Cognitive Behavioral Therapy
Simplified
Edited By

Stephen Jambunathan and Jesjeet Singh Gill
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

1
Introduction to the
general principles of CBT
Ste...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

What Is Cognitive Behavioural Therapy (CBT)?
CBT is...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

The basic structure in CBT
1. Behavioural methods:
...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Initial Interventions
A detailed psycho-evaluation ...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

2
Basic steps in CBT
Jesjeet Singh Gill & Stephen J...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Behavioural Aspects
Relaxation Techniques
There are...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Progressive Muscle Relaxation (PMR) - Jacobsen tech...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Cognitive Aspects
A. Explaining the mechanism and s...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Example 3
Unrealistic thoughts
• I am not good enou...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Cognitive Distortions
These are misinterpretations ...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

4. Selective Abstractions
Drawing conclusions from ...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Simple questions like those listed below can be use...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

• what does this mean to me
• how is it effecting p...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Dysfunctional Thought Chart 1
Situation

Emotion
(r...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

3
CBT in Anxiety and Depression
Jesjeet Singh Gill ...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

This chapter covers various aspects of CBT with exa...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

achieved carrying out the particular activity and a...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Thursday (12/4/01)

Time

(M)

(P)

6-7 am

Woke up...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Cognitive Aspects of CBT
A. Explaining Mechanism of...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Below are a few points that proved this thought to ...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

More examples of the first 3 steps of “Daily Record...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Example 1:
Emotion - Felt depressed (rated 60%)
Sit...
Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

Example 4:
Emotion - Felt depressed (rated 80%)
Sit...
Daily Record of Dysfunctional Thoughts
Outcome
(Automatic
thought re-rated)

Outcome
(Emotion
re-rated)

There is no evide...
C. Cognitive Restructuring
In the process of identifying and challenging dysfunctional automatic thoughts the
process of c...
Example 3
He knows I‟m emotionally unwell and doesn‟t want to bother me.
My boss is ungrateful.
Reinforcement by Socratic ...
4
CBT in Adolescence
Subash Kumar Pillai & Ahmad Hatim Sulaiman

30
30
Introduction
The general public is quite unaware of the occurrence of mood and anxiety disorders
in children and adolescen...
Although the core symptoms of depression are similar in adults and in children or
adolescents, there are symptoms that are...
resembles a living room may be more appropriate. There are numerous obstacles
that must be dealt with while working with a...
Conclusions
This book is not designed to make the reader an expert therapist
in CBT, but rather teach a few simple princip...
Cognitive Behavioral Therapy

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Cognitive Behavioral Therapy Simplified

