Implementing Cognitive Behavioral Skills in Routine Clinical Practice: Reflecting on the Five Areas Model and More

Margaret Elizabeth Myers, PhD, RMFT, CCC-S, RPLen Myers, BA, M.Div, D. Min., RMFT

1. Not “specialized” practice; perhaps generalized client ‘mix’;

2. Counsellor is comfortable with own “knowledge/understanding of client groups”;

3. Not cases you seek consultation/supervision for

or refer;

4. Session-to-session evaluation of clients’

progress occurs.

Routine Clinical Practice

Competencies for CBT Therapy

Meta

Competency

Problem Specific

Competencies req. Sup

(Exposures, DBT, OCD Groups)

Additional Model (req. Training/Evaluation) (CBT)

Fundamental/Generic Psychotherapy Skills

(Roth & Pilling, 2007)

Base Level: Fundamental/Generic Psychotherapy Skills

Knowledge of Mental Health Issues

Assessment Skills/Implement Interventions

Professional and Ethical Guidelines;

Discerns Competency/Client Requirements;

Assess Need for Referrals for Clients/CE/Supervision for Self;

Generic Model of Therapy/Implements Model in Practice (ie.

Gerald Corey);

Effectively Deals with Emotional Content of Sessions (Deal

with our “own stuff”

Engage Client/Foster & Maintain Therapeutic Alliance

Understand Clients World View/ Manage Endings

Displays Warmth, Acceptance, Empathy, & Focus on the

Other

Fundamental/Generic Psychotherapy

Skills

Fundamental/Generic Psychotherapy Skills

Using Additional Models

Art TherapyAttachment ModelsCognitive-Behavioural TherapyCouples/Relationship ModelsCulturally Specific ModelsEmotionally-Focused Therapy (Individual and Couples)Eye-Movement Desensitization and Reprocessing (EMDR)

Family Systems Theories (various)Family Therapy ModelsInternal Systems ModelMusic TherapyNarrative TherapyPerson-Centered TherapyPlay TherapySchema Therapy(and more…..)

There are many Models and Specialties

COMPANY NAME

Problem Specific Competencies

Fundamental/Generic Psychotherapy Skills

Using Additional Models

Problem Specific Competencies req. Sup

(Exposures, DBT, OCD Groups)

Generally requiring additional study and supervision Includes, but not limited to :1. Exposure Therapy; 2. Personality Disorders (the 10/ all A,B,C Clusters: Antisocial; Avoidant; Borderline; Dependent; Histrionic; Multiple; Dissociative Identity Disorder; Narcissistic; Obsessive-Compulsive (not OCD); Paranoid; Schizoid[ & Schizotypal); 3. Group CBT.

Meta Competencies

“The Tip of the CBT Competency Pyramid”

Meta Competencies

Can work across all levels of

client issues,

and adapt CBT to the needs of

each individual client.

Mindful Practice

Supervised Supervision

Not ‘rote practice’, maker higher

order link between theory and practice, use of critical thinking

Meta Competencies Don’t Automatically Appear

Meta

Competency

Problem Specific

Competencies req. Sup

(Exposures, DBT, OCD Groups)

Additional Model (req. Training/Evaluation) (CBT)

Fundamental/Generic Psychotherapy Skills

Benefits of CBT

Collaborative/Therapeutic Alliance; Client focused

Theory of psychopathology/Treatment

Short-term/Cost Effective

Objective Assessment and Monitoring/Scales/Tools

Strong Empirical Support

Effective with Medication; use alone/ with Medication

Structured, Goal Oriented;

Focus on Immediate Issues + Long Term Strategies;

Requires Active Involvement by the client

Flexible, Individualized, adapted to a wide range of clients and settings

Therapist Related: False Claims Made, Mechanistic Approaches…

Beck is Warm, Safe..

