COGNITIVE COGNITIVE BEHAVIORAL THERAPYBEHAVIORAL THERAPY

Ann Olincy, M.D.Ann Olincy, M.D.Associate Professor of Associate Professor of

PsychiatryPsychiatry

Uses of Cognitive Behavioral Uses of Cognitive Behavioral Therapy (CBT)Therapy (CBT)

Any disorder with distortions in Any disorder with distortions in thinking or dysfunctional behaviorthinking or dysfunctional behavior– Anxiety disorders Anxiety disorders

Post traumatic stress disorderPost traumatic stress disorderPanic disorderPanic disorderObsessive/compulsive disorderObsessive/compulsive disorder

– DepressionDepression– SchizophreniaSchizophrenia– Personality disordersPersonality disorders

First Step: LearningFirst Step: Learning

Begin with education about the Begin with education about the illnessillness– SymptomsSymptoms– CausesCauses

HeredityHeredityChildhood circumstancesChildhood circumstancesStressStressTriggersTriggersBrain chemicalsBrain chemicalsMedical conditionsMedical conditions

Second step: Identify Things That Second step: Identify Things That Maintain The Thoughts/BehaviorsMaintain The Thoughts/Behaviors

AvoidanceAvoidance Self talk-what you say in your mindSelf talk-what you say in your mind Mistaken beliefs-thoughts about Mistaken beliefs-thoughts about

yourself and your lifeyourself and your life Withheld feelings-anger, frustration, Withheld feelings-anger, frustration,

sadnesssadness Lack of assertivenessLack of assertiveness

Second step: Identify Things That Second step: Identify Things That Maintain The Thoughts/BehaviorsMaintain The Thoughts/Behaviors

Lack of self-nurturing skillsLack of self-nurturing skills Muscle tensionMuscle tension Stimulants or other diet factorsStimulants or other diet factors High stress lifestyleHigh stress lifestyle Lack of sense of purposeLack of sense of purpose

Third Step: Identify Things That Third Step: Identify Things That May Help In RecoveryMay Help In Recovery

PhysicalPhysical– Medical (medications)Medical (medications)– RelaxationRelaxation– Nutrition/dietNutrition/diet

EmotionalEmotional– Express suppressed feelingsExpress suppressed feelings

BehavioralBehavioral– Confront the things you avoidConfront the things you avoid

Third Step: Identify Things That Third Step: Identify Things That May Help In RecoveryMay Help In Recovery

MentalMental– Counter negative self-talkCounter negative self-talk

InterpersonalInterpersonal– Build strong, supportive relationshipsBuild strong, supportive relationships

Whole levelWhole level– Improve self esteemImprove self esteem

Third Step: Identify Things That Third Step: Identify Things That May Help In RecoveryMay Help In Recovery

MentalMental– Counter negative self-talkCounter negative self-talk

InterpersonalInterpersonal– Build strong, supportive relationshipsBuild strong, supportive relationships

Whole levelWhole level– Improve self esteemImprove self esteem

Third Step: Identify Things That Third Step: Identify Things That May Help In RecoveryMay Help In Recovery

Existential/spiritualExistential/spiritual– Find a broad purpose or direction in Find a broad purpose or direction in

their life that gives a person meaningtheir life that gives a person meaning Take responsibility for your problemsTake responsibility for your problems Examining motivations for illness and Examining motivations for illness and

overcoming secondary gainsovercoming secondary gains Willingness to take risksWillingness to take risks

– Make a commitment to changeMake a commitment to change

Fourth Step: Learn How to CopeFourth Step: Learn How to Cope

Deflate the danger-face symptoms don’t Deflate the danger-face symptoms don’t run from themrun from them

Coping statementsCoping statements– ””This feeling isn’t comfortable but I can handle This feeling isn’t comfortable but I can handle

it.”it.”– “ “This isn’t the worst thing that could happen.”This isn’t the worst thing that could happen.”– ““This will pass.”This will pass.”– ““These are just thoughts-not reality.”These are just thoughts-not reality.”– ““Nothing serious is going to happen to me.”Nothing serious is going to happen to me.”

