COUN A221F Lecture 6 CBTI Cognitive therapy_Done.pdf

LECTURE 6 COGNITIVE BEHAVIORAL THERAPY I: COGNITIVE THERAPY COUN A221F Theories and Practice in Counselling and Mental Health Hong Kong Metropolitan University LEARNING OUTCOMES ◼Identify the framework, stages, and challenges of cognitive behavioral therapy ◼Understand and apply the steps of case...

LECTURE 6 COGNITIVE BEHAVIORAL THERAPY I: COGNITIVE THERAPY COUN A221F Theories and Practice in Counselling and Mental Health Hong Kong Metropolitan University LEARNING OUTCOMES ◼Identify the framework, stages, and challenges of cognitive behavioral therapy ◼Understand and apply the steps of case formulation ◼Recognize the concepts of cognitive therapy, including cognitive schema, intermediate belief, and automatic thoughts ◼Apply the cognitive distortion in daily lives ◼Describe and apply cognitive therapeutic techniques DEVELOPMENT OF COGNITIVE BEHAVIOURAL THERAPY ◼Evidence-based medicine ◼Evidence-based psychotherapy ◼In the 1990s, there was a movement toward the identification of empirically supported treatments (Chambless & Ollendick, 2001). ◼Mental health disciplines within North America have endorsed the need for training and practice in empirically supported therapies. DEVELOPMENT OF COGNITIVE BEHAVIOURAL THERAPY ◼Some health care systems, such as United Kingdom, have been recommending a “stepped approach” whereby minimal interventions are used for mild problems. ◼If there is an evidence-based, manualized treatment for a particular problem, and a client with that same problem, then the clinician should closely follow to the manual and forgo his or her clinical judgment. INTRODUCTION TO COGNITIVE BEHAVIORAL THERAPY ◼CBT is a psychological treatment that addresses the interactions between how we think, feel and behave. It is usually time-limited (approximately 10-20 sessions, 10 – 30 – 10 rule for the minutes allocated for each 50 – minutes session), focuses on current problems and follows a structured style of intervention. ◼The development and administration of CBT have been closely guided by research. ◼CBT is a process of teaching, coaching, and reinforcing positive behaviors. CBT helps people to identify cognitive patterns or thoughts and emotions that are linked with behaviors. EXERCISE: IDENTIFY SITUATIONS, THOUGHTS, FEELINGS, PHYSICAL REACTIONS, AND BEHAVIOR Example Staying up late and studying No matter what I do, no one likes me. I feel tense all over. Even if I study hard, I will still fail. I am so happy. My boss hates my work. I am late for work. Situation, Thought, Feeling, Physical Reaction, or Behavior? COLLABORATIVE EMPIRICISM ◼Transparency about the therapy and the therapeutic process. ◼Clients are actively involved in planning the interventions, and they do all of the work involved outside of the session. ◼The client participates as a researcher, gathering data from behavioral experiments, thought records, or interpersonal practice assignments. ◼The results are analyzed when client comes back for next session to discuss outcomes and plan next strategy. STAGES OF COGNITIVE BEHAVIOURAL THERAPY Assessment Psychoeducation Cognitive restructuring Clinical case formulation Client monitoring behaviors and emotions Relapse prevention, maintenance, and ending therapy Feedback to client and reformulation Behavioral interventions Goal setting Client monitoring cognitions 1. ASSESSMENT ◼Good case conceptualization and treatment planning rest on a foundation of valid and appropriate assessment. ◼Collaborative interview ◼Self-rating scales (e.g., BDI, BAI) COGNITIVE SELF-MONITORING (THOUGHT RECORD) ◼Systematic self-observation and recording of the occurrences of specific behaviors and events ◼Date and time of emotional response ◼Situation that elicited emotional response ◼Behaviors the client engaged in ◼Emotions that were elicited ◼The associated thoughts that occurred during situation ◼Any other related responses 1. ASSESSMENT ◼Current coping and approach-avoidance patterns ◼Being overly passive or conflict avoidance when anxious ◼Withdrawing from people when depressed ◼Avoiding challenging situations ◼Avoidance of negative emotions ◼Avoidance of