Introduction to Cognitive-Behavioural Therapy

1. Introduction to Cognitive-Behavioural Therapy Dr Ben Wright Consultant Psychiatrist in Psychotherapy East London & The City Mental Health NHS Trust

2. Learning Objectives Give a theoretical description of exposure and response prevention. Construct an exposure hierarchy Name emotions and identify the likely underlying thought Explain each of the 13 thinking errors. Demonstrate 3 techniques for identifying thinking errors Demonstrate Socratic questioning Describe techniques used in restructuring core beliefs.

3. Comparisons of Cognitive Therapy to no-treatment, wait list, and placebo controls: review of 14 meta-analyses, n=9138; 325 studies, 465 comparisons (Butler & Beck 2000)

4. Historical Evolution of cognitive behavioural therapy- CBT

5. Historical evolution of CBT

6. Systematic desensitization Developed by Joseph Wolpe in 1950s Patient creates hierarchy of 20-30 items of ascending fearfulness Deep muscle relaxation practised whilst imagining each scene repeatedly until it could be imagined without anxiety (habituation) Pairing of opposite emotional experiences (relaxation with anxiety-provoking stimuli) was termed reciprocal inhibition.

7. Exposure-based treatments Developed by Marks, Gelder & Rachman in the late 60s and 70s at the Maudsley. Good results using graded exposure in vivo for phobias and OCD. Flooding is exposure to feared stimulus at maximal intensity until anxiety habituates – rapid & effective but very distressing for the patient.

8. Exposure therapy Graded Hierarchy – patient directed (lead) “Anxiety is unpleasant but does no harm” As real as possible (imagination < in vivo) , to produce the greatest level of discomfort / anxiety that the patient is willing to experience – (including cue exposure). Without internal or external distraction Until anxiety goes away or is reduced by at least 50%. “Anxiety eventually reduces” As frequent as possible “practice makes perfect”

9. Management of Specific Phobias Graded exposure usually very good response Only 1% will present for treatment

10. Treatment outcome to behavioural therapy Severe flying phobia 71% success at 2 year FU.(McCarthy 1995) Spiders, one, three hour exposure in group 82% improved.(Ost 1996) N.B. Blood injury phobia

11. Anxiety to exposure to word “sex” 1st exposure

14. Exposure Exposure is the most important behavioural technique in the treatment of anxiety disorders. This is theoretically underpinned by the axiom that anxiety is maintained by avoidance of the feared stimuli. Exposure to the feared stimuli Challenges the belief that there are negative consequences by coming into contact with the stimuli Allows physiological “habituation”.

15. Types of Exposure Imaginal exposure In vivo exposure

16. Imaginal exposure Patients imagine themselves coming into contact with the feared stimuli. Described coming into contact with the feared stimuli onto a tape recorder with their eyes closed Re-expose themselves to this recording

17. Imaginal exposure is used when: Exposure to live situations is too anxiety generating for the patient to tolerate. Live exposure is impractical. Exposure is not immediately available. The queues are not external but are internal e.g. memories.

18. In vivo exposure: This is the best form of exposure and should be used wherever possible. Patients can normally initiate their own exposure Initially this may be modelled by the therapist to assist this process. Once initiated in a clinical setting the patient is encouraged to repeat this as frequently as possible outside the therapy sessions.

19. Steps in conducting exposure Preparation. Creation of exposure hierarchy. Initial exposure. Repeated exposure.

20. Preparation for conducting exposure Explain treatment rationale. Explore advantages and perceived disadvantages of doing exposure. Obtain informed consent and commitment to carrying out exposure.

21. Creation of exposure hierarchy The patient should describes that all cues that evoke anxiety (alternatively describe the things they avoid) Rates each item on a 0-100% scale 0 being no discomfort/anxiety 100 being maximum discomfort/anxiety Can rate in imaginal contact Use rating to rank list

22. S.M.A.R.T. Specific Measurable Attainable Repeatable Time limited

23. ACTIVITY You have assessed a patient with one of the following simple phobias: spider (G1), balloon (G2), dog (G3), cat (G4), night (G5), blood and needle (G6) phobia or borontophobia (G7). In groups of 4 create a hierarchy for treatment with graded exposure for each patient Make each step SMART

24. Initial Exposure Graded exposure involves graduated exposure beginning with the item that produces least discomfort/anxiety and working up the scale. Habituation can take hours and sessions should be structured accordingly (initial exposure continued while another patient is being seen before the session may be continued). The patient should rate their anxiety/discomfort on a 0-100 scale every five minutes and exposure continued until anxiety has reduced by at least 50%.

