Download Cognitive Therapy CP10

COGNITIVE THERAPY
Slides created by
Barbara A. Cubic, Ph.D.
Professor
Eastern Virginia Medical School
To accompany
Current Psychotherapies 10
Learning Objectives
 This
presentation will focus on:
• Principles of learning and cognitive
theory relevant to psychotherapy
• History of cognitive therapy
• Overview of cognitive therapy
• Commonly used CT techniques
• Creative applications of CT
Basic Concepts of CT
Basic Concepts
 Cognitive therapy focuses
primarily on how information
is processed.
 Behavioral techniques and
cognitive restructuring
techniques are utilized to
elicit change.
Cognitive Model
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Processing of information is vital for
survival.
Survival systems are:
•
•
•
•

Cognitive
Behavioral
Affective
Motivational
Each system is comprised of structures.
• Schemas
Modes
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Information is processed through networks of
cognitive, affective, motivational, and behavioral
schemas.
Primal modes are evolutionary-based, universal,
tied to survival (e.g. anxiety) and operational
almost continuously in some cases (e.g.
personality disorders) while other modes are
minor and under conscious control.
Primal modes include primal thinking, which is
rigid, absolute, automatic, and biased.
Conscious intentions can override primal
thinking.
Cognitive Model
Behaviors
Situation
Automatic
Thoughts
Emotions
Physiological
Response

Automatic thoughts influence not only one’s
emotional response, but also one’s behavioral
and physiological responses.
Cognitive Model

In other words, the relationship is bidirectional (all systems act together as a
mode).
• Thoughts influence biological, affective,
behavioral (and motivational) processes.
• Simultaneously biology, emotions, behavior
(and motivation) influence thoughts.

Therefore biological treatments can change
thoughts and CBT can change biological
processes.
Cognitive Model
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We all have cognitive vulnerabilities (i.e.
core beliefs) which predispose us to
interpret information in a certain way.
These vulnerabilities are developed early.
When these beliefs are rigid, negative, and
ingrained we are predisposed to pathology.
Core beliefs give rise to conditional
assumptions (i.e. rules for living) as we
mature.
Cognitive Model
Behaviors
Situation
Underlying
Beliefs

Automatic
Thoughts
Emotions
Physiological
Response
Automatic thoughts are influenced by these
underlying core beliefs and conditional
assumptions
Cognitive Model
Withdrawal
Relationship
Breakup
I’m worthless
I’m unlovable
He doesn’t
want me
SNS Reaction
Poor Sleep
Depressed
Cognitive Shifts

In various types of psychopathology,
there is a systematic bias toward
selectively interpreting information in
a certain manner.
Characteristics of CT
Practical
 Symptom-focused
 Empirically-derived techniques
 Requires patient collaboration.
 Acknowledges underlying precursors
of symptoms (schemas), but presentoriented.
 Case conceptualization drives
treatment.

Roles of the CT Therapist
Conceptualize the patient in cognitive
terms.
 Structure the sessions.
 Use collaborative empiricism and
guided discovery to:
• Specify problems and set goals.
• Teach the patient CT techniques.

CT Strategies
Collaborative empiricism
 Guided discovery
 Deactivation of dysfunctional
modes:

• Deactivate them.
• Modify their content and structure.
• Construct more adaptive modes to
neutralize them.
Comparing CT to
Other Therapies
Compared with Psychoanalysis

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Both assume behavior influenced by beliefs
outside awareness.
CT focuses on:
• Linkages among symptoms, conscious beliefs
and current experiences.
• Little concern with unconscious feelings or
repressed emotions.
• Minimal focus on childhood issues except in
terms of assessment or when addressing core
beliefs.
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CT is highly structured and short-term (12-16
weeks) whereas psychoanalysis is long-term
and unstructured.
CT therapist actively collaborates with patient.
CT Compared with REBT
CT
REBT
Thoughts
Labeled
Dysfunctional
Irrational
Reasoning Used
Inductive
Deductive
Beliefs
Cognitive
Associated with specificity for
Psychopathology disorders
Core set of
irrational beliefs
View of the
Problem
Functional
Philosophical
Therapist’s
Approach
More
collaborative
More
confrontational
Compared to Behavior
Therapy

