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General Survey of Cognitive-Behavioral Therapy Strategies
The Model and The Techniques

Kevin D. Arnold, Ph.D., ABPP

Director, The Center for Cognitive and Behavioral Therapy of Greater Columbus

614.459.4490

Theory Behind CBT
Barlows Theory of Emotional DisordersBarlow (1991) & Moses and Barlow (2006)Key ConceptsEmotional RegulationEmotional MemoryAntecedent Cognitive AppraisalsEmotionally Driven Behaviors (EDBs)Avoidance

Theory Behind CBT
Emotional Regulation: Key Strategies*Situational Control
Situation Selection

Predictive Model of Emotional Arousal Features and Likelihoods

Costs and Benefits Assessment of Regulation vs. Experience

Situation Modification

Modification of the Physical, External Environment
Attention
Attention Deployment

Distraction to Other Situational Features or Away Completely

Concentration on Emotional Experience, Situational Factors, or Predictions

Theory Behind CBT

*Gross & Thompson, 2007

Theory Behind CBT
Emotional Regulation: Key Strategies*Appraisal
Cognitive Appraisal

Modification of Appraisal (e.g., threat value, label of event)
Response
Response Modulation

Relaxation Strategies

Expression of Emotion (Behavioral, Verbal)

Adaptive Response Alternatives

*Gross & Thompson, 2007

Theory Behind CBT

Theory Behind CBT
Emotional Memory* and AnxietyDisclaimerNot a NeuropsychologistRole of Amygdala and Prefrontal Cortex in Anxiety
Amygdala Stores Stress Arousal as Nondeclarative Memory

In Contrast, Hippocampus Stores Declarative Memory

PFC Necessary to Habituate to Anxiety

Habituation is New Learning Allowing PFC to Modulate Amygdala Arousal and Enhance Declarative Recall Through Hippocampus

PFC can also prevent the acquisition of fear conditioning or excite the amygdala and increase fear. (pp. 36-37)

*Quirk, 2007

Theory Behind CBT
Emotional Memory* and DepressionDisclaimerNot a NeuropsychologistRole of Amygdala and Prefrontal Cortex in Depression
PFC Activation Levels Needed to be Higher in Depressed Patients For Working Memory Performance

Predisposition to Serotonin Based Abnormalities Associated with Increased Activity in Amygdala and with Abnormalities in Connection of Prefrontal Cortex and Amygdala.

*Davidson, Fox & Kalin, 2007

Theory Behind CBT
Impact on the HPA AxisThe HPA Axis is the Hypothalamus-Pituitary-Adrenal AxisChanges in HPA Axis Functioning Have Been Found in Early Developmental Exposure to Trauma*
Predisposes to later MDD and PTSD Vulnerability
Early Trauma has been Shown to Reduce Hypothalamic MassIn utero Exposure to Stress Reveals Changes in Fetus and Infant Dysregulation of the HPA System Leading to Greater Degrees of Stress and Anxiety
*Shea, Walsh, MacMillan & Steiner (2006)

Theory Behind CBT

Theory Behind CBT
Antecedent Cognitive AppraisalsEarly Learning During Parenting Interactions or Traumas Regarding Self-Efficacy or ThreatsAppraisal of Likelihood of Negative Event OccurrenceAppraisal of Catastrophic OutcomeAppraisal of Incapacity to Effect Outcomes or Manage OutcomesAppraisal of Others as Harsh (Punitive Parenting) or Unsupportive (Dismissive Parenting)Overall Situational Appraisal & Development of Assumptive Schemas

Theory Behind CBT
Emotionally Driven Behaviors (EDBs)Behavioral Response ProbabilitiesActivation of Learned, Adaptive Responses to Over-generalized and Inappropriate Emotional RecallReduce Emotional Arousal
Negative Reinforcement
When EDBs Lead to Unhealthy Outcomes
Social Isolation, Avoidance of Adaptive Situations, Reduction in Relationship Connections

Theory Behind CBT
AvoidanceEscape is an EDB to Exit to Reduce ArousalAvoidance is to Prevent Arousal or Full ArousalForms of Avoidance
Subtle Behavioral Avoidance

Avoiding Eye Contact, Procrastination

Cognitive Avoidance

Distraction, Stonewalling, Mental Rituals, Thought Stopping

Safety Signals

Shaking Medicine Bottles, Keeping Positive Association Objects Handy, Good Luck Charms, Carrying Cleaners

