COGNITIVE BEHAVIOUR

THERAPY
DR GORDON AMBAYO
OUTLINE
• Introduction
• Rational for CBT
• Uses of CBT.
• Brief history of development of CBT.
• Phases in therapy
• CBT in clinical practice.
• CBT in depression.
• CBT in anxiety disorders.
INTRODUCTION
• Cognitive behavioral therapy (CBT) is a psycho-social
intervention that aims to improve mental health.
• CBT focuses on challenging and changing unhelpful cognitive
distortions (e.g. thoughts, beliefs, and attitudes) and behaviors,
improving emotional regulation, and the development of
personal coping strategies that target solving current problems.
• Originally, it was designed to treat depression, but its uses have been
expanded to include treatment of a number of mental health
conditions, including anxiety.
INTRODUCTION
• CBT is often used as an umbrella term referring to a number of
cognitive and/or behavior psychotherapies that treat defined
psychopathologies using evidence-based techniques and strategies.
• The CBT model is based on the combination of the basic principles
from behavioral and cognitive psychology.
• CBT is a "problem-focused" and "action-oriented" form of therapy,
meaning it is used to treat specific problems related to a diagnosed
mental disorder.
INTRODUCTION
• The therapist's role is to assist the client in finding and practicing
effective strategies to address the identified goals and decrease
symptoms of the disorder.
• CBT is based on the belief that thought distortions and maladaptive
behaviors play a role in the development and maintenance
of psychological disorders, and that symptoms and associated distress
can be reduced by teaching new information-processing skills and
coping mechanisms.
INTRODUCTION
• When compared to psychoactive medications, review studies have
found CBT alone to be as effective for treating less severe forms of
anxiety, posttraumatic stress disorder (PTSD), tics, substance
abuse, eating disorders, borderline personality disorder and
depression.
What is CBT?
• CBT is a type of psychotherapy (Talking therapy).
• CBT stands for cognitive behaviour therapy.
• Cognition refers to thoughts.
• Behaviour refers to actions
What is CBT?
• (CBT) is a form of psychotherapy that treats problems and
boosts happiness by modifying dysfunctional emotions, behaviors,
and thoughts.
• Unlike traditional Freudian psychoanalysis, which probes childhood
wounds to get at the root causes of conflict, CBT focuses on solutions,
encouraging patients to challenge distorted cognitions and change
destructive patterns of behavior.
Rational for CBT
• How one thinks (cognition) and how one acts (behaviour) can affect
how one feels(mood).
• Negative cognition and maladaptive behaviours can cause one to feel
low mood.
• By identifying and correcting negative cognitions and maladaptive
behaviours, the depressed mood can be improved.
Rational for CBT
• Therefore, CBT uses the idea that thoughts and perceptions influence
behavior.
• Feeling distressed, in some cases, may distort one’s perception of
reality.
• Beck’s cognitive triad, also known as the negative triad is a cognitive –
therapeutic view of three key elements of a person’s belief system
present in depression.
• The triad involves automatic, spontaneous and seemingly
uncontrollable negative thoughts about: the self, the world or
environment and the future.
Rational for CBT
• CBT aims to identify harmful thoughts, assess whether they are an
accurate depiction of reality, and, if they are not, employ strategies to
challenge and overcome them.
Uses of CBT
• CBT is appropriate for people of all ages, including children,
adolescents, and adults.
• CBT can benefit numerous conditions, such as major depressive
disorder, anxiety disorders, post-traumatic stress disorder, eating
disorders, obsessive-compulsive disorders, and many others.
• CBT can be delivered effectively online, in addition to face-to-face
therapy sessions.
History of development of CBT
• Aaron Beck is generally considered the pioneer of CBT.
• He was a professor of psychiatry at the University of Pennsylvania in
the USA.
• He initially developed cognitive therapy for treating depression.
• It was subsequently expanded to include behavioural components
and became CBT.
• Since then CBT has been successfully used for a range of disorders,
either on its own or in combination with medication.
Phases in therapy
CBT can be seen as having six phases:
• 1. Assessment or psychological assessment;
• 2. Reconceptualization;
• 3. Skills acquisition;
• 4. Skills consolidation and application training;
• 5. Generalization and maintenance;
• 6. Post-treatment assessment follow-up.
Phases in therapy
• These steps are based on a system created by Kanfer and Saslow.
After identifying the behaviors that need changing, whether
they be in excess or deficit, and treatment has occurred, the
psychologist must identify whether or not the intervention
succeeded.
