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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