TRANSDIAGNOSTIC CBT FOR EATING DISORDERS “CBT-E” Christopher G Fairburn .
Core Beliefs on Trial -...
Transcript of Core Beliefs on Trial -...
Handout for the Neuroscience Education Institute (NEI) online activity:
Core Beliefs on Trial: A Cognitive Therapy Approach for
Psychopharmacologists
Irismar Reis de Oliveira, MD Department of Neurosciences and Mental Health
Post-Graduation Program, Federal University of Bahia, Brazil
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
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
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
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 Record
o First use
o Social anxiety disorder
Trial-Based Cognitive Therapy
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
• A generally short-term psychotherapy model
o Developed by Aaron Beck at the University of Pennsylvania
o Goal-directed
o Present-oriented
o Based on the cognitive model of psychopathology and learning
theory
• Emphasis on:
o Current thoughts, emotions, and behaviors
o Undoing old learning and teaching new behaviors
What is cognitive therapy?
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Important Definitions
• Automatic thoughts
• Underlying assumptions
• Core beliefs
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Automatic Thoughts
• Perceptions that occur rapidly in response
to a situation
• Are not subjected to systematic, logical
analysis
• A person may be unaware of their presence
or significance
• May or may not be distorted
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Cognitive Distortion Definition Example
1 Dichotomous thinking (also
called “all-or-nothing” or
“black and white”)
I view a situation, a person, or an event
only in all- or-nothing terms, fitting them
into only 2 extreme categories instead of
on a continuum.
“I made a mistake, therefore I’m a failure.” “I ate
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.”
3 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,
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
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.”
Definitions and Examples of 15 Cognitive Distortions
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Underlying Assumptions
• Conditional rules or “should” statements used
to guide our behavior, emotional expression,
and understanding of how the world operates
(Padesky & Greenberger, 1995)
• Usually expressed as “if… then…” statements
o “If I go to the party, then people will know I am
awkward.”
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
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 people
experience in specific situations
o “I am incompetent” will likely predict that he will be unable to
function 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
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Cognitive Model
Situation Automatic thoughts
Underlying assumptions
Emotions
Behaviors
Physiological
responses
Core beliefs
(Schemas)
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Situation Automatic thoughts
Underlying assumptions
Emotions
Behaviors
Physiological
responses
Core beliefs
(Schemas)
1st level
2nd level
3rd level
A More Complex Cognitive Model
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
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 Record
o First use
o Social anxiety disorder
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
TBCT Conceptualization Diagram
Same components as standard cognitive therapy, but…
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
TBCT Conceptualization Diagram Phase 1: Before Treatment
Negative core beliefs predominantly activated
Situation
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
Activated negative core belief
1st level
-
Schema activation
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
TBCT Conceptualization Diagram Phase 1
Situation
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
1st level
Circuit 1
Circuit 1
Automatic Thought → Emotion→
Behavior and/or Physiological Response
→ Automatic Thought
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
TBCT Conceptualization Diagram Phase 1
Situation
I am invited to a party
I will be criticized
Anxious
I do not go to the
party
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
1st level
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
John’s TBCT Conceptualization Diagram Phase 1
Situation
I am invited to a party
I will be criticized People will find me awkward
Anxious More anxious I do not go to the
party I avoid people
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
1st level
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
John’s TBCT Conceptualization Diagram Phase 1
Situation
I am not invited to a new party
People really find me awkward
Anxious
I continue to avoid people
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
1st level
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
John’s TBCT Conceptualization Diagram Phase 1
Situation
I am not invited to a new party
People really find me awkward
Anxious I continue to avoid
people
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
I am awkward
Activated negative core belief
1st level
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
John’s TBCT Conceptualization Diagram Phase 1
Situation
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
1st level
2nd level Modulation by underlying
assumptions Circuit 2
Circuit 2
Underlying Assumption → Safety Behavior →
