© 2019 Beck Institute for Cognitive Behavior Therapy Permission Required for Reproduction of These Materials 1 Dr

Essentials of Cognitive Behavior Therapy

MICHAEL A. TOMPKINS, PHD, ABPP

Speakers Faculty, Beck Institute for Cognitive Behavior Therapy San Francisco Bay Area Center for Cognitive Therapy and University of California at Berkeley March 25, 2019

Financial Disclosures Honorarium: Advisory Board Member, Magination Press.

Royalties: American Psychological Association, Guilford Press, Magination Press, New Harbinger Publications, Springer Publications.

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Acknowledgements • Judith Beck, PhD

• Torrey Creed, PhD

• Robert Hindman, PhD

• Beck Institute for Cognitive Behavior Therapy

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 1 Dr. Aaron T. Beck developed CBT at the University of Pennsylvania in the 1960s. In 1994, Dr. Beck and his daughter, Dr. Judith Beck, established Beck Institute.

Beck Institute is a leading international source for training, therapy, and resources in Cognitive Behavior Therapy (CBT).

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About Beck Institute Our mission is to encourage the growth and dissemination of CBT throughout the world through leadership in the field and through the provision of professional training, outpatient clinical services and research.

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The Cognitive Behavioral Model

“It’s not the situations in our lives that cause distress, but rather our interpretations of those situations.” ~Aaron T. Beck

beckinstitute.org

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Agenda

• Overview of cognitive-behavior therapy • Cognitive model and case conceptualization • Cognitive model for depression and anxiety • Cognitive interventions • Behavioral interventions • Emotion exposure

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OVERVIEW OF COGNITIVE BEHAVIOR THERAPY

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• Semi-structured (but flexible and creative), efficient, active, guided by case conceptualization and a hypothesis- testing approach.

• Collaborative, respectful, and founded on a strong therapeutic alliance.

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General Principles of CBT

• Focused on developing skills and self- efficacy (client’s belief that he or she can apply skills learned in therapy in order to manage life problems effectively). • Interventions focused on cognitive change (flexibility), in the service of flexible behavioral and emotional change.

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Essential Components of CBT • Cognitive-behavioral conceptualization • Problem-solving orientation • Structured session • Action plans (out-of-session homework) • Evaluation of thoughts and core beliefs • Behavioral change • Relapse prevention

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Outcome Studies • Major Depressive Disorder • Bipolar Disorder (with meds) • Schizophrenia (with meds) • Generalized Anxiety Disorder • Panic Disorder • Social Phobia • Post-Traumatic Stress Disorder • Obsessive Compulsive Disorder • Hypochondriasis • Substance Misuse

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Outcome Studies for Disorders • Bulimia and Anorexia • Personality Disorders • Irritable Bowel Syndrome • Chronic Pain • Chronic Fatigue Syndrome • Migraine Headaches • HIV Depression • Colitis • Sexual Dysfunction • Fibromyalgia • Obesity

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ATTITUDE OF THERAPIST

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Model of Therapeutic Alliance

Bordin, E. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16, 252-260.

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 6 Attitude and Stance of Cognitive-Behavior Therapist • Compassionate • Curious • Collaborative • Pragmatic • Active • Firm but flexible

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Guided Discovery • Listen • Ask informational questions • Use summaries • Ask synthesizing and reflective questions

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Examples: Socratic Questions

• What is the evidence that your thought is true? What is the evidence that your thought is not true? • What’s an alternative explanation or viewpoint? • What’s the worst thing that could happen? How could you cope with that? What’s the best that could happen? What’s the most likely outcome?

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 7 Examples: Socratic Questions • What is the effect of telling yourself [this thought]? What could be the effect of changing your thinking? • What would you tell [a specific friend/family member] if he/she viewed this situation in this way? • What could you do now? • “Is this true for everyone in your situation?” • “Have you looked at this same situation in a different way in the past? Did that help?”

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STRUCTURED SESSION

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Rationale: Structured Session

• Assists therapist in using therapy time efficiently in order to carry out interventions and to accomplish treatment goals. • Models the types of skills and behaviors that are taught in cognitive-behavior therapy (i.e., goal-oriented, active, focused on solving concrete specific problems).

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Phases: CBT Therapy Session

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Start of Session • Greeting and check-in: mood; “What happened between last session and now that is important that I know? What successes did you have or when did you feel even a little better?” • Bridge: Summarize for client focus of last meeting, what was learned and practiced, link that work to client’s treatment goals, action plan that came out of session.