• For example, "If the goal was to decrease the behavior, then there
should be a decrease relative to the baseline. If the critical
behavior remains at or above the baseline, then the intervention has
failed."
Related techniques
• CBT may be delivered in conjunction with a variety of diverse but
related techniques such as exposure therapy, stress inoculation,
cognitive processing therapy, cognitive therapy, relaxation training,
dialectical behavior therapy, and acceptance and commitment
therapy.
Some practitioners promote a form of mindful cognitive therapy
which includes a greater emphasis on selfawareness as part of the
therapeutic process.
The steps in the assessment phase include:

• Step 1: Identify critical behaviors

• Step 2: Determine whether critical behaviors are excesses or deficits
• Step 3: Evaluate critical behaviors for frequency, duration, or intensity
(obtain a baseline)
• Step 4: If excess, attempt to decrease frequency, duration, or intensity
• of behaviors; if deficits, attempt to increase behaviors.
• The re-conceptualization phase makes up much of the "cognitive"
portion of CBT.
Delivery protocols
• There are different protocols for delivering cognitive behavioral
therapy, with important similarities among them.
• Use of the term CBT may refer to different interventions, including
"self-instructions (e.g. distraction, imagery, motivational self-talk),
relaxation and/or biofeedback, development of adaptive coping
strategies
(e.g. minimizing negative or self-defeating thoughts), changing
maladaptive beliefs about pain, and goal setting".
Delivery protocols
• Treatment is sometimes manualized, with brief, direct, and time
limited treatments for individual psychological disorders that are
• specific technique-driven. CBT is used in both individual and group
settings, and the techniques are often adapted for self-help
applications. Some clinicians and researchers are cognitively oriented
(e.g. cognitive restructuring), while others are more behaviorally
oriented (e.g. in vivo exposure therapy).
• Interventions such as imaginal exposure therapy combine both
approaches.
Use of CBT in Clinical Practice.
• CBT is a time limited therapy, usually 12 -16 sessions.
• Number of sessions is decided in advance.
• Sessions take place once a week.
• Each session lasts for about 50 minutes.
• The goals of treatment are clearly identified at the beginning of
therapy.
• The patient’s progress is regularly monitored during therapy.
• The patient is an active participant in the therapy.
Use of CBT in Clinical Practice.
• The patient is usually given tasks (homework) to complete between
sessions.
• Rating scales are usually used at the beginning of therapy and at the
end of therapy to assess effectiveness of therapy.
• In CBT the focus is on the ‘here and now’.
• The focus is not on the origin of the problem.
• The main objective of CBT is to help the patient use practical cognitive
and behavioural strategies to overcome the problem.
Initial assessment
• To include:
• Description of current difficulties.
• Identify goals of treatment ( needs to be realistic).
• Explain treatment rationale to the patient.
• Establish weather the patient would be willing to work in a CBT
model.
• If so, clearly explain structure and purpose of treatment sesions.
• Start treatment.
Structure of each treatment session
• Agree on agendas for the session.
• Review progress since previous session.
• Review homework tasks given to the patient/ any difficulty in doing
them.
• Discuss in detail a specific problem or difficulty the patient is
experiencing.
• Devise specific strategies to address the problem.
• Give homework tasks with clear instructions.
• Get feedback from the patient to ensure understanding.
CBT IN DEPRESSION
• The aim is to overcome negative cognitions and unhelpful behaviours
that maintain the depression.
• Examples of negative cognitions:
• “I am worthless”
• “It is all my fault”
• “I will never get better”
• Examples of unhelpful behaviors:
• Social withdrawal.
CBT IN DEPRESSION
• Avoiding activities.
• Staying in bed for long hours.
Some Key terms used in CBT in
depression
• Dysfunctional assumptions.
• Negative automatic thoughts.
• Cognitive distortions.
Dysfunctional assumptions
• These are extreme and inflexible opinions that people form about
themselves and about the world.
• People’s early life experiences influence what dysfunctional
assumptions they have.
• Examples of dysfunctional assumptions:
• “If I am not perfect, I cannot be happy”.
• “If I don’t succeed in everything I do, I am a failure”.
• Dysfunctional assumptions remain latent until there is a critical
stressful event, when they then lead to negative automatic thoughts.
Negative automatic thoughts
• Negative: Have negative themes.
• Automatic: Thoughts keep popping in one’s mind.
• The content of Negative Automatic thoughts tends to be related to
the Dysfunctional assumption that precede them.
• Examples of negative automatic thoughts:
• “I will never be happy”
• “I will always be a failure”.
