Cognitive Behavioural Therapy

Format

Many CBT therapists offer weekly sessions, over 8-12 weeks. Every two weeks is fine; every three weeks is less than optimal.

Other options include:

• reading materials to patients/clients (Mind Over Mood)
• computer-based models
• other therapy (ie supportive therapy)

It can be helpful to book a half day weekly to do therapy; it does take a certain headspace.

Introducing the Therapy

It is important, firstly, that you assess capacity and motivation. If someone is poorly suited, or not interested, then CBT may not be the best fit.

Describe the format of a typical session to the patient/client, including agenda setting, check-ins, and homework. This can help frame the therapy as a whole, and set the stage for optimal growth.

It can be very helpful to sketch out the relationship between schemas, cognitions, mood, and behaviour.

Choose a recent example in the patient's life. Get them to describe the situation, the emotions they experienced, the automatic thoughts which preceeded them, and the resulting behaviours.

Draw connections among them, showing how the patient's experience unfolds. This enables them to self-reflect and grow.

Agenda setting

You need to be deliberate about setting the agenda, to keep on time and ensure the important topics are covered.

Let patients choose which topic to approach first. Ideally, this is a smaller, manageable to learn the ropes and generate inertia with success.

A sample 45 minute session could include:

• mood checkin - 5 min
• feedback on previous week's homework - 15 min
• relationship with mom (troubleshooting) - 15 min
• planning next week's homework - 10 min

It is important, as mentioned, to link tasks with goals. Why will the patient/client be tackling a difficult task? How does this relate to the defined goals of therapy?

Early sessions

• set day's agenda
• review thought logs, including evidence columns and reformulated thoughts
• review behaviour

Taking Notes

Writing things down, with the patient a part of the process, can help settle scattered emotions and bring focus. Ask permission.

It can be helpful for the patient/client to see what is being written, to provide a framework for understanding and further depth.

It can also be helpful for the patient/client to have their own therapy notebook, to jot ideas and realizations down. This can also be used to review together as therapy comes to a close.

If a patient/client does not want to write things down, as them what their barrier is.

An approach to take is to ask them to think through a thought record (described below), then perform a written record. A comparison of the two approaches and outcomes can provide powerful motivation to begin, and continue, writing.

If a patient/client does not write things down, ask them how they remember things, and use this technique.

Effective questions

Ask regular questions to clarify or elicit further information. It can be helpful as well to have an understanding of where you are going. Questions can also be used to reflect and further information gathered. Responses such as 'uh-huh' can also be used to further a line of thinking for the patient/client.

Guiding questions can facilitate the depth of a conversation and move therapy in healing directions.

An "I don't know" answer can be common and disconcerting in therapy.

Begin by finding out what this means: is the question confusing? (ask simpler questions) Are you unsure? (create space for thought) Do you know, but don't want to say? (what might happen if you told me? how could we deal with that?)

Socratic dialogue

First, ask for evidence that supports the patient/client's belief. This helps build therapeutic alliance by ensuring them they are being heard, and avoids having them taking the stance of arguing FOR their belief, and helps the therapist understand.

Listen to their responses, and summarize.

Analytical and synthesizing questions, simple in nature ("what do you make of this?" "how does x go with y?" "How can you use these ideas to help yourself?") This allows the patient/client to own the learning.

Curiosity

It is important to ensure that you evoke a patient/client's curiosity - what are you going to say next? What is going to come out of this?

Old patterns of thought or emotion can be unexciting. Curiosity can be increased by asking patients/clients to come up with new ways of describing thoughts and emotions, as well as the introduction of behavioural experiments.

Be curious yourself, and be interested in the patient/client. If you communicate a desire to learn more about them, and especially their strengths, this will provide tremendous mileage.

Summarizing

It is important to accurately reflect what the patient/client is saying, using the patient's exact words as best as possible. Do this in conversation. Repeating a patient/client's words back to them reinforces that they are being listened to, and allows them to go deeper.

Write this information down to act as a record, for yourself and for the patient/client.

The therapist can help direct the focus through summarizing, by choosing specific points to reflect and to encourage furthering.

However, don't create summaries in which you've injected your own conclusion.

Time management

It is important to stick to the agenda as best as possible. If it looks as though time is running out, mention this and ask the patient/client how they would like to proceed. If the patient stops putting a pre-determined goal (ie procrastination) on the agenda, ask what is behind this.

If a patient/client talks non-stop, without pauses, it can be helpful to have a polite mechanism of interrupting. This can be difficult to do initially, and requires practice.

To get their attention, while smiling, say 'Time out', 'Can I ask a question?', say their name, or raise your hand as if asking a question. Follow this by saying "This is important information that you're giving, but I'm wondering if it would it be ok if I interrupted from time to time to ask questions as we went along to clarify?" Pay attention to their response and how they feel.

If a patient/client meanders across different topics, some strategies include:

• "It seems as though there are a few main issues here. Does this seem right?"
• "Can you help me undersand the connection between this and that topic?"