  1. 1. Cognitive Behavioral Therapy Simplified Edited By Stephen Jambunathan and Jesjeet Singh Gill
  2. 2. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d 1 Introduction to the general principles of CBT Stephen Jambunathan & Jesjeet Singh Gill 44
  3. 3. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d What Is Cognitive Behavioural Therapy (CBT)? CBT is a type of psychotherapy that helps a person change behaviour, thinking and emotions by understanding and reorganizing their relationship. The basis behind CBT is that cognition and emotions can be monitored and altered and desired behavioural change can be achieved through these changes. Thoughts help us define the mood we experience and also influence the way we behave. Thoughts and beliefs also affect our physical reaction. Our environment and subjective experiences influence attitudes, beliefs and thoughts. By understanding these connections one will be able to modify the emotional responses to our thoughts and environment. The main features of CBT are as follows: • Emphasis on the present In CBT there is no need to explore the past, as the main issue is to clarify and restructure current thinking processes and modify behaviour. • Collaborative empirism The patient and the therapist works together towards a common goal unlike the psychodynamic therapies where the therapist may evoke uncomfortable emotional reactions and transferences. In CBT, the atmosphere is one where resistance and competitiveness between the therapist and patient is reduced by a collaborative task-orientated alliance. • Specific goals One of the early steps in CBT is to identify areas to be addressed in therapy. The core structure of therapy will be determined by the goals set. With the help of the therapist the patient will be guided to target and achieve only realistic goals. The goals can be changed during the process of therapy depending on the needs of the patient. • Outcome evaluation In CBT the patient will be able to objectively evaluate the progress of therapy as he experiences changes in behaviour and mood. This is an important process that will help motivate the client to further develop his thinking skills. Although CBT is a highly structured form of therapy, the structure of the sessions can be modified depending on time constraints, the patients‟ needs and the patient-therapist contract. 55
  4. 4. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d The basic structure in CBT 1. Behavioural methods: A. Relaxation- Imagery, Breathing exercises, Progressive muscle relaxation B. Distraction- object focusing C. Distraction- sensory awareness D. Monitoring activities E. Scheduling activities F. Graded Tasks 2. Cognitive Methods: A. Explaining the mechanism and symptoms of the relevant disorder B. Identifying and challenging negative thoughts C. Cognitive restructuring Who will benefit from CBT? CBT can be of benefit to patients with most psychiatric disorders. This form of therapy is most commonly used in Depression, Anxiety disorders, Eating disorders, Substance abuse, Personality Disorders and under special supervision, for psychosis. The individual qualities of a client that would be beneficial when doing CBT include: 1. A good understanding of the basic principles of CBT 2. The ability to identify emotional responses to given situations 3. The capacity to identify automatic thoughts 4. The ability to critically analyze the evidence supporting the automatic thoughts 5. The sense of responsibility for one‟s own outcome 6. The ability to stay focused on the agreed upon targets 7. The willingness to participate actively in the home-work 66
  5. 5. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Initial Interventions A detailed psycho-evaluation is the most important first step before any form of therapy is to begin. This is to ensure a thorough understanding of the patient‟s needs and skills. Cognitive defusion will help the patient look at the problem objectively based on only the facts without being influenced by the affective component. It is a therapeutic technique to help a patient detect their thoughts and see them as a hypotheses rather than objective facts about the world. Stress reduction strategies such as relaxation therapies like breathing exercises and muscle relaxation are important to be taught early in therapy in order to enable the patient to experience relief when under acute discomfort. By being able to regulate and deal with stressful situations one will also have a subjective sense of control over particular difficult situations in their life. The patient is also encouraged to postpone all major life changes to avoid more stress and possible conflict. 77
  6. 6. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d 2 Basic steps in CBT Jesjeet Singh Gill & Stephen Jambunathan 88
  7. 7. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Behavioural Aspects Relaxation Techniques There are several techniques designed to help people learn how to relax voluntarily. Relaxation is a skill that can be learnt by anyone, applied in any situation and helps improve the state of mind. “Practice makes perfect” but one must practice only when calm. Once perfected it may be used in any tense or anxiety laden situation. If a person tries to practice this technique when under stress and without adequate mastery, the situation may become worse. Preparation for practice • A comfortable, conducive place. • No shoes, loose clothing. • Avoid eating, smoking or drinking. Preferably before meals. • Comfortable posture. • Do not force relaxation. Be patient; new skills take time to acquire. If you practice in bed at night be prepared to fall asleep midway. These sessions must be considered as additional to the basic practice sessions. Imagery Try to picture a relaxing scenic view that gives you pleasure like a beach or trees in a park. By doing so one will be distracted from the stressful situation and be able to calm down. Breathing Technique The correct technique of relaxing breathing is abdominal more than thoracic in nature and slow, deep and regular. During anxiety the pattern of breathing is fast, shallow and irregular. Self-monitoring and regular practice of correct technique in a calm state will enable a person to overcome the anxiety inducing rapid respiration. Ideally the patient is advised to control the breathing by slow inspiration for about 5 to 7 seconds, holding the breath for 5 to 7 seconds and finally slow controlled exhaling for 5 to 7 seconds. The exercise can be done in sets of 3 to 5 around 3 times daily. 99