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 9 Check-in • Review measures, such as the Beck Depression Inventory (BDI) or Beck Anxiety Inventory (BAI). • And/or ask client to rate mood on a 0-10 scale focused on a specific emotion (anxiety, depression, anger). • And/or ask client to rate degree of the problem on a 0-10 scale (procrastination 5/10; relationship difficulty 3/10).

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Guidelines: Check-In • Strive for brevity (2-5 minutes). • Distinguish check-in from body of therapy session. • Look for opportunities to make a check-in item an agenda item. • Use to debrief from last session, particularly if session was difficult. • Use to bridge from last session.

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Empirically-Driven Approach

Assessment Case Formulation Treatment (data collection) (hypothesis) Plan

Copyrighted Measures: • Beck Depression Inventory II (BDI-II) • Beck Anxiety Inventory (BAI) Public Domain Measures: • Patient Health Questionnaire (PHQ-9) Depression • General Anxiety Disorder (GAD-7) Anxiety • Depression Anxiety and Stress Scale (DASS)

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Treatment Progress: Jack

45 Y-BOCS Beck Depression Inventory 40

25 Outcome 20

Week of

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Treatment Progress: Gail

50 45 40 35 30 25 BDI BAI 20 15 10 5 0 1 4 7 10 13 16 19 22 25 28 SSS SPA

Session Number

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15 Y-BOCS

Week of

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Rationale: Bridge

• Connects current session with previous session. • Gives continuity and momentum to the treatment. • Reinforces learning and emphasizes important points during the previous session. • Identifies problems from the prior sessions and feedback about session in general.

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Guidelines: Bridge • What do you remember about last session? • Did anything stand out for you about last time? • What did you take away from our last session? • Was there anything you didn’t understand or that bothered you?

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• Set agenda –“What problems do you want to work on today?” “Would you tell me the NAMES of the problems you would like to work on today?” • Update – Action plan review – “How did the action plan go? Shall we take a look now at what you learned?”

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Agenda • Agenda is a short list of topics that client and therapist agree will be focus of therapy session. • Agenda is linked to treatment goals and provides a roadmap for session. • Agenda focuses on session and therapy anchors (new and old situations or problems, thoughts or emotions); or any point or matter about the therapy itself (e.g., changes in meeting time, reports from the client about a meeting with an adjunct therapist).

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Guidelines: Set Agenda • Set agenda collaboratively but keep eye on treatment goals; then prioritize. • If client has trouble identifying agenda item, review goals. • Set clear and specific agenda items – if client is vague, ask for concrete ways to work toward goals. • Be realistic: 1-2 things that would help client feel better and give a sense of progress.

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• Prioritize problems • Complete a thought record for a problem • Decide strategies to use • Use summaries to highlight important information or ask client to summarize • Ask client to repeat rationale for intervention • Ask client for ideas for action plans • Develop action plan

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End of Session • Summarize main points of session • Review action plan • Elicit feedback about what was learned • Elicit feedback about session itself • Elicit feedback about therapist

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ACTION PLANS

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 14 Guidelines: Action Plans • Be collaborative and provide clear rationale. • Be specific and concrete. • Tie to work in session: “Based on what we’ve worked on today, what would you like to try out this week?” • Start action plan assignment in session. • Rate confidence and adjust task. • Anticipate obstacles and develop plan to solve.

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Motivation: Action Plans • Better to have a small doable assignment than one that client does not complete; break tasks down, and lower barriers to adherence. • Set up as a “no lose” lesson – “Whether you complete it or not or whether it’s successful or not, we’ll learn something important that will help you.” • Rehearse in imagination (covert rehearsal), and adjust if necessary. • Include prompts to remind client to initiate action plan.

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COGNITIVE MODEL

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Automatic Thoughts • Generally arise spontaneously, brief and fleeting; co-exist with manifest stream of thoughts, often unnoticed. • Associated with specific emotions that depend on their content and meaning.

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Intermediate Beliefs

• Often the most difficult category of belief to identify correctly. • Attitudes, rules, assumptions that stem from core beliefs and fuel automatic thoughts. • Often, in the form of if-then statements.

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 16 Core Beliefs • Most central, fundamental beliefs about ourselves, others, and the world. • Three typical categories of self core beliefs: incompetent, unlovable, worthless. • Absolute and rigid, usually 1-2 words – “I’m worthless,” “I’m fragile.” • May result in biases in attention, information processing, and memory. • When activated, core beliefs are the lenses through which we interpret situations.

