Download Doing Cognitive-Behavioral Therapy With Depressed

Cognitive-Behavioral
Counseling:
Foundations and
Applications
Michele D. Aluoch, PCC
River of Life Professional
Counseling LLC
c. 2013
Depressive Disorders- DSM IV-TR
Depressive Episode
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5 or more in 2 week period
Change from previous functioning
Either: depressed mood or loss of pleasure
At least 5 out of 9:
 Depressed mood most of the day nearly every day, as
indicated by subjective report (e.g feel sad or empty) or
observation made by others (e.g. appears tearful). NOTE:
In children or teens can be irritable)
 Markedly diminished interest or pleasure in all or almost all
activities most of the day nearly every day as indicated by
either subjective account or observation made by others)
 Significant weight loss when not dieting or weight gain or
decrease or increase in appetite nearly every day
 Insomnia or hypersomnia nearly every day
Depressive Disorders- DSM IV-TR
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Psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings
of restlessness or being slowed down)
Fatigue or loss of energy nearly every day
Feelings of worthless or excessive and inappropriate
guilt (which may be delusional) nearly every day
Diminished ability to think or concentrate or
indecisiveness nearly every day (either by subjective
account or as observed by others)
Recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a plan, or a specific
plan for committing suicide
Impairment in social, occupational or other areas of
functioning
Depressive Disorders- DSM IV-TR
Specifiers
 Frequency: Single or recurrent
 Types: mild, moderate, severe
 Chronic- full criteria for depressive episode met
continuously for at least 2 years- either depression or
Bipolar
 Catatonic- motor immobility/stupor, excessive motor
activity (purposeless), extreme negativism, rigid
posture or mutism, grimmacing, echolalia or
echopraxia
 Melancholic- lack of pleasure in activities, lack of
reactivity to usually pleasurable activities and 3 or
more: depressed mood, depression worse in am,
marked psychomotor agitation or retardation,
anorexia, excessive or inappropriate guilt
Depressive Disorders- DSM IV-TR
Dysthymic Disorder
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Depressed mood most of the day for more days than
not as indicated either by subjective account or
observation of others for at least 2 years. (Note:
Children/teens- irritability for at least 1 year)
At least 2 of 6: 1) poor appetite or overeating
2) insomnia or hypersomnia
3) low energy or fatigue
4) low self esteem
5) poor concentration of difficulty making decisions
6) feelings of hopelessness
Depressive Disorders- DSM IV-TR
Depressive Disorder NOS
 Catch all for depression that does not
meet criteria for other depression dx.
Depression
Paradise, L. V., & Kirby, P.C. (Winter 2005).
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Roughly 10% to 25% of the population
experiences some form of depression.
Depression is the number one cause of disability
worldwide.
One third to more than 60% of mental health
professionals had reported a significant episode
of depression within the previous year.
Depression is 10 times as prevalent now as it
was in 1960!
While every objective indicator of well-being in
the U.S. has been increasing, every indicator of
subjective well-being is decreasing.
Anxiety Disorders- DSM IV-TR
Panic Attack:
 A discrete period of intense fear or discomfort in which 4 or more of the
following symptoms developed abruptly and reached a peak within 10 minutes
 palpitations
 sweating
 trembling or shaking
 sensations of shortness of breath or smothering
 feeling of choking
 chest pain or discomfort
 nausea or abdominal distress
 feeling dizzy, unsteady, lighthearted, or faint
 de-realization (unreality) or de-personalization (detached from oneself)
 fear of losing control or going crazy
 fear of dying
 paresthesias (numbness or tingling sensations)
 chills or hot flashes
Anxiety Disorders- DSM IV-TR
Agoraphobia- Anxiety about being in places from
which escape may not be possible (being outside
home alone, in a crowd, on a bridge, on a bus, in a
line in the store, etc.), breeds avoidance
Panic Disorder:
 Panic attacks
 1 or more: concern regarding additional attacks,
worry about implications of additional attacks
(heart attacks, going crazy), change in behaviors
following attacks
 With or without agoraphobia
Anxiety Disorders- DSM IV-TR
Specific Phobias:
 Marked, persistent fears
 Situationally bound panic attacks
 Realizes that they are excessive and
unreasonable
 Stimuli produce marked anxiety/distress
 Avoidance
Anxiety Disorders- DSM IV-TR
Social Phobia:
 Marked and persistent fear of one or more social or
performance situations in which the person is
exposed to unfamiliar people or to possible scrutiny
by others. The individual fears he or she will act in a
way where the anxiety will be humiliating or
embarrassing.
 Exposure to the feared social situation almost
invariably provokes anxiety which may take the form
of a situationally bound or situationally predisposed
panic attack
 The person realizes that the fear is excessive or
unreasonable
 The fear interferes with daily functioning
Anxiety Disorders- DSM IV-TR
Obsessive Compulsive Disorder (OCD):
 Either obsessions or compulsions”:
Obsessions:
 Recurrent and persistent thoughts, impulses or images that are
experienced at some time during the disturbance as intrusive and
inappropriate and that cause some marked anxiety or distress
 The thoughts, impulses, or images, are not simply excessive
worries about real life problems
 The person attempts to ignore or suppress such thoughts,
impulses, or images or to neutralize theme with some other
thought or action
 The person recognizes that the obsessional thoughts, impulses,
or images are a product of his or her own mind (not imposed
from without as thought insertion)
Anxiety Disorders- DSM IV-TR
Compulsions:
 repetitive behaviors that the person feels
driven to perform in response to an
obsession that must be applied rigidly
 2. The behaviors or mental acts are aimed at
preventing or reducing distress or preventing
some dreaded event or situation; however,
these behaviors or mental acts either are not
connected in a realistic way with what they
are designed to neutralize or prevent or are
clearly excessive
 Interfere with daily functioning
Anxiety Disorders- DSM IV-TR
PTSD:
Exposed to a traumatic event in which both of the following were present:
The person witnessed, experienced, or was confronted with an event or events
that involved actual or perceived death, threat or serious injury or a threat to
the physical integrity of others
 The person’s response involved intense fear, helplessness or horror (NOTE: in
children may=agitation)
