Introduction to Cognitive Behaviour Therapy Dr Sue Waite Psychiatrist TQEH 23/8/12.
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Transcript of Introduction to Cognitive Behaviour Therapy Dr Sue Waite Psychiatrist TQEH 23/8/12.
Introduction to Cognitive Behaviour Therapy
Dr Sue Waite
Psychiatrist
TQEH
23/8/12
Cognitive Theory
Emotions are experienced as a result of the way events are interpreted, rather than the events themselves
Aaron (Tim) Beck 1921-
Cognitive Model
A -------------------> B --------------------> C
Antecedents Beliefs Consequences
(Mood, Behaviour)
The First Wave of Cognitive Therapy
Classical Behaviour Therapy Focus on changing problematic behaviour
and emotions themselves
Behaviour Therapy
The Second Wave of Cognitive Therapy
Cognitive Behaviour Therapy Focus on changing content of dysfunctional
thoughts assumed to mediate problematic emotions and behaviour
The Third Wave of Cognitive Therapy
‘Thinking about thinking’ Mindfulness and metacognitive processing Focus on process rather than content of
thinking (e.g. rumination, worry) Leads to a non-judgemental acceptance of
events (thoughts, body sensations, emotions) rather than a change in their content or frequency
The Third Wave of Cognitive Therapy
Acceptance and Commitment Therapy (Hayes)
Dialectical Behavioural Therapy (Linehan)
Mindfulness-Based Cognitive Therapy (Williams, Teasdale, Segal)
Metacognitive Therapy (Wells)
Cognitive Theory
Depressed and people have continuous negative thoughts
With each negative thought the depressed feeling increases
BUT, the thoughts are only interpretations of some of the facts and not truths in themselves
SO, they may make a person feel depressed when there may be no objective reason to feel that way
Stance Of The Cognitive Therapist
Socratic Questioning- art of asking questions to encourage people to think for themselves to arrive at the objective truth
Socrates (470-399 BC)- Greek philosopher who believed the best method of understanding an issue or concept was to help students think through the matter critically. Questions aroused curiosity and led to more questions. New realisations were more powerfully believed as they came from within rather than being imparted by someone else.
Socratic Questioning and Guided Discovery
Asking informational questions What do you mean by____? Can you give me an example? What makes you think this is true?
Empathic listening and reflection
Socratic Questioning and Guided Discovery
Frequent summaries (To organise informationand help patient remember what has beendiscussed)
Synthesising/analytical questions that require the patient to apply the new information What do you make of this? How do you put it all together? What is an alternative way of looking at it?
What is CBT?
Brief (10-20 sessions) Time limited Goal oriented Structured (clear agenda each session with
homework between sessions) Here and now Symptom relieving
CBT Components
Behavioural activation Practical problem solving Behavioural experiments (To test thoughts) Exposure to feared situations or bodily
sensations Cognitive restructuring (Examining the
evidence for thoughts)
Criticism from others
INACTIVITYBuild up of unfinished tasks
NEGATIVETHOUGHTS
DEPRESSIONTirednessLethargyLoss of interestLoss ofmotivationLoss of pleasureIndecision
Rationale for Behavioural Activation
Distracts mind from painful thoughts Restores sense of control Increases self esteem May lead to re-experience of pleasure Reduces lethargy and fatigue Enhances motivation
Daily Activity Monitoring
Monitor activities hourly Rate Pleasure (P) and Mastery (M) Allows development of awareness of
variations in mood, activity levels and associated thoughts
Informs subsequent structuring of helpful activities
Daily Activity Scheduling
Plan each day in advance at set time Aim for balance of ‘fun’ activities and ‘work’
activities Start day with a ‘no lose’ activity Reward after difficult activity Record what is done Review at end of day and trouble shoot
Practical Problem Solving
Identify problem Brainstorm possible solutions Assess pros and cons of each solution Choose best option and devise step by step
plan to implement it Assess outcome
Behavioural Experiments
Planned experiments intended to test validity of patient’s beliefs
Observational expts- patient is observer or data gatherer. Useful if direct action too anxiety-provoking or more information is required. Includes direct observation of therapist, surveys, internet search etc.
Active expts- patient deliberately acts in a different way in a problem situation and notes outcome.
