Cognitive Behavioral Therapy

Front 1

Name 3 advantages of CBT

Back 1

1) short timeframe, 2) empirical support, and 3) interventions can be used with other theoretical orientations

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Classical Conditioning

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-studied by Ivan Pavlov
-stimuli that precede the behavior control the behavior
-Unconditioned stimulus (US) produces an automatic, unconditioned response (UR)
-pair a neutral stimulus, which becomes conditioned stimulus (CS), with US to produce the same response, which becomes the conditioned response (CR)
-The CS alone will eventually produce the CR

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Classical extinction

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the gradual disappearance of a conditioned response as the result of presentation of CS alone

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Extinction burst

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temporary increase in behavior attempting to extinguish

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Spontaneous recovery

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demonstrates that a conditioned response is not eliminated by extinction trials, just inhibited

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US, UP, CS (Little Albert example)

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US = loud bang
UP = crying
CS = fury things
CR = crying when sees fury things

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The Cognitive Model

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An individual's perceptions of internal/external events influences their emotions and behaviors

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Collaborative Empiricism

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patient and therapist share equal responsibility for solving patient's problems

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Prochaska & DiClemente Stages of Change Theory (1992)

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1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance

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Precontemplation

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-first stage in theory of change
-no intention to change behavior in the future

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Contemplation

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-second stage in theory of change
-aware problem exists and thinking of overcoming it, but haven't made a commitment to take action

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Preparation

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-third stage in theory of change
-intention to take action in near future, but have unsuccessfully taken action in the past

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Action

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-fourth stage in theory of change
-individual modifies their behavior, experiences, or environment

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Maintenance

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-fifth stage in theory of change
-work to prevent relapse and consolidate gains attained in action stage

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Judith Beck's Cognitive Model

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Situation-> Automatic Thoughts, which come from intermediate beliefs, which come from core beliefs -> Reactions (emotional, behavioral, physiological)

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Schema/Schemata

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-these are stable cognitive patterns that form the basis for the regularity of interpretations of a particular set of situations
-the basis for molding data into cognitions
-may be inactive for long periods of time buct come out with relevant stimuli

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D'Zurilla & Goldfried (1971) 5 Step Problem-Solving Strategy (SOLVE)

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State your problem
Outline your goals
List your alternatives
View the consequences
Evaluate your results

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Assertiveness LADDER technique (acronym)

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Look
Arrange
Define
Describe
Express
Reinforce

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L from LADDER technique

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Look at your rights, what you want, what you need, and what your feelings are about the situation

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A from LADDER technique

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Arrange a time and place to discuss your problem that is convenient for you and for the other person

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1st D from LADDER technique

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Define the problem situation as specifically as possible

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2nd D from LADDER technique

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Describe your feelings so that the other person has a better understanding of how important the issue is to you

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E from LADDER technique

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Express your request in one or two easy-to-understand sentences

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R from LADDER technique

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Reinforce the other person to give what you want

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Example of Self-Instructional Training - used with impulsive children (5 Step Process)

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1. Cognitive Modeling - adult modeled task while talking aloud to self
2. Cognitive Participant Modeling - Child performed task as model verbalizes the instructions
3. Overt Self-instruction - Child performed task while instructing self aloud
4. Fading Overt Self-Instruction - Child performed task while instructing self whispering
5. Covert Self-Instruction - Child performed task with private speech

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The Panic Cycle

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Cue -> Event -> Reflex Reaction -> Interpretive Reaction -> Panic Attack -> Panic Attack Ends -> Relief -> Anticipatory Stage ("What if this happens again?") -> Event

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Obstacles in Exposures

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1. Resistance
2. High Anxiety - could mean too big of jump between steps
3. Difficulty Progressing
4. Setbacks
5. Secondary gains - unconscious reason to hold on to the fear (examine if no progress being made)

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"Looming Vulnerability" Model (Riskind, 1997)

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-suggests anxiety is initiated and maintained by fear-provoking mental images and appraisals that portray threats as rapidly intensifying

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"Looming Cognitive Style" (LCS)

