Midterm 2 (Final) Flashcards
What are the core features of CBT?
- Structured (clear beginning (introduction) middle and end (wrap-up))
- Short-term (6-20 sessions)
- Present-oriented (focuses, at least initially, on the present moment as opposed to what happened in the past)
- Empirical (research based - from a nomothetic and idiographic perspective)
- Directed toward modifying dysfunctional thinking (main goal of CBT) -> consistent with Beck’s original conceptualization
- Treatment based on a cognitive case conceptualization/cognitive formulation which is individualized to the client (assessment is designed to gather info but also to create cognitive formulation that you’ll use to develop the treatment plan and will be modified as you get more info)
- Most of the techniques employed in CBT are designed to produce cognitive change (change in thinking, both at the level of daily automatic thoughts and more basic beliefs)
Describe the duration of CBT
- CBT tends to be short-term
- 6-20 sessions
- For very straightforward conditions -> 6-8 sessions can lead to symptom relief/improvement
- 20 sessions is the length of CBT for EDs which tend to be more complex
- There are a range of sessions lengths
- Depends on the presenting problem and the goals that the person has
- It’s possible that CBT can last up to a year depending if there’s some ingrained personality patterns that are getting in the way of the person making improvements
Describe how CBT can be empirical from both a nomothetic and idiographic perspective
- Nomothetic: it relies on research done on groups of participants to figure out for whom CBT works, for what conditions, what patient characteristics
- Idiographic: you’re collecting data on an ongoing basis to determine whether the treatment is being helpful for your client
Describe the basic cognitive model
- Situation (something happens)
- Thought (the situation is interpreted in some way)
- Emotion (a feeling occurs as a result of the thought)
- Behaviour (an action in response to the emotion)
- There’s also additional possibilities (ex: physiological reactions -> we see this a lot in anxiety) -> people might not be able to tap into their emotional state but they feel it in their body
Give an example of the basic cognitive model
- Situation: you walk by 2 people and they start laughing
- Emotion: one possible way of responding in this situation is to feel embarrassed
- Behaviour: as a result of feeling embarrassed you might walk faster
- Thought: if this were the way that the situation unfolded, the thought would probably be something like “maybe those people are laughing at me, maybe they don’t think my clothes are right or I have something on my face” -> an interpretation that’s internalizing the behaviour of these other people
- This situation might unfold differently if you have a different type of thought
- Ex: instead of thinking “maybe those people are laughing at me” you think “wow I wish I was in on the joke, they seem like they’re having a lot of fun”
- This would lead to a different emotion and behaviour -> not lead to feeling negative about yourself
What part of the basic cognitive model corresponds to the cognitive revolution?
- Thought
- Before it was just situation and behaviour
- Now we have this intermediate thinking/cognition that happens
- As a result of the thought, we have an emotion and a behaviour
What does the basic cognitive model tell us about how thoughts affect our emotions and behaviour?
The way that you interpret and think about a situation influences your emotions and your behaviour
What’s a main treatment technique especially towards the beginning of CBT?
- The process of identifying automatic thoughts
- What we’re trying to get people to figure out is what they’re thinking in situations when they notice a change in their emotions or their behaviour
- Often people notice those behavioural or emotional changes before they notice their thoughts and so a big part is just getting people to be aware of what they’re thinking
- As the treatment goes on, we work towards finding that these automatic thoughts tend to be lumped in themes and these themes tend to tell us something more about the basic beliefs that give rise to these automatic thoughts
- We start to work towards identifying intermediate beliefs as well as core beliefs
What are intermediate beliefs?
Rules, attitudes, and assumptions about how the world works or how it should work or how one should behave in the world
What are core beliefs?
Basic organizing principle in terms of how we experience ourselves in the world
Describe the interacting systems cognitive model
- Another way of depicting the cognitive model
- Comprised of cognition (thoughts and beliefs), affect (emotional states), physiology (bodily states), behaviour (what one does or says)
- Basic cognitive model shows how something unfolds step-by-step but these things can feed back into one another
- All of this is embedded within the person who has lots of different types of experiences, as well as the environment (where you are, who you’re with, what’s going on at the time) which can all influence how you’re going to make an interpretation and how you’re going to end up behaving
- Ex: if you’re with close friends vs people you don’t really know at a party vs with your family
- All of these things are going to influence this overall process
What are the basic principles of CBT?
