lecture 1 CBT 1 (1).pptx cognitive bwhavior tgerapy for paychological disorders

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1. COGNITIVE BEHAVIOR THERAPY (CBT) THEORY AND PRACTICE

2. ORIGIN OF CBT

3. Aaron Beck’s Cognitive Behavior Therapy Aaron Beck was psychoanalytic psychotherapists. In early 1960 Aaron Beck developed an approach known as cognitive therapy as a result of his research on depression. In psychoanalytic depression was thought to be based on retroflective hostility. But the beck findings did not support the psychoanalytic formulation. Aaron Beck observations of depressed clients revealed that they had a negative bias in their interpretation of certain life vents, which contributed to their cognitive distortions.

4. Aaron Beck’s Cognitive Behavior Therapy cont. Beck called it cognitive therapy because of the importance it places on thinking. It’s now known as cognitive-behavioral therapy (CBT) because the therapy employs behavioral techniques as well.

5. WHAT IS COGNITIVE BEHAVIOR THERAPY

6. DEFINITION “CBT is a process of teaching, coaching, and reinforcing positive behaviors. CBT helps people to identify cognitive patterns or thoughts and emotions that are linked with behaviors.” Thinking: Different people can think differently about the same event. The way in which we think about an event influences how we feel and how we act. A classic example is that when looking at a glass of water filled halfway, one person will see it half empty and feel discouraged and the other sees it half full and feels optimistic.

7. Behavior: What we do affects how we feel and think. The individual, who deals with an upcoming exam by putting off his studies until the last minute, is likely to experience more distress on the day of the exam than an individual who has studied well in advance. CBT helps people to learn new behaviors and new ways of coping with events, often involving the learning of particular skills. Therapy : Besides its special focus on the relationships between how we think, feel and behave, the following are fundamental to the practice of CBT. Qualities of the Therapeutic Relationship Goal-setting Focus on the Present Structure

8. ‘Men are disturbed, not by things, but by the principles and notions which they form concerning things.’ Epictetus

9. THEORETICAL ASSUMPTIONS OF CBT

10. Beck’s is based on the theoretical rationale that the way people feel and behave is determined by how the perceive and structure their experience. The theoretical assumptions of CBT are that people’s communication is accessible to introspections. that clients’ beliefs have highly personal meanings that these meanings can be discovered by the client rather than being taught or interpreted by the therapists.

11. CBT posits that psychological problems are caused and maintained by a mixture of factors, both internal and external to the person, that include emotions and physiological sensations, thoughts and beliefs, behaviors , information-processing biases, behavioral contingencies, and behavioral skill deficits. Understanding how those factors interact to cause the problem is at the core of developing effective interventions.

12. PRINCIPLES OF CBT

13. BASIC PRINCIPLES Cognitions affect behavior and emotion. Cognitions may be made aware, monitored and altered. Desired emotional and behavioral change can be achieved through cognitive change. Change mood states by using cognitive and behavioral strategies: Identifying/modifying automatic thoughts & core beliefs, Regulating routine, and Minimizing avoidance.

14. BASIC PRINCIPLES Emphasis on ‘here and now’ Preference for concrete examples Start with specific situation (complete thought log) Reliance on Socratic questioning Ask open-ended questions Empirical approach to test beliefs Challenge thoughts not based on evidence Cognitive restructuring The interactive system principle The continuum principle

15. ELEMENTS OF CBT

16. CBT has several defining elements. They are as follows: ACTIVE: The client must be involved in the therapeutic process not as an observer or as an occasional visitor, but as a core and key participant. MOTIVATIONAL: The therapist needs to take responsibility for helping to motivate the client toward a change in behavior, affect, or thinking. The therapist must be able to set up the format, and rationale for the client to consider change of value. TIME-LIMITED: Each therapy session should, ideally , stand alone. A time-limited focus is not a number of sessions, but rather way of looking at therapy.

