Cognitive Behavioral Therapy

Understanding  &  Benefits  of  Cogni2ve  Structuring    Shonaleei Somnath Datta

CBT –Impact on Life Success

•  Your beliefs and thinking impact your actions

•  Positive psychology supports accomplishments

•  Activity event have an impact on thinking and thereby life

•  CBT helps look at events more logically and thereby create your own success ecosystem

•  You can create your own success blueprint with CBT and remodel your life…

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Important aspects

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•  History •  Meaning of Cognitive •  Benefits •  Definitions •  Behavior Therapy (CBT) •  Basic principles of

treatment •  Course of treatment •  Interventions •  CBT With people

History of CBT

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Meaning: CBT

•  Set of ‘talk’ psychotherapies that treat psychiatric conditions.

•  Short-term focused treatment. •  Strong empirical support with randomized clinical

trials. •  As effective as psychiatric medications. •  Recommended as critical component of treatment,

particularly when medications are contraindicated or ineffective.

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CBT Benefits

•  Clear treatment approach for patients

•  Assumptions make sense to patients

•  Based on patient’s experience

•  Encourages practice and compliance

•  Patients have a sense of control

•  CBT works!

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Definition of Cbt/ct •  CBT is a focused form of psychotherapy focused on

psychiatric disorders involve dysfunctional thinking or behaviors

•  Human behavior is based on how they see and believe their ecosystem (Emotional and psychological reactions are accordingly influenced)

•  Modifying dysfunctional thinking and behavior leads to improvement in symptoms.

•  Modifying dysfunctional beliefs which underlie dysfunctional thinking leads to more durable improvement

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7 J. Beck, 1995

CBT WORKING

•  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.

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Beck et al., 1979

Cognitive perception

•  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 lack of love

•  Loneliness: fear of being alone, challenge in accommodating to people and environment,

•  Anxiety: Overestimation of physical and psychological threats. Core beliefs linked with risk, dangerousness, and uncontrollability.

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Cognitive background

• 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”

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Some disorder solutions

Anxiety Disorders “Well-Established Treatments”

“Probably Efficacious Treatments”

Specific Phobia 1. Participant Modeling*

2. Reinforced Practice*

1. Cognitive Behavior Therapy 2. Systematic Desensitization*

Generalized Anxiety Dx (GAD)

None 1.  Cognitive Behavior Therapy 2. Modeling* 3.  In Vivo Exposure* 4.  Relaxation Training* 5.  Reinforced Practice* 6.  Family Anxiety Management

Separation Anxiety

None Same 6 treatments as GAD

Agoraphobia None None OCD None None Panic Disorder None None

PTSD None None Social Phobia None None

* These can be considered components of CBT

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Depressive Disorders

“Well-Established Treatments”

“Probably Efficacious Treatments”

Major Depressive Disorder

1.  Interpersonal Therapy

1.  CBT 2.  Psychotropic

Medications

Dysthymic Disorder 1.  Interpersonal Therapy

1.  CBT 2.  Psych Med

Adjustment Disorder 1.  Interpersonal Therapy

1.  CBT 2.  Psych Med

Some disorder solutions

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Depressive Disorders

“Well-Established Treatments”

“Probably Efficacious Treatments”

Major Depressive Disorder

1.  Interpersonal Therapy

1.  CBT 2.  Psychotropic

Medications

Dysthymic Disorder 1.  Interpersonal Therapy

1.  CBT 2.  Psych Med

Adjustment Disorder 1.  Interpersonal Therapy

1.  CBT 2.  Psych Med

Some disorder solutions

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ADHD

“Well-Established Treatments” “Probably Efficacious Treatments”

1.  Stimulant Meds

2.  Behavioral Parent Training

3.  Behavioral Classroom Interventions

1.  Social Skills Training with Generalization Components

2.  Summer Treatment Programs

Some disorder solutions

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ODD/CD “Well-Established

Treatments” “Probably Efficacious Treatments”

1.  Parent Training Based on the book Living with Children

2.  Videotape Modeling Parent Training

For Preschool-Age Children: 1.) Parent-Child Interaction Therapy

2.) Time-Out Plus Signal Seat Treatment

3.) Parent Training Program

4.) Delinquency Prevention Program

For School-Age Children:

1.) Anger Coping Therapy

2.) Problem Solving Skills Training

For Adolescents/adults 1.) Anger Control Training with Stress

Inoculation

2.) Assertiveness Training

3.) Multi-systemic Therapy

4.) Rational Emotive Therapy

Some disorder solutions

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Cognitive Behavioral Therapy

