Chapter 1. Introduction 3
Brief Therapy Principles 3
Chapter 2. The Cognitive-Behavioural Framework 3
Tools to work with client 3
Fundamental characteristic of cognitive behavioural therapy 4
Chapter 3. Assessment 5
Chapter 4. Beginning Stage of Therapy 7
Chapter 5. Middle Stage of Therapy 9
The cognitive process 10
Help the client to work on problems in and out of therapy 10
Chapter 6. End Stage of Therapy 10
Therapist goals for end of therapy 10
Collaborative Therapeutic Relationship 11
Cognitive Model Process 11
Help client to work on problems in and out of therapy 11
Chapter 7. Additional Strategies and Techniques 11
Cognitive Imagery Techniques 11
Anti-future shock imagery 11
Aversive therapy 12
Coping Cards 12
Coping Imagery 12
Cost benefit analysis of beliefs 12
Decatastrophising continuum 12
Deserted Island technique 12
Letter writing 12
Motivation imagery 12
Rational-emotive imagery 13
Step up technique 13
Time projection imagery 13
Thought stopping 13
Verbal Economy 13
Behavioural Interventions 13
Contracting 13
Cost benefit analysis of behaviours or habits 13
Cue exposure 13
Habit control 13
Modelling 13
Response cost or penalty and reward 13
Response prevention 14
Self-monitoring and recording 14
Stimulus Control 14
Relaxation techniques 14
Progressive relaxation 14
Relaxation response 14
Chapter 8. Hypnosis as an Adjunct to Cognitive Behavioural Therapy 15
Chapter 9. Treatment Protocols. 15
Panic Disorder 15
Social Phobia 15
GAD 15
Depression 15
OCD 15
PTSD 15
Specific Phobia 16
Summary 16
To Do 16
Client Forms 1
Thinking Errors List 2
Thought Form 4
Cognitive Conceptualisation Chart 6
Goals\Sub goals\Task\Experiment Form 7
Problem solving sheet 8
Possible set back form 10
Questions to help question unhelpful thinking 11
Psychoeducation forms about major DSM categories (OTCT) 11
Need Risk assessment and suicide plan 11
Chapter 1. Introduction
·
Brief can mean increasing effectiveness,
beneficial to client, therapist and service
·
Most therapeutic work happens in first 6-8
sessions
·
Given that therapeutic change throughout life is
inevitable. Brief therapy can be used intermittently throughout a person’s life.
Short sessions, improve an area, have its effect generalise out to other areas.
Brief Therapy Principles
1.
Therapy is parsimonious and pragmatic. No
attempt is made to change the clients basic character, it is assumed that a
change in one area of a person’s life will spread to others
2.
Recognises therapeutic change is inevitable
throughout a person’s life.
3.
A persons problems are accepted and their
strengths\assets highlighted and utilized so the therapy is about building on
strength, not fixing their pathology
4.
Many positive changes will happen after therapy
finishes
5.
Effective therapy is not a timeless process,
limits will be placed on time
6.
Psychotherapy can be unhelpful if applied
unselectively
7.
Therapy is a means to an end, life is more
important than therapy.
Chapter 2. The Cognitive-Behavioural Framework
·
Thoughts, Emotions, Behaviours, physiology are
part of a unified system, changes to one part will affect the others
·
Emotions and behaviours are not caused by events
but by how we interpret them
·
Beck: dysfunctional thoughts can lead to
emotional disorders
·
Schemas: are abstract mental plans that guide
action. They give us structures for remembering, perceiving, interpreting
information and suggesting what behaviour to respond to events. Schemas are
hierarchical, from abstract to more concrete. Schemas are a filing cabinet of
ways of interpreting, supporting memories, ways to remember, emotions likely to
be felt, behavioural responses, cognitions i.e. core beliefs.
·
Intermediate beliefs: Attitudes are a value laden
description, it is dreadful to be in danger. Assumptions are If then statements
and rules are absolute, should, must, oughts, and always.
Core Beliefs
|
Intermediate beliefs
|
Automatic thoughts
|
Global
|
Attitudes
|
Stream of thought
|
Rigid
|
Rules\expectations
|
Images
|
Over generalised
|
Assumptions
|
Words\phrases
|
Tools to work with client
·
Core conditions to create the alliance
·
ABC, i.e. activating event, belief and
consequence. This helps show the client how beliefs relate to emotion\behaviour
·
First building block of work with clients is to
get them to recognise the relationship between thoughts\beliefs and
emotion\behaviour.
·
Second building block is to get them to look for
evidence for and against the unhelpful beliefs
·
Thinking errors
o
When you are distressed people tend to have
thoughts which they believe at the time but wouldn’t when they are not
distressed. What we also notice are
there some common “thinking errors” that go on in these times
1.
