Silvina Galperin, D. Psych., C. Psych

CBT workshopFor Internationally trained

Health Professionals

CAMH

Cognitive Therapy Definition

Cognitive therapy is an active, directed, time-limited, structured approach, used to treat a variety of psychiatric disorders (depression, anxiety, phobias, chronic pain and others)

It is based on an underlying theoretical rationale that an individual’s affect and behaviour are largely determined by the way in which he structures the word

Aaron Beck (1979)

Cognitive Therapy:Characterisitcs

Present oriented Based on an ongoing case

conceptualization Educative: teaches patient to

be self-therapist Time-limited Collaborative Structured Goal oriented: problem

focused Variety of techniques to

change thoughts, feelings and behaviour

Relapse prevention

Principles of Cognitive Therapy

Strong therapeutic alliance

Goal oriented and problem focused

Emphasizes skill acquisition Homework

Uses cognitive and behavioural techniques to change thinking, mood and behaviour.

Thought records, Socratic questioning, action plans, behavioral experiments, cognitive continuum, exposure and other techniques to evaluate and modify dysfunctional thoughts and beliefs (cognitive restructuring).

Suitability for Brief Cognitive Therapy

Dimensions:

Accessibility of Automatic Thoughts Awareness and differentiation of

emotions Acceptance of personal

responsibility with treatment Compatibility with cognitive

rationale Alliance potential (in-session) Alliance potential (out- of-session) Focality Security operations Chronicity vs. Acuteness Optimism vs. Pessimism

Safran, J., Segal, Z. (1990) Interpersonal process in Cognitive Therapy. Basic Books. New York

Structure of the CBT Session

Six components1. Mood check up How was your mood during the past week? What did you work on during the last week?

2. Bridge from previous session What did you learn in the last session? Was there anything that bothered you our last

session?

3. Agenda Setting What problems do you want to put on the

agenda? Which ones have priority for today’s

session?

4. Review of Homework5. Discussion of the Agenda, new

homework assignment6. Final summary and feedback What do you think about today’s session? What will be important for you to remember?

The Cognitive Model

The cognitive model states that the behaviour is reciprocally determined by the individual’s thoughts, feelings and physiological reactions.

None of these elements is necessarily more important.

The therapist can intervene by focusing on each of these areas at different times of the treatment.

Cognitive Model

Environment

Moods

Physiological reactions

Thoughts

Behaviour

How to use the Cognitive Model

with the clients: Examples

1. Pierre is a VP of multinational company. Three months ago he was diagnosed with rosacea. He thinks that to have his face red is a sign of weakness and that people will think he is afraid or nervous and this makes him feel extremely uncomfortable, irritable and anxious.

2. Chris is a 21 year old student that is afraid of meeting people. He has friends but when there are new people around he just can’t talk.

3. Greta is a 67 year old married, retired woman who has been avoiding to get out of her home for 2 months. She had several episodes of diarrhea at home and now she is afraid of having an “accident” anytime.

Other examples:

Typical cases of depression Typical cases of separation anxiety

Role PlayingIntroducing the Cognitive

Model to a client

-Groups of Three-1. Patient: Describes situation, answers therapist’s

questions2. Therapist: Asks questions to the client to clarify3. Observer: Assists therapist and/or client, gives

feedback Task:

1. Ask about a specific situation (where, when, with who, what happened) in which the change of mood occurred (started to feel afraid, embarrassed, anxious, etc.)

2. Ask about all the emotions that this situation triggered in the client and write it down

3. What was going through your mind just before you started to feel this way? What other thoughts did you have at that moment?

4. Ask about specific physical sensations associated

5. What was the resulting behaviour at that time

Goal Setting Why set goals for therapy?: CBT is a

time-limited. Setting some specific goals ensures that we work with a focus and clients get the most out of therapy. It also allows to track the progress in therapy.

Goals are based on the client’s expectations for therapy

What would you like to accomplish in therapy?

What woul ou like to be different in your life?

GeneralOverall areas that need

improvement I want to be healthier I want to take better care of myself I want to have friends

SpecificObservable and reasonable changes

that can be measured What can do to start? List small steps towards the goal Are the steps observable?

Goal Setting

SpecificMeasurableAchievableRealisticTime-limited

Questions to answer: Where are you now? Where you would like to

get? What small steps can you

take to get from where you are now to where you want to be?

Practice setting up goals

Define general goals Prioritize 3 (the ones that would

give most immediate relief)For each goal : Where are you now? Where would you like to be? Define small, reasonable,

achievable, measurable steps to take.

Rate level of difficulty of each step Arrange according to the level of

difficulty starting from the easiest. Ask: What would be the first sign

that you are making progress? Practice setting up 8 small steps

towards a specific goal.

Automatic Thoughts

Are thoughts that pop into our heads automatically throughout the day

We don’t have the intention of having them

Usually, we are not even aware of them

One of the goals of cognitive therapy is to bring automatic thoughts into awareness

I.E.: If you are late for an appointment, what would you think as you are traveling to get there?