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negative cognitive style that functions as a danger schema and involves imagery based mental representation of the intensification of threats
-the tendency to worry and avoid unpleasant emotions are based in the LCS

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LCS is hypothesized to function as a cognitive antecedent and maintain function in GAD by:

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1. leads individual to generate continuing stream of threatening, anxiety provoking mental representations of mundane potential threats - which causes the use of worry as an avoidance strategy
2. leads to higher levels of intensity and emotional experience and difficulties in regulating emotions
3. Fosters a schematic processing bias for threatening material
4. When LCS is activated it absorbs attentional resources the patient needs to cope with negative emotions

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Beck's Cognitive Model of Anxiety Disorder (1985)

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-Suggested anxiety is future-oriented and is related to over estimations of perceived threat and underestimations of one's personal resources for coping with threat
-primary appraisal of threat is fear; secondary appraisal is resources for coping with threat
-threat ideation is caused by an interaction between cognitive processes and individual's schema related to personal vulnerability to threat
-individual's with anxiety have developed "danger schemas" - maladaptive variants of cognitive structures that guide information processing

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According to Beck's Cognitive Model of Anxiety Disorder, patients with GAD have "danger schema" that bias them to:

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-overestimate the degree of threat that is represented by a wide range of given stimuli
-underestimate personal control, and
-experience heightened levels of threat-related thoughts and images

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Exposure Response Prevention (Meyer, 1966) - General info

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-include both prolonged exposure to obsessional cues and procedures aimed at blocking rituals
-ERP directly challenges and modifies faulty appraisals and beliefs
-Exposures can be done in vivo and imaginal
-Exposures are designed specifically to cause distress
-Suggests massed sessions (3 sessions/week, lasting 2 hrs each): 15 min review, 45 min imaginal exposure, 45 min in vivo exposure, 15 min homework assignment

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Execution of ERP Treatment

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-Initially create a hierarchy
-Plan the exposures
-Response Prevention - emphasize the need to restrict all rituals entirely, including mental rituals
-Initially, as sessions continue, have patient repeat exposure from previous session to determine whether the decrease in discomfort observed during that session has persisted
-Once patient can tolerate exposure, can move onto next item in hierarchy

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3 ideas shared by all CBT Theories

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1) Cognitive activity affects behavior
2) Cognitive activity may be monitored and altered
3) Desired behavioral change may be affected through cognitive change

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Reinforcement

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goal is always to increase a behavior
-present a positive reinforcer to increase behavior (i.e. money for good grades)
-take away a negative reinforcer to increase behavior (i.e. no parking ticket if you put money in the meter)

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Punishment

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Goal is to decrease a behavior
-punishment by application: spanking
-punishment by removal: lose car for a week

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3 major classes of CBT

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1) Coping skills therapies
2) Problem solving therapies
3) Cognitive restructuring methods

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6 Goals in every CBT session (J.Beck)

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1) Setting the agenda
2) Mood check
3) Review presenting problem and obtain data
4) Set homework
5) Provide a summary
6) Elicit feedback

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Socratic Questioning

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"guided discovery"; attempt to discover various themes which may be running through the patient's misconceptions/beliefs by looking at various facets of the patient's present experiences and past history; self-exploration; use leading questions to guide them to the interpretation; most common error is that therapist ends up lecturing instead of letting client realize the problem

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Automatic Thoughts

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a stream of thinking that coexists with a more manifest stream of thought; the person perceives these thoughts as though they are by reflex - without any prior reflection or reasoning
-direct impact on mood and well-being

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Characteristics of AT

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-often appear in shorthand
-experienced as spontaneous
-indiosyncratic (specific to person)
-almost always believed
-tend to "awfulize"
-repeat habitual themes
-persistent and self-perpetuating
-often in terms of "should, ought, must"
-differ from what is verbalized in public
-learned from family, media, friends, etc.