All or nothing thinking: Understanding the world
in extreme categories of black\white, good\bad
2.
Personalisation and blame: If something goes
wrong, it’s completely my fault, and it means there’s something deficient about
me.
3.
Catastrophizing: Clients dwell on the worst
possible outcome.
4.
Emotional reasoning: Where a person draws
conclusions about an event through how they feel and ignore any evidence to the
contrary
5.
Should or must statements. A person has a fixed
idea about how they or others should be. They become rigid demands and when
they are not met this creates emotional distress.
6.
Mental filter: a person dwells on negative
aspects regardless of any positive aspects
7.
Discounting the positives: when “positive”
achievement\praise is ignored or discounted.
8.
Overgeneralisation. Where because something bad
happened once, it means it will frequently happen
9.
Magnification\Minimization: where the bad is
magnified and the good is minimized.
10.
Labelling:
People are viewed in all or nothing terms, and labelled in a derogatory
term, e.g. my mother is a heartless bitch
11.
Jumping to conclusions: a person infers an
outcome will be negative without having any evidence for it. This can be mind
reading or fortune telling.
o
Thinking errors tend to come in clusters
2.
Third building block is to identify the thinking
errors for the client, but how are you going to work with them once you have
identified them? (QUESTION)
3.
Fourth building block is to identify NATs
Fundamental characteristic of cognitive behavioural therapy
1.
Therapeutic style
o
At start of therapy active\directive, looking to
move this control to the client, moderated with the core conditions.
2.
Formulation of problem
o
Conceptualise the clients problems identify
development of problem and maintaining factors
3.
Collaborative relationship
o
The strength of this, determines really the
extent of the work. Limited alliance should slow the work down, so the alliance
is attended to more than specific techniques worked on
4.
Structure to sessions and to therapy
o
Typical structure:
1. Check clients mood
2. Brief review of week
3.
Set agenda for current session
4. Feedback and link to previous session
5.
Review homework
6.
Discuss agenda items
7.
Set homework
8.
Feedback
5.
Goal directed therapy
o
Make behavioural goals so that we can work
towards them, monitor them. Brief therapy is not going to work without tight
goals and this is vital!! A wide variety of goals may indicate unsuitability
for brief CT.
6.
Examines and questions unhelpful thinking
o
Use Socratic thinking to establish worth of
thought/belief, but ensure you understand its meaning before you do. (SELF HELP AID QUESTION BELIEFS SHEET)
7.
Uses range of aids and techniques
8.
Teaches client to become their own therapist
o
Part of homework is getting client to become
their own therapist, learn the principles in life, use them see how they
work. It’s important to get the client
active in session, setting the agenda, leading the therapy.
9.
Homework setting
o
Call it assignment, use it to get client to
become own therapist, useful to use the time therapeutically makes therapy work
better, also enables it to be used after therapy stops.
10.
Time limited
11.
Audio-recording sessions
o
Offer tapes to clients.
·
When reviewing last week, ask what stood out for
you from last week’s session.
·
Get clients to get a therapy notebook, this will
link sessions, and link therapy to life
Chapter 3. Assessment
Key questions:
1.
What is the problem
2.
Is CBT suitable for the problem
3.
Is client suitable for CBT
4.
What are the thoughts underlying the problem
5.
Transcultural and gender issues
What is the problem?
Is the problem a reaction to something bad that happened
within 6 months? Yes in which case then you may want to wait, as there is a
natural reaction, e.g. grief that either watchful waiting or counselling is
better suited to.
Is CBT suitable for the problem?
Is it within the disorder specific canon? If there are
multiple problems, can we break one out that is amenable to change?
Is client suitable for CBT?
1.
Is the clients problem clearly definable
2.
Has the person responded well to CBT before
3.
Has the client motivation
Safran’s scale
This should take an hour to do and presupposes knowledge
about the client
1.
Accessibility of automatic thoughts
o
So do a thought record for a situation. If that
fails, do it imaginally, if that fails move to an in session emotion, if that
fails, then there’s a problem with CBT for this client
2.
Awareness and differentiation of emotions
o
What range of emotions have you felt during the
last year, can you give me an example of each one
3.
Acceptance of personal responsibility to change
o
As you look at their problem, do they see their
part in it, or is it the fault of someone else.
4.
Compatibility with cognitive rationale
o
Explaining the triangle, can they explain it
back to you
5.
Alliance potential (in session)
o
You’d need to judge this yourself
6.
Alliance potential (out of session)
o
Can client form positive relationships in general
in their life
7.
Chronicity versus acuteness
o
The more chronic a problem, the less appropriate
brief CBT is, but if the current episode is less acute than the previous ones
then this might count in his favour
8.
