SEMINAR ON

SUBMITTED TO SUBMITTED BY

MRS. kAVITHA M. PRIYADERSINI

TUTOR M.SC NURSING, IST YEAR,

JIPMER CON JIPMER CON

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INTRODUCTION

Cognitive Behavioral Therapy (CBT) is a general classification of psychotherapy, based on social

learning theory, which emphasizes how our thinking interacts with how we feel and what we do.
It’s based on the view that when a person experiences depression, anxiety, or anger that these
stressors can be exacerbated (or maintained) by exaggerated or biased ways of thinking and that
these patterns can be modified by reducing erroneous and maladaptive beliefs. A counselor using
CBT helps a client to recognize their style of thinking and to modify it through the use of evidence
and logic.

DEFINITION

Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been
demonstrated to be effective for a range of problems including depression, anxiety disorders,
alcohol and drug use problems, marital problems, eating disorders, and severe mental illness.
Numerous research studies suggest that CBT leads to significant improvement in functioning and
quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective
than, other forms of psychological therapy or psychiatric medications.

HISTORY

BECK’S COGNITIVE THERAPY

Beck’s Cognitive therapy teaches clients to identify faulty patterns of thinking. Clients are
introduced to intervention strategies that assist in changing thought patterns and consequently
changing behavior.

• Beck, born in 1921, Providence, Rohde Island, was initially attracted to the study of
neurology. It wasn’t long, however, before he discovered psychiatry was a more fitting
interest for him. Beck struggled with numerous fears throughout his life, including a fear of
public speaking and anxiety about his health. Beck used these fears to help him
understand himself and others which ultimately provided the basis on which he developed
his cognitive theory (Corey, 2005). Through his research, Beck discovered that people who
are suffering from depression often reported thinking that was characterized by errors in
logic. These errors, Beck called, ‘cognitive distortions’.Aaron Beck observations of
depressed clients revealed that they had a negative bias in their interpretation of certain
life events, which contributed to their cognitive distortions.Beck called it cognitive therapy

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 because of the importance it places on thinking. It’s now known as cognitive-behavioral
therapy (CBT) because the therapy employs behavioral techniques as well.

ELLIS’S RATIONAL EMOTIVE BEHAVIOUR THERAPY A-B-C sequence. This sequence describes the
relationship between

• A is the Activating event: It may refer to a real external event, an external event that is
anticipated to happen in the future or an internal event in the subject’s own mind (e.g.
image, memory, dream)

• B refers to the Beliefs of the subject: These include thoughts, personal expectations of
yourself, the world and other people and the meanings attached to events

• C refers to the Consequences: These include emotions, behaviours and the physical
sensations related to certain emotions.

TYPES OF CBT

 Brief CBT
 Cognitive emotional behavioral therapy
 Structured cognitive behavioral therapy
 Moral cognitive reconation therapy
 Stress inoculation training

INDICATION
 Schizophrenia Other conditions for which CBT may prove
 Eating disorders beneficial:
 Self-harm
 Addiction
 Anxiety
 Chronic fatigue syndrome
 Depression
 Chronic pain
 Bipolar disorder
 Personality disorders
 Depression in children
 Phobias
 Dementia
 Relationship problems
 Obsessive-Compulsive Disorder (OCD)
 Psychotic disorder
 Post Traumatic Stress Disorder (PTSD)
 Disturbed (violent) behavior

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BENEFITS OF COGNITIVE BEHAVIORAL THERAPY

Benefit #1: Support

Cognitive Behavioral Therapy provides a support network for people recovering from mental
disorders. Since it is action-based, patients know they have someone to turn to as they work
through their problem. Knowing that there is someone interested in them and their recovery
allows patients to work toward changing negative behaviors.

Benefit #2: Raises Self-Esteem

For many people, low self-esteem is at the root of their disorder. Cognitive Behavioral Therapy
allows patients to build self-esteem by focusing on problems and working toward the solution. As
patients find answers their belief in themselves grows and they are able to conquer the disorder.

