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Cognitive Behavioral Therapy APNA eLearning Center

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Cognitive Behavioral Therapy

Barbara Jones Warren, PhD, RN, CNS‐BC, PMH

This speaker has no conflicts of interest to discloseThis speaker has no conflicts of interest to disclose.

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Purposes of Today’s Dialogue

• Describe the use of cognitive behavioral therapy (CBT) in psychiatric mental health (PMH) settings

• Discuss the components of CBT

– Cognitive

– Rational emotive

• Explain the clinical application of CBT

– Case studies

– Treatment planning and implementation

– Evaluation of CBT

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Use of CBT in PMH Settings

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Use of CBT

• For self and personal growth

– Individuals

– Groups

– Families

– Couple, partner, marital relationships

– Workplace environments

• Mental health, wellness, illness foci

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Efficacy of CBT

• Mood disorders

• Anxiety disorders

• Obsessive Compulsive Disorder

• Panic disorder

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Life Just Isn’t Interesting or Fun!Clinically: One Cannot Function!

Rapid Psychler Press, www.psychler.com; 2012 6


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An Ongoing Low‐Grade Depression


Specific Time, Season of the Year


An Ongoing Low‐Grade Depression


Extreme Energy, Out‐of‐Control Behavior


Low‐Grade Ongoing Hyperactivity




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Components of CBT(Cognitive, Rational Emotive)

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Founders of CBT

• Epictetus: Greek philosopher, started the premise of the therapy

– People are not disturbed by things

– Disturbed by the view they have regarding what has happened

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Aaron Beck

Cognitive Therapy

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Beck’s Theory

Depressed people have a negative view of:

• Themselves

• The world

• The future

Depressed people have negative schemas or frames of reference through which they interpret all events and experiences

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Depression and Negative Schemas

Negative schemas:

• Always present

• Unconscious

• Become activated with stressful events

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Definition of CBT

• Focused form of psychotherapyMental illnesses involve dysfunctional thinking– Mental illnesses involve dysfunctional thinking

• Structure of experiences feelings and behaviors

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Premises for CBT

• Modifying dysfunctional thinking provides improvements in symptoms and modifying dysfunctional beliefs that underlie d f i l hi ki l ddysfunctional thinking leads to more durable improvement

• Therapy is driven by a cognitive conceptualization and uses a variety of strategies

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Premises for CBT

• Fact not assumptions

• Structured and directive – Maladaptive behaviors are not a result of skill deficits

– Unwanted reactions are learned

• Therapy is driven by a cognitive conceptualization and uses a variety of strategies

• Practice and assignments

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Progression of Thinking

Situation

Automatic Thoughts And Images

Reaction (Emotional,Behavioral and physiological)

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The Cognitive Triad

• Negative view of the self (e.g., I’m unlovable, ineffective)

• Negative view of the future (e g nothing willNegative view of the future (e.g., nothing will work out)

• Negative view of the world (e.g., world is hostile)

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The Cognitive ModelCore Beliefs

Assumptions

Compensatory/coping strategies

Situation

Automatic thoughts/images

Reaction (emotional/behavioral physiological)23

CBT: Collaborative Effort

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Roles

• Client

– Define goals

– Delineate concerns

– Implement techniquesp q

• Therapist

– Assist client to define goals

– Listen to the client

– Teach CBT techniques

– Reinforce and encourage

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Calmness & Neutrality

• Managing difficult situations

• Use calmness and neutrality

– Avoid 2 problems real problem and anxiety/ being upset

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Albert Ellis

Rational Emotive TherapyTherapy

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Premises of Rational Emotive Therapy

• Clients learn how to choose their reactions

• Self‐observation and personal change

• Here and now basis

• Self help techniques that facilitate coping• Self‐help techniques that facilitate coping

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Self‐Defeating Rules (Irrational Beliefs)

1. I need love and approval from those around to me.

2. I must avoid disapproval from any source.3. To be worthwhile as a person I must achieve

success at whatever I do.4 I can not allow myself to make mistakes4. I can not allow myself to make mistakes.5. People should always do the right thing.

When they behave obnoxiously, unfairly or selfishly, they must be blamed and punished.

6. Things must be the way I want them to be.7. My unhappiness is caused by things that are

outside my control – so there is nothing I can do to feel any better.

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8. I must worry about things that could be dangerous, unpleasant or frightening –otherwise they might happen.

9. I must avoid life’s difficulties, unpleasantness, and responsibilities.

10. Everyone needs to depend on someone stronger than themselves.

11 Events in my past are the cause of my11. Events in my past are the cause of my problems – and they continue to influence my feelings and behaviours now.

12. I should become upset when other people have problems, and feel unhappy when they’re sad.

13. I shouldn’t have to feel discomfort and pain.14. Every problem should have an ideal solution.

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Irrational Thinking and Emotional Disturbance

• A= Failure at work

• B= I am stupid, I’ll never be able to be good at work, I will always fail

• C= Depressive disorder

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Ellis’ List of Common Irrational Ideas

• I absolutely must have sincere love and approval almost all the time from all the significant people in my life

• I must be thoroughly competent, adequate and achieving in all respects, or I must at least have real competence or talent at something important; otherwise I am worthlessat something important; otherwise I am worthless.

• People who harm me or who do a bad thing are uniformly bad or wicked individuals, and I should severely blame, damn, and punish them for their sins and misdeeds

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Ellis’ List of Common Irrational Ideas (continued)

• When things do not go the way I would like them to go, life is awful, terrible, horrible, or catastrophic

• Unhappiness is caused by external events• Unhappiness is caused by external events

over which I have almost no control. I also have little ability to control my feelings or rid myself of feelings of depression and hostility.

