COGNITIVE THERAPY Slides created by Barbara A. Cubic, Ph.D. Professor Eastern Virginia Medical School To accompany Current Psychotherapies 10.

COGNITIVE THERAPYCOGNITIVE THERAPY

Slides created bySlides created by

Barbara A. Cubic, Ph.D.Barbara A. Cubic, Ph.D.ProfessorProfessor

Eastern Virginia Medical SchoolEastern Virginia Medical School

To accompany To accompany

Current Psychotherapies 10Current Psychotherapies 10

Learning ObjectivesLearning 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 CTBasic Concepts of CT

Basic Concepts Basic Concepts Cognitive therapy focuses

primarily on how information is processed.

Behavioral techniques and cognitive restructuring techniques are utilized to elicit change.

Cognitive ModelCognitive Model Processing of information is vital for

survival. Survival systems are:

• Cognitive• Behavioral• Affective • Motivational

Each system is comprised of structures.• Schemas

ModesModes 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 ModelCognitive Model

BehaviorsSituation Automatic

ThoughtsEmotions

Physiological Response

Automatic thoughts influence not only one’s emotional response, but also one’s behavioral and physiological responses.

Cognitive ModelCognitive Model In other words, the relationship is bi-

directional (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 ModelCognitive 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 ModelCognitive Model

Behaviors

Situation Automatic

Thoughts Emotions

Underlying Physiological

Beliefs Response

Automatic thoughts are influenced by these underlying core beliefs and conditional assumptions

Cognitive ModelCognitive Model

Withdrawal

Relationship

Breakup He doesn’t want me Depressed

I’m worthless SNS Reaction

I’m unlovable Poor Sleep

Cognitive ShiftsCognitive Shifts In various types of psychopathology,

there is a systematic bias toward selectively interpreting information in a certain manner.

Characteristics of CTCharacteristics of CT Practical Symptom-focused Empirically-derived techniques Requires patient collaboration. Acknowledges underlying precursors

of symptoms (schemas), but present-oriented.

Case conceptualization drives treatment.

Roles of the CT TherapistRoles of the CT Therapist Conceptualize the patient in cognitive Conceptualize the patient in cognitive

terms.terms. Structure the sessions.Structure the sessions. Use collaborative empiricism and Use collaborative empiricism and

guided discovery to:guided discovery to:

• Specify problems and set goals.Specify problems and set goals.

• Teach the patient CT techniques. Teach the patient CT techniques.

CT Strategies 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 Comparing CT to Other TherapiesOther Therapies

Compared with PsychoanalysisCompared 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 REBTCT Compared with REBTCT REBT

Thoughts Labeled

Dysfunctional Irrational

Reasoning Used Inductive Deductive

Beliefs Associated with Psychopathology

Cognitive specificity for disorders

Core set of irrational beliefs

View of the Problem

Functional Philosophical

Therapist’s Approach

More collaborative

More confrontational

Compared to Behavior Compared to Behavior TherapyTherapy

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 TherapyHistory of Cognitive Therapy

Cognitive TherapyCognitive 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 TherapyHistory of Cognitive Therapy

Major influences were: Major influences were: 1.1. Phenomenological Phenomenological

approachesapproaches

2.2. Structural theory Structural theory and depth and depth psychologypsychology

3.3. Cognitive Cognitive psychologypsychology

Current Status of CTCurrent Status of CT

Research on the Research on the Cognitive ModelCognitive 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 Cognitive Therapy and Medicationand 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 CTCurrent 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 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 CTResources 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 Understanding the TheoryTheory

Behind CT Behind CT

Cognitive Case Cognitive Case ConceptualizationConceptualization

Personality Dimensions:Personality Dimensions:Styles of BehavingStyles of Behaving

Sociotropy (social dependence):• Become depressed following

disruption of relationship(s).

• Organized around closeness, nurturance, and dependence.

Personality Dimensions:Personality Dimensions:Styles of BehavingStyles 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 ThinkingProblematic Thinking

Extreme Broad Catastrophic Negative Unscientific Pollyannaish

Idealistic Demanding Judgmental Comfort Seeking Obsessive Confusing

Problematic thinking is very:

Cognitive DistortionsCognitive 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 DistortionsCognitive 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 DistortionsCognitive 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 DistortionsCognitive 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 DistortionsCognitive Distortions

Personalization: Assuming personal responsibility for something for which you are not responsible.• Often seen in patients who are

sexually abused/assaulted.

Cognitive DistortionsCognitive 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 DistortionsCognitive 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 DistortionsCognitive 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 DistortionsCognitive 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 DepressionCognitive Triad of Depression

Negative

view of

Examples of Cognitive Shifts: Examples of Cognitive Shifts: Depression vs. AnxietyDepression vs. Anxiety

Negative view of Threatening view of

Future Future

Self World Self World

Illustration of the Cognitive Illustration of the Cognitive Model of AnxietyModel of Anxiety

Stimulus

(Environmental Or Internal)

Secondary appraisal:

“Risk: Resources ratio”

Reappraisals of danger, risk, resources

Behavioral inclination

(Flight, Freeze, Defend)

Affect

Anxiety, Terror

Physiological

Palpitations,Sweating,

Tension, etc.

Primary appraisal:

“Danger”

Cognitive Profile of Other Cognitive Profile of Other Psychological DisordersPsychological Disorders

Disorder Systematic Bias in Process

Hypomania Inflated view of self and future

Anxiety Physical and psychological danger

Panic Disorder

Catastrophic interpretation of physical and mental experiences

Phobia Danger in specific avoidable situation

Paranoid State

Attribution of bias to others

Hysteria Concept of motor or sensory abnormality

Cognitive Profile of Other Cognitive Profile of Other Psychological DisordersPsychological 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

Anorexia Nervosa

Fear of being fat

Hypochondriasis Attribution of serious medical disorder

Cognitive Therapy Cognitive Therapy TreatmentTreatment

Structure of a CBT SessionStructure 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 CTGeneral 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 ConceptsFundamental 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 TherapyProcess 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 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 ScheduleWeekly Activity Schedule

Mon Tue Wed Thu Fri Sat Sun

8-10 am

10-12 pm

12-2 pm

2-4 pm

4-6 pm

6-8 pm

8-10 pm

10-12 am

Patient records activities and rates them for pleasure and mastery

Weekly Activity MonitoringWeekly 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 ExamplesCognitive 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 RecordThought RecordSituation Mood

1- 100 Automatic Thought

Evidence For AT

Evidence Against

AT

Balanced/ Alternative Viewpoint

Re-rate Mood

Eliciting Automatic ThoughtsEliciting 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 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 Specific Examples of Socratic QuestioningSocratic 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 QuestionsNon-Socratic Questions(Questions NOT to Use)(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 Example: Downward Arrow to Obtain Less Accessible Beliefsto Obtain Less Accessible Beliefs

Situation Thoughts Emotions

Patient reports that a session hasn’t helped them.

Therapist thinks patient is right. That was a terrible session. I didn’t do anything right.

Guilty

Anxious

Example: Downward ArrowExample: Downward ArrowQuestionIf 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 HomeworkSetting 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 TechniquesOther 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: Applications of CT: Empirically Supported 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: Applications of CT: Empirically SupportedEmpirically Supported

Moderate effect sizes for:• Marital problems• Anger• Childhood somatic disorders• Chronic pain

Small effect sizes for:• Schizophrenia

• Bulimia nervosa

Applications of CT: Applications of CT: Empirically SupportedEmpirically Supported

CT yields lower relapse rates than antidepressant medications and reduces the risk of symptom relapse.