CBT

Question 1

the history of CBT was developed as an integration of what two therapeutic modalities?

Answer 1

> behaviour therapy (BT), 1st wave CBT
cognitive therapy (CT), 2nd wave CBt

Question 2

name 3 differences between Behavior therapy and cognitive therapy

Answer 2

BT:
>developed in 1950s and 1960s to mainly address anxiety difficulties
>systematic desensitization also used (gradual exposure to feared or avoided stimuli, joseph Wolfe)
>later incorporated techniques such as relaxation training and social skills training

CT:
>arose due to increasing recognition within BT that behaviour needs to be understood within context of thoughts and emotions
>becks approach later applied to a range of other diffculties
>BT became increasingly incorporated into CT, with CBT emerging as an integration of the two

Question 4

what does ANTs stand for

Answer 4

automatic negative thoughts

Question 5

what is the relationship between 2nd wave CBT and ANTs

Answer 5

> 2nd wave CBT focuses on working
collaboratively with the client to identify
and modify automatic negative
thoughts (ANTs).
CBT therapists argue that it’s not
always the situation itself, but the
unhelpful or inaccurate THOUGHTS
we have about the situation, that create distressing feelings.
Thoughts mediate the relationships between situations, moods, and behavior. This means when something doesn’t go our way, it’s the way we think about the situation that determines whether
it’s a permanent setback or just a challenge to be solved.it’s thus assumed that correcting distorted cognitions will create improvement in mood and behaviour.
Focus is thus on symptom reduction (although improved functioning is also a long-term goal) (Gaudiano, 2017).
We are constantly assigning meaning to our experiences, but often this happens implicitly or automatically.
Negative automatic thoughts are usually linked to specific triggers. People may have their own particular triggers.
ANTs arise spontaneously in the moment, without us reflecting or weighing things up; we don’t give them the same consideration as other thoughts, because we just assume them to be true. We don’t consciously control them and often aren’t consciously aware of them – just of how they
make us feel (often intense negative emotions like anxiety, shame, anger, guilt, despair).
So…when you notice a strong negative feeling, pay attention to what thoughts come to mind in that situation

Question 6

give 3 examples of ANTs

Answer 6

● I’m useless
● I always mess things up
● Nobody likes me

Question 7

provide a definition of ANTs

Answer 7

they are cognitive reflexes linked to core beliefs we hold about ourselves.
Beliefs like:
● I have to be perfect otherwise I’m worthless
● I mustn’t be too needy/demanding
● I’m not good enough
These are “rules for living” we develop in childhood and carry with us. Often we are not cognitively conscious of these core beliefs but with the help of a cognitive
therapist we can work backwards from our automatic thoughts to identify these core beliefs

Question 8

provide 5 common cognitive distortions that characterize ANTs. for each one provide a brief example/ explanation

Answer 8

1. All or nothing thinking
   -you see things in black and white categories
2. overgeneralization
   -you make broad conclusions that a single negative event represents pattern defeat, using words such as “always” and “never”
3. mental filter
   -you pick out a single negative detail and dwell on it
4. disqualifying the positive
   -u reject positive experiences by insisting they don’t count for some reason or the other
5. jumping to conclusions
   -you make negative interpretations even though there are no facts to support Ur conclusions

Question 9

what are the roots of ANTs and core beliefs

Answer 9

They don’t occur randomly: rather, they’re based on early experiences and lessons from relationships with people around us. We develop ways of making sense of the world through these experiences

Question 10

in the following example, identify the ANTs

Example 1: David had grown up in a household where his parents were very critical and placed great emphasis on academic achievement. His brother did well academically but David always struggled to meet his parent’s high standards. He has developed the core belief “I’m useless” and the (protective) assumption “As long as I achieve, I’ll be loved”.

