Basic Psychological Treatments: Cognitive Behaviour Therapy

Basic Psychological Treatments: Cognitive Behaviour Therapy (CBT)

Dr Simon Reid Milligan

Forensic Psychologist

Roseberry Park Hospital,

Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust

Session outline

1. Theory • Background

- Behavioural Theory

- Cognitive Theory

- CBT assumptions

• Levels of Thoughts

- Core Beliefs (Schemas)

- Underlying Assumptions

- Negative Automatic Thoughts

• Compensatory Strategies

• Problems

• Example

Session outline

2. Therapy

• Principles of CBT

• Assessment

• Treatment strategies

• Questions

NICE guidelines recommend CBT for a wide range of mental disorders. It is commonly used as a psychological treatment for:

• Depression

• Anxiety

• Phobias (including Social Phobia)

• Panic Disorder

• OCD

• GAD

• PTSD

• Schizophreniform disorders

• Bipolar Disorder

• Problems associated with some personality disorders (BPD, APD)

• Pain management

Theoretic model

• Two broad assumptions:

(i) bio-psychosocial context – development and maintenance of disorders

(ii) perception and agency are the focus of therapy

• Problematic thoughts, feelings and behavioural patterns are learned via the same processes of normal thoughts, feelings and behaviour

• Therapy

- constituent habits which comprise the disorder are identified through interview and observation

- involves coaching adaptive patterns of thoughts, feelings and behaviours

- challenge non-adaptive beliefs

Bio-psychosocial context

Behavioural Theory

• Behaviour is functional – it serves a purpose, even if it’s maladaptive

• Patterns of behaviour are the result of learning and anticipated consequence (conscious or not)

• Emphasis is on the external antecedents and consequences

• Antecedent – Behaviour - Consequence

Behavioural Theory

• Operant Conditioning (Skinner) – token economy

Type Definition Effect Eg

Positive reinforcement Pleasant stimulus that

follows a desired behaviour

Increases the likelihood of

the desired behaviour

Cash reward for

good job

Negative reinforcement Removal of an unpleasant

stimulus after a desired

behaviour occurs

Increases the likelihood of

the desired behaviour

Being let off

homework

Positive punishment Presentation of an

unpleasant stimulus after an

undesirable behaviour

Decreases the likelihood

of the desired behaviour

Being told off

Negative punishment Removal of a pleasant

stimulus after an undesired

behaviour occurs

Decreases the likelihood

of the desired behaviour

Having privileges

removed

REINFORCEMENT – increases likelihood of a behaviour (makes you want to do it again)

Positive reinforcement

• gives you something desirable

REINFORCEMENT

Negative reinforcement

• Takes something aversive away

PUNISHMENT – makes you less likely to do something

Positive punishment

• Gives you something aversive

PUNISHMENT

Negative Punishment

• taking away something you want

Behavioural Theory

• Classical Conditioning (Pavlov)

• Generalisation, extinction, systematic desensitisation

Neutral Stimulus Neutral Response

Unconditioned Stimulus (UCS)

Unconditioned Response (UCR)

Unconditioned Stimulus + Neutral Conditioned Stimulus (UCS + CS)

Unconditioned Response (UCR)

Conditioned Stimulus (CS)

Conditioned Response (CR)

Cognitive Theory

• Focus on distal developmental factors

• How we feel and behave is dependent upon how we interpret an event

• How we interpret an event is dependent upon what we believe about the world, and assumptions we make

• Emotional disorders stem from maladaptive patterns of interpretation and behaviour

• Therapy involves evaluating and modifying dysfunctional beliefs with healthier and more adaptive beliefs

(Johnstone & Dallos)

Three Levels of Thoughts (Beck)

• (Negative) Automatic Thoughts

• Underlying Assumptions/Heuristics

• Core Beliefs/Schemas

NATs

Assumptions

Core Beliefs

Core Beliefs (schemas)

• Built up through early experiences, including significant events, interactions with parents, siblings, teachers, peers, developmental experiences

• Define a person

• Pervasive and enduring (characterise aspects of personality)

• Fundamental and absolute

• Cognitive triad – thoughts and expectations about world, self and others

NATs

Assumptions

Core Beliefs

Core Beliefs (schemas)

• A schema is a cluster of core beliefs

• Beliefs can be active, inactive or latent

• Most people have core beliefs on a continuum,

- eg “I/others/world are sometimes...”

