What is CBT CBT Cognitive Behavioral Therapy Psychology Staff MaineGeneral Medical Center June 5 6, 2008

1. June, 2008 What Is CBT? 1 What is CBT?CBT = Cognitive Behavioral TherapyPsychology StaffMaineGeneral Medical CenterJune 5 & 6, 2008

2. June, 2008 What Is CBT? 2 Financial Disclosure Nothing.

3. June, 2008 What Is CBT? 3 Want Copies? If you would like references, pdf versions of articles mentioned, or the PowerPoint itself: jeff@hpmaine.com

4. June, 2008 What Is CBT? 4 Presenters Jeff Matranga, Ph.D. Stacy Whitcomb-Smith, Ph.D. Laura Holcomb, Ph.D. Jonathan Borkum, Ph.D. Glen Davis, Ph.D. William Bolduc, LCSW

5. June, 2008 What Is CBT? 5 CBT BasicsJeff Matranga, Ph.D., ABPPM.S. in Clinical Psychopharmacology What is CBT? How is it different? History, timeline. Myths, misunderstandings.

6. June, 2008 What Is CBT? 6 What Distinguishes BT/CBT? Direct, parsimonious focus on behaviors and cognitions. Defining problems in identifiable terms – e.g., behavioral excesses or deficits. Treatment strategies derived from basic psychological science. Rigorous examination of: Treatment efficacy Mechanisms of action.

7. June, 2008 What Is CBT? 7 3 Generations of CBT CBT: Behavioral: BT. 1950s CBT: Cognitive addition: C in CBT. 1970s 3rd wave of CBT: mindfulness, acceptance, e.g., ACT. Gaining popularity now, but goes back 30 years, e.g., DBT for borderline.

8. June, 2008 What Is CBT? 8 History: 1950s Simultaneous development in 3 English-speaking countries: South Africa. Wolpe, 1958. England. Eysenck, 1959. U.S. Skinnerian approaches.

9. June, 2008 What Is CBT? 9 CBT is a Family of Therapies Acceptance and Commitment Therapy (ACT) and other mindfulness approaches. Applied Behavioral Analysis Behavior Modification, contingency management. Behavioral activation (BA) Cognitive Therapy (CT) Computerized Cognitive Behavioral Therapy (CCBT) Dialectical Behavior Therapy (DBT) Exposure and response prevention (ERP) Prolonged Exposure Therapy Rational Emotive Behavior Therapy (REBT) Relapse Prevention Self Instructional Training Systematic desensitization CBT-I: CBT for Insomnia

10. June, 2008 What Is CBT? 10 History of Desensitization Tx 1958: Wolpe’s first book describing systematic desensitization. 1963: 5 years later: effects not measurement artifacts. 1965: 8 years later: effects were not due solely to non-specific effects of attention, greater than insight-oriented psychotherapy, and long-lasting. 1968: 10 years later, it was known how the complete treatment compared to its constituent structural elements. 1998: 40 years later, most essential feature of fear reduction is re-exposure, either in vivo or imaginal. Lohr et al., (1998, p. 149) Lohr, J.M., Tolin, D.F., & Lilienfeld, S.O. (1998). Efficacy of eye movement desensitization and reprocessing: Implications for behavior therapy. Behavior Therapy, 29, 123-156.Lohr, J.M., Tolin, D.F., & Lilienfeld, S.O. (1998). Efficacy of eye movement desensitization and reprocessing: Implications for behavior therapy. Behavior Therapy, 29, 123-156.

11. June, 2008 What Is CBT? 11 Myths, misunderstandings. Symptom substitution, hydraulic model. Myth debunked by mid-1970s. Surface, not depth. Changing behavior ? changes in brain functioning (functional imaging). Changing behavior changes cognitions. Changing behavior and cognitions changes emotions.