[Automatic Thought]* → Emotion → Behavior and/or
Physiological Response → Underlying Assumption
*May not exist or may be implicit
Underlying assumptions/rules: Compensatory strategies/safety behaviors:
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
TBCT Conceptualization Diagram Phase 1
Situation
I am invited to a party
I will be criticized People think I am awkward Anxious
I do not go to the
party I avoid people
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
1st level
2nd level
Underlying assumptions/rules: Compensatory strategies/safety behaviors:
Avoidance
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
John’s TBCT Conceptualization Diagram Phase 1
Situation
I am invited to a party
I will be criticized People think I am awkward Anxious
I do not go to
parties I avoid people
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
1st level
2nd level Modulation by underlying
assumptions
Underlying assumptions/rules:
If I do not avoid people, then they will criticize me Compensatory strategies/safety behaviors:
Avoidance
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
John’s TBCT Conceptualization Diagram Phase 1
Situation
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
Activated negative core belief
Inactive positive
core belief
1st level
2nd level
3rd level
Modulation by underlying assumptions
Circuit 3
Underlying assumptions/rules: Compensatory strategies/safety behaviors:
Relevant childhood data for: 1) Negative core belief 2) Positive core belief
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
TBCT Conceptualization Diagram Phase 1
Activated negative core belief
Inactive positive
core belief
1st level
2nd level
3rd level
Modulation by underlying assumptions
Circuit 3
Circuit 3
Underlying Assumption → Safety
Behavior → Core Belief → Underlying
Assumption
Underlying assumptions/rules: Compensatory strategies/safety behaviors:
Relevant childhood data for: 1) Negative core belief 2) Positive core belief
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
TBCT Conceptualization Diagram Phase 1
Situation
I am invited to a party
I will be criticized People think I am awkward Anxious
I do not go to
parties I avoid people
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
I am awkward
Activated negative core belief
Inactive positive
core belief
1st level
2nd level
3rd level
Modulation by underlying assumptions
Circuit 3
Underlying assumptions/rules:
If I do not avoid people, then they will criticize me Compensatory strategies/safety behaviors:
Avoidance
Relevant childhood data for: 1) Negative core belief 2) Positive core belief
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
John’s TBCT Conceptualization Diagram Phase 1
Situation
I am invited to a party
I will be criticized People think I am awkward Anxious
I do not go to
parties I avoid people
Automatic thought
Emotional reaction
Behavioral and/or
physiological response
I am awkward
Activated negative core belief
Inactive positive
core belief
1st level
2nd level
3rd level
Modulation by underlying assumptions
Underlying assumptions/rules:
If I do not avoid people, then they will criticize me Compensatory strategies/safety behaviors:
Avoidance
Relevant childhood data for: 1) Negative core belief 2) Positive core belief
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
John’s TBCT Conceptualization Diagram Phase 1
Phase 2: During Treatment
Positive core belief activation with TBCT
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Situation
Automatic thought
Emotional reaction
Modulation by underlying
assumptions
Behavioral and/or
physiological response
1st level
2nd level
3rd level
Inactive negative core belief
Activated positive
core belief
Circuit 3
Underlying assumptions/rules: Compensatory strategies/safety behaviors:
Relevant childhood data for: 1) Negative core belief 2) Positive core belief
Trial I Trial II.1
RG
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
TBCT Conceptualization Diagram Phase 2
Phase 3: After Treatment
Balance between positive and negative core belief activation
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Situation
Automatic thought
Emotional reaction
I am
normal
Modulation by underlying
assumptions
Trial I and II
Behavioral and/or
physiological response
1st level
2nd level
3rd level
Activated negative core belief
Activated positive
core belief
CD-Quest IntraDTR InterDTR
CRP and behavioral experiments Underlying assumptions/rules: Compensatory strategies/safety behaviors:
Relevant childhood data for: 1) Negative core belief 2) Positive core belief
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
TBCT Conceptualization Diagram Phase 3
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
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 Record
o First use
o Social anxiety disorder
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Literary Work
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Trial-Based Thought Record (Trial I)
• Designed to change core beliefs or schemas
• Inspiration from Franz Kafka’s surreal novel The Trial
o Self-accusation as a universal principle?
• Analogy or metaphor to a judicial process
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 evidence)
o Defense attorney’s response to the prosecutor’s plea (sentence reversal)
o Jurors’ verdict (debriefing)
o Preparation for the appeal (upward arrow and positive self-statements log) as homework
Where is the defense attorney?