• Negative automatic thoughts then make depression worse
Negative automatic thoughts
• One of the main focuses of cognitive behavioral therapy is on
changing the automatic negative thoughts that can contribute to and
exacerbate emotional difficulties, depression, and anxiety.
• These negative thoughts spring forward spontaneously, are accepted
as true, and tend to negatively influence the individual's mood.
• Through the CBT process, patients examine these thoughts and are
encouraged to look at evidence from reality that either supports or
refutes these thoughts.
Cognitive distortion in depression
• These are errors in thinking that are commonly seen in depression.
• These errors serve to maintain depression.
• CBT aims to aims to identify such errors, and helps to correct them.
• This process is called cognitive restructuring.
Examples of cognitive Distortions
• All or nothing thinking
• Jumping to conclusion.
• Magnification/Minimisation.
• Overgeneralization.
• Disqualifying the positive.
All or nothing thinking
• Thinking in absolute rather than in relative terms.
• Words such as “always”, “Never”, “Everything”, Nothing”, etc.
characterize this thinking.
• E.g a person applies for promotion at work. He does not get
promoted, while a colleague does, He concludes: “I will never get
promoted”, or I am always a failure”
Jumping to conclusions
• Coming to negative conclusions with insufficient evidence.
• Two types:
• 1. Mind reading; E.g. At work, a colleague does not smile back. The
person concludes, “He no longer likes me”.
• 2. Fortune-telling: E.g. The person fails his driving test the first time.
He concludes that he will never pass the driving test.
Magnification/minimization
• The person tends to magnify his mistakes while minimizing any
positive achievements.
• E.g.
• 1. Magnification: A person fails to meet deadline at work by just one
day. He feels very guilty about this.
• Minimization: The person succeeds in meeting a deadline at work,
several days in advance. He dismisses it feeling he was just lucky and
deserves no credit.
Overgeneralization
• Making sweeping generalizations from an isolated example.
• E.g.: The patient prepares dinner for friends. Apart from one item, all
the others come out very well. However, the person generalizes from
one poor item, and concludes, I am a terrible cook”.
Disqualifying the positive
• The patient dismisses any good attribute of oneself.
• Same example as previous.
CBT TECHNIQUES USED IN
DEPRESSION
• Cognitive strategies:
• Identifying/challenging negative automatic thoughts.
• Distraction techniques.
• Behavioural strategies:
• Monitoring activities on mastery and pleasure.
• Scheduling Activities
• Graded task assignment.
Identifying/Challenging Negative
Automatic thoughts
• Patient to maintain a record of negative thoughts that keep popping
into the mind.
• These negative thoughtsusualy involve one of the following 3 themes:
• 1) About oneself (I am worthless)
• 2) About the word/others (No one cares for me)
• 3) About the future (There is no hope for me)
Identifying/Challenging Negative
Automatic thoughts
• Once the negative thoughts are identified, the patient is advised to
challenge them to establish how true they are in reality.
• By repeatedly doing this exercise, the patient would see the link
between low mood and negative automatic thoughts, and between
challenging the negative automatic thoughts and improvement in
mood.
Distraction techniques
• These techniques are useful when one is extremely distressed
because of symptoms of anxiety or depression.
• By distracting oneself from depressive/anxiety thoughts, one can
reduce the acute severity of these symptoms.
• They are useful in the short term, while the patient is learning other
CBT techniques.
Examples of Distraction Techniques
• Focusing on an object.
• Doing some mental exercise.
• Thinking about pleasant memories and fantasies.
• Sensory awareness.
• Doing some absorbing activities.
Focusing on an object.
• The patient is taught to focus attention on an object.
• E.g. The patient is asked to look at an object nearby (e.g a wall clock)
and asked to mentally answer several questions such as:
• What is its location?
• How big is it?
• What is its colour?
• What is it made of?
• What time is it showing?
Mental Exercises
• Examples include:
• 1) Subtracting back from 1000 (1000- 6, 994 – 6, 988 -6, etc).
• 2) Thinking of objects beginning with a certain letter of alphabet.
Pleasant Memories and Fantasies.
• Patient is asked to think about past pleasant memories, or possible
future fantasies:
• E.g.
• 1) Thinking about a previous holiday that they enjoyed.
• 2) What would they do if they win a large amount in the lottery?
• (In depression, especially if it is severe, it is often difficult for the
patient to recall or think about anything positive).
Absorbing Activities
• Indulging in some activities that can distract the patient.
• E.g.
