Cognitive Therapy

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  • Venlafaxine is a dual-acting serotonin and norepinephrine reuptake inhibitor (SNRI), which has demonstrated superior clinical efficacy compared to a variety of SSRIs and the tricyclic imipramine.1-5
    Venlafaxine has demonstrated efficacy for the prevention of relapse in a six-month, double blind placebo substitution trial.6 Patients with recurrent depression in full remission after eight weeks of acute venlafaxine therapy were randomized to continue venlafaxine or switch to placebo. Remission was defined as a HAM-D21 <10 and CGI <3 and relapse as CGI >4 or two consecutive CGI >4. Cumulative relapse rates at three and six months were 18.8% and 28% with venlafaxine compared to 43.6% and 52.3 % with placebo. When drop-outs for unsatisfactory efficacy are included in survival estimates, cumulative probability of continued effectiveness was also significantly higher with venlafaxine (74%) than with placebo (50%),
    Venlafaxine has also demonstrated efficacy as long-term maintenance therapy for the prevention of recurrence of depression.7 Patients who had a sustained response for at least six months during open label venlafaxine therapy were randomized to either venlafaxine or placebo for 12 months. Recurrence, defined as CGI >4, occurred in 51% of patients treated with placebo compared to only 20% of venlafaxine treated patients.
    1.Poirier MF, Boyer P. Br J Psych 1999;175:12-6.2.Mehtonen OP, et al. J Clin Psychiatry 2000;61:95-100. 3. Ballus C, et al. Int Clin Psychopharmacol 2000;15:43-8. 4. Rudolph RL, Feiger AD. J Affect Dis 1999;56:171-81. 5.Lecrubier Y, et al. Acta Psych Scand 1997;95:485-93. 6. Entsuah R, et al. [Poster # PO-15-012]. Presented at the European College of Neuropsychopharmacology (ECNP) September 2000. 7. Hackett D, et al. Presented at the European College of Neuropsychopharmacology (ECNP) September 2000.
  • Venlafaxine is a dual-acting serotonin and norepinephrine reuptake inhibitor (SNRI), which has demonstrated superior clinical efficacy compared to a variety of SSRIs and the tricyclic imipramine.1-5
    Venlafaxine has demonstrated efficacy for the prevention of relapse in a six-month, double blind placebo substitution trial.6 Patients with recurrent depression in full remission after eight weeks of acute venlafaxine therapy were randomized to continue venlafaxine or switch to placebo. Remission was defined as a HAM-D21 <10 and CGI <3 and relapse as CGI >4 or two consecutive CGI >4. Cumulative relapse rates at three and six months were 18.8% and 28% with venlafaxine compared to 43.6% and 52.3 % with placebo. When drop-outs for unsatisfactory efficacy are included in survival estimates, cumulative probability of continued effectiveness was also significantly higher with venlafaxine (74%) than with placebo (50%),
    Venlafaxine has also demonstrated efficacy as long-term maintenance therapy for the prevention of recurrence of depression.7 Patients who had a sustained response for at least six months during open label venlafaxine therapy were randomized to either venlafaxine or placebo for 12 months. Recurrence, defined as CGI >4, occurred in 51% of patients treated with placebo compared to only 20% of venlafaxine treated patients.
    1.Poirier MF, Boyer P. Br J Psych 1999;175:12-6.2.Mehtonen OP, et al. J Clin Psychiatry 2000;61:95-100. 3. Ballus C, et al. Int Clin Psychopharmacol 2000;15:43-8. 4. Rudolph RL, Feiger AD. J Affect Dis 1999;56:171-81. 5.Lecrubier Y, et al. Acta Psych Scand 1997;95:485-93. 6. Entsuah R, et al. [Poster # PO-15-012]. Presented at the European College of Neuropsychopharmacology (ECNP) September 2000. 7. Hackett D, et al. Presented at the European College of Neuropsychopharmacology (ECNP) September 2000.
  • Cognitive Therapy

    1. 1. COGNITIVE THERAPYCOGNITIVE THERAPY Slides created bySlides created by Barbara A. Cubic, Ph.D.Barbara A. Cubic, Ph.D. Associate ProfessorAssociate Professor Eastern Virginia Medical SchoolEastern Virginia Medical School To accompanyTo accompany Current Psychotherapies 7Current Psychotherapies 7
    2. 2. Copyright©2005Brooks/Cole,a Learning ObjectivesLearning Objectives  This presentation will focus onThis presentation will focus on – An overview of cognitive therapyAn overview of cognitive therapy – Principles of learning and cognitive theoryPrinciples of learning and cognitive theory relevant to psychotherapyrelevant to psychotherapy – The history of cognitive therapyThe history of cognitive therapy – Ways to facilitate identification of thoughtsWays to facilitate identification of thoughts and feelingsand feelings – Commonly used CBT techniquesCommonly used CBT techniques – Creative applications of CBTCreative applications of CBT
    3. 3. Copyright©2005Brooks/Cole,a BasicBasic ConceptsConcepts
    4. 4. Copyright©2005Brooks/Cole,a Cognitive therapyCognitive therapy focuses primarily onfocuses primarily on how information ishow information is processed. Behavioralprocessed. Behavioral techniques andtechniques and cognitive restructuringcognitive restructuring techniques are utilizedtechniques are utilized to elicit change.to elicit change.
