Cognitive Behavior

Therapy
Introduction
• Cognitive behaviour therapy (CBT) was developed by Aaron T. Beck
• The university of Pennsylvania in 1960s
• CBT seeks to improve clients’ emotional distress by helping them
• To identify
• Examine
• Modify the distorted and maladaptive thinking
• Initially focused on depression
• Now applied to number of disorders
 Aaron Beck (early 1960s) developed ‘cognitive therapy”:
• structured,
• short-term,
• present oriented

directed toward solving current problems and modifying

What is
dysfunctional thinking and behavior.

Forms of CBT that share characteristics of Beck’s therapy:

CBT?
• rational emotional behavior therapy (Ellis, 1962),
• dialectical behavior therapy (Linehan, 1993),
• problem-solving therapy (D’Zurilla & Nezu, 2006),
• acceptance and commitment therapy (Hayes, Follette, & Linehan, 2004)
• exposure therapy (Foa & Rothbaum, 1998),
• cognitive processing therapy (Resick & Schnicke, 1993),
• cognitive behavioral analysis system of psychotherapy (McCullough, 1999),
• behavioral activation (Lewinsohn, Sullivan, & Grosscup, 1980; Martell, Addis, &
Jacobson, 2001),
• cognitive behavior modification (Meichenbaum, 1977)
 • Cognitive Behavioural Therapy is a type of talking
therapy which involves identifying and challenging
unhelpful thoughts and helping people learn how
Theory to modify their thinking patterns and behaviours,
to improve the way they feel.
underlying • CBT explores the relationship between feelings,
thoughts, and behaviours. As such, it arose from
CBT? two very distinct schools of psychology:
behaviourism and cognitive therapy. Its roots can
be traced to these two models and their
subsequent merging.
CT Theory
• It is not events per se which determine our feelings
but the meanings that we attach to these events

• Individuals are actively involved in constructing their reality

• A person choses her view point

• Information processing becomes distorted when we
experience emotional distress
• All or nothing thinking
• Jumping to conclusions
• Emotional reasoning
• Mind reading
• Labelling
• An emotional disorder is usually understood by examining
three levels of thinking
Usually outside the
Negative automatic • Situation-specific response awareness of the
thoughts (NATS) • Involuntarily ‘pop into’ mind individual but can
• During emotional distress bring into awareness

• Guide behaviour
Underlying • set standards • Acceptance
assumptions/rules • provide rules to follow (if then, • Competency
must, should) • Control
• Over generalized and
unconditional behaviour • About self
Core belief • About others
• Deepest
• Childhood experiences • About future
• Thoughts, feelings, behaviour, physiology and
environment are interconnected

• Cognitive change is the central to the human change process

• Emotional reactions to events are viewed along a
continuum normal- exaggerated

Mature thinking Primitive thinking

(Normal) (Exaggerated)
• Emotional disorders have a specific cognitive content
• Loss in depression

• Danger or threat in anxiety

• Inflated sense of responsibility in OCD

• Situationally specific danger in phobia

• Our thoughts and beliefs are both knowable and
accessible

• Tapping the internal communications’ and train ‘to focus on

introspections
• Maintenance of emotional disturbance
• Current cognitive functioning crucial to the maintenance and
persistence of psychological disturbance

• A historical perspective helps to understand how the present

difficulties developed
• The client as personal scientist
• Two scientists working together to define the latter’s problem, to formulate
and test hypotheses about it and find problem-solving options

• It is called collaborative empiricism

• Open-mindedness
• Both therapist and client speaks from collected data rather than from personal
opinion and prejudice
Characteristics of
Cognitive-Behavioral
Therapies:

• Thoughts cause Feelings and Behaviors.

• Brief and Time-Limited.
• Average # of sessions = 16 VS psychoanalysis = several years
• Emphasis placed on current behavior.
• CBT is a collaborative effort between the therapist and the client.
• Client role - define goals, express concerns, learn
& implement learning
• Therapist role - help client define goals, listen, teach, encourage.
• Teaches the benefit of remaining calm or at least neutral
when faced with difficult situations. (If you are upset by
your problems, you now have 2 problems:
• the problem, and 2) your upsetness.
• Based on "rational thought." - Fact not assumptions.
• CBT is structured and directive.
Assumption : that most emotional and behavioral reactions are learned.
Therefore, the goal of therapy is to help clients unlearn their unwanted
reactions and to learn a new way of reacting.

