by barbara lofrisco cognitive behavioral seminar university of south florida

By Barbara LoFrisco Cognitive Behavioral Seminar University of South Florida

Cognitive Therapy The Theory In order to understand an emotional disturbance, one must understand the mental processes or cognitions These mental events are readily accessible Patients beliefs are examined: him/herself, future and world Any concern will be in one of these domains This is the cognitive triad (Beck, Rush, Shaw & Emery, 1979) Common themes are found with both anxious and depressed patients

Cognitive Therapy- The Process 1. Patient becomes aware of cognition 2. Patient frames cognition as a hypothesis 3. Patient scrutinizes belief 4. Patient gradually arrives at a different view 5. Changes in the emotional reaction should follow 6. Eventually, concern over recent events will diminish 7. Thus, negative affect is removed from ruminations about said events 8. Result: Less negative mood

Cognitive Therapy- The Process Patient will start to apply these techniques to new events Many of the skills learned in Cognitive Therapy are used by people who have never had depression If the patient does not use these skills, the risk for relapse is high

Cognitive Therapy- Schema Work Cognitive errors (or automatic thoughts) are based on schema, or patterns of thinking These are the themes of dysfunctional thinking All patients have them They can be uncovered by examining cognitive errors Can be uncovered using Downward Arrow technique Or using If then logic. For example, If I fail this exam, then I am a failure as a person. Old schema can be replaced with new

Cognitive Therapy- Cognitive Errors We are all subject to cognitive errors They occur more often in affective episodes There is a list of common errors that patients can compare their own thoughts to: 1. All or nothing thinking 2. Over generalizing 3. Discounting the Positives 4. Jumping to conclusions

Cognitive Therapy- Cognitive Errors 5. Mind Reading 6. Fortunetelling 7. Magnifying/Minimizing 8. Emotional Reasoning 9. Making should statements 10. Labeling 11. Inappropriate Blaming

Cognitive Therapy- Cognitive Errors How many cognitive errors can you spot in this story? Mary felt isolated and alone. Mary had been married to an abusive man for 5 years and had finally decided to leave him. I should have done it much sooner, she reported. Mary reported that she had a history of attracting abusive men, so therefore all men must be abusive. What is wrong with me? Im never going to meet anyone!

Cognitive Therapy- Cognitive Errors Mary felt isolated and alone. Mary had been married to an abusive man for 5 years and had finally decided to leave him. I should have done it much sooner, she reported (#7 Minimizing, #9 should statements, #11 Inappropriate Blaming). Mary reported that she had a history of attracting abusive men, so therefore all men must be abusive (#2 Overgeneralization). What is wrong with me? Im never going to meet anyone! (#1 All or nothing thinking, #6 Fortune Telling).

Cognitive Therapy- Therapeutic Interaction Relationship is one of collaboration Patient is expert on his or her own experience, and the meaning he or she attaches to events Therapist is expert on the model Therapist does not make interpretations, rather solicits this information from clients More of a state of not knowing Thoughts are not replaced until patient understands the meaning of the thoughts and has decided they are not true

Cognitive Therapy- Therapeutic Interaction Meaning system of each patient is idiosyncratic Patients must take an active role in therapy Differs from Michenbaums Cognitive Behavioral Modification: thoughts are behaviors that can simply be modified without understanding underlying meaning Different from Michenbaums SIT (Self Instructional Training): client is taught to repeat specific self-coping statements rather than question their inferences Differs from Ellis REBT: therapist infers clients thinking errors

Cognitive Therapy Behavioral Methods Behavioral methods sometimes used to increase behaviors or provide experiences in pleasure Focus is always on changes in beliefs resulting from change in actions Behavioral changes serve as experiments to check out a hypothesis that the patient and therapist have developed; or formulate a new one But.Jacobson et al. (1996) found that 12 weeks of behavioral methods had outcomes comparable to 12 weeks of cognitive therapy.

Behavioral Methods- Applications: Self-Monitoring Hour-by-hour record of activities and associated moods is kept Patients record mood on a 0-100 scale, where 0 is the worst they have ever felt and 100 is the best Beck et al. (1979) suggests the patient also record the degree of mastery or pleasure associated with the activity Patients are sometimes surprised at how they are spending their time Can also serve as a baseline

Behavioral Methods- Applications: Self-Monitoring Detailed examination of this record is much better than patients memory for testing hypothesis Patients memory is often selective Therapist can ask patient to recall thoughts that occurred during both good and bad events Therapist can look for consistencies in the record: which events are associated with good or bad moods, or with mastery or pleasure

Behavioral Methods: Applications: Scheduling Activities Purpose is to get patient to engage in activities he or she is (unwisely) unwilling to do Remove decision making as an obstacle in initiation of activity Has decision making ever been an obstacle for you in initiating an activity? (Share with the class if you feel comfortable) Non-adherence can be addressed therapeutically Usually failures are similar to what has been troubling the patient.

