Post on 23-Sep-2020
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"ThankstoSonaDimidjian
Overview, cognitive model, and case conceptualization
Sequence and structure of treatment
Automatic thoughts
Underlying assumptions and core beliefs
Competence
Cogni2vetherapyisafocusedformofpsychotherapybasedonamodels2pula2ngthatpsychologicaldisordersinvolvedysfunc2onalthinking
Thewayanindividualfeelsandbehavesisinfluencedbythewayhe/shestructureshis/herexperiences(ABCmodel)
JS Beck 2003
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Modifying dysfunctional thinking provides improvement in symptoms
Modifying dysfunctional beliefs which underlie dysfunctional thinking leads to more durable improvement
CT involves a cognitive conceptualization of the disorder and of the particular patient and uses a variety of techniques: cognitive, behavioral, experiential, etc.
JS Beck 2003
Requiresastrong,posi2vetherapeu2calliance
Emphasizescollabora2onandac2vepar2cipa2on
Goalorientedandproblemfocused
Structured
Emphasison“hereandnow”
Timelimited,withemphasisonrelapsepreven2on
Psychoeduca2onal
Preferenceforconcrete,specificexamples
Relianceon“Socra2c”Ques2oning
Empiricalapproachtotestbeliefs
ATheEvent(antecedent)
BYourthoughts
(belief)
CYourfeelings(consequence)
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Characteris2cofdepressedpa2ents
Nega2veView Ofself Ofthefuture Oftheworldandothers
Allornothingthinking
Catastrophizing/FortuneTelling
Disqualifiyingordiscoun2ngtheposi2ve
Emo2onalreasoning
Labeling
Magnifica2on/minimiza2on
Mentalfilter
Mindreading
Overgeneraliza2on
Personaliza2on
Shouldandmuststatements
TunnelVision
JSBeck,1995
IncompetentCoreBeliefs Iamhelpless. Iampowerless. Iamoutofcontrol. Iamweak. Iamneedy. Iamtrapped. Iaminadequate. Iamineffec2ve. Iamincompetent. Iamafailure. Iamdisrespected. Iamnotgoodenough(intermsofachievement). Iamdefec2ve(i.e.,Idonotmeasureuptoothers). Adapted from JS Beck (1995)
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UnlovableCoreBeliefs• Iamunlovable.
• Iamunlikable.
• Iamundesirable.
• Iamuna^rac2ve.
• Iamunwanted.
• Iamuncaredfor.
• Iambad.
• Iamunworthy.
• Iamdifferent.
• Iamboundtoberejected.
• Iamboundtobealone.
• Iamboundtobeabandoned.
• Iamdefec2ve(i.e.,sootherswillnotloveme) Adapted from JS Beck (1995)
Myfrienddidn’tcallmeback
Myco‐workersdidn’tInvitemetolunch
Myneighborinvitedmetoherparty
I am unlovable
Myfrienddidn’tcallmeback
Myco‐workersdidn’tInvitemetolunch
MyneighborinvitedmetoherpartyBUTonlybecauseshe
invitedtheenFreneighborhood
Iamunlovable
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CoreBeliefs• I’mincompetent
AGtudes/Rules/AssumpFons• IfIworkhardalltheFme,I’llbeokay
• IfImakeamistake,I’vefailedandbadthingswillhappen
CoreBeliefs• I’mincompetent
AGtudes/Rules/AssumpFons• IfIworkhardalltheFme,I’llbeokay
• IfImakeamistake,I’vefailedandbadthingswillhappen
AutomaFcThoughts• Ican’tdothis
• Thereisnopoint
ReacFon• EmoFonal• Behavioral• Physiological
SituaFon• Importantdeadline
atwork
Cogni2vemapofpa2ent’spsychopathology Organizeskeyinforma2on Servesasaguide/roadmapfortreatment Showsblindspots
Fluid,ongoingprocess;constantlyrevisingandrefiningconceptualiza2on
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CoreBeliefs• Whatisthemostcentralbelief?
• Acceptedasabsolutetruths;global,rigid,overgeneral
AGtudes/Rules/AssumpFons• What+assumpFonhelpedthepaFentcopewiththebelief?
• Whatisthe‐counterparttothisassumpFon?
Compensatory/CopingStrategies• WhichbehaviorshelpthepaFentcopewiththebelief?
• ORennormalbehaviorsbutoverusedandrigid
RelevantChildhoodData• Whichexperiencescontributedtothedevelopment
andmaintenanceofthecorebelief?
AutomaFcThought/Image• WhatwentthroughthepaFent’smind?
• UsepaFent’sactualwords
MeaningoftheAT• Whatdidthethoughtmeantoher?
EmoFon• WhatwastheemoFon?Oneword.
• Sad,anxious,angry,happy,disgusted,annoyed,embarrassed
SituaFon• WhatwastheproblemaFcsituaFon?
Behavior• WhatdidthepaFentdothen?
Orien2ngtotreatment;providingra2onale
Behavioralac2va2onstrategies
Traininginself‐monitoring
Iden2fyingandmodifyingsitua2onspecificthoughtsandbiases
Iden2fyingandchangingcorebeliefsandunderlyingassump2ons
Relapsepreven2on
Termina2on;becomingowntherapist
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Briefupdateandmoodcheck
Bridgefromprevioussession
Setcollabora2veagenda Homeworkreview
Discussionofagendaitems,assigninghomework,periodicsummaries
Finalsummaryandfeedback
Setagenda(withra2onale)
Moodcheck
Reviewpresen2ngproblemandupdatesinceevalua2on
Iden2fyproblemsandgoals
Educa2onpa2entaboutcogni2vemodel
Elicitexpecta2onsfortherapy
Educatepa2entaboutdepression
Assignhomework
Summarizesession
Askforsessionfeedback(includingnega2ve)
Earlyintreatmentandwithmoreseveredepression
Ac2vityMonitoring&Scheduling Ac2vityschedulingtogetpeoplemoreac2ve,withfocus
onpossiblemasteryand/orpleasureac2vi2es(e.g.,whatwouldyoubedoingthisweekifyouwerenotdepressed?)