Homework is a central feature of CBT. This can include such activities as:
Therapy sessions are really
‘training sessions’, between
Reading Self-help exercises Experiential activities Thought Stopping Intentional Reframing
which the client tries out and
uses what they have learned.
 ABC MODEL OF CBT

• The ABC Model is one of the most famous cognitive behavioural therapy techniques for analysing
your thoughts, behaviour and emotions.

• The Basis of CBT

Cognitive behavioural therapy or CBT works on the assumption that your beliefs influence your
emotions and your behaviour and that by identifying and addressing problematic thoughts you can help
to change your behaviour and experiences for the better.

• The ABC Model of CBT

– The ABC Model asks you to record a sequence of events in terms of:
– A - Activating Event (also sometimes described as a 'Trigger')
– B - Beliefs (for example, the thoughts that occur to you when the Activating Event happens)
– C - Consequences - how you feel and behave when you have those Beliefs (consequences may be
divided into two parts: your actions and your emotions)
A. Activating event: Friend passed me in the street without acknowledging me.

B. Beliefs about A:

• He’s ignoring me. He doesn’t like me.

• I’m unacceptable as a friend – so I must be worthless.

• C. Consequence:
• Emotions: hurt, depressed.
• Behaviours: avoiding people generally.
STRUCTURE OF TREATMENT SESSIONS
Initial interview

- correct unrealistic expectations of

therapy
-a standard for measurement of
progress
-- focuses attention on the future
Subsequent sessions
@ beginning of session, “What do we want to work on today”

Brings out issues and incidents relevant to therapy

- Emphasizes the importance of self-help

- Allows identification of (otherwise undetected) difficulties
& misunderstandings
- Provides opportunity to reinforce independent functioning

-Follow logically from occurrences during session

- Clearly and concretely defined ( => recognition of success)
Cognitive Behavioral Strategies
NEGATIVE AUTOMATIC THOUGHTS

01 Nature: In terms of cognitive triad (Beck, 1967).

Distorted, negative views of:
(1) the self ('I'm useless')
(2) current experience ('Nothing I do turns out
Identifying NATs right')
(3) the future ('I will never get better')
Relation with depression:
02 - Behavioral and motivational symptoms are
associated with an expectation of negative
outcomes (e.g. 'I can't do it').
Questioning NATs - Affective symptoms : (Sadness with thoughts of
loss)

03 Characteristics: They are

- habitual (and so may be difficult to identify)
- automatic & involuntary (so may be hard to
Strategies control)
- plausible, especially when accompanying emotions
are strong (so may be difficult to challenge)
 1) Identifying NATs

• Dysfunctional Thoughts Record- It includes:

1. Identifying unpleasant emotions: what the emotions are and rate them for
intensity on a 0-100 scale.
2. Identifying the problem situation (in which 1 occur): what they were doing or
the general topic they were thinking about.
3. Identifying associated NATs: what went through their mind when they began
to feel bad, and rate intensity of their belief in each thought on a 0-100 scale.

2) Questioning NATs

1. What is the evidence ?( Supporting NAT)

2. What Alternative Views are there?
3. What are the Advantages and Disadvantages of this way of thinking?
4. What Logical errors am I making?
 Cognitive Distortions
Overgeneralization
Making sweeping
judgments on the basis of Selective'
single instances abstraction.
Attending only
Dichotomous to negative
Reasoning aspects of
experiences
Thinking in extremes.
Black and white Personalization
thinking.

