Cognitive Behavioural Therapy in psychotherapy.pptx

What is CBT?
 CBT is based on the cognitive model of mental illness, initially
developed by Beck (1964).
 In its simplest form, the cognitive model ‘hypothesizes that people’s
emotions and behaviours are influenced by their perceptions of
events.
 It is not a situation in and of itself that determines what people feel
but rather the way in which they construe a situation’ (Beck, 1964).
 In other words, how people feel is determined by the way in which
they interpret situations rather than by the situations per se.
 For example, depressed patients are considered to be excessively
negative in their interpretations of events (Beck, 1976).

 The underlying concept behind CBT is that our thoughts and feelings
play a fundamental role in our behavior.
 For example, a person who spends a lot of time thinking about plane
crashes, runway accidents and other air disasters may find themselves
avoiding air travel.
 The goal of cognitive behavior therapy is to teach patients that
while they cannot control every aspect of the world around them, they
can take control of how they interpret and deal with things in their
environment.
 Cognitive behavior therapy has become increasingly popular in recent
years with both mental health consumers and treatment professionals.
 Because CBT is usually a short-term treatment option, it is often more
affordable than some other types of therapy.
 CBT is also empirically supported and has been shown to effectively
help patients overcome a wide variety of maladaptive behaviors.

The diagram depicts how emotions, thoughts, and behaviors all influence each
other. The triangle in the middle represents CBT's tenet that all humans' core beliefs
can be summed up in three categories: self, others, future.
Cognitive behavioral therapy
Intervention

Automatic Negative Thoughts
 One of the main focuses of cognitive-behavioral therapy is on changing
the automatic negative thoughts that can contribute to and exacerbate
emotional difficulties, depression, and anxiety.
 These negative thoughts spring forward spontaneously, are accepted as
true, and tend to negatively influence the individual's mood.
 Through the CBT process, patients examine these thoughts and are
encouraged to look at evidence from reality that either supports or
refutes these thoughts.
 By doing this, people are able to take a more objective and realistic look
at the thoughts that contribute to their feelings of anxiety and depression.
 By becoming aware of the negative and often unrealistic thoughts that
dampen their feelings and moods, people are able to start engaging in
healthier thinking patterns.

Cognitive behavior therapy has been used to treat people suffering from a
wide range of disorders, including:
 Anxiety
 Phobias
 Depression
 Addictions
 Eating disorders
 Panic attacks
 Anger

 Butler et al. (2006) conducted a comprehensive review of 16 meta-
analyses comparing CBT to no-treatment, wait list and placebo
conditions.
 The authors found CBT to be an effective treatment for adult and
adolescent bipolar disorder, generalised anxiety disorder, panic
disorder with or without agoraphobia, social phobia, post traumatic
stress disorder, and childhood depressive and anxiety disorders.
 However, there is evidence from Scott et al. (2006) that CBT for bipolar
disorder may be less effective than treatment as usual in people who
have suffered more than 12 episodes. CBT fulfils the criteria for a
‘well-established’ empirically supported therapy, as its efficacy has
been established in two or more carefully designed methodologically
reliable randomised controlled trials (Meyer and Scott, 2008).

 Fundamental to the cognitive model is the way in
which cognition (the way we think about things and
the content of these thoughts) is conceptualised.
Beck (1976) outlined three levels of cognition:
 Core beliefs
 Dysfunctional assumptions
 Negative automatic thoughts

1. Core beliefs, or schemas, are deeply held beliefs
about self, others and the world. Core beliefs are
generally learned early in life and are influenced
by childhood experiences and seen as absolute.
The cognitive triad of negative core beliefs, as
depicted in Fig. 1, captures how they relate to:
 The self, e.g. ‘I’m useless’
 The world/others, e.g. ‘the world is unfair’
 The future, e.g. ‘things will never work out for me’

Fig 1; The cognitive triad of negative core beliefs. From Beck (1976).

2.Dysfunctional assumptions are rigid, conditional ‘rules
for living’ that people adopt. These may be unrealistic
and therefore maladaptive. For example, one may live
by the rule that ‘It’s better not to try than to risk failing’.
3.Negative automatic thoughts (NATs) are thoughts that
are involuntarily activated in certain situations. In
depression, NATs typically centre on themes of
negativity, low self-esteem and uselessness. For
example, when facing a task, a NAT may be ‘I’m going
to fail’. In anxiety disorders, automatic thoughts often
include overestimations of risk and underestimations of
ability to cope.

