Core Beliefs on Trial: A Cognitive Therapy Approach for...

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Webinar Handout

To submit a question during the webinar:

• Locate the Questions? box at the right side of the screen

• Type your question in the field at the bottom of the box

• Click the button at the right end of the box (Send)

Sponsored by the Neuroscience Education Institute Additionally sponsored by the American Society for the Advancement of Pharmacotherapy

Supported solely by the sponsor, the Neuroscience Education Institute

Copyright © 2011 Neuroscience Education Institute

Copyright © 2010 Neuroscience Education Institute 2 Copyright © 2011 Neuroscience Education Institute 2

CME Information

Overview Persistent core beliefs that are negative, global, and personal regarding life events and adverse outcomes are risk factors for recurrence of most psychiatric disorders. To combat these risk factors, Dr. Irismar Reis De Oliveira has created a novel three-level, three-phase intervention to modify a patient's core beliefs.

Dr. Reis De Oliveira will teach how to use this novel intervention method, Trial-Based Cognitive Therapy (TBCT), through a webinar titled "Core Beliefs on Trial: A Cognitive Therapy Approach for Psychopharmacologists".

One of TBCT's main techniques is the Trial-Based Thought Record (TBTR), a structured strategy that is presented as an analogy to a trial, in which the therapist engages the client in a simulation of the judicial process, including investigation, prosecutor statements/arguments, defense attorney statements/arguments, and a jury verdict. It is an empirically validated method of belief change, with preliminary, but promising, results shown to help patients constructively reduce attachment to negative core beliefs and corresponding emotions.

Learning Objectives After participating in this webinar, participants should be able to:

Explain the cognitive model to the patient according to the Trial-Based Cognitive Therapy (TBCT) conceptualization diagram

Describe the role of the Trial-Based Thought Record (TBTR) in changing patients' core beliefs

Describe the main research findings supporting the efficacy of TBTR

Target Audience This activity has been developed for prescribers specializing in psychiatry. There are no prerequisites. All health care providers interested in psychopharmacology, especially primary care physicians, nurses, psychologists, and pharmacists, are welcome for advanced study.

Accreditation and Credit Designation Statements The Neuroscience Education Institute is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Neuroscience Education Institute designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The American Society for the Advancement of Pharmacotherapy is approved by the American Psychological Association to sponsor continuing education for psychologists. The American Society for the Advancement of Pharmacotherapy maintains responsibility for this program and its content.

The American Society for the Advancement of Pharmacotherapy designates this program for 1.0 CE credit for psychologists. Nurses: for ALL of your CE requirements for recertification, the ANCC will accept category 1 credits from organizations accredited by the ACCME. Physician Assistants: the AAPA accepts AMA PRA Category 1 Credit™ from organizations accredited by the ACCME. A certificate of participation for completing this activity will also be available.

Instructions for CME Credit/Certificates To receive your certificate of CME credit or participation, please complete the posttest and activity evaluation found at the end of the activity. Alternatively, you may access the posttest/evaluation from www.neiglobal.com/cme, available for 90 days following the activity. If a score of 70% or more is achieved, you will be able to immediately print your certificate. There is no fee for CME credits for this activity. If you have questions, please call 888-535-5600, or email [email protected].

Copyright © 2011 Neuroscience Education Institute 2


CME Information, continued NEI Disclosure Policy It is the policy of the Neuroscience Education Institute to ensure balance, independence, objectivity, and scientific rigor in all its educational activities. Therefore, all individuals in a position to influence or control content development are required by NEI to disclose any financial relationships or apparent conflicts of interest that may have a direct bearing on the subject matter of the activity. Although potential conflicts of interest are identified and resolved prior to the activity being presented, it remains for the participant to determine whether outside interests reflect a possible bias in either the exposition or the conclusions presented.

These materials have been peer-reviewed to ensure the scientific accuracy and medical relevance of information presented and its independence from commercial bias. The Neuroscience Education Institute takes responsibility for the content, quality, and scientific integrity of this CME activity.

Individual Disclosure Statements

Faculty Author / Presenter

Irismar Reis De Oliveira, MD, PhD Professor of Psychiatry, Department of Neurosciences and Mental Health, Post-Graduation Program, Professor Edgar Santos University Hospital, Federal University of Bahia, Salvador, Brazil Grant/Research: AstraZeneca, Dainippon Sumitomo, Lilly, Roche, Servier Content Editors

Meghan Grady Director, Content Development, Neuroscience Education Institute, Carlsbad, CA No other financial relationships to disclose.

Debbi Ann Morrissette, PhD Adjunct Professor, Biological Sciences, California State University, San Marcos Medical Writer, Neuroscience Education Institute, Carlsbad, CA No other financial relationships to disclose. Peer Reviewers

Ronnie Gorman Swift, MD Professor and Associate Chairman, Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla Professor of Clinical Public Health, School of Public Health, New York; New York Medical College, Valhalla Chief of Psychiatry and Associate Medical Director, Metropolitan Hospital Center, New York City No other financial relationships to disclose.

Owen Nichols, PsyD, MBA, NHA, CPM, ABPP, ABMP President and CEO, NorthKey Community Care, Covington, KY No other financial relationships to disclose. Program Development

Rory Daley, MPH, Associate Director, Program Development, Neuroscience Education Institute, Carlsbad, CA No other financial relationships to disclose.

