Cheryl Jordan Lecturer KCL.

► ► What is your current understanding/training/experience with CBT? ► What do you see as being a key concept in CBT practice?

 Introduction to concepts, theories and models underpinning CBT practice  Assessment and formulation within CBT practice  The course of therapy  Overview of cognitive behavioural techniques  The therapeutic relationship in CBT

“Man is not affected by events but by the views he takes of them” ( Epictetus) “There is nothing good or bad but thinking makes it so” ( Hamlet, Shakespeare)

 Interacting systems

 Cognitive principle Emotional reactions are strongly influenced by cognitions

Behavioural principle What we do is crucial in maintaining or in changing psychological states

Fear of a particular situation /object Escape/avoidance No change to fear beliefs Client does not learn coping Strategies or expose beliefs to disconfirmation

Depression Negative thoughts ( activity is seen as pointless) Reduced activity Loss of positive rewards

The continuum principle Emotional problems arise from exaggerated versions of Normal process

 Here and now Focus on what’s happening in the present and what processes are maintaining it.

 Characteristic cognitions in different problems  Depression: themes of loss and failure  Anxiety: themes of threat and danger  Anger ?

Cognitive consequences Behaviour ( action Tendencies) Un/healthy negative emotion Overestimates Extent to which other person acted Deliberately. See’s malicious intent in action of other Self right other wrong Unable to see others point of view Plots to exact revenge Hit, shout, sulk, Recruits allies against others Seek revenge Anger

Cognitive consequences Behaviour ( action Tendencies) Un/healthy negative emotion Avoid, Denigrate the object/person Destroy object/person Envy Its unfair that they have it and I do not. It means I am not as good as them. Critical of them or object, pretend its not what I want. Give up. They don’t deserve it.

 Albert Ellis   considered as the second most influential psychotherapist in history ( USA,Canada) Carl RogersCarl Rogers ranked first Sigmund FreudSigmund Freud was ranked third

A Activating event Rational belief Flexible Self/other accepting High frustration tolerance Irrational Belief Rigid Self/other downing Low frustration tolerance Consequences healthy negative emotion helpful behaviour Adaptive Cognitions Consequences Unhealthy negative emotions Unhelpful behaviour Biased cognitions

A Rational belief I prefer to pass but it is possible I may not, if I do it proves I am a fallible Human and I can tolerate it Irrational Belief I want to pass therefore this must happen, If i don’t it’s Proof I am a total failure I can’t stand it Consequences concerned Focus on task at hand Giving it my best Consequences anxiety Procrastinate I going to fail, I’ ll never cope Completing assignment

 Please read the chapter  Fit the information given into the ABC model

A No current partner Rational belief I would prefer to be in a relationship, I can accept myself if i am not. Irrational Belief I want to be in a relationship, therefore I absolutely should be. The fact I am not is proof I am defective. Consequences Sad Seek out reinforcements Consequences Depression no one wants me There is something wrong with me Think about past failed relationships withdraw

 Watch the clip  Keep the ABC model in mind, see if you can identify the problem......

Cognitive consequences Behaviour ( action Tendencies) Un/healthy negative emotion

 Trained as a psychoanalytic analyst at the Philadelphia Psychoanalytic Institute. (1921-….)

Early Experience Core Beliefs Rules and Assumptions Critical Incident Emotionthinking Behaviour physiology Self, world, others If ……. Then…….. I must………

Early Experience Core Beliefs Rules and Assumptions Critical Incident Emotionthinking Behaviour Somatics I am defective If I am in a relationship then.... in a relationship if I am not then it proves I am ………… Relationship not working out Seeing others in relationships depression What am I doing wrong Think about past Relationships, no one wants me. Withdraw ruminates Low energy

Core Schema Assumptions Negative automatic thoughts

Informational Processing Styles

Trigger: critical incident Thoughts Mood Behaviour Physical

 Consider what you think about the basic principles of CBT. Do they make sense to you?  What do you think of the theory underpinning CBT? does it make sense ? Does it fit with your experience?

1) Therapeutic relationship: engage and facilitate collaborative working process 2) Comprehensive assessment: Detailed picture of problem within context of person’s life experiences and history 3) Problems & Goals: agree on a ‘CB’ definition of problem, set goals 4)Clinical Ratings: baseline ratings symptoms distress disability progress evaluated set time frame and target 5) Formulation; Develop shared understanding of problem and it’s maintenance.

6) Treatment rationale: explanations of how and why CBT could work with the problem 7) Interventions: aims reduce symptoms, increase coping 8) Evaluation: Of interventions for effectiveness 9) Relapse prevention: Maintain gains prevent relapse 10) Discharge. 11) Follow-up: further reflection on practice learnt. Set new long term goals

 Watch the clip  Analyse the information elicited by the therapist, use CBT theory to understand what the problem is and what might be maintaining it.  Take note of the questions the therapist asks to elicit the information and how the CBT approach is introduced.