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
I believe in the accusation: Emotion:
1. Inquiry
2. Prosecutor’s
plea
3. Defense
attorney’s plea
4. Prosecutor’s
response (but…)
5. Defense
attorney’s response (Sentence reversal)
6. Meaning of the
response: “It means
that…”
7. Juror
Who was more convincing? Who presented more evidence? Whose
evidence was more based on facts? Who made fewer
(cognitive) distortions?
Downward arrow
(core belief)
I am...
Automatic thoughts:
I believe: Emotion:
I believe: Emotion:
I believe: Emotion:
I believe: Emotion:
I believe: Emotion:
Verdict:
Upward arrow
(new core belief)
I am...
Trial-Based Thought Record (Trial I)
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
I believe in the accusation: Emotion:
1. Inquiry
2. Prosecutor’s
plea
3. Defense
attorney’s plea
4. Prosecutor’s
response (but…)
5. Defense
attorney’s response (Sentence reversal)
6. Meaning of the
response: “It means
that…”
7. Juror
Who was more convincing? Who presented more evidence? Whose
evidence was more based on facts? Who made fewer
(cognitive) distortions?
Downward arrow
(negative core belief)
I am...
Automatic thoughts:
I believe: Emotion:
I believe: Emotion:
I believe: Emotion:
I believe: Emotion:
I believe: Emotion:
Verdict:
Upward arrow
(positive core belief)
I am...
Deconstructive language
Constructive language
Trial-Based Thought Record (Trial I)
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Defense Attorney’s Preparation for the Appeal (Positive Self-Statements Log)
I am... (positive belief derived from the upward arrow technique)
Date (90%) 1.
2.
3.
Date ( %) 1.
2.
3.
Date ( %) 1.
2.
3.
Homework Assignment
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Case Report
Obsessive Compulsive Disorder and Borderline Personality Disorder
Described in the Common Language for Psychotherapy Procedures
http://www.commonlanguagepsychotherapy.org/
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Case Illustration
Ida, married and in her 30s, had been anxious,
angry, and aggressive for 3 years. She had
difficulty dealing with subordinates (she was a
manager in a company) and went on sick leave.
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
benzodiazepines.
Her benzodiazepines were tapered and
replaced with quetiapine. She also had weekly
cognitive restructuring of beliefs such as “I’m a
failure, incompetent, and inadequate” by
examining evidence for and against them.
Though her anxiety decreased, external events
reactivated her beliefs, and she mutilated
herself again.
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Case Illustration (cont.)
Six months before the session yielding the Trial
session described in this presentation, Ida
started to repeatedly verify her wallet for hours
daily, checking 13 items by touching and reading
each 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 months.
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Case Illustration (cont.)
INQUIRY
(downward
arrow
technique)
PROSECUTOR
(evidence
supporting the
accusation)
DEFENSE
ATTORNEY
(evidence not
supporting)
PROSECUTOR’S
RESPONSE
(yes, but...)
DEFENSE ATTORNEY’S
RESPONSE
(sentence reversal)
IT MEANS
THAT...
JUROR
(debriefing)
I am not
succeeding in
studying
I am too anxious
I will not finish
my master’s
degree course
ACCUSATION:
I AM
IMPERFECT
EMOTION:
ANXIETY
Initial Final
100%
100%
I’ve lost control
of my whole life
I can’t absorb
information
quickly
I’m slow at
reasoning
I don’t do well
when interacting
with people and
controlling my
environment
100%
100%
1. I don’t check my
driver’s license,
and I haven’t lost
control
2. My OCD score fell
today
3. I can remember
some techniques
without having to
reread the book
4. I’m completing the
evidence chart
80%
80%
1. I check on other
items
2. I’m not cured
3. I can’t remember
them all.
4. I still believe I’m
imperfect
90%
90%
1. I check on other items, BUT
I don’t check my driver’s
license and haven’t lost
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
having to reread the book
4. I still believe I’m imperfect,
BUT I’m completing the
evidence chart
1. I can stop
myself
checking
2. I can cure
myself
3. I can learn
4. I see the
other side of
my
imperfection
(that I am
normal)
70%
70%
___________
VERDICT:
TBTR: Described in the Common Language for Psychotherapy Procedures
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
INQUIRY
(downward
arrow
technique)
PROSECUTOR
(evidence
supporting the
accusation)
DEFENSE
ATTORNEY
(evidence not
supporting)
PROSECUTOR’S
RESPONSE
(yes, but...)