25. Repeated Exposure This should be continued on at least a daily basis Record each event as exposure is carried out. The patient moves up the hierarchy as they feel able.

26. Problems with Exposure: Exposure is most effective when it is: Evoking anxiety. Prolonged until habituation takes place. Repeated until the initial fear response declines across repetitions. Exposure will fail when: Exposure tasks do not include the relevant anxiety provoking cues. Patient is engaged in an avoidance either external (self distraction) or internal (disassociation).

27. Contraindication to exposure therapy Exposure is contraindicated when patients are in a state of: Acute psychological crisis. Actively abusing drugs or alcohol. Experiencing an acute psychotic breakdown. Under these conditions normally the overriding condition should be treated and then exposure maybe begun low and slow.

28. Interaction between BDZ & Exposure for panic / agoraphobia (Marks et al BJP 1993)

29. ActivityThe pink elephant exercise INFORMED CONSENT This exercise will give you a personal experience of the processes that occur in your mind. You will feel some discomfort when doing the exercise. At the end you will have a better understanding and experience of how to work effectively with your mind and how to help patients with OCD. The exercise involves imagining a pink elephant in your mind.

30. ActionThe pink elephant exercise Imagine a pink elephant in your mind Can’t do that? OK here is a picture of an elephant to help you!

31. Now make the elephant pink!

32. Like this! When you have read the instructions, close your eyes Let the image sit in your mind for 30 seconds. Now rate your discomfort from 0 (none) to 10 (maximum) Now rate the intrusiveness from 0 (none) to 10 (maximum) Open your eyes

33. Please report your rating Please report your discomfort 0 - 10 Please report the intrusiveness of the image 0 - 10

34. Step one Read these instructions to the end You are going to try to get the image out of your mind by forcing it out. You will have five minutes to do this. You cannot use distraction. The end result is a mind free from a pink elephant or any content that is connected to a pink elephant

35. Step One - five minutes of resistance Re-rating of discomfort and intrusiveness after 5 minutes of resistance Please report your discomfort 0 - 10 Please report the intrusiveness of the image 0 - 10

36. Step two Read these instructions to the end Now try keeping the image in your mind for five minutes. You will have five minutes to do this. Do not allow yourself to be distracted. Now close your eyes for 5 minutes and carry out step 2.

37. Please report your rating following step 2 Please report your discomfort 0 - 10 Please report the intrusiveness of the image 0 - 10

38. What did you learn? Attempting to exclude the image made it intrusive and uncomfortable Keeping the image in mind allowed it to fade away. Similar mechanisms occur in the development and treatment of OCD.

39. Role of distraction in mental illness. Ultimately this technique will fail The previously intruding images or thought will recur. These therefore must be dealt with in therapy. Distraction should never be used for obsessive thoughts as this causes worsening of the condition.

40. ERP – Exposure and Response Prevention The treatment for OCD Exposure to anxiety generating thought or action. The patient does not engage in reassurance, safety behaviours or other undoing behaviours during or after the exposure.

41. Difference between ERP and thought stopping Exposure and Response Prevention is used in the treatment of OCD. Thought stopping makes OCD worse. Thought stopping is only used in rumination and to stop anxiety reducing thoughts where indicated.

42. Thought stopping Goal: this is used as a coping strategy when the patient is overwhelmed by ruminative thinking or intrusive images. This is a temporary coping method - is likely to make the situation worse in long term. Can be used pending effective challenging of negative thoughts or exposure to intrusive images.

43. Thought stopping technique Describe the technique and rationale Demonstrate the technique Patients are asked to bring to mind some upsetting thoughts. The patient says stop in a loud voice and claps their hands. Repeat and simultaneously imagine a large stop sign. Practice technique.

