The ABCs of CBT. Understanding the basic foundation and implementation of Cognitive Behavioral Therapy

Transcription

1 The ABCs of CBT Understanding the basic fondation and implementation of Cognitive Behavioral Therapy Melissa A. Novak, LCSW, CST Licensed Clinical Social Worker Certified Sex Therapist MN Therapies

2 Objectives Knowledge of the cognitive model and the rationale for treatment Basic knowledge of key components to cognitive therapy sch as the cognitive model, cognitive conceptalization and their components. Understanding of the cognitive conceptalization, its formlation and how it is sed to gide treatment. Integrate varios skills and techniqes yo already know into the conceptalization

3 Why CBT? It is an adaptable, cohesive strctre. Holds the therapist and client accontable. Helps focs sessions and treatment. Clients love it. Research.

4 Cognitive Therapy Competency ACT Certification pblic/memberapp_description.cfm 2 Part Process Part I: Preliminary Review of training and knowledge of CBT Part II: Clinical Review of an actal case, inclding a taped session CBT_Competences_Map.pdf

5 Ability to implement CBT sing a collaborative approach Generic therapetic competences Basic CBT competences Specific behavioral and cognitive therapy Problem specific competences Metacompetences knowledge and nderstanding of mental health problems knowledge of, and ability to operate within, professional and ethical gidelines knowledge of a model of therapy, and the ability to nderstand and employ the model in practice ability to engage client ability to foster and maintain a good therapetic alliance, and to grasp the client s perspective and world view ability to deal with emotional content of sessions ability to manage endings ability to ndertake generic assessment (relevant history and identifying sitability for intervention) ability to make se of spervision knowledge of basic principles of CBT and rationale for treatment knowledge of common cognitive biases relevant to CBT knowledge of the role of safetyseeking behaviors ability to explain and demonstrate rationale for CBT to client ability to agree goals for the intervention Ability to strctre sessions Sharing responsibility for session strctre & content ability to adhere to an agreed agenda ability to plan and to review practice assignments ( homework ) sing smmaries and feedback to strctre the session ability to se measres and self monitoring to gide therapy and to monitor otcome ability to devise a maintenance cycle and se this to set targets exposre techniqes applied relaxation & applied tension activity monitoring & schedling Gided discovery & Socratic qestioning ability to se thoght records ability to identify and work with safety behaviors ability to detect, examine and help client reality test atomatic thoghts/images ability to elicit key cognitions/images ability to identify and help client modify assmptions, attitdes and rles ability to identify and help client modify core beliefs ability to employ imagery techniqes ability to plan and condct behavioral experiments Specific phobias Social Phobia Heimberg Social Phobia - Clark Panic Disorder (with or withot agoraphobia ) - Clark Panic Disorder (with or withot agoraphobia ) - Barlow OCD Steketee OCD Kozac GAD Borkovec GAD Dgas/ Ladocer GAD Zinbarg/Craske/Barlow PTSD - Foa & Rothbam PTSD - Resick PTSD Ehlers Depression High intensity interventions Cognitive Therapy Beck Behavioral Activation - Jacobson Depression Low intensity interventions Behavioral Activation Generic metacompetences capacity to se clinical jdgment when implementing treatment models capacity to adapt interventions in response to client feedback capacity to se and respond to hmor CBT specific metacompentencies capacity to implement CBT in a manner consonant with its nderlying philosophy capacity to formlate and to apply CBT models to the individal client capacity to select and apply most appropriate BT & CBT method capacity to strctre sessions and maintain appropriate pacing capacity to manage obstacles to CBT therapy problem solving ability to end therapy in a planned manner, and to plan for long-term maintenance of gains after treatment ability to develop formlation and se this to develop treatment plan /case conceptalisation 1 ability to nderstand client s inner world and response to therapy Gided CBT self help

6 Sitation Atomatic Thoght Reaction Boss calls yo in for a srprise meeting. I m going to get fired. God, they are annoying. I m going to look stpid. Finally, I m getting that raise. Emotional Behavioral Physiological Anxiety, fear, dread, relief Head to bathroom, take deep breaths, make a few notes to bring, do some recon with coworkers. Heart racing, SOB, sweating,

7 The Basic Cognitive Model Distorted or dysfnctional thinking (which inflences mood and emotions) is common to all psychological distrbances.

8 Sitation 1 What was the problematic sitation? Sitation 2 Sitation 3 Atomatic Thoght What went throgh her mind? Atomatic Thoght Atomatic Thoght Meaning of the A. T. What did the atomatic thoght mean to her? Meaning of the A. T. Meaning of the A. T. Emotion What emotion was associated with the atomatic thoght? Emotion Emotion Behavior What did the patient do then? Behavior Behavior

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10 Sitation 1 What was the problematic sitation? Sitation 2 Sitation 3 Atomatic Thoght What went throgh her mind? Atomatic Thoght Atomatic Thoght Meaning of the A. T. What did the atomatic thoght mean to her? Meaning of the A. T. Meaning of the A. T. Emotion What emotion was associated with the atomatic thoght? Emotion Emotion Behavior What did the patient do then? Behavior Behavior

11 Identifying Atomatic Thoghts/ Emotional and Behavioral Patterns Ask the client to speak abot a distressing sitation. Notice a shift in affect and then prompt. What went throgh yor mind jst then? Take a feeling statement and reflect back as an absolte or a prediction. ( I worry I might fail the test. -> I am going to fail the test. )

12 I wasn t thinking anything. Helpfl qestions to elicit elsive atomatic thoghts. Any hypotheses? Use another person. Emotions list Describe the physical state of feeling. Describe what yo did

