it's complete course for the cbt experts

complete overview of cbt

1. Zainab Manzoor Clinical psychologist

2. “Man can alter his life by altering his thinking.” William James

3. Cognitive Behavior Therapy Topic of discussion

4. Psychotherapy (also called talk therapy) refers to a variety of treatments that aim to help a person identify and change troubling emotions, thoughts, and behaviors. Most psychotherapy takes place one-on-one with a licensed mental health professional or with other patients in a group setting.

5. progresses through the four stages outlined above : commitment, process, change, and termination . To work most effectively with these clients, we must look through the lens of shame-informed therapy and follow the four therapeutic R’s : Recognizing the autonomic state the client is in, Respecting the adaptive survival response, Regulating or co-regulating with the client into a ventral vagal state, and then Re-storying.4ps for therapy predisposing, precipitating, perpetuating, and protective factor s

6. Cognitive Behavior Therapy (CBT) is a time-sensitive, structured, present-oriented psychotherapy directed toward solving current problems and teaching clients skills to modify dysfunctional thinking and behavior.

7. Cognitive behaviour therapy (CBT) is a type of psychotherapy. It may help you to change unhelpful or unhealthy ways of thinking, feeling and behaving. CBT uses practical self-help strategies. These are designed to immediately improve your quality of life.

8. Cognitive Therapy (CT), or Cognitive Behavior Therapy (CBT) was pioneered by Dr. Aaron T. Beck in the 1960s , while he was a psychiatrist at the University of Pennsylvania.

9. CBT is a psychotherapy that is based on the cognitive model: the way that individuals perceive a situation is more closely connected to their reaction than the situation itself.

10. The core principles of CBT are identifying negative or false beliefs and testing or restructuring them. Oftentimes someone being treated with CBT will have homework in between sessions where they practice replacing negative thoughts with more realistic thoughts based on prior experiences or record their negative thoughts in a journal.

11. Uses Cognitive behavioral therapy is used to treat a wide range of issues. It's often the preferred type of psychotherapy because it can quickly help you identify and cope with specific challenges. It generally requires fewer sessions than other types of therapy and is done in a structured way. CBT is a useful tool to address emotional challenges. For example, it may help you

12. Manage symptoms of mental illness Prevent a relapse of mental illness symptoms Treat a mental illness when medications aren't a good option Learn techniques for coping with stressful life situations Identify ways to manage emotions

13. Resolve relationship conflicts and learn better ways to communicate Cope with grief or loss Overcome emotional trauma related to abuse or violence Cope with a medical illness Manage chronic physical symptoms

14. Mental health disorders that may improve with CBT include: Sleep disorders Sexual disorders Depression Bipolar disorders Anxiety disorders

15. Phobias Obsessive-compulsive disorder ( OCD ) Eating disorders Substance use disorders Schizophrenia PTSD

16. General CBT Assumptions The cognitive approach believes that abnormality stems from faulty cognitions about others, our world and us. This faulty thinking may be through cognitive deficiencies (lack of planning) or cognitive distortions (processing information inaccurately).

17. These cognitions cause distortions in the way we see things; Ellis suggested it is through irrational thinking, while Beck proposed the cognitive triad. We interact with the world through our mental representation of it. If our mental representations are inaccurate or our ways of reasoning are inadequate then our emotions and behavior may become disordered.

18. Rationale for CBT Negative emotions are elicited by cognitive processes developed through influences of learning and temperament. Adverse life events elicit automatic processing, which is viewed as the causal factor. Cognitive triad: Negative automatic thoughts center around our understanding of: Ourselves Others (the world) Future Focus on examination of cognitive beliefs and developing rational responses to negative automatic thoughts. Beck et al., 1979

19. Topics of Concern Schemas Core beliefs Negative Automatic Thoughts Emotions Physical Symptoms Behaviors

20. Schema A schema is a cognitive framework or concept that helps organize and interpret information . Schemas can be useful because they allow us to take shortcuts in interpreting the vast amount of information that is available in our environment.