Fourth Step: Learn How to CopeFourth Step: Learn How to Cope

Explore the antecedents and identify Explore the antecedents and identify preliminary signs to preempt a full preliminary signs to preempt a full blown episodeblown episode

Do something that requires focused Do something that requires focused concentration to draw your attention concentration to draw your attention from the uncomfortable feelingsfrom the uncomfortable feelings

Fourth Step: Learn How to CopeFourth Step: Learn How to Cope

Express your emotionsExpress your emotions Practice thought stopping-shout Practice thought stopping-shout

“stop it” or if others are around, “stop it” or if others are around, visualize a stop signvisualize a stop sign

RelaxationRelaxation

Relaxation BenefitsRelaxation Benefits

Decrease heart rate, respiratory rate, Decrease heart rate, respiratory rate, blood pressure, muscle tension, blood pressure, muscle tension, metabolic rate, oxygen consumption, metabolic rate, oxygen consumption, analytical thinkinganalytical thinking

Increase energy and productivity, Increase energy and productivity, concentration and memoryconcentration and memory

Relaxation BenefitsRelaxation Benefits

Decrease insomnia and fatigueDecrease insomnia and fatigue Decrease psychosomatic disordersDecrease psychosomatic disorders Increase self-confidenceIncrease self-confidence Increase availability of feelingsIncrease availability of feelings

Relaxation TechniquesRelaxation Techniques

Abdominal breathingAbdominal breathing Progressive muscle relaxationProgressive muscle relaxation Visualizing a peaceful sceneVisualizing a peaceful scene MeditationMeditation Guided imageryGuided imagery BiofeedbackBiofeedback Sensory deprivationSensory deprivation Physical exercisePhysical exercise

Fifth Step: Behaviors- Fifth Step: Behaviors- DesensitizationDesensitization

Imagery desensitizationImagery desensitization– Unlearning the connection between Unlearning the connection between

emotion and particular situationemotion and particular situation– Visualize yourself in the situation that is Visualize yourself in the situation that is

disturbing and then practice relaxationdisturbing and then practice relaxation– Hierarchical-pick the least disturbing Hierarchical-pick the least disturbing

that you can tolerate and work up to the that you can tolerate and work up to the most disturbing when these are most disturbing when these are conqueredconquered

DesensitizationDesensitization

Real-life desensitizationReal-life desensitization– Put yourself in a real situation that is Put yourself in a real situation that is

disturbing and practice tolerating the disturbing and practice tolerating the feelingsfeelings

– Set goals for recoverySet goals for recovery– Use a support person at the beginningUse a support person at the beginning– Be aware of elements that make you Be aware of elements that make you

anxiousanxious

DesensitizationDesensitization

Real-life desensitizationReal-life desensitization– Be willing to take risksBe willing to take risks– Be willing to tolerate discomfortBe willing to tolerate discomfort– Avoid flooding (overexposure with lack Avoid flooding (overexposure with lack

of control over your emotions)of control over your emotions)– Plan for contingencies-things do go Plan for contingencies-things do go

wrongwrong

DesensitizationDesensitization

Real lifeReal life– Trust your own paceTrust your own pace– Reward yourself for small successesReward yourself for small successes– Use positive coping statements Use positive coping statements – Expect and know how to handle Expect and know how to handle

setbackssetbacks– Be prepared to experience strong Be prepared to experience strong

emotionsemotions

Sixth Step: Cognitions-Self-talkSixth Step: Cognitions-Self-talk

Automatic and subtleAutomatic and subtle One image or word contains scores One image or word contains scores

of memories, thoughts, associationsof memories, thoughts, associations Can be irrational but sounds like the Can be irrational but sounds like the

truthtruth Are learnedAre learned Perpetuates avoidancePerpetuates avoidance

Types of Self-talkTypes of Self-talk

WorrierWorrier– Imagines the worst case scenario, Imagines the worst case scenario,

overestimates the bad, creates images overestimates the bad, creates images of catastropheof catastrophe

– ““What if…”What if…” CriticCritic

– Points out flaws, limits, Points out flaws, limits, – ““You stupid…”You stupid…”

