Final cbt seminar

COGNITIVE BEHAVIOUR THERAPY Principles, Techniques & Practice PRESENTER : JYOTHSNA K A CHAIRPERSON : DR. AMEER HAMZA DISCUSSANT : DR. KAVITA JANGAM

OUTLINE OF THE PRESENTATION Introduction On CBT- Historical Background Principles – Assumptions & Theoretical Basis Components Of CBT Techniques Of CBT CBT Used In Various Disorders Models Of Psychotherapy Using CBT Indications And Contraindications For CBT Research On CBT CBT Practice With Children CBT Practice With Adults Advantages And Disadvantages CBT – TRAINING AND SKILLS OF The THERAPIST Simple Guidelines For Practice CBT And Social Work

INTRODUCTION ON CBT- HISTORICAL BACKGROUND Men are disturbed, not by things, but by the principles and notions which they form concerning things ( Epictetus 55 - 135 AD)

Mental Illness is defined as “ All diagnosable mental disorders, health conditions characterized by alterations in thinking, mood, behaviour ( or some combination thereof) associated with distress and / or impaired functioning “ (Surgeon General’s Report, US Health and Human Services, 1999) Mental health problems can be conceptualized as disruptions in the interactions between the individual, group, and the environment producing a diminished rate of positive mental health(Scanlon et al, 1997)

In a mental health setting, a multi-disciplinary team approach is practised in the treatment of mental illnesses/ mental health problems The psychiatrists and nursing is mainly focusing on pharmacotherapy The Psychiatric Social Workers and clinical psychologists look into psychosocial interventions They offer variety of psychotherapies

We may broadly consider 4 psychotherapies PSYCHOTHERAPIES PSYCHODYNAMIC HUMANISTIC & EXISTENTIAL BEHAVIOURAL COGNITIVE

PSYCHODYNAMIC Probes the past and does not tackle the immediate problem Explores the unconscious The goal is to bring insight into the client It takes a long time Methods used are free association, dream analysis and transference HUMANISTIC & EXISTENTIAL Client centred by Carl Rogers Focus on self actualization and explore the meaning of existence Emphasis on emotion and experience emphasis on non-directive approaches to therapy Empathy, warmth, active listening, unconditional positive regard

BEHAVIOURAL There are no mental processes (will, mind) Derived from classical and operant conditioning The focus is on changing the behavior Works on the immediate problem Focuses on the present Techniques based on classical, operant conditioning & learning COGNITIVE emphasis is on internal thought processes Addresses cognitive distortions challenges client’s distorted thinking through a process of checking beliefs against reality

The fundamentals of cognitive behaviour therapy have been around since ancient Greeks Cognitive Behavioural Theories evolved from bi-directional movements in the existing fields of cognitive psychology and behavioural science The evolution of CBT took place in 3 stages

Phase I: BEHAVIOUR THEORY Initially Behaviour Therapy in United Kingdom and then parallel in USA in 1950s Criticisms to strict behavioural approaches in 1970s Derived from ideas of Pavlov, Watson and Hull Major contributors were J. Wolpe, Eysenck, Skinner

Earlier, concentrated on neurotic disorders in adults Classical conditioning, operant conditioning and modelling The techniques used are systematic desensitization, aversive conditioning and exposure/ flooding, token economy

Phase II: COGNITIVE THEORY Cognitive research in 1960s demonstrated biases of people in information processing Leading proponents were Aaron Beck and Albert Ellis Behaviour techniques used to teach client cognitive strategies Emerged in 1960s Origin of RET by Ellis in 1962 During the expansion of research, researchers understood link between cognitive factors and behaviour

Somewhat differed from behaviourism Progressed to use alongside behaviour therapy and also emphasis on behavioural component of cognitive therapy Ellis was early advocate of directive form of cognitive therapy (RET) Albert Ellis – psychological problems stem from irrational and catastrophic thinking Aaron Beck – psychological problems stem from distorted thinking based on underlying cognitive schemata

Phase III: CBT dominance Over the past 20 years, the cognitive and behavioural theories have become more inter-connected, emphasizing both behaviour and thinking Cognitive-behavioural therapy is becoming the dominant paradigm in clinical psychology

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)

CBT is the integrative, unified theories of cognition and learning with treatment techniques derived from cognitive and behavioural therapies Focused form of psychotherapy based on a model suggesting that psychiatric or psychological disorders involve dysfunctional thinking