 In CBT, the ‘cognitive model’ is used as a framework in which to understand a person’s
mental distress or presenting problem.
 process of placing an individual’s idiosyncratic experiences within a cognitive
behavioural framework is known as ‘formulation’.
 A formulation is ‘A hypothesis about the causes, precipitants and maintaining
influences of a person’s problems’ (Eels, 1997).
 The formulation is intended to make sense of the individual’s experience and aid the
mutual understanding of the individual’s difficulties.
 Formulations can be developed using different formats, exemplified by different
ways of formulating depression.
 Beck et al. (1979) created a longitudinal formulation of depression. Within this
formulation, early experiences (e.g. rejection by parents) contribute to the
development of core beliefs, which lead to the development of dysfunctional
assumptions (e.g. ‘Unless I am loved I am worthless’), which are later activated
following a critical incident (e.g. loss), leading to NATs and the symptoms of
depression. Formulations can also be cross-sectional.
 For example, The ‘hot-cross bun model’ (Greenberger and Padesky, 1995), shown in
Fig. 2, emphasises how an individual’s thoughts, feelings, behaviour and physical
symptoms interact.

Figure 2. The hot-cross bun model of CBT formulation. From an idea attributed to Greenberger and Padesky
(1995).

What are the key assumptions of CBT?
 CBT ultimately aims to teach patients to be their own
therapist, by helping them to understand their
current ways of thinking and behaving, and by
equipping them with the tools to change their
maladaptive cognitive and behavioural patterns.
The key elements of CBT may be grouped into those
that help foster an environment of
1. collaborative empiricism
2. and those that support the structured, problem-
orientated focus of CBT.

1. Collaborative empiricism (Wright, 2006) is based upon the
establishment of a collaborative therapeutic relationship in
which the therapist and patient work together as a team to
identify maladaptive cognitions and behaviour, test their
validity, and make revisions if needed.
 A principal goal of this collaborative process is to help patients
effectively define problems and gain skills in managing these
problems.
 CBT also relies on the non-specific elements of the therapeutic
relationship, such as rapport, genuineness, understanding and
empathy.
 Initially, to aid the collaborative relationship, the therapist
explains the rationale of the cognitive behavioural model and
illustrates the description using examples from the patient’s own
experience.

2. The focus of CBT is problem-oriented, with an emphasis on the present.
 Unlike some of the other talking treatments, it focuses on ‘here and now’ problems and difficulties.
 Instead of focusing on the causes of distress or symptoms in the past, it looks for ways to improve
a patient’s current state of mind.
 CBT involves mutually agreed goal setting.
 Goals should be ‘SMART’, i.e. specific, measurable, achievable, realistic and time-limited. For
example, a goal for a patient with obsessive compulsive disorder may be to reduce the time
spent washing their hands from 5 hours per day to 1 hour per day by the end of 3 weeks of
therapy.
 The therapist helps the patient to prioritise goals by breaking down a problem and creating a
hierarchy of smaller goals to achieve.
 CBT sessions are structured to increase the efficiency of treatment, improve learning and focus
therapeutic efforts on specific problems and potential solutions.
 Sessions begin with an agenda-setting process in which the therapist assists the patient in
selecting items which can lead to productive therapeutic work in that particular session.
 Furthermore, homework assignments are used to extend the patient’s efforts beyond the confines
of the treatment session and to reinforce learning of CBT concepts.
CBT is a structured and time-limited treatment. For non-comorbid anxiety or depression, a course
of CBT typically lasts 5–20 sessions. If axis II disorders are present, which are personality
disorders or intellectual disabilities, treatment may need to be extended due to the lifelong,
pervasive pattern of these disorders and slower change that has been observed with CBT.

General CBT Assumptions:
 The cognitive approach believes that abnormality stems
from faulty cognitions about others, our world and us. This
faulty thinking may be through cognitive deficiencies (lack
of planning) or cognitive distortions (processing information
inaccurately).
 These cognitions cause distortions in the way we see things;
Ellis suggested it is through irrational thinking, while Beck
proposed the cognitive triad.
 We interact with the world through our mental
representation of it. If our mental representations are
inaccurate or our ways of reasoning are inadequate then
our emotions and behavior may become disordered.

