Cognitive Behavioural Therapy (CBT)

1. Cognitive Behavioural Therapy (CBT) May 13, 2019 Tanya Hansen, MSc (Clinical Mental Health Counselling); MTS (Coun) Canadian Certified Counsellor/Psychotherapist www.tanyahansentherapy.com

2. About me – Tanya Hansen • Originally from North Vancouver, BC, I live in Okotoks and am married with 2 children ages 10 and 14. I have worked in the field of counselling since 1993. My initial Masters degree is Masters of Theological Studies in Counselling – I initially worked as a chaplain, ran a group home for pregnant teens, ran a part-time private practice in a church setting, and worked in career/vocational rehabilitation for the Worker’s Compensation Board. • I completed further training at the Adler Institute in 1996 and become a fully licensed psychotherapist in 1997 and began more clinical work in the areas of depression, anxiety, couples therapy, family therapy and youth therapy, life transitions, and career/vocational counselling. • Trained with Dr. Albert Ellis in New York in 2001 where I received training in REBT • Have worked in private practice in Okotoks, AB since 2011 providing therapy and training /supervision of graduate students in counselling • 25 years after my initial degree, I completed a Master of Science in Clinical Mental Health Counselling in 2018 (Capella University – Minneapolis, MN) – completed internships at Foothills Composite High School and Homewood Health.

3. Premise of CBT What is the philosophy of CBT?

4. We are not disturbed by what happens to us, but by our thoughts about what happens to us Epictitus,c. 135 A.D. This does not mean that there are not disturbing things that can happen to us, and cause trauma, but that our thoughts can keep us prisoner and can lead to long-term anxiety and depression.

5. Anxiety and Depression • Anxiety and depression are two of the main symptoms/conditions that people attend therapy for and CBT is the recommended treatment of choice

6. What is Cognitive Behavioural Therapy? • Cognitive Behavioural Therapy is the primary treatment of choice for Anxiety and Depression • Cognitive Behavioural Therapy is recognized as an empirically supported therapy approach, considered to be the gold standard for treatment of anxiety and depression and recognized by the American Psychological Association. It includes cognitive and behavioural approaches. • Why is this important? Empirical support means there has been research with individuals who are seeking treatment for anxiety and/or depression and that in a controlled environment, they experience improvement through measurable change after being prescribed this treatment. Measurable change is often defined by improvement of symptoms through assessment of symptoms i.e. less or no panic attacks after 8 weeks of treatment

7. Founders of CBT • Dr. Aaron T, Beck – Cognitive Therapy, Cognitive Behavioural Therapy (CBT) • Philadelphia, PA, USA • Focus in determining cognitive distortions and using cognitive reframing • Dr. Albert Ellis – Rational Emotive Behaviour Therapy (REBT) • Manhattan, New York, USA • Focus on the ABCDE approach (Activating Event(s), Behaviour, (resulting) Consequences, Disputing Irrational Beliefs, and Effect. • Dr. Donald Meichenbaum – Cognitive Behavioural Modification (CBM), Cognitive Therapy • The focus is on challenging and changing negative self-talk in order to change negative, unhelpful, or destructive behaviours • from Ontario, Canada

8. What is cognitive and behavioural therapy – when combined create the approach of CBT (Cognitive Behavioural Therapy) • Cognitive • Identifying cognitive distortions or negative thinking and negative thinking patterns. • Looks at automatic thoughts and thought patterns that are negative and raise cortisol levels and/or depress serotonin in the brain • Challenging and changing thought processes • Behavioural • BF Skinner – founder of Behavioural Therapy • Focus is on behaviour modification techniques, changing behaviour is emphasized. • In CBT, a technique know as Behavioural Activation is part of the CBT therapeutic process. • Includes: exercise, healthy eating, socializing, seeking supportive relationships, healthy life choices

9. What is the focus of CBT? • Cognitive Behavioural Therapy would suggest that a combination of cognitive and behavioural techniques can assist individuals experiencing anxiety and/or depression. • A primary focus of the therapy approach is that cognitive distortions (CBT) or “irrational beliefs” (REBT) contribute to symptoms of anxiety and/or depression • CBT is normally recommended to be delivered over 8-20 sessions, sometimes with long-term follow-up or group psychotherapy at the completion of treatment. • It is important to consider if suicidal ideation or intent are present.

