Presentation gives brief overview of various cognitive therapies used in treating mental health disorders.

1. Cognitive
therapies.
Aratrika Roy

2. Overview
• Cognitive behaviour therapy (CBT)
• Dialectical behaviour therapy (DBT)
• Rational emotive behaviour therapy (REBT)
• Cognitive analytic therapy (CAT)
• Mindfulness based cognitive therapy (MBCT)
• Acceptance and commitment therapy (ACT)
• Problem solving therapy (PST)

3. Introduction.
• Approaches to psychotherapy fall under five broad categories:
Psychoanalysis
&psychodynamic
therapies
Sigmund
Freud,
Erikson
Behaviour
therapy
Pavlov, Skinner,
Thorndike
Cognitive therapy
Albert Ellis,
Aaron Beck
Humanistic
therapy
J.P. Satre, V.
Frankl, R. May,
Maslow, Rogers
Integrative/
holistic therapy

4. First wave
psychotherapy (BT)
Behaviour therapy
Second wave
psychotherapy (CBT)
Cognitive (Beckian)
therapy
Third wave CBT
• Mindfulness therapies
• Acceptance &
commitment therapy

5. Cognitive Behavioural
Therapy (CBT)
“The stronger person is not the one making the
most noise but the one who can quietly direct
the conversation toward defining and solving
problems.”
Aaron Temkin Beck.
(1921-2021)

6. Introduction.
• Initially developed in the early 1960s by Dr. Aaron Beck of the University of
Pennsylvania.
• During clients’ cognitive development they learn incorrect habits of
processing and interpreting information.
• Aim is thus to unravel these distortions and help them to learn more
different and realistic ways of processing and reality-testing information.

7. Basic concepts.
• ‘Cognition’ is defined as that function that involves inferences about
one’s experiences and about the occurrence and control of future
events. It includes the processes involved in identifying and predicting
complex relations among events for the purposes of adaptation.
• Humans have capacity for both primal/primitive and for higher level
cognitive processing.

8. Basic concepts.
• Schemas.
Structures that consist of people’s fundamental beliefs and assumptions.
They are meaning making cognitive structures. They are relatively stable
cognitive patterns that influence through their beliefs, how people select
and synthesize incoming information. Developed early in life through
personal experiences and identification with significant others and
reinforced by further learning experiences.

9. Basic concepts.
• Modes.
Networks of cognitive, affective, motivational and behavioural
schemas. Modes are fundamental to personality since they interpret
and adapt to emerging and ongoing situations. CBT approaches
dysfunctional modes by deactivating them, modifying their content
and structure and by constructing adaptive modes to neutralize them.

10. Basic concepts.
• Cognitive vulnerability.
Refers to humans’ cognitive frailty. Because of their schemas, each
person has a set of unique vulnerabilities and sensitivities that
predispose them to psychological distress. When they exhibit
psychological problems, their dysfunctional schemas and beliefs lead
them systematically to bias information in unhelpful ways.

12. Basic concepts.
• Automatic thoughts.
Thoughts which occur spontaneously, without effort or choice. In
psychological disorders, automatic thoughts are often distorted, extreme,
or otherwise inaccurate.
Not so deeply buried as beliefs and schemas. People’s self-evaluations and
self-instructions appear to be derived from deeper structures- their self-
schemas (deeper beliefs and assumptions).

14. Cognitive distortions.
Dichotomous thinking By thinking that something has to be either exactly as we want it or it is a failure.
“Unless I do extremely well in this exam, I’m a failure.”
Selective abstraction Picking out an idea or fact from an event to support their depressed or negative
thinking. The boyfriend who becomes jealous at seeing his GF tilt her head
towards a man at a noisy event.
Mind reading Refers to the idea that we know what another person is thinking about us.
Negative prediction When an individual believes that something bad is going to happen, and there is
no evidence to support this, this is a negative prediction.
Catastrophizing Taking one event that one is concerned about and exaggerating it so that he/she
becomes fearful. Stomach pain=cancer.
Overgeneralization. Making a rule based on a few negative events, individuals distort their thinking
through overgeneralization. A woman concludes after a disappointing date that
“All men are alike.”

15. Cognitive distortions.
Labeling and mislabeling A negative view of oneself is created by self-labeling based on some errors or
mistakes. “I faltered while speaking. I’m a horrible speaker.”
Magnification or
minimization
Cognitive distortions can occur when individuals magnify imperfections or
minimize good points. They lead to conclusions that support a belief of inferiority
and a feeling of depression.
Magnification= “If I appear the slightest bit nervous in class, it’ll be a disaster.”
Minimization= A man describing his terminally ill mother as having a slight ‘cold.’
Personalization Taking an event that is unrelated to the individual and making it meaningful
produces the cognitive distortion of personalization. “I must have done
something to offend him.”

