Learning CBT, an illustrated guide:Wright,Basco, Thase

 Learning CBT, an illustrated guide

Contents

Chapter 1 Basic Principles of CBT
Origins of CBT
CBT Model
Basic Concepts
Automatic Thoughts
Cognitive Errors
Schemas
Information Processing in Depression and Anxiety Disorders
Overview of therapy methods
Therapy and Length and focus
Case Conceptualisation
Therapeutic Relationship
Socratic Questioning
Structuring and Psycho-education
Cognitive Restructuring
Behavioural Methods
Building CBT Skills to Help Prevent Relapse

Chapter 2 The Therapeutic Relationship
Collaborative Empiricism in Action
Empathy, Warmth and genuineness
Collaborative Empiricism
Therapist Activity Level in CBT
The Therapist as a Teacher Coach
Using Humour in CBT
Flexibility and Sensitivity
Transference in CBT
Countertransference

Chapter 3 Assessment and Formulation
Assessment
Suitability
Dimensions to consider in evaluating patients for CBT
Case Conceptualisation in CBT
Summary

Chapter 4 Structuring and Educating
Structuring CBT
Structuring sessions throughout the course of CBT
Psycho-Education
Mini Lessons
Readings

Chapter 5 Working with Automatic Thoughts
Identifying Automatic Thoughts
Recognising mood shifts
Psycho-Education
Guided Discovery
Thought Recording
Imagery
Role Play
Checklist for Automatic Thoughts
Modifying Automatic Thoughts
Socratic Questioning
Thought Change Records
Generating Rational Alternatives
Identifying Cognitive Errors
Examining the evidence
Decatastropising
Reattribution
Cognitive Rehearsal
Coping Cards

Chapter 6 Behavioural methods 1
Improving Energy, Completing Tasks and solving problems
Behavioural Activation
Activity Scheduling
Activity Assessment
Increasing Pleasure and Mastery
Graded Task Assignment
Behavioural Rehearsal
Problem Solving
Working with Problem Solving Performance Deficits
Emotional Overload
Cognitive Distortions
Avoidance
Social factors
Practical problems
Strategy factors
Working with Deficits in Problem Solving skills
Summary

Chapter 7 Behavioural Methods 2
Reducing Anxiety and breaking patterns of avoidance
Behavioural Analysis of Anxiety Disorders
Overview of Behavioural Treatment Methods
Breaking the Stimulus-Response Connection
Sequencing Behavioural Interventions for Anxiety Symptoms
Step 1 Assessment of Symptoms triggers and coping strategies
Step 2 Identify targets for intervention
Step 3: Basic skills training
Developing a hierarchy for graded exposure
Imaginal Exposure
In vivo exposure
Response Prevention
Rewards
Summary

Chapter 8 Modifying Schemas
Identifying Schemas
Questioning techniques
Educating clients about schemas
Spotting patterns of automatic thoughts
Conducting a life history review
Using schema inventories
Modifying schemas
Socratic questioning
Examining the evidence
List Advantages and disadvantages
Cognitive continuum
Generating Alternatives
Cognitive and Behavioural rehearsal
Growth Orientated CBT
Summary

Chapter 9 Common Problems and Pitfalls
Learning from the challenges of Therapy
Homework non-compliance
Prevention
Recovery
Difficulty eliciting automatic thoughts
Prevention
Recovery
Overly verbal clients
Prevention
Recovery
Clients who are stuck in repeated behaviour
Prevention
Recovery
Progress derailed by environmental stress
Prevention
Recovery
Therapist Burn Out
Prevention
Recovery
Medical Regimen Non-Adherence
Prevention
Recovery

Chapter 10 Treating Chronic, Severe, or Complex Disorders
Severe, Chronic and treatment resistant depressive disorders
Bipolar Disorder
Personality Disorder
Substance Use Disorders
Eating Disorders
Schizophrenia

Chapter 1 Basic Principles of CBT

Origins of CBT

CBT is based on two central tenets:

1.       Our cognitions have a controlling influence on our emotions and behaviour

2.       How we act or behave can strongly affect our thought patterns and emotions

The origins of these thoughts can be traced to Epictectus the Greek stoic, who said “Men are disturbed not be things that happen but by our opinions about things”. Aaron Beck was the first person to develop cognitive and behavioural interventions in the therapeutic environment.  Beck early thinking focussed on how maladaptive thinking was a central role in depression and anxiety.  Depression he saw had a negative thinking style around self, world and future.

Beck focussed more on the cognitive aspect within CBT.  The behavioural aspect came from Pavlov and Skinner. This provided techniques such as desensitisation and relaxation training.

Whilst the CBT tenets can have a strong impact on a client in distress one critique of the CBT model would be the omission of how emotions arise. Emotions can be seen to be fast acting and to leave us quickly. The emotion of joy, anxiety and sadness comes on quickly and again will leave us as quickly. We talk about moods as being the general affective disposition to respond with certain emotions and we talk about character as the disposition to have certain moods. The link between emotions, moods and character is less clear in CBT. The implicit thought is that if we change the top level emotions that in turn will change moods. This would be done by a combination of cognitive restructuring of Negative Automatic Thoughts and behavioural intervention, e.g. graded task assignments in anxiety treatments.  The complexity here is that mood is related to perception. The way that you see the world is an outcome of your mood, in a happy mood the world looks different to when are in a depressed mood. The production of your mood is related to your being in the world, a product of your history, your society as well as your current situation. In other words a combination of your and societies past present and future.  CBT aims to work on your current cognitions, however these current cognitions are supported and enmeshed by beliefs and desires from the past and to the future.

 The implicit thought around character is that schemas, i.e. core beliefs, rules and assumptions for living are the construct for character and that through cognitive restructuring we can influence the character.  However the character can provide a sense of certainty in the world, it can provide the being that is considered lovable as was demonstrated by parents, thus the attachment to the character is likely to be strong and not something that can purely be cognitively restructured when there are so many gains that have been attributed from it, thus the change in character will more likely be something that can be moved from in very small steps and only on the basis of seeing that changes will enable the aforementioned gains.

CBT Model

The CBT model shows the relation between an event, its cognitive appraisal, the emotion generated out of this and the behaviour ensuing. The event itself is indeed the result of a prior cognitive appraisal and attentional focus.  This attentional focus, ie do I focus on self, environment, other, how do I focus on the events within this domain, do I see the sad events, the joyful ones are in turn influenced by how we feel. Indeed how we see an event, is determined by the schemas that are currently activated.

The CBT model shows how beliefs are deepened by behaviour, so that with a person anxious about travel in lifts, their initial belief that lifts are dangerous is strengthened by their behaviour of avoiding lifts. Indeed the initial belief that lifts are dangerous causes anxiety which is reduced by avoiding lifts, but at the cost of not challenging the belief. The repetition of this leads to a deepening in the belief of lifts are dangerous.

Whilst this model is a simplified model of reality, it provides a useful focus for interventions. In some way this points CBT to being an initial psychotherapy that helps people relate the situation, emotion, cognition and behaviours together. When they have started doing that, they can then start to look at a greater level of complexity, for instance the values that they have, or how they construct the situation.

Basic Concepts

CBT encourages patients to adopt more rational thinking and problem solving.  They also put considerable effort into changing relatively autonomous modes of thinking Automatic Thoughts and Schemas. Automatic thoughts are cognitions that stream rapidly into our minds when we are in a situation, we rarely subject these thoughts to careful analysis. Schemas are core beliefs, rules and assumptions that are the axioms, the structure that allow us to process information in the present. So stealing is wrong, it’s not something I will do, if I see someone do it I will call the police. 

Again here CBT points to being an initial psychotherapy. If we can be as rational as possible then we will reduce the thinking errors of absolutist thinking, catastrophising, personalisation etc. However what it won’t do is to look at people’s value systems, what they want to do in their lives to make them a satisfied human. CBT can clear out the problems with the current value system, but it can’t let a client investigate their values and purpose in the world.

Automatic Thoughts

A large number of thoughts happen just below the consciousness they happen in a rapid fire motion that enables us to evaluate a situation. They can also be described as pre-conscious as they can be conscious if we have our attention directed to them.  The assumption here is that any time we have an emotion there will be a thought related to it. If we aren’t aware of it then it is an automatic thought, which with a bit of investigation can be drawn out.

Automatic thoughts are a strange phenomenon in CBT, I would prefer to talk about them as preconscious thoughts as automatic suggests some are manual, that we choose our thoughts.  However this is vaguely nonsensical as whilst we might have a greater or lesser feeling of choosing our thoughts, you could never choose your thoughts as there would be an infinite regress, I’m going to choose to think about an elephant, fine but did you choose to make this choice and so on. In some ways desire are clearer, where I can decide I want to work for an hour then have a coffee seems to have more of a feeling of choice, then suddenly stopping work for a cup of tea, although they both fall victim to infinite regress. So let’s stick with preconscious it seems to make more sense, although automatic thoughts seem to be easier to explain to clients.

Cognitive Errors

Beck considered that there are some standard logical errors that are seen with emotional disorders. There are 6 main categories of error:

1.       Selective abstraction

a.       Ignoring the evidence, only seeing one side of an event

2.       Personalisation

a.       Over or under playing the importance of yourself in an event

3.       Over or under generalisation

a.       Because it went wrong therefore it will always go wrong

4.       Arbitrary inference

a.       A conclusion is reached despite the evidence, e.g. the plane will crash

5.       Magnification or minimisation

a.       Something goes wrong is exaggerated so that it becomes a catastrophe

6.       Absolutist thinking

a.       Things are seen in black or white, right or wrong

Schemas

Schemas are low level cognitive structures, that contain core beliefs and rules and assumptions for living. They are the foundation upon which Automatic thoughts and other types of thought are built. They are constructed through childhood and through critical events and are the basic way that we see the world.

3 Main types of schema

1.       Simple schema (Rules about everyday activities)

a.       Rules about nature, e.g. beliefs about the environment and how it operates, e.g.  be a defensive driver, shelter in a storm

2.       Intermediary beliefs\Rules and assumptions (Conditional statements that relate to self-esteem and emotional regulation)

a.       I must be successful to be accepted, If I work then I will succeed

3.       Core beliefs about self (Global and absolute rules for interpreting environmental stimuli related to self-esteem)

a.       I’m unlovable, I can’t trust others

There are both healthy and maladaptive schemas. Schemas hold values, so for instance I must prepare to do well, holds the value I want to do well. Where they seem to become maladaptive is where the rule or context is applied, so maladaptive I must prepare to do well and adaptive would be I would like to prepare to do well. Maladaptive schema I’m stupid, adaptive maybe sometimes I’m stupid. 

