1 Santa Clara Essentials of CBT PRESENTATION 2019 Final€¦ · Depression Inventory (BDI) or Beck Anxiety Inventory (BAI). • And/or ask client to rate mood on a 0-10 scale focused

© 2019 Beck Institute for Cognitive Behavior TherapyPermission required for reproduction of these materials www.beckinstitute.org 1

Essentials ofCognitive Behavior Therapy

MICHAEL A. TOMPKINS, PHD, ABPP

Speakers Faculty, Beck Institute for Cognitive Behavior TherapySan Francisco Bay Area Center for Cognitive Therapy

and University of California at Berkeley

March 25, 2019

Financial DisclosuresHonorarium: Advisory Board Member, Magination Press.

Royalties: American Psychological Association, Guilford Press, Magination Press, New Harbinger Publications, Springer Publications.

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Acknowledgements• Judith Beck, PhD

• Torrey Creed, PhD

• Robert Hindman, PhD

• Beck Institute for Cognitive Behavior Therapy

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Beck Institute is a leading international source for training,

therapy, and resources in Cognitive Behavior Therapy (CBT).

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Dr. Aaron T. Beck developed CBT at the University of Pennsylvania in the 1960s. In 1994, Dr. Beck and his daughter, Dr. Judith Beck, established Beck Institute.

About Beck Institute

Our mission is to encourage the growth and dissemination of CBT throughout the world through leadership in the field and through the provision of professional training, outpatient clinical services and research.

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The Cognitive Behavioral Model

“It’s not the situations in our lives that cause distress, but rather our interpretations of those situations.”~Aaron T. Beck

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Join the CBT Conversation

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Sign up for the Beck Institute newsletterbeckinstitute.org/subscribe

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Agenda• Overview of cognitive-behavior therapy• Cognitive model and case

conceptualization• Cognitive model for depression and anxiety• Cognitive interventions• Behavioral interventions• Emotion exposure

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OVERVIEW OFCOGNITIVE BEHAVIOR

THERAPY

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General Principles of CBT

• Semi-structured (but flexible and creative), efficient, active, guided by case conceptualization and a hypothesis-testing approach.

• Collaborative, respectful, and founded on a strong therapeutic alliance.

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General Principles of CBT• Focused on developing skills and self-

efficacy (client’s belief that he or she can apply skills learned in therapy in order to manage life problems effectively).

• Interventions focused on cognitive change (flexibility), in the service of flexible behavioral and emotional change.

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Essential Components of CBT• Cognitive-behavioral conceptualization• Problem-solving orientation• Structured session• Action plans (out-of-session homework)• Evaluation of thoughts and core beliefs• Behavioral change• Relapse prevention

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Phases: Cognitive-Behavior Therapy

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Outcome Studies• Major Depressive Disorder• Bipolar Disorder (with meds)• Schizophrenia (with meds)• Generalized Anxiety Disorder• Panic Disorder• Social Phobia• Post-Traumatic Stress Disorder• Obsessive Compulsive Disorder• Hypochondriasis• Substance Misuse

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Outcome Studies for Disorders• Bulimia and Anorexia• Personality Disorders• Irritable Bowel Syndrome• Chronic Pain• Chronic Fatigue Syndrome• Migraine Headaches• HIV Depression• Colitis• Sexual Dysfunction• Fibromyalgia• Obesity

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Comparison of Relapse Rates

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ATTITUDE OF THERAPIST

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Model of Therapeutic Alliance

Bordin, E. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16, 252-260.

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Attitude and Stance of Cognitive-Behavior Therapist• Compassionate• Curious• Collaborative• Pragmatic• Active• Firm but flexible

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Guided Discovery• Listen• Ask informational questions• Use summaries• Ask synthesizing and reflective questions

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Examples: Socratic Questions• What is the evidence that your thought is

true? What is the evidence that your thought is not true?

• What’s an alternative explanation or viewpoint?

• What’s the worst thing that could happen? How could you cope with that? What’s the best that could happen? What’s the most likely outcome?

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Examples: Socratic Questions• What is the effect of telling yourself [this

thought]? What could be the effect of changing your thinking?