Ac2vitymonitoringcanbeusedtotestthoughts(e.g.,“I’mnotdoinganything”“nothinggivesmepleasure”)
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Whatisanautoma2cthought? Actualwords/images Brief,automa2c,popintoyourmind Ogennotawareofautoma2cthoughts Logicallyconnectedtoemo2ons Frequentlynotvalid(distorted)ornotuseful
Howtoelicitautoma2cthoughts?
Whatwasgoingthroughyourmindjustthen?
Ask this question when you notice a shift in (or intensification of) affect during a session
Have the client describe a problematic situation or a time when they experienced a shift in affect and ask this question
If needed, have the client to use imagery to describe the specific situation in detail as if it’s happening right now and then ask this question
If needed, have the client do a role play of a specific interaction with you and then ask this question
Restate questions as statements
Other questions to ask to elicit automatic thoughts What do you guess you were thinking about? Do you think you could have been thinking _____ or ________? What did this situation mean to you? Were you thinking ____________? If I was in your situation, I might have been thinking __________ .
What is the evidence – pro and con? What is the evidence that supports this idea? What is the evidence against this idea?
Is there another way to look at this situation?
What is the worst that could happen? Could I live through it? What is the best that could happen? What is the most realistic outcome?
What is the effect of my believing this thought? What could be the effect of changing my thinking?
What should I do about it?
If _____ (friend’s name) was in this situation and had this thought, what would I tell him/her?
What is a more reasonable way to view this situation?
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Situa2on Who,what,when,where Specificandobservable
Automa2cThoughts Gettheiractualwords,images&ratedegreeofbelief Restateques2onsintostatements
Emo2ons Oneword&rateintensity
Besureclientdoesn’tconfusecategories
Makelogicalconnec2onsbetweenthoughtsandemo2ons yourtaskistounderstandhowthepar2cularthoughtgeneratesthepar2cularemo2on usethistoexplicitlyreinforceCTmodel(doesitmakesensethatifyouthink___,youwould
feel___?;ifyoudidn’tbelieve__,doyouthinkyouwoulds2llfeel___?)
Summarize!
Guidelinesforwhatthoughtstoselectforevalua2on Important(“hot”);typical;ifteaching,pickonethatseemsdistorted
ThreeQues2ons Whatistheevidenceforthatbelief? Isthereanalterna2veexplana2onforthatevent? Whataretherealimplica2onsiftrue?
OtherUsefulQues2ons Isitusefulformetothinkaboutthisrightnow? WhatwouldItellafriendinthissamesitua2on?
Examine,explore,evaluatevs.challenge!
Why? Pa2entswithhighaffectexperiencenarrowingoffocusandawareness;in
depression,focusedonnega2ves Socra2cQscanhelptowidenfocus Increaselikelihoodthatsolu2onswillfitwithclients’values Increaseopennesstonewperspec2ves,reducedefensiveness
How? Askinforma2onalques2ons Listenempathically‐bothtowhatisbeingsaidandnotsaid Makefrequentsummaries–helpsorganizeinforma2onandpromotes
likelihoodthatclientwillretainwhatyouarediscussing Asksynthesizingandanaly2cques2ons–whatdoyoumakeofthis?how
doyouputthisinforma2ontogether?AdaptedfromPadesky,
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Typically“if/then”quality(condi2onal) Rulesandassump2onspeopleliveby Ogenmanifestas“should”statements Ifnotinif/thenform,askmeaningques2onstoformulateasanassump2on
Absolutestatementsaboutself,other,world Lookforthemesacrossautoma2cthoughts Use“downwardarrow”toexploremeaning
Ifthisthoughtweretrue,what’ssobadaboutthat? Ifthisthoughtweretrue,what’stheworstpartaboutit? Ifthisthoughtweretrue,whatdoesthatmeantoyou?Aboutyou? Ifso,sowhat…?
Morecentralandabstractthanautoma2cthoughts Ogenmakebe^ersenseofaffect Showclientssamplelistofbeliefsifthingsgetstuck Gofor“hotcogni2ons”andlinktospecificaffect
Confirmthatthebeliefiscentral,stronglyheld,andrelatedtothepa2ent’scurrentdistress
Mentallyformulatemorefunc2onalbelief
Educatepa2entsaboutbeliefs Rangeofbeliefspossible;beliefsarelearned;canbeevaluatedandchanged;
canbestronglyheldand“felt”tobetrueands2llbemostlyoren2relyuntrue;newbeliefscanbelearned
Examineadvantagesanddisadvantagesofbeliefs
Concre2zeandTestLikeAnyBelief Socra2cques2oning Cogni2veConceptualiza2onDiagram CoreBeliefWorksheet Behavioralexperiments
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Usewhenyouhavealterna2vethoughtsthatyoudonotfullybelieve(“Everynewac2onchipsawayatoldbeliefs”)
Designanexperimentthatwillhelpyoutestthethought
Startsmallandbuildonsuccesses Domul2pleexperimentsbeforeexpec2ngbigchanges
Whenoutcomesarenotpreferred,don’tquit,problemsolve!
Writedownwhatyouno2cedandlearned