Beck: Cognitive Behavioral Therapy
CBT is based on several core principles, including:
1. Psychological problems are based, in part, on faulty or unhelpful ways of thinking. 2. Psychological problems are based, in part, on learned patterns of unhelpful behavior. 3. People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives.
Parts of the traditional (problem-based) CCD
1. Relevant Life History & Precipitants 2. Core Beliefs 3. Intermediate Beliefs 4. Coping Strategies 5. Situation 6. Automatic Thoughts 7. Meaning of Automatic Thoughts 8. Emotions 9. Behavior
Cognitions (both adaptive & maladaptive) occur at what 3 levels?
1. automatic thoughts 2. intermediate beliefs 3. core beliefs
Hierarchy of Cognition
1. core beliefs 2. intermediate beliefs (rules, attitudes, assumptions) 3. situation 4. automatic thoughts 5. reaction (emotional, behavioral, physiological)
The cognitive conceptualization helps do what?
1. understand patients, their strengths & weaknesses, aspirations & challenges 2. recognize how the pt developed a psychological disorder with dysfunctional thinking and maladaptive behavior 3. strengthen the therapeutic relationships 4. plan treatment within and across sessions 5. select appropriate interventions and adapt treatment as needed 6. overcome stuck points
How do you tailor the therapeutic relationship to the individual?
Assess and adjust your skills to needs of clients (such as cultural factors/needs), watch for clients' emotional reactions that can cue you how to adjust to their needs. Clients' cultures, age, gender, ethnicity, socioeconomic status, disability and sexual orientation can influence their therapeutic relationship
How was CBT developed?
BT was first developed in the 1960s by a psychiatrist named Aaron T. Beck, who formulated the idea for the therapy after noticing that many of his patients had internal dialogues that were almost a form of them talking to themselves. It was originally termed "cognitive therapy" because it focuses on each patient's thought process. It was a structured, short-term, present-oriented psychotherapy for depression.
What do you do in Part 1 (starting the session)?
Before the client enters your office, review records and any forms they have filled out. Meet with the client alone, initially, but discuss whether the client wants any family members/friends present for none, part, or all the sessions. It may be helpful to bring the person in at the end of the session to convey your initial assessment and gain family/friend's perspective of the problem. Introduce yourself and set the agenda.
What are the objectives of the evaluation session?
Collect information (both positive and negative) to make an accurate diagnosis and create an initial cognitive conceptualization and treatment plan. Determine whether you will be an appropriate therapist and can provide the appropriate "dose" of therapy (level of care, frequency of sessions, and duration of treatment) Figure out whether adjunctive services to treatment (such as meds) may be indicated. Initiate a therapeutic alliance with the client (and with family members, if relevant) Educate the client about CBT Set up an easy Action Plan.
What is the structure of the evaluation session?
Greet the client Collaboratively decide whether a family member or friend should participate in the session Set the agenda and convey appropriate expectations for the session Conduct the psychosocial assessment Set broad goals Relate your tentative diagnosis and your broad treatment plan and educate the client about CBT Collaboratively set an Action Plan Set expectations for treatment Summarize the session and offer feedback
How do you manage your negative reactions?
Have an accurate cognitive conceptualization of both your client and your own beliefs and behaviors. A good exercise is to ask yourself at the beginning of each day, "Which clients do I wish not to come in today?" Then use CBT techniques on yourself about the clients that come to mind and identify your cognitions about this client.
What does research tell us about the effectiveness of CBT?
Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.
What are four essential guidelines to keep in mind at every session?
Our objectives to make our clients feel safe, respected, understood and cared for. Example: 1. Treat every client at every session the way I'd like to be treated if I were a client. 2. Be a nice human being in the room and help the client feel safe. 3. Remember clients are supposed to pose challenges; that's why they need treatment. 4. Keep expectations for my client and my self reasonable.
What does a typical cognitive intervention look like?
Patients learn to become experts of their own behavior; examine their thoughts, recognize when negative thoughts are increasing, and then apply a number of strategies to alter those negative thoughts and emotions.
How do you ask for an update and review the Action Plan?
Review the Action Plan from the previous session. Have the client read the therapy notes and action plan to see if it still makes sense. Ask clients how well they followed their action plan and encourage them to take credit for things they accomplished.
What do you do in Part 6 (summarizing the session and eliciting feedback)?
Summarize the session to give the client a clear picture of what was accomplished and remind the client that treatment will begin next session. Elicit the client's reaction to the session.
How do automatic thoughts help you understand clients' reactions?
The key to understanding feelings and behaviors is by identifying the thoughts associated with them; reactions make sense once we know what the client is thinking The way people feel emotionally and the way they behave are associated with how they interpret and think about a situation.
How do you repair ruptures?
Use your conceptualization to prevent or repair problems. Provide positive reinforcement First ask yourself, "is the client right?" if so, model good apologizing & discuss a solution If the client isn't right and you haven't made a mistake, provide positive reinforcement for expressing their feedback and then express empathy, ask for additional information, then seek agreement to test the validity of their thought
How do you help clients generalize what they have learned to other relationships?