- Based on ever-evolving cognitive conceptualization
- Requires sound therapeutic alliance
- Continually monitors client progress
- Culturally adapted and tailors treatment to the individual
- Emphasizes the positive
- Emphasizes collaboration and active participation
- Aspirational, values-based, goal-oriented
- Initially emphasizes the present
- Aims to be educative
- Aims to be time limited
- Consists of structured sessions
- Teaches patients to identify, evaluate, and respond to dysfunctional beliefs
- Includes “Action Plans” (therapy homework)
- Uses a variety of techniques to change thinking, mood, and behaviour
Describe the “based on ever-evolving cognitive conceptualization” basic principle of CBT
- Starting to develop this from the 1st session
- Developed based on evaluation
- Refined based on ongoing sessions
- Typically have a number of evaluation sessions
- When in training this can be 2-3 or even 4 sessions
- People practicing often try to do this in 1 or 2 sessions
- As you’re gathering info, you’re trying to fit it in this puzzle, you’re trying to understand the person, where they’re coming from, how they showed up at your office
- You have an initial cognitive conceptualization and you’re often presenting this to the client to see whether they agree and whether there are changes to make (collaborative process)
- Overtime, you learn more and more about the person as you continue to meet with them -> get more details about their thoughts and beliefs as these are worked on in sessions
- Cognitive conceptualization is always being refined, it’s not static, it’s not that after the assessment sessions that’s it -> it’s constantly being reevaluated
Describe the “requires sound therapeutic alliance” basic principle of CBT
- There are myths about CBT that argue it doesn’t rely as much on the therapeutic alliance or that it’s not important in this type of treatment
- Therapeutic alliance is a necessary component of treatment
- Can’t get very far without it
- People drop-out and won’t stay if they don’t feel a connection to their therapist and hence won’t get better in therapy
Describe the “continually monitors client progress” basic principle of CBT
- Using either or both symptom and function-based outcome measures
- Goes back to the evidence-based practice
- The CPA Report talks about doing treatment outcome monitoring and making sure clients are getting better
- May be using a therapy that research has shown to be efficacious for people with depression and you have someone with depression in front of you but not everyone with depression is the same -> want to make sure that the therapy is working for the person, based on all the things going on for them and their different characteristics
- Monitoring them overtime
- Ex: Anderson article and the measure used in the clinic -> Outcome Questionnaire 45
- Used widely across clinics for this type of monitoring
Describe the “culturally adapted and tailors treatment to the individual” basic principle of CBT
- We have a general approach
- CBT manuals aren’t telling you what to do every single session -> more of a broad philosophy and suggestion about treatment techniques and about how the therapy should unfold
- Manual needs to be adapted to the person sitting in front of you
- CBT book states that CBT is a treatment that tends to be logical and cognitive which isn’t going to work for every client -> maybe as a result of where they grew up, their cultural background, or their individual preference or difference
- May need to adapt the treatment with the same goal in mind but in a way that you get to things related to thinking with the use of different terminology or different examples
- May need to adapt approach for individuals from different cultures
Describe the “emphasizes the positive” basic principle of CBT
- This is to counteract the fact that most clients presenting to treatment are going to be fairly negative
- Ex: people with depression or GAD
- You’re trying to bring out positive examples
- People end up having these filters on (ex: in a depressed state and end up having trouble seeing anything positive in their life)
- Even if something positive happens, it’s minimized or misinterpreted (ex: “these people are just trying to be nice to me, they don’t actually like me”)
- As the therapist, you’re trying to pay attention to any positive interactions or things that are happening in the person’s life and bring attention towards them to try and counteract all the negativity and the mental filter that these people have
Describe the “emphasizes collaboration and active participation” basic principle of CBT
- View therapy as “team work”
- Not a teaching session -> therapist is not sitting there and doing all the talking and teaching the client about exactly how to implement all of these thought-restructuring processes
- Interactive give and take relationship and requires a lot on the part of the client to participate and get as much as they can out of the sessions
- Collaborative empiricism: we’re both scientists and are both trying to figure it out and understand you as the client better and work towards helping you and we’re doing this together -> both in this together
