Cognitive Behavioural Therapy- CBT PDF

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Summary

Discusses the CBT model- both simple and complex formulations. Summarises the key components of CBT and potential limitiations to applying the treatment. ...

Description

Cognitive Behavioural Therapy: Principles and Techniques Learning Objectives   

To understand the basic philosophy of CBT To recognise the basic cognitive and behavioural principles underpinning CBT To critically discuss the key components and techniques used in CBT and their applications to common psychological disorders such as anxiety and depression

Basic Philosophy   

based on the assumption that there is a circular relationship between a person’s thoughts, behaviours and emotions the way in which a person behaves is determined by both the situation and, more importantly, the individual’s interpretation of it treatment involves helping the individual to change the distorted ways of interpreting events and to learn new behavioural strategies to cope with different situations

“Hot Cross Bun”- Vicious Circles

Relationship between all 4 components e.g. if you suffer anxiety, you’ll be anxious and will become sweaty and short of breathe and think you’re having a panic attack Cognitive-Behavioural Formulation- General Model

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simple model of a CBT formulation doesn’t just focus on the hear and now- looks at past history and early childhood all different as have different genetic contributions (e.g. temperament and how we regulate emotions) some babies like more cuddling than others. If the mum is depressed so doesn’t offer cuddles, some babies would be more affected as they’re prevented from this physiological need Predisposing factors include parenting style, how many kids in the family etc, how well they mix weith others at school, bullying experiences

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Vulnerability- e.g. low self-esteem, perfectionism, high standards of self, fear others views Once a problem has been developed the hot cross bun will keep it going

Behavioural Principles 

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developed out of principles of learning theories: - Classical Conditioning (Pavlov)- environment may become a cue for stress, e.g. office may trigger stress - Operant Conditioning (Skinner)- e.g. if have panic attacks in supermarkets. Every time you run out your anxiety decreases, reinforcing the behaviour. Form of negative reinforcement. as humans, we learn and change our behaviours through experience; what can be learnt can also be unlearnt or re-learnt goal of therapy is eliminate maladaptive behavioural patterns and to learn more healthy and constructive ones goal is to learn more healthy and constructive behaviours

Cognitive Principles    

psychological disorders commonly are characterised by dysfunctional thinking it is not the event per se that causes the problem but our interpretation of it “cognitions” refer to ideas and concepts, meanings, beliefs, expectations, attributions, etc. (see Beck, 1976) goal of therapy is to help the client to modify negative, irrational thoughts and belief, reality test their thinking and build more adaptive ways of responding to events.

“Hot Cross Bun”

Example

Key Components of CBT 

Formulation

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Setting Goals Psychoeducation Behavioural Techniques Cognitive Techniques Guided Discovery Relapse Prevention

Formulation  

Formulation is the process by which the client is helped to establish links between emotions, thoughts, behaviours, physical symptoms and triggering factors. It can be simple, focusing on one situation, or can be complex, representing the onset and maintenance of the problems

Example of Simple Formulation

Complex Formulation  

Complex formulation is sometimes known as longitudinal formulation, linking past experience, current circumstances and the presenting problems One commonly used method is the 5 ‘P’ model: - Presenting problems - Precipitating factors - Predisposing factors - Perpetuating factors - Protective factors

The 5P Model 

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Presenting problems - The problems or difficulties that are faced by the individual, such as symptoms presented at assessment - E.g. anxiety or depression Predisposing factors

Factors that contribute to the person’s problem over their lifetime, particularly in early childhood or early life experiences. E.g. environmental factors when growing up (depressed or over critical parents, bullying, admission to hospital to illness leading to social isolation) Precipitating factors - Factors that lead to the onset of the problems or illness, or the onset of a particular episode - Triggers leading to the onset of anxiety or a particular episode Perpetuating factors - Factors that maintain the negative symptoms or illness or condition - Maintaining factors (e.g. running out of supermarket to never face fear, having a supportive partner who always does the shopping for me, avoidance etc) Protective / Positive factors - Factors that mitigate the development the problem, or prevent or reduce a particular behaviour or distress - E.g. parents who aren’t emotionally supportive but the protective factor would be having spending lots of time with supportive and caring grandparents who meet their psychological needs -

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GOAL Setting What are SMART aims?     

S – Specific M – Measureable A – Achievable R – Realistic T – Timely / time-limited

Psychoeducation 

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‘Socialisation’ to the CBT model - Have to sell the model to them so they buy in and understand why you’re asking all the questions (e.g. about their childhood) “Disorder-specific” information - Anxiety, e.g., evolutionary origin and function of anxiety (i.e., fight or flight response) normal autonomic changes in anxiety lack of relationship between anxiety and ‘madness’- having anxiety isn’t abnormal, it’s a programmed response to threat but nowadays don’t need this response (like to a tiger) often the right response to the wrong circumstances Depression, e.g., - what is depression?- a psychological defence which your mind uses to protect you if e.g. experiencing an overwhelmingly difficult situation, then the mind shuts down as cant deal with it. By withdrawing from the situation you are temporarily taken away from the overwhelming situations. - physical and psychological symptoms of depression

