1. COGNITIVE THERAPY Slides created by Barbara A. Cubic, Ph.D. Professor
Eastern Virginia Medical School
To accompany
Current Psychotherapies 10

2. Learning Objectives This presentation will focus on:
Principles of learning and cognitive theory relevant to psychotherapy
History of cognitive therapy
Overview of cognitive therapy
Commonly used CT techniques
Creative applications of CT

3. Basic Concepts of CT

4. Basic Concepts
Cognitive therapy focuses primarily on how information is processed.
Behavioral techniques and cognitive restructuring techniques are utilized to elicit change.

5. Cognitive Model Processing of information is vital for survival.
Survival systems are:
Cognitive
Behavioral
Affective
Motivational
Each system is comprised of structures.
Schemas

6. Modes
Information is processed through networks of cognitive, affective, motivational, and behavioral schemas.
Primal modes are evolutionary-based, universal, tied to survival (e.g. anxiety) and operational almost continuously in some cases (e.g. personality disorders) while other modes are minor and under conscious control.
Primal modes include primal thinking, which is rigid, absolute, automatic, and biased.
Conscious intentions can override primal thinking.

7. Cognitive Model
Behaviors
Situation Automatic
Thoughts Emotions
Physiological
Response
Automatic thoughts influence not only one’s emotional response, but also one’s behavioral and physiological responses.

8. Cognitive Model
In other words, the relationship is bi-directional (all systems act together as a mode).
Thoughts influence biological, affective, behavioral (and motivational) processes.
Simultaneously biology, emotions, behavior (and motivation) influence thoughts.
Therefore biological treatments can change thoughts and CBT can change biological processes.

9. Cognitive Model
We all have cognitive vulnerabilities (i.e. core beliefs) which predispose us to interpret information in a certain way.
These vulnerabilities are developed early.
When these beliefs are rigid, negative, and ingrained we are predisposed to pathology.
Core beliefs give rise to conditional assumptions (i.e. rules for living) as we mature.

10. Cognitive Model
Behaviors
Situation Automatic
Thoughts Emotions
Underlying Physiological
Beliefs Response
Automatic thoughts are influenced by these underlying core beliefs and conditional assumptions

11. Cognitive Model
Withdrawal Relationship Breakup He doesn’t want me Depressed I’m worthless SNS Reaction I’m unlovable Poor Sleep

12. Cognitive Shifts
In various types of psychopathology, there is a systematic bias toward selectively interpreting information in a certain manner.

13. Characteristics of CT Practical Symptom-focused
Empirically-derived techniques
Requires patient collaboration.
Acknowledges underlying precursors of symptoms (schemas), but present-oriented.
Case conceptualization drives treatment.

14. Roles of the CT Therapist
Conceptualize the patient in cognitive terms.
Structure the sessions.
Use collaborative empiricism and guided discovery to:
Specify problems and set goals.
Teach the patient CT techniques.

15. CT Strategies Collaborative empiricism Guided discovery
Deactivation of dysfunctional modes:
Deactivate them.
Modify their content and structure.
Construct more adaptive modes to neutralize them.

16. Comparing CT to Other Therapies

17. Compared with Psychoanalysis
Both assume behavior influenced by beliefs outside awareness.
CT focuses on:
Linkages among symptoms, conscious beliefs and current experiences.
Little concern with unconscious feelings or repressed emotions.
Minimal focus on childhood issues except in terms of assessment or when addressing core beliefs.
CT is highly structured and short-term (12-16 weeks) whereas psychoanalysis is long-term and unstructured.
CT therapist actively collaborates with patient.