The way an individual feels and behaves is influenced by the way he/she structures his/her experiences Modifying dysfunctional thinking provides improvements in symptoms and modifying dysfunctional beliefs that underlie dysfunctional thinking leads to more durable improvement

PRINCIPLES – ASSUMPTIONS & THEORETICAL BASIS Individuals react to and interpret events in terms of their perceived significance: beliefs, expectations and attitudes effect behaviour Cognitive deficiencies can cause emotional disorders Faulty thinking is the cause of emotional and behavioural problems

BEHAVIOURAL PRINCIPLES Basic assumption of behavioural theories is that maladaptive behaviours are learned and can be unlearned, and that new, more adaptive behaviours can be learned Has been applied to a wide range of disorders and problems

COGNITIVE PRINCIPLES 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

Basic assumption of cognitive theories is that maladaptive behaviour results from irrational or distorted ways of thinking – emphasis is on internal thought processes Like psychodynamic theories, cognitive theories have been employed mostly with people with anxiety and mood disorders Like behavioural theories, there is a strong research emphasis in cognitive theories

Components of CBT Thoughts Feelings and emotions Behaviours

Early Experiences Core Beliefs & Assumptions Critical Incident BECK’S COGNITIVE MODEL (1979) Negative Automatic Thoughts (NATS) Feelings Behaviour

NEGATIVE AUTOMATIC THOUGHTS Automatic thoughts are the thoughts that come to mind involuntarily and effortlessly Most of our thoughts are automatic – they happen without being planned or intended Clients may not even notice them unless you make a point of looking for them They may or may not have an affect on client’s feelings, moods or behaviour When they do, their effects can be beneficial, harmful or neutral Some automatic thoughts can cause serious problems

MALADAPTIVE SCHEMAS Sometimes automatic thoughts turn out to have a shared theme called “schema” They take the form of basic assumptions, attitudes or beliefs that influence a person’s thinking indirectly but powerfully Eg : I am not a likable person

Cognitive Triad Negative view of self Negative view of Negative World view of Future

Cognitive Distortions Labeling Mind Reading Exaggeration Unrealistic Expectations Belief in Entitlement Belief in Absolute Fairness Personalization Minimization Magnification

TECHNIQUES AND PROCESS OF CBT Essentially has 3 stages Initial sessions Middle sessions Later sessions

INITIAL SESSIONS 1-3 sessions Developing a good therapeutic alliance Check client’s mood Assess client’s problems Consider the most important problems Clarify integral relationship between beliefs, affect and behaviour Help client to identify automatic thoughts Help clients to link automatic thoughts with emotion and behaviour

Outline the cognitive behavioural model Take client’s consent to move further Discuss client’s expectations of therapy Agree between session assignments Summarise session Begin to socialize the client into the model Emphasize on regular homework Obtain feedback on session

MIDDLE STAGE Approximately 4-10 sessions Help client to accept responsibility for personal change Establish the extent to which the client engages in behaviours that temporarily relieve and/or enable avoidance of the problem but which are counterproductive Continue to maintain a collaborative therapeutic relationship

Teach client about cognitive distortions Shift focus of therapy from negative automatic thoughts to more helpful thoughts Educate client about self-acceptance Pass responsibility for therapeutic work over to the client Encourage the client to become her own therapist

Refining and practicing social skills, problem solving skills, coping skills Encourage client to continue with tasks between sessions Prepare client for setbacks and ending therapy Continue to give feedback and encouragement

ENDING STAGE OF THERAPY 11-15 sessions Shift focus to eliciting, examining and modifying deeper cognitive structures Monitoring homework Relapse prevention prepare client for ending of therapy Consider dependency issues

Help the client to summarise what has been learnt and understands appropriate techniques Praise the client for genuine efforts Decide when to end therapy consistent with the development of cognitive conceptualisation Explore obstacles to ending Develop action plan for potential problems

Techniques………… COGNITIVE BEHAVIOURAL ASSESSMENT Education on CBT approach Behavioural Interview Interviews with key persons Direct observations in clinical settings Rating scales and questionnaires Establish suitability for CBT Gather specific information re current difficulties Initial formulation

BEHAVIOURAL TECHNIQUES Relaxation Rehearsing Systematic desensitisation Anger Management Homework assignments Cue response, graded exposure/flooding Response prevention Modelling Stimulus control Hypnotherapy Habit Control Aversion Role play

