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Principles of Cognitive Restructuring and Behavioral Exposure Therapy (CBT) for

Anxiety Disorders

Matt G. Kushner, Ph.D. University of Minnesota

December, 2013

Keys to Being an Effective CBT Therapist

•  Technique appropriate the problem being treated

•  Theory as a guide to explain the therapy and trouble-shoot inevitable problems

•  Structure activities during and between sessions

•  Supervision from a qualified CBT practitioner

Three Distinct CBT Techniques/ Therapies

•  Cognitive Restructuring – Aaron Beck, M.D. (psychoanalytic psychiatrist) – Albert Ellis, Ph.D. (psychoanalytic psychologist)

•  Exposure Therapy –  Ivan Pavlov, Ph.D. (experimental physiologist) –  J.B. Watson, J. Wolpe, E. Foa, Ph.D.s

(behavioral psychologists) •  Operant Conditioning

– B.F. Skinner, PhD. (experimental psychologist)

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Internalizing Externalizing

Distress Fear*

MDD Dysthymia

GAD Agora-phobia

Social Phobia

Specific Phobia

Panic Disorder

Alcohol Disord

Drug Disord

Conduct Disord

ASPD

.50

.95 .78

.86 .74 .84

.79 .71 .70

.78 .84 .59

.70 .75

Krueger and Markon, (2006), Annu. Rev. Clin. Psychol. 2:2.1-2.23

The Empirical Structure of DSM & CBT Technique Selection

Cognitive Restructuring

Exposure Therapy (also for OCD)

Operant Therapy and Skills Training

The Structure of CBT: (Regardless of Specific

Technique)

General CBT Approach •  Teaching Skills: Instilling new patterns of

behavior and thinking (not targeting biology, psychodynamics, human growth potential)

•  Homework: Progress stems from daily practice (NOT from session attendance; like learning to play an instrument)

•  Short-Term: Session last only long enough to teach, practice and consolidate new skills (usually 10-20 sessions)

•  Planned obsolescence for therapist: Therapist as teacher (rejects therapist as psychological prosthesis)

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CBT Sessions Have a Set Agenda

•  Check in (5-10 minutes) –  Status and issues

•  Review homework (5 - 10 minutes) – Compliance and trouble-shoot

•  Introduce and practice new skills (30 min) – Any assignments should be practiced in session

•  Assign homework (5-10 minutes) – Be sure it is written down

Course of CBT has a Set Structure

•  Early Sessions (1 - 3) – Assessment-conceptualize-treatment plan –  Introduce CBT model and techniques/plan

•  Middle sessions (3 - 6) – Practicing and refine skills

•  Late Sessions (7 – 10; but up to 20) – Consolidate skills and phase out therapist – Therapy ends even if symptoms are not

completely resolved.

Cognitive Restructuring

What most people mean when referring to CBT treatment

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The Guiding Philosophy of Cognitive Restructuring

Emotions and Behaviors are Reactions to One’s

Idiosyncratic Mental Constructions of Reality,

Not Reality Itself

The Same Event can Disturb

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

Epictetus – Slave and Stoic Philosopher

Reality (Nature) Has no Intrinsic Emotional Meaning

“There’s nothing either good or bad but thinking makes it so”

Shakespeare ‘s Hamlet

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Some Styles of Interpreting Reality Minimize Distress

“It’s a case of mind over matter.”

“If you don’t mind, it don’t matter.”

Alfred E. Neuman: “What? Me worry?”

Some Styles of Interpreting Reality Maximize Distress

“I don't want to achieve immortality through my work; I want to achieve immortality through not dying.” - Woody Allen

Interpretations of Reality can be Modified to Change Emotions

“You, my friend, are a victim of disorganized thinking! You are under the unfortunate impression that just because you run away you have no courage.”

The Wizard of Oz and the “Cowardly” Lion

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Habits of Thought Merge with Personality and Resist Change

“Such as are your habitual thoughts, such also will be the character of your mind; for the soul is dyed by the thoughts.”

Marcus Aurelius – Emperor and Stoic Philosopher

A Formalized Cognitive Therapy Developed in the 1950s-1970s

CT consist of testing the assumptions which one makes and identifying how certain of one's usually unquestioned thoughts are distorted, unrealistic and unhelpful

Aaron T. Beck, M.D.

