1. Dr. Paul Wong, D.Psyc.(Clinical)
SOWK6190/SOWK Cognitive Behavioural Therapy and Cognitive Behavioural Intervention
Week 3 - Cognitive conceptualization and Structure of the first therapy session
Dr. Paul Wong, D.Psyc.(Clinical)

2. A recap (and additional information) of the last two classes

3. Seven Basic Assumptions
Beck (1979) provides a list of general assumptions that underlie the theory (from p.8 in Beck, A. T., Rush, J. A., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press] 3

4. Seven Basic Assumptions
Beck (1979) provides a list of general assumptions that underlie the theory. CBT is based on the following:
Perception and experiencing in general are active processes which involve both inspective and introspective data.
The patient's cognitions represent a synthesis of internal and external stimuli.
How a person appraises a situation is generally evident in his cognitions (thoughts and visual images).
These cognitions constitute the person's “stream of consciousness” or phenomenal field, which reflects the person's configuration of himself, his world, his past and future.
Alterations in the content of the person's underlying cognitive structures affect his or her affective state and behavioral pattern.
Through psychological therapy a patient can become aware of his cognitive distortions.
Correction of these faulty dysfunctional constructs can lead to clinical improvement. (p. 8) 4

5. Basic Concepts
CT is based on the role information processing plays in survival
The theory behind cognitive therapy asserts that altering thoughts influences feelings, motivations and behaviors
The theory states cognition, behavior, affect, and motivation are intertwined and co-occurring
Therapeutic intervention focuses on the primacy of cognition 5

6. Basic Concepts
Cognitive Schema – a structure containing self-perceptions; thoughts about others and the world; our memories, goals, fantasies; and everything we’ve learned. Structures that contain an individual's core beliefs and assumptions are labeled Cognitive Schemas) Cognitive Theory states that an individual's fundamental beliefs and assumptions are contained in structures termed cognitive schemas.)
Cognitive Shift – a systematic bias in information processing
Cognitive Vulnerabilities – specific attitudes predisposing the interpretation of experiences
Cognitive Distortion - refers to a systematic error in reasoning 6

7. Basic Concepts
Mode
Networks of cognitive, affective, motivational, and behavioral schemas
Primal modes are universal and related to survival
They include primal thinking which is rigid, absolute, automatic and bias
Dysfunctional modes are treated by deactivating them, altering their structure and content and developing more adaptive modes 7

8. Pattern that triggers depression:
CT’s Cognitive Triad
Pattern that triggers depression:
Client holds negative view of themselves and blames themselves (self)
2. Selective abstraction: Client has tendency to interpret experiences in a negative manner (others)
3. Client has a gloomy vision and projections about the future (world) 8

9. Basic Characteristics of CT
Practical
Symptom focused
Empirically derived techniques
Collaboration
Acknowledges underlying precursors of symptoms while remaining in present
Case conceptualization drives treatment 9

10. Primary Roles of the CT Therapist
Conceptualizing the patient in cognitive terms
Structuring the sessions
Using collaborative empiricism and guided discovery to specify problems and set goals 10

11. The Cognitive Model Situation Automatic Response Thoughts Emotions
Behaviors
Situation Automatic
Thoughts Emotions
Underlying
Beliefs
Physiological
Response 11

12. The Cognitive Model
Automatic thoughts influence not only one’s emotional response, but also one’s behavioral, motivational, and physiological responses.
The relationship is bi-directional (all systems act together as a mode) therefore simultaneously biology, emotions, behavior (and motivation) influence thoughts
Subsequently, biological treatments can change thoughts and CBT can change biological processes. 12

13. The Cognitive Model
We all have cognitive vulnerabilities (i.e., core beliefs) which predispose us to interpret information a certain way.
These vulnerabilities are developed early
When these beliefs are rigid, negative, and ingrained we are predisposed to pathology
These core beliefs give rise to conditional assumptions, i.e., rules for living, as we mature
In psychopathology there are systematic biases toward selectively interpreting information in a certain manner which are disorder specific. 13

14. Modifying Core Beliefs creates the most significant change in a dysfunctional mode for a client14

15. Hierarchy of Beliefs (Adapted from Judith Beck’s Cognitive Therapy: Basics and Beyond)15

16. Situation Automatic Thoughts Emotion Intermediate Beliefs Core Beliefs
Hierarchy of Beliefs (Adapted from Judith Beck’s Cognitive Therapy: Basics and Beyond)
Situation
Automatic
Thoughts
Emotion
Intermediate Beliefs
Core Beliefs 16