Big Pharma Issues

Professional Amnesia (Kelly Bundy Syndrome); Knowledge Accumulates

Lack of Motivation/Commitment in Clients

Addicted Client Still Drinking/Using

Active Paranoid Personality Disorder

Therapist lacks interaction skill mix (assertive, directive, nonjudgmental & collaborative)

Client Lacks Time Necessary; Resents Time to Use Logs/Other assessments

Client Overwhelmed and Still on the Wheel; Lacks Basic Support

Client Refuses Homework, “Fix Me Here” [168 hrs in week]

SMI; Axix 11 not diagnosed. DSM5; ICD 10

CBT & Bad Press

But What About That Window of Opportunity?

After Fundamental/Generic Psychotherapy Skills

After Fundamental/Generic Psychotherapy Skills and learning other Model/s

Add to Fundamental/Generic Skills

Without Becoming a CBT Specialist

Add to Existing Psychotherapy Skills Without Becoming a CBT Specialist

The Legacy of Aaron T. Beck

Dr. Aaron Temkin Beck (Tim)Born July 18, 1921

Globally recognized as the father of Cognitive Therapy (CT)

One of the world's leading researchers in psychopathology

Psychiatrist; Worked as psychoanalyst

Example text

The Legacy of Beck

Point # 2

EBP: Researchers world wide empirically

tested theory in numerous conditions

Tim

Beck Institute of Cognitive Behaviour Therapy Academy of Cognitive Therapy (Certification and Registration)

Psychoanalyst (1940) found basic concepts of depression to be false;Re-conceptualized the cause and trajectory of Depression and Reaction from his peers….??

Controlled Outcome Studies on CBT

Unipolar Depression

Eating Disorders Anorexia

Bulimia

Generalized Anxiety Disorder

Social Phobia

Panic Disorder

Borderline P.D.

Schizophrenia

Chronic Depression

CBT Used for Clients with….

Mood DisordersUnipolar Depression

Bipolar Disorder

Dysthymia and Chronic Major Depressive Disorder (CMDD)

Anxiety DisordersGAD

Social Phobia

Panic Disorder

OCD

PTSD

CBT: Clients with …

Altered Eating DisordersGBR (Obesity)

LBR (Anorexia; Bulimia; Healthy BMI)

Marital Problems

Other

Headaches; Insomnia; Chronic Pain; Smoking Cessation; Hypochondriasis; Body Dysmorphic Disorder

Yes Maggie, but What About that Window of Opportunity?

After Fundamental/Generic Psychotherapy Skills

After Fundamental/Generic Psychotherapy Skills and learning other Model/s

Add to Fundamental/Generic Skills

Without Becoming a CBT Specialist

Add to Existing Psychotherapy Skills Without Becoming a CBT Specialist

Example text

The Five Areas Model: De-Jargonizing CBT

…Use [recommended] to wide range of HC practitioners including day-hospital and

community based psychiatrists, psychiatric nurses, clinical psychologists, behavioural

therapists, general practitioners, etc. Not a new approach, but a new way of communicating

the existing CBT approach to [wide range of practitioners]

Life Situations

Relationships

Practical Problems

Altered Thinking

Altered Emotions/

Mood/ Feelings

Altered Physical Feelings/

Symptoms

Altered Behaviour/

Activity Level

Standard Course of CBT

1. Assessment

2. Provide Rationale

3. Training in Self-Monitoring

4. Behavioral strategies1. Monitor relationship between situation/action and mood.

2. Applying new coping strategies to larger issues.

5. Identifying beliefs and biases

6. Evaluating and changing beliefs

7. Core beliefs and assumptions

8. Relapse prevention and termination

How can you do this?Collaborate with Client/ Build therapeutic alliance; Show Genuine Concern Explain how CBT worksCollaborative Goal SettingShow Genuine Empathy and Concern for ClientSafety AssessmentAccepting WHO the Client IS: Let him Live in His Own World (Peeps/Culture/ Sexual Orientation/Gender/Roles/Values/Health/Faith/Spirituality)Level of Support & Realistic Expectations (Who can you call at 2 am?)Client’s Experiences with Mental Health Professionals?Listen Well Before Conceptualizing Listen for Family History, Experiences; How Sense of Self Developed. Genogram (in your head if possible)Socratic QuestioningListen for Negative Automatic Thoughts Listen for Hope; Build on Hope/Positive Coping Skills; Listen for Hopelessness: Immediate response Necessary! Listen for Survival Narrative; How does client see herself …Use Assessment Tools; Introduce Logs:

Cognitive Restructuring Process

Socrates (470-399 BCE)

Socrates: First “Cognitive Therapist” in the West

Revealing the Issue: ‘What evidence supports this idea? And what evidence is against its being true?’