Security operations
o
How much does the client use safety behaviours,
avoidances, behavioural excesses to manage problems. How would you find this
out, well how do you manage your problems, are there things you do, or don’t do
to keep yourself safe
9.
Focality
o
Does client remain focussed on the problem
10.
General optimism\pessimism about therapy
o
Is client optimistic\pessimistic about therapy
4.
What are the thoughts underlying the problem
o
What are their NATS, IBs and CBs.
o
Components of a cognitive conceptualisation
1.
Predisposing factors: i.e. how beliefs learnt
2.
Precipitating factors: critical incident
3.
Maintaining factors
Chapter 4. Beginning Stage of Therapy
There are three stages of therapy that the therapist needs
specific goals in:
1.
Beginning
2.
Middle
3.
End
Beginning goals
1.
Treatment
o
Teach cognitive model
o
Ensure client can identify different emotions
o
Client can link thoughts to emotions
o
Establish security operations
o
Develop cognitive conceptualisation
o
Establish client goals
o
Enable client to challenge automatic thoughts
o
Psychoeducate client about disorder
2.
Process
o
Develop collaboration
o
Help the client see they are responsible and
capable of change
o
Elicit doubts about therapy and address through
psychoeducation
·
Critical for brief CBT
o
to get a collaborative conceptualisation
o
to get SMART goals
o
get clients to distinguish thoughts\feelings
§
so when ask what do you think, and you get what
they feel, or vice versa, stress the importance of distinguishing the two
o
client understands relations between
thought\feelings\behaviours through cognitive triangle and ABC. ABC probably is
the starting point, then you can get to the reciprocal relations with the
triangle
o
client understands thinking errors
o
client can generate alternative thoughts
·
Useful for brief CBT
o
To show the congruence between thoughts and
emotions. Start identifying cognitive types of thoughts, e.g. my anxious
thoughts and my depressive thoughts
·
With meta problem emotions it is better to work
on these secondary problems rather than the primary problems if
o
they are
likely to interfere with work on the primary problems
o
They have reached clinical significance
o
If the client wants to
·
Look for incongruence between thought and
emotion in formulation as you will be missing either cognitions of emotions and
you will be dealing with meta problems
·
You can notice when different emotions need to
be unpacked when you get I felt shitty/bad/dreadful. Here you need to tease out
the emotions, which have possibly been lumped together because they often occur
together and you might get primary, secondary and tertiary problems.
·
ABC.
o
So firstly elicit the clients ABC, and look at
the relation between the three. Firstly look at the relation between the B and
the C. You can supplement this by generating an alternative thought and see the
difference in emotion. You could also normalise the thought by understanding
how they learnt to have that thought, what the intermediate beliefs are. When
teaching the cognitive model, you don’t need to change thoughts, although
looking at alternative thoughts can help to illustrate the relationship so on
the basis of this, don’t look at intermediate beliefs.
o
A=Event!
o
B=Beliefs. To generate alternative thoughts: ask
the client for an alternative thought, if that doesn’t work, go Socratic with
other things they have said, if that doesn’t work suggest an idea see how that
makes them feel, if that doesn’t work ask them what they would say to a friend
o
C: Consequences, i.e.
emotions\behaviours\physiology
·
Clients may understand ABC intellectually but
not see how it can help their problems. Practice is the key.
·
When automatic thoughts do not show thinking
errors then probably problem solving is the way forward
·
Thinking errors: we often adopt beliefs that are
unhelpful to us and are not supported by any evidence, although they seem
plausible at the time. We can often see these because they contain thinking
errors. However we can over time challenge these beliefs and learn new ones.
·
Identifying automatic thoughts:
o
Stage 1 identify the thought prior to the
negative emotion
§
Ask client, ask client what that situation meant
to them, get client to visualise, ask
what a friend would think, use a stick man and bubble, role play, take a wild guess, socratically work on it, ,
offer a paradoxical suggestion, offer a suggestion
o
Stage 2: see it as unhelpful and lacking
evidence and contains a thinking error
§
Go through the unhelpful thinking sheet
§
Look for evidence for and against. Are there any
thinking errors in this evidence
o
Stage 3: generate an alternative
·
When you set goals with clients, create sub
goals, and tasks to achieve your goals, then experiments to test any
assumptions that are getting in the way of achieving them
·
When looking at security operations, look at
active ones, e.g. safety behaviours and passive ones e.g. avoidance
Structure of first therapy session
1.
Set agenda
2.
Review IAPT forms
3.
Review presenting problem and agree client goals
4.
Outline cognitive model
o
Recent example of down turn in mood, get
thoughts. Ask if they see a connection
5.
Review clients expectations for therapy
6.
Psychoeducate about clients particular disorder
7.
Agree between session assignments
8.
Summarize session
9.