18. CT Compared with REBT CT REBT Thoughts Labeled Dysfunctional
Irrational
Reasoning Used
Inductive
Deductive
Beliefs Associated with Psychopathology
Cognitive specificity for disorders
Core set of irrational beliefs
View of the Problem
Functional
Philosophical
Therapist’s Approach
More collaborative
More confrontational

19. Compared to Behavior Therapy
CT is very different from applied behavioral analysis.
CT is the most commonly practiced form of cognitive behavior therapy (CBT).
CBT: An overarching term to represent therapies that integrate cognitive and behavioral theories and techniques.
CT sees the individual as more active rather than passive in change process.
CT stresses expectations, interpretations and reactions.

20. History of Cognitive Therapy

21. Cognitive Therapy Developed by Aaron T. Beck, M.D.
Investigated “anger turned inward” psychoanalytic concept in 1960s and found evidence for negative cognitions.
Bandura, Ellis, Mahoney, and Meichenbaum were all influential and developing their approaches simultaneously.

22. History of Cognitive Therapy
Major influences were:
Phenomenological approaches
Structural theory and depth psychology
Cognitive psychology

23. Current Status of CT

24. Research on the Cognitive Model
Cognitive specificity hypothesis (i.e., distinct cognitive profile for each disorder) supported for many disorders.
Negatively biased interpretations have been found in all forms of depression.
Support for cognitive triad, negatively biased cognitive processing of stimuli and identifiable dysfunctional beliefs in depression.
Danger-related bias demonstrated in anxiety disorders.

25. Cognitive Therapy and Medication
Studies generally show CT to be equivalent to psychotropic medications for depression, bulimia and some anxiety disorders.
Generally, research suggests the combination of the two approaches is superior to either used in isolation.
CT shows longer efficacy (less relapse) and increased likelihood of continuing gains when treatment is discontinued.

26. Current Status of CT Controlled studies shown efficacy of CT with:
Depression
Panic disorder
Social phobia
Generalized anxiety disorder
Substance abuse
Eating disorders
Marital problems
Schizophrenia
OCD
PTSD

27. CT Assessment Measures
Beck Depression Inventory-II (BDI-II)
Beck Anxiety Inventory
Beck Hopelessness Scale (score of > 9 predictive of eventual suicide)
Beck Scale for Suicidal Ideation
Many others

28. Resources in CT
Center for Cognitive Therapy (U/Penn) and Beck Institute are the major training sites (both in Philadelphia).
Multiple other training sites in the United States and internationally:
Cognitive Therapy and Research
Journal of Cognitive Psychotherapy
Academy of Cognitive Therapy (

29. Understanding the Theory Behind CT

30. Cognitive Case Conceptualization
Genetics and Early Life Experiences
Core Beliefs
Conditional Assumptions
Compensatory Strategies
Current Situation
Automatic Thoughts
Reactions

31. Personality Dimensions: Styles of Behaving
Sociotropy (social dependence):
Become depressed following disruption of relationship(s).
Organized around closeness, nurturance, and dependence.

32. Personality Dimensions: Styles of Behaving
Autonomy:
Become depressed after defeat or failure to attain a desired goal.
Organized around independence, goal setting, self-determination, and self-imposed obligations.

33. Problematic Thinking Problematic thinking is very: Extreme Idealistic
Broad
Catastrophic
Negative
Unscientific
Pollyannaish
Idealistic
Demanding
Judgmental
Comfort Seeking
Obsessive
Confusing

34. Cognitive Distortions
Arbitrary inference: Drawing a conclusion without evidence or in the face of contradictory evidence.
Example: A young woman with anorexia nervosa believes she is fat although she is dying from starvation.

35. Cognitive Distortions
Selective abstraction: Dwelling on a single negative detail taken out of context.
Example: While on a date, you say one thing you wish you could have said differently and now see the entire evening as a disaster.

36. Cognitive Distortions
Overgeneralization: A single negative event is viewed as a never-ending pattern of defeat.
Example: Following a job interview, an accountant does not receive the job. He/she begins thinking that they will never find a job position despite their qualifications.

37. Cognitive Distortions
Magnification and/or minimization: The binocular trick. Things seem bigger or smaller than they are.
Example: An employee believes that a minor mistake will lead to being fired.
Example: An alcoholic believes he/she doesn’t have a problem.