Considering Reasonable Alternatives: ‘What might be another reason explanation or viewpoint of the situation? What else might be happening?’

Examining Various Potential Consequences: ‘What would be the best outcome? A bearable one? The most realistic one?’

Evaluating Consequences: ‘What do you feel like when you believe “X”? What do you think you would feel like if you no longer held onto this belief?’

Distancing: ‘Imagine “A” (friend/family member) in the same situation or if they saw the situation this way, what would you tell them?’

“W H” Question Types

WhoWhatWhereWhen

WhyHowHow Much

Schema, Assumptions, Dysfunctional Beliefs, Irrational Beliefs

Schemas (Belief set about the Self, Others, and the World)

Experiences are ‘screened’ through schemas

Strong maintenance systems/ Difficult to change

Negative Assumptions Rigid Rules Look for confirmationSchemas of Mistrust, Entitlement, Avoidance,Dependence My Thoughts

Myself/ My ‘Screens’

My Rules for

Living

The CBT Model

Thoughts

FeelingsBehaviour

Triggering Event

BehaviourNATs

Feelings

BehaviourNATsFeelings

The Basic Cognitive Model

Beliefs and Assumptions Triggering

Event

Automatic Thoughts

Emotional &Behavioural Responses

Triggering Event

(Partner leaves relationship/

Job Loss, etc).

Perception of EventI’m no good. It’s my fault. I

should have been more…..Behavior

Avoids family/friends;

withdrawal

Changes in Activity LevelLow energy, disruption of

sleep, increased fatigue

Depressed Mood

I can’t deal with it. I can’t cope

Resilience Level

Help Client to Develop more Flexible Rules

OLD RULE: I cannot show weakness to anyone at any time

NEW RULES:

It might be possible to show my weak points to

some people some times.

I can explore different ways of showing weak points – some might be better than others.

Taking the initiative sometimes could give me more sense of control.

Taking the initiative sometimes might also lessen the sense of dread about being ‘found out’.

Where is the Client’s Resilience?

Capacity to Roll with the Punches?

Flexibility, Competence and Self-Efficacy (Bandura, 1977)

Find the Resilience; the Strengths in Current Life

Research: resilience in “procedural knowing”/early attachment relationships.

Internalized dyadically: balanced between stability (not too rigid) and flow (not overflowing)

When regulation and empathy imbalanced, resilience compromised. NATs

Clients often present with a lack of resilience, become overwhelm, confused, passive, feel helpless. Return to Schematic Scripts.

Rupture vs. Repair; Retreat vs. Assertively Negotiate; Emotional Cut-Off vs Re-Connection, etc.

New patterns, behaviors, strategies; confidence/ self efficacy possible

Re-WriteRules

for Living

View of Others/World

View of Self

View of Future

Automatic thoughts (NATs) center around one’s:

The Negative Triad

Negative Triad Associated with Depression Self: “I am incompetent/unlovable”

Others: “People do not care about me”

Future: “The future has no promise”

Negative Triad Associated with AnxietySelf: “I am unable to protect myself”

Others: “People cannot be trusted”

Future: “It’s a matter of time before they hurt me”

Assessment with a Specific Purpose

As part of Professional Practice, you are Already…

AssessingConceptualizingPlanningImplementingEvaluating

(Put on a different pair of glasses)

Conceptualization the Client’s presenting “profile”

Depression: Negative view of self, others, and future. Core beliefs associated with helplessness, failure, incompetence, and not loveable

Anxiety: Overestimation of physical and psychological threats. Core beliefs linked with risk, level of danger, and one’s inability to control

Cognitive Conceptualization

Triggering

Event

NATs

About Self, World

and Others

Physiology

Feelings

Behavior

Early

Life EventsUnderlying Assumptions

and Core Beliefs

Compensatory

Strategies

For Example…

Triggering Event

Boyfriend says:

“I need time to

be with my friends”

NATsAutomatic response:

“Oh no, he’s losing interest

and is going to break up

with me….”

