CBT Midterm

Maximize HW Compliance

1) assignment is too difficult or is unrelated to the client's concerns 2) therapist fails to provide a good rationale 3) therapist forgets to review homework assigned during previous sessions 4) therapist does not stress the importance of daily homework 5) therapist does not explicitly teach the client how to do the assignment 6) therapist does not start the assignment in the session or ask about potential obstacles 7) therapist does not have the client write the homework assignment down 8) therapist non-collaboratively sets a homework assignment that the client does not want to do tailor the assignments to the individual, err on being too easy provide a rationale set h/w collaboratively make h/w a no-lose proposition begin the assignment in session set up a system for remembering to do the h/w anticipate possible problems to completion prepare for a negative outcome

Strategies to accomplish therapeutic goals:

1) build a sound therapeutic alliance 2) make specific the structure & process of tx 3) teach clt the cognitive model, & share conceptualization 4) alleviate clt distress through various strategies and problem solving 5) teach clt how to use these strategies independently, how to generalize use & motivate for use after termination

Cognitive Distortions

1. All-or-Nothing Thinking: Viewing situations on one extreme or another instead of on a continuum. Ex. "If my child does bad things, it's because I am a bad parent." 2. Catastrophizing: Predicting only negative outcomes for the future. Ex. "If I fail my final, my life will be over." 3. Disqualifying or Discounting the Positive: Telling yourself that the good things that happen to you don't count. Ex. "My daughter told her friend that I was the best Dad in the world, but I'm sure she was just being nice." 4. Emotional Reasoning: Feeling about something overrules facts to the contrary. Ex. "Even though Steve is here at work late everyday, I know I work harder than anyone else at my job." 5. Labeling: Giving someone or something a label without finding out more about it/them. Ex. "My daughter would never do anything I disapproved of." 6. Magnification/Minimization: Emphasizing the negative or downplaying the positive of a situation. Ex. "My professor said he made some corrections on my paper, so I know I'll probably fail the class." 7. Mental Filter/Tunnel Vision: Placing all your attention on the negatives of a situation or seeing only the negatives of a situation.. Ex. "My husband says he wished I was better at housekeeping, so I must be a lousy wife." EX. "My daughter's boyfriend got suspended from school. He's a loser and won't ever amount to anything." 8. Mind Reading: Believing you know what others are thinking. Ex. "My house was dirty when my friends came over, so I know they think I'm a slob." 9. Overgeneralization: Making an overall negative conclusion beyond the current situation. Ex. "My husband didn't kiss me when he came home this evening. Maybe he doesn't love me anymore." 10. Personalization: Thinking the negative behavior of others has something to do with you. Ex. "My daughter has been pretty quiet today. I wonder what I did to upset her." 11. "Should" and "Must" Statements: Having a concrete idea of how people should behave. Ex. "I should get all As to be a good student."

Factors to consider in tailoring tx to the individual:

1. clt's diagnosis 2. conceptualization of presenting problem 3. clt goals for tx 4. clt's most pressing concerns 5. therapist goals for tx 6. stage of tx 7. learning characteristics of clt 8. motivation of clt 9. nature & strength of therapeutic alliance

Techniques to deal with critical, angry clients:

1. disarming technique - find some truth in what the clt says 2. thought & feeling empathy - th demonstrates understanding by paraphrasing what the clt has said , reflects back feelings as well as content 3. inquiry - ask gentle questions to demonstrate your willingness to listen and understand better, convey curiosity rather than defensiveness 4. "I feel" statements - express what th feels about what clt has said, appear more genuine to clt 5. change focus - change focus from content to process 6. stroking - let clt know you value him/her inspite of anger or complaint

Ellis' ABC model

A - ACTIVATING EVENT Which may be a trigger or something happening in the environment B - BELIEFS The beliefs a person holds about the event or situation that has occurred. These may be rational or irrational. C - CONSEQUENCE This is the consequence of what the persons belief is. This is the emotion they experience although it can also affect behavior

dysfunctional thoughts

Automatic Thoughts: quick, evaluative thoughts that spring up spontaneously in response to a situation, rapid, brief and likely to be accepted uncritically. Intermediate beliefs: attitudes, rules, assumptions. "shoulds", "if...then" statements Core Beliefs: the most central ideas about self, other, the world, begin in childhood and are often unarticulated. Absolute truths. Global, rigid and overgeneralized. General themes of; helplessness, unlovable, worthlessness Why clients believe core beliefs so strongly: selective focus on data that confirms negative world view discounts data contrary to core belief fails to recognize contrary data Core beliefs about others: rigid, overgeneralized, dichotomous Core beliefs about the world: cannot get what client wants from the world due to obstacles. Automatic thoughts, are images or mental activity that occur as a response to a trigger (like an action or event). They are automatic and 'pop up' or 'flash' in your mind without conscious though -Automatic thoughts can be evaluated according to their validity and their utility -adaptively responding usually produces a + shift in affect. -Clients usually accept their automatic thoughts as true w/o reflection or evaluation. -Watch for verbal and visual cues that client is experiencing "hot cognitions" -can undermine clients self worth or adequacy -interfere w/ concentration in session -can interfere w/ therapeutic relationship -gives client opportunity to test and respond to thoughts immediately -Basic question: "What was going through your mind just then?"