    5. 5. Copyright©2005Brooks/Cole,a Basic Characteristics ofBasic Characteristics of CBTCBT  PracticalPractical  Symptom focusedSymptom focused  Empirically derived techniquesEmpirically derived techniques  Requires patient collaborationRequires patient collaboration  Acknowledges underlying precursors ofAcknowledges underlying precursors of symptoms (schemas), but presentsymptoms (schemas), but present orientedoriented  Case conceptualization drives treatmentCase conceptualization drives treatment
    6. 6. Copyright©2005Brooks/Cole,a Primary Roles of the CBTPrimary Roles of the CBT TherapistTherapist  Conceptualizing the patient inConceptualizing the patient in cognitive termscognitive terms  Structuring the sessionsStructuring the sessions  Using collaborative empiricism andUsing collaborative empiricism and guided discovery to:guided discovery to: –Specify problems and set goalsSpecify problems and set goals –Teach the patient CBT techniquesTeach the patient CBT techniques
    7. 7. Copyright©2005Brooks/Cole,a Cognitive ModelCognitive Model  Processing of information is vital for survivalProcessing of information is vital for survival  Survival systems are:Survival systems are: – CognitiveCognitive – BehavioralBehavioral – AffectiveAffective – MotivationalMotivational  Each system is comprised of structures (i.e.Each system is comprised of structures (i.e. schemas)schemas)
    8. 8. Copyright©2005Brooks/Cole,a The Cognitive ModelThe Cognitive Model BehaviorsBehaviors SituationSituation AutomaticAutomatic EmotionsEmotions ThoughtsThoughts PhysiologicalPhysiological ResponseResponse Automatic thoughts influence not only one’sAutomatic thoughts influence not only one’s emotional response, but also one’s behavioral andemotional response, but also one’s behavioral and physiological responses
    9. 9. Copyright©2005Brooks/Cole,a Cognitive ModelCognitive Model  In other words the relationship is bi-directionalIn other words the relationship is bi-directional (all systems act together as a mode)(all systems act together as a mode) – Thoughts influence biological, affective, behavioralThoughts influence biological, affective, behavioral (and motivational) processes(and motivational) processes – Simultaneously biology, emotions, behavior (andSimultaneously biology, emotions, behavior (and motivation) influence thoughtsmotivation) influence thoughts  Therefore biological treatments can changeTherefore biological treatments can change thoughts and CBT can change biologicalthoughts and CBT can change biological processesprocesses
    10. 10. Copyright©2005Brooks/Cole,a Cognitive ModelCognitive Model  We all have cognitive vulnerabilities (i.e. coreWe all have cognitive vulnerabilities (i.e. core beliefs) which predispose us to interpretbeliefs) which predispose us to interpret information in a certain wayinformation in a certain way  These vulnerabilities are developed earlyThese vulnerabilities are developed early  When these beliefs are rigid, negative, andWhen these beliefs are rigid, negative, and ingrained we are predisposed to pathologyingrained we are predisposed to pathology  These core beliefs give rise to conditionalThese core beliefs give rise to conditional assumptions, i.e. rules for living, as we matureassumptions, i.e. rules for living, as we mature
    11. 11. Copyright©2005Brooks/Cole,a The Cognitive ModelThe Cognitive Model (continued)(continued) BehaviorsBehaviors SituationSituation AutomaticAutomatic EmotionsEmotions ThoughtsThoughts UnderlyingUnderlying PhysiologicalPhysiological BeliefsBeliefs ResponseResponse Automatic thoughts are influenced by theseAutomatic thoughts are influenced by these underlying core beliefs and conditional assumptionsunderlying core beliefs and conditional assumptions
    12. 12. Copyright©2005Brooks/Cole,a The Cognitive ModelThe Cognitive Model (continued)(continued) WithdrawalWithdrawal RelationshipRelationship BreakupBreakup He doesn’tHe doesn’t DepressedDepressed want mewant me I’m unlovableI’m unlovable SNSSNS ReactionReaction Poor SleepPoor Sleep
    13. 13. Copyright©2005Brooks/Cole,a Cognitive ShiftsCognitive Shifts In various types ofIn various types of psychopathology there ispsychopathology there is a systematic bias towarda systematic bias toward selectively interpretingselectively interpreting information in a certaininformation in a certain mannermanner
    14. 14. Copyright©2005Brooks/Cole,a Cognitive Triad of DepressionCognitive Triad of Depression NegativeNegative view ofview of Self WorldFuture
    15. 15. Copyright©2005Brooks/Cole,a Examples of Cognitive ShiftsExamples of Cognitive Shifts Depression vs. AnxietyDepression vs. Anxiety NEGATIVE VIEW OF:NEGATIVE VIEW OF: THREATENING VIEWTHREATENING VIEW OF:OF: FUTUREFUTURE FUTUREFUTURE SELFSELF WORLDWORLD SELFSELF WORLDWORLD
    16. 16. Further Illustration of theFurther Illustration of the COGNITIVE MODEL OF ANXIETYCOGNITIVE MODEL OF ANXIETY STIMULUSSTIMULUS (Environmental(Environmental or Internal)or Internal) PRIMARY APPRAISAL: “DANGER” SECONDARY APPRAISAL: “RISK: RESOURCES RATIO” REAPPRAISALS OF DANGER, RISK, RESOURCES BEHAVIORAL INCLINATION (FLIGHT, FREEZE, DEFEND) AFFECT ANXIETY TERROR PHYSIOLOGICAL PALPITATIONS SWEATING TENSION, ETC.
