CBT Workshop. Welcome

Transcription

1 CBT Workshop Welcome Give description of workshop some lecture, lots of activities for you to do. Slides 2-4 Many of you may have been practicing CBT without knowing it. How many of you have children? How many of you have ever said what were you thinking after you child did something that wasn t so smart? You were recognizing that thoughts (or lack of thoughts) can lead to behavior. As we go through the training, you may be surprised at how many of the approaches you may already be using. The public has a rather narrow view of CBT (show Stuart Smalley clip). Many people see it as just saying nice things to your self. What we will be doing is examining the deeper principles and the skills needed to use CBT well. While the mental health field views CBT as one of the newer approaches, these theories have been around since the days of the classical Greek philosophers. o Our life is what our thoughts make it. Marcus Aurelius o Such as are your habitual thoughts, such also will be the character of your mind; for the soul is dyed by the thoughts. Marcus Aurelius o We are formed and molded by our thoughts. Those whose minds are shaped by selfless thoughts give joy when they speak or act. Joy follows them like a shadow that never leaves them. Buddha o We are shaped by our thoughts; we become what we think. When the mind is pure, joy follows like a shadow that never leaves. Buddha o A man is but the product of his thoughts what he thinks, he becomes. Mohandas Gandhi CBT refers to more than 20 approaches. I want you to do a little experiment with me. Close your eyes if you are comfortable doing so. Imagine that you just won the lottery. What would be the first thing that you would do? How would you feel paying off bills? What would your dream house look

2 like? Where would you travel? How would it feel knowing you didn t have to work if you didn t want to? What would you do with all of the relatives who you haven t seen in years who came calling? You just got another phone call from someone proposing a deal too good to be true who wants your investment? How are you feeling now? Get responses from audience. What feelings were triggered by this fantasy (maybe one you daydream of now and then)? How did feelings change throughout? As the situation changed, did your feelings change? Just a small example of the relationship between thoughts and feelings. We all engage in thinking that can either enrich our mood or ruin our mood. But this relationship is just the tip of the iceberg. The chronic problems brought to us by our clients involves layers of thoughts or cognitions that keep them locked into negative patterns. That is what we are going to focus on ways to break these cognitions so that clients can be freed from their destructive patterns. CT (Beck) refers to the idiosyncratic meaning that the individual assigns to events in order to understand their emotional and behavioral reacts to events. Same situation is appraised differently by different people leads to different emotional responses response based on the appraisal, not the situation itself. CBT doesn t look at unconscious processes. Stresses individual free will and capacity to change through cognitive restructuring. Reality testing is directed at client s thinking, not their overt behavior. I am going to begin with an overview of the theory-- I want you to have a picture of the elements to see how they all fit together. Slides 5 Theory 1. Subjective Construction of Reality a. Seeing world through the client s eyes. Subjective viewpoint=self-talk. Revealed through therapist questioning (tapping their internal communication [Beck]).

3 b. Self-talk fills in gap between Activating Event { } Emotional Consequences c. Training clients to tap into their self-talk is key. d. Key question is What was going through your mind at that moment to make you feel...? Sejal address examples of what kinds of self-talk children/adolescents might engage in. Slide 6: (It is not the situation/event that causes a negative reaction but it is one s beliefs or perception about the situation/event that creates the reaction) What is the most accessible layer of cognitions for you to help the client uncover? Slide 7: (automatic thoughts) *Automatic Thoughts thoughts that come rapidly, automatically, and involuntarily when person is in a negative frame of mind and are linked to specific emotional reactions (such as depression, anxiety). These thoughts lie outside of immediate awareness but can easily be brought into consciousness. Pop-up thoughts not arrived at through reflective reasoning. Can be trigger by (1) external event or (2) internal event (pounding heart). Automatic thoughts are situation specific. Negative appraisals can also occur in the form of images. If client says he/she is not thinking of anything in particular probe for presence of images connected to client s feeling about the situation. This should be a routine part of assessment. Client can learn to replace distressing imagery with coping imagery. Slides 8-9: Information-processing model During psychological distress a person s thinking becomes more rigid and distorted. Normal information processing abilities become faulty because we introduce a consistently negative bias into our thinking.

