By Barbara LoFrisco Cognitive Behavioral Seminar University of
South Florida
Slide 2
Cognitive Therapy The Theory In order to understand an
emotional disturbance, one must understand the mental processes or
cognitions These mental events are readily accessible Patients
beliefs are examined: him/herself, future and world Any concern
will be in one of these domains This is the cognitive triad (Beck,
Rush, Shaw & Emery, 1979) Common themes are found with both
anxious and depressed patients
Slide 3
Cognitive Therapy- The Process 1. Patient becomes aware of
cognition 2. Patient frames cognition as a hypothesis 3. Patient
scrutinizes belief 4. Patient gradually arrives at a different view
5. Changes in the emotional reaction should follow 6. Eventually,
concern over recent events will diminish 7. Thus, negative affect
is removed from ruminations about said events 8. Result: Less
negative mood
Slide 4
Cognitive Therapy- The Process Patient will start to apply
these techniques to new events Many of the skills learned in
Cognitive Therapy are used by people who have never had depression
If the patient does not use these skills, the risk for relapse is
high
Slide 5
Cognitive Therapy- Schema Work Cognitive errors (or automatic
thoughts) are based on schema, or patterns of thinking These are
the themes of dysfunctional thinking All patients have them They
can be uncovered by examining cognitive errors Can be uncovered
using Downward Arrow technique Or using If then logic. For example,
If I fail this exam, then I am a failure as a person. Old schema
can be replaced with new
Slide 6
Cognitive Therapy- Cognitive Errors We are all subject to
cognitive errors They occur more often in affective episodes There
is a list of common errors that patients can compare their own
thoughts to: 1. All or nothing thinking 2. Over generalizing 3.
Discounting the Positives 4. Jumping to conclusions
Slide 7
Cognitive Therapy- Cognitive Errors 5. Mind Reading 6.
Fortunetelling 7. Magnifying/Minimizing 8. Emotional Reasoning 9.
Making should statements 10. Labeling 11. Inappropriate
Blaming
Slide 8
Cognitive Therapy- Cognitive Errors How many cognitive errors
can you spot in this story? Mary felt isolated and alone. Mary had
been married to an abusive man for 5 years and had finally decided
to leave him. I should have done it much sooner, she reported. Mary
reported that she had a history of attracting abusive men, so
therefore all men must be abusive. What is wrong with me? Im never
going to meet anyone!
Slide 9
Cognitive Therapy- Cognitive Errors Mary felt isolated and
alone. Mary had been married to an abusive man for 5 years and had
finally decided to leave him. I should have done it much sooner,
she reported (#7 Minimizing, #9 should statements, #11
Inappropriate Blaming). Mary reported that she had a history of
attracting abusive men, so therefore all men must be abusive (#2
Overgeneralization). What is wrong with me? Im never going to meet
anyone! (#1 All or nothing thinking, #6 Fortune Telling).
Slide 10
Cognitive Therapy- Therapeutic Interaction Relationship is one
of collaboration Patient is expert on his or her own experience,
and the meaning he or she attaches to events Therapist is expert on
the model Therapist does not make interpretations, rather solicits
this information from clients More of a state of not knowing
Thoughts are not replaced until patient understands the meaning of
the thoughts and has decided they are not true
Slide 11
Cognitive Therapy- Therapeutic Interaction Meaning system of
each patient is idiosyncratic Patients must take an active role in
therapy Differs from Michenbaums Cognitive Behavioral Modification:
thoughts are behaviors that can simply be modified without
understanding underlying meaning Different from Michenbaums SIT
(Self Instructional Training): client is taught to repeat specific
self-coping statements rather than question their inferences
Differs from Ellis REBT: therapist infers clients thinking
errors
Slide 12
Cognitive Therapy Behavioral Methods Behavioral methods
sometimes used to increase behaviors or provide experiences in
pleasure Focus is always on changes in beliefs resulting from
change in actions Behavioral changes serve as experiments to check
out a hypothesis that the patient and therapist have developed; or
formulate a new one But.Jacobson et al. (1996) found that 12 weeks
of behavioral methods had outcomes comparable to 12 weeks of
cognitive therapy.
