Cognitive Behavioural Therapy

Cognitive Behavioral TherapyRegi L. Pamugas, MDAugust 3, 2011UP ManilaObjectives To define mental health/illnessTo discuss on the different types of treatment of mental illnessTo define Cognitive Behavioral Therapy (CBT)To discuss on CBT

ContentsDiscussion on mental health/illnessDiscussion on the treatment of mental illnessDiscussion on Cognitive Behavioral Therapy (CBT)Summary

What is a mental health? Health is a state of complete physical, mental and social well-being and not merely the absence of disease or inrmity. World Health OrganizationMental health problems - can have both psychological, social and somatic dimensions. These issues often make it hard for people to manage their lives and achieve their goals.

Mental IllnessPsychotics* schizophrenia, brief psychotic disorder, delusional disorder, shared psychosisNeurotics* Anxiety, somatoform, eating, sleeping, disorder, etc.Mood disorders* Bipolar I and IIPsychosis due to medical condition or substancesPsychosis not otherwise specified

Types of treatmentBiological/Pharmacologic* antidepressants, anxiolytics, antipsychoticsPsychotherapy* Psychodynamic, cognitive, behavioral, client-centered therapy, existential therapyCombination of drugs and psychoanalysisElectroconvulsive therapy (ECT)

Definition of TermsPsychotherapy - set of clinical techniques use to improve mental health.Counseling = psychotherapy. Behavior Therapy (Behavior Modification Therapy) - changing somebody's behaviorClassical Conditioning - creation of response to stimulus (Pavlov's dogs)Operant Conditoning - learning through positive and negative reinforcementCognitive Therapy - psychotherapy aimed at changing way of thinking. Several approaches to CBTRational Emotive Behavior TherapyRational Behavior TherapyRational Living TherapyCognitive TherapyDialectic Behavior Therapy

Psychodynamic TherapyProbes the pastDoesnt tackle the immediate problemThe goal is insightTakes a long timeExplores the unconsciousBehavioral TechniquesThere are no mental processes (will, mind)The focus is on changing the behaviorWorks on the immediate problemFocuses on the presentBehavioral TechniqueClassical conditioningIvan PavlovConditioning- learning that involves associations between environmental stimuli and the organisms responsesStimulus-response learningSystematic DesensitizationEx. Fear of flyingRead about safety flightLook at pictures of airplanesVisit at the airportTake a short flightTake a long flightClient-Centered TherapyTherapist uses techniques such as active listening within genuine, accepting, empathic, environment to facilitate clients growthClient adopts these views and becomes self-acceptingPromotes growth instead of curing illness Existential therapyHelps client explore meaning of existenceHelps client choose a destinyHelps client accept self-responsibilityCognitive Behavioral TherapyBrief History of Cognitive TherapyAlbert Ellis, PhD grandfather of CBTpublished Reason and Emotion in Psychotherapy in 1962Aaron Beck, MD wrote Self Concept in Depression with D. Stein in 1960

Cognitive Behavioral TherapyA form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do.

