Presentation on theme: "Theory and Practice of Cognitive Behavioral Therapy"— Presentation transcript:
1 Theory and Practice of Cognitive Behavioral Therapy University of Chicago, Department of Psychiatry, CBTTheory and Practice of Cognitive Behavioral TherapyShona N. Vas, Ph.D.Department of Psychiatry & Behavioral NeuroscienceCognitive-Behavior Therapy ProgramMS-3 Clerkship
2 University of Chicago, Department of Psychiatry, CBT OutlineWhat is Cognitive Behavior Therapy (CBT)?What are the basic principles of treatment?What is the course of treatment?What are some examples of interventions?Who is appropriate for CBT?
3 University of Chicago, Department of Psychiatry, CBT What is CBT?Set of ‘talk’ psychotherapies that treat psychiatric conditions.Short-term focused treatment.Strong empirical support with randomized clinical trials.As effective as psychiatric medications.Recommended as critical component of treatment, particularly when medications are contraindicated or ineffective.
4 University of Chicago, Department of Psychiatry, CBT Why So Popular?Clear treatment approach for patientsAssumptions make sense to patientsBased on patient’s experienceEncourages practice and compliancePatients have a sense of controlCBT works!
5 Definition of Cognitive Therapy CT is a focused form of psychotherapy based on a model stipulating that psychiatric disorders involve dysfunctional thinking.Dysfunctional/distorted thinking arises from both biological and psychological influencesIndividuals’ emotional, behavioral, and physiological reactions are influenced by the way they structure their environment.J. Beck, 1995
6 Definition of CT (continued…) Modifying dysfunctional thinking and behavior leads to improvement in symptoms.Modifying dysfunctional beliefs which underlie dysfunctional thinking leads to more durable improvement
7 Definition of CT (continued…) Cognitive therapy is defined by a cognitive formulation of the disorder and a cognitive conceptualization of the particular patient.Cognitive therapy is not defined by the use of exclusively cognitive techniques. Techniques from many modalities are used.CT also often referred to as Cognitive-Behavior Therapy (CBT).
8 University of Chicago, Department of Psychiatry, CBT Rationale for CBTNegative emotions are elicited by cognitive processes developed through influences of learning and temperament.Adverse life events elicit automatic processing, which is viewed as the causal factor.Cognitive triad: Negative automatic thoughts center around our understanding of:OurselvesOthers (the world)FutureFocus on examination of cognitive beliefs and developing rational responses to negative automatic thoughts.Beck et al., 1979
9 Cognitive Specificity Hypothesis University of Chicago, Department of Psychiatry, CBTCognitive Specificity HypothesisDistorted appraisals follow themes relevant to the specific psychiatric condition.Psychological disorders are characterized by a different psychological profile.Depression: Negative view of self, others, and future. Core beliefs associated with helplessness, failure, incompetence, and unlovability.Anxiety: Overestimation of physical and psychological threats. Core beliefs linked with risk, dangerousness, and uncontrollability.
