Cognitive Behavioral Therapy

Regi L. Pamugas, MDAugust 3, 2011UP Manila

Objectives To define mental health/illnessTo discuss on the different types

of treatment of mental illnessTo define Cognitive Behavioral

Therapy (CBT)To discuss on CBT

ContentsDiscussion on mental

health/illnessDiscussion on the treatment of

mental illnessDiscussion on Cognitive

Behavioral Therapy (CBT)Summary

What is a mental health? “Health is a state of complete

physical, mental and social well-being and not merely the absence of disease or infirmity.” – World Health Organization

Mental health problems - can have both psychological, social and somatic dimensions.

These issues often make it hard for people to manage their lives and achieve their goals.

Mental IllnessPsychotics* schizophrenia, brief psychotic disorder, delusional disorder, shared psychosisNeurotics* Anxiety, somatoform, eating, sleeping, disorder, etc.Mood disorders* Bipolar I and IIPsychosis due to medical condition or

substancesPsychosis not otherwise specified

Types of treatmentBiological/Pharmacologic* antidepressants, anxiolytics, antipsychoticsPsychotherapy* Psychodynamic, cognitive, behavioral, client-centered therapy, existential therapyCombination of drugs and

psychoanalysisElectroconvulsive therapy (ECT)

Definition of TermsPsychotherapy - set of clinical techniques

use to improve mental health.Counseling = psychotherapy. Behavior Therapy (Behavior Modification

Therapy) - changing somebody's behaviorClassical Conditioning - creation of

response to stimulus (Pavlov's dogs)Operant Conditoning - learning through

positive and negative reinforcementCognitive Therapy - psychotherapy aimed

at changing way of thinking.

Several approaches to CBTRational Emotive Behavior

TherapyRational Behavior TherapyRational Living TherapyCognitive TherapyDialectic Behavior Therapy

Psychodynamic TherapyProbes the pastDoesn’t tackle the immediate

problemThe goal is insightTakes a long timeExplores the unconscious

Behavioral TechniquesThere are no mental processes

(will, mind)The focus is on changing the

behaviorWorks on the immediate problemFocuses on the present

Behavioral TechniqueClassical conditioningIvan PavlovConditioning- learning that

involves associations between environmental stimuli and the organism’s responses

Stimulus-response learning

Systematic DesensitizationEx. Fear of flyingRead about safety flightLook at pictures of airplanesVisit at the airportTake a short flightTake a long flight

Client-Centered TherapyTherapist uses techniques such

as active listening within genuine, accepting, empathic, environment to facilitate client’s growth

Client adopts these views and becomes self-accepting

Promotes growth instead of curing illness

Existential therapyHelps client explore meaning of

existenceHelps client choose a destinyHelps client accept self-

responsibility

Cognitive Behavioral TherapyBrief History of Cognitive TherapyAlbert Ellis, PhD— grandfather of

CBTpublished “Reason and Emotion in Psychotherapy in 1962”Aaron Beck, MD– wrote “Self

Concept in Depression with D. Stein in 1960”

Cognitive Behavioral TherapyA form of psychotherapy that

emphasizes the important role of thinking in how we feel and what we do.

Indications of CBTIt is used to treat depression,

anxiety disorders, phobias, and other mental disorders

Treats alcoholism and drug addiction, especially as part of an overall program of recovery.

The basic goals of CBTTo challenge the thoughts about

a particular situation by identifying the cognitive traps

To help the patient to identify less threatening alternatives

To test out these alternatives in the real world

To challenge the assumptions that lead to the Automatic Thoughts

10 Characteristics of CBT

1. CBT is based on the Cognitive Model of Emotional ResponseCBT is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change.

10 Characteristics of CBT2. CBT is briefer and time-limited.12- 16 sessionsIs highly instructive nature and the fact that it makes use of homework assignments. Time-limited in that we help clients understand at the very beginning of the therapy process that there will be a point when the formal therapy will end. The ending of the formal therapy is a decision made by the therapist and client.

