Cognitive Behavioral Therapy Barbara Jones Warren, PhD, RN, CNS BC, PMH Thisspeakerhasnoconflictsofinterest speaker has of interest to disclose. Use of CBT For self and personal growth Individuals Groups Families Couple, partner, marital relationships Workplace environments Mental health, wellness, illness foci 1 4 Purposes of Today s Dialogue Describe the use of cognitive behavioral therapy (CBT) in psychiatric mental health (PMH) settings Discuss the components of CBT Cognitive Rational emotive Explain the clinical application of CBT Case studies Treatment planning and implementation Evaluation of CBT Efficacy of CBT Mood disorders Anxiety disorders Obsessive Compulsive Disorder Panic disorder 2 5 Life Just Isn t Interesting or Fun! Clinically: One CannotFunction! Use of CBT in PMH Settings 3 6 Warren 1
Cognitive Behavioral Therapy Extreme Energy, Out of Control Behavior An Ongoing Low Grade Depression 7 10 Low Grade Ongoing Hyperactivity Specific Time, Season of the Year 8 11 An Ongoing Low Grade Depression 9 Warren 12 2
Beck s Theory Components of CBT (Cognitive, Rational Emotive) Depressed people have a negative view of: Themselves The world The future Depressed people have negative schemas or frames of reference through which they interpret all events and experiences 13 16 Founders of CBT Epictetus: Greek philosopher, started the premise of the therapy People are not disturbed by things Disturbed by the view they have regarding what has happened Depression and Negative Schemas Negative schemas: Always present Unconscious Become activated with stressful events 14 17 Aaron Beck Definition of CBT Cognitive Therapy Focused form of psychotherapy Mental illnesses involve dysfunctionalthinking thinking Structure of experiences feelings and behaviors 15 18 Warren 3
Premises for CBT Modifying dysfunctional thinking provides improvements in symptoms and modifying dysfunctional beliefs that underlie dysfunctional thinking leads to more durable improvement Therapy is driven by a cognitive conceptualization and uses a variety of strategies The Cognitive Triad Negative view of the self (e.g., I m unlovable, ineffective) Negative view of the future (e.g., nothing will work out) Negative view of the world (e.g., world is hostile) 19 22 Premises for CBT Fact not assumptions Structured and directive Maladaptive behaviors are not a result of skill deficits Unwanted reactions are learned Therapy is driven by a cognitive conceptualization and uses a variety of strategies Practice and assignments The Cognitive Model Core Beliefs Assumptions Compensatory/coping strategies Situation Automatic thoughts/images 20 Reaction (emotional/behavioral physiological) 23 Progression of Thinking Situation CBT: Collaborative Effort Automatic Thoughts And Images Reaction (Emotional, Behavioral and physiological) 21 24 Warren 4
Roles Client Define goals Delineate concerns Implement techniques Therapist Assist client to define goals Listen to the client Teach CBT techniques Reinforce and encourage Premises of Rational Emotive Therapy Clients learn how to choose their reactions Self observation and personal change Here and now basis Self help techniques that facilitate coping 25 28 Calmness & Neutrality Managing difficult situations Use calmness and neutrality Avoid 2 problems real problem and anxiety/ being upset Self Defeating Rules (Irrational Beliefs) 1. I need love and approval from those around to me. 2. I must avoid disapproval from any source. 3. To be worthwhile as a person I must achieve success at whatever I do. 4. I can not allow myself to make mistakes. 5. People should always do the right thing. When they behave obnoxiously, unfairly or selfishly, they must be blamed and punished. 6. Things must be the way I want them to be. 7. My unhappiness is caused by things that are outside my control so there is nothing I can do to feel any better. 26 29 Albert Ellis Rational Emotive Therapy 8. I must worry about things that could be dangerous, unpleasant or frightening otherwise they might happen. 9. I must avoid life s difficulties, unpleasantness, and responsibilities. 10. Everyone needs to depend on someone stronger than themselves. 11. Events in my past are the cause of my problems and they continue to influence my feelings and behaviours now. 12. I should become upset when other people have problems, and feel unhappy when they re sad. 13. I shouldn t have to feel discomfort and pain. 14. Every problem should have an ideal solution. 27 30 Warren 5
Irrational Thinking and Emotional Disturbance A= Failure at work B= I am stupid, I ll never be able to be good at work, I will always fail C= Depressive disorder Clinical Application of CBT 31 34 Ellis List of Common Irrational Ideas I absolutely must have sincere love and approval almost all the time from all the significant people in my life I must be thoroughly competent, adequate and achieving in all respects, or I must at least have real competence or talent at something important; otherwise I am worthless. People who harm me or who do a bad thing are uniformly bad or wicked individuals, and I should severely blame, damn, and punish them for their sins and misdeeds CBT & RET RET: Identify patient s irrational beliefs CBT: Teach the patient to dispute the beliefs and substitute logical and rational beliefs Evaluate the effects of disputing their irrational beliefs Problem solving skills and assertiveness training 32 35 Ellis List of Common Irrational Ideas (continued) When things do not go the way I would like them to go, life is awful, terrible, horrible, or catastrophic Unhappiness is caused by external events over which I have almost no control. I also have little ability to control my feelings or rid myself of feelings of depression and hostility. Case Studies 33 36 Warren 6