CBT’s position with schemas is cognitive, however behaviour also forms part of this basic way of engaging with the world as does our mood and general ways of being in the world. Through our cognitive, behavioural and affective tracts we perceive the world in certain ways, we act in this environment showing wonder sometimes, control at others. Our base affective\cognitive and behavioural structures determine how we perceive the world creating our situation in which we think, behave and feel.  Thus our schema is wider than base cognitions. The worth of CBT is that it looks at unearthing our buried cognitions. How it is limited is when it thinks that this is all there is. It is also limited when it thinks the situation pre-exists our perception of it, but is rather constructed by it. It starts to look at this when it looks at some of the thinking errors involving selective attention.

Information Processing in Depression and Anxiety Disorders

Information Processing with Depression and Anxiety

Depression	Anxiety	Both
Hopelessness	Fears of harm or danger	Heightened automatic thinking
Low self esteem	Increased attention to potential threats	Increase of cognitive errors
Negative view of environment	Overestimates of risk	Reduced capacity for problem solving
Overestimates of negative feedback	NATs related to danger, risk and incapacity	Increased attention to self
	Misinterpretation of bodily stimulus

Attributional  Style In Depression

The way of attributing meaning for depressed people has three central aspects

1.       Internal vs. external

a.       A depressed person would see that they have caused a problem, where a non-depressed person would see an external event as the cause. For instance losing your job. A depressed person would see that it’s because they are not good enough, a non-depressed person would see it that there was a personality clash, or the job wasn’t right for them

2.       Global vs. specific

a.       A depressed person would see an event as being because that’s how they are or that’s how life is. So if they got sick then they’d think that they will always get sick, their body is weak. A non-depressed person would see it as that they have caught a disease and it was bad luck

3.       Fixed versus changeable

a.       If a bad event happens in a depressed person’s life then they think it won’t change whereas a non-depressed person will see it as just an incident

Distortions in response to Feedback

A depressed person will over estimate negative feedback and under estimate positive feedback.

Information Processing with Depression  Summary

Therefore the depressed persons thinking style is one where a problem will be seen to justify the fact that there is something wrong with them. The problem will be seen justify how they see the world and something that will not change. So the axis of thinking in depression is across self, world and future. Because of this view then there is no hope as the future is grim, there is no self-esteem as they see themselves as broken. Feedback from the world is likewise seen as negative as the world is a negative place. So the way that you can deal with this is either through the core beliefs that support this, and do pros and cons, thought experiments on this to challenge it. Alternatively the things that support this, the evidence from the self, world and future can be challenged. So the thinking error that personalises the problem that proves the self is broken can be challenged. The feedback from the world can be challenged to see if it is really as negative or non-positive as through. Likewise the invariance of a problem can be challenged to loosen up the sense of the future. In other words you can either challenge the core belief logically or you can weaken its maintenance by challenging the evidence.

Thinking Style in Anxiety Disorders

There is an overestimation of the levels of danger and an underestimation of the ability to cope with it. There is a speed of thought that goes through from initial fear to panic attack that prohibits rationalisation.  There is a deep fear of being out of either being out of control, something being wrong with them that will lose them acceptance by the other, or not being competent.

Learning, Memory and Cognitive Capacity

Depression is associated with a lowering of cognitive capacity, memory, recall and processing.  Depression takes up a lot of time, it is pervasive in thought and feeling through the past, present and future.  Therefore there is a logical relationship between depression and a lowering of cognitive faculties as if you’re spending all your time on one you spend little on the other.

Overview of therapy methods

Therapy and Length and focus

CBT is problem focussed and standardly is between 5 and 20 sessions, although a high level of comorbidity might see this as a longer course. Whilst CBT is present focussed it does also use longitudinal analysis to provide the context of the clients distress in terms of their experiences.

Case Conceptualisation

The case conceptualisation is the understanding of the client’s problems, how their thoughts, emotions, behaviour and situations are related. How a problem was originated and how it is being maintained. It is key within CBT work as it is both tested in an on-going manner with the client and also looks to be changed through doing cognitive restructuring and behavioural experiments, to see if the relationship between thoughts, emotions and behaviour can’t be changed.

Therapeutic Relationship

The alliance is critical to CBT , it is different from other forms of therapy as it is a collaborative empiricist alliance where hypothesis are generated, tested and unhelpful thinking and behaviour are revised and coping skills are increased. Underneath this pragmatic relationship there needs to be the core conditions of empathy, congruence and positive regard. Without this there is no trust, no feeling of safety for the client and there can be no collaborative empiricism. Likewise at certain times a client may want to sit with their feelings, have them contained, maybe explored but not fixed, or taken away. In CBT getting the relationship right between being and doing takes some art. If you focus more on doing you will lose clients, if you focus more on being you may achieve nothing, so getting the balance right is key.

Socratic Questioning

This is a key skill. The original Socratic questioning was where Socrates would meet someone who had a belief, then asking questions of this person show that their belief didn’t make sense.  In CBT this can be used to show dysfunctional thinking but another variant of it, guided discovery can help the client discover what their thinking is, what the relation between thoughts, feelings and behaviour is. The difference between the two is the knowledge of what the right answer is. In Socratic questioning there is the sense that the therapist knows and with guided discovery the therapist doesn’t know.

This skill is critical in CBT as it enables the client to find the answers. The teachers fallacy is that you can tell a client the right answer and that is all that is needed, show them how their behaviour or thinking maintains their distress. But knowledge is one thing and belief and action is another. I may believe that yoga is good for me but not do it. There is another level of belief and knowledge where it means something to you. This does remind me of the Teesdale split between propositional and implicational truth, the former is pure logical and rational, the latter is embedded within the behavioural and emotional realm, where both behaviour and emotion have embedded logic within them.

Finding things out for yourself rather than introjecting them from an authority figure provides for a belief that has affect around it, the belief matters to you and you act on it and it is this type of truth that is the holy grail of therapy.

Structuring and Psycho-education

To guide focus, to aim at problems there is structure in CBT sessions which are held within an agenda set at the start of the session in collaboration between client and therapist. This then provides a focus which seeks to reduce digression.

This is a slightly thorny area. Some clients resent the restriction to what they might say in session, where some clients will like it due to the structure and focus. Indeed some clients some days will like it and not at other times. Indeed it may be that only after a reasonable working alliance has been built that the clients will accept an agenda.

Cognitive Restructuring

Main methods

1.       Socratic questioning

2.       Thought records

Other commonly used techniques are

1.       Examining the evidence, i.e. pros and cons

2.       Reattribution,  i.e. modifying how they apply meaning to events, so global\specific, internal\external and fixed vs changeable.

3.       Cognitive rehearsal, by using imagination or role play

This is the process of changing maladaptive automatic thoughts and schemas. The method most frequently used in Socratic questioning and thought records. The process of Socratic questioning also models a more inquisitive form of thinking that can help the client to take more curiosity into their lives. Thought records can also help as they slow down the client’s experiences so that they can see the fast feelings and thoughts that can contribute to the sense of helplessness to think that’s how things are, that’s how I am.

Behavioural Methods

These are used to

1.       Break patterns of avoidance which can become secondary problems in themselves e.g. substance abuse

2.       Face feared situations

3.       Build coping skills

4.       Reduce painful emotions or autonomic arousal

The main methods used are

1.       Graded task assignments

2.       Exposure

3.       Pleasure mastery schedules

4.       Behavioural activation

The therapeutic alliance has to be quite strong and the client quite motivated to do these things. To get a client to do what they most fear can be a challenge even if the graded task starts at an infinitesimally small level. Like any homework there is the chance of either failure or non-compliance, so the tasks need to be set up as an experiment where succeed or fail we need to record information to find out what happen such that we can learn about the clients way of being. If the task is unsuccessful then this needs to lead to another piece of learning for the client.

Building CBT Skills to Help Prevent Relapse

Getting the client to have new skills will help prevent relapse. Likewise an increase client awareness of themselves can help prevent relapse as you get earlier interventions. MBCT was developed as a response to preventing reoccurrences of depression in clients. Through mindful techniques it does this by seeing a negative thought or event being something that happens in the world but not something that we need to attach to or identify with. The difficulty with depression is the amplification of negative aspects rather than the actual event, and through meditation this can and is reduced.

Chapter 2 The Therapeutic Relationship

Collaborative Empiricism in Action

The working alliances isn’t considered to be the principle mechanism of therapy but is considered critically important to enable a collaborative action orientated style of therapy which is CBT’s approach.

Empathy, Warmth and genuineness

Empathy is the ability to place yourself in the client’s shoes, to see things from their perspective. Therapeutic empathy also requires you to keep one foot in your world so that you can take perspective on any dysfunctions, or illogical thinking in their world.  Too much or too little personal warmth is a bad thing. Too little then the relationship will be cold and untrusting and the client won’t feel safe to do work. Too much and the client can see the therapist as trying too hard, or maybe lonely, or indeed effectively challenging some of the clients thoughts, why would they care so much about a loser like me. Timing is also important as the client won’t think you understand their plight if you empathise too quickly, understanding therefore breeds empathy and trust.

You also have to be cautious with empathy in terms of reinforcing dysfunctional thinking, so if you say I understand why you feel that way, can condone the emotion and the belief behind it, which maybe dysfunctional. Likewise if you continually nod your head whilst listening this can again provide tacit agreement.

In CBT empathy is still action oriented. So if a client is suffering then there is the requirement to both provide empathy and some possible solutions to the problem. I would also add here, that sometimes a client needs to stay with and explore their distress, so some transparency about possible solutions can be offered as well as the ability to investigate and sit with the emotions.

Collaborative Empiricism

The empirical collaboration should be through the whole process, setting agendas, defining problems, investigation, and producing solutions.  Cognitive distortions and unhelpful behaviours provide the opportunity for increased rationality, symptom relief and improved personal effectiveness.  However at the start of CBT with a client then it seems to me that the therapist becomes more directive and as trust increases and distress decreases for the client then they become more active. To ask a highly depressed client early in treatment to start setting agendas to me seems a step too far.

Therapist Activity Level in CBT

Prior to the client being fully socialised in the CBT model then the therapist is more active. Likewise the therapist may need to inject a sense of hopefulness, energy and animation in the process to get the client started and when the client can pick up on this and believe in the process then they can take more of a lead.