Answer 10

“I’m a complete failure”, characterized by the ‘all or nothing thinking’ error

Question 11

what is the difference between CBT and psychodynamic therpay

Answer 11

-CBT recognises an unconscious realm that is completely unknown to the client, but does not focus on it.
-It does focus on core beliefs about self and others that often underlie our automatic thoughts.
-These are often not immediately in our conscious awareness but we can become aware of them when asked (they are not completely repressed, but they are just below the surface of conscious awareness).
- Core beliefs are things we just assume to be true, we never really stop to consciously
look at them.
-CBT recognizes the importance of early history in setting up core beliefs (similar to
psychodynamic). But the focus is on how our thoughts and behaviors that derive from these core beliefs are maintaining current difficulties - and how to shift this (e.g. by changing our ways of thinking about these situations/relationships or changing our habitual ways of responding).
- Focus is more on symptom reduction (although improved functioning is also a long-term goal) (Gaudiano, 2017).

Question 12

how does 2nd wave CBT work?

Answer 12

-CBT is based on the principle of meta-cognition (thinking about our thinking): developing an awareness and understanding of our ways of thinking; tracking and identifying our ANTs and
cognitive distortions.
-Meta-cognition can help us to take a step back, review the basis for the conclusions that we habitually, automatically draw, and explore alternative meanings/conclusions that may be more helpful.

Question 13

explain the cognitive triangle

Answer 13

-One of the ways to develop our meta-cognition is to keep the concept of the cognitive triangle in mind: our thoughts, feelings and behaviours are constantly influencing each other.
-We can understand our reactions better by understanding how this process of influence takes place.
-Each component influences each other. They’re all interlinked.This means that changing thoughts, behaviour or feelings may result in changes in the other
components.
-But changing our feelings can be a long and difficult process. So CBT focuses on shifting thoughts and/or behaviours (as they’re easier to change), which in turn can improve the way we feel in a relatively brief time.

Question 14

what are thought records

Answer 14

-Another way to develop metacognition is to keep what is called a ‘thought record’.
-Requires us to stop and reflect on what was happening in a particular moment in which you were activated.
-A thought record may help one:
>understand what your trigger situations are and how they make you think, feel and do.
> pick up habitual thought patterns that we fall into.
>identify cognitive distortions and core beliefs.
>understand why you thought, felt or behaved the way you did.

Question 15

explain what shift thinking in CBT is

Answer 15

-Once the person has been able to identify their ANTs, core beliefs and common responses, they can work with the therapist to start putting in place a new way of responding.
-This is usually done by trying to shift the way they think in situations.
-In CBT therapy, the therapist and client will work collaboratively to challenge the power of ANTs by finding more balanced, realistic and helpful ways of thinking.
- Note this does not automatically imply ‘positive thinking’, which may not be realistic

Question 16

name 3 techniques to shift thinking in CBT

Answer 16

-Responsibility pie - re-allocating responsibility for things in a more realistic way. Clients often carry an unnecessarily high sense of responsibility that’s causing distress.
● Best friend role play - what would I tell a friend who was struggling with this?
● Lists and definitions - how realistic are the labels I have put on myself e.g. ‘worthless’ ?
What does it mean for someone to have worth?
● Weighing up the evidence e.g. what evidence is there for an ANT like “I can’t cope with anything”? What evidence is that ANT ignoring?

Question 17

what is 3rd wave/ contemporary CBT

Answer 17

> Over the last 10-15 years, CBT has developed substantially.
The narrow focus on changing thinking has broadened into a wide range of techniques.
- 3rd wave CBT either minimises or excludes the focus on cognitive distortion correction,
relying on more indirect methods of addressing distorted cognitions (if doings so at all) (Gaudiano, 2017).
Contemporary CBT = A family of related interventions with similar components; A number of common components, but delivered in varied ways.

Question 18

name two examples of contemporary CBT approaches

Answer 18

1. Diagnosis-specific approaches-Behavioural activation therapy for depression
   2.Transdiagnostic approaches-problem solving therapy