Behavioral Methods: Applications: Scheduling Activities A thorough analysis of cognitive obstacle can be performed 3 Types of Activities to schedule: 1. Those associated with mastery, pleasure or good mood 2. Those that had been rewarding in the past but that the patient has been avoiding 3. New activities that might be rewarding or informative

Behavioral Methods: Applications: Scheduling Activities Patient can use self-monitoring to monitor mood after activities Activities can be experiments Patients are more likely to do activities if they are framed as experiments

Behavioral Methods: Applications: Other Behavioral Activities Breaking down larger tasks into smaller units Makes task more concrete and less overwhelming This is called chunking Easier tasks can be accomplished first This is called Graded tasks Although simplistic, these methods can be effective because they change how patient views the (formerly) difficult task

Cognitive Methods: Daily Record of Dysfunctional Thoughts Find DRDT in Dobsons book. In mine its p. 359. Most of the work in Cognitive Therapy centers around Daily Record of Dysfunctional Thoughts (DRDT) Beck et al. (1979) Four most important columns correspond to the three points in the cognitive model (situation, belief, emotional consequence). Patients first use DRDT to record unpleasant or puzzling emotions Patient must first understand what emotions are (see handouts)

Cognitive Methods: Daily Record of Dysfunctional Thoughts Some patients dont know the difference between thoughts and feelings Therapist may have to educate patient Can give feeling chart to patients so that they can understand what different feelings are In addition to situation and emotions, patient must also record thoughts in DRDT This may be more difficult because patients often think situations cause emotions

Cognitive Methods: Daily Record of Dysfunctional Thoughts Teach patients that it is the thoughts about the situation, not the situation that produces the emotion Teach patient to examine his or her own inferences It is these inferences that are the cause of distress Automatic thoughts can be re-rated for strength of belief after alternative thought has been formulated If ratings are similar, then the initial concern is not resolved Affective response can also be re-rated in a similar way. Again, lack of change means something is missing

Cognitive Methods: Three Questions 1. What is evidence for and against this belief? 2. What are the alternative interpretations? 3. What are the real implications, if the belief is correct?

Cognitive Methods: Downward Arrow Technique Patients first thoughts are usually not therapeutically useful in that they do not describe the implications to the patient Use Downward Arrow Technique to uncover the implications of thought Ask What would it mean if.? Or What if it is true that.? Or What about that bothers you? Repeat until thought is produced that will benefit from cognitive therapy

Cognitive Methods: Cognitive Errors Teach patient to recognize when one of his or her thoughts falls into one of the categories of cognitive errors (p. 353 of Dobson, or slide #6) Teaches patients that these are common cognitive errors: normalization

Cognitive Methods: Identifying Schemata After a while in therapy, a certain consistency emerges in patients cognitive errors These consistencies, or themes are the schema They are found at the level of personal meaning Dysfunctional Attitude Scale (DAS; Weissman & Beck, 1978) to assess schemata and track changes during treatment

Cognitive Methods: Indentifying Schemata with DAS The DAS has 9 interpretable factors: 1. Vulnerability 2. Approval 3. Perfectionism 4. Need to please others 5. Imperatives 6. Need to impress others 7. Avoidance of weakness 8. Control over emotions 9. Disapproval Class give examples of 3 of them

Cognitive Methods: Socratic Questioning and Guided Discovery Probably the most distinctive stylistic feature Most difficult for therapists to master Guided discovery: through use of leading questions, helping patients arrive at new perspectives Therapists must walk a line between guiding patient and allowing patient to free-associate Common errors of inexperienced therapists is to be in a hurry and lecture the patient or ask overly leading questions. Even facial expression can be a factor (LoFrisco)

Cognitive Methods: Socratic Questioning and Guided Discovery Therapist should avoid closed questions and declarative statements This maximally engages client to think about problem and come up with solution Helps foster independence and prevent relapse (LoFrisco) Will have a greater chance of addressing any idiosyncratic issues; more client centered

Treatment Procedures- Beginning of Treatment Goals: 1. Assessment Beck Depression Inventory (BDI); also can be used as a session-to-session measure 2. Socializing patient into cognitive model Have patient read the booklet Coping With Depression (Beck & Greenberg, 1974) Helps to instill hope 2. Dealing with patients pessimism

Treatment Procedures- Middle Phase of Therapy Solidify work on cognitive coping skills Patient uses DRDT to track thoughts that produce negative affect Therapist uses Downward Arrow Technique to help patient fine-tune their responses Therapist reviews DRDT with patient Patterns associated with schemata are identified Developmental history of schemata is discussed. Why?