44. Thought stopping indications & contraindications Indicated for Anxiolytic thoughts Ruminations especially depressive Contraindicated for Anxiogenic thoughts Obsessive thoughts

45. Clinical example of ERP in OCD Intrusive thought of “not knowing” leading to personal loss. Adult patient 5+ year history Medication resistant

46. Impact of resistance and exposure to intrusiveness and discomfort of thought

47. Clinical example OCD (2) Young Asian student 8 year history OCD & Depression No response to low dose SSRI

49. Exposure & Response Prevention Identify the feared content of consciousness Clarify and operationaise the exact cognitive steps for each group of internal stimuli Specify the anxiolytic and anxiogenic compoents of the process.

50. Exposure & Response Prevention Educate the patient Do pink elephant exercise Gain consent Do live exposure to feared stimulus in session Identify self treatment tasks for between session work

51. Exposure & Response Prevention Following sessions review progress Help patient to identify their own target areas for self treatment. Relapse prevention Other points: “Hospital says no answer” Weeds in the garden 1 in 10,000?

52. Review of selected behavioural techniques

53. ACTIVITY Get into threes Identify a task that you can share with your colleagues that you need to do and have been putting off Identify observer, guide and discloser Spend 5 minute exploring the problem. Use open questions and offer no advice. Formulate the problem.

54. Feedback What made disclosure easier or harder list driving and restraining forces What made understanding easier: list driving and restraining forces Can you clearly conceptualize the problem? What would the discloser’s life look like if they had solved the task?

55. Graded task assignment This is used when patients feels daunted by a task. Method: Break the task down into small parts Keep going until each part is attainable in and of itself. E.g. breaking a tax return down into different areas, e.g. income, car expenses, work expenses, etc. Identify specific first act and subsequent steps

56. Activity 2 In same groups: Observer and discusser swap roles 5 minutes on graded tasks assignment Feedback - what were the driving and restraining forces?

57. Behavioural activation Goal: to increase behaviours that are likely to result in a patient being rewarded in some way. Rewards may be internal or external. Secondary goal is to decrease depressive ruminations by shifting the focus to external activities.

58. Behavioural activation   Monitoring current activities. Developing a list of rewarding activities. Planning these activities. Completing these activities.

59. Behavioural activation: Monitoring List all activities on an hour by hour basis and rate pleasure and mastery 0-10 scale.

60. Behavioural activation:Develop list of rewarding activities. These will include activities that the patient thinks they may enjoy, have enjoyed in the past or currently enjoy.

61. Behavioural activation:Planning rewarding activities Schedule some activities from the activities list each day, predict in advance how much they may enjoy or experience mastery from the activity using 0-10 scale.

62. Behavioural activation: Completing planned activities The patient engages in the planned activities according to the schedule, records them and rates the pleasure and mastery.

63. Self Reward A form of self conditioning Also challenges self punishing behaviours. Reduces the negative self critical behaviours Encourages a more positive & compassionate attitude to the self. The steps are:1. Listing possible rewards.2. Setting criteria for rewards.3. Administering rewards.

64. Activity 3 In same threes Identify rewards for the difficult steps Identify driving and restraining forces

65. Problem solving Were there forks in the road? Number of possible solutions? How did you choose between them? Possible ways: List advantages and disadvantages Ask a friend / family Decision matrix Toss a coin

66. Activity 4 Look at stuck points Observer and discussant discuss alternatives Discloser observe discussion.

67. Re-breathing Used in two contexts: During hyper ventilation to increase circulating CO2 e.g. by breathing into cupped hands or paper bag to reduce the effects of hypocapnia. As a behavioural experiment to confirm that hyperventilation causes the symptoms occurring during a panic episode.

68. Historical evolution of CBT

69. Cognitive therapies Albert Ellis described rational emotive therapy in 1962 Aaron Beck developed cognitive therapy for depression and anxiety in early 1970s. Both models view emotional disorder and behavioural problems as secondary to irrational beliefs or faulty information processing.

70. Cognitive therapies - rational emotive therapy ELLIS IN A NUTSHELL: In terms of dysfunctional beliefs, Ellis concluded, "Everything boils down to 3 things":         1.     I must do well         2.     You must treat me well         3.     The world must be easy. These beliefs require challenging.

