Opa basics of cognitive behavioral therapy

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Opa basics of cognitive behavioral therapy

  1. 1. General Survey of Cognitive-Behavioral Therapy Strategies The Model and The Techniques Kevin D. Arnold, Ph.D., ABPP Director, The Center for Cognitive and Behavioral Therapy of Greater Columbus 614.459.4490
  2. 2. Theory Behind CBT <ul><li>Barlow’s Theory of Emotional Disorders </li></ul><ul><ul><li>Barlow (1991) & Moses and Barlow (2006) </li></ul></ul><ul><li>Key Concepts </li></ul><ul><ul><li>Emotional Regulation </li></ul></ul><ul><ul><li>Emotional Memory </li></ul></ul><ul><ul><li>Antecedent Cognitive Appraisals </li></ul></ul><ul><ul><li>Emotionally Driven Behaviors (EDBs) </li></ul></ul><ul><ul><li>Avoidance </li></ul></ul>
  3. 3. Theory Behind CBT <ul><li>Emotional Regulation: Key Strategies* </li></ul><ul><ul><li>Situational Control </li></ul></ul><ul><ul><ul><li>Situation Selection </li></ul></ul></ul><ul><ul><ul><ul><li>Predictive Model of Emotional Arousal Features and Likelihoods </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Costs and Benefits Assessment of Regulation vs. Experience </li></ul></ul></ul></ul><ul><ul><ul><li>Situation Modification </li></ul></ul></ul><ul><ul><ul><ul><li>Modification of the Physical, External Environment </li></ul></ul></ul></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><ul><li>Attention Deployment </li></ul></ul></ul><ul><ul><ul><ul><li>Distraction to Other Situational Features or Away Completely </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Concentration on Emotional Experience, Situational Factors, or Predictions </li></ul></ul></ul></ul>Theory Behind CBT *Gross & Thompson, 2007
  4. 4. <ul><li>Emotional Regulation: Key Strategies* </li></ul><ul><ul><li>Appraisal </li></ul></ul><ul><ul><ul><li>Cognitive Appraisal </li></ul></ul></ul><ul><ul><ul><ul><li>Modification of Appraisal (e.g., threat value, label of event) </li></ul></ul></ul></ul><ul><ul><li>Response </li></ul></ul><ul><ul><ul><li>Response Modulation </li></ul></ul></ul><ul><ul><ul><ul><li>Relaxation Strategies </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Expression of Emotion (Behavioral, Verbal) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Adaptive Response Alternatives </li></ul></ul></ul></ul>Theory Behind CBT *Gross & Thompson, 2007
  5. 5. Theory Behind CBT
  6. 6. <ul><li>Emotional Memory* and Anxiety </li></ul><ul><ul><li>Disclaimer—Not a Neuropsychologist </li></ul></ul><ul><ul><li>Role of Amygdala and Prefrontal Cortex in Anxiety </li></ul></ul><ul><ul><ul><li>Amygdala Stores Stress Arousal as Nondeclarative Memory </li></ul></ul></ul><ul><ul><ul><li>In Contrast, Hippocampus Stores Declarative Memory </li></ul></ul></ul><ul><ul><ul><li>PFC Necessary to Habituate to Anxiety </li></ul></ul></ul><ul><ul><ul><ul><li>Habituation is New Learning Allowing PFC to Modulate Amygdala Arousal and Enhance Declarative Recall Through Hippocampus </li></ul></ul></ul></ul><ul><ul><ul><li>PFC can also “prevent the acquisition of fear conditioning” or “excite the amygdala and increase fear.” (pp. 36-37) </li></ul></ul></ul>Theory Behind CBT *Quirk, 2007
  7. 7. <ul><li>Emotional Memory* and Depression </li></ul><ul><ul><li>Disclaimer—Not a Neuropsychologist </li></ul></ul><ul><ul><li>Role of Amygdala and Prefrontal Cortex in Depression </li></ul></ul><ul><ul><ul><li>PFC Activation Levels Needed to be Higher in Depressed Patients For Working Memory Performance </li></ul></ul></ul><ul><ul><ul><li>Predisposition to Serotonin Based Abnormalities Associated with Increased Activity in Amygdala and with Abnormalities in Connection of Prefrontal Cortex and Amygdala. </li></ul></ul></ul>Theory Behind CBT *Davidson, Fox & Kalin, 2007