• Doing a crossword or Sudoku puzzle.
• Listening to music, or watching a favourite programme.
• Any physical activity such as cooking, cleaning, ironing, etc.
• (Due to reduced mental concentration and physical tiredness, the
patient may find doing these activities difficult).
Behavioural Strategies
• Monitoring Activities.
• Scheduling activities.
• Graded task assignment.
Example of a record of activities
• The patient is asked to keep a record of all the activities that they do
on a daily basis.
• The patient is asked to rate each activity, on a scale of 1 to 10, based
on the following:
• A) Mastery (How well did you do the activity?)
• B) Pleasure (How much enjoyment did you get while doing this
activity?)
Monitoring Activities
DATE ACTIVITY MASTERY (1 TO 10) PLEASURE (1TO 10) ANY COMMENTS
15TH FEBRUARY BRUSHING TEETH 8 2
PREPARING 4 4 FELT VERY TIRED
BREAKFAST
EATING BREAKFAST 5 6
TALKING ON THE 5 9 FELT ENERGISED BY
PHONE WITH FRIEN’S SUPPORT
AFRIEND
Monitoring Activities
• This record of activities, that the patient does every day, helps to
counter negative thoughts such as:
• “I don’t do anything”
• Even if I do something, I don’t do it well”
• “I don’t do anything that gives me pleasure”
Scheduling activities
• The previous task (Monitoring activities) would give an idea of the
kind of activities that the patient is able to enjoy.
• The next step is for the patient to plan each day in advance on an
hour-by-hour basis.
• The number of activities should be realistic, considering the patient’s
mood.
• The patient is asked to include activities that they enjoy.
• Planning in advance helps give the patient a greater sense of control.
Scheduling activities
• It also helps the patient to avoid repeated decision-making during the
day.
Graded Task Assignment
• If the person is unable to do a particular task in one go, he is advised
to break such a task into smaller, more manageable steps.
• This helps to overcome:
• 1) Procrastination (I can’t do it now, I will do it later”).
• 2) Negative cognitions (It’s too much for me’)
• 3) Hopelessness (I can never do this”).
CBT FOR ANXIETY DISORDERS
• CBT has been shown to be effective in a range of anxiety disorders
including:
• 1) Panic Disorder.
• 2) Phobias
• 3) Obssessive Compulsive Disosorder.
• 4) Generalised Anxiety Disorder
Panic disorder
• Characterized by episodic paroxysmal anxiety.
• The anxiety attacks come “out of the blue”
• In panic disorder there are both cognitive symptoms (e.g. faer of
fainting, fear of dying e.t.c.) as well as physical symptoms (e.g
palpitations, sweating trembling, etc.)
• Panic symptoms can also occur in phobic disorders in response to
exposure to the feared stimulus.
RELATIONSHIP BETWEEN PHYSICAL SYMPTOMS
AND COGNITIONS IN PANIC DISORDER
PHYSICAL SYMPTOMS ASSOCIATED COGNITIONS
PALPITATIONS “I AM HAVING A HEART ATTACK”
I AM GOING TO DIE
BREATHLESSNESS “I AM GOING TO SUFFOCATE”
DIZZINESS “I AM GOING TO FAINT”
PHOBIA
• Phobia is an anxiety disorder in which symptoms occur when the
person is exposed to the feared stimulus.
• Depending on the stimulus, there are different types of phobias:
• 1.Simple (Specific) phobia.
• 2. Agoraphobia.
• 3. Social phobia.
Simple (specific) Phobias
• The anxiety symptoms do not occur in the absence of feared
stimulus’.
• E.g
• 1) Fear of spiders (Arachnophobia).
• 2) Fear of heights.
• 3) Fear of enclosed spaces (Claustrophobia)
Agoraphobia
• In this condition the patient has fear of
• 1) Crowded places.
• 2) Travelling alone.
• 3) Leaving home.
• In severe cases the patient becomes totally house bound.
Social Phobia
• This is also called social anxiety disorder.
• In this condition, the anxiety symptoms manifest in social situations
such as:
• 1) Attending social events such as parties.
• 2) Public speaking.
• 3) Eating in public.
CBT IN ANXIETY
• In anxiety disorders such as panic and phobias, the behavioural
response of the patient to overcome the anxiety is usually one of the
following:
• 1) Avoidance.
• 2) Escape.
• CBT aims to change such maladaptive behaviours, and help the
patient deal with the anxiety.
• Avoidance and escape may provide short term relieve of anxiety, but
in the long run they reinforce the anxiety.