Theory and Practice of Theory and Practice of Cognitive Behavioral Cognitive Behavioral

Therapy Therapy

Department of Psychiatry & Department of Psychiatry & Behavioral NeuroscienceBehavioral Neuroscience

Cognitive-Behavior Therapy Cognitive-Behavior Therapy ProgramProgram

MS-3 Clerkship 2008-2009MS-3 Clerkship 2008-2009

Shona N. Vas, Ph.DShona N. Vas, Ph.D..

OutlineOutline

What is Cognitive Behavior Therapy (CBT)? What is Cognitive Behavior Therapy (CBT)?

What are the basic principles of treatment? What are the basic principles of treatment?

What is the course of treatment?What is the course of treatment?

What are some examples of interventions?What are some examples of interventions?

Who is appropriate for CBT?Who is appropriate for CBT?

What is CBT?What is CBT? Set of ‘talk’ psychotherapies that treat Set of ‘talk’ psychotherapies that treat

psychiatric conditions. psychiatric conditions. Short-term focused treatment. Short-term focused treatment. Strong empirical support with Strong empirical support with

randomized clinical trials.randomized clinical trials. As effective as psychiatric As effective as psychiatric

medications.medications. Recommended as critical component Recommended as critical component

of treatment, particularly when of treatment, particularly when medications are contraindicated or medications are contraindicated or ineffectiveineffective..

Why So Popular?Why So Popular?

Clear treatment approach for Clear treatment approach for patientspatients

Assumptions make sense to patients Assumptions make sense to patients Based on patient’s experienceBased on patient’s experience Encourages practice and complianceEncourages practice and compliance Patients have a sense of controlPatients have a sense of control CBT works!CBT works!

Definition of Cognitive Definition of Cognitive TherapyTherapy

CT is a focused form of psychotherapy CT is a focused form of psychotherapy based on a model stipulating that based on a model stipulating that psychiatric disorders involve dysfunctional psychiatric disorders involve dysfunctional thinking.thinking.

Dysfunctional/distorted thinking arises Dysfunctional/distorted thinking arises from both biological and psychological from both biological and psychological influencesinfluences

Individuals’ emotional, behavioral, and Individuals’ emotional, behavioral, and physiological reactions are influenced by physiological reactions are influenced by the way they structure their environment.the way they structure their environment.

J. Beck, 1995

Definition of CT Definition of CT (continued…)(continued…)

Modifying dysfunctional thinking and Modifying dysfunctional thinking and behavior leads to improvement in behavior leads to improvement in symptoms.symptoms.

Modifying dysfunctional beliefs which Modifying dysfunctional beliefs which underlie dysfunctional thinking leads underlie dysfunctional thinking leads to more durable improvementto more durable improvement

Definition of CT Definition of CT (continued…)(continued…)

Cognitive therapy is defined by a cognitive Cognitive therapy is defined by a cognitive formulation of the disorder and a cognitive formulation of the disorder and a cognitive conceptualization of the particular patient.conceptualization of the particular patient.

Cognitive therapy is not defined by the use Cognitive therapy is not defined by the use of exclusively cognitive techniques. of exclusively cognitive techniques. Techniques from many modalities are Techniques from many modalities are used.used.

CT also often referred to as Cognitive-CT also often referred to as Cognitive-Behavior Therapy (CBT). Behavior Therapy (CBT).

Rationale for CBTRationale for CBT

Negative emotions are elicited by cognitive Negative emotions are elicited by cognitive processes developed through influences of processes developed through influences of learning and temperament. learning and temperament.

Adverse life events elicit automatic processing, Adverse life events elicit automatic processing, which is viewed as the causal factor. which is viewed as the causal factor.

Cognitive triad: Negative automatic thoughts Cognitive triad: Negative automatic thoughts center around our understanding of:center around our understanding of:– OurselvesOurselves– Others (the world)Others (the world)– Future Future

Focus on examination of cognitive beliefs and Focus on examination of cognitive beliefs and developing rational responses to negative developing rational responses to negative automatic thoughts. automatic thoughts.

Beck et al., 1979Beck et al., 1979

Cognitive Specificity Cognitive Specificity HypothesisHypothesis

Distorted appraisals follow themes Distorted appraisals follow themes relevant to the specific psychiatric relevant to the specific psychiatric condition.condition.

Psychological disorders are characterized Psychological disorders are characterized by a different psychological profile.by a different psychological profile.

– DepressionDepression: Negative view of self, others, and : Negative view of self, others, and future. Core beliefs associated with future. Core beliefs associated with helplessness, failure, incompetence, and helplessness, failure, incompetence, and unlovability.unlovability.

– AnxietyAnxiety: Overestimation of physical and : Overestimation of physical and psychological threats. Core beliefs linked with psychological threats. Core beliefs linked with risk, dangerousness, and uncontrollability.risk, dangerousness, and uncontrollability.