13 Vignette: The Case of Jennifer 40 something, white, cisgender, female reqesting services to address recent break p and apartment cltter. Has been on disability since being fired from job 15 years ago. Family Dynamic Middle child, lots of inter-sibling rivalry and fighting Mother and father had tmltos relationship that ended; both had sbstance abse isses Social Active in high school and academically sccessfl Had friends bt often felt left ot and avoidant of bringing anyone home de to cltter and family Psych History of therapy with mltiple providers Previos diagnosis of MDD, dysthymic disorder, ADHD Was on a cocktail of psychotropic meds which was redced Obsessional, anxios, depressed, distrstfl, defensive, hopeless and entitled

14 Exploring Jennifer s Experience Sitation Atomatic Thoght Meaning of the A.T. Plled over and given a ticket. He was ot to get me. This is completely nfair. Ex-boyfriend says she s high maintenance. I m blamed for or problems. I m messed p. Emotion Hopeless; helpless and angry Sad, angry. Behavior Began chasing the cop and yelling at him. Call him to discss. Write him s and letters explaining her opinion. Obsess.

15 Assessing emotional intensity. LOW: Cognitive/Insight Techniqes Labeling distortions Thoght logs Hypothesis testing Reframes HIGH: Behavioral Techniqes Sensory/Labeling Exposres Acting as if Opposite Action Emotion Reglation Distress Tolerance Activity Planning

16 Challenging the Atomatic Thoghts Are they tre? Are they sefl? Thoght Logs Develop a hypothesis and test them (cognitive and behavioral options). Reframe and practice.

17 Cognitive Distortions

18 Challenging the Behavior and Emotion Acting as if Smiling/Posing Contrary Behavior Exposres Visalization Identifying needs

19 Thoght Logs

20 What wold initial treatment look like? Sitation Atomatic Thoght Meaning of the A.T. Plled over and given a ticket. He was ot to get me. This is completely nfair. Ex-boyfriend says she s high maintenance. I m blamed for or problems. I m messed p. Emotion Hopeless; helpless and angry Sad, angry. Behavior Began chasing the cop and yelling at him. Call him to discss. Write him s and letters explaining her opinion. Obsess.

21 Sitation 1 What was the problematic sitation? Sitation 2 Sitation 3 Atomatic Thoght What went throgh her mind? Meaning of the A. T. What did the atomatic thoght mean to her? Emotion What emotion was associated with the atomatic thoght? Behavior What did the patient do then? Atomatic Thoght Meaning of the A. T. Emotion Behavior Atomatic Thoght Meaning of the A. T. Emotion Behavior The meaning tells s why this matters and begins to help s see how the client sees herself, her world and her ftre. This is the beginning of downward arrow.

22 Exploring Jennifer s Experience Sitation Atomatic Thoght Meaning of the A.T. Plled over and given a ticket. He was ot to get me. This is completely nfair. Ex-boyfriend says she s high maintenance. I m blamed for or problems. I m messed p. Emotion Hopeless; helpless and angry Sad, angry. Behavior Began chasing the cop and yelling at him. Call him to discss. Write him s and letters explaining her opinion. Obsess.

23 Here is where we pt the behaviors we start to see repetitively. Here is where we pt the themes we find in downward arrow, or or hypotheses to later clarify with the client.

24 Downward Arrow Ask the client to examine what his/her thoghts mean, why they matter? And what if happens? So what? What s so bad abot? Compile themes of identified atomatic thoghts. The client s affect will typically significantly shift when yo ve identified the core belief. Often times clients will provide several distressing thoghts. Focs on one thoght by having them select the one that is most charged.

25 Using Downward Arrow Ex doesn t text back that day. He s with another girl I can t handle it. I m not important. I am rejected. I ll be alone forever. Friend is helping with ct s cell phone. I can t tell him to stop. I m ot of control. I m being difficlt. I won t have any friends. Saw an item she gave away in a magazine. I liked that piece. I sholdn t have given it away. I made a mistake. I can t do anything to fix it. My ftre is bleak. I m a failre. I m powerless.

26 Example of Complex Downward Arrow: Jennifer s conflict with boyfriend. I m blamed for all or problems. He doesn t respect or care abot me. No one will ever love me. I can t make it better. He will leave me. I will be alone forever. I won t achieve anything in my life. I m a total failre. I am nlovable.

27 Relevant Childhood Data Sbstance abse isses with both parents. Reports being victimized by siblings and high school friends. Dad often flakes on promises. History of critical/invalidating relationships with friends, family, bosses, and partners Core Beliefs People will hrt and disappoint me. I m powerless. The world is ot to get me. My ftre is bleak. I m a total failre. Conditional Assmptions/Attitdes/Rles I have to always make the right decisions or else I am a total failre. If I don t do as well as other s I m a failre. It is nbearable to be lonely. I shold be able to solve my problems easily. If I have any regret or am ncomfortable, I have made a bad decision. Compensatory Strategies Defensiveness Attacks others. Seeks reassrance. Over explains self. Researches everything exhastively. Does not get rid of items.

28 Cases & Goals Cases let s do this! What are yo taking with yo? What are yo going to try for every patient this week?

29 Thoghts are not trths. They are not realities. They are not certainty. Yet, people often act as sch. Thoghts are merely or perceptions habitally linked throgh charged langage and experience. Thoghts are the lenses to one s experience. If they are covered in crap, then all yo will see is crap.

30 Qestions? Resorces and References: Academy of Cognitive Therapy: Beck, Jdith. (1995). Cognitive Therapy: Basics and Beyond. New York: The Giliford Press. Leahy, Robert L. (2003). Cognitive Therapy Techniqes: A practitioner s gide. New York: The Gliford Press