The ABCs of CBT - Squarespacestatic1.squarespace.com/static/521a7b2ee4b0ee... · The ABCs of CBT Melissa A. Novak, LCSW, ... Sad, angry. I’m messed up. ... u Compile themes of identified

The ABCs of CBT

Melissa A. Novak, LCSW, CST Licensed Clinical Social Worker Certified Sex Therapist MN Therapies www.mntherapies.com [email protected]

Melissa A. Novak, LCSW © 2016

Understanding the basic foundation and implementation of Cognitive Behavioral

Therapy

Objectives u  Knowledge of the cognitive model and the

rationale for treatment

u  Basic knowledge of key components to cognitive therapy such as the cognitive model, cognitive conceptualization and their components.

u  Understanding of the cognitive conceptualization, its formulation and how it is used to guide treatment.

u  Integrate various skills and techniques you already know into the conceptualization


Why CBT? u  It is an adaptable,

cohesive structure.

u  Holds the therapist and client accountable.

u  Helps focus sessions and treatment.

u  Clients love it.

u  Research.


Cognitive Therapy Competency

u  ACT Certification u  http://www.academyofct.org/i4a/ams/

public/memberapp_description.cfm

u  2 Part Process u Part I: Preliminary Review of training and

knowledge of CBT

u Part II: Clinical Review of an actual case, including a taped session

u  http://www.ucl.ac.uk/clinical-psychology/CORE/CBT_Competences/CBT_Competences_Map.pdf


1

applied relaxation & applied tension

problem solving

Cognitive Therapy – Beck Behavioural Activation -Jacobson

exposure techniques Specific phobias

Specific behavioural and cognitive therapy

Problem specific competences

GAD – Borkovec GAD – Dugas/ Ladouceur GAD – Zinbarg/Craske/Barlow

Social Phobia – Heimberg Social Phobia - Clark

OCD – Steketee OCD – Kozac

activity monitoring & scheduling

Basic CBT competences

Sharing responsibility for session structure & content

ability to agree goals for the intervention

ability to plan and to review practice assignments (‘homework’)

using summaries and feedback to structure the session

ability to devise a maintenance cycle and use this to set targets

Guided discovery & Socratic questioning

ability to elicit key cognitions/images

ability to use thought records

ability to detect, examine and help client reality test automatic thoughts/images

ability to identify and help client modify assumptions, attitudes and rules

PTSD - Foa & Rothbaum PTSD - Resick PTSD – Ehlers

Behavioural Activation

ability to plan and conduct behavioural experiments

ability to develop formulation and use this to develop treatment plan /case conceptualisation

Panic Disorder (with or without agoraphobia ) - Clark Panic Disorder (with or without agoraphobia ) - Barlow

Metacompetences

ability to adhere to an agreed agenda

knowledge of common cognitive biases relevant to CBT

ability to identify and work with safety behaviours

ability to employ imagery techniques

ability to identify and help client modify core beliefs

capacity to implement CBT in a manner consonant with its underlying philosophy

capacity to manage obstacles to CBT therapy

capacity to use clinical judgment when implementing treatment models

knowledge of basic principles of CBT and rationale for treatment

ability to explain and demonstrate rationale for CBT to client

knowledge of the role of safety-seeking behaviours

Ability to structure sessions

ability to understand client’s inner world and response to therapy

Guided CBT self help

Depression – Low intensity interventions

Depression – High intensity interventions

capacity to adapt interventions in response to client feedback

capacity to formulate and to apply CBT models to the individual client

capacity to select and apply most appropriate BT & CBT method

CBT specific metacompentencies

capacity to structure sessions and maintain appropriate pacing

capacity to use and respond to humour

Generic metacompetences

ability to end therapy in a planned manner, and to plan for long-term maintenance of gains after treatment

ability to use measures and self monitoring to guide therapy and to monitor outcome

Ability to implement CBT using a collaborative approach

Generic therapeutic competences

knowledge and understanding of mental health problems

knowledge of, and ability to operate within, professional and ethical guidelines

knowledge of a model of therapy, and the ability to understand and employ the model in practice

ability to engage client

ability to foster and maintain a good therapeutic alliance, and to grasp the client’s perspective and ‘world view’

ability to deal with emotional content of sessions

ability to manage endings

ability to undertake generic assessment (relevant history and identifying suitability for intervention)

ability to make use of supervision

Situation

Boss calls you in for a surprise meeting.

Anxiety, fear, dread, relief

Head to bathroom, take deep breaths, make a few notes to bring, do some recon with coworkers.

Heart racing, SOB, sweating,

•  I’m going to get fired.

•  God, they are annoying.

•  I’m going to look stupid.

•  Finally, I’m getting that raise.

Reaction

Emotional

Behavioral

Physiological

Automatic Thought


The Basic Cognitive Model Distorted or dysfunctional thinking (which influences mood and

emotions) is common to all psychological disturbances.


Situation 1 What was the

problematic situation?

Situation 2 Situation 3

Automatic Thought What went through her

mind?

Automatic Thought Automatic Thought

Meaning of the A. T. What did the automatic thought mean to her?

Meaning of the A. T.

Emotion What emotion was associated with the automatic thought?

Behavior What did the patient do

then?


Emotion Emotion

Behavior Behavior





mind?






then?


Emotion Emotion

Behavior Behavior

Identifying Automatic Thoughts/Emotional and Behavioral Patterns

u  Ask the client to speak about a distressing situation.

u  Notice a shift in affect and then prompt.

u  “What went through your mind just then?”

u  Take a feeling statement and reflect back as an absolute or a prediction. (“I worry I might fail the test.” -> “I am going to fail the test.”)