excitement ◼Minimizing stimulation ◼Compulsively checking circumstances ◼Skills deficits, lack of knowledge 1. ASSESSMENT ◼Current social support, family concerns, or interpersonal or sexual problems ◼Other current problems: suicide risk, poor living arrangement, psychological abuse, domestic abuse, alcohol and drug use ◼Development and timeline of problems ◼History of treatment 2. CASE FORMULATION ◼Case formulation (case conceptualization) is the bridge from assessment to treatment. ◼It is “ a hypothesis about the nature of the psychological difficulty underlying the problems on the patient’s problem list” (Persons, 1989). ◼It is the way in which assessment leads to intervention, incorporating theoretical principles of approach into practice (Eells, 1997). ◼It also guide the timing and sequencing of interventions and predict difficulties with implementing therapy. STEPS IN CASE FORMULATION ◼Developing the problem list ◼Intervention at the problem level, rather than at diagnostic level, is the major purpose of CBT. ◼One of the strategies is to consider the inclusion of one or two problems that lead directly to a quick and effective intervention. Early success in therapy helps to engage the client in therapy process. ◼Why are you seeking help at this particular time? ◼Please describe the problems that bring you today. ◼How much control do you have over this problem? EXAMPLE ◼How have you been sleeping and eating recently? ◼How would you describe yourself as a person? ◼What purpose does this behavior serve for you? ◼What treatments have you had in the past? ◼What have you already tried to manage your problem? How did that work for you? STEPS IN CASE FORMULATION ◼Developing the initial case formulation ◼Chart that describes the interaction among life events, core beliefs and current thoughts, emotions, and behaviors. ◼Hypothesis seeks to explain the reasons why this person developed these problems at this point of time and changes among factors over time. ◼Obstacles also need to be identified both to minimize their negative impact on therapy and to develop possible solutions to them. STEPS IN CASE FORMULATION ◼Communicating the case formulation and assessment results ◼Consider using quotes from what client has already told you during assessment, particularly in relation to the client’s core beliefs. ◼Ask client to verify occasionally. 3. TREATMENT PLANNING, GOAL SETTING, AND THERAPEUTIC CONTRACT ◼It crucial for client be involved in, and committed to, both goal setting and the process of work toward his or her goals. ◼Formal contracts are defined as explicit agreements between all involved parties that outline the responsibilities for everyone: ◼Improve adherence and motivation ◼Clear intentions and goals for change ◼Less therapist input and more input on part of client 3. TREATMENT PLANNING, GOAL SETTING, AND THERAPEUTIC CONTRACT ◼Establish concrete criteria for knowing that this goal is being met ◼Goal attainment scaling is most useful when you set some achievable behavioral goals ◼Goals can be divided into affective, behavioral, cognitive, and interpersonal. 4. PSYCHOEDUCATION Teaching relevant psychological principles and knowledge to client Self-help manuals Websites Workbooks 5. COMPLETION AND PREVENTION OF RELAPSE ◼Remission: either full or partial improvement of symptoms, to the degree that diagnostic criteria are no longer met. ◼Recovery: remission lasting more than a prespecified period (e.g., 6 months). ◼Lapse: short term, temporary recurrence of symptoms or problem behavior. ◼Relapse: recurrence of symptoms or problem behavior following remission, to the degree that diagnostic criteria are met. 5. COMPLETION AND PREVENTION OF RELAPSE ▪Recurrence: occurrence of symptoms or problem behavior following recovery, including the presence of a new episode of a diagnosable problem. ▪Dependence: indication of client’s inability to form healthy relationships outside of therapy. COGNITIVE THERAPY THINKING AND PERCEPTION AARON BECK ◼Aaron Temkin Beck (born July 18, 1921) is an American psychiatrist. ◼He is widely regarded as the father of cognitive therapy. ◼His theories are widely used in the treatment of clinical