  8. 8. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Progressive Muscle Relaxation (PMR) - Jacobsen technique The idea behind this technique is that by making muscles tense before relaxing one is able to appreciate better the sense of relaxation. Distraction also plays a role here as the person applying this technique becomes totally engrossed in the activity, paying less attention to the stressful situation. Each group of muscles must be tensed for 5 seconds before relaxing for 30 seconds. Begin either from the head or toes and move on systematically towards the other end. • Raise both eye-brows; shut eyes tightly • Clench teeth; open mouth wide. • Force head back against raised shoulders; • Flex the neck till chin meets chest. • Clench right fist • Flex right elbow • Repeat on the left. • Raise both shoulders; rotate both shoulders. • Inhale deeply and hold the breath with shoulders pulled back; exhale allowing shoulders to hang. • Tighten abdominal wall; push it out. • Push right foot forward into the floor • Raise right heel • Flex toes of right foot • Repeat for left foot. At the end of PMR keep eyes closed, maintain state of relaxation while breathing deeply and slowly. Stretch. PMR and abdominal breathing may be practiced and applied alternatively 3 to 5 times each and 3 times a day. The following behavioural aspects of CBT will be discussed in detail in chapter 3. 1. Distraction - object focusing 2. Distraction - sensory awareness 3. Monitoring activities 4. Scheduling activities 5. Graded Tasks 10 10
  9. 9. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Cognitive Aspects A. Explaining the mechanism and symptoms of the relevant disorder Clients suffering from depression or anxiety very often do not understand the cause of their symptoms. Fear of the unknown leads to perpetuation of the disorder, often leading to further deterioration in health. An example of how this is applied is discussed in chapter 3. B. Identifying and challenging negative automatic thoughts The basic idea is to help the patient elicit and test automatic thoughts and come up with rational alternatives. This is to help the patient identify and modify underlying dysfunctional assumptions and schema. The process where a patient is guided to develop alternative cognitive responses to given situations is known as cognitive restructuring. One has to identify thoughts following an event that leads to uncomfortable emotions. These thoughts are usually cognitive distortions of a real situation that causes strong emotional reactions. These thinking errors are then challenged and substituted with a non-rigid appropriate rational thought that is not anxiety provoking or self-defeating. Practicing and self-monitoring of one‟s thinking patterns takes time and will need feedback from the therapist. Once the patient has mastered the skill he will be able to use this technique for all situations in the future. Realistic thoughts are usually self-enhancing, logical, accurate and flexible. Unrealistic thoughts on the other hand are self-defeating, illogical, inaccurate and rigid. The following are examples of various realistic and unrealistic thoughts Example 1 Unrealistic thoughts • Everything is going to go wrong. Realistic thoughts • Things may not turn out the way I expected but I still can do something about it. Example 2 Unrealistic thoughts • I cant cope. Realistic thoughts • I am in a difficult situation. I will try my best. I have done it before. 11 11
  10. 10. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Example 3 Unrealistic thoughts • I am not good enough. Realistic thoughts • I have my limitations but I can try my best. I will learn how to improve. I have pulled through in the past. Example 4 Unrealistic thoughts • I am sure I have a serious medical problem. I may be dying. Realistic thoughts • The doctors have said that my symptoms are that of an anxiety disorder. I may have symptoms but all the medical tests were negative. Example 5 Unrealistic thoughts • I am sure that something dreadful is going to happen. Realistic thoughts • There is no evidence that something bad is about to happen. Nothing has so far. Example 6 Unrealistic thoughts • I don‟t think I will be able to finish the job. Realistic thoughts • I know I worry a lot but I will try my best. Example 7 Unrealistic thoughts • Life is cruel. Realistic thoughts • Yes, I have bad times before but I also have many things in life to be grateful for. Example 8 Unrealistic thoughts • My life is a very sad story. Realistic thoughts • I can do something about. I can make changes. I can seek treatment. Unrealistic thoughts are a result of cognitive distortions, a way of coming to conclusions that are not accurate or without reason or evidence. As a result of persistent distortions of thinking one may develope negative automatic thoughts (NATs). 12 12
  11. 11. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Cognitive Distortions These are misinterpretations of reality that reinforce negative conclusions. Examples of cognitive distortions are as follows: 1. Arbitrary Inferences This occurs when one comes to conclusions about themselves or environment without suggestive evidence. Examples A person begins to think that he is the sole cause of his football team‟s defeat because his coach said that a few players played very badly. A secretary feels she is going to be sacked because the manager said that he will be sacking some staff. 2. Over-generalizing A single instance is taken as an example of a wide range of situations. Examples A child is scolded by her mother for not helping with the house cleaning. She concludes that she is not a good daughter. A person who has experienced a break-up in a relationship jumps to the conclusion that he is a failure in all relationships. 3. Dichotomous Thinking Also called Polarized or All or none thinking. This occurs when a person feels that the failure to achieve complete success indicates total failure. Examples “If I don‟t get first position in class examinations I am a total failure.” In this case even 2nd position is as good as complete failure. A person who feels everything must be perfect for them without considering the fact that it would be nice if everything was perfect and that not everything comes out the way they expect. 13 13