  8. 8. <ul><li>Impact on the HPA Axis </li></ul><ul><ul><li>The HPA Axis is the Hypothalamus-Pituitary-Adrenal Axis </li></ul></ul><ul><ul><li>Changes in HPA Axis Functioning Have Been Found in Early Developmental Exposure to Trauma* </li></ul></ul><ul><ul><ul><li>Predisposes to later MDD and PTSD Vulnerability </li></ul></ul></ul><ul><ul><li>Early Trauma has been Shown to Reduce Hypothalamic Mass </li></ul></ul><ul><ul><li>In utero Exposure to Stress Reveals Changes in Fetus and Infant Dysregulation of the HPA System Leading to Greater Degrees of Stress and Anxiety </li></ul></ul>Theory Behind CBT *Shea, Walsh, MacMillan & Steiner (2006)
  9. 9. Theory Behind CBT
  10. 10. <ul><li>Antecedent Cognitive Appraisals </li></ul><ul><ul><li>Early Learning During Parenting Interactions or Traumas Regarding Self-Efficacy or Threats </li></ul></ul><ul><ul><li>Appraisal of Likelihood of Negative Event Occurrence </li></ul></ul><ul><ul><li>Appraisal of Catastrophic Outcome </li></ul></ul><ul><ul><li>Appraisal of Incapacity to Effect Outcomes or Manage Outcomes </li></ul></ul><ul><ul><li>Appraisal of Others as Harsh (Punitive Parenting) or Unsupportive (Dismissive Parenting) </li></ul></ul><ul><ul><li>Overall Situational Appraisal & Development of Assumptive Schemas </li></ul></ul>Theory Behind CBT
  11. 11. <ul><li>Emotionally Driven Behaviors (EDBs) </li></ul><ul><ul><li>Behavioral Response Probabilities </li></ul></ul><ul><ul><li>Activation of Learned, Adaptive Responses to Over-generalized and Inappropriate Emotional Recall </li></ul></ul><ul><ul><li>Reduce Emotional Arousal </li></ul></ul><ul><ul><ul><li>Negative Reinforcement </li></ul></ul></ul><ul><ul><li>When EDBs Lead to Unhealthy Outcomes </li></ul></ul><ul><ul><ul><li>Social Isolation, Avoidance of Adaptive Situations, Reduction in Relationship Connections </li></ul></ul></ul>Theory Behind CBT
  12. 12. <ul><li>Avoidance </li></ul><ul><ul><li>Escape is an EDB to Exit to Reduce Arousal </li></ul></ul><ul><ul><li>Avoidance is to Prevent Arousal or Full Arousal </li></ul></ul><ul><ul><li>Forms of Avoidance </li></ul></ul><ul><ul><ul><li>Subtle Behavioral Avoidance </li></ul></ul></ul><ul><ul><ul><ul><li>Avoiding Eye Contact, Procrastination </li></ul></ul></ul></ul><ul><ul><ul><li>Cognitive Avoidance </li></ul></ul></ul><ul><ul><ul><ul><li>Distraction, Stonewalling, Mental Rituals, Thought Stopping </li></ul></ul></ul></ul><ul><ul><ul><li>Safety Signals </li></ul></ul></ul><ul><ul><ul><ul><li>Shaking Medicine Bottles, Keeping Positive Association Objects Handy, Good Luck Charms, Carrying Cleaners </li></ul></ul></ul></ul>Theory Behind CBT
  13. 13. Theory Behind CBT <ul><li>Examples from Moses & Barlow (2006) </li></ul>Social Phobia Carrying Items to Hide Face or Bodily Reactions Depression/GAD Carrying Good Feeling Objects OCD Good Luck Charms Safety Signals Generalized Anxiety Worrying Panic/Depression Distraction Depression Forced Positive Self Talk Cognitive Avoidance Generalized Anxiety Procrastination Panic/Depression Avoiding Physiological Arousal Social Phobia Avoid Eye Contact Behavioral Avoidance
  14. 14. The Basic CBT Model <ul><li>Beck & Other’s Approach </li></ul><ul><ul><li>Psychopathology is bio-psycho-social </li></ul></ul><ul><ul><li>Feelings can be managed through addressing cognitions and behaviors </li></ul></ul><ul><ul><li>Psychopathology has deficits in behaviors and maladaptive or distorted cognitions </li></ul></ul><ul><ul><li>Underlying assumptions have been learned in an “if-then” format </li></ul></ul><ul><ul><li>Schemas create a construction that is maladaptive now, but not when first developed </li></ul></ul>Theory Behind CBT
  15. 15. Cognitive Triad <ul><li>Cognitive Triad </li></ul><ul><ul><li>Distorted Thoughts are those that are mood congruent but not reflective of the evidence in life </li></ul></ul><ul><ul><li>These are sometimes referred to as Automatic Thoughts </li></ul></ul><ul><ul><li>The thoughts fit basically into three categories: Self, Others/World, or Future </li></ul></ul>Theory Behind CBT