21. Schema Examples Person schemas  are focused on specific individuals. For example, your schema for your friend might include information about her appearance , her behaviors , her personality , and her preferences . Social schemas   include general knowledge about how people behave in certain social situations. Self-schemas are focused on your knowledge about yourself . This can include both what you know about your current self as well as ideas about your idealized or future self . Event schemas  are focused on patterns of behavior that should be followed for certain events. This acts much like a script informing you of what you should do , how you should act , and what you should say in a particular situation .

22. Can Schemas Be Changed? The processes through which schemas are adjusted or changed are known as A ssimilation and A ccommodation. In  assimilation , new information is incorporated into pre-existing schemas. In  accommodation , existing schemas might be altered or new schemas might be formed as a person learns new information and has new experiences.

23. Schemas tend to be easier to change during childhood but can become increasingly rigid and difficult to modify as people grow older. Schemas will often persist even when people are presented with evidence that contradicts their beliefs. In many cases, people will only begin to slowly change their schemas when overwhelmed with a continual barrage of evidence pointing to the need to modify it .

24. How Do Schemas Affect the Learning Process? Schemas also play a role in the learning process. For example: Schemas influence what we pay  attention to.  People are more likely to pay attention to things that fit in with their current schemas. Schemas also impact how quickly people learn.  People also learn information more readily when it fits in with the existing schemas. Schemas help simplify the world.  Schemas can often make it easier for people to learn about the world around them. New information could be classified and categorized by comparing new experiences to existing schemas.

25. Schemas allow us to think quickly.  Even under conditions when things are rapidly changing our new information is coming in quickly, people do not usually have to spend a great deal of time interpreting it. Because of the existing schemas, people are able to assimilate this new information quickly and automatically. Schemas can also change how we interpret incoming information.  When learning new information that does not fit with existing schemas, people sometimes distort or alter the new information to make it fit with what they already know. Schemas can also be remarkably difficult to change.  People often cling to their existing schemas even in the face of contradictory information.

26. Core Beliefs Core beliefs are the very essence of how we see ourselves, other people, the world, and the future. Identifying and then challenging such core beliefs can not only change feelings but can also transform a person’s approach to life.

27. 1. There is something wrong with me. It can also sound like:  I’m defective, I’m fatally flawed,  I’m no good, I’m stupid, I’m worthless, everyone else is better than me, I don’t matter, I’m a bad person who can’t be fixed, I am a total failure, everything I do is wrong. If you have this core belief you will suffer from  low self-esteem . Often this sort of belief also causes  fear of intimacy . It feels easier to not let anyone really get to know you  than to get close to someone and have them see that you are flawed.

28. 2. I am unlovable. Nobody wants me, I’m better off alone, nobody understands me,  I bore others, people hate me, I don’t need other people anyway.  You might find that you avoid relationships altogether to avoid proving yet again that you can’t be loved. Or, you’ll choose  codependent relationships  where you have to ‘earn’ love. Another pattern believing you are unloveable can trigger is always choosing to be with others who fall treat you badly and  emotionally abuse you , such as those with  narcissistic traits.

29. 3. If I love someone, they will leave me. Everyone abandons me, it’s dangerous to love someone,  if you love someone you just get hurt, I have to deserve love, I can’t be happy unless I am with someone, everyone rejects me.  This core belief often means you leave relationships prematurely, so scared of  rejection  you pre-emptively abandon others first. Of course this means you are left  feeling alone  and awful. This core belief is common in those who suffer from  borderline personality disorder (BPD) .