  12. 12. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d 4. Selective Abstractions Drawing conclusions from only particular aspects of an event or situation without looking at the whole picture. Examples Feeling that one is responsible for a mishap when actually many other contributing factors were involved. A student who has failed in one subject at school feels as if he is a total failure and will never make it to university. He however fails to realize that he also scored straight A‟s in all other subjects. 5. Personalizing Feeling responsible for everything around or relating any external event to themselves. Examples Feeling solely responsible for the mistakes made by a team of people. Feeling that the class teacher does like him because she did not chose him when he raised his hand up as a volunteer for a project. 6. Minimizing and Magnification Down playing positive situations or exaggerating negative events respectively. Examples A person is given a complement by the boss but feels that his achievement was not all that special and did not deserve the complement. A high achiever is given some constructive criticism but feels that the criticism indicates that everything is not appreciated or recognized. Negative Automatic Thoughts (NATs) These are thoughts that automatically come to mind when in certain situations. These thoughts evoke emotions that often lead to a disorder. NATs can be challenged by rational questioning and examination of the evidence supporting this thought. 14 14
  13. 13. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Simple questions like those listed below can be used to check the accuracy of the NATs. • Is it true? • I am over reacting? • Can it be explained in any other way? • What is the evidence? • Am I experiencing an emotion without thinking about things first? • Am I jumping to conclusion? • Is it as bad as I think it is? Assumptions and Core Beliefs Assumptions and core beliefs are deeply ingrained patterns of thinking with regards to more general themes such as opinions about the world, life in general, past experiences and about people around us. These ways of thinking are beliefs that are formed through repeated past experiences. They are not easily assessed or accessed as they are deduced from recurrent cognitive distortions and automatic thoughts, mainly from childhood early experiences. Examples 1.Everyone is selfish 2.Life is full of failures 3.This world is unkind 4.You can never depend on anyone Cognitive Restructuring The process of cognitive restructuring basically helps the client to alter the cognitive appraisal by self questioning.The therapist can best help the client actively come up with alternative solutions and responses to a given situation by using the technique of socratic questioning. This is a style of questioning that encourages the client to exercise the skill of problem solving. Examples of Socratic questioning are as follows. • why do I feel like this • what are alternative explanations • what is the evidence 15 15
  14. 14. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d • what does this mean to me • how is it effecting people around me • can I do things a different way This form of questioning will help the client explore the relationship between conscious cognitions and dysfunctional assumptions. The key factor here is to help the client think rationally before reacting with emotions. Often emotions are evoked given a specific situation without a rational trigger. This dysfunctional process leads to exaggerated and uncomfortable emotions. The dysfunctional thought chart or thought record is used to monitor thoughts and emotions. This chart helps us develop the skills of writing down and analyzing our thoughts and not just automatically reacting emotionally to the negative automatic thoughts (NATs). By using the chart, one will come to realize that the NATs affects their emotions in certain situations without adequate reason. The severity of the mood disturbance is almost always out of proportion. Listing down the points in favour of the NATs and points against the NATs the client will come to realize how the cognitive distortions makes us jump to unhealthy and self-defeating conclusions. This chart can be modified depending on the suitability to the patient. The following two charts are examples of how the dysfunctional thoughts chart can be modified. The main outcome is for the patient to be able to realize that the Automatic Thoughts or NATs, if challenged will lead to a reduction in the severity of the emotions experienced. 16 16
  15. 15. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Dysfunctional Thought Chart 1 Situation Emotion (rate ) NATs Evidence in favour of NATs Emotion (re-rate) Evidence contradicting NATs This chart uses the columns to evaluate the pros and cons of the NATS and re-rate the intensity of mood. Dysfunctional Thought Chart 2 Emotion (rate ) Situation Automatic thoughts (rate) Alternative responses Outcome (Automatic thought re-rated) Outcome (Emotion re-rated) This chart uses the columns to evaluate, rate and re-rate conviction of NATs and the resulting intensity of emotions. 17 17
  16. 16. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d 3 CBT in Anxiety and Depression Jesjeet Singh Gill & Stephen Jambunathan 18 18
  17. 17. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d This chapter covers various aspects of CBT with examples from case studies. 1. Behavioural aspects of CBT 2. Cognitive aspects of CBT 1.Behavioural Aspects of CBT A. Relaxation - Breathing exercises (refer to previous chapter). B. Distraction - Object Focusing This can be used to distract the mind when the person is constantly thinking of matters that makes the person depressed or anxious. Teach the person to focus attention on an object, (using paper clips that are lying on the therapists table as example), and describe it or them in detail, and try to answer questions such as „where exactly are they?‟, „what exactly are they used for?‟, „what are they made of?‟, „what‟s their sizes?‟ etc. Remember, only with repeated practice will this be beneficial. C. Distraction - Sensory Awareness A distraction technique that can be used to distract the mind in someone who is depressed or anxious. Teach the person to focus on the surroundings, using all senses (sight, smell, touch, hearing, taste), and ask oneself questions such as: ~ what can I see around me? ~ what can I hear? ~ what can I feel on my body, head etc? Again remember, only with repeated practice will this be beneficial. D. Monitoring Activities Used when a depressed or anxious patient complains that she spends her time doing nothing useful or enjoyable. Activity monitoring provides information regarding the patients overall level of activity. This allows us to test the patients notion that she is not doing anything. If this so happens to be true, this self monitoring method helps identify how and where difficulties arise, and allows the planning of a more satisfying pattern of activities (refer to “Scheduling Activities” on page 20). Example: The patient was told to record what she does on an hourly basis in a “Weekly Activity Schedule” record sheet. She was told to rate each activity out of 10 for “Mastery”(M), where it was explained that a score of 10 indicates that she fully 19 19