4 Common processing errors: All-or-nothing thinking either/or rather than balanced and realistic way. Ex. If I am not first, I have failed. Mindreading thinking you can discern thoughts of others without any accompanying evidence. Ex. If you leave while I am speaking, I might think I am boring. Labeling rather than labeling the behavior, you attach the label to yourself. Ex. I failed my test so I am a failure. Should and must statements demands and commands made on self and terrible consequences when they are not met..ex. I must get this job or my life is over. Emotional reasoning assuming your disturbed or strong feelings are facts, that emotions reflect the way things really are (I feel like a bad friend so I must be a bad friend). Magnification and Minimization: Exaggerating or minimizing the importance of events. One might believe their own achievements are unimportant or that their mistakes are excessively important. Overgeneralization: Making broad interpretations from a single or a few events. Magical thinking: The belief that acts will influence unrelated situations. Personalization: The belief that one is responsible for events outside of their own control. Jumping to conclusions: Interpreting the meaning of a situation with little or no evidence. Mind reading: Interpreting the thoughts and behaviors of others without adequate evidence. Fortune telling: The expectation that a situation will turn out badly without adequate evidence. Disqualifying the positive: Recognizing only negative aspects of a situation while ignoring the positive. Sejal: Activity: Have group members pair up and come up with an example for each type as seen with students

5 Slide 10: (Core beliefs) Slide 11: a. *Core Beliefs (Schemas) The fundamental beliefs about ourselves, others, and the world. Usually have both positive and negative core beliefs. Formed through early learning experiences. Shape our outlook. Counselors bring in their own baggage from their personal histories. In emotional disturbance, rigid and overgeneralized negative core beliefs are activated. Information is processed in a biased way that confirms the core belief and disconfirms contradictory evidence. Once the disturbance has passed, negative one is deactivated or goes to a latent state. More positive outlook is re-established. (Client with personality disorder may have negative core beliefs activated most of the time). Two broad categories: (1) Helplessness (I am weak) and (2) unlovability. Must uncover and modify these. These can also occur in counselors which can create feelings of being ineffective or lead them to avoid confronting clients. When a person has a number of negative core beliefs that cause them emotional pain when these beliefs are activated, that person will act in one of three ways that help to maintain the core beliefs: Slide 12: Core beliefs about self Three basic categories of negative core beliefs about the self: Helplessness, unlovability, & worthlessness. In order to plan therapy effectively, should start gathering data from initial encounter and start generating hypotheses based on the data client provides. These will later be confirmed by the client. May have one category or combination of categories. 1. Helpless core beliefs (theme has to do with feeling ineffective in some way) a. I am inadequate, ineffective, incompetent; I can t cope. b. I am powerless, out of control; I can t change; I m stuck, trapped a victim.

6 c. I am vulnerable, weak, needy, likely to be hurt. d. I am inferior, a failure, a loser, not good enough; I don t measure up to others. Slide 13: 2. Unlovable (or unloved) core beliefs (fear that they will never obtain the intimacy and caring they want). a. I am unlikable, undesirable, ugly, boring; I have nothing to offer. b. I am unloved, unwanted, neglected. c. I will always be rejected, abandoned; I will always be alone. d. I am different, defective, not good enough to be loved. Slide 14: 3. Worthless core beliefs a. I am worthless, unacceptable bad crazy, broken, nothing, a waste. b. I am hurtful, dangerous, toxic, evil. c. I don t deserve to live. Worthless beliefs often have a moral tone. Have to check to see if this is the core belief with the worst meaning for the client or if unlovability or helplessness underlies that worthlessness. Is feeling worthless the worst part or is the worthlessness coming from not being able to be effective (helpless) or that you will never get the love you want (unlovable)? Sejal: Go back to sheet on distortions and see which category the distortion fits within. Slide 15: Core beliefs about others 1. Perceive others in rigid, overgeneralized, dichotomous way. 2. Do not perceive that others are complex humans who demonstrate traits to a greater or lesser degree in various situations. 3. Categorize others in all-or-nothing terms. 4. Perceptions are exaggeratedly negative (people are demeaning, uncaring, hurtful, sinister, manipulative. 5. May see others in an unrealistically positive way, as superior, completely effective, lovable, worthwhile (while they themselves are not.