16. Cognitive model of development of schemas.
• Individual beliefs begin in early childhood and develop throughout life. Early
childhood experiences lead to basic beliefs about oneself and one’s world.
• These beliefs can be organized into cognitive schemas.
• Positive experiences of support and love from parents, lead to beliefs such as “I
am lovable” and “I am competent,” which in turn lead to positive views/cognitive
schemas of themselves in adulthood.

17. Cognitive model of development of schemas.
• Persons who develop psychological dysfunctions, in contrast to those with healthy functioning,
have negative experiences that may lead to beliefs such as “I am unlovable” and “I am
inadequate.”
• These developmental experiences, along with critical incidents/traumatic experiences, influence
individuals’ belief systems.
• Negative experiences, such as being ridiculed by someone, may lead to conditional beliefs such
as “If others don’t like what I do, I am not valuable.”
• Such beliefs may become basic to the individual as negative/maladaptive cognitive schemas.

18. Cognitive model of development of schemas.
• Early maladaptive schemas.
Assumed to be true about themselves and their world.
Resistant to change
Cause difficulties in individual’s lives.
Usually activated by a change in one’s world (triggering event), such
as a loss of a job.

19. Cognitive model of development of schemas.
When these conditions occur, individuals often react with strong negative
emotions.
Are the result of previous dysfunctional childhood interactions with family
members.
Through these belief systems that children develop, they start to view
reality in ways that cause problems in functioning internally or with others.
Likely to continue through adolescence and adulthood.

20. The cognitive developmental model (for depression).

24. The cognitive developmental
model (for social anxiety).

25. Cognitive model of development of schemas.
Young (1999) identified 18 early maladaptive schemas which he
classified into the following 5 domains.
Disconnection &
rejection
Impaired autonomy &
performance
Impaired limits
Over-vigilance &
inhibitions
Other directedness

26. Goals of therapy.
Identifying negative automatic thoughts (NATs) and the
cognitive schemas that they represent.
Changing the dysfunctional cognitive schemas through:
Schema
reinterpretation
Schema
modification
Schema
restructuring

27. Goals of therapy.
To remove biases or distortions in thinking so that individuals may
function more effectively.
• NOTE: Generally, when establishing goals, cognitive therapists focus on
being specific, prioritizing goals, and working collaboratively with clients.
The goals may have affective, behavioral, and cognitive components.

28. Assessment in CBT.
• Careful attention is paid to
assessment of client problems and
cognitions, both at the beginning of
therapy and throughout the entire
process, so that the therapist may
clearly conceptualize and diagnose
the client’s problems.
• client interviews
• self-monitoring
• thought sampling,
• assessment of beliefs and
assumptions
• self-report questionnaires
Techniques.

29. Therapeutic process.
• Structured in approach.
Initial phase:
assessment of the problem
development of collaborative therapeutic
relationship
Case conceptualization
Middle phase:
helping client identify/learn about his
inaccurate thinking
identifying NATs
Guided discovery approach employed;
Homework assigned.
Termination phase:
insight developing
implementing learned strategies
moving towards change.

30. Therapeutic interventions.
Cognitive Behavioural
• Eliciting and identifying automatic thoughts.
 Providing reasons
 Questioning
 Encouraging clients to engage in feared activities.
 Focusing on imagery
 Self-monitoring of thoughts
 Reality testing and correcting automatic thoughts
 Conducting Socrates dialogue
 Identifying cognitive distortions
 Decatastrophizing
 Daily record of rational responses
 Identifying and modifying underlying beliefs
 Socrates questioning
 Hypothesis testing
 Using imagery
 Reliving childhood memories
 Activity scheduling
 Rating mastery and pleasure
 Hypothesis testing
 Rehearsing behaviour and role play
 Assigning graded tasks
 Diversion techniques
 Assigning homework

35. Socratic questioning

36. Activity scheduling

38. CBT effective treatment for:
• Depressive disorders
• Anxiety disorders
• Phobias
• Panic disorder
• Obsessive compulsive
disorder
• Addictive behaviours
• Personality disorders
• Eating disorders

39. Rational Emotive Behaviour
Therapy (REBT)
People and things do not upset us. Rather, we upset
ourselves by believing that they can upset us.
Albert Ellis.

40. Introduction.
• 1955: Rational therapy (RT).
• 1961: Name changed to ‘rational emotive therapy’ (RET).
• 1993: Name further changed to ‘rational emotive behaviour therapy’ (REBT).
• Based on the premise that our cognitions, emotions and behaviours are an integrated system
and when we are disturbed, we think-feel-act in dysfunctional, self-defeating ways.
• Besides aiming to teach clients rational and appropriate behaviours, REBT also aims to teach
clients how to dispute irrational ideas and self-defeating behaviours and how to use powerful
cognitive-emotive-behavioural methods as self-helping skills.

41. Introduction.
• Besides aiming to teach clients rational and appropriate behaviours,
REBT also aims to teach clients how to dispute irrational ideas and
self-defeating behaviours and how to use powerful cognitive-
emotive-behavioural methods as self-helping skills.

