Opa basics of cognitive behavioral therapy

General Survey of General Survey of Cognitive-Behavioral Cognitive-Behavioral Therapy StrategiesTherapy Strategies

The Model and The TechniquesThe Model and The Techniques

Kevin D. Arnold, Ph.D., ABPPKevin D. Arnold, Ph.D., ABPPDirector, The Center for Cognitive and Director, The Center for Cognitive and

Behavioral Therapy of Greater ColumbusBehavioral Therapy of Greater Columbus614.459.4490614.459.4490

Theory Behind CBTTheory Behind CBT

Barlow’s Theory of Emotional DisordersBarlow’s Theory of Emotional Disorders Barlow (1991) & Moses and Barlow (2006)Barlow (1991) & Moses and Barlow (2006)

Key ConceptsKey Concepts Emotional RegulationEmotional Regulation Emotional MemoryEmotional Memory Antecedent Cognitive AppraisalsAntecedent Cognitive Appraisals Emotionally Driven Behaviors (EDBs)Emotionally Driven Behaviors (EDBs) AvoidanceAvoidance


Emotional Regulation: Key Strategies*Emotional Regulation: Key Strategies* Situational ControlSituational Control

• Situation SelectionSituation Selection Predictive Model of Emotional Arousal Features and LikelihoodsPredictive Model of Emotional Arousal Features and Likelihoods Costs and Benefits Assessment of Regulation vs. ExperienceCosts and Benefits Assessment of Regulation vs. Experience

• Situation ModificationSituation Modification Modification of the Physical, External EnvironmentModification of the Physical, External Environment

AttentionAttention• Attention DeploymentAttention Deployment

Distraction to Other Situational Features or Away CompletelyDistraction to Other Situational Features or Away Completely Concentration on Emotional Experience, Situational Factors, or Concentration on Emotional Experience, Situational Factors, or

PredictionsPredictions


*Gross & Thompson, 2007

Emotional Regulation: Key Strategies*Emotional Regulation: Key Strategies* AppraisalAppraisal

• Cognitive AppraisalCognitive Appraisal Modification of Appraisal (e.g., threat value, label of Modification of Appraisal (e.g., threat value, label of

event)event)

ResponseResponse• Response ModulationResponse Modulation

Relaxation StrategiesRelaxation Strategies Expression of Emotion (Behavioral, Verbal)Expression of Emotion (Behavioral, Verbal) Adaptive Response Alternatives Adaptive Response Alternatives


*Gross & Thompson, 2007


Emotional Memory* and AnxietyEmotional Memory* and Anxiety Disclaimer—Not a NeuropsychologistDisclaimer—Not a Neuropsychologist Role of Amygdala and Prefrontal Cortex in AnxietyRole of Amygdala and Prefrontal Cortex in Anxiety

• Amygdala Stores Stress Arousal as Nondeclarative MemoryAmygdala Stores Stress Arousal as Nondeclarative Memory• In Contrast, Hippocampus Stores Declarative MemoryIn Contrast, Hippocampus Stores Declarative Memory• PFC Necessary to Habituate to AnxietyPFC Necessary to Habituate to Anxiety

Habituation is New Learning Allowing PFC to Modulate Habituation is New Learning Allowing PFC to Modulate Amygdala Arousal and Enhance Declarative Recall Through Amygdala Arousal and Enhance Declarative Recall Through Hippocampus Hippocampus

• PFC can also “prevent the acquisition of fear conditioning” or PFC can also “prevent the acquisition of fear conditioning” or “excite the amygdala and increase fear.” (pp. 36-37)“excite the amygdala and increase fear.” (pp. 36-37)


*Quirk, 2007

Emotional Memory* and DepressionEmotional Memory* and Depression Disclaimer—Not a NeuropsychologistDisclaimer—Not a Neuropsychologist Role of Amygdala and Prefrontal Cortex in Role of Amygdala and Prefrontal Cortex in

DepressionDepression• PFC Activation Levels Needed to be Higher in PFC Activation Levels Needed to be Higher in

Depressed Patients For Working Memory Depressed Patients For Working Memory PerformancePerformance

• Predisposition to Serotonin Based Abnormalities Predisposition to Serotonin Based Abnormalities Associated with Increased Activity in Amygdala Associated with Increased Activity in Amygdala and with Abnormalities in Connection of Prefrontal and with Abnormalities in Connection of Prefrontal Cortex and Amygdala. Cortex and Amygdala.


