10 MINUTE CBT AND SELF-HELP

FOR GPs

Simon Day – Clinical Lead for York & Selby

IAPT
November 2019
Aims for Today
 Learn how to introduce CBT as a therapeutic approach
 Learn how to help people make links between
cognition, mood and behaviour
 Learn how to help people start to consider how they
can make change for themselves
 Gain a list of resources that can be used to help people
on their journey to recovery
Why CBT?
 Cognitive Behavioural Therapy (CBT) is the most
evidence based psychotherapy
 Recommended in NICE Guidelines for:
 Depression
 Social Anxiety
 Panic Disorder
 PTSD
 OCD
 GAD
What is CBT?
 CBT is not a single therapy but a broad church with
disorder specific models and treatments as well as
different approaches
 All approaches currently taught and used within the
IAPT programme are based on or developed from the
Beckian model first developed by Aaron Beck in the
60s and 70s
 Therefore for this workshop and to maintain clarity we will focus on
this approach
What is CBT?
 Two main influences
 Behaviour Therapy (BT) developed by Wolpe and others in the 50s
and 60s
 Cognitive model developed by Beck in the 60s and 70s
 BT was a reaction against the Freudian psychodynamic approach
 Looking for empirical evidence of stimulus and response that
could be replicated
 Great success with anxiety disorders, particularly phobias and
OCD using systematic desensitization
 This led to empirical support developing for the approach as well
as an effective and timely treatment - economical
What is CBT?
 Two main influences
 Cognitive model
 In the 70s despite the success of BT some dissatisfaction about
the limitations of not attending to mental processes, which are
clearly part of all our lives
 Needed to bring in an approach that attended to and included
cognition that met the empirical parameters that BT had set
down
 Beck had started this work in the 50s and 60s and in 1979
published Cognitive Therapy for Depression with research
showing this treatment was as effective as medication
What is CBT?
 Principles of CBT
 Cognitive principle
 Think about the last few days…
 Have you had any noticeable changes in your mood? Either
positive or negative
 If I were to ask you what had caused that change what would
you say?
What is CBT?
 Principles of CBT
 Cognitive principle
 Common sense model

Event Emotion

 Cognitive model

Event Cognition Emotion

What is CBT?
 Principles of CBT
 Cognitive principle
 We all see and interpret the world differently
 This tends to be driven by our experiences and biases
 Therefore we all react differently/ idiosyncratically to the same
situation
 The biggest factor in how we react is the meaning we give a
situation or event
What is CBT?
 Principles of CBT
 Behavioural principle
 What we do, or don’t do, affects how we think and feel
 Using an example of doing an introduction to CBT presentation
to up to 50 GPs (Situation)
 They’re more qualified than me, they deal with mental health all
the time, I won’t bring anything useful (Cognition)
 Anxious, nervous (Emotion)
 Call in sick (Behaviour)
– Will that allow the presenter to be able to find out
their cognition was incorrect?
What is CBT?
 Principles of CBT
 Behavioural principle
 Gives us a chance to find out whether our thoughts were
accurate or not – no disconfirmatory evidence gained
 Changing what we do is an effective way of changing thoughts
and emotions
 Ultimately change has to be behavioural, otherwise it is
theoretical and unsustainable
What is CBT?
 Principles of CBT
 Continuum principle
 Have you ever felt depressed or anxious?
 Feeling is natural and part of the human experience
 When people have a common mental health problem this is
simply more exaggerated or intense
– Not abnormal
– CBT theory applies to everyone whether they are
classed as well or unwell
What is CBT?
 Principles of CBT
 Here and Now Principle
 Working on the symptoms and current processes maintaining
difficulties leads to reduced distress
 Although the processes may have been set in place a long time
ago changing our cognitive and behavioural processes as they
are currently leads to change
What is CBT?
 Principles of CBT
 Interacting Systems Principle
 “Hot Cross Bun” (Padesky and Greenberger, 1995)
Environment

