BEHAVIOR THERAPY

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Theory and Practice ofTheory and Practice of

Cognitive BehavioralCognitive BehavioralTherapyTherapyDepartment of Psychiatry &Department of Psychiatry &Behavioral NeuroscienceBehavioral Neuroscience

Cognitive-Behavior TherapyCognitive-Behavior TherapyProgramProgram

MS-3 Clership !""#-!""$MS-3 Clership !""#-!""$

Shona N% as' Ph%DShona N% as' Ph%D%%


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(utline(utline

)hat is Cognitive Behavior Therapy *CBT+,)hat is Cognitive Behavior Therapy *CBT+,

)hat are the asic principles of treatment,)hat are the asic principles of treatment,

)hat is the course of treatment,)hat is the course of treatment,

)hat are some e.amples of interventions,)hat are some e.amples of interventions,

)ho is appropriate for CBT,)ho is appropriate for CBT,


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)hat is CBT,)hat is CBT,

Set of /tal0 psychotherapies that treatSet of /tal0 psychotherapies that treatpsychiatric conditions%psychiatric conditions%

Short-term focused treatment%Short-term focused treatment% Strong empirical support 1ithStrong empirical support 1ith

randomi2ed clinical trials%randomi2ed clinical trials% s e4ective as psychiatric medications%s e4ective as psychiatric medications% 5ecommended as critical component of5ecommended as critical component of

treatment' particularly 1hentreatment' particularly 1henmedications are contraindicated ormedications are contraindicated orine4ectiveine4ective%%


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)hy So Popular,)h

y So Popular,

Clear treatment approach for patientsClear treatment approach for patients

ssumptions mae sense to patientsssumptions mae sense to patients

Based on patient0s e.perienceBased on patient0s e.perience 6ncourages practice and compliance6ncourages practice and compliance

Patients have a sense of controlPatients have a sense of control

CBT 1ors7CBT 1ors7


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De8nition of CognitiveDe8nition of Co

gnitive

TherapyThera

py CT is a focused form of psychotherapyCT is a focused form of psychotherapy

ased on a model stipulating thatased on a model stipulating that

psychiatric disorders involve dysfunctionalpsychiatric disorders involve dysfunctional

thining%thining% Dysfunctional9distorted thining arises fromDysfunctional9distorted thining arises from

oth iological and psychological in:uencesoth iological and psychological in:uences

;ndividuals0 emotional' ehavioral' and;ndividuals0 emotional' ehavioral' and

physiological reactions are in:uenced yphysiological reactions are in:uenced y

the 1ay they structure their environment%the 1ay they structure their environment%

J. Beck, 1995


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De8nition of CTDe8nition of CT

*continued


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De8nition of CTDe8nition of CT

*continued


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5ationale for CBT5ationale for CBT

Negative emotions are elicited y cognitiveNegative emotions are elicited y cognitiveprocesses developed through in:uences ofprocesses developed through in:uences oflearning and temperament%learning and temperament%

dverse life events elicit automatic processing'dverse life events elicit automatic processing'1hich is vie1ed as the causal factor%1hich is vie1ed as the causal factor%

Cognitive triad> Negative automatic thoughtsCognitive triad> Negative automatic thoughtscenter around our understanding of>center around our understanding of>? (urselves(urselves? (thers *the 1orld+(thers *the 1orld+? @uture@uture

@ocus on e.amination of cognitive eliefs and@ocus on e.amination of cognitive eliefs anddeveloping rational responses to negativedeveloping rational responses to negativeautomatic thoughts%automatic thoughts%

Beck et al., 1979Beck et al., 1979

i i i8 i


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Cognitive Speci8cityCognitive Speci8city

AypothesisAypothesis

Distorted appraisals follo1 themes relevantDistorted appraisals follo1 themes relevantto the speci8c psychiatric condition%to the speci8c psychiatric condition%

Psychological disorders are characteri2edPsychological disorders are characteri2edy a di4erent psychological pro8le%y a di4erent psychological pro8le%