10 Cognitive Specificity University of Chicago, Department of Psychiatry, CBTCognitive SpecificityNegative Triad Associated with DepressionSelf “I am incompetent/unlovable”Others “People do not care about me”Future “The future is bleak”Negative Triad Associated with AnxietySelf “I am unable to protect myself”Others “People will humiliate me”Future “It’s a matter of time before I am embarrassed”
11 Targeted Cognitions for Different Disorders OCD: appraisals of obsessive cognitionsAnorexia: control, worth, perfectionPanic: catastrophic misinterpretation of physical sensationsParanoia: trust, vulnerability
12 University of Chicago, Department of Psychiatry, CBT Working Model of CBTEventAppraisalMaladaptiveBehaviorAffective andBiological ArousalBehavioral InclinationThase et al., 1998
13 University of Chicago, Department of Psychiatry, CBT Cognitive ModelTriggering EventBill goes to collectionAppraisal“I can never do anything right…”BehaviorAvoidance; withdrawalBodily SensationsLow energy, disruption ofsleep, increased fatigueBehavioral Inclination“I don’t want to deal with it”“It’s too stressful to think about it”Thase et al., 1998
14 What are Automatic Thoughts? What was going through your mind? University of Chicago, Department of Psychiatry, CBTWhat are Automatic Thoughts? What was going through your mind?Happen spontaneously in response to situationOccur in shorthand: words or imagesDo not arise from reasoningNo logical sequenceHard to turn offMay be hard to articulateNegativeEmotionsStressfulSituationAutomatic Thoughts
15 Cognitive Distortions Patients tend to make consistent errors in their thinkingOften, there is a systematic negative bias in the cognitive processing of patients suffering from psychiatric disordersHelp patient identify the cognitive errors s/he is most likely to make
16 Types of Cognitive Distortions University of Chicago, Department of Psychiatry, CBTTypes of Cognitive DistortionsEmotional reasoning Feelings are factsAnticipating negative outcomes The worst will happenAll-or-nothing thinking All good or all badMind-reading Knowing what others are thinkingPersonalization Excess responsibilityMental filter Ignoring the positive
17 University of Chicago, Department of Psychiatry, CBT ExamplesCognitive DistortionsEmotional Reasoning: “I feel incompetent, so I know I’ll fail”Catastrophizing: “It is going to be terrible”Personalization: “It’s always my fault”Black or white thinking: “If it isn’t perfect, it’s no good at all.”
18 University of Chicago, Department of Psychiatry, CBT Core BeliefsCore beliefs underlie and produce automatic thoughts.These assumptions influence information processing and organize understanding about ourselves, others, and the future.These core beliefs remain dormant until activated by stress or negative life events.Categories of core beliefs (helpless, worthless, unlovable)Core BeliefsAutomatic Thoughts
19 Examples of Core Beliefs Helpless core beliefsI am inadequate, ineffective, incompetent, can’t copeI am powerless, out of control, trappedI am vulnerable, weak, needy, a victim, likely to be hurtI am inferior, a failure, a loser, defective, not good enough, don’t measure upUnlovable core beliefsI am unlikable, unwanted, will be rejected or abandoned, always be aloneI am undesirable, ugly, unattractive, boring, have nothing to offerI am different, flawed, defective, not good enough to be loved by othersWorthless core beliefsI am worthless, unacceptable, bad, crazy, broken, nothing, a wasteI am hurtful, dangerous, toxic, evilI don’t deserve to live
20 Cognitive Conceptualization University of Chicago, Department of Psychiatry, CBTCognitive ConceptualizationPhysiologyFeelingsBehaviorCurrentSituationAutomatic ThoughtsAbout self, worldAnd othersChildhoodAnd EarlyLife EventsCompensatoryStrategiesUnderlying Assumptions and Core Beliefs
21 University of Chicago, Department of Psychiatry, CBT Example 1PhysiologyHeart racingLump in throatFeelingsSadnessWorryAngerBehaviorSeek reassuranceWithdrawCrySituationPartner says:“I need time tobe with my friends”Automatic ThoughtsAutomatic response:“Oh no, he’s losing interestand is going to break up with me….”Underlying Assumptions & Core Beliefs“I’m flawed in numerous ways, which means I’m not worthy of consistent attention and care. People only care when they want something.”CompensatoryStrategiesBe independent andyou’ll be safe.Watch out – peopleare careless with you.ChildhoodExperiencesParental neglectand criticism
22 University of Chicago, Department of Psychiatry, CBT Example 2PhysiologyPit in stomachDry mouthFeelingsWorry, shame,DisappointmentHumiliation.BehaviorUse alcohol,Procrastinatewith homeworkSituationDisappointingexam resultAutomatic Thoughts“I am not going to getthrough this program -I’m not as smartas everyone else.People willdiscover this and Iwill be humiliated.”ChildhoodAdversitiesParental standardsreinforce academicachievementUnderlying Assumptions“If I don’t excel in school, I’m a total failure”CompensatoryStrategiesWork extra hardto offsetincompetence.