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Clinical Application of CBT

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CBT & RET

• RET:– Identify patient’s irrational beliefs

• CBT:– Teach the patient to dispute the beliefs andTeach the patient to dispute the beliefs and substitute logical and rational beliefs

– Evaluate the effects of disputing their irrational beliefs

• Problem solving skills and assertiveness training

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Case Studies

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Example of Negative Thinking

• Person with negative schema involving rejection will become depressed when a partner leaves him or her

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Original Meeting and Assessment Time

A 23 year old Jewish‐American woman comes to the office to see me. After my initial introduction, I ask her what she needs from me today and what would she describe as herme today and what would she describe as her primary need.

She answers, somewhat tearfully, that she is worried about how to manage her stress. “I don’t want to be like my Mother. She has been depressed her entire life and never got help.”

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Continued

She continues to talk about her current situation and says she had dropped out of school just recently due to stress. Her affect is flat and she is tearful throughout the ginterview. She mentions (with questioning) that she has had periodic times of “thinking of wanting to not be around” but has no plans or intent of pursuing these thoughts.

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Continued

Her social support primarily consists of her fiancé and some female friends who she has known since middle school. She is not particularly close to her Father, saying that he has never been supportive of her In addition he recently re married a muchher. In addition, he recently re‐married a much younger woman (Aged 28, Father is 70 yrs.) and is “spending money like mad. He never would buy my Mother or us anything. I do not understand why he is acting like this. My Mother is even more depressed about this circumstance.” The client also reports that her parents divorced when she was in the 3rd grade.

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Continued

The client reports no physical diagnoses. She is clean but somewhat disheveled in her overall appearance. He is appropriate in affect, shows no indication of psychosis but is slow to respond to questions evenpsychosis but is slow to respond to questions, even though her responses are appropriate. She is slightly overweight and mentions this as a concern for her.

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Continued

At this point, what is your impression of this client?

What initial diagnoses might you consider? Consider all of the Axes I ‐ V

Are there interventions that you would Are there interventions that you would consider regarding counseling techniques?

Are there medications that you might consider using?

Are there other issues that you see as meaningful to consider?

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Depression References

• Warren, B. J. (2010). Depression: Management of depressive disorders and suicidal behavior. In M.A. Boyd (Ed.), Psychiatric Nursing: Contemporary Practice (5th ed.) (Ch.24). Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins.

• Warren, B. J., & Lutz, W. J. (2007a). The state of nursing science: Cultural and lifespan issues Depression part II: Focus on adults. Issues in Mental Health Nursing, 28(7), 707‐748.

• Warren, B. J., & Lutz, W. J. (2007b). The state of nursing science: Cultural and lifespan issues Depression Part II: Focus on children and adolescents. Issues in Mental Health Nursing, 28(7), 749‐764.

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Treatment Planning & Implementation

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Treatment Plan• What members of the transdisciplinary team are

involved? • How do you, as a PMH nurse facilitate the use of

CBT & RET within your clinical setting?• Reinforce/implement CBT and RET interventions

included in the treatment plan.• Read the treatment plan & reinforce items within

your scope of practice• Chart to the treatment plan.• If the treatment Plan indicates “client will be

redirected using CBT techniques” you may chart something like, “client was redirected four times this evening.”

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CBT: Sessions

• Identify and changing maladaptive thoughts

• First sessions: therapist explains cognitive theory of emotional disorders (negative cognitions contribute to distress)

Middl S i Cli t i t ht t id tif• Middle Sessions: Client is taught to identify, evaluate and replace negative automatic thoughts were more positive cognitions

• Therapist is a collaborator

• Final Sessions: solidify gains, focus on prevention of recurrence

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CBT and RET

• Identifying Assumptions and Core Beliefs

• “If…, then…”

• Downward arrow

‐ If this thought is true, what’s so bad about that?

‐What’s the worst part about that?

‐What does it mean to you? About you?

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Relapse Prevention

• Solidify gains: broaden range of identified negative thoughts and strengthen more positive cognitions

• Anticipate future stressful life events that• Anticipate future stressful life events that might trigger a future depression and role play more adaptive responses

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Evaluation of CBT

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Nursing Clinical Reasoning Processes

OngoingBi h i l

Practice the techniques yourself!

BiopsychosocialAssessment & Monitoring

Burns, D.D, (1989). The feeling good handbook. New York, NY: Plume Book50

CBT & RET References

• Bernard, M. E. (1986). Staying Rational In an Irrational World: Albert Ellis and Bond, F.W. & Dryden, W. (2002). Handbook of Brief Cognitive Behaviour Therapy. Chichester. John Wiley & Sons Ltd.

• Dryden, W. (1995). Brief Rational Emotive Behaviour Therapy. Chichester. John Wiley & Sons.

• Ellis, A. (1988). How To Stubbornly Refuse To Make Yourself Miserable About Anything. New York. Lyle Stuart.

• Ellis, A. & Harper, R. A. (1975). A New Guide to Rational Living. Hollywood. Wilshire Book Co.

• Ellis, A., Wolfe, J. & Moseley, S. (1980). How to Raise an Emotionally Healthy, Happy Child. Hollywood. Wilshire Book Co

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CBT & RET References

• Ellis, A. & Dryden W. (1997). The Practice of REBT (Second edition). London. Free Association Books.

• National Association of Cognitive‐Behavioral Therapists, http://www.nacbt.org/whatiscbt.htm

• Still, A. & Dryden, W. (2003). Ellis and Epictetus: Dialogue vs. , y , ( ) p gmethod in psychotherapy. Journal of Rational‐Emotive & Cognitive‐Behaviour Therapy. 21(2), 37‐56

• Ziegler, D.J. (2002). Freud, Rogers, and Ellis: A comparative theoretical analysis. Journal of Rational‐Emotive and Cognitive‐Behavior Therapy. 20(2)

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