71. Tim Beck & Albert Ellis

72. Basic principles

73. Men are not moved by things but the views which they take of them. – Epictetus (55 – 135 CE)

74. Thinking and Emotion (Beck 1976)

75. Thinking and Emotion (Beck 1976)

76. Thinking and Emotion (Beck 1976)

77. General CBT Framework

78. General CBT Framework

79. General CBT Framework

80. General CBT Framework

81. General CBT Framework

82. General CBT Framework

83. General CBT Framework

84. General CBT Framework

85. Conventional CBT Framework

87. Recognising Emotions For each image Identify the emotion Identify the cognitive appraisal (in words or images) underpinning the emotion.

88. Essential reading Scientifically validated research on relationships Can predict with 98% accuracy whether partners will split up Gives an antidote to this

90. Happiness Cheek muscles rise Muscles round eyes contract Wrinkles round corner of eyes Symmetrical smile Cognition: gain in self or others

92. Sadness Inner corner of eyebrows come up and together Wrinkles - upside down U in middle of brow & Vertical furrow between eyes Corner lips down Cognition: loss in self or others

94. Anger Inner corner of eyebrows down, knit brow, Open eyelids, contract lower eyelids. Lips pressed Cognition: person broken my rules

96. Fear Horizontal eyebrows Horizontal wrinkles Eyes more open Lips pulled to side Cognition: threat to self or others

98. Disgust Wrinkle nose Raised upper lip Horizontal wrinkles between top of nose and eyes Cognition: Object of contamination that will cause harm (physical, social, psychological, spiritual).

100. Contempt Left corner of lip pulled to side creating a dimple. May have eye rolling Cognition: I’m better than denigrated other.

101. Negative Automatic Thought A spontaneously arising verbal or visual content of consciousness with distorted symbolic representation.

102. Negative Automatic Thoughts (NATs) Short, specific thoughts which often do not occur in sentences, but may consist of a few key words, images or memories Spontaneous and often extremely rapid Not the result of deliberation or reasoning Associated with negative emotional reactions Generally appear reasonable at the time but usually involve more distortion of reality than other types of thinking

103. Distorted automatic thoughts Mind reading Fortune telling Catastrophising Labelling or name-calling Discounting the positives Mental filter Over generalisation All or nothing thinking Should and “must” statements Personalisation Blaming Unfair comparisons Regret orientation What if thinking Emotional reasoning Thought fusion Judgement focus Magnification and minimisation Tunnel vision

104. Mind reading You assume you know what other people think without having sufficient evidence of their thoughts e.g. “he thinks I am pathetic”.

105. Fortune telling You future as if you are viewing your life through the fast forward button and predict either an extremely negative (or occasionally extremely positive) distorted outcome.

106. Catastrophising Here you believe either what has happened or is going to happen is so awful that you will not be able to cope with it and I will have a devastating impact on your life.

107. Labelling In labelling or name calling, you insult yourself or others e.g. “I am ugly” or “she is stupid”.

108. Discounting the positives You play down or exclude the positive aspects of what they have done e.g. that your successes do not count because you were “lucky” that a family member doing something nice to you does not count because they are expected to.

109. Mental filter This is also called “selective abstraction”. When we use negative filter it is like filtering out all the negatives in life and ignoring the positives. This is the mental equivalent of making a cup of filter coffee and eating the coffee grounds! When you are using a mental filter you would focus on all the people that do not like you rather than those who do like you.

110. Over generalisation With over generalisation you think the overall pattern of your life will be similar or identical to a single, usually bad incident. For example, you get a parking ticket you might think to yourself “it always happens to me, no one else gets parking tickets, this is how my life is, I am a very unlucky person”.

111. All or nothing thinking This is also referred to as “dichotomous” or “black and white” thinking. This is thinking in extremes and distorts your perspective on reality: either you are loved or hated, an event was either perfect or a complete waste of time, either you did extremely well at a task or completely failed at it. Standards for the positive end of dichotomous thinking are usually so extreme they can’t be reached. Therefore your whole life gets clumped together at the trash can end.

112. Should statements You tend to focus on how you expect things to be for either yourself or other people rather than focusing on what actually is. If things could be then they should be. Creates unrealistic expectations for yourself and other people Is often a prelude to anger.