PhysiologyHeart racing

Lump in throat

FeelingsSadness

Worry

Anger

BehaviorSeek reassurance

Withdraw

Cry

Childhood

ExperienceSaw Dad twice in 10

years; Mother

critical and

demanding

Underlying Assumptions &

Core Beliefs

“I’m was never good enough;

boyfriend has finally seen the

Real Me, People can’t be trusted

to care about me.”

Compensatory

StrategiesBe independent and

you’ll be safe.

Watch out – people

are careless with you.

Another Example

Triggering

EventFailed a Mid-

Term Test

NAT“I am not going to get

through this course and

I won’t get into med school.

I’m not as smart

as everyone else.

People will

discover this and I

will be so ashamed.”

PhysiologyPit in stomach

Dry mouth

FeelingsWorry, shame,

Disappointment

Humiliation.

BehaviorUse alcohol,

Procrastinate

with homework

Early

Experience

Parents highly

focused on

academic

results and future

career

Underlying Assumptions

“If I don’t do well academically,

I’m a total failure to my parents.

My life will be ruined”

Compensatory

Strategies

Work extra hard

to offset

incompetence.

Cognitive Distortion Example

Emotional reasoning I feel hopeless so the situation must be hopeless

All or Nothing Thinking My girlfriend broke up with me. I’ll never meet anyone else

Fortune telling I know I won’t get the job, so why should I try

Should Statements I should be able to door more, look better, etc.

Labelling I’m a failure; I’m lazy; I am not loveable

Personalization The accident happened because I’m being punished

Catastrophizing If I don’t get this job, no other job will be right for me

Mind Reading I know they say nasty things about me

Disqualifying the positive That doesn’t count because….

Selective Abstraction He said I need improvement an area, so he thinks I’m incompetent

Overgeneralization Mary doesn’t like me; nobody likes me

Irrational/Core Beliefs Example

Demand for Approval If someone doesn’t like me, I must be bad

Overly high expectations To be worthwhile, I must be competent in every area

Blame Proneness Certain people are bad and should be punished

Lack of Acceptance Things are horrible when not the way I want them to be

Emotionally Helplessness Misery is externally caused and I have no control over it

Anxious Over concern If something is remotely possible, I have to constantly be on my guard

Problem Avoidance Facing difficulties is too hard and its best to do nothing

Dependency I need someone stronger than me to rely on

Indelible past If something once had an effect on my life, that will never change

Perfectionism There is one right and correct way to do things

Irrational/Core Beliefs

Underlie and produce automatic thoughts.

Assumptions that influence our understanding about ourselves, others, and the future.

Latent until activated by stress/negative life events

Categories of core beliefs (helpless, worthless, unlovable)

Automatic ThoughtsCore Beliefs

Examples of Core Belief Sets

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 up

Unlovable core beliefs I 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 others

Worthless core beliefsI am worthless, unacceptable, bad, crazy, broken, nothing, a wasteI am hurtful, dangerous, toxic, evilI don’t deserve to live

Responding to Negative Thoughts

Define Situation: “I’m hearing you say that…”

Clarify meaning of cognitive appraisal

What 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….?

CBT Requires Full Client Commitment to the Process

Sample Thought Log

Situation Thoughts Emotions Rational

Response

Outcome

Going on vacation—Ask a colleague to do some work for me

She’ll say no…

I’m not doing a good job

The boss thinks I take too much time off

Anxiety (70%)

Guilt (40%)

Sadness (20%)

Cognitive

Distortions:

All/nothing

Mindreading

Fortune-Telling

Over-generalization

I 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%)

Basic Principles of CBT

Change mood states by using cognitive and behavioral strategies:

Identifying/modifying automatic thoughts & core beliefs,Regulating routine, and Minimizing avoidance.

