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Cognitive Behavioral Therapy

A psychotherapeutic presentation

Seth Frampton

on 12 March 2013

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Transcript of Cognitive Behavioral Therapy

Cognitive Behav oral Therapy l Overview Overview -Cognitive Behavioral Therapy (CBT) is the most widely researched psychotherapeutic model.
-Has demonstrated effectiveness in the treatment of a wide range of emotional and behavioral problems.
-CBT is the treatment of choice for most patients who need to enhance internal resources and coping skills. The therapist, together with the patient, structures each session and sets reasonable, measurable, specific goals so that both participants know when progress has been made. Mandy & Seth Present: -Each session ends with homework assigned, which is reviewed at the beginning of the next session.
-CBT is based on treatment plans which are clearly conceptualized and on tested theories that guide the clinician through each action, session, and overall plan of care. Guiding Principles -CBT therapy is a collaborative process of empirical investigation, reality testing, and problem solving between the therapist and the client.
-The basic premise is that depression is the result of cognitive distortions and that these distortions are learned errors in thinking. -CBT evolved primarily from the work of Aaron T. Beck.
-Beck, originally trained in psychoanalysis (Freudian), departed from psychoanalytic concepts.
-Beck concentrated on a person's distortions in self-image, thereby creating a more systematic cognitive-behavioral conceptualization of psychiatric disorders and personality structure. Through a series of studies on depression and suicidal thinking, Beck develop a systemic structuring of cognitive therapy with a blueprint of guiding principles and specific procedures to follow. The early years -It was in the 1970's that researchers began to apply behavioral theory to cognitive theories and strategies.
-This was a large adaptation of behavioral therapy which, up to that point, had only focused on using guided experiments to shape measurable behaviors such as avoidance and suicidal ideation.
-In the past, little attention had been paid to the cognitive processes involved in the behavioral changes. For example... -A good example of the way that little attention was paid to cognitive processes was how fearful responses were extinguished with exposure therapy.
-Researchers Meichenbaum & Lewinsohn began to incorporate these behavioral interventions within the cognitive theoretical structures.
-They observed that this method added depth, context, and deeper understanding to outcomes. Since then... -Extensive research has demonstrated that significant efficacy in the combined approach using cognitive techniques (cognitive restructuring) along with behavioral techniques (exposure therapy and relaxation training). Overview continued... -CBT is a "system of psychotherapy based on a theory which maintains that how an individual structures his or her experiences largely determines how he or she feels and behaves.
-This model posits that dysfunctional thoughts relating to self, the world, or others are rooted in irrational or illogical assumptions. This means... -The individual's view of self and the world are central to the determination of emotions and behaviors— by changing one's thoughts, emotions and behaviors can also be changed. -CBT places significant importance on cognitive information processing (how one interprets a certain event) and behavioral change according to said processing. Because of this, clinical strategies are used to help the individual recognize the dysfunctional nature of their thinking patterns. Theoretical refinement of the model and empirical testing have resulted in a consensus that it is the interplay among thoughts, feelings, and behaviors within a person's environment that results in psychopathology. Interventions must target all three of these foci (thoughts, feelings, behaviors) to affect sustainable changes in the patient, although cognition is the pivotal point. Appropriate Diagnoses for CBT CBT has been developed for specific problems and applied to patients with depression, anxiety, personality disorders, and substance abuse. Cognitive Model for Depression -Cognitive model of depression emphasizes the cognitive triad to illustrate depression generation and maintenance.
-The premise is that individuals develop and then maintain a negative self-view and that this attitude extends into the world, their experiences, and into the future.
-As a results, they perceive themselves as worthless, abandoned, and inadequate. CBT focuses on altering the person's view of themselves, their situations, and the resources around them.
-Therapy is structured, active, reality based, and time limited.
-Patients are taught to take specific steps to combat their depressive views. Through the use of brain imaging, researchers have discovered that cerebral blood flow in specific brain areas respond with equal vigor to CBT treatment and pharmacologic treatments of depression and anxiety disorders. Cognitive Model for Anxiety -Anxiety is an adaptive strategy.
-If there is an actual threat, the individual is prepared to respond adaptively. If there is no threat, the individual interprets the symptoms as anxiety, with the accompanying psychological response called fear. -As more and more attributions of threat occur (bridges, heights, public speaking), the person becomes more and more alert to potential activation.
-This sets up a "fear of fear response."
-This person develops behaviors that interfere with adaptive coping strategies and that makes him or her feel helpless to alter the symptoms. -Researchers Barlow and Clark observed that the constellation of cognitive symptoms that team with behavioral symptoms create a panic response.
-Combining cognitive techniques to modify fearful cognitions with specific behavioral approaches reduce or eliminate the panic reaction for most individuals. Cognitive Model for Personality Disorder -One of the hallmark treatments for personality disorder is CBT.
-Cognitive theorists and Psychoanalysts have agreed that it is imperative to identify and then modify core problems when treating individuals with personality disorders. -It is rare that individuals present for treatment of their personality disorder.
-Instead, they usually come at the behest of a significant other (sibling, parent, court, etc.)
-May also come to therapy for a secondary outcome of their behavior patterns such as depression, anxiety, or relationship issues. Cognitive Model for Substance Abuse -The community reinforcement approach (CRA) has been developed for patients who abuse drugs.
-Interventions include social, recreational, familial, and vocational reinforcers to help the person through the process of abstinence and maintenance. -Reinforcement models are typically used in therapy, such as providing a type of "payment" for specific behavioral outcomes such as a clean urine specimen, participation in treatment, and completion of treatment programs.
-Vouchers are used instead of cash to avoid triggering the patient's association of money with the purchasing of drugs.
-CBT is used in substance abuse to analyze substance abuse, drug refusal training, relaxation training, behavioral skills training, and reciprocal relationship counseling. Theoretical Constructs of CBT Theoretical Constructs Continued... Theoretical Construct Continued... -Activating Event: I build a porch and the railing comes loose.