“I am generally ok”

“Other people are mostly alright”

“The world usually provides”

• Problem experiences can lead to the development of maladaptive schemas

NATs

Assumptions

Core Beliefs

Maladaptive schemas (taken from Carr & McNulty)

• Neglectful or abusive parenting

Disconnection and Rejection: Expectation attachment needs won’t be met

• Overprotective parenting

Impaired Autonomy: Expectation one won’t function independently

Schema Sample beliefs

1. Abandonment/instability You will abandon me because you are: angry, unreliable, favour someone else, about to die

2. Mistrust/abuse I cannot trust you because you will hurt me

3. Emotional deprivation You will not give me nurturance, empathy or protection

4. Defectiveness/shame I am inferior because of my appearance, or sexual or aggressive urges; you will reject me

5. Social isolation I am different from others and don’t belong

6. Dependence/incompetent I can’t handle everyday responsibilities without your help

7. Vulnerability to harm I am in imminent danger of illness, accident or being victimised

8. Enmeshment I can’t separate from my parents because they need me; smothered; directionless

9. Failure I have failed to achieve my potential and I am stupid

NATs

Assumptions

Core Beliefs

Maladaptive schemas (taken from Carr & McNulty)

• Permissive parenting

Impaired limits: Deficient in following through on personal goals and commitment to others

Other Directedness: Expectation that sacrificing own needs may help my smallest attachment needs be met

Schema Sample beliefs

10. Entitled & Grandiose I am entitled to whatever I want because I am special and I want power to control others

11. Lack of self-control I can’t control my behaviour or complete my plans because my appetites and impulses prevent me

12. Subjugation If I sacrifice what my needs (which probably aren’t important to you), and I sacrifice my anger about doing this, then you won’t abandon me. But I feel trapped and coerced

13. Self-sacrifice If I suppress my wishes to meet your needs, then you won’t abandon me and I won’t feel selfish but I may feel resentful

14. Approval-seeking If I do all I can to get you attention /recognition/wealth/status, you won’t abandon me.

NATs

Assumptions

Core Beliefs

Maladaptive schemas (taken from Carr & McNulty)

Over-vigilance an inhibition: Expectation that prioritising high standards of performance and ethics, irrespective of own need for autonomy, spontaneity and intimacy, then own minimal needs for attachment and safety will be met

Schema Sample beliefs

15. Pessimism Most important things in my life will probably go wrong so I focus on negative aspects and fear any mistakes that lead to personal and financial ruin, without optimism

16. Emotional Inhibition If I suppress my positive emotions and desires, hide my emotional vulnerabilities and focus on rationality, then you won’t criticise or reject me

17. Hyper-criticalness If I am not efficient and perfect, and don’t meet ethical and high achievement standards, then you abandon me or criticise me

18. Punitiveness If I or others make mistakes then we deserve to be harshly punished and not forgiven

NATs

Assumptions

Core Beliefs

Common core beliefs in mental disorders

Depression

I am unlovable

The world is uncaring and unforgiving

I cannot succeed at anything

Life is a painful experience

I am unattractive and uninteresting

There is no hope, no one can help me

Schizophrenia

I am vulnerable

No one is trustworthy

My persecutors are very strong and I have to do something drastic to stop them

I have no control over the voices I hear

The world is a dangerous place

Borderline PD

I am unsure about who I want to be

I am unattractive and no one wants to love me

I have to do something drastic to gain attention

I cannot survive alone

Relationships are inherently destructive

I will eventually mess up

NATs

Assumptions

Core Beliefs

Assumptions/Heuristics

• Assumptions and rules emerge which are consistent with our core beliefs.

