408 Midterm 2

Question 1

what are the core features of CBT

Answer 1

• structured
• short-term (6-8 sessions can lead to symptom improvement, but will depend on disorder and presentation)
• present-oriented (as opposed to the past)
• empirical (both nomothetic and idiographic)
• directed toward modifying dysfunctional thinking
• based on cognitive case conceptualization/formulation for individual clients
• designed to produce cognitive change

Question 2

cognitive model

Answer 2

• situation = thought (interpretation) = emotion (result of the thought) = behaviour (result of the emotion)
• can also include a physiological reaction (instead of an emotion)
• different thoughts in responses to situations will incur different emotions, so different behaviours
• this is the process of identifying automatic thoughts: what are people thinking when they notice a change in their emotions or behaviours (people are better at noticing these more obvious shifts)

Question 3

intermediate beliefs & core beliefs & automatic thoughts

Answer 3

• core belief: basic organizing principle about how we experience ourselves in the world
• leads to intermediate beliefs: rules, attitudes, assumptions about how the world works, how it should work, how we should behave
• lead to automatic thoughts

Question 4

principles of CBT (14)

Answer 4

1. based on cognitive conceptualizations
2. requires a good therapeutic alliance
3. continually monitors client progress
4. culturally-adapted and tailored to the individual
5. emphasizes the positive
6. emphasizes collaboration and active participation
7. aspirational, values-based, goal-oriented
8. initially emphasizes the present
9. aims to be educating
10. aims to be time-limited
11. consists of structured sessions
12. teaches patients to identify, evaluate, and respond to dysfunctional beliefs
13. includes action plans (therapy homework)
14. uses a variety of techniques to change thinking, mood, and behaviour

Question 5

what does it mean that CBT is “culturally adapted and tailors treatment to the individual”

Answer 5

• there is a general approach in treatment manuals (broad philosophy and treatment technique suggestions), but needs to be adapted for the individual
• CBT tends to be ‘brainy’ and cognitive which may not work for everyone (using different examples instead of emphasizing the scientific approach and examples)

Question 6

what does it mean that CBT “emphasizes the positive”

Answer 6

• people have negative filters on, so you have trouble seeing anything positive in your life or you’re misinterpreting positive things as negative
• the therapist needs to bring attention to the positive

Question 7

what does it mean that CBT “emphasizes collaboration and active participation”

Answer 7

• collective empiricism: teamwork in trying to figure out the problem and how to help

Question 8

what does it mean that CBT is “aspirational, values-based, goal-oriented”

Answer 8

• values: ongoing important aspects of your life
• goals: concrete, there are moments when the goals are accomplished

Question 9

what does it mean that CBT “initially emphasizes the present”

Answer 9

• here-and-now focus: the things that contribute to psychopathology aren’t necessarily the things that maintain it (the etiology isn’t the same as the maintenance)
• getting people out of a vicious cycle requires focusing on maintenance factors
• with time (and only if necessary), we can explore the past to understand patterns of beliefs and how they arose
• for some clients, changing thinking patterns on a daily basis will be sufficient, but for others it might be important to move to the past eventually

Question 10

what does it mean that CBT “aims to be educating”

Answer 10

• educate client on cognitive model and techniques (why we think this works, what does changing your thought incur)
• teaching clients to evaluate their own dysfunctional thoughts (the therapist can’t do all the work, the clients needs to do it so it can generalize)
• teaching the client to “be their own therapist” and give them the necessary tools

Question 11

what does it mean that CBT “consists of structured sessions”

Answer 11

• maximize efficiency and effectiveness
• start with a mood rating: how was your week
• agenda (client and therapist both bring items to the agenda)
• feedback and wrap-up: what did the client take from the session, what do they want to be done differently (an essential part of therapy so that the client has agency in their own treatment)

Question 12

what does it mean that CBT “teaches patients to identify, evaluate, and respond to dysfunctional beliefs”

Answer 12

• guided discovery: leading the client to the answer by asking them questions so that they get there on their own
• behavioural experiments: testing beliefs by doing something in real life to challenge the beliefs

Question 13

what does it mean that CBT “involves action plans”

Answer 13

• what the client is doing in between sessions to get benefits (one session per week is not going to do anything)
• client needs to build new patterns and habits
• anything we want clients to remember should be written down

Question 14

what does it mean that CBT “uses a variety of techniques to change thinking, mood, and behaviour”

Answer 14

• not only cognitive strategies
• can pull from other treatment approaches (mindfulness, behavioural)

Question 15

deconstruct the Lucy example in what the therapist was doing

Answer 15

• following the cognitive model
• focusing on a particular situation (not going to a lecture) so that the person can reconstruct the experience
• then going through thoughts (typically “I” statements that will be negative in a depressed person)
• then going through emotions (one-word, which can be difficult to grasp for clients)
• physiology (what you feel in your body)
• behaviours (what ends up happening because of thoughts and emotions)
• then how do you feel afterward: helps clients notice that their behaviours aren’t helpful

Question 16

what is the main focus of a CBT assessment?