7 Slide 16: Core beliefs about the world 1. Often hold dysfunctional beliefs about their personal world. 2. May believe that they cannot get what t hey want from life because of obstacles that world presents. 3. May hold beliefs like the world is unfair, unfriendly, unpredictable, uncontrollable, dangerous. 4. Beliefs may be global and overgeneralized. If there are negative core beliefs about self, others, and the world, may not be able to find a safe place to function. Slide 17: Why is it important to identify the category of belief? First, knowing core belief helps guide treatment. Beliefs often determine coping strategies being used. Core belief Coping strategies I am inadequate Rely on others or try to overachieve I am nothing Withdraw, avoid intimacy, be dramatic, or act entitled I am vulnerable Act strong, dominate, or avoid any possibility of being hurt Slide 18: The goal is to elicit and modify client s most central dysfunctional thoughts, beliefs, and behaviors. Client might be successful on the job but feelings of being unlovable lead to relationship problems. Knowing the source of problems leads to designing behavioral experiments and mastery experiences. Develop mastery skills (combat helplessness) Build relationships (combat unlovability) Build self-worth (combat worthlessness) Slide 19: What maintains core beliefs? Client engages in processes to maintain core beliefs through (1) selectively focusing on data that confirms negative view (notices and labels self every time doesn t live up to

8 expectations or gets negative reaction from others); (2) Discounts data contrary to the belief (when positive things happen, find a way to lessen its importance); (3) Fails to recognize contrary data (doesn t even register the positive things that happen). Slide 20: Core beliefs are maintained in 3 main ways: 1. Scheme maintenance thinking and behaving in way that reinforces core beliefs (think you are worthless, choose partners that treat you badly, confirms view) 2. Scheme avoidance seek ways to avoid activating negative core beliefs and their painful feelings (believe you are failure so don t even try). 3. Scheme compensation acts in ways that appear to contradict the core belief (see self as failure take on many tasks to prove otherwise). Slide 21: What are the rules that a client evolves to protect themselves from their negative core beliefs? (Underlying assumptions) Slide 22: *Underlying Assumptions Often unarticulated conditional assumptions which guide our behavior. Provides our rules for behavior. If----Then. If I please others, they will like me (positive assumption). If I don t please others, they will reject me (negative assumption). Rules are expressed in should statements. As long as followed, person remains relatively stable and productive. Helps person avoid feeling core negative beliefs assumptions not used to examine and change core beliefs. If assumptions prove false, then vulnerable to emotional distress when negative core beliefs are activated Slide 23: This is how the three levels interact. Core beliefs give us a plan for processing information. Painful information is kept in check by the establishing rules that guide behavior (if I do what is right, I will be o.k.). When a situation occurs where the assumptions do not work, then the core beliefs are activated, causing emotional pain. Slides 24 Sejal: Go through example Client must be able to identify and examine distorted and rigid thinking. Slides 25-26

9 Reciprocal interaction of thoughts, feelings, behavior, physiology and environment. a. Not a linear model. Each component in capable of influencing the other. b. Environment may provide the trigger. i..insert Beck model. c. Usually start the change process with examining thoughts (are there other ways of viewing the situation?) Slide Cognitive Vulnerability a. Idiosyncratic vulnerabilities may predispose person to psychological disturbance. b. Interplay of factors (childhood experiences, traumas, inadequate coping mechanisms, rigid attitudes, developmental history, personality differences) determines now life experiences will be reacted to. c. May overestimate danger and underestimate coping resources. Sejal adds examples Slide Case Conceptualization/Understanding your client a. Primary focus is on cognitive-behavioral factors that maintain client s emotional difficulties and the underlying beliefs and assumptions, personal vulnerabilities, traumas, and life experiences related to problems. b. Past and present interact to produce clinical picture of presenting problem. Conceptualization is seen as tentative and subject to revision as further information is revealed. Also called case formulation. c. Need to ask yourself: i. How did this client end up here? ii. What vulnerabilities and life events (traumas, experiences, interactions) were significant? iii. How has client coped with vulnerabilities?