• Theories about how we and the world should operate

• Conditional:

“If…., then…”

• Example

Belief: I am unlovable

Assumption: If I am not in a relationship, then I am unlovable

Rule: I must be in a relationship, otherwise I am unlovable

• “If a client doesn’t improve, then…”

NATs

Assumptions

Core Beliefs

Assumptions/Heuristics

• Heuristics are rules for living which form from our underlying assumptions

- I should/I must…

- If I do…, then…will happen

- If I don’t…, then I am…

NATs

Assumptions

Core Beliefs

(Negative) Automatic Thoughts

• “Hot thoughts”

• Internal dialogue

• Triggered by specific situations (precipitating event)

• Emotionally-laden

• Immediate

• Seem real and logical to the client

• Typically accompanied by physiological response

• Inform our behaviour

What goes through your mind when walking into a room full of people you don’t know

Fight or flight

NATs

Assumptions

Core Beliefs

Spotting our own automatic thoughts

• What goes through your mind? • Words…

• Pictures…

• Sounds…

• Memories…

• How do you feel physically?

• Do you have any urges?

Automatic Thoughts?

Automatic Thoughts?

Automatic Thoughts?

Padesky’s Cognitive Model

Compensatory Strategies (behaviour)

• Behaviour serves a function. Antecedent – Behaviour - Consequences

Eg - Child gets a biscuit after screaming and shouting – he is likely to repeat the behaviour the next time he wants one

• We act to compensate for our core beliefs

Eg – I am unlovable. If I am not in a relationship then I am unlovable. Try to establish relationship

• Sometimes the behaviour is functional but maladaptive (problematic or risky).

Eg’s

- deliberate self-harm

- promiscuity

- withdrawal (isolation)

- eating disorders

Core belief If…then… Compensatory strategy

I won’t receive love

and affection

If I don’t receive love and

affection then I will be sad

Narcissism

- self promoting

- blame others

I will be alone.

Relationships will fail

If I am alone then I will be sad Desperately try to find

intimacy

- hospitalisation

- assault

- verbal sex abuse

Verbal, physical and

sexual abuse is an

effective means of

taking power

If people are abusive then they

will be protected from harm

Verbal, physical and sexual

abuse

Sexual violence is part

of a relationship

If I am in a relationship then

sexual abuse will happen

Sexually abusive

Relationships and

painful. I have no

control.

If I control a relationship then I

will be protected from being hurt

Take power in relationships

- domestic abuse

- sexual fantasies about taking

power

Abusing people is bad

If I am abusive then I am bad Shame and guilt

Blame others

Minimising

BREAK

Padesky’s Cognitive Model

Delivering Therapy

• Principles of CBT:

1. Ever-evolving formulation and cognitive conceptualisation

2. Sound therapeutic alliance

3. Collaboration and active participation

4. Goal-orientated and problem-focused

5. Initially emphasises the present

6. Teaches client to be their own therapist; emphasises relapse prevention

7. Time-limited

8. Structured

9. Identify, evaluate and respond to dysfunctional thoughts and beliefs

10. Variety of changing thinking, mood and behaviour

Delivering Therapy

• 5-20 weekly sessions

• 30-60 minutes

• 1:1, group, self-help programmes and computerised programmes

• Forms basis of many condition-specific programmes

How therapy works

• Form an alliance based on shared goals

• Explore the client’s experience in Socratic terms

• Generate hypotheses about stuck states

• Functional Analysis – what purpose does a behaviour serve (A-B-C; Behavioural Theory)

• Promote learning which breaks stuck cycles and opens new learning

Assessment

• Begin with assessment which leads to individualised case formulation. Use to plan treatment

• Set of hypotheses about development and maintenance of problem list. There may be one for each disorder

• Good practice to form contract for assessment of number of sessions, venue, timing, importance of homework

Assessment continued: Presenting problem list

• Orientate to referral and time-frame available

• Invite client to explain difficulties with limited interruption

• Helpful prompts:

“What led you to come here today?”

“How long have you been feeling like this?”

“Can you tell me more about that?”

“Can you give an example?”

