Cognitive Behavioral Therapy

Cognitive Behavioral Therapy

1. Cognitive Behavioural therapy – part 2 Presenter – Dr. Priyash Jain Guided by – Dr. Abhay Paliwal Sir Associate professor Department of Psychiatry MGM Medical College

2. Index Recap Cognitive behavioural therapy Depression OCD Anxiety Disorders Schizophrenia Summary

3. A Quick Recap

4. Cognitive processing is given a central role in the cognitive behavioural model because humans continually appraise the significance of events in the environment around them and within them, cognitions are often associated with emotional reactions . A Quick Recap

5. A Quick Recap

6. CBT in Depression

7. CBT in depression

8. Developing the therapeutic relationship. Demonstrate good counseling skills and accurate understanding. Share your conceptualization and treatment plan. Collaboratively make decisions. Seek feedback. Vary your style. Help patients solve their problems and alleviate their distress.

9. Developing the therapeutic relationship. Feel likable , when you are warm, friendly, and interested. Feel less alone , when you describe the process of working together as a team to solve their problems and work toward their goals. Feel more optimistic , as you present yourself as realistically hopeful that treatment will help. Feel a greater sense of self-efficacy , when you help them see how much credit they deserve for solving problems, doing homework, and engaging in other productive activities.

10. Planning Treatment and Structuring sessions Your goal in the first part of a therapy session is to establish the therapeutic alliance and collect data so you and the patient can collaboratively set and prioritize the agenda. In the second part of a session, you and the patient will discuss the problems on the agenda. In the context of solving these problems, you will teach the patient relevant cognitive, behavioral, problem-solving, and other skills.

11. Identifying And Responding To Dysfunctional Cognitions Guided Discovery Ascertain which cognition or cognitions are most upsetting to patients, ask them a series of questions to help them gain distance (i.e., see their cognitions as ideas, not necessarily as truths), evaluate the validity and utility of their cognitions

12. Identifying And Responding To Dysfunctional Cognitions Therapist : Okay, Sunita, you said you wanted to talk about a problem with finding a part-time job? Patient : [automatic thought] I won’t be able to handle a job. Therapist : [labeling her idea as a thought and linking it to her mood] And how does that thought make you feel? Patient : [emotion] Sad. Really low. Therapist : [beginning to evaluate the thought] What’s the evidence that you won’t be able to work? Patient : Well, I’m having trouble just getting through my classes. Therapist : Okay. What else? Patient : I don’t know . . . I’m still so tired. It’s hard to make myself even go and look for a job, much less go to work every day.

13. Identifying And Responding To Dysfunctional Cognitions Therapist : In a minute we’ll look at that. [suggesting an alternative view] Maybe it’s actually harder for you at this point to go out and investigate jobs than it would be for you to go to a job that you already had. In any case, is there any other evidence that you couldn’t handle a job, assuming that you can get one? Patient : . . . No, not that I can think of. Therapist : Any evidence on the other side? That you might be able to handle a job? Patient : I did work last year at a bookstore. And that was on top of school and other activities. But this year . . . I just don’t know.

14. Identifying And Responding To Dysfunctional Cognitions Therapist : And what’s the effect of changing your thinking, of realizing that possibly you could work in the bookstore? Patient : I’d feel better. I’d be more likely to apply for the job. Therapist : So what do you want to do about this? Patient : Go to the bookstore. I could go this afternoon.

15. Identifying And Responding To Dysfunctional Cognitions Behavioral Experiments Discussing the validity of patients’ ideas, as described above, can help them change their thinking, but the change may be significantly more profound if the cognition is amenable to a behavioral test, that is, if the patient can have an experience that disconfirms its validity.

16. Identifying And Responding To Dysfunctional Cognitions Behavioral Experiments A depressed patient, for example, might have the automatic thought, “If I try to read anything, I won’t be able to concentrate well enough to understand it.” You might ask the patient to read a short passage from a book in your office to see to what degree this thought is valid.

17. Emphasizing THE POSITIVE Most patients, especially those with depression, tend to focus unduly on the negative. When they are in a depressive mode, they automatically (i.e., without conscious awareness) and selectively attend to and put great emphasis on negative experiences, and they either discount or fail to recognize more positive experiences.