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COGNITIVE CASE CONCEPTUALIZATION

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Definition: Conceptualization

• A theory that explains or accounts for a particular client’s symptoms and problems, here and now. • Considers life experiences that lead client to think and behave in certain ways in certain situations. • Includes client’s strengths and weakness and focuses on relevant treatment goals.

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 17 Rationale: Conceptualization • Assists therapist in treatment process, including problems in the treatment itself. • Identifies relevant session anchors that focus the session and the treatment. • Enhances collaboration, understanding, and willingness. • Focuses therapist and client on relevant topics for a session and for action plans.

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Core Beliefs Influence Thoughts

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Maladaptive Coping Strategies

Actions (behaviors) or thought actions that either support or oppose beliefs:

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 18 Development: Beliefs and Compensatory Strategies • Core beliefs and behavioral patterns often develop in childhood; can be transmitted from the family and in response to repeated social and environmental events. • Family members communicate maladaptive thoughts and beliefs to client (e.g., “You’re a mess.”) and model maladaptive compensatory strategies (e.g., verbal or physical aggression when frustrated).

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Transmission: Maladaptive Beliefs Through Generations

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Case Conceptualization Diagram

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Guidelines: Problem List • Strive to be exhaustive, mutually agreed upon. • Include client’s chief complaint, use client’s words for problems. • Describe problem in 1-2 words (e.g., relationship difficulties), quantify (BDI = 33). • State problems in concrete, behavioral terms. • Describe mood, behavioral, and cognitive components of each problem.

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Problem Domains • Psychological symptoms, problems, disorders • Medical symptoms, problems, disorders • Interpersonal difficulties • Work difficulties • Financial difficulties • Housing difficulties • Legal difficulties • Leisure difficulties

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• Attend to automatic thoughts, particularly those that occur repeatedly. • Attend to automatic thoughts that occur across a variety of situations. • Use downward arrow technique.

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Exercise: Case Conceptualization

• Break into triads. Develop a case conceptualization for a favorite character from literature (e.g., Harry Potter, Hermione Granger, Orphan Annie, Peter Pan, Charlie in Charlie and the Chocolate Factory) or, from a favorite movie or television show (“Orange is the New Black,” “Breaking Bad”). • Complete CCD for character. Include two typical situations (trigger, AT, meaning of AT, emotion, behavior).

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COGNITIVE MODEL OF DEPRESSION

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Paralysis Negative of Will Self View Depressed Mood

Increased Negative Dependency View of Future Suicidal Wishes

Negative View of Avoidance Wishes World

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Cognitive Model of Depression

EARLY EXPERIENCE Abusive, neglectful, angry mother and absent father Critical older siblings Child must fend for herself ↓

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Cognitive Model of Depression FORMATION OF BELIEFS I’m incompetent. ↓ FORMATION OF DYSFUNCTIONAL ASSUMPTIONS If I make a mistake, it will show how incompetent I am. If I do everything perfectly, I’ll be okay.

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 22 Cognitive Model of Depression CRITICAL INCIDENTS Good (not excellent) rating by supervisor Critical coworker Physical Illness persists

NEGATIVE AUTOMATIC THOUGHTS (COGNITIVE TRIAD) I can’t do anything right. I will probably get fired. I’ll never get better.

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Cognitive Model of Depression SYMPTOMS OF DEPRESSION

BEHAVIORAL AFFECTIVE MOTIVATIONAL Lower activity levels Sadness Lower activity levels Withdrawn from Guilt Withdrawn from positive activities Shame positive activities Impaired coping Anxiety Impaired coping with practical Anger with practical problems problems COGNITIVE PHYSICAL Indecisiveness Sleep disturbance Poor concentration Loss of appetite and memory Loss of sexual Rumination desire

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Cognitive Triad of Depression

Paralysis Negative of Will Self View Depressed Mood

Increased Negative Dependency View of Future Suicidal Wishes

Negative View of Avoidance World Wishes

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• I am inadequate, ineffective, incompetent, can’t cope. • I am powerless, out of control, trapped, vulnerable, weak, needy, likely to be hurt. • I am inferior, a failure, a loser, not good enough, defective, don’t measure up.

2011, Beck, J.S. Cognitive Behavior Therapy: Basics and Beyond (2nd ed.)