• Validate as you go to build alliance! Show understanding of their difficulty. Repeat, paraphrase

• Group and prioritise problems in a clinically meaningful way: (i) life-threatening behaviour, (ii) therapy-interfering behaviour, (iii) quality-of-life interfering behaviour

Assessment continued: ABC problem analysis

• Most psychological problems are amenable to ABC analysis

• The way antecedent factors (A), intervening beliefs (B), and emotional, cognitive, physiological and behavioural consequences (C) maintain problems

• Conduct by observing the client go through a micro-episode of the problem in the therapy room, request they complete self-monitoring homework task or ask about it:

“Can you describe the last time the problem happened?”

“What happened next?” “What went through your mind?”

“What did you do/want to do?” “How did that make you feel?”

“What did your body do?” “How did other people react?”

• After you have completed an ABC analysis, summarise it, and check it with the client for accuracy

• Clients can find it hard to capture their automatic thoughts. The therapist must teach them to thought-catch

• Strategies:

- Direct questions

- Strong affect

- Imagery

- Role plays

Assessment continued: ABC problem analysis

• Events which prompt episodes of the problem can be identified by a lifeline exercise.

• They can be classified as:

- Exits

- Entrances

- Illnesses/injuries

- Other transitions

Assessment continued: precipitating factors

Assessment continued: Predisposing factors

• Core beliefs triggered by precipitating event

• Distal external/internal factors vulnerability factors

• Focus for more in-depth treatment (Schema Therapy)

• Stress-Vulnerability Model

• Can be identified using Socratic questioning and the downward arrow technique

“If that were true, why would it be a problem?

What would it mean about you?”

Eg what would it mean if you were to fail an exam?

Assessment continued: Protective factors and Goal-setting

Protective factors

• Need to be considered because they have an impact on the efficacy of therapy

• Capacity to form therapeutic relationship is important

• Motivation to engage (do homework)

• Internal locus of control

Goal-setting

• Goals can be: short-term (this session), mid-term (this couple of sessions), long-term (for life)

• SMART

• Measure routinely, e.g. psychometric scores or increased/decreased behaviours

Assessment: Contracting

• Agree contract once intake assessment is complete and working formulation model has been constructed

• Client must understand and (collaboratively) agree with formulation and treatment goals. Establish:

1. Problems

2. ABC analysis

3. Predisposing factors – core beliefs

4. Precipitating factors

5. Protective factors

6. Therapy Goals

Session structure

- Orientation to session structure

- Check-in

- Set agenda

- Work through agenda, including review of homework

- Agree homework

- Summarise and request feedback

Treatment strategies

• Cognitive strategies aim to modify NATs and cognitive distortions to alter problem mood states

• They aim to reduce vulnerability to relapse by modifying core beliefs

• Modify assumptions rather than replace them with opposites

• Behavioural strategies aim to help clients alter activating events or engage them in activities which have a direct and positive impact on emotion states which are intrinsically reinforcing (Carr & McNulty)

• Clinicians draw from an menu of strategies when tailoring individualised programmes for particular clients. This depends on formulation, although specific protocols exist for particular disorders

Cognitive treatment: Socratic questioning

• “cornerstone of cognitive therapy”

• Use questions to elicit adaptive responses from clients. Planned questions to identify how problems are maintained and how they might be altered

• “guided discovery” Asking, rather than telling the problem, aids self-discovery and greater commitment to altering underlying problem belief

Socratic questioning

Type of Question Examples

1. Clarification questions Tell me about… What was that like…? What do you think/feel about…? Can you give me an example?

2. Probing assumptions What would happen if…? What does it mean if that’s true? What sort of person would that make you?

3. Probing rationale What do you think causes…? How do you know this? What evidence is there that supports…? What is the evidence against…?

4. Questioning viewpoints What are alternatives ways of looking at this? What would you say if somebody else told you this?