Answer 16

• assessing the current problem (what brought you in right now, what pushed you to start therapy)
• ask clients to detail a recent occasion when problem symptoms were experienced (what happened before, during, after)
• break the presenting problem into four internal systems (cognitions, emotions, behaviour, physiology) and the environment (larger context)
• the present is a relevant source of information (how is the problem being maintained?)

Question 17

what are triggers and modifying factors

Answer 17

• antecedents, part of a CBT assessment
• triggers: what factors make the problem more or less likely to occur (can be external in the environment or internal)
• modifiers: contextual factors that impact how severe the problem is when it occurs

Question 18

what are consequences and how are they helpful in an assessment

Answer 18

• what has happened as a result of current problems
• when the problem does occur, what are the emotions, behaviour, physiology, relationship changes that are the consequences
• consequences give insight into maintaining processes (the function)
• all our behaviours serve a function, we should find some way to serve that function in a different way
• the past is not relevant to why the person is struggling right now

Question 19

what are maintaining processes

Answer 19

• vicious cycles that keep the problem going (this is where we intervene)
• different disorders have different common maintaining processes (but assessments must still be individualized)
• binge eating can be positive reinforcement or negative reinforcement depending on the episode and/or the person
• escape/avoidance (reducing aversive anxiety)
• reduction in activity (depression = withdrawal = lack of reward = more withdrawal)
• short-term reward (pleasurable experiences with maladaptive long-term consequences)

Question 20

what is past history and problem development in CBT assessment

Answer 20

• vulnerability factors: things that set the stage for a problem to develop, but are neither necessary nor sufficient (the diathesis like family history of a disorder, will not be expressed without a stressor)
• precipitants: events or situations that provoke onset of symptoms (more immediate stressors and life events, can be traumatic or normal events, even positive), activating a pre-existing vulnerability belief
• modifiers: changes to life circumstances that affect the severity of a problem (someone who is generally anxious has just experienced something that increased the severity of their anxiety, so they cam to therapy)

Question 21

cognitive model/conceptualization

Answer 21

• we always start at the level of automatic thoughts (most accessible and easiest to change because they’re situational)
• basic model: situation = thought = emotion = behaviour
• simple thought record: when you notice a change in emotion, try to identify what you’re thinking in that moment (used in cognitive restructuring and in assessment)

Question 22

expanded cognitive model

Answer 22

• includes core beliefs (enduring cognitive phenomena that are deeply rooted and difficult to access)
• people focus selectively on information that confirms core beliefs and disregard information that doesn’t (in CBT we try to consider the entire situation, not just confirmatory information)

Question 23

core beliefs

Answer 23

• global (apply to everything), rigid (difficult to change), overgeneralized
• fall into 3 categories:
  1. incompetence (achievement-related and internal): I’m stupid, I’m a failure
  2. unlovable (interpersonal): I’m bound to be rejected
  3. worthless (especially in people with suicidal ideation): I’m bad, I don’t deserve anything good

Question 24

intermediate beliefs

Answer 24

• between automatic thoughts and core beliefs
• attitudes: applies to everyone and all situations (not an I statement)
• rules: often includes “I” and “should”
• assumptions: often an If…Then statement
• also falls into 3 categories: helpless (incompetence core belief), unlovable, worthless
• the assumption is the easiest to work with because of implied causality (try to transform rules or attitudes into assumptions to be able to work with them)

Question 25

downward arrow technique

Answer 25

• technique for identifying intermediate and core beliefs
• people do thought records, find patterns in automatic thoughts
• ask clients about the meaning of automatic thoughts that likely come from core beliefs (if the thought is true, what does it mean?)