The Therapist as a Teacher Coach

CBT has far more of a teacher student relationship than other forms of therapy, indeed psycho-education is part of its remit. Good coaches teach via Socratic methods as pupils learn better if they find it out themselves.

Good teachers have the following qualities

1.       Friendly

a.       Friendly, kind and non-intimidating is a good place to start, so get a good rapport

2.       Engaging

a.       If you are interested and inspired by the process then there’s chances the client will be too

3.       Creative

a.       Clients may often be stuck in ways of thinking, so thinking outside the box and being creative in the session will help by way of modelling a different way to be. Try to use learning methods that draw on the clients creative and inspired aspects, so use their strengths as much as is possible

4.       Empowering

a.       The client needs to have a ha moments not yourself, they need to take ownership of the tools CBT uses not merely be given them to use by you

5.       Action orientated

a.       The CBT tools need to be put into practice in real life, and not merely talked about in the session. So reflect, learn and act.

Using Humour in CBT

Risks using humour are client may see this as

1.       Trivialising a problem

2.       Humiliating

However the benefits are

1.       Brings emotional relief

2.       Gives distance from the problem

3.       Makes for an enjoyable relationship and increases the alliance

4.       Can restore the clients sense of humour

5.       Can normalise  distress

6.       Can break the client out of ingrained patterns

When humour is used it should be

1.       Spontaneous and genuine

2.       Constructive, i.e. achieves one of the above benefits

3.       Focusses on an external problem, not part of the clients behaviour

Flexibility and Sensitivity

People are different and therefore you can never develop a one size fits all approach. Therapy needs to be tailored to individual client’s needs. Likewise clients can vary week to week, so you can’t even get a specific approach for a client, but again it may need to be varied week to week.  There are three factors that influence the changes that you need to make

1.       Situational issues

2.       Sociocultural issues

3.       Diagnosis and symptoms

Situational Issues

The client may present with anxiety, then during treatment lose their job and be even more anxious because of this. This would then require that a greater emphasis is paid to the core conditions during this time and standard treatment protocols suspended until this distress is soothed.

Sociocultural Background

Watch when you work with people with different backgrounds to yourself, you need to be aware of any adverse reactions and to look at any beliefs that underpin your reactions.  Again you may want to read up, or take training courses to familiarise yourself with some of the issues facing people from say a specific cultural background.

Diagnosis and Symptoms

Look at the therapeutic relationship to see if their symptoms and diagnosis are being played out there. So a depressed person may be very passive in the relationship. So one of the treatment outcomes should be to enable them to be more active in the relationship.  Strive for equanimity in your relationship even when in highly difficult situations where the client may be acting out towards you, or creating a difficult relationship,

Transference in CBT

Because CBT is problem orientated and short term the amount of transference and countertransference is more muted than in other psychotherapeutic relationships. This being said though schemas may be as a result of previous formative relationships.  The working alliance can also be used to see if these schemas are being used. This can be highly effective as this is an in vivo experience that can be looked at in detail. The working alliance can then be adapted to work around these problems, or better still they can be worked through, using the standard CBT toolkit.

If you identify transference is occurring then you need to ask

1.       Is it healthy?

a.       If so it bears no need for comment

2.       Could it be a problem in the future

a.       If so then some preventative measures can be useful

3.       Does it need attention now, is it having an adverse effect

a.       If it is, bring it into the room, and use CBT tools to deal with it

Countertransference

A good way to spot these is via emotional and bodily reactions as they come from automatic thoughts and are outside of consciousness, although amenable to it when attention is given.  So if you’re frustrated or bored, or overly attracted look to see what is happening for you. If you spot this then you need to do thought records, identify your schemas and challenge this.

Chapter 3 Assessment and Formulation

Whilst CBT assessment focusses mainly on cognitive and behavioural factors, biological and social influences are also important to know

Assessment

This requires a full history and mental status examination, what are the clients:

1.       Symptoms

a.       Detailed description of the current problem, its frequency and intensity

2.       Interpersonal relationships

3.       Socio cultural background, i.e. parents socio cultural factors.

a.       So what type of culture has been their upbringing, very religious, very hard working? In terms of society what was their experience of childhood what were their parents doing in terms of lifestyle, work, friends etc. and how was their interactions

4.       Personal strengths

a.       You need to know these so you can build on them in therapy. Whilst you can ask a direct question it may be that these only come out during the sessions as the depressed person may say none

5.       Genetics

a.       Has there been similar malady in the family

6.       Medical illnesses

a.        what major illnesses have there been, have there been any that have had an impact on the current condition

Suitability

CBT has been proven as an effective monotherapy for many conditions. It is not suitable as the sole intervention for schizophrenia and bi-polar but has been shown to be effective used alongside pharmacotherapy.

Poor candidates for CBT are, they require more long term approaches outside of the standard 2-4 month CBT time scale

1.       Advanced dementia

2.       Severe amnesiac disorders

3.       Delirium

4.       Drug intoxication

5.       Severe anti-social personality disorder

Best candidates for CBT are

1.       Adult in good health

2.       With up to acute anxiety or non-psychotic depression

3.       Good verbal skills

4.       Motivated

5.       Some past success in relationships

6.       Adequate housing and financial resources

7.       Good interpersonal relationships

Dimensions to consider in evaluating patients for CBT

1.       Chronicity and Complexity

a.       Long standing and or complex problems require a long treatment plane. If the client has had many unsuccessful therapists then this is an indicator of depth of problem

2.       Optimism about the chances of success in therapy

a.       Pessimism and depression can be the presenting problems, but if the pessimism is extreme it may interfere with the ability to see progress in the work. If it is extreme hospitalisation or drugs might be required. If this is picked up on, then this could well be important to look at in each session to see what progress is being made so the client increases optimism and values the process

3.       Acceptance of responsibility for change

a.       Why has the client come to therapy, what do they want to change, how much personal effort are they wanting to put in to achieve this. You might also want to ask what you think the causes of depression are and what the role of the client is in therapy. If they see they have no responsibility, then this might guide how you work with them, showing how they do have some choice, some responsibility in improving their life.

4.       Compatibility with CBT rationale

a.       People who value CBT have better outcomes. People who are prepared to do homework have better outcomes. CBT capitalises on peoples strengths rather than correcting their weakness, so a client with high level of dysfunctional thoughts may not do as well as someone with greater assets.

5.       Ability to access automatic thoughts and identify accompanying emotions

a.       This is key to success in CBT and you may well want to find out what their current levels of ability are by asking what waiting happened waiting in the waiting room, or coming to the session was like for them and do a SETB formulation. It is useful to be able to access emotions as they can be used to identify hot thoughts.

6.       Capacity to engage in a therapeutic alliance

a.       After finding out about personal relationships, within the first session gauge the ability to form a relationship of the client, amount of eye contact, how comfortable they feel with you. Again if you see difficulties in forming relationships this then might guide how you work with them as you need a good working alliance to get collaborative empiricism

7.       Ability to maintain and work within a problem orientated focus

a.       This has two focuses.

                                                               i.      Firstly security, how does the client respond when threatened

1.       Use control

2.       Uses avoidance

3.       Uses verbiage

                                                             ii.      Focality

1.       Ability to stick to the topic

Here the security aspect means that you need to work with this resistance if you are to get to significant and sensitive areas. Maybe you need to bring this into the room and to note it when it happens. Once it is a topic then you can use CBT to look at this, and in time this will clear a pathway through to be able to work on more emotionally difficult areas.

Case Conceptualisation in CBT

The following areas need to be understood to provide a working hypothesis

1.       Diagnosis/Symptoms

a.       What is the current problem you want to work on? What are its symptoms, its frequency, its history, its duration?

2.       Formative influences

a.       So what have been the major influences from people in your life that contribute to these symptoms?

3.       Situation\Interpersonal issues

a.       What are the current situations that modulate the problem

4.       Biological genetic and medical factors

a.       Has your family a history of this problem, people around you. What are the major medical problems you have had during your life, physical and psychological?

5.       Strengths\Assets

a.       What are your strengths and assets

6.       Typical automatic thoughts, emotions and behaviours

a.       These will come out through an analysis of a recent incident of the problem. From the basis of this formulation then you can look to see if this is a common occurrence

7.       Underlying schemas

a.       From the analysis of a recent incident you can draw out NATs, then use a downward arrow technique to find out more about this until you get to a schema

When the working hypothesis is created then you can develop a treatment plan

The recommendation for the academy of cognitive therapy recommends a longitudinal and cross sectional view of CBT factors that may influence the symptom.

Cross sectional analysis

This shows what is happening now and looks at how major precipitants (e.g. relationship break up) and activating situations (currently occurring situations) stimulate the problem and produce automatic thoughts, emotions and behaviours. A cross sectional analysis really would be a hot cross bun.

Longitudinal analysis

This looks at how the problem develops over time and shows formative influences that produce core beliefs and schemas.

Summary

Assessment and conceptualisation are possibly the most important part of CBT. After doing the contract with the client this will be the first thing that you do. So here you need to build a relationship with a possibly worried and distressed client, who is meeting you for the first time.  The assessment and conceptualisation are quite closely linked. The assessment needs to find out general details about the client to get an idea about the lifestyle that surrounds the problem as there might be within here clues to the problem or indeed factors that make the problem worse.  Within the assessment will come up the suitability of the client for CBT and any interpersonal issues that the therapeutic relationship needs to take into account.

