Men are disturbed, not by things, but by the principles and notions which they form concerning things

Roman (Greek-born) slave & Stoic philosopher

Cognitive Therapy is a system of psychotherapy that attempts to reduce excessive emotional reactions and self-

defeating behaviour, by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions

Beck et al 1976, 1979, 1993

Collaborative (builds trust)

Active

Based on open-ended questioning

Highly structured and focused

Event

Event

Emotion

EmotionMeaning we give the event

‘Common Sense’ Model

Cognitive Model

Cognitive principle –

it is interpretations of events, not events themselves, which are crucial.

Behavioural principle –

what we do has a powerful influence on our thoughts and emotions

The continuum principle –

mental health problems are best conceptualised as exaggerations of normal processes

‘Here and now’

principle –

it is usually more

fruitful to focus on current processes rather than the past

Interacting systems principle –

it is helpful to

look at problems as interactions between thoughts, emotions, behaviour and physiology and the environment in which the person operates

ENVIRONMENT

THOUGHTS

BIOLOGY MOOD / FEELINGS

BEHAVIOUR

ENVIRONMENTOn Plane

Turbulence

THOUGHTSWe might crash

BIOLOGYHeart racingPalpitations

Rapid breathingDifficult to breathe – choking sensation

MOOD / FEELINGSAnxious 90%

BEHAVIOURReassurance

seeking

Negative Automatic Thoughts

Assumptions

Core beliefs

Stream of thoughts that we can notice if we try to pay attention to them (automatic)

Negatively tinged appraisals or interpretations –

meanings we take from

what happens around us or within us

Specific thoughts about specific events or situations

Brief, frequent, habitual –

often not heard

Plausible and taken as obviously true, especially when emotions are strong

Shifts in Affect

Distinguish between thoughts and emotion and behaviour

Check for images

Negative cognitive triad◦

Biased views of

Oneself

I am bad, useless, unlovable, worthless, a failure

The world in general

Nothing good happens, life is just a series of trials

The future

It will always be like this, nothing I can do will make any difference, what’s the point of anything?

Negative filter◦

Remembering events

◦

Interpreting current events / situations◦

Overgeneralising

from small negative event to broad

negative conclusion

Help the client counteract negative cognitive biases, and develop more balanced view of herself, the world, and the future

Restore activity levels –

especially those that

give sense of pleasure or achievement

Increase active engagement and problem solving

Identify specific problem list (& prioritise)◦

Eg. Poor sleep, relationship difficulties etc

Introduce cognitive model –

how it might

apply to client

Goals (SMART)

Reduce symptoms through behavioural or simple cognitive strategies

Identify and challenge NATs

Relapse prevention

Referral

Assessment: suitability, therapeutic relationship

Assessment (ongoing): problem analysis, wider picture, measures

Problem list & prioritise

Goals for therapy (SMART)

Formulation (ongoing): Sharing model, maintaining factors, predisposing factors, rationale for treatment

Assessment, Formulation

Treatment: start with symptom focused intervention

Review: every six sessions, repeat measures

Discharge: repeat measures, relapse prevention

Follow up / booster sessions:

1,3,6,12 month ?

Mood check

Set collaborative agenda

Review homework

Focus on major topics for the session

Negotiate homework

Potential problems with completing homework

Feedback on session

Engagement

Warmth and empathy

Collaboration

Guided discovery –

socratic

questioning

Feedback and summarising

Agenda setting –

structure and focus

Open and closed questioning

Ability to identify & describe negative thoughts

Awareness & differentiation of emotion

Compatibility with CBT rationale

Acceptance of personal responsibility for change

Alliance potential

Chronicity

of problem

Optimism/pessimism regarding therapy

The concept of measures is central to the CBT approach, as it enables both client and practitioner to evaluate the impact of interventions (Grant et al 2004)

They are important in the process of assessment and aid the practitioner to develop a credible formulation for the client, so that appropriate cognitive and behavioural interventions can be used

Assessment –

to provide information

Baseline –

subsequent measures will show

extent of change

Effectiveness –

helps to (objectively)

demonstrate effectiveness of therapy, and allow modification of treatment

Feedback

Knowledge -

data collection & suggests

areas for future research

Standardised –

developed for particular

populations and problems◦

Eg. Beck Depression Inventory◦

Beck Anxiety Inventory◦

Agoraphobic Cognitions Questionnaire

•• Individualised Individualised –– allow for more specific allow for more specific information for assessment and formulation. information for assessment and formulation. –– EgEg. Problem definition, Targets of therapy, Diaries, . Problem definition, Targets of therapy, Diaries,

% Belief Ratings, Ratings of specific emotions% Belief Ratings, Ratings of specific emotions

Restructuring thoughts and beliefs◦

Guided discovery◦

Thought diaries◦

Challenging NATs

(looking at evidence)

◦

Addressing thinking errors◦

Cost/Benefit Analysis◦

Downward Arrow technique

Education Eg. Written information on thinking errors, disorder specific info

Continuous use of formulation

Imagery techniques

Role play & role reversal

Action Plan

Education in Body systems (symptoms)

Very powerful method of bringing about change

Key component of CBT intervention

Borrowed and adapted from Behaviour Therapy

Incorporate different methodological approaches

Similar in BT / CBT, but fundamentally different

In BT, it is the end product, in CBT, a means to an end ie. Cognitive change

In BT –

graduated, repeated and prolonged

exposure

In CBT -

New ideas are put to the test.

Means of testing the validity thoughts, perceptions, beliefs.

Identify problem to be worked on

Think of as many solutions as possible

Consider each solution –

pros & cons

Pick solution that appears best

Small steps

Action & review

No formulation No CBT

Use CB techniques◦

Bibliotherapy: e.g. Mind Over Mood◦

Challenge negative thoughts

Court Case

Evidence

More balanced/alternative thought

Downward arrow

◦

Behavioural experiments / exposure◦

Activity Diaries◦

Relaxation?

www.get.gg◦

Self help

Workbooks

online CBT programmes –

printable forms etc

Online

Professional links

CBT organisations

Therapist manuals online

Books

The Cognitive Behaviour Counselling Primer.◦

Branch, Dryden. 2008. PCCS.

Cognitive Therapy of Anxiety Disorders.◦

Wells. 1997. Wiley.

Mind Over Mood.◦

Greenberger, Padesky. 1995. Guilford.

The Oxford Guide to Behavioural Experiments in Cognitive Therapy

Bennett-Levy et al. 2004. Oxford