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Unlovable Core Beliefs • I am unlikable, unwanted, will be rejected or abandoned, always be alone. • I am undesirable, unattractive, ugly, boring, unimportant, have nothing to offer. • I am different, defective, not good enough to be loved by others, a nerd.

2011, Beck, J.S. Cognitive Behavior Therapy: Basics and Beyond (2nd ed.)

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Worthless Core Beliefs

• I am worthless, unacceptable, bad, crazy, broken, defective, a nothing, a waste. • I am hurtful, dangerous, toxic, evil. • I don’t deserve to live.

2011, Beck, J.S. Cognitive Behavior Therapy: Basics and Beyond (2nd ed.)

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Situation

Automatic Thoughts and Images

Reaction

Emotional Behavioral Physiological

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Thought Record to Formulate Case • Focus on specific situation when client was feeling down or depressed. • Connect situation to thoughts; thoughts to emotion; emotion to response with arrows on the thought record. • Complete thought records for several situations when client’s mood dipped. • Therapist completes thought record when client’s mood improved to demonstrate role of thoughts in lifting mood.

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COGNITIVE MODEL OF ANXIETY

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Appraisals: Risk and Resource

• Overestimating risk ► Believe probability of risk/threat is high ► Believe severity of threat is high

• Underestimating Resources to Cope ► Internal resources ► External resources

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Cognitive Model: Avoidance

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COGNITIVE RESTRUCTURING

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Steps in Cognitive Restructuring

1. Identify

2. Evaluate Problem Solving

3. Respond

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Identifying Automatic Thoughts When you notice or infer a reaction (change of affect, behavior, physiology), or when a patient has described such, ask: • “What was just going through your mind?” or • “What were you thinking just then?” or • “What is going through your mind right now?”

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Identifying Automatic Thoughts

Listen for automatic thoughts as the client talks about the problem: • Negativity • Extreme words: never, always, must • Patterns/themes • Self-criticism “How much do you believe the thought?” (0 – 100%) “What feeling is connected to that thought? How strong is the feeling?” (0 – 10).

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 28 When Client Cannot Identify Automatic Thoughts • Focus on client’s emotions and/or physiological response initially. • Facilitate re-experiencing of situation. ► Through imagery ► Through roleplay • Ask about images, “What picture or image went through your mind just then?”

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Thought Record to Identify Automatic Thoughts • Introduce client to thought record. • Ask questions to elicit data for each column (situation, thoughts, emotions, responses). • Focus thought record on a specific problem that is linked to client’s treatment goals. • Help client to distinguish between thoughts that precede mood induction and thought actions that follow mood induction.

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EVALUATING AUTOMATIC THOUGHTS

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 29 Guidelines: Evaluating Automatic Thoughts • Assist client in deciding whether a thought is accurate or helpful; use Socratic questions. • When automatic thought is accurate, shift client to problem solving or acceptance. • However, watch that client has not drawn an invalid conclusion regarding the automatic thought (e.g., I have a chronic illness and therefore my life is unbearable).

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Socratic Questions: Evaluate AT

• What makes me think the thought is true? • What makes me think the thought is not true or not completely true? ► What's another way to look at this? • What’s the worst that could happen? What could I do then? • What's the best that could happen? • What will probably happen?

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Socratic Questions: Evaluate AT

• What will happen if I keep telling myself the same thing? • What would I tell my friend ______if this happened to him or her? • What could I do now that might be more helpful? • What could happen if I change my thinking?

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 30 Identify Thinking Errors • All-or-nothing thinking • Overgeneralization • Jumping to conclusions • Emotional reasoning • Catastrophizing • Magnification or minimization • Personalization • Mental filter • Mindreading

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RESPONDING TO AUTOMATIC THOUGHTS

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Rationale: Thought Record

Thought record is a tool clients can use to arrive at an alternative view of a problematic situation that allows them to feel and function better. • Step 1 – Examine usefulness of client’s cognitions in a problematic situation (advantages vs. disadvantages). • Step 2 – Identify cognitive distortions. • Step 3 – Examine the evidence.

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 31 Guidelines: Thought Record to Respond • Use guided discovery as much as possible. • Select focus for thought record (problem emotion or problem behavior). • Focus on a concrete, specific situation. • Follow the affect. • Encourage client to use thought record. • Remember, you are teaching a skill.