10 iv. What are the automatic thoughts and from what beliefs did they spring? d. If therapist puts self in client s shoes (history and set of beliefs), client s perceptions, emotions, thoughts, and behavior make sense. e. Therapy is a journey and the conceptualization is the road map. f. Conceptualization begins with first contact. Hypotheses are formed based on what client presents and are confirmed, disconfirmed, or modified as new data emerges. Slide Focus on here and now a. Therapeutic focus is on factors maintaining client s problems. Don t focus on past unless connected to current problem. When past is mentioned, ask do you still see yourself that way now? Past cannot be changed or modified. Knowing how problem originated is unlikely to improve the treatment. b. Beck suggests that attention shifts to the past when: i. Client expresses a strong desire to do so; ii. When work directed toward current problems produces little or no cognitive, behavioral, or emotional changes; and iii. When therapist judges it is important to understand how and when important dysfunctional ideas originated and how these ideas affect client today. c. Need to present client with clinical rationale for the ahistorical (here and now) stance. 3. Becoming a self therapist a. As client becomes more adept at problem-solving, therapist becomes less active. Movement to self-therapist is facilitated by between session assignments. Model is more of a psychoeducational one. 4. Additional features a. Active-directive: therapist actively guides client to important aspects of presenting problem. Therapist actively collects assessment data for

11 cognitive conceptualization of problems and directs client toward connections between thoughts, feelings, and behaviors. b. Socialization into Cognitive Therapy: Must sell the model to clients. Present the model, encourage client to assume role of co-collaborator, develop a conceptualization of problem and a treatment plan based on it, outline expected course of therapy. c. Agenda setting: client and therapist agree which topics are to be put on agenda in each session. Focus is problem-focused. Usual items: 1. Review homework 2. Topics to be discussed in the present 3. Negotiating new homework 4. Feedback at end of session Slide 31: Understanding ABC model Sejal: Identify a problem that involves negative thinking. Help client break it down in ABC model. Slides Case conceptualization a. Based on a highly individualized understanding of client problems within cognitive framework. Hypothesizes how client s problems are maintained and underlying factors that predispose them to experience their problem. b. Clients describe this process in terms of overt difficulties (depression, panic attacks, etc.) and underlying psychological mechanisms (dysfunctional beliefs and assumptions). c. Differs from diagnosis tries to understand client s internal reality rather than label. 2. Use of measure a. Can establish a baseline for determining progress (Beck Depression, Beck Anxiety).

12 b. Reports about previous week. Give at beginning of session. Guides session. Slide 33 Main features of assessment c. 3 main areas to cover i. Detailed description of presenting problem ii. An ABC cross-sectional analysis of problem iii. A historical or longitudinal understanding of the problem d. Can take one or more sessions to complete. e. Continual process of refining. i. Draw up problem list ii. Establish goals for change iii. Agree to first homework task iv. Get session feedback Slide 34 Structure of the First Session Prior to a first session is some type of intake evaluation. A thorough diagnostic examination is essential for effective treatment planning (will differ if Axis I or Axis II diagnosis will discuss this later). Attend to: (1) presenting problem; (2) current functioning; (3) symptoms; (4) history. Therapist jots down agenda items to cover during initial session on therapy notes sheet Have a number of goals for the initial session: 1. Establish rapport and trust. Ongoing process that is accomplished through therapist demonstrating commitment to and understanding the client through words, tone of voice, facial expressions, and body language. Rapport easy to establish with client with Axis I diagnosis. Does not have to use large number of direct statements of empathy. Client feels valued and understood when therapist demonstrates empathy and accurate comprehension of their problems and ideas through thoughtful questions and statements. a. Implicit and sometimes explicit messages: i. Therapist cares about and values the client

13 ii. Confident they can work together iii. Believe can help client and client can learn to help self iv. Really wants to understand what client is experiencing and what it is like to walk in her shoes v. Therapist is not overwhelmed by client s problems even though client might be vi. Therapist has seen and helped others much like the client. vii. Believes cognitive therapy is the appropriate treatment for the client and that client will get better. b. Demonstrates collaboration by checking on the client s perception of the therapeutic process and of the therapist at the end of the session. Helps strengthen the therapeutic alliance. Can correct any misperceptions. Slides Setting the agenda discuss with client that we will decide what to talk about today and will do this at the beginning of each session. a. Can share that you have some items to suggest and will ask them what they want to add. b. Share that first session will be a little different because needing to get to know each other better. c. Will want to know about how client has been feeling, what brought them in, what you want to accomplish and what some of the problems are, and what is expected from therapy. d. Also will want to find out what they know about cognitive therapy and will explain how therapy will proceed. e. Will discuss what might try for homework f. Will summarize session. g. Will ask for client s feedback on how session went. 3. Slide 36 Mood Check a. can use standardized instruments if available. b. If not, spend some time teaching client to provide a rating of mood on a scale to keep objective track of how client is doing. ( Thinking back