17. Elements of CBT CONT. STRUCTURED: CBT is structured in two ways. First, the overall therapy follow structure that approximates the treatment plan. Sessions have identifiable beginning, middle and end. COLLABORATIVE: Therapeutic collaboration cannot be 50/50. for severe depressed client the possibility to generate 50% of the therapeutic effort is impossible. Initially, the collaboration may be 90/10. For each client, the therapist must evaluate the client’s ability and motivation for the therapy. PROBLEM-ORIENTED: CBT focuses on discrete problems rather than vague and amorphous goals of feeling good, getting better, or increasing self-esteem

18. Elements of CBT Cont. PSYCHO EDUCATION: The therapist works as a change agent. Many to problems that bring people therapy involve skills deficits. The therapist may have to teach by direct instruction , modeling, role playing. SOLUTION-FOCUSED: The CBT therapists works with the client on generating solutions not simply gaining insight into the problem. DYNAMICS: The dynamic level of CBT is to help clients to identify, understand, modify their schema. The schema are the basic templates for understanding one’s world. Schema may be personal, religious, cultural, gender-related.

19. Levels ’ of cognitions

20. CORE BELIEFS Core beliefs underlie and produce automatic thoughts. Represents a person’s “bottom line,” their fundamental beliefs about themselves, other people or the world in general. These core beliefs remain dormant until activated by stress or negative life events. Categories of core beliefs (helpless, worthless, unlovable) CORE BELIEFS AUTOMATIC THOUGHTS

21. Characteristics of Core Beliefs Most of them are not immediately accessible to consciousness Manifest as general and absolute statements “I am bad,” “others are not to be trusted.” seen by the person as fundamental truths that apply to all situations Usually learned early on in life as a result of childhood experiences but they may sometimes change or develop later in life as a result of severe trauma

22. Core beliefs are people’s most basic understandings about themselves, their worlds and other people People with psychological disturbances have negative dysfunctional, very rigid and global and overgeneralized These core beliefs fall into three categories and people may have core beliefs in all three categories or predominantly in one or two

23. These are Helplessness Unlovability Worthlessness These core beliefs are very painful to the clients and they cope by developing certain rules for living or assumptions. These rules are then translated into patterns of behaviors or coping strategies

24. Core belief of unlovability When people have a core belief of unlovability they are afraid that there is something within them that’s going to stop their ability to get the love and intimacy that they really want from other people. They may express it in a variety of ways I don’t fit in, I am unlable , I am unlikable, I am unappealing, I have nothing to offer other people, ill be rejected, ill be abandoned

25. Core belief of helplessness It has three subcategories, may have belief in all three or one or two of them In first category clients are concerned that they are ineffective in getting things done. Use phases like: I am incapable, I am helpless, I cant do anything right In second category clients believe that they are ineffective in being able to protect themselves either emotionally or physically. Use phases like: I am vulnerable, I am weak, I am out of control

26. In the third category people believe that they are ineffective as compared to other people. They might say: I don’t measure up, I am a failure, I am not as good as other people in terms of achievement

27. Core belief of worthlessness When clients have this core belief they are not really talking about being worthless because they don’t measure up to other people, and they are not talking about being worthless so that no one will love them. In this category people believe that they are just morally bad, that there is something inside of them which is just terrible. They might phrase it as: I am bad, I am evil or toxic, I am worthless, I am danger to other people

28. Reflection Was there a period in your life when you were highly distressed ? Which of your own core beliefs become activated? Were these beliefs situation specific or did they generalize across situations? How long did these beliefs persist? How long was it before you regained your former sense of self?