COGNITIVE TECHNIQUES Education De-catastrophising continuum Letter writing Imagery techniques Cost benefit analysis of beliefs Thought stopping Experimentation Self-monitoring and recording Dysfunctional Thought Record and Downward Arrow Guided Discovery Challenging irrational beliefs Cognitive Restructuring Coping skills and problem solving skills Socratic questioning Reframing the situation

CBT USED IN VARIOUS DISORDERS Mood Disorders First developed as a treatment for depression First line of psychotherapy for unipolar depression Identifying negative automatic thoughts Challenging thoughts Behaviour and cognitive strategies to change thoughts and behaviour Homework assignments Monitoring outcome Preventive strategies

Anxiety Disorders (OCD/ Panic/ Others ) ABC analysis Thought diaries Teaching the techniques Graded exposure/ Flooding/ imagery/ audio exposure Response prevention Homework and diary Self monitoring

Eating disorders Assessing key features of eating disorder Psycho education Rationale for treatment Prescribing normal eating patterns Self monitoring and meal plan Initial cognitive interventions Challenging body image issues, modifying self concept Practicing, reviewing and self dependency, relapse prevention

Personality Disorders Success rate better in BPD Assessment Therapy uses less Socratic and more confrontative Skills training More research is on the way

Sexual dysfunctions Assessment Problem formulation Education Counselling Homework assignments Termination

Alcohol use/ substance use disorders Behaviour self control Cues exposure related training Self monitoring Relapse prevention Follow up

Families and Couples Assessment of beliefs about relationship Modification of unrealistic expectations in the relationship Correction of faulty attributions in relationship interactions Communication training and problem solving training

SOMATIZATION PROBLEMS Reduce physiological arousal through relaxation Activity Scheduling focused on pleasurable activities Increase the awareness of emotions Modify dysfunctional beliefs Enhance communication of thoughts and emotions Reduce family reinforcement of illness behaviour

PREMENSTRUAL SYNDROME Psychoeducation Analysis of negative thoughts and anxious preoccupation Imparting coping skills Teaching anger management Relaxation techniques Management of anxiety/ depressive symptoms Encouraging positive thinking

Chronic pain, Neurological & Neurosurgical Problems Interventions for depression in patients with Parkinson’s Disease Interventions for patients with anxiety after surgery for brain tumors and injuries Interventions for grief and anxiety in patients with cancer Pain management Migraine and headaches using relaxation and cognitive techniques

MODELS OF PSYCHOTHERAPY USING CBT COGNITIVE THERAPY RATIONAL EMOTIVE BEHAVIOUR THERAPY MINDFULNESS & MBCT DIALECTICAL BEHAVIOUR THRAPY ACCEPTANCE & COMMITMENT THERAPY MULTIMODAL THERAPY BEHAVIOUR THERAPY CBT

INDICATIONS FOR CBT Neurotic disorders Client to have insight to some extent Good therapeutic relationship Considered effective treatment for depression Also considered first line of psychotherapy for anxiety disorders, sexual dysfunctions as in uncomplicated cases Cases of schizophrenia with negative symptoms

CONTRAINDICATIONS FOR CBT Generally not indicated for people with thought disorders People with compromised intelligence People with organic brain disorders People who do not have good grasp of therapy language People not accepting the premise of the treatment Schizophrenia cases with positive symptoms Severe suicidal ideas

RESEARCH ON CBT Conclusions based on systematic Cochrane Review “ Cognitive interventions combined with exercise is recommended for chronic low backache in carefully selected patients after active rehabilitation programmes during 2 yrs time have failed” (Van Tulder et al., 2006)

Randomized trial study among 204 patients with somatoform disorders in primary care setting in Spain revealed effectiveness of group and individual CBT (Rosa Magallon et al, 2008) Results of a meta analytical investigation CBT for adolescent depression supported the efficacy of CBT(J B Klein, 2008) Meta- analytical study on CBT with children with OCD revealed further need for enhanced use of CBT ( Jennifer Freeman, 2007)

A study on CBT for survivors after brain injury with anxiety disorders, showed that survivors made significant improvement (Williams, Evans and Fleminger, 2003) CBT for Irritable Bowel Syndrome has efficacy in primary care as per randomized trial control study in 149 patients in UK primary care centre (Tom Kennedy et al, 2005) Results of applying Social Cognition Model with 50 adults with HIV positive in Tamil Nadu, showed need for further cognitive behavioural based interventions with such groups ( Nalini T et al, 2006)

