1. Introduction to Cognitive Behaviour Therapy
Valérie KHODARA 
Psychologue/Psychologist, Psychothérapeute TCC/Psychotherapist CBT

2. Epictetus AD
“Men are disturbed, not by things, but by the principles and notions which they form concerning things”
Roman (Greek-born) slave & Stoic philosopher
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3. “Cognitive Therapy is a system of psychotherapy that attempts to reduce …
excessive emotional reactions and
self-defeating behaviour,
by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions”
Beck et al 1976, 1979, 1993
“Cognitive Therapy is a system of psychotherapy that attempts to reduce …
excessive emotional reactions and
self-defeating behaviour,
by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions”
Beck et al 1976, 1979, 1993
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4. The approach is: Collaborative (builds trust) Active
Based on open-ended questioning
Highly structured and focused
Collaborative (builds trust)
Active
Based on open-ended questioning
Highly structured and focused
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5. Meaning we give to the event Event Emotion
‘Common Sense’ Model
Event
Emotion
Cognitive Model
Meaning we give to the event
Event
Emotion
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6. Example : You’re walking down the High Street, and someone you know walks by without acknowledging you…
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7. What could you think in this situation? and what could you feel?
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8. 4 interpretations – 4 emotions
I don’t want her to see me, I won’t know what to say – she’ll think I’m stupid & boring
Nobody wants to talk to me, no-one likes me
She’s got a nerve being so snooty!
She’s probably still hung over from that party last night!
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10. Cognitive principle – it is interpretations of events, not events themselves, which are crucial.
Behavioural principle – what we do has a powerful influence on our thoughts and emotions
Avoidant strategies
Exposure (phobia)
Testing a belief
Cognitive principle – it is interpretations of events, not events themselves, which are crucial.
Behavioural principle – what we do has a powerful influence on our thoughts and emotions
Avoidant strategies
Exposure (phobia)
Testing a belief
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11. The continuum principle – mental health problems are best conceptualised as exaggerations of normal processes
normal anxiety pathological anxiety
wishing to succeed need to be perfect
having a drink with friends getting drunk, alone
The continuum principle – mental health problems are best conceptualised as exaggerations of normal processes
normal anxiety pathological anxiety
wishing to succeed need to be perfect
having a drink with friends getting drunk, alone
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12. ‘Here and now’ principle
It is usually more fruitful to focus on current processes rather than on the past
What studies show…
The dog and the feather….
Here and now’ principle
It is usually more fruitful to focus on current processes rather than on the past
What studies show…
The dog and the feather….
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13. How do we become anxious?
The Napalkov’s experiment (1963)
dogs.
Inconditional Stimulus = a gun shot behind the hear of the dog
Inconditional Response = increase of the blood pressure
 Rapid habituation of the dog’s response to the gun shot
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14. Blood pressure Gun shots 0 10 20 30 40 50 ml/sang…
Gun shots
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15. Next step of the experiment
Neutral Stimulus = a feather
Unconditioned Stimulus: a shot gun
We will see how a feather (NS) can become a Conditioned Stimulus
we touch the dog’s ear with a feather and a shot gun is fired immediately after (0,5 sec.)
Only one association. No more shot guns after.
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16. Blood pressure 0 10 20 30 40 50 60 250 ml/sang
bang
ppppppppppppppppppppppppp …
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17. Interacting systems principle
CBT sees problems as an interaction between
thoughts,
emotions,
behaviour and
physiology and the environment in which the person operates
Interacting systems principle
CBT sees problems as an interaction between
thoughts,
emotions,
behaviour and
physiology and the environment in which the person operates
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18. lesTCC
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20. Padesky’s 5 Aspects Model (1986)
ENVIRONMENT
THOUGHTS
BIOLOGY
MOOD / FEELINGS
BEHAVIOUR
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21. Difficult to breathe – choking sensation
ENVIRONMENT
On Plane
Turbulence
THOUGHTS
We might crash
BIOLOGY
Heart racing
Palpitations
Rapid breathing
Difficult to breathe – choking sensation
MOOD / FEELINGS
Anxious 90%
BEHAVIOUR
Reassurance seeking
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22. Feelings & commonly associated thoughts
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23. Clinical example
Mrs K,50 years old, maried, 2 kids, work in a notarial office
Complaint: excessive anger and claustrophobia
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24. Mrs K
Motif de la consultation : colère fréquente et intense pendant des situations conflictuelles avec son fils
Séquence : son fils, François, 14 ans, joue un jeu en réseau, Mme K prépare le repas. Il est l’heure de passer à table, Mme appelle François qui répond « Attends, il faut que je termine la partie ». Mme, après 5 minutes, le rappelle. Réponse : « mais attends, je n’ai pas encore terminé ».
