Theory and Practice of Cognitive Behavioral Therapy

Department of Psychiatry & Behavioral Neuroscience

Cognitive-Behavior Therapy Program MS-3 Clerkship 2008-2009

Shona N. Vas, Ph.D.

Outline

n What is Cognitive Behavior Therapy (CBT)?

n What are the basic principles of treatment?

n What is the course of treatment?

n What are some examples of interventions?

n Who is appropriate for CBT?

What is CBT?

n Set of ‘talk’ psychotherapies that treat psychiatric conditions.

n Short-term focused treatment. n Strong empirical support with

randomized clinical trials. n As effective as psychiatric medications. n Recommended as critical component of

treatment, particularly when medications are contraindicated or ineffective.

Why So Popular?

n Clear treatment approach for patients n Assumptions make sense to patients n Based on patient’s experience n Encourages practice and compliance n Patients have a sense of control n CBT works!

Definition of Cognitive Therapy

n  CT is a focused form of psychotherapy based on a model stipulating that psychiatric disorders involve dysfunctional thinking.

n  Dysfunctional/distorted thinking arises from both biological and psychological influences

n  Individuals’ emotional, behavioral, and physiological reactions are influenced by the way they structure their environment.

J. Beck, 1995

Definition of CT (continued…)

n Modifying dysfunctional thinking and behavior leads to improvement in symptoms.

n Modifying dysfunctional beliefs which underlie dysfunctional thinking leads to more durable improvement

Definition of CT (continued…) n  Cognitive therapy is defined by a cognitive

formulation of the disorder and a cognitive conceptualization of the particular patient.

n  Cognitive therapy is not defined by the use of exclusively cognitive techniques. Techniques from many modalities are used.

n  CT also often referred to as Cognitive-Behavior Therapy (CBT).

Rationale for CBT

n  Negative emotions are elicited by cognitive processes developed through influences of learning and temperament.

n  Adverse life events elicit automatic processing, which is viewed as the causal factor.

n  Cognitive triad: Negative automatic thoughts center around our understanding of: –  Ourselves –  Others (the world) –  Future

n  Focus on examination of cognitive beliefs and developing rational responses to negative automatic thoughts.

Beck et al., 1979

Cognitive Specificity Hypothesis

n  Distorted appraisals follow themes relevant to the specific psychiatric condition.

n  Psychological disorders are characterized by a different psychological profile.

–  Depression: Negative view of self, others, and future. Core beliefs associated with helplessness, failure, incompetence, and unlovability.

–  Anxiety: Overestimation of physical and psychological threats. Core beliefs linked with risk, dangerousness, and uncontrollability.

Cognitive Specificity

n Negative Triad Associated with Depression –  Self “I am incompetent/unlovable” – Others “People do not care about me” –  Future “The future is bleak”

n Negative Triad Associated with Anxiety –  Self “I am unable to protect myself” – Others “People will humiliate me” –  Future “It’s a matter of time before I am

embarrassed”

Targeted Cognitions for Different Disorders

n OCD: appraisals of obsessive cognitions n Anorexia: control, worth, perfection n Panic: catastrophic misinterpretation of

physical sensations n Paranoia: trust, vulnerability

Working Model of CBT

Event Appraisal

Maladaptive Behavior

Affective and Biological Arousal

Behavioral Inclination

Thase et al., 1998

Cognitive Model

Triggering Event Bill goes to collection

Appraisal “I can never do anything right…” Behavior

Avoidance; withdrawal

Bodily Sensations Low energy, disruption of sleep, increased fatigue

Behavioral Inclination “I don’t want to deal with it” “It’s too stressful to think about it”

Thase et al., 1998

What are Automatic Thoughts? What was going through your mind? n  Happen spontaneously in response to situation n  Occur in shorthand: words or images n  Do not arise from reasoning n  No logical sequence n  Hard to turn off n  May be hard to articulate

Stressful Situation

Automatic Thoughts

Negative

Emotions

Cognitive Distortions

n Patients tend to make consistent errors in their thinking

n Often, there is a systematic negative bias in the cognitive processing of patients suffering from psychiatric disorders

n Help patient identify the cognitive errors s/he is most likely to make

Types of Cognitive Distortions –  Emotional reasoning Feelings are facts –  Anticipating negative outcomes The worst will happen –  All-or-nothing thinking All good or all bad –  Mind-reading Knowing what others are thinking –  Personalization Excess responsibility –  Mental filter Ignoring the positive

Examples

n  Cognitive Distortions –  Emotional Reasoning: “I feel incompetent, so I

know I’ll fail” –  Catastrophizing: “It is going to be terrible” –  Personalization: “It’s always my fault” –  Black or white thinking: “If it isn’t perfect, it’s

no good at all.”

Core Beliefs n  Core beliefs underlie and produce

automatic thoughts. n  These assumptions influence information

processing and organize understanding about ourselves, others, and the future.

n  These core beliefs remain dormant until activated by stress or negative life events.

n  Categories of core beliefs (helpless, worthless, unlovable)

Automatic Thoughts Core Beliefs

Examples of Core Beliefs n  Helpless core beliefs

–  I am inadequate, ineffective, incompetent, can’t cope –  I am powerless, out of control, trapped –  I am vulnerable, weak, needy, a victim, likely to be hurt –  I am inferior, a failure, a loser, defective, not good enough, don’t

measure up n  Unlovable core beliefs

–  I am unlikable, unwanted, will be rejected or abandoned, always be alone

–  I am undesirable, ugly, unattractive, boring, have nothing to offer –  I am different, flawed, defective, not good enough to be loved by

others n  Worthless core beliefs

–  I am worthless, unacceptable, bad, crazy, broken, nothing, a waste –  I am hurtful, dangerous, toxic, evil –  I don’t deserve to live

Cognitive Conceptualization

Current Situation

Automatic Thoughts About self, world

And others

Physiology Feelings Behavior

Childhood And Early Life Events

Underlying Assumptions and Core Beliefs

Compensatory Strategies

Example 1

Situation Partner says: “I need time to be with my friends”

Automatic Thoughts

Automatic response: “Oh no, he’s losing interest

and is going to break up with me….”