12. June, 2008 What Is CBT? 12 Myths of Symptom Substitution “…when I spoke to KU Med interns and residents about the myth of symptom substitution. I offered a $500 reward for every case of symptom substitution brought to me because I wanted to research each real case of symptom substitution I could find. I could find no detailed cases described in recent published books or journal articles…” Ogden R Lindsley, M.D. Psychiatrist. 1922-2004. Letter from bed as he was dying of cancer at 82. Ogden R Lindsley, M.D. Psychiatrist. 1922-2004 Letter from bed as he was dying of cancer at 82. Hi to my friends, colleagues and associates: As all 82 year old scientists and other rational persons know, something – we don't know what – is going to get us fairly soon. We live and work with a cloud over our shoulders; a feeling I associate with flying through flak fields in a WWII bomber. It feels like the future is governed almost entirely by chance. Most of us do not know the terminal illnesses of our relatives, nor do we know the extent of our exposure to toxins. Bette Davis said, "Old age is not for sissies," and I add that old age is also a crap shoot – something, don't know when, where, what, or how – is going to kill us. I became ill in August with what we thought was an irritated gall bladder. It was removed, in what was to be a simple, 30 minute, laparoscopic operation at the beginning of September. But, during the surgery, which lasted three and a half hours, my surgeon confirmed that I have bile duct (cholangiocarcinoma) cancer. It is not as rapid growing as pancreatic cancer cells, but much more metastatic and pervasive, rare (1/1000), and common in Asian populations. It has spread to my liver and even interferes with the clotting of my blood. I am a patient in the KU Medical Center in Kansas City, where I came from Boston in 1965 to be professor of educational research in the Childrens Rehabilitation Unit, Department of Pediatrics. KUMC is an excellent institution and I have come full circle here. I am well cared for by my oncologist who was a trainee in 1967 when I spoke to KU Med interns and residents about the myth of symptom substitution. I offered a $500 reward for every case of symptom substitution brought to me because I wanted to research each real case of symptom substitution I could find. I could find no detailed cases described in recent published books or journal articles. It appeared that "symptom substitution" functioned as a warning to stop people from directly and rapidly removing nail biting, nose picking, leg jerking, smoking, excess coffee drinking, and even belching and farting. While standing by my bedside for the first time and squeezing my knee; recognizing me, he exclaimed, "I remember you; you're very controversial around here." He said that after my scheduled lecture to all the KUMed interns and residents 37 years ago, the head of psychiatry held an emergency special meeting with them. He told them to ignore what I had said. My oncologist said most of his classmates still agreed with what I had told them after that meeting. Organic medicine still rejected Freudian myths. Psychiatry at KUMed, Kansas Neurological Institute, Topeka VA, Kansas City VA, and most of the other hospitals in Kansas and Western Missouri was controlled by the deeply Freudian Menninger Clinic. It maintained its Freudian treatment to the bitter end, recently dying in bankruptcy. Sic transit Freud. http://www.behavior.org/member_news/index.cfm?page=http%3A//www.behavior.org/member_news/rr_og.cfmOgden R Lindsley, M.D. Psychiatrist. 1922-2004 Letter from bed as he was dying of cancer at 82. Hi to my friends, colleagues and associates: As all 82 year old scientists and other rational persons know, something – we don't know what – is going to get us fairly soon. We live and work with a cloud over our shoulders; a feeling I associate with flying through flak fields in a WWII bomber. It feels like the future is governed almost entirely by chance. Most of us do not know the terminal illnesses of our relatives, nor do we know the extent of our exposure to toxins. Bette Davis said, "Old age is not for sissies," and I add that old age is also a crap shoot – something, don't know when, where, what, or how – is going to kill us. I became ill in August with what we thought was an irritated gall bladder. It was removed, in what was to be a simple, 30 minute, laparoscopic operation at the beginning of September. But, during the surgery, which lasted three and a half hours, my surgeon confirmed that I have bile duct (cholangiocarcinoma) cancer. It is not as rapid growing as pancreatic cancer cells, but much more metastatic and pervasive, rare (1/1000), and common in Asian populations. It has spread to my liver and even interferes with the clotting of my blood. I am a patient in the KU Medical Center in Kansas City, where I came from Boston in 1965 to be professor of educational research in the Childrens Rehabilitation Unit, Department of Pediatrics. KUMC is an excellent institution and I have come full circle here. I am well cared for by my oncologist who was a trainee in 1967 when I spoke to KU Med interns and residents about the myth of symptom substitution. I offered a $500 reward for every case of symptom substitution brought to me because I wanted to research each real case of symptom substitution I could find. I could find no detailed cases described in recent published books or journal articles. It appeared that "symptom substitution" functioned as a warning to stop people from directly and rapidly removing nail biting, nose picking, leg jerking, smoking, excess coffee drinking, and even belching and farting. While standing by my bedside for the first time and squeezing my knee; recognizing me, he exclaimed, "I remember you; you're very controversial around here." He said that after my scheduled lecture to all the KUMed interns and residents 37 years ago, the head of psychiatry held an emergency special meeting with them. He told them to ignore what I had said. My oncologist said most of his classmates still agreed with what I had told them after that meeting. Organic medicine still rejected Freudian myths. Psychiatry at KUMed, Kansas Neurological Institute, Topeka VA, Kansas City VA, and most of the other hospitals in Kansas and Western Missouri was controlled by the deeply Freudian Menninger Clinic. It maintained its Freudian treatment to the bitter end, recently dying in bankruptcy. Sic transit Freud. http://www.behavior.org/member_news/index.cfm?page=http%3A//www.behavior.org/member_news/rr_og.cfm