10 Characteristics of CBT3. A sound therapeutic relationship is necessary for effective therapy.Some forms of therapy assume that the main reason people get better in therapy is because of the positive relationship between the therapist and client. Have a good, trusting relationship, but that is not enough. Clients change because they learn how to think differently and they act on that learning. Therefore, CBT therapists focus on teaching rational self-counselling skills.

10. Characteristics of CBT

4. A collaborative effort between the therapist and the client. Therapists seek to learn what their clients want out of life (their goals) and then help their clients achieve those goals. The therapist's role is to listen, teach, and encourage, while the client's roles is to express concerns, learn, and implement that learning.

10 Characteristics of CBT5. CBT can be based on stoic philosophy or notBeck's Cognitive Therapy is not based on stoicism. If we are upset about our problems, we have two problems -- the problem, and our upset about it. Most people want to have the fewest number of problems possible. So when we learn how to move calmly accept a personal problem, not only do we feel better, but we usually put ourselves in a better position to make use of our intelligence, knowledge, energy, and resources to resolve the problem.

10 Characteristics of CBT

6. CBT uses the Socratic Method.Therapists want to gain a very good understanding of their clients' concerns. Asking questions. Therapist encourages their clients to ask questions of themselves, like, "How do I really know that those people are laughing at me?" "Could they be laughing about something else?"

10. Characteristics of CBT

7. CBT is structured and directive.Therapists have a specific agenda for each session. Specific techniques / concepts are taught during each session. CBT focuses on the client's goals. We do not tell our clients what their goals "should" be, or what they "should" tolerate. Therapists teach their clients how to do.

10 Characteristics of CBT

8. CBT is based on an educational model.CBT is based on the scientifically supported assumption that most emotional and behavioral reactions are learned. Therefore, the goal of therapy is to help clients unlearn their unwanted reactions and to learn a new way of reacting.

10 Characteristics of CBT9. CBT theory and techniques rely on the Inductive Method.A central aspect of Rational thinking is that it is based on fact. Often, we upset ourselves about things when, in fact, the situation isn't like we think it is. Therefore, the inductive method encourages us to look at our thoughts as being hypotheses or guesses that can be questioned and tested.

10 Characteristics of CBT

10. Homework is a central feature of CBT.If when you attempted to learn your multiplication tables you spent only one hour per week studying them, you might still be wondering what 5 X 5 equals. You very likely spent a great deal of time at home studying your multiplication tables, maybe with flashcards.

10 Characteristics of CBT

10. Homework is a central feature of CBT.The same is the case with psychotherapy. Goal achievement (if obtained) could take a very long time if the person were only to think about the techniques and topics taught was for one hour per week. Therapist encourage their clients to practice the techniques learned.

The Cognitive TriadNegative view of the self (e.g.,

I’m unlovable, ineffective)

Negative view of the future (e.g., nothing will work out)

Negative view of the world (e.g., world is hostile)

Automatic thoughtsAre repetitive, automatic self-

statements that we always say to ourselves in certain situations. They can be positive or negative. Psychological problems develop when our automatic thoughts are consistently negative.

They are automatic, because they are not the result of an analysis of the problem, they are a "knee-jerk" reaction to specific situations

Automatic thoughtsEx.: In social situations, do you

always presume the other person dislikes you, or thinks you are stupid?

When automatic thoughts control our emotional response to people, problems, and events, we ignore evidence that contradicts the automatic thought. If we cannot ignore it, we explain the evidence in terms of the automatic thought.

Automatic thoughtsEx.: If we talk to someone and they smile,

they are really laughing at us, rather than being pleased to see us.

The automatic thoughts create an expectancy of something negative. Since many things in life are vague, and can be interpreted in many ways, we learn how to negatively evaluate the world, so it agrees with our negative automatic thoughts.

Therapist help you to identify your negative automatic thoughts, and how to develop positive challenges to those negative ideas.

Situation:Therapist asks Maria about her goals for therapy

↓Automatic Thoughts“Why is she asking me that? It’s so superficial.

