1. Introduction to Cognitive Behaviour Therapy
Carol Vivyan 2007

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

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

4. The approach is: Collaborative (builds trust) Active
Based on open-ended questioning
Highly structured and focused

5. Meaning we give the event Event Emotion
‘Common Sense’ Model
Event
Emotion
Cognitive Model
Meaning we give the event
Event
Emotion

6. You’re walking down the High Street, and someone you know walks by without acknowledging you…

7. 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!

9. 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
The continuum principle – mental health problems are best conceptualised as exaggerations of normal processes

10. ‘Here and now’ principle – it is usually more fruitful to focus on current processes rather than the past
Interacting systems principle – it is helpful to look at problems as interactions between thoughts, emotions, behaviour and physiology and the environment in which the person operates

13. Padesky’s 5 Aspects Model (1986)
ENVIRONMENT
THOUGHTS
BIOLOGY
MOOD / FEELINGS
BEHAVIOUR

14. 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

15. Feelings & commonly associated thoughts

16. 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

17. 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?

18. Cognitive Model of Panic Internal / External Trigger Perceived Threat
Internal / External Trigger
Turbulent flight
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!

19. Cognitive Model of Depression
Early Experiences
Cognitive Model of Depression
Core Beliefs & Assumptions
Beck (1979)
Critical Incident
Negative Automatic Thoughts (NATS)
Behaviour
Feelings

20. Negative Automatic Thoughts
Assumptions
Core beliefs

21. 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

22. Identifying NATs Shifts in Affect
Distinguish between thoughts and emotion and behaviour
Check for images

23. Cognitive Model of Depression
Negative cognitive triad
Biased views 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?
Negative filter
Remembering events
Interpreting current events / situations
Overgeneralising from small negative event to broad negative conclusion

24. 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

25. Course of treatment Identify specific problem list (& prioritise)
Eg. Poor sleep, relationship difficulties etc
Introduce cognitive model – how it might apply to client
Goals (SMART)
Reduce symptoms through behavioural or simple cognitive strategies
Identify and challenge NATs
Relapse prevention

26. Overview of a typical course of therapy
Referral
Assessment: suitability, therapeutic relationship
Assessment (ongoing): problem analysis, wider picture, measures
Problem list & prioritise
Goals for therapy (SMART)
Formulation (ongoing): Sharing model, maintaining factors, predisposing factors, rationale for treatment

27. Overview 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 ?

28. 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

29. Therapy Skills Engagement Warmth and empathy Collaboration
Guided discovery – socratic questioning
Feedback and summarising
Agenda setting – structure and focus
Open and closed questioning

30. Aims of Assessment Initiate & develop therapeutic relationship
Establish suitability for CBT
Gather specific information re current difficulties
Elicit maintaining factors
Initial formulation
Socialise to CBT model
Establish joint understanding of the presenting problem

31. 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
Security operations
Focality
Optimism/pessimism regarding therapy

32. 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?

33. Measures
The concept of measures is central to the CBT approach, as it enables both client and practitioner to evaluate the impact of interventions (Grant et al 2004)
They are important in the process of assessment and aid the practitioner to develop a credible formulation for the client, so that appropriate cognitive and behavioural interventions can be used

34. Why Measures? 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

35. 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

36. 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

37. 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)

38. Behavioural Interventions
Very powerful method of bringing about change
Key component of CBT intervention
Borrowed and adapted from Behaviour Therapy
Incorporate different methodological approaches

39. Behavioural Experiments
Similar in BT / CBT, but fundamentally different
In BT, it is the end product, in CBT, a means to an end ie. Cognitive change
In BT – graduated, repeated and prolonged exposure
In CBT - New ideas are put to the test. Means of testing the validity thoughts, perceptions, beliefs.

40. Examples Hyperventilation to simulate panic
Activity monitoring and scheduling
Metaphors – South American tribe?
Consider experiment for client with OCD, believes something terrible will happen to family if he doesn’t neutralise his thought by doing rituals for up to an hour

41. 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

42. 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?

43. Coping with Relapse How can I make sense of this lapse?
What have I learnt from it?
With hindsight, what would I do differently?

44. Introduction to CBT
This presentation gives you an introduction to the rationale of CBT
It does not enable you to perform CBT
Using Cognitive Behavioural interventions may be helpful for your clients
CBT - Guided self-help?

47. Summary No formulation No CBT Use CB techniques
Bibliotherapy: e.g. Mind Over Mood
Challenge negative thoughts
Court Case
Evidence
More balanced/alternative thought
Downward arrow
Behavioural experiments / exposure
Activity Diaries
Relaxation?

48. More information & resources
Self help
Workbooks
online CBT programmes – printable forms etc
Online
Professional links
CBT organisations
Therapist manuals online
Books

49. Bibliography Certificate in Cognitive Behaviour Therapy.
Salford Cognitive Therapy Training Centre
An introduction to Cognitive Behaviour Therapy: Skills & Applications.
Westbrook, Kennerley, Kirk, Sage.
Treatment Plans & Interventions for Depression & Anxiety Disorders.
Leahy Guilford.
Cognitive Therapy of Anxiety Disorders.
Wells Wiley.
Mind Over Mood.
Greenberger, Padesky Guilford.