42. Philosophical underpinnings.
Humanism
Rationality
Responsible
hedonism
Responsible hedonism.
• Concerns maintaining pleasure over the
long term by avoiding short-term
pleasures that lead to pain, such as drug
abuse and alcohol addiction. Ellis believes
that people are often extremely
hedonistic but need to focus on long-
range rather than short-range hedonism.

43. Philosophical underpinnings.
Humanism.
• Human beings are viewed as holistic, goal-directed organisms who are
important because they are alive; is consistent with that of ethical
humanism, which emphasizes human interests over the interests of a deity.
• Ellis believes that individuals preferably should have unconditional self-
acceptance (USA). They should accept that they make mistakes, that they
have worth, and that some of their own assets and qualities are stronger
than other assets that they or others possess.

44. Philosophical underpinnings.
Rationality.
• Refers to people using efficient, flexible, logical, and scientific ways of
attempting to achieve their values and goals not to the absence of feelings
or emotions.

45. Basic concepts.
1) Fundamental and primary goals.
• 3 fundamental goals (FG): to survive, to be relatively free from pain and to be reasonable
satisfied and content.
• REBT sees humans’ basic goals as preferences/ desires rather than needs or necessities.
Rational living consists of:
 thinking/feeling/behaving in ways which contribute to the attainment of the chosen
goals;
 striking a sensible balance between short-range and long-range pleasures/ hedonism.
• Irrational living consists of thinking/feeling/behaving in ways which block the attainment
of the chosen goals.

46. Basic concepts.
2) Emotion, cognition and behaviour.
• Emotion thinking are so closely related that they
usually accompany each other, act in a circular
cause and effect relationship, and in certain
respects are essentially the same thing. And
one’s thinking and emotion both interact with
behaviour. For instance, people usually act on
the basis of thoughts and emotions and their
actions influence how they think and feel.

47. Basic concepts.
3) Healthy and unhealthy emotions.
• REBT emphasizes health or appropriate emotions.
• Healthy emotions are those which help in achieving a balance between short-range and long-range hedonism
while unhealthy emotions are those which interfere in this process.
• Both positive/pleasurable/enjoyable and negative emotions can be healthy as well as unhealthy.
Pride
Excessive
pride/arrogance
Positive
emotion
Disappointment
Frustration
Regret
Hostility
Excessive anxiety
Negative
emotion

49. Basic concepts.
4) Two biological tendencies.
• A tension exists between two opposing creative biological tendencies.
• Despite a stronger tendency towards irrationality, humans also have some degree of free choice in how much
they make themselves emotionally disturbed.
Rationality Irrationality

50. Basic concepts.
5) ABC theory of personality.
G: goals, both fundamental and primary;
A: adversities or activating events in a person’s life;
B: beliefs, both rational and irrational;
C: consequences, both emotional and behavioural;
D: disputing irrational beliefs (DIBS);
E: effective new philosophy of life.
D and E has been added later. G can
be added at the beginning to provide
a context for people’s ABCs.
A*B= C Activating event*belief (rational/irrational)= consequences (emotional/behavioural)

52. Basic concepts.
Rational beliefs Irrational beliefs
• Healthy.
• Productive, adaptive, consistent with social reality.
• Generally consists of preferences, desires and wants.
• Characterised by ‘preferential thinking.’
• When faced with adversities (A) which sabotage their
goals (G), people engaging in preferential thinking,
explicitly react with their belief systems (Bs) in realistic
ways experiencing appropriate emotional and goal-
oriented behavioural consequences (Cs).
• Unhealthy.
• Rigid, dogmatic, unhealthy, maladaptive
• Get in the way of people’s efforts to achieve their goals.
They comprise ‘demands,’ ‘musts’ and ‘shoulds.’
Characterized by ‘demanding thinking.’
• React with their belief systems (Bs) in unrealistic ways
experiencing inappropriate emotional and behavioural
consequences (Cs).

54. Basic concepts.
Irrational
beliefs
Primary
demanding
beliefs
Derivatives of
PDB
Secondary
demanding
beliefs
Derivatives of
SDB

55. Basic concepts.
People’s main
demands and
commands in
relation to
the adversity.
PDB
• Awfulizing
• I-can’t-
stand-it-it is
• Damning
oneself and
others.
Derivatives
of PDB
• To think that a certain bad event
must not exist.
• Characterized by ‘musturbatory’
thinking.
• Musts/shoulds/ought to/got to-
s/have to-s.
• When you awfulize about some
adverse situation it may serve you
well to think of this awfulizing
as falsely catastrophic.