 The event is re-experienced persistently in one of the following ways:
 Recurrent and intrusive distressing recollections of the event including images
or perceptions
 Recurrent distressing dreams of the event
 Acting or feeling as if the traumatic event were occurring
 Intense psychological distress at exposure to internal or external cues that
symbolize or represent an aspect of the traumatic event
 Physiological reactivity on exposure to internal or external cues that symbolize
or resemble an aspect of the traumatic event
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Anxiety Disorders- DSM IV-TR
Persistent avoidance of stimuli associated with the trauma and a numbing or
general responsiveness (not present before the trauma), as indicated by 3 or
more of the following:
 Efforts to avoid thoughts, feelings, or conversations associated with the trauma
 Efforts to avoid activities, places or people that arouse recollections of the
trauma
 Inability to recall an important aspect of the trauma
 Markedly diminished interest or participation in significant activities
 Feeling of detachment or estrangement from others
 Restricted range of affect
 Sense of a foreshortened future
Persistent feelings of increased arousal (not present before the trauma), as
indicated by 2 or more:
 Difficulty falling sleep or staying asleep
 Irritability or outbursts of anger
 Difficulty concentrating
 Hypervigilance
 Exaggerated startle response
 Causes distress and impairment in daily functioning
Anxiety Disorders- DSM IV-TR
Acute Stress Disorder:
 Differences with PTSD: minimum, of 2
days-4 weeks
 Within 4 weeks of the traumatic event
Anxiety Disorders- DSM IV-TR
Generalized Anxiety Disorder:
 Excessive anxiety and worry about a number of
events or activities for at least 6 months
 Difficulty controlling the worry
 3 or more (1 for children):
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Restlessness or being keyed up and on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
Causes impairment in daily functioning
Generalized Anxiety
 5-6% of Americans at some point in their lives
 First in young adulthood throughout 50s
Areas To Assess (Shear, Belnap, Mazumdar, Houck,& Rollman, 2006):
1) Frequency of Worries
◦ How often do you worry about things? Do you worry every day? On average how much of
your time per day is occupied with worries?
2) Distress Due To Worrying
◦ How much distress does worrying cause you? How upset or uncomfortable do you feel when
worrying?
3) Frequency of Associated Symptoms (restlessness, feeling keyed up or
on edge, irritability, muscle tension, difficulty concentrating, mind going
blank, fatigue, sleep disturbance)
◦ How often do you have these symptoms? Every day? How much of the day?
4) Severity and distress due to associated symptoms
◦ During the past week, when you had these symptoms, how intense were they? How much
distress did they cause you? How upset or uncomfortable were you when you had them?
Generalized Anxiety
5. Impairment/Interference in work functioning
◦ How much do the symptoms we have been discussing
interfere with your ability to work and/or carry out
responsibilities at home- our ability to get things done as
quickly and effectively? Are there things you are not
doing because of your anxiety? Does anxiety ever cause
you to take short cuts or request assistance to get things
done?
6. Impairment/interference in social functioning
◦ How much do the symptoms we have been discussing
interfere with your social life? Are you spending less
time with friends and relatives than you use to? Do you
turn down requests of opportunities to socialize? Are
there certain restrictions in your social life about where
or how long you will socialize?
Generalized Anxiety Disorder
The “Looming Cognitive Style” (Riskind &
Williams, 2005)
 Mental scenarios and appraisals of events
1) Anxiety and depression
2)Worry
3)Attempts at Thought Suppression
Threat Appraisals:
1. Likelihood Estimations
2. Lack of Control
3. Imminence
Generalized Anxiety Disorder
Anxiety and Depression
 Attending to the “negative” or unpleasant
 Stimuli viewed as negative, dangerous,
impending
 Self viewed as helpless or hopeless
 Sense of stimuli gaining velocity and
gathering momentum (unfolding,
changing, advancing)
 Self protective
Generalized Anxiety Disorder
Worry
 A chain of thoughts and anticipatory processes
 A repetitive habitual means of verbal thoughts
regarding potential or possible threatening events
 Paradoxical: actually lessens autonomic system
arousal, reduces the somatic component
 Helps avoid aversive imagery
 Believed (by the client) to be a coping mechanism
 Beliefs regarding thoroughly considering all the
possible outcomes and being able to mentally
manipulate circumstances
 Fears are all-encompassing network and even include
“neutral” stimuli
GAD versus OCD (Fergus, Wu,
2010)
Intolerance of Uncertainty (can’t deal w/ambiguity)
 GAD-worry, OCD- compulsions
Perfectionism
 OCD-a way to decrease anxiety about the uncertainty
of the future
Negative Problem Orientation
 GAD-Higher negative problem orientation (attentional
bias)
Responsibility and Threat Estimation
 Related to anxiety in general
Importance of and Control of Thoughts
 Central to OCD
Obsessive-Compulsive Disorder
Obsessions & Compulsions
Obsessions- Upsetting thoughts, images, or urges that intrude, unbidden into
the person’s stream of consciousness
 Compulsions- behaviors or mental acts that the person feels compelled to
perform, usually with a desire to resist; are connected to what they are
intended to prevent
(e.g. checking, washing, hoarding, ordering or memory compulsions, cognitive
restructuring, neutralizing rituals, themed rituals- religious, sexual,
aggressive)
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Dysfunctional Beliefs
(Taylor, Coles, Abramowitz, Wu, Olatunji, Timpano, McKay, Kim, Cramin, & Tolin,
2010):
 1) Inflated personal responsibility- belief that the client has the power to
cause, and the duty to prevent, negative outcomes
 2) Over-estimation of threat (negative events are likely to occur and their
occurrence would be terrible)
 3) Over-importance of thoughts (belief that control over one’s thoughts is
entirely possible)
 4)Perfectionism- belief that mistakes and imperfection are unacceptable
 5) intolerance of uncertainty- belief that it is necessary and plausible to be
completely certain that negative outcomes will not occur
Obsessive-Compulsive Disorder
Three Aspects of Perfectionism
(Ashby, Rice, & Martin, 2006):
Self-oriented- high standards for self
 Socially Prescribed Perfectionism- belief
that others set high standards for you
 Other-oriented Perfectionism- setting high
standards for others
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Post-Traumatic Stress Disorder