• What would you tell [a specific friend/family member] if he/she viewed this situation in this way?

• What could you do now?• “Is this true for everyone in your situation?”• “Have you looked at this same situation in a

different way in the past? Did that help?”

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STRUCTURED SESSION

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Rationale: Structured Session• Assists therapist in using therapy time

efficiently in order to carry out interventions and to accomplish treatment goals.

• Models the types of skills and behaviors that are taught in cognitive-behavior therapy (i.e., goal-oriented, active, focused on solving concrete specific problems).

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Structure: CBT Session

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Phases: CBT Therapy Session

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Start of Session• Greeting and check-in: mood; “What

happened between last session and now that is important that I know? What successes did you have or when did you feel even a little better?”

• Bridge: Summarize for client focus of last meeting, what was learned and practiced, link that work to client’s treatment goals, action plan that came out of session.

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Check-in• Review measures, such as the Beck

Depression Inventory (BDI) or Beck Anxiety Inventory (BAI).

• And/or ask client to rate mood on a 0-10 scale focused on a specific emotion (anxiety, depression, anger).

• And/or ask client to rate degree of the problem on a 0-10 scale (procrastination 5/10; relationship difficulty 3/10).

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Guidelines: Check-In• Strive for brevity (2-5 minutes).• Distinguish check-in from body of therapy

session.• Look for opportunities to make a check-in

item an agenda item.• Use to debrief from last session,

particularly if session was difficult.• Use to bridge from last session.

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Assessment

(data collection)Treatment

PlanCase Formulation

(hypothesis)

Empirically-Driven Approach

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Progress Monitoring MeasuresCopyrighted Measures:• Beck Depression Inventory II (BDI-II)• Beck Anxiety Inventory (BAI)

Public Domain Measures:• Patient Health Questionnaire (PHQ-9)

Depression• General Anxiety Disorder (GAD-7) Anxiety• Depression Anxiety and Stress Scale (DASS)

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Treatment Progress: Jack

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Out

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Week of

Y-BOCSBeck Depression Inventory

Treatment Progress: Gail

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101520253035404550

1 4 7 10 13 16 19 22 25 28

Session Number

BDI BAI

SSS SPA

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Treatment Progress: Jill

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Week of

Rationale: Bridge• Connects current session with previous

session.• Gives continuity and momentum to the

treatment.• Reinforces learning and emphasizes

important points during the previous session.

• Identifies problems from the prior sessions and feedback about session in general.

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Guidelines: Bridge• What do you remember about last

session?• Did anything stand out for you about

last time?• What did you take away from our last

session?• Was there anything you didn’t

understand or that bothered you?

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Start of Session• Set agenda – “What problems do you

want to work on today?” “Would you tell me the NAMES of the problems you would like to work on today?”

• Update – Action plan review – “How did the action plan go? Shall we take a look now at what you learned?”

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Agenda• Agenda is a short list of topics that client and

therapist agree will be focus of therapy session.

• Agenda is linked to treatment goals and provides a roadmap for session.

• Agenda focuses on session and therapy anchors (new and old situations or problems, thoughts or emotions); or any point or matter about the therapy itself (e.g., changes in meeting time, reports from the client about a meeting with an adjunct therapist).

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Guidelines: Set Agenda• Set agenda collaboratively but keep eye

on treatment goals; then prioritize.• If client has trouble identifying agenda

item, review goals.• Set clear and specific agenda items – if

client is vague, ask for concrete ways to work toward goals.

• Be realistic: 1-2 things that would help client feel better and give a sense of progress.

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Middle of Session• Prioritize problems• Complete a thought record for a problem• Decide strategies to use• Use summaries to highlight important

information or ask client to summarize• Ask client to repeat rationale for intervention• Ask client for ideas for action plans• Develop action plan

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End of Session• Summarize main points of session• Review action plan• Elicit feedback about what was

learned• Elicit feedback about session itself• Elicit feedback about therapist

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ACTION PLANS

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Guidelines: Action Plans• Be collaborative and provide clear rationale.• Be specific and concrete.• Tie to work in session: “Based on what we’ve

worked on today, what would you like to try out this week?”