Obtain feedback
Chapter 5. Middle Stage of Therapy
Therapist goals for middle stage
1.
Collaborative therapeutic relationship
o
Look to enhance through feedback
2.
Cognitive model process
o
Shift from NATs to IBs and CBs
o
Psychoeducated
3.
Help client work on problems
o
Shift the responsibility for therapeutic work to
client
o
Encourage client to be their own therapist
o
Encourage homework
o
Prepare client for any set back
·
Use feedback to let the client know that he is
on track
·
Sometimes shifting NATs is all that is required
to get someone to recovery
·
Attitudes are evaluative, rules are demanding
and assumptions are conditional
·
IB’s can be presented as AT’s
·
When doing downward arrow, use “suppose that
were true, what would that mean about you”
·
When you do downward arrow, make sure it’s
related to the clients presenting problem, this keeps you focussed!!
·
You know when you’ve hit a CB as there’s a
change in affect, or you go around in circles
·
Look for common NAT themes from DTRs, then check
it out with the client, or get them to do it
·
You can also use partial completion If I don’t
work hard then…
·
You can loosen CBs longitudinally, i.e. you
learnt CB because X, if X had have been different would you still have CB, this
shows that the CB was learnt, but isn’t objectively true.
·
Again loosen a CB with congruence, i.e. when
depressed you believe CB when you’re not depressed you believe CB less
·
CBs act as mental filters, so you only recognise
the things that support the CB
·
CBs are general ways to understand the world and
are useful as they enable us to deal with large amounts of information. However
when depressed, or anxious they can cause problems as they filter out
information which would challenge them.
·
Check understanding by asking them to explain
the idea to you then you your partner
·
Again with NATs only work with those that are
germane to the presenting issue
·
When restructuring IBs and CBS clients will need
a replacement to believe in for those times that they use these IBs and CBs.
Generally they already have these they just need to be activated, sometimes
they need to be generated afresh, or rather constructed out of the components
the client already have.
·
IBs always produce a conditional assumption
prior to working with it
·
What would happen if you had a belief, e.g.
oranges are the best fruit, but then you only ate bananas for a year, you would
change you belief, would this in turn reinforce your change of behaviour. This
is acting as if, acting as if the new rule is true
·
Countering: if a client argues against an
irrational thought repeatedly it becomes weaker. So do it in role play, get a
list of support for and against the thought. First therapist is challenger,
then the client is
·
When doing behavioural experiments record NATs,
if you have an experiment that doesn’t work, check NATs
·
You can investigate beliefs by client looking at
people who don’t hold it and people who do to their detriment
The cognitive process
·
Psychoeducate the person to see that human
beings are far too complex for global labels like I’m stupid. It is more
functional to accept yourself good bits and bad bits. You can show this with
Big I and little eye. Draw a big I on the board, the totality of you, then draw
get a list of all the things people say about the client, and attributes client
may say about themselves. So within the big eye there are good things and bad
things, so when you say I’m a total failure, how does one little I define the
Big I.
·
Metaphors can help does any one thing define a
room, if you have one rotten piece of fruit in a fruit bowl would you throw all
the fruit away, would you scrap a car as one tyre is flat
Help the client to work on problems in and out of therapy
·
Pass responsibility for therapeutic work to
client
o
Write important points in notebook
o
Create agenda items
o
Client sets homework
o
Ask client what the main points for him are
during a section
·
Encourage client to be his own therapist
o
Encourage client to take action when problems
occur rather than engage in either negative thinking or avoidance
·
Encourage client to continue with between
session tasks
·
Prepare client for setbacks
o
If things are going well, ask client what the
outcome would be if you had a thought I must always make progress in therapy,
and you had a setback. How would this compare to someone who thought sometimes
I will make progress and sometimes I might have setbacks, but I know I making
progress overall
Chapter 6. End Stage of Therapy
·
Ensure clients have mastered a particular skill
or concept before moving on. Makes me think of a client triangle, with
thoughts=>emotions at bottom, challenging NATs above it, avoidance above
that.
Therapist goals for end of therapy
1.
Collaborative therapeutic relationship
o
Prepare client for ending, i.e. continuing the
work
o
Consider dependency issues, i.e. we did this
2.
Cognitive Model process
o
Client summarises what they have learnt
o
Therapist acknowledges client effort
o
Explore obstacles to ending
3.
Help client to work on own problems
o
Client becomes own therapist
o
Lapse and relapse reduction, develop action plan
Collaborative Therapeutic Relationship
1.
Prepare client for ending of therapy
2.
Consider dependency issues
o
Ask client how they will find continuing the
work, new skills etc. after therapy. They may feel they need emotional support
from therapist or that they might not be able to apply these skills after they
have finished. In which case explore, understand these beliefs, and work out
how the client can continue to do this work.