18. Emphasizing THE POSITIVE From the first session on, you will elicit positive data from the preceding week (“What positive things happened since I saw you last? What positive things did you do?”). You will orient sessions toward the positive, helping patients have a better week.

19. Facilitating Cognitive And Behavioral Change Between Sessions (Homework) Because patients tend to forget much of what occurs in therapy sessions, it is important that anything you want them to remember, be recorded so they can review it at home. Either you or they should write down their self-help assignments in a therapy notebook

20. Facilitating Cognitive And Behavioral Change Between Sessions (Homework) Homework can be Behavioral changes as a result of problem solving and/or skills training in session Identifying automatic thoughts and beliefs when patients notice a dysfunctional change in affect, behavior, or physiology,

21. Cognitive Conceptualisation

22. Cognitive Conceptualization “What is the patient’s diagnosis(es)?” “What are his current problems? How did these problems develop and how are they maintained?” “What dysfunctional thoughts and beliefs are associated with the problems? What reactions are associated with his thinking?” “How does the patient view himself, others, his personal world, his future?” “What stressors contributed to the development of his current psychological problems, or interfere with solving these problems?”

23. Cognitive Conceptualization Reader A thinks, “This really makes sense. finally, a book that will really teach me to be a good therapist!” Reader A feels mildly excited and keeps reading. Reader B, on the other hand, thinks, “This approach is too simplistic. It will never work.” Reader B feels disappointed and closes the book. Reader C has different thoughts: “This is just too hard. I’m so dumb. I’ll never master this. I’ll never make it as a therapist.” Reader C feels sad and turns on the television.

24. Cognitive Conceptualization Reader C tends to focus selectively on information that confirms his core belief, disregarding or discounting information to the contrary. For example, Reader C did not consider that other intelligent, competent people might not fully understand the material in their first reading. Nor did he entertain the possibility that the author had not presented the material well . He did not recognize that his difficulty in comprehension could be due to a lack of concentration, rather than a lack of brainpower . He forgot that he often had difficulty initially when presented with a body of new information, but later had a good track record of mastery

25. Cognitive Conceptualization

26. Cognitive Conceptualization Core beliefs influence the development of an intermediate class of beliefs, which consists of attitudes, rules, and assumptions. Reader C, for example, had the following intermediate beliefs: Attitude: “It’s terrible to fail.” Rule: “Give up if a challenge seems too great.” Assumptions: “If I try to do something difficult, I’ll fail. If I avoid doing it, I’ll be okay.”

27. Cognitive Conceptualization

28. Cognitive Conceptualization How do core beliefs and intermediate beliefs arise? Reader C had difficult parenting. His parents were never content with his grades no matter how good they were. He was always compared to his sibling who was far better in academics then him. So growing up in that kind of environment he started believing that he is incompetent and dumb.

29. Cognitive Conceptualization When patients’ beliefs are entrenched, you can lose credibility and endanger the therapeutic alliance if you question the validity of core beliefs too early. The usual course of treatment in cognitive behavior therapy, therefore, involves an initial emphasis on identifying and modifying automatic thoughts that derive from the core beliefs.

30. Behavioral Activation One of the most important initial goals for depressed patients is scheduling activities. Most have withdrawn from at least some activities that had previously given them a sense of achievement or pleasure and lifted their mood. And they frequently have increased certain behaviors (staying in bed, watching television, sitting around) that maintain or increase their current dysphoria.

31. Behavioral Activation Situation: Thinking about initiating an activity [Common] Automatic thoughts: “I’m too tired. I won’t enjoy it. My friends won’t want to spend time with me. I won’t be able to do it. Nothing can help me feel better.” Behavioral Activation [Common] Emotional reactions: Sadness, anxiety, hopelessness [Common] Behavior: Remain inactive.

32. Behavioral Activation Situation: Engaging in an activity [Common] Automatic thoughts: “I’m doing a terrible job. I should have done this long ago. There’s still so much left to do. I can’t do this as well as I used to. This used to be more fun. I don’t deserve to be doing this.” [Common] Emotional reactions: Sadness, guilt, anger at self [Common] Behaviors: Stop the activity. Push self beyond a reasonable point. Fail to repeat this activity in the future.

