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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 Processing of information is vital for survival. Survival systems are: • • • • Cognitive Behavioral Affective Motivational Each system is comprised of structures. • Schemas Modes 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 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 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. 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 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. 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 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 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: • • • • • • • • • • 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 Resources in CT 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. Middle sessions • Emphasis shifts from symptoms to patterns of thinking. Termination • Expectation that therapy is time limited. Behavioral Intervention Examples 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 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 If that were true, what would it mean about you? If that were true what would it mean to you? And, then what? Response “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 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: • • • • • Major depression Generalized anxiety disorder Panic disorder Social phobia Childhood depressive and anxiety disorders Applications of CT: Empirically Supported Moderate effect sizes for: • • • • 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.