Setting goals won’t help. My problems are too deep. She should know that. Didn’t she read the evaluator’s report? She probably thinks I’m just like everyone else. I’m not going to let her get away with treating me like this.”

↓Reaction:Emotional: AngerPhysiological: Tension in face, arms and

shouldersBehavioral: Shrugs, avoids eye contact and

says nothing

The Cognitive ModelCore Beliefs Assumptions Coping Strategies Situation Automatic Thoughts/ Images Reaction (Emotional, Behavioral, Physiological)

Basic Cognitive-Behavioral Model

Event

Behavior Cognitive Appraisal

Emotion

Automatic thoughts

Physiologic

People evaluate their health threats by constructing their own representations or perceptions of their illness, which in turn influences their pattern of coping and adjustment.

Cognitive distortionsLabelingMind readingExaggerationUnrealistic expectationsBelief in entitlementBelief in absolute fairness

Irrational ideas & BeliefsAlbert Ellis first presented the idea

that irrational beliefs are at the core of most psychological problems.

We could also call these beliefs unrealistic, incorrect, or maladaptive.

Therapists have also suggested that these ideas are irrational because they are not logical, or are based on false assumptions.

Overgeneralizing or CatastrophizingCatastrophizing is a negative

overgeneralization. For example:You make a small mistake on a

project, and assume that you will be fired when the boss finds out.

You try your hand at a new hobby, and it does not turn out well. You conclude, "I'm no good at anything."

Cognitive distortionsAnother form of irrational ideas,

overgeneralizing of simple mistakes, or developing false assumptions about what other people think about us, or expect from us.

We are distorting reality by the way we are evaluating a situation.

The concept of cognitive distortion highlights the importance of perceptions, assumptions and judgments in coping with the world

Cognitive distortionsTherapist help us determine what

evaluations are distortions by providing objective feedback about our evaluations of the world, and by teaching us how to change the way we are perceiving problems.

Pessimistic ThinkingIt is easier to become depressed

if you tend to view the world with considerable pessimism.

Pessimism is a tendency to think that things won't work out as you wish, that you won't get what you want. Pessimism feeds the negative cognitive distortions and self-talk.

Fighting dysfunctional thoughtsHot Thoughts Cool ThoughtsHe is always mean * Maybe he

had to me a bad day

I did a lousy job * It’ll be better next time

I deserve better * But people are people

That jerk. * It’s his problem

Dysfunctional ThoughtSituation

Emotion rate (1-100%)

Automatic thoughts

Cognitive distortion

Rational response

Outcome rate (1-100%)

Fight with spouse

Angry 99%Sad 50 %

I will never have a normal marriage

I deserve better

He’s stubborn

Magnification

Entitlement Labelling

It’s not the end of the world

That’s normalMaybe he had a bad day at work

Angry 50%Sad 10%

Modifying AT: Thought Change

Catch Check Change

Pedro is upset with me

I am jumping to conclusion

I can ask Pedro why he is upset with me.

I am an idiot I am name-calling

One small mistake does not make me an idiot.

Behavioral MethodsBehavioral Activation: * What could you do?Activity Scheduling & Monitoring * Keep a schedule * Monitor for Mastery and Pleasure * Increase Mastery and Pleasure activities

Behavioral MethodsGraded Task Assignment * Break into steps Behavioral Rehearsal * Role playing Specific skills * Thought stopping * Breathing RetrainingProblem solving

Summary of Cognitive Psychotherapy ApproachThe essence of cognitive therapy is the

assumption that irrational thoughts and beliefs, overgeneralization of negative events, a pessimistic outlook on life, a tendency to focus on problems and failures, and negative self assessment, as well as other cognitive distortions, promote the development of psychological problems, like anxiety and depression.

Therapist use cognitive therapy to help you identify and understand how these cognitive distortions affect your life.

Cognitive therapy helps you to change, so that these issues will not rule your life.

If you are feeling overburdened, that life is not working for you, and you don't know what to do next, talk to someone who can help.

“Men are disturbed not by things, but by the view which they take of them.”

Epictetus (55-135, Greek Stoic)

Maraming Salamat.