• Start action plan assignment in session.• Rate confidence and adjust task.• Anticipate obstacles and develop plan to

solve.

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Motivation: Action Plans• Better to have a small doable assignment than

one that client does not complete; break tasks down, and lower barriers to adherence.

• Set up as a “no lose” lesson – “Whether you complete it or not or whether it’s successful or not, we’ll learn something important that will help you.”

• Rehearse in imagination (covert rehearsal), and adjust if necessary.

• Include prompts to remind client to initiate action plan.

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COGNITIVE MODEL

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Cognitive Model

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Automatic Thoughts• Generally arise spontaneously, brief

and fleeting; co-exist with manifest stream of thoughts, often unnoticed.

• Associated with specific emotions that depend on their content and meaning.

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Intermediate Beliefs• Often the most difficult category of belief

to identify correctly.

• Attitudes, rules, assumptions that stem from core beliefs and fuel automatic thoughts.

• Often, in the form of if-then statements.

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Core Beliefs• Most central, fundamental beliefs about

ourselves, others, and the world.• Three typical categories of self core beliefs:

incompetent, unlovable, worthless.• Absolute and rigid, usually 1-2 words – “I’m

worthless,” “I’m fragile.”• May result in biases in attention, information

processing, and memory.• When activated, core beliefs are the lenses

through which we interpret situations.

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COGNITIVE CASE CONCEPTUALIZATION

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Definition: Conceptualization• A theory that explains or accounts for a

particular client’s symptoms and problems, here and now.

• Considers life experiences that lead client to think and behave in certain ways in certain situations.

• Includes client’s strengths and weakness and focuses on relevant treatment goals.

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Rationale: Conceptualization• Assists therapist in treatment process,

including problems in the treatment itself.• Identifies relevant session anchors that

focus the session and the treatment.• Enhances collaboration, understanding,

and willingness.• Focuses therapist and client on relevant

topics for a session and for action plans.

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Core Beliefs Influence Thoughts

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Maladaptive Coping StrategiesActions (behaviors) or thought actions that either support or oppose beliefs:

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Development: Beliefs and Compensatory Strategies• Core beliefs and behavioral patterns often

develop in childhood; can be transmitted from the family and in response to repeated social and environmental events.

• Family members communicate maladaptive thoughts and beliefs to client (e.g., “You’re a mess.”) and model maladaptive compensatory strategies (e.g., verbal or physical aggression when frustrated).

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Transmission: Maladaptive Beliefs Through Generations

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Case Conceptualization Diagram

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Mini Case Conceptualization

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Guidelines: Problem List• Strive to be exhaustive, mutually agreed

upon.• Include client’s chief complaint, use client’s

words for problems.• Describe problem in 1-2 words (e.g.,

relationship difficulties), quantify (BDI = 33).• State problems in concrete, behavioral

terms.• Describe mood, behavioral, and cognitive

components of each problem.

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Problem Domains• Psychological symptoms, problems,

disorders• Medical symptoms, problems, disorders• Interpersonal difficulties• Work difficulties• Financial difficulties• Housing difficulties• Legal difficulties• Leisure difficulties

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Strategies: Belief Hypotheses

• Attend to automatic thoughts, particularly those that occur repeatedly.

• Attend to automatic thoughts that occur across a variety of situations.

• Use downward arrow technique.

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Exercise: Case Conceptualization

• Break into triads. Develop a case conceptualization for a favorite character from literature (e.g., Harry Potter, Hermione Granger, Orphan Annie, Peter Pan, Charlie in Charlie and the Chocolate Factory) or, from a favorite movie or television show (“Orange is the New Black,” “Breaking Bad”).

• Complete CCD for character. Include two typical situations (trigger, AT, meaning of AT, emotion, behavior).

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COGNITIVE MODELOF DEPRESSION

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Cognitive Triad of Depression

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NegativeSelf View

Paralysis of Will

Depressed Mood

Suicidal Wishes

IncreasedDependency

AvoidanceWishes

Negative View ofWorld

Negative View ofFuture

Cognitive Model of Depression

EARLY EXPERIENCEAbusive, neglectful, angry mother and

absent fatherCritical older siblings

Child must fend for herself↓

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Cognitive Model of DepressionFORMATION OF BELIEFS

I’m incompetent.↓

FORMATION OF DYSFUNCTIONAL ASSUMPTIONS

If I make a mistake, it will show how incompetent I am.