23 Responding to Negative Thoughts Define SituationClarify meaning of cognitive appraisalWhat was going through your mind just then?What did the situation mean for you?Evaluate interpretationEvidence: For and against this belief?Alternatives: Any other explanation(s)?Implications: So what….?
24 Evaluating Negative Thoughts What is the effect of telling myself this thought?What could be the effect of changing my thinking?What would I tell ___ (a friend/family member) if s/he viewed this situation in this way?What can I do now?
25 Sample Thought Log Situation Thoughts Emotions Rational Response OutcomeGoing on vacation—Ask a colleague to do some work for meShe’ll say no…I’m not doing a good jobThe boss thinks I take too much time offAnxiety (70%)Guilt (40%)Sadness (20%)CognitiveDistortions:All/nothingMindreadingFortune-TellingOver-generalizationI haven’t taken a day off in 6 months. We work as a team, so it’s also her job to track the samples.Anxiety (10%)Guilt (0%)Relief (40%)
26 Common Components of CBT University of Chicago, Department of Psychiatry, CBTCommon Components of CBTEstablish good therapeutic relationshipEducate patients - model, disorder, therapyAssess illness objectively, set goalsUse evidence to guide treatment decisionsStructure treatment sessions with agendaLimit treatment lengthIssue and review homework to generalize learning
27 University of Chicago, Department of Psychiatry, CBT Course of TreatmentAssessmentProvide rationaleTraining in self-monitoringBehavioral strategiesMonitor relationship between situation/action and mood.Applying new coping strategies to larger issues.Identifying beliefs and biasesEvaluating and changing beliefsCore beliefs and assumptionsRelapse prevention and termination
28 University of Chicago, Department of Psychiatry, CBT Basic PrinciplesChange mood states by using cognitive and behavioral strategies:Identifying/modifying automatic thoughts & core beliefs,Regulating routine, andMinimizing avoidance.Emphasis on ‘here and now’Preference for concrete examplesStart with specific situation (complete thought log)Reliance on Socratic questioningAsk open-ended questionsEmpirical approach to test beliefsChallenge thoughts not based on evidenceCognitive restructuringPromote rapid symptom change
29 Behavioral Interventions University of Chicago, Department of Psychiatry, CBTBehavioral InterventionsBreathing retrainingRelaxationBehavioral activationInterpersonal effectiveness trainingProblem-solving skillsExposure and response preventionSocial skills trainingGraded task assignment
30 Cognitive Interventions University of Chicago, Department of Psychiatry, CBTCognitive InterventionsMonitor automatic thoughtsTeach imagery techniquesPromote cognitive restructuringExamine alternative evidenceModify core beliefsGenerate rational alternatives
31 Efficacy Cognitive and behavioral approaches are effective Supported by over 325 controlled outcome studiesState-of-the-art therapy, manualized
32 University of Chicago, Department of Psychiatry, CBT Applications of CBTMood DisordersUnipolar Depression (1979)Bipolar Disorder (1996)Dysthymia and Chronic MDD (2000)Anxiety DisordersGAD (1985)Social Phobia (1985)Panic Disorder (1986)OCD (1988)PTSD (1991)Emotional Disorders (2006)
34 Controlled Outcome Studies on CBT University of Chicago, Department of Psychiatry, CBTControlled Outcome Studies on CBTSocial Phobia (~14)Panic Disorder (~10)Borderline P.D. (2)Schizophrenia (~45)C/A Depression (8)Chronic Depression (1)Unipolar Depression (~30)Eating DisordersAnorexia (~5)Bulimia (~15)Generalized Anxiety Disorder (~12)
35 University of Chicago, Department of Psychiatry, CBT ConclusionsSystem of psychotherapiesUnified theory of psychopathologyShort-term treatmentObjective assessment and monitoringStrong empirical supportAs effective as pharmacotherapy
36 Psychiatry Department Office: A-312 Questions? Comments?Dr. Shona Vas(773)Psychiatry Department Office: A-312