-Thought: I can never do anything right.

Feeling: Anger and sadness

Behavior: Kick the railing
-Core beliefs/Perspectives that influence the way in which one views the world.
-Guide individuals through every action, reaction, and interpretation.
-Constant state of change and adaptation across different situations. Schema Therapy Schema Therapy continued... -Combination of schema therapy and CBT.
-Created throughout an individual's life.
-Schemas can be applied to new situations
-Example Thoughts Emotions Behavior Case Study #1 -Bethany is a 44 year-old woman who has been married for 20 years to her step-uncle, who raised her after her parents died and is 40 years her senior.
-Both of her parents are deceased, which caused her step-uncle to raise her after their deaths.
-Bethany has had more than 10 years of treatment with medications and a variety of psychotherapeutic techniques for her self-reported depression and ADD and denies suicidal ideation or intent.
-No evidence of hallucinations, delusions or cognitive impairment.
-Reports having occasional affairs but that they are less frequent and less pleasurable than they used to be. Presenting symptoms -Reports significant sleep problems, that she is no longer creative, productive or happy and that she has felt this way for a long time.
-Extremely tearful during the interview.
-She is also feeling overwhelmed, hopeless, and exhausted, along with extreme guilt toward not being the wife that her husband deserves.
-Experiences moderate to severe pain related to fibromyalgia and arthritis.
-Finally, she feels irritable, indecisive, and like a "total failure at life." Medical History -Treatment has included several long- and short-acting opiate pain relievers and gabapentin for neuropathic pain relief.
-Previous diagnoses included recurrent, severe major depression and nonhyperactive-type attention deficit disorder (ADD).
-Medication attempt had included more than 10 different antidepressants (none was effective) and several stimulants for treatment of her ADD. Factors contributing to her depressive symptoms -Chronic pain from fibromyalgia— patients with chronic pain are susceptible to depression due to the feeling of being trapped with the pain, a lack of hope, and disturbed sleep.
-Her frequent use of chronic pain relievers— narcotics are notorious for problematic side effects that include somnolence, insomnia, and confusion.
-Stimulant use— these medications have known side effects including nervousness, depression, and drowsiness. Treatment Plan -Accurate diagnosis is important when developing a treatment plan.
-Evaluation of Bethany's symptoms included exploration of hypomanic episodes to rule out a cyclical mood disorder such as Bipolar Disorder.
-As it turned out, Bethany had two episodes of spending in excess that included a reduced need for sleep were uncovered in the previous 12 years.
-While these episodes were memorable to Bethany, they did not cause any severe hardship on herself or her husband thereby meeting the criteria for hypomania. -Bethany's diagnosis was changed to bipolar II disorder.
-Her narcotic medications were tapered to limit the dose to the most effective dose for pain while minimizing cognitive impairment or confusion, lack of concentration and somnolence.
-Her ADD medication was tapered and discontinued due to the fact that Bethany had never actually experienced symptoms of distraction and lack of concentration before her depression became severe and these problems were most likely caused by hypomania and agitation. -Prescribed a course of lamotrigine, which is indicated for bipolar disorders with a primarily depressive quality.
-Important to know that patients who are incapacitated by depressive cognitions are not as likely to respond to cognitive interventions until the depressive symptoms begin to abate.
-Bethany would have to begin by "undoing" the automatic thoughts that perpetuated the depression.
-This is where the CBT comes into play in her treatment. Course of Therapy -Initial session included the components of assessment, preparation for therapy, introdrucing the patient to cognitive therapy, problem conceptualization, and initial goal development.
-Second session included reinforcing these components and medication changes were begun.
-Each session after these two included a medication and symptom check before psychotherapy. -Sessions typically began with a review of any homework and then interventions were incorporated that were behavioral in content given the level of cognitive impairment she was suffering.
-For example, Bethany's level of physical inactivity was affecting her energy, self-concept, and negative cognitions.
-Because of this, a daily exercise program was negotiated with Bethany that included 20 minutes of walking each morning. Using CBT in Bethany's sessions -Some of the sessions focused on uncovering specific irrational automatic thoughts as they appeared in the session.
-After a thought was identified, the therapist repeated the thought and discussed it with the patient.
-For example, Bethany said, "Everyone thinks I'm such a slug!"
-Therapist: "Everyone? Virtually everyone?"
-Bethany: "Well no. Not everyone. Almost everyone."
-After further investigation, it turned out that the only person who had complained about Bethany's activity level was her boss. -Decatastrophizing techniques were used when Bethany began escalating, beginning with a small, discrete problem: "I couldn't find my keys for a couple of minutes," and a larger problem, "My mind is a mess! I can't remember anything!"

