The document provides an overview of cognitive-behavioral therapy (CBT) strategies and techniques. It discusses Barlow's model of emotional disorders and how CBT addresses emotional regulation, cognitive appraisals, emotionally-driven behaviors, and avoidance. The basic CBT model examines psychopathology through a bio-psycho-social lens and addresses maladaptive cognitions and behaviors. Common CBT techniques include identifying cognitive distortions, challenging thoughts through questioning and experimentation, and behavioral activation methods like activity scheduling.

1. General Survey of Cognitive-Behavioral Therapy Strategies The Model and The Techniques Kevin D. Arnold, Ph.D., ABPP Director, The Center for Cognitive and Behavioral Therapy of Greater Columbus 614.459.4490

2. Theory Behind CBT Barlow’s Theory of Emotional Disorders Barlow (1991) & Moses and Barlow (2006) Key Concepts Emotional Regulation Emotional Memory Antecedent Cognitive Appraisals Emotionally Driven Behaviors (EDBs) Avoidance

3. Theory Behind CBT Emotional Regulation: Key Strategies* Situational Control Situation Selection Predictive Model of Emotional Arousal Features and Likelihoods Costs and Benefits Assessment of Regulation vs. Experience Situation Modification Modification of the Physical, External Environment Attention Attention Deployment Distraction to Other Situational Features or Away Completely Concentration on Emotional Experience, Situational Factors, or Predictions Theory Behind CBT *Gross & Thompson, 2007

4. Emotional Regulation: Key Strategies* Appraisal Cognitive Appraisal Modification of Appraisal (e.g., threat value, label of event) Response Response Modulation Relaxation Strategies Expression of Emotion (Behavioral, Verbal) Adaptive Response Alternatives Theory Behind CBT *Gross & Thompson, 2007

5. Theory Behind CBT

6. Emotional Memory* and Anxiety Disclaimer—Not a Neuropsychologist Role of Amygdala and Prefrontal Cortex in Anxiety Amygdala Stores Stress Arousal as Nondeclarative Memory In Contrast, Hippocampus Stores Declarative Memory PFC Necessary to Habituate to Anxiety Habituation is New Learning Allowing PFC to Modulate Amygdala Arousal and Enhance Declarative Recall Through Hippocampus PFC can also “prevent the acquisition of fear conditioning” or “excite the amygdala and increase fear.” (pp. 36-37) Theory Behind CBT *Quirk, 2007

7. Emotional Memory* and Depression Disclaimer—Not a Neuropsychologist Role of Amygdala and Prefrontal Cortex in Depression PFC Activation Levels Needed to be Higher in Depressed Patients For Working Memory Performance Predisposition to Serotonin Based Abnormalities Associated with Increased Activity in Amygdala and with Abnormalities in Connection of Prefrontal Cortex and Amygdala. Theory Behind CBT *Davidson, Fox & Kalin, 2007

8. Impact on the HPA Axis The HPA Axis is the Hypothalamus-Pituitary-Adrenal Axis Changes in HPA Axis Functioning Have Been Found in Early Developmental Exposure to Trauma* Predisposes to later MDD and PTSD Vulnerability Early Trauma has been Shown to Reduce Hypothalamic Mass In utero Exposure to Stress Reveals Changes in Fetus and Infant Dysregulation of the HPA System Leading to Greater Degrees of Stress and Anxiety Theory Behind CBT *Shea, Walsh, MacMillan & Steiner (2006)

9. Theory Behind CBT

10. Antecedent Cognitive Appraisals Early Learning During Parenting Interactions or Traumas Regarding Self-Efficacy or Threats Appraisal of Likelihood of Negative Event Occurrence Appraisal of Catastrophic Outcome Appraisal of Incapacity to Effect Outcomes or Manage Outcomes Appraisal of Others as Harsh (Punitive Parenting) or Unsupportive (Dismissive Parenting) Overall Situational Appraisal & Development of Assumptive Schemas Theory Behind CBT

11. Emotionally Driven Behaviors (EDBs) Behavioral Response Probabilities Activation of Learned, Adaptive Responses to Over-generalized and Inappropriate Emotional Recall Reduce Emotional Arousal Negative Reinforcement When EDBs Lead to Unhealthy Outcomes Social Isolation, Avoidance of Adaptive Situations, Reduction in Relationship Connections Theory Behind CBT

12. Avoidance Escape is an EDB to Exit to Reduce Arousal Avoidance is to Prevent Arousal or Full Arousal Forms of Avoidance Subtle Behavioral Avoidance Avoiding Eye Contact, Procrastination Cognitive Avoidance Distraction, Stonewalling, Mental Rituals, Thought Stopping Safety Signals Shaking Medicine Bottles, Keeping Positive Association Objects Handy, Good Luck Charms, Carrying Cleaners Theory Behind CBT