  18. 18. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d achieved carrying out the particular activity and a score of 0 indicates she was not able to carry out the activity at all. She was also instructed to rate the “Pleasure”(P) that she experienced in carrying out the activity, where a score of 10 meant she fully enjoyed the activity and a score of 0 indicates there was no pleasure at all associated with the activity. An example of a completed “Weekly Activity Schedule” is illustrated on page 21. Going through the recorded activities, the therapist pointed out that it was not exactly true that the patient did not do anything the whole day. It was probably only during the afternoons and evenings that the patient was inactive. The therapist together with the patient also detected the activities that gives some degree of pleasure to the patient, particularly cooking (M = 6, P = 6-7) and chatting with her sister (M = 9, P = 8). Activities such as watching television, listening to radio and reading newspapers were also rated low in both the Mastery and Pleasure scales. E. Scheduling Activities Explain to the patient that people generally function better when they have a schedule and it allows them to avoid inactivity and engage in activities that are mainly pleasurable. Using the same example in “Monitoring Activities”, it was decided that the patient will take sole responsibility for carrying out the cooking chores at home for every meal (including breakfast). This would enable her to spend longer periods cooking. The patient decided to try to start doing some gardening, an activity she felt she could enjoy in the afternoon. F. Graded Task Assignments A depressed person can become unmotivated and lose the ability to carry out routine tasks which they could do before. By using a graded or „step by step‟ method, they may be capable of completing these tasks. When they do so, they usually experience satisfaction and an improvement in their mood, which motivates them to tackle more difficult tasks. Example: A patient who was previously good at knitting, is unable to do so now (M = 1, P = 1). The therapist and the patient came up with a „graded‟ method of carrying it out. It was decided that the patient would target 3 lines of stitching a day only. By achieving this limited target the patient began to enjoy the activity more and experienced a sense of achievement. 20 20
  19. 19. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Thursday (12/4/01) Time (M) (P) 6-7 am Woke up, prayers 2 2 7-8 am Took shower 9 2 8-9 am Breakfast 8 3 9-10 am Do washing 5 3 10-11 am Helped sister cook 6 7 11-12 pm Listen to radio 1 2 12-1 pm Read newspaper 5 3 1-2 pm Lunch 1 3 2-3 pm Talking to sister 9 8 3-4 pm Slept 5 5 4-5 pm Watch TV 3 3 5-6 pm Watch TV 3 3 6-7 pm Watch TV 3 3 7-8 pm Helped sister cook 6 6 8-9 pm Watch TV 3 4 9-10 pm Went to bed 2 2 Weekly Activity Schedule 21 21
  20. 20. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Cognitive Aspects of CBT A. Explaining Mechanism of Depression and Anxiety Simple explanations on how depressive and anxiety disorders occur and how they cause physical symptoms will reduce the level of worry or anxiety and as a result help reduce the severity of the disorder. Explain that depression gives rise to negative thoughts, which may frequently be illogical, and which would in turn worsen the depression. Similarly, inaccurate beliefs about bodily sensations may lead to panic attacks. These beliefs along with the subsequent beliefs about the origin of the panic attacks may worsen the situation. The aim of CBT is help the patient identify, understand and challenge these beliefs or thoughts in order for him to feel better. B. Identifying and Challenging Negative Thoughts Explain that depressed persons frequently have negative views about themselves, their current experiences and the future, and these beliefs are formed as a result of negative or dysfunctional thoughts. These thoughts occur automatically, are usually illogical or irrational, and worsen their depression. In anxiety disorders negative thoughts such as misinterpretation of bodily sensations may result in a catastrophic reaction. In order to improve, one should be able to identify and challenge these thoughts. Give examples to the patient to help him understand. Examples A depressed clerk felt sad and useless as she thought her boss hated her as he did not acknowledge her as she passed his desk. It was explained that here, the negative thought was “my boss hates me” and it was deemed irrational as there are many possible reasons to why her boss did not acknowledge her; for example, he was to engrossed in his work. A 40 year old man had a panic attack and felt he was going to die of a heart attack. A relative had passed away due to a heart ailment one month earlier. The therapist help the patient identify the dysfunctional thought by a series of Socratic questions. The NAT the patient eventually uncovered was “ I am having a heart attack. I am going to die”. 22 22