Question 18

name and explain 5 shared components of 3RD Wave CBT

Answer 18

1: Being time limited: usually between 8 to 12 sessions long. Thus more cost effective.
Psychodynamic therapy operates on a much more long term model.
2: Goal-oriented and focused on current problems. Clear treatment goals are set, based on the client’s priorities. Psychodynamic more interested in excavating the client’s past and looking at
how it influences their present. CBT does recognise that our early history influences our core beliefs and patterns, but doesn’t focus on it.
3: Emphasis on collaboration and active participation. Therapist and client work actively as a team to set treatment goals, role-playing and practising new skills etc.
4: Emphasis on values and life goals rather than just ‘fixing faulty thinking.’
5: Focused on skills development to empower client:
- Coping skills (cognitive coping, emotion regulation)
- Problem solving skills (addressing most important life problems in a systematic way; can
include a focus on economic and livelihood solutions)
- Relational skills (to address interpersonal difficulties and enhance social supports)
- Mindfulness skills (accepting and non-judgemental awareness of the present moment)
Behavioural techniques from 1st wave are still used to address unhelpful avoidant behaviours and to encourage behaviours that are consistent with client’s goals and values.

Question 19

name and explain 4 examples of diagnosis-specific approaches

Answer 19

> Behavioural activation therapy (BA) for depression – focus is on replacing negative or avoidant behaviours with new rewarding behaviours (linked to valued goals) that are self-reinforcing. E.g.self-care, exercise.
Trauma-focused CBT (TF-CBT) - aims to process traumatic memories, and the feelings and beliefs that accompany them, in more helpful ways.
Motivational interviewing (MI) for substance abuse – focus is on exploring client’s ambivalence about changing their behaviour and strengthening their motivation for, and commitment to,
change in accordance with the person’s values and beliefs.
Dialectical behaviour therapy (DBT) for borderline personality and complex trauma – focus is ondeveloping better emotion regulation and interpersonal skills

Question 20

name and explain two examples of transdiagnostic approaches

Answer 20

> Acceptance and commitment therapy (ACT) - focus is on developing psychological flexibility and identifying personal values that can guide behaviour. Accepting but not being consumed or overwhelmed by negative thoughts and feelings. Focusing on the present rather than thinking
about things that might happen.
Problem solving therapy (PST) – focus is on identifying most important current problems that can be addressed, and then generating, evaluating and implementing solutions.
Recognises that sometimes you can’t change the situation you’re in, but can change the way you respond to or choose to approach it.Used particularly often in LMICs.

Question 21

discuss how effective CBT is

Answer 21

> In HICs, CBT approaches have the largest RCT evidence base of all psychotherapies, largely due to being easy to package into standardised manuals (it’s short and everyone gets the same components of treatment).
Hasn’t been researched much in LMICs until the last few years.
Most research looks at anxiety and depression (also the most common disorders).
For anxiety disorders: CBT found to be consistently more effective than passive control conditions (no intervention, or on a waiting list) and often more effective than active control conditions.
Has more sustainable treatment gains in the longer term than medication, and increases treatment gains when used to supplement/augment medication.
Results for depression are more mixed – CBT is always better than no intervention but not always more effective than other therapies or medication.
In some studies CBT with medication is better than CBT alone for depression, and CBT is better than meds at preventing relapse in the long-term.
Overall, treatment gains for depression and anxiety are maintained at 6 and 12 month followups.
CBT can be effective in group and individual formats (group formats of course more costeffective). May thus be suitable for scaling-up within mental health system

Question 22

what are the critiques of CBT

Answer 22

> Focuses on addressing symptoms / problems, not causes of problems?
Focuses on individual change, not changing the structural causes of mental health difficulties?
- Although this is also true of other therapies and medical treatments that work at an individual level.
Too many techniques, not enough empathic listening/therapeutic alliance?
“Opponents have frequently argued that the approach is too mechanistic and fails to address the concerns of the ‘‘whole’’ patient” (Gaudiano, 2017)