“Probably Efficacious Treatment” •  Specific Phobia

•  Generalized Anxiety Disorder (GAD) •  Separation Anxiety

•  Major Depressive Disorder

•  Dysthymic Disorder •  Adjustment Disorder

While does not meet EST criteria, also often used for: •  Agoraphobia, OCD, Panic Disorder, PTSD, Social Phobia

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Cognitive techniques: Background

•  Goal: Target maladaptive thoughts 1.  Negative view of themselves (e.g., inadequate) 2.  Negative view of the world (e.g., unfair)

3.  Negative view of the future (e.g., I will always fail)

•  Examples of maladaptive thoughts •  When things do not go the way I would like, life is awful, terrible,

horrible, or catastrophic

•  Unhappiness is caused by uncontrollable external events

•  I must have sincere love and approval from all significant people in my life

Impact of maladaptive thoughts

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Cognitive techniques •  Cognitive Restructuring/Reframing

•  Replace or reframe cognitive distortions or maladaptive thoughts with more balanced and realistic thoughts and beliefs about oneself, the future, and the world around us

•  ELVES •  E: Evidence

•  L: Likelihood

•  V: Over generalization •  E: Estimation

•  S: Standards

Some disorder solutions

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Cognitive techniques •  Fear thermometer 10

9 8 7 6 5 4 3 2 1 0

Really scared or upset

Pretty scared or upset

Not at all scared or upset

A little bit scared or upset

Some disorder solutions

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Behavioral techniques •  Diaphragmatic breathing

•  Relaxation training •  Activity scheduling

•  Exposure and response prevention exercises

Some disorder solutions

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Other Solutions resources Behavioral techniques: •  Relaxation training

•  Progressive Muscle Relaxation (PMR) •  Systematic tensing and relaxation of major muscle groups of whole

body •  With practice, goal is to learn to become deeply relaxed rapidly •  Impossible to be tense and relaxed at same time

•  Can implement skill when noticing that you are starting to become tense and anxious

•  Guided Imagery •  Visualization

Behavioral techniques: •  Activity scheduling

•  Pleasurable Activities •  E.g., walk dog, movie with friends, dinner with family, play a game

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Behavioral techniques: •  Exposure and response prevention exercises

•  Other Exposure •  Real-life exposure exercises

•  Practice approaching and confronting a feared situation or object •  (e.g., germs)

•  Sessions begin with easy situations and gradually work their way up to scarier and harder situations •  Fear hierarchy

•  Ideal for OCD and phobias

•  Extreme versions: implosive therapy, flooding

Other Solutions resources

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Behavioral techniques: •  Exposure and response prevention

exercises •  Participant Modeling

•  Combines modeling and in vivo exposure 1.  Model (e.g. therapist) demonstrates

fearlessness and coping responses when confronting the feared situation or object

2.  The model assists the child in practicing approaching and confronting the feared situation or object.

•  Sessions begin with easy situations and gradually work their way up to scarier and harder situations

Other Solutions resources

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Behavioral  techniques:  •  Exposure  and  response  preven2on  exercises  

•  Addi2onal  tools  • Fear  Hierarchy  

• List  of  items  from  0  (no  fear)  to  100  (most  fear  imaginable)  

• Subjec2ve  Units  of  Distress  Scale  (SUDS)  • Ra2ng  system  for  amount  of  fear  

•  Usually  use  a  0-­‐10  scale  for  younger  children  • Used  during  exposure  exercises  as  a  way  to  monitor  fear  response  –  ask  for  SUDS  ra2ng  at  beginning  of  exercise  then  wait  for  value  to  decrease  to  normal  levels  

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Other Solutions resources

Targeted Cognitions for Disorders

•  OCD:  appraisals  of  obsessive  cogni2ons  

•  Anorexia:  control,  worth,  perfec2on  

•  Panic:  catastrophic  misinterpreta2on  of  physical  sensa2ons  

•  Paranoia:  trust,  vulnerability  

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Working Model of CBT

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Event Appraisal

Maladaptive Behavior

Affective and Biological Arousal

Behavioral Inclination

Thase et al., 1998

Cognitive Model

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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

Automatic Thoughts …going through your mind

• 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

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28 Stressful Situation

Automatic Thoughts

Negative

Emotions

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

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Types of Cognitive Distortions  

•  Emo2onal  reasoning                Feelings  are  facts  •  An2cipa2ng  nega2ve  outcomes                The  worst  will  happen                  •  All-­‐or-­‐nothing  thinking                                                All  good  or  all  bad  •  Mind-­‐reading                          Knowing  what  others  are  thinking  •  Personaliza2on                                            Excess  responsibility  •  Mental  filter                          Ignoring  the  posi2ve      

 

 

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Core Beliefs

• Core beliefs produce automatic thoughts. • Assumptions influence information processing

and organize understanding about ourselves, others, and the future.