*Davidson, Fox & Kalin, 2007

Impact on the HPA AxisImpact on the HPA Axis The HPA Axis is the Hypothalamus-Pituitary-Adrenal The HPA Axis is the Hypothalamus-Pituitary-Adrenal

AxisAxis Changes in HPA Axis Functioning Have Been Found Changes in HPA Axis Functioning Have Been Found

in Early Developmental Exposure to Trauma*in Early Developmental Exposure to Trauma*• Predisposes to later MDD and PTSD VulnerabilityPredisposes to later MDD and PTSD Vulnerability

Early Trauma has been Shown to Reduce Early Trauma has been Shown to Reduce Hypothalamic MassHypothalamic Mass

In utero Exposure to Stress Reveals Changes in In utero Exposure to Stress Reveals Changes in Fetus and Infant Dysregulation of the HPA System Fetus and Infant Dysregulation of the HPA System Leading to Greater Degrees of Stress and AnxietyLeading to Greater Degrees of Stress and Anxiety


*Shea, Walsh, MacMillan & Steiner (2006)


Antecedent Cognitive AppraisalsAntecedent Cognitive Appraisals Early Learning During Parenting Interactions or Early Learning During Parenting Interactions or

Traumas Regarding Self-Efficacy or ThreatsTraumas Regarding Self-Efficacy or Threats Appraisal of Likelihood of Negative Event OccurrenceAppraisal of Likelihood of Negative Event Occurrence Appraisal of Catastrophic OutcomeAppraisal of Catastrophic Outcome Appraisal of Incapacity to Effect Outcomes or Manage Appraisal of Incapacity to Effect Outcomes or Manage

OutcomesOutcomes Appraisal of Others as Harsh (Punitive Parenting) or Appraisal of Others as Harsh (Punitive Parenting) or

Unsupportive (Dismissive Parenting)Unsupportive (Dismissive Parenting) Overall Situational Appraisal & Development of Overall Situational Appraisal & Development of

Assumptive SchemasAssumptive Schemas


Emotionally Driven Behaviors (EDBs)Emotionally Driven Behaviors (EDBs) Behavioral Response ProbabilitiesBehavioral Response Probabilities Activation of Learned, Adaptive Responses to Activation of Learned, Adaptive Responses to

Over-generalized and Inappropriate Emotional Over-generalized and Inappropriate Emotional RecallRecall

Reduce Emotional ArousalReduce Emotional Arousal• Negative ReinforcementNegative Reinforcement

When EDBs Lead to Unhealthy OutcomesWhen EDBs Lead to Unhealthy Outcomes• Social Isolation, Avoidance of Adaptive Situations, Social Isolation, Avoidance of Adaptive Situations,

Reduction in Relationship ConnectionsReduction in Relationship Connections


AvoidanceAvoidance Escape is an EDB to Exit to Reduce ArousalEscape is an EDB to Exit to Reduce Arousal Avoidance is to Prevent Arousal or Full ArousalAvoidance is to Prevent Arousal or Full Arousal Forms of AvoidanceForms of Avoidance

• Subtle Behavioral Avoidance Subtle Behavioral Avoidance Avoiding Eye Contact, ProcrastinationAvoiding Eye Contact, Procrastination

• Cognitive AvoidanceCognitive Avoidance Distraction, Stonewalling, Mental Rituals, Thought StoppingDistraction, Stonewalling, Mental Rituals, Thought Stopping

• Safety SignalsSafety Signals Shaking Medicine Bottles, Keeping Positive Association Shaking Medicine Bottles, Keeping Positive Association

Objects Handy, Good Luck Charms, Carrying CleanersObjects Handy, Good Luck Charms, Carrying Cleaners


Theory Behind CBTTheory Behind CBT Examples from Moses & Barlow (2006)Examples from Moses & Barlow (2006)Behavioral AvoidanceBehavioral Avoidance Avoid Eye ContactAvoid Eye Contact Social PhobiaSocial Phobia

Avoiding Physiological Avoiding Physiological ArousalArousal

Panic/DepressionPanic/Depression

ProcrastinationProcrastination Generalized AnxietyGeneralized Anxiety

Cognitive AvoidanceCognitive Avoidance Forced Positive Self TalkForced Positive Self Talk DepressionDepression