113. Should statements and intermediate beliefs Should statements can be expressed as “if then” statements (representations of an intermediate belief); “I should do well” = “If I don’t do well then I am a failure.”

114. Personalisation You blame yourself for negative events and think that you are personally to blame Or that people carry out negative actions to get at you personally. When you are thinking this way you fail to consider the other factors that might have lead to these behaviours.

115. Blaming You locate responsibility for negative events outside yourself and onto other people. You tend to see yourself as the passive victim of other people’s actions rather than seeing what you might have contributed to the event to prevent it occurring. This way of thinking makes you feel powerless.

116. Unfair comparisons You may compare yourself to others in an unrealistic way. e.g. thinking yourself a lousy footballer because you don’t do as well as an international football player.

117. Regret orientation You tend to focus on the past and what has happened to you particularly less desirable events rather than focusing on what you can do in the here and now. This way of thinking tends to keep you tied to the past and limits you from thinking about your present and the future.

118. “What if” thinking You are constantly thinking about what negative things might happen in the future. This is similar to catastrophisation except that you tend to think about all the various possibilities of what might happen in the future.

119. Emotional reasoning You allow how you feelings to guide how you see the world thereby reinforcing the feelings. if you feel guilty then “I must have done something wrong” if you feel anxious then “I must be in danger” if you feel lonely you think “nobody loves me”.

120. Thought fusion You have an inability to disconfirm a negative thought. You believe that once you have a thought it must be true and therefore reject as irrelevant any evidence that contradicts your thought. You have fused to the thought and identify closely with it, seeing the thought as part of yourself. This form of stubbornness often prevents you from moving forward with your life and being liberated from thoughts which are unhelpful.

121. Judgement focus You are constantly looking at your own and others actions in terms of its value; good or bad, superior or inferior, rather than describing the behaviour and consequences of that behaviour. This judgemental focus on life often results in low mood or anger as this is difficult for you and others to live up to the high standards.

122. Magnification and minimisation You focus in on specific events and allow these to colour your view of the world. e.g. say you are preparing a meal and there is a delay in serving the main course you might focus on that delay to the exclusion of everything else. e.g. say you are in a social situation and make a slight error. You might focus on that error to the exclusion of everything else that happened in the evening. Magnifying that specific event and minimising the positive things.

123. Tunnel vision With tunnel vision you focus in on an event, action or thought in past, present or future and exclude everything else. e.g. say you were wronged in the past you might focus in on that single event and ignore every other aspect of your life e.g. if you have task coming up in the future like a work deadline you might focus on that to the exclusion of all your other responsibilities and family relationships.

124. Identifying and challenging cognitive distortions First step is to identify negative beliefs. Write descriptions of situations where they experienced disturbing emotions. Document their emotions as these will give a clue as to the likely cognitive distortion underlying their difficult emotions. Write down negative thoughts.

125. Challenging negative thoughts Identify thoughts and rate each thought strength of belief 0-100%. Identify hot thought. Focus on hot thought. Advantages of thought. Disadvantages of thought. Evidence in favour of thought. Evidence against thought. Reframe evidence in favour of thought. Identify alternative functional thought. Re-rate old thought.

126. Socratic questioning Socrates 470-399 BCE Greek philosopher & teacher Approach to teaching Disciplined rigorously thoughtful dialogue The recipient can examine ideas logically to determine validity Individual can recognise their own contradictions

127. Socratic questioning (2) Teacher is model of critical thinking Respects student’s viewpoints Probes their understanding Show genuine interest in their thinking Teacher poses questions more meaningful than a novice might propose

128. Socratic questioning (3) Seeking information that a patient can (or is able to) give. Helps to redirect attention and refocus the nature of the problem Moves from the specific to the more general  so that the patients Gains increasing insight into their general/basic beliefs Develops the skills to challenge and change key conclusions and beliefs

129. Socratic questioning (4) Who What When Where How Not why - unless dealing with PD in late phase treatment then difficult to avoid. Following are academic examples. Use them as ideas and for understanding. Use sparingly Focus on using your innate curiosity for guided discovery

130. Socratic questions: questions for clarification What do you mean by ______? How does ____ relate to ____? Could you put that another way? What do you think is the main issue here? Let me see if I understand you; do you mean _____ or _____?