29. Some people may also have pervasive negative beliefs about other people for example they may believe that until strongly proven otherwise, that other people will try to hurt them, may try to control them or manipulate them in some way. They may see other people as superior or demeaning. They see them as untrustworthy, critical, dangerous or judgmental

30. Some clients may also have negative beliefs about the world. They may see world as fundamentally hostile or dangerous. These may have some validity to them but they are usually overgeneralized and extreme

31. Coping strategies The characteristic ways that clients behave in order to protect themselves from the activation of their core beliefs

32. Dysfunctional Assumptions Bridging the gap between core beliefs and NATs. They provide the soil from which NATs spout. DA can be thought of as “rule for living,” more specific in their applicability of core beliefs but more general than NATs. Often take the form of conditional “if…then” propositions or are framed as should or must statements

33. For example if I believe that I am fundamentally unlovable, I may develop the assumption if I always try to please other people then they will tolerate me but if I stand up for my own need I will be rejected or I must always put others’ needs first otherwise they will reject me

34. Guide us how to live our life as to overcome some of the effects of the core beliefs When one of the DA is violated then NATs and strong emotions are likely to be triggered

35. Characteristics of DA May not be as obvious as NATs Usually Conditional statements if..then , should/ must..otherwise Some may be culturally reinforced for example putting others first Too rigid, over-generalized, not flexible enough to cope with the inevitable complications and setbacks of life

36. AUTOMATIC THOUGHTS Thoughts that automatically come to mind when a particular situation occurs is called as automatic thoughts. stream of thoughts that almost all of us can notice if we try to pay attention to them Happen spontaneously in response to situation STRESSFUL SITUATION AUTOMATIC THOUGHTS NEGATIVE EMOTIONS

37. Characteristics of NATs Happen automatically and without effort specific thoughts about specific events or situations, vary from time to time and situation to situation are or can easily become conscious May be brief and frequent and hence we become habitual to them Often plausible and taken as obviously true, we do not question them and shallow them whole

38. can be thoughts about something that happened right now or in past or may be the client is having NATs about the future and is making a negative prediction They can also have NATs about their thoughts (I cant believe he did this to me), emotions (I cant stand feeling like this), behaviors (I shouldn’t have told him the whole story) or physiological response (I cant stop crying)

39. Beck contends that people with emotional difficulties tend to commit characteristic “logical error” that tilt objective reality in the direction of self-destruction. Cognitive therapy perceives psychological problems as stemming from commonplace processes such as faulty thinking, making incorrect inferences on the basis of inadequate or incorrect information and failing to distinguish between fantasy and reality.

40. Illustration of levels’ of cognitions more specific more accessible easier to change more general less accessible harder to change NATs “I am boring”, “I don’t know what to say”, “they think I am stupid”, ”she doesn’t like me” DA “if people get to know me, they will find out how useless I am and reject me” “I must be perfect at everything I do otherwise my uselessness will be revealed Core belief “I am unlovable, I am useless”

41. Reflection Your friend has texted you at the last moment to cancel a plan to go to a concert, a concert you really wanted to go. If you think oh no what if she/he is in trouble. What emotion are you likely to feel? how inconsiderate, s/he is always doing this to me. What emotion are you likely to feel? oh that’s great now I can go with my other friends instead. What emotion are you likely to feel ? S/He is probably cancelling because s/he doesn’t want to go with me. s/he doesn’t really like me. What emotion are you likely to feel?

42. If you are significantly late for an important meeting. If you are angry Anxious Sad happy what thoughts had just gone though your mind

43. Thought-Feeling Connection Identify what are the likely mood stemming from the following thoughts Alex is rude, he is insulting me by ignoring me Possible moods irritable sad nervous caring Alex doesn’t find me interesting, I bore everybody Possible moods irritable sad nervous caring Alex seems shy, he is probably too uncomfortable to look at me Possible moods irritable sad nervous caring

44. Even situations you might think would create the same mood for everyone –such as losing a job- may in fact leads to different moods because of different personal beliefs and meanings. For example one person facing job loss might think I am a failure, the other might think they have no right to fire me this is discrimination and still another think I don’t like this but now is my chance to try a new job

45. Thoughts help define which mood we experience in a given situation. Once a mood is present, it is accompanied by additional thoughts that support and strengthen the mood. For example angry people think about the ways they have been hurt, depressed about how unfortunate life has become and anxious people see danger everywhere