30. 4. The world is a dangerous place. You can never trust anyone or anything, others are out to get me, I’m powerless, I’m helpless, I’m weak, you have to be in control to survive, never let your guard down,  you should never be vulnerable, don’t ever reveal who you really are.  This belief leads to ongoing  anxiety  and  fear of change .  You will make choices based on what is ‘safe’ over what you truly want. Suffering from a constant sense you that you ‘missing out’ on life, you will not living up to your potential. Another side effect of this belief can be that you are a  control freak , always trying to monitor everything and everyone around you

31. 5. I am not good enough. I am a failure, I can’t change, I will never succeed, I can’t, I’m a loser, everyone else is better than me, I’m always second best, there is no point in trying in life. This belief also leaves you mired in  low self-esteem  and often leads to  depression . You might, however, hide your low self-esteem and sadness behind perfectionism . Or, you might give up on even trying to feel worthy and instead let others manipulate you, even allowing abusive or  dependent relationships.

32. 6. I’m different/ an outsider . I don’t belong, it’s like I’m from another planet,  nobody understands me, I don’t fit in, there is something wrong with me, I have to hide who I am to be liked. If this is you, you might suffer from  extreme loneliness   even when in a crowd, or  struggle to understand yourself .

33. 7. You have to be happy to be liked If you do bad things you are a bad person, I can’t have bad thoughts, if I am angry I am unloveable , nobody likes a sad person, feelings are dangerous.  This sort of core belief often comes from a childhood where you were only loved if you were ‘good’ or ‘quiet’, etc. You will likely have attachment issues in relationships, identity issues, and struggle to have authentic relationships.

34. 8. Everything is my fault. I always get it wrong, I need to try harder, if I love people hard enough I can fix them, I have to help everyone, I am selfish to think about myself, I have to be perfect, you shouldn’t hurt others. If this is your way of thinking, you will probably have codependent relationships, lack personal boundaries , have  trouble saying no  to others, and be  passive aggressive.

35. 9. I’m special. I’m entitled to better, I deserve attention, if people criticise me they are bad, I’m superior, I have to excel, I am above rules, people can’t understand me, I can’t go wrong. This sort of core belief leads right to  grandiosity or  narcissism . It can mean you manipulate others, have  anger management issues , and never experience  true love and intimacy .

36. Automatic Thought Automatic thoughts , a concept in cognitive behavioral therapy, are images or mental activity that occur as a response to a trigger (like an action or event). They are  automatic  and 'pop up' or 'flash' in your mind without conscious  thought .

37. Negative Automatic Thoughts  (NATs) Negative automatic thoughts  (NATs), as first described by Beck, are a stream of  thoughts  that we can notice, if we pay attention to them. They are  negatively  framed interpretations of what we think is happening to us. And they usually have an impact on our mood and our feelings, that isn't positive.

38. 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.

39. There two main reason we have nat First, you may be surprised to learn that having negative thoughts is perfectly normal. So right now you can stop beating yourself up for having them; they exist to keep you safe. Your ancestors survived by constantly being on the lookout for threats, fixing problems as they arose, and then learning from their mistakes. Imagination is one of the greatest capacities of the human mind and you use it to imagine potential threats and problems. This enables you to solve them before you get into trouble. But this capability to imagine threats can also work against you by turning your mind into a “random negative thought generator.”

40. The second reason you may have so many automatic negative thoughts is that your negative thinking has become a habit . This is evidenced by the fact that 90% of all thoughts are repetitive — you’ll have virtually the same thoughts today that you had yesterday! If you do something often enough, including thinking negative thoughts, you create a neural pathway . The more you do it, the stronger the connections in the brain become. This is how habits get formed and why it’s so hard to stop a bad habit.

41. The negative effects of automatic negative thinking include: Reducing beneficial brain chemicals like the feel-good neurotransmitters serotonin and dopamine Slowing the production of brain-derived neurotrophic factor (BDNF), a protein required for new brain cell formation Shrinking the size of your brain but enlarging your brain’s fear center, the amygdala.

42. Increasing your risk of psychiatric and neurodegenerative diseases Accelerating the brain’s aging process It might feel like your negative thoughts are keeping you safe, but what they are really doing is holding you captive in a vicious cycle of stress and resulting misery.