Slide 13
Behavioral Methods- Applications: Self-Monitoring Hour-by-hour
record of activities and associated moods is kept Patients record
mood on a 0-100 scale, where 0 is the worst they have ever felt and
100 is the best Beck et al. (1979) suggests the patient also record
the degree of mastery or pleasure associated with the activity
Patients are sometimes surprised at how they are spending their
time Can also serve as a baseline
Slide 14
Behavioral Methods- Applications: Self-Monitoring Detailed
examination of this record is much better than patients memory for
testing hypothesis Patients memory is often selective Therapist can
ask patient to recall thoughts that occurred during both good and
bad events Therapist can look for consistencies in the record:
which events are associated with good or bad moods, or with mastery
or pleasure
Slide 15
Behavioral Methods: Applications: Scheduling Activities Purpose
is to get patient to engage in activities he or she is (unwisely)
unwilling to do Remove decision making as an obstacle in initiation
of activity Has decision making ever been an obstacle for you in
initiating an activity? (Share with the class if you feel
comfortable) Non-adherence can be addressed therapeutically Usually
failures are similar to what has been troubling the patient.
Slide 16
Behavioral Methods: Applications: Scheduling Activities A
thorough analysis of cognitive obstacle can be performed 3 Types of
Activities to schedule: 1. Those associated with mastery, pleasure
or good mood 2. Those that had been rewarding in the past but that
the patient has been avoiding 3. New activities that might be
rewarding or informative
Slide 17
Behavioral Methods: Applications: Scheduling Activities Patient
can use self-monitoring to monitor mood after activities Activities
can be experiments Patients are more likely to do activities if
they are framed as experiments
Slide 18
Behavioral Methods: Applications: Other Behavioral Activities
Breaking down larger tasks into smaller units Makes task more
concrete and less overwhelming This is called chunking Easier tasks
can be accomplished first This is called Graded tasks Although
simplistic, these methods can be effective because they change how
patient views the (formerly) difficult task
Slide 19
Cognitive Methods: Daily Record of Dysfunctional Thoughts Find
DRDT in Dobsons book. In mine its p. 359. Most of the work in
Cognitive Therapy centers around Daily Record of Dysfunctional
Thoughts (DRDT) Beck et al. (1979) Four most important columns
correspond to the three points in the cognitive model (situation,
belief, emotional consequence). Patients first use DRDT to record
unpleasant or puzzling emotions Patient must first understand what
emotions are (see handouts)
Slide 20
Cognitive Methods: Daily Record of Dysfunctional Thoughts Some
patients dont know the difference between thoughts and feelings
Therapist may have to educate patient Can give feeling chart to
patients so that they can understand what different feelings are In
addition to situation and emotions, patient must also record
thoughts in DRDT This may be more difficult because patients often
think situations cause emotions
Slide 21
Cognitive Methods: Daily Record of Dysfunctional Thoughts Teach
patients that it is the thoughts about the situation, not the
situation that produces the emotion Teach patient to examine his or
her own inferences It is these inferences that are the cause of
distress Automatic thoughts can be re-rated for strength of belief
after alternative thought has been formulated If ratings are
similar, then the initial concern is not resolved Affective
response can also be re-rated in a similar way. Again, lack of
change means something is missing
Slide 22
Cognitive Methods: Three Questions 1. What is evidence for and
against this belief? 2. What are the alternative interpretations?
3. What are the real implications, if the belief is correct?
Slide 23
Cognitive Methods: Downward Arrow Technique Patients first
thoughts are usually not therapeutically useful in that they do not
describe the implications to the patient Use Downward Arrow
Technique to uncover the implications of thought Ask What would it
mean if.? Or What if it is true that.? Or What about that bothers
you? Repeat until thought is produced that will benefit from
cognitive therapy
Slide 24
Cognitive Methods: Cognitive Errors Teach patient to recognize
when one of his or her thoughts falls into one of the categories of
cognitive errors (p. 353 of Dobson, or slide #6) Teaches patients
that these are common cognitive errors: normalization
Slide 25
Cognitive Methods: Identifying Schemata After a while in
therapy, a certain consistency emerges in patients cognitive errors
These consistencies, or themes are the schema They are found at the
level of personal meaning Dysfunctional Attitude Scale (DAS;
Weissman & Beck, 1978) to assess schemata and track changes
during treatment
Slide 26
Cognitive Methods: Indentifying Schemata with DAS The DAS has 9
interpretable factors: 1. Vulnerability 2. Approval 3.