depression. ◼Beck also developed self-report measures of depression and anxiety including Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). COLLABORATIVE EMPIRICISM ◼Beck is not interested in convincing clients of their irrational beliefs. Instead, he uses a style he refers to as collaborative empiricism – he works together with clients to help them discover for themselves the maladaptive nature of their automatic thoughts. ◼This approach requires therapist to work within client’s frame of reference, trying to see world through client’s eyes. CHARACTERISTICS OF BECK’S THEORY ◼Individuals are exposed to a variety of specific life events or situations, some of which trigger automatic, maladaptive thoughts. ◼Maladaptive thoughts are characterized by too narrow, too broad, too extreme, or simple inaccurate. ◼Maladaptive thoughts are usually derived from deeply held maladaptive core beliefs or schemas. ◼Individual acquire these core beliefs during childhood. 01 02 03 04 05 06 Childhood Experience Core Belief/ Schema Intermediate beliefs Situation Automatic Thoughts Emotion and Behaviours CONCEPTS OF COGNITIVE THERAPY CORE BELIEFS AND SCHEMAS ◼Relatively permanent notions about objects, people, or concepts, and the relationships among them. ◼“Schema concept refers to cognitive structures of organized prior knowledge, abstracted from experience with specific instances; schemas guide the processing of new information and the retrieval of stored information” (Kovacs & Beck, 1978). CORE BELIEFS AND SCHEMAS ◼As in psychoanalytic theory, the notion of cognitive schemas suggests the power of unconscious processes in influencing thought, affect, and behavior. ◼However, unlike the psychodynamic unconscious, schemas exert their influence through unconscious information processing, rather than through unconscious motivation and instinctual drives. HOW CORE BELIEFS INFLUENCE THOUGHTS About self: I am smart, I am lovable, I am selfish, I am incompetent, I am unlovable. About others: Others are kind, others will take care of me, others are mean, others will take advantage of me. About the world: The world is just, the world is stable, the world is dangerous, the world is unjust. INTERMEDIATE BELIEFS (CONDITIONAL ASSUMPTIONS) ◼Beliefs at an intermediate level (intermediate beliefs or conditional assumptions) are in the form of "if. . . then" rules. ◼“If I do whatever people want, then they will like me.” ◼“If I trust others, I'll get hurt.” ◼“Unless I am perfect, I will fail.” ◼“If I yell, then people will listen to me.” ◼“If people see the real me, then they will reject me.” AUTOMATIC THOUGHTS ◼Automatic thoughts are moment-to-moment cognitions that occur without effort, or spontaneously, in response to specific situations. ◼They are significant in that they are tightly linked to both the individual's mood and his or her behavioral responses to situations. ◼"I'm going to fail this test," ◼"She thinks I'm really boring," ◼"Now I'll never get a job." ▪ For AUTOMATIC THOUGHTS example, anxiety is based on anticipating problems as threat and danger in the future: ▪ “I will die” ▪ “I will lose my job” ▪ “My partner will leave me” ▪ “I will make a fool of myself.” NEGATIVE AUTOMATIC THOUGHTS ◼Negative automatic thoughts (ATs) are the observable, products of errors in processing through which perceptions and interpretations of experience are distorted. ◼Errors in processing include an emphasis on the negative aspects of life events, a preoccupation with the possible adverse meanings of events, and self-attribution and self-blame for problems across all situations. ◼Examples include: ◼“My life is meaningless” ◼“Nobody cares about me” EXAMPLE Situation: At lunch with classmates Automatic thought:“They are much smarter than I am, I am a failure.” Emotion: Sad EXAMPLE Situation: Thinking hanging out with friends Automatic thought: “They won’t want to hang out with me.” Emotion: Sad Behavior: Stay at home EXAMPLE: DIFFERENT PEOPLE HAVE DIFFERENT THOUGHTS EXAMPLE: CARE BELIEFS AFFECT THINKING IN DIFFERENT SCENARIOS Core Belief “I am incompetent” Intermediate Beliefs “If I try to do something difficult, I will fail” “If I avoid doing it, I will be ok.” Automatic Thought “I’ll never master this.” “This is just too hard.” Situation “Reading a new test” Reaction Emotional: Discouragement Behavioral: Avoid task Physiological: Heaviness in body EXAMPLE ▪你 經歷了 惡劣的 一 天，感到受夠了， 因此出外購物。 ▪在 路上， 一個你 認 識的人經過，好像 不理會你的樣子。 EXERCISE COMMON COGNITIVE DISTORTIONS (BECK, 1995) ◼All-or-nothing thinking (or “black and white” thinking) ◼We must be perfect or we’re a failure — there is no middle ground. You place people or situations in “either/or” categories, with no shades of gray or allowing for the complexity of most people and situations. If your performance falls short of perfect, you see yourself as a total failure. ◼“If I cannot get 100 marks, I am a failure.” ◼Catastrophizing ◼Predicting disaster in future and ignoring a possible positive future. ◼“I will be so upset; I won’t be able to function at all.” COMMON COGNITIVE DISTORTIONS (BECK, 1995) ◼Disqualifying the positive ◼Not attending to, or giving due weight to, positive information. ◼“I did that project well, but it is only because I got lucky.” ◼Overgeneralization ◼We come to a general conclusion based on a single incident or a single piece of evidence. If something bad happens only once, we expect it to happen repeatedly. ◼[Argued with Peter last night] “I do not have any friends” COMMON COGNITIVE DISTORTIONS (BECK, 1995) ◼Personalization ◼Thinking that you cause negative things, rather than examining other causes. ◼“Mary feel uncomfortable because I did something wrong.” ◼Emotional reasoning ◼Arguing that because something feels bad, it must be bad. ◼A feeling of knowing, a sense that something `feels right'. For example, a sense of `certainty' that something bad is going to happen will lead to anxiety; and people with obsessive checking rituals may need to repeat them until it `feels right'. ◼“I know I do a lot of things okay at work, but I still feel like I am a failure.” COMMON COGNITIVE DISTORTIONS (BECK, 1995) ◼Mind reading ◼Predicting or believing you know what other people think. ◼“He thinks that I am so stupid and do not know anything about the project.” ◼Labelling ◼Putting a general label on someone or something, rather than describing the behaviors or aspects of the thing. ◼“I am a loser.” ◼Fortune telling ◼Predicting the future with limited evidence. ◼“I must fail the exam tomorrow.” COGNITIVE DISTORTION CYCLE VIDEO SHARING ▪ Role Play: Cognitive Behaviour Therapy ▪ https://www.youtube.com/watch?v=x7HJmVx3qN4 ▪ 認知行為治療 (1) - 概念簡介(臨床心理學家陳雅文) ▪ https://www.youtube.com/watch?v=hyYX8XtM-0c ▪ 認知行為治療 (2) - 應用示範 (臨床心理學家陳雅文) ▪ https://www.youtube.com/watch?v=QlNUuXmi4D0&t=340s ▪ Case study clinical example CBT: First session with a client with symptoms of depression ▪ https://www.youtube.com/watch?v=7LD8iC4NqXM THERAPEUTIC TECHNIQUES ◼Examine the evidence related to negative thoughts ◼Identifying unrealistic expectations ◼Worse case outcome, best possible outcome, and most realistic outcome ◼Examine attribution biases ◼Depression is related to make internal, stable, and global attributions for failures, but external, unstable, and specific attributions for success. ◼Anger problems tend to make external, stable, and global attributions for negative outcomes. Reattributing causes using pie charts Change labeling THERAPEUTIC TECHNIQUES Changing dichotomous thinking into graduate thinking Generate and alternative thoughts evaluate Cultivating positive thoughts / reframing QUESTIONING TECHNIQUES Awareness of automatic thoughts and core beliefs Evaluation of usefulness and accuracy of automatic thoughts and core beliefs Possible strategies for modifying automatic thoughts and core beliefs What is the evidence that x is true? What is the evidence against x being true? What might be the worst that could happen? And if that happened, what then? EXAMPLES What leads you to think that might happen? How does thinking that make you feel? How would that work in your body? Is there any other way of seeing the situation? What might you tell a friend to do in this situation? Is there something else you could say to yourself that might be more helpful? INTERVENTION FOR NEGATIVE THINKING 01 02 03 What is the evidence for and