  16. 16. Cognitive Blockade <ul><li>Cognitive Blockade </li></ul><ul><ul><li>Mood or other pathologic processes create a filtering of information that is state-dependent </li></ul></ul><ul><ul><li>Information, both internal and external, is filtered so that only mood congruent information is a) perceived, or b) valued. </li></ul></ul><ul><ul><li>Overcoming the impact of the blockade is a major goal of CBT </li></ul></ul>Theory Behind CBT
  17. 17. Treatment Method: General <ul><li>IT IS AN APPROACH, NOT A MANUAL </li></ul><ul><li>Cognitive Therapy is collaborative so that the patient and therapist are a team working on problems together </li></ul><ul><li>Cognitive Therapy is active and engages the patient through a treatment relationship that encourages but respects the patient through empathy </li></ul><ul><li>Cognitive Therapy uses the Socratic Method, using questions whenever possible </li></ul>
  18. 18. <ul><li>Socratic Method </li></ul><ul><ul><li>Questions are used in CBT to </li></ul></ul><ul><ul><ul><li>Help the patient become aware of thoughts </li></ul></ul></ul><ul><ul><ul><li>Examine thoughts to identify distortions </li></ul></ul></ul><ul><ul><ul><li>Replace distortions with health and evidenced based ideas </li></ul></ul></ul><ul><ul><ul><li>Plan to develop new thinking patterns </li></ul></ul></ul><ul><ul><ul><li>Self-Awareness of EDBs </li></ul></ul></ul>Treatment Method: General
  19. 19. <ul><li>Collaborative </li></ul><ul><ul><li>Therapy is guided by a team approach to problems </li></ul></ul><ul><ul><ul><li>The treatment conceptualization is created collaboratively as a basis for the treatment methods </li></ul></ul></ul><ul><ul><ul><li>The structure of the sessions is agreed upon as a way of keeping the collaborative work moving </li></ul></ul></ul><ul><ul><ul><li>Both agree on structure and direction </li></ul></ul></ul>Treatment Method: General
  20. 20. <ul><li>Structure and Direction </li></ul><ul><ul><li>All sessions use the following template </li></ul></ul><ul><ul><ul><li>Setting an agenda </li></ul></ul></ul><ul><ul><ul><li>Bridging back to the previous session </li></ul></ul></ul><ul><ul><ul><li>Setting a target for the session </li></ul></ul></ul><ul><ul><ul><li>Application of the CBT techniques to the target </li></ul></ul></ul><ul><ul><ul><li>Summarization of the session </li></ul></ul></ul><ul><ul><ul><li>Setting homework </li></ul></ul></ul><ul><ul><ul><li>Feedback on the session </li></ul></ul></ul>Treatment Method: General
  21. 21. <ul><li>Problem Orientation </li></ul><ul><ul><li>Conceptualization: Patients problems within a present, learning context </li></ul></ul><ul><ul><li>Orientation to the Present/Here and Now </li></ul></ul><ul><ul><li>Selection of strategies and techniques </li></ul></ul><ul><ul><li>Assess the effectiveness of the CBT on the problem within its context </li></ul></ul>Treatment Method: General
  22. 22. Common Strategies in CBT <ul><li>Simplify </li></ul><ul><li>Do it now </li></ul><ul><li>You can’t know unless you experiment </li></ul><ul><li>If you are off track, do the opposite </li></ul><ul><li>Persistence will produce change </li></ul><ul><li>Break it down and take one thing at a time </li></ul><ul><li>Do that which you don’t expect yourself to do </li></ul><ul><li>Pull, don’t push/Flow </li></ul>Treatment Method: General
  23. 23. <ul><li>Educate </li></ul><ul><ul><li>CBT educates patients to be their own therapists </li></ul></ul><ul><ul><ul><li>Help the patient to learn how to learn </li></ul></ul></ul><ul><ul><ul><ul><li>It’s not resistance, it’s reluctance </li></ul></ul></ul></ul><ul><ul><ul><ul><li>It’s not resistance, it’s slowness </li></ul></ul></ul></ul><ul><ul><ul><li>Patients learn inductively </li></ul></ul></ul><ul><ul><ul><ul><li>Beliefs are hypothesis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Testing them can provide insight or new ways of thinking </li></ul></ul></ul></ul>Treatment Method: General