Cognitive SpecificityCognitive Specificity

Negative Triad Associated with Negative Triad Associated with DepressionDepression– Self Self “I am incompetent/unlovable”“I am incompetent/unlovable”– Others Others “People do not care about me”“People do not care about me” – Future Future “The future is bleak”“The future is bleak”

Negative Triad Associated with AnxietyNegative Triad Associated with Anxiety– Self Self “I am unable to protect myself”“I am unable to protect myself”– Others Others “People will humiliate me”“People will humiliate me” – Future Future “It’s a matter of time before I am “It’s a matter of time before I am

embarrassed” embarrassed”

Targeted Cognitions for Different Targeted Cognitions for Different DisordersDisorders

OCD: appraisals of obsessive OCD: appraisals of obsessive cognitionscognitions

Anorexia: control, worth, perfectionAnorexia: control, worth, perfection Panic: catastrophic misinterpretation Panic: catastrophic misinterpretation

of physical sensationsof physical sensations Paranoia: trust, vulnerabilityParanoia: trust, vulnerability

Working Model of CBTWorking Model of CBT

Event Appraisal

Maladaptive Behavior

Affective andBiological Arousal

Behavioral Inclination

Thase et al., 1998Thase et al., 1998

Cognitive ModelCognitive Model

Triggering EventBill goes to collection

Appraisal “I can never do anything right…”Behavior

Avoidance; withdrawal

Bodily SensationsLow energy, disruption ofsleep, increased fatigue

Behavioral Inclination“I don’t want to deal with it”“It’s too stressful to think about it”

Thase et al., 1998Thase et al., 1998

What are Automatic What are Automatic Thoughts?Thoughts?

What was going through your What was going through your mind?mind? Happen spontaneously in response to Happen spontaneously in response to

situationsituation Occur in shorthand: words or imagesOccur in shorthand: words or images Do not arise from reasoningDo not arise from reasoning No logical sequenceNo logical sequence Hard to turn offHard to turn off May be hard to articulateMay be hard to articulate

Stressful Situation

Automatic Thoughts Negative

Emotions

Cognitive DistortionsCognitive Distortions

Patients tend to make consistent Patients tend to make consistent errors in their thinkingerrors in their thinking

Often, there is a systematic negative Often, there is a systematic negative bias in the cognitive processing of bias in the cognitive processing of patients suffering from psychiatric patients suffering from psychiatric disordersdisorders

Help patient identify the cognitive Help patient identify the cognitive errors s/he is most likely to makeerrors s/he is most likely to make

Types of Cognitive DistortionsTypes of Cognitive Distortions

– Emotional reasoningEmotional reasoning Feelings are facts Feelings are facts– Anticipating negative outcomes The worst will Anticipating negative outcomes The worst will

happen happen – All-or-nothing thinking All-or-nothing thinking All good or all All good or all

badbad– Mind-readingMind-reading Knowing what others are Knowing what others are

thinkingthinking– PersonalizationPersonalization Excess Excess

responsibilityresponsibility– Mental filterMental filter Ignoring the Ignoring the

positivepositive

Examples Examples

Cognitive DistortionsCognitive Distortions– Emotional Reasoning: Emotional Reasoning: “I feel incompetent, so I “I feel incompetent, so I

know I’ll fail”know I’ll fail”– Catastrophizing: Catastrophizing: “It is going to be terrible”“It is going to be terrible”– Personalization:Personalization: “It’s always my fault” “It’s always my fault”– Black or white thinking: Black or white thinking: “If it isn’t perfect, it’s “If it isn’t perfect, it’s

no good at no good at all.”all.”

Core BeliefsCore Beliefs Core beliefs underlie and produce Core beliefs underlie and produce

automatic thoughts.automatic thoughts. These assumptions influence information These assumptions influence information

processing and organize understanding processing and organize understanding about ourselves, others, and the future.about ourselves, others, and the future.

These core beliefs remain dormant until These core beliefs remain dormant until activated by stress or negative life activated by stress or negative life events. events.

Categories of core beliefs (helpless, Categories of core beliefs (helpless, worthless, unlovable)worthless, unlovable)

Automatic ThoughtsCore Beliefs

Examples of Core BeliefsExamples of Core Beliefs Helpless core beliefsHelpless core beliefs

– I am inadequate, ineffective, incompetent, can’t copeI am inadequate, ineffective, incompetent, can’t cope– I am powerless, out of control, trappedI am powerless, out of control, trapped– I am vulnerable, weak, needy, a victim, likely to be hurtI am vulnerable, weak, needy, a victim, likely to be hurt– I am inferior, a failure, a loser, defective, not good enough, don’t I am inferior, a failure, a loser, defective, not good enough, don’t

measure upmeasure up Unlovable core beliefsUnlovable core beliefs

– I am unlikable, unwanted, will be rejected or abandoned, always I am unlikable, unwanted, will be rejected or abandoned, always be alonebe alone