Question 26

what is a CBT conceptualization and what is it used for

Answer 26

• road map to therapy
• develop a treatment plan based on conceptualization
• there are different conceptualizations based on different disorders that get personalized based on the person
• a series of hypotheses about the client that are refined based on incoming data (developed in initial sessions but will change)
• always present the conceptualization to the client to see if it rings true (share a diagnosis if you have enough information, get feedback from the client, often presented using diagrams with arrows to depict maintenance processes)

Question 27

questions to answer when creating a case conceptualization

Answer 27

• how did the person develop this disorder
• what were significant life events, experiences related to this vulnerability
• what are the person’s basic beliefs about themselves, the world, and others (cognitive triad, rules, attitudes, assumptions)
• what are the person’s attitudes, rules, and assumptions?
• what strategies has the patient used to cope with beliefs (typically maladaptive)
• what automatic thoughts, images, and behaviours maintain the disorder
• how did beliefs interact with life events to make the person vulnerable to disorder?
• what is happening in their life right now and what are the patient’s perceptions about that? (one of the most important questions)
• diagram to present automatic thoughts (using examples provided by the client) including life history, core beliefs, intermediate beliefs, coping strategies, critical incidents
• emotions, thoughts, behaviours are not linear, everything affects everything

Question 28

how do we identify automatic thoughts

Answer 28

• they come in verbal, visual or both forms (for most people they’re verbal)
• often embedded within a broader statement or phrased as a question (try to re-phrase as a simple statement)
• basic question: what was going through my mind just then? in response to changes in emotions, mind/body, urge to engage in a dysfunctional way

Question 29

types of automatic thoughts

Answer 29

• distorted: occurring despite evidence to the contrary
• thought is accurate but conclusion is distorted
• thought is accurate, but not helpful

Question 30

evaluating automatic thoughts

Answer 30

• reviewing evidence for and against the thought
• worst case, best case, most realistic case
• advantages and disadvantages of having the thought
• distance self from thought
• problem-solving
• always assess the outcome of the automatic thought evaluation process (how much did it change mood, physiology, etc. after evaluating it)

Question 31

reviewing evidence for and against the thought

Answer 31

• what supports the thought (what is the reason this thought has occurred?) and evidence that doesn’t support the thought
• be as objective as possible (not just hearsay or feelings) and don’t dismiss the supportive evidence
• then come to a more balanced thought
• most people with depression think in a negative way, so thoughts are distorted
• used for distorted thoughts

Question 32

worse case, best case, most realistic case

Answer 32

• what is the worst thing that could happen? If it did happen, how would I cope?
• used for people with GAD who catastrophize and worry about the future
• for some people, even something with a small likelihood of happening may be worth worrying about

Question 33

advantages and disadvantages of having the thought

Answer 33

• what are the effects of believing vs. not believing the thought? how do you behave in response to the thought
• if the thought is accurate, we can’t evaluate evidence, but the thought is not helpful
• come up with a different way of thinking about it

Question 34

distance self from thought

Answer 34

• what would you tell a friend or family member in this situation
• used for accurate thoughts and for distorted thoughts
• easier to be compassionate toward others

Question 35

problem-solving method of evaluating automatic thoughts

Answer 35

• what can you do in this situation? what could you do differently next time?
• if the thought is accurate, there’s no getting out of the situation right now, but can change next time

Question 36

CBT thought record

Answer 36

• situation (what, who, when, where)
• emotion or feeling (one-word answers) rated 0-100
• negative automatic thought (what images, thoughts were going through your mind)
• evidence supporting and not supporting the thought (completely true all the time? what would you tell a friend? experiences that contradict the thought?)
• alternative thought
• re-rate emotion or feeling

Question 37

cognitive distortions

Answer 37

• unhelpful thinking styles that are very common and normal
• patterns in our automatic thoughts; ways that we generally think that create the automatic thoughts
• with a selection of automatic thoughts, we start to work with cognitive distortions (this will generalize)

Question 38

all-or-nothing

Answer 38

• black or white, only seeing extremes
• try to get people to see things in the middle
• in thought restructuring, evidence for and against, then come to a more balanced thought
• identify the extremes (worst case, best case), explore the steps in between

Question 39

mental filter

Answer 39

• seeing only the evidence that fits with how you think about yourself
• try to be more like a scientist and pay attention to all instances of an event and note both good and bad (get a more representative sample of information)

Question 40

behavioural experiments

Answer 40

• planned experiential activities undertaken to test validity of patient’s beliefs and construct more adaptive beliefs
• like exposure, but has a different purpose (exposure designed to provoke anxiety and learn that it decreases, experiments are about developing realistic beliefs)
• hypothesis testing (how will the person react in this situation) vs. discovery (gathering information)
• active (speaking to someone) vs. observational (watching people interact)
• can also be spontaneous

Question 41

what are some guidelines for successful behavioural experiments

Answer 41

• clients should push themselves, but also avoid setbacks (don’t do too much too fast)
• set it up so that the client learns something either way (if the experiment doesn’t go as planned)
• prepare for challenges ahead of time, set the client up for success
• client needs to be fully engaged rather than going through the motions (so they can’t make excuses after the experiment)
• monitor thoughts/feelings throughout
• be flexible and respond to the unexpected
• always debrief after the experiment: what actually happened? did this fit with predictions? what did you learn? what could you do differently next time?