  24. 24. <ul><li>Key Elements </li></ul><ul><ul><li>Behavioral Experimentation </li></ul></ul><ul><ul><li>Daily Activity Records </li></ul></ul><ul><ul><li>Activity Scheduling </li></ul></ul><ul><ul><li>Pleasure Scheduling </li></ul></ul><ul><ul><li>Identify Distortions through Self-Monitoring (3 Column) and Labeling Automatic Thoughts </li></ul></ul><ul><ul><li>Test the Evidence </li></ul></ul><ul><ul><li>Challenge and Create New Thoughts (5 Column) </li></ul></ul>Treatment Method: General
  25. 25. Cognitive Distortions <ul><li>Related to Mood </li></ul><ul><li>Don’t represent evidence or have gone unchallenged </li></ul><ul><li>Have not been evaluated, instead assumed to be true </li></ul><ul><li>Learned based on history </li></ul><ul><li>See Handout </li></ul>
  26. 26. <ul><li>Assessing the Automatic Thoughts </li></ul><ul><ul><li>Question, Question, Question </li></ul></ul><ul><ul><li>Listen, Listen, Listen </li></ul></ul><ul><ul><li>Downward Arrow </li></ul></ul><ul><ul><li>Imaging a Situation </li></ul></ul><ul><ul><li>Noticing Affect and Calling Out the Thoughts </li></ul></ul>Cognitive Distortions
  27. 27. <ul><li>Strategies for Challenging and Restructuring Cognitive Distortions </li></ul><ul><ul><li>Defining Terms  </li></ul></ul><ul><ul><li>Cost-Benefit Analysis of Idea or Belief  </li></ul></ul><ul><ul><li>Modified 5-Column/Testing the Evidence  </li></ul></ul><ul><ul><li>Testing the Utility of the Evidence  </li></ul></ul><ul><ul><li>Evaluating Labels  </li></ul></ul><ul><ul><li>Changing Behavior to Test Ideas  </li></ul></ul><ul><ul><li>Examining Should Statements  </li></ul></ul><ul><ul><li>Articulating Values and Changing Them  </li></ul></ul><ul><ul><li>Progress not Perfection  </li></ul></ul><ul><ul><li>Old Rules, New Rules  </li></ul></ul><ul><ul><li>New Bill of Rights  </li></ul></ul><ul><ul><li>Monitor Feelings/Ideas and Label Distortions  </li></ul></ul><ul><ul><li>Downward Arrow/Vertical Decent  </li></ul></ul>Cognitive Distortions Loosely Based on Leahy, 2003
  28. 28. <ul><li>Cognitive Distortions </li></ul><ul><ul><li>Mind Reading : Assuming you know what others are thinking </li></ul></ul><ul><ul><li>Future Predicting : Appraisal of future events </li></ul></ul><ul><ul><li>Catastrophizing : Predicting the worst possible outcome </li></ul></ul><ul><ul><li>Labeling : Using global labels to describe yourself or others </li></ul></ul><ul><ul><li>Black-White Reasoning : Thinking in all or none terms not shades of gray </li></ul></ul><ul><ul><li>Regret Orientation : Looking back and not living in the moment of the now </li></ul></ul><ul><ul><li>Arbitrary Inferences : Drawing conclusions from little or no evidence </li></ul></ul><ul><ul><li>Filtering : Noticing only the things that confirm your ideas </li></ul></ul><ul><ul><li>Personalizing : Thinking that everything is your fault or that others are targeting you specifically </li></ul></ul><ul><ul><li>Overgeneralizing : Using evidence from a specific context and applying a “rule” to many other contexts </li></ul></ul><ul><ul><li>Should/Would/Could : Thinking in terms of morals or shoulds, rather than the actual evidence in the situation </li></ul></ul>Cognitive Distortions Loosely Based on Leahy, 2003
  29. 29. Behavioral Activation <ul><li>Behavioral Activation is Designing Actions into a Patient’s Behavioral Repertoire </li></ul><ul><ul><li>Activity Scheduling </li></ul></ul><ul><ul><li>Pleasure Scheduling </li></ul></ul><ul><ul><li>Functional Behavior Analysis in the Session </li></ul></ul><ul><li>Reward Erosion and Mood Problems </li></ul><ul><ul><li>+ + - </li></ul></ul>