Emphasis on ‘here and now’

Preference for concrete examplesStart with specific situation (complete thought log)

Reliance on Socratic questioningAsk open-ended questions

Empirical approach to test beliefsChallenge thoughts not based on evidenceCognitive restructuring

Promote symptom change

Behavioral Interventions

Breathing retraining

Relaxation

Behavioral activation

Interpersonal effectiveness training

Problem-solving skills

Exposure and response prevention

Social skills training

Graded task assignment

Cognitive Interventions

Monitor automatic thoughts

Teach imagery techniques

Promote cognitive restructuring

Examine alternative evidence

Modify core beliefs

Generate rational alternatives

What works in CBT?

Developing the Therapeutic Relationship

Shared Problem Definition/Collaborative Decision Making

Agendas, Goals, Plans, Instruments (BDI, BAI, Thought Records/Active Experiments)

Examination of cognitive beliefs and developing rational responses to NATs

Cognitive Restructuring/Behaviour Experiments /Activation (observing, comparing, reflecting, imitating and experimenting)

Relapse Prevention

The client prefers psychological interventions, alone or in addition to

medication

The “Target CBT Problems” are present (extreme, unhelpful

thinking; reduced activity; avoidant or unhelpful behaviours)

No improvement/ partial improvement on medication

Side-effects prevent an effective medication dosage (over an

adequate period)

Significant psychosocial problems (e.g. relationship problems,

difficulties at work or unhelpful behaviours such as self-cutting or

alcohol misuse) present that will not be adequately addressed by

medication alone

Circumstances in which CBT is indicated?

Advantages of CBT

Short Term (average 16 sessions)

Problem Focused Psychosocial Intervention (emphasis on long-term results --correcting problematic underlying assumptions)

Evidence based from randomized controlled trials and meta-analysis

Clear underlying model/structure/plan

Cross-cultural; based on universal laws of human behavior. Fundamental principle (that thoughts cause feelings and behaviours) makes CBT Adaptive

Focuses on the client's goals, not therapist's goals; Timely; focuses on current problems relevant to the client

Structured and results focused, but not mechanistic; reduces the possibility that sessions will become "chat sessions" in which not much is accomplished therapeutically

Compatible with a range other treatments such as medication or supportive counsellingBecause the individual is actively involved in their treatment they are more likely to stick with it.Client can use CBT model to approach other problems in life.

Client is actively involved in treatment and more likely to stick with changes madeFlexible and individualised, it can be adapted to a wide range of individuals and a variety of settings.

Disadvantages of CBT

To benefit from CBT, client must be committed to the process. Does not work without client participation. 168hrs/wk—167 outside therapy

Attending regular CBT sessions and carrying out necessary homework is time consuming

Because of structure, can be challenging for people with complex mental health needs or learning difficulties

Because emotions and anxieties are challenged, there are often initial periods of more anxiety/emotionaldiscomfort

Many current issues are rooted in unhelpful distortions created in childhood, and CBT does not focus on childhood issues or underlying causes of mental health conditions

CBT focuses on client capacity to change themselves (their thoughts, feelings and behaviours), and does not address wider problems in systems or families that often have a significant impact on an individual’s health and wellbeing.