Setting

Encourage the patient/client to describe the setting as richly as possible:

• when did this happen?
• where was it?
• who was there?
• what was happening? what did you do?
• why did you make these choices?
• how did this end?

Moods

Helping patients/clients to connect with the setting allows for a deepening of the experienced emotions. This 'stirring up' prompts.

Observation and Self-Monitoring

It is important to help facilitate awareness of emotions, including what the emotion is, how strong the emotion is, and what the energy is. Along with this, ask the patient/client to identify physiological responses, such as abdominal discomfort, muscle tension, shortness of breath, etc.

This is done initially with the therapist by discussing a recent event, and assisting the patient/client to re-experience their emotion.

It can be helpful to share a list of mood words with people to help them identify, with one word, what they are feeling. These can be found here. Again, reflect back what you hear.

Activity schedule

Building on self-observation, an activity schedule can help build awareness in the moment. Provide a framework, with blocks of 1 hour or so; ask patient/client to identify the setting (again, as specifically as possible), and what feeling(s) they are experiencing, and the intensity of this mood.

Thoughts

Again, there are many types of thoughts: automatic thoughts, underlying assumptions, and core beliefs. These are certainly linked.

Identifying thoughts

Some helpful questions to help patients/clients identify their thoughts:

• What went through your mind just then/right now?
• Did you experience any images, mental pictures, sounds, smells, or memories?
• Can you help me understand what made you feel so ______ ?
• Was there anything else that made you feel this way, or bothered you?
• What does this mean to you?
• What does this mean about others?

Asking 'what are you thinking' limits what people are able to connect with.

Identifying Underlying Assumptions

Ask "If you ______, then ...." and leave a space for the patient/client to fill it in. These can be used for behavioural experiments.

Thought Records

Thought records link together events, feelings, thoughts, and behaviours, but are designed primarily to get to thoughts. It is ideal for people with depression, and for anger, guilt, and shame; not as helpful for anxiety.

It is designed for when the patient/client feels a strong emotion, such as anger, fear, or sadness.

Initially done with therapist, but ideally patient/client does this on own. Helps teach alternative ways of thinking.

Begin with columns 1-3 over the first few weeks.

There is a lot of skill required for use with thought record. Initially the therapist can help prompt for the thoughts, but the goal is certianly to have patients identify their own thoughts.

The thought record can be used to ask questions, moving back and forth between the hottest emotion and thoughts to get to the hot thought.

If a fact comes up as a hot thought, this is not an ANT, assumption, or core belief. One can't stop here, however; you need to dig down to find out what identity/purpose thoughts are association.

Reflection and guiding questions are helpful for this. "What is so distressing about failing the test?"

If a question is the "thought", this needs to be more explored: "What is the answer to the question that makes you feel hot mood?"

Ask what thought is connected to the 'hot mood' that is the answer to the question?

Go through the TR with the patient/client, trouble-shooting while praising what they did well. Ensure the situation is specifically detailed, moods are identified and rated, the hot mood circled, and thoughts are well-targeted to the mood. Encourage 4-5 thoughts. Circle the hot thought.

Ask for as much detail about images or memory as possible. When looking at evidence, ask if the image details are congruent with reality or past experience.

Look for evidence supporting and not supporting the thought, as much as possible from the situation in column 1. Evdience (for or against) gathered from a lifetime is less effective, as the 'supporting' evidence can often overwhelm the 'against'. Column five is one of the most important of them all.

Assist the patient/client to shift perspective out of their mood state (MoM, p 71).

• If your friend said this, what would you say to them?
• Five years into the future, what would you say to yourself?

Column 6 should summarize Col's 4 &5.

This alternative thought should also prompt a significant mood shift, if it is substantial enough. If there is not a shift, it is probably helpful to

TR is designed to investigate thoughts and moods. 90% of the time, mood will improve with a realization that the hot thought was fueled by faulty evidence.

If the hot thought appears true, create an action plan to address this. This can help with mood shift as well.

If the hot thought is a core belief, this will be very very very hard to budge with evidence. In this case,

Challenging Distortions

"no one is going to like me" - some poeple will like you

"I'm going to fail" -

20 questions to challenge negative thinking

• what is the evidence?
• etc
• am I thinking in all-or-nothing terms?
• am I using a double standard?
• am I overestimating the changes of disaster?
• on CD from FMF 2009

Core Belief Log

How do you want to see yourself?

Keep a daily diary of tiny bits of evidence that support this desired belief. Behavioural experiments may also be helpful.

The goal is to gather evidence to convince the pt.ct of otherwise.

"schema change processes" in clinical corner of Padesky.com

Behaviours

CBT focuses on behaviours as a major aspect of understanding and change.

Identifying Behaviours

As therapy is getting underway, it is helpful to understand current negative (safety) behaviours. Questions to ask include:

• how do you cope?
• is there anything you do/think to prevent a bad thing from happening?
• I noticed you doing xyz. Can you tell me about what this means?

Behavioural Experiments

Behavioural experiments are planned experiments or observations that can happen in or out of therapy sessions to test beliefs. "Behavioural experiments are the crossroads of cognitive therapy" (Padesky, 2004).