  21. 21. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Below are a few points that proved this thought to be irrational and self-defeating. 1. I have just completed a heart examination and the doctor said I was well. 2. I know that I have panic attacks and it does go away when I do breathing exercises. 3. I am still upset and preoccupied with the death of my relative. Teach the patient to recognize negative thoughts in three steps by using a “Daily Record of Dysfunctional Thoughts” form. (refer to pages 17 and 27 ) Step 1 Identify adverse emotions when they occur (ie: sad, angry, anxious) and rate the intensity or severity in percentage. Using the same example, „sad - 80%‟ would be filled in the adverse emotion column in the “Daily Record of Dysfunctional Thoughts” form. Step 2 Identify the situation this emotion occurs in. Here, „boss did not acknowledge me as I passed his desk‟ would be filled in the adverse situation column. Step 3 Identify „Negative automatic thoughts‟ or „dysfunctional thoughts‟. These thoughts are identified by recollecting their thoughts at that time that could have led to the emotion. The patient believed that her boss hated her and this made her feel sad. Ask the patient to then rate in percentage how much she believed in this thought. She said 75%. Therefore “my boss hates me - 75%” and this was filled in the Negative automatic thoughts column. Give as many examples as possible to help the patient understand better. Once she has grasped the concept, encourage her to fill in the “Daily Record of Dysfunctional Thoughts” form each time she experiences an unpleasant emotion and rate the emotion and accompanying dysfunctional thoughts. Only the first three columns are used initially so as to enable the patient to master this skill in steps. Remember, only with practice can the patient be adequately skilled in identifying negative thoughts. You may have to go through this several times with the patient. Only when the patient is able to do this task smoothly, should you proceed to step 4, Challenging Negative Thoughts and the subsequent steps. 23 23
  22. 22. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d More examples of the first 3 steps of “Daily Record of Dysfunctional Thoughts” are as follows: Emotion - Felt depressed (rated 60%) Situation - Sat in front of the television the whole evening doing nothing Automatic thoughts - I will never get a job as I can‟t even do anything (belief rated 80%) Emotion - Felt anxious (rated 10%) Situation - Walked to a nearby stall to by some cakes for the house Automatic thoughts - I might get a panic attack (belief rated 10%) Emotion - Felt depressed (rated 70%) Situation - A friend called on the phone. Later wondered why my boss has not called me up in a long time. Automatic thoughts - I must be useless that even my boss doesn‟t bother to call me (belief rated 60%). Challenging Negative Thoughts (refer to chart on page 27) Once the patient is adequately skilled in identifying negative thoughts, the next step is to teach her how to challenge them. This is done by using the skills of Socratic questioning. Examples: ~ what is the evidence? ~ what alternate rational explanations are there? ~ what are the advantages / disadvantages of this way of thinking? Once the alternate rational explanations are elicited, the patient‟s belief in these new thoughts should be rated in percentages and filled in the “Alternative Thoughts Column” in the Daily Record of Dysfunctional Thoughts form.Teach the patient to compare these thoughts and beliefs with the initial negative thoughts. Now, the patient should re-rate both the initial unpleasant emotion (sad, angry, and anxious) and negative thoughts in the “Outcome” column. Below are several examples that can be used to teach the patient. Another way of using the chart is by rating only the emotions and NATs and re-rating the NATs and Emotions after challenging the dysfunctional thoughts. In the example discussed above, the alternative thoughts were also rated. The columns that are rated and rerated may vary depending on the patient‟s skills and ability to analyze their own thoughts. 24 24
  23. 23. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Example 1: Emotion - Felt depressed (rated 60%) Situation - Sat in front of the television the whole evening doing nothing Automatic thoughts - I will never get a job as I can‟t even do anything (belief rated 80%) Alternative responses - There is no evidence as I‟ve not even tried to look for a job (belief rated 90%) I‟m ill at the moment but my illness is improving and soon will be able to go back to work (belief rated 80%) Outcome - Automatic thought re-rated 40% Emotion re-rated 20% Example 2: Emotion - Felt anxious (rated 20%) Situation - Walked to a nearby stall to by some cakes for the house Automatic thoughts - I might get a panic attack (belief rated 40%) Alternative responses - Even if I get an attack, I know now that it is not life threatening (belief rated 70%) Even if I start to experience an attack, I know counter measures to make it stop. (belief rated 80%) Outcome - Automatic thought re-rated 10% Emotion re-rated 10% Example 3: Emotion - Felt depressed (rated 70%) Situation - Wondered why my boss has not called me in a long time. Automatic thoughts - I must be useless. Even my boss doesn‟t bother to call me (belief rated 60%) Alternative responses - He knows I‟m emotionally unwell and doesn‟t want to bother me (belief rated 75%) My boss is ungrateful (belief rated 80%) Outcome - Automatic thought re-rated 10% Emotion re-rated 10% 25 25
  24. 24. Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Example 4: Emotion - Felt depressed (rated 80%) Situation - Called up a old friend at her workplace but was informed that she doesn‟t work there anymore. Automatic thoughts - She never bothered to inform me. I must be insignificant. (belief rated 80%) Alternative responses - She forgot to inform me as we haven‟t been in contact for such a long time (rated 90%) Outcome - Automatic thought re-rated 40% Emotion re-rated 40% Example 5: Emotion - Felt depressed and angry (rated 70%) Situation - Woke up late on the morning of my appointment with the doctor. My sister didn‟t wake me up. Automatic thoughts - My sister must not like or bother about me as she did not wake me up even though she knows I have a doctor‟s appointment. (belief rated 60%) Alternative responses - She forgot (belief rated 80%) She didn‟t want to disturb me as I don‟t always manage to sleep late (belief rated 70%) Outcome - Automatic thought re-rated 10% Emotion re-rated 10% 26 26