13. Theory Behind CBT Examples from Moses & Barlow (2006) Social Phobia Carrying Items to Hide Face or Bodily Reactions Depression/GAD Carrying Good Feeling Objects OCD Good Luck Charms Safety Signals Generalized Anxiety Worrying Panic/Depression Distraction Depression Forced Positive Self Talk Cognitive Avoidance Generalized Anxiety Procrastination Panic/Depression Avoiding Physiological Arousal Social Phobia Avoid Eye Contact Behavioral Avoidance

14. The Basic CBT Model Beck & Other’s Approach Psychopathology is bio-psycho-social Feelings can be managed through addressing cognitions and behaviors Psychopathology has deficits in behaviors and maladaptive or distorted cognitions Underlying assumptions have been learned in an “if-then” format Schemas create a construction that is maladaptive now, but not when first developed Theory Behind CBT

15. Cognitive Triad Cognitive Triad Distorted Thoughts are those that are mood congruent but not reflective of the evidence in life These are sometimes referred to as Automatic Thoughts The thoughts fit basically into three categories: Self, Others/World, or Future Theory Behind CBT

16. Cognitive Blockade Cognitive Blockade Mood or other pathologic processes create a filtering of information that is state-dependent Information, both internal and external, is filtered so that only mood congruent information is a) perceived, or b) valued. Overcoming the impact of the blockade is a major goal of CBT Theory Behind CBT

17. Treatment Method: General IT IS AN APPROACH, NOT A MANUAL Cognitive Therapy is collaborative so that the patient and therapist are a team working on problems together Cognitive Therapy is active and engages the patient through a treatment relationship that encourages but respects the patient through empathy Cognitive Therapy uses the Socratic Method, using questions whenever possible

18. Socratic Method Questions are used in CBT to Help the patient become aware of thoughts Examine thoughts to identify distortions Replace distortions with health and evidenced based ideas Plan to develop new thinking patterns Self-Awareness of EDBs Treatment Method: General

19. Collaborative Therapy is guided by a team approach to problems The treatment conceptualization is created collaboratively as a basis for the treatment methods The structure of the sessions is agreed upon as a way of keeping the collaborative work moving Both agree on structure and direction Treatment Method: General

20. Structure and Direction All sessions use the following template Setting an agenda Bridging back to the previous session Setting a target for the session Application of the CBT techniques to the target Summarization of the session Setting homework Feedback on the session Treatment Method: General

21. Problem Orientation Conceptualization: Patients problems within a present, learning context Orientation to the Present/Here and Now Selection of strategies and techniques Assess the effectiveness of the CBT on the problem within its context Treatment Method: General

22. Common Strategies in CBT Simplify Do it now You can’t know unless you experiment If you are off track, do the opposite Persistence will produce change Break it down and take one thing at a time Do that which you don’t expect yourself to do Pull, don’t push/Flow Treatment Method: General

23. Educate CBT educates patients to be their own therapists Help the patient to learn how to learn It’s not resistance, it’s reluctance It’s not resistance, it’s slowness Patients learn inductively Beliefs are hypothesis Testing them can provide insight or new ways of thinking Treatment Method: General

24. Key Elements Behavioral Experimentation Daily Activity Records Activity Scheduling Pleasure Scheduling Identify Distortions through Self-Monitoring (3 Column) and Labeling Automatic Thoughts Test the Evidence Challenge and Create New Thoughts (5 Column) Treatment Method: General

25. Cognitive Distortions Related to Mood Don’t represent evidence or have gone unchallenged Have not been evaluated, instead assumed to be true Learned based on history See Handout

26. Assessing the Automatic Thoughts Question, Question, Question Listen, Listen, Listen Downward Arrow Imaging a Situation Noticing Affect and Calling Out the Thoughts Cognitive Distortions

27. Strategies for Challenging and Restructuring Cognitive Distortions Defining Terms  Cost-Benefit Analysis of Idea or Belief  Modified 5-Column/Testing the Evidence  Testing the Utility of the Evidence  Evaluating Labels  Changing Behavior to Test Ideas  Examining Should Statements  Articulating Values and Changing Them  Progress not Perfection  Old Rules, New Rules  New Bill of Rights  Monitor Feelings/Ideas and Label Distortions  Downward Arrow/Vertical Decent  Cognitive Distortions Loosely Based on Leahy, 2003