? DepressionDepression> Negative vie1 of self' others' and> Negative vie1 of self' others' andfuture% Core eliefs associated 1ithfuture% Core eliefs associated 1ithhelplessness' failure' incompetence' andhelplessness' failure' incompetence' andunlovaility%unlovaility%

? n.ietyn.iety> (verestimation of physical and> (verestimation of physical andpsychological threats% Core eliefs lined 1ithpsychological threats% Core eliefs lined 1ith

ris' dangerousness' and uncontrollaility%ris' dangerousness' and uncontrollaility%


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Cognitive Speci8cityCognitive Speci8city

Negative Triad ssociated 1ith DepressionNegative Triad ssociated 1ith Depression? SelfSelf I am incompetent/unlovableI am incompetent/unlovable

? (thers(thers People do not care about mePeople do not care about me? @uture@uture The future is bleakThe future is bleak

Negative Triad ssociated 1ith n.ietyNegative Triad ssociated 1ith n.iety? SelfSelf I am unable to protect myselfI am unable to protect myself

? (thers(thers People will humiliate mePeople will humiliate me

? @uture@uture Its a matter of time before I amIts a matter of time before I amembarrassedembarrassed


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Targeted Cognitions for Di4erentTargeted Cognitions for Di4erent

DisordersDisorders

(CD> appraisals of osessive(CD> appraisals of osessive

cognitionscognitions

nore.ia> control' 1orth' perfectionnore.ia> control' 1orth' perfection Panic> catastrophic misinterpretationPanic> catastrophic misinterpretation

of physical sensationsof physical sensations

Paranoia> trust' vulnerailityParanoia> trust' vulneraility


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)oring Model of CBT)oring Model of CBT

Event Appraisal

Maladaptive

Behavior

Affective and

Biological ArousalBehavioral

Inclination

Thase et al., 1998Thase et al., 1998


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Cognitive ModelCognitive Model

Triggering EventBill goes to collectionAppraisalI can never do

anything rightBehavior

Avoidance; withdrawal

Bodily Sensationsow energy! disruption of

sleep! increased fatigue

Behavioral InclinationI don"t want to deal with it

It"s too stressful to thin#

a$out it

Thase et al., 1998Thase et al., 1998


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)hat are utomatic)hat are utomatic

Thoughts,Thoughts,

)hat 1as going through your)hat 1as going through yourmind,mind, Aappen spontaneously in response toAappen spontaneously in response to

situationsituation

(ccur in shorthand> 1ords or images(ccur in shorthand> 1ords or images Do not arise from reasoningDo not arise from reasoning

No logical se=uenceNo logical se=uence

Aard to turn o4Aard to turn o4 May e hard to articulateMay e hard to articulate

Stressful

Situation

Auto%atic Thoughts&egative

E%otions


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Cognitive DistortionsCognitive Distortions

Patients tend to mae consistentPatients tend to mae consistent

errors in their thiningerrors in their thining

(ften' there is a systematic negative(ften' there is a systematic negative

ias in the cognitive processing ofias in the cognitive processing of

patients su4ering from psychiatricpatients su4ering from psychiatric

disordersdisorders

Aelp patient identify the cognitiveAelp patient identify the cognitive

errors s9he is most liely to maeerrors s9he is most liely to mae


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Types of Cognitive DistortionsTypes of Cognitive Distortions

? 6motional reasoning6motional reasoning @eelings are facts @eelings are facts

? nticipating negative outcomes The 1orst 1illnticipating negative outcomes The 1orst 1ill

happenhappen

? ll-or-nothing thiningll-or-nothing thining ll good orll good orall adall ad

? Mind-readingMind-reading no1ing 1hat others areno1ing 1hat others arethiningthining

? Personali2ationPersonali2ation 6.cess6.cessresponsiilityresponsiility

? Mental 8lterMental 8lter ;gnoring the positive;gnoring the positive


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6.amples6.amples

Cognitive DistortionsCognitive Distortions? 6motional 5easoning>6motional 5easoning> I feel incompetent,I feel incompetent,

so I know Ill failso I know Ill fail? Catastrophi2ing>Catastrophi2ing> It is going to be terribleIt is going to be terrible

