Cognitive Behavioral Therapy

1. Cognitive Behavioral Therapy Regi L. Pamugas, MD August 3, 2011 UP Manila

2. Objectives • To define mental health/illness • To discuss on the different types of treatment of mental illness • To define Cognitive Behavioral Therapy (CBT) • To discuss on CBT

3. Contents • Discussion on mental health/illness • Discussion on the treatment of mental illness • Discussion on Cognitive Behavioral Therapy (CBT) • Summary

4. What is a mental health? • “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” – World Health Organization

5. Mental health problems - can have both psychological, social and somatic dimensions. • These issues often make it hard for people to manage their lives and achieve their goals.

6. Mental Illness • Psychotics * schizophrenia, brief psychotic disorder, delusional disorder, shared psychosis • Neurotics * Anxiety, somatoform, eating, sleeping, disorder, etc. • Mood disorders * Bipolar I and II • Psychosis due to medical condition or substances • Psychosis not otherwise specified

7. Types of treatment • Biological/Pharmacologic * antidepressants, anxiolytics, antipsychotics • Psychotherapy * Psychodynamic, cognitive, behavioral, client-centered therapy, existential therapy • Combination of drugs and psychoanalysis • Electroconvulsive therapy (ECT)

8. Definition of Terms • Psychotherapy - set of clinical techniques use to improve mental health. • Counseling = psychotherapy. • Behavior Therapy (Behavior Modification Therapy) - changing somebody's behavior • Classical Conditioning - creation of response to stimulus (Pavlov's dogs) • Operant Conditoning - learning through positive and negative reinforcement • Cognitive Therapy - psychotherapy aimed at changing way of thinking.

9. Several approaches to CBT • Rational Emotive Behavior Therapy • Rational Behavior Therapy • Rational Living Therapy • Cognitive Therapy • Dialectic Behavior Therapy

10. Psychodynamic Therapy • Probes the past • Doesn’t tackle the immediate problem • The goal is insight • Takes a long time • Explores the unconscious

11. Behavioral Techniques • There are no mental processes (will, mind) • The focus is on changing the behavior • Works on the immediate problem • Focuses on the present

12. Behavioral Technique • Classical conditioning • Ivan Pavlov • Conditioning- learning that involves associations between environmental stimuli and the organism’s responses • Stimulus-response learning

13. Systematic Desensitization • Ex. Fear of flying • Read about safety flight • Look at pictures of airplanes • Visit at the airport • Take a short flight • Take a long flight

14. Client-Centered Therapy • Therapist uses techniques such as active listening within genuine, accepting, empathic, environment to facilitate client’s growth • Client adopts these views and becomes self-accepting • Promotes growth instead of curing illness

15. Existential therapy • Helps client explore meaning of existence • Helps client choose a destiny • Helps client accept self-responsibility

16. Cognitive Behavioral Therapy • Brief History of Cognitive Therapy • Albert Ellis, PhD— grandfather of CBT published “Reason and Emotion in Psychotherapy in 1962” • Aaron Beck, MD– wrote “Self Concept in Depression with D. Stein in 1960”

17. Cognitive Behavioral Therapy • Aform of psychotherapy that emphasizes the important role of thinking in how we feel and what we do.

18. Indications of CBT • It is used to treat depression, anxiety disorders, phobias, and other mental disorders • Treats alcoholism and drug addiction, especially as part of an overall program of recovery.

19. The basic goals of CBT • To challenge the thoughts about a particular situation by identifying the cognitive traps • To help the patient to identify less threatening alternatives • To test out these alternatives in the real world • To challenge the assumptions that lead to the Automatic Thoughts

20. 10 Characteristics of CBT 1. CBT is based on the Cognitive Model of Emotional Response CBT is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change.

21. 10 Characteristics of CBT 2. CBT is briefer and time-limited. 12- 16 sessions Is highly instructive nature and the fact that it makes use of homework assignments. Time-limited in that we help clients understand at the very beginning of the therapy process that there will be a point when the formal therapy will end. The ending of the formal therapy is a decision made by the therapist and client.

22. 10 Characteristics of CBT 3. A sound therapeutic relationship is necessary for effective therapy. Some forms of therapy assume that the main reason people get better in therapy is because of the positive relationship between the therapist and client. Have a good, trusting relationship, but that is not enough.  Clients change because they learn how to think differently and they act on that learning. Therefore, CBT therapists focus on teaching rational self-counselling skills.

23. 10. Characteristics of CBT 4. A collaborative effort between the therapist and the client.  Therapists seek to learn what their clients want out of life (their goals) and then help their clients achieve those goals. The therapist's role is to listen, teach, and encourage, while the client's roles is to express concerns, learn, and implement that learning.

24. 10 Characteristics of CBT 5. CBT can be based on stoic philosophy or not Beck's Cognitive Therapy is not based on stoicism. If we are upset about our problems, we have two problems -- the problem, and our upset about it. Most people want to have the fewest number of problems possible. So when we learn how to move calmly accept a personal problem, not only do we feel better, but we usually put ourselves in a better position to make use of our intelligence, knowledge, energy, and resources to resolve the problem.

25. 10 Characteristics of CBT 6. CBT uses the Socratic Method. Therapists want to gain a very good understanding of their clients' concerns. Asking questions. Therapist encourages their clients to ask questions of themselves, like, "How do I really know that those people are laughing at me?" "Could they be laughing about something else?"

26. 10. Characteristics of CBT 7. CBT is structured and directive. Therapists have a specific agenda for each session. Specific techniques / concepts are taught during each session. CBT focuses on the client's goals. We do not tell our clients what their goals "should" be, or what they "should" tolerate. Therapists teach their clients how to do.