Question 42

making decisions CBT technique

Answer 42

• advantages and disadvantages analysis
• weigh the advantages of both options and rate their importance from 1-10 (not every pro and con is of equal importance)

Question 43

refocusing CBT technique

Answer 43

• when evaluating automatic thoughts isn’t desirable or feasible (in the middle of an exam)
• label the automatic thought, then deliberately refocus attention on the task at hand (let it go, now I’m doing this)

Question 44

graded task assignments CBT technique

Answer 44

• if you have a really big task that is overwhelming
• break goal down into smaller pieces, focus on one step at a time
• success encourages further action

Question 45

pie technique CBT technique

Answer 45

• useful for setting goals or determining relative responsibility
• for EDs: how people evaluate themselves where weight/shape takes up a lot of the pie (try to allocate less space to it over time)

Question 46

self-comparisons and credit lists CBT techniques

Answer 46

• are you comparing yourself to you at your best or your worst (not always fair to compare yourself to your best, choose a more appropriate comparison point)
• give yourself credit when it’s due (take time to realize you’ve accomplished something)

Question 47

historical aspects of exposure for anxiety

Answer 47

• systematic desensitization developed after Joseph Wolpe was dissatisfied with psychoanalytic treatment for PTSD
• pairing things that were distressing with food, and the fear response was extinguished
• reciprocal inhibition: the experience of fear is incompatible with the experience of pleasure
• pair exposure with relaxation techniques
• Wolpe developed Subjective Units of Distress Scale (SUDS)

Question 48

model of exposure

Answer 48

• based on how fear develops
• neutral stimulus evokes fear response
• avoidance/safety behaviour maintains fear (lack of learning that the stimulus is neutral)
• trauma = generalizing from one specific instance
• benign stimuli associated with the event begin to evoke fear response
• exposure therapy designed to undo conditioning processes (teaching clients to approach rather than avoid)
• exposure may be paired with relaxation techniques and/or prevention of compulsions or safety behaviours (developing corrective information about the feared stimulus)

Question 49

exposure mechanisms of change

Answer 49

• habituation: over time, physical sensations associated with fear naturally reduce (cannot maintain arousal over time)
• extinction: feared stimulus is no longer paired with escape or avoidance, may be paired with relaxation (a new association is learned)
• learning corrective information (inhibitory learning): over repeated trials, clients learn that feared outcome doesn’t happen (change in cognitive expectations)
• increased self-efficacy: even if fear response isn’t completely extinguished, client learns that they can handle fear

Question 50

graded exposure

Answer 50

• type of exposure
• slowly exposed to increasingly difficult stimuli
• building a hierarchy and start at the bottom so that it’s not too overwhelming

Question 51

systematic desensitization

Answer 51

• type of exposure
• graded exposure with added relaxation techniques (incompatible states)
• not everyone like relaxation techniques

Question 52

prolonged exposure

Answer 52

• type of exposure
• designed to treat PTSD
• repeated revisiting of traumatic event; client recounts experience in great detail
• re-processing details surrounding the event
• exposures to situations or objects or individuals that are reminders of the traumatic event, but that do not pose a threat
• facilitates emotional processing of event (all emotions, but a complex constellation of feelings in PTSD)

Question 53

one-session exposure

Answer 53

• type of exposure
• extended, up to 3hrs
• includes instruction, modelling, exposure, cognitive challenge
• shown to be efficacious in adults, some evidence for kids
• need to be set up for many types of exposures because you need to move up the hierarchy within one session

Question 54

modes of delivery

Answer 54

• in vivo
• imaginal
• virtual reality
• interoceptive
• modelling (adjunct)

Question 55

in vivo exposure

Answer 55

• mode of delivery
• exposure to actual feared stimulus, or some approximation
• can require some creativity

Question 56

imaginal exposure

Answer 56

• mode of delivery
• client imagines feared stimulus when it isn’t feasible to do in vivo exposure
• frequently used for PTSD (cannot recreate the event), GAD (fearing future possibilities), phobias of uncommon stimuli
• not all clients will be able to engage in this (need good visualization skills)

Question 57

virtual reality

Answer 57

• mode of delivery
• when in vivo isn’t feasible
• good alternative to imaginal for clients who have difficulty visualizing
• becoming more accessible, not widely used yet