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CT is very different from applied behavioral
analysis.
CT is the most commonly practiced form of
cognitive behavior therapy (CBT).
• CBT: An overarching term to represent therapies
that integrate cognitive and behavioral theories
and techniques.
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CT sees the individual as more active rather
than passive in change process.
CT stresses expectations, interpretations
and reactions.
History of Cognitive Therapy
Cognitive Therapy
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Developed by Aaron T. Beck,
M.D.
• Investigated “anger turned
inward” psychoanalytic
concept in 1960s and found
evidence for negative
cognitions.
Bandura, Ellis, Mahoney, and
Meichenbaum were all
influential and developing their
approaches simultaneously.
History of Cognitive Therapy
Major influences were:
1. Phenomenological
approaches
2. Structural theory
and depth
psychology
3. Cognitive
psychology
Current Status of CT
Research on the
Cognitive Model

Cognitive specificity hypothesis (i.e.,
distinct cognitive profile for each disorder)
supported for many disorders.
• Negatively biased interpretations have been
found in all forms of depression.
• Support for cognitive triad, negatively biased
cognitive processing of stimuli and identifiable
dysfunctional beliefs in depression.
• Danger-related bias demonstrated in anxiety
disorders.
Cognitive Therapy
and Medication
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Studies generally show CT to be equivalent
to psychotropic medications for depression,
bulimia and some anxiety disorders.
Generally, research suggests the
combination of the two approaches is
superior to either used in isolation.
CT shows longer efficacy (less relapse) and
increased likelihood of continuing gains
when treatment is discontinued.
Current Status of CT

Controlled studies shown efficacy of CT
with:
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Depression
Panic disorder
Social phobia
Generalized anxiety disorder
Substance abuse
Eating disorders
Marital problems
Schizophrenia
OCD
PTSD
CT Assessment Measures
Beck Depression Inventory-II (BDI-II)
 Beck Anxiety Inventory
 Beck Hopelessness Scale (score of
> 9 predictive of eventual suicide)
 Beck Scale for Suicidal Ideation
 Many others
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Resources in CT
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Center for Cognitive Therapy (U/Penn) and
Beck Institute are the major training sites
(both in Philadelphia).
Multiple other training sites in the United
States and internationally:
• Cognitive Therapy and Research
• Journal of Cognitive Psychotherapy
• Academy of Cognitive Therapy
(www.academyofct.org)
Understanding the
Theory
Behind CT
Cognitive Case
Conceptualization
Genetics and Early Life Experiences
Core Beliefs
Conditional Assumptions
Compensatory Strategies
Current
Situation
Automatic
Thoughts
Reactions
Personality Dimensions:
Styles of Behaving
 Sociotropy
(social dependence):
• Become depressed following
disruption of relationship(s).
• Organized around closeness,
nurturance, and dependence.
Personality Dimensions:
Styles of Behaving
 Autonomy:
• Become depressed after defeat or
failure to attain a desired goal.
• Organized around independence,
goal setting, self-determination, and
self-imposed obligations.
Problematic Thinking
Problematic thinking is very:
Extreme
 Broad
 Catastrophic
 Negative
 Unscientific
 Pollyannaish

Idealistic
 Demanding
 Judgmental
 Comfort Seeking
 Obsessive
 Confusing

Cognitive Distortions
 Arbitrary
inference: Drawing a
conclusion without evidence
or in the face of contradictory
evidence.
• Example: A young woman with
anorexia nervosa believes she is
fat although she is dying from
starvation.
Cognitive Distortions
 Selective
abstraction: Dwelling
on a single negative detail
taken out of context.
• Example: While on a date, you
say one thing you wish you
could have said differently and
now see the entire evening as a
disaster.
Cognitive Distortions
 Overgeneralization:
A single
negative event is viewed as a
never-ending pattern of defeat.
• Example: Following a job interview,
an accountant does not receive the
job. He/she begins thinking that they
will never find a job position despite
their qualifications.
Cognitive Distortions
 Magnification
and/or minimization:
The binocular trick. Things seem
bigger or smaller than they are.
• Example: An employee believes that
a minor mistake will lead to being
fired.
• Example: An alcoholic believes
he/she doesn’t have a problem.
Cognitive Distortions
 Personalization:
Assuming
personal responsibility for
something for which you are
not responsible.
• Often seen in patients who are
sexually abused/assaulted.
Cognitive Distortions
 Dichotomous
thinking: Things
are seen as black and white,
there is no gray or middle
ground.
• Things are wonderful or awful,
good or bad, perfect or a failure.
Cognitive Distortions

Mind reading: Assuming someone is
responding negatively to you without
checking it out.
• Example: If your husband is in a bad
mood, you assume it is your fault and
don’t ask what is wrong.

