Cognitive Behavioral Therapy


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A presentation to students in the joint Physician\'s Assistant program between Washington State University and University of Washington.

Cognitive Behavioral Therapy

  1. 1. Cognitive Behavioral Therapy Considerations, Applications, Techniques and Evaluations December 5 th , 2008. Ryan Sain, Ph.D. – Eastern Washington University
  2. 2. Cognitive Behavioral Therapy <ul><li>A form of psychotherapy based on the concept that the way we think about things affects how we feel emotionally and behave overtly. </li></ul><ul><ul><li>Is often done in a short-term sense, unlike other therapies </li></ul></ul><ul><ul><li>Addresses the interactions between thoughts, feelings and behavior. </li></ul></ul><ul><ul><li>It is not Freudian Psychotherapy </li></ul></ul><ul><li>Cognitive therapists generally seek to eliminate unproductive, debilitating thoughts or beliefs and replace them with more constructive ones. </li></ul>
  3. 3. Variations <ul><li>Cognitive behavioral therapy is part of a class of therapies called cognitive therapy. </li></ul><ul><ul><li>Any therapy that focuses primarily on thoughts and feelings as they relate to actions (behavior) </li></ul></ul><ul><li>It is often known as cognitive behavior modification </li></ul><ul><li>It is not behavior modification </li></ul><ul><ul><li>It uses all of the same techniques (for the most part) but implements them in different ways. </li></ul></ul>
  4. 4. Cognition <ul><li>Cognition means: belief, thought, expectancy, attitude or perception </li></ul><ul><ul><li>These all become points of action in CBT </li></ul></ul><ul><ul><ul><li>Addressing beliefs </li></ul></ul></ul><ul><ul><ul><li>Examining thoughts </li></ul></ul></ul><ul><ul><ul><li>Assessing expectancies </li></ul></ul></ul><ul><ul><ul><li>Evaluating attitudes </li></ul></ul></ul><ul><ul><ul><li>Investigating perceptions </li></ul></ul></ul><ul><ul><li>These are all private events </li></ul></ul><ul><ul><li>You cannot observe them directly </li></ul></ul>
  5. 5. Behavior <ul><li>Behavior is most easily defined as anything the person does. </li></ul><ul><ul><li>Any action is therefore a behavior </li></ul></ul><ul><ul><ul><li>Thinking, feeling, emoting, drinking, etc. </li></ul></ul></ul><ul><li>The behavior component of CBT is arguably the most important </li></ul><ul><li>Behavior is the method by which we evaluate if the therapy is working </li></ul><ul><ul><li>A change in behavior is the goal of the therapy. </li></ul></ul><ul><li>There are many techniques that CBT has borrowed from the behavioral modification literature (and in turn, vice versa). </li></ul>
  6. 6. How Behavior Operates <ul><li>Stimulus – response theories </li></ul><ul><ul><li>A stimulus evokes a response </li></ul></ul><ul><ul><li>To modify behavior you then have to change the stimulus or train a new response to it. </li></ul></ul><ul><li>Stimulus – response – stimulus theories </li></ul><ul><ul><li>Stimulus cues a response but does not evoke it, but the consequence (the second stimulus) is what actually changes behavior. </li></ul></ul><ul><ul><li>Change consequences and you modify behavior (generally) </li></ul></ul><ul><li>Stimulus – Organism – Response – Stimulus theories </li></ul><ul><ul><li>After the initial stimulus, the person interprets and decides what to do. Their actions are then acted upon by the consequences in place. </li></ul></ul><ul><ul><li>Modifying behavior happens at the organism or consequence stages (generally) </li></ul></ul><ul><ul><li>This is the logic of CBT </li></ul></ul>
  7. 7. Conditioning <ul><li>To understand CBT we need to understand the concept of conditioning. </li></ul><ul><li>Conditioning is the term used to describe behavior change (learning). </li></ul><ul><ul><li>Respondent conditioning </li></ul></ul><ul><ul><ul><li>Involves the conditioning of reflexes </li></ul></ul></ul><ul><ul><li>Operant conditioning </li></ul></ul><ul><ul><ul><li>Involves the conditioning of ‘voluntary’ behavior. </li></ul></ul></ul><ul><li>The procedures in conditioning are well established (some over 100 years old) and extremely robust. </li></ul><ul><ul><li>The principles have been observed across all species tested. </li></ul></ul><ul><li>They are usually focused on overt behavior </li></ul><ul><li>However, in CBT – we are focused on covert behavior (private events). </li></ul>
