COGNITIVE BEHAVIOR THERAPY (CBT) THEORY AND PRACTICE

PRESENTED BY : WUZNA HAROON &

ANAM ILLYAS

ORIGIN OF CBT

Aaron Beck’s Cognitive Behavior Therapy

• Aaron Beck was psychoanalytic psychotherapists. • In early 1960 Aaron beck developed an approach known

as cognitive therapy as a result of his research on depression.

• In psychoanalytic depression was thought to be based on retroflective hostility. But the beck findings did not support the psychoanalytic formulation.

• Aaron Beck observations of depressed clients revealed that they had a negative bias in their interpretation of certain life vents, which contributed to their cognitive distortions.

•

Aaron Beck’s Cognitive Behavior Therapy cont.

• Beck called it cognitive therapy because of the importance it places on thinking. It’s now known as cognitive-behavioral therapy (CBT) because the therapy employs behavioral techniques as well.

WHAT IS COGNITIVE BEHAVIOR THERAPY

DEFINITION “CBT is a process of teaching, coaching, and

reinforcing positive behaviors. CBT helps people to identify cognitive patterns or thoughts and

emotions that are linked with behaviors.”• Thinking: Different people can think differently about the

same event. The way in which we think about an event influences how we feel and how we act. A classic example is that when looking at a glass of water filled halfway, one person will see it half empty and feel discouraged and the other sees it half full and feels optimistic.

• Behavior: What we do affects how we feel and think. The individual, who deals with an upcoming exam by putting off his studies until the last minute, is likely to experience more distress on the day of the exam than an individual who has studied well in advance. CBT helps people to learn new behaviors and new ways of coping with events, often involving the learning of particular skills.

• Therapy : Besides its special focus on the relationships between how we think, feel and behave, the following are fundamental to the practice of CBT.

o Qualities of the Therapeutic Relationshipo Goal-settingo Focus on the Presento Structure

THEORETICAL ASSUMPTIONS OF CBT

• Beck’s is based on the theoretical rationale that the way people feel and behave is determined by how the perceive and structure their experience.

• The theoretical assumptions of CBT are

1) that people’s communication is accessible to

introspections.

2) that clients’ beliefs have highly personal

meanings

3) that these meanings can be discovered by the

client rather than being taught or interpreted by

the therapists.

PRINCIPLES OF CBT

BASIC PRINCIPLES • Cognitions affect behavior and emotion.

• Cognitions may be made aware, monitored and altered.

• Desired emotional and behavioral change can be

achieved through cognitive change.

• Change mood states by using cognitive and behavioral

strategies:

o Identifying/modifying automatic thoughts & core beliefs,

o Regulating routine, and

o Minimizing avoidance.

BASIC PRINCIPLES

• Emphasis on ‘here and now’

• Preference for concrete exampleso Start with specific situation (complete thought log)

• Reliance on Socratic questioningo Ask open-ended questions

• Empirical approach to test beliefs

o Challenge thoughts not based on evidence

o Cognitive restructuring

ELEMENTS OF CBT

• CBT has several defining elements. They are as follows:o ACTIVE: The client must be involved in the

therapeutic process not as an observer or as an occasional visitor, but as a core and key participant.

o MOTIVATIONAL: The therapist needs to take responsibility for helping to motivate the client toward a change in behavior, affect, or thinking. The therapist must be able to set up the format, and rationale for the client to consider change of value.

o DIRECTIVE: The therapist must be able to develop a treatment plan and then to help the client to understand, contribute to, and see the treatment plan as a template for change.

