Lecture - CBT Flashcards
What are the modalities of psychotherapies?
The ‘other’ group have a good evidence base but are rarely used in the NHS.
How did behaviour therapy develop? What is the main theory backing it?
Started with behavioural therapy
1950s/60s – Wolpe/Eysenck/Skinner
Arose as reaction against dominant Freudian psychodynamic psychotherapy – ‘not empirical’
Learning Theory: how individuals learn associations between STIMULI and RESPONSES. BASED ON THE IDEA THAT MALADAPTIVE BEHAVIOUR IS LEARNED, THEREFORE ADAPTIVE BEHAVIOUR CAN ALSO BE LEARNED
What is the difference between operant and classical conditioning?
Operant Conditioning - rewards “behaviour modified by consequence” eg social skills training (learning difficulties) e.g star for good behaviour
Classical Conditioning – stimulus/response “behaviour modified by antecedent” e.g. Pavlov’s dog, ringing bell caused salivation before dogs even saw the food
What is reciprocal inhibition conditioning?
Train the patient to use relaxation so that they become really good at it
“anxiety inhibited by a feeling or response not compatible with the feeling of anxiety” i.e. using relaxation techniques
Led to:
- Systematic Desensitisation (Wolpe)
- overcoming fear gradually (hierarchy)
- & pairing with relaxation (phobias)
What does this show?
With each exposure the anxiety gets lower. Basis of CBT
What does escape/avoidance cause?
It causes a rapid decrease in the fear but the person will never learn to reduce anxiety in the long term so it is quite damaging
What kinds of exposure therapies are used in CBT?
- Hierarchies
- Gradual exposure
- Habituation
- Extinction
- Safety behaviours -Salkovskis (‘91) - this is what you are trying to avoid the person from doing
What is behaviour therapy useful and not useful for?
Underlying principle - what we do has a powerful influence on our thoughts and emotions
BUT although successful with simple phobias and OCD, pure behaviour therapy had very limited success with other anxiety disorders and depression
How did cognitive therapy develop?
Aaron Beck – 1960s:
Cognitive Therapy Psychoanalyst researching depressed patients - discovered stream of parallel thinking spontaneous, fleeting negative ‘automatic thoughts’
(NAT’s) - negative cognitive triad (!)
What is the Beck’s negative cognitive triad?
Negative views of
- World
- Self
- Future
What was the precursor of CBT? What acronym was used?
ABC of CBT
- A - activating event
- B - thoughts, attitudes, asumptions
- C - behaviour or emotion, cosequences
NB: ABC meaning (antecedent)(behaviour)(consequence) is different
What is the basis of this kind of response?
Negative automatic thought
Transference affects this
How is formulation done (cognitive model)?
Explore:
- Origin
- Current status
- Maintenace
Done in collaboration
Different types of formulation e.g. cross-sectional, longitudinal
Describe this longitudinal formulation.
Failure can lead to the bottom cycle which can lead to depression.
Give an example of the cross-sectional formulation.
This may be useful if you are trying to figure out if CBT would be useful for the patient.
What is the structure of a CBT session?
- Set final goals
- Agenda
- Pprogress and homework from previous session
- Specific CBT interventions (thought records, behavioural experiments, eliciting core beliefs)
- Homework
What would the formulation be for this patient? (next card)
What initial behavioural component can be used in CBT? Why might this be difficult?
Difficult already to do things for a person with depression.
Can be made easier if you tell the person to fill in what they do when they have their breaks.
Can be useful as helps them see patterns which are useful and which you can increase.
Why is the activity schedule successful?
- Links mood and activities/lack of activity + –> what changes in behaviour might improve mood?
- Build in activities that bring sense of pleasure and achievement
A - achievement; P - pleasure
- Stopped doing enjoyable activities
- Avoiding family and friends
- Isolating self in bedroom
- Using more alcohol to cope
Goal:
- Restart pleasurable activities eg reading, gardening
- Decrease avoidance of family and friends eg stay up with family until 10.00 p.m.
- Gradually reduce symptomatic use of alcohol
What is used to target negative automatic thoughts (NATs) in CBT?
A thought record is used which is a table as shown below.
- Identify situations that lead you to feel worse
- Where you were, what was happening.
- Describe the emotion and rate from 0-10.