    17. 17. Copyright©2005Brooks/Cole,a Strategies of Cognitive TherapyStrategies of Cognitive Therapy  Collaborative EmpiricismCollaborative Empiricism  Guided DiscoveryGuided Discovery  Deactivation of DysfunctionalDeactivation of Dysfunctional ModesModes – Deactivating themDeactivating them – Modifying their content and structureModifying their content and structure – Constructing more adaptive modes toConstructing more adaptive modes to neutralize themneutralize them
    18. 18. Comparing CT to OtherComparing CT to Other TherapiesTherapies
    19. 19. Copyright©2005Brooks/Cole,a CT Compared with PsychoanalysisCT Compared with Psychoanalysis  Both assume behavior is influenced by beliefs ofBoth assume behavior is influenced by beliefs of which we may be unawarewhich we may be unaware  CT focuses on linkages among symptoms,CT focuses on linkages among symptoms, conscious beliefs and current experiences; littleconscious beliefs and current experiences; little concern with unconscious feelings or repressedconcern with unconscious feelings or repressed emotions as in psychoanalysisemotions as in psychoanalysis  CT has minimal focus on childhood orCT has minimal focus on childhood or developmental issues except in terms ofdevelopmental issues except in terms of assessment or when addressing core beliefsassessment or when addressing core beliefs  CT is highly structured and short term (12 - 16CT is highly structured and short term (12 - 16 weeks) whereas psychoanalysis is long-term andweeks) whereas psychoanalysis is long-term and unstructuredunstructured  In CT therapist actively collaborates with theIn CT therapist actively collaborates with the patientpatient
    20. 20. Copyright©2005Brooks/Cole,a CT Compared with REBTCT Compared with REBT CTCT REBTREBT Thoughts LabeledThoughts Labeled dysfunctionaldysfunctional irrationalirrational Type or ReasoningType or Reasoning UsedUsed inductiveinductive deductivedeductive Beliefs Associated withBeliefs Associated with PsychopathologyPsychopathology cognitive specificitycognitive specificity for each disorderfor each disorder core set ofcore set of irrational beliefsirrational beliefs View of the ProblemView of the Problem functionalfunctional philosophicalphilosophical Therapist’s ApproachTherapist’s Approach more collaborativemore collaborative moremore confrontationalconfrontational
    21. 21. Copyright©2005Brooks/Cole,a CT Compared to BehaviorCT Compared to Behavior TherapyTherapy  CT is very different from Applied BehavioralCT is very different from Applied Behavioral AnalysisAnalysis  CT is the most commonly practiced form ofCT is the most commonly practiced form of Cognitive Behavior Therapy (CBT), anCognitive Behavior Therapy (CBT), an overarching term to represent therapies whichoverarching term to represent therapies which integrate cognitive and behavioral theoriesintegrate cognitive and behavioral theories and techniquesand techniques  CT sees the individual as moreCT sees the individual as more activeactive ratherrather thanthan passivepassive in change processin change process  CT stresses expectations, interpretations andCT stresses expectations, interpretations and reactionsreactions
    22. 22. Copyright©2005Brooks/Cole,a Cognitive Therapy andCognitive Therapy and MedicationMedication  Studies generally show CT to beStudies generally show CT to be equivalent to psychotropic medicationsequivalent to psychotropic medications for depression, bulimia and somefor depression, bulimia and some anxiety disordersanxiety disorders  Generally research suggests theGenerally research suggests the combination of the two approaches iscombination of the two approaches is superior to either used in isolationsuperior to either used in isolation  CT shows longer efficacy (less relapse)CT shows longer efficacy (less relapse) and increased likelihood of continuingand increased likelihood of continuing gains when treatment is discontinuedgains when treatment is discontinued
    23. 23. Copyright©2005Brooks/Cole,a CT and AntidepressantsCT and Antidepressants (TCAs/1(TCAs/1stst Generation SSRIs)Generation SSRIs) show equal efficacy ratesshow equal efficacy rates 0 10 20 30 40 50 60 70 1 2 3 4 Randomized Trials Cognitive Therapy Antidepressants %Response 1 = Blackburn (1981) 2 = Murphy (1984) 3 = Elkin (`1989) 4 = Hollon (1992)