56. Primary Demanding Beliefs

57. Derivatives of Primary Demanding Beliefs

59. Basic concepts.
The tendency to
transform the
negative
consequences
(C) of the PDB
into an adversity
or activating
event (A)
SDB
People can now
choose to create
and derive
awfulizing,
Derivatives
of SDB

61. Basic concepts.
6) Ego disturbance and low frustration tolerance.
• Ego disturbance (self-damning): arises from the belief, “I must do well and win approval for
my performances” because it leads people to thinking and feeling that they are inadequate
and undeserving persons when they do not perform as well as they must.
• Low frustration tolerance (LFT): arises from the grandiose belief that people think they are
so special that conditions must be easy and satisfying for them. (“Others must treat me
kindly and considerably!”).

62. Therapeutic goals.
Inelegant change goals Elegant change goals
• Targets symptomatic relief.
• At D, REBT targets the cognitions, emotions and
behaviours that accompany self-defeating
feelings (anxiety/ depression/ dysfunctional
behaviours like social anxiety).
• The E, focuses merely on individual
symptoms/problems.
• Targets significant lessening of client’s
‘disturbability.’
• At D, ‘musturbatory thinking’ is challenged.
• E targets symptomatic relief and most importantly
developing and implementing an effective new
philosophy of life.
 Unconditional self-acceptance (USA)
 Unconditional other-acceptance (UOA)
 High frustration tolerance (HFT)

64. Therapeutic interventions.
Detecting irrational beliefs
and their derivatives.
Disputing irrational beliefs and
their derivatives.

65. Therapeutic interventions.
Cognitive/Rational Emotive Behavioural
• Scientific questioning
(cognitive disputing)
• Rational coping
statements
• Discussion of various
aspects of irrational
thinking
• Cognitive homework
• Problem solving
• Rational-emotive-imagery
• Forceful dispute
• Role-playing
• Reverse role-playing
• Humour
• Unconditional acceptance
• Assignments that
challenge demandingness
• Shame-attacking exercises
• Skill training
• Use of rewards and
penalties

68. REBT effective treatment for:
• Depression
• Anxiety
• Addictive behaviours
• Phobias
• Overwhelming feelings of
anger, guilt, or rage
• Procrastination
• Disordered eating habits
• Aggression
• Sleep problems

69. Dialectical Behaviour
Therapy (DBT)
“Radical acceptance rests on letting go
of the illusion of control and a
willingness to accept and notice things
as they are right now, without judging.”
Marsha Linehan.

70. Introduction.
• A psychosocial treatment initially developed by Marsha Linehan for the treatment
of individuals diagnosed with borderline personality disorder (BPD).
• Cognitive-behavioural approach.
• Can help people who have difficulty with emotional regulation or are exhibiting
self-destructive behaviours (such as eating disorders and substance use disorders.
This type of therapy is also sometimes used to treat post-traumatic stress
disorder (PTSD).

71. Underlying theories.
Biosocial
theory
(Linehan, 1993)
Behavioral
theory
Dialectical
philosophy

72. Underlying theories.
1. Biosocial theory (Marsha Linehan, 1993).
• BPD primarily a disorder of emotion dysregulation;
• Emerges from transactions between individuals with biological vulnerabilities and specific
environmental influences.
• Contribution of an invalidating developmental context (characterized by intolerance toward the
expression of private emotional experiences, in particular emotions that are not supported by
observable events).
• Failure to learn how to understand, label, regulate, or tolerate emotional responses leading to
oscillation between emotional inhibition and extreme emotional lability.

74. Underlying theories.
2. Behavioural theory.
• "Behaviour" refers to anything an individual does, and includes thoughts, feelings,
and overt action.
• Any behaviour can be conceptualized according to the principles of classical and
operant conditioning and observational learning (modeling). It thus contributes
to the non-judgmental stance in DBT that every behaviour is caused.
• Behavioural interventions designed to increase the frequency of adaptive
behaviours and decrease the frequency of maladaptive behaviours.

75. Underlying theories.
3. Dialectical philosophy.
• Reality is interrelated and connected, made of opposing forces, and always changing.
• Opposite views can exist in one person at the same time (e.g., "I want to die" and "I want
to live," or "I wish to be sober" and "I want to continue to use substances"), leading to
tension and conflict, and conflict may be necessary to bring about change.
• The aim is to enhance dialectical thinking patterns (looking for truth in both positions) to
replace rigid, dichotomous thinking.
• The primary dialectic in DBT is between change and acceptance.

76. Stages of treatment.
Stage IV: Incompleteness
Stage III: Problems in living
Stage II: Quiet desperation
Stage I: Life in hell
Pretreatment stage
Pretreatment stage.
• Setting treatment goals
• Obtaining commitment to therapy
Stage I.
• Reducing ‘dyscontrol’
• Reducing life threatening behaviours
• Reducing therapy interfering behaviours
• Decreasing quality of life interfering behaviours
Increasing behavioural skills.
Stage II.
• Addressing issues of invalidation, inhibited grieving,
boredom, and emptiness.
Stage III.
• Increasing self-respect
• Improving quality of life.
Stage IV.
• Awareness of self, feelings of incompleteness, and
spiritual fulfilment.

