Cognitive Behavior Therapy (CBT) - Overview

What is CBT

• Its a Type of Psychotherapy(Talking Therapy)
• Cognition refers to thoughts
• Behavior refers to actions

Rational

• How one thinks(cognition) and how one acts(behavior) can affect how one feels(mood)
• Negative cognitions and maladaptive behaviors can cause one to feel low in mood
• By identifying and correcting negative cognitions and bad behavior, mood can be improved

History: Aaron Beck is considered the pioneer of CBT

Use of CBT in Clinical Practice

• Time limited therapy: Usually 12-16 sessions
• One a week/50 minute sessions
• Goals of treatment are identified at beginning
• Progress is regularly monitored during therapy
• Patient is an active participant
• Patient is given homework tasks
• Rating scales are used at beginning and end of therapy
• Focus is on here and now
  • Not about the origin of issues
• Objective is to use practical cognitive and behavioral strategies to overcome the problem

Initial Assessment

• Description of current difficulties
• Identify goals of treatment(Needs to be realistic)
• Explain treatment ration to patient
• Establish whether patient would be willing to work in CBT model
• If so, clearly explain structure and purpose of treatment sessions
• Start treatment

Structure of each treatment session

• Agree on an agenda for the session
• Review progress since previous session
• Review homework tasks - any difficulties in doing them
• Discuss a specific problem that client is facing
• Devise specific strategies to address the problem
• Give homework tasks with clear instructions
• Feedback from client to ensure understanding

CBT in Depression

Aim is to overcome negative cognitions and unhelpful behaviors that maintain the depression

Examples of negative thoughts

• "I'm worthless"
• Its all my fault
• I'll never get better

Examples of unhelpful behavior

• Social withdrawal
• Avoiding activities
• Staying in bed for long hours.

Dysfunctional Assumptions

Extreme and inflexible opinions that people form about themselves and about the world. Early life experiences influence/create this.

Examples...

• If I'm not prefect I cannot be happy
• If I don't succeed in everything I do, I'm a failure

These remain latent until there is a critical stressful event, when they lead to negative automatic thoughts

Negative Automatic Thoughts

Content tends to be related to the dysfunctional assumptions they have. Examples...

• I'll never be happy
• I'll always be a failure

They will makes depression worse

Cognitive Distortions

• Black or white thinking
• All or nothing
  • Words like always, never, all, none are used
• Over generalization
  • Sweeping generalizations from an isolated example
• Cognitive Filtering
• Disqualifying the good
  • Dismisses any good attribute about themselves
• Jumping to conclusions
  • Mind Reading
  • Fortune Telling
• Emotional Reasoning
• Rigid Rule Keeping
• Catastrophic / Worst case scenario-ing
• Labeling/Self Labeling
• Magnification/Minimization
  • Magnify their mistakes while minimizing their achievements

Solution: cognition restructuring

CBT Techniques used in depression

Cognitive strategies

• Identify/challenging Negative Automatic Thoughts
  • Maintain record/journal of negative thought that keep popping into the mind
  • Themes
    • About oneself - I'm worthless
    • About the world/others - No one cares for me
    • About the future - There is no hope for me
  • Once these are identified the patient is advised to challenge them to establish how true they are
  • By repeating, patient would see the link between low mood and these thoughts. Challenging these would improve the mood
• Distraction techniques
  • Useful when one is extremely distressed because of symptoms of anxiety or depression
  • Distracting can reduce the acute severity
  • Useful in short-term, while patient is learning other CBT techniques. Examples...
    • Focusing on an object
    • Mental exercises
    • Thinking about pleasant memories or fantasies
    • Sensory awareness
    • Doing some absorbing activities

Behavioral strategies

Monitoring activities on Mastery and Pleasure

• Patient is asked to keep a record of all the activities that they do
• Rate each activity on scale of 1-10...
  • Master - How well did you do the activity
  • Pleasure - How much did you enjoy doing the activity

Scheduled Activities

• Plan each day in advance on hour by hour
• Should be realistic
• Include activities that they enjoy
• Gives greater sense of control

Graded Task Assignment

• In unable to do task in one go, break the task into smaller chunks
  • Avoids
    • Procrastination
    • Negative thoughts - its too much for me
    • Hopelessness

CBT for Anxiety Disorder

Panic Disorder

• Characterized by episodic paroxysmal(sudden recurrence or intensification of symptoms) anxiety
• Attacks come out of the blue
• There are both cognitive symptoms(Fer of dying), as well as physical symptoms(palpitations, sweating, etc)

Phobias

Depending of stimulus - types of phobias

• Simple(Specific) Phobia
• Agoraphobia
  • Crowded places
  • Traveling alone
  • Leaving Home
• Social Phobia

Behavioral response

• Avoidance
• Escape
  • CBT aims to change these behaviors by helping the client to deal with the anxiety

OCD

Obsession are repetitive, intrusive, unpleasant thoughts that keep coming up despite the patient's attempt to resist the thoughts. Examples...

• Fear of contamination
• Fear for one's safety
• Need for symmetry

Compulsions are repetitive behaviors that are done in order to reduce the anxiety associated with the obsessions. Examples...

• Repeated hand washing
• Repeated Checking
• Arranging

Generalized Anxiety Disorder

• Patient feels 'tense' or 'on edge' most of the time
• Associated symptoms are muscle tension, being fidgety, restlessness, insomnia, headache, fatigue, difficulty concentrating, etc.

CBT Techniques used in Anxiety Disorders

Relaxation Exercises

• Applied relaxation technique
  • Progressive Muscular Relaxation
    • Body is devised into a series of large muscle groups and each group is tensed and then relaxed
    • By alternating tension and relaxation, patient is thought to distinguish between the two states
• Should be regularly practiced so it can be more easily used in bad situations

Exposure and response prevention

• Exposed to feared stimulus
• This would induce anxiety - but patient is prevent from the habitual maladaptive response - escaping.
• Patient is advised a few general principles that will help
  • However distressing these symptoms are, they...
    • Will not kill you
    • Will not last forever
• Exposure is done in a graded manner(Show a picture of a spider, show a small spider, show a large spider)

Distracting Techniques

• Identifying Anxiety inducing thoughts and finding alternatives

Skill Sets for a Counselor

• Being a nice person – non judgmental, respectful and empathetic
• Listening closely to what you are saying without judgment
• Asking questions where necessary and encouraging you to explore the issue/problem in more depth
• Reflecting and summarizing what it is you are saying and feeling
• Clarifying the key issues or problems that you are facing
• Observing and noting your body language for additional clues about how you are feeling – Interpreting or re-framing some of your experiences in order to help you take different perspectives or understand better the meaning of the - sue/problem
• Where appropriate, offering suggestions, feedback or information in relation to the problem or potential solutions
• Where appropriate (and where trust has been developed), using confrontation or challenging to shift your perspective on an issue