Question 58

interoceptive exposure

Answer 58

• mode of delivery
• exposure to physical sensations
• especially for panic disorder or clients who find physical anxiety symptoms to be unacceptable
• fear of fear: catastrophizing physiological anxiety
• clients learn that symptoms are not dangerous
• turning in an office chair, breathing through a straw, running in place

Question 59

modelling exposure

Answer 59

• mode of delivery
• not a primary intervention, but used as an adjunct
• can help ease clients into exposure
• shows clients that the feared outcome is unlikely or impossible
• we shouldn’t ask the client to do anything what we wouldn’t do (getting a sense of their experience)
• going past the reasonable experiences that we’re likely to experience in daily life to make sure generalization sticks
• model the type of response you want the client to show

Question 60

early sessions in typical course of therapy EX/RP for Caroline

Answer 60

• assessment of symptoms and interference (multiple obsessions and compulsions interfering with daily life as time-consuming and interpersonal avoidance)
• psychoeducation: describe nature of OCD, explain how compulsions maintain anxiety
• provide a rationale for exposure: extinction
  (stop feeding obsessions with compulsions), explain that improvement will take time (initial worsening), describe empirical findings
• introduce symptom monitoring and SUDS (shows patterns of anxiety; triggers, thoughts, distress, responses)
• construct fear hierarchy based on symptom monitoring and SUDS (start with items with SUDS<30 and end with over-and-beyond items)
• plan exposure exercises, prevention of rituals (for each obsession and compulsion)
• build rapport (client needs to trust the therapist)

Question 61

middle sessions typical course of EX/RP for Caroline

Answer 61

• in-session exposure (therapist-guided, prevention of compulsions) with SUDS ratings throughout
• do no move up the hierarchy until the client can complete with little anxiety and without compulsions
• homework: out-of-session exposures (generalization and self-efficacy), continue symptom monitoring
• keys to success: manageable, refrain from compulsions, master one step before moving on, repeated over time
• modify the hierarchy as needed (according to changes in Sx, new behaviours, reactions to exposures)
• assess overall symptoms to track progress (severity over time)

Question 62

cognitive restructuring typical course of EX/RP for Caroline

Answer 62

• EXRP is very behavioural, but there is an added benefit of cognition
• can help clients engage in therapy more readily (more appealing, subjectively safe, to clients)
• introducing cognitions too early in therapy can result in clients using this cognitive restructuring to neutralize anxiety during exposure

Question 63

late sessions in typical course of EXRP for Caroline

Answer 63

• generalization and maintenance
• may not have time to go through every obsession or compulsion in therapy, so client needs to continue on their own
• have client develop additional hierarchies and response prevention strategies
• relapse prevention: predict challenges, problem-solve, normal to have slip-ups (doesn’t mean that progress is undone), what can you deal with on your own and when do you re-contact the therapist

Question 64

advantages of exposure therapy

Answer 64

• highly efficacious for various problems
• often superior to pharmacological treatment
• relatively brief (under 15 sessions) and can be done many times per week

Question 65

disadvantages of exposure therapy

Answer 65

• high dropout and refusal rate (aversive for clients)
• therapists find it aversive (pushing someone to do something they don’t want to do)
• several barriers: noncompliance, subtle avoidance, family involvement (maintaining symptoms and reinforcing rituals), comorbidities

Question 66

what are some main cognitive distortions

Answer 66

• all-or-nothing
• mental filter
• jumping to conclusions (making an unjustified inference)
• mind reading
• overgeneralizing (going from one instance to everything)
• personalization (it’s my fault)
• emotional reasoning (the strength of the feeling = the truth)
• labelling
• disqualifying the positive
• should and must statements
• magnification and minimization (similar to overgeneralization)

Question 67

BA model

Answer 67

• originated from behavioural models of depression (behaviour therapy)
• depression associated with a particular behaviour-environment relationship that evolves over time (maintains depression)
• reciprocal relationship between actions and behaviour and the environment is occurs in + the responses from the environment (usually people)
• if-then contingencies; what are the consequences of the behaviour (we don’t care about the behaviour itself)
• Ferster model
• Lewinsohn model

Question 68

Ferster model of depression

Answer 68

• decreased rates of response-contingent reinforcement = turning inward, doing nothin, escape and avoidance
• not getting reinforcement from your environment = withdraw from environment = negative reinforcement of depression

Question 69

Lewinsohn model of depression

Answer 69

• social avoidance core to depression
• people not engaging in social relationships = not getting reinforcement from social life

Question 70

behavioural activation model

Answer 70

• behavioural responses reduce our ability to experience positive reward from the environment
• depression characterized by high negative affect, but also a lack of positive affect (lack of reward) which leads to withdrawal and lack of engagement
• treatment focuses on activation and processes that inhibit activation (like escape and avoidance and ruminative thinking)
• breaking the cycle; depressed = withdrawal = no reinforcement = more depression

