10 MINUTE CBT AND SELF-HELP

FOR GPs

Simon Day – Clinical Lead for York & Selby

IAPT

November 2019

Aims for Today

Learn how to introduce CBT as a therapeutic approach

Learn how to help people make links between

cognition, mood and behaviour

Learn how to help people start to consider how they

can make change for themselves

Gain a list of resources that can be used to help people

on their journey to recovery

Why CBT?

Cognitive Behavioural Therapy (CBT) is the most

evidence based psychotherapy

Recommended in NICE Guidelines for:

Depression

Social Anxiety

Panic Disorder

PTSD

OCD

GAD

What is CBT?

CBT is not a single therapy but a broad church with

disorder specific models and treatments as well as

different approaches

All approaches currently taught and used within the

IAPT programme are based on or developed from the

Beckian model first developed by Aaron Beck in the

60s and 70s

Therefore for this workshop and to maintain clarity we will focus on

this approach

What is CBT?

Two main influences

Behaviour Therapy (BT) developed by Wolpe and others in the 50s

and 60s

Cognitive model developed by Beck in the 60s and 70s

BT was a reaction against the Freudian psychodynamic approach

Looking for empirical evidence of stimulus and response that

could be replicated

Great success with anxiety disorders, particularly phobias and

OCD using systematic desensitization

This led to empirical support developing for the approach as well

as an effective and timely treatment - economical

What is CBT?

Two main influences

Cognitive model

In the 70s despite the success of BT some dissatisfaction about

the limitations of not attending to mental processes, which are

clearly part of all our lives

Needed to bring in an approach that attended to and included

cognition that met the empirical parameters that BT had set

down

Beck had started this work in the 50s and 60s and in 1979

published Cognitive Therapy for Depression with research

showing this treatment was as effective as medication

What is CBT?

Principles of CBT

Cognitive principle

Think about the last few days…

Have you had any noticeable changes in your mood? Either

positive or negative

If I were to ask you what had caused that change what would

you say?

What is CBT?

Principles of CBT

Cognitive principle

Common sense model

Cognitive model

Event Emotion

Event Emotion Cognition

What is CBT?

Principles of CBT

Cognitive principle

We all see and interpret the world differently

This tends to be driven by our experiences and biases

Therefore we all react differently/ idiosyncratically to the same

situation

The biggest factor in how we react is the meaning we give a

situation or event

What is CBT?

Principles of CBT

Behavioural principle

What we do, or don’t do, affects how we think and feel

Using an example of doing an introduction to CBT presentation

to up to 50 GPs (Situation)

They’re more qualified than me, they deal with mental health all

the time, I won’t bring anything useful (Cognition)

Anxious, nervous (Emotion)

Call in sick (Behaviour)

– Will that allow the presenter to be able to find out

their cognition was incorrect?

What is CBT?

Principles of CBT

Behavioural principle

Gives us a chance to find out whether our thoughts were

accurate or not – no disconfirmatory evidence gained

Changing what we do is an effective way of changing thoughts

and emotions

Ultimately change has to be behavioural, otherwise it is

theoretical and unsustainable

What is CBT?

Principles of CBT

Continuum principle

Have you ever felt depressed or anxious?

Feeling is natural and part of the human experience

When people have a common mental health problem this is

simply more exaggerated or intense

– Not abnormal

– CBT theory applies to everyone whether they are

classed as well or unwell

What is CBT?

Principles of CBT

Here and Now Principle

Working on the symptoms and current processes maintaining

difficulties leads to reduced distress

Although the processes may have been set in place a long time

ago changing our cognitive and behavioural processes as they

are currently leads to change

What is CBT?

Principles of CBT

Interacting Systems Principle

“Hot Cross Bun” (Padesky and Greenberger, 1995)

Cognition

Physiology

Affect Behaviour

Environment

What is CBT?

Principles of CBT

Empiricism

Based on well researched theories and models that have proven

to be effective

– And can continue to evolve

Can offer assurance to patients that if they engage then

treatment is likely to be effective

Offers assurance that limited mental health resource is being

used as effectively as possible

What is CBT?

Levels of Cognition

Negative Automatic Thoughts (NATs)

Negative appraisals of what is going on around us or within us

– Fairly easy to identify, if we pay attention to them

– Taken as true, particularly when linked to strong

emotion

Dysfunctional Assumptions

Often reframed as “rules for living”

– Conditional “if….then..” propositions or should/must

statements

– Less easy to verbalise – often derived from patterns or

behaviour or NATs

What is CBT?