DEFENSE ATTORNEY’S
RESPONSE
(sentence reversal)
IT MEANS
THAT...
JUROR
(debriefing)
I am not
succeeding in
studying
I am too anxious
I will not finish
my master’s
degree course
ACCUSATION:
I AM
IMPERFECT
EMOTION:
ANXIETY
Initial Final
100%
100%
I’ve lost control
of my whole life
(A)
I can’t absorb
information
quickly (C)
I’m slow at
reasoning (C)
I don’t do well
when interacting
with people and
controlling my
environment (B,
C)
100%
100%
1. I don’t check my
driver’s license
and I haven’t lost
control
2. My OCD score fell
today
3. I can remember
some techniques
without having to
reread the book
4. I’m completing the
evidence chart
80%
80%
1. I check on other
items (B)
2. I’m not cured (B)
3. I can’t remember
them all (B)
4. I still believe I’m
imperfect (B)
90%
90%
1. I check on other items, BUT
I don’t check my driver’s
license and haven’t lost
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
having to reread the book
4. I still believe I’m imperfect,
BUT I’m completing the
evidence chart
1. I can stop
myself
checking
2. I can cure
myself
3. I can learn
4. I see the
other side of
my
imperfection
(that I am
normal)
70%
70%
The prosecutor
made errors:
overgeneraliza
tion (A),
discounting
positives (B),
and all-or-
nothing
thinking (C)
The defense
attorney
made no
distortions and
gave fairer and
more
consistent
arguments
___________
VERDICT:
55%
55%
Innocent
TBTR: Described in the Common Language for Psychotherapy Procedures
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
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.
Date (60%)
1. I succeeded in
conquering the
driver’s license
2. I managed to
conquer the student
card
3.
Date ( %)
1.
2.
3.
Date ( %)
1.
2.
3.
Homework Assignment Defense Attorney’s Preparation for the Appeal (Positive Self-Statements Logs)
I am normal (positive belief derived from the upward arrow technique)
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
TBTR: Described in the Common Language for Psychotherapy Procedures
INQUIRY
(downward
arrow
technique)
PROSECUTOR
(evidence
supporting the
accusation)
DEFENSE
ATTORNEY
(evidence not
supporting)
PROSECUTOR’S
RESPONSE
(yes, but...)
DEFENSE ATTORNEY’S
RESPONSE
(sentence reversal)
IT MEANS
THAT...
JUROR
(debriefing)
I am not
succeeding in
studying
I am too anxious
I will not finish
my master’s
degree course
ACCUSATION:
I AM
IMPERFECT
EMOTION:
ANXIETY
Initial Final
100% 40%
100% 40%
I’ve lost control
of my whole life
(A)
I can’t absorb
information
quickly (C)
I’m slow at
reasoning (C)
I don’t do well
when interacting
with people and
controlling my
environment (B,
C)
100%
100%
1. I don’t check my
driver’s license,
and I haven’t lost
control
2. My OCD score fell
today
3. I can remember
some techniques
without having to
reread the book
4. I’m completing the
evidence chart
80%
80%
1. I check on other
items (B)
2. I’m not cured
(B)
3. I can’t
remember them
all (B)
4. I still believe I’m
imperfect (B)
90%
90%
1. I check on other items, BUT I
don’t check my driver’s
license and haven’t lost
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 having
to reread the book
4. I still believe I’m imperfect,
BUT I’m completing the
evidence chart
1. I can stop
myself
checking
2. I can cure
myself
3. I can learn
4. I see the
other side of
my
imperfection
(that I am
normal)
70%
70%
The prosecutor
made errors:
overgeneralization
(A), discounting
positives (B), and
all-or-nothing
thinking (C)
The defense
attorney
made no
distortions and
gave fairer and
more consistent
arguments
___________
VERDICT:
55%
55%
Innocent
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
I am a capable person
I am normal I am assertive
I am a truthful person
I am lovable I am a reasonable person
11/10 – 40%
1. I sent comments to my supervisor
2. I reviewed a thesis
11/10 – 60%
11/10 – 40%
1. I sent comments to my supervisor
2. I reviewed a thesis
11/10 – 50% 11/10 – 60%
1. My husband told me I was the most important person for him
11/10 – 50%
1. I gave a telephone call to R
12/10 – 45%
12/10 – 60%
1. I woke up feeling well
12/10 – 45%
1. I sent a card to my goddaughter
12/10 – 55%
1. I told my mother I would not have lunch with her today
12/10 – 60%
12/10 – 55%
1. I sent a card to my goddaughter
13/10 – 50%
1. I got to limit my OCD rituals
2. I was able to leave the bedroom this morning
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%
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Homework Assignment
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Case Report
Panic Disorder
Described in the Common Language for Psychotherapy Procedures
http://www.commonlanguagepsychotherapy.org/
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Case Illustration
Two weeks before consulting a psychiatrist, Karen,
age 28, developed panic attacks and stopped
going out alone for fear of further panics. Panic
attacks vanished for a whole year within weeks of
starting 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
resume normal activities.