17. Strategies of Cognitive Therapy
Collaborative Empiricism
Guided Discovery (Guided discovery refers to the process by which a therapist serves as a guide to clarify problem behaviors and thoughts)
Deactivation of Dysfunctional Modes
Techniques which directly deactivate them
Modifying their content and structure
Constructing more adaptive modes to neutralize them 17

18. CT’s View of Personality
Thinking is Problematic or Distorted when it is very ...
Extreme
Broad
Catastrophic
Negative
Unscientific
Idealistic
Demanding
Judgmental
Comfort Seeking
Obsessive
Confusing 18

19. Cognitive Distortions
Arbitrary Inference: Drawing a conclusion without evidence or in the face of contradictory evidence. Example - a young woman with anorexia nervosa believes that she is fat although she is dying of starvation
Selective Abstraction: Dwelling on a single negative detail taken out of context. Example – While on a date you say one thing you wish you could have said differently and now see the entire evening as a disaster. 19

20. Cognitive Distortions
3. Overgeneralization: A single negative event is viewed as a never-ending pattern of defeat. Example - Following a job interview an accountant does not receive the job. She/he begins thinking that they will never find a job despite their qualifications
4. Magnification and/or Minimization: The binocular trick. Things seem bigger or smaller than they truly are (depending on which lens you are looking through). Example: An employee believes that a minor mistake will lead to being fire vs. an alcoholic who believes he/she doesn’t have a problem. 20

21. Cognitive Distortions
5. Personalization: Assuming personal responsibility for something for which you are not responsible. (Attributing external events to oneself without evidence supporting a causal connection is termed Personalization.) Example – sometimes seen in patients who have been sexually or physically abused.
6. Dichotomous Thinking: Is All or Nothing Thinking - Things are seen as black or white, there is no gray (middle ground). Example 1 – Things are wonderful or awful, good or bad, perfect or a failure. Example 2 - Kate has anorexia nervosa and when she gains one pound she believes she is fat. If she loses one pound she can perceive herself as thin. Kate's thought process reflects Dichotomous Thinking. Example 3 - A patient with anorexia nervosa believes that she is thin when she exercises, but fat if she eats. This would be an example of the all or nothing thinking cognitive distortion 21

22. Cognitive Distortions
7. Mind Reading: Assuming you know the motives, thoughts, intentions of others. Example – If your friend is in a bad mood you assume it’s your fault and don’t asked what is wrong.
8. Fortune Teller Error: Creating a negative self fulfilling prophesy. Example: You believe you will fail an important exam so you do not study and fail. 22

23. Cognitive Distortions
9. Emotional Reasoning: You assume your negative feelings result from the fact that things are negative. Example – If you feel bad, then that means that the world or situation is bad. You don’t consider that your feelings are a misrepresentation of the facts.
10. Should Statements: The use of words like should, ought, must rather than “it would be preferred” to guilt self. Example: “I should be perfect”.
11. Labeling and Mislabeling: Labeling yourself or others in a demeaning way. Example: Name calling “I am worthless” or “He’s a total failure”. 23

24. Process of CBT

25. Process of Psychotherapy in CT
Early in treatment a cognitive therapist may rely more on behavioral techniques whereas later in treatment the focus shifts towards cognitive techniques
Through the process of guided discovery cognitive therapy patients create homework assignments for themselves called "behavioral experiments" with input from their therapist. 25

26. Process of Psychotherapy in CT
Structure of a CBT Session
Mood check
Setting the Agenda
Bridging from last session
Today’s agenda items
Homework assignment
Summarizing throughout and at the end
Feedback from patient 26

27. General Principles of CT
Goal is to correct dysfunctional thinking and help patients modify erroneous assumptions
Patient is taught to be a scientist who generate and tests hypotheses
Relationship between patient and therapist is collaborative 27

28. Collaborative Empiricism – goal is to demystify therapy
Fundamental Concepts
Collaborative Empiricism – goal is to demystify therapy
Socratic Dialogue – form of questioning used to help patients come to their own conclusions about their thoughts and behaviors
Guided Discovery – therapist collaborates with patient to develop behavioral experiments to test hypothesis 28