  30. 30. Behavioral Activation <ul><li>Activity Scheduling </li></ul><ul><ul><li>Activity Monitoring and Recording </li></ul></ul><ul><ul><ul><li>Mastery </li></ul></ul></ul><ul><ul><ul><li>Pleasure </li></ul></ul></ul><ul><ul><ul><li>Hour Blocks vs. Sections of the Day </li></ul></ul></ul><ul><ul><li>Activity Scheduling </li></ul></ul><ul><ul><ul><li>Designing Routines </li></ul></ul></ul><ul><ul><ul><li>Increasing High Ms and Ps </li></ul></ul></ul>
  31. 31. Behavioral Activation <ul><li>Pleasure Scheduling </li></ul><ul><ul><li>Inventories </li></ul></ul><ul><ul><ul><li>Past </li></ul></ul></ul><ul><ul><ul><li>Present </li></ul></ul></ul><ul><ul><ul><li>Wishes </li></ul></ul></ul><ul><ul><li>Scheduling the Pleasure </li></ul></ul><ul><ul><ul><li>Behavioral Experiments </li></ul></ul></ul><ul><ul><ul><li>Self-Monitoring </li></ul></ul></ul><ul><ul><ul><li>Foot in the Door First </li></ul></ul></ul>
  32. 32. Behavioral Activation <ul><li>Application of Functional Analysis </li></ul><ul><ul><li>Use of the Therapy Relationship to Differentially Deliver Reinforcement or Punishment </li></ul></ul><ul><ul><li>Identification of Clinically Relevant Behaviors </li></ul></ul><ul><ul><ul><li>CRB1: Those to Decrease </li></ul></ul></ul><ul><ul><ul><li>CRB2: Those to Increase </li></ul></ul></ul><ul><ul><li>Observe CRBs </li></ul></ul><ul><ul><li>Elicit CRBs </li></ul></ul><ul><ul><ul><li>Develop Alternate Behaviors to CRB1s </li></ul></ul></ul><ul><ul><li>Differentially Apply Rewards </li></ul></ul><ul><ul><li>Design Generalization invivo </li></ul></ul><ul><li>Cuijpers, van Straten, and Warmerdam (2007) showed in meta-analysis that Behavioral Activation was Effective </li></ul>See Kanter, Manos, Busch, and Rusch, 2008
  33. 33. Behavioral Activation <ul><li>Self-Determination </li></ul><ul><ul><li>Development of Personal Goals </li></ul></ul><ul><ul><li>Identification of Stimuli to Old Behaviors </li></ul></ul><ul><ul><li>Modification of Stimuli Exposure </li></ul></ul><ul><ul><li>Training New Behaviors to Stimuli (Self-Regulation of Natural Prompts) </li></ul></ul>
  34. 34. Relaxation Therapy <ul><li>Controlled Breathing </li></ul><ul><ul><li>Concentration </li></ul></ul><ul><ul><ul><li>Rhythm </li></ul></ul></ul><ul><ul><ul><li>Sensations </li></ul></ul></ul><ul><ul><li>Suggestive Relaxation </li></ul></ul><ul><ul><li>16 Muscle Group PMR </li></ul></ul><ul><ul><li>Practice 2x per day </li></ul></ul>
  35. 35. Relaxation Therapy <ul><li>Uses of Relaxation Therapy </li></ul><ul><ul><li>Cued Affect Management </li></ul></ul><ul><ul><li>Counter-conditioning </li></ul></ul><ul><ul><li>Management of Physiologic Stimuli </li></ul></ul>
  36. 36. Overcoming “Resistance” <ul><li>Use of Socratic Methods </li></ul><ul><ul><li>How Likely to Do? </li></ul></ul><ul><ul><li>Reasons Not To? </li></ul></ul><ul><ul><li>How to Overcome Not To </li></ul></ul><ul><li>Framework of “No Choice” List </li></ul><ul><li>Pros/Cons </li></ul><ul><li>Application of Stages of Change </li></ul>
  37. 37. Overcoming “Resistance” <ul><li>Stages of Change </li></ul><ul><ul><li>Pre-Contemplative </li></ul></ul><ul><ul><ul><li>Educate Patient </li></ul></ul></ul><ul><ul><li>Contemplative </li></ul></ul><ul><ul><ul><li>Strategies such as Pros-Cons or Cross-Examiner </li></ul></ul></ul><ul><ul><li>Decision </li></ul></ul><ul><ul><ul><li>Decision to/Decision not to, Pros-Cons </li></ul></ul></ul><ul><ul><li>Action </li></ul></ul><ul><ul><ul><li>Graduated Exposure Strategy </li></ul></ul></ul><ul><ul><ul><li>Foot in the Door </li></ul></ul></ul><ul><ul><ul><li>Noticing Action and its Impact </li></ul></ul></ul><ul><ul><li>Anti-Contemplative </li></ul></ul><ul><ul><ul><li>A Different Day, A Different Time </li></ul></ul></ul><ul><ul><ul><li>Push-Pull Strategy </li></ul></ul></ul>