Theory Behind CBT
Examples from Moses & Barlow (2006)Behavioral AvoidanceAvoid Eye ContactSocial PhobiaAvoiding Physiological ArousalPanic/DepressionProcrastinationGeneralized AnxietyCognitive AvoidanceForced Positive Self TalkDepressionDistractionPanic/DepressionWorryingGeneralized AnxietySafety SignalsGood Luck CharmsOCDCarrying Good Feeling ObjectsDepression/GADCarrying Items to Hide Face or Bodily ReactionsSocial Phobia

The Basic CBT Model
Beck & Others ApproachPsychopathology is bio-psycho-socialFeelings can be managed through addressing cognitions and behaviorsPsychopathology has deficits in behaviors and maladaptive or distorted cognitionsUnderlying assumptions have been learned in an if-then formatSchemas create a construction that is maladaptive now, but not when first developed
Theory Behind CBT

Cognitive Triad
Cognitive TriadDistorted Thoughts are those that are mood congruent but not reflective of the evidence in lifeThese are sometimes referred to as Automatic ThoughtsThe thoughts fit basically into three categories: Self, Others/World, or Future
Theory Behind CBT

Cognitive Blockade
Cognitive BlockadeMood or other pathologic processes create a filtering of information that is state-dependentInformation, both internal and external, is filtered so that only mood congruent information is a) perceived, or b) valued.Overcoming the impact of the blockade is a major goal of CBT
Theory Behind CBT

Treatment Method: General
IT IS AN APPROACH, NOT A MANUALCognitive Therapy is collaborative so that the patient and therapist are a team working on problems togetherCognitive Therapy is active and engages the patient through a treatment relationship that encourages but respects the patient through empathyCognitive Therapy uses the Socratic Method, using questions whenever possible

Socratic MethodQuestions are used in CBT to
Help the patient become aware of thoughts

Examine thoughts to identify distortions

Replace distortions with health and evidenced based ideas

Plan to develop new thinking patterns

Self-Awareness of EDBs


CollaborativeTherapy is guided by a team approach to problems
The treatment conceptualization is created collaboratively as a basis for the treatment methods

The structure of the sessions is agreed upon as a way of keeping the collaborative work moving

Both agree on structure and direction


Structure and DirectionAll sessions use the following template
Setting an agenda

Bridging back to the previous session

Setting a target for the session

Application of the CBT techniques to the target

Summarization of the session

Setting homework

Feedback on the session

Problem OrientationConceptualization: Patients problems within a present, learning contextOrientation to the Present/Here and NowSelection of strategies and techniquesAssess the effectiveness of the CBT on the problem within its context

Common Strategies in CBT
SimplifyDo it nowYou cant know unless you experimentIf you are off track, do the oppositePersistence will produce changeBreak it down and take one thing at a timeDo that which you dont expect yourself to doPull, dont push/Flow

EducateCBT educates patients to be their own therapists
Help the patient to learn how to learn

Its not resistance, its reluctance

Its not resistance, its slowness

Patients learn inductively

Beliefs are hypothesis

Testing them can provide insight or new ways of thinking

Key ElementsBehavioral ExperimentationDaily Activity RecordsActivity SchedulingPleasure SchedulingIdentify Distortions through Self-Monitoring (3 Column) and Labeling Automatic ThoughtsTest the EvidenceChallenge and Create New Thoughts (5 Column)

Cognitive Distortions
Related to MoodDont represent evidence or have gone unchallengedHave not been evaluated, instead assumed to be trueLearned based on historySee Handout

Assessing the Automatic ThoughtsQuestion, Question, QuestionListen, Listen, ListenDownward ArrowImaging a SituationNoticing Affect and Calling Out the Thoughts

Strategies for Challenging and Restructuring Cognitive DistortionsDefining Terms Cost-Benefit Analysis of Idea or Belief Modified 5-Column/Testing the Evidence Testing the Utility of the Evidence Evaluating Labels Changing Behavior to Test Ideas Examining Should Statements Articulating Values and Changing Them Progress not Perfection Old Rules, New Rules New Bill of Rights Monitor Feelings/Ideas and Label Distortions Downward Arrow/Vertical Decent
Loosely Based on Leahy, 2003

Cognitive DistortionsMind Reading: Assuming you know what others are thinkingFuture Predicting: Appraisal of future eventsCatastrophizing: Predicting the worst possible outcomeLabeling: Using global labels to describe yourself or othersBlack-White Reasoning: Thinking in all or none terms not shades of grayRegret Orientation: Looking back and not living in the moment of the nowArbitrary Inferences: Drawing conclusions from little or no evidenceFiltering: Noticing only the things that confirm your ideasPersonalizing: Thinking that everything is your fault or that others are targeting you specificallyOvergeneralizing: Using evidence from a specific context and applying a rule to many other contextsShould/Would/Could: Thinking in terms of morals or shoulds, rather than the actual evidence in the situation
Loosely Based on Leahy, 2003