Steve Smith, President and COO, Neuroscience Education Institute, Carlsbad, CA No other financial relationships to disclose. Disclosed financial relationships have been reviewed by the Neuroscience Education Institute CME Advisory Board to resolve any potential conflicts of interest. All faculty and planning committee members have attested that their financial relationships do not affect their ability to present well-balanced, evidence-based content for this activity.


Copyright © 2010 Neuroscience Education Institute 4 Copyright © 2011 Neuroscience Education Institute 4

CME Information, continued

Disclosure of Off-Label Use This educational activity may include discussion of products or devices that are not currently labeled for such use by the FDA. Please consult the product prescribing information for full disclosure of labeled uses.

Disclaimer The information presented in this educational activity is not meant to define a standard of care, nor is it intended to dictate an exclusive course of patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this educational activity should not be used by clinicians without full evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. Primary references and full prescribing information should be consulted.

Participants have an implied responsibility to use the newly acquired information from this activity to enhance patient outcomes and their own professional development. The participant should use his/her clinical judgment, knowledge, experience, and diagnostic decision-making before applying any information, whether provided here or by others, for any professional use.

Cultural and Linguistic Competency A variety of resources addressing cultural and linguistic competency can be found in this linked handout (http://www.neiglobal.com/forms/cme/regulations/CA_AB_1195_handout_NON-CA_2008.pdf).

Sponsor Sponsored by the Neuroscience Education Institute. Additionally sponsored by the American Society for the Advancement of Pharmacotherapy.

Support This activity is supported solely by the sponsor, Neuroscience Education Institute.

Special Needs Neuroscience Education Institute is committed to making its activities accessible to all individuals. If you have special needs as addressed by the Americans with Disabilities Act (ADA) and need assistance, contact NEI at 888-535-5600 or [email protected].

To submit a question during the webinar:

Locate the Questions? box at the right side of the screen

Type your question in the field at the bottom of the box

Click the button at the right end of the box (Send)


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Learning Objectives

• Explain the cognitive model to the patient according to the Trial-Based Cognitive Therapy (TBCT) conceptualization diagram

• Describe the role of the Trial-Based Thought Record (TBTR) in changing patients' core beliefs

• Describe the main research findings supporting the efficacy of TBTR

Core Beliefs on Trial: A Cognitive Therapy Approach for Psychopharmacologists

Copyright © 2011 Irismar Reis de Oliveira. All rights reserved. 5

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C B li f T i lCore Beliefs on Trial:A Cognitive Therapy Approach for

P h h l i tPsychopharmacologists



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Learning Objectives

After participating in this webinar, participants p p g , p pshould be able to:

• Explain the cognitive model to the patient according to th T i l B d C iti Th (TBCT)the Trial-Based Cognitive Therapy (TBCT) conceptualization diagram

• Describe the role of the Trial-Based Thought RecordDescribe the role of the Trial Based Thought Record (TBTR) in changing patients' core beliefs

• Describe the main research findings supporting the ffi f TBTRefficacy of TBTR



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Trial-Based Cognitive Therapy

1. Important definitions• Automatic thoughts, underlying assumptions, and core

beliefs

2. Conceptualization diagram• Circuits hypothesis

3. Trial-Based Thought Record• Obsessive-Compulsive Disorder• Panic disorder

4. Research• Trial-Based Thought Recordg

o First useo Social anxiety disorder



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What is cognitive therapy?

• A generally short-term psychotherapy modelo Developed by Aaron Beck at the University of Pennsylvania

o Goal-directed

Present orientedo Present-oriented

o Based on the cognitive model of psychopathology and learning theory

• Emphasis on:o Current thoughts, emotions, and behaviorsg , ,

o Undoing old learning and teaching new behaviors



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Important Definitions

• Automatic thoughtsAutomatic thoughts

• Underlying assumptions

• Core beliefs



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Automatic Thoughts

• Perceptions that occur rapidly in responsePerceptions that occur rapidly in response to a situation

• Are not subjected to systematic logicalAre not subjected to systematic, logical analysis

• A person may be unaware of their presenceA person may be unaware of their presence or significance

• May or may not be distorted• May or may not be distorted



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Definitions and Examples of 15 Cognitive Distortions

Cognitive Distortion Definition Example

1 Dichotomous thinking (also called “all-or-nothing” or

I view a situation, a person, or an event only in all- or-nothing terms, fitting them

“I made a mistake, therefore I’m a failure.” “I ate more than I planned, so I blew my diet completely.”called all or nothing or

“black and white”)only in all or nothing terms, fitting them into only 2 extreme categories instead of on a continuum.

more than I planned, so I blew my diet completely.

2 Fortune telling (also called “catastrophizing”)

I predict the future in negative terms and believe that what will happen will be so awful that I will not be able to stand it.

“I will fail, and this will be unbearable.” “I’ll be so upset that I won’t be able to concentrate for the exam.”

Di ti I di lif d di t iti “I d th b t I j t l k ” “G i t3 Discounting or disqualifying the positive

I disqualify and discount positive experiences or events, insisting that they do not count.

“I passed the exam, but I was just lucky.” “Going to college is not a big deal; anyone can do it.”

4 Emotional reasoning I believe my emotions reflect reality and let them guide my attitudes and judgments.

“I feel she loves me, so it must be true.” “I am terrified of airplanes, so flying must be dangerous.”