? Personali2ation>Personali2ation> Its always my faultIts always my fault

? Blac or 1hite thining>Blac or 1hite thining> If it isnt perfect,If it isnt perfect,

itsits no good at allno good at all


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Core BeliefsCore Beliefs

Core eliefs underlie and produceCore eliefs underlie and produceautomatic thoughts%automatic thoughts%

These assumptions in:uence informationThese assumptions in:uence informationprocessing and organi2e understandingprocessing and organi2e understanding

aout ourselves' others' and the future%aout ourselves' others' and the future%These core eliefs remain dormant untilThese core eliefs remain dormant until

activated y stress or negative lifeactivated y stress or negative lifeevents%events%

Categories of core eliefs *helpless'Categories of core eliefs *helpless'1orthless' unlovale+1orthless' unlovale+

Auto%atic Thoughts'ore Beliefs


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6.amples of Core Beliefs6.amples of Core Beliefs

Aelpless core eliefsAelpless core eliefs? ; am inade=uate' ine4ective' incompetent' can0t cope; am inade=uate' ine4ective' incompetent' can0t cope? ; am po1erless' out of control' trapped; am po1erless' out of control' trapped? ; am vulnerale' 1ea' needy' a victim' liely to e hurt; am vulnerale' 1ea' needy' a victim' liely to e hurt? ; am inferior' a failure' a loser' defective' not good enough' don0t; am inferior' a failure' a loser' defective' not good enough' don0t

measure upmeasure up nlovale core eliefsnlovale core eliefs

? ; am unliale' un1anted' 1ill e reected or aandoned' al1ays; am unliale' un1anted' 1ill e reected or aandoned' al1ayse alonee alone

? ; am undesirale' ugly' unattractive' oring' have nothing to o4er; am undesirale' ugly' unattractive' oring' have nothing to o4er? ; am di4erent' :a1ed' defective' not good enough to e loved y; am di4erent' :a1ed' defective' not good enough to e loved y

othersothers

)orthless core eliefs)orthless core eliefs? ; am 1orthless' unacceptale' ad' cra2y' roen' nothing' a; am 1orthless' unacceptale' ad' cra2y' roen' nothing' a

1aste1aste? ; am hurtful' dangerous' to.ic' evil; am hurtful' dangerous' to.ic' evil? ; don0t deserve to live; don0t deserve to live


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Cognitive Conceptuali2ationCognitive Conceptuali2ation

'urrent

Situation

Auto%atic ThoughtsA$out self! world

And others

(hysiology

)eelings

Behavior

'hildhoodAnd Early

ife Events

*nderlying Assu%ptions

and 'ore Beliefs

'o%pensatoryStrategies


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6.ample E6.ample E

SituationPartner says:I need time to

be with my friends

Auto%atic ThoughtsAutomatic response:Oh no, hes losing interest

and is going to break up

with me!

(hysiology"eart racing

#ump in throat

)eelings$adness

%orry

Anger

Behavior

$eek reassurance%ithdraw

&ry

'hildhood

E+periencesParental neglect

and criticism

*nderlying Assu%ptions ,

'ore Beliefs

Im flawed in numerous ways,

which means Im not worthy of

consistent attention and care!

People only care when they wantsomething!

'o%pensatoryStrategies'e independent and

youll be safe!

%atch out ( people

are careless with you!


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6.ample !6.ample !

Situation)isappointing

e*am result

Auto%atic ThoughtsI am not going to get

through this program +Im not as smart

as eeryone else!

People will

discoer this and I

will be humiliated!

(hysiologyPit in stomach

)ry mouth

)eelings%orry, shame,

)isappointment

"umiliation!

Behavior-se alcohol,

Procrastinate

with homework

'hildhoodAdversities

Parental standards

reinforce academic

achieement

*nderlying Assu%ptionsIf I dont e*cel in school, Im a

total failure

'o%pensatoryStrategies

%ork e*tra hard

to offset

incompetence!


