Cognitive Behavioural Therapy Workshop Sydney Campus 10am .
Cognitive Behavioural TherapyworkshopSydney campus10am – 1pmJanuary 12 2017Dr Vicki Hutton (vicki.hutton@acap.edu.au)CONTENTS1. COGNITIVE BEHAVIOURAL THERAPY: AN EVIDENCE-BASEDPSYCHOLOGICAL INTERVENTION .22. OTHER THERAPIES RELATED TO CBT .33. DEFINING AND DESCRIBING CBT .44. ROLE OF THERAPIST .55. ROLE OF CLIENT .66. STRUCTURE (including INTERVENTIONS) .77. GROUP THERAPY .238. APPENDIX – SAMPLE WORKSHEETS .281
1. COGNITIVE BEHAVIOURAL THERAPY: AN EVIDENCE-BASEDPSYCHOLOGICAL INTERVENTIONCognitive Behavioural Therapy (CBT) has made a massive contribution to mental health care,but it is a broad tradition with some practitioners at the cognitive end and some at thebehavioural end. CBT has also evolved over the years.APS definition:Cognitive Behaviour Therapy (CBT) is a focused approach based on the premise that cognitionsinfluence feelings and behaviours and, that subsequent behaviours and emotions can influencecognitions. The therapist helps individuals identify unhelpful thoughts, emotions andbehaviours. CBT has two aspects: behaviour therapy and cognitive therapy. Behaviour therapyis based on the theory that behaviour is learned and therefore can be changed. Examples ofbehavioural techniques include exposure, activity scheduling, relaxation, and behaviourmodification. Cognitive therapy is based on the theory that distressing emotions andmaladaptive behaviours are the result of faulty patterns of thinking. Therefore, therapeuticinterventions, such as cognitive restructuring and self-instructional training are aimed atreplacing such dysfunctional thoughts with more helpful cognitions, which leads to analleviation of problem thoughts, emotions and behaviour. Skills training (e.g., stressmanagement, social skills training, parent training, and anger management), is anotherimportant component of CBT.Evidence-based Psychological Interventions in the Treatment of Mental Disorders: A LiteratureReview third edition (Copyright 2010 The Australian Psychological Society Ltd.)Why is CBT so popular?CBT has the most research evidence of effectiveness for a wide range of mental healthdisorders. (Mental disorder is a term used to describe a range of clinically diagnosabledisorders that significantly interfere with an individual’s cognitive, emotional or socialfunctioning.)(Better Access to Mental Health Care initiative, 2007)CBT is used in some of our placement agencies for clients experiencing a range of conditions,including: Mood/anxiety disordersPTSDPersonality disordersSelf-esteem issuesEating disordersSelf-injurySuicidal ideation2
2. OTHER THERAPIES RELATED TO CBTBehavioural activation (BA): a method that recognises that individuals with depression maychoose inactivity rather than activities they previously enjoyed. Methods such as positivereinforcement are used to increase the person’s activities. (See ‘Behavioural Activation’worksheet in the Appendix).Rational emotive behaviour therapy (REBT) (Albert Ellis): first of the cognitive behaviourtherapies. It is based on the assumption that cognitions, emotions and behaviours interactsignificantly and have a reciprocal cause-and-effect relationship (A-B-C-D-E model – Activatingevent emotional or behavioural Consequence/reaction. Beliefs about A create C. Disputing new Effective philosophy).Cognitive therapy (CT) (Aaron Beck): CT is active, directive, time-limited, present-centred,problem-oriented, collaborative, structured, and empirical. There are three theoreticalassumptions: (1) people’s thought processes are accessible to introspection; (2) people’sbeliefs have highly personal meanings; (3) people can discover these meanings themselvesrather than being taught or having them interpreted by the therapist.Cognitive-behaviour modification (Donald Meichenbaum): Focus on changing self-talk, butnot as direct and confrontational in uncovering and disputing irrational thoughts as REBT.Cognitive narrative approach to CBT: Focus on plots, characters and themes in the storiespeople tell about themselves and others regarding significant events in their lives.Schema-Focused Therapy: Focus on identifying and changing maladaptive schemas and theirassociated ineffective coping strategies through cognitive and experiential work.In addition, the third wave of CBT