5 Labeling I put a fixed global label usually negative “I’m a loser ” “He’s a rotten person ” “She’s a5 Labeling I put a fixed, global label, usually negative, on myself or others.

I m a loser. He s a rotten person. She s a complete jerk.”

6 Magnification/minimization I evaluate myself, others, and situations, magnifying the negatives and/or minimizing the positives.

“I got a B. This proves how inferior I am.” “I got an A. It doesn’t mean I’m smart.”

7 Selective abstraction (also I pay attention to one or a few details and “My boss said he liked my presentation but since he7 Selective abstraction (also called “mental filter” and “tunnel vision”)

I pay attention to one or a few details and fail to see the whole picture.

My boss said he liked my presentation, but since he corrected a slide, I know he did not mean it.” “Even though the group said my work was good, one person pointed out an error so I know I will be fired.”



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Definitions and Examples of 15 Cognitive Distortions

Cognitive Distortion Definition Example

1 Dichotomous thinking (also called “all-or-nothing” or

I view a situation, a person, or an event only in all- or-nothing terms, fitting them

“I made a mistake, therefore I’m a failure.” “I ate more than I planned, so I blew my diet completely.”called all or nothing or

“black and white”)only in all or nothing terms, fitting them into only 2 extreme categories instead of on a continuum.

more than I planned, so I blew my diet completely.

2 Fortune telling (also called “catastrophizing”)

I predict the future in negative terms and believe that what will happen will be so awful that I will not be able to stand it.

“I will fail, and this will be unbearable.” “I’ll be so upset that I won’t be able to concentrate for the exam.”

f “ “G3 Discounting or disqualifying the positive

I disqualify and discount positive experiences or events, insisting that they do not count.

“I passed the exam, but I was just lucky.” “Going to college is not a big deal; anyone can do it.”

4 Emotional reasoning I believe my emotions reflect reality and let them guide my attitudes and judgments.

“I feel she loves me, so it must be true.” “I am terrified of airplanes, so flying must be dangerous.”

5 Labeling I put a fixed global label usually negative “I’m a loser ” “He’s a rotten person ” “She’s a5 Labeling I put a fixed, global label, usually negative, on myself or others.

“I’m a loser.” “He’s a rotten person.” “She’s a complete jerk.”

6 Magnification/minimization I evaluate myself, others, and situations, magnifying the negatives and/or minimizing the positives.

“I got a B. This proves how inferior I am.” “I got an A. It doesn’t mean I’m smart.”

7 Selective abstraction (also I pay attention to one or a few details and “My boss said he liked my presentation but since he7 Selective abstraction (also called “mental filter” and “tunnel vision”)

I pay attention to one or a few details and fail to see the whole picture.

My boss said he liked my presentation, but since he corrected a slide, I know he did not mean it.” “Even though the group said my work was good, one person pointed out an error so I know I will be fired.”



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Underlying Assumptions

• Conditional rules or “should” statements used to guide our behavior, emotional expression, and understanding of how the world operates (Padesky & Greenberger 1995)(Padesky & Greenberger, 1995)

• Usually expressed as “if… then…” statementso “If I go to the party then people will know I amo If I go to the party, then people will know I am

awkward.”



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Core Beliefs

• Also sometimes called “schemas”

• Are global, rigid, and fundamental beliefs that people have about themselves, the world, and/or the future

• Influence the types of thoughts (cognitions) that peopleInfluence the types of thoughts (cognitions) that people experience in specific situations

o “I am incompetent” will likely predict that he will be unable to function adequately during a job interviewfunction adequately during a job interview

o “I am unlikable” will likely predict that others will not be interested in what she has to say at a social gathering

o As a result, both of these people would likely experience a great deal of social anxiety



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Cognitive Model

Behaviors

Situation Automatic thoughts Emotions

Behaviors

Underlying assumptions

Physiologicalresponses

Core beliefs(Schemas)(Schemas)



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A More Complex Cognitive Model

Emotions

Situation Automatic thoughts Behaviors1st level

Underlying assumptions

Physiologicalresponses

2nd level

Core beliefs(Schemas)

3rd level

(Schemas)

Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.



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1. Important definitions• Automatic thoughts, underlying assumptions, and core

beliefs

2. Conceptualization diagram• Circuits hypothesis


4. Research• Trial-Based Thought Record


go First useo Social anxiety disorder



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TBCT Conceptualization Diagram

Same components as standard cognitive therapy, but…




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TBCT Conceptualization DiagramPhase 1: Before Treatment

Negative core beliefs predominantly activated




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Situation

Automatic thought

TBCT Conceptualization Diagram Phase 1

Emotional reaction

Behavioral and/or physiological response

1st level




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Situation

Automatic thought


Emotional reaction


1st level

-

Activated negativecore belief




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Situation

Automatic thought


Emotional reaction


1st level

-

SchemaSchemaactivation





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Situation

Automatic thought Circuit 1


Emotional reaction


1st level




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Situation

Automatic thought Circuit 1


Emotional reaction


1st level

Circuit 1

Automatic Thought → Emotion→ Behavior and/or Physiological Response

→ Automatic Thought




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Situation

I am invited to a Automatic thought

John’s TBCT Conceptualization Diagram Phase 1

party I will be criticized

AnxiousEmotional reaction


I do not go to the party1st level




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Situation



party I will be criticizedPeople will find me awkward Anxious

More anxious

Emotional reaction


I do not go to the partyI avoid people

1st level




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Situation

I am not invited to a Automatic thought


new party People really find me awkward



I continue to avoid people1st level




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Situation

I am not invited to a Automatic thought


new party People really find me awkward



I continue to avoid people1st level

I am awkward





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Situation

Automatic thought


Emotional reaction


1st level

Underlying assumptions/rules:

2nd level


Compensatory strategies/safety behaviors:




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Situation

Automatic thought


Emotional reaction


1st level


2nd levelModulation by underlying

assumptions






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Situation

Automatic thought


Emotional reaction


1st level



assumptionsCircuit 2



Circuit 2

Underlying Assumption → Safety Behavior → [Automatic Thought]* → Emotion → Behavior and/or[Automatic Thought] → Emotion → Behavior and/or Physiological Response → Underlying Assumption

*May not exist or may be implicitCopyright © 2011 Irismar Reis de Oliveira. All rights reserved.



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Situation



party I will be criticizedPeople think I amawkward Anxious

Emotional reaction


I do not go to the partyI avoid people

1st level


2nd level



Avoidance




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Situation



party I will be criticizedPeople think I am awkward Anxious

Emotional reaction


I do not go to partiesI avoid people

1st level



assumptions



Avoidance




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Situation




Emotional reaction



1st level



assumptions


If I do not avoid people, then they will criticize meCompensatory strategies/safety behaviors:

Avoidance




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Situation

Automatic thought


Emotional reaction


1st level



assumptions



3rd levelCircuit 3 Relevant childhood data for:

1) Negative core belief


Inactive positivecore belief

2) Positive core belief




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C 3


Circuit 3

Underlying Assumption → Safety Behavior → Core Belief → Underlying

Ass mption1st level

Assumption



assumptions











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Situation




Emotional reaction



1st level



assumptions


If I do not avoid people, then they willcriticize meCompensatory strategies/safety behaviors:

Avoidance

I am awkward3rd levelCircuit 3 Relevant childhood data for:








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Situation




Emotional reaction



1st level



assumptions


If I do not avoid people, then they will criticize meCompensatory strategies/safety behaviors:

Avoidance

I am awkward3rd levelRelevant childhood data for:1) Negative core belief







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Phase 2: During TreatmentPositive core belief activation with TBCT




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Situation

Automatic thought


Emotional reaction


1st level


Modulation by underlying assumptions

2nd level



3rd levelRelevant childhood data for:1) Negative core belief

2) Positive core beliefInactive negative

core beliefActivated positive

core belief





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Situation

Automatic thought


Emotional reaction


1st level

Underlying assumptions/rules:Trial I


2nd level



Trial ITrial II.1

RG



2) Positive core beliefInactive negative


core belief





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Phase 3: After Treatmentase 3 te eat e tBalance between positive and negative core belief activation




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Situation

Automatic thought

CD‐QuestIntraDTR


Emotional reaction


InterDTR

1st level

CRP and behavioral experiments Underlying assumptions/rules:


2nd level



Relevant childhood data for:Trial I and II3rd level


Activated positivecore belief




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Situation

Automatic thought

CD‐QuestIntraDTR


Emotional reaction


InterDTR

1st level



2nd level



I am normal

Trial I and II3rd level

Relevant childhood data for:1) Negative core belief

normalActivated negative


core belief2) Positive core belief




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1. Important definitionsAutomatic thoughts underlying assumptions and core• Automatic thoughts, underlying assumptions, and core beliefs

2. Conceptualization diagramCi it h th i• Circuits hypothesis




o First useo Social anxiety disorder



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Franz Kafka 1883-1924




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Literary Work




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Trial-Based Thought Record (Trial I)

• Designed to change core beliefs or schemas

• Inspiration from Franz Kafka’s surreal novel The Trial• Inspiration from Franz Kafka s surreal novel The Trialo Self-accusation as a universal principle?

• Analogy or metaphor to a judicial processI i (d d )o Inquiry (downward arrow)

o Prosecutor’s plea (evidence supporting the core belief)o Defense attorney’s plea (evidence not supporting the core belief)o Prosecutor’s response to the defendant’s plea (discounting the p p ( g

evidence)o Defense attorney’s response to the prosecutor’s plea (sentence

reversal)o Jurors’ verdict (debriefing)


( g)o Preparation for the appeal (upward arrow and positive self-statements

log) as homework



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Wh i th d f tt ?Where is the defense attorney?




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1. Inquiry

2. Prosecutor’s

3.Defense

4.Prosecutor’s

5.Defense

6.Meaning of the

7.Juror

Trial-Based Thought Record (Trial I)q y

plea attorney’s plea response(but…)

attorney’s response(Sentence reversal)

gresponse:“It means

that…”

Who was more convincing? Who presented more

evidence? Whose evidence was more

based on facts? Who made fewer

(cognitive) distortions?

Automaticthoughts:

Downward arrow

(core belief)

Verdict:

Upward arrow

(new core belief)

I b li i

(core belief)

I am...

(new core belief)

I am...