Question 71

BA treatment rationale

Answer 71

• events in your life and how you respond influence how you feel (but we’re not focused on thoughts, just behaviour)
• lives that provide too many problems and not enough reward can lead to depression (too much negative, not enough positive = depression)
• people pull away from the world when life is less rewarding
• withdrawal = depression = difficulty solving problems
• treatment isn’t just ‘doing more’ but figuring out what activities are most helpful (personalized)

Question 72

BA form of treatment

Answer 72

• daily monitoring forms (pleasure and mastery)
• use monitoring forms to look for contingencies maintaining behaviour
• use activity monitoring to design intervention
• activity scheduling
• ACTION
• engagement strategies

Question 73

daily monitoring forms BA

Answer 73

• reporting what you do throughout the day + planning your days
• rating two aspects of reward (mastery and pleasure) for all activities
• see how activities are associated with different ratings to find contingencies
• positive reinforcement from family/friends can be a contingency (accommodating)
• negative reinforcement through escape and avoidance of painful feelings

Question 74

how to design a BA intervention

Answer 74

• use activity monitoring
• what would you be doing if you weren’t depressed? (what would you enjoy doing is not useful because happiness is often a foreign concept)
• look at relationships between specific activities or life contexts or problems and ratings of mastery and pleasure (expected or in the past)
• trying to distinguish between pleasure and mastery for the client
• explain how avoidance and withdrawal and rumination contribute to depression via negative reinforcement
• increase activities that have the potential to bring pleasure and mastery (and decrease activities related to avoidance and withdrawal)

Question 75

how to do activity scheduling in BA

Answer 75

• help clients maximize success (don’t over-schedule or aim for big events)
• public commitment: telling people the plan, doing activities with others (added benefit of social interaction, more reward) = holding you accountable
• structure the environment (putting workout clothes next to the door)
• arbitrary reinforcers (any type of reinforcer is helpful at this point, but it’s most effective if the reinforcers are naturally in the environment/activity you’re doing)
• aversive contingencies (like punishment, not ideal, but sometimes necessary)
• record context and consequences of activation (what environments promote activation vs. ones that dissuade from action = ratings of mastery and pleasure)
• gather information about incomplete homework to understand barriers and avoidance patterns

Question 76

ACTION

Answer 76

• targeting avoidance of tasks, emotions, interpersonal conflicts, etc.
• Assess whether the behaviour is approach or avoidance (foster approach, minimize avoidance)
• Choose to continue the behaviour (even if it’s making you feel worse), or choose a new behaviour
• Try the chosen behaviour
• Integrate a new behaviour into your routine (give it a fair chance)
• Observe the results (monitor the effects through ratings of mastery and pleasure–how long do they last?)
• Never give up! Change requires repeated efforts and attempts

Question 77

engagement strategies

Answer 77

• when people are doing the approach behaviours, they have to be fully engaged (not going through motions)
• rumination prevents people from engaging with their activities and environments
• unlike in cognitive therapy, we don’t care about the content of rumination (not trying to change the thoughts), but we care about function
• if the client isn’t experiencing pleasure, explore level of engagement in the activity
• draw attention to experience to ensure that people are benefitting

Question 78

rumination

Answer 78

• purpose could be to keep yourself detached from a stressful environment
• can be negatively reinforced (removing the engagement to avoid negative feelings)
• not able to experience positive affect if ruminating

Question 79

Dimidjian perinatal study

Answer 79

• pragmatic effectiveness RCT conducted at four sites (done in the context of existing treatment in clinics)
• randomized to BA or TAU
• BA: 10 sessions provided in-clinic, phone, in-home, delivered by health care professionals naive to BA (not an efficacy trial)
• primary outcomes: change in symptoms and remission rates based on Patient Health Questionnaire
• secondary outcomes: anxiety, stress, treatment satisfaction
• tested whether changes in early activation and environmental reward would mediate association between treatment condition and improvement in symptoms
• found more symptom reduction in BA vs. TAU at all follow-up points (small-to-moderate effect size)
• 56% remission in BA vs. 30% in TAU
• BA reduced anxiety and stress
• support for mediation model)
• conclusion: BA is a scalable intervention consistent with patient preferences to improve depression symptoms during pregnancy

Question 80

scalable

Answer 80

• can reach many people because it’s brief and simple and can be administered easily
• doesn’t require ltos of training