• Core beliefs remain dormant until activated by stress or negative life events.

• Categories of core beliefs (helpless, worthless, unlovable)

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31 Automatic Thoughts Core Beliefs

Examples of Core Beliefs •  Helpless  core  beliefs  

•  I  am  inadequate,  ineffec2ve,  incompetent,  can’t  cope  •  I  am  powerless,  out  of  control,  trapped  •  I  am  vulnerable,  weak,  needy,  a  vic2m,  likely  to  be  hurt  •  I  am  inferior,  a  failure,  a  loser,  defec2ve,  not  good  enough,  don’t  measure  up  

•  Unlovable  core  beliefs    •  I  am  unlikable,  unwanted,  will  be  rejected  or  abandoned,  always  be  alone  

•  I  am  undesirable,  ugly,  unaYrac2ve,  boring,  have  nothing  to  offer  •  I  am  different,  flawed,  defec2ve,  not  good  enough  to  be  loved  by  others  

•  Worthless  core  beliefs  •  I  am  worthless,  unacceptable,  bad,  crazy,  broken,  nothing,  a  waste  •  I  am  hur\ul,  dangerous,  toxic,  evil  •  I  don’t  deserve  to  live  

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Cognitive Conceptualization

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Current Situation

Automatic Thoughts About self, world

And others

Physiology Feelings Behavior

Childhood And Early Life Events

Underlying Assumptions and Core Beliefs

Compensatory Strategies

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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

•  Define Situation

•  Clarify meaning of cognitive appraisal

•  What was going through your mind just then? •  What did the situation mean for you?

•  Evaluate interpretation •  Evidence: For and against this belief? •  Alternatives: Any other explanation(s)? •  Implications: So what….?

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METHOD OF RESTRUCTURING

Evaluating Negative Thoughts •  What is the effect of telling myself this thought? •  What could be the effect of changing my thinking? •  What would I tell ___ (a friend/family member) if s/he

viewed this situation in this way? •  What can I do now?

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PATTERN OF COGNITIVE THOUGHT

Situation Thoughts Emotions Rational Response

Outcome

Going on vacation—Ask a colleague to do some work for me

She’ll say no… I’m not doing a good job The boss thinks I take too much time off

Anxiety (70%) Guilt (40%) Sadness (20%) Cognitive Distortions: All/nothing Mindreading Fortune-Telling Over-generalization

I haven’t taken a day off in 6 months. We work as a team, so it’s also her job to track the samples.

Anxiety (10%) Guilt (0%) Relief (40%)

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Common Components of CBT

•  Establish good therapeutic relationship

•  Educate patients - model, disorder, therapy

•  Assess illness objectively, set goals

•  Use evidence to guide treatment decisions

•  Structure treatment sessions with agenda

•  Limit treatment length •  Issue and review homework

to generalize learning

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Course of Treatment

1.  Assessment

2.  Provide rationale 3.  Training in self-monitoring

4.  Behavioral strategies 1.  Monitor relationship between

situation/action and mood.

2.  Applying new coping strategies to larger issues.

5.  Identifying beliefs and biases

6.  Evaluating and changing beliefs 7.  Core beliefs and assumptions

8.  Relapse prevention and termination

CBT : Behavioral Interventions

•  Breathing retraining •  Relaxation •  Behavioral activation •  Interpersonal

effectiveness training •  Problem-solving skills •  Exposure and response

prevention •  Social skills training •  Graded task assignment

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Applications of CBT

Disorders  •  Mood Disorders

•  Unipolar Depression (1979) •  Bipolar Disorder (1996) •  Dysthymia and Chronic

MDD (2000) •  Anxiety Disorders

•  GAD (1985) •  Social Phobia (1985) •  Panic Disorder (1986) •  OCD (1988) •  PTSD (1991)

•  Emotional Disorders (2006)

Disorders  •  Eating Disorders

•  Anorexia (~5) •  Bulimia (~15)

•  Generalized Anxiety Disorder (~12)

•  Social Phobia (~14) •  Panic Disorder (~10) •  Borderline P.D. (2) •  Schizophrenia (~45) •  C/A Depression (8) •  Chronic Depression (1)

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Questions? Comments?

Shonaleei Somnath Datta www.shonaleei.com www.success-studios.com https://in.linkedin.com/in/shonaleei

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