includes holistic, reflexive and experiential themes:Dialectical behaviour therapy (DBT): The overall goal is the reduction of ineffective actiontendencies linked with deregulated emotions. It is delivered in four modes of therapy:(1) Traditional didactic relationship with the therapist;(2) Skills training, which involves teaching the four basic DBT skills of mindfulness, distresstolerance, emotion regulation and interpersonal effectiveness;(3) Skills generalisation in which the focus is on helping the individual integrate the skillslearnt into real-life situations;(4) Team consultation.Acceptance and commitment therapy (ACT): ACT helps individuals increase their acceptanceof the full range of subjective experiences, including distressing thoughts, beliefs, sensations,and feelings, in an effort to promote desired behaviour change that will lead to improvedquality of life. ACT reframes symptoms as ‘difficult thoughts and feelings’ and advocates forpeople to perceive these thoughts and feelings as harmless and transient.Mindfulness-based cognitive therapy (MBCT): Group treatment that emphasises mindfulnessmeditation as the primary therapeutic technique. In MBCT, the emphasis is on changing therelationship to thoughts, rather than challenging them.3
3. DEFINING AND DESCRIBING CBTCBT is a therapy that helps people look at the different situations that they find themselves in,and to understand their thoughts, emotions and behaviours.The CBT model proposes that it is not the situation that causes the emotional distress that anindividual experiences. Rather, it is the individual’s interpretation or view of that event orsituation which causes the emotional distress.Key therapeutic principles underpinning CBT: Therapy is regarded as a collaborative project between client and counsellorThe work is problem-focused and structuredTherapy is time-limitedPractice is informed by researchWestbrook, D., Kennerley, H., & Kirk, J. (2001). An introduction to Cognitive Behaviour Therapy:Skills and applications (2nd ed.). London: Sage.4
4. ROLE OF THE THERAPISTPercentage (%) of total psychotherapy outcome variance attributable to therapeutic factors.*Unexplained variance: expectancy, extra-therapeutic change and moreNorcross, J.C. (2011, p.13)Psychotherapy relationships that work: Evidence-based responsivenessOxford Scholarship On-lineOne of the fundamental principles of CBT is that there needs to be a collaborative relationshipbetween the client and therapist. This collaboration takes the form of a therapeutic alliance inwhich the therapist and client work together to fight a common enemy: the client's distress.To establish a collaborative relationship, the therapist needs to strike a balance between beingdirective and imposing structure on the one hand, and allowing the client to make choices andtake responsibility on the other. This balance involves deciding when to talk and when tolisten; when to confront and when to back off; when to offer suggestions and when to wait forthe client to make their own suggestions.Beck Institute for Cognitive Behavior Therapy: Cognitive Therapy and the Emotional Disorders,pp. 220-221; Cognitive Therapy of Depression, pp. 50-545
According to Dryden (2015), general therapeutic goals at the outset of therapy include: Develop an effective working allianceProvide a safe place for clients to discuss what is importantHelp clients see that they can effectively address concernsShow clients you are genuine with them, understand them from their frame of reference,accept themEstablish a communication forum where you both talk freely about mutual experiences oftherapy (i.e. establish meta-therapy dialogue)Dryden, W. (2015). How to help your clients get the most out of CBT: A therapist’s guide. NewYork, NY: Routledge.5. ROLE OF THE CLIENTThe client’s role in CBT includes: Speak openly about their problemsBe active in the therapeutic process, speak up, giving their opinion about therapyUndertake to carry out agreed tasks in the service of goalsDryden, W. (2015). How to help your clients get the most out of CBT: A therapist’s guide. NewYork, NY: Routledge.Clients who are suitable for the CBT approach to therapy: Can recognise automatic thoughts or imagesCan recognise and distinguish changes in affect or emotionsCan recognise helpful and unhelpful behaviour in self or in othersHave some optimism regarding therapyAccept both responsibility and the need for changeAre willing to carry out homework assignmentsAre able to concentrate and focus on an agreed agendaCorrie, S., Townend, M., & Cockx, A. (2016). Assessment and case formulation in CognitiveBehavioural Therapy. London: Sage Publications Ltd.6