131. Clarification (2) Jane, would you summarize in your own words what Richard has said?...Richard, is that what you meant? Could you give me an example? Would this be an example: ____? Could you explain that further? Could you expand upon that?

132. Questions About the Initial Question or Issue (less frequently used): How can we find out? To answer this question, what questions would we have to answer first? Is this the same issue as ____? How would ____ put this issue? Why is this question important? Does this question lead to other questions or issues?

133. Assumption Probes (less frequently used). What are you assuming You seem to be assuming ____. Do I understand you correctly? Why have you based your reasoning on ____ rather than ___? Is it always the case? Why do you think the assumption holds here?

134. Reason and Evidence Probes What would be an example? How do you know? Why do you think that is true? Do you have any evidence for that? What difference does that make?

135. Reason and evidence probes (2) What are your reasons for saying that? What other information do we need? Could you explain your reasons to us? Are these reasons adequate?

136. Reason and evidence probe (3) Can you explain how you logically got from ____ to ____? Do you see any difficulties with their reasoning here? Why did you say that? What led you to that belief? How does that apply to this case? What would change your mind?

137. Reason and evidence probe (4) But is that good evidence to believe that? Is there reason to doubt that evidence? Who is in a position to know if that is so? What would you say to someone who said ____? Can someone else give evidence to support that response? By what reasoning did you come to that conclusion? How could we find out whether that is true?

138. Origin or Source Questions Where did you get this idea? Do your friends or family feel the same way? Have you been influenced by media? Have you always felt this way? What caused you to feel this way? Did you originate this idea or get it from someone else?

139. Implication & Consequence Probes When you say ____, are you implying ____? And if that happened, what effect would that have? Would that necessarily happen or only probably happen? What is an alternative? If this and this are the case, then what else must also be true? If we say that this is unethical, how about that?

140. Viewpoint Questions You seem to be approaching this issue from ____ perspective. Why have you chosen this rather than that perspective? How would other groups/types of people respond? What would influence them? How could you answer the objection that ____ would make?

141. Activity Break into threes The discloser select an idea that is unlikely to be known to the discussers Using questions only the discussers can ask and try to elicit the idea. If you have time see if you can use question alone to identify weaknesses in the idea Observers call stop if a non-question is used!

142. CT Techniques (1) Socialising. Establish therapeutic contract. Bibliotherapy. Indicate how thoughts create a feeling. Dististinguishing thoughts from facts. Identifying and categorising distorted automatic thoughts

143. CT Techniques (2) Challenging distorted automatic thoughts Provide direct psycho-education. Define terms (semantic analysis). Examining testability of thoughts. Examining logic of thoughts. Examining limits of patients information. Vertical arrow. Double standard.

144. CT Techniques (3) Challenging recursive self criticism (e.g. I think I am a failure because I am depressed and I am depressed because I think I am a failure). Examining internal contradictions. Reduction ad absurdum e.g. if I am single I am unlovable therefore all people before they were married were single therefore all people are unlovable.

145. CT Techniques (4) Identifying variability and degrees. Weighing evidence for and against thought. Examining quality of evidence “would it stand up in court!”. Keeping a daily log (of evidence that contradicts thoughts).

146. CT Techniques (5) Distinguishing behaviours from persons. Challenging reification e.g. distinguishing between preferences and reality. Surveying others opinions. Cost - benefit analysis (of thought). Alternative interpretation. Negation of problems (reframing the problem in positive terms).

147. CT Techniques (6) The I accuse technique (court room drama). Behavioural experiment. Continuum technique. Putting situation into perspective (how would it be seen by someone with a terminal illness or in 100 years time). Pie chart technique.

148. CT Techniques (7) Looking at mitigating factors and reattribution. Externalising through role play to identify both sides. Using role play to apply a negative thought to a friend and how they would react to it. Acting “as if”.

149. CT Techniques (8) Challenging absolute thinking (e.g. you believe no one likes you, is it possible that there is anybody in the entire world who could like you). Depolarising comparisons e.g. comparing the best and worst on continuum. Positive reframing “finding the positive in negatives”.