Arbitrary Taking responsibility for

inference things that have little or
nothing to do with
Jumping to oneself
conclusions on the
basis of inadequate
evidence
CBT Practice
• Setting the scene
• Welcoming the client
• A little chit-chat to break the ice
• Informed choice
• Expectation from therapy
• Previous therapy experiences
• Confidentiality
Undertaking an assessment

• A detailed description of the presenting problem

• Measures are used to assess the severity

• A longitudinal (historical) analysis

Client suitability

• Accessibility of automatic thoughts

• Awareness and differentiation of emotions

• Acceptance of personal responsibility

• Compatibility with the cognitive rationale

• Alliance potential (Rapport)

• Client optimism
 Developing A Case Conceptualization
Early childhood experiences

Core belief & assumptions

Critical incidents

Activation of NATS

Behaviour Emotions

Reduced
Crying Avoidance sadness rejection Anger
social life
Detecting NATS
• Cardinal question of cognitive therapy
• What was just going through my mind?

• Guided discovery (Socratic Questioning)

• Socratic questioning is driven by the therapist’s genuine curiosity to
understand the client’s viewpoint
• Stimulate thought and increase awareness, rather than requiring a correct
answer

• Making suggestions
• Thought diary

A B C
Antecedents or Situations Appraisals and Beliefs Emotional and
Behavioural
Consequences

At home alone, reflecting on the I don’t deserve this, why did he Depressed and tearful
end of the relationship leave me? I cant be happy without
her
• In vivo exposure

• Role play
Examining and responding to NATS
• Answering back
• You told Nobody loves love but u also told husband asks your opinion and
gives u money for shopping, is it..?

• Weighing the evidence

• Confirmational data

• Observational data

• Conjectural data-intuition
• Constructing alternative explanations
• list alternative interpretations of a situation and then establishing the
realistic probability of each interpretation
• Reattribution
• Internal factors Self blame

• External factors

• Behavioural experiments
• Socratic questioning (guided discovery)

1. Asking informational questions

2. Listening attentively and reflecting back

3. Summarizing newly acquired information

4. Asking analytical or synthesizing questions to apply the new

information to the client’s original problem or thought
• Writing down alternative responses to NATS
Home work
• To practise in everyday life the CT skills they have learned
• To have intellectual and emotional insight
• To develop competence and confidence in tackling their problems
• Bibliotherapy (creative arts – storytelling)
• Listening
• Writing
• Coping imagery
• Inaction versus action imagery
Behavioural assignments

• Activity scheduling

• Graded task assignments

• Experiments
Interventions Using CBT Model

• Behavioral Strategies:
• Activity Scheduling:
• Plan each day in advance on hour-to-hour basis.
•Reduces an apparently overwhelming mass of tasks to a manageable list.
•Increases patients' sense of control over their lives.
•Aids normal functioning

• Graded task assignment:

• Breaking tasks down into small, manageable steps, each of which is reinforced
• Each step is facilitated by identifying and challenging cognitive blocks to progress. (“It’s too
much for me.”)
• Counters hopelessness by encouraging patients to increase the frequency of self-reward,
and to redefine success realistically, taking into account how they feel
Cognitive Strategies

•Distraction Technique:

• Sensory awareness (focus on surroundings as a whole, using sight,

smell etc)
• Mental exercises (any absorbing mental activity eg- 100-7s)
• Pleasant memories & fantasies (vivid concrete memories of past
pleasures and fantasies)
• Absorbing activities (selecting activities which occupy mind and body
alike eg- puzzles)

• Counting Thoughts:

• To promote distance from negative thinking

• Learning to note the occurrence of NAT and putting it aside
• Disadvantage: may result in person being more distressed
 COGNITIVE RESTRUCTURING
Cognitive • Monitor Thoughts and Feelings

Behaviora •
•
Questioning The Evidence
Examining the alternatives
l •
•
Reframing
Thought Stopping
Strategies STRESS REDUCTION
• Relaxation Training
• Desensitization
CASE VIGNETTE
• A 22 Year Old College Student born out of non consanguineous
parents, presented with a 3 year history of gradual onset, progressive
impairment of co-ordination. He reported an incident of his friends
making fun of him after a fall in college. After this he started feeling
embarrassed to go to public places because he thought people will
make fun of him and his condition.