DistractionDistraction Panic/DepressionPanic/Depression

WorryingWorrying Generalized AnxietyGeneralized Anxiety

Safety SignalsSafety Signals Good Luck CharmsGood Luck Charms OCDOCD

Carrying Good Feeling Carrying Good Feeling ObjectsObjects

Depression/GADDepression/GAD

Carrying Items to Hide Face Carrying Items to Hide Face or Bodily Reactionsor Bodily Reactions

Social PhobiaSocial Phobia

The Basic CBT ModelThe Basic CBT Model

Beck & Other’s ApproachBeck & Other’s Approach Psychopathology is bio-psycho-socialPsychopathology is bio-psycho-social Feelings can be managed through addressing Feelings can be managed through addressing

cognitions and behaviorscognitions and behaviors Psychopathology has deficits in behaviors and Psychopathology has deficits in behaviors and

maladaptive or distorted cognitionsmaladaptive or distorted cognitions Underlying assumptions have been learned in an “if-Underlying assumptions have been learned in an “if-

then” formatthen” format Schemas create a construction that is maladaptive Schemas create a construction that is maladaptive

now, but not when first developednow, but not when first developed


Cognitive TriadCognitive Triad

Cognitive TriadCognitive Triad Distorted Thoughts are those that are mood Distorted Thoughts are those that are mood

congruent but not reflective of the evidence in congruent but not reflective of the evidence in lifelife

These are sometimes referred to as These are sometimes referred to as Automatic ThoughtsAutomatic Thoughts

The thoughts fit basically into three The thoughts fit basically into three categories: Self, Others/World, or Futurecategories: Self, Others/World, or Future


Cognitive BlockadeCognitive Blockade

Cognitive BlockadeCognitive Blockade Mood or other pathologic processes create a Mood or other pathologic processes create a

filtering of information that is state-dependentfiltering of information that is state-dependent Information, both internal and external, is Information, both internal and external, is

filtered so that only mood congruent filtered so that only mood congruent information is a) perceived, or b) valued.information is a) perceived, or b) valued.

Overcoming the impact of the blockade is a Overcoming the impact of the blockade is a major goal of CBTmajor goal of CBT


Treatment Method: GeneralTreatment Method: General

IT IS AN APPROACH, NOT A MANUALIT IS AN APPROACH, NOT A MANUAL Cognitive Therapy is collaborative so that the Cognitive Therapy is collaborative so that the

patient and therapist are a team working on patient and therapist are a team working on problems togetherproblems together

Cognitive Therapy is active and engages the Cognitive Therapy is active and engages the patient through a treatment relationship that patient through a treatment relationship that encourages but respects the patient through encourages but respects the patient through empathyempathy

Cognitive Therapy uses the Socratic Method, Cognitive Therapy uses the Socratic Method, using questions whenever possibleusing questions whenever possible

Socratic MethodSocratic Method Questions are used in CBT to Questions are used in CBT to

• Help the patient become aware of thoughtsHelp the patient become aware of thoughts• Examine thoughts to identify distortionsExamine thoughts to identify distortions• Replace distortions with health and evidenced Replace distortions with health and evidenced

based ideasbased ideas• Plan to develop new thinking patternsPlan to develop new thinking patterns• Self-Awareness of EDBsSelf-Awareness of EDBs


Treatment Method: GeneralTreatment Method: General CollaborativeCollaborative

Therapy is guided by a team approach to Therapy is guided by a team approach to problemsproblems• The treatment conceptualization is created The treatment conceptualization is created

collaboratively as a basis for the treatment collaboratively as a basis for the treatment methodsmethods

• The structure of the sessions is agreed upon as a The structure of the sessions is agreed upon as a way of keeping the collaborative work movingway of keeping the collaborative work moving

• Both agree on structure and directionBoth agree on structure and direction

Structure and DirectionStructure and Direction All sessions use the following templateAll sessions use the following template

• Setting an agendaSetting an agenda• Bridging back to the previous sessionBridging back to the previous session• Setting a target for the sessionSetting a target for the session• Application of the CBT techniques to the targetApplication of the CBT techniques to the target• Summarization of the sessionSummarization of the session• Setting homeworkSetting homework• Feedback on the sessionFeedback on the session