I believe in the accusation:

Emotion:

I believe:

Emotion:

I believe:

Emotion:

I believe:

Emotion:

I believe:

Emotion:

I believe:

Emotion:




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1. Inquiry

2. Prosecutor’s

3.Defense

4.Prosecutor’s

5.Defense

6.Meaning of the

7.Juror

Trial-Based Thought Record (Trial I)q y

plea attorney’s plea response(but…)

attorney’s response(Sentence reversal)

gresponse:“It means

that…”

Who was more convincing? Who presented more

evidence? Whose evidence was more

based on facts? Who made fewer

(cognitive) distortions?

Automaticthoughts:

Deconstructive language

Downward arrow

(negative core

Verdict:

Upward arrow

(positive core

Constructive language

I b li i

(negative core belief)

I am...

(positive core belief)

I am...

I believe in the accusation:

Emotion:

I believe:

Emotion:

I believe:

Emotion:

I believe:

Emotion:

I believe:

Emotion:

I believe:

Emotion:




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Defense Attorney’s Preparation for the Appeal (Positive Self-Statements Log)I am... (positive belief derived from the upward arrow technique)

Homework Assignment

Date (90%)1.

2.

3.

Date ( %)1.

2.

3.

Date ( %)1.

2.

3.




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Case ReportCase ReportObsessive Compulsive Disorder and Borderline Personality Disorder

Described in the Common Language for Psychotherapy Procedureshttp://www.commonlanguagepsychotherapy.org/




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Case Illustration

Ida, married and in her 30s, had been anxious, d i f 3 Sh h dangry, and aggressive for 3 years. She had

difficulty dealing with subordinates (she was a manager in a company) and went on sick leave.g p y)

Her depression worsened. Ida could not resume work and stopped her master’s degree studies. She mutilated herself and attempted suicide due to severe anxiety, which did not reduce with antidepressants and high doses of


antidepressants and high doses of benzodiazepines.



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Case Illustration (cont.)

Her benzodiazepines were tapered and l d ith ti i Sh l h d klreplaced with quetiapine. She also had weekly

cognitive restructuring of beliefs such as “I’m a failure, incompetent, and inadequate” by p q yexamining evidence for and against them.

Though her anxiety decreased, external events reactivated her beliefs, and she mutilated herself again.




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Six months before the session yielding the Trial i d ib d i thi t ti Idsession described in this presentation, Ida

started to repeatedly verify her wallet for hours daily, checking 13 items by touching and reading y g y g geach word in the documents and cards.

Intensive exposure, ritual prevention, and cognitive restructuring therapy (2‒3 weekly sessions to a total of 18 sessions) stopped her checking within 2 monthschecking within 2 months.




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INQUIRY(downward

PROSECUTOR(evidence

ti th

DEFENSE ATTORNEY( id t

PROSECUTOR’S RESPONSE( b t )

DEFENSE ATTORNEY’S RESPONSE( t l)

IT MEANS THAT...

JUROR(debriefing)

TBTR: Described in the Common Language for Psychotherapy Procedures

arrow technique)

supporting the accusation)

(evidence not supporting)

(yes, but...) (sentence reversal)

I am not succeeding in studying

I am too anxious

I will not finish my master’s degree course

ACCUSATION:___________VERDICT:ACCUSATION:

I AM IMPERFECT

EMOTION:ANXIETY

VERDICT:

Initial Final100%100%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)





I’ve lost control of my whole life

I am too anxious


I can’t absorbinformation quickly

I’m slow at reasoning

I d ’t d ll

ACCUSATION:

I don’t do well when interacting with people and controlling my environment

___________VERDICT:ACCUSATION:

I AM IMPERFECT

EMOTION:ANXIETY

VERDICT:

Initial Final100% 100%

100%100%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)






1. I don’t check my driver’s license, and I haven’t lost control

I am too anxious




I d ’t d ll

control

2. My OCD score fell today

3. I can remember some techniques without having to

d th b k

ACCUSATION:


reread the book

4. I’m completing theevidence chart


I AM IMPERFECT

EMOTION:ANXIETY

VERDICT:


100%100%

80%80%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)







1. I check on other items

I am too anxious




I d ’t d ll

control



d th b k

2. I’m not cured

3. I can’t remember them all

ACCUSATION:


reread the book


4. I still believe I’m imperfect


I AM IMPERFECT

EMOTION:ANXIETY

VERDICT:


100%100%

80%80%

90%90%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)







1. I check on other items

1. I check on other items, BUT I don’t check my driver’s license and haven’t lost control

1. I can stop myself checking

I am too anxious




I d ’t d ll

control



d th b k

2. I’m not cured

3. I can’t remember them all.

control

2. I’m not cured, BUT my OCD score fell today

3. I can’t remember them all, BUT I can remember some of the techniques without h i t d th b k

2. I can cure myself

3. I can learn

ACCUSATION


reread the book


4. I still believe I’m imperfect

having to reread the book

4. I still believe I’m imperfect, BUT I’m completing theevidence chart

4. I see the other side of my imperfection (that I am normal)

___________VERDICTACCUSATION:

I AM IMPERFECT

EMOTION:ANXIETY

normal) VERDICT:


100%100%

80%80%

90%90%

70%70%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)





I’ve lost control of my whole life (A)


1. I check on other items (B)



The prosecutor made errors:overgeneralization (A), discounting

I am too anxious


I can’t absorbinformation quickly (C)

I’m slow at reasoning (C)