So the following questions need to be worked through, although it is difficult to think how to get this information without feeling like this is an interview. You need the information but it should be got gently.  However usually this is undertaken as the referral point, so it may well be that you do not get to see the client, so this would need to be conducted within the hour

1.       Problem (5 W’s)

a.       What is the main problem

                                                               i.      Could need a problem list here and prioritise

b.      Where does it occur

c.       With whom

d.      What are the feared consequences of it

e.      When does it occur

2.       FIND

a.       What is the frequency of the problem

b.      What is the intensity

c.       What number of times does

d.      How long does an episode of the problem last

3.       ABC Analysis

a.       Antecedents

                                                               i.      What are the triggers, what are you thinking, feeling, how is your body

b.      Behaviour          

                                                               i.      What does the person do, what are they thinking, feeling, how is your body

c.       Consequences

                                                               i.      What happens in terms of thoughts\cognitions\bodily feelings? What makes the problem better\worse

4.       Development of the problem

a.       Develop a timeline of the problem with key events

5.       Goals for therapy

a.       What do you want to achieve

6.       Medication

a.       Are any drugs prescription or otherwise being taken

b.      How much alcohol do you consume

c.       Caffeine intake

d.      Tobacco intake

7.       Assets and strengths

a.       What are your strengths and assets

b.      What are you coping strategies when things go wrong

8.       Impact of the problem on clients life

a.       How does it affect your life

9.       Physical

a.       What is your diet like

b.      How is your sleep

c.       Do you exercise

10.   Medical History

a.       Have you had previous therapy for problem

b.      What is their medical, psychiatric history

11.   Personal history

a.       What is their housing situation

                                                               i.      Any problems

b.      What is their work situation

c.       What are your interpersonal relationships like

12.   Family history

a.       How was your relationship with your parents

b.      How was your relationship with your siblings

13.   Genetic

a.       Is there a history of this problem within your family

14.   Development

a.       What were the important events from childhood

b.      What was the atmosphere like at home

c.       How was schooling

From the basis of the assessment then the case conceptualisation can be created.  The additional information needs to be derived:

1.       Situations that cause the problems

2.       Do SETB on three instances of the problem

Chapter 4 Structuring and Educating

Structuring CBT

To structure session and to stay focussed on the problem provides, hope and focus. A Client may present feeling overwhelmed, depleted of resources and demoralised. To structure a session can provide some relief to this. Setting goals also gives the clear message if you stay focussed on the problem then the answer will follow.

Some difficulty lies with this, as clients can feel restricted in terms of agenda and goal, and find the process mechanistic.

Structure of session

1.       Goal setting

a.       Show value of SMART goals, i.e. feeling of pleasure and mastery as you can achieve them. Specific goals you can focus energy on.  Goal setting typically follows at the end of the first session when you have assessed a client’s problems and strengths.

A goal gives a sense of direction. It can be useful to pick a short and a long term goal.  Picking a short term goal, which maybe isn’t the ultimate solution but something that is going to improve the clients lot,  may be able to accomplish fairly soon. This will give a sense of mastery and give more ability to achieve a longer term goal. To get smart goals then you can ask how might we know that we have achieved the goal, get specific. As soon as you have a short term goal, then you can ask the client what steps they can think of taking to enable their goal between now and next time. If it’s a specific goal then this will be achievable if not, then more troubling

2.       Agenda Setting

a.       Agendas should be shown to be beneficial to the client, their use should be discussed to see if they are appropriate. The benefits are staying focussed to get maximum bang for buck. They provide a means of ensuring that the most important things are given the time they need. The downsides are they provide too much structure and stifle creativity and prevents you following valuable leads. When agendas are best used when they stimulate creativity. A work of art has structure and a feeling of spontaneity; this is the aim of an agenda.

Agendas should contain

b.      One achievable goal

c.       Achievable goals during session are useful

d.      Relevant to overall goals

e.      Items that can be actioned as well as purely discussed

3.       Performing Symptom checks

a.       Beginning of each session perform a brief symptom check, out of ten how is your depression? This can be added in with a brief update on latest developments, to understand how the client is.

4.       Bridging sessions

a.       This can be done by a small summary at the beginning of the session or by getting the client and yourself to review notes. From this then items for follow up can be brought forward from the last session

5.       Providing feedback

a.       This can build the relationship by asking for feedback on how the session is going. It can also be useful to get feedback on what they understand thus far.  Depressed people have a filter that doesn’t allow positive feedback to be heard, and anxious people have very rigid information processing styles. So when you give feedback these need to be taken into account as a depressed person may not hear positive feedback and an anxious person may reject it as it falls outside their thinking style. To get around this then you can make both these issues something to be looked at maybe do a thought record for each one. Maybe explain the nature of the filters.

                                                               i.      Provide feedback that

1.       Helps stay on topic

2.       Highlights clients strengths

3.       Is encouraging and neutral, e.g. seems as if you were quite tenacious there, as opposed to just being positive as the client may feel soft soaped

6.       Pacing sessions

a.       The pace of sessions is critical there may be times when a client isn’t ready for an intervention, times when a client needs containing rather than exploring or “fixing” an issue.  If you have a need for a certain level of progress in sessions then this could come across as frustration with your client, which will not be helpful.  You need to work at their pace, rather than yours, however this is between a manic and a depressed response. Likewise you may introduce a topic, show a skill, get a client to do them, but yet for them to have this as a natural part of their life, they may well need to repeat it. Then the question of how you go over the same subject comes up without making it boring. If you are non-directive the sessions go nowhere, if you are too directive the client can felt unheard and forced and resent therapy where they are merely told what to do. 

Pacing can also be an issue if you miss important items on the agenda. You can deal with this by allocating a time slot to each item.  A good session should end with some action taken by the client to improve his life, if this doesn’t happen then there is an issue with pacing, agenda or overall formulation. The ideal with pacing is that both client and therapist are part of ensuring this. This then enables collaborative decision making processes

7.       Assigning homework

a.       When assigning a thought record do so for a specific event, when you have a stressful event, or strong emotion. Homework needs to be not too hard, not too easy and relevant to the client’s problems. Bringing out the worth of the homework is vital.

Structuring sessions throughout the course of CBT

Early session can be characterised as having more structure, more directive and more symptom laden. As CBT skills of the client increase then they are less directive, less symptomatic and more collaborative.

Early session structure

1.       Greet client

2.       Perform symptom check

3.       Set agenda

4.       Review homework

5.       Work on agenda items using CBT

6.       Socialise to CBT model

7.       Develop homework assignment

8.       Review key points from session, give and receive feedback

Middle session structure

1.       Greet client

2.       Perform symptom check

3.       Set agenda

4.       Review homework

5.       Work on agenda items using CBT

6.       Develop homework assignment

7.       Review key points from session, give and receive feedback

Late session structure

1.       Greet client

2.       Perform symptom check

3.       Set agenda

4.       Review homework

5.       Work on agenda items using CBT

6.       Work on relapse prevention, prepare for termination

7.       Develop homework assignment

8.       Review key points from session, give and receive feedback

Oh dear I do find it difficult with these agendas, they are tight and useful, but constricting. Maybe useful in a business arena, but even then I can find the structure gets paid nominal attention, and doesn’t always stimulate useful meetings.  It also presupposes quite a functional client and I’ve had many who haven’t been able to construct agendas. I do like the bit about socialising to CBT it’s not something that I have done and something I think that I should.

Psycho-Education

Imparting skills will help a client both currently but also for relapse prevention. Psycho-Education can be just teaching in the session or giving a book to read.

Mini Lessons

Avoid lecturing, but rather try Socratic questioning, ground all lessons in an example from the client’s life.

Readings

Could be very useful for a therapist to prepare a reading list for different disorders and then give specific readings to clients.

Chapter 5 Working with Automatic Thoughts

Automatic thoughts are one of the most important basic constructs of CBT. There are two aspects of them, identify and modify.  Because of their importance the concept is often introduced to the client early in the sessions. Automatic thoughts are habitual thought patterns, quite often they occur without our being conscious of them, although we can turn our attention to them. They can often happen quickly and we will act on them, or they will produce emotions. The trick here is to pay attention to them so that we can look at their validity, look at their effect then on the basis of them then we can start challenging them or modify them.

The difficulty I have found has been when you ask a client what they thought at the time, they say nothing, what do you do from there. One option would be to get them to reimagine in great detail the situation. The other option could be to ask what they thought they were thinking. The other option would be to work back from the emotions, so if anxiety, then what do you think you were afraid of, but this can sometimes be the locus of the problem rather than the road to its solution

Methods for identifying automatic thoughts

1.       Recognising mood shifts

2.       Psycho-Education

3.       Guided discovery

4.       Thought recording

5.       Imagery exercises

6.       Role-play exercises

7.       Use of check lists

Methods for modifying

1.       Socratic questioning

2.       Use of thought records

3.       Generating rational alternatives

4.       Identifying cognitive errors

5.       Examining the evidence

6.       Decatastrophising

7.       Reattribution

8.       Cognitive rehearsal

Identifying Automatic Thoughts

Recognising mood shifts

Strong emotions are a good indicator that automatic thoughts are around.  Likewise strong emotions also correlate with strong memory of events so if there have been strong emotions then the automatic thoughts that are associated with them can be remembered as well.

Psycho-Education

You can best teach the concept of automatic thoughts after they have been had in the session, either because of something that has come up during the session or that has been reported from a recent event. Teaching without this experience is likely to be weaker, so should be avoided.

Guided Discovery

Some key questions that can be used here are, what went through your mind when a situation happened, did you have any more thoughts, were there any images that you had in your mind.

Guided discovery for automatic thoughts, high yield strategy

1.       Pursue lines of questioning that stimulate emotions

a.       An emotion shows that the topic is important to the client and therefore can confirm you are on the right track. Memory is generally increased

2.       Be specific

a.       General topic gives diffuse thoughts, specific topics give specific thoughts

3.       Focus on recent events

a.       The memory will be better, there will be greater emotions attached with recent events. This will make the work more relevant to the current situation

4.       Stick with one line of questioning and topic

a.       If you learn well to do the basics, then you gain automatic thoughts for one situation see how they affect emotions, see how you can change them. On the basis of this, you can look for generalities where situations bring out the same automatic thoughts

5.       Dig deeper

a.       The trick here is to not push, or make the client feel inadequate as they can’t remember what you are demanding. So following questions may be useful

                                                               i.      Let’s stay with that a bit longer

                                                             ii.      Can you remember any other thoughts

                                                            iii.      Use Socratic questioning

1.       How did you see yourself, what did you think about yourself, the other person, the future, the world, what are the consequence of having that thought(downward arrow)

6.       Use your empathy skills

a.       By engaging with what the client might have thought and felt in a situation, you may be able to say, when I heard you say that it felt you were quite sad and that may open up a conversation

7.       Rely on Case formulation for direction

a.       So the case formulation will be about antecedents, modulators, maintainers, strengths and diagnosis

Thought Recording

It can be useful to introduce thought recording in a piece by piece approach

1.       Identify automatic thought

2.       Generate rational alternative

3.       Label thinking errors

Imagery

When you cannot get at the automatic thought, then you can use imagery. In this case get the person to relive their experience in imagination to bring it into the room. On the basis of this imagination that is relived then you can often get a greater access to automatic thoughts. When you try to stimulate imagination then use all the senses, detail as much as you can about the event and its antecedents.