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Hot cognitions

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these are important AT (visual and thoughts) when they arise during the therapy session and are assiciated with change in behaviors and emotions (ex. guy starts getting uneasy while telling a story)

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Types of cognitive distortions

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1) All-or-nothing thinking
2) Catastrophizing
3) disqualifying or discounting the positive
4) Emotional reasoning
5) Labeling
6) Magnification/minimization
7) Mental filter (aka selective abstraction)
8) Mind reading
9) Overgeneralization
10) Personalization
11) "Should" and "must" (imperatives)
12) Tunnel vision
13) Blaming
14) Fallacies

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Al-or-nothing thinking

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you view a situation in only two categories instead of a continuum
-ex. "If I'm not a total success, I'm a failure."

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Catastrophizing

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You predict the future negatively without considering other, more likely outcomes
-ex. "I'll be so upset, I won't be able to function at all."

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Disqualifying or discounting the positive

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You unreasonably tell yourself that positive experiences, deeds, or qualities do not count
-ex. "I did that project well, but that doesn't mean I'm competent; I just got lucky."

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Emotional Reasoning

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You think something must be true because you "feel" (actually believe) it so strongly, ignoring or discounting evidence to the contrary
-ex. "I know I do a lot of things okay at work, but I still feel like I'm a failure."

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Labeling

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You put a fixed, global label on yourself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion.
-ex. "I'm a loser. He's no good." "All doctors are uncaring."

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Magnification/minimization

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When you evaluate yourself, another person, or a situation, you unreasonably magnify the negativde and/or minimize the positive
-ex. "Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn't mean I'm smart."

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Mental filter (selective abstraction)

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You pay undue attention to one negative detail instead of seeing the whole picture
-ex. looking at a beautiful picture and they only see the black dot in the corner

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Mind reading

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You believe you know what others are thinking, failing to consider other, more likely possibilities
-ex. "He's thinking that I don't know the first thing about this project."

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Overgeneralization

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You make a sweeping negative conclusion that goes far beyond the current situation
-ex. "[Because I felt uncomfortable at the meeting] I don't have what it takes to make friends."

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Personalization

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You believe others are behaving negatively because of you, without considering more plausible explanations for their behavior
-ex. "My kids did poorly because of me."

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"Should" and "Must" (imperatives)

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You have a precise, fixed idea of how you or others should behave and you overestimate how bad it is that these expectations are not met
-ex. "It's terrible that I made a mistake. I should always do my best."

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Tunnel vision

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You only see the negative aspects of a situation
-ex. "My son's teacher can't do anything right. He's critical and insensitive and lousy at teaching."

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Blaming

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Always holding other people responsible

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Fallacies

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External/internal control fallacies
-external: environment controls everything
-internal: you control everything

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Self-Efficacy Model: Bandura

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Bandura says perceived self-efficacy is a major determinant in whether a behavior is initiated or not, in the amount of effort expended, and in how long an individual will persist in the face of adverse circumstances
-outcome expectancy: individual's judgment about whether the performance of a certain behavior will produce a certain outcome
-efficacy expectancy: individual's estimate about whether they can successfully execute that behavior

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4 sources of information that leads to formation of efficacy expectations

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1) Actual performance accomplishments
2) vicarious experiences (watching others)
3) Verbal persuasion
4) physiological and affective states - arousal can interfere; calmness and relaxation good

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Self-instructional Training

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-model assumes an individual's self-instructions mediate behavior and behavioral change
-model is a form of self-management

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Roles of Self-instructions in governing desired behavior

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1) can serve as useful cues for the recall of appropriate behavior or for redirecting/correcting behavioral errors
2) can interrupt automatic cognition or behavior chaining and can prompt the use of more adaptive responses

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3 phases of self-instructional training

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1) information gathering
2) "trying on" the concept of the problem
3) active attempts to change the patient's self-statements to modify behavior

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3 Stages of Recovery in PTSD

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1) Victim stage - 3 phases: a) prediscovery of the trauma, b) early awareness, c) discovery
2) Survivor Stage - individual makes a commitment to therapy and confronts the trauma and its effects
3) Thriver Stage - personal goals, rather than the trauma, become the individual's central focus: although some PTSD symptoms may exist, they are fewer and less intense

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Depression Cognitive Triad

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depressed individual views him/herself, experiences/others, and the future in a negative manner

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anxious apprehension

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future oriented mood state where one becomes ready or prepared to attempt to to cope with upcoming negative events

