Introduction to

Cognitive Behaviour Therapy

Carol Vivyan 2007

Epictetus 55 - 135 AD

•Men are disturbed, not by

things, but by the principles
and notions which they form
concerning things
• Roman (Greek-born) slave & Stoic philosopher
• Cognitive Therapy is a system of
psychotherapy that attempts to
reduce excessive emotional
reactions and self-defeating
behaviour, by modifying the faulty
or erroneous thinking and
maladaptive beliefs that underlie
these reactions
• Beck et al 1976, 1979, 1993
The approach is:

• Collaborative (builds trust)

• Active
• Based on open-ended questioning
• Highly structured and focused
 ‘Common Sense’ Model

Event Emotion

Cognitive Model

Meaning
Event we give Emotion
the event
You’re walking down the High
Street, and someone you know
walks by without acknowledging
you…
4 interpretations – 4 emotions
• I don’t want her to see me, I won’t know
what to say – she’ll think I’m stupid &
boring

•Nobody wants to talk to me, no-one likes me

•She’s got a nerve being so snooty!
•She’s probably still hung over from that
party last night!
• Cognitive principle – it is
interpretations of events, not events
themselves, which are crucial.
• Behavioural principle – what we do
has a powerful influence on our
thoughts and emotions
• The continuum principle – mental
health problems are best
conceptualised as exaggerations of
normal processes
• ‘Here and now’ principle – it is usually
more fruitful to focus on current processes
rather than the past
• Interacting systems principle – it is helpful
to look at problems as interactions
between thoughts, emotions, behaviour
and physiology and the environment in
which the person operates
Padesky’s 5 Aspects Model (1986)

ENVIRONMENT

THOUGHTS

BIOLOGY MOOD /
FEELINGS

BEHAVIOUR
 ENVIRONMENT
On Plane
Turbulence

THOUGHTS
We might crash

BIOLOGY
Heart racing MOOD / FEELINGS
Palpitations
Anxious 90%
Rapid breathing
Difficult to breathe –
choking sensation

BEHAVIOUR
Reassurance
seeking
Feelings & commonly associated thoughts
Groups
• Think of a recent situation or event which
resulted in a negative mood shift
– Anxiety
– Sadness
– Anger
• Groups: therapist / client / observer
– Identify:
• thoughts / feelings / behaviours
• Identify a recent significant shift in
mood (emotion)
• What was the situation?
• How did you feel? (emotion/physiology)
• What was going through your mind at
the time? (thoughts)
• What did you do? (behaviours)
• What were the consequences?
Cognitive Internal / External Trigger

Model of Turbulent flight

Panic
 
  Perceived Threat
  We might crash
  I’m going to die
 
 
 
Anxiety / Panic 90%

Catastrophic Physical / Cognitive

Interpretation of Symptoms
Symptoms Heart racing
Breathless
I’ll suffocate and die Difficulty breathing –
Avoidance & Safety Behaviours choking sensation
Reassurance seeking: Shaking
Ask companion Sweating
Look at faces of other travellers
Ask cabin crew
Avoid flying!
 Early Experiences
Cognitive
Model of
Depression
 
 
Core Beliefs &
Assumptions
 
  Beck (1979)
 
  Critical Incident
 
 
 
 
  Negative Automatic
 
 
Thoughts (NATS)
 
 
 
 
 
 
  Behaviour Feelings
 
 
 
Negative Automatic Thoughts

Assumptions

Core
beliefs
Negative Automatic Thoughts
• Stream of thoughts that we can notice if we try
to pay attention to them (automatic)
• Negatively tinged appraisals or interpretations –
meanings we take from what happens around us
or within us
• Specific thoughts about specific events or
situations
• Brief, frequent, habitual – often not heard
• Plausible and taken as obviously true, especially
when emotions are strong
Identifying NATs
• Shifts in Affect
• Distinguish between thoughts and
emotion and behaviour
• Check for images
Cognitive Model of Depression
• Negative cognitive triad
– Biased views of
• Oneself
– I am bad, useless, unlovable, worthless, a failure
• The world in general
– Nothing good happens, life is just a series of trials
• The future
– It will always be like this, nothing I can do will make any
difference, what’s the point of anything?

• Negative filter
– Remembering events
– Interpreting current events / situations
– Overgeneralising from small negative event to broad negative
conclusion
Goals of therapy

• Help the client counteract negative cognitive

biases, and develop more balanced view of
herself, the world, and the future
• Restore activity levels – especially those that
give sense of pleasure or achievement
• Increase active engagement and problem
solving
Course of treatment
• Identify specific problem list (& prioritise)
– Eg. Poor sleep, relationship difficulties etc
• Introduce cognitive model – how it might apply
to client
• Goals (SMART)
• Reduce symptoms through behavioural or simple
cognitive strategies
• Identify and challenge NATs
• Relapse prevention
Overview of a typical
course of therapy
• Referral
• Assessment: suitability, therapeutic relationship
• Assessment (ongoing): problem analysis, wider
picture, measures
• Problem list & prioritise
• Goals for therapy (SMART)
• Formulation (ongoing): Sharing model,
maintaining factors, predisposing factors,
rationale for treatment
Overview of a typical
course of therapy
• Assessment, Formulation
• Treatment: start with symptom focused
intervention
• Review: every six sessions, repeat measures
• Discharge: repeat measures, relapse
prevention
• Follow up / booster sessions:
• 1,3,6,12 month ?
Typical CBT treatment session

