Foundation in Cognitive Behaviour Therapy

1. Newcastle Cognitive and Behavioural Therapies Centre Dr. Sally Standart MRCPsych 2011 Northumberland, Tyne and WearNHS Foundation Trust Foundation in Cognitive Behaviour Therapy

2. To ask - What is CBT? This is an introduction to CBT; we won’t be covering all aspects of treatment using CBT Is CBT for me?” How well does it fit my needs, aspirations etc? To get to know the model by reflecting on our own reactions in thoughts, feelings, behaviour To get a taster of the basics of CBT theory What kind of conversation goes on in CBT? An introduction to Socratic dialogue. How to socialise the client to the session structure Aims of the Course

3. What would you like to get out of the next 2 afternoons? Are there any particular questions you would like us to try and address? Let’s see if we can collaboratively address them… Your objectives for the course…

4. It may be more accurate & helpful to think of “the C & B T’s” No one single set of interventions; A family of theories and practices A mixed marriage of two fundamentally different theory sets: Behaviourism – theory built on observable environment–organism interactions “Cognitivism” – theory built on the understanding that people perpetually interpret their environment & feel & act accordingly This workshop is going to major on this second side of the “family” – group members going on in CBT training should become well acquainted with Behavioural theory and practice What is CBT?

5. The basic theory

6. “We are what we think. All that we are arises with our thoughts. With our thoughts we make the world.” GAUTAMA BUDDHA, Dhammapada Agree? Disagree? What did he mean? What is CBT?

7. Spotting our own automatic thoughts: Exercise

8. What was going through your mind when you knew what the exercise was? Words… Pictures… Sounds… Memories… How did you feel physically? Did you do anything to prepare for the noise? Take some time and write down your responses-there is no right or wrong answer Exercise……..

9. What were you focussing on most? Did you have any urges to act? leave the room, move away Interrupt the exercise Laugh it off If yes, what were you trying to achieve (e.g. Were you concerned about how you might react in front of the group?) Did the way you wereyour thinking change? Speed up? Get less clear? Go round in circles? Shift to the future? Discussion…………..

10. In response to being told the balloon would pop – we reacted Our immediate thoughts were instant – not thought out or considered We experienced physical changes Emotions altered We had the urge to do something Our attention was focussed on the balloon, or ourselves, or the rest of the group Our memory accessed previous similar experiences Observations

11. When we feel a certain way we tend to act accordingly. E.g. - It’s been a long, tiring, stressful week. We might put off going out with friends and stay home on our own with a few drinks instead We tend to notice our emotions and what we do before our thoughts Emotions and Actions

12. Think about a time recently when you felt a bit down, stressed or tired. Can you recall: What you did as a result? What you were thinking at the time? Is one easier to recall than the other? When you pause to reflect now, does anything come to mind more clearly? Exercise 2

13. The way we think can affect how we feel emotionally, physically and what we do. When distressed our thinking tends to change. Thoughts can become extreme, worsening how we feel. We may then behave in a way that prolongs their distress Psychological ailments can be understood as persistent stuck patterns of thinking, feeling and acting that obstruct an individual’s need to change How does this relate to CBT?

14. …helps clients recognise their own thoughts, feelings and ways of coping with everyday situations that have become problematic …helps clients understand the links between thoughts, feelings and reactions …helps clients find and test out new, more helpful ways of thinking and doing for themselves So what does CBT do?

15. Because CBT seeks to treat a range of different problems, there are many disorder-specific models. Depression Panic, Social Anxiety, OCD, GAD, PTSD Eating Disorders Delusions Voices Personality disorders In this workshop we’re focussing on the generic model underpinning these, derived from the work of Aaron T. Beck “models” in CBT

16. How I remember What I notice What I remember How I think about it What I think about it What do we mean by “Cognitive”? situation Cognition How I react

17. “thinking” Behaviour emotions Physical reactions An illustration of the Cognitive Behavioural Model situation

18. “What if I make a fool of myself”? Heart rate changes, get a bit hot… nervous Hunch shoulders, hold breath An illustration of the Cognitive Behavioural Model Balloon Exercise

19. Raw, immediate, “the first thing that comes into my mind” “gut reactions”, “hot” thoughts Emotion-laden Behaviour-driving More limited in scope than assumptions and beliefs So how does a CBTist help a client get hold of this stuff? Automatic Thoughts: What do we mean?

20. Think of someone you’ve been working with recently Think of particular instance of raised emotion or unhelpful behaviour Get specific – think about minutes rather than days Can you put it together as per the previous slides? Exercise 3

21. Thus far we’ve only considered what happens in the here-and-now But what do these here-and-now thoughts rest on? In the examples from the previous, what is your understanding of the background to the specific episode? Building our understanding

22. It’s no good. I’ll fail Go back & re-write Miserable, anxious Purely here-and-now Working on essay

23. “It’s no good. I’ll fail” Go back & re-write A little background… Working on essay Remember the essays I messed up Only attend to mistakes Worry about failing Miserable, anxious

24. “It’s no good. I’ll fail” Limit re-writing Balanced thinking & helpful action… doing something new Working on essay Remember a range of ok & poor essays Worry about failing Check mistakes & good points A bit miserable, somewhat anxious

25. Appraises performance according to rule Activates assumption I should do everything well. Less than 100% = failure It’s no good. I’ll fail Go back & re-write Miserable, anxious But if we have deeper-set ways of thinking… Working on essay

26. Appraises performance according to belief Activates assumption Fits with memory of emotionally abusive upbringing I must do everything perfectly or else “People are vicious” I’ll fail & get punished Re-write? Give up? Miserable, anxious & if we have yet deeper-set ways of thinking… Working on essay

