Fundamentals of CBT Flashcards
What is CBT?
It is the dominant model used. It is a talking therapy (individual or group). It is time limited, very structured compared to psychodynamic approaches. Deals with the here and now (‘what brought you here today), short time-frame on treatment because of good evidence of this (12-16 sessions). Brief (50-60 minutes sessions). Collaborative – clinician explains the person is an expert in themselves, and they therefore have to work together to find a solution for their problems. Skill people to become their own best therapist. Problem orientated – you are thinking about dealing with a specific problem, dealing with the here and now. Touch on the past but don’t dwell on what happened in the past that led to the difficulties. Used to treat a range of mental health difficulties.
Why use CBT?
NICE recommends CBT be used as a first line of treatment for GAD, OCD, panic disorder, social phobia, specific phobias, PTSD, depression, and psychosis. Larger number of treatments in IAPT from 2016-2017 (178,769). Interpersonal psychotherapy offered for people with more complex and long standing difficulties.
What are core principles of CBT?
The way we think effects our affect, physiology and behaviour. The meaning you attach to an event influences your emotional response to that event. Different people attach different meanings to the same event.
Four systems that all affect each other - our cognitions (our thoughts/beliefs), our affect (our emotional distress), our physiology (our bodily states) and our behaviour (what we do).
How is panic disorder defined in the DSM 5?
Panic attack - Period of intense fear or discomfort, in which four or more symptoms developed abruptly and reached a peak within 10 minute. Big evidence to suggest that CBT for panic disorder is very effective
PANIC DISORDER
1. Recurrent and unexpected panic attacks – come out of the blue, very little explanation for them
2. ≥1 attack has been followed by 1 month or more of 1 or more of:
¥ Persistent concern about additional attacks.
¥ Worry about the implications of the attack or its consequences – wondering whether you have something physically or psychologically wrong with you
¥ A significant change in behaviour related to the attacks – e.g. avoidance of certain places or avoiding going outside.
What is the cognitive model of panic disorder?
Clarke (1986), what CBT is based on today. Key notion - we experience a panic attack when we interpret normal bodily sensations as being dangerous also called - catastrophic misinterpretation. It is the meaning that we attribute to the bodily sensations that makes them seem important, but it is actually a misinterpretation.
What is the panic formulation?
(Have a look on formulation sheet for visual). The panic formulation - proposes people with panic disorder have a trigger (e.g. noticing a heart beat, memory of previous panic attack etc.), this causes an emotional response, which serves to heighten awareness of physiological sensations, and this can affect the interpretations of these physical sensation. Often the attention spotlight is focused too much on one thing e.g. physical sensations. Last bit of the model is thinking about behaviours – concept of safety behaviours (if someone is feeling particularly anxious and focusing on physical sensations, what can you do to make this better? These safety behaviours perpetuate the belief that something is wrong, and serve to keep anxiety alive).
What is treatment for panic disorder?
NICE recommends (depending on severity, complexity, and need)
Step 2 treatment mild to moderate panic disorder
¬ Facilitated or non-facilitated self-help
Step 3 treatment moderate to severe panic disorder
¬ CBT 7 – 14 hours, face-to-face therapy
¬ Or an antidepressant if the disorder is long-standing or the person has not benefitted from or has declined psychological intervention.
What are techniques used in CBT?
A key role of the CBT therapist is to help clients identify:
1. The thoughts that have a negative impact on the way we feel and behave
2. The behaviours that affect our thoughts and feelings
Key stages of CBT include:
1. Psychoeducation
2. Cognitive techniques
3. Behavioural techniques
4. Want to make sure people are prepared for the end of therapy and have a relapse prevention plan in place.
What is psychoeducation?
Giving information about symptoms helps to normalise people’s experiences, give people common symptoms. Aimed at correcting unhelpful beliefs. Sharing formulation diagram – in 1st/2nd session begin to draw out formulation that is meaningful to them, and help them to understand the experiences they are having. If run in groups, the sharing of symptoms can give people reassurance that they are not alone, and that there is treatment for what they are struggling with.
What are cognitive techniques?
¥ AIM of cognitive techniques – help to loosen conviction in the beliefs about physical sensations (for example) so that behavioural work can be done.
1. Elicit evidence for the belief
2. Examine that evidence
3. Elicit evidence against the belief
Feel like they need to do what they do because their belief of it is so strong, so its important to challenge the behaviour they are doing
¥ Theory A Theory B technique – used to contrast threat belief with alternative belief. Technique to look at evidence for and against the beliefs that they have, e.g. get them to look up evidence of a heart attack, and compare that to the symptoms that they’re having. If Theory A is true, what does life look like? (going to hospital, being worried, not the type of life you’d want to lead). Then look at Theory B – problem is that you worry, so evidence is that you’ve had panic attacks many times but never a heart attack, and if Theory B is true, what do you need to do? (So avoiding trigger places, stop safety behaviours). Loosing up strong convictions about what physical sensations mean.
What are behavioural techniques?
Bennett-Levy et al., 2004
Behavioral experiments are:
1. Planned experiential activities based on experimentation or observation
2. Their design is derived from a cognitive formulation of the problem
AIMS:
⎫ Test the validity of the patient’s existing beliefs about themselves, others, and the world
⎫ Construct and/or test new more adaptive beliefs
⎫ Contribute to the development and verification of the cognitive formulation
⎫ Get people to rate their belief
⎫ Have a behavioral experiment record sheet – write target cognitions, rate belief in cognitions, do an experiment, predict what will happen, report the outcome, write what they learned, and then rate strength of belief again.
What is the overall structure of CBT?
⎫ Time limited 12-16 weeks
⎫ Starts with formulation
⎫ Cognitive and behavioural work in the middle
⎫ Therapy blueprint at the end - used to reinforce therapy gains at the end of therapy and as a relapse-prevention technique
What is the session structure of CBT?
⎫ Starts with an agenda, set collaboratively
⎫ Assessment of mood
⎫ Discussion of homework - set-backs or learning points
⎫ Session topics for discussion
⎫ Planning of next homework
⎫ Feedback on how client has experienced the session
What is socratic questioning (used in CBT)?
¥ Socratic questioning is a method used in CBT which is part of the collaborative and empowering approach that CBT advocates. Helps build therapeutic alliance in CBT.
A ‘good’ Socratic question is one that:
1. Your client can work out an answer to
2. The answer reveals new perspectives
Helpful questions to aid Socratic enquiry (Greenberger and Padesky, 1995):
⎫ What is going through our mind, how much do you believe it
⎫ What supports/contradicts this?
⎫ How would someone else see this
⎫ What evidence is there to support this?
⎫ Can the problem situation be changed?
⎫ What can be done differently?
What did Beck suggest? (reading)
¥ Beck suggested that depression is the result of hostility turned inward toward the self. Tested the dreams of depressed people, found fewer themes of hostility – themes paralleled thinking when awake
¥ Found two streams of thinking – a free-association stream and quick, evaluative thoughts about themselves. Experience “automatic” negative thoughts
¥ CBT for depression – focus on helping patients solve problems, become behaviourally activated, and identify, evaluate, and respond to their depressed thinking about self, world, and future. Need to decrease avoidance and confront feared situations
¥ Session structure – introductory part (doing mood check, briefly reviewing the week, collaboratively setting an agenda for the session), a middle part (reviewing homework, discussing problems on the agenda, setting new homework, summarising), and a final part (eliciting feedback). Increases the likelihood they will be able to do self-therapy after termination
Decrease physiological arousal through guided discovery, using questioning (Socratic questioning) to evaluate their thinking. Do behavioural experiments to test their thinking. Engage in collaborative empiricism.
