Theory and Practice of Cognitive Behavioral Therapy

1. Theory and Practice of Cognitive Behavioral Therapy Shona N. Vas, Ph.D. Department of Psychiatry & Behavioral Neuroscience Cognitive-Behavior Therapy Program MS-3 Clerkship 2008-2009

2. Outline • What is Cognitive Behavior Therapy (CBT)? • What are the basic principles of treatment? • What is the course of treatment? • What are some examples of interventions? • Who is appropriate for CBT?

3. What is 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.

4. Why So Popular? • 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!

5. Definition of Cognitive Therapy • CT is a focused form of psychotherapy based on a model stipulating that psychiatric disorders involve dysfunctional thinking. • Dysfunctional/distorted thinking arises from both biological and psychological influences • Individuals’ emotional, behavioral, and physiological reactions are influenced by the way they structure their environment. J. Beck, 1995

6. Definition of CT (continued…) • Modifying dysfunctional thinking and behavior leads to improvement in symptoms. • Modifying dysfunctional beliefs which underlie dysfunctional thinking leads to more durable improvement

7. Definition of CT (continued…) • Cognitive therapy is defined by a cognitive formulation of the disorder and a cognitive conceptualization of the particular patient. • Cognitive therapy is not defined by the use of exclusively cognitive techniques. Techniques from many modalities are used. • CT also often referred to as Cognitive-Behavior Therapy (CBT).

8. 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

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

10. 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”

11. Targeted Cognitions for Different Disorders • OCD: appraisals of obsessive cognitions • Anorexia: control, worth, perfection • Panic: catastrophic misinterpretation of physical sensations • Paranoia: trust, vulnerability

12. Working Model of CBT Event Appraisal Maladaptive Behavior Affective and Biological Arousal Behavioral Inclination Thase et al., 1998

13. 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

14. What are Automatic Thoughts?What was 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 Negative Emotions Stressful Situation Automatic Thoughts

15. 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

16. Types of Cognitive Distortions • Emotional reasoning Feelings are facts • Anticipating negative outcomes The worst will happen • All-or-nothing thinking All good or all bad • Mind-reading Knowing what others are thinking • Personalization Excess responsibility • Mental filter Ignoring the positive

17. Examples • Cognitive Distortions • Emotional Reasoning: “I feel incompetent, so I know I’ll fail” • Catastrophizing: “It is going to be terrible” • Personalization: “It’s always my fault” • Black or white thinking: “If it isn’t perfect, it’s no good at all.”

18. Core Beliefs • Core beliefs underlie and produce automatic thoughts. • These assumptions influence information processing and organize understanding about ourselves, others, and the future. • These core beliefs remain dormant until activated by stress or negative life events. • Categories of core beliefs (helpless, worthless, unlovable) Core Beliefs Automatic Thoughts

19. Examples of Core Beliefs • Helpless core beliefs • I am inadequate, ineffective, incompetent, can’t cope • I am powerless, out of control, trapped • I am vulnerable, weak, needy, a victim, likely to be hurt • I am inferior, a failure, a loser, defective, 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, unattractive, boring, have nothing to offer • I am different, flawed, defective, not good enough to be loved by others • Worthless core beliefs • I am worthless, unacceptable, bad, crazy, broken, nothing, a waste • I am hurtful, dangerous, toxic, evil • I don’t deserve to live

20. Cognitive Conceptualization Physiology Feelings Behavior Current Situation Automatic Thoughts About self, world And others Childhood And Early Life Events Compensatory Strategies Underlying Assumptions and Core Beliefs

21. Example 1 Physiology Heart racing Lump in throat Feelings Sadness Worry Anger Behavior Seek reassurance Withdraw Cry 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 upwith me….” 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. Childhood Experiences Parental neglect and criticism

22. Example 2 Physiology Pit in stomach Dry mouth Feelings Worry, shame, Disappointment Humiliation. Behavior Use alcohol, Procrastinate with homework 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.” 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.

23. Responding to Negative Thoughts • 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….?

24. 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?

25. Sample Thought Log

26. 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

27. Course of Treatment Assessment Provide rationale Training in self-monitoring Behavioral strategies Monitor relationship between situation/action and mood. Applying new coping strategies to larger issues. Identifying beliefs and biases Evaluating and changing beliefs Core beliefs and assumptions Relapse prevention and termination

28. Basic Principles • Change mood states by using cognitive and behavioral strategies: • Identifying/modifying automatic thoughts & core beliefs, • Regulating routine, and • Minimizing avoidance. • 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 • Promote rapid symptom change

29. Behavioral Interventions • Breathing retraining • Relaxation • Behavioral activation • Interpersonal effectiveness training • Problem-solving skills • Exposure and response prevention • Social skills training • Graded task assignment

30. Cognitive Interventions • Monitor automatic thoughts • Teach imagery techniques • Promote cognitive restructuring • Examine alternative evidence • Modify core beliefs • Generate rational alternatives

31. Efficacy • Cognitive and behavioral approaches are effective • Supported by over 325 controlled outcome studies • State-of-the-art therapy, manualized

32. 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) Applications of CBT

33. Eating Disorders (1981) Marital Problems Behavioral Medicine Headaches (1985) Insomnia (1987) Chronic Pain (1988) Smoking Cessation Hypochondriasis Body Dysmorphic Disorder Applications of CBT(Continued…)

34. Unipolar Depression (~30) 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) Controlled Outcome Studies on CBT

35. Conclusions • System of psychotherapies • Unified theory of psychopathology • Short-term treatment • Objective assessment and monitoring • Strong empirical support • As effective as pharmacotherapy

36. Questions? Comments? Dr. Shona Vas (773) 702-1517 Psychiatry Department Office: A-312 svas@yoda.bsd.uchicago.edu