Benefit #3:Creation of Positive Thought

With many mental disorders, negative thought patterns emerge and take over the life of the
patient. Negative thinking becomes automatic with many patients. Cognitive Behavioral Therapy
teaches patients how to turn negative thoughts into positive, realistic ones.

Benefit #4: Anger Management

Controlling one’s anger and learning to direct anger is a major issue with the mentally ill patient.
Patients feel guilt and shame and these feelings turn into anger at the world. Cognitive Behavioral
Therapy addresses the underlying issues that allow emotions to become overwhelming. It teaches
patients various methods to help control emotional responses and to assist them in recognizing
the reasons behind the anger.

Benefit #5: Better Communication Skills

Maintaining relationships is difficult when suffering from depression, addiction, and social anxiety.
Cognitive Behavioral Therapy helps patients to learn how to communicate their feelings to others
without becoming anger or feeling shame.

Benefit #6: Coping Skills Improve

The cause of many disorders is an inability to cope with stressful situations such as grief or
trauma. Cognitive Behavioral Therapy provides patients avenues to deal with such situations. They
learn to express themselves instead of bottling things up.

Benefit #7: Relapse Prevention

Patients suffering from mental disorders often relapse. Cognitive Behavioral Therapy provides
patients with the tools they need to prevent relapses. Because patients have learned to identify
their problems and learned coping methods, they are better equipped to recognize the thought
patterns they need to avoid.

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STAGES OF CBT

1 Assessment stage

2 Cognitive stage

3 Behaviour stage

4 Learning stage

In the Assessment stage, you and your therapist get to know each other. Your therapist usually
forms a treatment plan, and often has some idea about how long your treatment might take.

In the Cognitive stage, you and your therapist work together to understand your thoughts. You
might spend some time discussing past events that have made you think the way you do.

In the Behavior stage, you and your therapist work together to find new patterns of thinking. You
apply your new patterns of thinking to new behaviours.

In the Learning stage, you and your therapist work together to make sure that the changes are
permanent. Learn how to use the principles of CBT in future, so that you can cope with future
events without needing any more therapy.

PRINCIPLE

• Cognitions affect behavior and emotion.

• Cognitions may be made aware, monitored and altered.
• Desired emotional and behavioral change can be achieved through cognitive change.
• Change mood states by using cognitive and behavioral strategies:
 Identifying/modifying automatic thoughts & core beliefs,
 Regulating routine, and
 Minimizing avoidance.
Emphasis on ‘here and now’
 Preference for concrete examples
 Start with specific situation (complete thought log)
Reliance on Socratic questioning

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  Ask open-ended questions
Empirical approach to test beliefs
 Challenge thoughts not based on evidence
 Cognitive restructuring
ELEMENTS OF CBT
STRUCTURED: CBT is structured in two ways. First, the overall therapy follow structure that
approximates the treatment plan. Sessions have identifiable beginning, middle and end.
COLLABORATIVE: Therapeutic collaboration cannot be 50/50. for severe depressed client the
possibility to generate 50% of the therapeutic effort is impossible. Initially, the collaboration may
be 90/10. For each client, the therapist must evaluate the client’s ability and motivation for the
therapy.
PROBLEM-ORIENTED: CBT focuses on discrete problems rather than vague and amorphous goals
of feeling good, getting better, or increasing self-esteem
PSYCHO EDUCATION: The therapist works as a change agent. Many to problems that bring people
therapy involve skills deficits. The therapist may have to teach by direct instruction, modeling, role
playing.
SOLUTION-FOCUSED: The CBT therapists works with the client on generating solutions not simply
gaining insight into the problem.
DYNAMICS: The dynamic level of CBT is to help clients to identify, understand, modify their
schema.
The schema are the basic templates for understanding one’s world. Schema may be personal,
religious, cultural, gender-related.
TIME-LIMITED: Each therapy session should, ideally, stand alone. A time-limited focus is not a
number of sessions, but rather way of looking at therapy.