Behavioural Techniques 

Anxiety, e.g., - Physical methods are important as they help to reduce the actual anxiety - Managing bodily changes Relaxation training / Controlled breathing - Dealing with anxiety-related behaviours Distraction (e.g. look at the shelves, take a tin and try to describe in minute details what it is in that tinewhat picture is on it, what colour is the wrapping paper, how big is the font size etc). takes your mind off others and the physical sensations which slows down the viscious circle. Systematic desensitisation/in-vivo graded exposure- useful for simple phobia. Behavioural experiment (e.g., reality testing)

Managing associated difficulties Problem solving Assertiveness training Time management Depression, e.g., - Self-monitoring - Alleviating mood Scheduling activities (to maximise mastery and pleasure) - Improving confidence Graded task assignments - Mindfulness (a new addition to traditional model) -

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Unhelpful Thinking Patterns: 

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All or nothing: - Sometimes called ‘black and white thinking’ - If im not perfect I’ve failed - Either I do it right or not at all Mental Filter: - Only paying attention to certain types of evidence - Noticing our failures but not seeing our successes Emotional Reasoning: - Assuming that because we feel a certain way what we think must be true - I feel embarrassed so I must be an idiot Magnification (catastrophising) and minimisation: - Blowing things out of proportion or inappropriately shrinking something to make it seem less important

Cognitive Techniques         

Overgeneralisation o Magnification Selective abstraction o Catastrophising Disqualifying positives o Emotional reasoning Dichotomous thinking o Mind reading Personalisation o Labelling Arbitrary inference o Using imperatives Assumption is that people who suffer from MH have unhealthy thinking patterns like these (above) Everyone has these thought but the difference is the degree and frequency of unhelpful thoughts Similar principles but different focus for various problems - identifying negative thoughts - identifying situations when negative thoughts occur - monitoring mood states associated with negative thoughts - looking for rational alternatives - looking for evidence to support all alternatives (including negative thoughts) - aiming to reach a reasonable conclusion

Guided Discovery       

Not a technique in itself it’s a process which goes through the whole CBT intervention Use of Socratic Questioning The phrase “Socratic dialogue” comes from a philosophic tradition begun over 2000 years ago by Socrates and other philosophers It refers to “a conversation between two or more people that encourages the participants to reflect and think independently and critically” AND “to enable participants to come up with…. their own answers to a critical question…. instead of being provided by readymade solutions” ASK not TELL In CBT, Socratic dialogue is used in two basic ways:

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- To find out the way a client is reasoning - To stimulate people to challenge and reflect on the reasoning and see if it still holds good This is about helping the client to gain evidence for and against their initial belief

Use of self-monitoring: - Diaries, thought records Behavioural experiments: - E.g. reality testing - E.g. trying out new behaviours

Relapse Prevention  

Consolidation of progress Identification of early warning signs of relapse - E.g. anxiety Increased avoidance behaviours Increased feelings of irritability - E.g. depressed Loss of interest Feeling more tired than usual

Limitations Of (Traditional) CBT   

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Limited focus on emotions (cf. 3rd wave CBT) - Newer versions focus on compassion, distress tolerance etc which address the limited focus on emotion Relies on self-motivation - What happens when motivation level is affected (e.g. low mood, ambivalence etc) Does not address wider systematic issues (e.g. family, extreme external circumstances etc) - If tis complex family dynamics it focuses on the person’s own thinking/behaviour patterns- how effective is that when there are so many issues maintaining the problems? Limited effectiveness on complex co-morbid issues, e.g. personality disorders - CBT needs a focus to work on and some presentations are v broad, such as personality disorders

Readings

Stefan et al (2012) 

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Abstract: - Aim to do a meta-analyses examining the efficacy of CBT - Examined CBT treating substance abuse, Sz and other psychotic disorders, depression and dysthymia, bipolar, anxiety, EDs, insomnia, PDs, anger and aggression, criminal behaviours, stress, chronic pain and fatigue etc. - CBT showed strongest support for anxiety disorders, somatoform disorders, bulimia, anger control problems and general stress - CBT showed higher response rates than the comparison condition in 7 of these reviews and only 1 review reported CBT had a lower response rate compared to other treatments Intro: - The core premise of this treatment is that maladaptive cognitions contribute to the maintenance of emotional distress and behavioural problems (Beck, 1970; Ellis, 1962) - A number of disorder-specific CBT protocols have been developed that specifically address various cognitive and behavioural maintenance factors of the various disorders. They all share the same core model and the general approach to treatment Discussion: - For treating addiction and substance use disorders, the effect sizes of CBT ranged from small to medium, depending on the type of substance abuse - CBT was less effective than other treatments for treatment SZ and other psychotic disorders for chronic symptoms or relapse prevention - CBT for depression and dysthymia was mixed - Use of CBT for anxiety disorders was consistently strong. Large effect sizes were reported for treatment of OCD, at least medium for social anxiety, panic disorder and PTSD - For bulimia CBT was consistently more effective than other forms of psychotherapies - CBT demonstrated superior efficacy for insomnia for sleep quality, total sleep time, waking time and sleep efficiency outcomes - CBT was more effective than other treatments for stress management

Gega, Smith & Reynolds (2013) 

Abstract: - Compares patient experiences between 2 modalities of CBT for depression: computerized CBT (cCBT) and therapist-delivered CBT (tCBT) - Patients found cCBT sessions less meaningful, less positive and less helpful compared to CBT in terms of developing understanding, facilitating problem-solving and building a therapeutic relationship...