“I wasn’t thinking anything.”

u Helpful questions to elicit “elusive” automatic thoughts. u Any hypotheses?

u Use another person.

u Emotions list

u Describe the physical state of feeling.

u Describe what you did


Vignette: The Case of Jennifer u  40 something, white, cisgender, female requesting services to address recent break

up and apartment clutter.

u  Has been on disability since being fired from job 15 years ago.

u  Family Dynamic

u  Middle child, lots of inter-sibling rivalry and fighting

u  Mother and father had tumultuous relationship that ended; both had substance abuse issues

u  Social

u  Active in high school and academically successful

u  Had friends but often felt left out and avoidant of bringing anyone home due to clutter and family

u  Psych

u  History of therapy with multiple providers

u  Previous diagnosis of MDD, dysthymic disorder, ADHD

u  Was on a cocktail of psychotropic meds which was reduced

u  Obsessional, anxious, depressed, distrustful, defensive, hopeless and entitled

Exploring Jennifer’s Experience

Sad, angry.

I’m messed up.

I’m blamed for our problems.

Ex-boyfriend says she’s high maintenance.

Pulled over and given a ticket.

He was out to get me.

This is completely unfair.

Hopeless; helpless and angry

Began chasing the cop and yelling at him.

Call him to discuss. Write him emails and letters explaining her opinion. Obsess.

Situation

Automatic Thought

Meaning of the A.T.

Emotion

Behavior


Assessing emotional intensity.

u  LOW:

Cognitive/Insight Techniques

u  Labeling distortions

u  Thought logs u  Hypothesis

testing u  Reframes

u  HIGH: Behavioral Techniques

u  Sensory/Labeling u  Exposures u  Acting “as if” u  Opposite Action u  Emotion

Regulation u  Distress

Tolerance u  Activity Planning


Challenging the Automatic Thoughts

u  Are they true?

u  Are they useful?

u  Thought Logs

u  Develop a hypothesis and test them (cognitive and behavioral options).

u  Reframe and practice.


Cognitive Distortions…

Challenging the Behavior and Emotion

u  Acting “as if”

u  Smiling/Posing

u  Contrary Behavior

u  Exposures

u  Visualization

u  Identifying needs


Thought Logs

What would initial treatment look like?

Sad, angry.

I’m messed up.









Situation

Automatic Thought

Meaning of the A.T.

Emotion

Behavior






mind?






then?


Emotion Emotion

Behavior Behavior

The meaning tells us why this matters and begins to help us see how the client sees herself, her world and her future. This is the beginning of downward arrow.

Exploring Jennifer’s Experience

Sad, angry.

I’m messed up.









Situation

Automatic Thought

Meaning of the A.T.

Emotion

Behavior


Here is where we put the themes we find in downward arrow, or our hypotheses to later clarify with the client.

Here is where we put the behaviors we start to see repetitively.


Downward Arrow u  Ask the client to examine what his/her thoughts mean, why they

matter?

u  “And what if _______ happens?”

u  “So what?”

u  “What’s so bad about _________?”

u  Compile themes of identified automatic thoughts.

u  The client’s affect will typically significantly shift when you’ve identified the core belief.

u  Often times clients will provide several distressing thoughts. Focus on one thought by having them select the one that is most charged.


Using Downward Arrow

Ex doesn’t text back…that day.

He’s with another girl

I can’t handle it.

I’m not important.

I am rejected.

I’ll be alone forever.

My future is bleak.

Friend is “helping” with ct’s cell phone.

I can’t tell him to stop.

I’m out of control.

I’m being difficult.

I won’t have any friends.

I’m a failure.

Saw an item she gave away in a magazine.

I liked that piece.

I shouldn’t have given it away.

I can’t do anything to fix it.

I made a mistake.

I’m powerless.


Example of Complex Downward Arrow: Jennifer’s conflict with boyfriend.

I’m a total failure.

I won’t achieve anything in my life.

I will be alone forever.

I’m blamed for all our problems.

He doesn’t respect or care about me.

He will leave me.

I can’t make it better.

No one will ever love me.

I am unlovable. Melissa A. Novak, LCSW © 2016

Compensatory Strategies

Defensiveness Attacks others. Seeks reassurance. Over explains self. Researches everything exhaustively.

Does not get rid of items.

Conditional Assumptions/Attitudes/Rules I have to always make the right decisions or else I am

a total failure.

If I don’t do as well as other’s I’m a failure.

It is unbearable to be lonely.

I should be able to solve my problems easily.

If I have any regret or am uncomfortable, I have made a bad decision.

Core Beliefs

People will hurt and disappoint me. I’m powerless. The world is out to get me. My future is bleak. I’m a total failure.

Relevant Childhood Data

Substance abuse issues with both parents.

Reports being victimized by siblings and high school friends. Dad often flakes on promises.

History of critical/invalidating relationships with friends, family,

bosses, and partners


Cases & Goals

What are you taking with you? What are you going to try for every patient this week?

Cases…let’s do this!

Thoughts are not truths. They are not realities. They are not certainty. Yet, people often act as such. Thoughts are merely our perceptions habitually linked through charged language and experience.

Thoughts are the lenses to one’s experience. If they are covered in crap, then all you will see is crap.


Questions?

u  Academy of Cognitive Therapy: www.academyofct.org

u  Beck, Judith. (1995). Cognitive Therapy: Basics and Beyond. New York: The Guiliford Press.

u  Leahy, Robert L. (2003). Cognitive Therapy Techniques: A practitioner’s guide. New York: The Guliford Press

Resources and References:


Documents

The ABCs of CBT - Squarespacestatic1.squarespace.com/static/521a7b2ee4b0ee... · The ABCs of CBT Melissa A. Novak, LCSW, ... Sad, angry. I’m messed up. ... u Compile themes of identified