Example of Negative Thinking Person with negative schema involving rejection will become depressed when a partner leaves him or her Continued Her social support primarily consists of her fiancé and some female friends who she has known since middle school. She is not particularly close to her Father, saying that he has never been supportive of her. In addition, he recently re married a much younger woman (Aged 28, Father is 70 yrs.) and is spending money like mad. He never would buy my Mother or us anything. I do not understand why he is acting like this. My Mother is even more depressed about this circumstance. The client also reports that her parents divorced when she was in the 3 rd grade. 37 40 Original Meeting and Assessment Time A 23 year old Jewish American woman comes to the office to see me. After my initial introduction, I ask her what she needs from me today and what would she describe as her primary need. She answers, somewhat tearfully, that she is worried about how to manage her stress. I don t want to be like my Mother. She has been depressed her entire life and never got help. Continued The client reports no physical diagnoses. She is clean but somewhat disheveled in her overall appearance. He is appropriate in affect, shows no indication of psychosis but is slow to respond to questions, even though her responses are appropriate. She is slightly overweight and mentions this as a concern for her. 38 41 Continued She continues to talk about her current situation and says she had dropped out of school just recently due to stress. Her affect is flat and she is tearful throughout the interview. She mentions (with questioning) that she has had periodic times of thinking of wanting to not be around but has no plans or intent of pursuing these thoughts. Continued At this point, what is your impression of this client? What initial diagnoses might you consider? Consider all of the Axes I V Arethereinterventions that you would consider regarding counseling techniques? Are there medications that you might consider using? Are there other issues that you see as meaningful to consider? 39 42 Warren 7
Depression References Warren, B. J. (2010). Depression: Management of depressive disorders and suicidal behavior. In M.A. Boyd (Ed.), Psychiatric Nursing: Contemporary Practice (5 th ed.) (Ch.24). Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins. Warren, B. J., & Lutz, W. J. (2007a). The state of nursing science: Cultural and lifespan issues Depression part II: Focus on adults. Issues in Mental Health Nursing, 28(7), 707 748. Warren, B. J., & Lutz, W. J. (2007b). The state of nursing science: Cultural and lifespan issues Depression Part II: Focus on children and adolescents. Issues in Mental Health Nursing, 28(7), 749 764. 43 CBT: Sessions Identify and changing maladaptive thoughts First sessions: therapist explains cognitive theory of emotional disorders (negative cognitions contribute to distress) Middle Sessions: Client is taught to identify, evaluate and replace negative automatic thoughts were more positive cognitions Therapist is a collaborator Final Sessions: solidify gains, focus on prevention of recurrence 46 CBT and RET Treatment Planning & Implementation Identifying Assumptions and Core Beliefs If, then Downward arrow If this thought is true, what s so bad about that? What s the worst part about that? What does it mean to you? About you? 44 47 Treatment Plan What members of the transdisciplinary team are involved? How do you, as a PMH nurse facilitate the use of CBT & RET within your clinical setting? Reinforce/implement CBT and RET interventions included in the treatment plan. Read the treatment plan & reinforce items within your scope of practice Chart to the treatment plan. If the treatment Plan indicates client will be redirected using CBT techniques you may chart something like, client was redirected four times this evening. Relapse Prevention Solidify gains: broaden range of identified negative thoughts and strengthen more positive cognitions Anticipate future stressful life events that might trigger a future depression and role play more adaptive responses 45 48 Warren 8
CBT & RET References Evaluation of CBT Ellis, A. & Dryden W. (1997). The Practice of REBT (Second edition). London. Free Association Books. National Association of Cognitive Behavioral Therapists, http://www.nacbt.org/whatiscbt.htm Still, A. & Dryden, W. (2003). Ellis and Epictetus: Dialogue vs. method in psychotherapy. Journal of Rational Emotive & Cognitive Behaviour Therapy. 21(2), 37 56 Ziegler, D.J. (2002). Freud, Rogers, and Ellis: A comparative theoretical analysis. Journal of Rational Emotive and Cognitive Behavior Therapy. 20(2) 49 52 Nursing Clinical Reasoning Processes Practice the techniques yourself! Ongoing Biopsychosocial i Assessment & Monitoring Burns, D.D, (1989). The feeling good handbook. New York, NY: Plume Book 50 CBT & RET References Bernard, M. E. (1986). Staying Rational In an Irrational World: Albert Ellis and Bond, F.W. & Dryden, W. (2002). Handbook of Brief Cognitive Behaviour Therapy. Chichester. John Wiley & Sons Ltd. Dryden, W. (1995). Brief Rational Emotive Behaviour Therapy. Chichester. John Wiley & Sons. Ellis, A. (1988). How To Stubbornly Refuse To Make Yourself Miserable About Anything. New York. Lyle Stuart. Ellis, A. & Harper, R. A. (1975). A New Guide to Rational Living. Hollywood. Wilshire Book Co. Ellis, A., Wolfe, J. & Moseley, S. (1980). How to Raise an Emotionally Healthy, Happy Child. Hollywood. Wilshire Book Co 51 Warren 9