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Mowrer's 2 Factor Theory of Learning

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1st stage: conditioning process - neutral object paired with stimulus that by nature provokes distress or anxiety
2nd Stage: escape or avoidance responses that are developed to decrease distress/anxiety evoked by conditioned stimuli

*developed by classical conditioning, maintained by operational conditioning

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Dialectical Behavior Therapy (DBT)

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-developed specifically for Borderline Personality Disorder
-based on a dialectical worldview and biosocial theory of BPD

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Dialectics

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the fundamental nature of reality and persuasive dialogue and relationship

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Characteristics of Dialectics

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1) stresses the fundamental interrelatedness/wholeness of reality
2) reality is not static but compromised of internal opposing forces
3) fundamental nature of reality is change and process rather than content and structure

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4 areas of emphasis in DBT

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1) acceptance and validation of behavior in the moment
2) Treating therapy interfering behaviors of the patient and therapist
3) therapeutic relationship
4) dialectic process

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4 types of skills taught in DBT

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1) Core mindfulness skills
2) interpersonal effectiveness skills
3) emotion regulation skills
4) distress tolerance skills

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Core Mindfulness Skills

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-first skills taught in treatment
-3 primary states of mind: "reasonable mind", "emotion mind", "wise mind"
-skills taught to achieve balance: "what" skills (learning to observe, describe, and participate) and "how" skills (take nonjudgmental stance, focus on the moment, and doing what works)

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Interpersonal effectiveness skills

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-teach strategies for attending to relationships, balancing priorities vs. demands, balancing the wants vs. shoulds, building mastery and self-respect
-often possess good interpersonal skills in general sense but have problems applying these skills in certain situations

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Emotional Regulation Skills

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-Core feature is emotional dysregulation
-suggests individual's emotional distress is result of secondary responses to primary emotions
-skills taught: identify and label affect, identify obstacles to bringing about change, decrease vulnerability to "emotion mind", increase positive emotional events, increase mindfulness to current emotions, take opposite action, apply distress tolerance skills

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Distress Tolerance Skills

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-emphasize learning to bear the distress skillfully
-4 set crisis survival strategies:
1) Distraction
2) Self-soothing
3) Improving the moment
4) Thinking of pros/cons

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Schema Therapy for Borderline Personality Disorder

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-Emphasized early schemas and stressed importance of understanding pt's early history and life patterns
-pts continually shift from mode to mode
*5 modes of pts with BPD
1) Abandoned Child
2) Angry and Impulsive child
3) Punitive Parent
4) Detached protector
5) Healthy Adult

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Schema Therapy Treatment goals

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1. Empathize with and protect the abandoned child
2. help abandoned child to give and receive love
3. fight against and expunge punitive parent
4. set limits on behavior of angry and impulsive child, and help pt in this mode express emotions and needs appropriately
5. reassure and gradually replace the detached protector with the healthy adult

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3 main stages of Schema Therapy treatment

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1. bonding and emotional regulation stage
2. schema mode changing stage
3. autonomy stage

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Principles of Motivational Interviewing

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1) Express empathy
2) help patient realize discrepancy between what he/she believes and what he/she does
3) Roll with resistance
4) support self-efficacy

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Motivational interviewing reflections

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1) simple - restatement
2) Amplified - over agree with patient
3) Double-sided - link consequence with the benefits of use

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Alpha drinking style

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psychological dependence, no physical complications develop, no tolerance to effects, individual can abstain for short time, drinking pattern is stable, rarely progressive

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Beta drinking style

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psychological dependence, physical complications develop, no tolerance to effects, individual can abstain for short time, drinking pattern is stable, possibly progresses to Gamma

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Delta drinking style

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psychological dependence, minimal to no physical complications develop, tolerance to effects, individual cannot abstain, drinking pattern is stable, strong chance of progressing to Gamma

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Gamma drinking style

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psychological dependence, many and serious physical complications develop, tolerance to effects, individual cannot abstain, drinking pattern is stable, does not progress

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Epsilon drinking style (binge drinking)

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possible psychological dependence, possible but rare physical complications develop, possible tolerance to effects, individual can abstain, stability is unknown, progression unknown