43. Vicious circle of Negative Thoughts

44. CBT: Basic Techniques Eliciting Negative Automatic Thoughts (NAT) Verbal Reattribution Techniques Behavior Reattribution Techniques Emotional ventilation Techniques

45. AGENDA SETTING IN CBT This is a collaborative process between your therapist and you to determine how to best make use of each session. At the start of each appointment both you and your therapist suggest items you’d like to discuss. A decision is then made on the order the points will be discussed, and how much time each one needs.

46. The point of agenda setting is to make sure that the session is well spent , and that the hour isn’t lost to something that isn’t of itself productive , like simply rehashing the events of the week. It is always a good idea to be thinking before your session about what you want to put on the agenda, so you don’t walk away feeling something important was missed.

47. In the first few sessions your therapist will model for you how to set agendas . So you don’t have to instantly feel comfortable enough to add items to the agenda yourself, but can learn over time. This is itself a valuable process, helping you take charge of your problems and their solutions.

48. GOAL-SETTING IN CBT Again, this is a collaborative process designed to maintain structure and focus. The point is to make the goals for your therapy those that are relevant to you, with input from your therapist to make sure they are clear and are what you actually want as opposed to what you think you should want. Goal-setting makes CBT productive by highlighting the possibility of change, making impossible problems appear more manageable, and increasing your hope of overcoming them.

49. Smart goal setting While there are many different approaches to goal setting, one of the more common techniques used by CBT therapists is the SMART way. SMART goal setting creates a clear and vivid picture of your goal and helps you maintain your motivation for achieving it. This is what the abbreviation stands for:

50. Specific: Avoid generalization. Be clear and focused on exactly what you want. A specific goal has a much greater chance of being accomplished than a general goal. Measurable: Establish concrete criteria for measuring progress toward the attainment of each goal you set. Ask yourself questions such as, “How much?” and “How many?” “How will I know when I have met my goal?” Achievable: Make your goals attainable and feasible! How are you going to make this goal a reality? What can you do to make it more achievable?

51. Realistic: Is your goal realistic given your skills, time frame, etc.? While setting high goals can be a great way of increasing motivation, it can also be disheartening when they are so high that you cannot reach them. This can leave you feeling like a failure. Timely: Set realistic time-frames to avoid procrastination or giving up on your goal.

52. An example of a CBT SMART goal in action: Let’s say a depressed client wishes to exercise more frequently despite not presently doing any exercise. This is what they might come up with. Specific: I want to walk in the park next to my house every day for 30 minutes. Measurable: I can make a diary to record how often I have been out for and for how long. Achievable: I can take the dog with me so that I have to go out.

53. Realistic: 30 minutes is about the time it takes to walk around the park, so it’s not too much and not too little. Plus, walking is quite cheap so it won’t affect my lack of money. Timely: I will aim to do this for one month, and then review to see if I have achieved this goal.

54. 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

55. What are Automatic Thoughts Happen spontaneously in response to situation Occur in shorthand: words or images Do not arise from reasoning No logical sequence Hard to turn off May be hard to articulate Stressful Situation Automatic Thoughts Negative Emotions

56. Cognitive Distortions Patients tend to make consistent errors in their thinking Often, there is a systematic negative bias in the cognitive processing of patients suffering from psychiatric disorders Help patient identify the cognitive errors s/he is most likely to make

57. The Most Common Cognitive Distortions In 1976, psychologist Aaron Beck first proposed the theory behind cognitive distortions and in the 1980s, David Burns was responsible for popularizing it with common names and examples for the distortions.

58. 1. Black-and-White Thinking A person with this dichotomous thinking pattern typically sees things in terms of either/or. Something is either good or bad, right or wrong, all or nothing. Black-and-white thinking fails to acknowledge that there are almost always several shades of gray that exist between black and white. By seeing only two possible sides or outcomes to something, a person ignores the middle—and possibly more reasonable—ground.

59. 2. Personalization When engaging in this type of thinking, an individual tends to take things personally. He or she may attribute things that other people do as the result of his or her own actions or behaviors. This type of thinking also causes a person to blame himself or herself for external circumstances outside the person’s control.