-When Bethany exemplified this type of thinking, the APPN modeled slowing down and evaluating the pattern of escalation by beginning with the activating event (the keys).

-This allows Bethany to view her thinking to see how one small thought turns into a large one. Case Study #2 -OCD involves excessive worry about threatening and nonthreatening stimuli coupled with impairing rituals believed to reduce anxiety.

-Autism Spectrum Disorder are characterized by impairment in social and communicative activities as well as restricted behaviors.

-This report describes a 12-year-old male with autism who was treated successfully with cognitive behavioral therapy with exposure and response prevention. Case Example -Jason is a 12 year old white male who was evaluated at the age of 2 years due to a loss of expressive language functioning, presences of echolalia, preoccupation with household items (rather than toys), repetitive play, and poor social relationships.

-Review of medical history ruled out any possible trauma or medical explanation of his symptoms.

-Was diagnosed with high-functioning autism at the age of 2 years. -At the age of 11 years, Jason began exhibiting a significant number of ritualistic behaviors. It is not unusual for a child to develop symptoms of OCD at this age.

-Experienced contamination fears, hand washing rituals, excessive use of hand sanitizer, avoidance of contaminated items (door knobs, bathrooms).

-His symptoms began interfering with his academic, social, and family functioning around his twelfth birthday and beginning of sixth grade.

-Was referred by his physician for eval and treatment. Treatment -Jason was seen for ten 50-minute outpatient CBT sessions over 16 weeks.

-The cognitive component was changed to meet Jason's developmental level.

-Jason was not able to identify specific obsessions and therefore it was neither possible nor practical to engage in typical restructuring activities and imagined exposure. -Thus, for Jason, the cognitive component of treatment focused on identifying feelings of distress and learning coping statements to ameliorate his anxiety.

-Sample statements used include "I know that nothing bad will happen" and "Doing the exposures will help me get better."

-Parents were integral components in treatment to enhance generalization of skills and to limit family accommodation. -As an example of exposures, Jason was required to touch several common items in the hospital where the therapist's office is located (elevator buttons, door handles) and exposures were repeated until Jason habituated to the anxiety.

-Though initially hesitant to participate in exposure therapy, Jason eventually completed them with encouragement and became proud of himself for completing the acts.

-Homework was also assigned and reviewed which typically included completing exposures in the classroom settings where he experienced difficulty (passing out papers, using contaminated items). Discussion -Although Jason had some difficulty with cognitive restructuring activities, he was able to self-monitor his behaviors by tracking compulsions and times when he resisted his urges to perform a compulsion, which is critical to treatment participation.

-This case provides evidence that CBT is effective in treating OCD symptoms in children with Autism when appropriate modifications are made to the treatment protocol.