When they have an incorrect view of you, they probably have an incorrect view of others, too. If so, help them draw a conclusion about your relationship and then have them test in the context of other relationships.
What do you do between the evaluation and the first treatment session?
Write up your evaluation report and initial treatment plan. Obtain consent and contact the client's previous mental health provider and health professionals to obtain reports, ask questions, and ask additional information. Contact relevant current health providers to coordinate care.
What is cognitive behavioral therapy (CBT)?
a form of psychological treatment that that incorporates techniques from cognitive therapy and behavior therapy to correct faulty thinking and change maladaptive behaviors; hands on, practical approach to problem solving
intermediate beliefs
attitudes, rules, and assumptions derived from schemas that organize goals and motivate behavior
How do you complete a Cognitive Conceptualization Diagram (CCD)?
based on data patient presents, in their actual words regard hypothesis tentative until confirmed by patient continually reevaluate and refine diagram as collect additional data - not complete until treatment is terminated
core beliefs
beliefs that people have actively engaged in and created over the course of their lives
What is the theory behind CBT?
cognitive model: "thinking influences emotions & behavior"
Typical relevant childhood data includes such significant events as:
continual or periodic strife among parents or other family members parental divorce negative interactions with parents, siblings, teachers, peers, or others in which the child felt blamed, criticized, or otherwise devalued serious medical conditions or disabilities deaths of significant others bullying physical or sexual abuse emotional trauma other adverse life conditions (moving frequently, poverty, chronic discrimination, etc.)
What is cognitive conceptualization?
cornerstone of CBT that provides the framework for treatment & helps you plan for efficient and effective therapy it is the process of formulating and understanding a patient's problems within a specific framework
What do you do in Part 4 (setting an Action Plan)?
create an easy Action Plan w/clients at the evaluation; gets them accustomed to the idea that it's important for them to carry on the work of the session throughout the week.
CBT has been demonstrated to be effective for a range of problems including:
depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness
How do you set an initial agenda?
done quickly tell patient how you would like to structure the session find out what is most important for the client to discuss and work on
How do you demonstrate good counseling skills?
empathetic statements, choice of words, tone of voice, facial expressions, body language
Rogerian counseling skills that are especially important to CBT
empathy genuineness positive regard
What do you do in Part 3 (relating your diagnostic impressions, setting broad goals, and relating your general treatment plan)?
explain your diagnostic impression set goals and relate to your general treatment plan elicit feedback when relating the treatment plan
What do you do in Part 2 (conducting the assessment)?
explore the patient's current and past experience determine the degree to which pt might be homicidal or suicidal elicit a description of a typical day respond to hopelessness and skepticism seek additional information involve a trusted person
What do you do in Part 5 (establishing expectations for treatment)?
give clients reasonable expectations for treatment which can reduce the possibility of termination and lead to better outcomes give clients a general sense of how long their treatment should take
What things can the client understand after you present the CCD to them?
how their earlier experiences contributed to the development of their beliefs how they developed certain assumptions or rules for living how these assumptions led to developing particular coping strategies and patterns of behavior
How do you collaborate with clients?
jointly make decisions with client act as a team
automatic thoughts
most superficial level of thoughts that occur spontaneously - outside of conscious awareness (not deliberate or reasoned); typically quite rapid and brief/in response to a trigger; often used to describe problematic thoughts that maintain mental disorders When associated with mental illness, these thoughts are often irrational and harmful.
How do you monitor clients' affect and elicit feedback?
observe facial expressions and body language, their choice of words, and tone of voice
What is Abe's conceptualization?
persistent sadness, anxiety, loneliness (dx: MDD, severe, with anxious distress)
What is CT-R?
recovery-oriented cognitive therapy; an evidence-based treatment focused on engagement, achievement of goals, and elimination of obstacles for people diagnosed with serious mental illness
How do you use self-disclosure?
should be used judiciously and have a definite purpose, such as therapeutic relationship, normalizing the clients' difficulties, demonstrating how CBT techniques can help, modeling a skill or serving as a role model
Cognitive Model
the view that emphasizes thinking as the key element in causing psychological disorders; perceptions of, or spontaneous thoughts about, situations influence emotional, behavioral (and often physiological) reactions; concentrates on the faulty thinking that underlies abnormal behavior (dysfunctional thinking is common to all psychological disturbances)
How do you do a mood/medication (or other treatments) check?
this should be brief use published scales to assess the client's moode and level of suicidality, aggression, homicidality assign a # (0-10) to how they have been feeling check for adherence, problems, or side effects of medications
What is the goal of CBT?
to change patterns of thinking or behavior that are responsible for clients difficulties, and thereby change the way they feel
What is a more complex cognitive model?
understanding that thinking, mood, behavior, and physiology can affect one another: 1. core beliefs 2. intermediate beliefs (rules, attitudes, assumptions) 3. trigger situation 4. automatic thoughts - emotion - behavior
How do you initiate the process of conceptualization?
you begin to construct the conceptualization (by gathering information) during your first contact with a patient and refine it at every subsequent contact
