Approaches to Treatment- Cognitive-Behavioural

Question 1

What is the Cognitive Behavioural Approach?

Answer 1

The pioneer of this approach described it as:
“An active, directive, time-limited, structured approach.” (Beck et al., 1979)

All our responses are a result of a complex interplay of actions and reactions

It is the loops of cause and effect within ourselves that are of special interest

Is often referred to as Cognitive Behaviour Therapy (CBT)
CBT is both a specific treatment approach AND an umbrella term that covers multiple different types of cognitive behavioural treatments such as Acceptance Commitment Therapy.

Question 2

Loops of cause and effect

Answer 2

Interactions with the outside world (external environment) cause multiple reactions and interactions within your internal environment

Our internal reactions then inform our behaviour and potentially, future actions/reactions.

The meaning we attach to events varies, both in terms of variation in response between individuals, but also within ourselves

Beck proposed that we create schemas based on our experiences and reactions to help simplify and organise the world – these schemas can be positive or negative and can be about the self, the world or the future

A response to a single event is of minor consequence, issues can arise when there becomes a pattern. i.e., where various events/interactions are attached with the same meaning

Having categories (schemas) and a set of beliefs/attitudes that we regularly refer to can be very helpful and in most circumstances is “normal”. Sometimes however the categories/attitudes become problematic

Question 3

The Hot Cross Bun model

Answer 3

Behaviour is reciprocally determined by both the environment and the individual- Behaviour, thoughts, emotions and physical sensations.

Question 4

Cognitive Summary

Answer 4

Cognitive behavioural approaches to treatment of psychopathology come into play when recognising patterns of distorted thinking and dysfunctional behaviour

Cognitive behavioural approaches will then adopt a systematic discursive (talking) approach to help people evaluate and modify their thoughts, behaviours and emotional responses to make them adaptive rather than maladaptive.

The aim of cognitive behavioural approaches therefore is successful cognitive restructuring.

CBA focuses on four internal aspects: Thoughts, Behaviour, Emotions and Physical Sensations.

Does require the individual to be able to engage with the process of adaption – underlying assumption of individuals as “active agents” in the process.

Question 5

Vicious Circle

Answer 5

Originally referred to as the exacerbation cycle (Beck, 1976)

A person creates self-fulfilling prophecies that then maintain the distorted thinking and dysfunctional behaviour

Identifying and breaking unhelpful circles for individuals is part of the cognitive behavioural treatment

Question 6

Automatic Thoughts

Answer 6

Many of the thoughts we have are not conscious e.g., once you have burnt yourself on a kitchen hob your cognitions “know” it is hot, you don’t need to consciously draw on that thought every time you go to cook in order to not get burnt…..it becomes “automatic”

Automatic thoughts can combine with the schemas we develop, and all of us, to some degree or another, can develop cognitive biases.

Beck proposed several cognitive biases in his Theory of Depression

There are multiple cognitive biases in practice and they can affect all areas of decision-making behaviour – so not all cognitive biases are relevant to psychopathology!

Question 7

Cognitive biases relevant to CBT

Answer 7

All or nothing thinking

Catastrophising

Disqualifying or discounting positive aspects

Emotional reasoning

Labelling

Magnification/minimisation

Selective abstraction

Mind-reading

Overgeneralisation

Personalisation

“Should” or “Must ” behaviour statements
Tunnel-vision

Question 8

The clinical interview

Answer 8

The clinical interview in a CBA context is a “focused conversation”. It is the way that a psychologist will abstract information in order to help them diagnose and plan treatment for the individual client.

The distinction between client and health professional is maintained throughout the process i.e., important to maintain a clear and professional therapist/client relationship

With cognitive behavioural approaches, because it is focused towards determining and achieving specific goals – moving from maladaptive behaviours/cognitions towards adaptive behaviours/cognitions – this can influence the style and content of cognitive behavioural clinical interviews

Question 9

Cognitive Behavioural Clinical Interviews

Answer 9

Note taking; 
Psycho-education; 
Formulation and contract-setting;
Agenda setting; 
Directing Conversation; 
Intrusive Questioning; 
Socratic Questioning; 
Record keeping 
Homework Assignments

Question 10

Assessment

Answer 10

Assessment is the first part of the aim to “diagnose and plan treatment”

Remember CBA has the central premise that our reactions to events are determined by the complex interplay of thoughts, emotions, behaviour and physical sensation

Different patterns of interactions between these four elements can lead to different responses to an event and ultimately determine with the response is helpful or unhelpful to the individual

A clinical assessment by a health care professional is aiming to assess the patients experience of problems, problems influencing occurrence, coping strategies and repercussions

Aim of a cognitive behavioural assessment is to develop a shared understanding of the problem(s) – considering the specific interactions of the four elements that relate to that problem

Question 11

How is assessment done?