Designing Behavioural Experiments
Identify target cognition and rate belief intensity
Identify any alternative perspectives Determine which variables are to be
manipulated so thought can be challenged- often involves safety behaviours
Make a testable prediction
Designing Behavioural Experiments
Anticipate possible problems Determine what is to be observed (thoughts,
feelings, sensations, behavior of self and others, environment) and how (e.g. video)
Record outcome and re-rate beliefs Plan follow up expts to reduce degree of
target cognitions further
Behavioural Experiment- Example
Survey for social phobia
Behavioural Experiment- Example
Behavioural experiment for procrastination
Behavioural Experiment - PTSD
Target Cognition- If I allow myself to think about the accident, I’ll lose the plot.
(Avoids talking about accident, engages in thought suppression and avoidance of reminders)
Behavioural Experiment- Bipolar Disorder
Target Cognition- My friends don’t like me unless I’m the life of the party.
(Tries to be vivacious, fills in gaps in conversation, exaggerates recent events to sound more interesting)
Behavioural Experiment- Panic Disorder
Target Cognition- If my heart races, I must rest otherwise I will pass out.
(Avoids exercise, takes pulse, sits down if notices increase in HR)
Behavioural Experiment- Social Phobia
Target Cognition- I can’t let people see me blush. They'll think I’m weak and reject me.
(Hides face with hair and hat, avoids eye contact, rarely socialises)
Behavioural Experiment- Depression
Target Cognition- There’s no point doing anything until I feel better. It will just make me feel worse.
(Makes excuses not to attend social gatherings, rarely engages in conversation, spends lots of time in bed)
Behavioural Experiment- Psychosis
Target Cognition- I can’t disobey my voices or they will destroy me.
(Responds immediately to command hallucinations, denies symptoms when questioned by doctors or friends)
Exposure
Graded exposure to feared situations or sensations leads to a reduction in anxiety (habituation)
Exposure must be repeated (3/week),
prolonged (stay in situation until anxiety halves)
and focused Hierarchy of least feared to most feared situation Mainly used for OCD, simple phobias and in panic
disorder (for feared sensations)
Thought Records
Monitoring thoughts and questioning the evidencewith thought records. Identifying unhelpful thinking styles.
What is the evidence to suggest this belief may not be true? What is another way of looking at the problem? What would your best friend say if they knew you were thinking
this way? What advice would you give your best friend if you knew they
were thinking this way When you weren’t so depressed/anxious how might you view
this?
Thought Records
In 5 years time will this still be important? Even if your worst fears come true, can you
cope? What is a more compassionate way to think
about this? Is it helpful to think this way?
Being a Good Coach
Work together as a team on the problem Help the person remain focussed on the task at hand
(NB distraction and avoidance) Provide emotional support (e.g. “ I can see how hard
this is for you”) Show empathy Ask open-ended questions (e.g. “How are you
feeling right now?”, “What is going through your mind?”)
Summarise your understanding of their thoughts and feelings
Being a Good Coach
Don’t argue. When you notice yourself directing, persuading or telling your patient what to do, you are essentially putting them in the position not to change. Take time out.
Help the person make decisions but don’t make decisions for them (e.g. “Is this helpful in getting over your problem?”) Look at pros and cons of changing versus not changing.
Predict into the future (e.g. “In 5 years time if you still have this problem, what will things be like?”, “If you no longer have this problem, what will things be like?”)
Be a cheerleader. Remind client of task, tell them you believe they can do it, congratulate them for their achievements.
Reading List
Beck J. (1995). Cognitive Therapy: Basics and Beyond. New York: Guilford Press.
Beck AT, Rush A. et al. (1979). Cognitive Therapy of Depression. New York: Guilford Press.
Burns D. (1990, revised 1999). The Feeling Good Handbook. London: Plume.
Greenberger D. & Padesky C. (1995). Mind Over Mood. London: Guilford Books.
Overcoming self help book series- www.overcoming.co.uk/
Internet Sites
www.cci.health.wa.gov.au
resources- consumers (detailed), medical
practitioners (brief)
www.moodgym.anu.edu.au
thiswayup.org.au/clinic
www.blackdoginstitute.org.au
www.beyondblue.org.au