Treatment Procedures- Middle Phase of Therapy Answer: to help client make sense of his or her schemata

Treatment Procedures- Final Phase Gains are reviewed Relapse prevention: Anticipate situations that would tax patient and review the skills they have learned Becausepatients usually attribute their improvement to changes in their environment, not changes in themselves

Treatment Procedures- Final Phase Patients feelings or beliefs about terminating therapy are addressed Patient may feel like they cant do it on their own Schedule booster or check-up sessions Jarrett et al. (1998) found that monthly check-up sessions helped to prevent relapse Even less frequent boosters can be beneficial

Empirical Status- Depression Rush et al. (1977) found that patients treated with cognitive therapy experienced greater symptom remission at the end of 12 weeks compared with those taking a tricyclic antidepressant (randomized trial) Blackburn et al. (1981) and Murphy et al. (1984) did a similar study and found cognitive therapy equally effective Dobson (1989) meta-analysis: a greater degree of change than wait-list, pharmacotherapy, behavior therapy and other psychotherapies

Empirical Status- Depression ThenElkin et al. (1989) discovered that cognitive therapy did not perform as well as medication in severely depressed patients A later report (Elkin et al., 1995) showed even more dismal results The saga continuesHollon et al. (1992) found that cognitive therapy performed at least as well as medication, even among the severely depressed OK, lets get serious. DeRubeis et al. (1999) performed a mega-analysis from these studies and found cognitive therapy just as effective as medication.

Empirical Status- Depression Finally, in another placebo-controlled randomized study, Jarrett et al. (1999) found that the two treatments performed equally well. Conclusion? Even in the short run, cognitive therapy is a potent alternative to medication. But does it last?

Empirical Status- Depression Rush et al. (1977) found that at 12-month follow-up (but not at 6) that CT patients scored lower on depression severity measures than the antidepressant group Murphy et al. (1984) found patients that received CT during the acute treatment phase were less likely to relapse than those treated with drugs Hollon et al. (1992) had similar results Several studies have found that a relatively short course of CT following a successful course of antidepressants is as effective in preventing relapse as is continuing the meds.

Depression- Therapist Behavior Collaborative Study Psychotherapy Rating Scale (CSPRS) measures therapists adherence to CBT model. CT- Concrete: measures active methods CT- Abstract measures discussions about CT rationale DeRubeis & Feeley (1990); Feeley et al. (1999) discovered that CT-Concrete was associated with greater changes in BDI; and CT-Abstract was not Therefore, it is critical for therapists to focus on problem-solving aspects of CT, at least early on

Depression-Patient Cognitions Hollon et al. (1988) proposed 3 kinds of changes that occur: 1. Deactivation suppress old schema 2. Accommodation modify/create new schema 3. Development of compensatory skills applying CT skills to future situations

Depression- Patient Cognitions DeRubeis (1990) studied patients from the Holland et al. (1992) study, found that improvement on the: Beck Hopelessness Scale DAS Attributional Style Questionnaire Play a meditational role. (patients who improved on these measures also had subsequent change in depressive symptoms) Therefore, attributional style and dysfunctional attitudes mediate the reduction of risk of CT

Depression- Patient Cognitions But.Miranda and Persons (1988) disagreed, stating that the depressive schemata may simply be latent. So.they developed a negative mood induction procedure prior to administering the DAS. Segal et al. (1996) found that scores on mood induced DAS predicted relapse, just like Hollon had found. Measures of changes in compensory skills are less plentiful Most measures of coping skills came from interests other than CT

Depression- Patient Cognitions A method is needed to require a patient to PRODUCE rather than RECOGNIZE coping skills. Most patients can recognize them. Barber and DeRubeis (1992) developed the Ways of Responding (WOR) to address this need. To measure changes in beliefs as they occur in session (rather than a static measurement) Tang and DeRubeis (1999) developed Patient Cognitive Change Scale.