If I do everything perfectly, I’ll be okay.

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Cognitive Model of DepressionCRITICAL INCIDENTS

Good (not excellent) rating by supervisorCritical coworker

Physical Illness persists

NEGATIVE AUTOMATIC THOUGHTS(COGNITIVE TRIAD)

I can’t do anything right.I will probably get fired.

I’ll never get better.

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Cognitive Model of DepressionSYMPTOMS OF DEPRESSION

BEHAVIORALLower activity levels

Withdrawn from positive activitiesImpaired coping

with practical problems

AFFECTIVESadness

GuiltShameAnxietyAnger

MOTIVATIONALLower activity levels

Withdrawn from positive activitiesImpaired coping

with practical problems

COGNITIVEIndecisiveness

Poor concentrationand memory Rumination

PHYSICALSleep disturbanceLoss of appetite

Loss of sexual desire

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Cognitive Triad of Depression

NegativeSelf View

Paralysis of Will

Depressed Mood

Suicidal Wishes

IncreasedDependency

AvoidanceWishes

Negative View ofWorld

Negative View ofFuture

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Helpless Core Beliefs• I am inadequate, ineffective,

incompetent, can’t cope.• I am powerless, out of control, trapped,

vulnerable, weak, needy, likely to be hurt.• I am inferior, a failure, a loser, not good

enough, defective, don’t measure up.

2011, Beck, J.S. Cognitive Behavior Therapy: Basics and Beyond (2nd ed.)

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Unlovable Core Beliefs• I am unlikable, unwanted, will be rejected

or abandoned, always be alone.• I am undesirable, unattractive, ugly,

boring, unimportant, have nothing to offer.

• I am different, defective, not good enough to be loved by others, a nerd.


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Worthless Core Beliefs• I am worthless, unacceptable, bad,

crazy, broken, defective, a nothing, a waste.

• I am hurtful, dangerous, toxic, evil.• I don’t deserve to live.


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Cognitive-Behavioral Model

Situation

Automatic Thoughts and Images

Reaction

PhysiologicalBehavioralEmotional

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Thought Record to Formulate Case• Focus on specific situation when client was

feeling down or depressed.• Connect situation to thoughts; thoughts to

emotion; emotion to response with arrows on the thought record.

• Complete thought records for several situations when client’s mood dipped.

• Therapist completes thought record when client’s mood improved to demonstrate role of thoughts in lifting mood.

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COGNITIVE MODELOF ANXIETY

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Risk and Resource Model

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Appraisals: Risk and Resource• Overestimating risk

► Believe probability of risk/threat is high► Believe severity of threat is high

• Underestimating Resources to Cope► Internal resources► External resources

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Cognitive Model: Avoidance

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Cognitive Model: Safety Behaviors

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COGNITIVE RESTRUCTURING

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Steps in Cognitive Restructuring

1. Identify

2. Evaluate

3. Respond

Problem Solving

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IDENTIFYING AUTOMATIC THOUGHTS

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Identifying Automatic ThoughtsWhen you notice or infer a reaction (change of affect, behavior, physiology), or when a patient has described such, ask:

• “What was just going through your mind?” or

• “What were you thinking just then?”or

• “What is going through your mind right now?”

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Identifying Automatic ThoughtsListen for automatic thoughts as the client talks about the problem:

• Negativity• Extreme words: never, always, must• Patterns/themes• Self-criticism

“How much do you believe the thought?” (0 –100%) “What feeling is connected to that thought? How strong is the feeling?” (0 – 10).

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When Client Cannot Identify Automatic Thoughts

• Focus on client’s emotions and/or physiological response initially.

• Facilitate re-experiencing of situation.► Through imagery► Through roleplay

• Ask about images, “What picture or image went through your mind just then?”