    24. 24. Copyright©2005Brooks/Cole,a Prevention of Relapse inPrevention of Relapse in DepressionDepression 19% 60% 75% 0% 20% 40% 60% 80% 100% %Patients Maintaing Gains Meds then Placebo Meds Throughout CT + 3 Sessions HAMD > 19 at study entry Relapse Rate at 12 mos. for Venlafaxine vs. Acute CT Hollon et al., (2002) Amer Psychiat Assn N=240, both active treatments > placebo
    25. 25. Copyright©2005Brooks/Cole,a Cognitive Therapy and Medication Metabolic increases = orange; decreases = blue. Frontal and parietal decreases and hippocampal increases found with CBT; reverse pattern is seen with paroxetine. Both treatments lead to decreases in ventral lateral prefrontal cortex Goldapple et al., 2003
    26. 26. Copyright©2005Brooks/Cole,a History of Cognitive TherapyHistory of Cognitive Therapy  Developed by Aaron T. Beck, M.D.Developed by Aaron T. Beck, M.D. – investigated “anger turned inward” psychoanalyticinvestigated “anger turned inward” psychoanalytic concept in 1960s and found evidence for negativeconcept in 1960s and found evidence for negative cognitionscognitions  Bandura, Ellis, Mahoney, and MeichenbaumBandura, Ellis, Mahoney, and Meichenbaum were all influential and developing theirwere all influential and developing their approaches simultaneouslyapproaches simultaneously
    27. 27. Copyright©2005Brooks/Cole,a History of Cognitive TherapyHistory of Cognitive Therapy Major Influences wereMajor Influences were 1.1. PhenomenologicalPhenomenological ApproachesApproaches 2.2. Structural Theory andStructural Theory and Depth PsychologyDepth Psychology 3.3. Cognitive PsychologyCognitive Psychology
    28. 28. Copyright©2005Brooks/Cole,a Current Status of CTCurrent Status of CT Controlled studies have shown theControlled studies have shown the efficacy of CT with:efficacy of CT with:  DepressionDepression  Panic DisorderPanic Disorder  Social PhobiaSocial Phobia  Generalized Anxiety DisorderGeneralized Anxiety Disorder  Substance AbuseSubstance Abuse  Eating DisordersEating Disorders  Marital ProblemsMarital Problems  Obsessive-Compulsive DisorderObsessive-Compulsive Disorder  Post-Traumatic Stress DisorderPost-Traumatic Stress Disorder  SchizophreniaSchizophrenia
    29. 29. Copyright©2005Brooks/Cole,a Current Status of CTCurrent Status of CT (Resources in CT)(Resources in CT)  Center for Cognitive Therapy (U/Penn)Center for Cognitive Therapy (U/Penn) and Beck Institute are the Major Trainingand Beck Institute are the Major Training Sites (both in Philadelphia)Sites (both in Philadelphia)  Multiple other training sites in the UnitedMultiple other training sites in the United States and internationallyStates and internationally  Cognitive Therapy and ResearchCognitive Therapy and Research && Journal of Cognitive PsychotherapyJournal of Cognitive Psychotherapy  Academy of Cognitive Therapy (for moreAcademy of Cognitive Therapy (for more information hitinformation hit www.academyofct.orgwww.academyofct.org ))
    30. 30. Understanding the TheoryUnderstanding the Theory Behind CTBehind CT
    31. 31. Copyright©2005Brooks/Cole,a Thinking is Problematic orThinking is Problematic or Distorted When it isDistorted When it is Very……………..Very……………..  ExtremeExtreme  BroadBroad  CatastrophicCatastrophic  NegativeNegative  UnscientificUnscientific  PollyanishPollyanish  IdealisticIdealistic  DemandingDemanding  JudgmentalJudgmental  Comfort SeekingComfort Seeking  ObsessiveObsessive  ConfusingConfusing
    32. 32. Copyright©2005Brooks/Cole,a Cognitive DistortionsCognitive Distortions Arbitrary InferenceArbitrary Inference: Drawing a: Drawing a conclusion without evidence or inconclusion without evidence or in the face of contradictory evidence.the face of contradictory evidence. For example, a young woman withFor example, a young woman with anorexia nervosa believes she isanorexia nervosa believes she is fat although she is dying fromfat although she is dying from starvation.starvation.
    33. 33. Copyright©2005Brooks/Cole,a Cognitive DistortionsCognitive Distortions Selective Abstraction:Selective Abstraction: DwellingDwelling on a single negative detailon a single negative detail taken out of context. While ontaken out of context. While on a date you say one thing youa date you say one thing you wish you could have saidwish you could have said differently and now see thedifferently and now see the entire evening as a disaster.entire evening as a disaster.
