1. Theory and Practice of Cognitive Behavioral Therapy
University of Chicago, Department of Psychiatry, CBT
Theory and Practice of Cognitive Behavioral Therapy
Shona N. Vas, Ph.D.
Department of Psychiatry & Behavioral Neuroscience
Cognitive-Behavior Therapy Program
MS-3 Clerkship

2. University of Chicago, Department of Psychiatry, CBT
Outline
What is Cognitive Behavior Therapy (CBT)?
What are the basic principles of treatment?
What is the course of treatment?
What are some examples of interventions?
Who is appropriate for CBT?

3. University of Chicago, Department of Psychiatry, CBT
What is CBT?
Set of ‘talk’ psychotherapies that treat psychiatric conditions.
Short-term focused treatment.
Strong empirical support with randomized clinical trials.
As effective as psychiatric medications.
Recommended as critical component of treatment, particularly when medications are contraindicated or ineffective.

4. University of Chicago, Department of Psychiatry, CBT
Why So Popular?
Clear treatment approach for patients
Assumptions make sense to patients
Based on patient’s experience
Encourages practice and compliance
Patients have a sense of control
CBT works!

5. Definition of Cognitive Therapy
CT is a focused form of psychotherapy based on a model stipulating that psychiatric disorders involve dysfunctional thinking.
Dysfunctional/distorted thinking arises from both biological and psychological influences
Individuals’ emotional, behavioral, and physiological reactions are influenced by the way they structure their environment.
J. Beck, 1995

6. Definition of CT (continued…)
Modifying dysfunctional thinking and behavior leads to improvement in symptoms.
Modifying dysfunctional beliefs which underlie dysfunctional thinking leads to more durable improvement

7. Definition of CT (continued…)
Cognitive therapy is defined by a cognitive formulation of the disorder and a cognitive conceptualization of the particular patient.
Cognitive therapy is not defined by the use of exclusively cognitive techniques. Techniques from many modalities are used.
CT also often referred to as Cognitive-Behavior Therapy (CBT).

8. University of Chicago, Department of Psychiatry, CBT
Rationale for CBT
Negative emotions are elicited by cognitive processes developed through influences of learning and temperament.
Adverse life events elicit automatic processing, which is viewed as the causal factor.
Cognitive triad: Negative automatic thoughts center around our understanding of:
Ourselves
Others (the world)
Future
Focus on examination of cognitive beliefs and developing rational responses to negative automatic thoughts.
Beck et al., 1979

9. Cognitive Specificity Hypothesis
University of Chicago, Department of Psychiatry, CBT
Cognitive Specificity Hypothesis
Distorted appraisals follow themes relevant to the specific psychiatric condition.
Psychological disorders are characterized by a different psychological profile.
Depression: Negative view of self, others, and future. Core beliefs associated with helplessness, failure, incompetence, and unlovability.
Anxiety: Overestimation of physical and psychological threats. Core beliefs linked with risk, dangerousness, and uncontrollability.

10. Cognitive Specificity
University of Chicago, Department of Psychiatry, CBT
Cognitive Specificity
Negative Triad Associated with Depression
Self “I am incompetent/unlovable”
Others “People do not care about me”
Future “The future is bleak”
Negative Triad Associated with Anxiety
Self “I am unable to protect myself”
Others “People will humiliate me”
Future “It’s a matter of time before I am embarrassed”

11. Targeted Cognitions for Different Disorders
OCD: appraisals of obsessive cognitions
Anorexia: control, worth, perfection
Panic: catastrophic misinterpretation of physical sensations
Paranoia: trust, vulnerability

12. University of Chicago, Department of Psychiatry, CBT
Working Model of CBT
Event
Appraisal
Maladaptive
Behavior
Affective and
Biological Arousal
Behavioral Inclination
Thase et al., 1998

13. University of Chicago, Department of Psychiatry, CBT
Cognitive Model
Triggering Event
Bill goes to collection
Appraisal
“I can never do anything right…”
Behavior
Avoidance; withdrawal
Bodily Sensations
Low energy, disruption of
sleep, increased fatigue
Behavioral Inclination
“I don’t want to deal with it”
“It’s too stressful to think about it”
Thase et al., 1998