CT Course of Change Ilardi and Craighead (1994) observed that 60% - 70% of symptom improvement occurs in the first 4 weeks. But this was inferred from group mean. Actually.Tang and DeRubeis (1999) report 40% - 60% of change occurs in the first 4 weeks. Why would this be clinically relevant? Tang and DeRubeis (1999): In addition to a shorter course, individual therapy gains can be much more sudden than group therapy gains; called sudden gains Occurs among more than 50% of patients Accounts for more than 50% of total relief

Therapist Patient Alliance Recent research continues to show a positive relationship between alliance and outcome Good therapeutic alliance tends to be the RESULT of symptom improvement, rather than a PREDICTOR So.therapists should adhere to concrete CT, and they will build alliance This differs from past findings. Studies that took the average over time of the alliance, and then correlated it to the outcome

Therapist Patient Alliance As opposed to measuring it at various points during the therapy process Beckham (1989), DeRubeis and Feeley (1990), Feeley et al. (1999) found that therapeutic alliance measured early in therapy process did not predict good outcome Furthermore, DeRubeis and Feeley (1990), Feeley et al. (1999) found that later in therapy, alliance was actually predicted by outcome Lastly, Tang and DeRubeis (1999) found that alliance in the session prior to the sudden gain was significantly lower as compared to the session after the gain.

Panic Disorder and Agoraphobia There is also cognitive therapy for OCD, anxiety and hypochondriasis, which follows a similar form to what was just described (for depression).

Panic Disorder and Agoraphobia The phenomenology and treatment of panic disorder have been well developed: Patient feels a particular symptom Attributes it to the start of a panic attack (from experience) Because he/she thinks its pathological, the progression of the panic attack continues I.e.. chest pain= heart attack But there are other explanations for these symptoms I.e.. You will be lightheaded if you get up too fast

Panic Disorder and Agoraphobia Patient focuses on catastrophic consequences of symptom ** Patient loses ability to view symptoms objectively*** This is what turns anxiety into a panic attack Vicious cycle: fear makes symptoms worse, which makes fear worse, etc. At this point symptoms seem uncontrollable This spontaneous attack is a phobia of internal conditions

Panic Disorder and Agoraphobia Recent development in treatment: beware of dependence on safety behaviors In the mid-eighties, using relaxation or distraction procedures was the norm This has been recently found to prevent full recovery in certain cases Because patients think they MUST do them to stop panic attack Harmless?

Panic Disorder and Agoraphobia Cognitive Therapy Treatment: 1. Therapist and patient map out vicious cycle 2. Patient beliefs are identified (i.e.. If I hyperventilate I will die.) 3. Beliefs are challenged using safety behaviors (i.e.. controlled breathing) 4. Safety behaviors used only to disprove belief 5. More realistic beliefs are identified 6. Images experienced by patient are altered

Panic Disorder and Agoraphobia Behavioral Methods: Establish methods to induce panic Patient learns that the methods did not result in catastrophy Thus these symptoms are not reliable warnings of danger Patients are encouraged to expose themselves to situations they have avoided due to fear

Panic Disorder and Agoraphobia If patient has learned controlled breathing, patient may think that if they dont get control of their breathing the results will be catastrophic (because then they will definitely have the anxiety attack) This is reinforced continually via negative reinforcement (patient does breathing exercise and they do not faint) Harmless? Now what do you think?

Empirical Status of Panic Disorder Sanchez et al. (2010) did a meta-analysis of various treatments for panic d/o with or w/out acrophobia. CT was moderately useful on its own, but its effectiveness increased dramatically when paired with exposure therapy. Clark (1996) showed that across 5 different studies, between 74% - 94% of CT patients remained panic- free. CT was found to be superior to applied relaxation, exposure and pharmacotherapy.

Empirical Status of Anxiety/OCD Chambless & Gillis (1993) reviewed 9 clinical trials and found mostly support for CTs effectiveness in treating GAD Two additional studies, Barlow et al. (1992) and Durham et al., 1994) support this For OCD, Van Oppen et al. (1995) found CT equivalent to exposure and response prevention (an OCD treatment with established efficacy). A number of studies (Compas et al., 1998) have found CT effective for bulimia nervosa

Impediments to CBT Treatment for Anxiety Disorders Anxiety disorders are the most prevalent class of disorders (Gunter & Whittal, 2010) CBT treatments are poorly disseminated to practitioners Of 84% of adults w/ anxiety that saw a health care practitioner, only 23% received appropriate treatment Only 11% received appropriate psychological services Psychopharmacology: $2305; individual counseling: $1357; group $523

Impediments to CBT Treatment for Anxiety Disorders CBT approaches are the only empirically supported approaches to anxiety (EMDR for PTSD a possible exception) Gap between research findings and clinical practice is large WHY?