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Witnessing an event perceived as traumatic
Traumatic to self or other
Event causing distress
Could be either: a) Restrictions experiencing
emotion/emotional responsivity (emotional numbing) OR
b) intense arousal
Belief that risk of bodily injury or death
Horror
Re-experiencing (nightmares, intrusive memories,
flashbacks)
Hyperarousal (disturbed sleep, irritability, being easily
startled)
Hypoarousal (avoidance)
The past invading the present, short term stuck in long
term memory: moved to limbic system of the brain
PTSD (Cont.)
More numbing predicts worse outcomes.
 More emotional “outbursts” predict better
prognosis.
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PTSD (cont.)
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Proposed domains to address
Biology (developmental problems, increased medical
problems)
Cognitive- difficulties in attention, information processing,
learning
Dissociation- depersonalization, derealization, impaired
memory
Affect regulation- poor emotional self-regulation,
difficulty labeling emotions
Attachment- social isolation, difficulty with perspective
taking
Behavioral control- poor impulse control, aggression,
oppositional behavior
Self-concept- low self-esteem shame and guilt, lack of
sense of self
Social Phobia
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Marked and persistent fear of social
situations
Concerns about possible scrutiny by others
Presumptions of judgment and rejection
Anticipating incompetence on part of self
Avoidance behaviors
Ignoring social cues which may be helpful
Cognitive Biases (e.g “I will mess up.”, “They
will see how bad I am at this.”)
Panic Disorder
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Negative interpretations limited to self- different
explanations regarding such symptoms in others
Interpretation bias
Cognitive errors: double messages- self and othersnote inconsistencies
A number of people with panic disorder were found to
have strongly influencing and significant life events
which predisposed them to panic (loss separation,
bereavement, health related concerns starting in
childhood or young adulthood, major separation from
significant caregivers)
Associated and correlated with neuroticism- low
perception of pleasantness, perceived control, goal
achievement and higher sense of moral violation
Cognitive Behavioral Cycle
Using proven REBT- Rational Emotive Behavior Therapy (Albert
Ellis) but incorporating client belief systems and spiritual
worldview
 Compared to baseline
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A- Activating
event
B- Belief
about A
CConsequence
Dealing With the Feelings
Situation
Feelings,
Emotions
Thought
Cognitive Behavioral Principles
Early life experiences
 Maintained throughout time
 Maintained by behaviors that may not be
useful
 Maintained by looking for thoughts and
behaviors that keep the cycle going
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Cognitive Behavioral Principles
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Continuing to elicit negative thoughts and record more
helpful ways of thinking about situations, self and others to
influence emotion positively.
Reviewing thoughts, particularly expectations for self and
‘shoulds’ rather than ‘wants’.
Identifying rules for living and examining their helpfulness.
Identifying unhelpful thinking styles that lower mood.
Encouraging the client to analyze thoughts and then step
back from them.
Reviewing alternative explanations for negative automatic
thoughts.
Conducting behavioral experiments to help increase
believability of alternative thoughts.
Listing goals with an emphasis on own needs and
expectations.
Thinking Error Types
1) Awfulizing/Catastrophizing- Predicting only negative
outcomes for the future: “ ____ is awful, terrible,
catastrophic or as bad as it could possibly be”, “If ___
happens my life is over.”
2) Disqualifying/Discounting- Overlooking the positive and
only seeing the negative, believing that good things don’t
count: “I am sure even when my family complimented me
they had to because they are my relatives. They had to be
nice.”
3) All or nothing- Viewing the situation on one end of
extremes: “If my boss corrects me I must be the worst
employee”, “If my child does something wrong I failed as a
parent”, “If I didn’t pass one exam I am an unsuccessful
student.”
4 Low Frustration Tolerance- Belief that things should not be
inconvenient: “I can’t stand _____” ; “_____ is too much
and is intolerable or unbearable.”
Thinking Error Types
5) Self Downing- Self deprecating thoughts: “I am no
good, worthless, useless, and utter failure, beyond
hope or help, devoid of value.”
6) Other downing- Derogatory beliefs about others:
“You are no good, worthless, useless, an utter failure,
beyond hope, of no value.”
7) Emotional reasoning- Letting emotions totally
overrule facts to the contrary: “I feel as if everyone is
talking about me.”
8) Labeling- Giving a label or stereotype without
testing beliefs out:” All of them are like that.”
9) Mind reading- Trying to predict things based on
limited aspects of a situation: “ I know they will think
I’m poor because I can’t afford the latest clothes.”
Thinking Error Types
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10) Overgeneralization- Making broad
conclusions about an event based on limited
information: “My husband doesn’t love me
because he is always busy when I am
around.”
11) Personalization- Assuming that others
behaviors are all about you: “My wife is
quiet. Something must be on her mind.”
12) Shoulds/musts- Having an absolute
concrete standard about how things ought to
be: “ Successful people in life only get As in
school.”
Cognitions Related To Anxiety
Cognitions Supporting Worry:
(Dugas & Koerner, 2005)
 “Worrying is helpful.”
 “Worrying, thinking about possible outcomes can
help me deter or change events.”
 “Worry can prevent negative outcomes.
 “Worry is a sign of a caring concerned person.”
 “Worrying is a positive personality trait.”
 “Worrying aids in problem solving and helps me
plan.”
 “Worrying motivates me.”
Cognitions Related To Anxiety
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“I am losing control.”
“I cannot handle this anymore.”
“My life is falling apart.”
“Everyone knows how socially inept I am.”
“I can’t deal with this stress anymore. It
is absolutely overwhelming and
immobilizing.”
“I know I will absolutely fail.”
“This is bound to happen again.”
Cognitions Related To Anxiety
“Something bad is going to happen to
me.”
 “I must be having a heart attack or other
serious health issue if I am having these
symptoms. Next thing I know I’ll die.”
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Anxiety Versus Depression- Self Statements
(Safren, Heimberg, Lerner, Henin, Warman, Kendall,
2000)
Inability to cope