COMPONENTS OF CBT

Functional Analysis and Skills Training. Functional Analysis plays a critical role in helping the client
and counselor assess high risk situations that are likely to lead to substance use and providing
insights into what may trigger or stimulate the client’s substance use (e.g., interpersonal
difficulties, opportunities to take risks or feel euphoria not otherwise available in the patient’s life,
etc.).

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Later in treatment, functional analysis of substance use episodes helps identify those situations or
states in which the individual still has difficulty coping.

An example might look like this as the counselor asks a series of questions aimed at eliciting
insights into the client’s thinking and recollections:

 To get an idea of how all this works, let’s go through an example.

 Tell me all you can about the last time you used cocaine.
 Where you and what where were you doing?
 What happened before? How were you feeling?
 When was the first time you were aware of wanting to use?
 What was it like later?

Skills Training can be viewed as a highly individualized training program to help the client unlearn
old habits associated with substance use and learn or relearn healthier skills. In CBT, the goal is to
identify and reduce habits associated with a drug using lifestyle by substituting more enduring,
positive activities and rewards. The client learns to recognize and cope with urges to use
substances. In addition, the skills can improve interpersonal functioning, enhance social supports,
and help clients learn to tolerate feelings like depression and anger.

The highly individualized nature of CBT requires the counselor to be sensitive in matching the
content, timing, and presentation of new skills and behaviors to the client’s readiness for change.

Critical Tasks : The primary objectives of CBT are to:

• Foster motivation for abstinence. CBT methods such as functional analysis, which clarifies what
the client stands to lose or gain by using substances, can enhance the client’s motivation to stop
use.

• Teach coping skills. This is the core of CBT to help clients recognize the high risk situations in
which they are most likely to use substances and to develop other, more effective

• Change reinforces. CBT focuses on identifying and reducing habits associated with drug use by
substituting positive activities and rewards.

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• Foster management of painful feelings. CBT skills help the client recognize and cope with urges
to use substances and learn to tolerate other strong feelings such as depression and anger.

• Improve interpersonal relationships and social supports. CBT trains the client in interpersonal
skills and strategies to help them increase their support networks and build healthy relationships.

Structure and Format of CBT Sessions

The NIDA publication, A Cognitive Behavioral Approach:

An example for atypical 60 minute sessions:

First 20 minutes

• Assess substance abuse, craving, and high risk situations since last session,

• Listen for/ elicit patient’s concerns, and

• Review and discuss the homework practice exercise

Second 20 minutes

• Introduce and discuss the session topic, and

• Relate the session topic to the client’s current concerns

Third 20 minutes

• Explore the client’s understanding of and reactions to the topic,

• Assign a practice exercise for the next week, and

• Review plans for the week and anticipate potential high risk situations.

Getting Started

Clients typically participate in approximately 16 CBT sessions over a 12 week period. There is,
however, great variability. CBT can be delivered in individual or group counseling settings.

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Whichever you use there are some tasks to accomplish in the beginning to properly orient the
client to CBT and set the stage for productive work. In getting started the counselor assesses the
client as a candidate for CBT. The counselor:

• Reviews all assessment information, Begins establishing a relationship,

• Works to enhance client’s motivation for change,

•Presents the CBT model,

•Introduces functional analysis,

•Negotiates treatment goals and specific objectives, and

•Provides a rationale for homework practice assignments.

The first session is the most important and may need to be scheduled for a longer period than
usual because ever all issues need to be addressed:

•Building rapport to establish a relationship with client,

• Assessing the client’s substance use and other problems that may be important to address
during treatment,

•Provide a rationale for CBT treatment,

•Review the structure for the following sessions, and

•Begin skills training. The next issue of this AM series on CBT will provide more details on
individual session topics and skills building development.