Problem OrientationProblem Orientation Conceptualization: Patients problems within a Conceptualization: Patients problems within a

present, learning contextpresent, learning context Orientation to the Present/Here and NowOrientation to the Present/Here and Now Selection of strategies and techniquesSelection of strategies and techniques Assess the effectiveness of the CBT on the Assess the effectiveness of the CBT on the

problem within its contextproblem within its context


Common Strategies in CBTCommon Strategies in CBT SimplifySimplify Do it nowDo it now You can’t know unless you You can’t know unless you

experimentexperiment If you are off track, do the If you are off track, do the

oppositeopposite

Persistence will produce Persistence will produce changechange

Break it down and take one Break it down and take one thing at a timething at a time

Do that which you don’t expect Do that which you don’t expect yourself to doyourself to do

Pull, don’t push/FlowPull, don’t push/Flow


EducateEducate CBT educates patients to be their own CBT educates patients to be their own

therapiststherapists• Help the patient to learn how to learnHelp the patient to learn how to learn

It’s not resistance, it’s reluctanceIt’s not resistance, it’s reluctance It’s not resistance, it’s slownessIt’s not resistance, it’s slowness

• Patients learn inductivelyPatients learn inductively Beliefs are hypothesisBeliefs are hypothesis Testing them can provide insight or new ways of thinkingTesting them can provide insight or new ways of thinking


Key ElementsKey Elements Behavioral ExperimentationBehavioral Experimentation Daily Activity RecordsDaily Activity Records Activity SchedulingActivity Scheduling Pleasure SchedulingPleasure Scheduling Identify Distortions through Self-Monitoring (3 Identify Distortions through Self-Monitoring (3

Column) and Labeling Automatic ThoughtsColumn) and Labeling Automatic Thoughts Test the EvidenceTest the Evidence Challenge and Create New Thoughts (5 Column)Challenge and Create New Thoughts (5 Column)


Cognitive DistortionsCognitive Distortions

Related to MoodRelated to Mood Don’t represent evidence or have gone Don’t represent evidence or have gone

unchallengedunchallenged Have not been evaluated, instead Have not been evaluated, instead

assumed to be trueassumed to be true Learned based on historyLearned based on history See Handout See Handout

Assessing the Automatic ThoughtsAssessing the Automatic Thoughts Question, Question, QuestionQuestion, Question, Question Listen, Listen, ListenListen, Listen, Listen Downward ArrowDownward Arrow Imaging a SituationImaging a Situation Noticing Affect and Calling Out the ThoughtsNoticing Affect and Calling Out the Thoughts


Strategies for Challenging and Restructuring Cognitive DistortionsStrategies for Challenging and Restructuring Cognitive Distortions Defining Terms Defining Terms Cost-Benefit Analysis of Idea or Belief Cost-Benefit Analysis of Idea or Belief Modified 5-Column/Testing the Evidence Modified 5-Column/Testing the Evidence Testing the Utility of the Evidence Testing the Utility of the Evidence Evaluating Labels Evaluating Labels Changing Behavior to Test Ideas Changing Behavior to Test Ideas Examining Should Statements Examining Should Statements Articulating Values and Changing Them Articulating Values and Changing Them Progress not Perfection Progress not Perfection Old Rules, New Rules Old Rules, New Rules New Bill of Rights New Bill of Rights Monitor Feelings/Ideas and Label Distortions Monitor Feelings/Ideas and Label Distortions Downward Arrow/Vertical Decent Downward Arrow/Vertical Decent


Loosely Based on Leahy, 2003

Cognitive DistortionsCognitive Distortions Mind ReadingMind Reading: Assuming you know what others are thinking: Assuming you know what others are thinking Future PredictingFuture Predicting: Appraisal of future events: Appraisal of future events CatastrophizingCatastrophizing: Predicting the worst possible outcome: Predicting the worst possible outcome LabelingLabeling: Using global labels to describe yourself or others: Using global labels to describe yourself or others Black-White ReasoningBlack-White Reasoning: Thinking in all or none terms not shades of gray: Thinking in all or none terms not shades of gray Regret OrientationRegret Orientation: Looking back and not living in the moment of the : Looking back and not living in the moment of the

nownow Arbitrary InferencesArbitrary Inferences: Drawing conclusions from little or no evidence: Drawing conclusions from little or no evidence FilteringFiltering: Noticing only the things that confirm your ideas: Noticing only the things that confirm your ideas PersonalizingPersonalizing: Thinking that everything is your fault or that others are : Thinking that everything is your fault or that others are

targeting you specificallytargeting you specifically OvergeneralizingOvergeneralizing: Using evidence from a specific context and applying a : Using evidence from a specific context and applying a