• Set collaborative agenda

• Review time since last session
• Feedback on last session
• Review homework
• Focus on major topics for the session
• Set homework
• Potential problems with completing homework
• Feedback on session
Therapy Skills
• Engagement
• Warmth and empathy
• Collaboration
• Guided discovery – socratic questioning
• Feedback and summarising
• Agenda setting – structure and focus
• Open and closed questioning
Aims of Assessment
• Initiate & develop therapeutic relationship
• Establish suitability for CBT
• Gather specific information re current difficulties
• Elicit maintaining factors
• Initial formulation
• Socialise to CBT model
• Establish joint understanding of the presenting
problem
Suitability for short term
CBT
• Ability to identify & describe negative thoughts
• Awareness & differentiation of emotion
• Compatibility with CBT rationale
• Acceptance of personal responsibility for change
• Alliance potential
• Chronicity of problem
• Security operations
• Focality
• Optimism/pessimism regarding therapy
Homework
• Identify a recent significant shift in mood
• What was the situation?
• How did you feel?
• What was going through your mind at
the time?
• What did you do?
• What were the consequences?
Measures
• The concept of measures is central to the
CBT approach, as it enables both client and
practitioner to evaluate the impact of
interventions (Grant et al 2004)
• They are important in the process of
assessment and aid the practitioner to
develop a credible formulation for the client,
so that appropriate cognitive and behavioural
interventions can be used
Why Measures?
• Assessment – to provide information
• Baseline – subsequent measures will show
extent of change
• Effectiveness – helps to (objectively)
demonstrate effectiveness of therapy, and allow
modification of treatment
• Feedback
• Knowledge - data collection & suggests areas
for future research
What measures?
• Standardised – developed for particular
populations and problems
– Eg. Beck Depression Inventory
– Beck Anxiety Inventory
– Agoraphobic Cognitions Questionnaire

• Individualised – allow for more specific

information for assessment and formulation.
– Eg. Problem definition, Targets of therapy, Diaries,
% Belief Ratings, Ratings of specific emotions
Cognitive Interventions
• Restructuring thoughts and beliefs
– Guided discovery
– Thought diaries
– Challenging NATs (looking at evidence)
– Addressing thinking errors
– Responsibility Pie
– Cost/Benefit Analysis
– Downward Arrow technique
Cognitive Interventions
• Education Eg. Written information on
thinking errors, disorder specific info
• Continuous use of formulation
• Imagery techniques
• Role play & role reversal
• Action Plan
• Education in Body systems (symptoms)
Behavioural Interventions
• Very powerful method of bringing about
change
• Key component of CBT intervention
• Borrowed and adapted from Behaviour
Therapy
• Incorporate different methodological
approaches
Behavioural Experiments
• Similar in BT / CBT, but fundamentally different
• In BT, it is the end product, in CBT, a means to
an end ie. Cognitive change
• In BT – graduated, repeated and prolonged
exposure
• In CBT - New ideas are put to the test. Means
of testing the validity thoughts, perceptions,
beliefs.
Examples
• Hyperventilation to simulate panic
• Activity monitoring and scheduling
• Metaphors – South American tribe?
• Consider experiment for client with OCD,
believes something terrible will happen to
family if he doesn’t neutralise his thought
by doing rituals for up to an hour
Problem solving

• Identify problem to be worked on

• Think of as many solutions as possible
• Consider each solution – pros & cons
• Pick solution that appears best
• Small steps
• Action & review
Relapse Prevention

• What have I learned?

• What was most useful?
• What can I continue to do?
• When will I be at risk of this happening again?
• What are the signs?
• What could I do to avoid losing control?
• What could I do if I did lose control?
Coping with Relapse

• How can I make sense of this lapse?

• What have I learnt from it?
• With hindsight, what would I do
differently?
Introduction to CBT
• This presentation gives you an
introduction to the rationale of CBT
• It does not enable you to perform CBT
• Using Cognitive Behavioural
interventions may be helpful for your
clients
• CBT - Guided self-help?
 Summary

• No formulation No CBT
• Use CB techniques
– Bibliotherapy: e.g. Mind Over Mood
– Challenge negative thoughts
• Court Case
• Evidence
• More balanced/alternative thought
• Downward arrow
– Behavioural experiments / exposure
– Activity Diaries
– Relaxation?
More information & resources
• www.get.gg
– Self help
– Workbooks
– online CBT programmes – printable forms etc
– Online
• Professional links
– CBT organisations
– Therapist manuals online
– Books
Bibliography
• Certificate in Cognitive Behaviour Therapy.
– Salford Cognitive Therapy Training Centre. 2006
• An introduction to Cognitive Behaviour Therapy:
Skills & Applications.
– Westbrook, Kennerley, Kirk, 2007. Sage.
• Treatment Plans & Interventions for Depression &
Anxiety Disorders.
– Leahy. 2000. Guilford.
• Cognitive Therapy of Anxiety Disorders.
– Wells. 1997. Wiley.
• Mind Over Mood.
– Greenberger, Padesky. 1995. Guilford.