27. 10 Characteristics of CBT 8. CBT is based on an educational model. CBT is based on the scientifically supported assumption that most emotional and behavioral reactions are learned. Therefore, the goal of therapy is to help clients unlearn their unwanted reactions and to learn a new way of reacting.

28. 10 Characteristics of CBT 9. CBT theory and techniques rely on the Inductive Method. A central aspect of Rational thinking is that it is based on fact. Often, we upset ourselves about things when, in fact, the situation isn't like we think it is. Therefore, the inductive method encourages us to look at our thoughts as being hypotheses or guesses that can be questioned and tested.

29. 10 Characteristics of CBT 10. Homework is a central feature of CBT. If when you attempted to learn your multiplication tables you spent only one hour per week studying them, you might still be wondering what 5 X 5 equals. You very likely spent a great deal of time at home studying your multiplication tables, maybe with flashcards.

30. 10 Characteristics of CBT 10. Homework is a central feature of CBT. The same is the case with psychotherapy. Goal achievement (if obtained) could take a very long time if the person were only to think about the techniques and topics taught was for one hour per week. Therapist encourage their clients to practice the techniques learned.

31. The Cognitive Triad • Negative view of the self (e.g., I’m unlovable, ineffective) • Negative view of the future (e.g., nothing will work out) • Negative view of the world (e.g., world is hostile)

32. Automatic thoughts • Are repetitive, automatic self-statements that we always say to ourselves in certain situations. They can be positive or negative. Psychological problems develop when our automatic thoughts are consistently negative. • They are automatic, because they are not the result of an analysis of the problem, they are a "knee-jerk" reaction to specific situations

33. Automatic thoughts • Ex.: In social situations, do you always presume the other person dislikes you, or thinks you are stupid? • When automatic thoughts control our emotional response to people, problems, and events, we ignore evidence that contradicts the automatic thought. If we cannot ignore it, we explain the evidence in terms of the automatic thought.

34. Automatic thoughts • Ex.: If we talk to someone and they smile, they are really laughing at us, rather than being pleased to see us. • The automatic thoughts create an expectancy of something negative. Since many things in life are vague, and can be interpreted in many ways, we learn how to negatively evaluate the world, so it agrees with our negative automatic thoughts. • Therapist help you to identify your negative automatic thoughts, and how to develop positive challenges to those negative ideas.

35. Situation:Therapist asks Maria about her goals for therapy ↓ • Automatic Thoughts • “Why is she asking me that? It’s so superficial. Setting goals won’t help. My problems are too deep. She should know that. Didn’t she read the evaluator’s report? She probably thinks I’m just like everyone else. I’m not going to let her get away with treating me like this.” ↓ • Reaction: • Emotional: Anger • Physiological: Tension in face, arms and shoulders • Behavioral: Shrugs, avoids eye contact and says nothing

36. The Cognitive Model • Core Beliefs Assumptions Coping Strategies Situation Automatic Thoughts/ Images Reaction (Emotional, Behavioral, Physiological)

37. Basic Cognitive-Behavioral Model Event Physiologic Cognitive Appraisal Behavior Emotion Automatic thoughts

38. People evaluate their health threats by constructing their own representations or perceptions of their illness, which in turn influences their pattern of coping and adjustment.

39. Cognitive distortions • Labeling • Mind reading • Exaggeration • Unrealistic expectations • Belief in entitlement • Belief in absolute fairness

40. Irrational ideas & Beliefs • Albert Ellis first presented the idea that irrational beliefs are at the core of most psychological problems. • We could also call these beliefs unrealistic, incorrect, or maladaptive. • Therapists have also suggested that these ideas are irrational because they are not logical, or are based on false assumptions.

41. Overgeneralizing or Catastrophizing • Catastrophizing is a negative overgeneralization. • For example: • You make a small mistake on a project, and assume that you will be fired when the boss finds out. • You try your hand at a new hobby, and it does not turn out well. You conclude, "I'm no good at anything."

42. Cognitive distortions • Another form of irrational ideas, overgeneralizing of simple mistakes, or developing false assumptions about what other people think about us, or expect from us. • We are distorting reality by the way we are evaluating a situation. • The concept of cognitive distortion highlights the importance of perceptions, assumptions and judgments in coping with the world

43. Cognitive distortions • Therapist help us determine what evaluations are distortions by providing objective feedback about our evaluations of the world, and by teaching us how to change the way we are perceiving problems.

44. Pessimistic Thinking • It is easier to become depressed if you tend to view the world with considerable pessimism. • Pessimism is a tendency to think that things won't work out as you wish, that you won't get what you want. Pessimism feeds the negative cognitive distortions and self-talk.

45. Fighting dysfunctional thoughts Hot ThoughtsCool Thoughts • He is always mean * Maybe he had to me a bad day • I did a lousy job * It’ll be better next time • I deserve better * But people are people • That jerk. * It’s his problem

46. Dysfunctional Thought

47. Modifying AT: Thought Change

48. Behavioral Methods • BehavioralActivation: * What could you do? • Activity Scheduling & Monitoring * Keep a schedule * Monitor for Mastery and Pleasure * Increase Mastery and Pleasure activities

49. Behavioral Methods • Graded Task Assignment * Break into steps • Behavioral Rehearsal * Role playing • Specific skills * Thought stopping * Breathing Retraining • Problem solving

50. Summary of Cognitive Psychotherapy Approach • The essence of cognitive therapy is the assumption that irrational thoughts and beliefs, overgeneralization of negative events, a pessimistic outlook on life, a tendency to focus on problems and failures, and negative self assessment, as well as other cognitive distortions, promote the development of psychological problems, like anxiety and depression.