77. Treatment module.
• Contains four treatment
modes designed to address
five functions/goals. It is
most effective when used as
full model.
Individual
therapy
Skills
training
(usually in
group form)
Phone
consultation
Therapist
consultation
team

78. Treatment module.
The five functions:
• to increase the client's motivation to change;
• to enhance the client's capabilities;
• to generalize the client's gains to his or her larger environment
• to structure the environment to reinforce the client's gains;
• to increase therapist motivation and competence

79. Individual treatment strategies.
• Diary Card, a monitoring tool on which clients record daily ratings of
emotions, problem behaviours, and skills use. If suicidal or self-injurious
behaviours have occurred, these are the primary targets of the session.
• Addressing therapy interfering behaviours such as homework non-
completion or lateness to session.
• This is followed by quality of life interfering behaviours, such as substance
use or moderate to severe depression, and behavioural skills building.

80. Individual treatment strategies.
• The therapist and client address the highest order target with a behaviour chain
analysis in which they identify links (thoughts, feelings, behaviours, and external
events) that lead up to a problem behaviour as well as consequences of
behaviour.
• A solution analysis is then used to identify points of intervention that would
disrupt this chain of events and prevent the problem behaviour from recurring.
• The therapist uses DBT strategies to increase commitment to trying the new
behaviour. Role-plays and imaginational rehearsal are used in session to help
the client practice new behaviours.

81. Group skills training.
• Skills training generally
occurs in weekly groups.
• Groups are conducted in a
psychoeducational format in
four modules.

82. Phone consultation
• Used on an as-needed basis to help clients generalize skills use outside of
the therapy room.
• Clients are encouraged to call their individual therapist when they either
need help utilizing a particular skill or when they do not know what skill to
use.
• Calls typically last between five and 15 min.
• Notably, the "24-hr rule" prohibits calling for phone coaching within 24 hr
of self-injury.

83. Therapist consultation team.
• Functions to enhance the therapists' motivation and capability to deliver effective
treatment and to adhere to DBT principles.
• Team typically comprised of 4 to 8 therapists who meet weekly for 60 to 120 min.
• Team meetings are conducted by a leader who guides the team in a mindfulness
exercise and then sets the agenda according to members' needs.
• Team members may seek help applying DBT to individual cases or may ask for
support when feeling burned out.

84. DBT effective treatment for:
• Attention-deficit/hyperactivity
disorder (ADHD)
• Bipolar disorder
• Borderline personality disorder (BPD)
• Eating disorders (such as anorexia
nervosa, binge eating disorder, and
bulimia nervosa)
• Generalized anxiety disorder (GAD)
• Major depressive disorder (including
treatment-resistant major depression
and chronic depression)
• Non-suicidal self-injury
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Substance use disorder
• Suicidal behaviour

85. Cognitive Analytic
Therapy (CAT)
Ryle, 1984.
Anthony Ryle.

86. Introduction.
• Brief focal therapy conforming to cognitive and psychodynamic roots.
• Developed by Anthony Ryle since late 1970s.
• Initially was mainly concerned with treatment of neurotic disorders. Over
the past years, has been adapted to treat personality disorders, specifically
BPD.
• Imbibed ideas from both ‘object relations theory’ and the work of
Vygotsky.

87. Structure/ underlying theories.
1) Procedural sequence model (PSM).
An attempt to understand aim-directed action, supposing that all aim-
directed activity is the consequence of ordered sequence of aims generation,
environmental evaluation, plan formation, action, evaluation of consequences
if necessary and remedial procedural revision.
Procedural sequences are based on the basis of experiences and they are
checked at the last step and revised accordingly if not effective.

88. Structure/ underlying theories.
1) Procedural sequence (PS) model.
While procedural sequences are therefore usually effective and adaptive,
some might be faulty and repeatedly used without any revision. The
repetitive use of these sequences thus lead to the development of
psychological disorders.
PS have cognitive, motivational, affective and behavioural elements.

89. A procedural sequence.

90. Structure/ underlying theories.
Unrevised faulty procedures.
Traps Dilemmas SNAG (subtle negative aspect of
goals)
• Represent repetitive cycles of
behaviour in which the
consequences of behaviour feed
back into its perpetuation.
• Representation of false choices or
of unduly narrowed options. The
final ‘check-step’ functions but
immediately switches the
individual to an opposing and
equally maladaptive procedure,
the check-stop of which in turn
switches back to the first
procedure
• Anticipations of the future
consequences of actions that are
so negative that they are capable
of halting a procedure before it
even begins.