Perfectionism 4. Need to please others 5. Imperatives 6. Need to
impress others 7. Avoidance of weakness 8. Control over emotions 9.
Disapproval Class give examples of 3 of them
Slide 27
Cognitive Methods: Socratic Questioning and Guided Discovery
Probably the most distinctive stylistic feature Most difficult for
therapists to master Guided discovery: through use of leading
questions, helping patients arrive at new perspectives Therapists
must walk a line between guiding patient and allowing patient to
free-associate Common errors of inexperienced therapists is to be
in a hurry and lecture the patient or ask overly leading questions.
Even facial expression can be a factor (LoFrisco)
Slide 28
Cognitive Methods: Socratic Questioning and Guided Discovery
Therapist should avoid closed questions and declarative statements
This maximally engages client to think about problem and come up
with solution Helps foster independence and prevent relapse
(LoFrisco) Will have a greater chance of addressing any
idiosyncratic issues; more client centered
Slide 29
Treatment Procedures- Beginning of Treatment Goals: 1.
Assessment Beck Depression Inventory (BDI); also can be used as a
session-to-session measure 2. Socializing patient into cognitive
model Have patient read the booklet Coping With Depression (Beck
& Greenberg, 1974) Helps to instill hope 2. Dealing with
patients pessimism
Slide 30
Treatment Procedures- Middle Phase of Therapy Solidify work on
cognitive coping skills Patient uses DRDT to track thoughts that
produce negative affect Therapist uses Downward Arrow Technique to
help patient fine-tune their responses Therapist reviews DRDT with
patient Patterns associated with schemata are identified
Developmental history of schemata is discussed. Why?
Slide 31
Treatment Procedures- Middle Phase of Therapy Answer: to help
client make sense of his or her schemata
Slide 32
Treatment Procedures- Final Phase Gains are reviewed Relapse
prevention: Anticipate situations that would tax patient and review
the skills they have learned Becausepatients usually attribute
their improvement to changes in their environment, not changes in
themselves
Slide 33
Treatment Procedures- Final Phase Patients feelings or beliefs
about terminating therapy are addressed Patient may feel like they
cant do it on their own Schedule booster or check-up sessions
Jarrett et al. (1998) found that monthly check-up sessions helped
to prevent relapse Even less frequent boosters can be
beneficial
Slide 34
Empirical Status- Depression Rush et al. (1977) found that
patients treated with cognitive therapy experienced greater symptom
remission at the end of 12 weeks compared with those taking a
tricyclic antidepressant (randomized trial) Blackburn et al. (1981)
and Murphy et al. (1984) did a similar study and found cognitive
therapy equally effective Dobson (1989) meta-analysis: a greater
degree of change than wait-list, pharmacotherapy, behavior therapy
and other psychotherapies
Slide 35
Empirical Status- Depression ThenElkin et al. (1989) discovered
that cognitive therapy did not perform as well as medication in
severely depressed patients A later report (Elkin et al., 1995)
showed even more dismal results The saga continuesHollon et al.
(1992) found that cognitive therapy performed at least as well as
medication, even among the severely depressed OK, lets get serious.
DeRubeis et al. (1999) performed a mega-analysis from these studies
and found cognitive therapy just as effective as medication.
Slide 36
Empirical Status- Depression Finally, in another
placebo-controlled randomized study, Jarrett et al. (1999) found
that the two treatments performed equally well. Conclusion? Even in
the short run, cognitive therapy is a potent alternative to
medication. But does it last?