I d ’t d ll

control



d th b k

2. I’m not cured (B)

3. I can’t remember them all (B)

control




3. I can learn

discounting positives (B), and all-or-nothing thinking (C)

The defense attorney

d

ACCUSATION

I don’t do well when interacting with people and controlling my environment (B, C)

reread the book


4. I still believe I’m imperfect (B)




made no distortions and gave fairer and more consistent arguments___________VERDICTACCUSATION:

I AM IMPERFECT

EMOTION:ANXIETY

normal) VERDICT:


100%100%

80%80%

90%90%

70%70%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)






1. I don’t check my driver’s license and I haven’t lost control





I am too anxious




I d ’t d ll

control



d th b k



control




3. I can learn

discounting positives (B), and all-or-nothing thinking (C)

The defense attorney

d

ACCUSATION:

I don’t do well when interacting with people and controlling my environment (B, C)

reread the book






made no distortions and gave fairer and more consistent arguments___________VERDICT:ACCUSATION:

I AM IMPERFECT

EMOTION:ANXIETY

normal) VERDICT:

Innocent


100%100%

80%80%

90%90%

70%70%

55%55%




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Upward Arrow Technique

T: If the defense attorney’s statements are right, what do they mean about

?you?

P: I AM NORMAL!


De-Oliveira IR (2007) Sentence-reversion-based thought record (SRBTR): a new strategy to deal with “yes, but...” dysfunctional thoughts in cognitive therapy. European Review of Applied Psychology, 57:17-22.



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Homework AssignmentDefense Attorney’s Preparation for the Appeal (Positive Self-Statements Logs)

I am normal (positive belief derived from the upward arrow technique)

Date (60%)1. I succeeded in conquering the driver’s license2. I managed to conquer the student cardcard3.

Date ( %)1.

2.

3.

Date ( %)1.

2.

3.




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INQUIRY(downward

PROSECUTOR(evidence

i h

DEFENSE ATTORNEY( id

PROSECUTOR’S RESPONSE( b )

DEFENSE ATTORNEY’S RESPONSE( l)

IT MEANS THAT...

JUROR(debriefing)

arrow technique)











I am too anxious




I d ’t d ll

control



d th b k



control


3. I can’t remember them all, BUT I can remember some of the techniques without having t d th b k


3. I can learn

(A), discounting positives (B), and all-or-nothing thinking (C)

The defense attorneymade no di t ti dI don’t do well

when interacting with people and controlling my environment (B, C)

reread the book



to reread the book



distortions and gave fairer and more consistent arguments

___________VERDICT:

ACCUSATION:I AM

IMPERFECT

EMOTION:ANXIETY

normal)

Innocent

Initial Final100% 40%100% 40%

100%100%

80%80%

90%90%

70%70%

55%55%




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I am a capable

I am normal I am asse ti e

I am a t thf l

I am lovable I am a easonable

Homework Assignment

capable person

assertive truthfulperson

reasonable person

11/10 – 40%1. I sent comments to my supervisor

11/10 – 60% 11/10 – 40%1. I sent comments to my supervisor

11/10 – 50% 11/10 – 60%1. My husband told me I was the most

11/10 – 50%1. I gave a telephone call to Ry p

2. I reviewed a thesis

y p2. I reviewed a thesis

important person for him

12/10 – 45% 12/10 – 60%1. I woke up

12/10 – 45%1. I sent a card

12/10 – 55%1. I told my

12/10 – 60% 12/10 – 55%1. I sent a card 1. I woke up

feeling well1. I sent a card to my goddaughter

1. I told my mother I would not have lunch with her today

1. I sent a card to my goddaughter

13/10 – 50%1. I got to limit my OCD rituals2. I was able to leave the bedroom this

13/10 – 60% 13/10 – 50%1. I got to limit my OCD rituals

13/10 – 55% 13/10 – 60%1. My husband gave me support while I was feeling pain

13/10 – 60%

bedroom this morning

p




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Case ReportCase ReportPanic Disorder


Described in the Common Language for Psychotherapy Procedureshttp://www.commonlanguagepsychotherapy.org/



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Case Illustration

Two weeks before consulting a psychiatrist, Karen, age 28, developed panic attacks and stopped g , p p ppgoing out alone for fear of further panics. Panic attacks vanished for a whole year within weeks of starting escitalopram and clonazepam butstarting escitalopram and clonazepam, but returned after drug discontinuation; resuming those medications no longer helped.

Karen’s panic attacks improved dramatically with 2 sessions of cognitive restructuring and interoceptive exposure and she was able to


interoceptive exposure, and she was able to resume normal activities.



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Karen remained well during a year, even not taking any medication. Then, during a stressful period, y , g p ,Karen started fearing new panic attacks, and worrying about health problems and dying. She was no longer able to go out alonewas no longer able to go out alone.




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)




I have several chronic diseases that can lead to sudden death.

A psychological disorder may evolve into a physical disease.

ACCUSATION

___________VERDICT:

ACCUSATION:I AM

VULNERABLE

EMOTION:SAD

Initial Final70%50%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)





My grandfather died suddenly.

I have a genetic


gpredisposition, and I can also die.

My sister had an infarction when she was 13, due t i l

ACCUSATION

to a viral infection.

I have panic disorder.

___________VERDICT:

ACCUSATION:I AM

VULNERABLE

EMOTION:SAD

Initial Final70%50%

90%80%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)






I have a genetic

1) I have gone through many difficult situations, and I always




ysurvived.