CBT Techniques and Tools

ANXIETY REDUCTION

RELAXATION TRAINING

As a therapeutic tool, relaxation technique effectively decreases tension and anxiety. It can be
used alone in combination with other cognitive behavioral technique, or in addition to supportive

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or insight therapy. The basic premise is that muscle tension is related to anxiety. If tense muscle
can be made to relax, anxiety will be reduced.

All relaxation producers involve rhythmic breathing, reduced muscle tension, and an altered state
of consciousness. Clinical experience suggests that there are individual difference in the
experience of relaxation. Not everyone demonstrates all the characteristics of a relaxed
physiological. The physiological state. The physiological, cognitive and behavioral manifestation of
relaxation are

Anxiety reduction Cognitive restructuring Learning new behavior

Relaxation training Monitoring thoughts and Modeling
Biofeedback feelings Shaping
Systematic desensitization Questioning the evidence Token economy
Interceptive exposure Examining alternatives Role playing
Flooding Decatastrophizing Social skills training
Vestibular desensitization training Reframing Aversive therapy
Response prevention Thought stopping Contingency contracting
Eye movement desensitization
And reprocessing

Systematic relaxation training involve tensing and relaxing voluntary muscles in an orderly
sequence until the body, as a whole, is relaxed. For this technique, the patient should be seated in
a comfortable chair. Soft music or pleasant visual cues may be present. Before beginning the
exercise, a brief explanation should be given about how anxiety is related to muscle be described.

The patient begins by taking a deep breath and exhaling slowly. This is followed by a sequence of
tension relaxation exercises beginning with the hands and ending with the feet. The patient is
instructed to tense each muscle group for approximately 10 seconds while the nurse describe how
tense and uncomfortable this body part feels. The nurse then asks the patient to relax this muscle
group as the nurse comments, “notice how all the hardness and tension is draining from your
hands. Now notice how they feel-warm, soft and calm. Compare this feeling to when they were
tense and see how much better they feel now.” The patient should be minded to tense only the
muscle group named. The patient then proceeds to the next muscle group in the sequence listed

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Physiological Cognitive Behavioral
Decreased pulse Altered state of Lack of attention to and
Decreased blood pressure consciousness concern for environmental
Decreased respiration Heightened concentration on stimuli
Decreased oxygen consumption single mental image No voluntary change of
Decreased metabolic rate Receptively to positive position
Pupil constriction suggestion Passive movement easy
Peripheral vasodilation
Increased peripheral
temperature

The final exercise asks the patient to become completely relaxed, beginning with the toes and
moving up through the body to the eyes and forehead. Once the patient has learned the
procedure, these exercise can be performed only for the muscles that usually become tense. This
is different for each person and may include the shoulders, forehead, and back, or neck. Patients
may also eliminate for tensing exercise and perform only the relaxation ones.

Meditation also may be used to evoke the relaxation response. It may follow replace systematic
relaxation. The basic components for medication include the following

 A quiet environment
 A passive attitude
 A comfortable position
 A word or scene to focus on

The first three components are necessary for any relaxation procedure. The fourth component
refers to visualization- the process in which the patients selects a cue word or scene with pleasant
connotations. The nurse then instructs the patient to close both eyes, relax each of the major
muscle groups and begins repeating the word silently at each exhalation.

Other relaxation techniques include guided imaginary, centering, mindful meditation and
focusing. Although each of these approaches varies slightly, the intent of all of them is to use the
mind to get in touch with the inner self. As such, they have been found to promote relaxation,
enhance sleep, reduce pain and increased creativity. This is another technique that is not specific
to CBT but will be familiar to practitioners of mindfulness. There are many ways to relax and bring

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regularity to your breath, including guided and unguided imagery, audio recordings, YouTube
videos, and scripts. Bringing regularity and calm to your breath will allow you to approach your
problems from a place of balance, facilitating more effective and rational decision making

These techniques can help those suffering from a range of mental illnesses and afflictions,
including anxiety, depression, OCD, and panic disorder, and they can be practiced with or without
the guidance of a therapist. To try some of these techniques without the help of a therapist, see
the next section for worksheets and handouts to assist with your practice.