  38. 38. Application to Anxiety <ul><li>Retraining the Brain: Habituation </li></ul><ul><ul><li>Habituation is the result of extended exposure to an anxiety provoking stimulus </li></ul></ul><ul><ul><ul><li>Anxiety typically elevates beyond typical levels due to defeat of avoidance or escape </li></ul></ul></ul><ul><ul><ul><li>Anxiety begins to drop after extended exposure </li></ul></ul></ul><ul><ul><ul><li>Anxiety usually flattens and persists at a reduced level for several minutes during the exposure </li></ul></ul></ul><ul><ul><ul><li>Over repeated exposure activities, anxiety ceases to elevate clinically when the anxiety provoking stimulus is presented </li></ul></ul></ul><ul><ul><ul><li>Habituation is seen in </li></ul></ul></ul><ul><ul><ul><ul><li>Systematic Desensitization using Graduated Exposure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Exposure and Response Prevention (ExRP) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Direct Exposure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Narrative Story Telling Interventions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Flooding </li></ul></ul></ul></ul>
  39. 39. Application to Anxiety <ul><li>OCD </li></ul><ul><ul><li>OCD is conceptualized as an anxiety disorder driven by </li></ul></ul><ul><ul><ul><li>mis-appraisal of the threat posed by intrusive, obsessive thoughts </li></ul></ul></ul><ul><ul><ul><li>use of ritualized behaviors or cognitive patterns to escape the anxiety </li></ul></ul></ul><ul><ul><ul><li>use of avoidance behaviors to end exposure to triggers associated with the obsessive thoughts </li></ul></ul></ul>
  40. 40. Application to Anxiety <ul><li>OCD </li></ul><ul><ul><li>Assessment in CBT is typically done with one of several instruments, although usually it is the Yale-Brown Obsessive Compulsive Scale (YBOCS) </li></ul></ul><ul><ul><ul><li>Identification of historical and current obsessions and compulsions </li></ul></ul></ul><ul><ul><ul><li>Identification of target obsessions and compulsions, with SUDS ratings of each to create a hierarchy </li></ul></ul></ul><ul><ul><ul><li>Identification of avoidance behaviors </li></ul></ul></ul><ul><ul><ul><ul><li>SUDS = Subjective Units of Distress Scale using 0 to 100 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Must create behavioral anchors to ratings for patient </li></ul></ul></ul></ul>
  41. 41. Application to Anxiety <ul><li>OCD </li></ul><ul><ul><li>Treatment with CBT is primarily Exposure and Response Prevention (ExRP) Therapy </li></ul></ul><ul><ul><ul><li>Exposure </li></ul></ul></ul><ul><ul><ul><ul><li>Patient collection of obsessive thoughts per theme </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Creation of Exposure Narrative—Often recorded </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Design of 90 minute exposure to be done daily </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Creation of SUDS tracking form throughout Exposure exercise </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Safety plan for atypical NSEs </li></ul></ul></ul></ul>
  42. 42. Application to Anxiety <ul><li>OCD </li></ul><ul><ul><li>Treatment with CBT is primarily Exposure and Response Prevention (ExRP) Therapy </li></ul></ul><ul><ul><ul><li>Response Prevention </li></ul></ul></ul><ul><ul><ul><ul><li>Identification of Ritual Structure for each Obsession </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Identification of Avoidance Patterns </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Creation of Behavioral Plan to stop Rituals and Avoidance </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Creation of tracking form for ritual and avoidance performance </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Behavioral Description </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Situational Factors </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Emotional Experiences </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Outcome of Ritual or Avoidance </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Used to Create Better Response Prevention Plans </li></ul></ul></ul></ul></ul>