Fortune teller error: Creating a negative
self-fulfilling prophecy.
• Example: You believe you will fail an exam
so you don’t study and fail.
Cognitive Distortions
 Emotional
reasoning: You
assume that your negative
feeling results from the fact that
things are negative.
• Example: If you feel bad, then that
means the world or situation is
bad. You don’t consider that your
feelings are a misrepresentation of
the facts.
Cognitive Distortions
 Should
statements: Use words
like should, must, ought rather
than “it would be preferred” to
guilt self.
 Labeling and mislabeling:
Name-calling (such as “he’s a
jerk”) rather than just
criticizing the behavior.
Cognitive Triad of Depression
Negative
view of
Self
Future
World
Examples of Cognitive Shifts:
Depression vs. Anxiety
Negative view of
Threatening view of
Future
Future
Self
World
Self
World
Illustration of the Cognitive
Model of Anxiety
Stimulus
(Environmental
Or Internal)
Primary appraisal:
Secondary appraisal:
“Danger”
“Risk: Resources ratio”
Reappraisals of danger, risk, resources
Behavioral inclination
Affect
(Flight, Freeze, Defend)
Anxiety,
Terror
Physiological
Palpitations,
Sweating,
Tension, etc.
Cognitive Profile of Other
Psychological Disorders
Disorder
Hypomania
Anxiety
Panic
Disorder
Phobia
Paranoid
State
Systematic Bias in Process
Inflated view of self and future
Physical and psychological danger
Catastrophic interpretation of physical
and mental experiences
Danger in specific avoidable situation
Attribution of bias to others
Hysteria
Concept of motor or sensory
abnormality
Cognitive Profile of Other
Psychological Disorders
Disorder
Systematic Bias in Process
Obsession
Repeated doubts about safety
Compulsion
Rituals to ward off perceived
Threats
Suicidal State
Hopelessness; deficiencies in
problem-solving
Fear of being fat
Anorexia
Nervosa
Hypochondriasis Attribution of serious medical
disorder
Cognitive Therapy
Treatment
Structure of a CBT Session
 Mood
check
 Setting the agenda
 Bridging from last session
 Today’s agenda items
 Homework assignment
 Summarizing throughout and at end
 Feedback from patient
General Principles of CT
 Goal
is to correct dysfunctional
thinking and help patients modify
erroneous assumptions.
 Patient is taught to be a scientist
who generates and tests
hypotheses.
 Relationship between patient and
therapist is collaborative.
Fundamental Concepts
Collaborative empiricism:
• Goal is to demystify therapy.
 Socratic dialogue:
• Questioning used to help patient
come to their own conclusions.
 Guided discovery:
• Therapist collaborates with patient to
develop behavioral experiments to
test hypotheses.

Process of Therapy

Initial sessions
• Essential to build rapport.
• Focus is problem definition, goal-setting and
symptom relief.
• Therapist provides psychoeducation in initial
sessions.
• Behavioral interventions more prominent.
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Middle sessions
• Emphasis shifts from symptoms to patterns of
thinking.
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Termination
• Expectation that therapy is time limited.
Behavioral Intervention Examples
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Activity scheduling
Mastery and pleasure
Graded task assignment
Conducting behavioral experiments
(e.g. being assertive to assess what
happens)
Exposure type techniques
Role plays
Weekly Activity Schedule
Patient records activities and rates them for pleasure and mastery
Mon
8-10 am
10-12 pm
12-2 pm
2-4 pm
4-6 pm
6-8 pm
8-10 pm
10-12 am
Tue
Wed
Thu
Fri
Sat
Sun
Weekly Activity Monitoring