IdentifyingAutomatic Thoughts

Basic question:

What was going through your mind when you had that strong feeling (or reaction to something)?

1. Ask this question when you notice a shift in affect during a session.

2. Have the client describe a problematic situation or a time during which he/she experienced a shift in affect

3. If needed, use imagery to describe the situation in detail "as if it's happening now« 

4. If needed have the client roleplay a specific interaction

Other questions to elicit automatic thoughts:

5. What do you guess you were thinking about? 6. What did this situation mean to you?7. What images or memories did you have in

this situation?8. What were you afraid might happen?9. Were you thinking____________? (Therapist

supplies an automatic thought opposite to the expected one.)

10. What does this say about you, your life, your future?

What are the cognitions we evaluate in therapy?

Interpretations Meanings

Predictions Judgments

Labels Memories (selective)

Images Self-talk

Perceptions Attributions of cause as

to why things

happen

Hot Thought

Is the thought that is more emotionally charged -- strongly connected with the emotional shift.

Is the thought that triggers the mood change.

Appear spontaneously during the day.

It can be words, images or memories.

We circle the Hot Thought in the Thought Record and focus on this thought.

THOUGHT RECORD

Situation Mood 1- 100

Automatic Thought

Evidence For AT

Evidence Against AT

Balanced/ Alternative Viewpoint

Re-rate Mood

Thought RecordFirst 3 columns

Situation

1. What2. When3. Where4. With who

Mood(Rate 0-100%)

AutomaticThoughts(Circle Hot Thought)

Evidence that supports the Hot

Thought We ask for facts, things that

actually happened in the past.

This includes situations, experiences, reactions, consequences, etc.

We don’t write down ideas, interpretations of facts or thoughts in this column

Evidence Against the Hot Thought

Have I had any experiences that don’t support the H.T. or that would indicate that it is not 100% true?

If my best friend would have this thought, what would I tell him/her?

When I am not feeling this way, do I think differently in the same situations? How?

When I felt this way in the past, what helped me feel better?

In five years from now, would I look at this situation differently? Would I focus on a different part of my experience?

Are there any positives in me or the situation that I am ignoring?

Am I blaming myself for something over which I do not have complete control?

Adaptation from Mind over Mood, Greenberger, Padesky 1995 Guildford Press

THOUGHT RECORD

Situation Mood 1- 100

Automatic Thought

Evidence For AT

Evidence Against AT

Balanced/ Alternative Viewpoint

Re-rate Mood

How to create a Balanced or Alternative Thought

Considering the information listed for and against the hot thought, is there an alternative way of understanding or thinking about this situation?

Write one sentence summarizing or combining the information of both columns (using “even though”, “and”, etc.)

Can other people think of other way of understanding this situation?

If a friend of mine would be in this situation, how would I suggest to understand it?

If my hot thought is true, what is the worst, the best and the most realistic outcome?

Adaptation from Mind over Mood, Greenberger, Padesky 1995 Guildford Press

Cognitive Distortions

Are patterns of dysfunctional thinking

Instead of reacting to the reality of an event, an individual reacts with a personal interpretation that is partial.

For example, a person may conclude that is worthless just because he was not invited to a party or did not pass an exam.

Cognitive therapists make patients aware of these distorted thinking patterns.

COGNITIVE DISTORTIONS-Patterns of negative thinking-

1. All or nothing thinking: You view a situation in only two categories instead of on a continuum."If I'm not a total success, I'm a failure."

2. Castastrophizing: You predict the future negatively without considering other, more likely outcomes." I’ll be so upset, I won't be able to function at all."

3. Disqualifying or discounting the positive: Youunreasonably tell yourself that positive experiences or qualities do not count. I did that project well, but that doesn't mean I'm competent; I just got lucky."

4. Emotional reasoning: You think something must be true because you "feel" (actually believe) it so strongly, ignoring or discounting evidence to the contrary."I know I do a lot of things okay at work, but I still feel like a failure.»

5. Labeling: You put a fixed, global label on yourself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion."I'm a loser." " He's no good. »

6. Magnification/minimization: When you evaluate yourself, another person, or a situation, you unreasonably magnify the negative and/or minimize the positive."Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn't mean I'm smart."

David Burns3 columns exercise to identify

cognitive distortions

Automatic Thought

IdentifyCognitive Distortions

Alternative Thought

If I don’t present an excellent report to my boss, he might fire me and I won’t have money to support my family.(Anxious 90% Afraid 80% )

Mental FilterCatastrophizing

Even if this report is not presented in an excellent way, I am an efficient, reliable and experienced employee and would not be so easy to replace me.(Anxious 50%, Afraid 40%)

Examples of Non-Socratic Questions/Comments

(note how much less useful they are. )

1. Why are you being so hard on yourself?

2. What's the big deal about yelling atyour kids? Almost everyone does it.

3. Didn't your parents ever yell at you?

4. I'm sure your kids will get over it. It doesn't seem so bad to me .

5. You're basically a great mother; don't you remember what you told me you did for your kids the other day?

Read more about Cognitive Behavioural Therapy here:

http://www.cbtpsychology.com

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Thank you!