91. Structure/ underlying theories.
Restricted repertoire of procedures.
• CAT supposes that neurotic difficulty results from the operation of unrevised
maladaptive procedural sequences.
• A second cause of difficulty was undue restriction in the procedural repertoire. Causes:
• Impoverished
environmental
opportunities for
learning new
procedures.
• E.g., in cases of
emotional deprivation
and neglect
• Deliberate attempts
by caregivers to
restrict procedural
repertoires.
• E.g., by injunctions to
secrecy in cases of
sexual abuse.
• Difficulty in new
emotional learning
owing to previously
learned faulty
procedures.

92. Structure/ underlying theories.
2) Theory of reciprocal roles
(RR).
• Was developed to improve CAT’s
capacity to deal with more debilitating
disorders (like personality disorders).
• Our early learning about the social
world is stored in the form of
internalized templates of reciprocal
roles.
RR
Role for self
Role for
other
A paradigm
for their reln.

93. Structure/ underlying theories.
• RRs are thus commonly shared
templates.
• Individual internalizes the roles
learned from their significant others
and also as a result of experiences.
• Later deployed in life which if
maladaptive can lead to interpersonal
problems with the person with whom
the particular individual was sharing a
RR.
RR
Functional or
benign
Caregiver/
care-receiver
Harsh or
dysfunctional
Bully/ victim

94. Commonly used concepts/words.
• Reciprocal roles (RRs): A named pattern of relating, originating in childhood
with an actual or internalized other.
• Reciprocal roles procedures (RRPs): the feelings/actions/beliefs resulting from being at
one end of a reciprocal role.
• Target problem procedure (TPP): the problematic RRPs that are the focus of the therapy.
The unconscious redirection of inappropriate feelings in the present, of a relationship
that was important in the past. This is helpful was identifying RRs and RRPs.

95. Commonly used concepts/words.
• Zone of proximal development (ZPD): refers to patient’s potential space for
change, with the help of another, namely the therapist.
• Scaffolding: The provision by the therapist of just sufficient support to allow
clients to do with the therapist what they cannot yet do alone. Providing a
structure (e.g., the timetable).

96. Stages.
Stage 1: Assess suitability for CAT by excluding active psychosis and substance misuse;
discuss the nature and duration of treatment (duration: approximately one session).
Stage 2: Explores client history, and uses the patient–therapist relationship as well as the
Psychotherapy File and Personality Structure Questionnaire in order to create a
reformulation of the patient’s difficulties. Patient and therapist collaborate to create a
sequential diagrammatic reformulation and narrative reformulation letter (duration:
approximately four sessions).
Stage 3: patient encouraged to use diaries and self-monitoring to identify problem
procedures. The reformulation is used to understand developments in the therapeutic
relationship, and to assimilate memories and feelings accessed as result of the work.
Awareness of the end of therapy is maintained.
Stage 4: Therapist and patient reflect upon the implications of ending therapy and
record thoughts and feelings in goodbye letters.

97. Stages/ the three ‘R’s of CAT.
Reformulation Recognition Revision

98. Brief concepts/ tools.
• The psychotherapy file.
A structured, clinical questionnaire covering a number of particular reciprocal roles and
problem procedures.
• Sequential Diagrammatic Reformulation (SDR).
The SDR provides a visual map of the reformulation, naming key reciprocal roles and
procedures which are to be the focus of therapy. Through the course of the therapy exits
will be added to the map.

99. Brief concepts/ tools.
• The reformulation letter.
A narrative account of the patient’s life story which makes clear the developmental
origins of the maladaptive repetitive patterns and dysfunctional reciprocal roles.
Aim: to identify, improve, alter and interact with the reformulation letter.

100. Brief concepts/ tools.
• The goodbye letter.
Briefly outlines the reason the patient came to treatment and recounts the story of the
therapy
Gives an account of what has been achieved during therapy and also to mention things
that have not yet been achieved.
Outlines the therapist’s hopes and fears for the patient in the future.
Many patients choose to give the therapist a goodbye letter of their own.

101. CAT effective treatment for:
• addictions
• anxiety
• depression
• disordered eating
• obsessions and
compulsions
• phobias
• relationship issues
• self-harm
• stress

102. Mindfulness Based Cognitive
Therapy (MBCT)
“We take care of the future best by taking care of the
present now.”
Jon Kabat-Zinn.

103. Introduction.
• Root in Buddhist traditions extending back over 2500 years.
• An adaption of MBSR (mindfulness based stress reduction) as
developed at the University of Massachusetts Medical Centre by Jon
Kabat-Zinn and colleagues (1990).

104. What is mindfulness?
• The awareness that emerges through paying attention on purpose
in the present moment non-judgementally.

105. Three core elements of mindfulness.
• Intention
• Attention
• Attitude
Attitudinal foundations of mindfulness practice.
• Non-judgement
• Patience
• Beginner’s mind
• Trust
• Non-striving
• Acceptance
• Letting go

106. What mindfulness is NOT.
• A relaxation practice;
• Not a religion;
• About transcending ordinary life;
• Not about emptying the mind of thoughts;
• Not an escape from pain;
• Not difficult; not easy.