    34. 34. Copyright©2005Brooks/Cole,a Cognitive DistortionsCognitive Distortions OvergeneralizationOvergeneralization: A single: A single negative event is viewed as anegative event is viewed as a never-ending pattern of defeat.never-ending pattern of defeat. Following a job interview anFollowing a job interview an accountant does not receive theaccountant does not receive the job. He/she begins thinking thatjob. He/she begins thinking that they will never find a job positionthey will never find a job position despite their qualifications.despite their qualifications.
    35. 35. Copyright©2005Brooks/Cole,a Cognitive DistortionsCognitive Distortions Magnification and/or MinimizationMagnification and/or Minimization:: The binocular trick. Things seemThe binocular trick. Things seem bigger or smaller than they truly are.bigger or smaller than they truly are. An employee believes that a minorAn employee believes that a minor mistake will lead to being fired vs.mistake will lead to being fired vs. an alcoholic who believes he/ shean alcoholic who believes he/ she doesn’t have a problem.doesn’t have a problem.
    36. 36. Copyright©2005Brooks/Cole,a Cognitive DistortionsCognitive Distortions PersonalizationPersonalization: Assuming personal: Assuming personal responsibility for something for whichresponsibility for something for which you are not responsible. Often seen inyou are not responsible. Often seen in patients who are sexuallypatients who are sexually abuse/assaulted.abuse/assaulted.
    37. 37. Copyright©2005Brooks/Cole,a Cognitive DistortionsCognitive Distortions Dichotomous thinkingDichotomous thinking: Things are: Things are seen as black and white, there isseen as black and white, there is no gray or middle ground. Thingsno gray or middle ground. Things are wonderful or awful, good orare wonderful or awful, good or bad, perfect or a failure.bad, perfect or a failure.
    38. 38. Copyright©2005Brooks/Cole,a Mind readingMind reading: Assuming someone is: Assuming someone is responding negatively to you withoutresponding negatively to you without checking it out. If your husband is in a badchecking it out. If your husband is in a bad mood you assume it is your fault andmood you assume it is your fault and don’t ask what is wrong.don’t ask what is wrong. Fortune Teller ErrorFortune Teller Error: Creating a negative self: Creating a negative self fulfilling prophecy. You believe you will failfulfilling prophecy. You believe you will fail an important exam so you do not studyan important exam so you do not study and fail.and fail. Cognitive DistortionsCognitive Distortions
    39. 39. Copyright©2005Brooks/Cole,a Cognitive DistortionsCognitive Distortions Emotional ReasoningEmotional Reasoning: You assume: You assume that your negative feeling resultsthat your negative feeling results from the fact that things arefrom the fact that things are negative. If you feel bad, then thatnegative. If you feel bad, then that means the world or situation ismeans the world or situation is bad. You don’t consider that yourbad. You don’t consider that your feelings are a misrepresentation offeelings are a misrepresentation of the facts.the facts.
    40. 40. Copyright©2005Brooks/Cole,a Cognitive DistortionsCognitive Distortions Should StatementsShould Statements: Use words like: Use words like should, must, ought rather than “itshould, must, ought rather than “it would be preferred” to guilt self.would be preferred” to guilt self. Labeling and MislabelingLabeling and Mislabeling: Name calling: Name calling such as “He’s a Jerk” rather than justsuch as “He’s a Jerk” rather than just criticizing the behavior.criticizing the behavior.