Biofeedback

Biofeedback uses a machine to reduce anxiety and modify behavioral responses. Small electrodes
connected to the biofeedback equipment are attached to the patient’s forehead. Brain waves,
muscle tension, body temperature, heart rate and blood pressure can then be monitored for small
changes. These changes are communicated to the patient by auditory and visual means. The
more relaxed the patient becomes, the more pleasant are the sounds or sights presented. These
pleasant sights and sounds stop when the reachieves the relaxed state. After developing the
ability to relax, the patient is encouraged to apply the technique during stressful situations.

Systematic desensitization

Systematic desensitization was designed to decrease the avoidance behavior linked to a specific
stimulus ( eg. Heights, airplane travel). The goal of systematic desensitization is to help the patient
change his or her response to a threatening stimulus. It involves combining deep muscle
relaxation with imagined scenes of situation that cause anxiety. Therefore if the persons is taught
to relax while imagining such scenes the real life situation depicted by the scene will cause much
less anxiety.

With systematic desensitization, the patient must first be able to relax the muscles. Next, a
hierarchy of the anxiety provoking or feared situations is constructed. These situations are ranked
from 1 to 10 in order of difficulty, with 1 evoking little or no anxiety and 10 evoking intense or
severe anxiety.

With in vitro, or imagined, desensitization, the patient proceeds with the imagined pairing of the
hierarchy items with the relaxed state, progressing from the least anxiety provoking item to the
most anxiety provoking items.

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In vivo desensitization exposes the patient to real rather than imagined life situations. In vivo
exposure is widel0y considered to be the treatment of choice for simple and social phobia and for
obsessive compulsive disorders.

INTEROGATIVE EXPOSURE

Interrogative exposure is a technique used to desensitize a patient to catastrophic interpretation

of internal bodily cues such as tachycardia, blurred vision, and shortness of breath. A hierarchy is
made of the specific symptoms that increase the patients anxiety. The patient is then asked to do
the things that cause these cues. Patients can be asked to jump in place, run up a flight of stairs,
or spin in circles. This technique is especially helpful for patients who do not have agoraphobia but
have spontaneous, unprovoked panic attacks that cause them increased worry and anxiety.

This technique is intended to treat panic and anxiety. It involves exposure to feared bodily
sensations in order to elicit the response, activates any unhelpful beliefs associated with the
sensations, maintains the sensations without distraction or avoidance, and allow new learning
about the sensations to take place. It is intended to help the sufferer see that symptoms of panic
are not dangerous, although they may be uncomfortable.

Flooding

Flooding is another form of exposure therapy in which the patient is immediately exposed to the
most anxiety provoking stimulus instead of being exposed gradually or systematically to a
hierarchy of feared stimuli. If this technique uses an imaginary event instead of a real life event, it
is called implosion.

Vestibular Desensitization Training

Vestibular Desensitization Training is an exposure therapy for patient whose panic attacks are
provoked by environmental cues that cause them to have symptoms of motion sickness ( e.g.
dizziness, imbalance, vertigo, nausea, tinnitus, blurred vision or headache). These environmental
cues can include suddenly changing position, walking on floors with patterns, walking down a
grocery store is stacked high with products on both sides, or riding in a car on a hilly road

A desensitization hierarchy is created to include activity that cause these symptoms, such as
getting up suddenly from a prone position, making sudden head movements, or making sudden
stop-and go movements. Patients who get motion sickness when standing in a wide open space

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with no object to break the horizon are taught to turn in a full circle while keeping their eyes on a
selected object for orientation, much like baller dancers do when they turn repetitively.

Response Prevention

In response prevention the patient is encouraging to face a particular fear or situation without
engaging in the accompanying behavior. This technique is basedon the concept that repeated
exposure to an anxiety-producing stimulus without the presence of the anxiety reduction because
the feared consequences does not occur.

