Cognitive-Behavioral Applicationsin Primary Care

Scott S. Meit, PsyD, MBA, FAACPScott S. Meit, PsyD, MBA, FAACP

Vice Chair for PsychologyVice Chair for Psychology

Department of Psychiatry and Department of Psychiatry and PsychologyPsychology

The Cleveland ClinicThe Cleveland Clinic

Learning Objectives

To incorporate a fundamental model of CBT To gain skill in identifying common thought

distortions To prep for basic application of CBT

methodology & techniques in the primary care setting

What is “Talk Therapy” ?

a. A generic term used by many docs making a referral for counseling

b. A non-descript term that irritates Scott

c. a & b

So… What is Cognitive-Behavioral

Therapy?(The Basics)

How we think (cognition), how we feel (emotion & affect), and how we act (behavior) all interact

our thoughts influence our feelings and behavior

our feelings influence our behavior and thoughts

our behavior influences our emotions and thoughts

A CBT Model

© Copyright 1986 Center for Cognitive Therapy

Learn your ABCs (courtesy of Ellis)

A = antecedent events B = beliefs C = consequences

10 common thought distortions(courtesy of Beck)

1. All-or-Nothing Thinking

2. Overgeneralization

3. Mental Filter

4. Disqualifying the Positive

5. Jumping to Conclusions

6. Magnification and Minimization

7. Emotional Reasoning

8. Should Statements

9. Labeling and Mislabeling

10. Personalization

A little practice…

Donna just “cheated” on her diet. I'm a fat, lazy pig, she thinks.

Labeling

Reframe =

“I slipped; what do I need to do differently?”

As Mary is driving home, a man waves her to go ahead of him (as she merges into traffic). Later in her trip, another driver cuts her off. She grumbles to herself, “there are nothing but rude and insensitive people in this town.”

Mental Filter

Re-calibrating question?

“Nothing but rude & insensitive people in this town?! If you had to, do you think you could prove that in a court of law – before a jury of your peers?”

Jean's son is doing poorly in school. She feels that she must be a bad mother. She feels that it's all her fault that he isn't studying

Personalization

Problem-solving Questions =1. What are the “high probability” (rule-in)

explanations for my son’s academic difficulties?

2. What are the “ingredients" of this unsavory broth?

3. How might the identified problems, suggest reasonable solutions?

Jumping to Conclusions

A re-calibrating question =

What are alternative high probability explanations (for her being late)?

Chuck is waiting for his date at a restaurant. She's 20 minutes late. Chuck laments he must have done something wrong; she has stood him up! Meanwhile, across town, his date is stuck in traffic.

Cognitive Re-structuring

is

The process of learning to refute cognitive distortions; fundamentally, challenging "faulty” thinking.

Goal = replace irrational, counter-factual beliefs with more accurate and beneficial ones.

Unrealistic expectations are particularly malignant

"Everyone must love me” “Making mistakes is terrible” “I have to be the best at everything" “I must be married/make “partner”/make my

1st million by age ______”

Remember…

Unrealistic beliefs are directly responsible for generating dysfunctional emotions and their resultant behaviors, like stress, depression, anxiety, and social withdrawal. One can rid themselves of such emotions (and their effects) by dismantling the beliefs that give them life

3 Simple Steps

1. Gain awareness of detrimental thought habits

2. Learn to challenge them

3. Substitute life-enhancing thoughts and beliefs

Other CBT Techniques

Thought Records Experiments

Thought Recordsadapted from Greenberger & Padesky, Mind over Mood © 1995

Situations(the who, when, where)

Thanksgiving at

son’s home

They’re all pretty busy doing their own thing

Thoughts(automatic, “hot thoughts”)

I’m not needed

anymore

Feelings(concomitant, generated emotion)

Very sad

Evidence(not supporting “hot thoughts”)

Son did ask me questions about maybe building a deck next spring; granddaughter asked me what I thought of her outfit before she left for a date

Integration(bringing it all together)

The family may not ask me for the same kind of help (as in the past), but they still do ask for my opinions & advise

Experiments(used to challenge catastrophic predictions)

“I could never learn to golf”

(Experiment = take golf lessons) “No one would ever go to prom with me”

(Experiment = commit to asking at least 5 potential dates)

“I could never get into college”

(Experiment = meet with your h.s. guidance counselor and create and implement a college application plan)

What’s the Evidence for CBT?

American Psychiatric Association Practice Guidelines (April 2000) indicate that, among psychotherapeutic approaches, cognitive behavioral therapy (and interpersonal psychotherapy) has the best-documented efficacy for treatment

of major depressive disorder. In an article reviewing the various treatments for Panic Disorder

with Agoraphobia (PDA), Michelson and Marchione (1991) concluded that CBT is the treatment of choice for PDA.

Cochrane Review (2007) confirms effectiveness of CBT for

Generalized Anxiety Disorder

Further Reading & Resources

American Psychiatric Association (2000). Treatment Recommendations for Patients with Major Depressive Disorder. (Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Second Edition). http://www.psych.org/psych_pract/treatg/pg/MDD2e_05-15-06.pdfRetrieved on October 14, 2007.

Beck, Aaron T (1975). Cognitive Therapy and the Emotional Disorders.International Universities Press Inc., ISBN 0-8236-0990-1

Ellis, Albert (2001). Overcoming Destructive Beliefs, Feelings, and Behaviors. Prometheus Books. ISBN 978-1573928793. 

Greenberger, D. & Padesky, C. (1995). Mind over Mood. The Guilford Press; 1st edition (March 15, 1995) ISBN-10: 0898621283

Hunot V, Churchill R, Silva de Lima M, Teixeira V. Psychological therapies for generalised anxiety disorder (Review). Cochrane Database of Systematic Rev; 2007,1.

Michelson, L.K. & Marchione, K. (1991).  Behavioral, Cognitive, and Pharmacological Treatments of PDA: Critique and Synthesis.  Journal of Consulting and Clinical Psychology, 59, 100-114.