14 over the past week, on the average, how has your depression/anxiety/anger/etc. been on a scale, 0 meaning no depression at all and 100 meaning the most depression you ve ever felt? c. Can graph these numbers each week to watch for progress. 4. Slide 37 Review of presenting problem, problem identification, and goal setting Slide 38 a. Can summarize what therapist knows from the intake form. See if anything new has occurred since intake. b. Help turn problems into goals to work on in therapy c. IF SUICIDAL IDEATION PRESENT, THIS BECOMES FOCUS OF SESSION. MOVE TO CRISIS INTERVENTION. FOCUS ON HOPELESSNESS. d. Identify what client wants to accomplish in therapy. How would you like for your life to be different? i. Get client to describe in behavioral terms what she would be doing differently (If you were happier, what would you be doing?) ii. Have client write out goal list (he uses carbonless paper so each has a copy) iii. Homework can be reading through the list and seeing if want to add anything. 5. Assessment and Socialization into CBT Introducing client to CBT a. In first session, important to teach client the relationship between thoughts and feelings. You decide when to introduce this model. Can take client description of feelings and build on it (if present with anxiety, does feeling reduce while talking to you?) Or can you use didactic approach once you gain some understanding of client s problems. Include basic understanding of model, idea of collaboration. Make illustration of model as concrete as possible. Then ask clients if they can make a connection between their thoughts and feelings. b. Can you think of any time in the past few days when you noticed your mood change? then have client tell about it. Do you remember what was going through your mind? Restate So you had the thoughts..?

15 f. Guide client through diagram [Situation] [Thought] [Emotion] using own example. For adolescents, diagrams often are more helpful than words. g. Check out to see if client understands connection between thoughts and feelings. Can you tell me in your own words about the connection between thoughts and feelings? h. Homework then becomes observing this relationship and writing it down. Has client write down what was going through her head not what was she thinking since she might have an image rather than words. Writes homework down on carbonless paper so each has a copy. Think about words other than homework for adolescents. Slide Expectations for therapy a. Check with client for their expectations. Do they think therapist will cure them? Or do they think the therapist will help them but they have to do the work? b. Length of therapy. Often 8-14 sessions, moving to every other week then once/mo. Longer for Axis II (year or more) 7. Educating client about his/her disorder a. Better to stay away from labels. Clients often just want to know if they are crazy. b. Can also normalize that you have seen others with similar situations make progress. Can focus on the characteristics of the diagnosis such as depression means you probably are having issues with sleep, appetite, energy. c. Can look for automatic thoughts associated with their behavior. 8. Slide 40 End-of-session summary and setting of homework a. Ties together the threads of the session and reinforces important points. b. Includes what client agreed to do with homework. If client seems reluctant, checks that out and withdraws homework. Also may change term homework c. In later sessions, asks client to summarize. 9. Slide 41 Feedback

16 a. Ask client how he/she felt session went. Can verbally give feedback or write it down. b. Strengthens rapport shows therapist values client c. Can resolve any misunderstandings Sejal: Break into triads (Client, therapist, and observer). Observer uses rating sheet to see how therapist addresses each of the parts of the session. Rotate roles. Sejal: Slide 42 Working with Children and Adolescents 1. Same format is followed but it must be adjusted in terms of pacing the content and the speed of the therapy. 2. The younger the child, the less they are able to deal with metacognitions (thinking about their thinking) and the less aptitude they have in labelling feelings. 3. Many children and adolescents have deficits in social skills and interpersonal problem-solving. This may be the focus in the session. Develop skills and change thoughts about themselves. 4. Cognitive distortion is one of main problems. Sejal: Slide The content of the cognition may be typical of the disorder or mood. For example, depression may raise thoughts of worthlessness and personal loss no one will love me, I will be alone ; anxiety may give thoughts of danger, fears for personal well-being in the future and catastrophising it will be a disaster, I'm going to crack up ; and anger may see transgression of personal rules it's not fair.