107. Mind wandering.
• We notice when the mind has wandered off, we note where it has
gone and with gentle acceptance, we let go and refocus our attention
back to the object of meditation. We are just noticing something
important about the nature of the mind.
• Thoughts are like waves on the ocean, coming and going. It is
important to learn that YOU are NOT your thoughts.

108. Being mode vs doing mode.
• Being mode of mind is intentional.
• Time focus is the present and the processing of present moment
experience.
• Direct experience rather than ‘thinking about.’
• Thoughts and feelings are experienced as passing phenomena.

112. Three minute breathe - practice.
• An Awareness Practice shift to Being Mode.
• Three steps:
1. AWARENESS: Thoughts, Body Sensations and
Emotions
2. GATHERING: Breathe in the Belly
3. EXPANDING: out to the Body as a whole

113. The triangle of awareness.
Body
sensations
Thoughts
Emotions

114. Mindfulness Based Cognitive Therapy (MBCT)
Program.
• 8 week group program, 2 hours;
• First half – concentration/steadying the mind and Second half – wider
awareness/relapse prevention;
• Includes both Formal and Informal Mindfulness Practices;
• Includes CBT information and exercises for preventing relapse

115. Essentials of MBCT program.
1) Identifying and stepping out of automatic pilot
2) Dealing with barriers
3) Mindfulness of Breath
4) Staying Present
5) Allowing and Letting Be
6) Thoughts are Not Facts
7) Taking Care of Ourselves – Nourishing Activities
8) 8) Using what has been learned

116. Some Practices and Exercises.
• Mindful Eating and other Every
Day Activities
• Mindful Hearing and Seeing
• Body Scan
• Breath Awareness Meditation
• Sounds and Thought Meditation
• 3 Minute Breathing Space/Coping
• Mindful Movement
• Noticing – Pleasant/Unpleasant
Events
• Thought records
• Reviewing new coping strategies

117. MBCT differs from CBT.
• Different from CBT in that it encourages participants to “allow” difficult
thoughts and feelings simply to be there – not changing them in any way –
accepting and bringing them a kindly awareness.
• Works with PROCESS rather than content
• Participants come to experience the coming and going of thoughts, emotions
and feelings and this is profound and life changing.

118. Integration of Mindfulness and CBT.
• Mindfulness helps us to shift into a different relationship to the body,
emotions, sensations and thoughts.
• Cognitive Behaviour Therapy (CBT) helps identify thought content that might be
contributing to suffering.

119. Mindfulness and CBT together aim to increase
resiliency by:
• Increasing awareness of habits of mind, body, and emotions.
• Teaching strategies to manage habitual reactions that increase stress.
• Working with difficult emotional states to decrease the distress they cause

120. MBCT effective treatment for:
• Anxiety disorders
• Bipolar disorder
• Depression associated with
medical illnesses
• Low mood
• Unhappiness
• Depression-relapse
prevention
• Treatment-resistant
depression

121. Acceptance and Commitment
Therapy (ACT)
“Accept yourself and all your thoughts, feelings, and
emotions.”
Steve Hayes.

122. Introduction.
• Grounded in behaviourism but is underpinned by analysis of cognitive
processes.
• Chief purpose: to encourage individuals to respond to situations
constructively, while simultaneously negotiating and accepting
challenging cognitive events and corresponding feelings, rather than
replacing them.

123. Theoretical underpinnings.
• Functional contextualism
A pragmatic philosophical position that recognises that psychological
events (encompassing cognition, affective responses and behaviour)
are influenced by antecedents within a specific context.

124. Theoretical underpinnings.
• Relational frame theory
• A conceptual framework for understanding “the learned ability to arbitrarily relate
events, mutually and in combination, and to change the functions of events based on
these relations.”
• According to RFT maladaptive processes occur as a result of the individual avoiding
“private events” (cognitive processes and affective responses) based on their negative
appraisal of these events. As the individual engages in ACT they learn to integrate these
private events, consolidate personal values and adopt new ways of behaving.

125. ACT acronyms.
• Psychological inflexibility (FEAR)
Fusion with thoughts
Evaluation of experience
Avoidance of experience
Reason –giving for behaviour.
• Psychological flexibility (ACT)
Accept reactions
Choose a valued direction
Take action

126. ACT acronyms.
• Psychological inflexibility
Experiential avoidance
Unclarified values
Inaction, impulsive action,
persistent avoidance
• Psychological flexibility
Cognitive fusion
Conceptualized self
Conceptualised past and future

127. ACT acronyms.
• Psychological flexibility
Psychological flexibility is contacting the present moment fully as a
conscious, historical human being, and based on what the situation
affords changing or persisting in behaviour in the service of chosen
values.

128. Essential/core components of ACT.
• Contact with the present moment
• Acceptance
• Defusion
• Self as context
• Committed action
• Values.