150. CT Techniques (9) Decatastrophizing. Examining the feared reality. Anticipating future reactions (how would you feel about this in a week, month or year). Examining past predictions. Testing predictions. Examining past worries.

151. CT Techniques (10) Examining future distractions (that are likely to strike the patient from current concerns). Distinguishing possibility from probability. Calculating sequential probabilities. Addressing over-generalisation (inevitability of predictions?).

152. CT Techniques (11) Challenging the need for certainty. Advocating acceptance. Using point counter point with difficult thoughts. Identifying maladaptive assumptions Specifying the rule book, should musts and “if … … then … … ”s.

153. CT Techniques (12) Re-evaluating standards. Identifying the patients chosen values system. Identifying social standards. Distinguishing progress from perfection. Challenging idealisation of others.

154. CT Techniques (13) The utility of adaptability and flexibility. Using others perspective. Use of curiosity and growth rather than perfection. Cost benefit analysis of intermediate beliefs system.

155. CT Techniques (14) Challenging dysfunctional schemas  Identifying source of schemers. Exploring schemers through role play. Use of imagery, restructuring, rewriting and life scripts. Writing letters to the source.

156. CT Techniques (15) Imagery and emotion. Coping imagery. Miniaturising the frightening image. Desensitising images. Nurturance self statements. “Bill of Rights”.

157. CT Techniques (16) Re-examining original schemas and developing new more adaptive schemas. Problem solving and self control Identifying a problem. Accepting the problem. Examining the goal generating alternative goals.

158. CT Techniques (17) Anti-procrastination steps (micro step analysis with cost benefit for each). Self correction. Coping cards. Decision delaying. Canvassing friends.

159. CT Techniques (18) Anticipating problems. Inoculation (role playing, challenge of worst possible thoughts/scenario). Self reward statements. Problem solution review (as part of relapse prevention).

160. Repertoire of common C & B techniques Pleasant event / Activity scheduling Thought counting Problem solving Diary keeping / self monitoring Relaxation Worry periods Graded exposure Covert sensitization Habit reversal, response cost Stimulus control Loop tapes Blame pie charts Social Skills Symptom contrast Modeling and role play Behavioural experiments Exposure and response prevention Anger management Event rehearsal Stress inoculation Challenging NAT Guided discovery Restructuring IB &CB Imagery Work Mindfulness Relapse prevention

161. Schema “a structure for screening, coding and evaluating the stimuli that impinge on the organism. It is the mode by which the environment is broken down and organised into its many psychologically relevant facets. On the basis of schemas, the individual is able to categorise and interpret his experiences in a meaningful way.” A.T. Beck

162. CBT formulation

163. CBT formulation

165. Personality structures What are the intermediate beliefs for each structure? You can also use the surrender/counterattack/escape model.

166. Avoidant. View of self; socially inept, incompetent, vulnerable to depreciation and social rejection. View of others; critical, demeaning, superior.

167. Avoidant (2) Main beliefs; if people knew the real me they would reject me and I would be unable to tolerate the feelings that would arise from this. Behaviours; avoid evaluative situations, avoid unpleasant feelings or thoughts.

168. Dependent View of self; needy, weak, helpless, incompetent. View of others; idealised, nurturing, supportive, competent.

169. Dependent (2) Main beliefs; I need other people to survive/be happy to give me support and encouragement. Behaviours; cultivate dependent relationships and engage in behaviours to avoid abandonment.

170. Passive aggressive View of self; self sufficient and vulnerable to control and interference. View of others; intrusive, demanding, interfering, controlling, dominating.

171. Passive aggressive (2) Main beliefs; others interfere with my freedom and action, control by others is intolerable if I express my needs then there will be severe counter attack from others or I will feel guilty. Main behaviours; avoid direct expression of needs, views and preferences, avoid conflict, resist passively, surface submissiveness.

172. Obsessive compulsive  View of self; responsible, accountable, fastidious, competent. View of others; irresponsible, casual, incompetent, self indulgent.

173. Obsessive compulsive (2) Main beliefs; I must get it right to avoid catastrophe and it is my responsibility to do so, I know what is best and people should be better/try harder. Behaviours; perfectionism, apply rules, evaluate of control, use should criticise and punish.