14. What are Automatic Thoughts? What was going through your mind?
University of Chicago, Department of Psychiatry, CBT
What are Automatic Thoughts? What was going through your mind?
Happen spontaneously in response to situation
Occur in shorthand: words or images
Do not arise from reasoning
No logical sequence
Hard to turn off
May be hard to articulate
Negative
Emotions
Stressful
Situation
Automatic Thoughts

15. Cognitive Distortions
Patients tend to make consistent errors in their thinking
Often, there is a systematic negative bias in the cognitive processing of patients suffering from psychiatric disorders
Help patient identify the cognitive errors s/he is most likely to make

16. Types of Cognitive Distortions
University of Chicago, Department of Psychiatry, CBT
Types of Cognitive Distortions
Emotional reasoning Feelings are facts
Anticipating negative outcomes The worst will happen
All-or-nothing thinking All good or all bad
Mind-reading Knowing what others are thinking
Personalization Excess responsibility
Mental filter Ignoring the positive

17. University of Chicago, Department of Psychiatry, CBT
Examples
Cognitive Distortions
Emotional Reasoning: “I feel incompetent, so I know I’ll fail”
Catastrophizing: “It is going to be terrible”
Personalization: “It’s always my fault”
Black or white thinking: “If it isn’t perfect, it’s no good at all.”

18. University of Chicago, Department of Psychiatry, CBT
Core Beliefs
Core beliefs underlie and produce automatic thoughts.
These assumptions influence information processing and organize understanding about ourselves, others, and the future.
These core beliefs remain dormant until activated by stress or negative life events.
Categories of core beliefs (helpless, worthless, unlovable)
Core Beliefs
Automatic Thoughts

19. Examples of Core Beliefs
Helpless core beliefs
I am inadequate, ineffective, incompetent, can’t cope
I am powerless, out of control, trapped
I am vulnerable, weak, needy, a victim, likely to be hurt
I am inferior, a failure, a loser, defective, not good enough, don’t measure up
Unlovable core beliefs
I am unlikable, unwanted, will be rejected or abandoned, always be alone
I am undesirable, ugly, unattractive, boring, have nothing to offer
I am different, flawed, defective, not good enough to be loved by others
Worthless core beliefs
I am worthless, unacceptable, bad, crazy, broken, nothing, a waste
I am hurtful, dangerous, toxic, evil
I don’t deserve to live

20. Cognitive Conceptualization
University of Chicago, Department of Psychiatry, CBT
Cognitive Conceptualization
Physiology
Feelings
Behavior
Current
Situation
Automatic Thoughts
About self, world
And others
Childhood
And Early
Life Events
Compensatory
Strategies
Underlying Assumptions and Core Beliefs

21. University of Chicago, Department of Psychiatry, CBT
Example 1
Physiology
Heart racing
Lump in throat
Feelings
Sadness
Worry
Anger
Behavior
Seek reassurance
Withdraw
Cry
Situation
Partner says:
“I need time to
be with my friends”
Automatic Thoughts
Automatic response:
“Oh no, he’s losing interest
and is going to break up with me….”
Underlying Assumptions & Core Beliefs
“I’m flawed in numerous ways, which means I’m not worthy of consistent attention and care. People only care when they want something.”
Compensatory
Strategies
Be independent and
you’ll be safe.
Watch out – people
are careless with you.
Childhood
Experiences
Parental neglect
and criticism

22. University of Chicago, Department of Psychiatry, CBT
Example 2
Physiology
Pit in stomach
Dry mouth
Feelings
Worry, shame,
Disappointment
Humiliation.
Behavior
Use alcohol,
Procrastinate
with homework
Situation
Disappointing
exam result
Automatic Thoughts
“I am not going to get
through this program -
I’m not as smart
as everyone else.
People will
discover this and I
will be humiliated.”
Childhood
Adversities
Parental standards
reinforce academic
achievement
Underlying Assumptions
“If I don’t excel in school, I’m a total failure”
Compensatory
Strategies
Work extra hard
to offset
incompetence.

23. Responding to Negative Thoughts
Define Situation
Clarify meaning of cognitive appraisal
What was going through your mind just then?
What did the situation mean for you?
Evaluate interpretation
Evidence: For and against this belief?
Alternatives: Any other explanation(s)?
Implications: So what….?