 I can’t take it anymore.
 I can’t stand it.
 I wish I could escape.
 I don’t want to feel this way.
 I cant cope.
 I can’t get through this
 Something has to change.
Uncertainty About the Future
 How will I handle myself?
 Can I overcome the uncertainties?
 What will happen to me?
 Will I make it?
 Can I make it?
 Am I going to make it?
 What am I going to do with my life?
 I want to fight back but I’m afraid to do so.
Anxiety Versus Depression- Self Statements
(Safren, Heimberg, Lerner, Henin, Warman, Kendall,
2000)
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I don’t feel good.
I don’t feel very happy.
I am not safe warm, comfortable.
I am not sure that I can accomplish this.
I don’t feel so good about myself/my life.
I hate myself.
I feel like a loser.
I’m worthless/a failure.
Something is wrong with me.
No one understands me.
I don’t think I can go on.
I wish I could die.
I’m against the world.
I can’t get started.
I’ll never make it.
I’m no good.
Cognitions Related To Depression
Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C.
(2005)
Relationships, Entitlements, Achievements
If people criticize me, I am not a worthwhile person.
Other people’s approval is very important to me.
I can make everyone like me if I just try hard
enough.
 The most important thing in the world to me is to be
accepted by other people.
 I find it impossible to go against other people’s
wishes.
 Unless I get constant praise I feel that I am not
worthwhile.
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Cognitions Related To Depression
Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C.
(2005)
LOVE
Life is unbearable unless I am loved by my family.
If I am not loved it is because I am unlovable.
If I love somebody who doesn’t love me, I must be
inadequate.
I need to be constantly told I’m loved to feel secure.
If I were a better person then somebody would love
me.
 In order to be happy, I need someone to really love
me.
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Cognitions Related To Depression
Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C.
(2005)
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Influence
I can prevent people being upset by thinking
about what they might need.
If I have a fight with my friends, it must be
my fault.
I should be able to please everybody.
I am responsible for other people’s
happiness.
If people are uncomfortable around me it is
my fault.
If the people around me are upset, I usually
worry that I have upset them.
Cognitions Related To Depression
Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C.
(2005)
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Success
I can’t feel equal to others unless I’m really
good at something.
I only feel valued if I achieve my goals.
My success in life defines my goals.
I need to be successful in all areas that are
important to me.
Life is pointless if I don’t have goals to chase.
Without success in life, it is impossible to be
happy.
Cognitions Related To Depression
Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C.
(2005)
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Perfection
I see no point in doing anything unless it can be done
perfectly.
There are no second prizes in life.
Things must be done to certain standards, otherwise
there is no point in doing them.
If I make mistakes then others will think less of me.
If I don’t do something perfectly then I don’t like
myself very much.
I never seem to be able to reach my own high
standards.
Cognitions Related To Depression
Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C.
(2005)
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External
I can only be happy if I have the good things
in life.
Unless I have expensive possessions,
people won’t approve of me.
If I were rewarded for the goals I achieve,
know I could be happy.
If my friends are unhappy, then I cannot be
happy. Everything has to be going well in
order for me to be happy.
My happiness depends on others.
Cognitions Related To Depression
Parslow, R.A., Christensen, H., Griffiths, K.M., Groves, C.
(2005)
Rights
If obstacles are placed in my path, it is natural
that I would get angry.
 Things should always go right for me.
 If I do the right things people should
acknowledge it.
 If I feel that I deserve something, I should get it.
 If I go out of my way to help others, they should
do the same for me when I need it.
 I shouldn’t have to work so hard to get the
things I want.
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Behaviors Related To Anxiety
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Attending to the disturbing stimulus to the
neglect of additional environmental
information
 Intolerance of uncertainty- the tendency
to react negatively on an emotional,
cognitive, and behavioral level to
uncertain situations and events
 Maladaptive schemas related to earlier
life: disconnection and rejection, impaired
performance, impaired limits, etc.
Overcoming Depression and
Anxiety
“You can look at what happened to you; it was
truly horrible, but it is not unthinkable or
unfaceable. You do not have to run from it day
and night, and you do not need to totally
curtail your life for fear of a recurrence. You
can live in a world where this once happened
and where there is a remote chance that it
could happen again. Moreover, you MUST look
at it. You must face it down, because what is
happening now is what happens when you
don’t.”
(Bergner, 2009)
Essential Elements
Cognitive Restructuring
(Hope, Burns, Hayes, Herbert, Warner, 2010)
 Identify and change dysfunctional cognitive beliefs/automatic thoughts
 Replace anxiety producing thoughts with more socially adaptable ones
 Through Socratic questioning
 Challenge the voracity of assumptions regarding social situations
 Living in new attitudes about self and others by applying new rational rebuttals
to the irrational beliefs and behaviors
 Targets 3 areas: 1. experiencing anxiety, 2. negative self evaluation, 3. fear of
negative evaluation
 Use a hierarchy of thoughts- surface to core (keep asking “what would that
mean?” until 4-6th= core)
Exposure
 Reducing disabling behaviors
 Finding exceptions
 Systematically facing feared situations in context they feared
 Redirecting attention
Essential Elements
Social Reappraisal Therapy
(Hoffman & Scepkowski, 2006)
Factors which influence formation=social
apprehension, high social standards and goals,
increased self attention (50-60%), high estimated
social cost, perceived poor social skills, low
perceived control, post event rumination
Create at least one social mishap per week
Switch focus on environment rather than inwardlysee the genuine observer’s perspective rather than
the client’s own perspective
Realistically appraise the social cost
Reframe to increase sense of emotional control
Essential Elements