  43. 43. Application to Anxiety <ul><li>OCD </li></ul><ul><ul><li>Relapse Prevention and Fading </li></ul></ul><ul><ul><ul><li>Use of graphs to create evidence </li></ul></ul></ul><ul><ul><ul><li>Cognitive Restructuring regarding beliefs about competency to manage OCD </li></ul></ul></ul><ul><ul><ul><li>Cognitive Restructuring to differentiate self from OCD </li></ul></ul></ul><ul><ul><ul><li>Fading the session length and frequency as habituation occurs </li></ul></ul></ul><ul><ul><ul><li>Development of plan should obsessions become more controlling again </li></ul></ul></ul><ul><ul><ul><li>Booster Sessions as a normative expectation </li></ul></ul></ul>
  44. 44. Application to Anxiety <ul><li>OCD </li></ul><ul><ul><li>Case Example </li></ul></ul><ul><ul><ul><li>Exposure Tape  </li></ul></ul></ul><ul><ul><ul><li>SUDS data </li></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>
  45. 45. Application to Anxiety <ul><li>Generalized Anxiety Disorder </li></ul><ul><ul><li>Characterized by Uncontrollable Worrisome Thoughts that have several themes </li></ul></ul><ul><ul><li>Anxiety Provocation is Based on the Appraisal of Risks in the Cognitions coupled with Estimates of Probability and Believability </li></ul></ul><ul><ul><li>Anxiety is experienced as elevated but not panic-like, and occurs physically as well as subjectively </li></ul></ul>
  46. 46. Application to Anxiety <ul><li>Generalized Anxiety Disorder </li></ul><ul><ul><li>Assessment </li></ul></ul><ul><ul><ul><li>Use of Scale like Beck Anxiety Scale or Zung </li></ul></ul></ul><ul><ul><ul><li>Collect Diary of Worrisome Thoughts </li></ul></ul></ul><ul><ul><ul><li>Develop SUDS for each Theme </li></ul></ul></ul><ul><ul><ul><li>Identify Anxiety Components (e.g., subjective experience, physiologic arousal) </li></ul></ul></ul><ul><ul><ul><li>Identify Safety Behaviors </li></ul></ul></ul><ul><ul><ul><ul><li>Self vs. Other Behaviors </li></ul></ul></ul></ul><ul><ul><ul><li>Identify Magic Cognitions (Worry Prevents Catastrophe) </li></ul></ul></ul>
  47. 47. Application to Anxiety <ul><li>Generalized Anxiety Disorder </li></ul><ul><ul><li>Treatment Components </li></ul></ul><ul><ul><ul><li>Relaxation Therapy to Manage Anxiety Arousal </li></ul></ul></ul><ul><ul><ul><li>Use of Theme-based Scripts for Exposure Exercises </li></ul></ul></ul><ul><ul><ul><li>Cognitive Restructuring to Modify Estimates of Likelihood and Believability </li></ul></ul></ul><ul><ul><ul><li>Modification of Safety Behaviors (e.g., calling spouse to see if safe) </li></ul></ul></ul>
  48. 48. Application to PTSD <ul><li>Rape Trauma </li></ul><ul><ul><li>Direct Exposure Therapy </li></ul></ul><ul><ul><li>Use of Cognitive Reprocessing </li></ul></ul><ul><ul><ul><li>Modification of View of Self </li></ul></ul></ul><ul><ul><ul><li>Modification of Limited Event Recall </li></ul></ul></ul><ul><ul><li>Development of Realistic Risk Appraisal </li></ul></ul><ul><ul><li>Development of Personal Safety Skills (Coping) </li></ul></ul>
  49. 49. Application to PTSD <ul><li>Childhood Trauma </li></ul><ul><ul><li>STAIR </li></ul></ul><ul><ul><ul><li>Affect Regulation </li></ul></ul></ul><ul><ul><ul><ul><li>Development of Language of Emotion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Development of Emotional Self-Soothing Skills </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cognitive Distraction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Distress Tolerance & Behavioral Activation of Pleasurable Experiences </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Acceptance of Emotions and Reframing Emotions as Valued </li></ul></ul></ul></ul>