Question 23

What is the global mental health movement

Answer 23

> Inspired by Treatment Action Campaign in SA which promotes access to HIV treatment as a fundamental human right, and denial of treatment as a violation.
Argues that mental illness exists across cultures (it’s not just a ‘western’ construct) and creates a substantial burden of disease globally.
Prioritises mental health as a key component of health care under the slogan ‘No health without mental health’.
Mental health is an integral part of health care.
Aims to close the mental health treatment gap in LMICs (based on TAC’s idea of it as a human rights issue primarily).
In LMICS, they see a need to supplement existing indigenous healing systems with brief, evidence-supported, cost-effective mental health interventions (ideally through task shifting to increase access).
- Not saying that they should replace local systems, but that they’re inadequate on their own.
- Remember: treatment gap in SA is 75%. Gap is much higher in some other African
countries, reaching 90%.
The GMHM and CBT have become rather synonymous over the last few years. CBT is there recommended approach.
CBT-based interventions (including task-shifting interventions) have been found to be effective for treating common mental illnesses in a range of LMICs and are therefore strongly promoted by the GMHM.
Easy to scale-up due to brevity and being based on manuals.
Also acknowledge the need for cultural adaptation, achieved through:
- Community-based participatory research to identify treatment needs and goals.
- Identifying the treatments that may meet these needs. Consulting local stakeholders,
clinic staff and patients, community leaders etc to help decide which will be most suitable.
- Once selected, the main ingredients of the treatment ‘recipe’ stay the same, but with
culturally appropriate examples, terminology, and practice exercises. Local stakeholders will guide and inform this process.
- Length of sessions may be extended to allow for fewer sessions overall, due to resource constraints

Question 24

how does CBT look within SA and AFrica

Answer 24

> Several randomised controlled trials (RCTs) have found CBT approaches to be highly effective in reducing depression, anxiety and substance use (CMHDs) in SA and in other African countries.
Used within a task- shifting/sharing approach in primary health care (via nurses) or community based settings (via CMHWs; community mental health workers).
“several components of TF-CBT itself, and CBT more generally, naturally lend themselves to cultural responsiveness.” (Woods-Jaeger et al., 2017).

Question 25

provide some examples of how CBT has been applied to SA/Africa

Answer 25

●MI + PST for substance abuse in South Africa (Sorsdahl et al., 2015). MI is usually used by itself in HICs, but the researchers found that it would be inadequate in SA where life stress was high. Thus included a problem solving module. Compressed into 5 sessions. RCT showed combined therapy to be more effective.
● Friendship Bench: CMHW-delivered PST to adults with common mental illnesses in
Zimbabwe (Chibanda et al., 2016).
● Group-based cognitive coping + PST + income generating skills for depression at
primary health care clinics in Uganda (Nakimuli-Mpungu et al. 2015). Thus targeting one of the causes of depression (poverty), not just the symptoms.
● CMHW-delivered group CBT for depression at primary health care clinics in South Africa (Petersen et al., 2014).
● Trauma-focused CBT delivered by social workers to sexually abused girls in DRC
(O’Callaghan et al., 2013).
● Trauma-focused CBT delivered by CMHWs to children in Zambia (Murray et al., 2015)
and Tanzania (Woods-Jaeger et al., 2017).

Question 26

what are some key points on the debate about whether such interventions could be labelled cultural imperialism (the
new ‘scramble for Africa’), or helping to equalise mental health care

Answer 26

-Might marginalise or exclude local healing systems. Researchers “racing” to conduct
CBT studies in Africa and have their interventions adopted.
- But could be an effective way of closing the treatment gap and helping people in need.

Question 27

explain how culture should be taken into account when applying CBT to countries like SA

Answer 27

> Need to take multiple factors into account, such as poverty and HIV
- “Social determinants of health, in particular the unmet social and economic needs of participants, were noted by counselors as challenging to the delivery of TF-CBT in a manner responsive to participants’ context” (Woods-Faeger et al., 2017).
Also need to respect cultural norms: “the specific cultural expectations for how to behave in a given situation” (Andersen & Taylor, 2012, p.33).
- E.g. not expressing certain feelings, talking about death, or talking ill of the deceased.
Must show cultural humility: “The seminal definition of cultural humility provided by Tervalon and Murray-Garcia (1998), “commitment and active engagement in a lifelong learning process that
individuals enter into on an ongoing basis with patients, communities, colleagues, and themselves”.”
- “respecting the guardians’ expertise and highlighting these skills as different and
effective rather than right, or the only option, which may imply that what the
parent/guardian was already doing was wrong” (Woods-Faeger et al., 2017).
May also need to address the distress experienced by lay counselors themselves as it may serve as a barrier to task-sharing approaches.