Levels of Cognition

Negative Automatic Thoughts (NATs)

Negative appraisals of what is going on around us or within us

– Fairly easy to identify, if we pay attention to them

– Taken as true, particularly when linked to strong

emotion

– Can be verbal or an image

What is CBT

Levels of Cognition

Dysfunctional Assumptions

Often reframed as “rules for living”

– Conditional “if….then..” propositions or should/must

statements

– Less easy to verbalise – often derived from

assessment/ analysis of patterns of behaviour or NATs

What is CBT?

Levels of Cognition

Core Beliefs

Fundamental beliefs about themselves, others and the world in

general

– Global

– Often formed in childhood but can be formed and

changed by significant events in adulthood

– Not within consciousness

– Very powerful

– Problems arise when negative beliefs are confirmed or

positive beliefs are challenged

Depression

Cognitive triad

Negative view of self

I am bad/ useless/ unloveable/ a failure

Negative view of the world

Others are judgemental/ nothing good happens/ life is just full of

problems

Negative view of the future

Nothing will get better/ I will never succeed or be happy

Anxiety

Primarily we see cognitions that overestimate threat,

but content varies depending on the disorder

Panic disorder

Catastrophic misinterpretation of physical symptoms

– I’ll collapse/die, lose control, go mad

Health Anxiety

Catastrophic misinterpretation of phsycial symptoms over a

longer period

– I must have *disease or illness*

Anxiety Social Anxiety

Fear of negative evaluation by others

– They will think, and see, I’m weird/ weak/ stupid/ boring

OCD

Intrusive thoughts about being responsible for harm befallling

self or others

– Often images of self or others being hurt

GAD

Excessive hypothetical worrisome thoughts that spiral due to

uncertainty

– What if…..?

Maintenance

Safety Behaviours

Anxious clients usually take steps to avoid or prevent the threat they

imagine

However this usually only offers short term relief and actually

perpetuates the problem

– E.g. hold tight to prevent collapsing/ have drink with

me/ don’t go on my own/ pills in my bag/ seek

reassurance/ be quiet/ be loud/ don’t make eye contact

Vampires in Translyvania example

Maintenance

Escape/ Avoidance

A type of safety behaviour but prevalent across all anxiety disorders

Worth highlighting separately as the easiest for patients to recognise

as unhelpful and therefore able to see how their own behaviour is

maintaining the problem

Maintenance

Catastrophic Misinterpretation

Usually a misinterpretation of usual bodily process

Physical changes in Panic and Health Anxiety

– Something bad will happen to me

“Odd” intrusive thoughts in OCD

– Having these thoughts means they are likely to happen

and it will be my fault

Leads to more anxiety and more catastrophic misinterpretation and

so on (and on)

Maintenance

Scanning/ Hypervigilance

If we look out for something we will usually see it

How many of you noticed a red car this week?

– If I ask you to look out for them, how many will you see

next week

In disorders such as health anxiety patients will regularly scan

their body looking for symptoms and find them

– Become anxious and then notice more symptoms

Maintenance

Reduced Activity

Most typical in depression but seen to greater or lesser degrees in

other common mental health problems

When we are depressed and/or tired things can feel more of an

effort

– So we stop doing them

When we stop doing the things that matter to us our mood drops

as life loses some meaning

– Also increases self criticism, so more depressed and so

on (and on)

Putting It Together

In Groups of 2-3 Practice:

Using the examples complete a basic “hot cross bun” formulation

This allows the patient to understand how thoughts, feelings

behaviours and physiology are linked, and highlights that we can

create change

Each person to talk through a formulation

5 minutes each

Putting It Together

“Hot Cross Bun” (Padesky and Greenberger, 1995)

Cognition

Physiology

Affect Behaviour

Environment

Making Change

Behavioural - Depression

Behavioural Activation – A treatment to reduce rumination, increase

valued activity and reduce avoidance

Ask patient to complete an activity diary

Consider what is missing or has stopped doing

What has helped in the past

Physical health and general wellbeing

Making Change

Behavioural – Depression

Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday

7am-8am

8am-9am

9am-10am

10am-11am

11am-12pm

12pm-1pm

1pm-2pm

2pm-3pm

3pm-4pm

4pm-5pm

5pm-6pm

6pm-7pm

7pm-8pm

8pm-9pm

9pm-10pm

10pm-11pm

11pm-12am

12am-7am

Making Change

Cognitive Restructuring – For Depression and most

Anxiety Disorders

Unhelpful thinking styles

Increase awareness of NATs

Developing alternatives

Not replacing with positive thinking – continuum – more helpful

appraisal

Is the thought the truth? What might you say to a friend in the

same situation?