24. Evaluating Negative Thoughts
What is the effect of telling myself this thought?
What could be the effect of changing my thinking?
What would I tell ___ (a friend/family member) if s/he viewed this situation in this way?
What can I do now?

25. Sample Thought Log Situation Thoughts Emotions Rational Response
Outcome
Going on vacation—Ask a colleague to do some work for me
She’ll say no…
I’m not doing a good job
The boss thinks I take too much time off
Anxiety (70%)
Guilt (40%)
Sadness (20%)
Cognitive
Distortions:
All/nothing
Mindreading
Fortune-Telling
Over-generalization
I haven’t taken a day off in 6 months. We work as a team, so it’s also her job to track the samples.
Anxiety (10%)
Guilt (0%)
Relief (40%)

26. Common Components of CBT
University of Chicago, Department of Psychiatry, CBT
Common Components of CBT
Establish good therapeutic relationship
Educate patients - model, disorder, therapy
Assess illness objectively, set goals
Use evidence to guide treatment decisions
Structure treatment sessions with agenda
Limit treatment length
Issue and review homework to generalize learning

27. University of Chicago, Department of Psychiatry, CBT
Course of Treatment
Assessment
Provide rationale
Training in self-monitoring
Behavioral strategies
Monitor relationship between situation/action and mood.
Applying new coping strategies to larger issues.
Identifying beliefs and biases
Evaluating and changing beliefs
Core beliefs and assumptions
Relapse prevention and termination

28. University of Chicago, Department of Psychiatry, CBT
Basic Principles
Change mood states by using cognitive and behavioral strategies:
Identifying/modifying automatic thoughts & core beliefs,
Regulating routine, and
Minimizing avoidance.
Emphasis on ‘here and now’
Preference for concrete examples
Start with specific situation (complete thought log)
Reliance on Socratic questioning
Ask open-ended questions
Empirical approach to test beliefs
Challenge thoughts not based on evidence
Cognitive restructuring
Promote rapid symptom change

29. Behavioral Interventions
University of Chicago, Department of Psychiatry, CBT
Behavioral Interventions
Breathing retraining
Relaxation
Behavioral activation
Interpersonal effectiveness training
Problem-solving skills
Exposure and response prevention
Social skills training
Graded task assignment

30. Cognitive Interventions
University of Chicago, Department of Psychiatry, CBT
Cognitive Interventions
Monitor automatic thoughts
Teach imagery techniques
Promote cognitive restructuring
Examine alternative evidence
Modify core beliefs
Generate rational alternatives
                              

31. Efficacy Cognitive and behavioral approaches are effective
Supported by over 325 controlled outcome studies
State-of-the-art therapy, manualized

32. University of Chicago, Department of Psychiatry, CBT
Applications of CBT
Mood Disorders
Unipolar Depression (1979)
Bipolar Disorder (1996)
Dysthymia and Chronic MDD (2000)
Anxiety Disorders
GAD (1985)
Social Phobia (1985)
Panic Disorder (1986)
OCD (1988)
PTSD (1991)
Emotional Disorders (2006)

33. Applications of CBT (Continued…)
Eating Disorders (1981)
Marital Problems
Behavioral Medicine
Headaches (1985)
Insomnia (1987)
Chronic Pain (1988)
Smoking Cessation
Hypochondriasis
Body Dysmorphic Disorder

34. Controlled Outcome Studies on CBT
University of Chicago, Department of Psychiatry, CBT
Controlled Outcome Studies on CBT
Social Phobia (~14)
Panic Disorder (~10)
Borderline P.D. (2)
Schizophrenia (~45)
C/A Depression (8)
Chronic Depression (1)
Unipolar Depression (~30)
Eating Disorders
Anorexia (~5)
Bulimia (~15)
Generalized Anxiety Disorder (~12)

35. University of Chicago, Department of Psychiatry, CBT
Conclusions
System of psychotherapies
Unified theory of psychopathology
Short-term treatment
Objective assessment and monitoring
Strong empirical support
As effective as pharmacotherapy

36. Psychiatry Department Office: A-312
Questions? Comments?
Dr. Shona Vas
(773)
Psychiatry Department Office: A-312