Question 81

evidence for BA

Answer 81

• Dimidjian (2006): among moderate-to-severe depression, BA was superior to cognitive therapy and equivalent or superior to meds (severe depression = unable to engage in cognitive effort, something simpler might be more effective in the beginning to relieve brain fog)
• Ekers meta-analysis: BA superior to control and antidepressants
• Richard et al: BA delivered by junior mental health workers was not inferior to CBT delivered by psychological therapists (scalability; BA can be taught and used widely, but CBT too complex)

Question 82

transdiagnostic formulation

Answer 82

• treatment for all EDs, not one specific one (CBT-E is the newest version that takes a transdiagnostic approach)
• many ED features present across diagnoses (weight/shape concerns, binge eating, purging, dietary restriction)
• most patients migrate across diagnoses over time (AN binge-purge = weight gain = BN, then purging stops = BED)
• over-evaluation of shape and weight is a central maintenance factor of all EDs
• precise form of applied treatment is individualized (level of intensity specific to weight status; BMI>17.5 is 20 sessions over 20 weeks, BMI<17.5 is 40 sessions over 40 weeks)

Question 83

CBT-E added components

Answer 83

• to make it enhanced, added modules that can be used to address symptoms external to core ED
• these modules should sustain remission over time instead of just targeting ED features
• perfectionism (globally, not just applied to eating behaviour), low self-esteem (generalized sense of failure and worthlessness), major interpersonal problem (often accompanied by emotional regulation problems)

Question 84

what is the “starting well” aspect of CBT-E

Answer 84

• start with self-monitoring, weekly weighing, regular eating
• engage the patient in treatment and change, increase motivation and commitment to treatment (AN w/o binge eating = low motivation to change (don’t want to gain weight), BED may have greater motivation)
• talking about pros and cons of changing or maintaining status quo
• collaboratively create a personalized formulation (symptoms)
• psychoeducation about treatment and EDs (consequences of EDs, of purging for dental health or cardiac complications)

Question 85

standard transdiagnostic formulation

Answer 85

• ED is a vicious cycles maintained by interactions among thoughts, behaviours, and beliefs
• over-evaluation of control over eating, shape, or weight (core maintenance factor)
• then engaging in strict dieting or other compensatory behaviours
• then one of two paths: either binge eating (because you’re hungry) OR features of under-eating and/or low weight (both of which act as reinforcers for over-evaluation of weight/shape)
• start with the behaviours at the bottom, the work your way to the more cognitive maintaining factors

Question 86

self-monitoring CBT-E

Answer 86

• better understanding processes maintaining ED (informs the formulation)
• continued throughout Tx
• get an accurate record of patient’s food intake (retrospective is unreliable)
• highlights key behaviours, feelings, thoughts, contexts in which they occur
• use these as examples for sessions
• allows therapeutic work between sessions
• increase patient self-awareness (an intervention for binge eating: writing everything down is so aversive that it decreases frequency or intensity)
• encourage self-monitoring in real time
• record time, food consumed, place, type of food (snack, binge, purge, meal), exercise, circumstances (thoughts, feelings)

Question 87

weekly weighing

Answer 87

• establish right at the beginning of treatment
• patients fall into 2 groups: either completely avoiding getting on a scale OR obsessively weighing themselves
• showing patients that weight will fluctuate throughout the day, in a week (misinterpreting inconsequential fluctuations is likely to result in weight control behaviours, no matter whether weight is up or down)
• procedure: no weighing at home, only in-session once a week (jointly; not hiding information)
• joint plotting of weight graph: we should see stable weight (CBT isn’t a weight loss program); by replacing binge eating and purging with regular eating, the end result is not weight gain

Question 88

regular eating in CBT-E

Answer 88

• introduced at the beginning of treatment and continues throughout
• prescribed pattern of regular eating
• 3 meals and 2-3 planned snacks per day
• no more than 3-4 hours between meals (hunger can be a trigger for binge eating)
• people don’t have a good sense of their hunger and fullness cues, so this is based on time and is very mechanical
• eating takes precedence over other activities
• initial emphasis on when people eat (later examine what they eat)
• we use their definition of a meal (no matter if it’s more of a snack or only low-cal)
• urge to eat between meals/snacks = problem-solve, use incompatible behaviours, surf the urge (wait long enough = craving dissipates)
• very effective to solve binge eating

Question 89

compensatory behaviour in CBT-E

Answer 89

• vomiting: education about ineffectiveness (only rids self of 30-50% of calories, so doesn’t eliminate binge episode), review consequences of vomiting (dental health, electrolyte imbalance), delay (feel an urge = what happens if you delay the behaviour?)
• laxatives and diuretics: ineffective at preventing calorie absorption, throw away supplies or plan a schedule of withdrawal
• if regular eating is effective at reducing binge eating, then the reduction in compensatory behaviours reduce naturally (purging disorder as an exception)