• ABC Model:
• Antecedents : Friend’s Made Fun of him.
• Behavior: Stopped going out much and Others are watching me/ are critical.
• Consequence: Social Anxiety and Isolation.
Interventions

• Re-engage in Avoided Activities:

• Scheduling Specific Tasks at specific times. Scheduled social activities other activities
that could bring a sense of pleasure.

• Reconnect with others:

• Scheduled times to get together with friends and family, assessing which friend will be
easier to meet and evaluating automatic thoughts(They’ll be critical of me/ laugh at me).

• Improving Communication Skills:

• Teaching communicating skills such as assertion.
Case example
• 41 year old married woman, educated upto Diploma Nursing, house wife
reported with sadness of mood, crying spell, anger outburst, decreased
interest and not able carry out day today activities
• She was born in a normal family, had four sibling. She was sent to an
convent for education even though she wanted to stay back with family
and didn’t like staying away. She completed diploma in nursing but
couldn’t take up any job.
• She got married to a person who is 10 year older to her. The husband
had some business and stayed away from her most of the time. Husband
was less emotional and less caring.
• Make the conceptualization.
Supportive
Psychotherapy
 a form of long-term psychotherapy that aims to optimise
patients’ functioning, promote their autonomy, enhance
psychotherapy their self-esteem, and lessen their anxiety and distress.

Unlike other forms of therapy, supportive psychotherapy

does not aim to produce major change in the person.
Supportive

While behavioural treatments aim to alter the way people

act, cognitive therapy the way people think, and dynamic
therapy the patterns of their defences, supportive
psychotherapy aims not to change, but rather to strengthen
their existing coping mechanisms.
 Knight (1954) describes it as a “superficial
psychotherapy” that utilizes inspiration,
reassurance, suggestion, persuasion, counselling,
re-education and other techniques for patients
who are too psychological fragile, inflexible or
defensive for exploratory devices.
Definitions

Bloch (1979) Stresses sustenance and

maintenance rather than suppression and
repression as the focus of supportive
psychotherapy.
 • To bring the patient to an emotional equilibrium
• ´ Amelioration of symptoms, so that the patient can
function at approximately his or her norm.
• ´ To strengthen existing defences.
• ´ To elaborate better “mechanisms of control
• ´ To remove or to reduce detrimental external factors that
Objectives act as sources of stress.
• ´ There is no intent to change personality structure.
• ´ supportive therapy attempts the achievement of symptom
relief or symptom removal.
Assessment
 Praise

• Praise may be reinforcement of accomplishments or of more adaptive

behaviours, provided that the patient is likely to agree that praise is
deserved.

Reassurance.

• reassurance is based on an understanding of his or her unique situation.

Reassurance that is given before the patient has detailed his or her concerns
is likely to be doubted.

Encouragement.
Techniques • Encouragement too has a major role in general medicine and rehabilitation.
Encouragement is powerful because people want to believe that their
efforts will lead to something. The other meaning is “to give hope.”

Rationalizing and Reframing.

• Reframing involves looking at something in a different light or from a

different perspective. The challenge in using rationalizing and reframing is to
avoid sounding fatuous and to avoid what may appear to be argument or
contradiction. Reframing should provide a welcome new way of looking at
thigs.
Advice and Teaching.
• Advice is an important tactic of supportive psychotherapy.
Advice is meaningful when the patient sees it as pertinent to
his or her needs

Anticipatory Guidance.
• Rehearsal, or anticipatory guidance, is a technique as useful in
supportive psychotherapy as in cognitive-behavioural therapy.
The objective is to consider in advance what obstacles there
might be to a proposed course of action, and then to prepare
strategies for dealing with them.

Reducing and preventing anxiety.

• The supportive psychotherapist intends not only to deal with
overt anxiety, a symptom, but to prevent emergence of
anxiety. the therapist shares his or her agenda with the
patient, making clear the reason for questions or topics. .
Naming the problem.

• The patient’s sense of control may be enhanced, and thus anxiety minimized, by
naming problems. Naming the problem is also meeting the familiar medical
responsibility of explaining the diagnosis, prognosis, and proposed treatment
• Expanding the patient ‘s awareness.