Role Play

Again role playing a situation can stimulate automatic thoughts. There can be some issues here in terms of the client reacting negatively to the therapist after they have felt angry towards them playing their dad.  So the client needs to be able to have enough reality testing to see that afterwards the therapist isn’t their father.

Checklist for Automatic Thoughts

There are checklists out there ATQ that have generic automatic thoughts, that a client may identify with.

Modifying Automatic Thoughts

Socratic Questioning

1.       Ask questions that reveal opportunities for change

a.       Good questions open up possibilities, so ask questions that show if a client changes how they think then they will change how they feel

2.       Ask questions that get results

a.       Good questions break through rigid thinking. Good questions should produce emotional and behavioural responses.

3.       Ask questions that get the client involved in the learning process

a.       Socratic questioning is a useful role model in terms of thinking, showing curiosity, flexibility and finding of new perspectives.

4.       Pitch questions at the right level

a.       You need to challenge without intimidating, so ask questions that there is a good chance they can answer

5.       Don’t ask leading questions

a.       This is a guided discovery, not an argument! Clients need to do the work not you!

6.       Use open ended questions

a.       See above

Thought Change Records

TCR are the five column thought records.  So Column 1: Event Column 2: Automatic Thought + degree of belief Column 3 Emotion + degree of intensity Column 4 Rational Response Column 5 Outcome.

If there is little change in the outcome after producing a more rational response then there is strong evidence to suggest that this may result from a deeply held schema or ingrained behavioural pattern. In this instance then more intense interventions will be required.

Generating Rational Alternatives

1.       Open your mind to possibilities

a.       Think like a detective, or like a good friend

2.       Think like your old self

a.       Before the distress started

3.       Brainstorm

a.       Produce ideas without sanction

4.       Learn from others

a.       Ask others for advice, although you may get the ideas that you most fear although you need to ask the question how much can you trust the person to tell the truth and still be supportive

Identifying Cognitive Errors

You can psycho-educate clients on thinking errors and show with examples what they are and why they are an error, almost using Socratic questioning to get there. So in some ways what you need to do is to look at the thinking errors, see logically why they are wrong and also what their consequence is so absolutistic thinking prevents seeing anything else, either things are one thing or another, but that prevents them from being a whole host of other things, so therefore absolutist thinking reduces your world. You can also look at the emotional outcomes, so you get angry when things are bad and pleased when they are good.

Examining the evidence

Looking for the evidence of a thought can be powerful in terms of changing it as a thought such as I’m going to be fired, when looked at, actually has little evidence, lots of emotional facts but few external facts. So you can do evidence for and evidence against a fact.

Decatastrophising

People with anxiety and depression have catastrophic predictions about the future. In depression it shows that there’s something wrong with me, in anxiety I think I won’t be able to cope with it.

To do this you can look at the evidence, look for historical outcomes and coping strategies, look at the difference between possibility and probability.

Reattribution

At attributional style, is the style that a person has in attributing meaning to their world. In depression then people see things as not changing, i.e. bad stuff, they see themselves more responsible for bad stuff than others, they see one instance of bad stuff meaning things are bad, rather than this was bad but other stuff is good. You can reattribute using Socratic questioning, examining the evidence of thought records, you can use responsibility pies (useful for internal vs. external)

Cognitive Rehearsal

Top athletes visualise success before they go into competition, this can be a useful technique for say people with social anxiety.

This technique is usually used after the ground work has been done with thought records etc.

One way of doing this is get a client to

1.       Think through a situation in advance

2.       Identify automatic thoughts and behaviours

3.       Modify automatic thoughts by doing a TCR

4.       Rehearse more adaptive ways of thinking and behaving in their mind

5.       Implement the strategy

Coping Cards

Coping cards best work when specific. So write the situation and the adaptive responses to it and maybe even some motivational phrases.

Chapter 6 Behavioural methods 1

Improving Energy, Completing Tasks and solving problems

People with depression have

1.       Low energy

2.       Decrease ability to enjoy activities (anhedonia)

3.       Decrease problem solving ability

Behavioural procedures are likely to be associated with more adaptive thinking styles, so improved automatic though patterns can increase levels of behaviour.

Behavioural Activation

This is making an action change that makes a change in how he feels. So if client has a major problem, a simple question like is there anything that you can do to improve how you feel in the next couple of days, don’t tackle the whole problem just make things better. The action that is chosen needs to be achievable as this will give a sense of pleasure and mastery. Behavioural activation isn’t a complicated technique but it can help clients break out of withdrawal and inactivity.

So to get to behavioural activation then

1.       What are you doing at the moment= being depressed doing x

2.       How does it feel doing x=makes me feel depressed

3.       Is there anything you can do between now and next week to stop doing x, or do less of it

Tips for using behavioural activation

1.       Develop a collaborative relationship before trying

a.       A client who is working with you, is likely to work for  you

2.       Let client decide

a.       Then he is motivated to do it, as he is invested

3.       Judge the clients readiness to change

a.       If there is no motivation then you can’t go down this route

4.       Prepare the client for behavioural activation

a.       Socratic questions can pave the way, what’s the effect of sitting in the sofa all day, also how would making a change to this make you feel

5.       Design assignments that are manageable

6.        

Activity Scheduling

When a client believes they can experience little pleasure, and they have little energy, then activity scheduling can be used, in other words it is a measure for quite extreme cases. So it is used for moderate to severe cases of depression.

Activity Assessment

Depressed people under report the pleasure\mastery they are having in their lives, so an activity assessment can actually increase the level of pleasure and mastery feelings.  Also self-report may not be as accurate as it actually is.

So the assessment can be used to show current levels of pleasure and mastery where they exist and where they don’t. This can then give you the ability to build on strengths and address areas of weakness. Each of the items of the assessment need to be graded against pleasure and mastery. Mastery is the sense of accomplishment, e.g. building a wall, mastery high, pleasure low maybe. The feelings of pleasure and mastery are contextual. Given I feel x at the moment, the pleasure and mastery given by y, is high, now when I’m not feeling z then this pleasure and mastery changes. Whilst clients with depression have muted feelings of pleasure and mastery they are encouraged to never give a zero but rather start at one.

Using the assessment:

1.       Look to schedule more of the higher pleasure and mastery items, to replace the low

2.       See if there are another types of high pleasure\mastery items that could be done

3.       Are there times of the day when assessment is high or lower

4.       Are ratings higher when other people are involved

5.       What activities in the past have been stopped

6.       Are there any possibilities that you have been ignoring, so brain storm what can be done

7.       With items with high ratings, then an investigation of these items can start to derive an understanding of what gives pleasure and what gives mastery. Likewise what doesn’t give pleasure or mastery, what is it that gets in the way

Increasing Pleasure and Mastery

To increase pleasure and mastery then generate a pleasure list, a list of things that can give pleasure, work on things that give pleasure from the assessment plus brainstorm some possibilities. Then write up a pleasure and mastery plan. Then do the same with mastery.

When the plan has been completed then get the client to estimate their predictions for success. This can open up negative automatic thoughts that can be worked through in the session. Pleasure and mastery is used early in sessions

Graded Task Assignment

This is a technique for breaking large tasks down into more manageable pieces. If Nat’s are getting in the way then do a DTR before moving onto behavioural work. So a client thinks about doing x, then has NAT's and behaves in a certain way, e.g. avoids. Get them to imagine they didn’t have the Nat and see how they think they would behave.  With GTA then again show how changes in behaviour can change mood and thoughts, how it creates a positive cycle.

Troubleshooting

If GTA isn’t successful, it can be that the steps are too large so break them down into smaller steps, the steps need to be matched to the levels of energy.  If GTA isn’t successful it can be that there are a flooding of NAT’s. In this instance then work needs to be done on cognitive restructuring to loosen the NATs, and get the client maybe to do a DTR prior to doing each step of the GTA.

Behavioural Rehearsal

Any behavioural plan that you want to implement can be rehearsed in the room

This can

1.       Increase motivation and decrease fear

2.       Spot potential obstacles

3.       Increase skills, or show skills deficit and learn new behaviours

4.       Give feedback to the client

5.       Get to the point where you can see that the plan will have a positive outcome

An example of behavioural rehearsal: being assertive in communicating with others

1.       Start with a general idea, of how the client would like things to be. So think about purpose

a.       Gives the client a gentle way to get into the idea

2.       Shape the general idea into a specific idea

3.       Use the good news bad news good news approach (shit sandwich)

4.       Role play the interaction with the client

a.       Do a best case and a worst case

5.       Elicit the clients predictions for the interaction

a.       Best case, worst case and most likely case

b.      Make a recovery plan for worst case

Problem Solving

Difficulties with solving problems is either a performance deficit or a skills deficit. With the former they have the skills but don’t use them with the later they don’t have the skills.

Working with Problem Solving Performance Deficits

Obstacles to problem solving

1.       Cognitive impairment

a.       Poor concentration, can be caused by depression, environmental issues etc. So it’s a question of looking for what causes the impairment and working around them.

Emotional Overload

b.      Feeling overwhelmed and all energy going on emotions. Here cognitive restructuring can help, or breaking the task down into smaller sections. Likewise self-care, baths, massage etc. can help to produce calmer times to enable the task.

Cognitive Distortions

c.       NATs causing problems. So do DTRs, address cognitive errors, act as if can be helpful

Avoidance

Social factors

d.      Contradictory advice being given by people, criticism etc. Doing a cost benefit analysis can help decided on your position on advice. Sometimes people can feel bad through not taking the advice of others.

Practical problems

e.      Lack of resources. There are many places where assistance can be got, so brainstorm these possibilities. Watch out for your own NAT’s when someone’s situation seems hopeless. Ask the person what they would do in this situation when they didn’t have any distress

Strategy factors

f.        Looking for perfect solution prevents improvement, often the simple solutions are discounted. Find out what current problem solving skills are and utilise these

Working with Deficits in Problem Solving skills

1.       Slow down to sort it out

a.       When problems are linked with other problems, have deep meanings and long histories they can seem difficult to sort out. Likewise if there are a lot of problems likewise this can seem daunting, if you can pick out some targets for attention this can make things seem easier. Prioritize the problems can help here.