6. STRUCTURE (Individual therapy)CBT is a structured stage-by-stage programme, in which the problem behaviour that has beentroubling the client is identified and then modified in a systematic, step-by-step manner. Thefollowing stages are fundamental to CBT:a.b.c.d.e.f.Therapeutic relationshipAssessmentCase formulationInterventionMonitoringRelapsea. Therapeutic relationship Establishing rapport and creating a working allianceSocialisation of the client to the cognitive-behavioural modelWarmth, genuineness and congruenceBeing accepting, respectful and non-judgmentalAttentiveness to the clientAccurate empathyNotion of client-counsellor collaboration - sharing responsibility for defining problems andsolutionsMcLeod, J. (2013). An introduction to counselling (5th ed.). Maidenhead, Berkshire: OpenUniversity Press.b. AssessmentThe assessment is not a list of questions, asked in rigid succession. It is a task around whichclient and therapist work collaboratively and begin to develop a relationship of understandingand trust.The therapist seeks information in four key domains:COGNITIONS – what thoughts and images are occurring, and how is information processed;what words, phrases, images are in the mind of the client when experiencing the problematicsituation?EMOTIONS – different feeling states that occur around the manifestation of the problem.BEHAVIOUR – what does the person do?PHYSICAL – what physical sensations or reactions occur, what physiological or bodilysymptoms are associated with the problem?7
IMPORTANT: You need to elicit information about specific events, not generalised accounts ofwhat usually happens.Steps:1. Invite the client to talk about problematic events and use these descriptions to find out asmuch as possible about: CONTENT that is present within each of the four domains; INTENSITY of the experience; SEQUENCING of elements or their re-occurrence in repeating cycles of dysfunctionalactivity.2. Construct an understanding of how cognitions, emotions, actions and physical states arelinked together.Assessment phase sets the scene for case formulation, treatment planning andimplementation of interventions, but can be therapeutic in itself.Corrie, S., Townend, M., & Cockx, A. (2016). Assessment and case formulation in CognitiveBehavioural Therapy. London: Sage Publications Ltd.ACTIVITYThe ‘Five Areas Assessment of Joan Smith, a 40-year old married woman’ provides an exampleof how to include information from the four key domains in your assessment.Please read the case study, Case 5.2 ‘Panic’ (DSM-5 Clinical Case studies. Anxiety disorders.Retrieved 05#x83514.8290309Work in pairs or groups to develop a ‘five areas assessment’ for this case.Note: The ‘Panic Assessment’ worksheet in the Appendix is also a handy tool to help with thisparticular assessment.8
Williams, C., & Garland, A. (2002). A cognitive-behavioural therapy assessment model for usein everyday clinical practice. Advances in Psychiatric Treatment, 8, 172-179.9
Life situation, relationships and practical problemsAltered thinkingAltered emotionsAltered physical symptoms/feelingsAltered behaviour or activity levels10
Case 5.2 PanicCarlo Faravelli, M.D.Maria Greco was a 23-year-old single woman who was referred for psychiatric evaluation byher cardiologist. In the prior 2 months, she had presented to the emergency room four timesfor acute complaints of palpitations, shortness of breath, sweats, trembling, and the fear thatshe was about to die. Each of these events had a rapid onset. The symptoms peaked withinminutes, leaving her scared, exhausted, and fully convinced that she had just experienced aheart attack. Medical evaluations done right after these episodes yielded normal physicalexam findings, vital signs, lab results, toxicology screens, and electrocardiograms.The patient reported a total of five such attacks in the prior 3 months, with the panic occurringat work, at home, and while driving a car. She had developed a persistent