Indications of CBTIt is used to treat depression, anxiety disorders, phobias, and other mental disordersTreats alcoholism and drug addiction, especially as part of an overall program of recovery.The basic goals of CBTTo challenge the thoughts about a particular situation by identifying the cognitive trapsTo help the patient to identify less threatening alternativesTo test out these alternatives in the real worldTo challenge the assumptions that lead to the Automatic Thoughts10 Characteristics of CBT1. CBT is based on the Cognitive Model of Emotional ResponseCBT is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change.10 Characteristics of CBT2. CBT is briefer and time-limited.12- 16 sessionsIs highly instructive nature and the fact that it makes use of homework assignments. Time-limited in that we help clients understand at the very beginning of the therapy process that there will be a point when the formal therapy will end. The ending of the formal therapy is a decision made by the therapist and client. 10 Characteristics of CBT3. A sound therapeutic relationship is necessary for effective therapy.Some forms of therapy assume that the main reason people get better in therapy is because of the positive relationship between the therapist and client. Have a good, trusting relationship, but that is not enough. Clients change because they learn how to think differently and they act on that learning. Therefore, CBT therapists focus on teaching rational self-counselling skills.10. Characteristics of CBT4. A collaborative effort between the therapist and the client. Therapists seek to learn what their clients want out of life (their goals) and then help their clients achieve those goals. The therapist's role is to listen, teach, and encourage, while the client's roles is to express concerns, learn, and implement that learning.10 Characteristics of CBT5. CBT can be based on stoic philosophy or notBeck's Cognitive Therapy is not based on stoicism. If we are upset about our problems, we have two problems -- the problem, and our upset about it. Most people want to have the fewest number of problems possible. So when we learn how to move calmly accept a personal problem, not only do we feel better, but we usually put ourselves in a better position to make use of our intelligence, knowledge, energy, and resources to resolve the problem.10 Characteristics of CBT6. CBT uses the Socratic Method.Therapists want to gain a very good understanding of their clients' concerns. Asking questions. Therapist encourages their clients to ask questions of themselves, like, "How do I really know that those people are laughing at me?" "Could they be laughing about something else?"10. Characteristics of CBT7. CBT is structured and directive.Therapists have a specific agenda for each session. Specific techniques / concepts are taught during each session. CBT focuses on the client's goals. We do not tell our clients what their goals "should" be, or what they "should" tolerate. Therapists teach their clients how to do.10 Characteristics of CBT8. CBT is based on an educational model.CBT is based on the scientifically supported assumption that most emotional and behavioral reactions are learned. Therefore, the goal of therapy is to help clients unlearn their unwanted reactions and to learn a new way of reacting. 10 Characteristics of CBT9. CBT theory and techniques rely on the Inductive Method.A central aspect of Rational thinking is that it is based on fact. Often, we upset ourselves about things when, in fact, the situation isn't like we think it is. Therefore, the inductive method encourages us to look at our thoughts as being hypotheses or guesses that can be questioned and tested. 10 Characteristics of CBT10. Homework is a central feature of CBT.If when you attempted to learn your multiplication tables you spent only one hour per week studying them, you might still be wondering what 5 X 5 equals. You very likely spent a great deal of time at home studying your multiplication tables, maybe with flashcards.

10 Characteristics of CBT10. Homework is a central feature of CBT.The same is the case with psychotherapy. Goal achievement (if obtained) could take a very long time if the person were only to think about the techniques and topics taught was for one hour per week. Therapist encourage their clients to practice the techniques learned.

The Cognitive TriadNegative view of the self (e.g., Im unlovable, ineffective)

Negative view of the future (e.g., nothing will work out)

Negative view of the world (e.g., world is hostile)

Automatic thoughtsAre repetitive, automatic self-statements that we always say to ourselves in certain situations. They can be positive or negative. Psychological problems develop when our automatic thoughts are consistently negative. They are automatic, because they are not the result of an analysis of the problem, they are a "knee-jerk" reaction to specific situationsAutomatic thoughtsEx.: In social situations, do you always presume the other person dislikes you, or thinks you are stupid?When automatic thoughts control our emotional response to people, problems, and events, we ignore evidence that contradicts the automatic thought. If we cannot ignore it, we explain the evidence in terms of the automatic thought.