Cognition

Behaviour Affect

Physiology
What is CBT?
 Principles of CBT
 Empiricism
 Based on well researched theories and models that have proven
to be effective
– And can continue to evolve
 Can offer assurance to patients that if they engage then
treatment is likely to be effective
 Offers assurance that limited mental health resource is being
used as effectively as possible
What is CBT?
 Levels of Cognition
 Negative Automatic Thoughts (NATs)
 Negative appraisals of what is going on around us or within us
– Fairly easy to identify, if we pay attention to them
– Taken as true, particularly when linked to strong
emotion
 Dysfunctional Assumptions
 Often reframed as “rules for living”
– Conditional “if….then..” propositions or should/must
statements
– Less easy to verbalise – often derived from patterns or
behaviour or NATs
What is CBT?
 Levels of Cognition
 Negative Automatic Thoughts (NATs)
 Negative appraisals of what is going on around us or within us
– Fairly easy to identify, if we pay attention to them
– Taken as true, particularly when linked to strong
emotion
– Can be verbal or an image
What is CBT
 Levels of Cognition
 Dysfunctional Assumptions
 Often reframed as “rules for living”
– Conditional “if….then..” propositions or should/must
statements
– Less easy to verbalise – often derived from
assessment/ analysis of patterns of behaviour or NATs
What is CBT?
 Levels of Cognition
 Core Beliefs
 Fundamental beliefs about themselves, others and the world in
general
– Global
– Often formed in childhood but can be formed and
changed by significant events in adulthood
– Not within consciousness
– Very powerful
– Problems arise when negative beliefs are confirmed or
positive beliefs are challenged
Depression
 Cognitive triad
 Negative view of self
 I am bad/ useless/ unloveable/ a failure
 Negative view of the world
 Others are judgemental/ nothing good happens/ life is just full of
problems
 Negative view of the future
 Nothing will get better/ I will never succeed or be happy
Anxiety
 Primarily we see cognitions that overestimate threat,
but content varies depending on the disorder
 Panic disorder
 Catastrophic misinterpretation of physical symptoms
– I’ll collapse/die, lose control, go mad
 Health Anxiety
 Catastrophic misinterpretation of phsycial symptoms over a
longer period
– I must have *disease or illness*
Anxiety
 Social Anxiety
 Fear of negative evaluation by others
– They will think, and see, I’m weird/ weak/ stupid/ boring
 OCD
 Intrusive thoughts about being responsible for harm befallling
self or others
– Often images of self or others being hurt
 GAD
 Excessive hypothetical worrisome thoughts that spiral due to
uncertainty
– What if…..?
Maintenance
 Safety Behaviours
 Anxious clients usually take steps to avoid or prevent the threat they
imagine
 However this usually only offers short term relief and actually
perpetuates the problem
– E.g. hold tight to prevent collapsing/ have drink with
me/ don’t go on my own/ pills in my bag/ seek
reassurance/ be quiet/ be loud/ don’t make eye contact
 Vampires in Translyvania example
Maintenance
 Escape/ Avoidance
 A type of safety behaviour but prevalent across all anxiety disorders
 Worth highlighting separately as the easiest for patients to recognise
as unhelpful and therefore able to see how their own behaviour is
maintaining the problem
Maintenance
 Catastrophic Misinterpretation
 Usually a misinterpretation of usual bodily process
 Physical changes in Panic and Health Anxiety
– Something bad will happen to me
 “Odd” intrusive thoughts in OCD
– Having these thoughts means they are likely to happen
and it will be my fault
 Leads to more anxiety and more catastrophic misinterpretation and
so on (and on)
Maintenance
 Scanning/ Hypervigilance
 If we look out for something we will usually see it
 How many of you noticed a red car this week?
– If I ask you to look out for them, how many will you see
next week
 In disorders such as health anxiety patients will regularly scan
their body looking for symptoms and find them
– Become anxious and then notice more symptoms
Maintenance
 Reduced Activity
 Most typical in depression but seen to greater or lesser degrees in
other common mental health problems
 When we are depressed and/or tired things can feel more of an
effort
– So we stop doing them
 When we stop doing the things that matter to us our mood drops
as life loses some meaning
– Also increases self criticism, so more depressed and so
on (and on)
Putting It Together
 In Groups of 2-3 Practice:
 Using the examples complete a basic “hot cross bun” formulation
 This allows the patient to understand how thoughts, feelings
behaviours and physiology are linked, and highlights that we can
create change
 Each person to talk through a formulation
 5 minutes each
Putting It Together
 “Hot Cross Bun” (Padesky and Greenberger, 1995)