Cognitive Model Process
1.
Client summarizes what has been learnt and
understands tools and techniques
a.
When you introduce a new concept get more
feedback that the client understands until as such time as you are confident in
their use of the idea
b.
Again new concepts, encourage client to write
this down. Is this a new idea to you, is
it useful, how best do you think you can remember it
2.
Therapist attributes values to clients efforts
a.
Positive reinforcement important for client
gains, make sure its level is appropriate for the client
3.
Decide when to end therapy in line with the
conceptualisation
a.
Therapy ending is related to the clients goals,
be aware of goals shifting to extend therapy
4.
Explore obstacles to ending
a.
Look out for emotions related to the ending and
explore NATs underpinning them.
Help client to work on problems in and out of therapy
1.
Client to be own therapist
o
All through therapy, focus on empowering the
client, and the client learning new skills
2.
Lapse\relapse reduction
o
Create an action plan for potential problems
o
Get the client to imagine having a future
problem and then get them to think through how they can deal with it. Useful to
get the client relaxed by using a relaxation technique prior to doing this
Chapter 7. Additional Strategies and Techniques
Cognitive Imagery Techniques
Anti-future shock imagery
·
Get client to imagine themselves coping with a
future feared event. Do this after you have generated a list of possibilities.
Use relaxation before starting this.
Aversive therapy
·
Associate an unpleasant image with a trigger
that generates an unpleasant response. E.g. wanting a cigarette, imagine a
shylock who is trying to get you trapped in a lifetime of debt
·
Or imagine a cigarette filling your body with
poison.
·
Habituation will weaken the image, so don’t use
it for more than 5 minutes at a time and change it monthly
Coping Cards
·
When NAT is restructured, produce a coping card
with the NAT and a collapsed version of its restructuring
Coping Imagery
·
First work out what the desired behaviour in the
situation is, then imaginally get them to see themselves coping
Cost benefit analysis of beliefs
What are the benefits of keeping the belief, what are the
benefits of not keeping the belief?
Decatastrophising continuum
So if you weren’t so worried about what you present, would
it make it easier? Yes, then do a continuum: So use a scale of badness, then
rate the presented situation, rate other bad things happening.
Deserted Island technique
Used to psychoeducate about the relationship between
thoughts and feelings.
So you’re on a desert island, alone but all you have all
your needs taken care of. Suppose you have a belief that I’d prefer to have
company but if I don’t its ok, how would you feel. Suppose you had a belief,
that I must have company how would you feel. If a plane dropped a person onto
the island and you thought I must have company how would you feel as you saw
him come onto the island. How would you feel in a couple of weeks, the anxiety
would come back as he could leave? This
is useful to demonstrate how rigid rules and beliefs lead to emotional
problems, and a more flexible belief or rule, will make life easier. TICs are task interfering cognitions and tocs
are task orientated cognitions.
Letter writing
If a client has difficulty with expressing how they feel
about someone get them to write a letter to them but don’t send it. Discuss what they have learnt and any
unhelpful beliefs.
Motivation imagery
Get client to imagine their future when they avoid their
problem, then get them to imagine their future as they deal with their problem. Do this partly cognitively, partly
imaginally, what would happen if you didn’t deal with your problems, imagine
that.. Do the inaction first, get a client summary, then do the action image,
and then get a summary. You only want to
do this when the client isn’t severely depressed or suicidal, as it might
exacerbate the problem
Rational-emotive imagery
Client imagines their distressing situation, then repeatedly
repeats their agreed coping statement.
Practice the technique in session and monitor emotion before and after
to ensure that it’s working before getting them to do it in vivo.
Step up technique
Useful when client fears a future event, but the underlying
beliefs are not clear. Get them to imagine the worst possible outcome of the
feared event, this may help elicit the prime fear, then work out how to deal
with the problem.
Time projection imagery
If the client is depressed due to something that has just
happened, then ask them to imagine what they will be doing in 6 months’ time, a
year, 5 years.
Thought stopping
Get the client to have the thought and shout stop, get them
to reduce the sound and then to shout it to themselves. This can be used in the early stages of
therapy. Habituation can occur to this though
Verbal Economy
Use the minimum amount of words to explain a concept, we are
time limited!!
Behavioural Interventions
Contracting
Make a contract with a significant other or to yourself to
change a behaviour. The target behaviour should not be complex and should be
agreed by both parties.
Cost benefit analysis of behaviours or habits
Do a CBA of the problem behaviour and the target behaviour.
Cue exposure
Get the client to rate the strength of their craving over
time, get them to see it subsides, then get them to craving surf. Alternatively look for ways the client can
cope with that, cognitive distraction aversive image, or relaxation techniques.