A study by NIMHANS on HIV and Psychiatric disorders indicated a need for psychosocial interventions like CBT (Dr. Prabha Chandra & Dr. Geeta Desai, 2005) A study by NIMHANS regarding CBT for Bronchial Asthma revealed that it helps in the management of asthma ( Prasad Rao et al, 2002) NIMHANS study on effectiveness on CBT for neurotic depressives on 25 samples using Beck’s approach revealed reduction in negative thoughts and depressive features (Nalini NR & Dr. Subbukrishna, 1996 )

CBT PRACTICE WITH CHILDREN Research shows children suffer from a variety of Anxiety Disorders CBT is considered the first line of treatment parallel to pharmacotherapy Cognitive approaches to parents of children with eating disorders, ODD, LD and sleeping disorders help parents in better management of such children

CBT is also used in cases of children with ADHD, panic disorder, phobias, OCD, PTSD Also for children and adolescents with unipolar depression Treatment option for aggressive behaviour in youth

CBT PRACTICE WITH ADULTS In case of adults, CBT is extensively used for depression There are more studies supporting good outcome in OCD Persons with alcohol and substance use disorders can be helped through CBT

Other wide range of disorders like PTSD, other anxiety disorders and phobias, personality disorders, eating disorders and sexual dysfunctions Effective in somatization problems, couples problems, family problems

ADVANTAGES AND DISADVANTAGES Advantages of Cognitive Behavior Therapy It has established human thought processes as data or events that can be studied. It validated a number of relaxation techniques. It has enhanced the rational therapies such as Rational Emotive Behavior Therapy. Uses the systematic scientist-practitioner model

Disadvantages of Cognitive Behavior Therapy It has been harshly judged by feminists, multiculturalists and ecologists because it mirrors masculine and Euro-American worldviews and does not adequately take culture into consideration. It requires a lot of training and skill. The therapist needs to not only understand cognitive techniques but also have a vast understanding of behavioral and learning theories. The therapist needs to have strong discipline and there is less tolerance for error.

CBT –SKILLS AND TRAINING OF THERAPIST Assessment Accurate Empathy Being ‘with’ the client Get the client’s meaning Communicate empathic understanding Communicate unconditional positive regard

The minimum requirement as in abroad is a diploma in CBT -3 months course The students or practitioners of ther froms of psychotherapy can attend the workshops whenever conducted The graduation and post graduation in psychology offers training Clinical practice and adequate supervision and guidance from well established practitioners

SIMPLE GUIDELINES FOR PRACTICE Assessment Building Therapeutic Relationship A B C Analysis Problem formulation Listing hierarchy and working on priority Planning and Structuring sessions Guiding the client in implementation Homework and review Termination

Social Work Practice and CBT Client’s shift from passive recipient to active partner in treatment Need for incorporation of diversity issues into interventions Call for evidence based practice

Social workers should look for short-term, concrete, operational, and effective treatment methods which are measurable learn to routinely apply initial assessment tools as well as evaluation methods to research their own treatment outcomes a powerful need exists to teach clients specific skills that will enable them to resolve and cope with their own problems

Social work and CBT – Commonalities CBT and SW shares common components Individualism – focusing on individual Rational thinking – understanding of thinking, emotions and behaviours of client Select objects for change – assessment Assessment, evaluation and interventions planning Prediction in treatment Developing skills for behaviour change Empowerment – to solve problems using skills (CBT – Clinical Social work practice; Tammie Ronen & Arthur Freeman, 2006)

CBT application by the students in Dept PSW An analysis of case records done in Psychiatric Social Work Department Case Records from 2004 to 2009 60 case records were analysed CBT was used in 50 cases out of 306 cases The following was the impression based on symptom reduction

outcome Other therapies sessions Therapy Diagnosis Moderate to Good Family/ Supportive 25 CBT/CT Depression Moderate Family/ Supportive 12 CBT/CT Bipolar Affective Disorder Moderate Family/ Supportive 20 CBT Social Anxiety Disorder Good Family/ Supportive 25 ERP Obsessive Compulsive Disorder

CONCLUSION CBT is an integrative therapeutic approach that assumes that cognitions, physiology and behaviours are all functionally interrelated. The treatment aims at identifying and modifying biased and distorted thought processes, attitudes and attributions as well as problematic behaviours via techniques actively involving the client participation in cognitive restructuring, self monitoring As such the treatment goal is to develop more rational and adaptive cognitive structure as a pathway to rid off maladaptive patterns of behaviour and improve affect

Final cbt seminar

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Final cbt seminar