CBT 1 (Development of CBT ( Albert Bandura (1969) Principles of behaviour…
Cognitive Behaviour Therapy
- “Cognitive behaviour therapy (CBT) describes a number of therapies that all have a similar approach to solving problems - these can range from sleeping difficulties or relationship problems, to drug and alcohol abuse or anxiety and depression. CBT works by changing people's attitudes and their behaviour.”
- The focus is often on the relationship between a person’s thoughts, feelings, physical sensations and their behaviour.
- “CBT is a form of psychotherapy which combines cognitive and behavioural therapy. Cognitive therapy looks at how our thoughts can create our feelings and mood. Behavioural therapy pays close attention to the relationship between our problems, our behaviour and our thoughts.” (MIND, 2010)
Components of CBT
- Collaboration/Therapeutic Relationship (.non-judgemental, empathic, trustworthy, expert, positive reinforcing, normalising problem, calming, transparency, being genuine, allows exploration, being able to provide psychological explanations, don’t disregard the patients formulation/hypothesis straight away, help to normalise, able to give and elicit feedback, being able to summarise, encouraging self-reflection, guiding a patient to discover...)
- Structure and Active Engagement
- Time-limited and brief
- Empirical – involves evaluation of effectiveness
- Problem-oriented approach
- Uses variety of techniques to change thinking, mood, & behaviour (e.g., cognitive and behavioural techniques)
- Direct challenging of negative automatic thoughts (evidence for versus evidence against).
- Graded exposure
- Activity schedules
- Behavioural experiments
- Third person perspective (getting the patient into someone else’s shows and getting them to help and advice themselves)
- Mindfulness/awareness without judgement
- Responsibility pie; The prejudice model; Schema flash cards; Continuums; Imagery interventions; Metaphor; Positive data logs Unpacking meaning; Therapy blueprint
Formulating using a cognitive-behavioural framework
- How could your formulation lead on to intervention
- What possible intervention points does your formulation highlight?
Eliciting meaning – assumptions, rules and beliefs
- Downward arrow
- Start with an A-C event i.e. an event when an Activating event (A) was associated with an emotional Consequence (C)
- What was the first automatic thoughts you can identify (the B in the A-B-C sequence)
- Ask – What does that mean to you? If that were true what would that mean to you?, What is it about that, that, that upsets you?
- Follow the line of questioning until it feels like you have reached the bottom line i.e. the assumptions or core beliefs that fuel the negative automatic thoughts
- Core beliefs can be recognised by their general nature and are usually in the form of an absolute assertion – I am worthless.
- BE CAREFUL about doing this too early in the overall process as you can elicit distressing beliefs too quickly and have little support to draw upon to help the client manage – can make them feel very exposed and vulnerable. At assessment use it to elaborate meaning at a Dysfunctional Assumption Level rather than trying to access core beliefs
Considering alternatives: useful questionsEvidence
- What is the evidence / reason for thinking this?
- What is the evidence against this?
- What’s the effect of thinking this way?
- What would a good friend say to you?
- What would you say to a good friend in this situation?
- What do you think when you’re feeling …?
- Are you jumping to conclusions?
- Are you concentrating on your weaknesses and losing sight of your strengths?
- Are you expecting yourself to be perfect?
- Are you thinking in all or nothing terms?
What to ask? J Beck
- ‘Gentle persistence’
- What was going through your mind?
- What were you thinking?
- What were you imagining / predicting / remembering?
- What did the situation mean to you / say about you?
- What was the worst part of it for you / what’s the worst that could happen?
- Leading questions:
- If I was in that situation I might think …
- Some people say that they have thoughts like…
What are automatic thoughts & images in depression?
- Automatic – autonomous, involuntary
- Usually momentary, rapid, fleeting
- Maybe verbal, visual, memories
- Idiosyncratic content but focus on theme of loss
- Situation specific but linked to private meaning and underlying cognition
- So – often habitual and repetitive
- Triggers may be overt or covert (internal or external)
Why focus on thoughts & images?
- Aim of CBT is to support the person
- Understand what’s maintaining his / her problems
- Effect change in distress and disability, if they choose to do so
- Aim is not to change thoughts
- Cognition is central to the maintenance of depression
- Relatively accessible and open to re-evaluation
- Re-evaluation of thought effects change in distress and disability
The ABCs of Irrational Beliefs
- A major aid in cognitive therapy is what Albert Ellis (1913-2007) called the ABC Technique of Irrational Beliefs.
- A - Activating Event or objective situation - an event that ultimately leads to some type of high emotional response or negative dysfunctional thinking.