For example, a patient may fear using a public restroom and engage in hand washing upto 20
times a day. With response prevention treatment, the patient daily schedule would include using
a public restroom, turning on the water faucets and washing hands for only 30 seconds. Overtime,
the maladaptive behaviors would be reduced because the feared consequence of germs and
illness did not occur.

EYE MOVEMENT DESENSITIZATION AND REPROCESSING

Eye movement desensitization and reprocessing (EMDR) based on specific and repetitive rapid
eye movements similar to those experienced naturally in rapid eye movement (REM) sleep. The
principle behind this treatment is that the brain lays down biological memory tracks during early
traumatic experience. These memory tracks are provoked later during seemingly unrelated
events, causing anxiety and perhaps depression.

With EMDR, the patient is asked to think about past traumatic events while the therapist moves
his or her hand back and forth of the patients face; the patient eyes follow the therapist’s hands.
In this way, the neural tracks hypothesized to became reprogrammed and less sensitized to
anxiety-provoking experience.

EMDR is being used to treat a variety of psychological problems, including stress, anxiety, phobias,
recurrent nightmares, substance abuse and post- traumatic stress disorder

COGNITIVE RESTRUCTURING

Monitoring thoughts and feelings

Changing cognitive begins with identifying what reinforcing and maintain the patient’s
dysfunctional thinking and maladaptive behavior. An important first step is for patient to become
more aware of and monitor their own thinking and feeling. Patients can be helped to do this

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through the use of the daily record of dysfunctional thoughts form. The patient uses this form by
recording information in each of five columns, beginning with a brief description of a particular
situations or events in the first column. The patient writes down his or her feelings or emotions, as
well as the automatic thoughts in response to the situation. The strength of each is also rated by
the patient. The patient is then encouraged to think of a more rational response to the situations
and record that in the fourth column. Finally, in the last column, the patient reevaluates his or her
level of belief in the automatic thought and subsequent emotions.

By using such a form, patient are taught to distinguish between thoughts and feelings and to
identify more adaptive responses to problematic situations. They also begin to recognize the
connection between certain thoughts and maladaptive emotions and behaviors

QUESTIONING THE EVIDENCE.

The next step is for the patient and therapist to examine the evidence that is used to support a
certain belief. Questioning the evidence also involves examining the sources of the data. Patient’s
with distorted thinking often give equal weight to all sources on information or ignore all data
except those that support their distorted thinking. Having patient’s question their evidence with
staff, family and other members of their social support network can clarify misinformation and in
more realistic and appropriate interpretations of the evidence.

EXAMINING ALTERNATIVES

Many patients see themselves as having lost all options. This type of thinking is particularly
evident in suicidal patients. Examining alternatives involves working with patients to generate
additional options based on their strength and coping resources.

DECATASTROPHIZING

Decatastrophizing is also called the ‘”what- if” technique. It involves helping patients evaluate
whether they are overestimating the catastrophic nature of the situation. Questions that the
nurse can ask include, “what is the worst thing that can happen?” “would it be so terrible if that
really tool place?”

How would other people cope with such an event?” the goal of this intervention is to help the
patient see that the consequences of life actions are generally not all or nothing and thus are less
catastrophic

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REFRAMING

Reframing is a strategy that changes patient perception of a situation or behavior. It involves

focusing on other aspects of the problem or encouraging a patient to see the issue from a
different perspective.

Patients who dichotomize events may see only one side of a situation. Weighing the advantages
and disadvantages of maintaining a particular beliefs or behavior can help patients gain balance
and develop new perspective. By understanding both the positive and negative consequence of an
issue, the patient can attain a broader perspective of it. For example, suggesting that a mother’s
over involvement with her son is actually a sign of her loving concern may help a family see the
situation in a new light.

This strategy also creates an opportunity to help challenge the meaning of a problem or behavior;
once the meaning of a behavior changes, the persons response will also change. For example: this
strategy, might involve helping a patient see an adversity as a potentially positive event. The loss
of a job may be perceived as a stressor, but it also can be viewed as an opportunity for pursuing a
new job or carrier.

