Cognitive-Behavioral Counseling: - PowerPoint Presentation

Slide1

Cognitive-Behavioral Counseling: Therapeutic considerations and Applications

Michele D. Aluoch, LPCC

c. 2017Slide2

Depressive Disorders

Depressive Episode

5 or more in 2 week period

Change from previous functioning

Either: depressed mood or loss of

pleasure

At least 5 out of 9

:

Depressed mood most of the day nearly every day, as indicated by subjective report (

e.g

feel sad or empty) or observation made by others (e.g. appears tearful). NOTE: In children or teens can be irritable)

Markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day as indicated by either subjective account or observation made by others)

Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day

Insomnia or hypersomnia nearly every daySlide3

Depressive Disorders

Psychomotor agitation

or

retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

Fatigue or loss of energy nearly every day

Feelings of worthless or excessive and inappropriate guilt (which may be delusional) nearly every day

Diminished ability to think or concentrate or indecisiveness nearly every day (either by subjective account or as observed by others)

Recurrent thoughts of death (not just

fear

of dying), recurrent suicidal ideation without a plan, or a specific plan for committing suicide

Impairment in

social,

occupational or other areas of functioningSlide4

Depressive Disorders- DSM IV-TR

Specifiers

Frequency

: Single or recurrent

Types

: mild, moderate, severe

Chronic

- full criteria for depressive episode met continuously for at least 2 years- either depression or Bipolar

Catatonic

- motor immobility/stupor, excessive motor activity (purposeless), extreme negativism, rigid posture or

mutism

,

grimmacing

, echolalia or

echopraxia

Melancholic

-

lack of pleasure in activities, lack of reactivity to usually pleasurable activities and 3 or more: depressed mood, depression worse in am, marked psychomotor agitation or retardation, anorexia, excessive or inappropriate guiltSlide5

Depressive Disorders- DSM IV-TR

Dysthymic

Disorder

Depressed mood most of the day for more days than not as indicated either by subjective account or observation of others for at least 2 years. (Note: Children/teens- irritability for at least 1 year)

At least 2 of 6: 1) poor appetite or overeating

2) insomnia or hypersomnia

3) low energy or fatigue

4) low self esteem

5) poor concentration of difficulty making decisions

6) feelings of hopelessnessSlide6

Depressive Disorders- DSM IV-TR

Depressive Disorder NOS

Catch all for depression that does not meet criteria for other depression dx.Slide7

DepressionParadise, L. V., & Kirby, P.C. (Winter 2005).

R

oughly

10% to 25% of

the population

experiences some form of depression.

Depression is

the

number one

cause of disability

worldwide.

One

third to more than 60%

of mental

health professionals had reported a significant

episode of

depression within the previous

year.

D

epression

is 10 times as prevalent now as it was

in 1960!

W

hile

every objective indicator

of well-being

in the U.S. has been increasing, every indicator

of subjective

well-being is decreasing.Slide8

Anxiety Disorders

Panic Attack

:

A discrete period of intense fear or discomfort in which 4 or more of the following symptoms developed abruptly and reached a peak within 10 minutes

palpitations

sweating

trembling or shaking

sensations of shortness of breath or smothering

feeling of choking

chest pain or discomfort

nausea or abdominal distress

feeling dizzy, unsteady

,

l

ighthearted

, or faint

de-realization (unreality) or de-personalization (detached from oneself)

fear of losing control or going crazy

fear of

dying

paresthesias

(numbness or tingling sensations)

chills or hot flashesSlide9

Anxiety Disorders

Agoraphobia

- Anxiety about being in places from which escape may not be possible (being outside home alone, in a crowd, on a bridge, on a bus, in a line in the store, etc.), breeds

avoidance

Panic Disorder

:

Panic attacks

1 or more: concern regarding additional attacks, worry about implications of additional attacks (heart attacks, going crazy), change in behaviors following attacks

With or without agoraphobiaSlide10

Anxiety Disorders- DSM IV-TR

Specific Phobias

:

Marked, persistent fears

Situationally

bound panic attacks

Realizes that they are excessive and unreasonable

Stimuli produce marked anxiety/distress

AvoidanceSlide11

Anxiety Disorders- DSM IV-TR

Social Phobia

:

Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears he or she will act in a way where the anxiety will be humiliating or embarrassing.