Cognitive-Behavioral Treatment: Key Aspects
(Lamplugh, Bele Milicevic, & Starcevic, 2008)
Understanding anxiety and the flight or fight response
Understanding the role of hypervigilence
Promoting a sense of ‘riding out the wave’ of anxiety in an
accepting manner instead of trying to control symptoms
Realistic appraisal of body sensations
Acknowledgment of physical feelings rather than distraction
away from those feelings
Rating the intensity of physical feelings rather than
anticipating the worst
Abandoning anxiety
Acknowledgement that catastrophic misinterpretations of
physical feelings are problematic, not the physical feelings
themselves
Cessation of maladaptive behaviors that maintain the
problem
Essential Elements







Collaboration, cooperation between therapist
and client
Clinician skills in CBT
Ability to psychoeducational foundation
regarding thoughts, feelings, and behaviors
Ability of client to have insight and awareness
Desire of client to modify thoughts and
behaviors
Homework and exercises for applications for
client outside of session
4-6, 6-8 sessions
Essential Elements
Forsyth, D.M., Poppe, K., Nash, V., Alarcon, R.D., &
Kung, S
(October 2010)

Gains in positivity are more closely related
to emotional healing from depression and
anxiety than loss of negativity.
Who Might Benefit?











Anxiety
Depression
Assertiveness Building
Diet and Health Issues
Social Isolation
Medical concerns
Grief
Alcohol Dependence
PTSD
Divorce
Life stressors
Video Clips: Cognitions and
Behaviors

Identify the thought patterns and toxic
behavior choices in the video clips.
Problem Orientation
positive problem orientation a
protective factor that facilitates the
initiation of proactive problem-solution
skills to manage or minimize early signs
or symptoms of psychological distress
 negative problem orientation- a
serious threat to their well-being, respond
with strong negative emotions (e.g.,
anxiety and/or depression), and avoid or
postpone dealing with a problem

Depression and Anxiety
Transdiagnostic Approach
(Clark, 2009; McManus, Shafran, & Cooper, 2010)
Moving away from diagnosis specific treatments
Symptoms overlap between similar disorders
“A therapy that is made available to individuals with a wide rage of diagnoses, and does
not rely on knowledge of thee diagnoses to operate effectively.”


Assumptions:
General cognitive-behavioral processes which are shared
 Absence of diagnostic assessment
Adoption of a convergent or integrative scientific approach
Commonalities:
1) Altering incorrect or faulty appraisals based on emotions about self or other
2) Prevention of avoidance
3) Psychoeducation
4)Behavior modification
Challenging Thought Patterns








Shoulds
“Why?”
“if only ____, then _____”
Have tos
_____ “enough”
Absolutes: always/never
Right/wrong
Good/bad _____
Challenging Thought Patterns

Cognitive distortions- the different
types of distorted cognitive processes that
produce automatic negative thoughts,
which in turn, evoke or strengthen early
symptoms of psychological distress and
emotional and/or behavioral disorders
Cognitive Reframing

Instead of “if he/she would…….”
Use:
 “If I could just get a grip on _____ then
we’d finally be happy.”
 Watch where you put your BUTs:
 __________ BUT __________.
Who Does Cognitive-Behavioral
Therapy Work For?
Strong Motivation To Change
 Time Commitment
 Cognitive Functioning/Educational Level
 Observant People
 Insightful People
 Those who will do work outside of session

Conceptualizing The Problem
Antecedents
What happened before?
 Something triggered this
 Not Out of The Blue
 (e.g. Boy throwing cars around the roomIs it a behavior issue really?)

