Silvina Galperin, D. Psych., C.

Psych

CBT workshop For Internationally trained Health Professionals

CAMH

Cognitive Therapy Definition
Cognitive therapy is an active, directed, time-limited, structured approach, used to treat a variety of psychiatric disorders (depression, anxiety, phobias, chronic pain and others) It is based on an underlying theoretical rationale that an individual’s affect and behaviour are largely determined by the way in which he structures the word Aaron Beck (1979)

Cognitive Therapy: Characterisitcs


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Present oriented Based on an ongoing case conceptualization Educative: teaches patient to be selftherapist Time-limited Collaborative Structured Goal oriented: problem focused Variety of techniques to change thoughts, feelings and behaviour Relapse prevention

Principles of Cognitive Therapy

Strong therapeutic alliance Goal oriented and problem focused Emphasizes skill acquisition  Homework Uses cognitive and behavioural techniques to change thinking, mood and behaviour. Thought records, Socratic questioning, action plans, behavioral experiments, cognitive continuum, exposure and other techniques to evaluate and modify dysfunctional thoughts and beliefs (cognitive restructuring).

Suitability for Brief Cognitive Therapy
Dimensions:

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Accessibility of Automatic Thoughts Awareness and differentiation of emotions Acceptance of personal responsibility with treatment Compatibility with cognitive rationale Alliance potential (in-session) Alliance potential (out- of-session) Focality Security operations Chronicity vs. Acuteness Optimism vs. Pessimism
Safran, J., Segal, Z. (1990) Interpersonal process in Cognitive Therapy. Basic Books. New York

Structure of the CBT Session
Six components 1. Mood check up

How was your mood during the past week? What did you work on during the last week?
What did you learn in the last session? Was there anything that bothered you our last session?

2. Bridge from previous session
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3. Agenda Setting
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What problems do you want to put on the agenda? Which ones have priority for today’s session?

4. Review of Homework 5. Discussion of the Agenda, new homework assignment 6. Final summary and feedback
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What do you think about today’s session? What will be important for you to remember?

The Cognitive Model

The cognitive model states that the behaviour is reciprocally determined by the individual’s thoughts, feelings and physiological reactions. None of these elements is necessarily more important. The therapist can intervene by focusing on each of these areas at different times of the treatment.

Cognitive Model
Thoughts

Environment

Moods Physiological reactions

Behaviour

How to use the Cognitive Model with the clients: Examples

1. Pierre is a VP of multinational company. Three months ago he was diagnosed with rosacea. He thinks that to have his face red is a sign of weakness and that people will think he is afraid or nervous and this makes him feel extremely uncomfortable, irritable and anxious. 2. Chris is a 21 year old student that is afraid of meeting people. He has friends but when there are new people around he just can’t talk. 3. Greta is a 67 year old married, retired woman who has been avoiding to get out of her home for 2 months. She had several episodes of diarrhea at home and now she is afraid of having an “accident” anytime.

Other examples:
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Typical cases of depression Typical cases of separation anxiety

Role Playing Introducing the Cognitive Model to a client
-Groups of Three1. Patient: Describes situation, answers therapist’s questions 2. Therapist: Asks questions to the client to clarify 3. Observer: Assists therapist and/or client, gives feedback Task:
1.

Ask about a specific situation (where, when, with who, what happened) in which the change of mood occurred (started to feel afraid, embarrassed, anxious, etc.) Ask about all the emotions that this situation triggered in the client and write it down What was going through your mind just before you started to feel this way? What other thoughts did you have at that moment? Ask about specific physical sensations associated What was the resulting behaviour at that time

2.

3.

4.

5.

Goal Setting

Why set goals for therapy?: CBT is a time-limited. Setting some specific goals ensures that we work with a focus and clients get the most out of therapy. It also allows to track the progress in therapy.

Goals are based on the client’s expectations for therapy
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What would you like to accomplish in therapy? What woul ou like to be different in your life?

General Overall areas that need improvement
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I want to be healthier I want to take better care of myself I want to have friends

Specific Observable and reasonable changes that can be measured
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What can do to start? List small steps towards the goal Are the steps observable?

Goal Setting
Specific Measurable Achievable Realistic Time-limited Questions to answer:  Where are you now?  Where you would like to get?  What small steps can you take to get from where you are now to where you want to be?

Practice setting up goals
Define general goals  Prioritize 3 (the ones that would give most immediate relief) For each goal :  Where are you now?  Where would you like to be?  Define small, reasonable, achievable, measurable steps to take.  Rate level of difficulty of each step  Arrange according to the level of difficulty starting from the easiest.  Ask: What would be the first sign that you are making progress?  Practice setting up 8 small steps towards a specific goal.

Automatic Thoughts

Are thoughts that pop into our heads automatically throughout the day We don’t have the intention of having them Usually, we are not even aware of them One of the goals of cognitive therapy is to bring automatic thoughts into awareness I.E.: If you are late for an appointment, what would you think as you are traveling to get there?

