Cognitive Behavioral Therapy

Amira Amjad

Copyright: Dr. Shona Vas, Department of

Psychiatry and Behavioural Neuroscience,
Cognitive Behavior Therapy Program MS-3
Clerkship 2008-2009
 outline
• What is Cognitive Behavior Therapy (CBT)?
• What are the basic principles of treatment?
• What is the course of treatment?
• What are some examples of interventions?
• Who is appropriate for CBT?

Copyright: Dr. Shona Vas, Department of

Psychiatry and Behavioural Neuroscience,
Cognitive Behavior Therapy Program MS-3
 Definition of cognitive therapy
• CT is a focused form of psychotherapy based
on a model stipulating that psychiatric
disorders involve dysfunctional thinking.
• Dysfunctional/distorted thinking arises from
both biological and psychological influences
• Individuals’ emotional, behavioral, and
physiological reactions are influenced by the
way they structure their environment.
Copyright: Dr. Shona Vas, Department of
Psychiatry and Behavioural Neuroscience,
Cognitive Behavior Therapy Program MS-3
 What is CBT
• Set of ‘talk’ psychotherapies that treat
psychiatric conditions.
• Short-term focused treatment.
• Strong empirical support with randomized
clinical trials.
• As effective as psychiatric medications.
• Recommended as critical component of
treatment, particularly when medications are
contraindicated or ineffective.
Copyright: Dr. Shona Vas, Department of
Psychiatry and Behavioural Neuroscience,
Cognitive Behavior Therapy Program MS-3
 Why So Popular?
• Clear treatment approach for patients
• Assumptions make sense to patients
• Based on patient’s experience
• Encourages practice and compliance
• Patients have a sense of control
• CBT works!

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Definition of CT (continued…)
• Modifying dysfunctional thinking and behavior
leads to improvement in symptoms.

• Modifying dysfunctional beliefs which

underlie dysfunctional thinking leads to more
durable improvement

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Definition of CT (continued…)
• Cognitive therapy is defined by a cognitive
formulation of the disorder and a cognitive
conceptualization of the particular patient.

• Cognitive therapy is not defined by the use of

exclusively cognitive techniques. Techniques from
many modalities are used.

• CT also often referred to as Cognitive-Behavior

Therapy (CBT).

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Rationale for CBT
• Negative emotions are elicited by cognitive processes
developed through influences of learning and
temperament.
• Adverse life events elicit automatic processing, which is
viewed as the causal factor.
• Cognitive triad: Negative automatic thoughts center
around our understanding of:
– Ourselves
– Others (the world)
– Future
• Focus on examination of cognitive beliefs and developing
rational responses to negative automatic thoughts.

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Beck et al., 1979
Cognitive Behavior Therapy Program MS-3
 Cognitive Specificity Hypothesis

• Distorted appraisals follow themes relevant to the

specific psychiatric condition.
• Psychological disorders are characterized by a
different psychological profile.
– Depression: Negative view of self, others, and future.
Core beliefs associated with helplessness, failure,
incompetence, and unlovability.
– Anxiety: Overestimation of physical and psychological
threats. Core beliefs linked with risk, dangerousness, and
uncontrollability.

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Cognitive Specificity
• Negative Triad Associated with Depression
– Self “I am incompetent/unlovable”
– Others “People do not care about me”
– Future “The future is bleak”
• Negative Triad Associated with Anxiety
– Self “I am unable to protect myself”
– Others “People will humiliate me”
– Future “It’s a matter of time before I am embarrassed”

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
Targeted Cognitions for Different Disorders

• OCD: appraisals of obsessive cognitions

• Anorexia: control, worth, perfection
• Panic: catastrophic misinterpretation of
physical sensations
• Paranoia: trust, vulnerability

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Working Model of CBT

Event
Appraisal
Maladaptive
Behavior

Behavioral Affective and

Inclination Biological Arousal

copyright: Dr. Shona N. Vas, Dept of Thase et al., 1998

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Cognitive Model
Triggering Event
Bill goes to collection
Appraisal
“I can never do
Behavior anything right…”
Avoidance; withdrawal