THOUGHT STOPPING

Dysfunctional thinking often can have a snowfall effect on patients. What begins as a small or
insignificant problem can, over time, gather importance and momentum that can be difficult to
stop. The technique of thought stopping is best used when the dysfunctional thought first begins,
the patient can picture a stop sign, imagine a bell going off, or envision a brick wall to stop the
progression of the dysfunctional thoughts.

LEARNING NEW BEHAVIOUR

MODELLING:

The person is exposed to ‘model’ behavior and is induced to copy it. This can also be used to
avoid certain behaviors. Modeling is a method of teaching by demonstration, wherein the
therapist shows how a specific behavior is to be performed. In modeling the patient observes
other patients indulging in target behaviors and getting rewards for those behaviors. This will
make the patient repeat the same behavior and earn rewards in the same manner.

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SHAPING

In shaping the components of a particular skill, the behavior is reinforced step by step. The
therapist starts shaping by reinforcing the existing behavior. Once it is established he reinforces
the responses whichare closesto the desired behavior, and ignores the other responses.
For example, to establish eye-to-eye contact, the therapist sits opposite the patient and reinforces
him even if he moves his upper body towards him. Once this is established, he reinforces the
person's head movement in his direction and this procedure continues till eye-to-eye contact is
established.
TOKEN ECONOMY

It is a positive reinforcement. This program involves giving token rewards for appropriate or
desired target behaviors performed by the patient. The token can later be exchanged for other
rewards.
For example on inpatient hospital wards, patients receive a reward for performing a desired
behavior, such as tokens which they may use to purchase luxury items or certain privileges.
ROLE PLAYING

Role playing allows patients to rehearse problematic issues and obtain feedback about their
behavior. It can provide practice for decision making and exploring consequences. A related
practice is role reversal, in which the patient switches roles with someone else and thus
experiences the difficulty situation from another point of view.

SOCIAL SKILL TRAINING

Assertiveness and socialskill training: Assertiveness training is a behavior therapy technique in

which the patient is given training to bring about change in emotional and other behavioral
pattern by being assertive. Client is encouraged not to be afraid of showing an appropriate
response, negative or positive, to an idea or suggestion.
Assertive behavior training is given by the therapist, first by role play and then by practice in a real
life situation. Attention is focused on more effective interpersonal skills. Smooth Social
functioning is central to most human activity and social skill problem exists in many psychiatrically
ill patients. Social skill training is based on the belief that skills are learned and therefore can be
taught to those who do not have them. Social skills training helps to improve social manners like
encouraging eye contact, speaking appropriately, observing simple etiquette, and relating to
people. The principle of skill acquisition include the following

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  Guidance
 Demonstration
 Practice
 Feedback

AVERSION THERAPY

Aversion therapy is used for the treatment of conditions which are pleasant but felt undesirable
by the patient, e.g. alcohol dependence, transvestism, ego dystonic , homosexuality, other sexual
deviations. The underlying principle is pairing of the pleasant stimulus (such as alcohol) with an
unpleasant response (such as brief electrical stimulus), so that even in absence of unpleasant
response (after the therapy is over), the pleasant stimulus becomes unpleasant by association.

The unpleasant aversion can be produced by electric stimulus (low voltage), drugs (such as
apomorphine and disulfiram) or even by fantasy (when it is called as covert sensitisation).
Typically, 20-40 sessions are needed, with each session lasting about 1 hour. After completion of
treatment, booster sessions may be given. The current use of aversion therapy has declined
sharply in the Western world (and also elsewhere) as it is felt by many that it may violate the
human rights of the patient.

CONTINGENCY CONTRACTING

It involves a formal contract between the patient and the therapist, defining what behaviors are
to be changed and what consequences follow the performance of these behaviors. Included are
positive consequences for desired behavior and negative consequences for desired behavior.