13. June, 2008 What Is CBT? 13 Stacy Whitcomb-Smith, Ph.D. What is empirically-based practice?

14. June, 2008 What Is CBT? 14 What is the evidence that psychotherapy works? Initial review studies suggested that psychotherapy was no better than passage of time (1952) or that all approaches were about equal in efficacy (1975). Improved research including identifying problem and treatment approach How do we know Psychotherapy works? It is an empirical question Well-designed research provides evidence to support or discredit hypotheses about efficacy Design studies so that alternative explanations for improved symptoms are able to be ruled out

15. June, 2008 What Is CBT? 15 APA Division 12 Task Force on Empirically Validated Therapies Empirically Supported Treatments (Chambless & Ollendick, 1998, 2001) Well established treatments At least 2 good between groups studies showing efficacy as superior to placebo or equivalence to established treatment OR large series of single case experiments comparing to other treatment Treatment manuals or equivalent description of tx Specify characteristics of sample Demonstration of effects by at least 2 different investigators Probably efficacious treatments Experimental treatments

16. June, 2008 What Is CBT? 16 Other workgroups EST criteria Treatments That Work (Nathan & Gorman, 2007, 3rd Ed) What Works for Whom (Roth & Fonagy, 2005, 2nd Ed.) Special section J.Pediatric Psychology (Spirito, 1999) Special section J of Clinical Child Psychology (1998) Treatments for older adults (Gatz et al, 1998) Treatments for Chronic Pain (Wilson & Gil, 1996)

17. June, 2008 What Is CBT? 17 Efficacy vs. Effectiveness Efficacy: When all other variables are controlled (laboratory setting), does the treatment appear to work for a given problem? Effectiveness: In real-world settings (i.e., community clinic with patients co-morbid physical and mental health problems) does the treatment appear to work for a given problem(s)?

18. June, 2008 What Is CBT? 18 Hallmarks of good RCT Specific, measurable/operationalized hypotheses Randomized assignment of participants and therapists Identified population (Inclusion/exclusion criteria) Enough patients to be able to detect differences (power) Specified, (manualized) treatment of pre-determined length Use of control group Validated outcome measures Use of raters blind to condition for assessment of treatment and outcome (and reliability/agreement of raters measured) Trained and supervised therapists Measures of adherence/integrity of treatment Replication by other than initial research team

19. June, 2008 What Is CBT? 19 Single Case Experimental Design

20. June, 2008 What Is CBT? 20 Acceptance and Commitment Therapy (ACT) “Third-wave of Behavior Therapy” Empirically based Mindfulness Focus on the present moment as it is (not as you want or as your mind says it is) Observer self that can notice without reacting mindlessly Acceptance Willingness to experience Valued driven behaviors Focus on “Living the kind of life you want” rather than on managing symptoms

21. June, 2008 What Is CBT? 21 Depression (unipolar)

22. June, 2008 What Is CBT? 22 CBT for Depression Behavioral activation. Get people moving, engaged, solving problems, avoiding avoidance. Activity menu. Activity log with mood ratings. Cognitive. Challenging and changing negative thought patterns.

23. June, 2008 What Is CBT? 23

24. June, 2008 What Is CBT? 24 Outcome: CBT for Depression Same efficacy as meds for response and remission rates. Combo stronger than either one alone. FAR LESS RELAPSE if CBT is either the tx plan or part of tx plan. See handout.

25. June, 2008 What Is CBT? 25 Brief Mentions Bipolar disorder – CBT & other psychosocial TXs reduce hospitalizations. Schizophrenia: same as #1. Form of CBT is standard of care in the U.K. Insomnia: CBT superior to meds for chronic insomnia. Chronic disease: CBT helpful. Adult ADHD

26. CBT for Anxiety Disorders What Happens in Treatment

27. Educate the Patient Consider Medical Alternatives (cardiac, thyroid, etc.) Anxiety as Normal vs. Disorder- A Matter of Degree No, You’re Not Going Crazy!

28. Anxiety Disorder Development Precipitating trauma or stressful life event Learning from modeling Maintenance Stacking the deck Cycle of Anxious Avoidance The Amygdala- threat detector in overdrive Distraction or escape- “Make it stop- NOW” Do or think about something else Leave the scene Relaxation techniques PRN benzodiazepines Reassurance seeking Relief as reinforcement of avoidance in future

29. Treatment Basics- Desensitization Teaching the Amygdala- experiential learning Exposure to anxiety-provoking stimuli In Session Exposure May involve exposure to internal sensations, graded exposure to a feared stimulus, or development of a hierarchy of stimuli Emphasize patient control Focus and allow the experience of anxiety Peaks and valleys of anxiety levels Progression of patient responses “I don’t know if I can do this.” “I can’t do this!!!” (This step is optional!) “This is getting boring!” “WOW, I CAN do this!” In Vivo Exposure Practice not buying into fear Exposure to feared/avoided places or activities in “real life”

30. Treatment Basics- Exposure to What?

31. Treatment Basics- Relaxation Diaphragmatic Breathing Autogenic relaxation (warm and heavy) Visualization (the happy place) Progressive Muscle Relaxation Biofeedback Thermal Skin Conductance Level Surface EMG

32. Treatment Basics- Cognitive Restructuring Identify anxious thoughts/cognitive traps All or nothing thinking Catastrophization Should thinking Fortune telling Mind reading And others Challenge anxious thoughts How true is this thought? (evidence?) How helpful is this thought (alternatives?) SO WHAT?!!! (Worst case scenario? Chances? Plan?)