Slide 37
Empirical Status- Depression Rush et al. (1977) found that at
12-month follow-up (but not at 6) that CT patients scored lower on
depression severity measures than the antidepressant group Murphy
et al. (1984) found patients that received CT during the acute
treatment phase were less likely to relapse than those treated with
drugs Hollon et al. (1992) had similar results Several studies have
found that a relatively short course of CT following a successful
course of antidepressants is as effective in preventing relapse as
is continuing the meds.
Slide 38
Depression- Therapist Behavior Collaborative Study
Psychotherapy Rating Scale (CSPRS) measures therapists adherence to
CBT model. CT- Concrete: measures active methods CT- Abstract
measures discussions about CT rationale DeRubeis & Feeley
(1990); Feeley et al. (1999) discovered that CT-Concrete was
associated with greater changes in BDI; and CT-Abstract was not
Therefore, it is critical for therapists to focus on
problem-solving aspects of CT, at least early on
Slide 39
Depression-Patient Cognitions Hollon et al. (1988) proposed 3
kinds of changes that occur: 1. Deactivation suppress old schema 2.
Accommodation modify/create new schema 3. Development of
compensatory skills applying CT skills to future situations
Slide 40
Depression- Patient Cognitions DeRubeis (1990) studied patients
from the Holland et al. (1992) study, found that improvement on
the: Beck Hopelessness Scale DAS Attributional Style Questionnaire
Play a meditational role. (patients who improved on these measures
also had subsequent change in depressive symptoms) Therefore,
attributional style and dysfunctional attitudes mediate the
reduction of risk of CT
Slide 41
Depression- Patient Cognitions But.Miranda and Persons (1988)
disagreed, stating that the depressive schemata may simply be
latent. So.they developed a negative mood induction procedure prior
to administering the DAS. Segal et al. (1996) found that scores on
mood induced DAS predicted relapse, just like Hollon had found.
Measures of changes in compensory skills are less plentiful Most
measures of coping skills came from interests other than CT
Slide 42
Depression- Patient Cognitions A method is needed to require a
patient to PRODUCE rather than RECOGNIZE coping skills. Most
patients can recognize them. Barber and DeRubeis (1992) developed
the Ways of Responding (WOR) to address this need. To measure
changes in beliefs as they occur in session (rather than a static
measurement) Tang and DeRubeis (1999) developed Patient Cognitive
Change Scale.
Slide 43
CT Course of Change Ilardi and Craighead (1994) observed that
60% - 70% of symptom improvement occurs in the first 4 weeks. But
this was inferred from group mean. Actually.Tang and DeRubeis
(1999) report 40% - 60% of change occurs in the first 4 weeks. Why
would this be clinically relevant? Tang and DeRubeis (1999): In
addition to a shorter course, individual therapy gains can be much
more sudden than group therapy gains; called sudden gains Occurs
among more than 50% of patients Accounts for more than 50% of total
relief
Slide 44
Therapist Patient Alliance Recent research continues to show a
positive relationship between alliance and outcome Good therapeutic
alliance tends to be the RESULT of symptom improvement, rather than
a PREDICTOR So.therapists should adhere to concrete CT, and they
will build alliance This differs from past findings. Studies that
took the average over time of the alliance, and then correlated it
to the outcome
Slide 45
Therapist Patient Alliance As opposed to measuring it at
various points during the therapy process Beckham (1989), DeRubeis
and Feeley (1990), Feeley et al. (1999) found that therapeutic
alliance measured early in therapy process did not predict good
outcome Furthermore, DeRubeis and Feeley (1990), Feeley et al.
(1999) found that later in therapy, alliance was actually predicted
by outcome Lastly, Tang and DeRubeis (1999) found that alliance in
the session prior to the sudden gain was significantly lower as
compared to the session after the gain.
Slide 46
Panic Disorder and Agoraphobia There is also cognitive therapy
for OCD, anxiety and hypochondriasis, which follows a similar form
to what was just described (for depression).
Slide 47
Panic Disorder and Agoraphobia The phenomenology and treatment
of panic disorder have been well developed: Patient feels a
particular symptom Attributes it to the start of a panic attack
(from experience) Because he/she thinks its pathological, the
progression of the panic attack continues I.e.. chest pain= heart
attack But there are other explanations for these symptoms I.e..