Mme : « J’en ai marre, c’est prêt et chaud, bouge-toi, viens immédiatement »
François : « C’est toujours pareil, t’avais qu’à me prévenir avant, tu peux attendre, je manges après, en plus je n’aime pas ton plat »
Mme débranche l’ordinateur et crie sur son fils
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25. Mrs K’s thoughts and emotions
Frustration
Colère
Anxiété
Tristesse
Thoughts
Il n’est pas content
Il n’est pas éduqué
Il ne me respecte pas et je ne sais pas me faire respecter
Il se fout de moi
Je suis une mauvaise mère
Je ne sais pas l’éduquer
J’ai raté, je n’ai pas de valeur
Il ne m’aime pas
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26. Situation 2 : Je regarde la télé, j’aperçois une tâche sur la vitre
Émotions/Sensations : « Anxiété, Tristesse, Tension interne »
Pensée automatique : « Ma maison est sale ». « Il faut nettoyer», « Tout doit être propre
Comportements: Je me lève et je nettoie
Signification de la P.A. : « Je suis mauvaise, sans valeur »
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27. Situation 3 : Relaxation
Émotion : « Angoisse, Culpabilité, Tristesse »
Pensée automatique : « Je ne fais rien»
Comportement : J’évite de ne rien faire. Je m’active
Signification de la P.A. : « Je suis mauvais, nulle »
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28. Beliefs and rules Unconditionnal rules Conditionnal rules
« I cannot disappoint people »
« One has to be perfect to have value »
Conditionnal rules
« If someone dispproves of me then I have no value »
« If I make an error then I am worth nothing »
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29. Where do come from these rules and beliefs?
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30. Personal history analysis
Eléments diachroniques
Père exigeant, mère effacée
Mme K était punie si les résultats scolaires n’étaient pas excellents: son père exigeait qu’elle soit la première de la classe
Punitions physique
Privations (enfermée dans le placard), privée de loisirs
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31. Groups
Think of a recent situation or event which resulted in a negative mood shift
Anxiety
Sadness
Anger
Groups: therapist / client / observer
Identify:
thoughts / feelings / behaviours
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32. Identify a recent significant shift in mood (emotion)
What was the situation?
How did you feel? (emotion/physiology)
What was going through your mind at the time? (thoughts)
What did you do? (behaviours)
What were the consequences?
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33. Examples from the pathological field…
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34. Cognitive Model of Panic
Internal / External Trigger
Turbulent flight
Cognitive Model of Panic
Perceived Threat
We might crash
I’m going to die
Anxiety / Panic 90%
Catastrophic Interpretation of Symptoms
I’ll suffocate and die
Physical / Cognitive Symptoms
Heart racing
Breathless
Difficulty breathing – choking sensation
Shaking
Sweating
Avoidance & Safety Behaviours
Reassurance seeking:
Ask companion
Look at faces of other travellers
Ask cabin crew
Avoid flying!
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35. Cognitive Model of Depression
Early Experiences
Core Beliefs & Assumptions
Beck (1979)
Critical Incident
Negative Automatic Thoughts (NATS)
Behaviour
Feelings
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36. Negative Automatic Thoughts
Assumptions
Core beliefs
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37. Negative Automatic Thoughts
Stream of thoughts that we can notice if we try to pay attention to them (automatic)
Negatively tinged appraisals or interpretations – meanings we take from what happens around us or within us
Specific thoughts about specific events or situations
Brief, frequent, habitual – often not heard
Plausible and taken as obviously true, especially when emotions are strong
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38. Identifying NATs Shifts in Affect
Distinguish between thoughts and emotion and behaviour
Check for images
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39. Cognitive Model of Depression
The Negative cognitive Triad
A biased view of :
Oneself
I am bad, useless, unlovable, worthless, a failure
The world in general
Nothing good happens, life is just a series of trials
The future
It will always be like this, nothing I can do will make any difference, what’s the point of anything?