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Thought Record to Identify Automatic Thoughts

• Introduce client to thought record.• Ask questions to elicit data for each column

(situation, thoughts, emotions, responses).• Focus thought record on a specific problem that

is linked to client’s treatment goals.• Help client to distinguish between thoughts that

precede mood induction and thought actions that follow mood induction.

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EVALUATING AUTOMATIC THOUGHTS

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Guidelines: Evaluating Automatic Thoughts• Assist client in deciding whether a thought is

accurate or helpful; use Socratic questions.• When automatic thought is accurate, shift

client to problem solving or acceptance.• However, watch that client has not drawn an

invalid conclusion regarding the automatic thought (e.g., I have a chronic illness and therefore my life is unbearable).

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Socratic Questions: Evaluate AT• What makes me think the thought is true? • What makes me think the thought is not true

or not completely true? ► What's another way to look at this?

• What’s the worst that could happen? What could I do then?

• What's the best that could happen? • What will probably happen?

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Socratic Questions: Evaluate AT

• What will happen if I keep telling myself the same thing?

• What would I tell my friend _______ if this happened to him or her?

• What could I do now that might be more helpful?

• What could happen if I change my thinking?

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Identify Thinking Errors• All-or-nothing thinking• Overgeneralization• Jumping to conclusions• Emotional reasoning• Catastrophizing• Magnification or minimization• Personalization• Mental filter• Mindreading

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RESPONDING TOAUTOMATIC THOUGHTS

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Rationale: Thought RecordThought record is a tool clients can use to arrive at an alternative view of a problematic situation that allows them to feel and function better.

• Step 1 – Examine usefulness of client’s cognitions in a problematic situation (advantages vs. disadvantages).

• Step 2 – Identify cognitive distortions.• Step 3 – Examine the evidence.

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Guidelines: Thought Record to Respond• Use guided discovery as much as possible.• Select focus for thought record (problem

emotion or problem behavior).• Focus on a concrete, specific situation.• Follow the affect.• Encourage client to use thought record.• Remember, you are teaching a skill.

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5-Column Thought RecordDATE/TIME

SITUATION

1. What actual event or stream of thoughts, or daydreams, or recollection led to the unpleasant emotion?

2. What (if any) distressing physical sensations did you have?

AUTOMATIC THOUGHT(S)

1. What thought(s) and/or image(s) went through your mind?

2. How much did you believe (0-100) each one at the time?

EMOTION(S)

1. What emotion(s) (sad, anxious, angry, etc.) did you feel at the time?

2. How intense (0-100) was the emotion?

ALTERNATIVE RESPONSE

1. (optional) What cognitive distortion did you make? (e.g., all-or-nothing thinking, mind-reading, catastrophizing.)

2. Use questions at bottom to compose a response to the automatic thought(s).

3. How much do you believe each response?

OUTCOME

1. How much do you now believe each automatic thought?

2. What emotion(s) do you feel now? How intense (0-100) is the emotion?

3. What will you do (or did you do)?

© 2017, Beck, J.S. Cognitive therapy worksheet packet. www.beckinstitute.org

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5-Column Thought RecordDATE/TIME

SITUATION

Thinking about the phone bill I forgot to pay.

AUTOMATIC THOUGHT(S)

How could I forget?

I’m so terrible.

EMOTION(S)

Sad (75)

ALTERNATIVE RESPONSE

I did forget to pay the phone bill, but this is the first time. Usually I am prompt. I forgot because I’ve been working late, not because I’m bad. Good people do make mistakes. The worst that’ll happen is I’ll keep forgetting to pay my bills. The best is I’ll never forget again. The most realistic outcome is I’ll occasionally forget. I should stop blaming myself and accept that it’s human to make mistakes. If I realize it’s really pretty minor, I’ll feel better. I’d tell Joanne it’s ridiculous to consider herself terrible for one mistake. 80%

OUTCOME

1. AT = 50

2. Sad = 50

© 2017, Beck, J.S. Cognitive therapy worksheet packet. www.beckinstitute.org

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Questions: Generate Rational Responses• What makes me think the thought is true?

What makes me think the thought is not true or not completely true?

• What would I tell my friend if this happened to him or her?