46. Example: Jen X Jen X 38, an actor made a rare appearance in public today after husband Y, a singer was admitted to the famous Betty Ford clinic . X hasn’t been seen for weeks . Sources close to the actor say she has been increasingly worried about the singer’s behaviour. ‘She’s looking really drawn and a bit depressed ’ says a close friend. ‘She says she can’t bear to go out of the house and it’s really starting to get to her’. It is thought that X’s two adopted children are being cared for by family . Module 3 Trigger Behaviour Thoughts Feelings Consequences of behaviour Presenting issue

47. What’s That Noise? Must be a cat OH NO! There’s someone out there Module 4

48. Simplified CBT Model Module 2

49. ABC Model Module 2

50. BASIC FEATURES OF CBT

51. Rationale of 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.

52. Cognitive Theory of Psychopathology The cognitive theory of psychopathology is based on an information processing model which posits that during psychological distress a person’s thinking becomes more rigid and distorted, judgments become overgeneralized and absolute, and the person’s basic beliefs about the self, others and the world become fixed

53. Cognitive theory claims that the central pathway to psychological functioning or adaptation consists of the meaning-making structures of cognition, termed schemas. – All psychological systems—cognitive, behavioral, affective, and motivational—is composed of structures known as schemas.

54. COGNITIVE SPECIFICITY HYPOTHESIS Distorted appraisals follow themes relevant to the specific psychiatric condition. 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 un lovability. Anxiety: Overestimation of physical and psychological threats. Core beliefs linked with risk, dangerousness, and uncontrollability.

55. Cognitions Emotions Behaviors Depression Belief that I am worthless Sadness Spend excessive time in bed Mania belief that I am all-powerful Excitement, high energy, decreased need for sleep Impulsive sex, spending Panic Belief that I am dying Fear, increased heart rate, dizziness Avoidance, seeking reassurance Borderline Belief that others will abandon me and it will be devastating all of the above at different times Cutting, suicide threats, throwing things

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

57. Cognitive Content Specificity The meanings made by a person have implications that are translated into specific patterns of emotion, attention, memory and behaviour . This proposes that each emotional disorder has its own typical cognitive content or theme. – For example, devaluation or loss in depression; danger or threat in anxiety; unjustified intrusion in paranoia; transgression of one’s rules in anger; moral lapse in guilt

58. Cognitive content specificity has been refined to pinpoint key themes in each of the anxiety disorders, such as an imminent physical catastrophe in panic (e.g. dying, going mad, passing out) or losing mental or behavioural control that results in harm to oneself or others in obsessive- compulsive disorder (e.g. violent thoughts will be acted upon if not suppressed ). I n OCD , thoughts are about being responsible for, and/or needing to prevent, some harm to oneself or others.

59. In health anxiety , there is a similar misinterpretation of harmless symptoms as indicating illness , but on a longer time scale: e.g. I might have a disease that will make me die sometime in the future. In social anxiety , thoughts are about being negatively evaluated by others , e.g. ‘They will think I am stupid (or boring, or peculiar, or …)’.

60. References Barlow. D. H & Nathar . P. E.,(2011). The Oxford Handbook of Clinical Psychology. Published by Oxford Press.Inc , New York. Carson. R.C. , Butcher J. N & Mineka . S., (2001). Abnormal Psychology and Modern Life. ( 11 th Ed). Published by Pearson education, Inc. and Dorling Kindersley Publishing Inc. Doboson . D & Dobson. K., (2009). Evidence-Based Practice of Cognitive -Behavior Therapy. Published by Guilford publication.Inc . Ronen. T & Freeman. A.,( 2007) CBT in Social Work Practice. Published by Spring publishing Company,LLC . Sheldon. B.,(2011). Cognitive Behavior Therapy Research and Practice in Health and Social Care. (2 nd Ed). Published by Routledge publication New York.