Environment

Cognition

Behaviour Affect

Physiology
Making Change
 Behavioural - Depression
 Behavioural Activation – A treatment to reduce rumination, increase
valued activity and reduce avoidance
 Ask patient to complete an activity diary
 Consider what is missing or has stopped doing
 What has helped in the past
 Physical health and general wellbeing
Making Change
 Behavioural – Depression
Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7am-8am
8am-9am
9am-10am
10am-11am
11am-12pm
12pm-1pm
1pm-2pm
2pm-3pm
3pm-4pm
4pm-5pm
5pm-6pm
6pm-7pm
7pm-8pm
8pm-9pm
9pm-10pm
10pm-11pm
11pm-12am
12am-7am
Making Change
 Cognitive Restructuring – For Depression and most
Anxiety Disorders
 Unhelpful thinking styles
 Increase awareness of NATs
 Developing alternatives
 Not replacing with positive thinking – continuum – more helpful
appraisal
 Is the thought the truth? What might you say to a friend in the
same situation?
 Link to behavioural change – what could I do differently?
Making Change
 Cognitive – Unhelpful Thinking Styles
 Mental Filter
 This thinking styles involves a "filtering in" and "filtering out" process – a sort of "tunnel vision,"
focusing on only one part of a situation and ignoring the rest. Usually this means looking at the
negative parts of a situation and forgetting the positive parts, and the whole picture is coloured by
what may be a single negative detail.
 Jumping to Conclusions
 We jump to conclusions when we assume that we know what someone else is thinking (mind
reading) and when we make predictions about what is going to happen in the future (predictive
thinking).
 Personalisation
 This involves blaming yourself for everything that goes wrong or could go wrong, even when you
may only be partly responsible or not responsible at all. You might be taking 100% responsibility
for the occurrence of external events.
 Catastrophising
 Catastrophising occurs when we “blow things out of proportion“., and we view the situation as
terrible, awful, dreadful, and horrible, even though the reality is that the problem itself is quite
small.
Making Change
 Cognitive
 Unhelpful thinking styles

 Black & White Thinking

 This thinking style involves seeing only one extreme or the other. You are either wrong or right, good or bad and
so on. There are no in-betweens or shades of gray.
 Shoulding and Musting
 Sometimes by saying “I should…” or “I must…” you can put unreasonable demands or pressure on yourself and
others. Although these statements are not always unhelpful (eg “I should not get drunk and drive home”), they
can sometimes create unrealistic expectations.
 Overgeneralisation
 When we overgeneralise, we take one instance in the past or present, and impose it on all current or future
situations. If we say “You always…” or “Everyone…”, or “I never…” then we are probably overgeneralising.
 Labelling
 We label ourselves and others when we make global statements based on behaviour in specific situations. We
might use this label even though there are many more examples that aren’t consistent with that label.
Making Change
 Cognitive
 Unhelpful thinking styles

 Emotional Reasoning
 This thinking style involves basing your view of situations or yourself on the way you are feeling. For example, the
only evidence that something bad is going to happen is that you feel like something bad is going to happen.
 Magnification and Minimisation
 In this thinking style, you magnify the positive attributes of other people and minimise your own positive attributes.
It’s as though you’re explaining away your own positive characteristics or achievements as though they’re not
important
Making Change
 Cognitive Restructuring
Situation
What was happening?
Did something trigger this?
Thought
What was going through your
mind about the situation?
Were you remembering
something? If so what?
Did a thought or image pop
into your mind? If so what?
Emotion/ Feeling
Typically this is one word e.g.
sad, angry, happy
What Did I Do (Or Unhelpful Thinking Is there an alternative What could I do to test
not do)? Style view? to see if the
alternative thought is
true?
How did you cope? Mental Filter If it were happening to
Jumping to Conclusions someone else what would I tell
Personalisation them?
Catastrophising Am I being fair?
Black & White Thinking
Should or Must Thinking
Overgeneralisation
Labelling
Emotional Reasoning
Magnification/Minimisation
Making Change
 Cognitive
 Worry Awareness – GAD
Making Change
 Physiological
 Belly Breathing
 Demonstration
– Slowly breath in through your nose and out through
your mouth at a pace that feels right for you
– Breathing into your belly
– Keep your shoulders loose
– Focus on your breath
– If your mind drifts come back to focus on your breath
– Continue for 2-5 minutes
Making Change
 Time Allowing: In your groups of 2-3:

 Introduce idea of behavioural activation

 Introduce unhelpful thinking styles and thought record
 Introduce belly breathing
Resources – Freely Available

 http://www.selfhelpguides.ntw.nhs.uk/tewv/
 https://www.cci.health.wa.gov.au/Resources/For-
Clinicians
 https://www.getselfhelp.co.uk/
 https://slam-iapt.nhs.uk/additional-resources-and-links/
Resources – To Buy

 Overcoming Series books :

https://overcoming.co.uk/7/Home
Resources – Apps

 Beat Panic
 Catch It
 My Positive Self
 Stress & Anxiety Companion
 Thrive
 All NHS approved apps: https://www.nhs.uk/apps-library/
Resources – IAPT ;)

 REFER TO IAPT!
 IAPT is a primary care mental health service for people with common
mental health problems
 If patients are referred early they can access less intensive
treatments that typically have little to no waits