cultural considerations

CBT: potential strengths with culturally diverse populations • emphasis on the uniqueness of the individual, treatment must be adapted to meet the needs of the individual, also in consonance with social work values • focus on client empowerment, client is in control of their own thoughts & emotions and can make changes, teaches skills and contributes to a collaborative relationship in which individual and cultural differences are appreciated rather than negated, also in consonance with social work values • attention to conscious process and specific behaviors is more appropriate when therapy is conducted in a client's second language or with an interpreter, minimizes conceptual inequivalencies • continuous assessment, emphasis on client goals and progress, use of multiple measures, respect for the client's opinions and perspectives, collaborative, social work value of dignity and respect for others CBT: limitations • values change • embodies Euro-American values; assertiveness, personal independence, verbal ability, self control, can overlook the impact of racism and oppression on minority clients when the therapist is from the dominant cultural group • lack of attention to the client's history may reinforce the impact of cultural differences in the client's childhood and experiences • emphasis on rational thinking and scientific method reinforces the Euro-American and masculine way of viewing the world and may devalue less linear thinking, more spiritual beliefs or cooperative/communal interactional styles Utilizing a holistic, culturally competent assessment and treatment strategy that reinforces culture specific strengths and coping strategies can overcome CBT biases. Social work's practice of person in environment is important here. The problem must be defined in relation to the client's cultural norms. Ex: Native American, Latino, Asian and Arab cultures, in which the quality of respect is more highly valued than that of assertiveness. It is the therapist's role to help the client expand her/his repertoire of copying behaviors and understand how such behaviors may be perceived in the dominant culture, but it is the client who decides which behaviors to use and when and where to use them.

Core Beliefs

Helplessness Core Beliefs: ex I am helpless. I am inadequate. I am powerless. I am trapped. I can't do anything right. I am a loser. Unlovable Core Beliefs: ex I am unlovable. I am not good enough (to be loved). I am unlikable. I am different. I am unwanted. I am bound to be alone. Worthlessness Core Beliefs: ex I am worthless. I am immoral. I am bad. I am dangerous. I am a waste. I don't deserve to live.

Behavioral Activation

One of the most important goals for depressed clients is to schedule activities. This helps clients to become more active and to give themselves credit for their efforts. This works to strengthen self-efficacy by demonstrating to clients that they can take more control of their mood than they had previously believed. When scheduling activities, it is important to anticipate automatic thoughts that could interfere with a client's initiation of activities, as well as thoughts that could diminish a sense of pleasure or achievement during or after an activity. Review daily schedule; • Which activities are clients doing too much or too little of? • Do clients have a good sense of balance in activities? • What activities seem to perpetuate the dysphoria? Be incremental in scheduling activities, don't overwhelm the client. Busy clients may need more balance in their schedules or making time for pleasurable activities.

The overarching therapeutic goal

The overarching therapeutic goal is to improve the client's mood during the session and to create a plan so the client can feel better and behave more functionally during the week. You will do this by: • Reestablish the therapeutic alliance and collect data to collaboratively set and prioritize the agenda for the session. • Discuss agenda items and teach cognitive, behavioral, problem solving and other relevant skills. • Continually reinforce the cognitive model, help clients evaluate and respond to their automatic thoughts, do problem solving and summarize new understandings. • Assign homework that furthers the work in session. • Elicit a summary and feedback from client. Guided discovery: the therapist initiates a series of questions to help a client gain distance from the problem, evaluate the validity and utility of their cognitions/ or decatastrophize their fears

structure of session 2 and beyond

Typical agenda for session 2 & beyond Initial part of session 1) check on mood (meds, substance abuse) 2) set agenda 3) obtain an update 4) review homework 5) prioritize the agenda Middle part of agenda 6) work on a specific problem, teach CBT skills 7) set new homework, 8) work on a 2nd problem End of session 9) final summary 10) review new homework assignments 11) elicit feedback Therapist goals for 2nd session: 1) help client select important problems to work on 2) teach relevant skills 3) reinforce cognitive model & identify automatic thoughts a. continue socialization into cog model b. follow session format c. work collaboratively d. provide feedback e. view past in light of cognitive model 4) build therapeutic alliance 5) decrease symptoms 6) relapse prevention when client is feeling better

GOALS of CBT

the *promotion of self-awareness and emotional intelligence by teaching clients to "read" their emotions and distinguish healthy from unhealthy feelings* *helping clients understand how distorted perceptions and thoughts contribute to painful feelings* the *rapid reduction of symptoms* with an emphasis on examining the client's current situation and solving current problems the development of self-control by teaching clients specific techniques to identify and challenge distorted thinking prevention of future episodes of emotional distress and development of personal growth by helping clients change core beliefs that are often at the heart of their suffering.