Habit control
When the client notices they have an urge to do their habit
to something contrary, so if you want to pull then push. Or it could just be
clench your fists.
Modelling
Therapist models desired behaviour to the client.
Response cost or penalty and reward
So agree a payment to your least favourite political
party\football team. Alternatively look
for rewards, but we know natural reinforcement is best
Response prevention
For OCD behavioural interventions are essential. Expose client to the cue, get them to grade
the strength of the urge over time and again see how the urge subsides. Alternatively ask the client to prolong the
time between urge and response and the frequency of the rituals and gradually
extend this.
Self-monitoring and recording
Really useful distances the client from their behaviour so
they can reflect on it more
Stimulus Control
Change environment so there aren’t any cues to the
problematic behaviour
Relaxation techniques
Multimodal relaxation method
Muscle contraction could raise blood pressure, deep
breathing can induce panic. So maybe avoid those. Get client to choose a relaxing image. Some client find that saying one or relax on
the outbreath does the trick.
1.
Close your eyes
2.
pause
3.
Listen to noises outside the room
4.
Long pause
5.
Listen to any noises inside the room
6.
Pause
7.
Let these noise go
8.
Pause
9.
Keep your eyelids close don’t move your head
look upwards
10.
Notice the feeling of tiredness
11.
And relaxation
12.
In your eye muscles
13.
Not let your eyes drop back down
14.
Now relax every part of your body
15.
Every time you breathe out you feel more relaxed
16.
As you breathe out say relax
17.
Now concentrate on your favourite place
18.
See it in great detail, with all the senses
19.
Now every time you breathe out, you feel more
relaxed.
Progressive relaxation
This is the muscle relaxation.
Chapter 8. Hypnosis as an Adjunct to Cognitive Behavioural Therapy
Will read this later when I have a CBT approach.
Chapter 9. Treatment Protocols.
Panic Disorder
·
Main approach is to challenge the
misinterpretation of bodily sensations
·
Safety behaviours are significant in keeping the
misinterpretation believable
·
Fear of fear also signification
·
Expose to panic, challenge interpretation,
establish impact of safety behaviours and then drop. Psychoeducation on the
panic curve useful
Social Phobia
·
Main approach is to challenge the belief that
poor social performance would have a catastrophic result
·
Key aspects processing self as an object, safety
behaviours, pre and post processing.
GAD
This can either be intolerance of uncertainty or type 2
worry problems.
Depression
Here you can either go Beck=restructure NATS\IBs\CBs or
Martell BA
OCD
·
Establish triggers, then do an ABC on it to get
thoughts and compulsions
·
You must do theory A\theory B and have this is a
problem about worry or a direct problem
·
Prioritize the obsessions and compulsions
·
You can also do habituation of the compulsive
thought by writing it down
PTSD
·
Elicit coping strategies, which are commonly
emotional\cognitive avoidance
·
Do
Big I little I, to see that the person is more than just a trauma victim
·
Reliving
·
Beliefs pre and post trauma useful, as the pre
gives you an immediate restructure from the post, and gives you a way to
challenge the trauma memory
·
Rebuild life
·
Think through what an emotion means rather than
being reactive
Specific Phobia
·
Once you’ve formulated you expose. That’s it,
graded, each step is challenging but not overwhelming.
Summary
Assessing Client
1.
Introduce Forms
2.
Request Audio
3.
Introduce CBT as a problem focussed approach and
look to develop new approaches to improve a problem. The theory underpinning
this is that thoughts\emotions\behaviours all relate to each other. This
requires homework and a notebook.
4.
Introduce CBT as working together
5.
Introduce CBT structure, number of sessions and
agenda
6.
Assess for Risk
7.
Formulate current incident into 5 aspect (Ensure
psychoeducation of relation of SETB)
8.
Establish the impact the problem is having on
their lives
9.
Set a SMART Goal Tasks, and subtasks and how we
monitor it. Make sure the goal is positive, i.e. not stop worrying, but what
you would like to do instead
10.
Establish client strengths and assets they have
or have had over their lives to deal with this (Motivation)
11.
Homework: Depends if this is going to be more
cognitive or more behavioural work
o
Psychoeducation on Problem
o
Monitor problem (Need sheet per problem)
o
ABC analysis (relating thoughts and emotions)
o
Client does a task related to their goal and use
this for the ABC
o
Client to bring in agenda item related to our
goal
Standard Session
1.
Review Forms
2.
Review goal
3.
Brief summary of what you found important from
last week’s session
4.
Set agenda
5.
Set homework
Session 2
Develop Conceptualisation
Homework Cognitive=Challenge NATS, Behavioural=Schedule
activity in
To choose the predominant approach, behavioural or
cognitive, then look to see if its cognitions\behaviours that are driving the
problem.