Behavioral Activation
Behavioral Activation is Designing Actions into a Patients Behavioral RepertoireActivity SchedulingPleasure SchedulingFunctional Behavior Analysis in the SessionReward Erosion and Mood Problems+ + -

Activity SchedulingActivity Monitoring and Recording
Mastery

Pleasure

Hour Blocks vs. Sections of the Day
Activity Scheduling
Designing Routines

Increasing High Ms and Ps

Pleasure SchedulingInventories
Past

Present

Wishes
Scheduling the Pleasure
Behavioral Experiments

Self-Monitoring

Foot in the Door First

Application of Functional AnalysisUse of the Therapy Relationship to Differentially Deliver Reinforcement or PunishmentIdentification of Clinically Relevant Behaviors
CRB1: Those to Decrease

CRB2: Those to Increase
Observe CRBsElicit CRBs
Develop Alternate Behaviors to CRB1s
Differentially Apply RewardsDesign Generalization invivo Cuijpers, van Straten, and Warmerdam (2007) showed in meta-analysis that Behavioral Activation was Effective
See Kanter, Manos, Busch, and Rusch, 2008

Self-DeterminationDevelopment of Personal GoalsIdentification of Stimuli to Old BehaviorsModification of Stimuli ExposureTraining New Behaviors to Stimuli (Self-Regulation of Natural Prompts)

Relaxation Therapy
Controlled BreathingConcentration
Rhythm

Sensations
Suggestive Relaxation16 Muscle Group PMRPractice 2x per day

Relaxation Therapy
Uses of Relaxation TherapyCued Affect ManagementCounter-conditioningManagement of Physiologic Stimuli

Overcoming Resistance
Use of Socratic MethodsHow Likely to Do?Reasons Not To?How to Overcome Not ToFramework of No Choice ListPros/ConsApplication of Stages of Change

Overcoming Resistance
Stages of ChangePre-Contemplative
Educate Patient
Contemplative
Strategies such as Pros-Cons or Cross-Examiner
Decision
Decision to/Decision not to, Pros-Cons
Action
Graduated Exposure Strategy

Foot in the Door

Noticing Action and its Impact
Anti-Contemplative
A Different Day, A Different Time

Push-Pull Strategy

Application to Anxiety
Retraining the Brain: HabituationHabituation is the result of extended exposure to an anxiety provoking stimulus
Anxiety typically elevates beyond typical levels due to defeat of avoidance or escape

Anxiety begins to drop after extended exposure

Anxiety usually flattens and persists at a reduced level for several minutes during the exposure

Over repeated exposure activities, anxiety ceases to elevate clinically when the anxiety provoking stimulus is presented

Habituation is seen in

Systematic Desensitization using Graduated Exposure

Exposure and Response Prevention (ExRP)

Direct Exposure

Narrative Story Telling Interventions

Flooding

OCDOCD is conceptualized as an anxiety disorder driven by
mis-appraisal of the threat posed by intrusive, obsessive thoughts

use of ritualized behaviors or cognitive patterns to escape the anxiety

use of avoidance behaviors to end exposure to triggers associated with the obsessive thoughts

OCDAssessment in CBT is typically done with one of several instruments, although usually it is the Yale-Brown Obsessive Compulsive Scale (YBOCS)
Identification of historical and current obsessions and compulsions

Identification of target obsessions and compulsions, with SUDS ratings of each to create a hierarchy

Identification of avoidance behaviors

SUDS = Subjective Units of Distress Scale using 0 to 100

Must create behavioral anchors to ratings for patient

OCDTreatment with CBT is primarily Exposure and Response Prevention (ExRP) Therapy
Exposure

Patient collection of obsessive thoughts per theme

Creation of Exposure NarrativeOften recorded

Design of 90 minute exposure to be done daily

Creation of SUDS tracking form throughout Exposure exercise

Safety plan for atypical NSEs

OCDTreatment with CBT is primarily Exposure and Response Prevention (ExRP) Therapy
Response Prevention

