Cognitve Behavior Therapy

Theory and Practice of
Cognitive
Shona N. Behavioral
Vas, Ph.D.
Therapy
Department
of Psychiatry &
Behavioral Neuroscience
Cognitive-Behavior Therapy
Program
MS-3 Clerkship 2008-2009
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?
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.
Why So Popular?
Clear
treatment approach for patients

Assumptions make sense to patients
Based on patients experience
Encourages practice and compliance
Patients have a sense of control
CBT works!
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
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
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 CognitiveBehavior Therapy (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
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.
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 Its a matter of time before I am
embarrassed
Targeted Cognitions for Different

Disorders
OCD:
appraisals of obsessive
cognitions
Anorexia: control, worth, perfection
Panic: catastrophic misinterpretation
of physical sensations
Paranoia: trust, vulnerability
Working Model of CBT

Event
Appraisal
Maladaptive
Behavior
Behavioral
Inclination
Affective and
Biological Arousal
Thase et al., 1998
Cognitive Model
Triggering Event
Bill goes to collection
Behavior
Appraisal
I can never do
anything right
Avoidance; withdrawal
Behavioral Inclination
I dont want to deal with it
Its too stressful to think
about it
Bodily Sensations
Low energy, disruption of
sleep, increased fatigue
Thase et al., 1998
What are Automatic

Thoughts?
What was going through your

Happen spontaneously
mind? 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
Stressful
Situation
Automatic Thoughts
Negative
Emotions
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
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
Examples
Cognitive Distortions
Emotional Reasoning: I feel incompetent,
so I know Ill fail
Catastrophizing: It is going to be terrible
Personalization: Its always my fault
Black or white thinking: If it isnt perfect,
its
no good at all.
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
Examples of Core Beliefs
Helpless core beliefs
I am inadequate, ineffective, incompetent, cant 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, dont
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 dont deserve to live
Cognitive Conceptualization
Current
Situation
Automatic Thoughts
About self, world
And others
Physiology
Feelings
Behavior
Childhood
And Early
Life Events
Underlying Assumptions
and Core Beliefs
Compensatory
Strategies
Example 1
Situation
Partner says:
I need time to
be with my friends
Automatic Thoughts
Automatic response:
Oh no, hes losing interest
and is going to break up
with me.
Physiology
Heart racing
Lump in throat
Feelings
Sadness
Worry
Anger
Behavior
Seek reassurance
Withdraw
Cry
Childhood
Experiences
Parental neglect
and criticism
Underlying Assumptions &

Core Beliefs
Im flawed in numerous ways,
which means Im not worthy of
consistent attention and care.
People only care when they want
something.
Compensatory
Strategies
Be independent and
youll be safe.
Watch out people
are careless with you.
Example 2
Automatic Thoughts
Situation
Disappointing
exam result
I am not going to get

through this program Im not as smart
as everyone else.
People will
discover this and I
will be humiliated.
Physiology
Pit in stomach
Dry mouth
Feelings
Worry, shame,
Disappointment
Humiliation.
Behavior
Use alcohol,
Procrastinate
with homework
Childhood
Adversities
Parental standards
reinforce academic
achievement
Underlying Assumptions
If I dont excel in school, Im a
total failure
Compensatory
Strategies
Work extra hard
to offset
incompetence.
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.?
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?
Sample Thought Log

Situation
Thoughts
Emotion
s
Rational
Response
Outcome
Going on
vacationAsk
a colleague to
do some work
for me
Shell say no
Im not doing a
good job
The boss thinks I
take too much
time off
Anxiety
(70%)
Guilt (40%)
Sadness
(20%)
I havent
taken a day
off in 6
months. We
work as a
team, so its
also her job to
track the
samples.
Anxiety (10%)
Guilt (0%)
Relief (40%)
Cognitive
Distortions:
All/nothing
Mindreadin
g
FortuneTelling
Overgeneralizatio
n
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
Course of Treatment
1.
2.
3.
4.
Assessment
Provide rationale
Training in self-monitoring
Behavioral strategies
1.
2.
5.
6.
7.
8.
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
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
Behavioral Interventions
Breathing
retraining
Relaxation
Behavioral activation
Interpersonal effectiveness training
Problem-solving skills
Exposure and response prevention
Social skills training
Graded task assignment
Cognitive Interventions
Monitor
automatic thoughts
Teach imagery techniques
Promote cognitive restructuring
Examine alternative evidence
Modify core beliefs
Generate rational alternatives
Efficacy
Cognitive
and behavioral
approaches are effective
Supported
by over 325 controlled

outcome studies
State-of-the-art
therapy, manualized
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)
Applications of CBT (Continued)
Eating Disorders (1981)

Marital Problems
Behavioral Medicine
Headaches (1985)
Insomnia (1987)
Chronic Pain (1988)
Smoking Cessation
Hypochondriasis
Body Dysmorphic Disorder
Controlled Outcome Studies

on CBT
Unipolar
Depression (~30)
Eating Disorders
Anorexia (~5)
Bulimia (~15)
Generalized
Anxiety Disorder
(~12)
Social Phobia (~14)

Panic Disorder (~10)
Borderline P.D. (2)
Schizophrenia (~45)
C/A Depression (8)
Chronic Depression
(1)
Conclusions
System
of psychotherapies
Unified theory of psychopathology
Short-term treatment
Objective assessment and
monitoring
Strong empirical support
As effective as pharmacotherapy
Questions?
Comments?
Dr. Shona Vas
(773) 702-1517
Psychiatry Department Office: A312
[email protected]

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Theory and Practice of

is Cognitive Behavior Therapy (CBT)?

are the basic principles of treatment?

is the course of treatment?

are some examples of interventions?

is appropriate for CBT?

of talk psychotherapies that treat

treatment approach for patients

CT is a focused form of psychotherapy

dysfunctional thinking and

dysfunctional beliefs which

Cognitive therapy is defined by a cognitive

Cognitive therapy is not defined by the use

CT also often referred to as CognitiveBehavior Therapy (CBT).

Rationale for CBT

Negative emotions are elicited by cognitive

Focus on examination of cognitive beliefs and

Distorted appraisals follow themes relevant

Negative Triad Associated with Depression

Negative Triad Associated with Anxiety

Targeted Cognitions for Different

Working Model of CBT

Thase et al., 1998

What are Automatic

What was going through your

tend to make consistent

Types of Cognitive Distortions

Examples of Core Beliefs

Helpless core beliefs

I am inadequate, ineffective, incompetent, cant cope

Unlovable core beliefs

I am unlikable, unwanted, will be rejected or abandoned, always

Worthless core beliefs

I am worthless, unacceptable, bad, crazy, broken, nothing, a

Underlying Assumptions &

I am not going to get

Clarify meaning of cognitive appraisal

Evidence: For and against this belief?

is the effect of telling myself

Sample Thought Log

Common Components of CBT

Establish good therapeutic relationship

Monitor relationship between situation/action and

Identifying beliefs and biases

Change mood states by using cognitive and behavioral

Emphasis on here and now

Start with specific situation (complete thought log)

Reliance on Socratic questioning

Empirical approach to test beliefs

Challenge thoughts not based on evidence

Promote rapid symptom change

by over 325 controlled

Unipolar Depression (1979)

Emotional Disorders (2006)

Applications of CBT (Continued)

Eating Disorders (1981)

Controlled Outcome Studies

Social Phobia (~14)