  25. 25. Daily Record of Dysfunctional Thoughts Outcome (Automatic thought re-rated) Outcome (Emotion re-rated) There is no evidence as I‟ve not even tried to look for a job - 90% I‟m ill at the moment but my illness is improving and soon will be able to go back to work - 80% Automatic thought re-rated 40% Emotion re-rated 20% I might get a panic attack - 40% Even if I get an attack, I know now that it is not life threatening - 70% Even if I start to experience an attack, I know counter measures to take stop it - 80% Automatic thought re-rated 10% Emotion re-rated 10% I must be useless that even my boss doesn‟t bother to call me - 60% He knows I‟m emotionally unwell and doesn‟t want to bother me - 75% My boss is ungrateful 80% Automatic thought re-rated 10% Emotion re-rated 10% Sad 80% 27 Situation Sat in front of television the whole evening doing nothing I will never get a job as I can‟t even do anything - 80% Anxious 20% Walked to a nearby stall to buy some cakes for the house Depressed 70% A friend called on the phone. Later wondered why my boss has not called me up in a long time. Alternative responses (Rate) Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d Automatic thoughts (Rate) Emotion (Rate)
  26. 26. C. Cognitive Restructuring In the process of identifying and challenging dysfunctional automatic thoughts the process of cognitive restructuring has begun. Further emphasis on the alternative responses to NATs and how these responses prevent self defeating thinking patterns will help the client re-structure the way he thinks in response to any given situation. Socratic questioning such as questions like “What does this mean to me?”, “Are there any alternative solutions?”, “What would I advise a friend in the same position?” will help the client replace the rigid, illogical and self defeating thoughts with flexible, logical and self-enhancing thoughts. Practice and revision will eventually help the client restructure his way of thinking when in difficult and uncomfortable situations. With regards to the case scenarios discussed in this chapter, restructuring of cognition was evident when the client was able to come up with the following: Example 1 There is no evidence as I‟ve not even tried to look for a job. I‟m ill at the moment but my illness is improving and soon will be able to go back to work. Reinforcement by Socratic questioning to ensure cognitive restructuring. I should not jump to the conclusion that everything will always turn out bad for me. If I try, I may succeed. Illness will always get people down. I always work well when I am well. Example 2 Even if I get an attack, I know now that it is not life threatening. Even if I start to experience an attack, I know counter measures to take stop it. Reinforcement by Socratic questioning to ensure cognitive restructuring. Now that I am aware of the physical manifestations of stress, I will be able to cope with it. Not all symptoms suggest a near death experience. 28 28
  27. 27. Example 3 He knows I‟m emotionally unwell and doesn‟t want to bother me. My boss is ungrateful. Reinforcement by Socratic questioning to ensure cognitive restructuring. In future I will not let my worries make me come to wrong conclusions. There is always a different side to every story. I just have to think about it first. Example 4 She forgot to inform me as we haven‟t been in contact for such a long time. Reinforcement by Socratic questioning to ensure cognitive restructuring. I should not let isolated incidents make me derive at irrational conclusions without looking at things from other points of view. She may be having her own personal issues to tend to and she may be very busy. She has always been there for me and perhaps I may be taking her for granted. Example 5 She forgot. She didn‟t want to disturb me as I don‟t always manage to sleep late. Reinforcement by Socratic questioning to ensure cognitive restructuring. Perhaps I worry too much about the negative things that people might think when there are always other possibilities. Looking at my pattern of thinking, it looks to me that I tend to jump to negative conclusions without looking at other possible explanations. 29 29
  28. 28. 4 CBT in Adolescence Subash Kumar Pillai & Ahmad Hatim Sulaiman 30 30
  29. 29. Introduction The general public is quite unaware of the occurrence of mood and anxiety disorders in children and adolescents. It is customary to believe that depression can only occur in adults. Children do experience depression but it is mostly overlooked because the symptoms are unclear or tend to be more behavioural in nature. Whether it occurs in adults or in children, it still remains one of the most disabling conditions that a person can experience. According to some studies as high as 20-25% of adolescents would have at least one depressive episode by the time they reach the age of 18. It is also shown that at least 8% of high school students make serious suicidal attempts each year and there are at least 13/100,000 completed suicides each year among adolescents. It is also seen that the prevalence of depression among this group is increasing while the age of onset seems to be decreasing. There are many factors that are considered to be risk factors for depression in this group of patients. One risk factor is gender. As in adults, the female sex are more at risk of developing depression. It is also more common if there are parents with depression. Environmental stressors also play a role in causing depression. These common stressors include parental conflict, loss of parent, school failure, peer rejection, trauma or physical illness and also poor social adjustment. The other factors that may also play a role include being in a disadvantaged position (economic, ethnic, social). A chronic sense of low self esteem as well as substance abuse are additional risk factors that can contribute to the development of depression in this group. The Many Faces of Depression The diagnosis of depression in adults and children is similar. However, symptoms are very often unclear and may manifest only in behavioural changes. The common symptoms of depressin are as follows: • • • • • • • • • • • Persistent depressed/irritable mood Change in sleep Change in appetite/weight Fatigue Decreased concentration Psychomotor change Anhedonia Worthlessness Thoughts of death / suicide Guilt Hopelessness 31 31