• What could I do now?• What's the best that could happen? What

will probably happen?

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Questions: Generate Rational Responses• What's another way to look at this? • What’s the worst that could happen?

What could I do then?• What will happen if I keep telling myself

the same thing?• What could happen if I change my

thinking?

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Highlight: Cognitive Change

• “Now how much do you believe the thought? The adaptive response?”

• “What’s your mood now? How strong is the sadness 0-100?”

• Even if the client feels only 10% better, the intervention highlights both the value of the strategy and the influence of cognition on mood change.

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Coping Card: Respond to AT

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Exercise: Evaluate ATAssist client in evaluating one of the following automatic thoughts:

• “I’m a bad mother.” • “I can’t do anything right.” • “What’s the point of trying, I’ll just screw things

up again.”

Use Testing Your Thoughts Worksheet. Explore first whether thought is accurate or helpful. Ask about images.

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Rationale: Cognitive Rehearsal• Use to rehearse client’s application of

rational responses.• Use to anticipate obstacles or barriers

when scheduling activities, developing action plans, when planning application of any skill to a new or typical situation.

• Use to increase confidence and thereby increase likelihood client will try and succeed.

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IDENTIFYING AND EVALUATINGCORE BELIEFS

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Guidelines: Identify Core Beliefs• Follow the affect.• Identify (if possible) all three types of core

beliefs and specific intermediate beliefs.• Use client’s specific language to express

belief.• Identify beliefs (helpful and unhelpful,

accurate and inaccurate) that client expresses in absolute terms (e.g., I am worthless).

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Downward Arrow Technique

• "If that's true, what's so bad about that...?"• "What's the worst part about...?"• "So what if...?"• "What does that mean about you?"• Vary questions to elicit meaning of

automatic thought.

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RESPONDING TOAND MODIFYING

BELIEFS

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Opening the Belief Aperture

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Rationale: Belief Change Strategies• To restructure deep cognitive structures

(beliefs) assumed to contribute to depressive symptoms

• To weaken maladaptive beliefs• To develop and/or strengthen more

adaptive beliefs

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Modify Core Beliefs• Provide psychoeducation about core beliefs and

process of change (i.e., It takes patience to correct a self-prejudice).

• Collaboratively develop a new core belief.• Examine evidence of new core belief.• Continually reframe evidence that supports old core

belief.• Continually identify evidence that supports new core

belief.• Rehearse alternative core belief (i.e., Let’s try it on

for size).Cognitive Behavior Therapy: Basics and Beyond (Beck, 2011)

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Definition: Positive Data Log (PDL)• Log of evidence in support of a client’s

positive or balancing belief.• Teaches client to notice the multiple

situations in which beliefs are activated.• Helps client strengthen the positive or

balancing belief.• Helps the client notice and overcome

biases in processing information that are driven by maladaptive core beliefs.

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Guidelines: Set Up PDL• Provide a rationale.• Identify the balancing core belief.• Start the positive data log in session.• Instruct client to enter evidence on the

positive data log as soon as possible.• Instruct client to enter all evidence, no

matter how small, and place a question mark next to evidence that client doubts is appropriate.

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Probe Questions: PDL• “Why don’t you walk me through the day?

Let’s see if we can find something that you missed.”

• “Tell me about the interactions you’ve had with people this week? Let’s see if we can find something that you missed.”

• “If people thought you were ……. (alternative belief) what might they notice about you? Did you do anything like that this week?”

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Probe Questions: PDL• “If you really believed you were… (alternative

belief) what might you be doing or saying? Did you say or do anything like that this week?”

• “Can you think of someone who has a lot of this quality we’ve called [alternative belief]? What do you do or say that makes you think they’re [alternative belief]? Did you do or say anything like that this week?”

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Guidelines: Review PDL

• Review the positive data log.• Reward small steps.• Watch for activation of maladaptive core

belief when reviewing positive data log.• Watch for opportunities in session to add

items to the positive data log.

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BEHAVIORAL INTERVENTIONS

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Common Behavioral Interventions

• Graded task assignment• Problem-solving training• Behavioral experiments• Assertiveness, communication, and social

skills training

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Graded Task Assignment• Provide rationale for intervention.• Select specific task that client is

interested in trying.• Avoid trap of helping client break down

a task that the client thinks he or she should do rather than a task the client wants to do.