- B - Beliefs indicates the clients’ negative thoughts that occurred to him or her
- C – Consequence (s) indicates the negative disturbed feelings and dysfunctional behaviours that ensued. (emotional and behavioural consequences)
- Reframing. After irrational beliefs have been identified, the therapist will often work with the client in challenging the negative thoughts on the basis of evidence from the client's experience by reframing it, meaning to re-interpret it in a more realistic light. This helps the client to develop more rational beliefs and healthy coping strategies.
Typical cognitive biases
- All or nothing / dichotomous thinking
- Seeing thinks in black and white categories, missing the grey
- e.g. “If he leaves me I may as well be dead”; “If I don’t do it perfectly, there’s no point doing it at all”
- Seeing a single negative event as an indication of everything always being negative
- e.g. “I’ve failed this exam. I’ll never pass another one”; “I never get anything right”
- Selective abstraction (mental crusher/sieve and sponge metaphors)
- Picking out one or two features and ignoring others (generally features noticed are those consistent with mood)
- e.g. “I didn’t have a moment’s pleasure today”; “OK so I got my work done today, so what. It’s only what’s expected of me”
- Arbitrary inference
- Jumping to conclusions on basis of inadequate evidence
- Exaggerating importance of negative events and underestimating importance of positive events
- e.g. “I made a real fool of myself at that party. I’ll never be able to face them”
- Attributing bad things to the self despite evidence to the contrary
- e.g. “Why does it always rain on the day I decide to go to Wimbledon?”
- Emotional reasoning
- Assuming what you feel must be true
- e.g. “I feel guilty so I must have done something wrong”
- Condemning oneself as a total persona on the basis of a single event
- e.g. “I was so irritable with the children this morning. I’m a
Socialising to Cognitive modelAim:
- To enhance understanding of problems using a cognitive framework
- Suitable for use in a wide range of emotional problems in primary care including Depression, Anxiety, and psychotic disorders.
- Specific and focused and easy to apply
- Encourages collaboration and patients taking responsibility of their recovery
Cognitive Behaviour Therapy
- Cognitive techniques (such as challenging negative thoughts) and behavioural techniques (such as exposure therapy that gradually desensitizes the client to their phobia and relaxation techniques) are used to relieve symptoms of anxiety and depression
by changing irrational thoughts, beliefs and behaviour.
- Contemporary CBT – places more emphasis on process
- How one relates to thoughts, feelings, physiology & behaviours
- Beck’s (1976) cognitive theory of depression has 3 components. Depressed people seem to:
- Have negative automatic thoughts that seem to come out of the blue. Cognitive triad of negative views about self (e.g. I can’t even knock a nail in); the world (this neighbourhood is a terrible place); and the future (I can’t see that this will ever change)
- Show systematic biases in their thinking processes
- Hold longstanding depressogenic schemas. A schema is an attitude or assumption. When this gets triggered, it’s used for filtering information, e.g. I’m a failure (and this person only seems to notice things that confirm this view)
- The 4th construct was proposed by Judith Beck – dysfunctional assumptions/rules for living
Development of CBT
- Albert Bandura (1969) Principles of behaviour modification: consideration of thought processes and experience on behaviour within the conceptual framework of social learning
- Arnold Lazarus (1972) Need for cognitive restructuring: “the correction of misconceptions”
- Albert Ellis (1973) Rational-Emotive Psychotherapy: links activating event (A) to emotional/behavioural consequences (C) by the intervening belief
A = Activating event; B = beliefs; C = emotional consequence
- Aaron Beck (1976) Cognitive model of depression Therapists helps the patient identify unhelpful thinking (he believed that e.g. depression being the result of negative thought content but occurring outside of awareness)
Classical Conditioning (associative learning)
Operant Conditioning (consequences)
- Ivan Pavlov (1972) – Dogs
- John Watson – White Rats
- Edwards Thorndike (1905) – Cats (believed: behaviours change because of its consequences)
- B. F. Skinner (1938)
- Applied Behaviour Analysis, functional behavioural assessment
- Reinforcement (increasing the likelihood of a behaviour being repeated – can be positive or negative), punishment (decrease the likelihood of a behaviour being repeated) and extinction
- Epictetus 4th century philosopher (ca. 50-ca.135)
- “We are disturbed not by events, but by the views we take of them”
- Socrates (469-399BC)
- Socratic dialogue involves asking questions to extend thought
- Alder (1919)
- “it is the meaning that we attach to events that determines behaviour”
- Kelly (1940) Social Learning Theory
- Cognitive concepts such as personal constructs and assumptions
- “What you think you become”