174. Paranoid View of self; righteous, incident, noble, vulnerable and victimised. View of others; interfering, malicious, discriminatory, abusive.

175. Paranoid (2) Main beliefs; I must be on guard, not trust others and others motives are suspect. Behaviours; look for hidden motives, be wary, accuse and counter attack.

176. Anti social View of self; loner, autonomous and strong. View of others; vulnerable and exploitative or exploitable.

177. Antisocial (2) Main beliefs; I am entitled to break the rules, others are either exploitative- in which case I must defend myself or exploitable in which case I am entitled to take advantage of them. Behaviours; attack, rob, deceive, manipulate.

178. Narcissistic View of self; special, unique, deserving special rules, superior and above the rules. View of others; inferior admirers.

179. Narcissistic (2) Main beliefs; since I am special I deserve special rules, normal rules do not apply to me and I am better than other people. Main behaviours; use others, ignore rules, ignore emotional consequences of one’s behaviour in others, compete with others.

180. Histrionic View of self; glamorous and impressive. View of others; seducible, receptive admirers.

181. Histrionic (2) Main beliefs; others are there to admire me and have no right to deny me what I deserve. Main behaviours; use dramatics, charm, through temper tantrums, cry, make suicidal gestures.

182. Schizoid View of self; self sufficient loner. View of others; intrusive.

183. Schizoid (2) Main beliefs; others are unrewarding, relationships are messy and undesirable. Main behaviours; avoid intimacy with other adults.

184. The CBT Practitioner Is an empirically based scientist practitioner. Holds the tension between acceptance of the patient and promoting change in the target area. Is warm, compassionate, respectful and transparent.

185. Principles of CBT Is based on an evolving collaborative cognitive case conceptualisation of the patient. Requires a sound therapeutic alliance. Emphasises collaborative and active participation in the therapeutic process. Is goal orientated and solution focused. Initially emphasises the present (here-and-now). Is educative, aims to teach the patient to be their own therapist and emphasises relapse prevention. Aims to be time limited. Sessions are structured. Teaches patients to identify, evaluate & respond to their dysfunctional thoughts & beliefs. Uses a variety of techniques to change thinking, feeling and behaviour.

188. Treatment sequencing in CBT

189. Treatment sequencing Engagement, explanation of treatment rational and socialisation Psychoeducation Self monitoring- ABCS Reattribution of NAT Behavioral experiments linked with ERP Altering schema Relapse prevention

190. Measuring change Problems & goals are defined at start of therapy and rated by patient & therapist Variety of questionnaires and rating scales Other ways of measuring change include direct observation of behaviour, behavioural by-products etc.

191. Challenging NATs & assumptions Patient first learns to identify / monitor their unhelpful thoughts Socratic questioning (guided discovery) is used to challenge thoughts & beliefs Patient is taught to look for disconfirmatory evidence Collaborative style very important Alternative thoughts & beliefs are then tested out using behavioural experiments

192. Behavioural Experiments - Method Identify key target cognitions e.g. I will lose control, No one will help me, I’m going to die. Operationalise cognitions Agree manipulated variables Establish testable prediction Rate belief Exposure plus disconfirmatory manoeuvre Re-rate belief, discuss, summarise and repeat.

193. Beck’s negative cognitive triad

194. Cognitive Model of Depression

195. Depression treatment outcome Effect size Any psychotherapy 0.73, and 0.68 @ FU CBT .85-1.02 (some report up to 2.15) TCA 0.55, MAOI 0.39 Overall efficacy BT 55.3%, CT 46.6% IPT 52.3% Brief PDP 34.8%

196. Effectiveness of CBT Empirical validation is a key principle of CBT Close links between theory, research & practice Important to control for non-specific effects of therapy

197. Assessment

198. Goals of assessment establishing a good working relationship normalising the patient’s difficulties and instilling hope shared cognitive-behavioural formulation of problems (cross-sectional then longitudinal) educating the patient about the CBT approach goal-setting initiating the therapeutic process

199. Modes of assessment interview self-report measures self-monitoring information from other people direct observation of behaviour behavioural by-products physiological measures