“rule” to many other contexts“rule” to many other contexts Should/Would/CouldShould/Would/Could: Thinking in terms of morals or shoulds, rather than : Thinking in terms of morals or shoulds, rather than

the actual evidence in the situationthe actual evidence in the situation


Loosely Based on Leahy, 2003

Behavioral ActivationBehavioral Activation

Behavioral Activation is Designing Actions Behavioral Activation is Designing Actions into a Patient’s Behavioral Repertoireinto a Patient’s Behavioral Repertoire Activity SchedulingActivity Scheduling Pleasure SchedulingPleasure Scheduling Functional Behavior Analysis in the SessionFunctional Behavior Analysis in the Session

Reward Erosion and Mood ProblemsReward Erosion and Mood Problems

++ + - + -


Activity SchedulingActivity Scheduling Activity Monitoring and RecordingActivity Monitoring and Recording

• MasteryMastery• PleasurePleasure• Hour Blocks vs. Sections of the DayHour Blocks vs. Sections of the Day

Activity SchedulingActivity Scheduling• Designing RoutinesDesigning Routines• Increasing High Ms and PsIncreasing High Ms and Ps


Pleasure SchedulingPleasure Scheduling InventoriesInventories

• PastPast• PresentPresent• WishesWishes

Scheduling the PleasureScheduling the Pleasure• Behavioral ExperimentsBehavioral Experiments• Self-MonitoringSelf-Monitoring• Foot in the Door FirstFoot in the Door First


Application of Functional AnalysisApplication of Functional Analysis Use of the Therapy Relationship to Differentially Deliver Use of the Therapy Relationship to Differentially Deliver

Reinforcement or PunishmentReinforcement or Punishment Identification of Clinically Relevant BehaviorsIdentification of Clinically Relevant Behaviors

• CRB1: Those to DecreaseCRB1: Those to Decrease• CRB2: Those to IncreaseCRB2: Those to Increase

Observe CRBsObserve CRBs Elicit CRBsElicit CRBs

• Develop Alternate Behaviors to CRB1sDevelop Alternate Behaviors to CRB1s Differentially Apply RewardsDifferentially Apply Rewards Design Generalization invivo Design Generalization invivo

Cuijpers, van Straten, and Warmerdam (2007) showed Cuijpers, van Straten, and Warmerdam (2007) showed in meta-analysis that Behavioral Activation was Effectivein meta-analysis that Behavioral Activation was Effective

See Kanter, Manos, Busch, and Rusch, 2008


Self-DeterminationSelf-Determination Development of Personal GoalsDevelopment of Personal Goals Identification of Stimuli to Old BehaviorsIdentification of Stimuli to Old Behaviors Modification of Stimuli ExposureModification of Stimuli Exposure Training New Behaviors to Stimuli (Self-Training New Behaviors to Stimuli (Self-

Regulation of Natural Prompts)Regulation of Natural Prompts)

Relaxation TherapyRelaxation Therapy

Controlled BreathingControlled Breathing ConcentrationConcentration

• RhythmRhythm• SensationsSensations

Suggestive RelaxationSuggestive Relaxation

16 Muscle Group PMR16 Muscle Group PMR Practice 2x per dayPractice 2x per day

Dm200119.wma

Relaxation TherapyRelaxation Therapy

Uses of Relaxation TherapyUses of Relaxation Therapy Cued Affect ManagementCued Affect Management Counter-conditioningCounter-conditioning Management of Physiologic StimuliManagement of Physiologic Stimuli

Overcoming “Resistance”Overcoming “Resistance”

Use of Socratic MethodsUse of Socratic Methods How Likely to Do?How Likely to Do? Reasons Not To?Reasons Not To? How to Overcome Not ToHow to Overcome Not To

Framework of “No Choice” ListFramework of “No Choice” List Pros/ConsPros/Cons Application of Stages of ChangeApplication of Stages of Change

Overcoming “Resistance”Overcoming “Resistance”

Stages of ChangeStages of Change Pre-ContemplativePre-Contemplative

• Educate PatientEducate Patient ContemplativeContemplative

• Strategies such as Pros-Cons or Cross-ExaminerStrategies such as Pros-Cons or Cross-Examiner DecisionDecision