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40. Negative filters Remembering events
Interpreting current events / situations
Overgeneralising from small negative event to broad negative conclusion
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41. Goals of therapy
Help the client counteract negative cognitive biases, and develop more balanced view of herself, the world, and the future
Restore activity levels – especially those that give sense of pleasure or achievement
Increase active engagement and problem solving
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42. Course of treatment Practically, we will:
Identify specific problem list (& prioritise)
Eg. Poor sleep, relationship difficulties etc
Introduce cognitive model – how it might apply to client
Goals
Reduce symptoms through behavioural, cognitive strategies and emotional technics
Identify and challenge NATs
Relapse prevention
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43. Phases of a typical course of therapy
Assessment, Formulation
Treatment: start with symptom focused intervention
Review: every six sessions, repeat measures
Discharge: repeat measures, relapse prevention
Follow up / booster sessions:
1,3,6,12 month ?
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44. Typical CBT treatment session
Set collaborative agenda
Review time since last session
Feedback on last session
Review homework
Focus on major topics for the session
Set homework
Potential problems with completing homework
Feedback on session
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45. Therapy Skills Engagement Warmth and empathy Collaboration
Guided discovery – Socratic questioning
Feedback and summarising
Agenda setting – structure and focus
Open and closed questioning
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46. Aims of Assessment Initiate & develop therapeutic relationship
Establish suitability for CBT
Gather specific information recurrent difficulties
Elicit maintaining factors
Initial formulation
Socialise to CBT model
Establish joint understanding of the presenting problem
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47. Suitability for short term CBT
Ability to identify & describe negative thoughts
Awareness & differentiation of emotion
Compatibility with CBT rationale
Acceptance of personal responsibility for change
Alliance potential
Chronicity of problem
Optimism/pessimism regarding therapy
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48. Homework Identify a recent significant shift in mood
What was the situation?
How did you feel?
What was going through your mind at the time?
What did you do?
What were the consequences?
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49. Why Measures? The concept of measures is central to the CBT approach:
Assessment – to provide information
Baseline – subsequent measures will show extent of change
Effectiveness – helps to (objectively) demonstrate effectiveness of therapy, and allow modification of treatment
Feedback
Knowledge - data collection & suggests areas for future research
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50. What measures?
Standardised – developed for particular populations and problems
Eg. Beck Depression Inventory
Beck Anxiety Inventory
Agoraphobic Cognitions Questionnaire
Individualised – allow for more specific information for assessment and formulation.
Eg. Problem definition, Targets of therapy, Diaries, % Belief Ratings, Ratings of specific emotions
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51. Cognitive Interventions
Restructuring thoughts and beliefs
Guided discovery
Thought diaries
Challenging NATs (looking at evidence)
Addressing thinking errors
Responsibility Pie
Cost/Benefit Analysis
Downward Arrow technique
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52. Cognitive Interventions
Education Eg. Written information on thinking errors, disorder specific info
Continuous use of formulation
Imagery techniques
Role play & role reversal
Action Plan
Education in Body systems (symptoms)
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53. Behavioural Interventions
Very powerful method of bringing about change
Key component of CBT intervention
Borrowed and adapted from Behaviour Therapy
Incorporate different methodological approaches
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54. Examples Hyperventilation to simulate panic
Activity monitoring and scheduling
Metaphors – South American tribe:
Consider experiment for client with OCD who believes something terrible will happen to his family if he doesn’t neutralise his thoughts by doing rituals for up to an hour
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55. Problem solving Identify problem to be worked on
Think of as many solutions as possible
Consider each solution – pros & cons
Pick solution that appears best
Small steps
Action & review
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56. Emotionnal Interventions
Relaxation
Mindfulness
Exposure to emotions
Music
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57. Relapse Prevention What have I learned? What was most useful?
What can I continue to do?
When will I be at risk of this happening again?
What are the signs?
What could I do to avoid losing control?
What could I do if I did lose control?
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58. Coping with Relapse How can I make sense of this lapse?
What have I learnt from it?
With hindsight, what would I do differently?
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60. Conclusion
This presentation just gave you an introduction to the rationale of CBT
Thank you for your attention
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