Conceptualizing The Problem
Affective
Relational
Somatic
Antecdents
Behavioral
Contextual
Cognitive
Conceptualizing The Problem
Antecedents:
 What happened right before that? (Affective)
 What happens to you physically before this
happens? Do you feel sick? (Somatic)
 How do you normally act right before this
happens? (Behavioral)
 What thoughts go through your head before this
happens? (Cognitive)
 Where and when does this usually happen?
(Contextual)
 Do you do this with everyone or just when you
are around certain people? (Relational)
Conceptualizing The Problem
Behaviors
 What the client does in response





Examples:
I avoiding going out of the house.
I stomped off my job.
I yelled at the kids.
I cried and staying in my room.
Exercise: Responses to The
Antecedent
Antecedent
I was playing with my
child but had to leave
to get the laundry.
I expected to get the
job but found out it
was offered to
someone else.
I had a flashback of a
trauma from my
childhood.
I discovered my
boyfriend was
cheating.
Behavior Reaction
Feeling Reaction
Exercise: Responses to The
Antecedent
Antecedent
The doctor told me I
have cancer.
I got a pay cut.
My child failed school.
I do not look the way
I want.
Behavioral
Response
Feelings Response
What Could the Antecedent Be?
Antecedent
Behavioral
Response
Feelings Response
My son threw his
crayons across the
room
My son cried and
kicked.
I covered my eyes
and shook.
I stayed in bed all
day.
I felt disappointed in
myself, unhappy with
my life.
What Could The Antecedent Be?
Antecedent
Behavioral
Response
I slammed the phone
down.
The teenager put the
music on as loud as
possible.
My spouse drove
away.
I left the busy
concert.
Feelings Response
What Could The Antecedent Be?
Antecedent
Behavioral
response
Feelings response
I felt like throwing up
as my heart raced
and I experienced
panic.
I resolved not to try
anything again
because “nothing
ever works for me.”
I tried again – “next
time could be better.”
Challenging Attributions
1) Am I ascribing something like “This situation
happened because ______?”
2)Am I making a judgment about another person’s
personality because of this event? What am I telling
myself about what this means? (Because this
happened, it means---)
3) Am I using adjectives to describe the other person’s
personality, intentions rather than simply describing
the behavior? (e.g. “You are always so lazy. You
never care about our house.” versus “I am concerned
about the amount of cleaning we still have to do. I
realize we have busy tiring jobs but I am wondering
how we plan to get the dishes done and get our
things set up for tomorrow plus help the kids to finish
their homework. How do we plan to get to divide
these things up- any ideas?”)
Challenging Attributions

4) Is the way I’m thinking about this
definitely 100% a fact?

5) Is there any other way of looking at
the situation? Come up with at least three
exceptions.

6) Have I assumed that because
something is (perceived by me to be)
such and such way that I am powerless
over it?
Attributions Exercises



1) My spouse came home late two days this
week. His clothes were a little disheveled
looking- he must be having an affair.
2) My wife was supposed to meet me for the
romantic dinner. She was ½ hour late and
did not call me. When I saw her I had to yell
at her because I knew she did not make our
dinner a priority.
3) My coworker left a pile of unfinished work
on her desk. It must be that she is lazy and
planned to have me do all her dirty work.
Attributions Exercise



4) The group of popular people looked at me
and smiled. I knew they were talking behind
my back badly about me.
5) When I walked by they got quiet. I am
sure they noticed my hand me down clothes
compared to their name brand outfits.
6) Every time my mother comes over she
helps me clean the house. I knew she always
thought I was a slob and couldn’t do
anything right.
Setting Behavioral Goals




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Concrete
Specific
Manageable
Achievable
With accountability for follow through
Goal Setting Process
Broad Goal
Small
Steps
Application
Setting Goals Exercises
Broad Goal
Specific Step
Outcome Desired
Feel less depressed
Get out of bed and
get set for the day
Be bathed, dressed
and get out of the
house for at least one
hour per day
Stop fearing
Go to a public place
everyone’s reaction of three times per week
me
for at least ½ hour
and find out that the
worst doesn’t
happen.
Learn to talk to
strangers without
automatic belief and
avoidance because I
assume that
everyone’s out to get
me.
Setting Behavioral Goals
Broad Goal
Feel more self
confident
Have a better self
concept, believe I
have self worth
Try new things
without fear of
rejection
Specific Goal
Desired Outcome
Tips For Goal Setting





Tell what you want to happen rather than
what you don’t want to happen.
State observations- what would
you/others see?
What would be the benefits of such an
action?
Use 1-100 scaling to identify priorities.
Behavioral outcomes should be
inconsistent with the depression and
anxiety symptoms
Tips For Goal Setting
Reintroduce prior successes
 Reintroduce pleasant activities
 Choose active helping (e.g. taking some
proactive behavior action to relieve a
stressor)
 Don’t avoid.