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5-Column Thought Record

DATE/ SITUATION AUTOMATIC EMOTION(S) ALTERNATIVE RESPONSE OUTCOME TIME THOUGHT(S)

1. What actual event 1. What 1. What 1. (optional) What 1. How much do or stream of thought(s) emotion(s) cognitive distortion did you now believe thoughts, or and/or image(s) (sad, anxious, you make? (e.g., all-or- each automatic daydreams, or went through angry, etc.) did nothing thinking, mind- thought? recollection led to the your mind? you feel at the reading, catastrophizing.) unpleasant emotion? time? 2. What 2. How much 2. Use questions at emotion(s) do 2. What (if any) did you believe 2. How intense bottom to compose a you feel now? distressing physical (0-100) each (0-100) was the response to the automatic How intense (0- sensations did you one at the emotion? thought(s). 100) is the have? time? emotion? 3. How much do you believe each response? 3. What will you do (or did you do)?

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5-Column Thought Record

DATE/ SITUATION AUTOMATIC EMOTION(S) ALTERNATIVE RESPONSE OUTCOME TIME THOUGHT(S) I did forget to pay the phone Thinking about the How could I Sad (75) bill, but this is the first time. 1. AT = 50 phone bill I forgot to forget? Usually I am prompt. I forgot pay. because I’ve been working 2. Sad = 50 late, not because I’m bad. Good people do make I’m so terrible. mistakes. The worst that’ll happen is I’ll keep forgetting to pay my bills. The best is I’ll never forget again. The most realistic outcome is I’ll occasionally forget. I should stop blaming myself and accept that it’s human to make mistakes. If I realize it’s really pretty minor, I’ll feel better. I’d tell Joanne it’s ridiculous to consider herself terrible for one mistake. 80%

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 32 Questions: Generate Rational Responses • What makes me think the thought is true? What makes me think the thought is not true or not completely true? • What would I tell my friend if this happened to him or her? • What could I do now? • What's the best that could happen? What will probably happen?

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Questions: Generate Rational Responses • What's another way to look at this? • What’s the worst that could happen? What could I do then? • What will happen if I keep telling myself the same thing? • What could happen if I change my thinking?

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Highlight: Cognitive Change

• “Now how much do you believe the thought? The adaptive response?” • “What’s your mood now? How strong is the sadness 0-100?” • Even if the client feels only 10% better, the intervention highlights both the value of the strategy and the influence of cognition on mood change.

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Exercise: Evaluate AT

Assist client in evaluating one of the following automatic thoughts: • “I’m a bad mother.” • “I can’t do anything right.” • “What’s the point of trying, I’ll just screw things up again.” Use Testing Your Thoughts Worksheet. Explore first whether thought is accurate or helpful. Ask about images.

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Rationale: Cognitive Rehearsal • Use to rehearse client’s application of rational responses. • Use to anticipate obstacles or barriers when scheduling activities, developing action plans, when planning application of any skill to a new or typical situation. • Use to increase confidence and thereby increase likelihood client will try and succeed.

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Guidelines: Identify Core Beliefs

• Follow the affect. • Identify (if possible) all three types of core beliefs and specific intermediate beliefs. • Use client’s specific language to express belief. • Identify beliefs (helpful and unhelpful, accurate and inaccurate) that client expresses in absolute terms (e.g., I am worthless).

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Downward Arrow Technique

• "If that's true, what's so bad about that...?" • "What's the worst part about...?" • "So what if...?" • "What does that mean about you?" • Vary questions to elicit meaning of automatic thought.

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Opening the Belief Aperture __

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Rationale: Belief Change Strategies • To restructure deep cognitive structures (beliefs) assumed to contribute to depressive symptoms • To weaken maladaptive beliefs • To develop and/or strengthen more adaptive beliefs

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 36 Modify Core Beliefs • Provide psychoeducation about core beliefs and process of change (i.e., It takes patience to correct a self-prejudice). • Collaboratively develop a new core belief. • Examine evidence of new core belief. • Continually reframe evidence that supports old core belief. • Continually identify evidence that supports new core belief. • Rehearse alternative core belief (i.e., Let’s try it on for size). Cognitive Behavior Therapy: Basics and Beyond (Beck, 2011)

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Definition: Positive Data Log (PDL) • Log of evidence in support of a client’s positive or balancing belief. • Teaches client to notice the multiple situations in which beliefs are activated. • Helps client strengthen the positive or balancing belief. • Helps the client notice and overcome biases in processing information that are driven by maladaptive core beliefs.