What techniques are used in CBT?
 CBT aims to change how a person thinks (‘cognitive’) and what they do
(‘behaviour’).
 CBT therefore uses both cognitive and behavioural techniques.
 The specific interventions chosen depend on the individual’s formulation.
 This technique acknowledges that there may be behaviors that cannot be controlled
through rational thought, but rather emerge based on prior conditioning from the
environment and other external and/or internal stimuli.
 CBT is "problem-focused" (undertaken for specific problems) and "action-oriented"
(therapist tries to assist the client in selecting specific strategies to help address those
problems),or directive in its therapeutic approach.
 Cognitive therapists believed that conscious thoughts could influence a person’s
behavior all on its own.

Cognitive techniques used
1. A key cognitive concept in CBT is ‘guided discovery’ (Padesky, 1993). This is a therapeutic stance which involves
trying to understand the patient’s view of things and help them expand their thinking to become aware of their
underlying assumptions, and discover alternative perspectives and solutions for themselves.
An aspect of guided discovery is Socratic questioning, which is a method of questioning based on the way in
which Socrates (c. 400 BC) helped his students to reach a conclusion without directly telling them. Padesky (1993)
explained that Socratic questions should draw the patient’s attention to something outside of their current focus.
 Therapists use questions to probe a patient’s assumptions, question the reasons and evidence for their beliefs,
highlight other perspectives and probe implications. For example, ‘What else could we assume?’, ‘What do you think
causes …?’, ‘What alternative ways of looking at this are there?’ and ‘Why is … important?’. Guided discovery is
central to the interventions aimed at each level of cognition.
2. To target maladaptive core beliefs, the patient can be asked to keep a positive data log (Padesky, 1994), in
which the patient keeps a daily log of all observations that are consistent with a new, more adaptive schema (e.g.
‘I am useful to people’).
 Core beliefs are the least accessible level of cognition and so are tackled later in therapy than dysfunctional
assumptions and negative automatic thoughts.
 To target dysfunctional assumptions, the patient can be asked to provide evidence that supports/does not support
their assumptions.
 The mixed evidence can help remould the rules to make them more ‘elastic’ and accurate.
 Thought records are used to make a patient aware of their NATs, distinguish thoughts from facts, and see how they
impact upon their mood.
 They encourage the consideration of alternative thoughts and the resulting change in emotion. These are used to
challenge NATs.
 Filling out a seven-column thought record (Greenberger and Padesky, 1995) involves detailing the situation, mood,
the NAT, evidence for this NAT, evidence against this NAT, the development of an alternative rational response, and
a rerating of mood.

Behavioural techniques used
 Activity scheduling and graded task assignment aim to enhance functioning and systematically increase pleasurable or
productive experiences.
 Activity scheduling is used to plan each day in advance. The therapist and patient work to reduce the mass of tasks to a
manageable list, which removes the need for repeated decision making.
 The graded task assignments create manageable steps to help overcome procrastination and anxiety-provoking situations.
 These techniques involve obtaining a baseline of activities during a day or week, rating activities on the degree of mastery
and/or pleasure, and then collaboratively designing changes that will reactivate the patient, stimulate a greater sense of
enjoyment in life, or change patterns of isolation or procrastination.
 These techniques help patients re-establish daily routines, increase pleasurable activities and deal with problems and difficult
issues by increasing problem solving.
 Behavioural experiments are mainly used with anxiety-based mental health disorders. The technique allows a person to test
out their catastrophic predictions (e.g. ‘If I leave the house, something terrible will happen’).
 Concurrently, behavioural experiments also help patients to learn to tolerate anxiety. The patient makes a prediction before
completing a task (e.g. walking to the shop) and then records whether that prediction came true.
 Over time, the patient will thereby be re-evaluating their catastrophic thoughts, by developing helpful evidence against their
predictions.
 The therapist works with the client to develop hierarchical tasks, starting from lowest anxiety-provoking task going up to high
anxiety-provoking tasks.
 Behavioural experiments are also used to help patients gather evidence against the use of ‘safety behaviours’ (Salkovskis
, 1996), which are avoidance and escape behaviours. Within the cognitive model, safety behaviours reinforce anxiety as
they make disconfirmation of dysfunctional assumptions and negative automatic beliefs impossible. For example, if a patient
avoids going on public transport because they believe something terrible will happen, they will believe that avoiding public
transport ‘saves’ them from this perceived threat. A behavioural experiment would allow the patient to gather evidence to
discount the predictions that something terrible will happen and that the safety behaviour of avoidance is necessary to
remain safe.
 Progressive relaxation training and breathing exercises may be used to reduce levels of autonomic arousal related to
anxiety. These techniques may be used to help manage panic attacks or other symptoms of anxiety disorders.