You will be lightheaded if you get up too fast
Slide 48
Panic Disorder and Agoraphobia Patient focuses on catastrophic
consequences of symptom ** Patient loses ability to view symptoms
objectively*** This is what turns anxiety into a panic attack
Vicious cycle: fear makes symptoms worse, which makes fear worse,
etc. At this point symptoms seem uncontrollable This spontaneous
attack is a phobia of internal conditions
Slide 49
Panic Disorder and Agoraphobia Recent development in treatment:
beware of dependence on safety behaviors In the mid-eighties, using
relaxation or distraction procedures was the norm This has been
recently found to prevent full recovery in certain cases Because
patients think they MUST do them to stop panic attack
Harmless?
Slide 50
Panic Disorder and Agoraphobia Cognitive Therapy Treatment: 1.
Therapist and patient map out vicious cycle 2. Patient beliefs are
identified (i.e.. If I hyperventilate I will die.) 3. Beliefs are
challenged using safety behaviors (i.e.. controlled breathing) 4.
Safety behaviors used only to disprove belief 5. More realistic
beliefs are identified 6. Images experienced by patient are
altered
Slide 51
Panic Disorder and Agoraphobia Behavioral Methods: Establish
methods to induce panic Patient learns that the methods did not
result in catastrophy Thus these symptoms are not reliable warnings
of danger Patients are encouraged to expose themselves to
situations they have avoided due to fear
Slide 52
Panic Disorder and Agoraphobia If patient has learned
controlled breathing, patient may think that if they dont get
control of their breathing the results will be catastrophic
(because then they will definitely have the anxiety attack) This is
reinforced continually via negative reinforcement (patient does
breathing exercise and they do not faint) Harmless? Now what do you
think?
Slide 53
Empirical Status of Panic Disorder Sanchez et al. (2010) did a
meta-analysis of various treatments for panic d/o with or w/out
acrophobia. CT was moderately useful on its own, but its
effectiveness increased dramatically when paired with exposure
therapy. Clark (1996) showed that across 5 different studies,
between 74% - 94% of CT patients remained panic- free. CT was found
to be superior to applied relaxation, exposure and
pharmacotherapy.
Slide 54
Empirical Status of Anxiety/OCD Chambless & Gillis (1993)
reviewed 9 clinical trials and found mostly support for CTs
effectiveness in treating GAD Two additional studies, Barlow et al.
(1992) and Durham et al., 1994) support this For OCD, Van Oppen et
al. (1995) found CT equivalent to exposure and response prevention
(an OCD treatment with established efficacy). A number of studies
(Compas et al., 1998) have found CT effective for bulimia
nervosa
Slide 55
Impediments to CBT Treatment for Anxiety Disorders Anxiety
disorders are the most prevalent class of disorders (Gunter &
Whittal, 2010) CBT treatments are poorly disseminated to
practitioners Of 84% of adults w/ anxiety that saw a health care
practitioner, only 23% received appropriate treatment Only 11%
received appropriate psychological services Psychopharmacology:
$2305; individual counseling: $1357; group $523
Slide 56
Impediments to CBT Treatment for Anxiety Disorders CBT
approaches are the only empirically supported approaches to anxiety
(EMDR for PTSD a possible exception) Gap between research findings
and clinical practice is large WHY?