Key Points to Remember:

1. CBT, or Cognitive-Behavioral Therapy, is based on research – so we know it works!

2. CBT teaches you new ways of thinking and behaving.

3. Thoughts, feelings, and behaviors are inter-connected, so if you change one, it has an effect on
the other two.

4. If you change the way you think and behave, you can also change the way you feel.

Key Factors Influencing the Effective Delivery of CBT

• Therapeutic relationship – a trusting, safe, therapeutic alliance is essential but not sufficient for
successful CBT.
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• Collaboration

 Is a way of being with clients based on an equal partnership, each party bringing
something to the relationship. The therapist brings skills and knowedge of psychological
processes, theories of emotion and techniques that have helped others and could help the
current client. The client is an expert in their own experience, and brings their own
resources.

• Formulation – a unique map or hypothesis of presenting problems or situations which integrate

information from assessments within a coherent CBT framework drawing upon theory and
evidence based practice.

• Socratic dialogue/ guided discovery – is a style of questioning to both gently probe for people’s
meanings and to stimulate alternative ideas. It involves exploring and reflecting on styles of
reasoning and thinking and possibilities to think differently. CBT is not about trying to prove a
client wrong and the therapist right, or getting into unhelpful debates – rather by skilfully
collaborating, clients come to see for themselves (discover) that there are alternatives

• Homework – the client tries things out in between therapy sessions, putting what has been
learned into practice. This is referred to as homework and sometimes includes behavioral
experiments.

STRENGTHS AND WEAKNESSES

STRENGTHS WEAKNESSES
Well supported by scientific research Requires clients to be attuned to nuances in mood
or attentive to previously unconscious thoughts

Wide application Can be overly prescriptive and ignore individual

factors
Has been used successfully with personality and Requires the ability to think abstractly (ie. to think
mood disorders ƒ Requires the ability to think about thinking).
abstractly (ie. to think about thinking).
Provides a structured plan and sequence for therapy May not be as depth orientated as some clients
may prefer or see as necessary for change
Myths about CBT: Author: Alex Hedger

• It’s All About Thinking Positively

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 • It’s A Long Term Psychotherapy

• It’s Too Short That It doesn’t Fully Solve Problems

• It’s An Easy Therapy

• It Works For Every Mental Health Problem

CONCLUSION

• CBT is an evidence-based therapy that has been shown to be useful in the management of
many psychological conditions including depression, anxiety and OCD. The main principle
of CBT is that our thoughts control our emotions and how we react to events (Activating
event – Beliefs – Consequences). CBT encourages people to recognise errors in their
thinking, in order to help them to react healthily to events

Journals :A Randomized Controlled Trial of Cognitive-Behavioral Therapy for Persistent

Symptoms in Schizophrenia Resistant to Medication

AbstractBackground : Research evidence supports the efficacy of cognitive-behavioral therapy in

the treatment of drug-refractory positive symptoms of schizophrenia. Although the cumulative
evidence is strong, early controlled trials showed methodological limitations.

Methods A randomized controlled design was used to compare the efficacy of manualized
cognitive-behavioral therapy developed particularly for schizophrenia with that of a nonspecific
befriending control intervention. Both interventions were delivered by 2 experienced nurses who
received regular supervision. Patients were assessed by blind raters at baseline, after treatment
(lasting up to 9 months), and at a 9-month follow-up evaluation. Patients continued to receive
routine care throughout the study. An assessor blind to the patients' treatment groups rated the
technical quality of audiotaped sessions chosen at random. Analysis was by intention to treat

Results Ninety patients received a mean of 19 individual treatment sessions over 9 months, with
no significant between-group differences in treatment duration. Both interventions resulted in
significant reductions in positive and negative symptoms and depression. At the 9-month follow-
up evaluation, patients who had received cognitive therapy continued to improve, while those in
the befriending group did not. These results were not attributable to changes in prescribed
medication.

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Conclusion Cognitive-behavioral therapy is effective in treating negative as well as positive
symptoms in schizophrenia resistant to standard antipsychotic drugs, with its efficacy sustained
over 9 months of follow-up

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Clinical psychological review

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