29. Process of Therapy
Initial Sessions – essential to build rapport, focus on problem definition, goal setting, and symptom relief, psychoeducation, behavior interventions. (Symptom relief is a primary goal in the initial cognitive therapy interview)
Middle Sessions – emphasis shifts from symptom/behaviors to patterns of thinking
Termination – Expectation that therapy is time-limited. 29

30. Goals: First session Establishing trust and rapport
Educate the patient about CBT, her presenting problems/disorders/the cognitive model/process of therapy
Eliciting (and correcting, if necessary) the patient’s expectations for therapy.
Gathering additional information about the patient's expectations for therapy.
Using this information to develop a goal list

31. Structure
Setting the agenda
Doing a mood check
Briefly reviewing the presenting problem and obtaining an update
Identifying problems and setting goals
Educating the patient about the cognitive model
Eliciting the patient’s expectations for therapy
Educating the patient about her disorder
Setting homework
Eliciting feedback

32. Check is the patient is taking medication
Caution!!
Check is the patient is taking medication
If patient is suicidal, forget about the structure, do CRISIS INTERVENTION

33. Setting the agenda Key statements (pp.28):
“I’d like to start off our session by setting the agenda…. We will do this at the beginning of every session so we make sure we have time to cover the most important things”.
“This first session is a little different from other sessions because we have a lot of ground to cover and we need to know each other better…”
“We will be doing these…… today”. “Is there anything you want to add to the agenda today”.

34. Mood Check
USE Beck Depression Inventory, Beck Anxiety Inventory, and Beck Hopelessness Scale
If no, then spend some time to teach the patient to provide a rating of her mood on a scale
Key statement:
“If it’s okay with you, I’d like you to come to every session a few minutes early so you can fill out these three forms”.

35. Review of presenting problem, problem identification, and goal setting
Key statements:
“(summarized what you have just talked about)…. (then briefly review what you know about the patient)… Is that right?”
“Can you tell me SPECIFICALLY what problems you’ve been having?”
“Helping the patient to focus and to break down the problems into a more manageable size) Okay, it sounds like you have two major problems right now…..”.
“What would you like to accomplish in therapy?”
“If you were happier (a term that the client used), what would you be doing?”
“Do you want to write down a goal list?””
“Okay, before we finish, let me quickly summarize what we have done so far.”

36. Educating the patient about the cognitive model
“Can you tell me what you know about cognitive behavioural therapy?”
“First, I’d like to find out how your thinking affects how you feel. Can you think of a moment that you have a sudden mood change?”
“Do you remember what was going through your mind?”
Show client the model if necessary
“Can you tell me in your own words about the connection between thoughts and feelings?”
Set homework for the client to write down events using the cognitive model
“… what we’ll be doing together is identifying these thoughts which seem to be upsetting you.Then we will examine those thoughts and see how accurate they are. Lots of times I think we will find that these thoughts are not completely accurate.”
KEY : make sure the patient can explain the relationship between thoughts and mood in his/her own words.

37. Expectations for therapy
Key: Check what the patient expect to do with and get from you
“some patients have the idea that a therapist will cure them. Some expects to do some work with the therapist o make themselves better.”
“I’ll help you learn some tools to get over depression and you will be able to use these tools for the rest of your life when you are sad or unhappy before you become depressed again”.
“It’s hard to predict now how long you should be in therapy. My best guess is somewhere around 8 to 14 sessions.”

38. Educating the patient about her disorder
Key – do some preparations before hand, and please do make sure the information is updated and accurate/evidence-based

39. End-of-session summary and setting of homework
“Let me summarize, we set the agenda, checked your mood, set some goals and explained how your thoughts influence your feelings, how therapy will go. We are going to be doing two major things: working on your problems and goals and changing your thinking when you find it’s not accurate. Now let’s see what you’ve written for homework.”
Key: mood check using cognitive model, think about what to talk about next time, do some relaxation exercises.

40. Feedback
Asking for feedback further strengths rapport, providing the message that the therapist cares about what the patient thinks.
Verbal or written form (pp.42 – therapy report).

41. In –class activity
Please from a group of two, then one acts as a client, and one as a therapist. Role play session1. After that, if we have time, we can have some discussion.

42. Homework
Please do follow the guidelines from the text and pretend that your are the client, and finish the homework as set by the therapist.