    41. 41. Copyright©2005Brooks/Cole,a Cognitive CaseCognitive Case ConceptualizationConceptualization C u r r e n t S i t u a t i o n A u t o m a t i c T h o u g h t s R e a c t i o n C o m p e n s a t o r y S t r a t e g i e s C o n d i t i o n a l A s s u m p t i o n s C o r e B e l i e f s G e n e t i c s a n d E a r l y L i f e E x p e r i e n c e s
    42. 42. Copyright©2005Brooks/Cole,a Cognitive CaseCognitive Case ConceptualizationConceptualization N e w B o y f r i e n d S i t u a t i o n M u s t b e o n m y b e s t b e h a v i o r D o w h a t h e w a n t s F r u s t r a t i o n A n x i e t y F a k e P e r f e c t i o n i s t i c O v e r l y T r i e s t o p l e a s e O t h e r s D i s t a n t i n R e l a t i o n s h i p s I f I l e t p e o p l e k n o w m e t h e y w i l l f i n d o u t h o w w o r t h l e s s I a m I f I a m p e r f e c t a n d a l w a y s l i k e d I a m w o r t h s o m e t h i n g I a m u n l o v a b l e , w o r t h l e s s A l c o h o l i c F a t h e r A b u s i v e M o t h e r P a r e n t s D i v o r c e F r e q u e n t M o v e s
    43. 43. CT TreatmentCT Treatment   
    44. 44. Copyright©2005Brooks/Cole,a Structure of a CBT SessionStructure of a CBT Session  Mood CheckMood Check  Setting the AgendaSetting the Agenda  Bridging from Last SessionBridging from Last Session  Today’s Agenda ItemsToday’s Agenda Items  Homework AssignmentHomework Assignment  Summarizing Throughout and at EndSummarizing Throughout and at End  Feedback from PatientFeedback from Patient
    45. 45. Copyright©2005Brooks/Cole,a General Principles of CTGeneral Principles of CT  Goal is to correct dysfunctionalGoal is to correct dysfunctional thinking and help patients modifythinking and help patients modify erroneous assumptionserroneous assumptions  Patient is taught to be a scientist whoPatient is taught to be a scientist who generates and tests hypothesesgenerates and tests hypotheses  Relationship between patient andRelationship between patient and therapist is collaborativetherapist is collaborative
    46. 46. Copyright©2005Brooks/Cole,a Fundamental ConceptsFundamental Concepts  Collaborative EmpiricismCollaborative Empiricism – goal is to demystify therapygoal is to demystify therapy  Socratic DialogueSocratic Dialogue – questioning used to help patient come toquestioning used to help patient come to their own conclusions about their thoughtstheir own conclusions about their thoughts and behaviorand behavior  Guided DiscoveryGuided Discovery – therapist collaborates with patient totherapist collaborates with patient to developdevelop behavioral experimentsbehavioral experiments to testto test hypotheseshypotheses
    47. 47. Copyright©2005Brooks/Cole,a Process of TherapyProcess of Therapy  Initial SessionsInitial Sessions – Essential to build rapportEssential to build rapport – Focus is problem definition, goal setting and symptomFocus is problem definition, goal setting and symptom reliefrelief – Therapist provides psychoeducation in initial sessionsTherapist provides psychoeducation in initial sessions – Behavioral interventions may more prominentBehavioral interventions may more prominent  Middle SessionsMiddle Sessions – Emphasis shifts from symptoms to patterns of thinkingEmphasis shifts from symptoms to patterns of thinking  TerminationTermination – Expectation that therapy is time limitedExpectation that therapy is time limited
    48. 48. Copyright©2005Brooks/Cole,a Examples of BehavioralExamples of Behavioral Interventions in CTInterventions in CT  Activity SchedulingActivity Scheduling  Mastery and PleasureMastery and Pleasure  Graded Task AssignmentGraded Task Assignment  Conducting Behavioral ExperimentsConducting Behavioral Experiments (e.g. being assertive to assess what(e.g. being assertive to assess what happens)happens)  Exposure Type TechniquesExposure Type Techniques  Role PlaysRole Plays
    49. 49. Copyright©2005Brooks/Cole,a WEEKLY ACTIVITY SCHEDULEWEEKLY ACTIVITY SCHEDULE (patient records activities and rates them(patient records activities and rates them for pleasure and mastery)for pleasure and mastery) Mon Tue Wed Thu Fri Sat Sun 8-10 am 10-12 pm 12-2 pm 2-4 pm 4-6 pm 6-8 pm 8-10 pm 10-12 am
    50. 50. Copyright©2005Brooks/Cole,a Weekly Activity MonitoringWeekly Activity Monitoring Weekly activity monitoring can be used in severalWeekly activity monitoring can be used in several different ways. As a monitor, the chart allows thedifferent ways. As a monitor, the chart allows the therapist and the patient to:therapist and the patient to:  Assess how patients are spending their timeAssess how patients are spending their time  Measure the sense of accomplishment and/orMeasure the sense of accomplishment and/or pleasure received from various activitiespleasure received from various activities  Determine which activities are occurring too muchDetermine which activities are occurring too much or too littleor too little  Evaluate automatic thoughts or emotional shiftsEvaluate automatic thoughts or emotional shifts  Fill in specific times with planned activities, such asFill in specific times with planned activities, such as pleasant activities for depressed patients orpleasant activities for depressed patients or activities that must be done for procrastinatingactivities that must be done for procrastinating patientspatients  Compare predicted ratings of accomplishment andCompare predicted ratings of accomplishment and pleasurepleasure with actual ratingswith actual ratings