10. Cognitive Distortions, Unhelpful Thinking Styles, and Irrational Beliefs What do YOU think?

11. What are cognitive distortions? • The more common term for cognitive distortions is Unhelpful Thinking Styles • There are 10 Unhelpful Thinking Styles which can perpetuate anxious thoughts and depressive thoughts. • Our thoughts create our emotions which have a powerful impact on us, both physically, emotionally, cognitively, neurochemically, and spiritually. • If our thoughts are negative, this will create and maintain symptoms of depression and anxiety • If our thoughts are positive, this will improve our mood and improve our physical and emotional well-being in the long-term

12. Cognitive Distortions – 10 Unhelpful Thinking Styles – see handout (next page) • All or nothing thinking • Mental Filter • Jumping to conclusions • Emotional Reasoning • Labelling • Over-generalizing • Disqualifying the positive • Magnification (Catastrophizing) or Minimization • Should/Must thinking • Personalization

14. Irrational Beliefs – REBT (Rational Emotive Behavioural Therapy) • The premise of irrational beliefs are based on demands which can be about ourselves, others, or our environment • Should, must, or ought are core negative words that Dr. Ellis noted are words that are concerns/red flags for negative thinking patterns • Focus on the ABCDE approach (Activating Event(s)), Behaviour, (resulting) Consequences, Disputing Irrational Beliefs, and Effect.

15. What about anti-depressants? Anti-anxiety medication?Can’t patients just take a pill? Why not medication only instead of CBT… • There is a wide variation of opinions on the effectiveness of anti-depressant medication. In particular, many physicians, psychiatrists, psychotherapists, counsellors, clinical social workers, and psychologists would suggest that a combination of medication and CBT “may” be the best approach. Some professionals suggest medication as the best approach and some suggest CBT as the most effective approach. All professionals and patients need to decide what is best for their own individual situation. • The decision of whether to take medication only, CBT only, or a combination of the two needs to be made with professionals involved. Ideally several professionals could be involved in treatment planning.

16. What are common anti-depressants/anti-anxiety medications • Anxiety Medication • Lorazipam (also known as Ativan) • Depression (and often for Anxiety) Medication • sertraline (Zoloft) • fluoxetine (Prozac, Sarafem) • citalopram (Celexa) • escitalopram (Lexapro) • paroxetine (Paxil, Pexeva, Brisdelle) • fluvoxamine (Luvox)

17. What is a Black Box warning? • The warning recommends that anyone considering the use of that drug (or any antidepressant) in patients younger than 18 needs to carefully monitor patients for behavioural and emotional changes, including an increased risk of suicidal thoughts. Monitoring for suicidal thoughts or other signs of potential for suicidal behaviour is advised in patients of all ages. It also recommends that family members and caregivers closely watch for warning signs of suicide in a child or young adult taking an antidepressant. Health Canada requests that this same package warning be handed out with each prescription or refill of an antidepressant. • Source: • https://www.healthlinkbc.ca/health-topics/zu1129

18. What is a CBT Counselling Session Like? • There are a variety of approaches depending upon the individual counsellor/psychotherapist • Dr. Judith Beck demonstrates CBT and the TEAM (Dr. David Burns) approach will be reviewed, due its brief and structured approach

19. Learning from the Best – CBT in action • Dr. Judith Beck explaining and demonstrating CBT • Brief video demonstration • https://www.youtube.com/watch?v=45U1F7cDH5k • There are several videos available on youtube with Dr. Judith Beck and Dr. Aaron T. Beck – founders of CBT

20. TEAM approach to CBT – part 1 • Here is a brief description of the TEAM approach:T = Testing E = Empathy A = Agenda Setting M = Methods • Testing • Sometimes people know that they don’t feel quite right, but they can’t put their finger on what is bothering them. Testing can help clarify what the problem is. It involves completing questionnaires that assess your mood and other symptoms at the beginning and end of every session. The questionnaires also allow patients to give their therapists feedback about how the session went. This way, we can measure progress in therapy and stay on track, increasing your chances for success in therapy. • Empathy • Most people benefit from having a place to talk freely and openly, knowing that they can just be themselves and that they will be accepted, valued, understood and respected. We believe that the empathic connection is a necessary ingredient for successful therapy. We offer our patients more than just empathy, but we strongly believe that even the most sophisticated methods are much more effective once the empathic connection has been established