- What was going through your mind at the time (words / images)
What do we do with the thought record?
- Identify the cognitive distortions
- Challenge
- ‘Chain down’to deeper levels
You look at their thoughts and ask them if it fits with any of the cognitive distorsions below.
Cognitive distorsions
Cognitive distortions allow events to fit in with underlying assumptions and beliefs
Assumption - ‘In order to be happy I must be liked by everybody’
Cognitive error - ‘mind reading’
How do you challenge distorsions?
- Tools/techniques - behavioural experiments/ thought records
- Guided discovery - socratic questioning
What is the evidence?
What alternative views are there?
What is the effect of thinking the way I do?
It’s not about ‘positive thinking’ but more FLEXIBLE BALANCED thinking
Is CBT about positive thinking?
It’s not about ‘positive thinking’ but more FLEXIBLE BALANCED thinking
COMMON ‘IRRATIONAL’ ASSUMPTIONS
- In order to be worthy, I must always be successful
- ‘If I make a mistake then I’m inept’.
- ‘If anybody disagrees with me, it means he/she doesn’t like me’.
- ‘My value as a person totally depends on what others think of me.’
- Developing a therapeutic relationship
- Empathic and collaborative
- Socratic questioning
- Time-limited
- Agenda-setting / goals
- Formulation
- Homework
- Relapse prevention
What is the efficacy of CBT?
- Highly effective Rx superior to both relaxation and antidepressant groups ( Clark ’94)
- 80 – 90 % became panic free (v 25 & 40%)
- Gains monitored at F/U
- One year – 5 v 40% relapse
What are the NICE guidelines for depression?
Moderate to severe - CBT or IPT + antidepressants
Mild to moderate - CBT/ IPT /Behavioural Activation /Behavioral couples therapy/ Counselling for depression/ Short term psychodynamic th
What are the NICE guidelines for depression?
CBT for all anxiety disorders
Additionally:
- Social Anx Disorder - CBT / Short term p’dynamic
- PTSD - CBT / EMDR
PTSD - ‘reliving’ trauma EMDR (Francine Shapiro)
OCD - CBT incorporates Exposure and Response Prevention (ERP)
Bulimia Nervosa – CBT /IPT
Anorexia Nervosa – In patient weight gain prog. CBT/ IPT/ CAT
Borderline – Schema focussed CBT, DBT (Marsha Linehan), Mentalization (Fonagy)
Anti-social - Group based CBT
Schizophrenia - NICE guidance is CBT and family therapy
What is the goal of third-wave CBT?
Target the process of thoughts (rather than their content)
What are the other types of CBT?
Mindfulness Based CBT (MBCT): 3+ episodes of depression; reduces further relapse (Nice Guidelines)
Dialectical Behaviour Therapy (DBT)
Acceptance and Commitment Therapy (ACT)
Can CBT be used in physical illness?
- Comorbid psychiatric disorder
- Adherence to treatment
- Problems related to illness behaviours
Health Psychology
Which aspect of physical illness is CBT useful in?
Treatment adherence which is low in physical illness
- WHO -only approx. 50% of patients with chronic diseases adhere to treatment recommendations
- CBT intervenes at the level of beliefs that are influencing adherence behaviours
- Medication adherence in stroke patients (IAMSS trial, Stirling) -2 session intervention increases antihypertensive adherence
What is the future of CBT?
Refining CBT - Which elements work best for which disorder in which people?
Neuroscience and CBT - neurobiological changes occur after CBT
Technology
- Self-help: computerised CBT / Apps
- Within therapy
Virtual Reality CBT
Avatar therapy to confront auditory hallucinations in schizophrenia (Leff et al, UCL – pilot study 2013, promising results, clinical trial ongoing)
Computer avatars are designed by patients to give a form to the voices they hear and then the avatars are controlled by therapists to encourage patients to oppose the voices so that the voices gradually come under the patient’s control.
New Scientist Avatar Therapy Videohttps://www.youtube.com/watch?v=aYfG53fgwXc
‘in virtuo’ exposure instead of ‘in vivo’ RCT -virtuo exposure superior to in vivo exposure in social anxiety (6 month follow-up) Bouchard et al, BJPsych 2017 ‘in virtuo’ exposure video https://www.youtube.com/watch?v=2GeW45OytuA