28. Cognitive Distortions Mind Reading : Assuming you know what others are thinking Future Predicting : Appraisal of future events Catastrophizing : Predicting the worst possible outcome Labeling : Using global labels to describe yourself or others Black-White Reasoning : Thinking in all or none terms not shades of gray Regret Orientation : Looking back and not living in the moment of the now Arbitrary Inferences : Drawing conclusions from little or no evidence Filtering : Noticing only the things that confirm your ideas Personalizing : Thinking that everything is your fault or that others are targeting you specifically Overgeneralizing : Using evidence from a specific context and applying a “rule” to many other contexts Should/Would/Could : Thinking in terms of morals or shoulds, rather than the actual evidence in the situation Cognitive Distortions Loosely Based on Leahy, 2003

29. Behavioral Activation Behavioral Activation is Designing Actions into a Patient’s Behavioral Repertoire Activity Scheduling Pleasure Scheduling Functional Behavior Analysis in the Session Reward Erosion and Mood Problems + + -

30. Behavioral Activation Activity Scheduling Activity Monitoring and Recording Mastery Pleasure Hour Blocks vs. Sections of the Day Activity Scheduling Designing Routines Increasing High Ms and Ps

31. Behavioral Activation Pleasure Scheduling Inventories Past Present Wishes Scheduling the Pleasure Behavioral Experiments Self-Monitoring Foot in the Door First

32. Behavioral Activation Application of Functional Analysis Use of the Therapy Relationship to Differentially Deliver Reinforcement or Punishment Identification of Clinically Relevant Behaviors CRB1: Those to Decrease CRB2: Those to Increase Observe CRBs Elicit CRBs Develop Alternate Behaviors to CRB1s Differentially Apply Rewards Design Generalization invivo Cuijpers, van Straten, and Warmerdam (2007) showed in meta-analysis that Behavioral Activation was Effective See Kanter, Manos, Busch, and Rusch, 2008

33. Behavioral Activation Self-Determination Development of Personal Goals Identification of Stimuli to Old Behaviors Modification of Stimuli Exposure Training New Behaviors to Stimuli (Self-Regulation of Natural Prompts)

34. Relaxation Therapy Controlled Breathing Concentration Rhythm Sensations Suggestive Relaxation 16 Muscle Group PMR Practice 2x per day

35. Relaxation Therapy Uses of Relaxation Therapy Cued Affect Management Counter-conditioning Management of Physiologic Stimuli

36. Overcoming “Resistance” Use of Socratic Methods How Likely to Do? Reasons Not To? How to Overcome Not To Framework of “No Choice” List Pros/Cons Application of Stages of Change

37. Overcoming “Resistance” Stages of Change Pre-Contemplative Educate Patient Contemplative Strategies such as Pros-Cons or Cross-Examiner Decision Decision to/Decision not to, Pros-Cons Action Graduated Exposure Strategy Foot in the Door Noticing Action and its Impact Anti-Contemplative A Different Day, A Different Time Push-Pull Strategy

38. Application to Anxiety Retraining the Brain: Habituation Habituation is the result of extended exposure to an anxiety provoking stimulus Anxiety typically elevates beyond typical levels due to defeat of avoidance or escape Anxiety begins to drop after extended exposure Anxiety usually flattens and persists at a reduced level for several minutes during the exposure Over repeated exposure activities, anxiety ceases to elevate clinically when the anxiety provoking stimulus is presented Habituation is seen in Systematic Desensitization using Graduated Exposure Exposure and Response Prevention (ExRP) Direct Exposure Narrative Story Telling Interventions Flooding

39. Application to Anxiety OCD OCD is conceptualized as an anxiety disorder driven by mis-appraisal of the threat posed by intrusive, obsessive thoughts use of ritualized behaviors or cognitive patterns to escape the anxiety use of avoidance behaviors to end exposure to triggers associated with the obsessive thoughts

40. Application to Anxiety OCD Assessment in CBT is typically done with one of several instruments, although usually it is the Yale-Brown Obsessive Compulsive Scale (YBOCS) Identification of historical and current obsessions and compulsions Identification of target obsessions and compulsions, with SUDS ratings of each to create a hierarchy Identification of avoidance behaviors SUDS = Subjective Units of Distress Scale using 0 to 100 Must create behavioral anchors to ratings for patient

41. Application to Anxiety OCD Treatment with CBT is primarily Exposure and Response Prevention (ExRP) Therapy Exposure Patient collection of obsessive thoughts per theme Creation of Exposure Narrative—Often recorded Design of 90 minute exposure to be done daily Creation of SUDS tracking form throughout Exposure exercise Safety plan for atypical NSEs