– I am undesirable, ugly, unattractive, boring, have nothing to offerI am undesirable, ugly, unattractive, boring, have nothing to offer– I am different, flawed, defective, not good enough to be loved by I am different, flawed, defective, not good enough to be loved by

othersothers Worthless core beliefsWorthless core beliefs

– I am worthless, unacceptable, bad, crazy, broken, nothing, a I am worthless, unacceptable, bad, crazy, broken, nothing, a wastewaste

– I am hurtful, dangerous, toxic, evilI am hurtful, dangerous, toxic, evil– I don’t deserve to liveI don’t deserve to live

Cognitive ConceptualizationCognitive Conceptualization

Current Situation

Automatic ThoughtsAbout self, world

And others

Physiology

Feelings

Behavior

Childhood And EarlyLife Events

Underlying Assumptions and Core Beliefs

Compensatory Strategies

Example 1Example 1

SituationPartner says: “I need time to be with my friends”

Automatic ThoughtsAutomatic response:

“Oh no, he’s losing interest and is going to break up

with me….”

PhysiologyHeart racingLump in throat

FeelingsSadnessWorryAnger

BehaviorSeek reassuranceWithdrawCry

Childhood ExperiencesParental neglectand criticism

Underlying Assumptions & Core Beliefs

“I’m flawed in numerous ways, which means I’m not worthy of consistent attention and care. People only care when they want something.”

Compensatory StrategiesBe independent and you’ll be safe.Watch out – people are careless with you.

Example 2Example 2

SituationDisappointingexam result

Automatic Thoughts“I am not going to get through this program -

I’m not as smart as everyone else.

People willdiscover this and I will be humiliated.”

PhysiologyPit in stomachDry mouth

FeelingsWorry, shame,DisappointmentHumiliation.

BehaviorUse alcohol,Procrastinate with homework

Childhood Adversities

Parental standardsreinforce academic

achievement

Underlying Assumptions

“If I don’t excel in school, I’m a total failure”

Compensatory Strategies

Work extra hardto offset

incompetence.

Responding to Negative Responding to Negative ThoughtsThoughts

Define SituationDefine Situation

Clarify meaning of cognitive appraisalClarify meaning of cognitive appraisal

– What was going through your mind just then?What was going through your mind just then?– What did the situation mean for you?What did the situation mean for you?

Evaluate interpretationEvaluate interpretation– Evidence:Evidence: For and against this belief? For and against this belief?– Alternatives:Alternatives: Any other explanation(s)? Any other explanation(s)?– Implications:Implications: So what….? So what….?

Evaluating Negative Evaluating Negative ThoughtsThoughts

What is the effect of telling myself What is the effect of telling myself this thought?this thought?

What could be the effect of changing What could be the effect of changing my thinking?my thinking?

What would I tell ___ (a friend/family What would I tell ___ (a friend/family member) if s/he viewed this situation member) if s/he viewed this situation in this way?in this way?

What can I do now?What can I do now?

Sample Thought LogSample Thought Log

SituationSituation ThoughtsThoughts EmotionEmotionss

RationalRational

ResponseResponseOutcomeOutcome

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

She’ll say no…She’ll say no…

I’m not doing a I’m not doing a good jobgood job

The boss thinks I The boss thinks I take too much take too much time offtime off

Anxiety Anxiety (70%)(70%)

Guilt (40%)Guilt (40%)

Sadness Sadness (20%)(20%)

Cognitive Cognitive

Distortions:Distortions:

All/nothingAll/nothing

MindreadinMindreadingg

Fortune-Fortune-TellingTellingOver-Over-generalizatiogeneralizationn

I haven’t I haven’t taken a day taken a day off in 6 off in 6 months. We months. We work as a work as a team, so it’s team, so it’s also her job to also her job to track the track the samples.samples.

Anxiety (10%)Anxiety (10%)

Guilt (0%)Guilt (0%)

Relief (40%)Relief (40%)

Common Components of CBTCommon Components of CBT

Establish good therapeutic relationshipEstablish good therapeutic relationship Educate patients - model, disorder, Educate patients - model, disorder,

therapytherapy Assess illness objectively, set goalsAssess illness objectively, set goals Use evidence to guide treatment decisionsUse evidence to guide treatment decisions Structure treatment sessions with agendaStructure treatment sessions with agenda Limit treatment lengthLimit treatment length Issue and review homework to generalize Issue and review homework to generalize

learninglearning

Course of TreatmentCourse of Treatment1.1. Assessment Assessment

2.2. Provide rationale Provide rationale

3.3. Training in self-monitoringTraining in self-monitoring

4.4. Behavioral strategiesBehavioral strategies1.1. Monitor relationship between situation/action and Monitor relationship between situation/action and

mood.mood.