Describe the “aspirational, values-based, goal-oriented” basic principle of CBT
- We want to work towards and focus on both values and goals in the context of talking to people about what’s important to them
- Values: things that are important to people that don’t necessarily have an end to them
- Ex: you value your family and the time spent with your family but you’re not necessarily going to think you have gotten to a point where you have spent enough time with your family and now no longer need to be working on that
- It’s an ongoing important aspect of your life
- Goals: more concrete, have more of a timeline to them
- You can say whether you have accomplished a goal or not
- Ex: studying for 3 hrs -> you can say you set the timer and have accomplished the goal
Describe the “initially emphasizes the present” basic principle of CBT
- “Here-and-now” focus
- Because the things that initially contribute to the development of a form of psychopathology are not necessarily the same things that keep it going
- The developmental factors or the etiology are not necessarily the same things as the maintenance processes
- When trying to get someone out of a vicious cycle, we’re looking at the maintenance processes
- Maintenance processes: the things happening right now (ex: the antecedents, behaviours, consequences or the situations, thoughts, emotions, behaviours)
- These are the things that are happening on an ongoing basis and that’s what we’re focusing on at least initially in CBT
- Explore past to understand patterns of beliefs
- With time and if deemed necessary, then you can explore more of the past and understand the development of some of these core beliefs that underlie the things that are happening on a daily basis and try and work with those beliefs
- This work comes after and for some people it’s not necessary
- If you practice enough to change your thinking on a daily basis then the idea is that it’s going to have a downward effect, but this may still be something that’s necessary for some clients
Describe the “aims to be educative” basic principle of CBT
- Educate client on cognitive model and techniques
- Teach client how to evaluate dysfunctional thoughts
- Not during the whole session but this is part of what we’re doing
- Not just presenting to them things and expecting them to take this for granted and to just listen and believe what we say because we told them, but actually talk about why do we think this works, why do we think that change in dysfunctional thoughts works
- You can see in the cognitive model that if you change that thought and have a different thought then you’ll have a different outcome -> walking through this with clients
- Not on the therapist to do the evaluation of dysfunctional thoughts themselves -> can do it the first time if the client really needs it but if the therapists are the ones doing it, it means the clients not going to be able to generalize this outside of sessions and once they’re done therapy
- Trying to teach the client to be their own therapist (catch phrase)
- Trying to give them all the tools so that they can do this on their own
Describe the “aims to be time limited” basic principle of CBT
- Straight-forward clients: 6-16 sessions
- Sometimes people need more sessions
- Quite short
- Some clients require a year or more in treatment (longer course of treatment)
Describe the “consists of structured sessions” basic principle of CBT
- Maximize efficiency and effectiveness
- Check-in, agenda, “business of week”, feedback
- Typical course of a session: check-in with client (how is your week -> often given a mood rating for their week), what are we going to talk about today? -> the client brings items to the agenda based on the past week and the therapist brings items to the agenda based on specific skills or techniques that they want to introduce to the client, then they cover the agenda, and then end the session with a formal wrap up and ask the client to give them feedback about how they think this session went and if there’s anything that they should do differently next time
- Important especially at the beginning of treatment, to make sure that the client feels listened to and that they have an opportunity to say if something’s not going well
- A lot of clients (often due to their psychopathology or their personality functioning) feel as though the therapist is an expert and they need to just do whatever they say and they don’t feel comfortable and if you don’t ask them for feedback, they’re probably not going to give it to you or they may just drop-out and that’s the feedback
- Asking them on an ongoing basis to try and prevent that from happening is important
Describe the “teaches patients to identify, evaluate, and respond to dysfunctional beliefs” basic principle of CBT
- Using things like guided discovery or behavioural experiments
- Guided discovery: when you ask questions to lead the client to the answer, without telling them the answer
- Leading them to the answer with the types of questions that you’re asking
- Behavioural experiments: clients are testing out some of their beliefs by doing something, for example, in real life to try and challenge some of the beliefs that they hold