• Decision to/Decision not to, Pros-ConsDecision to/Decision not to, Pros-Cons ActionAction

• Graduated Exposure StrategyGraduated Exposure Strategy• Foot in the DoorFoot in the Door• Noticing Action and its ImpactNoticing Action and its Impact

Anti-ContemplativeAnti-Contemplative• A Different Day, A Different TimeA Different Day, A Different Time• Push-Pull StrategyPush-Pull Strategy

Application to AnxietyApplication to Anxiety Retraining the Brain: HabituationRetraining the Brain: Habituation

Habituation is the result of extended exposure to an anxiety Habituation is the result of extended exposure to an anxiety provoking stimulusprovoking stimulus

• Anxiety typically elevates beyond typical levels due to defeat of Anxiety typically elevates beyond typical levels due to defeat of avoidance or escapeavoidance or escape

• Anxiety begins to drop after extended exposureAnxiety begins to drop after extended exposure• Anxiety usually flattens and persists at a reduced level for several Anxiety usually flattens and persists at a reduced level for several

minutes during the exposureminutes during the exposure• Over repeated exposure activities, anxiety ceases to elevate Over repeated exposure activities, anxiety ceases to elevate

clinically when the anxiety provoking stimulus is presentedclinically when the anxiety provoking stimulus is presented• Habituation is seen inHabituation is seen in

Systematic Desensitization using Graduated ExposureSystematic Desensitization using Graduated Exposure Exposure and Response Prevention (ExRP)Exposure and Response Prevention (ExRP) Direct ExposureDirect Exposure Narrative Story Telling InterventionsNarrative Story Telling Interventions FloodingFlooding

Application to AnxietyApplication to Anxiety

OCDOCD OCD is conceptualized as an anxiety disorder OCD is conceptualized as an anxiety disorder

driven by driven by • mis-appraisal of the threat posed by intrusive, mis-appraisal of the threat posed by intrusive,

obsessive thoughtsobsessive thoughts• use of ritualized behaviors or cognitive patterns to use of ritualized behaviors or cognitive patterns to

escape the anxietyescape the anxiety• use of avoidance behaviors to end exposure to use of avoidance behaviors to end exposure to

triggers associated with the obsessive thoughtstriggers associated with the obsessive thoughts


OCDOCD Assessment in CBT is typically done with one of Assessment in CBT is typically done with one of

several instruments, although usually it is the Yale-several instruments, although usually it is the Yale-Brown Obsessive Compulsive Scale (YBOCS)Brown Obsessive Compulsive Scale (YBOCS)

• Identification of historical and current obsessions and Identification of historical and current obsessions and compulsionscompulsions

• Identification of target obsessions and compulsions, with Identification of target obsessions and compulsions, with SUDS ratings of each to create a hierarchySUDS ratings of each to create a hierarchy

• Identification of avoidance behaviorsIdentification of avoidance behaviors SUDS = Subjective Units of Distress Scale using 0 to 100SUDS = Subjective Units of Distress Scale using 0 to 100 Must create behavioral anchors to ratings for patientMust create behavioral anchors to ratings for patient


OCDOCD Treatment with CBT is primarily Exposure and Treatment with CBT is primarily Exposure and

Response Prevention (ExRP) TherapyResponse Prevention (ExRP) Therapy• ExposureExposure

Patient collection of obsessive thoughts per themePatient collection of obsessive thoughts per theme Creation of Exposure Narrative—Often recordedCreation of Exposure Narrative—Often recorded Design of 90 minute exposure to be done dailyDesign of 90 minute exposure to be done daily Creation of SUDS tracking form throughout Exposure Creation of SUDS tracking form throughout Exposure

exerciseexercise Safety plan for atypical NSEsSafety plan for atypical NSEs


OCDOCD Treatment with CBT is primarily Exposure and Treatment with CBT is primarily Exposure and

Response Prevention (ExRP) TherapyResponse Prevention (ExRP) Therapy• Response PreventionResponse Prevention

Identification of Ritual Structure for each ObsessionIdentification of Ritual Structure for each Obsession Identification of Avoidance PatternsIdentification of Avoidance Patterns Creation of Behavioral Plan to stop Rituals and AvoidanceCreation of Behavioral Plan to stop Rituals and Avoidance Creation of tracking form for ritual and avoidance performanceCreation of tracking form for ritual and avoidance performance