60. 3. ‘Should’ Statements Thoughts that include “should,” “ought,” or “must” are almost always related to a cognitive distortion. For example: “I should have arrived to the meeting earlier,” or, “I must lose weight to be more attractive.” This type of thinking may induce feelings of  guilt or  shame . “Should” statements also are common when referring to others in our lives.

61. These thoughts may go something like, “He should have called me earlier,” or, “She ought to thank me for all the help I’ve given her.” Such thoughts can lead a person to feel frustration,  anger , and bitterness when others fail to meet unrealistic expectations. No matter how hard we wish to sometimes, we cannot control the behavior of another, so thinking about what others should do serves no healthy purpose.

62. 4. Catastrophizing This occurs when a person sees any unpleasant occurrence as the worst possible outcome. A person who is catastrophizing might fail an exam and immediately think he or she has likely failed the entire course. A person may not have even taken the exam yet and already believe he or she will fail—assuming the worst, or preemptively catastrophizing.

63. 5. Magnifying With this type of cognitive distortion, things are exaggerated or blown out of proportion, though not quite to the extent of catastrophizing. It is the real-life version of the old saying, “Making a mountain out of a molehill.”

64. 6. Minimizing The same person who experiences the magnifying distortion may minimize positive events. These distortions sometimes occur in conjunction with each other. A person who distorts reality by minimizing may think something like, “Yes, I got a raise, but it wasn’t very big and I’m still not very good at my job.”

65. 7. Mindreading This type of thinker may assume the role of psychic and may think he or she knows what someone else thinks or feels. The person may think he or she knows what another person thinks despite no external confirmation that his or her assumption is true.

66. 8. Fortune Telling A fortune-telling-type thinker tends to predict the future, and usually foresees a negative outcome. Such a thinker arbitrarily predicts that things will turn out poorly. Before a concert or movie, you might hear him or her say, “I just know that all the tickets will be sold out when we get there.”

67. 9. Overgeneralization When overgeneralizing, a person may come to a conclusion based on one or two single events, despite the fact reality is too complex to make such generalizations. If a friend misses a lunch date, this doesn’t mean he or she will always fail to keep commitments. Overgeneralizing statements often include the words “always,” “never,” “every,” or “all.”

68. 10. Discounting the Positive This extreme form of all-or-nothing thinking occurs when a person discounts positive information about a performance, event, or experience and sees only negative aspects. A person engaging in this type of distortion might disregard any compliments or positive reinforcement he or she receives.

69. 11. Filtering This cognitive distortion, similar to discounting the positive, occurs when a person filters out information, negative or positive. For example, a person may look at his or her feedback on an assignment in school or at work and exclude positive notes to focus on one critical comment.

70. 12. Labeling This distortion, a more severe type of overgeneralization, occurs when a person labels someone or something based on one experience or event. Instead of believing that he or she made a mistake, people engaging in this type of thinking might automatically label themselves as failures.

71. 13. Blaming This is the opposite of personalization. Instead of seeing everything as your fault, all blame is put on someone or something else.

72. 14. Emotional Reasoning Mistaking one’s feelings for reality is emotional reasoning. If this type of thinker feels scared, there must be real danger. If this type of thinker feels stupid, then to him or her this must be true. This type of thinking can be severe and may manifest as  obsessive compulsion . For example, a person may feel dirty even though he or she has showered twice within the past hour.

73. 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.

74. Cognitive principle – it is interpretations of events, not events themselves, which are crucial. Behavioural principle – what we do has a powerful influence on our thoughts and emotions The continuum principle – mental health problems are best conceptualised as exaggerations of normal processes

75. ‘Here and now’ principle – it is usually more fruitful to focus on current processes rather than the past Interacting systems principle – it is helpful to look at problems as interactions between thoughts, emotions, behaviour and physiology and the environment in which the person operates

76. Padesky’s 5 Aspects Model (1986) ENVIRONMENT THOUGHTS BIOLOGY MOOD / FEELINGS BEHAVIOUR