Types of Self-talkTypes of Self-talk

VictimVictim– Helpless, hopeless, something inherently Helpless, hopeless, something inherently

wrongwrong– ““I can’t…”I can’t…”– ““I’ll never be able to…”I’ll never be able to…”

PerfectionistPerfectionist– Efforts not good enough, intolerant of mistakes Efforts not good enough, intolerant of mistakes

or setbacksor setbacks– ““I should…”I should…”– ““I must…”I must…”

Cognitive DistortionsCognitive Distortions

FilteringFiltering– Focus on the negative aspect of a Focus on the negative aspect of a

situationsituation– Worthless, hopeless, pointless, stupid, Worthless, hopeless, pointless, stupid,

failure, dangerous, unfairfailure, dangerous, unfair Emotional reasoningEmotional reasoning

– Judge illogically only on basis of own Judge illogically only on basis of own feelingsfeelings

Should statementsShould statements– Should, must, have toShould, must, have to

Types Of Unrealistic Thinking-Types Of Unrealistic Thinking-Cognitive DistortionsCognitive Distortions

Overestimating odds of negative Overestimating odds of negative outcomeoutcome

CatastrophizingCatastrophizing– Terrible, insufferable, catastrophicTerrible, insufferable, catastrophic

Over generalizingOver generalizing– One bad experience will repeat itselfOne bad experience will repeat itself– Never, always, all, every, none, no one, Never, always, all, every, none, no one,

nobody, everyone, everythingnobody, everyone, everything

Mistaken BeliefsMistaken Beliefs

I’m powerlessI’m powerless Life is a struggleLife is a struggle If I take a risk I’ll failIf I take a risk I’ll fail I should always look and act good no I should always look and act good no

matter how I feelmatter how I feel If I worry enough this problem will If I worry enough this problem will

get betterget better

Mistaken BeliefsMistaken Beliefs

I can’t cope with difficult situationsI can’t cope with difficult situations The outside world is dangerousThe outside world is dangerous My needs don’t matterMy needs don’t matter I’m worthlessI’m worthless I’m unlovableI’m unlovable

Challenging Mistaken BeliefsChallenging Mistaken Beliefs

What is the evidence for the belief?What is the evidence for the belief? Is this invariably or always true?Is this invariably or always true? Does this look at the whole picture?Does this look at the whole picture? Does this promote well-being?Does this promote well-being? Did I choose this belief on my own?Did I choose this belief on my own?

Positive CounterstatementsPositive Counterstatements

The worrierThe worrier– ““So what”So what”

The criticThe critic– ““I’m ok the way I am”I’m ok the way I am”– ““I accept and believe in myself”I accept and believe in myself”

The victimThe victim– ““It’s never too late to change”It’s never too late to change”

The perfectionistThe perfectionist– ““It’s ok to make mistakes”It’s ok to make mistakes”

Positive CounterstatementsPositive Counterstatements

Write down and rehearseWrite down and rehearse Examine the evidenceExamine the evidence

– What are the odds of this really What are the odds of this really happening?happening?

– Is this always true?Is this always true?– What is the worst that could happen?What is the worst that could happen?– Am I looking at the whole picture?Am I looking at the whole picture?– Am I fully objective?Am I fully objective?

Daily Record of Dysfunctional Daily Record of Dysfunctional ThoughtsThoughts

Date Date Situation Situation EmotionsEmotions Automatic Automatic Thoughts Thoughts

Rational Rational Response Response

OutcomeOutcome

Describe:Describe:

Actual Actual event event leading to leading to unpleasant unpleasant emotion emotion

Specify Specify emotion emotion

Write Write automatic automatic thought that thought that preceded preceded emotion emotion

Write rational Write rational response to response to automatic automatic thought thought

Re-rate belief Re-rate belief in automatic in automatic thoughtthought

0-1000-100

Stream ofStream of

thoughts thoughts leading to leading to unpleasant unpleasant emotion emotion

Rate degree Rate degree of emotion of emotion

0-100 0-100

Rate belief Rate belief in automatic in automatic thoughtsthoughts

0-1000-100

Rate belief in Rate belief in rational rational responseresponse

0-1000-100

Specify and Specify and rate rate subsequent subsequent emotionsemotions

0-1000-100