• Behavioral DescriptionBehavioral Description• Situational FactorsSituational Factors• Emotional ExperiencesEmotional Experiences• Outcome of Ritual or AvoidanceOutcome of Ritual or Avoidance• Used to Create Better Response Prevention PlansUsed to Create Better Response Prevention Plans


OCDOCD Relapse Prevention and FadingRelapse Prevention and Fading

• Use of graphs to create evidenceUse of graphs to create evidence• Cognitive Restructuring regarding beliefs about competency Cognitive Restructuring regarding beliefs about competency

to manage OCDto manage OCD• Cognitive Restructuring to differentiate self from OCDCognitive Restructuring to differentiate self from OCD• Fading the session length and frequency as habituation Fading the session length and frequency as habituation

occursoccurs• Development of plan should obsessions become more Development of plan should obsessions become more

controlling againcontrolling again• Booster Sessions as a normative expectationBooster Sessions as a normative expectation


OCDOCD Case ExampleCase Example

• Exposure Tape Exposure Tape • SUDS dataSUDS data


Generalized Anxiety DisorderGeneralized Anxiety Disorder Characterized by Uncontrollable Worrisome Characterized by Uncontrollable Worrisome

Thoughts that have several themesThoughts that have several themes Anxiety Provocation is Based on the Appraisal Anxiety Provocation is Based on the Appraisal

of Risks in the Cognitions coupled with of Risks in the Cognitions coupled with Estimates of Probability and BelievabilityEstimates of Probability and Believability

Anxiety is experienced as elevated but not Anxiety is experienced as elevated but not panic-like, and occurs physically as well as panic-like, and occurs physically as well as subjectivelysubjectively


Generalized Anxiety DisorderGeneralized Anxiety Disorder AssessmentAssessment

• Use of Scale like Beck Anxiety Scale or ZungUse of Scale like Beck Anxiety Scale or Zung• Collect Diary of Worrisome ThoughtsCollect Diary of Worrisome Thoughts• Develop SUDS for each ThemeDevelop SUDS for each Theme• Identify Anxiety Components (e.g., subjective Identify Anxiety Components (e.g., subjective

experience, physiologic arousal)experience, physiologic arousal)• Identify Safety BehaviorsIdentify Safety Behaviors

Self vs. Other BehaviorsSelf vs. Other Behaviors

• Identify Magic Cognitions (Worry Prevents Identify Magic Cognitions (Worry Prevents Catastrophe)Catastrophe)


Generalized Anxiety DisorderGeneralized Anxiety Disorder Treatment ComponentsTreatment Components

• Relaxation Therapy to Manage Anxiety ArousalRelaxation Therapy to Manage Anxiety Arousal• Use of Theme-based Scripts for Exposure Use of Theme-based Scripts for Exposure

ExercisesExercises• Cognitive Restructuring to Modify Estimates of Cognitive Restructuring to Modify Estimates of

Likelihood and BelievabilityLikelihood and Believability• Modification of Safety Behaviors (e.g., calling Modification of Safety Behaviors (e.g., calling

spouse to see if safe)spouse to see if safe)

Application to PTSDApplication to PTSD

Rape TraumaRape Trauma Direct Exposure TherapyDirect Exposure Therapy Use of Cognitive ReprocessingUse of Cognitive Reprocessing

• Modification of View of SelfModification of View of Self• Modification of Limited Event RecallModification of Limited Event Recall

Development of Realistic Risk AppraisalDevelopment of Realistic Risk Appraisal Development of Personal Safety Skills Development of Personal Safety Skills

(Coping)(Coping)


Childhood Trauma Childhood Trauma STAIRSTAIR

• Affect RegulationAffect Regulation Development of Language of EmotionDevelopment of Language of Emotion Development of Emotional Self-Soothing SkillsDevelopment of Emotional Self-Soothing Skills Cognitive DistractionCognitive Distraction Distress Tolerance & Behavioral Activation of Distress Tolerance & Behavioral Activation of

Pleasurable ExperiencesPleasurable Experiences Acceptance of Emotions and Reframing Emotions as Acceptance of Emotions and Reframing Emotions as

ValuedValued



• Interpersonal ConnectionInterpersonal Connection Identification of Interpersonal Schemas & Common Life Identification of Interpersonal Schemas & Common Life

BehaviorsBehaviors Self-Awareness of Conflict between Trauma Emotions vs. Self-Awareness of Conflict between Trauma Emotions vs.