Identification of Ritual Structure for each Obsession

Identification of Avoidance Patterns

Creation of Behavioral Plan to stop Rituals and Avoidance

Creation of tracking form for ritual and avoidance performance

Behavioral Description

Situational Factors

Emotional Experiences

Outcome of Ritual or Avoidance

Used to Create Better Response Prevention Plans

OCDRelapse Prevention and Fading
Use of graphs to create evidence

Cognitive Restructuring regarding beliefs about competency to manage OCD

Cognitive Restructuring to differentiate self from OCD

Fading the session length and frequency as habituation occurs

Development of plan should obsessions become more controlling again

Booster Sessions as a normative expectation

OCDCase Example
Exposure Tape

SUDS data

Generalized Anxiety DisorderCharacterized by Uncontrollable Worrisome Thoughts that have several themesAnxiety Provocation is Based on the Appraisal of Risks in the Cognitions coupled with Estimates of Probability and BelievabilityAnxiety is experienced as elevated but not panic-like, and occurs physically as well as subjectively

Generalized Anxiety DisorderAssessment
Use of Scale like Beck Anxiety Scale or Zung

Collect Diary of Worrisome Thoughts

Develop SUDS for each Theme

Identify Anxiety Components (e.g., subjective experience, physiologic arousal)

Identify Safety Behaviors

Self vs. Other Behaviors

Identify Magic Cognitions (Worry Prevents Catastrophe)

Generalized Anxiety DisorderTreatment Components
Relaxation Therapy to Manage Anxiety Arousal

Use of Theme-based Scripts for Exposure Exercises

Cognitive Restructuring to Modify Estimates of Likelihood and Believability

Modification of Safety Behaviors (e.g., calling spouse to see if safe)

Application to PTSD
Rape TraumaDirect Exposure TherapyUse of Cognitive Reprocessing
Modification of View of Self

Modification of Limited Event Recall
Development of Realistic Risk AppraisalDevelopment of Personal Safety Skills (Coping)

Application to PTSD

Childhood Trauma
STAIR
Affect Regulation

Development of Language of Emotion

Development of Emotional Self-Soothing Skills

Cognitive Distraction

Distress Tolerance & Behavioral Activation of Pleasurable Experiences

Acceptance of Emotions and Reframing Emotions as Valued

Application to PTSD

Childhood Trauma
STAIR
Interpersonal Connection

Identification of Interpersonal Schemas & Common Life Behaviors

Self-Awareness of Conflict between Trauma Emotions vs. Goals for Interpersonal Relationships

Modification of Self-Defeating Behaviors Through Role Playing

Identification of Power and Control Issues in Role Playing

Assertiveness Skills and Beliefs of Basic Rights

Creation of Interpersonal Conflict Management Skills

Fostering Flexibility Within Power-Differential Relationships

Application to PTSD

Childhood Trauma
STAIR
Narrative Story Telling as Exposure

Creation of Memory Targets

Assurance of Hope and Betterment of Life

Skills Using Emotional Management Strategies at end of Exposure & Staying in the Present

Identification of Negative Emotions During Narrative

Identification of Negative Interpersonal Schemas in the Narrative

Contrasting Present Interpersonal Reality and New Skills to Learned Schemas

Applying Coping Skills to Real-Life Situations and Healthier Interpersonal Behaviors in Present Relationship

Application to Depression
Self-Monitoring of MoodOrientation to Descriptions of MoodMood LogsThree Column StrategyBehavioral Self-MonitoringActivity LogCataloging Positive Experiences

Behavioral ActivationDevelopment of Three Lists
Current Pleasure

Past Pleasure

Hopes/Dreams Planning
Scheduling Daily Activities and StructureScheduling Pleasure

Cognitive RestructuringDevelopment of Evidence Testing Skills From Mood Logs and Activity RecordsUnderstanding of Automatic and Distorted CognitionsLabeling Distorted CognitionsModifying Distortions and Mood Through 5-ColumnUsing Pros/Cons and Other Cognitive Restructuring StrategiesStimulus ControlNegative Mood Triggers and Management of ExposureDevelopment of Coping Mechanisms for Mood Triggers
Skills Enhancement (e.g., parenting skills, conflict management)

Applications to Other Disorders
Mastery of Your ADHDHabit Reversal Therapy for Hair PullingAnger Management Using Stimulus Control and Cognitive RestructuringWeight Loss Protocol Developed by Judith BeckPositive Parenting Program for ADHD and Modification of Parental Incompetence Distortions

What to Do
Develop CBT competenciesIdentify Useful Texts Like Leahys booksTake Training from one of the CentersSeek ABPP and/or ACT Certification

Questions

Dm200119.wma

Documents

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