  8. 8. Private events <ul><li>Imagining </li></ul><ul><ul><li>If you close your eyes and imagine sitting in your back yard on a clear blue sky summer’s day you will ‘see’ all sorts of things. </li></ul></ul><ul><ul><li>This is because all those things have been conditioned to the words “blue sky” or “summer day” </li></ul></ul><ul><ul><li>You are not actually seeing them. But your body is acting as if you actually are seeing them. </li></ul></ul><ul><li>This happens for all sorts of things. </li></ul><ul><ul><li>Smells, sounds, sights, feelings, etc. </li></ul></ul><ul><ul><li>We call it conditioned sensing (respondent behavior) </li></ul></ul><ul><li>Self talk </li></ul><ul><ul><li>We learn to think to ourselves at a very early age. </li></ul></ul><ul><ul><li>This is an example of private operant behavior </li></ul></ul>
  9. 9. Private events - feelings <ul><li>Feelings are behavior </li></ul><ul><ul><li>Activity of the autonomic nervous system </li></ul></ul><ul><ul><ul><li>Breathing, heart rate, glandular secretions, etc. </li></ul></ul></ul><ul><ul><li>These covert behaviors respond well to the principles of operant and respondent conditioning. </li></ul></ul><ul><li>CBT then utilizes the techniques and methods of ‘behavior modification’ (operant and respondent conditioning) to modify private events, which will help you modify overt behavior. </li></ul>
  10. 10. A case study - Carol <ul><li>“ I’m a failure. I feel ugly and useless. I keep thinking about not being able to stay in a relationship, not being able to have a husband. I get really down and I don’t want to do anything. And then I start crying. Sometimes at work, when I’m thinking of how Fred left me, I go to the bathroom and cry. Sometimes I can’t stop crying for a whole hour.” </li></ul><ul><li>Fred and Carol were engaged for 3 years. Fred left Carol for another woman. </li></ul><ul><li>Carol has since suffered obsessive thoughts about Fred and herself. This had a negative effect on her job performance (an indicator of serious problems). </li></ul><ul><li>The therapist got carol to report her days on a 0-5 scale. 0 being very good (no ruminating thoughts) and 5 being extremely bad (obsessing about Fred) </li></ul><ul><li>Each time she experienced a thought that was going to make her cry she closed her eyes and silently yelled “stop” to herself. </li></ul><ul><li>She then brought out a set of photographs that pictured her doing things without Fred and having a grand time. </li></ul><ul><ul><li>While looking at the back of them she read statements she had written on each (e.g., I am my own boss, I can do what I want to do). The procedure took about 2 minutes to complete. </li></ul></ul>
  11. 11. Carol’s results <ul><li>Carol responded very well to the CBT </li></ul><ul><li>She changed her thoughts by engaging in private and public behavior </li></ul>
  12. 12. Case study - Dumasani <ul><li>Dumasani was a patient at SHMC. 13 yr old presented with 60% burns. 30% of which were 3 rd degree. </li></ul><ul><li>He became very violent upon wound cleaning and bandage change time. He kicked and punched and eventually broke a nurse’s nose. </li></ul><ul><li>He often stated that he was really frustrated (he did a lot for his family – even at 13 – and now couldn’t do anything). We identified that he loved taking care of kids. So we got him to feel useful by ‘watching’ some of the younger kids in the pediatric ward. </li></ul><ul><li>But he was still violent at cleaning time (but only the first one of the day). So we looked at the clock. The nurses would wake him up at 6am for a 6:15 cleaning. </li></ul><ul><li>We simply implemented a procedure where the nurse would wake him up at 5:30 for his 6:15 cleaning time. </li></ul><ul><li>From that point on – he did not fight, kick, punch or scream at any nurses. He just needed time to wake up. </li></ul>