Elements of CBT CONT.o STRUCTURED: CBT is structured in two ways. First, the overall

therapy follow structure that approximates the treatment plan. Sessions have identifiable beginning, middle and end.

o COLLABORATIVE: Therapeutic collaboration cannot be 50/50. for severe depressed client the possibility to generate 50% of the therapeutic effort is impossible. Initially, the collaboration may be 90/10. For each client, the therapist must evaluate the client’s ability and motivation for the therapy.

o PROBLEM-ORIENTED: CBT focuses on discrete problems rather than vague and amorphous goals of feeling good, getting better, or increasing self-esteem

Elements of CBT Cont.o PSYCHO EDUCATION: The therapist works as a change

agent. Many to problems that bring people therapy involve skills deficits. The therapist may have to teach by direct instruction , modeling, role playing.

o SOLUTION-FOCUSED: The CBT therapists works with the client on generating solutions not simply gaining insight into the problem.

o DYNAMICS: The dynamic level of CBT is to help clients to identify, understand, modify their schema. The schema are the basic templates for understanding one’s world. Schema may be personal, religious, cultural, gender-related.

o TIME-LIMITED: Each therapy session should, ideally , stand alone. A time-limited focus is not a number of sessions, but rather way of looking at therapy.

BASIC FEATURES OF CBT

Rationale of CBT • Negative emotions are elicited by cognitive processes

developed through influences of learning and temperament.

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

• Cognitive triad: Negative automatic thoughts center around our understanding of:o Ourselveso Others (the world)o Future

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

COGNITIVE SPECIFICITY HYPOTHESIS • Distorted appraisals follow themes relevant to the specific

psychiatric condition.• Psychological disorders are characterized by a different

psychological profile.o Depression: Negative view of self, others, and future. Core

beliefs associated with helplessness, failure, incompetence, and un lovability.

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

COGNITIVE SPECIFICITY • Negative Triad Associated with Depression

o Self “I am incompetent/unlovable”o Others “People do not care about me” o Future “The future is bleak”

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

embarrassed”

Working Model of CBT

EVENTBill goes to collection APPRAISAL

“I can never do anything right”

AFFECTIVE & BIOLOGICAL AROUSAL

decreased sleep, low energy

BEHAVIORAL INCLINATION

I don’t want to deal with it

MALADAPTIVE BEHAVIOR

Withdrawal, avoidance

CORE BELIEFS • Core beliefs underlie and produce automatic thoughts.• These assumptions influence information processing and organize

understanding about ourselves, others, and the future.• These core beliefs remain dormant until activated by stress or

negative life events.• Categories of core beliefs (helpless, worthless, unlovable)

CORE BELIEFS AUTOMATIC THOUGHTS

AUTOMATIC THOUGHTS • Thoughts that automatically come to mind when a

particular situation occurs is called as automatic thoughts.

• Happen spontaneously in response to situation• Do not arise from reasoning• No logical sequence

STRESSFUL SITUATION

AUTOMATIC THOUGHTS

NEGATIVE EMOTIONS

COGNITIVE DISTORTIONS The systematic errors in reasoning that lead to faulty assumptions

and misconceptions which are termed as cognitive distortions. • Arbitrary Inference: refers to making conclusions without

supporting and relevant evidence. This includes “catastrophizing” or thinking of absolute worst scenario and outcomes for most situations.

• Selective abstraction: consists of forming conclusions based on an isolation detail of an event. In this process other information is ignored and the significance of total context is missed.

• Overgeneralization: is a process of holding extreme beliefs on the basis of a single incident and applying them inappropriately to dissimilar events and settings.

• Magnification and minimization: consist of perceiving a case or situation in a greater or lesser light than it truly deserves.

COGNITIVE DISTORTIONS cont.• Personalization: is a tendency for individuals to relate external

events to themselves, even when there is no basis for making this connection.

• Labeling and Mislabeling: involve portraying one’s identity on the basis of imperfections and mistakes made past and allowing them to define one’s true identity.

• Polarized Thinking: involve thinking and interpreting in all-or-nothing terms, or categorizing experiences in either or extremes. With such dichotomous thinking, events are labeled in black or white terms.

Beck contends that people with emotional difficulties tend

to commit characteristic “logical error” that tilt objective

reality in the direction of self-destruction. Cognitive therapy

perceives psychological problems as stemming from

commonplace processes such as faulty thinking, making

incorrect inferences on the basis of inadequate or incorrect

information and failing to distinguish between fantasy and

reality.

TECHNIQUES OF CBT

Techniques of CBT

The cognitive behavioral therapy techniques are an

interesting set of exercises that help modify a person's

behavioral patterns. The behavioral patterns are

modified in order to bring about positive changes in

the personality.