2.       Pick a target

a.       Eliminate problems over which they have no control, and try another approach to them for instance acceptance. Then consider the most pressing problem which they can do something about

3.       Define the problem accurately

a.       How can you define the problem so that you know that you are making progress with it

4.       Generate solutions

a.       Ask others

b.      Check on internet

c.       Consider living with the problem

5.       Select the most reasonable solution

a.       Eliminate any solutions that are not implementable

b.      Look at pros and cons of solution

6.       Implement the plan

a.       Select a time and day to implement. Rehearse beforehand, think about possible obstacles

7.       Evaluate the outcome and repeat the steps if needed

a.       Take a learning attitude to whatever outcome is achieved, always think about a no lose outcome

Summary

Behavioural changes will have an effect on mood and cognitions.  The first steps in this is to make an assessment of where we are, this can be done with a pleasure and mastery assessment, this is most often used with clients who have low levels of pleasure and mastery and will usually be found in people suffering from depression. On the basis of the assessment then you can get the client to understand what they like and what the blocks to what the like are. On the basis of this then you can build on the clients current levels of pleasure and mastery and produce a plan.

If clients have large problems they are having difficulty facing then you can use a graded task assignment which can help break problems down into smaller steps, then move clients up each rung of the steps. The steps need to be small enough to be able to succeed in doing. There can be many automatic thoughts that can prevent the movement up the rungs so, these should be looked at. The GTA can be useful for people with anxiety or depression, but probably more often with people with anxiety as within GTA there is something of breaking down something overwhelming.

Problem solving is a client wide issue. Here the trick is to be able to provide focus on a problem to be able to do something about it. It can be difficult here as a client may want to understand a problem in all its complexity, in all its impact, in its causal aspects. This can then provide a richer understanding of the problem, but that’s where it’s left at, an understanding, the trick is to do something about it.

There are also some simple steps to be taken in terms of behavioural activation. This is literally what the client can do differently to improve their problem. So if a client is depressed, then the question becomes what can you do differently to improve things for yourself.  What you need to be able to use behavioural activation is an understanding of a client’s current behaviour, this can be done either through a formal activity assessment or by asking how a client’s week was, what they did and what the emotional outcome of this, then by asking them to see a relation between their behaviour and their emotion. Once the relation between behaviour and emotion is created, then you can ask what could you do differently to improve your emotions.

Chapter 7 Behavioural Methods 2

Reducing Anxiety and breaking patterns of avoidance

Behavioural Analysis of Anxiety Disorders

The basis of CBT’s behavioural methods for anxiety come from learning theory. Learning theory is that there is a stimulus and then a response. So someone who has social anxiety face with a party has thought responses, I’ll make a fool of myself, physical responses, heart beating and behavioural responses, leaving the party. The original stimulus is known as the unconditioned stimulus. This stimulus is then generalised such that any non-functional interaction with people where small talk might be required, e.g. meeting people at a course, or indeed going outside the house produces the same responses.  Maybe a better example would be PTSD. The UCS would be the war in Afghanistan which provided panic responses then the conditioned responses would be when any loud bang produces the responses.

In anxiety and phobias there is an initial stimulus, which is known as an unconditioned stimulus, and this produces and unconditioned response. This is the generalised and events that remind us of this then create the response which is known as conditioned responses. The movement from one to the other is known as stimulus generalisation. The responses that are produced with anxiety are so aversive that people do whatever it takes to get away from them.

With people with phobia then the horror of the response is so great they will do whatever it takes to stay away from the stimulus. Thus avoidant behaviour is rewarded with emotional relief, as it reduces anxiety then the avoidant behaviour is more likely to occur again. Therefore every time you avoid something you get the anxiety diminishing then the avoidance becomes more entrenched, but what you don’t do is to challenge the dysfunctional belief, that the stimulus is going to produce such a bad reaction, it did do once, but you have changed, and you can learn how to deal with it.

Therefore what avoidant behaviour does is to maintain the conditioned response and not to challenge the belief that firstly the conditioned stimulus isn’t the unconditioned stimulus, and also that the unconditioned stimulus needs to produce the unconditioned response. For example if you are afraid of plans then avoiding planes doesn’t challenge the belief that planes will harm you.

The key features of the contributions of learning theory to the CBT model for anxiety disorders are:

1.       An initial unconditioned stimulus causes a fearful unconditioned response and is generalised to conditioned stimuli that in turn produce conditioned responses

2.       A pattern of avoidance of the feared stimuli reinforces the belief that the client cannot cope with the stimulus

3.       The pattern of avoidance must be broken for the client to overcome the anxiety

Anxiety= over estimation of danger and under estimation of ability to cope. Quite often there is no single event that causes the anxiety or OCD rather there is a more complex formulation.  Within the overestimation of danger and inability to cope are many illogical automatic thoughts. These often get constructed by significant events and people within the client’s life, e.g. parents and traumatic events. Often there is not one event that caused the core beliefs that get activated within anxious events but rather there is a complex formulation.

Overview of Behavioural Treatment Methods

Breaking the Stimulus-Response Connection

Behavioural treatment methods therefore look to sever the link between the unconditioned and conditioned stimulus, i.e. the stimulus generalisation, or between the responses. In learning theory this is known as un-pairing.

The most generally used techniques for un-pairing is exposure and reciprocal inhibition.

Reciprocal Inhibition: this is the process of associating an incompatible emotion to anxiety with the stimulus, i.e. so get into a deep state of relaxation and pair this with a spider

Exposure: This has the exact opposite effect to avoidance. If you expose yourself to the feared object then fear is time limited and will dissipate. So if you can sit with the feared object then the fear levels cannot be maintained and you will adapt to the situation.

Cognitive restructuring: this can also break the relation between stimulus and response. So that when the stimulus occurs there are many NAT's that can be DTR'd. You can also use thought stopping where you replace an unpleasant thought with a pleasant one

Decatastrophising: Evaluate the likelihood of feared event happening. Develop a plan to reduce the probability of the event happening. Prepare for ability to cope with the feared event should it do so

Treatments in anxiety disorders are similar:

1.       Teach the patient skills for coping with their thoughts, behaviours and emotions

2.       Look for symptoms, triggers and coping strategies

3.       Then do either reciprocal inhibition or exposure

Sequencing Behavioural Interventions for Anxiety Symptoms

Step 1 Assessment of Symptoms triggers and coping strategies

Clearly delineate:

1.       Events that trigger (try to get both original unconditioned and conditioned)

2.       Automatic thoughts, cognitive errors and underlying schema

3.       Emotional and physiological responses

4.       Habitual behaviour, such as panic or avoidance

Some of the coping strategies will be adaptive, these needs highlighting and strengthening, so will be maladaptive

Some safety behaviours are unfortunate, a family member tries to help, so if they are agoraphobic and the friend gets them a takeout then there is a positive reinforcement of a friend getting a takeout, i.e. giving a positive stroke for being agoraphobic, people without agoraphobia have to get their own dinner! So look out for the positive reinforcement that some safety behaviour produces.

Step 2 Identify targets for intervention

Many people with anxiety have multiple forms of anxiety, so start with one that is manageable and that you can get some success with and get some confidence with.

Step 3: Basic skills training

Relaxation training

a.       Muscular relaxation is the best way to get mental relaxation

Thought stopping

This can be useful for people with panic attacks or phobias, but can provide an intensification of thought for people with OCD so use with caution.

a.       Recognise there is a dysfunctional thought

b.      Give a self-command to stop the thought

c.       Evoke a visual image to reinforce the signal

d.      Switch the image to a pleasant image

Distraction

a.       Careful this doesn’t get used safety behaviour. This should only be  a precursor to exposure

Decatastrophisation

a.       Estimate the likelihood

b.      Evaluate the evidence for and against the event

c.       Review the evidence list and re-estimate, usually this will be lower but if higher then do cognitive restricting on the element that became higher

d.      Assess perceived control= ask client the level they feel they have control over events

e.      Create an action plan to reduce the possibilities of catastrophe

f.        Develop a coping plan should the catastrophe occur

g.       Reassess the likelihood that the event will happen and reassess the feeling of control that you have

Breathing retraining

You can produce panic-attack like symptoms by getting a client to hyperventilate. Then on the basis of this you can show them how returning to normal breathing reduces these symptoms.

a.       Normal breathing 15 times a minute, when having a panic-attack much higher. When you breathe too fast is you breathe out too much carbon dioxide. Slow your breathing down to one breath in and out every 15 seconds. Use imagery to facilitate this, so have a happy place that you can see

b.      With hyperventilation, your body has too much oxygen. To use this oxygen (to extract it from your blood), your body needs a certain amount of Carbon Dioxide (CO2).       When you hyperventilate, you do not give your body long enough to retain CO2, and so your body cannot use the oxygen you have. This causes you to feel as if you are short of air, when actually you have too much. This is why the following techniques work to get rid of hyperventilation.

                                                               i.      Some hyperventilation and panic attack symptoms are:

1.       Light headiness

                                                             ii.      Giddiness

                                                            iii.      Dizziness

                                                           iv.      Shortness of breath

                                                             v.      Heart palpitations

                                                           vi.      Numbness

                                                          vii.      Chest pains

                                                        viii.      Dry mouth

                                                           ix.      Clammy hands

                                                             x.      Difficulty swallowing

                                                           xi.      Tremors

                                                          xii.      Sweating

                                                        xiii.      Weakness

                                                        xiv.      Fatigue

Exposure

a.       You can use flooding or systematic desensitisation. This always comes last after the person has learnt relaxation skills. To counter avoidance then you should pair graded exposure with cognitive restructuring and relaxation techniques.

Developing a hierarchy for graded exposure

1.       Be specific          

2.       Rate degrees of difficulty, try to get client to give items for the full range

3.       Choose steps collaboratively

4.       Get client to develop over the top fear, which will have the effect of pushing the rest of the rankings downwards

Imaginal Exposure

There are two types of exposure imaginal and in vivo. In imaginal exposure, get the client to imagine the situation, what they do, what they think and how they feel. Then get them to imagine coping with this using breathing exercises and cognitive restructuring.

1.       Use environmental cues to create vivid images of the feared stimuli

2.       Use cognitive restructuring, relaxation, thought stopping to decrease anxiety

3.       Present the images in a hierarchical fashion

4.       Coach the patient on ways to cope with anxiety

5.       Repeat the imaginal exposure until the anxiety is reduced

In vivo exposure

1.       If the therapist accompanies then it can make the situation seem safer, so not true in vivo

2.       Patient should record anxiety before and after and note the amount of anxiety reduced

Response Prevention

General term to stop behaviour that are perpetuating disorder, e.g. walk out of the house after checking once and don’t return within a certain time frame. Best when they are determined collaboratively.