Karen remained well during a year, even not taking
any medication. Then, during a stressful period,
Karen started fearing new panic attacks, and
worrying about health problems and dying. She
was no longer able to go out alone.
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Case Illustration (cont.)
INQUIRY
(downward
arrow
technique)
PROSECUTOR
(evidence
supporting the
accusation)
DEFENSE
ATTORNEY
(evidence not
supporting)
PROSECUTOR’S
RESPONSE
(yes, but...)
DEFENSE ATTORNEY’S
RESPONSE
(sentence reversal)
IT MEANS
THAT...
JUROR
(debriefing)
I have several
chronic diseases
that can lead to
sudden death.
A psychological
disorder may
evolve into a
physical
disease.
ACCUSATION:
I AM
VULNERABLE
EMOTION:
SAD
Initial Final
70%
50%
My grandfather
died suddenly.
I have a genetic
predisposition,
and I can also
die.
My sister had an
infarction when
she was 13, due
to a viral
infection.
I have panic
disorder.
90%
80%
1) I have gone
through many
difficult situations,
and I always
survived.
2) I have never had
a serious disease; to
the contrary, I am
always the last to
become ill.
3) My eating habits
are healthy, I do
physical exercises,
and I visit the doctor
regularly.
50%
20%
1) … BUT I can go
through a worse
situation and not
survive.
2) ... BUT I may
have a physical
disease.
3) ... BUT I may
have a genetic
predisposition to a
physical disease.
90%
80%
1) I can go through a worse
situation and not survive, BUT
I have gone through many
difficult situations and I
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.
3) I may have a genetic
predisposition to a physical
disease, BUT my eating
habits are healthy, I do
physical exercises, and I visit
the doctor regularly.
1)... the
expression “I can”
is abstract.
Indeed, I always
survived.
2) ... the
expression “I may”
is just an
assumption and,
in fact, I have
never had a
serious disease.
3) ... I have
always behaved in
the most careful
and preventive
way. 0%
0%
The defense
attorney
seems more
convincing and
presented
more evidence
based on facts.
The prosecutor
tends to make
more
distortions as
discounting
positives and
catastrophic
thinking.
___________
VERDICT:
0%
0%
Innocent
TBTR: Described in the Common Language for Psychotherapy Procedures
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Upward Arrow Technique
54
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.
Date.... (90%)
1. I came to therapy
by myself.
2. I took care of my
children this morning.
3.
Date ( %)
1.
2.
3.
Date ( %)
1.
2.
3.