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5esponding to Negative5esponding to NegativeThoughtsThoughts

De8ne SituationDe8ne Situation

Clarify meaning of cognitive appraisalClarify meaning of cognitive appraisal

? )hat 1as going through your mind ust then,)hat 1as going through your mind ust then,

? )hat did the situation mean for you,)hat did the situation mean for you,

6valuate interpretation6valuate interpretation? 6vidence>6vidence>@or and against this elief,@or and against this elief,

? lternatives>lternatives>ny other e.planation*s+,ny other e.planation*s+,? ;mplications>;mplications> So 1hat


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6valuating Negative6valuating Negative

ThoughtsThoughts )hat is the e4ect of telling myself)hat is the e4ect of telling myself

this thought,this thought, )hat could e the e4ect of changing)hat could e the e4ect of changing

my thining,my thining, )hat 1ould ; tell FFF *a friend9family)hat 1ould ; tell FFF *a friend9family

memer+ if s9he vie1ed this situationmemer+ if s9he vie1ed this situation

in this 1ay,in this 1ay, )hat can ; do no1,)hat can ; do no1,


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Sample Thought GogSample Thought Gog

SituationSituation ThoughtsThoughts 6motion6motionss

5ational5ational

5esponse5esponse

(utcome(utcome

Hoing onHoing onvacationIsvacationIsa colleague toa colleague to

do some 1ordo some 1orfor mefor me

She0ll say noDistortions>

ll9nothingll9nothing

MindreadinMindreadingg

@ortune-@ortune-TellingTelling

(ver-(ver-generali2atiogenerali2ationn

; haven0t; haven0ttaen a daytaen a dayo4 in o4 in

months% )emonths% )e1or as a1or as ateam' so it0steam' so it0salso her o toalso her o totrac thetrac thesamples%samples%

n.iety *E"K+n.iety *E"K+

Huilt *"K+Huilt *"K+

5elief *L"K+5elief *L"K+


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Common Components of CBTCommon Components of CBT

6stalish good therapeutic relationship6stalish good therapeutic relationship 6ducate patients - model' disorder' therapy6ducate patients - model' disorder' therapy

ssess illness oectively' set goalsssess illness oectively' set goals

se evidence to guide treatment decisionsse evidence to guide treatment decisions

Structure treatment sessions 1ith agendaStructure treatment sessions 1ith agenda Gimit treatment lengthGimit treatment length

;ssue and revie1 home1or to generali2e;ssue and revie1 home1or to generali2e

learninglearning


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Course of TreatmentCourse of TreatmentE%E% ssessmentssessment

!%!% Provide rationaleProvide rationale

3%3% Training in self-monitoringTraining in self-monitoring

L%L% Behavioral strategiesBehavioral strategies

E%E% Monitor relationship et1een situation9action andMonitor relationship et1een situation9action and

mood%mood%

!%!% pplying ne1 coping strategies to larger issues%pplying ne1 coping strategies to larger issues%

%% ;dentifying eliefs and iases;dentifying eliefs and iases

%% 6valuating and changing eliefs6valuating and changing eliefs

J%J% Core eliefs and assumptionsCore eliefs and assumptions

#%#% 5elapse prevention and termination5elapse prevention and termination


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Basic PrinciplesBasic Principles

Change mood states y using cognitive and ehavioralChange mood states y using cognitive and ehavioralstrategies>strategies>? ;dentifying9modifying automatic thoughts & core eliefs';dentifying9modifying automatic thoughts & core eliefs'? 5egulating routine' and5egulating routine' and? Minimi2ing avoidance%Minimi2ing avoidance%

6mphasis on /here and no106mphasis on /here and no10

Preference for concrete e.amplesPreference for concrete e.amples? Start 1ith speci8c situation *complete thought log+Start 1ith speci8c situation *complete thought log+ 5eliance on Socratic =uestioning5eliance on Socratic =uestioning