33. Behavioral Activation Perhaps the easiest and quickest way to get patients behaviorally activated is to review their typical daily schedule

34. Behavioral Activation

35. Behavioral Activation

36. Graded task assignment Break down an activity into a series of smaller, more manageable steps. The patient is encouraged to initially attempt to complete the first step only. Once that step has been completed, the patient can move on to the next step. Example: If the task is to prepare meal it can be divided into individual steps like Step 1 – decide what to prepare Step 2 – buy groceries

37. Graded task assignment Step 3 – make the necessary preparations Step 4 – Prepare meal

38. Other techniques in CBT Re-attribution A common cognitive pattern in depression involves incorrectly assigning the blame or responsibility for adverse events to oneself. Clients especially depressed patients are particularly prone to blaming themselves. ‘Re -attribution’ can be used when a young person unrealistically blames themselves for occurrences.

39. Other techniques in CBT Diary Keeping records of cognitions are most likely to be accurate if they are made at or near the time the thought occurs . The records can range from simply counting thoughts also. The client is encouraged to tune into relevant thoughts, stand back from them and ultimately evaluate them.

40. Other techniques in CBT Reality testing This involves examining the evidence for a thought or belief Reviewing the existing evidence of the predicted outcome Planning an appropriate experimental strategy to test out the validity of the prediction. Noting and learning from the results Drawing specific conclusions from the experimentation.

41. Other techniques in CBT Behavioural Rehearsal: Any behavioural plan that the therapist can ask the patient to complete outside therapy can first be rehearsed in a treatment session to check on the patient’s ability to carry out the activity, practice behavioural skills, give feedback to the patient, spot potential roadblocks, and coach the patient on ways to ensure that the plan will have a positive outcome.

42. Other techniques in CBT Thought Stopping It aims to stop the process of negative thinking and replace it with more positive or adaptive though ts. Procedures for thought stopping are as follows: Recognize that a dysfunctional thought process is active. Give self-command to stop the thought – for example, tell yourself in commanding tone, “Stop!” or “Quit thinking that way!” The command can either be an internal thought or spoken aloud.

43. Other techniques in CBT Evoke a visual image to reinforce the command, such as a stop sign, a red traffic light, or the gloved hand to the police officer directing traffic.

44. Other techniques in CBT Switch the image from stop sign to a pleasant or relaxing scene. The image should be something created in the mind such as a vacation memory, the face of a pleasant person, or a photograph or painting one has seen.

45. Setting up Sessions The Evaluation Session Formulate the case and create an initial cognitive conceptualization of the patient. Determine whether you will be an appropriate therapist. Determine whether you can provide the appropriate “dose” of therapy (e.g., if you are able to provide only weekly therapy but the patient requires a day program).

46. Setting up Sessions Determine whether adjunctive treatment or services (such as medication) may be indicated. Initiate a therapeutic alliance with the patient (and with family members, if relevant). Begin to socialize the patient into the structure and process of therapy. Identify important problems and set broad goals.

47. Setting up Sessions Do a mood check. Set goals. Start working on a problem. Set homework. Elicit feedback.

48. Setting up Sessions

49. Subsequent sessions Reestablish rapport. Mood Check Review homework. Elicit the names of problems patients want help in solving. Collect data that may indicate other important problem areas to discuss. Prioritize the problems on the agenda.

50. CBT in OCD

51. CBT in OCD Cognitive models propose that intrusive thoughts, images, or urges develop into obsessions when they are given excessive negative importance. For instance, a woman has an image of dropping her baby and believes, “(Having images of dropping my baby means) I’m a bad person and I will lose control and do it.” These beliefs are referred to as fusion beliefs. The aforementioned intrusion is a thought-action fusion as the individual believes thinking about performing an action can cause the action to occur.

52. CBT in OCD A related process is ‘moral thought–action fusion’, which is the belief that thinking about a bad action is morally equivalent to doing it. Other fusion beliefs are thought-event fusion (thinking about an event means it will or has already happened) Lastly, there is ‘thought–object fusion’, which is a belief that objects can become contaminated by ‘catching’ memories or other people’s experiences ( Gwilliam et al, 2004).