Homework Assignment Defense Attorney’s Preparation for the Appeal (Positive Self-Statements Logs)
I am normal (positive belief derived from the upward arrow technique)
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
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 Record
o First use
o Social anxiety disorder
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Trial-Based Cognitive Therapy
Revista Brasileira de Psiquiatria, 30(1):12-18, 2008
Impact factor: 1.25
Trial-Based Thought Record: Preliminary data on a strategy to deal with
core beliefs by combining sentence reversion and the use of analogy
with a judicial process
Irismar Reis de Oliveira
Department of Neurosciences and Mental Health
Federal University of Bahia
http://www.scielo.br/scielo.php?pid=1516-4446&script=sci_serial
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
TBTR Applied to 30 Patients With Different Psychiatric Diagnoses
40,7
26,8
32,8
67,8
80,276,1
30,5
58,2
72,867,5
39,3
25,8
0,0
10,0
20,0
30,0
40,0
50,0
60,0
70,0
80,0
90,0
T1 T2 T3 T4 T5 T6
(%)
Belief
Emotion
Results: T1 – Inquiry T2 – Prosecutor T3 – Defense attorney T4 – Prosecutor’s response T5 – Defense attorney’s response 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) T5-T6, p = 0,005 (B) T5-T6, p = 0,02 (E) Kruskal-Wallis and Wilcoxon’s Signed Rank Test B= Belief E= Emotion
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Efficacy of the Trial-Based Thought Record,
a New Cognitive Therapy Strategy Designed To
Change Core Beliefs, in Social Phobia:
A Randomized Controlled Study
De Oliveira et al. (2011)
Journal of Clinical Pharmacy and Therapeutics (in press)
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Results Assessed for eligibility: n = 77
Randomized: n = 47
Excluded: n = 30 Not meeting inclusion criteria or meeting exclusion criteria
Allocated to TBTR: n = 25 Allocated to conventional: n = 22
Dropouts before intervention: n=3
Received allocated intervention: n = 19 (intention-to-treat analysis) Completers analysis: n = 14
Dropouts before intervention: n = 8
Received allocated intervention: n = 17 (intention-to-treat analysis) Completers analysis: n = 16
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
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**
Social phobia scale (Liebowitz, 1987) Baseline Final P***
86.82 (28.23) 54.94 (32.17)
0.000
82.58 (24.31) 61.63 (25.37)
0.000
0.64 0.49
Social avoidance and distress scale Baseline Final P***
21.88 (6.32) 12.18 (8.43)
0.000
22.05 (4.22) 17.47 (6.57)
0.000
0.92 0.04
Fear of negative evaluation Baseline Final P***
23.76 (5.87) 17.41 (7.08)
0.003
26.16 (4.27) 24.95 (5.65)
0.19
0.17
0.001
Beck anxiety inventory Baseline Final P***
18.76 (9.40) 7.12 (5.66)
0.000
21.21 (12.53) 11.32 (11.22)
0.000
0.52 0.17
CGI-I Baseline Final P***
4.06 (1.09) 1.82 (1.13)
0.000
4.11 (1.15) 2.21 (1.08)
0.000
0.90 0.30
*Intention-to-treat analysis **Independent-samples t-test ***Paired-samples t-test
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
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**
Social phobia scale (Liebowitz, 1987) Baseline Final P***
86.82 (28.23) 54.94 (32.17)
0.000
82.58 (24.31) 61.63 (25.37)
0.000
0.64 0.49
Social avoidance and distress scale Baseline Final P***
21.88 (6.32) 12.18 (8.43)
0.000
22.05 (4.22) 17.47 (6.57)
0.000
0.92 0.04
Fear of negative evaluation Baseline Final P***
23.76 (5.87) 17.41 (7.08)
0.003
26.16 (4.27) 24.95 (5.65)
0.19
0.17
0.001
Beck anxiety inventory Baseline Final P***
18.76 (9.40) 7.12 (5.66)
0.000
21.21 (12.53) 11.32 (11.22)
0.000
0.52 0.17
CGI-I Baseline Final P***
4.06 (1.09) 1.82 (1.13)
0.000
4.11 (1.15) 2.21 (1.08)
0.000
0.90 0.30
*Intention-to-treat analysis **Independent-samples t-test ***Paired-samples t-test
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Conclusion
• In this study, TBTR seemed to be:
o as efficacious as conventional CBT regarding Liebowitz Social Anxiety Scale and Beck Anxiety Inventory scores;
o more efficacious than conventional CBT regarding Fear of Negative Evaluation and Social Avoidance and Distress Scale scores
• Results support other studies of TBTR in social anxiety disorder and other psychiatric disorders
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Copyright © 2011 Irismar Reis de Oliveira. All rights reserved.
Trial-Based Cognitive Therapy
Techniques/Diagrams/Forms Session
TBCT 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 needed
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
Trial II.1 Usually from session 7 on
Trial II.2 (Trial-Based Empty Chair) Usually from session 8 on