38. Cognitive Distortions
Personalization: Assuming personal responsibility for something for which you are not responsible.
Often seen in patients who are sexually abused/assaulted.

39. Cognitive Distortions
Dichotomous thinking: Things are seen as black and white, there is no gray or middle ground.
Things are wonderful or awful, good or bad, perfect or a failure.

40. Cognitive Distortions
Mind reading: Assuming someone is responding negatively to you without checking it out.
Example: If your husband is in a bad mood, you assume it is your fault and don’t ask what is wrong.
Fortune teller error: Creating a negative self-fulfilling prophecy.
Example: You believe you will fail an exam so you don’t study and fail.

41. Cognitive Distortions
Emotional reasoning: You assume that your negative feeling results from the fact that things are negative.
Example: If you feel bad, then that means the world or situation is bad. You don’t consider that your feelings are a misrepresentation of the facts.

42. Cognitive Distortions
Should statements: Use words like should, must, ought rather than “it would be preferred” to guilt self.
Labeling and mislabeling: Name-calling (such as “he’s a jerk”) rather than just criticizing the behavior.

43. Cognitive Triad of Depression
Self
World
Future
Negative
view of

44. Examples of Cognitive Shifts: Depression vs. Anxiety
Negative view of
Threatening view of
Future
Future
World
Self
World
Self

45. Illustration of the Cognitive Model of Anxiety
Stimulus
(Environmental Or Internal)
Secondary appraisal:
“Risk: Resources ratio”
Primary appraisal:
“Danger”
Reappraisals of danger, risk, resources
Physiological
Palpitations, Sweating, Tension, etc.
Affect
Anxiety, Terror
Behavioral inclination
(Flight, Freeze, Defend)

46. Cognitive Profile of Other Psychological Disorders
Systematic Bias in Process
Hypomania
Inflated view of self and future
Anxiety
Physical and psychological danger
Panic Disorder
Catastrophic interpretation of physical and mental experiences
Phobia
Danger in specific avoidable situation
Paranoid State
Attribution of bias to others
Hysteria
Concept of motor or sensory abnormality

47. Cognitive Profile of Other Psychological Disorders
Systematic Bias in Process
Obsession
Repeated doubts about safety
Compulsion
Rituals to ward off perceived Threats
Suicidal State
Hopelessness; deficiencies in problem-solving
Anorexia Nervosa
Fear of being fat
Hypochondriasis
Attribution of serious medical disorder

48. Cognitive Therapy Treatment

49. Structure of a CBT Session
Mood check
Setting the agenda
Bridging from last session
Today’s agenda items
Homework assignment
Summarizing throughout and at end
Feedback from patient

50. General Principles of CT
Goal is to correct dysfunctional thinking and help patients modify erroneous assumptions.
Patient is taught to be a scientist who generates and tests hypotheses.
Relationship between patient and therapist is collaborative.

51. Fundamental Concepts Collaborative empiricism:
Goal is to demystify therapy.
Socratic dialogue:
Questioning used to help patient come to their own conclusions.
Guided discovery:
Therapist collaborates with patient to develop behavioral experiments to test hypotheses.

52. Process of Therapy Initial sessions Middle sessions Termination
Essential to build rapport.
Focus is problem definition, goal-setting and symptom relief.
Therapist provides psychoeducation in initial sessions.
Behavioral interventions more prominent.
Middle sessions
Emphasis shifts from symptoms to patterns of thinking.
Termination
Expectation that therapy is time limited.