2) I have never had a serious disease; to the contrary, I am always the last to become ill.

ACCUSATION



3) My eating habits are healthy, I do physical exercises, and I visit the doctor regularly.

___________VERDICT:

ACCUSATION:I AM

VULNERABLE

EMOTION:SAD

g y

Initial Final70%50%

90%80%

50%20%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)






I have a genetic


1) … BUT I can go through a worse situation and not survive.




ysurvived.


2) ... BUT I may have a physical disease.

ACCUSATION




3) ... BUT I may have a genetic predisposition to a physical disease. ___________

VERDICT:ACCUSATION:

I AM VULNERABLE

EMOTION:SAD

g y

Initial Final70%50%

90%80%

50%20%

90%80%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)






I have a genetic



1) I can go through a worse situation and not survive, BUT I have gone through many difficult situations and I

1)... the expression “I can” is abstract. Indeed, I always




ysurvived.



always survived.

2) I may have a physical disease, BUT I have never had a serious disease; to the contrary, I am always the last to become ill.

, ysurvived.

2) ... the expression “I may” is just an assumption and, in fact, I have

h d

ACCUSATION




3) ... BUT I may have a genetic predisposition to a physical disease.

3) I may have a genetic predisposition to a physical disease, BUT my eating habits are healthy, I do physical exercises, and I visit

never had a serious disease.

3) ... I have always behaved in the most careful and preventive way.

___________VERDICT:

ACCUSATION:I AM

VULNERABLE

EMOTION:SAD

g y p y ,the doctor regularly.

y

Initial Final70%50%

90%80%

50%20%

90%80%

0%0%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)






I have a genetic





The defense attorney seems more convincing and




ysurvived.



always survived.


, ysurvived.


h d

convincing and presented more evidence based on facts. The prosecutor tends to make more distortions as

ACCUSATION








discounting positives and catastrophic thinking.

___________VERDICT:

ACCUSATION:I AM

VULNERABLE

EMOTION:SAD


y

Initial Final70%50%

90%80%

50%20%

90%80%

0%0%




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INQUIRY(downward

PROSECUTOR(evidence

ti th




IT MEANS THAT...

JUROR(debriefing)


arrow technique)






I have a genetic





The defense attorney seems more convincing and




ysurvived.



always survived.


, ysurvived.


h d

convincing and presented more evidence based on facts. The prosecutor tends to make more distortions as

ACCUSATION








discounting positives and catastrophic thinking.

___________VERDICT:

ACCUSATION:I AM

VULNERABLE

EMOTION:SAD


y

Innocent

Initial Final70%50%

90%80%

50%20%

90%80%

0%0%

0%0%




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Upward Arrow Technique

T: If the defense attorney’s statements are right, what do they mean about

?you?

P: I AM NORMAL!

Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.75

De-Oliveira IR (2007) Sentence-reversion-based thought record (SRBTR): a new strategy to deal with “yes, but...” dysfunctional thoughts in cognitive therapy. European Review of Applied Psychology, 57:17-22.



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Homework AssignmentDefense Attorney’s Preparation for the Appeal (Positive Self-Statements Logs)

I am normal (positive belief derived from the upward arrow technique)

Date.... (90%)1. I came to therapyby myself.

2. I took care of mychildren this morning.

3.

Date ( %)1.

2.

3.

Date ( %)11.

2.

3.




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1. Important definitions• Automatic thoughts underlying assumptions and coreAutomatic thoughts, underlying assumptions, and core

beliefs

2. Conceptualization diagram• Circuits hypothesis• Circuits hypothesis

3. Trial-Based Thought Record• Obsessive-Compulsive Disorder

Panic disorder• Panic disorder


Fi to First useo Social anxiety disorder




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Revista Brasileira de Psiquiatria, 30(1):12-18, 2008Impact factor: 1.25p

Trial-Based Thought Record: Preliminary data on a strategy to deal with core beliefs by combining sentence reversion and the use of analogywith a judicial processwith a judicial process

Irismar Reis de OliveiraD t t f N i d M t l H lthDepartment of Neurosciences and Mental HealthFederal University of Bahia

http://www.scielo.br/scielo.php?pid=1516-4446&script=sci_serial




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TBTR Applied to 30 Patients WithDifferent Psychiatric Diagnoses

80,276,180 0

90,0 BeliefResults:

T1 – Inquiry

40 7

67,872,8

67,5

50 0

60,0

70,0

80,0 Emotion T2 – ProsecutorT3 – Defense attorneyT4 – Prosecutor’s responseT5 – Defense attorney’s responseT6 Verdict by the juror40,7

26,832,8

30,5

58,2

39,3

25,820 0

30,0

40,0

50,0

(%) T6 – Verdict by the juror

T1-T3, p < 0,001 (B and E)T1-T6, p < 0,001 (B and E)T1-T6, p < 0,001 (B and E)T3-T5, p = 0,009 (B and E),

0,0

10,0

20,0

T1 T2 T3 T4 T5 T6

T3 T5, p 0,009 (B and E)T5-T6, p = 0,005 (B)T5-T6, p = 0,02 (E)

Kruskal-Wallis andWilcoxon’s Signed Rank TestT1 T2 T3 T4 T5 T6B= BeliefE= Emotion