Question 90

addressing over-evaluation of shape and weight in CBT-E

Answer 90

• develop new domains for self-evaluation (identify and try interests and activities, use pie chart technique)
• decrease importance of shape and weight (body checking and avoidance, feeling fat)

Question 91

how to address shape checking

Answer 91

• either focused on shape with comparisons OR avoidance of shape (not looking in the mirror, baggy clothing)
• identify forms of shape checking (self-monitor to increase awareness of the behaviour)
• think before you look in the mirror: what am I trying to find out? can I find this out? Is there a risk that I will get unhelpful information?

Question 92

how to address body avoidance

Answer 92

• identify forms of avoidance and encourage exposure
• controlled mirror exposure

Question 93

how to address body comparison to others

Answer 93

• reduce frequency by bringing it into people’s awareness
• behavioural experiments: compare to every 5th woman you pass (illustrating sample bias by comparing in a more systematic way)
• we tend to compare ourselves to the extremes: upward (attractive and thin) or downward (at least I don’t look like them)

Question 94

how to address ‘feeling fat’

Answer 94

• feelings fluctuate over time, but actual weight is more stable
• your actual weight isn’t the main contributor to feeling fat
• identify triggers (monitor) and address them
• psychoeducation
• “What else am I feeling right now?” fat is not a feeling, there’s an underlying emotion
• feeling fat can lead to dieting or binge eating or purging as a way to cope

Question 95

dietary restraint vs. restriction

Answer 95

• restraint: attempted under-eating and food rules (cognitive aspect; doesn’t mean that someone is successful, could have many lapses)
• restriction: actual under-eating (behavioural aspect; leads to weight loss or promotes binge eating), almost everyone will restrict at some point (this is a maintenance mechanism)

Question 96

how to address dietary restraint and restriction

Answer 96

• restricting: regular eating
• restraint: dealt with later in treatment, decrease avoidance of certain foods using systematic exposure (of fear foods, foods people binge eat, food rules)
• foods people binge become ‘forbidden’ until the person has lost control over their eating (they would be less appealing if they were integrated into regular eating)
• create a food hierarchy: gradual exposure to feared foods using systematic exposure (in-session or in a natural environment), incorporate other fears (eating at night, eating in public)
• goal: decrease patient fear of loss of control, modify distorted assumptions
• plan ahead: identify food, when, where, etc.

Question 97

how to address residual binge eating

Answer 97

• regular eating should stop most binge eating (and subsequent compensatory behaviours)
• may not work for everyone, there may be lapses or residual
• residual binge eating may arise from: breaking a dietary rule, being disinhibited (drinking alcohol), under-eating (not adhering to the plan), adverse event or mood (relief from negative affect)
• binge analysis: identifying triggers that lead to residual binge eating

Question 98

evidence for CBT-E

Answer 98

• meta-analysis of 7 trials (3 with BN sample, 4 with transdiagnostic) = CBT-E performed better than IPT, psychoanalytic, no treatment, CBT-E equivalent to integrative cognitive affective therapy (broad (enhanced version) and focused (targeting only ED) were equivalent)
• remission rates were very variable (22-67%) due to differences in sample and variability in operationalization of clinically significant change
• Tatham et al. CBT-T

Question 99

Tatham et al.

Answer 99

• cohort comparison (not random) between patients treated with CBT-E vs. CBT-T (for non-underweight, non-severe patients)
• CBT-T shorter (10 sessions instead of 20), more scalable
• differences in treatment: focus on early parts of treatment protocol (more behavioural than cognitive components), delivered by assistant psychologists (BA degree), more exposure exercises (mirror exposure, coming from recent research that anxiety is an important component)
• change in ED symptoms and clinical impairment was similar in CBT-E and CBT-T (large decreases during Tx with gains maintained at 6-month follow-up)
• limitation: lack of random assignment, screened out for severity
• implications: cost efficiency, saving time = less waitlists (saving intensive Tx for those who are more severe), especially important because Tx for EDs is most effective if done early

Question 100

main components of BA

Answer 100

1. psychoeducation: explaining the rationale, present the treatment model (maintenance cycle)
2. daily activity monitoring form: socialize the client with what the Tx will entail AND gather information to guide Tx
3. look for contingencies maintaining behaviour (pleasure and mastery ratings-activities)
4. use activity monitoring to design intervention (adding activities back into routine, fake it till you make it)
5. work with clients to schedule activities
6. ACTION
7. help client engagement strategies (ruminating, worrying, cognitive interference)