17 Sejal: Slides Early Experience Parents quarrel and separate Father leaves home Formation of dysfunctional core beliefs I always drive people away I m no good Development of dysfunctional assumptions Unless I always please people, they ll reject me If people get to know me, they ll see I m no good Critical incident Boyfriend goes out with another girl Assumptions activated Negative automatic thoughts It s my fault I ll never have another friend No one loves me, I ll be alone forever I m worthless Symptoms Behavioral: social withdrawal, stays at home Motivational: loss of interest and pleasure,everything an effort, procrastinates Emotional: sadness, guilt, shame, anxiety Cognitive: poor concentration, self-criticism,memory problems Physiological/somatic: poor sleep, reduced appetite

18 Slide 46 The format is similar to what is followed for adults. Each session includes: o Setting the agenda show collaboration and making a problem list helps to clarify things (move from everything is awful ) o Review of homework (may want to use other terms). o Goals setting of tasks for the session Practicing tasks in session o Homework is agreed, which may involve tasks practices in session o Problem-solving to anticipate difficulties o Summarizing with feedback from the adolescent. Slide Need to help adolescent in the session distinguish between different emotional states. 2. Start linking emotions with events and thoughts a. Expand by self-monitoring, using charts and diaries in which the young person observes his or her thoughts and makes specific causal links between events, mood, and thoughts. 3. Can use activity scheduling to overcome social withdrawal that may go along with depression. 4. Coping skills training will help with social interaction (how to start a conversation) 5. Social problem solving how to resolve a conflict without antagonizing others. Slides Slide 34 Information Processing Model Often helpful in explaining to client why they believe their core beliefs so strongly but why the core beliefs may not be true, or not completely true. The circular figure with the rectangular opening represents the client s schema, the mental structure that organizes information. The content of the schema is the client s core beliefs.

19 How to explain to client: 1. Client identifies a long-held negative belief. 2. I have a theory about the reason you believe this so strongly. But you have to tell me whether you think this is right or wrong. a. It is almost as if there is a part of your mind that is shaped like this you see it is like a circle with a rectangular opening. b. Inside this part of your mind is the idea (ex., I am a failure) c. Now let s say something happens. Maybe you made a mistake at work and your boss reprimanded you. What did you say to yourself? Did you have to think about it (probably had an instant reaction) d. It is as if this event made a mistake at work is contained in a negative rectangle. e. Do you see how since it is a rectangle, it fits right into the rectangular opening? And every time a rectangle goes in, it makes this idea I am a failure stronger. f. Try another situation. (may be one client mentioned earlier I didn t get a promotion and my mom said I will never get a better job). What does this mean to you? How does it fit I am a failure? g. Let s try one more. When else this week did you feel like a failure? When I got stopped for not completely stopping at a stop sign. h. There seems to be a pattern here. What do you think of this theory? Whenever something happens or you do anything that could possibly mean you re a failure, that information immediately goes straight to the part of your mind (point to diagram) without you even thinking much about it.

20 i. O.k., here is my second theory. When anything happens that could possibly mean you are not a failure, that information doesn t go straight in. I think something happens to it. For example (choose something client has told you), your boss gave you a special project to do because it would give you some added experience for the future. When she did that, were you able to say to yourself that your boss has some plans for you? (If no, check on if this is another negative message given to self). j. It is like you put this message somewhere else, such as in a triangle. Do you see that the triangle cannot fit in the rectangular opening? It has to get changed to get in. So you might change it to my boss must be desperate to ask me to do this. She is really hard up for help. k. So you make the positive fit into one of negative thoughts so it can now fit in. It strengthens the I am a failure even more. l. Can work on coming up with other positives and see how client modifies them to make them negative. m. Also can explore how other positive information just bounce off don t really recognize that these things are positive. n. What do you think of that theory that almost anything you do, or anything that happens to you that is positive, either gets changed into a negative or it bounces off, you just don t notice it. o. What happens over time is that you strengthen this negative belief. p. (Slide 55) This approach can evolve into a homework assignment