Behavioral Inclination Bodily Sensations

“I don’t want to deal with it” Low energy, disruption of
“It’s too stressful to think sleep, increased fatigue
about it”

copyright: Dr. Shona N. Vas, Dept of Thase et al., 1998

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 What are Automatic Thoughts?
What was going through your mind?
• Happen spontaneously in response to situation
• Occur in shorthand: words or images
• Do not arise from reasoning
• No logical sequence
• Hard to turn off
• May be hard to articulate

Negative
Stressful Automatic Thoughts
copyright: Dr. Shona N. Vas, Dept of
Situation Psychiatry & Behavioral Neuroscience Emotions
Cognitive Behavior Therapy Program MS-3
 Cognitive Distortions
• Patients tend to make consistent errors in
their thinking
• Often, there is a systematic negative bias in
the cognitive processing of patients suffering
from psychiatric disorders
• Help patient identify the cognitive errors s/he
is most likely to make

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Types of Cognitive Distortions
– Emotional reasoning Feelings are facts
– Anticipating negative outcomes The worst will happen
– All-or-nothing thinking All good or all bad
– Mind-reading Knowing what others are thinking
– Personalization Excess responsibility
– Mental filter Ignoring the positive

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Examples

• Cognitive Distortions
– Emotional Reasoning: “I feel incompetent, so I know
I’ll fail”
– Catastrophizing: “It is going to be terrible”
– Personalization: “It’s always my fault”
– Black or white thinking: “If it isn’t perfect, it’s
no good at all.”

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Core Beliefs
• Core beliefs underlie and produce automatic
thoughts.
• These assumptions influence information
processing and organize understanding about
ourselves, others, and the future.
• These core beliefs remain dormant until
activated by stress or negative life events.
• Categories of core beliefs (helpless, worthless,
unlovable)

Core Beliefs Automatic Thoughts

copyright: Dr. Shona N. Vas, Dept of
Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Examples of Core Beliefs
• Helpless core beliefs
– I am inadequate, ineffective, incompetent, can’t cope
– I am powerless, out of control, trapped
– I am vulnerable, weak, needy, a victim, likely to be hurt
– I am inferior, a failure, a loser, defective, not good enough, don’t measure up
• Unlovable core beliefs
– I am unlikable, unwanted, will be rejected or abandoned, always be alone
– I am undesirable, ugly, unattractive, boring, have nothing to offer
– I am different, flawed, defective, not good enough to be loved by others
• Worthless core beliefs
– I am worthless, unacceptable, bad, crazy, broken, nothing, a waste
– I am hurtful, dangerous, toxic, evil
– I don’t deserve to live

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Cognitive Conceptualization
Physiology
Current Automatic Thoughts
Situation About self, world Feelings
And others
Behavior

Childhood Compensatory
Underlying Assumptions
And Early Strategies
and Core Beliefs
Life Events

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Example 1 Physiology
Heart racing
Lump in throat
Situation Automatic Thoughts Feelings
Partner says: Automatic response:
Sadness
“I need time to “Oh no, he’s losing interest
Worry
be with my friends” and is going to break up
Anger
with me….”
Behavior
Seek reassurance
Withdraw
Cry

Underlying Assumptions &

Compensatory
Childhood Core Beliefs
Strategies
Experiences “I’m flawed in numerous ways, Be independent and
Parental neglect which means I’m not worthy of you’ll be safe.
and criticism
copyright: Dr. Shona N. Vas, Dept of
consistent attention and care. Watch out – people
Psychiatry & Behavioral Neuroscience People only care when they want are careless with you.
Cognitive Behavior Therapy Program MS-3
Clerkship 2008-2009 something.”
 Example 2 Physiology
Automatic Thoughts Pit in stomach
“I am not going to get Dry mouth
through this program -
Situation Feelings
I’m not as smart
Disappointing Worry, shame,
as everyone else.
exam result Disappointment
People will
discover this and I Humiliation.
will be humiliated.”
Behavior
Use alcohol,
Procrastinate
with homework

Childhood Underlying Assumptions

Adversities Compensatory
“If I don’t excel in school, I’m a
Parental standards Strategies
total failure”
reinforce academic Work extra hard
achievement to offset
copyright: Dr. Shona N. Vas, Dept of
Psychiatry & Behavioral Neuroscience incompetence.
Cognitive Behavior Therapy Program MS-3
 Responding to Negative Thoughts
• Define Situation
• Clarify meaning of cognitive appraisal
– What was going through your mind just then?
– What did the situation mean for you?