42. Application to Anxiety OCD Treatment with CBT is primarily Exposure and Response Prevention (ExRP) Therapy Response Prevention Identification of Ritual Structure for each Obsession Identification of Avoidance Patterns Creation of Behavioral Plan to stop Rituals and Avoidance Creation of tracking form for ritual and avoidance performance Behavioral Description Situational Factors Emotional Experiences Outcome of Ritual or Avoidance Used to Create Better Response Prevention Plans

43. Application to Anxiety OCD Relapse Prevention and Fading Use of graphs to create evidence Cognitive Restructuring regarding beliefs about competency to manage OCD Cognitive Restructuring to differentiate self from OCD Fading the session length and frequency as habituation occurs Development of plan should obsessions become more controlling again Booster Sessions as a normative expectation

44. Application to Anxiety OCD Case Example Exposure Tape  SUDS data 

45. Application to Anxiety Generalized Anxiety Disorder Characterized by Uncontrollable Worrisome Thoughts that have several themes Anxiety Provocation is Based on the Appraisal of Risks in the Cognitions coupled with Estimates of Probability and Believability Anxiety is experienced as elevated but not panic-like, and occurs physically as well as subjectively

46. Application to Anxiety Generalized Anxiety Disorder Assessment Use of Scale like Beck Anxiety Scale or Zung Collect Diary of Worrisome Thoughts Develop SUDS for each Theme Identify Anxiety Components (e.g., subjective experience, physiologic arousal) Identify Safety Behaviors Self vs. Other Behaviors Identify Magic Cognitions (Worry Prevents Catastrophe)

47. Application to Anxiety Generalized Anxiety Disorder Treatment Components Relaxation Therapy to Manage Anxiety Arousal Use of Theme-based Scripts for Exposure Exercises Cognitive Restructuring to Modify Estimates of Likelihood and Believability Modification of Safety Behaviors (e.g., calling spouse to see if safe)

48. Application to PTSD Rape Trauma Direct Exposure Therapy Use of Cognitive Reprocessing Modification of View of Self Modification of Limited Event Recall Development of Realistic Risk Appraisal Development of Personal Safety Skills (Coping)

49. Application to PTSD Childhood Trauma STAIR Affect Regulation Development of Language of Emotion Development of Emotional Self-Soothing Skills Cognitive Distraction Distress Tolerance & Behavioral Activation of Pleasurable Experiences Acceptance of Emotions and Reframing Emotions as Valued

50. Application to PTSD Childhood Trauma STAIR Interpersonal Connection Identification of Interpersonal Schemas & Common Life Behaviors Self-Awareness of Conflict between Trauma Emotions vs. Goals for Interpersonal Relationships Modification of Self-Defeating Behaviors Through Role Playing Identification of Power and Control Issues in Role Playing Assertiveness Skills and Beliefs of Basic Rights Creation of Interpersonal Conflict Management Skills Fostering Flexibility Within Power-Differential Relationships

51. Application to PTSD Childhood Trauma STAIR Narrative Story Telling as Exposure Creation of Memory Targets Assurance of Hope and Betterment of Life Skills Using Emotional Management Strategies at end of Exposure & Staying in the Present Identification of Negative Emotions During Narrative Identification of Negative Interpersonal Schemas in the Narrative Contrasting Present Interpersonal Reality and New Skills to Learned Schemas Applying Coping Skills to Real-Life Situations and Healthier Interpersonal Behaviors in Present Relationship

52. Application to Depression Self-Monitoring of Mood Orientation to Descriptions of Mood Mood Logs Three Column Strategy Behavioral Self-Monitoring Activity Log Cataloging Positive Experiences

53. Application to Depression Behavioral Activation Development of Three Lists Current Pleasure Past Pleasure Hopes/Dreams Planning Scheduling Daily Activities and Structure Scheduling Pleasure

54. Application to Depression Cognitive Restructuring Development of Evidence Testing Skills From Mood Logs and Activity Records Understanding of Automatic and Distorted Cognitions Labeling Distorted Cognitions Modifying Distortions and Mood Through 5-Column Using Pros/Cons and Other Cognitive Restructuring Strategies Stimulus Control Negative Mood Triggers and Management of Exposure Development of Coping Mechanisms for Mood Triggers Skills Enhancement (e.g., parenting skills, conflict management)

55. Applications to Other Disorders Mastery of Your ADHD Habit Reversal Therapy for Hair Pulling Anger Management Using Stimulus Control and Cognitive Restructuring Weight Loss Protocol Developed by Judith Beck Positive Parenting Program for ADHD and Modification of Parental Incompetence Distortions

56. What to Do Develop CBT competencies Identify Useful Texts Like Leahy’s books Take Training from one of the Centers Seek ABPP and/or ACT Certification

57. Questions