A Formalized Rational Emotive Therapy Developed in the 1950s-1970s

The fundamental premise of RET is that humans, in most cases, do not merely get upset by unfortunate adversities, but also by how they construct their views of reality through their language, evaluative beliefs, meanings and philosophies about the world, themselves and others.

Albert Ellis, Ph.D.

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While Developed Independently, Beck’s CT and Ellis’ RET are both Based on the Technique of

Cognitive Restructuring CT was later renamed Cognitive

Behavioral Therapy (CBT) and RET was later renamed Rational Emotive

Behavioral Therapy (REBT)

Cognitive Restructuring: The A-B-C Mnemonic

•  Activating Event occurs (reality) •  Belief about what the event (A)

means (a mental construction) •  Consequences in terms of emotions

and behaviors stem from “B” rather than from “A”

(A) NOISE

(B1) Burglar (B2) Cat (B3) Spouse arriving safe

(C1) Panic à 911

(C2) Irritated

(C3) Relief/ Happy

One “A” Can Produce Multiple Bs and Cs: Example 1

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(A) DIVORCE

(B1) Failure as a mother

(B2) Kids can adapt

(B3) Saving kids from bad

home life

(C1) Self-Loathing

(C2) Hopeful

(C3) Proud

One “A” Can Produce Multiple Bs and Cs: Example 2

(A) RAPID HR

(B1) Heart Attack

(B2) Too much coffee

(B3) I’m in Love

(C1) Panic (C2) Neutral (C3) Joy

One “A” Can Produce Multiple Bs and Cs: Example 3

Reality to Belief Alignment Regarding Danger

Bel

ief

Reality

Dan

ger

Safe

Safe Danger

False Alarm

False Safety

True Safety

True Alarm

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“Important if True” •  If you correctly believe you are in

immediate danger, panic and help seeking may save your life (true alarm)

•  If you mistakenly believe you are in immediate danger panic and help seeking is unnecessary (false alarm)

•  Repeated false alarms are dysfunctional and ultimately constitute an anxiety disorder.

The Goal of CR: Alignment of Belief with Reality

Bel

ief

Reality

HR

=Dan

ger

HR

=Saf

e

Safe Danger

False Alarm

False Safety

True Safety

True Danger

CB

T

CB

T

How Can we Evaluate the Probability that an Alarm is True? 1.  Organize information using the A-B-C

formulation 2.  Conduct truth testing exercises

•  Analytical •  Empirical

3.  Repetition of exercise in real-time is critical for cognitive restructuring to become established.

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Identify the A-B-Cs the Test the B Date/Time A

(Activating Event)

SITUATION

C (Consequence) (Rate

intensity 0-100)

EMOTION/ BEHAVIOR

B (Belief)

(Rate certainty 0-100)

AUTOMATIC THOUGHT

D (Dispute)

TRUTH TESTING OF THE

BELIEF

11/1, 1 a.m. Notice rapid

heart rate, sweating, SOB

panic 100% Go to ER

I’m having a heart attack – 80% I’m dying 100%

The Technology of “Truth Testing” Beliefs in CT

1.  Socratic Questioning as an analytic method to examine premises and assumptions leading to errors.

2.  Behavioral Experiments as an empirical method for testing beliefs

3.  Labeling Thinking Errors as a means of identifying characteristic repetitive errors in thinking.

“Socratic Questioning” Minimizes Resistance to New Thinking

•  What is the evidence for the upsetting belief?

•  What is the evidence against the upsetting belief?

•  Given the evidence, what is the probability of the belief being truth?

•  What are alternatives explanations for the facts other than the upsetting belief?

•  How bad would it be if the belief were true?

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Behavioral Experiments to Test Hypotheses Related to Beliefs

•  Therapist: If you were having a HA, why aren’t you dead?

•  Patient: If I hadn’t gotten out of the store when I did, I would have died. I will next time.

•  Therapist: How do you know? Did you ever try staying to see what would happen?

•  Patient: No. •  Therapist: What experiments could we conduct

to test this upsetting belief?

Note: All patients are first medically evaluated and behavioral experiments deemed medically safe

Labeling Common Thinking Errors Helps to “Short-Hand” Results

•  Overestimating: Alarm in response to serious but unlikely threat (e.g., HA, die in a car crash, becoming homeless)

•  Catastrophizing: Alarm in response to a likely but not serious threat (e.g., sweating, being average, not having found a mate)

Thought-Mood Log Date/Time A

(Activating Event)

SITUATION

C (Consequence) (Rate intensity

0-100)

EMOTION

B (Belief)

(Rate certainty 0-100)

AUTOMATIC THOUGHT

D (Dispute)

RATIONAL RESPONSE

11/1, 1 a.m. Notice

rapid heart rate

panic 100 Go to ER

I’m having a heart attack – 80% I’m dying 100%

1)   What is the evidence for and against HA?