? s open-ended =uestionss open-ended =uestions

6mpirical approach to test eliefs6mpirical approach to test eliefs? Challenge thoughts not ased on evidenceChallenge thoughts not ased on evidence? Cognitive restructuringCognitive restructuring

Promote rapid symptom changePromote rapid symptom change


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Behavioral ;nterventionsBehavioral ;nterventions

Breathing retrainingBreathing retraining 5ela.ation5ela.ation Behavioral activationBehavioral activation

;nterpersonal e4ectiveness training;nterpersonal e4ectiveness training Prolem-solving sillsProlem-solving sills 6.posure and response prevention6.posure and response prevention Social sills trainingSocial sills training

Hraded tas assignmentHraded tas assignment


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Cognitive ;nterventionsCognitive ;nterventions

Monitor automatic thoughtsMonitor automatic thoughtsTeach imagery techni=uesTeach imagery techni=ues

Promote cognitive restructuringPromote cognitive restructuring 6.amine alternative evidence6.amine alternative evidenceModify core eliefsModify core eliefs

Henerate rational alternativesHenerate rational alternatives


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6cacy6cacy

Cognitive and ehavioralCognitive and ehavioralapproaches are e4ectiveapproaches are e4ective

Supported y over 3! controlledSupported y over 3! controlledoutcome studiesoutcome studies

State-of-the-art therapy' manuali2edState-of-the-art therapy' manuali2ed


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pplications of CBTpplications of CBT

Mood DisordersMood Disorders? nipolar Depression *E$J$+nipolar Depression *E$J$+? Bipolar Disorder *E$$+Bipolar Disorder *E$$+

? Dysthymia and Chronic MDD *!"""+Dysthymia and Chronic MDD *!"""+

n.iety Disordersn.iety Disorders? HD *E$#+HD *E$#+

? Social Phoia *E$#+Social Phoia *E$#+

? Panic Disorder *E$#+Panic Disorder *E$#+

? (CD *E$##+(CD *E$##+

? PTSD *E$$E+PTSD *E$$E+

6motional Disorders *!""+6motional Disorders *!""+


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pplications of CBTpplications of CBT!"ontinued#$!"ontinued#$

6ating Disorders *E$#E+6ating Disorders *E$#E+ Marital ProlemsMarital Prolems Behavioral MedicineBehavioral Medicine

? Aeadaches *E$#+Aeadaches *E$#+? ;nsomnia *E$#J+;nsomnia *E$#J+

? Chronic Pain *E$##+Chronic Pain *E$##+

? Smoing CessationSmoing Cessation

? AypochondriasisAypochondriasis? Body Dysmorphic DisorderBody Dysmorphic Disorder


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Controlled (utcome StudiesControlled (utcome Studieson CBTon CBT

nipolarnipolarDepression *Q3"+Depression *Q3"+

6ating Disorders6ating Disorders? nore.ia *Q+nore.ia *Q+

? Bulimia *QE+Bulimia *QE+

Henerali2edHenerali2edn.iety Disordern.iety Disorder

*QE!+*QE!+

Social Phoia *QEL+Social Phoia *QEL+

Panic Disorder *QE"+Panic Disorder *QE"+

Borderline P%D% *!+Borderline P%D% *!+ Schi2ophrenia *QL+Schi2ophrenia *QL+

C9 Depression *#+C9 Depression *#+

Chronic DepressionChronic Depression*E+*E+


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ConclusionsConclusions

System of psychotherapiesSystem of psychotherapies

ni8ed theory of psychopathologyni8ed theory of psychopathology

Short-term treatmentShort-term treatment (ective assessment and(ective assessment and

monitoringmonitoring

Strong empirical supportStrong empirical support s e4ective as pharmacotherapys e4ective as pharmacotherapy


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Ruestions,Ruestions,

Comments,Comments,Dr% Shona asDr% Shona as

*JJ3+ J"!-EEJ*JJ3+ J"!-EEJ

Psychiatry Department (ce> -Psychiatry Department (ce> -3E!3E!

svasyoda%sd%uchicago%edusvasyoda%sd%uchicago%edu

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