Relaxation
Tension Reduction
 Perceived control over stress
 Progressive muscle relaxation- one by one
relaxing and tensing various muscle
groups

Imagery





Imagining yourself as successful in
identifying what that would take.
Involve as many senses as possible.
Strengths based- what would you like to
see happen? When has this happened?
How would you act if the new improved
situation, feeling, behavior was going on?
Set aside time to ponder this.
Schedule a thinking time.
5
• Briefly review patient’s mood and/or physical
functioning.
5
• Bridge discussion from previous session with the
current session.
5
• Set the agenda for the current session and prioritize
the items.
• Review and homework given in the previous
5-10
session.
20-25
5
• Discuss agenda items and set up homework.
• Summarize the current session and exchange
feedback.
Typical Session Outline
Questions For Ongoing CBT






What points did we come to since last
session?
Anything you learned as you thought over
things?
Anything you were uncomfortable with?
Things better or worse?
Treatment agenda- where are we? What
to focus on today? What to amend?
Completed or not completed homework?
Setting Homework







Done collaboratively
Don’t assume follow up- ask. (e/g. couple I
counseled re. communication interchanges)
Affirm the value of outside practices.
Highlight attempts and successes- build on
Start by modeling and practicing in session.
Inquire re. homework.
Anticipate problems.
Other Ways of Presenting
Homework







Bibliotherapy
Progress
Tasks
Experiments
Observations
Exercises
Not about doing things “right”
When Thoughts are Hard to
Determine
Observe behaviors
 Observe body language
 Observe positioning, tone, facial
expressions, hand gestures.
 Observe what emphasized more or less.

Mindfulness Approaches
Use decentering to switch from a judgmental problem focus which
promotes negativity to a present here and now nonjudmental stance
 Examples:

◦ What did you notice in your thinking, emotions, or sensations?
◦ Did you notice the sense of tightening or tension in any particular place in your
body?
◦ So, these difficult thoughts and emotions were present in your awareness.?
Key Components:
Begin in the initial assessment session. The participant is provided an
opportunity to describe his or her experience of depression. Together, the
therapist and participant explore ways in which MBCT may effectively
reduce relapse risk.
 The therapist enhances a sense of mutuality and connection with
participants.
 The process of inquiry should be a genuine exchange during which the
therapist uses questions to help the participant deepen awareness of his
or her practice, while also embodying the present-focused, open, and
warm attitudes of mindfulness.


Mindfulness





Choosing to control our focus of attention
Example: Washing dishes: instead of
thinking of the stresses of the day and
how much more to do- “Listen to the
bubbles. They are fun!”
Just observe
Accepting things as they are rather than
trying to always change them.
Stop thinking too much. Just let it be.
Cognitive Behavioral Overview

Increase insight and awareness then elicit more health positive
outcomes

Note negative thoughts and record more helpful ways of thinking
about situations, self and others to influence emotion positively.

Review thoughts, particularly expectations for self and ‘shoulds’
rather than ‘wants’. Identifying rules for living and examining
their helpfulness.

Self monitor. Identify unhelpful thinking styles that lower mood.
Encouraging the client to analyze her thoughts and then step
back from them.

Consider alternative explanations to negative automatic thoughts
or behaviors.
Cognitive Behavioral Overview

Conducting behavioral experiments to
help increase believability of alternative
thoughts.

Analyze self-criticisms with focus on
undoing negative automatic thoughts and
behaviors.

List goals with an emphasis on own needs
and expectations.
Patient Self Guided CBT
Ridgway, N., & Williams, C. (December 2011)







General principles taught
Resources tailored to client
Audios, videos, workbooks
Bibliotherapy
May be computerized
Emphasis on homework
As effective with mild to moderate depression and anxiety
as face to face therapist guided CBT











Patient Self Guided CBT
Ridgway, N., & Williams, C. (December 2011).
Strengths
Many people like to read
As effective as in person CBT
Can teach key information and skills
Uses a clear structure
Paper-based tasks and records
Ability to personalize what is read
Low cost and can be copied
Can incorporate many modalities, e.g. reading, listening,
video, etc.
Interactive learning
Automated alerts can be used if deterioration or risk is
recorded
Online forums can provide added support
Patient Self Guided CBT
Ridgway, N., & Williams, C. (December 2011)









Weaknesses
Text used can be difficult to understand if foundations not
properly laid
Licensing may make copying expensive
Need online access or to travel to a fixed unit
Needs flash and adobe reader plus adequate bandwidth
and access to soundcard/speakers
Making sure the client has proper equipment – E.g. Newer
delivery mechanisms use MP3 or certain video formats
Audios or videos are fun to many people
Documentary style may make people feel as if they are not
alone
May watch but not learn or apply
Needs ways of helping people implement what they are
learning
Evaluation Questions
Situational
Questions
Feelings Questions
Thought Questions
• What happened?
What were you
doing?
• Who was there?
• Who were you
speaking to?
• When was this?
• What time of day
was it?
• Where were you?
• How were you
feeling before this
happened?
• How did you feel
while this was
happening?
• What mood were
you in after this
happened?
• Rate your mood:
1-100.
• What was going
through your mind
before you started
to feel this way?
• What thoughts
bothered you?
• What are you
afraid might
happen?
• What if what you
think is true?
• Are there other
ways of thinking
about things?
Thought Log
Event
Thought
Consequence
Alternate Response
Anxiety Ladder
Rate 0-100, Systematically challenge one by one, pair with relaxation
Cognitive Debating Strategies







Is this a fact/strong opinion?
What evidence is there for this? Any evidence
against this?
Alternative explanations that are more
reasonable/possible?
Is there another way of feeling or thinking?
What would someone else make of this
situation?
What advice would I give someone else?
Is this a type of unhelpful thinking habits?
Is this an automatic thought?
Cognitive Debating Strategies
What am I actually reacting to?
Am I getting anything out of proportion?
What harm has actually been done?
Am I overestimating the bad? The danger?
Am I underestimating my ability to cope?
Am I going to a negative automatic place?
How is pressuring myself or others helping me get
through this?
 Just because I feel bad is it really bad?
 Are things really totally black or white- as clear cut as
I am making them?
 Can there be more than one solution to this problem?