Slide 57
Impediments to CBT Treatment for Anxiety Disorders Limited
training opportunities Dissemination of CBT is complex Treating
anxiety requires temporarily increasing symptoms (i.e.. exposure)
Most psychological treatments do not do this Thus, exposure
treatments have a bad rap Counter to ethical mandate: do no harm
Many therapists fear hurting their clients Perceived
contraindications lack empirical support
Slide 58
Impediments to CBT Treatment for Anxiety Disorders Lack of
training at the doctoral/internship levels From 1993 2003 there has
been very little increase in the amount of CBT training available
Many therapists eclectic, including non-CBT approaches Almost all
effective approaches for anxiety are forms of CBT Practitioners
tend to rely on their clinical experience, rather than outcome
studies
Slide 59
Impediments to CBT Treatment for Anxiety Disorders Perception
is that study was done on patients with only one very specific
disorder, rather than the more complex mix we see typically in
patients General lack of attention to practitioner concerns
Standardized treatment protocols are cold and calculated Difficulty
in finding the funding to train clinicians appropriately
Slide 60
CBT and Dyspareunia Kabaki & Batur (2003) studied 16
Turkish couples who were treated for vaginismus at a hospital. CBT
treatment included cognitive reframing. All couples were able to
achieve successful intercourse Bergeron et al (2001) found that
CBT, including cognitive restructuring was effective in treating
dyspareunia Butit was no more effective than biofeedback (Bergeron
et al., 2001) . And less effective than vestibulectomy (Bergeron et
al., 2001)
Slide 61
OCD and Hoarding Hoarding not usually related to OCD (Tolin et
al., 2010). More likely related to anxiety and depression Its a
public health problem Behavioral treatments and medication for OCD
fair poorly Possibly because hoarders generally have poor insight
Previous studies may not have represented hoarders, as they do not
always identify with having OCD
Slide 62
OCD and Hoarding Tolin et al. (2010) studied 558 hoarders,
primarily Caucasian and female They found that insight was related
to hoarding behavior Future treatments of hoarding should be
centered around raising awareness and insight
Slide 63
References Beck, A. T. & Greenburg, R. L. (1974). Coping
with depression. New York: Institute for Rational Living. Beck, A.
T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive
therapy of depression. New York: Guilford Press. Bergeron, S.,
Binik, Y. M., Khalif, S., Pagidas, K., Glazer, H. I., Meana, M., et
al. (2001). A randomized comparison of group cognitive-behavioral
therapy, surface electromyographic biofeedback, and vestibulectomy
in the treatment of dyspareunia resulting from vulvar vestibulitis.
Pain, 91(3), 297-306. Dobson, K.S. (2003). Handbook of Cognitive
Behavioral Therapies. New York: The Guilford Press.
Slide 64
References Dugas, M. J., Brillon, P., Savard, P., Turcotte, J.,
Gaudet, A., Ladouceur, R., et al. (2010). A randomized clinical
trial of cognitive-behavioral therapy and applied relaxation for
adults with generalized anxiety disorder. Behavior Therapy, 41(1),
46-58. Gunter, R. W., & Whittal, M. L. (2010). Dissemination of
cognitive-behavioral treatments for anxiety disorders: Overcoming
barriers and improving patient access. Clinical Psychology Review,
30(2), 194-202.
Slide 65
References Jacobson, N.S. & Hollon, S.D. (1996a).
Cognitive-behavior therapy versus pharmacotherapy: Now that the
jurys returned its verdict, its time to present the rest of the
evidence. Journal of Consulting and Clinical Psychology, 64, 74-80.
Jarrett, R. B., Basco, M. R., Risser, R., Ramanan, J., Marwill, M.,
Kraft, D., & Rush, A. J. (1998). Is there a role for
continuation phase cognitive therapy for depressed oupatients?
Journal of Counseling and Clinical Psychology, 66, 1036-1040.
Kabaki, E., & Batur, S. (2003). Who benefits from cognitive
behavioral therapy for vaginismus. Journal of Sex & Marital
Therapy, 29(4), 277-288.
Slide 66
References Snchez-Meca, J., Rosa-Alczar, A. I., Marn-Martnez,
F., & Gmez-Conesa, A. (2010). Psychological treatment of panic
disorder with or without agoraphobia: A meta-analysis. Clinical
Psychology Review, 30(1), 37-50. Tolin, D. F., Fitch, K. E., Frost,
R. O., & Steketee, G. (2010). Family informants perceptions of
insight in compulsive hoarding. Cognitive Therapy and Research,
34(1), 69-81. Weissman, A. N., & Beck, A. T., (1978).
Development and validation of the Dysfunctional Attitude Scale: A
preliminary investigation. Paper presented at the meeting of the
American Educational Research Association, Toronto.