  50. 50. Application to PTSD <ul><li>Childhood Trauma </li></ul><ul><ul><li>STAIR </li></ul></ul><ul><ul><ul><li>Interpersonal Connection </li></ul></ul></ul><ul><ul><ul><ul><li>Identification of Interpersonal Schemas & Common Life Behaviors </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Self-Awareness of Conflict between Trauma Emotions vs. Goals for Interpersonal Relationships </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Modification of Self-Defeating Behaviors Through Role Playing </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Identification of Power and Control Issues in Role Playing </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Assertiveness Skills and Beliefs of Basic Rights </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Creation of Interpersonal Conflict Management Skills </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fostering Flexibility Within Power-Differential Relationships </li></ul></ul></ul></ul></ul>
  51. 51. Application to PTSD <ul><li>Childhood Trauma </li></ul><ul><ul><li>STAIR </li></ul></ul><ul><ul><ul><li>Narrative Story Telling as Exposure </li></ul></ul></ul><ul><ul><ul><ul><li>Creation of Memory Targets </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Assurance of Hope and Betterment of Life </li></ul></ul></ul></ul><ul><ul><ul><li>Skills Using Emotional Management Strategies at end of Exposure & Staying in the Present </li></ul></ul></ul><ul><ul><ul><li>Identification of Negative Emotions During Narrative </li></ul></ul></ul><ul><ul><ul><li>Identification of Negative Interpersonal Schemas in the Narrative </li></ul></ul></ul><ul><ul><ul><li>Contrasting Present Interpersonal Reality and New Skills to Learned Schemas </li></ul></ul></ul><ul><ul><ul><li>Applying Coping Skills to Real-Life Situations and Healthier Interpersonal Behaviors in Present Relationship </li></ul></ul></ul>
  52. 52. Application to Depression <ul><li>Self-Monitoring of Mood </li></ul><ul><ul><li>Orientation to Descriptions of Mood </li></ul></ul><ul><ul><li>Mood Logs </li></ul></ul><ul><ul><li>Three Column Strategy </li></ul></ul><ul><li>Behavioral Self-Monitoring </li></ul><ul><ul><li>Activity Log </li></ul></ul><ul><ul><li>Cataloging Positive Experiences </li></ul></ul>
  53. 53. Application to Depression <ul><li>Behavioral Activation </li></ul><ul><ul><li>Development of Three Lists </li></ul></ul><ul><ul><ul><li>Current Pleasure </li></ul></ul></ul><ul><ul><ul><li>Past Pleasure </li></ul></ul></ul><ul><ul><ul><li>Hopes/Dreams Planning </li></ul></ul></ul><ul><ul><li>Scheduling Daily Activities and Structure </li></ul></ul><ul><ul><li>Scheduling Pleasure </li></ul></ul>
  54. 54. Application to Depression <ul><li>Cognitive Restructuring </li></ul><ul><ul><li>Development of Evidence Testing Skills From Mood Logs and Activity Records </li></ul></ul><ul><ul><li>Understanding of Automatic and Distorted Cognitions </li></ul></ul><ul><ul><li>Labeling Distorted Cognitions </li></ul></ul><ul><ul><li>Modifying Distortions and Mood Through 5-Column </li></ul></ul><ul><ul><li>Using Pros/Cons and Other Cognitive Restructuring Strategies </li></ul></ul><ul><li>Stimulus Control </li></ul><ul><ul><li>Negative Mood Triggers and Management of Exposure </li></ul></ul><ul><ul><li>Development of Coping Mechanisms for Mood Triggers </li></ul></ul><ul><ul><ul><li>Skills Enhancement (e.g., parenting skills, conflict management) </li></ul></ul></ul>
  55. 55. Applications to Other Disorders <ul><li>Mastery of Your ADHD </li></ul><ul><li>Habit Reversal Therapy for Hair Pulling </li></ul><ul><li>Anger Management Using Stimulus Control and Cognitive Restructuring </li></ul><ul><li>Weight Loss Protocol Developed by Judith Beck </li></ul><ul><li>Positive Parenting Program for ADHD and Modification of Parental Incompetence Distortions </li></ul>
  56. 56. What to Do <ul><li>Develop CBT competencies </li></ul><ul><li>Identify Useful Texts Like Leahy’s books </li></ul><ul><li>Take Training from one of the Centers </li></ul><ul><li>Seek ABPP and/or ACT Certification </li></ul>
  57. 57. Questions
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