53. Behavioral Intervention Examples
Activity scheduling
Mastery and pleasure
Graded task assignment
Conducting behavioral experiments (e.g. being assertive to assess what happens)
Exposure type techniques
Role plays

54. Weekly Activity Schedule
Patient records activities and rates them for pleasure and mastery

55. Weekly Activity Monitoring
A self-rated chart that allows the therapist and the patient to:
Assess how patients are spending their time.
Measure the sense of accomplishment and/or pleasure received from various activities.
Determine which activities are occurring too much or too little.
Evaluate automatic thoughts/emotional shifts.
Fill in specific times with planned/pleasant activities for depressed patients or activities needed for procrastinating patients.
Compare predicted versus actual ratings of accomplishment and pleasure.

56. Cognitive Interventions Examples
Elicit automatic thoughts on thought records.
Identify whether the thoughts represent distortions in information processing.
Use Socratic questions to evaluate the thought process.
Generate alternatives in terms of how to think or how to behave differently.

57. Thought Record

58. Eliciting Automatic Thoughts
Basic question: What thought just went through your mind?
Ask when an emotional shift is noted in session.
Create an emotional shift by having the patient describe or visualize a recent situation when they felt intense emotions and then answer the question.
If patient can’t answer the question try asking:
Do you think you were thinking _____________?
If someone else was in the situation what do you think they might have been thinking?
Were you thinking _____________ (insert something paradoxical)?

59. Examples of Socratic Questions
What evidence supports the belief?
What evidence do you have to refute it?
What would your spouse, best friend, sibling (or anyone whom you admire greatly) say in this situation?
What would you say to your spouse, best friend, or sibling if they were thinking the same thing you are?
How could you look at this situation so you would feel less depressed?
Is this view as reasonable as your first choice?

60. Specific Examples of Socratic Questioning
Situation: Patient feels like a bad wife.
What makes you think you are a bad wife?
What would a good wife have done?
On a scale from 0-100, how do you rate as a wife? Why do you place yourself there on the scale?
How does it help to call yourself a bad wife?
Besides labeling yourself as a bad wife what else could you do in this situation?

61. Non-Socratic Questions (Questions NOT to Use)
Don’t you think most women get mad at their husbands?
Doesn’t your husband ever yell at you?
I’m sure everything will work out OK, don’t you?
I think you are a good wife based on other things you’ve told me. Could you focus on the positives?

62. Example: Downward Arrow to Obtain Less Accessible Beliefs
Situation
Thoughts
Emotions
Patient reports that a session hasn’t helped them.
Therapist thinks patient is right. That was a terrible session. I didn’t do anything right.
Guilty
Anxious

63. Example: Downward Arrow
Question
If that were true, what would it mean about you?
If that were true what would it mean to you?
And, then what?
Response
“That I had done a bad job.”
“Sooner or later I would be found out.”
“Everyone would know I was an imposter and incompetent.”

64. Setting Effective CT Homework
Make sure rationale is clear.
When feasible, have patient chose the task.
Personalize task to therapy goals.
Begin where patient is, not where patient thinks he/she should be.
Be specific and concrete: where, when, who.
Formalize the task (e.g., write on paper).
Plan ahead for obstacles/trouble shoot.
Practice the task in session.
Review homework at beginning of each session.

65. Other CT Techniques De-catastrophizing: Reattribution: Redefining:
“What if that happened? Then what?”
Reattribution:
Alternative explanations systematically examined.
Redefining:
Help patient see the problem differently.
Example: “Nobody ever talks to me” becomes “I need to try to initiate conversation so other people become interested in talking to me.”
Decentering:
Patient is taught to see that thoughts are just thoughts and not “them” or “reality.”

66. Applications of CT: Empirically Supported
Meta-analyses and other recent methodologically rigorous studies have found CT to have large effect sizes for:
Major depression
Generalized anxiety disorder
Panic disorder
Social phobia
Childhood depressive and anxiety disorders

67. Applications of CT: Empirically Supported
Moderate effect sizes for:
Marital problems
Anger
Childhood somatic disorders
Chronic pain
Small effect sizes for:
Schizophrenia
Bulimia nervosa

68. Applications of CT: Empirically Supported
CT yields lower relapse rates than antidepressant medications and reduces the risk of symptom relapse.