Answer 11

Detailed and specific questioning around the problem i.e., Socrates questioning

First real point to introduce the CBA to the patient

May be the first time the patient has thought about the problem in relation to the thoughts, emotions behaviours and physical sensations associated with it

Three core questions guide all assessments:
What is the problem that person would like help with?
What are the situations, thoughts, emotions, behaviours and physical sensations associated with the problem?
What are the immediate and longer-term consequences of the problem?

Question 12

Assessment tools

Answer 12

Often used to supplement the info collected during the conversation, patients may be asked to complete questionnaires, diaries or record forms

Tools can determine presence and severity of various symptoms e.g., pain, fatigue, anxiety etc BUT their value in this context is in measuring change over time NOT acting as a diagnostic tool.

Although primary assessment occurs in the first session, the assessment process carries on throughout treatment – new insights, new information, patient experiences will lead to a need to revisit and revise the assessment

Question 13

Formulation

Answer 13

Now we have our cognitive behavioural assessment we need to come up with a formulation of the problem that will indicate the most appropriate initial target for intervention.

The term formulation refers to an understanding of the patients identified problem and of factors that have contributed to, and/or are maintaining, the problem.

With CBA you achieve this understanding whilst working through the assessment – it is a collaborative method and the formulation needs to make sense to both patient and healthcare professional and belongs to both

A formulation describes a very specific sequence of thoughts, emotions, physical sensations and behaviours that follow a triggering event and lead to a particular event*

Two common types of formulation diagrams are the vicious cycle and the downward spiral

The vicious cycle as referred to earlier representing how the interaction of factors loops back to perpetuate and reinforce the problem

The downward spiral formulation illustrating more of a domino effect – i.e. one thing leads to another

Question 14

Goal Setting/bringing about change

Answer 14

Once you have decided what, and where, to target within the formulation you then start to come up with an intervention plan to bring about change. A key part of this is to set specific goals for the individual.

Developing a shift of emphasis towards the possibility of change may be a surprise, and a challenge for individuals.

The focus becomes on looking at the common threads identified within the problem and considering how to change them so that the outcomes also change

Need to identify what the individual wants to achieve – what is hoped for and what is possible.

Question 15

The characteristics of suitable goals

Answer 15

The goal addresses problems relevant to the individuals’ reasons for seeking help

The goal is relevant to your professional role with the individual and is within your competencies

The goal can be worked on frequently enough

The nature of this goal is within the scope of what the individual can influence and change

Achieving this goal will bring benefits that the individual desires

The goal will be achieved at acceptable personal cost and risk

The goal is a SMART goal

Question 16

Measuring change

Answer 16

Number of different ways to measure change and in practice it is likely that you would use multiple different ways

Can measure change using different criteria – no of symptoms, strength/severity of occurrences

Predominantly self-report but can have some more objective measures
Medication use, hospitalisation events
Questionnaires and rating scales, e.g., Distress Thermometer, BDI, HADS
Diaries and record forms
Behaviour change e.g., reduction in alcohol/drug use, increased activity, return to work

Question 17

Summary

Answer 17

Cognitive behavioural approaches to treatment are active, structured treatments that focus on how interactions with the outside world create multiple reactions/interactions with our internal world

How we apply meaning, and the schemas we create, in response to events influence our future behaviour and cognitions.

Behaviour, Physical Sensation, Thoughts and Emotions are the four internal aspects central to cognitive behaviour treatments.

Question 18

Do Cognitive Behavioural Treatment approaches work?

Answer 18

When trying to weigh up the evidence for the efficacy of any treatment approach it is important to remain critical and consider methodological weaknesses

When reviewing an individual study there are some key questions to consider
Is a manualised or individual approach evident?
Is this a clinical population? Is there a comparative group
Where in the individual’s condition/treatment is the intervention occurring
What is the follow up period
How is change being measured?

If trying to determine whether a cognitive behavioural approach is effective for the situation/condition you are focused upon, if you can, use a meta-analysis as your initial source of research evidence.

A meta-analysis is a statistical analysis undertaken as part of a systematic review of multiple research studies that look at the same research question. This analysis creates a weighted average from the results of the
individual studies and therefore increases the statistical power and you end up with a clearer estimate of actual effects.

Question 19

What the evidence indicates:

Answer 19

In 2001 the Dept. of Health & National Institute for Clinical Excellence (NICE) commissioned a review of psychological therapy treatments.

The meta-review concluded that cognitive behavioural treatment is effective with depression, panic disorder, social phobia, obsessive compulsive disorder, bulimia and generalised anxiety disorder.

A lot of other evidence out there that looks at the efficacy in relation to specific illness/health conditions e.g., Chronic Pain, Cancer. In practice there is significant overlap between physical and mental health and seeing them as separate is problematic