Describe the “includes “Action Plans” (therapy homework)” basic principle of CBT
- Historically we would call this homework but people often don’t have great memories associated with the term homework -> action plan is the new term
- Action plan: what we’re going to do in between sessions
- 50 mins/week isn’t enough for a patient to make sustained change
- You have to be doing these things and practicing these skills in between sessions
- You have all these other hours of the week where you could be continuing the same patterns
- Important to build new patterns/habits
- Anything we want the client to remember should be recorded
- Should be written down so that the client remembers what they’re supposed to do and the types of processes they’re supposed to go through
Describe the “uses a variety of techniques to change thinking, mood, and behaviour” basic principle of CBT
- Not just cognitive strategies are used
- There are other strategies incorporated into CBT that are more of the behavioural or mindfulness
- These got borrowed from other treatments but have been shown to be really helpful
- The therapist can pull techniques from other treatment approaches -> very common way for therapists to practice
Describe key points from the cognitive model example of Lucy
- Student with depression in the UK
- Trying to deconstruct the problems that she’s having with the CBT model
- Therapist focused in on a particular situation, rather than taking all of the times that the client doesn’t go to lecture, so that Lucy can remember what that experience was like
- Going through the thoughts (cognitions), which are typically, especially with someone with depression, “I” statements that are negative and reflect badly on the person
- The therapist had to differentiate for the client the difference between thoughts and emotions (common) -> emotions are typically one word and are often reflected on the face
- The therapist asks about physiology
- The therapist added what happens afterwards (behaviour)? How do you feel afterwards?
- This is to motivate people to see that what they’ve been doing (behaviour) hasn’t been helping, it’s not making them feel better
- This was the first session: they went through information gathering and now the therapist is able to introduce the client to this cognitive model, write it down and then give it to the client to take home to think about more and build on this in future sessions
What are the things we look at with a CBT assessment?
- Assessing current problem
- Identify triggers and modifying factors
- Consequences
- Maintaining processes
- Past history and problem development
Describe the “assessing current problem” component of the CBT assessment
- When conducting an assessment in CBT the main thing we’re interested in is the current problem
- A common start to the 1st session is “what brought you to therapy right now?”
- A lot of people have been struggling with their mental health for a long time but we’re interested in what brought the person through the door right now
- Want to get a good picture of what’s happening right now to understand how to intervene
- Involves structured questions to obtain detailed
information - Ask a lot about the current problems
- Ask clients to detail a recent occasion when the problem occurred and problem symptoms were experienced
- Trying to get all the little details and types of things that you would then put into the cognitive conceptualization (ex: what happened before, in the middle, after (antecedents, behaviours, consequences))
- Break presenting problems into 4 internal systems (cognitions, emotions, behaviour, physiology) and the environment
- Breaking the problem into the pieces that are part of the cognitive model (either the situation, the automatic thoughts, the emotions, the behaviours, the physiology)
- What was happening in the environment? What’s the larger context for when this problem occurs?
- When we want to figure out how to help the person right now and what they’re going through right now, then this is going to be the more relevant source of info (how is this problem being maintained?)
- We want to break that ongoing cycle
Describe the “identify triggers and modifying factors” component of the CBT assessment
- Identify antecedent factors (triggers and modifying factors)
- Triggers: what factors make the problem more or less likely to occur
- Ex: things in the environment, internal things (thoughts or emotions) that prompt the behaviour
- Modifiers: contextual factors that impact how severe the problem is when it occurs
- Ex: for someone who has problems with alcohol:
- A trigger might be walking past a bar which makes the problem more likely to occur
- A modifier might be whether or not they’re with other people (ex: someone with a problem with alcohol may be less likely to enter the bar if they’re with other people who know they have a problem and need to cut down on their drinking, but if they’re by themselves they may be more likely to go in and drink more)
Describe the “consequences” component of the CBT assessment
- What has happened/is happening as a result of current problems?
- What happens immediately after the current problem?