5. Probing consequences What are the consequences of this assumption? What happens when other people do…? [Behavioural experiments]

Cognitive treatment strategies

• How to do it: 1. Engage client in A-B-C exercise 2. Ask them to specify problem thought (B) 3. Ask what event (A) triggered it 4. Ask to rate conviction of thought (1-10) 5. Ask about consequent emotion (C) and intensity (1-10) 6. Engage client in cognitive strategy (e.g. experiment or questioning evidence) 7. Write down an alternative assumption to replace the NAT which fits with the evidence from the treatment strategy 8. Rate conviction of alternative (B) thought (1-10) 9. Identify emotion (C) from new thought and intensity 10. Ask client if there has been an improvement in their emotional state

Cognitive treatment strategies

Questioning the evidence • Client must distance themselves from their NAT and acknowledge it is only one possible

interpretation, not fact. They then weigh up evidence for and against

“What evidence can you give me that this interpretation of the situation is accurate?”

“Can you think of anything that might not fit with that situation?”

“If your interpretation is true, would it be as bad as you made it out to be – a catastrophe – or just a temporary nuisance?”

“How would it be if that was true of someone else? What would you think of them?”

• When clients can ‘catch their thoughts’ they can complete thought records and suggest alternatives as homework

Cognitive treatment strategies

Behavioural experiments • These can take the form of: observational (monitoring activities), graded task/graded

exposure, direct test of core beliefs, interview others, perspective-taking (what would someone else do?), video-recording

- Identify underlying assumptions

- Make very specific predictions

- Plan the experiment

- Anticipate problems

- Do the experiment (multiple times if necessary)

- Record outcomes

- Analyse outcome patterns

- Be alert for disqualifiers (eg it only turned out like that because…)

Cognitive treatment strategies

Safety Behaviour Experiments • Establish what the client does to avoid an aversive outcome. Invite them to give up the

safety behaviour and test whether feared consequence occurs. If so, why. If not, observe reduced anxiety

Belief surveys • Ask friends to what extent they believe in the client’s NAT. Discuss verbatim responses

in next session

Think in shades of grey • Rephrase one NAT or assumption in less concrete language (mindfulness helps address

assumptions

Re-attribution • Rephrase problem assumption to practise shifting blame between internal and

external factors

Cognitive treatment strategies

Cognitive Distortions • Invite the client to identify distortions in their NAT, assumption or belief

• Weigh evidence for and against

Distortion Description

Selective abstraction Drawing conclusions from only the negatives of a situation

Over-generalisation Generalise from one instance to all

Personalisation He looked angry, it must have been something I’ve done

Emotional reasoning Take feelings as facts

Discount the positives It was a fluke

Mind reading Assume others’ interpretations in silence

Catastrophising Predict extreme negatives on limited evidence

All or nothing thinking Either I’m a success or I’m a failure

Should and must Absolute statements about how self or others ought to be(have)

Cognitive treatment strategies

Cost-benefit analysis • What are the costs and benefits of holding problematic thoughts and giving them up

Pie chart analysis • Apportion responsibility amongst all parties involved for a perceived negative event to

break perception of being solely responsible

Core belief test • Downward-arrow to core beliefs then list evidence which shows core belief is not

universally true

Show self-compassion

Focus on the positives

Positive daily log

Take control of mood:

• set up situations which are less distressing

• learn to tolerate being in difficult situations with certain coping strategies

How: complete ABC and rate intensity. Invite coping skill then measure intensity of consequent emotion

Behavioural treatment strategies

Distraction/thought-stopping/grounding

• Identify activating event then temporarily focus on another aspect of the situation, distracting technique. Actively postpone rumination, flashcard, wristband, bang on table, say STOP (Distress Tolerance)

Relaxation

• Progressive muscle relaxation, paced breathing (5 in, 5 out)

Imagery

• Relaxation and distraction used in systematic desensitisation. Relax in advance then bring distressing image to mind. Imagine positive not negative outcome

Behavioural treatment strategies

Physical Activity • Part of PLEASE skills to reduce vulnerability to problematic emotions

Pleasant event • Fill diary with all obligations, pleasant events can be filled into the vacant slots

Graded challenges • Construct hierarchies of graded challenges, including increasingly fear-inducing or

anger-provoking situations

Self-reward • Use self-praise and tangible award

Behavioural treatment strategies

Relapse Prevention

• Identify triggers

- risky thoughts, emotions and situations

• Look for early warning signs

• Recognise distortions

• Plan how to cope (effective strategies) when you recognise these signs

- If this happens…, then I will do this…