Psychoeducuation requirements
1.
Its not events that cause emotions but how we
interpret them
2.
How we think affects how we feel
3.
How we behave affects how we feel
4.
How we feel affects how we think (emotional
congruence)
Client Forms
Thinking Errors List
1. ALL-OR-NOTHING THINKING – Also
called Black and White Thinking – Thinking of things in absolute terms, like
“always”, “every” or “never”. For example, if your performance falls short of
perfect, you see yourself as a total failure. Few aspects of human behaviour
are so absolute. Nothing is 100%. No one is all bad, or all good, we all have
grades. To beat this cognitive distortion:
o Ask
yourself, “Has there ever been a time when it was NOT that way?” (all or
nothing thinking does not allow exceptions so if even one exception can be
found, it’s no longer “all” or “nothing”)
o Ask
yourself, “Never?” or “Always?” (depending upon what you are thinking)
2. PERSONALIZATION & BLAME – This
distortion is known as “the mother of guilt.” Personalization occurs when you
hold yourself personally responsible for an event that isn’t entirely under
your control. For example, “My son is doing poorly in school. I must be a bad
mother…” and “What’s that say about you as a person?” – Instead of trying to
pinpoint the cause of the problem so that she could be helpful to her child.
When another woman’s husband beat her, she told herself, “lf only I were better
in bed, he wouldn’t beat me.” Personalization leads to guilt, shame, and
feelings of inadequacy. On the flip side of personalization is blame. Some
people blame other people or their circumstances for their problems, and they
overlook ways that they might be contributing to the problem: “The reason my
marriage is so lousy is because my spouse is totally unreasonable.” – Instead
of investigating their own behaviour and beliefs that can be changed. To beat
this cognitive distortion:
o Ask, “How
do you know [I am to blame]?” “SAYS WHO?”
o Ask,
“Who/what else is involved in this problem?”
o Ask
yourself, “Realistically, how much of this problem is actually my
responsibility?”
o Ask, “If
there was no blame involved here, what would be left for me/us to look at?”
3. OVERGENERALIZATION – Taking isolated cases and
using them to make wide generalizations. For example, you see a single negative
event as a never-ending pattern of defeat: “She yelled at me. She’s always
yelling at me. She must not like me.” To beat this cognitive distortion:
o Catch
yourself overgeneralizing
o Say to
yourself, “Just because one event happened, does not necessarily mean I am (or
you are or he/she is…[some way of being])”
4. MENTAL FILTER – Focusing exclusively on certain,
usually negative or upsetting, aspects of something while ignoring the rest.
For example, you selectively hear the one tiny negative thing surrounded by all
the HUGE POSITIVE STUFF. Often this includes being associated in negative (“I
am so stupid!”), and dissociated in positive (“You have to be pretty smart to
do my job”). To beat this cognitive distortion:
o Learn to
look for the silver lining in every cloud
o Count up
your negatives vs. your positives – for every negative event, stack up a
positive against it. Make a list of both negative and positive character
attributes and behaviours.
5. DISQUALIFYING THE POSITIVE –
Continually “discounting” positive experiences for arbitrary, ad hoc reasons.
In this way you can maintain a negative belief that is contradicted by your
everyday experiences. The good stuff doesn’t count because the rest of your
life is a mess. “That doesn’t count because my life is a mess!” To beat this
cognitive distortion:
o Ask
yourself, “So what does count then?” “In what way?”
o Accept
compliments with a simple, “Thank you.”
o Make lists
of personal strengths and accomplishments
6. JUMPING TO CONCLUSIONS – Assuming
something negative where there is actually no evidence to support it. Two
specific subtypes are also identified:
o Mind
reading – assuming the intentions of others. You arbitrarily conclude that
someone is reacting negatively to you, and you don’t bother to check it out. To
beat this one, you need to let go of your need for approval – you can’t please
everyone all the time. Ask yourself, “How do you know that…?” Check out
“supporting” facts with an open mind.
o Fortune
telling – anticipating that things will turn out badly, you feel convinced that
your prediction is an already established fact. To beat this, ask, “How do you
know it will turn out in that way?” Again, check out the facts. To beat this
cognitive distortion:
1. When the
conclusion is based on a prior cause (for example, the last time your spouse
behaved in this manner s/he said it was because s/he felt angry so s/he must be
angry this time, too), ask yourself, “What evidence do you have to support your
notion that s/he feels…” “How did you arrive at that understanding” “What other
conclusion might this evidence support?”
2. When the
conclusion is based on a future consequence (“I’ll die for sure if she keeps going
on about this…”) Ask yourself, “How does this conclusion serve you?” and “If
you continue to think that way… [what will happen to you]?” and “Imagine 5
years from now…”.