33. Treatment Basics- Psychotropic Medications SSRI (Selective Serotonin Reuptake Inhibitor- sertraline, citalopram, fluoxetine, paroxetine) Preferably used as adjunct to CBT for anxiety when patients unable to tolerate CBT alone Fewer side effects than tricyclic antidepressants SNRI (Serotonin Norepinephrine Reuptake Inhibitor- venlafaxine, duloxetine) May also be helpful with neuropathic pain Higher doses are needed to insure dual activation of serotonin and norepinephrine Benzodiazepines (alprazolam, lorazepam, clonazepam) If used, best for very short-term treatment of anxiety only, at the lowest effective dosage, then tapered off Fixed schedule of longer-acting (such as clonazepam) generally preferrable as PRN dosing reinforces cycle of anxious avoidance Tricyclic Antidepressants (amitriptyline, nortriptyline) Often less preferred because of side effects (sedation, dry mouth, weight gain, etc.) May be helpful in low doses as sleep aid (and can help with pain) Avoid in suicidal patients because of toxicity and potential overdose Beta Blockers (propranolol)

34. Cognitive-Behavioral Tools for Pain Self-Management

35. The analgesic effects of absorption work through the same mechanisms as opiates and can be measured in mg morphine Tools: Asking about life, looking for the spark, problem-solving and encouraging (differential reinforcement of non-pain behaviors).

36. Receiving disability does not remove the task of living a meaningful life. Tool: Hypothetical planning, in sufficient detail, can become reality.

37. Catastrophic thinking about pain increases the pace of windup, directly activates emotional pain centers and predicts future levels of pain, disability, and depression Tools: Teaching mastery; tracking antecedents, testing self-management techniques, and quantifying effectiveness

38. Self-efficacy is a strong predictor of future control over pain Tools: Noticing and enjoying small successes as an indication of a shift in momentum away from the pain

39. Pain-contingent rest rewards pain sensitivity and causes an erosion in pain thresholds Tools: Drawing from ergonomics, body mechanics, and strategic rest breaks a constructive somatic awareness

40. Depression, like illness, increases sensitivity to internal pain Tool: All of the preceding; restoration of the experience of success

41. June, 2008 What Is CBT? 41 Glen Davis, Ph.D. Behavior Therapy & CBT applied to children

43. Child/Adolescent Cognitive-Behavioral Treatment of Conduct Problems Modeling/training child problem-solving, social skills and conflict resolution skills Review conflict interactions (videotaped), review feelings/appraisal, manage problematic arousal, generate ideas for effective responses, and role-play alternative scenarios

44. Behavior Classroom Management for Children with AD/HD contingency management training, i.e., Objectively defining and consistently monitoring target behaviors (+ and -) Increased reinforcement of positive behavior, Point systems, and Time out

45. Treatment of Early Pervasive Developmental Disorder (Autism): Applied Behavior Analysis Applied behavior analysis refers to teaching principles in which: observable behaviors are objectively defined, goals are established, specific target behaviors directed toward these goals are taught The child receives ample reinforcement for successive approximations Data is collected to assess progress and to inform program decision-making

46. Practice Guidelines – Autism and Pervasive Developmental Disorders Treatment of unwanted or challenging behaviors: positive behavioral supports Build spontaneous functional communication skills Engage children in meaningful age-appropriate learning activities Peer interactions are a crucial part of intervention programs Assure generalization of new skills and behaviors Parents and family members need to be included in the intervention

47. Cognitive-Behavioral Treatment: Children Exposed to Traumatic Events Parent training cognitive reframing to address parental attributions of blame and fears that the abuse would cause irreversible damage, teach active listening, reflection, and empathy teach behavior management skills, especially contingency management to address disruptive behavior Teach parents strategies for coping with their own emotional distress

48. Cognitive-Behavioral Treatment: Children Exposed to Traumatic Events Child intervention: Education Cognitive training/restructuring Relaxation training, Thought stopping, Positive imagery, Exposure, response prevention, and desensitization.

50. Who to Treat & Who to Train Who benefits: On the one hand, those functional enough to do homework and show up for appointments. On the other hand…established efficacy for less functional individuals. Training: What is adequate training in CBT? Day-long training for interested professionals if hospital coordinates the CMEs? Grant option to Provide services to additional people? Train and supervise others?