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Guidelines: Set Up PDL • Provide a rationale. • Identify the balancing core belief. • Start the positive data log in session. • Instruct client to enter evidence on the positive data log as soon as possible. • Instruct client to enter all evidence, no matter how small, and place a question mark next to evidence that client doubts is appropriate.

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 37 Probe Questions: PDL • “Why don’t you walk me through the day? Let’s see if we can find something that you missed.” • “Tell me about the interactions you’ve had with people this week? Let’s see if we can find something that you missed.” • “If people thought you were ……. (alternative belief) what might they notice about you? Did you do anything like that this week?”

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Probe Questions: PDL

• “If you really believed you were… (alternative belief) what might you be doing or saying? Did you say or do anything like that this week?”

• “Can you think of someone who has a lot of this quality we’ve called [alternative belief]? What do you do or say that makes you think they’re [alternative belief]? Did you do or say anything like that this week?”

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Guidelines: Review PDL

• Review the positive data log. • Reward small steps. • Watch for activation of maladaptive core belief when reviewing positive data log. • Watch for opportunities in session to add items to the positive data log.

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Common Behavioral Interventions

• Graded task assignment • Problem-solving training • Behavioral experiments • Assertiveness, communication, and social skills training

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Graded Task Assignment • Provide rationale for intervention. • Select specific task that client is interested in trying. • Avoid trap of helping client break down a task that the client thinks he or she should do rather than a task the client wants to do.

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 39 Problem Solving • Ability to problem solve influenced by developmental age. • Ability to problem solve influenced by affect. • Ability to problem solve influenced by cultural context.

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ITCH

• Identify the problem. • Think about possible solutions. • Choose a solution to implement. • How well did it work?

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Identify the Problem • Easier said than done and perhaps the most critical step. • Select one problem, prioritize multiple problems if necessary. • Define the problem in concrete, specific terms, e.g., “No one talks to me at lunch.”

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 40 Think of Possible Solutions • Brainstorm all possible solutions and be neutral, i.e. “That’s a solution,” versus “That’s a great solution.” • Encourage client to lead. • Ask permission to throw out an idea. • If client is stuck, model problem solving with a problem you encountered recently.

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Choose a Solution to Try • Evaluate pluses and minuses of each solution. • Select solution most likely to work and least likely to cause problems. • Set up as experiment. • Identify steps required to implement the selected solution. • Include in solution steps skills to make solution more likely to work and avoid problems.

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How Well Did It Work? • Evaluate how well solution worked, examine the pluses and minuses. • “Didn’t even come close” – repeat ITCH. • “Missed the mark but close” – modify based on what was learned and try again. • “Bulls eye” – continue the solution.

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 41 Problem or Problem of Perception • “Everyone hates me” – client is disliked because of inappropriate behaviors or client interprets benign neglect to mean people hate him. • “Job is boring” – client is bored because job is not challenging or client avoids more challenging tasks because he fears failing. • Use cognitive and behavioral interventions that target these thoughts and beliefs.

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Behavioral Experiments • To test validity of client’s existing beliefs about self, others, and world. • To construct and/or test new, more adaptive beliefs or alternative perspectives. • To contribute to the development and verification of the case conceptualization. • “So how can we test that out?”

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Experiential Learning Circle

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Types: Behavioral Experiments

• Active experiments – real or simulated (roleplays).

• Observational (discovery) experiments – direct observation, surveys, data gathering from sources other than people (e.g., internet).

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Guidelines: Behavioral Experiments

• Step 1: Present the rationale. • Step 2: Develop a prediction. • Step 3: Set up the detailed experiment. • Step 4: Record the outcome. • Step 5: Review the outcome in session and summarize.

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Rationale: Emotion Exposure • Key to treating emotional disorders. • Targets behavioral (avoidance) and cognitive (misappraisals) that maintain problematic anxiety-mood disorders. • Behavioral activation is an emotion exposure strategy for depressive disorders. • Graded exposure is an emotion exposure strategy for anxiety disorders.

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GRADED FEAR EXPOSURE

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 44 Advantages: Fear Exposure • Client gains more “control” over anxious response, not less “control.” • Client learns that they can handle or cope with anxious response. • Client learns that they can break the pattern of anxious thinking. • Client learns that anxious actions are not necessary.