A self-rated chart that allows the therapist
and the patient to:
• Assess how patients are spending their time.
• Measure the sense of accomplishment and/or
pleasure received from various activities.
• Determine which activities are occurring too
much or too little.
• Evaluate automatic thoughts/emotional shifts.
• Fill in specific times with planned/pleasant
activities for depressed patients or activities
needed for procrastinating patients.
• Compare predicted versus actual ratings of
accomplishment and pleasure.
Cognitive Interventions Examples
 Elicit automatic thoughts on thought
records.
 Identify whether the thoughts
represent distortions in information
processing.
 Use Socratic questions to evaluate the
thought process.
 Generate alternatives in terms of how
to think or how to behave differently.
Thought Record
Situation Mood Automatic Evidence Evidence Balanced/
1- 100 Thought
For AT
Against Alternative
AT
Viewpoint
Re-rate
Mood
Eliciting Automatic Thoughts

Basic question: What thought just went through
your mind?
• Ask when an emotional shift is noted in session.
• Create an emotional shift by having the patient describe
or visualize a recent situation when they felt intense
emotions and then answer the question.

If patient can’t answer the question try asking:
• Do you think you were thinking _____________?
• If someone else was in the situation what do you think
they might have been thinking?
• Were you thinking _____________ (insert something
paradoxical)?
Examples of Socratic Questions
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What evidence supports the belief?
What evidence do you have to refute it?
What would your spouse, best friend, sibling (or
anyone whom you admire greatly) say in this
situation?
What would you say to your spouse, best friend,
or sibling if they were thinking the same thing
you are?
How could you look at this situation so you
would feel less depressed?
Is this view as reasonable as your first choice?
Specific Examples of
Socratic Questioning
Situation: Patient feels like a bad wife.
 What makes you think you are a bad wife?
 What would a good wife have done?
 On a scale from 0-100, how do you rate as a
wife? Why do you place yourself there on
the scale?
 How does it help to call yourself a bad wife?
 Besides labeling yourself as a bad wife what
else could you do in this situation?
Non-Socratic Questions
(Questions NOT to Use)
Don’t you think most women get mad
at their husbands?
 Doesn’t your husband ever yell at you?
 I’m sure everything will work out OK,
don’t you?
 I think you are a good wife based on
other things you’ve told me. Could you
focus on the positives?

Example: Downward Arrow
to Obtain Less Accessible Beliefs
Situation
Patient reports
that a session
hasn’t helped
them.
Thoughts
Emotions
Therapist thinks
Guilty
patient is right. That Anxious
was a terrible
session. I didn’t do
anything right.
Example: Downward Arrow
Question
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If that were true,
what would it mean
about you?
If that were true
what would it mean
to you?
And, then what?
Response
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“That I had done a
bad job.”
“Sooner or later I
would be found
out.”
“Everyone would
know I was an
imposter and
incompetent.”
Setting Effective CT Homework
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Make sure rationale is clear.
When feasible, have patient chose the task.
Personalize task to therapy goals.
Begin where patient is, not where patient thinks
he/she should be.
Be specific and concrete: where, when, who.
Formalize the task (e.g., write on paper).
Plan ahead for obstacles/trouble shoot.
Practice the task in session.
Review homework at beginning of each session.
Other CT Techniques
 De-catastrophizing:
 “What if that happened? Then what?”
 Reattribution:
 Alternative explanations systematically examined.
 Redefining:
 Help patient see the problem differently.
 Example: “Nobody ever talks to me” becomes “I need to
try to initiate conversation so other people become
interested in talking to me.”
 Decentering:
 Patient is taught to see that thoughts are just
thoughts and not “them” or “reality.”
Applications of CT:
Empirically Supported

Meta-analyses and other recent
methodologically rigorous studies
have found CT to have large effect
sizes for:
•
•
•
•
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Major depression
Generalized anxiety disorder
Panic disorder
Social phobia
Childhood depressive and anxiety
disorders
Applications of CT:
Empirically Supported
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Moderate effect sizes for:
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Marital problems
Anger
Childhood somatic disorders
Chronic pain
Small effect sizes for:
• Schizophrenia
• Bulimia nervosa
Applications of CT:
Empirically Supported
 CT
yields lower relapse rates
than antidepressant medications
and reduces the risk of symptom
relapse.