129. Essential/core components of ACT.
Contact with the present moment/ mindfulness.
Conscious awareness of your experience in the present moment enables
you to perceive accurately what is happening in the ‘here and now.’
Acceptance
Noticing private experiences without attempts to alter or prevent them,
allowing them to run their course without defense.

130. Essential/core components of ACT.
Defusion
Looking at thoughts, rather than from thoughts. Noticing thoughts, rather than
being caught up in thoughts. Seeing thoughts as what they are, not as what they
seem to be.
Self as context
A transcendent sense of self: a consistent perspective from which to observe and
accept all changing experiences. (Often called The Observing Self/ pure awareness).

131. Essential/core components of ACT.
Values.
Chosen life directions; what one wants to be; what things one wishes to
do; different from goals.
Committed action
Overt behaviour in the service of values (may require skills training)
Committed action is: values-guided, effective & mindful.

132. ACT effective treatment for:
• workplace stress
• test anxiety
• Social anxiety disorder
• depression
• obsessive-compulsive disorder,
• psychosis.
• It has also been used to help
treat medical conditions such
as chronic pain, substance
abuse, and diabetes.

133. Problem Solving
Therapy (PST)

134. Introduction.
• Cognitive–behavioural intervention geared to improve an individual's ability to
cope with stressful life experiences.
• When such stressful problems either create psychological problems or exacerbate
existing medical problems, PST may be of help, either as a sole intervention or in
combination with other approaches.
• The underlying assumption of this approach is that symptoms of
psychopathology can often be understood as the negative consequences of
ineffective or maladaptive coping.

135. Introduction.
• Broadly speaking, one can divide people who can be helped by
problem solving into:
1. Those who generally cope well but are not able to do so at present,
perhaps because of the illness or the nature of the
dilemma/problem;
2. Those with poor coping resources (requires long-term intervention).

136. Steps in assessment of problem solving.
Identify patient’s
problems
Identify patient’s
resources: assets
& supports
Obtain
information from
other sources
Decide whether
problem solving
is appropriate
Decide on
practical
arrangements
Establish
therapeutic
contact

137. Steps in problem solving.
Decide which
problem(s) to be
tackled first
Agree goal(s)
Work out steps
necessary to
achieve those
goal(s)
Decide tasks
necessary to tackle
first step
Review progress in
next session
(difficulties
encountered)
decide on next step
based on progress;
agree subsequent
tasks
Proceed as above to
agreed goals or
redefine problems &
goals.
Work on further
problems if
necessary

138. Problem-solving therapy can provide training in adaptive problem-
solving skills as a means of better resolving and/or coping with stressful
problems. Such skills include:
• Making effective decisions.
• Generating creative means of dealing with problems.
• Accurately identifying barriers to reaching one’s goals.
Skills taught.

139. • To identify which types of stressors tend to trigger emotions, such as sadness, tension, and
anger.
• Better understand and manage negative emotions.
Become more hopeful about your abilities to deal with difficult problems in life.
• Be more accepting of problems that are unsolvable.
• Be more planful and systematic in the way you attempt to resolve stressful problems.
• Be less avoidant when problems occur.
• Be less impulsive about wanting a “quick fix” solution.
Goals of PST.

140. • Generating possible solutions
to problems
• Examining alternatives
• Cognitive rehearsal
• Role-play and role reversal
Intervention strategies.
• Activity scheduling
• Challenging erroneous beliefs
• Contingency management
• Providing information and
advice

141. PST effective treatment for:
• Major depressive disorder
• Generalized anxiety disorder
• Emotional distress
• Suicidal ideation
• Relationship difficulties
• Certain personality disorders
• Poor quality of life and
emotional distress related to
medical illness, such as cancer
or diabetes.

142. Therapy Author Year Country Profession Important books
Cognitive therapy (CT) Aaron Temkin
Beck
1960s America Psychiatrist • Numerous CBT books
• Love Is Never Enough.
Rational emotive
behaviour therapy
(REBT)
Albert Ellis 1955 America Psychologist &
psychotherapist
REBT: It Works for Me -- It Can
Work for You
All Out!: An Autobiography.
Cognitive analytic
theory (CAT)
Anthony Ryle 1984 England Doctor (Medicine)
Psychotherapist
Diary From The Edge
Frames and Cages
Student Casualties
Dialectical behaviour
therapy (DBT)
Marsha
Linehan
1993 America Psychologist Building a Life Worth Living
Problem solving
therapy (PST)
- - - -
Acceptance and
commitment therapy
(ACT)
Steve Hayes 1987 America Clinical psychologist Get Out of Your Mind and Into
Your Life
A Liberated Mind
Mindfulness based
cognitive therapy
(MBCT)
Jon-Kabat Zinn 1990 America Professor of medicine/
molecular biologist
Full Catastrophe Living
Wherever You Go, There You
Are

143. Next week!
• Systemic therapies.
Family therapy
Marital therapy
Group therapy
Sex therapy
Interpersonal therapy

144. Thank you!