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Efficacy of the Trial-Based Thought Record, a New Cognitive Therapy Strategy Designed To

Change Core Beliefs in Social Phobia:Change Core Beliefs, in Social Phobia: A Randomized Controlled Study

De Oliveira et al (2011)De Oliveira et al. (2011)Journal of Clinical Pharmacy and Therapeutics (in press)




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ResultsAssessed for eligibility: n = 77

Excluded: n = 30Not meeting inclusion criteria ormeeting exclusion criteria

Randomized: n = 47

Allocated to TBTR: n = 25 Allocated to conventional: n = 22

Dropouts before intervention: n=3

Received allocated intervention: n = 19

Dropouts before intervention: n = 8

Received allocated intervention: n = 17 (intention‐to‐treat analysis) Completers analysis: n = 14

(intention‐to‐treat analysis)Completers analysis: n = 16




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Social phobia scale, social avoidance and distress scale, fear of negative evaluation scale, Beck anxiety inventory, and clinical global impression-improvement at baseline and week 14 in the groups*

TBTR (n= 17) Conventional (n= 19) P**TBTR (n= 17) Conventional (n= 19) PSocial phobia scale (Liebowitz, 1987)

BaselineFinalP***

86.82 (28.23)54.94 (32.17)

0.000

82.58 (24.31)61.63 (25.37)

0.000

0.640.49

Social avoidance and distress scaleBaselineFinalP***

21.88 (6.32)12.18 (8.43)

0.000

22.05 (4.22)17.47 (6.57)

0.000

0.920.04

Fear of negative evaluationFear of negative evaluationBaselineFinalP***

23.76 (5.87)17.41 (7.08)

0.003

26.16 (4.27)24.95 (5.65)

0.19

0.170.001

Beck anxiety inventoryBaseline 18 76 (9 40) 21 21 (12 53) 0 52BaselineFinalP***

18.76 (9.40)7.12 (5.66)

0.000

21.21 (12.53)11.32 (11.22)

0.000

0.520.17

CGI‐IBaselineFi l

4.06 (1.09)1 82 (1 13)

4.11 (1.15)2 21 (1 08)

0.900 30Final

P***1.82 (1.13)

0.0002.21 (1.08)

0.0000.30

*Intention-to-treat analysis**Independent-samples t-test***Paired-samples t-test




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BaselineFinalP***

86.82 (28.23)54.94 (32.17)

0.000

82.58 (24.31)61.63 (25.37)

0.000

0.640.49


21.88 (6.32)12.18 (8.43)

0.000

22.05 (4.22)17.47 (6.57)

0.000

0.920.04


23.76 (5.87)17.41 (7.08)

0.003

26.16 (4.27)24.95 (5.65)

0.19

0.170.001


18.76 (9.40)7.12 (5.66)

0.000

21.21 (12.53)11.32 (11.22)

0.000

0.520.17

CGI‐IBaselineFi l

4.06 (1.09)1 82 (1 13)

4.11 (1.15)2 21 (1 08)

0.900 30Final

P***1.82 (1.13)

0.0002.21 (1.08)

0.0000.30





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BaselineFinalP***

86.82 (28.23)54.94 (32.17)

0.000

82.58 (24.31)61.63 (25.37)

0.000

0.640.49


21.88 (6.32)12.18 (8.43)

0.000

22.05 (4.22)17.47 (6.57)

0.000

0.920.04


23.76 (5.87)17.41 (7.08)

0.003

26.16 (4.27)24.95 (5.65)

0.19

0.170.001


18.76 (9.40)7.12 (5.66)

0.000

21.21 (12.53)11.32 (11.22)

0.000

0.520.17

CGI‐IBaselineFinal

4.06 (1.09)1 82 (1 13)

4.11 (1.15)2 21 (1 08)

0.900 30Final

P***1.82 (1.13)

0.0002.21 (1.08)

0.0000.30





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Conclusion

• In this study, TBTR seemed to be:o as efficacious as conventional CBT regarding LiebowitzSocial Anxiety Scale and Beck Anxiety Inventory scores;

o more efficacious than conventional CBT regarding Fearo more efficacious than conventional CBT regarding Fearof Negative Evaluation and Social Avoidance andDistress Scale scores

• Results support other studies of TBTR in social anxiety disorder and other psychiatric disorders




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Techniques/Diagrams/Forms Session

TBCT Conceptualization Diagram All sessionsTBCT Conceptualization Diagram All sessions

Cognitive Distortions Questionnaire (CD-Quest) All from session 2 on

Intrapersonal Thought Record (IntraTR) Any from session 2 or 3 as neededp g ( ) y

Interpersonal Thought Record (InterTR) Any from session 2 or 3 as needed

Consensus Role-Play (CRP) Any from session 3 or 4 as needed

Responsibility Grid (RG) Any session (as needed) for guilt/shame

Trial-Based Thought Record (TBTR or “Trial I”) Usually from session 5 on

U ll f i 7


Trial II.1 Usually from session 7 on

Trial II.2 (Trial-Based Empty Chair) Usually from session 8 on



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Question & Answer PeriodQuestion & Answer Period

Host

Dr. Irismar Reis de Oliveira

To submit a question: • Locate the Questions? box at the right side of the screen

Type your question in the field at the bottom of the box• Type your question in the field at the bottom of the box

• Click the button at the right end of the box (Send)



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