Automatic thoughtsEx.: If we talk to someone and they smile, they are really laughing at us, rather than being pleased to see us. The automatic thoughts create an expectancy of something negative. Since many things in life are vague, and can be interpreted in many ways, we learn how to negatively evaluate the world, so it agrees with our negative automatic thoughts. Therapist help you to identify your negative automatic thoughts, and how to develop positive challenges to those negative ideas.Situation:Therapist asks Maria about her goals for therapy Automatic ThoughtsWhy is she asking me that? Its so superficial. Setting goals wont help. My problems are too deep. She should know that. Didnt she read the evaluators report? She probably thinks Im just like everyone else. Im not going to let her get away with treating me like this. Reaction:Emotional: AngerPhysiological: Tension in face, arms and shouldersBehavioral: Shrugs, avoids eye contact and says nothingThe Cognitive ModelCore Beliefs Assumptions Coping Strategies Situation Automatic Thoughts/ Images Reaction (Emotional, Behavioral, Physiological)Basic Cognitive-Behavioral ModelEvent Behavior Cognitive AppraisalEmotionAutomatic thoughts

PhysiologicPeople evaluate their health threats by constructing their own representations or perceptions of their illness, which in turn influences their pattern of coping and adjustment.Cognitive distortionsLabelingMind readingExaggerationUnrealistic expectationsBelief in entitlementBelief in absolute fairness

Irrational ideas & BeliefsAlbert Ellis first presented the idea that irrational beliefs are at the core of most psychological problems. We could also call these beliefs unrealistic, incorrect, or maladaptive. Therapists have also suggested that these ideas are irrational because they are not logical, or are based on false assumptions. Overgeneralizing or CatastrophizingCatastrophizing is a negative overgeneralization. For example:You make a small mistake on a project, and assume that you will be fired when the boss finds out. You try your hand at a new hobby, and it does not turn out well. You conclude, "I'm no good at anything."

Cognitive distortionsAnother form of irrational ideas, overgeneralizing of simple mistakes, or developing false assumptions about what other people think about us, or expect from us. We are distorting reality by the way we are evaluating a situation. The concept of cognitive distortion highlights the importance of perceptions, assumptions and judgments in coping with the worldCognitive distortionsTherapist help us determine what evaluations are distortions by providing objective feedback about our evaluations of the world, and by teaching us how to change the way we are perceiving problems.

Pessimistic ThinkingIt is easier to become depressed if you tend to view the world with considerable pessimism. Pessimism is a tendency to think that things won't work out as you wish, that you won't get what you want. Pessimism feeds the negative cognitive distortions and self-talk. Fighting dysfunctional thoughtsHot Thoughts Cool ThoughtsHe is always mean * Maybe he had to me a bad dayI did a lousy job* Itll be better next timeI deserve better * But people are peopleThat jerk. * Its his problem Dysfunctional ThoughtSituationEmotion rate (1-100%)Automatic thoughtsCognitive distortionRational responseOutcome rate (1-100%)Fight with spouseAngry 99%Sad 50 %I will never have a normal marriage

I deserve better

Hes stubborn Magnification

Entitlement Labelling Its not the end of the world

Thats normalMaybe he had a bad day at work

Angry 50%Sad 10%Modifying AT: Thought ChangeCatchCheckChange Pedro is upset with meI am jumping to conclusionI can ask Pedro why he is upset with me.I am an idiotI am name-callingOne small mistake does not make me an idiot.Behavioral MethodsBehavioral Activation: * What could you do?Activity Scheduling & Monitoring * Keep a schedule * Monitor for Mastery and Pleasure * Increase Mastery and Pleasure activities Behavioral MethodsGraded Task Assignment * Break into steps Behavioral Rehearsal * Role playing Specific skills * Thought stopping * Breathing RetrainingProblem solving

Summary of Cognitive Psychotherapy ApproachThe essence of cognitive therapy is the assumption that irrational thoughts and beliefs, overgeneralization of negative events, a pessimistic outlook on life, a tendency to focus on problems and failures, and negative self assessment, as well as other cognitive distortions, promote the development of psychological problems, like anxiety and depression.Therapist use cognitive therapy to help you identify and understand how these cognitive distortions affect your life. Cognitive therapy helps you to change, so that these issues will not rule your life. If you are feeling overburdened, that life is not working for you, and you don't know what to do next, talk to someone who can help.

Men are disturbed not by things, but by the view which they take of them.

Epictetus (55-135, Greek Stoic)Maraming Salamat.