What are the advantages of using CBT?
1. Long-term outcome
 CBT has been shown to have an enduring positive effect for patients. In a
randomised trial, Dobson et al. (2008) found that depressed patients who had
previously been treated with anti-depressant medication (ADM) had a
greater chance of relapse through 1 year follow-up than patients who had
previously received CBT. In fact, prior CBT had an enduring effect (in terms of
prevention of relapse and recurrence during the follow-up period) that was at
least as strong as continuing patients on ADM.
2. Cost-effectiveness
 In a randomised trial of CBT and ADM, Dobson et al. (2008) found that,
although CBT was more expensive to provide initially, the cumulative cost of
continued medications proved to be more expensive by the end of the first
year of follow-up. Furthermore, mindfulness-based CBT is a particularly cost-
effective approach, because it is delivered in a group format.

Types of Cognitive Behavior Therapy
 According to the British Association of Behavioural
and Cognitive Psychotherapies, "Cognitive and
behavioural psychotherapies are a range of
therapies based on concepts and principles derived
from psychological models of human emotion and
behaviour.
 They include a wide range of treatment approaches
for emotional disorders, along a continuum from
structured individual psychotherapy to self help
material."

The Process of Cognitive Behavior Therapy
 During the process of CBT, the therapist tends to take a very
active role.
 CBT is highly goal-oriented and focused, and the client and
therapist work together as collaborators toward the mutually
established goals.
 The therapist will typically explain the process in detail and
the client will often be given homework to complete between
sessions.
 Cognitive-behavior therapy can be effectively used as a
short-term treatment centered on helping the client deal with
a very specific problem.

There are distinct steps in a cognitive behavioral session as detailed by Liese and Beck (1997).
1. Check-in: greeting and getting an assessment of how the supervisee is feeling
2. Agenda setting: determining what will be accomplished in the session. This also encourages
the supervisee to come to the session prepared to work.
3. Bridge for previous session: a review of what was learned or accomplished in the last
supervision session
4. Inquiry about previously supervised therapy cases: update on the progress of cases
5. Review of homework since previous supervision session: discussion of any assigned readings
or research, utilization of newly learned techniques, etc.
6. Prioritization and discussion of agenda items: Review of taped-recorded sessions, role-
playing or teaching of new techniques
7. Assignment of new homework: assign activities to further develop knowledge and skills
8. Supervisor's capsule summaries: reflection on the work of the session with emphasis on
important elements
9. Elicit feedback from supervisee: elicit feedback from supervisee on the session and what
was learned

specific types of therapeutic approaches that involve CBT that are regularly
used by mental health professionals.
1. Rational Emotive Behavior Therapy (REBT): This type of CBT is centered on
identifying and altering irrational beliefs. The process of REBT involves
identifying the underlying irrational beliefs, actively challenging these
beliefs, and finally learning to recognize and change these thought patterns.
2. Cognitive Therapy: This form of therapy is centered on identifying and
changing inaccurate or distorted thinking patterns, emotional responses, and
behaviors.
3. Multimodal Therapy: This form of CBT suggests that psychological issues must
be treated by addressing seven different but interconnected modalities,
which are behavior, affect, sensation, imagery, cognition, interpersonal
factors and drug/biological considerations.
4. Dialectical Behavior Therapy: This type of cognitive-behavioral therapy
addresses thinking patterns and behaviors and incorporates strategies such
as emotional regulation and mindfulness.