Rewards

Link positive reinforcement with each step that is achieved in the feared hierarchy and not adopting the standard safety behaviour.

Summary

So this behavioural work is around dealing with fear, so it is usually seen in the anxiety register of distress. The main idea is that there was one original fear that produced a stimulus, then this is generalised to wider situations. It could either be that the original response was either adaptive and then generalised, or not adaptive, i.e. that it was an irrational fear.  The way that the fear is maintained is through avoidance because there is the belief that the level of fear is too great to cope with. So the idea here is that this is an irrational fear and that needs to be challenged. What prevents this being challenge is an inability to tolerate the feeling of fear.

So what is done here is to teach methods to deal with fear. This can be cognitively through thought records, examining the evidence, de-catastrophising, thought stopping and distraction. Physiologically it is done through relaxation training, breathing training. When the techniques to cope with feared responses are in place then you can start to expose the client to their feared hierarchy.

So here’s how to do it

1.       Identify feared situations and responses

2.       Formulate and psycho-educate how the safety behaviour is leaving the illogical belief in place and the nature of stimulus generalisation

3.       Practice fear coping skills use them in the session with imagined feared situations to see how they can make a difference

4.       Build a feared hierarchy

5.       Do an imaginal exposure pairing the coping skills with an item on the list

6.       Do an in vivo exposure

Chapter 8 Modifying Schemas

Schemas

1.       Are how we screen information, i.e. our attention filter

2.       How we make decisions, i.e. set of values and beliefs

3.       Drive patterns of behaviour (when depressed then comfort eat)

Schemas get developed over time by significant interactions with people, significant events and genetics. There are both adaptive and maladaptive schemas. Thus when you work with a maladaptive schema you can either try to change it, or to replace it with an adaptive schema the client has.

It is from schemas that automatic thoughts and rules and assumptions for living arise.  Maladaptive schemas and beliefs are only activated during stressful events. Modifying schemas will both reduce current symptoms and also provide resistance against stress in the future

Clients have adaptive and maladaptive schemas.

You should only look to work with clients on schemas collaboratively and with a plan of what you are going to do once you find them.

Only go to the level that the client is happy with

You can find schema as the nexus for commonly occurring together NATs

CBT for Axis 1 is geared towards symptom relief not personality change.  Modifying schemas can have effects of changing personalities.

Finding origin of Core beliefs

For all of the following influences find out why beliefs have been derived from each

Identifying Schemas

Methods for identifying schemas

1.       Questioning techniques

2.       Pscyhoeducation

3.       Spotting patterns of automatic thoughts

4.       Conducting a life history review

5.       Using schema inventories

6.       Keeping a personal schema list

Questioning techniques

a.       Guided discovery

                                                               i.       Socratic questioning, imagery and role play can uncover schemas.  These are the same technique for finding automatic thoughts, but when looking for schemas the therapist is guided by an idea of what the core belief might be.  So what this means is that when you spot what might be a core belief, ask about what are the rules you follow to be achieve your outcome. You can also ask straight out do you have any fundamental beliefs that support this rule.

b.      Mood shifts

                                                               i.      Mood shifts can be an indicator that a schema is at work.  So when you see a mood change you can ask what upsets you about what we are talking about.

c.       Downward arrow technique

                                                               i.      If this thought that you have about yourself is true, what does it mean for you. So you need to have a thought about yourself, or if it’s about the world, what does it mean about the world, or if it is about the other, what does it mean about the other. Be aware of the entry belief about what aspect of Self, World Other or maybe future it is about and then keep the meaning at this same scope, often people when asked what does it mean change their scope which gets confusing.

                                                             ii.      How to use the downward arrow technique

1.       Start on an automatic thought that is causing distress

2.       Generate an hypothesis about the underlying schema of this automatic thought

3.       Explain the downward arrow technique, so that the client understands that you are asking some slightly odd questions in the purpose of something.

4.       Emphasise the collaborative aspect of this technique so that there is the modelling of curiosity

5.       Think how the client will react to uncovering a schema, is now a good time to do this, how will you pull out of schema uncover if you think you are going too fast

6.       How will you help the client when the schema is uncovered

7.       Use if then questioning. If your automatic thought is true, then what does it say about self, world and other.

8.       Be empathic and show that uncovering a maladaptive schema can boost your self-esteem and can aid growth

Educating clients about schemas

Mind over mood, getting your life back contains sections on schemas that could be good bibliotherapy.

Spotting patterns of automatic thoughts

a.       Themes during therapy, recurrent automatic thoughts indicate an underlying schema.

b.      Review thought records in therapy and look for commonality

c.       Review of thought records for a homework assignment Ask client to look for common themes and see if there are any rules and assumptions for living or foundational beliefs that are the nexus between them.

d.      Review a list of NATs. Getting the client to produce a written list, which summarises each NAT can help them spot patterns. You can then get clients to identify the schema for each NAT they have

Conducting a life history review

On the basis of a hot topic, one where the client has a strong affective response, then this provides the inroad to doing a life review. The topics areas that can be covered are as follows. The aim being to understand any rules for living that have come from these or fundamental beliefs.

a.       Significant people in life

b.      Ask how core beliefs have been shaped by experience

c.       Ask about interests, jobs, spiritual involvement

d.      Ask about education and self-study

Using schema inventories

a.       There are schema lists with both the adaptive and maladaptive schemas that the client can then see that they identify with. These can be useful when clients are struggling to identify their core beliefs. It is important to look at both adaptive and maladaptive schemas, as otherwise the process may reinforce a negative view for the client of themselves.

2.       Keeping a personal schema list

a.       People can learn their schema in therapy but forget outside, so get a list. Schemas are outside consciousness, pre conscious if you like that can be seen if you pay attention to them, for this reason they are easily forgotten is session, so keep a list. Indeed you could keep a collaborative list of both adaptive and maladaptive schemas.

Modifying schemas

Socratic questioning

So if there schema is I’m a failure, how would the Socratic questioning be on this?

C:  I’m a failure

T: Is this something that you’ve always thought

C: No it started when I was a teenager

T: Where there things that happened then that led you to this conclusion

C: Yes some stuff

T:So on the basis of stuff happening you decided you were a failure

T: Do you always think you’re a failure?

C: Sometimes I don’t

T: To think you’re a failure, means you have some idea of success, what’s that like

C: Oh you know good at things

T: So you understanding of success defines your understanding of yourself as a failure

C: How does thinking you’re a failure help you achieve being a success

a.       Encourages enquiry, rather than a fixed maladaptive view of the world

b.      Use questions to help the client see contradictions in their thinking

c.       Ask questions that encourage the client to recognise adaptive beliefs

d.      Questions that enable significant emotions will aid learning as we remember what we have big emotions around

Examining the evidence

a.       With core beliefs then there may be a lot of evidence a client has to support these ideas but you can look for evidence for and against, so you need to be empathic of the problems faced. In this instance some gentle reframing can be useful, you can also try imagining if the opposite core belief was true how would you interpret the event.

b.      How to examine the evidence

a.       Explain the procedure

b.      Write out evidence on a worksheet

c.       Evidence is often absolutistic look for cognitive errors

d.      Look for skills training that the evidence for the schema shows up

e.      Be creative in looking for evidence against

f.        Collect as much or more evidence against the schema

g.       Ask for a statement of a modified core belief on the basis of this investigation

List Advantages and disadvantages

Schemas are kept and used as they have a payoff even if they have negative effects. What are those pay offs, through identifying these, then you can look for more adaptive ways of achieving them. 

As soon you modify schema, then you need to get the client acting as if the modified schema is true

Cognitive continuum

Schemas can be expressed I absolutist terms, I’m a loser. To then grade this, to say ok, well if you were a 100% what would that look like, if you were 0%, then once you have it on the continuum it tends to reduce the level of being a loser they feel. The technique here is to get the client to grade their failures, then to do zero, 50% and 100% then to see where they fit

Generating Alternatives

Ok so you say you’re worthless, this is quite extreme as it talks about your being, is there a way to soften this, so I have experienced some failures in my life. You can also look at changing one or two of the words, e.g. I must be in control, to I’d like to be in control

Cognitive and Behavioural rehearsal

The key to predicting core belief change is to practice, practice practice. On generating a new one then act as if it’s true.

Tips to practice new schemas

1.       Develop a written plan to try out revised schema, i.e. relate the behaviours that relate to the modified core belief

2.       Use imagination to rehearse the behaviour

3.       Look at obstacles and develop coping strategies

4.       Develop a homework assignment to try out new behaviours

5.       Repeat the mantra practice, practice, practice

Growth Orientated CBT

Whilst CBT is standardly targeted at symptom relief and relapse prevention, it can be also used for growth purposes.  So in other words how can we both strengthen adaptive schemas and ones that add meaning and purpose to a person’s life. Viktor Frankl can be of use here.

Summary

Schemas are both adaptive and maladaptive. They are the base ways we engage with the world, they are the ways we look at the world, i.e. conceive it, the base beliefs that we have about the world, the rules and assumptions we have about the world and generate our automatic thoughts. They also generate patterns of behaviour. Different schemas are activated at different times.  They are developed over time through the influence of significant people, events and genetics.

To work with clients on them, first of all you need to have enough time in session to be able to do something about them, so restructure them. You need to know that the client has enough resource to be able to cope with them. So the first stage is to psychoeducate to show the client what they are, and how they came to be, how they can have an impact on their lives.  You also need to take the decision to work on schemas as opposed to NAT’s. Typically this decision would be taken when you have worked with NAT’s and had some success but found many NAT’s with the same underlying theme, or when work with NAT’s isn’t successful.

To identify them then you can use

1.       Themes in NATS

2.       Mood Change in session

3.       Downward arrow, what does it say about you?

4.       You could if you get stuck in any of the above techniques use a schema inventory, but this would only be a precursor to the above techniques, and there is the worry here that you are merely putting the words in the mouth of the clients

5.       You can also ask them directly. So how this works is that you are looking at a topic. It seems like you need to feel in control to feel ok about yourself, have you any rules for life that you give yourself, do you have any fundamental beliefs around this. This is quite a gentle way of eliciting the information. So a question might be what rule do you have for yourself about what it means to be loved or successful.  Did you develop any fundamental beliefs for yourself around this rule?