2.2. Applying new coping strategies to larger issues.Applying new coping strategies to larger issues.

5.5. Identifying beliefs and biasesIdentifying beliefs and biases

6.6. Evaluating and changing beliefs Evaluating and changing beliefs

7.7. Core beliefs and assumptionsCore beliefs and assumptions

8.8. Relapse prevention and terminationRelapse prevention and termination

Basic PrinciplesBasic Principles Change mood states by using cognitive and Change mood states by using cognitive and

behavioral strategies:behavioral strategies:– Identifying/modifying automatic thoughts & core beliefs,Identifying/modifying automatic thoughts & core beliefs,– Regulating routine, and Regulating routine, and – Minimizing avoidance. Minimizing avoidance.

Emphasis on ‘here and now’Emphasis on ‘here and now’ Preference for concrete examplesPreference for concrete examples

– Start with specific situation (complete thought log) Start with specific situation (complete thought log) Reliance on Socratic questioningReliance on Socratic questioning

– Ask open-ended questionsAsk open-ended questions Empirical approach to test beliefsEmpirical approach to test beliefs

– Challenge thoughts not based on evidenceChallenge thoughts not based on evidence– Cognitive restructuringCognitive restructuring

Promote rapid symptom changePromote rapid symptom change

Behavioral InterventionsBehavioral Interventions

Breathing retrainingBreathing retraining Relaxation Relaxation Behavioral activation Behavioral activation Interpersonal effectiveness training Interpersonal effectiveness training Problem-solving skillsProblem-solving skills Exposure and response preventionExposure and response prevention Social skills trainingSocial skills training Graded task assignmentGraded task assignment

Cognitive InterventionsCognitive Interventions

Monitor automatic thoughtsMonitor automatic thoughts Teach imagery techniquesTeach imagery techniques Promote cognitive restructuring Promote cognitive restructuring Examine alternative evidenceExamine alternative evidence Modify core beliefs Modify core beliefs Generate rational alternativesGenerate rational alternatives                                                            

EfficacyEfficacy

Cognitive and behavioral approaches Cognitive and behavioral approaches are effectiveare effective

Supported by over 325 controlled Supported by over 325 controlled outcome studiesoutcome studies

State-of-the-art therapy, manualizedState-of-the-art therapy, manualized

Applications of CBTApplications of CBT Mood DisordersMood Disorders

– Unipolar Depression (1979)Unipolar Depression (1979)– Bipolar Disorder (1996)Bipolar Disorder (1996)– Dysthymia and Chronic MDD (2000)Dysthymia and Chronic MDD (2000)

Anxiety DisordersAnxiety Disorders– GAD (1985)GAD (1985)– Social Phobia (1985)Social Phobia (1985)– Panic Disorder (1986)Panic Disorder (1986)– OCD (1988)OCD (1988)– PTSD (1991)PTSD (1991)

Emotional Disorders (2006)Emotional Disorders (2006)

Applications of CBTApplications of CBT (Continued…)(Continued…)

Eating Disorders (1981)Eating Disorders (1981) Marital ProblemsMarital Problems Behavioral MedicineBehavioral Medicine

– Headaches (1985)Headaches (1985)– Insomnia (1987)Insomnia (1987)– Chronic Pain (1988)Chronic Pain (1988)– Smoking CessationSmoking Cessation– HypochondriasisHypochondriasis– Body Dysmorphic DisorderBody Dysmorphic Disorder

Controlled Outcome Studies Controlled Outcome Studies on CBTon CBT

Unipolar Unipolar Depression (~30)Depression (~30)

Eating Disorders Eating Disorders – Anorexia (~5)Anorexia (~5)– Bulimia (~15)Bulimia (~15)

Generalized Generalized Anxiety Disorder Anxiety Disorder (~12)(~12)

Social Phobia (~14) Social Phobia (~14) Panic Disorder (~10) Panic Disorder (~10) Borderline P.D. (2)Borderline P.D. (2) Schizophrenia (~45)Schizophrenia (~45) C/A Depression (8)C/A Depression (8) Chronic Depression Chronic Depression

(1)(1)

ConclusionsConclusions

System of psychotherapies System of psychotherapies Unified theory of psychopathologyUnified theory of psychopathology Short-term treatmentShort-term treatment Objective assessment and Objective assessment and

monitoringmonitoring Strong empirical supportStrong empirical support As effective as pharmacotherapyAs effective as pharmacotherapy

Questions? Questions? Comments?Comments?

Dr. Shona VasDr. Shona Vas(773) 702-1517(773) 702-1517

Psychiatry Department Office: A-Psychiatry Department Office: A-312312

svas@yoda.bsd.uchicago.edusvas@yoda.bsd.uchicago.edu