53. CBT in OCD The content of intrusions usually violates patients’ deeply held values and may be related to earlier experiences. For example, the woman who imagined herself dropping her baby had taken care of a younger sibling when she grew up. Her mother had frequently told her to be extremely careful when handling her young sibling.

54. CBT in OCD Focus of attention is allocated toward intrusive thoughts as they are assigned excessive importance. One of the core features of OCD is an overinflated sense of responsibility for harm or its prevention. Responsibility is defined here as: ‘The belief that one has power that is pivotal to bring about or prevent subjectively crucial negative outcomes.

55. CBT in OCD Take the example of Sheela, a woman with OCD who has intrusive thoughts of molesting a child. Therapist: ‘I want to see if we can build a better understanding of what your problem is and therefore how to solve it. It seems to me there are two explanations to test out.

56. CBT in OCD The first explanation, which I will call theory A, is the one you have been using for the past few years, that is, the problem is that you are a paedophile . Theory B, which we would like to test out in therapy, is that you are extremely worried about being a paedophile and in your values care very deeply about children.

57. CBT in OCD theory A makes the worry and distress about being a paedophile worse Would you be prepared to act as if it was theory B for at least 3 months and then review your progress?

58. CBT in Anxiety

59. CBT in Anxiety

60. CBT in Anxiety

61. CBT in Anxiety

62. CBT in Anxiety

63. CBT in Schizophrenia

64. CBT in Schizophrenia The negative symptoms of schizophrenia are mediated, at least in part, by dysfunctional beliefs: “I’m helpless,” “I’m unlikeable,” “There’s no use in engaging with others because they’ll just reject me,” “If I try to be productive, I’ll just fail.” Individuals with this disorder tend to isolate themselves and avoid tasks they view as challenging, even some fundamental activities of daily living.

65. CBT in Schizophrenia Delusions are believed to develop, in part, due to information processing biases, cognitive errors, and impaired reality testing. Individuals experiencing delusions tend to have a self-referential bias, perceiving themselves to be the center and central focus of events, while also interpreting their subjective experiences as having an external causation.

66. CBT in Schizophrenia For example, an individual sees a commercial for cereal on television and thinks that it was aired solely for him because he has eaten that specific cereal in the past. He then stays up most of the night trying to figure out why the commercial was aired, feels tired, and attributes being tired to someone putting drugs in his food.

67. CBT in Schizophrenia Impaired reality testing, or the inability to distance oneself from beliefs and interpretations to consider whether they are accurate, is believed to be related to limited cognitive resources in these individuals. Individuals may not fully accept their delusion as true initially, but over time they selectively attend to information they believe confirms the delusion and do not consider evidence that contradicts their belief.

68. CBT in Schizophrenia A cognitive model of hallucinations describes factors that are precursors to hallucinations, lead individuals to fixate on them, and then maintain their occurrence. One predisposing factor is a low threshold for internal auditory and visual imagining that seems real or almost real. This low threshold interacts with activated cognitive schemas that produce cognitions related to the schema and not to reality

69. CBT in Schizophrenia For instance, an individual with a “failure” schema may have an intrusive, automatic thought that is perceived as an auditory hallucination saying, “You can’t do anything right.” The hallucination is perceived as coming from an external source due to externalization bias, cognitive errors, and impaired reality testing.

70. Summary CBT focuses on challenging and changing cognitive distortions (e.g. thoughts, beliefs, and attitudes) and behaviors, improving emotional regulation, and the development of personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include the treatment of a number of mental health conditions, including OCD, anxiety etc.

71. References Sadock B, Sadock V, Ruiz P. Kaplan & Saddocks comprehensive textbook of psychiatry, volume 1 and 2. 10th ed. Philadelphia: Lippincott Williams and Wilkins; 2009. Beck J, Beck A. Cognitive behavior therapy: basics and beyond. Colin Hughes, Stephen Herron and Joanne Younge, CBT for Mild to Moderate Depression and Anxiety. Veale D. Cognitive– behavioural therapy for obsessive–compulsive disorder. Advances in Psychiatric Treatment. 2007;13(6):438-446.

72. “The stronger person is not the one making the most noise but the one who can quietly direct the conversation toward defining and solving problems.” Aaron Beck ( uly 18, 1921 – November 1, 2021 ) Thank You