27. Automatic thoughts… tend to rest on assumptions & rules… which tend to rest on our beliefs We tend not to notice our thoughts as readily as we notice our emotions and actions Our rules, assumptions & beliefs tend to operate implicitly rather than being explicitly voiced ATs are easier to access than underpinning assumptions and beliefs CBT therefore typically deals with Behaviour and ATs before deeper-set cognition Layers of cognition

28. Back to the previous example Can you suggest (you may know or need to hypothesize) the rules, assumptions, beliefs underpinning the ATs? What do you know about the person’s life experience via which these may have been learned? Exercise 4

29. The basics of practice CBT & Socratic Dialogue

30. Role play to demonstrate links between thoughts, emotions, physical reactions and behaviour. Look out for all of the above Does the information help make sense of the client’s experience? What do you observe about the way the therapist communicates? Role play demonstration

31. In the moment unhelpful behaviours are switching on E.g., “what were you thinking as you began to run away”? In the moment that you notice emotion rising E.g. “ What went through your mind in the moments you began to feel scared”? In the moment of marked distressing physiological changes E.g. “What were you most concerned about when you felt your heart pounding”? How the therapist helped the client focus on ATs

32. What do you observe about the way the therapist communicated? The style of the dialogue

33. Semi open (generally not “yes or no” responses but directed to some extent) What was happening just then? What went through your mind? What did that mean to you? How did you feel? What emotional impact did that have? What physical symptoms did you have? What did you do when you felt really upset? What are Socratic Questions?

34. CBT has a very distinctive style: An active, enquiring therapist Socratic questions. Frequent Summaries. Giving & getting Feedback. Building summaries into formulations as dialogue progresses Questioning and Summaries

35. Giving feedback… It sounds to me that….. Let me see if I have got this right…. Have I understood this correctly?... Getting Feedback… Have I missed anything important? How would you put that in your own words? Could you feed back your own understanding of what we’ve been discussing? What things stand out as most important in our discussion so far? I’m not putting you on the spot, but I want to check that I’ve explained things clearly, so could you summarise what’s been said so far? Putting it together Itt looks like things link up this way… Feedback & Summaries

36. Ask questions that the person is capable of answering Avoid “Why?” questions Ask sequences of simple questions rather than single complex questions Summarise regularly (give and invite feedback) The longer the chain, the easier to get lost Don’t assume that client assent to your summary indicates understanding Client should not feel interrogated by the therapist Take responsibility for the question your client can’t answer Remember your basic counselling & communication skills Focus on the problems you agree to tackle Socratic questions

37. Collaborative Specific Promotes client-owned learning Testing of hypotheses rather than presuming you know Accesses theory without “fitting the patient into boxes” Engages client, promotes shared understanding What’s useful about this style?

38. Helping the client change

39. CBT doesn’t simply seek understanding, but to change To open up stuck patterns of thought, feeling & behaviour To bring about new learning But people’s stuck patterns serve purposes (e.g. maintain a sesne of sefety) so change can be anxiety provoking Goal orientation is therefore a key foundation to the process Get your goals wrong & therapy has no sound foundation Learning and Change

40. Goals can be short-term (for this session), mid-term (for this course of sessions, this month…) Long-term (life) For therapy have a tangible, measured impact on the client’s life goals need to be tangible, measurable & achievable Well-set goals can Guide learning inspire hope Build confidence Establish teamwork Goals and Change

41. Specific and achievable Designed to have a positive, consistent impact on a client’s life Prepares the client for change through consideration Allows for discussion of fears (often predictive and testable) Informs a collaborative approach Goal Setting

42. Observe therapist and client elicit, formulate and set goals Discussion Role Play

43. Consider one or two specific goals that you would like to set yourselves over the next week Avoid life-changers at this stage – we’re simply trying to get at the way goals work Use previous slides as guide Phrase positively –i.e. what you want to achieve Can you come up with time settings? In Pairs

44. Consider some recent or pivotal learning in your own experience How do we learn? Exercise…

45. Concrete Experience: doing/”hands-on” experience Reflection: standing back, observing, reviewing the experience Conceptualisation: making coherent sense of, coming to conclusions from the experience Planning: Trying a new/different way of doing or thinking Back to the next phase… Concreteexperience Planning Reflection Conceptualisation Kolb’s Experiential Learning Theory

46. How current patterns are maintained, e.g. Via Safety-seeking behaviours that prevent us from checking out the real level of risk Via mental behaviours (e.g. rumination) which take up vast amounts of time & prevent us from getting new info into our system Via depressive withdrawal & anxious avoidance Via reassurance-seeking rather than information-getting Via drugs alcohol etc What kinds of learning happen in CBT?

47. How current thinking, feeling & acting is affected by past experiences. Formulating to make sense Building client understanding & therapist empathy Helping to show how the present & the future can be different What kinds of learning happen in CBT?

48. How to recognise what I am thinking How to recognise how I’m thinking Overgeneralising Catastrophising Personalising Ruminating Worrying What kinds of learning happen in CBT?

49. How to generate and use new thoughts and beliefs Thought diaries Data logs Re-evaluation methods How to work out new ways of thinking If I can spot rumination & worry, what alternatives can I employ? There I am personalising again, what’s a less personalised way of looking at this? How to generate and practice new ways of behaving Reaction X doesn’t help; let’s try Y… What kinds of learning happen in CBT?

50. Back to the examples we’ve used in our formulation exercises… Based on the way we have formulated the person’s problems what do they need to learn Re thoughts… Re behaviour… Try to frame their learning need as a goal Now consider the learning cycles they will need to go through… Applying the theory in our work…