They represent a laboratory for patients/clients, where true experiments are done, with no guarantee of success (although it is good to choose experiments that have a good chance of working out).

Types of BEs include:

• surveys (often administered by therapist, under direction of patient/client; can use tape recorder too)
• observations: list 10 people who are/do ________ ; what are your thoughts about them?
• direct tests of if/then tests
• graded tasks: breaking avoided tasks into small steps
• prediction logs
• role plays

Experiments should be be concrete and very specific. Write down predictions and outcomes.

Once is not enough, and it is important to discuss what will be considered success. Do 5 experiments to test a given belief.

Graded tasks, using a hierarchy of small steps, can be helpful. Try BE's yourself to ensure they are realistic, and to learn yourself! Convey excitement - "this is going to be fun!"

"fake it till you make it"

Goal Setting

behavioural goals are usually at least as important as addresisng cognitions

Goals need to be SMART

Time-out

this has very little cognitive components to it

Homework

It is important to assist and encourage the patient/client to put concepts into practice throughout the weeks. However, avoid calling it homework; better words are "experimenting" or "noticing".

Each of the various methods can be done, including moods, thoughts, and behaviours. However, behavioural experiments are the most likely to be completed, especially if they are fun!

Start homework in the therapy session to ensure the mechanism is satisfactory. Give a short description of what is expected, and what is not (neatness, etc). Expect trouble, and ask what the barriers might be. Pre-emptively come up with solutions to them. Finish by saying "I'm excited to hear what you come up with!"

When patients/clients return, check in with their homework, complimenting good observations. Socratic dialogue (described under therapy structures -> questions, above).

Depression

level A evidence that CBT is as effective as medication for mild-to-moderate depression. It also appears to reduce the relapse rate. However, pharmacotherapy can improve symptoms faster. Dr Beck calls depression a thinking disorder, rathern than a mood disorder. It is characterized by a negative view of self, world, and future.

"My life is a mess, it's all my fault, and it will never get better". Dr Padesky's synopsis of depression.

Pessimism, self-criticism, and hopelessness. Hopelessness is one of the best predictors of suicide.

Structure

Focus primarily on the automatic thought level.

First few sessions: activity is a mood boost, especially pleasurable or anti-avoidance activities.

Thought records in sessions 4-6.

Behavioural Experiments

Design experiments that get patients/clients out doing activities

• are enjoyable
• involve mastery
• overcoming avoidance

Rate mood before and after activity.

Five minutes rule: do it for five minutes; this leads to receipt of full credit. Pushing through these five minutes usually overcomes motivation.

Exploration of Thoughts

The next phase of treatment for depression involves testing automatic thoughts. Some questions to identify these thoughts include:

• what went through your mind?
• what does this say/mean about you? your life? your future?
• what images or memories come to mind? do you have any images of killing yourself? what emotions are surrounding this?

Thought records, action plans, and behavioural experiments are helpful tools.

MoM, p 52: ANT to consider

Underlying Assumptions

Anxiety

Level A evidence that CBT should be used as first line for adults and children, when possible, for generalized anxiety disorder. Here, patients/clients are primarily future-focused, with an emphasis on threats, danger, and an inability to cope.

Structures

There are specific treatment protocols for specific anxiety disorders that relate to a given danger.

For generalized anxiety, 12-20 sessions are usual for adults. This includes education, examining unrealistic beliefs, emotional regulation, exposure, problem solving, and relapse prevention.

Panic disorders frequently respond to intense, jump-right-in therapy. In fact, patients/clients can often make tremendous recovery in as little as 4-6 sessions.

Phobias can be treated with graded exposure. They can often be treated in 3-4 treatments.

Exploration of Thoughts

It is important to first identify the source of the danger.

Key questions to hone in on anxiety:

• what is going through your mind?
• what is the worst that could happen?
• how can you see yourself reacting?
• what images or memories come to mind?

Need to identify underlying assumptions in anxiety

PTSD: organize the memory of the trauma, re-examine the threat and place it in the past, challenge victim mentality and move to one of freedom.

Behavioural Experiments

People's fears should be tested in directive behavioural experiments. Don't give them options!

most common is exposure and response prevention, to prevent reinforcement and promote habituation. It is especially useful in patients with mild-to-moderate symptoms, or with contraindications to medications (pregnancy, bipolarity).

Design experiments explicitly to cause fear.

Panic disorder: cause the sensation (ie by hyperventilation) and explore alternate explanations

OCD: exposure and response prevention eg touch something dirty and don't wash hands; monitor emotions and watch them decrease

health worries: stop all tests and reassurance seeking for a set amount of time (ie 3-6 months)

PTSD: challenge safety behaviours

Anger

Anger is an other-focused emotion, with an emphasis on hurt or violation.

Key questions for thoughts include:

• what does this mean to you?
• what does this say about other people?
• what images or memories come to mind?

Personality Disorders

Help construct positive core beliefs, as it appears that they are unapaired negative core beliefs.

It is also effective (and faster) to address underlying assumptions.