    51. 51. Copyright©2005Brooks/Cole,a Examples of CognitiveExamples of Cognitive Interventions in CTInterventions in CT  Eliciting automatic thoughts throughEliciting automatic thoughts through Thought RecordsThought Records  Identifying whether the thoughts representIdentifying whether the thoughts represent distortions in information processingdistortions in information processing  UsingUsing Socratic QuestionsSocratic Questions to evaluate theto evaluate the thought processthought process  Generating alternatives in terms of how toGenerating alternatives in terms of how to think or how to behave differentlythink or how to behave differently
    52. 52. Copyright©2005Brooks/Cole,a THOUGHT RECORDTHOUGHT RECORD Situation Mood 1- 100 Automatic Thought Evidence For AT Evidence Against AT Balanced/ Alternative Viewpoint Re-rate Mood
    53. 53. Copyright©2005Brooks/Cole,a Eliciting AutomaticEliciting Automatic ThoughtsThoughts  Basic Question: What thought just went through yourBasic Question: What thought just went through your mind?mind? – Ask when an emotional shift is noted in sessionAsk when an emotional shift is noted in session – Create an emotional shift by having the patient describe orCreate an emotional shift by having the patient describe or visualize a recent situation when they felt intense emotionsvisualize a recent situation when they felt intense emotions and then answer the questionand then answer the question  If patient can’t answer the question try asking:If patient can’t answer the question try asking: – Do you think you were thinking _____________?Do you think you were thinking _____________? – If someone else was in the situation what do you think theyIf someone else was in the situation what do you think they might have been thinking?might have been thinking? – Were you thinking ______________ ? (insert somethingWere you thinking ______________ ? (insert something paradoxical)paradoxical)
    54. 54. Copyright©2005Brooks/Cole,a Examples of SocraticExamples of Socratic QuestionsQuestions  What evidence do you have to support the belief?What evidence do you have to support the belief?  What evidence do you have to refute it?What evidence do you have to refute it?  What would your spouse, best friend, sibling (orWhat would your spouse, best friend, sibling (or anyone whom you admire greatly) say in thisanyone whom you admire greatly) say in this situation?situation?  What would you say to your spouse, best friend, orWhat would you say to your spouse, best friend, or sibling if they were thinking the same thing you are?sibling if they were thinking the same thing you are?  How could you look at this situation so you would feelHow could you look at this situation so you would feel less depressed? Is this view as reasonable as yourless depressed? Is this view as reasonable as your
    55. 55. Copyright©2005Brooks/Cole,a Examples of Socratic QuestionsExamples of Socratic Questions (specific example)(specific example) Situation: Patient feels like a bad wife.Situation: Patient feels like a bad wife. What makes you think you are a bad wife?What makes you think you are a bad wife? What would a good wife have done?What would a good wife have done? On a scale from (bad)0-100(good) how doOn a scale from (bad)0-100(good) how do you rate as a wife? Why do you placeyou rate as a wife? Why do you place yourself there on the scale?yourself there on the scale? How does it help to call yourself a bad wife?How does it help to call yourself a bad wife? Besides labeling yourself as a bad wife whatBesides labeling yourself as a bad wife what else could you do in this situation?else could you do in this situation?
    56. 56. Copyright©2005Brooks/Cole,a Examples of Non-SocraticExamples of Non-Socratic QuestionsQuestions (questions not to use)(questions not to use)  Don’t you think most women get mad atDon’t you think most women get mad at their husbands?their husbands?  Doesn’t your husband ever yell at you?Doesn’t your husband ever yell at you?  I’m sure everything will work out OK, don’tI’m sure everything will work out OK, don’t you?you?  I think you are a good wife based on otherI think you are a good wife based on other things you’ve told me, could you focus onthings you’ve told me, could you focus on the positives?the positives?
    57. 57. Copyright©2005Brooks/Cole,a Example: Downward Arrow toExample: Downward Arrow to Obtain Less Accessible BeliefsObtain Less Accessible Beliefs SituationSituation ThoughtsThoughts EmotionsEmotions Patient reportsPatient reports that a sessionthat a session hasn’t helpedhasn’t helped themthem The patient isThe patient is right. That wasright. That was a terriblea terrible session. I didn’tsession. I didn’t do anythingdo anything right.right. GuiltyGuilty AnxiousAnxious
    58. 58. Copyright©2005Brooks/Cole,a Example: Downward ArrowExample: Downward Arrow (con’t)(con’t) QuestionQuestion ResponseResponse If that were trueIf that were true ““That I had done aThat I had done a what would it meanwhat would it mean bad jobbad job”” to you?to you? If that were true whatIf that were true what ““Sooner or later ISooner or later I would it mean to you?would it mean to you? would be found outwould be found out”” And, then what?And, then what? ““Everyone wouldEveryone would know I was an Iknow I was an I imposter andimposter and incompetentincompetent””