against this thought? What are the alternative ways to think in this situation? What are the implications of thinking this way? EXAMPLE: ANXIETY Client’s avoidance in action Client's Need for Reassurance AVOIDANCE IN ACTION ▪ Avoidance can lead clients to want to stop counselling as soon as they feel somewhat better, rather than going on to look at what is underlying their fears. AVOIDANCE IN ACTION ▪ One way of identifying when there is avoidance in action is if the sessions start feeling dry, dull and intellectual, when the client is describing upsetting or difficult material in an emotionless or flat way. ▪ If I begin to talk about it, I'll get so upset that I'll have to go to bed for ever. ▪ Talking about it will make me so anxious that I'll explode. ▪ Being anxious means that I cannot cope with anything. ▪ It is easier to bottle up the past than let it go, since the anxiety will kill me. AVOIDANCE IN ACTION ▪ It is important to try to raise the emotional temperature, by reflecting the unspoken feelings behind the words: ▪ “When you thought you were going to die, that sounds terrifying” ▪ “Having to check so many times is so upsetting.” ▪ Reflecting the actual words the client is using, along with appropriate affect, or saying how such events would make you feel: ▪ “I don't know how you coped, I would have wanted to cry, I'd feel so upset.” NEED FOR REASSURANCE ▪ The client who worries about everything frequently needs to be reassured that their worries will not at all costs come true. ▪ He therefore frequently asks friends and family for reassurance that bad things will not happen and, if they do happen, support will be at hand. ▪ Gaining reassurance means that the responsibility for making decisions is passed on to someone else. NEED FOR REASSURANCE ▪ The degree of need for reassurance influences the therapist to pull back from facilitating the client to take necessary risks in confronting fears. ▪ This can result in clients not gaining in confidence and independence and getting stuck in cycles of worsening anxiety. IDENTIFYING ANXIOUS THOUGHTS Key steps in identifying anxious thoughts • Pick a concrete example • Ask about feelings • “And when you felt that, what went through your mind?' • Aim to identify specific thoughts. • Turn questions into statements, e.g., `What do other people think?' becomes • `They think I'm really stupid'. `What if X should happen?' becomes `If X happens, it would be a complete disaster.' IDENTIFYING ANXIOUS THOUGHTS ▪ It is important to elicit specific thoughts, in statements rather than questions. ▪ For example, when the client reports the thought `What if I couldn't cope?', ▪ Rephrase it as `If I didn't cope, it would be a complete disaster and I'd make a real fool of myself', thereby eliciting more emotion. EXAMPLE: DEPRESSION ◼Negative evaluation of self: “I am unworthy” ◼Negative evaluation of world or specific events: “everything is just more evidence that the world is falling apart” ◼Negative evaluation of future: “nothing will ever get better” EXAMPLE: DEPRESSION Avoidant attached individual • Self is loneliness • Others are unwilling to provide comfort Anxiously attached • Self is helpless individual • Others are unpredictable Disorganized • Both self and other are unavailable attached individual REFERENCES ◼ Archer, J., & McCarthy, C. J. (2007). Theories of Counseling and Psychotherapy: Contemporary Applications.Upper Saddle River, NJ: Merrill Prentice Hall. ◼ Corey , G (2008). Theory and Practice of Counseling and Psychotherapy, Thomson Learning. ◼ Deborah, D., & Keith, S. D. (2009). Evidence-based Practice of Cognitive Behavioral Therapy.US: Guilford Press. ◼ Mcleod, J. (2003) An Introduction to Counselling.(3rd ed.). Open University Press. ◼ Raymond, J. C., & Danny, W. (2005). Current Psychotherapies. (7th ed.). Thomson Brooks / Cole. ANSWER Example Situation, Thought, Feeling, Physical Reaction, or Behavior? Staying up late and studying Situation No matter what I do, no one likes me. Thought I feel tense all over. Physical reaction Even if I study hard, I will still fail. Thought I am so happy. Feeling My boss hates my work. Thought I am late for work. Situation