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Guidelines: Exposure Hierarchy • Try for 10-20 items (may be more for OCD). • Focus on reasonable risk (Would you do it?). • Identify variety of situations to enhance learning and generalization. • Details: What, when, where, how. • Identify predicted feared outcome or expectancy (rate likelihood or intensity). • Identify predicted ability to cope. • Identify potential safety behaviors and what client will do instead.

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Building Exposure Hierarchy Hierarchy guides treatment and to titrate level of anxiety client experiences: • Step 1 – List situations, objects, and internal content that trigger anxious response. • Step 2 – Adjust situations based on what influences intensity of anxious response. • Step 3 – Rank situations from least to most anxiety-evoking. • Step 4 – Identify safety behaviors to resist.

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Develop: Graded Exposure • Begin with easy exposures. • Ensure exposures are frequent and long enough (more than 30” or anxiety decreased at least 50% at maximum). • Include value statement to enhance motivation.

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Types: Fear Exposure Strategies

• In vivo – confront anxiety-evoking or phobic objects or situations in structured “real life” exercises. • In vitro – confront anxiety-evoking or phobic objects or situations in session with therapist assistance. • Imaginal – confront anxiety evoking or phobic objects or situations in structured imaginal exercises.

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Examples: Imaginal Hierarchy

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Implement: Graded Exposure • Rate anxiety at the beginning, every 10-15 minutes, and when the exposure ends. • Search for safety cues or data that disproves the client’s prediction. • Goal is to drop all safety behaviors • If client is unwilling, gradually phase them out. • Practice exposures in office first. • Mass exposures • Include response prevention (block safety behaviors).

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 47 Reflect: Graded Exposure • Reflect what client learned from the exposure immediately after completed. • Did predicted feared outcome occur? • Did predicted ability to cope occur? • Did client use safety behaviors? • What happened to anxiety over time? • Evaluate automatic thoughts recorded. • Summarize what was learned.

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EMOTION EXPOSURE

BEHAVIORAL ACTIVATION

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Depression Spiral

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 48 Definition: Behavioral Activation • Therapist works with client to schedule enjoyable and goal-directed activities to increase activity level and thereby improve mood and allow client to obtain evidence to disconfirm negative views.

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Rationale: Behavioral Activation • Most people wait to feel better before becoming more active. In fact, becoming more active comes first. • Helps combat the withdrawal, passivity, and sedentary life-style that maintains depression. • Helps to distract client from preoccupation with negative thinking. • May lead to cognitive restructuring. • Manages suicidal thoughts and impulses. • Helps motivate passive, stuck clients.

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For Clients: Behavioral Activation

• Who are passive, immobilized • Who are procrastinating, avoiding, or feeling “stuck” • Who are having trouble getting moving because they are overwhelmed and have too much to do • Who are experiencing suicidal thoughts or impulses

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© 2019 Beck Institute for Cognitive Behavior Therapy Permission required for reproduction of these materials www.beckinstitute.org 49 Features: Behavioral Activation • Evaluate current activity level and types. • Identify pleasant and/or mastery activities. • Select focus for activity scheduling. • Schedule pleasant and/or mastery activities. • Use pleasure predicting to enhance willingness to engage in activities.

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Focus: Behavioral Activation

• Select a time of the day or week when client is not using his or her time well. • Select a time of day or week when client is most at risk for self-harm or is most depressed. • Select an activity to improve personal care. • Select an activity to increase socialization, pleasure, or treatment adherence.

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Guidelines: Behavioral Activation

• Provide a rationale and use guided discovery. • Assess confidence level: “How likely is it that you’ll do this?” “What do you think might get in the way of following the plan?” • Use cognitive rehearsal to identify obstacles to trying activity and brainstorm solutions (use problem-solving strategy). • Start where clients are, not where they think they should be.

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• Test problematic beliefs with behavioral experiments: “I don’t enjoy anything.” (e.g., pleasure predicting); “I can’t do it because I don’t feel like it.” (e.g., break down task); “I have to do things perfectly for them to be fun.” (e.g., identify activities that can be fun, even if done “imperfectly”).

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Summary • CBT is an evidence-based treatment applied to a variety of clinical problems. • Structured sessions are essential to efficient and effective CBT. • CBT is guided by a cognitive case conceptualization. • Cognitive restructuring and emotion exposure strategies are essential in treatment of emotional disorders.

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CBT Training through Beck Institute

• Workshops in Philadelphia • Training for Organizations (at your location) • Supervision • Consultation • Online Training (www.beckcbtonline.org)

For more information email [email protected]

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