    59. 59. Copyright©2005Brooks/Cole,a Principles for Setting Effective HomeworkPrinciples for Setting Effective Homework  Make sure rationale is clearMake sure rationale is clear  When feasible, have patient chose the taskWhen feasible, have patient chose the task  Personalize task to therapy goalsPersonalize task to therapy goals  Begin where patient is, not where patient thinks he/sheBegin where patient is, not where patient thinks he/she should beshould be  Be specific and concrete: where, when, with whom etc.Be specific and concrete: where, when, with whom etc.  Formalize the task (e.g., write on paper)Formalize the task (e.g., write on paper)  Plan ahead for potential obstacles and “trouble shoot”Plan ahead for potential obstacles and “trouble shoot”  Practice the task in sessionPractice the task in session  Review homework at the beginning of each sessionReview homework at the beginning of each session
    60. 60. Copyright©2005Brooks/Cole,a Other Cognitive Therapy TechniquesOther Cognitive Therapy Techniques  De-catastrophizing:De-catastrophizing:  ““What if that happened, then what?”What if that happened, then what?”  Reattribution:Reattribution:  Alternative explanations systematically examinedAlternative explanations systematically examined  Redefining:Redefining:  Help patient see the problem differently (e.g. “Help patient see the problem differently (e.g. “ NobodyNobody ever talks to meever talks to me” becomes “” becomes “ I need to try to initiateI need to try to initiate conversation so other people become interested in talkingconversation so other people become interested in talking to meto me”)”)  Decentering:Decentering:  Used with social anxiety to shift the focus; Patient isUsed with social anxiety to shift the focus; Patient is taught to see that thoughts are just thoughts and nottaught to see that thoughts are just thoughts and not “them” or “reality”“them” or “reality”
    61. 61. Copyright©2005Brooks/Cole,a The Future of CT (An Example of an Innovation): Integrating Mindfulness Based Approaches ““Mindfulness means paying attention in a particular way; onMindfulness means paying attention in a particular way; on purpose, in the present moment and non-judgmentally.”purpose, in the present moment and non-judgmentally.” Jon Kabat-ZinnJon Kabat-Zinn
    62. 62. Copyright©2005Brooks/Cole,a Integrating Concepts ofIntegrating Concepts of Mindfulness and DecenteringMindfulness and Decentering ““The simple act of recognizing your thoughtsThe simple act of recognizing your thoughts as thoughtsas thoughts can free you from the distortedcan free you from the distorted reality they often create and allow for morereality they often create and allow for more clear sightedness and a greater sense ofclear sightedness and a greater sense of manageability in your life.”manageability in your life.” Jon Kabat-ZinnJon Kabat-Zinn
    63. 63. Copyright©2005Brooks/Cole,a MINDFULNESS-BASED COGNITIVE THERAPY:MINDFULNESS-BASED COGNITIVE THERAPY: RATIONALERATIONALE  When combined with CT these approaches reduceWhen combined with CT these approaches reduce depression relapse rates through changing thoughtsdepression relapse rates through changing thoughts activated by states of sadnessactivated by states of sadness  Goal is to decrease sadness which is reactivated byGoal is to decrease sadness which is reactivated by pervasive negative thoughts seen in depressionpervasive negative thoughts seen in depression  Based on concept that it is not desirable for treatment toBased on concept that it is not desirable for treatment to eliminate sadness (a normal human emotion)eliminate sadness (a normal human emotion)  Thought patterns which occur during sadness are notThought patterns which occur during sadness are not “forced” to go away, just observed“forced” to go away, just observed
    64. 64. Copyright©2005Brooks/Cole,a MINDFULNESS-BASED COGNITIVE THERAPY:MINDFULNESS-BASED COGNITIVE THERAPY: INTERVENTIONSINTERVENTIONS  Patient taught to ‘turn towards’ possiblePatient taught to ‘turn towards’ possible difficulties rather than ‘away’ from them, whichdifficulties rather than ‘away’ from them, which may lead to earlier detection of negativemay lead to earlier detection of negative thoughtsthoughts  Goal is to stop the dysfunctional thoughtsGoal is to stop the dysfunctional thoughts  Mindfulness meditation helps patients to focusMindfulness meditation helps patients to focus attentively while experiencing negativeattentively while experiencing negative automatic thoughtsautomatic thoughts
    65. 65. Copyright©2005Brooks/Cole,a Example of a Mindfulness InterventionExample of a Mindfulness Intervention  Approximately eight two hour weekly sessions conductedApproximately eight two hour weekly sessions conducted with four follow-up sessionswith four follow-up sessions  Daily homework is givenDaily homework is given  Sessions focus onSessions focus on  Body ScanBody Scan  Mindful Stretching/YogaMindful Stretching/Yoga  Mindfulness of breath/body/sounds/thoughtsMindfulness of breath/body/sounds/thoughts  Homework focuses onHomework focuses on  Brief breathing exercisesBrief breathing exercises  Mindfulness during everyday activitiesMindfulness during everyday activities
    66. 66. Copyright©2005Brooks/Cole,a Relapse Rates: CT and MindfulnessRelapse Rates: CT and Mindfulness vs. Treatment as Usualvs. Treatment as Usual 80% 50% 22% 64%* 0% 20% 40% 60% 80% 100% %Patients Surviving 1-2 Prev. MDD 3+ Prev. MDD Effects of MBCT Over 1 year Follow Up TAU MBCT Ma and Teasdale (2003), N= 37 per group, *survival effect for MBCT in 3+ gp., p<.05

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