7. MAGNIFICATION & MINIMIZATION –
Exaggerating negatives and understating positives. Often the positive
characteristics of other people are exaggerated and negatives understated.
There is one subtype of magnification/catastrophizing – focusing on the worst
possible outcome, however unlikely, or thinking that a situation is unbearable
or impossible when it is really just uncomfortable: “I can’t stand this.” To
beat this cognitive distortion:
o Ask
yourself, “What would happen if you did [stand this]?”
o Ask
yourself, “How specifically is [this/that/he/she] so good/too much/too
many/etc. or so bad/not good enough/too little/etc.?” Then ask yourself,
“Compared to what/whom?”
8. EMOTIONAL REASONING – Making decisions and arguments based on how you feel
rather than objective reality. People who allow themselves to get caught up in
emotional reasoning can become completely blinded to the difference between
feelings and facts. To beat this cognitive distortion:
9. SHOULDING – Must, Can’t thinking. Shoulding
is focusing on what you can’t control. For example, you try to persuade another
of your views. Concentrating on what you think “should” or ought to be rather
than the actual situation you are faced with will simply stress you out. What
you choose to do, and then do, will (to some degree, at least) change the
world. What you “should” do will just make you miserable. To beat this
cognitive distortion
o Ask, “What
would it feel like, look like, sound like if you could/did or could not/did
not?” or, “What would happen if you did/didn’t?” or, “What prevents you from
just doing it then?” or, “What rule or law says you/I SHOULD?” or, “Why should
I?” or, “Could you just prefer instead?” or, “Why SHOULD I/YOU?”
10. LABELLING and MISLABELING – Related
to overgeneralization, explaining by naming. Rather than describing the
specific behaviour, you assign a label to someone or yourself that puts them in
absolute and unalterable negative terms. This is a logic level error in that we
make a logic leap from behaviour/action (“he called me a name…”) to identity
(“therefore, he’s an idiot”). To beat this cognitive distortion:
o Ask
yourself, “What could be a better way of looking at this that would truly
empower you/me?” or, “Is there another possible more positive meaning for
this?”
o When you
recognize you are labelling or are being labelled, ask, “How specifically?” Example:
“How specifically am I an idiot?” – Which will evoke behaviours rather than
identity.
o Remember
who you/others are in spite of behaviours: “Even though I failed the test, I’m
still a worthy person.”
Thought Form
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Cognitive Conceptualisation Chart
Personal Development
|
Cognitive Development
|
Early Experience
|
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Critical Incident
|
Intermediate and core beliefs
activated
|
Maintaining factors
|
Negative Automatic Thoughts
|
Emotions:
|
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Behaviour:
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Physiology:
|
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Goals\Sub goals\Task\Experiment Form
Goal
|
Sub Goal
|
Task
|
How do we monitor Success?
|
Impact of achieving Goal
(What
would you be doing, feeling, thinking?)
|
Problem solving sheet
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Possible set back form
Possible setbacks
|
My unhelpful response
|
What I can do-helpful response
|
Within first month
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Within three months
|
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Within six months
|
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Within one year
|
Questions to help question unhelpful thinking
·
Is it logical?
·
Would a scientist agree with my logic?
·
Where is the evidence for my belief?
·
Where is the belief written (apart from in my
own head)
·
Is my belief realistic?
·
Would my friends and colleagues agree with my
idea?
·
Does everybody share my attitude? If not, why
not?
·
Am I expecting myself or others to be perfect as
opposed to fallible human beings?
·
What makes the situation so terrible, awful or
horrible?
·
Am I making a mountain out of a molehill?
·
Will it
seem this bad in one, three, six or twelve months’ time?
·
Will it be important for me in two years’ time?
·
Am I exaggerating the importance of this
problem?
·
Am I fortune telling with little evidence that
the worst case scenario will actually happen?
·
If I can’t stand it or can’t bear it, what will
really happen?
·
If I can’t stand it will I really fall apart?
·
Am I concentrating on my own (or others)
weaknesses and neglecting strengths?
·
Am I agonizing about how I think things should
be instead of dealing with them as they are?
·
Where is this thought or attitude getting me?
·
Is my belief helping me to attain my goals?
·
Is my belief goal focussed and problem solving?
·
If a friend made a similar mistake, would I be
so critical?
·
Am I thinking in all-or-nothing terms: is there
any middle ground?
·
Am I labelling myself, somebody or something
else? Is this logical and a fair thing to do?
·
Just because a problem has occurred does it mean
that I\they\it are stupid, a failure, useless or hopeless?
·
Am I placing rules on myself for others (should,
musts etc.)If so are they proving helpful and constructive?
·
Am I taking things too personally?
·
Am I blaming others unfairly just to make myself
(temporarily) feel better?
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