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Problem Solving• Ability to problem solve influenced by

developmental age.

• Ability to problem solve influenced by affect.

• Ability to problem solve influenced by cultural context.

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ITCH

• Identify the problem.

• Think about possible solutions.

• Choose a solution to implement.

• How well did it work?

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Identify the Problem• Easier said than done and perhaps the

most critical step.

• Select one problem, prioritize multiple problems if necessary.

• Define the problem in concrete, specific terms, e.g., “No one talks to me at lunch.”

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Think of Possible Solutions• Brainstorm all possible solutions and be

neutral, i.e. “That’s a solution,” versus “That’s a great solution.”

• Encourage client to lead.• Ask permission to throw out an idea.• If client is stuck, model problem solving

with a problem you encountered recently.

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Choose a Solution to Try• Evaluate pluses and minuses of each

solution.

• Select solution most likely to work and least likely to cause problems.

• Set up as experiment.

• Identify steps required to implement the selected solution.

• Include in solution steps skills to make solution more likely to work and avoid problems.

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How Well Did It Work?• Evaluate how well solution worked,

examine the pluses and minuses.• “Didn’t even come close” – repeat ITCH.• “Missed the mark but close” – modify

based on what was learned and try again.

• “Bulls eye” – continue the solution.

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Problem or Problem of Perception• “Everyone hates me” – client is disliked

because of inappropriate behaviors or client interprets benign neglect to mean people hate him.

• “Job is boring” – client is bored because job is not challenging or client avoids more challenging tasks because he fears failing.

• Use cognitive and behavioral interventions that target these thoughts and beliefs.

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Behavioral Experiments• To test validity of client’s existing beliefs

about self, others, and world.• To construct and/or test new, more

adaptive beliefs or alternative perspectives.

• To contribute to the development and verification of the case conceptualization.

• “So how can we test that out?”

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Experiential Learning Circle

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BE Target Multi-level Change

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Types: Behavioral Experiments• Active experiments – real or simulated

(roleplays).

• Observational (discovery) experiments –direct observation, surveys, data gathering from sources other than people (e.g., internet).

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Guidelines: Behavioral Experiments

• Step 1: Present the rationale.• Step 2: Develop a prediction.• Step 3: Set up the detailed experiment.• Step 4: Record the outcome.• Step 5: Review the outcome in session and

summarize.

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EMOTION EXPOSURE

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Rationale: Emotion Exposure• Key to treating emotional disorders.• Targets behavioral (avoidance) and

cognitive (misappraisals) that maintain problematic anxiety-mood disorders.

• Behavioral activation is an emotion exposure strategy for depressive disorders.

• Graded exposure is an emotion exposure strategy for anxiety disorders.

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GRADED FEAR EXPOSURE

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Advantages: Fear Exposure• Client gains more “control” over anxious

response, not less “control.”

• Client learns that they can handle or cope with anxious response.

• Client learns that they can break the pattern of anxious thinking.

• Client learns that anxious actions are not necessary.

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Guidelines: Exposure Hierarchy• Try for 10-20 items (may be more for OCD).• Focus on reasonable risk (Would you do it?).• Identify variety of situations to enhance learning

and generalization.• Details: What, when, where, how.• Identify predicted feared outcome or

expectancy (rate likelihood or intensity).• Identify predicted ability to cope.• Identify potential safety behaviors and what

client will do instead.

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Building Exposure HierarchyHierarchy guides treatment and to titrate level of anxiety client experiences:• Step 1 – List situations, objects, and internal

content that trigger anxious response.• Step 2 – Adjust situations based on what

influences intensity of anxious response.• Step 3 – Rank situations from least to most

anxiety-evoking.• Step 4 – Identify safety behaviors to resist.

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Graded Exposure Hierarchy

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Develop: Graded Exposure• Begin with easy exposures.• Ensure exposures are frequent and long

enough (more than 30” or anxiety decreased at least 50% at maximum).

• Include value statement to enhance motivation.