Impediments to CBT Treatment for Anxiety Disorders Limited training opportunities Dissemination of CBT is complex Treating anxiety requires temporarily increasing symptoms (i.e.. exposure) Most psychological treatments do not do this Thus, exposure treatments have a bad rap Counter to ethical mandate: do no harm Many therapists fear hurting their clients Perceived contraindications lack empirical support

Impediments to CBT Treatment for Anxiety Disorders Lack of training at the doctoral/internship levels From 1993 2003 there has been very little increase in the amount of CBT training available Many therapists eclectic, including non-CBT approaches Almost all effective approaches for anxiety are forms of CBT Practitioners tend to rely on their clinical experience, rather than outcome studies

Impediments to CBT Treatment for Anxiety Disorders Perception is that study was done on patients with only one very specific disorder, rather than the more complex mix we see typically in patients General lack of attention to practitioner concerns Standardized treatment protocols are cold and calculated Difficulty in finding the funding to train clinicians appropriately

CBT and Dyspareunia Kabaki & Batur (2003) studied 16 Turkish couples who were treated for vaginismus at a hospital. CBT treatment included cognitive reframing. All couples were able to achieve successful intercourse Bergeron et al (2001) found that CBT, including cognitive restructuring was effective in treating dyspareunia Butit was no more effective than biofeedback (Bergeron et al., 2001) . And less effective than vestibulectomy (Bergeron et al., 2001)

OCD and Hoarding Hoarding not usually related to OCD (Tolin et al., 2010). More likely related to anxiety and depression Its a public health problem Behavioral treatments and medication for OCD fair poorly Possibly because hoarders generally have poor insight Previous studies may not have represented hoarders, as they do not always identify with having OCD

OCD and Hoarding Tolin et al. (2010) studied 558 hoarders, primarily Caucasian and female They found that insight was related to hoarding behavior Future treatments of hoarding should be centered around raising awareness and insight

References Beck, A. T. & Greenburg, R. L. (1974). Coping with depression. New York: Institute for Rational Living. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Bergeron, S., Binik, Y. M., Khalif, S., Pagidas, K., Glazer, H. I., Meana, M., et al. (2001). A randomized comparison of group cognitive-behavioral therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain, 91(3), 297-306. Dobson, K.S. (2003). Handbook of Cognitive Behavioral Therapies. New York: The Guilford Press.

References Dugas, M. J., Brillon, P., Savard, P., Turcotte, J., Gaudet, A., Ladouceur, R., et al. (2010). A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. Behavior Therapy, 41(1), 46-58. Gunter, R. W., & Whittal, M. L. (2010). Dissemination of cognitive-behavioral treatments for anxiety disorders: Overcoming barriers and improving patient access. Clinical Psychology Review, 30(2), 194-202.

References Jacobson, N.S. & Hollon, S.D. (1996a). Cognitive-behavior therapy versus pharmacotherapy: Now that the jurys returned its verdict, its time to present the rest of the evidence. Journal of Consulting and Clinical Psychology, 64, 74-80. Jarrett, R. B., Basco, M. R., Risser, R., Ramanan, J., Marwill, M., Kraft, D., & Rush, A. J. (1998). Is there a role for continuation phase cognitive therapy for depressed oupatients? Journal of Counseling and Clinical Psychology, 66, 1036-1040. Kabaki, E., & Batur, S. (2003). Who benefits from cognitive behavioral therapy for vaginismus. Journal of Sex & Marital Therapy, 29(4), 277-288.

References Snchez-Meca, J., Rosa-Alczar, A. I., Marn-Martnez, F., & Gmez-Conesa, A. (2010). Psychological treatment of panic disorder with or without agoraphobia: A meta-analysis. Clinical Psychology Review, 30(1), 37-50. Tolin, D. F., Fitch, K. E., Frost, R. O., & Steketee, G. (2010). Family informants perceptions of insight in compulsive hoarding. Cognitive Therapy and Research, 34(1), 69-81. Weissman, A. N., & Beck, A. T., (1978). Development and validation of the Dysfunctional Attitude Scale: A preliminary investigation. Paper presented at the meeting of the American Educational Research Association, Toronto.

by barbara lofrisco cognitive behavioral seminar university of south florida

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