-Initially, Jason presented with moderate symptoms of OCD which were impairing his ability to function at home and at school. At the end of the ten treatment sessions, his symptoms had remitted and he no longer met OCD criteria. Additional Evidence of Effectiveness of CBT Additional Evidence of Effectiveness of CBT Meta-Analysis Evidence of Effectiveness of CBT (Butler, et al., 2006) Meta-Analysis Evidence of Effectiveness of CBT (Butler, et al., 2006) Meta-Analysis Evidence of Effectiveness of CBT (Butler, et al., 2006) The following table presents results of a meta-analysis of published meta-analyses with effect sizes greater than 0.7
These results demonstrate the efficacy of CBT for many disorders.
Reference: Butler, A., Chapman, J., Forman, E., Beck, A. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17-31. Meta-Analysis Evidence of Effectiveness of CBT: Reference: Effectiveness of CBT well-demonstrated in literature.
Current trend: meta-analysis.
Meta-analysis computes an “effect size” for each study as a way to standardize comparisons among studies.
The interpretation of effect sizes are the following: low=0.0 - 0.2; medium = 0.5 - 0.8; high = greater than 0.8. Studying the Effectiveness of CBT: The Use of Meta-Analysis Case Study #3 -70-year-old female patient with activity limitations of walking, standing, and forward bending.

-Disability Questionnaire score was 19/50 and Fear-Avoidance Belief Questionnaire physical activity subscale was 23/24.

-CBT-based patient education was provided in combination with manual therapy and exercise. CBT techniques included cognitive restructuring, goal setting, activity pacing, problem-solving strategies, graded exposure, encouraging exposure to pleasant experiences, and maintenance strategies. Behavioral Techniques
Homework – Hallmark behavioral technique!
- Reinforce and allow continuation of what has been learned in therapy sessions

Psychoeducation – component used in all CBT techniques
- Should be skillfully interwoven throughout therapy Techniques Used Behavioral Technique

Exposure or Prolonged Exposure – aim is to activate the fear response until it is wiped out
Use of environmental cues or imagery
When a person is afraid of a stimulus, they avoid it, and this negatively reinforces the person
Therapist gradually exposes the pt to the anxiety-producing stimulus until anxiety no longer disables pt Techniques Used Behavioral Techniques
Contingency Management – relies on the pt’s self-motivation
Used for patient’s who have difficulty with self-control
Basic principle is positive reinforcement or rewarding positive changes in behavior
Social Skills Training – aimed at instructing pt on how to behave to foster successful social interactions
- role-playing skills – practice eye contact during interview, firm handshake, etc. Techniques Used Automatic Thought Records:
Key Component!
Therapist and pt work together to identify dysfunctional thought processes in order to debate, challenge, and clarify those thoughts

Cognitive Restructuring
Changing negative thinking patterns through automatic thought records and other techniques Other Cognitive Techniques Used Cognitive Techniques continued…
Decatastrophizing – enables pt to get balance and realistic focus by exploring the worst possible outcome
- Used for anxious patients

Paradox or Exaggeration – therapist takes an issue to an extreme in order to help pt see the irrationality of his/her viewpoints
- Only to be used by skilled therapist Techniques Used Match role play example to correct cognitive technique:

Socratic Dialogue
Downward Arrow
Idiosyncratic Meaning
Questioning the Evidence ROLE PLAY TIME!
Now you try!

Calming/Deep Breathing Exercise
Progressive Muscle Relaxation Techniques Used Behavioral Techniques
Behavioral Rehearsal – behavioral experiments are used to gather information and to allow pt to develop effective responses
- role play is then carried out during therapy session
Graded Task Assignments – series of steps that increase in difficulty that are used to desensitize fears/threats that produce anxiety Techniques Used

Imagine a pt you have seen in practice and write down a possible example through this homework assignment Cognitive Technique Match role play example to correct cognitive technique:

Examining Options and Alternatives
Paradox or Exaggeration ROLE PLAY TIME! Cognitive Techniques continued…

Examining Options and Alternatives – an alternative to using one-way thinking. Enables the pt to examine different options before generating an opinion.

Reattribution – technique used to enable pt to redistribute blame/responsibility appropriately
- Used for personality disorders Techniques Used Cognitive Techniques continued…

Idiosyncratic Meaning – clarifying statements that are unclear in meaning

Questioning the Evidence – therapist assists pt in questioning the facts which are related to the pt’s thoughts and conclusions Techniques Used Cognitive Techniques:

Socratic Dialogue – therapist guides the pt through a series of questions and answers which leads the pt to greater insight, realizations, and self discoveries.