- When the problem does occur, what are the consequences in terms of emotions, behaviour, physiology, relationships, interactions with other people
- Interested in consequences because these are what give us a clue about the maintaining processes (the function)
- All of our behaviours despite how maladaptive they might be serve a function and we want to figure out what that function is to see if we can get it served in another way
Describe the “maintaining processes” component of the CBT assessment
- It’s the maintenance processes that we’re trying to break in therapy
- Even though we care about what’s happened earlier in life, that’s not necessarily relevant to why the client is struggling still or right now
- The vicious cycles that keep the problem going
- Different disorders have different common maintaining processes, but assessment must be individualized to client
- Ex: escape/avoidance, reduction in activity, short-term reward
What are some common maintaining processes/functions?
- Escape and avoidance: common with anxiety disorders, people don’t like to feel the physiological sensation of anxiety and are trying to escape or avoid it from happening in the first place, this only reinforces that anxiety is something that needs to be avoided and needs to not be experienced rather than seeing it as a normal experience that everyone has from time to time
- Reduction in activity: relevant for depression, the more someone withdraws from their environment, the less that they have the opportunity to experience pleasurable events and emotions which reinforces the depression and then the more they want to continue to withdraw
- Short-term reward: seen in more addictive disorders (ex: substance-use and binge eating) where taking the substance or the food or gambling is pleasurable (there’s a dopamine and opioid release in the brain when people are engaging in the experience) but in the long term it’s maladaptive and people are seeking that short-term reward without considering the longer term consequences
Describe the “past history and problem development” component of the CBT assessment
- We care about past history to some extent and how the problem initially developed
- Consider vulnerability factors, precipitants, and modifiers
What are vulnerability factors?
- Things that set the stage for a problem to develop, but are neither necessary nor sufficient
- In the diathesis-stress model, these would be the diatheses
- The things that put someone at risk for developing a mental health problem
- Ex: family history of a mental health problem or particular personality or coping style
- Diathesis-stress model -> in the absence of any major stressful event, it may be that the diathesis never gets expressed, it’s sort of latent
- Why mental health problems run in families but aren’t necessarily present in every generation -> they can skip a generation
What are precipitants?
- Things that come more directly before the problem is expressed
- Events or situations that provoke the onset of symptoms
- Ex: stressors or major life events, which don’t have to be traumatic events (can be normal life events, like starting a new university or moving to a new town, which are generally seen as positive or have the potential to be positive but are stressful nonetheless)
- These can activate some of the diatheses
- Ex: the breakup of a relationship in someone who has had negative views about themselves, which really activates those views and brings them to the forefront and leads to depression
- Likely that these event(s) activate a pre-existing vulnerability belief
- These vulnerability beliefs may have come from early life experiences around family, friendships, or romantic relationships and then they get activated or reactivated in the case of people who might have multiple episodes of depression
What are modifiers?
- These could be changes to life circumstances that affect the severity of the problem
- For someone who’s generally an anxious person and has had a longstanding history with anxiety, you’re interested in why they’re coming to therapy now, what brought them in now?
- It’s possible that there’s something that could’ve been present that’s contributing to their anxiety symptoms and is the result for initially presenting to therapy or returning to therapy (for people who have done it before, why are they coming back? What just happened to increase the severity of their problems?)
How are CBT assessment and the cognitive model connected?
With the assessment, we’re trying to put the info into our cognitive model or cognitive conceptualization
Describe the basic cognitive model
- Situation/event (ex: bad grade on test) -> automatic thought (ex: all my studying was useless!) -> reaction (emotional, behavioural, physiological) (ex: feel sad and hopeless, not motivated to study next time, don’t study next time and confirm this thought)
With CBT, we always start at what level of the cognitive model?
With CBT, we always start at the level of the automatic thoughts because these are the things that are the most accessible to the person and easiest to change as they’re specific to a situation as opposed to being more global
How do we assess the basic cognitive model?