fear of having otherattacks, which led her to take many days off work and to avoid exercise, driving, and coffee.Her sleep quality declined, as did her mood. She avoided social relationships. She did notaccept the reassurance offered to her by friends and physicians, believing that the medicalworkups were negative because they were performed after the resolution of the symptoms.She continued to suspect that something was wrong with her heart and that without anaccurate diagnosis, she was going to die. When she had a panic attack while asleep in themiddle of the night, she finally agreed to see a psychiatrist.Ms. Greco denied a history of previous psychiatric disorders except for a history of anxietyduring childhood that had been diagnosed as a “school phobia.”The patient’s mother had committed suicide by overdose 4 years earlier in the context of arecurrent major depression. At the time of the evaluation, the patient was living with herfather and two younger siblings. The patient had graduated from high school, was working as atelephone operator, and was not dating anyone. Her family and social histories were otherwisenoncontributory.On examination, the patient was an anxious-appearing, cooperative, coherent young woman.She denied depression but did appear worried and was preoccupied with ideas of having heartdisease. She denied psychotic symptoms, confusion, and all suicidality. Her cognition wasintact, insight was limited, and judgment was fair.Diagnosis: Panic disorder11
c. Case formulationFormulation is a psychologically-informed explanation of the client’s problems which canprovide the basis for how to approach the task (Corrie, Townend & Cockx, 2016).For CBT therapists, the aim of developing a case formulation is to arrive at an individualisedtheory of a client’s difficulties that is derived from cognitive and/or behavioural theory.The case formulation is shared with the client, and the client’s response helps sharpen theformulation.Formulation allows the client to begin to learn about CBT concepts and become their owntherapist.WHENEVER POSSIBLE, IT IS PREFERABLE TO BASE A FORMULATION ON AN ACTUAL INCIDENTRATHER THAN WHAT GENERALLY HAPPENS WHEN THE CLIENT GETS CAUGHT UP IN THEPROBLEM.Some ways to approach case formulation:1) The following elements can be included: Problem list – itemising the client’s difficulties in terms of cognitive, behavioural andemotional components (as identified in the case assessment) Hypothesised mechanisms – one or two physiological mechanisms underlying theclient’s difficulties Account/narrative of how the hypothesised mechanisms lead to the overt difficulties Current precipitants – events or situations that are activating the client’s vulnerabilityat this time Origins of the underlying vulnerability (client history) Treatment plan Obstacles to treatmentPersons, J.B., & Tompkins, M.A. (2007). Cognitive-behavioral case formulation. In T.D. Eells(ed.). Handbook of Psychotherapy Case Formulation, 2nd ed. New York: Guildford Press.2) The five ‘Ps’ approach (Dudley & Kuyken 2006): Presenting issues Precipitating factors Perpetuating factors Predisposing factors Protecting factors (person’s resilience, strengths, safety activities)Dudley, R., & Kuyken, W. (2006). Formulation in cognitive-behavioural therapy. In L. Johnstoneand R. Dallos (eds). Formulation in Psychology and Psychotherapy: Making sense of people’sproblems. London: Routledge.12
No matter what approach you take, it is important for the therapist to check continually to becertain that the client understands the therapist's formulations. For example, clients who aredepressed often indicate understanding simply out of compliance (Beck Institute for CognitiveBehavior Therapy, 2016).ACTIVITYWork in pairs or groups to complete a 5 p’s formulation for Case 5.2 ‘Panic’.The formulation diagram ‘How did “the problem” develop?’ presents the 5 p's in anaccessible way.Note:Based on the case formulation, therapy goals would be developed. Suggested goals for PanicDisorder could be:(a) Identification of catastrophic misinterpretations;(b) Promoting the ability to generate alternative appraisals;(c) Testing the validity of both catastrophic and non-catastrophic interpretationsCorrie, S., Townend, M., & Cockx, A. (2016). Assessment and case formulation in CognitiveBehavioural Therapy. London: Sage Publications Ltd.13