Downward Arrow – Helps to uncover underlying assumptions in logic and reasoning through questioning the pt. Techniques Used Behavioral Techniques

Guided Relaxation and Meditation – methods include deep breathing, relaxation training, meditation, and other exercises
- Goal: reduce responses to anxiety
- Helps pt distract from anxiety and become self- aware of control over their breathing and other manifestations of anxiety Techniques Used Tune in, and keep a thought diary.
Underline the words that are unhealthy
Write a list of positive statements that counter the negative thoughts
Continue to notice negative thoughts
Stop the messages through distraction (such as snapping a rubber band on wrist)
Change the negative thought to a positive statement
Contine practicing steps 4-6 for 2 weeks Cognitive Restructuring:
Box 6-3 pg.185 “I’m either a success or failure”

“They probably think that I am incompetent”
“I must be the best absolutely all of the time”

“My worth depends on what others think of me”

“I am not as competent as my coworkers or supervisors” Sample Statement All-or-Nothing

Mind reading

Unrealistic Expectations

Externalization of self-worth

Comparing Type of Distortion Other Cognitive Technique Used:
Labeling of Distortions Outcomes -The patient was discharged after 7 visits distributed over 21 weeks.

-Case report describes the use of CBT techniques during patient education by a physical therapist.

-The patient demonstrated clinically measurable and significant improvements in disability. -Improvements in both self-efficacy beliefs related to exercise and activity avoidance beliefs were associated with improvement in disability.

-Additional research is needed to determine best practices for CBT-based patient education by physical therapists. -CBT is an effective intervention for patients with persistent pain.

-This case report describes how specific CBT strategies can be integrated with multimodal physical therapist management of a patient with persistent low back pain. Guided Relaxation... close your eyes and listen! Ahmadi, S., Kajbaf, M., Doost, H. (2012). Efficacy of trauma focused cognitive behavior therapy on symptoms of post-traumatic stress disorder (PTSD) in displaced war-exposed adolescents in Afghanistan: a comparison study of TF-CBT with psychological debriefing. Interdisciplinary Journal of Contemporary Research in Business, 4 (4), 1084-1089.Aznavour, L. Thought Stopping Technique (Video file). Retrieved from http://www.youtube.com/watch?v=nyAgeUAK6igBeck, R., & Fernandez, E. (1998). Cognitive-behavioral therapy in the treatment of anger: A meta-analysis. Cognitive Therapy and Research, 22, 63–74.Bourne, E. (1995). The Anxiety and Phobia Workbook. Oakland, CA: New Harbinger Publications, Inc.Butler, A., Chapman, J., Forman, E., Beck, A. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17-31.Covin, R., Ouimel, A., Seeds, P., & Dajois, D. A. (2008). Meta-analysis of CBT for pathological worry among clients with GAD. Journal of Anxiety Disorders, 22 (1), 108-116.Dunn, R. L., & Schwebel, A. I. (1995). Meta-analytic review of marital therapy outcome research. Journal of Family Psychology, 9, 58–68.Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. (1998). A meta-analysis of the effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49, 59-72.Gould, R. A., Otto, M. W., Pollack, M. H., & Yap, L. (1997). Cognitive behavioral and pharmacological treatment of generalized anxiety disorder: A preliminary meta-analysis. Behavior Therapy, 28, 285– 305.Gould, R. A., Buckminster, S., Pollack, M. H., Otto, M. W., & Yap, L. (1997). Cognitive-behavioral and pharmacological treatment for social phobia: A meta-analysis. Clinical Psychology: Science & Practice, 4, 291– 306.Gould, R. A., Otto, M. W., & Pollack, M. H. (1995). A meta-analysis of treatment outcome for panic disorder. Clinical Psychology Review, 15(8), 819–844.Grossman, P. B., & Hughes, J. N. (1992). Self-control interventions with internalizing disorders: A review and analysis. School Psychology Review, 21(2), 229– 245Lehmkuhl, H., Storch, E., Bodfish, J., Geffken, G. (2008) Brief report: exposure and response prevention for obsessive compulsive disorder in a 12-year-old with autism. Journal of Autism & Developmental Disorders, 38 (5): 977-81. Marriage, D. & Henderson, J. (2012). Cognitive behavior therapy for anxiety in children with asthma. Nursing Children and Young People, 24 (9), 30-35.Ono, Y., Furukawa, T., Shimizu, E., Okamoto, Y., Nakagawa, A., Fujisawa, D., Nakagawa, A., Ishii, T., & Nakajima, S. (2011). Current status of research on cognitive therapy/cognitive behavior therapy in Japan. Psychiatry and Clinical Neurosciences, 65, 121-129.Reinecke, M. A., Ryan, N. E., & DuBois, D. L. (1998). Cognitive-behavioral therapy of depression and depressive symptoms during adolescence: A review and meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 37(1), 26– 34.Rundell, S., Davenport, T. (2010). Patient education based on principles of cognition behavioral therapy for a patient with persistent low back pain: a case report. JOSPT, 40(8): 494-501.Wheeler, K. (2008). Psychotherapy for the Advanced Practice Psychiatric Nurse. St. Louis, MO: Mosby, Elsevier. Reference
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