Cognitive Rehearsal• In this technique, the patient is asked to recall a problematic

situation of the past. • The therapist and patient both work together to find out a solution

for the problem or a way in which the difficult situation, if it occurs in the future can be sorted out.

• The therapist asks the patient to rehearse positive thoughts cognitively in order to make appropriate changes to the latter's thought processes.

• Power of imagination proves to be of great use in such exercises.

Validity Testing

• In this techniques the therapist tests validity of beliefs/thoughts of the patient.

• The patient is allowed to defend his viewpoint by means of objective evidence.

• The faulty nature or invalidity of the beliefs of the patient is exposed if he/she is unable to produce any kind of objective evidence

Writing in a Journal• It is the practice of maintaining a diary to keep an account of

situations that arise in day-to-day life• Thoughts that are associated with these situations and the

behavior exhibited in response to them are also mentioned in the diary.

• The therapist and patient together review the matter written in the journal and find out maladaptive thought pattern.

• The discussion that takes place between them proves to be useful in finding different ways in which behavior of the patient gets affected

Guided Discovery

• The objective or purpose behind using this technique is

that of helping patients by enabling them to

understand their cognitive distortions.

• Patients are made aware of and assisted by therapists

in understanding how they process information.

• The activity of understanding how information is

processed allows patients to alter the same

(information processing) if required.

Guided Discovery

• Basically, the patient's perception of the world

undergoes great change and he/she sees things in a

different way than earlier.

• This change in perception allows the patient to

modify his/her behavior in a better manner

Modeling• It is one of the cognitive therapy techniques in

which therapists perform role-playing exercises aimed at responding in a way that is helpful to overcome difficult situations.

• The patient makes use of this behavior of the therapist as a model in order to solve problems he/she comes across.

Homework:

• The homework is actually a set of assignments given by therapists to patients.

• The patient may have to take notes during sessions with therapists, review audiotapes of a particular session or read articles/books related to the therapy.

Aversive Conditioning• Amongst the different CBT techniques used

by therapists, aversive conditioning technique makes use of dissuasion so as to lessen the appeal of a maladaptive behavior.

• The patient while being engaged in a particular behavior or thought for which he has to be treated, is exposed to an unpleasant stimulus.

• Thus, the unpleasant stimulus gets associated with these thoughts/behavior and then the patient exhibits an aversive behavior towards them

Systematic Positive Reinforcement

• The systematic positive reinforcement is one of the techniques of CBT therapy in which certain (positive) behavior of a person are rewarded with positive reinforcement.

• A reinforcement system is established for the of certain positive behavior.

Just like positive reinforcement proves to be helpful in encouraging a particular behavior, withholding the reinforcement deliberately also is instrumental in eradicating a maladaptive behavior.

Self-Instructional Methods• In self-instructional coping methods, the therapist attempts not to

completely change the way you think, but rather teaches coping methods that equip you to handle harmful thought processes. One such therapeutic process is stress inoculation training.

• This therapy -- which helps the patient deal with stressful events' aftermath -- aims to prevent negative reactions to stress-inducing factors by teaching the patient to break down these situations into short-term and long-term coping goals

Problem-Solving Methods• Cognitive-behavioral therapy -- which sees irrational

thought processes as resolvable -- incorporates

problem-solving methods. After illogical thought

patterns are found, the patient must suggest several

alternative solutions.

• Through the decision-making process, negative

solutions are weeded out until an acceptable, positive

approach is discovered. This type of therapy

sometimes is used in child psychotherapy when

dealing with oppositional defiant disorder.

Computer-Assisted Therapy• One method of conducting cognitive-

behavioral therapy is through computer-based programs. This therapy tends to decrease time spent with an actual therapist. Since computer-assisted CBT is relatively new, as of publication, most of the information is in the testing phase.

However, primary-care treatment programs that have

begun integrating the method for treating co-morbid

anxiety and mood disorders have found promise in this

type of therapy, states researchers in "Depression and

Anxiety," the official journal of the Anxiety Disorders

Association of America

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