 What do you think the differences might be when undertaking a cognitive behavioural assessment ?

Treatment plans Agreed working formulation Discuss with client and modify as necessary initial ideas about formulation Develop hypotheses about important processes Analyse info using CBT theory Gather Information Decide what further Info will help test hypotheses Note further info acquired During treatment Modify formulation

 Helps client and therapist understand the problem  Bridge between CBT theory about problem development and maintenance and clients experience  Shared rationale and guide for therapy  Opens up new ways of thinking  Helps therapist understand/predict difficulties in therapy or therapeutic relationship

What’s the problem? Ask for a recent example Critical Incident Thoughts Affect Behaviour physical What’s going through your mind when you feel……..? What do you do or feel like doing when you feel..? What’s the consequences of doing this? What do you feel most …. about ? How frequent? how intense? Duration? What does it mean to you? What? Where? When? With Whom? Do you notice anything happening in your body ?

Fear of a particular situation /object Escape/avoidance No change to fear beliefs Client does not learn coping Strategies or expose beliefs to disconfirmation

Depression Negative thoughts ( activity is seen as pointless) Reduced activity Loss of positive rewards

 Problem: I feel X ( emotion) about X ( situation) and this leads to X ( behaviour)  Overall goal: I would like to feel X ( emotion) about X ( situation) and this would lead to X ( behaviour)  Smart goals : set week to week ( Dryden W, 2001 )

 Divide into groups of 4  Cheryl to play patient  Plan your questions to elicit info on the following:  Thoughts  Emotions/physical sensation  Behaviour  Situation  Patients goals for therapy  1 person from each group to ask the questions  Others observe  Carry out assessment. In your small groups begin to construct a formulation, need anymore info?

 Art or science?  Do different therapists agree the exact same formulation for the same client? (Beiling & Kuyken 2003) Is treatment based on formulation more effective ? (Schulte et al 1992) ( Ghaderi, 2006)

 Think about one of your own fears and consider to what extent they are maintained by the way you think about them and behave in relation to them.

An Overview Cognitive behavioural strategies  Two main methods ◦ Questioning unhelpful beliefs ◦ Devising behavioural tests

Types of question  Evidence for questions  Evidence against questions  Alternative view questions  consequences of questions

Guided discovery Principles :  Ask a series of questions to uncover relevant information outside of the client’s awareness  Tease out :  false assumptions,  inconsistencies in belief,  contradictory views  Double standards  Faulty conclusions  Develop a way forward

 Behavioural Experiments  Involve testing predictions about physical, social or psychological danger or gathering information  Focus is on belief change through experience  Experiment must have a clear hypothesis from client, followed by a task that tests out that belief in an appropriate setting

 The client has the ability to answer or work out an answer  The answer reveals new perspectives

 ‘People are generally better persuaded by the reasons which they themselves discovered, than by those which have come into the minds of others.’ (Pascal 17 th Century French Philosopher)

 Exercise:  Socrates in action  Clinical application

 What did you like about the therapists style?  What’s the aim of this session?  What’s thoughts/beliefs are tested?  Are any behavioural experiments proposed?

 In your groups:  Thinking back to the role play and your formulation  What beliefs might it be useful to check out? What questions could you ask to help with this?  Can you identify 2 behavioural experiments that it might be useful to carry out?

 Survey by Wright and Davis(1994), found that clients wanted their therapists to:  Offer physically safe, private, confidential setting free from distractions  Be respectful  Treat concerns seriously  Prioritise client interests over own  Be competent  Share information  Permit client to make own choices  Be flexible not assume the client fits a theory  Review progress  Pace, not rush or keep changing appointments

What works in Therapy? – Traditional view Adapted from Lambert (1992)

 Phobic disorders  Anxiety disorders (GAD panic disorder)  Obsessive compulsive disorder  Mild-moderate depression  Post-traumatic stress disorder  Eating disorder  Substance abuse (alcohol, cocaine)  Sexual dysfunction  Habit & impulse control disorders  Psychosis

 Bipolar disorders  Delusional disorders  Personality disorders  Severe depression  Depression and anxiety associated with long term chronic health problems

 Branch R, Dryden W 2008, The cognitive behaviour counselling Primer. Athenoeum Press, UK.  Dryden W, steps to positive living. Sage. London  Hawton K, Salkovskis P, Kirk J, Clark D, 1993, Cognitive behaviour therapy for psychiatric Problems. Oxford University Press.Oxford.  Beck A T, The current state of Cognitive Behaviour Therapy.Archive of Gen Psy 2005;