  13. 13. CBT - Procedures <ul><li>Cognitive restructuring methods </li></ul><ul><ul><li>Rational Emotive Behavior Therapy </li></ul></ul><ul><ul><ul><li>“ scientists have just learned that the earth will crash into the sun within 24 hours” says the tv reporter. </li></ul></ul></ul><ul><ul><ul><li>“ oh well, it’s not so bad. There are still other planets.” Says the watcher. </li></ul></ul></ul><ul><li>Self-Instructional coping methods </li></ul><ul><ul><li>Helping clients develop coping skills for dealing with stressful situations that are out of their control </li></ul></ul><ul><li>Problem solving methods </li></ul><ul><ul><li>The above two focus on counteracting dysfunctional thinking and negative self-talk </li></ul></ul><ul><ul><li>This method focuses the client to develop satisfactory solutions to personal problems </li></ul></ul>
  14. 14. Rational emotive behavioral therapy <ul><li>REBT </li></ul><ul><ul><li>Problems stem from irrational statements </li></ul></ul><ul><ul><li>“ Things are so horrible I can’t possibly stand it” </li></ul></ul><ul><ul><ul><li>My fiancee is in South Africa – we don’t have good contact – primarily email. This can be overwhelming. </li></ul></ul></ul><ul><ul><ul><ul><li>But at least we are better off than my grandmother was when my grandfather was at Normandie Beach in WWII </li></ul></ul></ul></ul><ul><ul><li>The therapist will challenge irrational thoughts with with rational interpretations of disturbing events. </li></ul></ul><ul><ul><li>See Dryden and DiGiuseppe (1990) and Yankurn and Dryden (1997) </li></ul></ul><ul><li>Beck’s cognitive therapy </li></ul><ul><ul><li>Not the same as REBT but very similar </li></ul></ul><ul><ul><ul><li>Identify dysfunctional thoughts and maladaptive assumptions </li></ul></ul></ul><ul><ul><ul><li>Counteract using reality checking and hypothesis testing </li></ul></ul></ul><ul><li>Both of these procedures rely heavily on behavioral modification outside of the client’s office. </li></ul><ul><ul><li>Depressed individuals often engage in relatively few behaviors. </li></ul></ul><ul><ul><li>The therapists will direct the clients to reinstate some of these. </li></ul></ul>
  15. 15. Self-Instructional coping methods <ul><li>Use the methods of REBT and Beck but add more </li></ul><ul><li>Teach the client to cope with negative emotions rather than to just replace them. </li></ul><ul><ul><li>“ it makes me able to be in the situation, not to be comfortable, but to tolerate it. I don’t’ talk myself out of being afraid, just out of appearing afraid…you immediately react to the things you’re afriad of and then start to reason with yourself. I talk myself out of panic.” </li></ul></ul><ul><li>Identify the internal stimuli produced by the stressful situation and thoughts. </li></ul><ul><ul><li>You then teach new responses to these. </li></ul></ul><ul><li>Self instruct the methods for appropriate action </li></ul><ul><li>Self reinforcement for engaging in the coping response. </li></ul>
  16. 16. Problem solving methods <ul><li>Use this method on combination with the others </li></ul><ul><ul><li>General orientation </li></ul></ul><ul><ul><ul><li>Identify problem – and act systematically. </li></ul></ul></ul><ul><ul><ul><ul><li>Here is the issue, how can I rephrase it as a problem to be solved </li></ul></ul></ul></ul><ul><ul><li>Problem definition </li></ul></ul><ul><ul><ul><li>Specifically identify the problem. In detail. No general statements allowed </li></ul></ul></ul><ul><ul><li>Generation of alternatives </li></ul></ul><ul><ul><ul><li>Brainstorm solutions to the problem </li></ul></ul></ul><ul><ul><li>Decision making </li></ul></ul><ul><ul><ul><li>Work through the possible solutions from the previous step </li></ul></ul></ul><ul><ul><ul><li>Choose the one or two that are most likely to be implemented </li></ul></ul></ul><ul><ul><li>Verification </li></ul></ul><ul><ul><ul><li>Track your results! If not effective, work through the process again. </li></ul></ul></ul>