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Types: Fear Exposure Strategies• In vivo – confront anxiety-evoking or phobic

objects or situations in structured “real life” exercises.

• In vitro – confront anxiety-evoking or phobic objects or situations in session with therapist assistance.

• Imaginal – confront anxiety evoking or phobic objects or situations in structured imaginal exercises.

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Examples: Situational Hierarchy

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Examples: Imaginal Hierarchy

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Implement: Graded Exposure• Rate anxiety at the beginning, every 10-15

minutes, and when the exposure ends.• Search for safety cues or data that disproves

the client’s prediction.• Goal is to drop all safety behaviors• If client is unwilling, gradually phase them out.• Practice exposures in office first.• Mass exposures• Include response prevention (block safety

behaviors).

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Reflect: Graded Exposure• Reflect what client learned from the

exposure immediately after completed.• Did predicted feared outcome occur?• Did predicted ability to cope occur?• Did client use safety behaviors?• What happened to anxiety over time?• Evaluate automatic thoughts recorded.• Summarize what was learned.

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EMOTION EXPOSURE

BEHAVIORAL ACTIVATION

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Depression Spiral

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Definition: Behavioral Activation• Therapist works with client to schedule

enjoyable and goal-directed activities to increase activity level and thereby improve mood and allow client to obtain evidence to disconfirm negative views.

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Rationale: Behavioral Activation• Most people wait to feel better before

becoming more active. In fact, becoming more active comes first.

• Helps combat the withdrawal, passivity, and sedentary life-style that maintains depression.

• Helps to distract client from preoccupation with negative thinking.

• May lead to cognitive restructuring.• Manages suicidal thoughts and impulses.• Helps motivate passive, stuck clients.

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For Clients: Behavioral Activation

• Who are passive, immobilized• Who are procrastinating, avoiding, or

feeling “stuck”• Who are having trouble getting moving

because they are overwhelmed and have too much to do

• Who are experiencing suicidal thoughts or impulses

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Features: Behavioral Activation• Evaluate current activity level and types.• Identify pleasant and/or mastery

activities.• Select focus for activity scheduling.• Schedule pleasant and/or mastery

activities.• Use pleasure predicting to enhance

willingness to engage in activities.

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Focus: Behavioral Activation

• Select a time of the day or week when client is not using his or her time well.

• Select a time of day or week when client is most at risk for self-harm or is most depressed.

• Select an activity to improve personal care.

• Select an activity to increase socialization, pleasure, or treatment adherence.

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Guidelines: Behavioral Activation• Provide a rationale and use guided discovery.• Assess confidence level: “How likely is it that

you’ll do this?” “What do you think might get in the way of following the plan?”

• Use cognitive rehearsal to identify obstacles to trying activity and brainstorm solutions (use problem-solving strategy).

• Start where clients are, not where they think they should be.

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Obstacles: Behavioral Activation

• Test problematic beliefs with behavioral experiments: “I don’t enjoy anything.” (e.g., pleasure predicting); “I can’t do it because I don’t feel like it.” (e.g., break down task); “I have to do things perfectly for them to be fun.” (e.g., identify activities that can be fun, even if done “imperfectly”).

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Summary• CBT is an evidence-based treatment

applied to a variety of clinical problems.• Structured sessions are essential to

efficient and effective CBT.• CBT is guided by a cognitive case

conceptualization.• Cognitive restructuring and emotion

exposure strategies are essential in treatment of emotional disorders.

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CBT Training through Beck Institute

• Workshops in Philadelphia• Training for Organizations (at your location)• Supervision• Consultation• Online Training (www.beckcbtonline.org)

For more information email [email protected]

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Beck Institute CBT Certification

Get Beck Certified!

Learn more athttps://beckinstitute.org/certification/

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Join the CBT Conversation

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Sign up for the Beck Institute newsletterbeckinstitute.org/subscribe

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youtube.com/BeckInstitute

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Documents

1 Santa Clara Essentials of CBT PRESENTATION 2019 Final€¦ · Depression Inventory (BDI) or Beck Anxiety Inventory (BAI). • And/or ask client to rate mood on a 0-10 scale focused