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d. Intervention strategiesThere are many different therapeutic tactics available to the CBT therapist. Without an overallstrategy for a given case, the therapy may become trial-and-error. The strategy for changeshould follow logically from the case formulation.The overall strategy for change generally incorporates techniques drawn from one or more ofthree intervention categories: testing automatic thoughts, modifying assumptions, andchanging behaviours (Beck Institute for Cognitive Behavior Therapy, 2016).TESTING AUTOMATIC THOUGHTSOnce a key automatic thought has been identified (see worksheet ‘Automatic Thoughts’ in theAppendix), the therapist asks the client to temporarily suspend their conviction that thethought is undeniably true and instead to view the thought as a hypothesis to be tested. Thetherapist and client collaborate in gathering data, evaluating evidence, and drawingconclusions.There are several techniques for testing the validity of automatic thoughts: The therapist asks the client to draw on his/her previous experiences to list the evidencesupporting and contradicting the hypothesis (see ‘Challenging Negative Thoughts’worksheet in the Appendix). After weighing all available evidence, clients may reject theirautomatic thoughts as false, inaccurate, or exaggerated. The therapist asks the client to design an experiment to test the hypothesis. Once theexperiment has been planned, the client predicts what the outcome will be, then gathersdata. Frequently the data contradicts the client's prediction, and the client can reject theautomatic thoughtsREATTRIBUTIONWhen clients unrealistically blame themselves for unpleasant events, the therapist and clientcan review the situation to find other factors that may explain what happened other than, orin addition to, the client's behaviour.MODIFYING UNDERLYING ASSUMPTIONSThe cognitive therapist emphasizes questioning in the modification of underlying assumptions.After an assumption has been identified, the therapist asks the client a series of questions todemonstrate the contradictions or problems inherent in the assumption (see SocraticQuestioning).Another strategy for testing assumptions is for the therapist and client to generate lists of theadvantages and disadvantages of changing an assumption. Once the lists have beencompleted, the therapist and client can discuss and weigh the competing considerations.15
According to Corrie, Townend and Cockx (2016), underlying assumptions are often b
Cognitive Behavioural Therapy (CBT) has made a massive contribution to mental health care, but it is a broad tradition with some practitioners at the cognitive end and some at the behavioural end. CBT has also evolved over the years. APS definition: Cognitive Behaviour Therapy (CBT) is a focused approach based on the premise that cognitions
Cognitive-Behavioural Therapy EVIDENCE BRIEF Cognitive-Behavioural Therapy (CBT) is a core form of psychological treatment for . training would be vital as to be effective, CBT . behavioural skills to help them manage problematic emotional states such as anger, and increase their capacity for self-control.
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7. Principal methods of cognitive-behavioural work 55 Therapeutic approaches and ‘schools’ Behaviour modification Behaviour therapy methods Social skills training Self -instructional traini ng Problem -solving training Rational -Emotive Therapy Cognitive therapy Schema-focused therapy Inter -relationships and overlaps 8. Change processes 67
Cognitive-Behaviour Therapy 1 Cognitive-Behaviour Therapy and Problem Drinking: A Meta-analysis Introduction Cognitive-Behavioural Therapy (CBT) is a form of psychotherapy that combines cognitive-based and behaviour-based techniques in an effort to effect behaviour change (Beck, 1970; El
Cognitive-behavioural therapy (CBT) –CBT is a general model of psychotherapy, within which several specific approaches can be identified, which vary in terms of the target problem(s) they address and specific intervention components. In general, however, CBT approaches use a combination of behavioural and cognitive principles and interventions.
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