  17. 17. Evaluations of treatment <ul><li>REBT alone has very little empirical support. </li></ul><ul><ul><li>In a survey of 107 studies focusing on REBT it was only better than other methods 46% of the time in terms of behavioral outcomes </li></ul></ul><ul><ul><li>Only 27% of the cases showed improvement over other techniques in reducing emotional stress. </li></ul></ul><ul><li>Beck’s method </li></ul><ul><ul><li>Mixed support – but generally not positive. A large clinical trial by the NIMH resulted in a general assessment that it was no better than placebo treatment </li></ul></ul><ul><ul><ul><li>The placebo treatment turned out to be very effective. </li></ul></ul></ul><ul><ul><li>The same study found that at some sites it was equally as effective as imipramine </li></ul></ul><ul><li>In general cognitive therapy is more effective than dynamic psychotherapy but less effective than behavioral treatments alone. </li></ul>
  18. 18. Depression <ul><li>Beck’s method is a very common approach to dealing with depression. </li></ul><ul><li>However, it receives mixed results. </li></ul><ul><li>Mixing Beck’s method with drug treatment yields better results. </li></ul><ul><ul><li>But this doesn’t address the circularity of drug treatments for psychological conditions. </li></ul></ul><ul><li>Combining Beck’s method with behavioral components (as is typically done now days) produces better results than Beck’s approach alone. </li></ul>
  19. 19. Anxiety Disorders <ul><li>Generalized anxiety disorder can take on many components </li></ul><ul><ul><li>Obsession, worries, panic, bothersome thoughts </li></ul></ul><ul><li>There are a very wide range of treatments available and each treatment is usually focused on one of the specific components in the disorder. </li></ul><ul><li>CBT shows quality evidence of dealing with this disorder as does Behavioral Therapy. </li></ul><ul><li>Pharmacological treatments generally show the least amount of success for some of these conditions (phobias, panic attacks). </li></ul><ul><ul><li>But are very effective for some others – obsessions and compulsions specifically. </li></ul></ul><ul><ul><li>This research is highly plagued by placebo effects. </li></ul></ul>
  20. 20. Bulimia Nervosa <ul><li>Often treatments are a strong combination of behavioral therapy and cognitive behavioral therapy </li></ul><ul><li>Cognitive restructuring is used to change the ruminating about body weight. </li></ul><ul><li>Behavioral therapies are used to modify the behaviors of binging, purging and laxative use. </li></ul><ul><li>Behavioral contracts are frequently used. </li></ul><ul><li>This is a VERY difficult disorder to treat. </li></ul>
  21. 21. A comment about pharmacological treatments <ul><li>Pills are not a panacea </li></ul><ul><li>They often improve function in clients </li></ul><ul><li>But they DO NOT address the underlying cause of the condition. </li></ul><ul><ul><li>Yes – neurotransmitter changes cause changes in behavior. But what led to the neurotransmitter change? </li></ul></ul><ul><ul><li>The answer is often behavior. </li></ul></ul><ul><ul><li>So we must address the behaviors in question while treating with drugs to maximize the effect. </li></ul></ul><ul><ul><li>A depressed patient has no reason to be on anti-depressants for years and years. </li></ul></ul>
  22. 22. No pigeon-holing <ul><li>Do not pigeon hole any of these techniques as being the best at treating a particular disorder. </li></ul><ul><ul><li>Look at a biopsychosocial approach to treatment. </li></ul></ul><ul><ul><li>All three of these components are interacting to produce the problems you are seeing </li></ul></ul><ul><ul><ul><li>So each individual may need different treatments to deal with the issues at hand. </li></ul></ul></ul><ul><li>That said – treatments that focus on overt behavior change (no matter how you go about it) – generally see better results than ones that don’t. </li></ul>