Goals for Interpersonal RelationshipsGoals for Interpersonal Relationships Modification of Self-Defeating Behaviors Through Role PlayingModification of Self-Defeating Behaviors Through Role Playing

• Identification of Power and Control Issues in Role PlayingIdentification of Power and Control Issues in Role Playing

• Assertiveness Skills and Beliefs of Basic RightsAssertiveness Skills and Beliefs of Basic Rights

• Creation of Interpersonal Conflict Management SkillsCreation of Interpersonal Conflict Management Skills

• Fostering Flexibility Within Power-Differential RelationshipsFostering Flexibility Within Power-Differential Relationships



• Narrative Story Telling as ExposureNarrative Story Telling as Exposure Creation of Memory TargetsCreation of Memory Targets Assurance of Hope and Betterment of LifeAssurance of Hope and Betterment of Life

• Skills Using Emotional Management Strategies at end of Skills Using Emotional Management Strategies at end of Exposure & Staying in the PresentExposure & Staying in the Present

• Identification of Negative Emotions During NarrativeIdentification of Negative Emotions During Narrative• Identification of Negative Interpersonal Schemas in the Identification of Negative Interpersonal Schemas in the

NarrativeNarrative• Contrasting Present Interpersonal Reality and New Skills to Contrasting Present Interpersonal Reality and New Skills to

Learned SchemasLearned Schemas• Applying Coping Skills to Real-Life Situations and Healthier Applying Coping Skills to Real-Life Situations and Healthier

Interpersonal Behaviors in Present RelationshipInterpersonal Behaviors in Present Relationship

Application to DepressionApplication to Depression

Self-Monitoring of MoodSelf-Monitoring of Mood Orientation to Descriptions of MoodOrientation to Descriptions of Mood Mood LogsMood Logs Three Column StrategyThree Column Strategy

Behavioral Self-MonitoringBehavioral Self-Monitoring Activity LogActivity Log Cataloging Positive ExperiencesCataloging Positive Experiences


Behavioral ActivationBehavioral Activation Development of Three ListsDevelopment of Three Lists

• Current PleasureCurrent Pleasure• Past PleasurePast Pleasure• Hopes/Dreams PlanningHopes/Dreams Planning

Scheduling Daily Activities and StructureScheduling Daily Activities and Structure Scheduling PleasureScheduling Pleasure


Cognitive RestructuringCognitive Restructuring Development of Evidence Testing Skills From Mood Logs and Development of Evidence Testing Skills From Mood Logs and

Activity RecordsActivity Records Understanding of Automatic and Distorted CognitionsUnderstanding of Automatic and Distorted Cognitions Labeling Distorted CognitionsLabeling Distorted Cognitions Modifying Distortions and Mood Through 5-ColumnModifying Distortions and Mood Through 5-Column Using Pros/Cons and Other Cognitive Restructuring StrategiesUsing Pros/Cons and Other Cognitive Restructuring Strategies

Stimulus ControlStimulus Control Negative Mood Triggers and Management of ExposureNegative Mood Triggers and Management of Exposure Development of Coping Mechanisms for Mood TriggersDevelopment of Coping Mechanisms for Mood Triggers

• Skills Enhancement (e.g., parenting skills, conflict management)Skills Enhancement (e.g., parenting skills, conflict management)

Applications to Other DisordersApplications to Other Disorders

Mastery of Your ADHDMastery of Your ADHD Habit Reversal Therapy for Hair PullingHabit Reversal Therapy for Hair Pulling Anger Management Using Stimulus Anger Management Using Stimulus

Control and Cognitive RestructuringControl and Cognitive Restructuring Weight Loss Protocol Developed by Judith Weight Loss Protocol Developed by Judith

BeckBeck Positive Parenting Program for ADHD and Positive Parenting Program for ADHD and

Modification of Parental Incompetence Modification of Parental Incompetence DistortionsDistortions

What to DoWhat to Do

Develop CBT competenciesDevelop CBT competencies Identify Useful Texts Like Leahy’s booksIdentify Useful Texts Like Leahy’s books Take Training from one of the CentersTake Training from one of the Centers Seek ABPP and/or ACT Certification Seek ABPP and/or ACT Certification

QuestionsQuestions

Health & Medicine

Opa basics of cognitive behavioral therapy