Clarification: is summarizing, paraphrasing, or organizing what

the patient has said.

Confrontation: as bringing to the patient’s attention a pattern of

behaviour, ideas, or feelings he or she has not recognized or has
avoided.

Interpretation: “the meaning of the patient’s thoughts or the

intent of his behaviour
  Cover the mechanics – Discus time, cost, flexibility and
availability. Determine frequency of sessions, trial vs fixed
plan, fixed vs variable duration, discuss treatment
contracts and contingent arrangements.
 Listen to the patients – personally, professionally
Phases :  Develop your own impression
Initiating  React and adjust to the patient’s style of communication
therapy  Generate and convey empathy
 Explore surface issues
 Develop and individualize goals
 Correct early problems
 Generate and expectation of realistic gains.
 The middle course of therapy
• A common question in this place is “Are we making
progress? in supportive therapy. Progress is measured by
the patients. Patients learn in SPT if often not expressed in
words but is shown in behaviour. Trying for make gradually
achieves competence in more demanding settings. If one
concludes the progress is less than expected, one may wish
to explore.
 Termination and transfer to future care
• Therapy may be terminated unilaterally by the patient or
therapist, or by mutual agreement. The therapist may
consider the therapy to be successfully complete,
progressing or stalemated However, unresolved
dependency by the patient or continuing wish for nurturing
on the therapist part may prolong the therapy.
Patients’ selection for long term SPT

Chronically deficient or Chronic stress from

Low capacity for Poor social support, Poor
acutely weakened coping A history of acting out environment family or
introspection, object relations,
skills illness,

Strong dependency Lack of motivation for

Poor impulse control, Poor reality testing, Primitive defenses,
needs, treatment,

Cognitive disorganization
A tendency to somatize
Inability to contain or or impairment (short
or an inability to speak of
tolerate affect, term memory should be
emotions (alexithymia)
intact),
  Previously or usually strong coping skills
 An acute crisis requiring temporary intervention
 A sense of internal conflict

Patients’  Good object relations

 Good impulse control
selection for  Good reality testing
short term  Intact cognitive abilities

SPT  The ability to obtain symptom relief through understanding

 The ability to contain or tolerate affect
 Motivation for treatment
 Mature defense
 Psychological mindedness
 The ability to identify and speak of emotions
 Good social support or temporarily disrupted social support
Exclusion criteria for SPT:

• Better suited for another form of treatment.

• (In crisis, but effectively utilizing social supports, not in crisis and able to afford and benefit, Primary problem
of antisocial therapy, Primary problem social or family related).

• Unable to benefit.

• (Not requiring therapy of any modality, dangerously hostile to treatment or therapist, Significant cognitive or
memory impairment. Severe mental retardation, Malingering Factious illness, failed to benefit or worsened
in previous SPT

• Unable to engage in treatment.

• (Treatment simply not wanted, Total denial of illness)

Skills
 First level : communication

• Managing the transference, talking and listening , generating and conveying empathy, Reassuring, Observing,
Expressing interest and concern , Echoing, Tracking, Commenting, Restating, Eliciting current life
reports ,Encouraging ventilation and expression of affect

 Second level : Confrontation

• Directing attention to inconsistencies in behavior

• Directing attention to conflicting goals and motivation

 Third level: Explanation, clarification, and interpretation

• Clarification (of information available to the patient but which he /she is not aware )

• Explanation (of mechanisms responsible for patient’s behavior)

• Interpretation – Defenses, Inexact, displaced, universalized, generalized

Stages in Family Management:

• Assess family,Build alliance,Establish partnership, not expert role Use a

Denial stage tentative diagnosis

Acceptance and • Educate the family about the diseases process, Reduce overinvolvement with
adjustment to loss and criticism of patient, Distinguish salutary neglect from limit setting
stage

Long term coping and • Develop the family’s advocacy role for the patient, Return the family to
maximized functioning, Enable family to identify warning signs and
stabilized functioning prodromal symptoms of relapse ,Identify dysfunctional family roles, Support
stage family caregiving role and prevent burnout.