  30. 30. Although the core symptoms of depression are similar in adults and in children or adolescents, there are symptoms that are peculiar to certain age groups. There is a greater presence of somatic symptoms and behavioural problems in children who are in pre-school and in primary school. In the pre-school children typical symptoms are often missed as they may be misunderstood as attention seeking behaviour or simply misbehaviour. Other symptoms include behavior that is regressive, a loss of interest in playing or curiousness, irritability as well as crying spells. One key symptom that needs to be assessed is the change in the level of interaction that the child has with its caregivers. Primary school children pose another challenge as again the predominating symptoms are mostly behavioural. These children often complain that they are bored and often show a gradual deterioration in their performance in school. Adolescence can be a difficult and stressful period for youngsters. It is a time when teenagers go through a phase where they experience hormonal changes and also begin to take on responsibilities as a young adult in order to achieve an identity of their own. Teenagers who are depressed tend to complain of feeling bored or even stupid. Their mood, however does not usually remain persistently low but tends to be rather reactive; where the mood does brighten up with welcomed events. This again may give the impression that the teenager is not depressed but just having a normal emotional reaction. The behavioural changes seen in depression in boys include temper tantrums and conduct problems. This may be misdiagnosed as conduct disorder. Girls on the other hand have been known to show disinhibited behaviour, sometimes misdiagnosed as a bipolar mania. Teenagers who are depressed also tend to be very sensitive to rejection and may also be intensely self-consciousness about their bodies and appearance. Cognitive Behavioral Therapy in Adolescents Cognitive behavior therapy in adolescents is generally based on adult models, including skill deficits or deviant cognitive structure present in adult repertoires. However it is only the method or manner in which the therapy is carried out that differs from adults. All emotions, thoughts and behaviors are connected and interact with environment. Adolescents seem to be more influenced by environment (modeling, prompting, rewarding, punishing) than adults. CBT seeks to identify and modify maladaptive beliefs, attitudes and behaviors and teach coping skills. The key factor in successfully implementing CBT in adolescents lies in the first few visits. These visits, if successful will allow the child to form a healthy therapeutic relationship with the therapist. It is important that the therapist see the child first instead of the parents on the first visit. If the parents insist on seeing the therapist first, then it would be advisable to spend a short time with the parents ( just to allay their fears) and spend more time with the child. The sessions should, if possible take place in a comfortable room that does not resemble a clinic. An arrangement that 32 32
  31. 31. resembles a living room may be more appropriate. There are numerous obstacles that must be dealt with while working with adolescents. Firstly, unlike adults who mostly come on their own to seek help, most teenagers would have been forced by their parents to see the therapist. The second issue is of course the stigma that is attached to seeing a psychiatrist. This often causes the child to be rather guarded or difficult in the initial sessions. These two issues may cause the initial ice breaking session to take longer, sometimes as long as a few weeks before the teenager is comfortable enough to trust the therapist. It is of utmost importance that the therapist remains patient until this happens. Most clinicians agree that humour is a good tool for ice breaking and it may be also helpful to delay talking about the stressors on the first session. It may be necessary to talk about neutral subjects until the adolescent is comfortable or ready to talk about his problems. Do not feel pressured to get results quickly. Teenagers must be reassured about the confidentiality of the sessions as many feel that the therapist is always on the side of the parents. Most sessions will often take about 45 minutes. Sometimes it may be necessary to use drawings or other tools to help the teenager express himself better. Combined or joint sessions with parents can be done at a later stage when the child is ready. If there is a need for corroborative history or clarification, a separate appointment for the parents without the child should be made at a later date. Sessions should be more flexible than the adult sessions, giving room for the adolescent to speak and express themselves freely without too much emphasis on the goals of therapy. The introduction of mood charts and relaxation/breathing exercises can be done once the sessions are on the way. The general principles remain similar to adult CBT except that it may be necessary to simplify it to some extent. The use of the activity monitoring and dysfunctional thought monitoring charts should be made more simple to ensure better comprehension and participation for the younger age group. For the very young age group who do not have the adequate writing and reading skills the emphasis should be more on the behavioural component where the effective and desired change is reinforced by positive reinforcement. 33 33
  32. 32. Conclusions This book is not designed to make the reader an expert therapist in CBT, but rather teach a few simple principles of CBT that can be applied to clients. The reader does not have to apply all the principles presented here, but rather choose the ones that might benefit clients the most, taking into account what their predominant symptoms are. Someone who complains of many anxiety symptoms would mainly benefit from the behavioural methods such as relaxation, breathing exercises and the distraction methods. Someone who complains of inactivity and low motivation can benefit from the „Monitoring and Scheduling‟ activities. Those who predominantly complain of negative automatic thoughts should be trained in the cognitive methods of identifying and challenging negative thoughts. Always remind your clients that only with practice can he or she master these methods. You may have to go through the methods several times with the client before they start to benefit from them. The principles discussed here are the simpler methods of CBT. There are of course other principles that are more specialized such as identifying Basic Schema / Silent Assumptions and Core Beliefs. Proper training should be obtained if one is to treat patients with severe disorders. 42
  33. 33. Cognitive Behavioral Therapy Simplified

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