Collaborative Relationship is Essential; Requires therapist knowledge and skills in therapeutic presence and partnering relationships

In great demand but limited numbers of specialized therapists trained; post-grad training is expensive and limited to larger centers

Highly technical language and jargon needs to be unplugged to be useful to clients (Beck’s 1979 CT of Depression dense—Flesch-Kincaid 17 years education)

Insurance companies are 20 years behind in understanding EBP

Use Reasonable Language

Classic CBT Terms Jargon “Unplugged”

1. Thinking Errors/Faulty Information Processing 1. Unhelpful Thinking Styles

2. Negative Automatic Thoughts (NATS) 2. Extreme Thinking/Unhelpful Thinking

3. Arbitrary Inference 3. Jumping to Conclusions

4. Selective Abstraction 4. Putting a Negative Slant on Things

5. Overgeneralization 5. Making Blanket Statements or Rules

6. Magnification and Minimization 6. Focusing on the Negative and Downplayingthe Positive

7. Personification 7. Taking things to heart; Taking unfair share of responsibility

8. Absolutistic Dichotomous Thinking 8. All or nothing (black or white) thinking

9. Cognitive Distortions

10. Cognitive Schemas 10. Ways of looking at yourself, other people and the world

The Vicious Cycle of the “C” and the “B” & Benefits of T

“C”Cognitions (Depressed or Anxious): Unhelpful; self-critical/dismiss strengths; dwell in the past; negative slant; negative predictions about the future; jump to conclusions; mindsecond-guess others; feel overly responsible; overly high standards for self and/or others; out of proportion thoughts

“B”(Altered) Behaviour to Feel Better: (Reduced Activity/Avoidance): With depression and anxiety, normal to experience difficulty doing things. Low energy, tiredness; Negative Thinking, so decreased interest in events, experiences, Low Mood, so reluctance to take part in activityFeelings of guilt, so “don’t deserve” pleasureAnxious thoughts, so reduce activity, things and placesLak of activity/avoidance exacerbates feelings of depression/anxiety

“T”Because problems are maintained by vicious cycles of C & B, the goal of Therapy is to help client to identify and break cycles that are part of the current problem

Five AreasAssessment

Five Areas Assessment Model informs treatmentInforms the impact of problem on client’s lifeHelps clients gain insight into relationship between C & BDoes not rule out life events & relationships, hereditary factors, neurochemistry, vicarious learning from modelling Helps match our clinical skills to patient’s problems

PRESENTER NAME

Give Clients Tools and Measure Progress

Encourage Consistent Use of Tools

Encourage Excitement about Progress!

PRESENTER NAME

Encourage Support Systems

Journey With Clients

Your footnote

See Them Meet Their Goals

counselcarecanada@bell.net

ReferencesBandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change.

Psychological Review, 84, 191-215.

Garland, A., Fox, R., & Williams, C. (2002). Overcoming reduced activity and avoidance: a Five Areas approach. Advances in Psychiatric Treatment, 8:453462.

Williams, C., & Garland, A. (2002). A cognitive-behavioural therapy assessment model for use in everyday clinical practice. Advances in Psychiatric Treatment, 8, 172-179.

Roth, A.D., & Pilling, S. (2007). The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders. A Report Commissioned by Centre for Outcomes, Research and Effectiveness (CORE), Sub-Department of Clinical Health Psychology, University College London, UK.

http://www.ucl.ac.uk/clinicalpsychology/CORE/CBT_Competences/CBT_Competence_List.pdf

Williams, C., & Garland, A. (2002). Identifying and challenging unhelpful thinking. Advances in Psychiatric Treatment, 8:377-386.

Whitfield, G., & Williams, C. (2003). The evidence base for cognitive−behavioural therapy in depression: delivery in busy clinical settings. Advances in Psychiatric Treatment, 9:21-30.

Wright, B., Williams, C., & Garland, A. (2002). Using the Five Areas cognitive- behavioural therapy model with psychiatric patients. Advances in Psychiatric Treatment, 8:307-315.

Common Components of CBTA ‘talk’ psychotherapy

Short-term focused treatment

Empirical support with randomized clinical trials

As effective as medications/ use with medication or when medications are contraindicated/ineffective.

Therapy defined by cognitive conceptualization

Establish good therapeutic relationship

Educate patients - model, disorder, therapy

Assess illness objectively, set goals

Use evidence to guide treatment decisions

Structure treatment sessions with agenda

Limit treatment length

Issue and review homework to generalize learning