When you have found a core belief, then before moving on to modify you may well want to look at what its effects are, behaviourally, emotionally and the automatic thoughts and rules for living that ensure for it. In this way doing this will solidify the understanding of the schema to find out more about it, and to see what’s at stake through changing it. At this point you also need to look at how developmentally it was created.

So when the schema has been identified, described and understood, then you can think about modifying it.

To modify it, then the following techniques can be used.  The first second looks to dispute the schema, the second looks to modify it

1.       Dispute

a.       Evidence for and against, here look for thinking errors

b.      Pros and cons for the schema

c.       Cognitive continuum

2.       Revise

a.       When you have looked at these, try getting the client to produce a revised

b.      Looking to soften the statement by changing some words

3.       Embed

a.       Look to develop a behavioural plan to act on this revision

                                                               i.      Act as if it’s true

                                                             ii.      Look for roadblocks

                                                            iii.      Do imaginal rehearsal

Chapter 9 Common Problems and Pitfalls

Learning from the challenges of Therapy

Homework non-compliance

Homework non-compliance can be because:

1.       The client is not prepared well for the assignment

2.       The assignment is not challenging enough or too challenging

3.       Client issues, low energy, motivation etc.

Prevention

Preventing homework non-compliance

1.       Request the clients input when designing homework

2.       Rehearse homework assignments in advance

a.       Do it in the session

3.       Always follow up on a homework assignment

4.       Don’t use the term homework, maybe assignment, or during session work, but you need a good phrase for this.

Recovery

1.       Evaluate the usefulness of the assignment, is the assignment still worth doing, should it be modified?

2.       Complete missed homework during the session, sometimes all that is needed is for the therapist to get started on the task.

3.       Evaluate the negative thoughts about the homework task

4.       Use homework non-completion as a learning opportunity. This can be very useful as it is a live experience and can increase the ability to do assignments. In some ways assignments can show a client’s uptake of what is going on in the session, so non-compliance can be a useful thing to work through.

Difficulty eliciting automatic thoughts

Prevention

1.       Let the client tell a story about an upsetting event. During this listen out for automatic thoughts and note them down, then when you ask about automatic thoughts then you can offer some of these back as a stimulus.

2.       Explore the meaning of events: what was it that upset you, not explain the emotion.  Also when someone else evokes an emotion in you, find out what it was about them, what do you think they were saying or meaning to you. You can also look at the behaviour they took, why did they do that

3.       Try hot spot cognitions;  intense emotions means that ATs have emerged

4.       Ask about the persons actions during the upsetting event. Why did your action seem reasonable? So work back from action to cognition. If you could turn back time what would you have done and why did you do what you did do rather than what you would have preferred to do.  You can also ask what prevented them doing their preferred action. Doing this will highlight the decision point which would be the automatic thought.

Recovery

1.       Avoid asking forced choice, i.e. closed questions,  rather use what kind of thoughts  were stirred up by this event, how did you feel about yourself and others

2.       Stay with a topic : Imagery or role play may help a client identify automatic thoughts

3.       Record thoughts as close to a stressful event as possible, so set homework assignments to record thoughts and experience as soon after the event as possible

4.       Use a checklist or other treatment adjunct: there are published lists , the ATQ

Overly verbal clients

Prevention

1.       Some clients  will talk in an unstructured and unfocussed way, especially those who have had  therapy previously

a.       Socialise to CBT, stress that its problem focussed, here and now work. It seeks to teach reusable skills.

b.      You may need to interrupt the client: do you mind if I interrupt you.. Before you go on, I was wondering if you could

Recovery

1.       Balance open discussion and agenda items

2.       When someone is venting then you may want to pick out the automatic thoughts, to focus attention by summarising what happened

Clients who are stuck in repeated behaviour

Some people like to talk, some people having experience other types of therapy, want to talk. Whilst this is useful in building the relationship sometimes this needs to be channelled.

Prevention

1.       Ask how the clients symptoms might interfere with his plans for changing behaviour, then create a strategy to work around them

a.       So depression = low energy and won’t do much anxiety fearful it will go to shit won’t do much

2.       Draw on patients strengths to design intervention. Ask PW what made him do the things he did and what made him lazy. It is for this reason when you do an assessment you need to find out about a client’s strengths.

3.       Look ahead for problems the patient might have in breaking old habits. So if they drink in the evening after 7pm then put in some work pre seven

4.       Elicit and modify cognitions that are promoting procrastination avoidance or helplessness

5.       Encourage self-monitoring. This provides some distance from the problem, some understanding of the problem and can help

6.       Use a graded approach, shape tasks, break them down into small units

Recovery

1.       Try again, old habits take some chipping away at them

2.       Cognitive rehearsal, old habits can require a run up at them

3.       Pros and cons , what’s the positive reinforcement of the behaviour, can we get this elsewhere

Progress derailed by environmental stress

There can be new events in a client’s life that can derail plans and progress. Indeed client sessions can turn into crisis management.

Prevention

1.       Try not to get overwhelmed in the clients problems.  Look at your automatic thoughts to cope

2.       Choose one target problem at a time, doing this will reduce the feelings of being overwhelmed

3.       Teach problem solving skills, i.e. prioritizing, setting effective goals, ensuring that there are enough resources.

Recovery

1.       Regroup: summarise problems, create a problem list and prioritise

2.       Bring in reinforcements, enlist friends, family and other professionals

3.       Use the past as a guide: find out what strategies have been successful before

Therapist Burn Out

Prevention

1.       Take care of yourself

2.       Find your case load limit

3.       Balance work and play

Recovery

1.       Rest: use a different part of your being to rest

2.       Supervision

3.       Learn some new technique, or approach if you are feeling bored\stifled

Medical Regimen Non-Adherence

Prevention

1.       Create a comfortable environment to discuss adherence, don’t pass judgement

2.       Anticipate obstacles, so when planning plan in possible obstacles

3.       Create a plan to ensure adherence

4.       Check for adherence regularly

Recovery

1.       Assess clients automatic thoughts about adherence

2.       Use behavioural strategies, so pair it with a pleasurable task

3.       Help the client talk to their doctor. Write down concerns and automatic thoughts and take them to the doctor.

4.       Set goals for adherence, do activity schedules to find out when the problems are.

Chapter 10 Treating Chronic, Severe, or Complex Disorders

There are several common strands to treating all severe conditions

1.       CBT and pharmacotherapy work well together

2.       You should be collaborative in your work

3.       All sessions should have a structure, agenda, work, homework and  summary

4.       Homework builds on in session work

5.       Family members can be invited in to sessions

6.       Outcomes are assessed

The outlines below only discuss empirical evidence and guidelines, but you would need to read up on specific areas, as they have detailed methods in other literature.

Severe, Chronic and treatment resistant depressive disorders

Likely to have a biological element.  Clients can become burned out with treatment and lack any optimism of improvement of condition. Behavioural strategies can yield benefit, as cognitive faculties are likely to be impaired. Likewise low energy levels and anhedonia will result in difficulties in treatment so raising the energy levels and amount of pleasure in their life will increase optimism which will make treatment easier. Likewise targeting hopelessness with cognitive restructuring can be important as this again will make treatment easier. Again a client may have a tendency to discount small gains, this needs targeting as without being able to get small or big gains they will be stuck.  Thought stopping could be useful, where DTR’s do not have an impact.

Bipolar Disorder

Evidence suggests drugs alone don’t work, that stress will cause episodes, not taking drugs will produce relapse. CBT without using drugs has not been effective. In the initial stages CBT should be used to keep the client taking the drugs.

Goals of treatment in order

1.       Biology of bi polar

2.       Pharmacotherapy of disorder

3.       Effects of stress on symptoms

4.       CBT elements of depression and mania

5.       Self-monitoring

Self-monitoring

1.       helps split normal from disease behaviour.

2.       Sees the effects of disease

3.       Develop early warning system

4.       Identify psychotherapeutic targets for interventions

In identifying the targets then you can either challenge NAT’s or look to modify behaviour to respond to certain feelings to prevent a full blown outbreak.

1.       Educate about bipolar

2.       Teach self-monitoring

3.       Develop relapse prevention strategies

4.        Enhance adherence to pharmacotherapy regime

5.       Relieve symptoms with CBT

6.       Develop a plan to manage bi-polar

Relapse prevention is on the basis of an early warning system. So when the signs are there that a manic episode is coming list techniques that can be used to prevent this. Do an advantages and disadvantages of ideas, check with a friend etc.

Early warning system should contain, mild, moderate and severe symptoms to indicate how close to outbreak they are.

Pairing can be used to ensure drugs are taken, so either before a pleasant activity or with a routine activity can help.

Personality Disorder

These are viewed as being created through either developmental or genetic reasons. CBT focusses a lot on schema work and on coping strategies. Therapy is longer than with Axis 1 treatment and more attention is paid to the relationship and transference.  Repeated practice is needed to cope with chronic problems.  DBT is one of the adaptations of CBT for Personality Disorders.

DBT

1.       Acceptance and validation of behaviour

2.       Emphasis on identifying and treating therapy interfering symptoms

3.       Focus on dialectical processes. DBT believes that there is a payoff even in dysfunctional behaviour, therefore it focusses on identifying the pay off and finding more functional ways to achieve them. It also aims to get clients to balance competing goals, strategies used to attain these are mindful approaches.  To manage painful emotions then thought stopping, relaxation training and breath retraining are used.

Substance Use Disorders

Beck saw that substance use is directly linked with automatic thoughts. Initial work can be to show this relation between drinking and thoughts. Urges to drink can be seen to be cognitive, cravings to drink can be seen as biological and the combination of them can become irresistible, or “addictive”. There are also situational cues, such as smells, places, people, etc. Beliefs against the harm of substance can decrease, as can the worth of doing other things apart from drinking. Likewise the amount of permissive beliefs can increase, i.e. I’ll get wrecked tonight then straighten up tomorrow. There are also many beliefs about cravings and abstinence.

Eating Disorders

In a study where people were partially starved, the volunteers became obsessed with food, had diminished libido, mood and sleep disorders and cold intolerance. Eating disorders, like substance abuse can cause problems in themselves from the behaviour.

Schizophrenia

This is the toughest disease with low rates of complete remission. Clients need to stabilise with drugs before using CBT.  Delusions can be seen to be an extreme version of logical errors.  Hallucinations can be normalised in terms of under extreme situations, sleep deprivation or drug abuse, everyone will hallucinate. Behavioural interventions with hearing voices target quietening down the voices.