Cognitive Debating Strategies





Is believing this life giving or death
producing?
How important is this really?
How will things be in 1 week? 1 month? 6
months? 1 year? If I continue thinking or
behaving this way?
What would happen if I tried to see this
situation as an outside observer? How would
things look? Would things have a different
meaning?
What is the bigger picture?
The Helicopter View

What can I see in this situation as I look
higher and higher?
Helping Kids





What is making you scared? Sad?
What are you expecting will happen?
Are you in a thinking trap?
Are you 100% sure this will happen?
Could there be any other ending to the
story?
STOP
S Signs of anxiety or
depression
 T Thoughts of anxiety or
depression
 O Other better ways of
thinking or feeling?
 P Praise for new plan for
next time

Hindsight Bias
A type of memory distortion
 “ I knew it all along phenomenon”
 Needs to be confronted just like other
distortions
 Thinking that we knew more or could
predict more than we could

Old Versus New Systems
I am…
People are…
The world is…
Old Rules that Protect Me:
I am…
People are…
The world is…
New Rules that Protect Me…
Positive Self Talk






I can be anxious/angry/sad and still deal with
this.
I have done this before so I can do it again.
I don’t have to feel happy all the time to get
through what I need to do in life.
These are just feelings. They won’t last
forever.
I don’t need to rush. I can take things one by
one.
I have gotten through things before. I will
get through them again.
Generalizing Skills Outside
Sessions
Ongoing homework
 Planning for reassessing thoughts and
behaviors often
 Planning for alternatives to depression
and anxiety: if/when ___ happens I will
do ___.
 Booster sessions

Modified ABC Model
 Activating Event
 Beliefs
 Consequences
 Disputations of Beliefs
 Effective New Beliefs
Summary: Depression & Anxiety
Physical
Thought
Behs.
Feelings
Anxious
Tense, shaky,
worried,
energized, HR
increase,
can’t
concentrate
I’m in
danger,
Have to get
out, I can’t
cope
Avoid,
Fidget,
Escape,
Ruminate
Nervous, edgy,
apprehensive,
panicked,
terrified
Depressed
Tired,
lethargic,
withdrawn,
eating or
sleeping
changes, loss
of interest in
hobbies,
restlessness,
poor ADLs
I’m
worthless,
Life’s awful,
Bad things
happen to
me, It’s
hopeless
Do less, talk
less or
quieter
voice, Eat or
sleep less or
more,
isolate
Sad, gloomy,
unhappy,
despairing,
hopeless
Summary: Depression & Anxiety
New Thoughts
New Behaviors
Depression
Even if I feel sad I
will get through, If I
do something I will
feel better, This is
just my habitual
gloomy way of
thinking.
Do things anyway,
Get out, talk to
someone, Get
dressed, Do an
activity I used to
enjoy, Relax, Focus
attention elsewhere
Anxiety
Is this really a
threat? I could be
overestimating the
threat, I have gotten
through before even
when I was worried
or panicked.
Problem solve, Don’t
avoid or you’ll never
find out that the
worst doesn’t
happen.
Changing Distortions
Type of thinking
Neg. impact
Replacement
All or nothing
Discouragement, no
middle ground
Continuum thinking
Overgeneralization
Makes all problems
last forever
Focus on the here
and now
Negativity
Make the positive
impossible
Appreciate the
positives
Discounting positive
Eliminates real joy in
the present
Purposely find and
enjoy the positives
Changing Distortions
Jumping to
Conclusions
Anger, anxiety,
depression
Consider all
possibilities
Predictions
Dread, disaster, panic
Stay in present
Mind Reading
Anxiety, sadness,
anger, assumptions
Clear communication
Magnification
Treating people
unfairly
See strengths in self
and others
Emotional reasoning
Upsetting judgments
made without
evidence
Listen to your head
and heart
Changing Distortions
Shoulds
Discouragement at
self, Anger at others
Bring expectations in
line with reality
Labeling
Discouragement at
self, Anger at others
Stick to specific
circumstances
Blame
Discouragement at
self, Anger at others
Stick to specific
circumstances
Videos: Doing Treatment

Watch the videos and see how the
irrational cognitions and unhealthy
behavior choices are addressed.
Bibliography
Ashby, J.S., Rive, KG., & Martin, J.L. (Spring 2006). Perfectionism, shame, and depressive symptoms.
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Bergner, R.M. (2009). Trauma, exposure, and world reconstruction. American Journal of
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Beck, J.S. (2995). Cognitive therapy: Basics and beyond. New York: Guilford Press.
Bond, F.W., & Dryden, W. (2002). Handbook or rbief cognitive behaviour therapy. San Francisco: Wiley.
Brinker, J. K., & Dozois, D. J. A. (2009). Ruminative thought style and depressed mood. Journal of
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Broeren, S., Muris, P., Bouwmeester, S., Van der Heijden, K.B., Abee, A. (May 26, 2010). The role of
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