• Evaluate interpretation
– Evidence: For and against this belief?
– Alternatives: Any other explanation(s)?
– Implications: So what….?

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Evaluating Negative Thoughts
• What is the effect of telling myself this
thought?
• What could be the effect of changing my
thinking?
• What would I tell ___ (a friend/family
member) if s/he viewed this situation in this
way?
• What can I do now?

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
Situation
Sample
Thoughts
Thought Log
Emotions Rational Outcome
Response
Going on She’ll say no… Anxiety I haven’t taken Anxiety (10%)
vacation—Ask a I’m not doing a (70%) a day off in 6 Guilt (0%)
colleague to do good job Guilt (40%) months. We Relief (40%)
some work for The boss thinks I Sadness work as a team,
me take too much time (20%) so it’s also her
off job to track the
samples.

Cognitive
Distortions:
All/nothing
Mindreading
Fortune-
Telling
Over-
generalization

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
Clerkship 2008-2009
 Common Components of CBT
• Establish good therapeutic relationship
• Educate patients - model, disorder, therapy
• Assess illness objectively, set goals
• Use evidence to guide treatment decisions
• Structure treatment sessions with agenda
• Limit treatment length
• Issue and review homework to generalize learning

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
Course of Treatment
1. Assessment
2. Provide rationale
3. Training in self-monitoring
4. Behavioral strategies
1. Monitor relationship between situation/action and mood.
2. Applying new coping strategies to larger issues.
5. Identifying beliefs and biases
6. Evaluating and changing beliefs
7. Core beliefs and assumptions
8. Relapse prevention and termination

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
Clerkship 2008-2009
 Basic Principles
• Change mood states by using cognitive and behavioral
strategies:
– Identifying/modifying automatic thoughts & core beliefs,
– Regulating routine, and
– Minimizing avoidance.
• Emphasis on ‘here and now’
• Preference for concrete examples
– Start with specific situation (complete thought log)
• Reliance on Socratic questioning
– Ask open-ended questions
• Empirical approach to test beliefs
– Challenge thoughts not based on evidence
– Cognitive restructuring
• Promote rapid symptom change

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Behavioral Interventions
• Breathing retraining
• Relaxation
• Behavioral activation
• Interpersonal effectiveness training
• Problem-solving skills
• Exposure and response prevention
• Social skills training
• Graded task assignment

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Cognitive Interventions

• Monitor automatic thoughts

• Teach imagery techniques
• Promote cognitive restructuring
• Examine alternative evidence
• Modify core beliefs
• Generate rational alternatives

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Efficacy
• Cognitive and behavioral approaches are
effective
• Supported by over 325 controlled
outcome studies
• State-of-the-art therapy, manualized

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Applications of CBT
• Mood Disorders
– Unipolar Depression (1979)
– Bipolar Disorder (1996)
– Dysthymia and Chronic MDD (2000)

• Anxiety Disorders
– GAD (1985)
– Social Phobia (1985)
– Panic Disorder (1986)
– OCD (1988)
– PTSD (1991)
• Emotional Disorders (2006)
copyright: Dr. Shona N. Vas, Dept of
Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Applications of CBT (Continued…)
• Eating Disorders (1981)
• Marital Problems
• Behavioral Medicine
– Headaches (1985)
– Insomnia (1987)
– Chronic Pain (1988)
– Smoking Cessation
– Hypochondriasis
– Body Dysmorphic Disorder

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Controlled Outcome Studies on CBT

• Unipolar Depression • Social Phobia (~14)

(~30) • Panic Disorder (~10)
• Eating Disorders
• Borderline P.D. (2)
– Anorexia (~5)
– Bulimia (~15) • Schizophrenia (~45)
• Generalized Anxiety • C/A Depression (8)
Disorder (~12) • Chronic Depression (1)

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
 Conclusions

• System of psychotherapies
• Unified theory of psychopathology
• Short-term treatment
• Objective assessment and monitoring
• Strong empirical support
• As effective as pharmacotherapy

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
Questions? Comments?

copyright: Dr. Shona N. Vas, Dept of

Psychiatry & Behavioral Neuroscience
Cognitive Behavior Therapy Program MS-3
Clerkship 2008-2009