- Using the simple thought record
- Has columns for situation (who, what, when, where?), feelings (what did you feel? Rate your emotion 0-100%), thoughts (what was going through your mind as you started to feel this way? Thoughts or images)
- The columns for feelings and thoughts are switched
- Although the order or the way we think this happens is that there’s a situation which leads to interpretation of the situation which leads to a reaction (technically the thought should be in the middle), people have an easier time, in terms of noticing when they have an emotional change or a change in their body
- We tell people that once they experience that change, they have to tap into what they were thinking (what was going through your mind as you started to feel this way?)
- Helping people to get to the thoughts
- Easier to do if they pay attention to their feelings (emotional or physical or behavioural)
- This type of simple thought record is the basis of cognitive restructuring but we do use it in the course of an assessment in those early sessions
What are some reasons for why we use a simple thought record in the course of an assessment in early CBT sessions?
- To get people familiar with the process of completing these types of records outside of sessions
- To get more data to inform our case conceptualization (we may have initial ideas about people’s automatic thoughts and basic beliefs) but this allows us to have more confidence in what we think are those core beliefs
What are core beliefs?
- Enduring cognitive phenomena that are deeply rooted
- Develop early-on based on our early life experiences
- Hard to access especially early-on in therapy
- Idea that people focus selectively on information that confirms core beliefs, and disregard information that doesn’t
- This doesn’t always happen
- Everyone has core beliefs, not everyone has negative core beliefs but many do
- They may not be activated or come up unless there’s situations that activate them or unless someone’s in the midst of a mental health problem
Ex: if they’re in a current depressive episode or they’re in a place where they have increased anxiety -> going to be more likely to go through this process where in terms of what they view in the world, they’re selectively attending to those events that confirm the view of themselves and disregarding the other info - In CBT, we pay attention to everything and not just the things that confirm our negative views of ourselves
- Global (can apply to lots of different situations), rigid (hard to change), overgeneralized
What are intermediate beliefs?
- 3 categories: attitudes, rules, and assumptions
- Attitudes: general beliefs about outcomes
- They apply generally to the world or to people, not really “I” statements
- Believed to be true for everyone and true in all situations
- Rules: often involves a “should” statement
- Something that you’re applying to yourself that you think you should do
- Assumptions: often involves an “if…then…” statement
- Assumption about the workings of the world and what’s going to happen
- Intermediate beliefs fall in between core beliefs and automatic thoughts
- The rule, attitude, assumption distinction isn’t all that important and it’s kind of confusing to clients
- Main thing is that the assumption is the easiest to work with because it has this “if…then…” statement which is an implied causality or that this is always going to be the case
- These things are easier to work with than the rules and the attitudes
- Often what happens is that if people are providing these types of beliefs as rules or attitudes, you’re kind of reworking them as assumptions to be able to work on that together
Describe the Expanded Cognitive Model
Core beliefs (ex: I’m incompetent -> this is global and not specific to a situation, very general. If you believe that you’re incompetent, this is going to be a hard thing to easily change) -> intermediate beliefs (ex: attitude -> it’s terrible to fail, rule -> I should give up if something is too hard, assumption -> if I try something difficult, I’ll fail) -> automatic thoughts (applying general beliefs about failure to specific situations) (ex: all of my studying was useless!)
What are the 3 categories that core beliefs are generally divided into?
- Incompetent:
- Generally achievement related
- Ex: work, school, hobbies, etc.
- More internal (ex: “I’m stupid”, “I can’t do anything right”, “I don’t measure up”, “I’m a failure”)
- Unlovable:
- Related to interpersonal and connection with other people
- Ex: “I’m unlovable”, “I’m different”, “I’m bound to be abandoned/rejected”, “I’m defective; others will not love me”
- Worthless:
- Especially seen in people with suicidal ideation
- Worthlessness is important to assess in terms of considering suicidal ideation
- Ex: “I’m worthless”, “I’m bad”, “I’m evil”, “I’m a waste”, “I don’t deserve anything good”
- More of a severe belief
- Initially it was thought that incompetent and unlovable were the 2 main core belief categories, but then as people worked more with clients with depression, there was a 3rd category added (worthless)
- It’s possible to have all of these or to feel both incompetent and unlovable
- Some clients might present more with one than the other or one might be more relevant to the current situation and the current problem