Link to behavioural change – what could I do differently?

Making Change Cognitive – Unhelpful Thinking Styles

Mental Filter

This thinking styles involves a "filtering in" and "filtering out" process – a sort of "tunnel vision,"

focusing on only one part of a situation and ignoring the rest. Usually this means looking at the

negative parts of a situation and forgetting the positive parts, and the whole picture is coloured by

what may be a single negative detail.

Jumping to Conclusions

We jump to conclusions when we assume that we know what someone else is thinking (mind

reading) and when we make predictions about what is going to happen in the future (predictive

thinking).

Personalisation

This involves blaming yourself for everything that goes wrong or could go wrong, even when you

may only be partly responsible or not responsible at all. You might be taking 100% responsibility

for the occurrence of external events.

Catastrophising

Catastrophising occurs when we “blow things out of proportion“., and we view the situation as

terrible, awful, dreadful, and horrible, even though the reality is that the problem itself is quite

small.

Making Change Cognitive

Unhelpful thinking styles

Black & White Thinking

This thinking style involves seeing only one extreme or the other. You are either wrong or right, good or bad and

so on. There are no in-betweens or shades of gray.

Shoulding and Musting

Sometimes by saying “I should…” or “I must…” you can put unreasonable demands or pressure on yourself and

others. Although these statements are not always unhelpful (eg “I should not get drunk and drive home”), they

can sometimes create unrealistic expectations.

Overgeneralisation

When we overgeneralise, we take one instance in the past or present, and impose it on all current or future

situations. If we say “You always…” or “Everyone…”, or “I never…” then we are probably overgeneralising.

Labelling

We label ourselves and others when we make global statements based on behaviour in specific situations. We

might use this label even though there are many more examples that aren’t consistent with that label.

Making Change Cognitive

Unhelpful thinking styles

Emotional Reasoning

This thinking style involves basing your view of situations or yourself on the way you are feeling. For example, the

only evidence that something bad is going to happen is that you feel like something bad is going to happen.

Magnification and Minimisation

In this thinking style, you magnify the positive attributes of other people and minimise your own positive attributes.

It’s as though you’re explaining away your own positive characteristics or achievements as though they’re not

important

Making Change

Cognitive Restructuring Situation Thought Emotion/ Feeling What Did I Do (Or

not do)?

Unhelpful Thinking

Style

Is there an alternative

view?

What could I do to test

to see if the

alternative thought is

true? What was happening?

Did something trigger this?

What was going through your

mind about the situation?

Were you remembering

something? If so what?

Did a thought or image pop

into your mind? If so what?

Typically this is one word e.g.

sad, angry, happy

How did you cope?

Mental Filter

Jumping to Conclusions

Personalisation

Catastrophising

Black & White Thinking

Should or Must Thinking

Overgeneralisation

Labelling

Emotional Reasoning

Magnification/Minimisation

If it were happening to

someone else what would I tell

them?

Am I being fair?

Making Change

Cognitive

Worry Awareness – GAD

Making Change

Physiological

Belly Breathing

Demonstration

– Slowly breath in through your nose and out through

your mouth at a pace that feels right for you

– Breathing into your belly

– Keep your shoulders loose

– Focus on your breath

– If your mind drifts come back to focus on your breath

– Continue for 2-5 minutes

Making Change

Time Allowing: In your groups of 2-3:

Introduce idea of behavioural activation

Introduce unhelpful thinking styles and thought record

Introduce belly breathing

Resources – Freely Available

http://www.selfhelpguides.ntw.nhs.uk/tewv/

https://www.cci.health.wa.gov.au/Resources/For-

Clinicians

https://www.getselfhelp.co.uk/

https://slam-iapt.nhs.uk/additional-resources-and-links/

Resources – To Buy

Overcoming Series books :

https://overcoming.co.uk/7/Home

Resources – Apps

Beat Panic

Catch It

My Positive Self

Stress & Anxiety Companion

Thrive

All NHS approved apps: https://www.nhs.uk/apps-library/

Resources – IAPT ;)

REFER TO IAPT!

IAPT is a primary care mental health service for people with common

mental health problems

If patients are referred early they can access less intensive

treatments that typically have little to no waits