Duration
 A typical CBT programme would consist of face-to-
face sessions between patient and therapist, made
up of 6-18 sessions of around an hour each with a
gap of a 1–3 weeks between sessions.

Strengths of CBT
1. Model has great appeal because it focuses on human thought.
Human cognitive abilities has been responsible for our many
accomplishments so may also be responsible for our problems.
2. Cognitive theories lend themselves to testing. When experimental
subjects are manipulated into adopting unpleasant assumptions or
thought they became more anxious and depressed (Rimm & Litvak,
1969).
3. Many people with psychological disorders, particularly depressive ,
anxiety , and sexual disorders have been found to display
maladaptive assumptions and thoughts (Beck et al., 1983).
4. Cognitive therapy has been very effective for treating depression
(Hollon & Beck, 1994), and moderately effective for anxiety
problems (Beck, 1993).

Limitations of CBT
1. The precise role of cognitive processes is yet to be determined. It is not clear whether
faulty cognitions are a cause of the psychopathology or a consequence of it.
2. Lewinsohn (1981) studied a group of participants before any of them became
depressed, and found that those who later became depressed were no more likely to
have negative thoughts than those who did not develop depression. This suggests that
hopeless and negative thinking may be the result of depression, rather than the cause
of it.
3. The cognitive model is narrow in scope - thinking is just one part of human functioning,
broader issues need to be addressed.
4. Ethical issues: RET is a directive therapy aimed at changing cognitions sometimes quite
forcefully. For some, this may be considered an unethical approach.

Stress Inoculation Therapy (SIT) (Meichenbaum)
 is a psychotherapy method intended to help
patients prepare themselves in advance to handle
stressful events successfully and with a minimum of
upset. The use of the term "inoculation" in SIT is
based on the idea that a therapist is inoculating or
preparing patients to become resistant to the
effects of stressors in a manner similar to how a
vaccination works to make patients resistant to the
effects of particular diseases.

SIT consists of three interlocking and overlapping phases:
1. A conceptual educational phase
2. A skills acquisition and skills consolidation phase
3. An application and follow-through phase.

REBT
 According to Ellis, "people are not disturbed by things
but rather by their view of things." The fundamental
assertion of rational emotive behavior therapy (REBT)
is that the way people feel is largely influenced by
how they think.
 When people hold irrational beliefs about themselves
or the world, problems can result. Because of this, the
goal of REBT is to help people alter illogical beliefs
and negative thinking patterns in order to overcome
psychological problems and mental distress.

The ABC Model(ELLIS)
 Ellis suggested that people mistakenly blame external events for
unhappiness. He argued, however, that it is our interpretation of these
events that truly lies at the heart of our psychological distress.
 To explain this process, Ellis developed what he referred to as the ABC
Model:
 A – Activating Event: Something happens in the environment around you.
 B – Beliefs: You hold a belief about the event or situation.
 C – Consequence: You have an emotional response to your belief.
 The events and situations that people encounter throughout life are only
one piece of the puzzle.
 In order to understand the impact of such events, it is also essential to look
at the beliefs people hold about these experiences as well as the emotions
that arise as a result of those beliefs.

Cognitive Distortions(Beck)
Beck (1967)
identifies a number
of illogical thinking
processes (i.e.
distortions of
thought processes).
These illogical
thought patterns
are self-defeating,
and can cause
great anxiety or
depression for the
individual.
• Arbitrary interference: Drawing conclusions on the basis of sufficient or
irrelevant evidence: for example, thinking you are worthless because
an open air concert you were going to see has been rained off.
• Selective abstraction: Focusing on a single aspect of a situation and
ignoring others: E.g., you feel responsible for your team losing a
football match even though you are just one of the players on the
field.
• Magnification: exaggerating the importance of undesirable events.
E.g., if you scrape a bit of paint work on your car and, therefore, see
yourself as totally awful driver.
• Minimisation: underplaying the significance of an event. E.g., you get
praised by your teachers for an excellent term’s work, but you see this
as trivial.
• Overgeneralization: drawing broad negative conclusions on the basis
of a single insignificant event. E.g., you get a D for an exam when you
normally get straight As and you, therefore, think you are stupid.
• Personalisation: Attributing the negative feelings of others to yourself.
E.g., your teacher looks really cross when he comes into the room, so
he must be cross with you.

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