Physiology Heart racing Lump in throat Feelings Sadness Worry Anger

Behavior Seek reassurance Withdraw Cry Childhood

Experiences Parental neglect and criticism

Underlying Assumptions & Core Beliefs “I’m flawed in numerous ways, which means I’m not worthy of consistent attention and care. People only care when they want something.”

Compensatory Strategies Be independent and you’ll be safe. Watch out – people are careless with you.

Example 2

Situation Disappointing exam result

Automatic Thoughts “I am not going to get through this program -

I’m not as smart as everyone else.

People will discover this and I

will be humiliated.”

Physiology Pit in stomach Dry mouth

Feelings Worry, shame, Disappointment Humiliation.

Behavior Use alcohol, Procrastinate with homework

Childhood Adversities

Parental standards reinforce academic

achievement

Underlying Assumptions “If I don’t excel in school, I’m a

total failure”

Compensatory Strategies

Work extra hard to offset

incompetence.

Responding to Negative Thoughts

n  Define Situation

n  Clarify meaning of cognitive appraisal

–  What was going through your mind just then? –  What did the situation mean for you?

n  Evaluate interpretation –  Evidence: For and against this belief? –  Alternatives: Any other explanation(s)? –  Implications: So what….?

Evaluating Negative Thoughts

n What is the effect of telling myself this thought?

n What could be the effect of changing my thinking?

n What would I tell ___ (a friend/family member) if s/he viewed this situation in this way?

n What can I do now?

Sample Thought Log Situation Thoughts Emotions Rational

Response Outcome

Going on vacation—Ask a colleague to do some work for me

She’ll say no… I’m not doing a good job The boss thinks I take too much time off

Anxiety (70%) Guilt (40%) Sadness (20%) Cognitive Distortions: All/nothing Mindreading Fortune-Telling Over-generalization

I haven’t taken a day off in 6 months. We work as a team, so it’s also her job to track the samples.

Anxiety (10%) Guilt (0%) Relief (40%)

Common Components of CBT

n  Establish good therapeutic relationship n  Educate patients - model, disorder, therapy n  Assess illness objectively, set goals n  Use evidence to guide treatment decisions n  Structure treatment sessions with agenda n  Limit treatment length n  Issue and review homework to generalize

learning

Course of Treatment

1.  Assessment 2.  Provide rationale 3.  Training in self-monitoring 4.  Behavioral strategies

1.  Monitor relationship between situation/action and mood. 2.  Applying new coping strategies to larger issues.

5.  Identifying beliefs and biases 6.  Evaluating and changing beliefs 7.  Core beliefs and assumptions 8.  Relapse prevention and termination

Basic Principles n  Change mood states by using cognitive and

behavioral strategies: –  Identifying/modifying automatic thoughts & core beliefs, –  Regulating routine, and –  Minimizing avoidance.

n  Emphasis on ‘here and now’ n  Preference for concrete examples

–  Start with specific situation (complete thought log)

n  Reliance on Socratic questioning –  Ask open-ended questions

n  Empirical approach to test beliefs –  Challenge thoughts not based on evidence –  Cognitive restructuring

n  Promote rapid symptom change

Behavioral Interventions

n Breathing retraining n Relaxation n Behavioral activation n  Interpersonal effectiveness training n Problem-solving skills n Exposure and response prevention n Social skills training n Graded task assignment

Cognitive Interventions

n Monitor automatic thoughts n Teach imagery techniques n Promote cognitive restructuring n Examine alternative evidence n Modify core beliefs n Generate rational alternatives

Efficacy

n Cognitive and behavioral approaches are effective

n Supported by over 325 controlled outcome studies

n State-of-the-art therapy, manualized

Applications of CBT n Mood Disorders

–  Unipolar Depression (1979) –  Bipolar Disorder (1996) –  Dysthymia and Chronic MDD (2000)

n Anxiety Disorders –  GAD (1985) –  Social Phobia (1985) –  Panic Disorder (1986) –  OCD (1988) –  PTSD (1991)

n  Emotional Disorders (2006)

Applications of CBT (Continued…)

n  Eating Disorders (1981) n  Marital Problems n  Behavioral Medicine

–  Headaches (1985) –  Insomnia (1987) –  Chronic Pain (1988) –  Smoking Cessation –  Hypochondriasis –  Body Dysmorphic Disorder

Controlled Outcome Studies on CBT

n  Unipolar Depression (~30)

n  Eating Disorders –  Anorexia (~5) –  Bulimia (~15)

n  Generalized Anxiety Disorder (~12)

n  Social Phobia (~14) n  Panic Disorder (~10) n  Borderline P.D. (2) n  Schizophrenia (~45) n  C/A Depression (8) n  Chronic Depression (1)

Conclusions

n System of psychotherapies n Unified theory of psychopathology n Short-term treatment n Objective assessment and monitoring n Strong empirical support n As effective as pharmacotherapy

Questions? Comments? Dr. Shona Vas (773) 702-1517

Psychiatry Department Office: A-312 svas@yoda.bsd.uchicago.edu