2)   What can explain symptoms other than a HA?

3)   Behavioral Experiments?

4)   Thinking Errors?

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Arbitrary “Rules” (Schema) Can Maintain Dysfunctional Thinking

•  I must be loved/liked by everyone

•  Evil people must be made to pay

•  It’s unacceptable when things don’t go as I’ve hoped

•  I need to respond to all possible dangers

•  I need someone to take care of me

•  I need to be competent and high achieving in all respects

•  I should have control over things important to me

Faulty Reasoning Can Maintain Dysfunctional Thinking

1.  All or nothing thinking 2.  Over-generalization 3.  Mental Filter 4.  Disqualifying the positive 5.  Jumping to conclusions 6.  Magnification and minimization 7.  Emotional reasoning 8.  Shoulding 9.  Labeling 10. Personalization and blame

Exposure Therapy (ET)

Also called Exposure with Ritual Prevention (ERP)

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Classical Conditioning is the Foundation for Exposure Therapy

Classically Conditioned Fear

Red Light

Neutral Stimulus

Painful Shock

Unconditioned Stimulus

Fear of light

Conditioned Stimulus

Classically Conditioned Fear: OCD Model

Toilet

NS

Association with Illness

UCS

Fear of Toilets

CS

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Classical Extinction Training

Conditioned Stimulus

No Unconditioned

Stimulus

Decreased fear of CS:

“Extinction Learning”

I feel safe

again

Exposure: Clinical Equivalent of Extinction Learning

1.  Identify 10 or more gradations of the feared stimulus

2. Arrange triggers from lowest to highest elicitors of the CR

3. Start with less fear provoking daily exposures until habituation (extinction) occurs then increase intensity.

Extinction Training: OCD (“Exposure Therapy”)

Touch Toilet

Conditioned Stimulus

No Illness Follows

No Unconditioned

Stimulus

Habituation of Contamination

Fears

Right?

Wrong!

Contamination Fears Continue

even with no UCS

Why?

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Ongoing Rituals Block Extinction Learning

•  Rituals do not allow disconfirming evidence to result from the exposure – washing hands immediately after exposure

•  Rituals are a form of avoidance –  “I would have gotten sick from touching the

toilet but I washed off the germs.” •  Negative reinforcement (e.g., relief from

not getting sick) strengthens rituals and prevents habituation

Exposure in OCD Must Include Ritual Prevention

•  Chair = 40 •  Doorknob = 50 •  Public phone = 60 •  Money = 65 •  Reddish stain = 75 •  Bathroom door = 80 •  Bathroom sink = 80

•  Bathroom stall door = 85

•  Toilet seat = 95 •  Flush handle = 100

Note: No washing rituals for at least 2-4 hours after each exposure exercise.

Three Traditional Indicators of Successful Exposure Therapy

1.  Physiological arousal and subjective fear occurs during the exposure

2.  Fear responses gradually diminish during the exposure

3.  Initial fear response at the beginning of each exposure session gradually diminishes

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“Habituation” (Extinction Learning) Over One Week of Exposure

Subj

ectiv

e D

istr

ess

0

100

Exposure Practice Days 1 2 3 4 5 6 7

1hr exposure 1hr

exposure 1hr

exposure 1hr exposure 1hr

exposure 1hr exposure 1hr

exposure

--

--

--

--

50

75

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Types of “Feared” Stimuli and Exposure Approach

“Introceptive” Exposures

“Imaginal” Exposures

“Situational” Exposures

Short of breath Blasphemy Crowds, dogs, high places, bugs

Sweat, tremble Pedophile Parties (social)

Rapid Heart Kill Driving

Dizzy Gay Bathrooms (OCD contamination triggers)

Innovations on the Horizon

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Emerging Areas of Research Advancing CBT Effectiveness

•  Integrated/Trans-Diagnostic Protocols – Rather than a distinct protocol/manual for

each diagnosis •  Integration of Neuroscience of Learning

(chemical, magnetic, electrical) – Enhancement of therapeutic learning (e.g.,

D-Cycloserine) – Blockade of (even erasure) of pathological

memories (e.g., beta-blockers)

END