Identifying Automatic Thoughts
Basic question: What was going through your mind when you had that strong feeling (or reaction to something)?
1.

2.

3.

4.

Ask this question when you notice a shift in affect during a session. Have the client describe a problematic situation or a time during which he/she experienced a shift in affect If needed, use imagery to describe the situation in detail "as if it's happening now« If needed have the client roleplay a specific interaction

Other questions to elicit automatic thoughts:
1. 2. 3. 4. 5.

6.

What do you guess you were thinking about? What did this situation mean to you? What images or memories did you have in this situation? What were you afraid might happen? Were you thinking____________? (Therapist supplies an automatic thought opposite to the expected one.) What does this say about you, your life, your future?

What are the cognitions we evaluate in therapy?
Interpretations Predictions Labels Meanings Judgments Memories (selective) Self-talk Attributions of cause as to why things happen

Images Perceptions

Hot Thought

Is the thought that is more emotionally charged -- strongly connected with the emotional shift.
Is the thought that triggers the mood change. Appear spontaneously during the day.


It can be words, images or memories.
We circle the Hot Thought in the Thought Record and focus on this thought.

THOUGHT RECORD
Situation Mood Automatic Evidence Evidence Balanced/ Re-rate 1- 100 Thought For AT Against Alternative Mood AT Viewpoint

Thought Record First 3 columns
Situation
1. 2. 3. 4.

Mood (Rate 0-100%)

Automatic Thoughts
(Circle Hot Thought)

What When Where With who

Evidence that supports the Hot Thought

We ask for facts, things that actually happened in the past.
This includes situations, experiences, reactions, consequences, etc. We don’t write down ideas, interpretations of facts or thoughts in this column

Evidence Against the Hot Thought
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Have I had any experiences that don’t support the H.T. or that would indicate that it is not 100% true? If my best friend would have this thought, what would I tell him/her? When I am not feeling this way, do I think differently in the same situations? How? When I felt this way in the past, what helped me feel better? In five years from now, would I look at this situation differently? Would I focus on a different part of my experience? Are there any positives in me or the situation that I am ignoring? Am I blaming myself for something over which I do not have complete control?

Adaptation from Mind over Mood, Greenberger, Padesky 1995 Guildford Press

THOUGHT RECORD
Situation Mood Automatic Evidence Evidence Balanced/ Re-rate 1- 100 Thought For AT Against Alternative Mood AT Viewpoint

How to create a Balanced or Alternative Thought

Considering the information listed for and against the hot thought, is there an alternative way of understanding or thinking about this situation? Write one sentence summarizing or combining the information of both columns (using “even though”, “and”, etc.) Can other people think of other way of understanding this situation? If a friend of mine would be in this situation, how would I suggest to understand it? If my hot thought is true, what is the worst, the best and the most realistic outcome?
Adaptation from Mind over Mood, Greenberger, Padesky 1995 Guildford Press

Cognitive Distortions

Are patterns of dysfunctional thinking Instead of reacting to the reality of an event, an individual reacts with a personal interpretation that is partial. For example, a person may conclude that is worthless just because he was not invited to a party or did not pass an exam. Cognitive therapists make patients aware of these distorted thinking patterns.

COGNITIVE DISTORTIONS -Patterns of negative thinking1. All or nothing thinking: You view a situation in only two categories instead of on a continuum. "If I'm not a total success, I'm a failure." 2. Castastrophizing: You predict the future negatively without considering other, more likely outcomes. " I’ll be so upset, I won't be able to function at all." 3. Disqualifying or discounting the positive: You unreasonably tell yourself that positive experiences or qualities do not count. I did that project well, but that doesn't mean I'm competent; I just got lucky." 4. Emotional reasoning: You think something must be true because you "feel" (actually believe) it so strongly, ignoring or discounting evidence to the contrary. "I know I do a lot of things okay at work, but I still feel like a failure.» 5. Labeling: You put a fixed, global label on yourself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion. "I'm a loser." " He's no good. » 6. Magnification/minimization: When you evaluate yourself, another person, or a situation, you unreasonably magnify the negative and/or minimize the positive. "Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn't mean I'm smart."

David Burns 3 columns exercise to identify cognitive distortions

Automatic Thought

Identify Cognitive Distortions

Alternative Thought
Even if this report is not presented in an excellent way, I am an efficient, reliable and experienced employee and would not be so easy to replace me. (Anxious 50%, Afraid 40%)

If I don’t present Mental Filter an excellent report Catastrophizing to my boss, he might fire me and I won’t have money to support my family. (Anxious 90% Afraid 80% )

Examples of Non-Socratic Questions/Comments (note how much less useful they are. )
1. Why are you being so hard on yourself? 2. What's the big deal about yelling at your kids? Almost everyone does it.

3. Didn't your parents ever yell at you?
4. I'm sure your kids will get over it. It doesn't seem so bad to me . 5. You're basically a great mother; don't you remember what you told me you did for your kids the other day?

Read more about Cognitive Behavioural Therapy here: http://www.cbtpsychology.com/
Thank you!

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