21. TEAM approach to CBT – part 2 Agenda Setting • Once we have established a connection and a clear sense of the change that you want to accomplish, we will talk about the pros and cons of change and what is likely to be required in order to meet your goals. Some people discover that there are hidden advantages to their symptoms. Maybe anxiety is helping you avoid real danger. Maybe guilt is a reflection of your good value system. Maybe hopelessness is saving you from disappointment.Regardless of the type of problem you have, it is likely that you will have at least some mixed feelings about the process of recovery. Agenda setting helps us to sort out your motivation to change and whether the rewards are worth the cost. • Methods • There are many extremely powerful cognitive, behavioral and interpersonal methods that we have to offer. These methods can help you with depression, anxiety, habits, addictions, and relationship problems. • Source: • http://www.feelinggoodinstitute.com/feeling-good-institute/what-is-team-therapy/

22. Testing/assessment example and testing • Beck Depression Inventory • Beck Anxiety Inventory • (Screen for Child Anxiety Related Disorders) – SCARED – 17 and under • Distress (DASS-21) • Depression (PHQ 9) • Quick Inventory of Depressive Inventory(Self-Report) (QIDS-SR16) • Generalized Anxiety (GAD 7) • Columbia Suicide Severity Rating Scale (tests suicidal ideation or intent) • What I use: • https://www.greenspacehealth.ca • Assessments sent automatically every 2-4 weeks. 2 weeks is often best.

23. Empathy – what it is and isn’t • Empathy is a therapeutic approach to counselling where the therapist attempts not only to “hear” what the client is saying, but also understand how they are FEELING. The therapist does not have to have experienced the same thing as the client in order to have empathy. • Not to be confused with sympathy, which could include: giving assurances or having shared experiences of what the person sharing has gone through. This would be similar to debriefing with a trusted friend or family member. Sympathy could also include feeling sorry for the person sharing. Sympathy is not a negative approach to someone in distress, but it is not necessarily a therapeutic approach, it would be considered to be more a supportive approach. We should all be grateful to have at least one person to turn to in times of distress. I recommend that all of my patients/clients identify at least one support person in their life, ideally a personal support person, but a professional such as a teacher, is also a good choice.

24. Agenda Setting • The process of setting goals for the session

25. Methods • Behavioural Activation • What can we do, to improve mood. • Examples include: • Exercise, healthy eating, fun activities, time with friends and family, pets (pet therapy), and finding things you enjoy (even watching a good movie!) • Journalling and Identifying negative thoughts/cognitions • Journalling thoughts is usually done over 1-7 days and given as therapy homework • Therapy Homework • Almost always given in CBT

26. Putting it all together Ted Talk with Dr. David Burns – an excellent explanation of CBT and why/how it works…

27. Ted Talk – Dr. David Burns • https://www.youtube.com/watch?v=H1T5uMeYv9Q • Dr. David Burns - Discusses the impact of CBT and that medications don’t always work, at least not on their own. Do not discontinue or reduce any anti-depressant medication without medical supervision. • Author of Feeling Good: The New Mood Therapy • https://www.amazon.ca/Feeling-Good-New-Mood-Therapy/dp/0380810336/ref=sr_1_1?crid=2TGUE0WN7SB20&keywords=feeling+good+david+burns&qid=1557592578&s=gateway&sprefix=Feeling+%2Caps%2C197&sr=8-1

28. Books and Workbooks for CBT • Dr. David Burns – Feeling Good • Burns, D. D. (1981). Feeling good: The new mood therapy. New York, N.Y: Penguin Books. • Retrain Your Brain: Cognitive Behavioural Therapy in 7 Weeks : A Workbooks for Managing Depression and Anxiety • Gillihan, S.J. (2016). Retrain Your Brain: Cognitive Behavioral Therapy in 7 Weeks: A Workbook for Managing Depression and Anxiety. Althea Press: Dunedin, New Zealand. • Greenberger, D., & Padesky, C. (2016). Mind over mood: changing how you feel by changing the way you think. New York: Guilford Press.

29. Sources and Resources • Beck, A. (1989). Principles of cognitive therapy. In: A. Beck, ed., Cognitive therapy and the emotional disorders, 1st ed. London, England: Penguin. • Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond. 2nd ed. New York: Guilford • Burns, D. D. (1981). Feeling good: The new mood therapy. New York, N.Y: Penguin Books. • Ellis, A. (1994). Reason and Emotion in Psychotherapy. Secaucus, NJ: Birscj Lane. • Ellis A., Dryden W. (1997). The Practice of Rational-Emotive Behavior Therapy. New York, NY: Springer Publishing Company. • Ellis, A., & Harper, R. A. (1997). A guide to rational living (3rd ed.). North Hollywood, CA: Wilshire • Meichenbaum, D. (1977). Cognitive-behavior modification: An integrative approach. New York: Plenum Press.

30. Questions ?????????????

31. Thank you!!!!