Exposure to the feared social situation almost invariably

provokes

anxiety which may take the form of a

situationally

bound or

situationally

predisposed panic attack

The person realizes that the fear is excessive or unreasonable

The fear interferes with daily functioningSlide12

Anxiety Disorders- DSM IV-TR

Obsessive Compulsive Disorder (OCD)

:

Either obsessions or compulsions”:

Obsessions

:

Recurrent and persistent thoughts, impulses or images that are experienced at some time during the disturbance as intrusive and inappropriate and that cause some marked anxiety or distress

The thoughts, impulses, or images, are not simply excessive worries about real life problems

The person attempts to ignore

or

suppress such thoughts, impulses, or images or to neutralize theme with some other thought or

action

The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as thought insertion)Slide13

Anxiety Disorders- DSM IV-TR

Compulsions:

repetitive behaviors that the person feels driven to perform in response to an obsession that must be applied rigidly

2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are

designed

to neutralize or prevent or are clearly excessive

Interfere with daily functioningSlide14

Anxiety Disorders- DSM IV-TR

PTSD

:

Exposed to a traumatic event in which both of the following were present:

The person witnessed, experienced, or was confronted with an event or events that involved actual or perceived death, threat or serious injury or a threat to the physical integrity of others

The person’s response involved intense fear, helplessness or horror (NOTE: in children may=agitation)

The event is re-experienced persistently in one of the following ways:

Recurrent and intrusive distressing recollections of the event including images or perceptions

Recurrent distressing dreams of the event

Acting or feeling as if the traumatic event were occurring

Intense psychological distress at exposure to internal or external cues that symbolize or represent an aspect of the traumatic event

Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic eventSlide15

Anxiety Disorders- DSM IV-TR

Persistent avoidance of stimuli associated with the trauma and a numbing or general responsiveness (not present before the trauma), as indicated by 3 or more of the following:

Efforts to avoid thoughts, feelings, or conversations associated with the trauma

Efforts to avoid activities, places or people that arouse recollections of the trauma

Inability to recall an important aspect of the trauma

Markedly diminished interest or participation in significant activities

Feeling of detachment or estrangement from others

Restricted range of affect

Sense of a foreshortened

future

Persistent feelings of increased arousal (not present before the trauma), as indicated by 2 or more:

Difficulty falling sleep or staying asleep

Irritability or outbursts of anger

Difficulty concentrating

Hypervigilance

Exaggerated startle response

Causes distress and impairment in daily functioningSlide16

Anxiety Disorders- DSM IV-TR

Acute Stress Disorder:

Differences with PTSD: minimum, of 2 days-4 weeks

Within 4 weeks of the traumatic eventSlide17

Anxiety Disorders- DSM IV-TR

Generalized Anxiety Disorder:

Excessive anxiety and worry about a number of events or activities for at least 6 months

Difficulty controlling the worry

3 or more (1 for children):

Restlessness or being keyed up and on edge

Being easily fatigued

Difficulty concentrating or mind going blank

Irritability

Muscle tension

Sleep disturbance

Causes impairment in daily functioningSlide18

Generalized Anxiety

5-6% of Americans at some point in their

lives

First in young adulthood throughout 50s

Areas To Assess (Shear,

Belnap

,

Mazumdar

, Houck,&

Rollman

, 2006):

1)

Frequency of Worries

How often do you worry about things? Do you worry every day? On average how much of your time per day is occupied with worries?

2)

Distress Due To Worrying

How much distress does worrying cause you? How upset or uncomfortable do you feel when worrying?

3)

Frequency of Associated Symptoms

(restlessness, feeling keyed up or on edge, irritability, muscle tension, difficulty concentrating, mind going blank, fatigue, sleep disturbance)

How often do you have these symptoms? Every day? How much of the day?

4) Severity and distress due to associated symptoms

During the past week, when you had these symptoms, how intense were they? How much distress did they cause you? How upset or uncomfortable were you when you had them?Slide19

Generalized Anxiety

5. Impairment/Interference in work functioning

How much do the symptoms we have been discussing interfere with your ability to work and/or carry out responsibilities at home- our ability to get things done as quickly and effectively? Are there things you are not doing because of your anxiety? Does anxiety ever cause you to take short cuts or request assistance to get things done?

6. Impairment/interference in social functioning

How much do the symptoms we have been discussing interfere with your social life? Are you spending less time with friends and relatives than you use to? Do you turn down requests of opportunities to socialize? Are there certain restrictions in your social life about where or how long you will socialize

?Slide20

Generalized Anxiety Disorder

The “Looming Cognitive Style” (

Riskind

& Williams, 2005)

Mental scenarios and appraisals of events

1) Anxiety and depression

2)Worry

3)Attempts at

Thought

Suppression

Threat Appraisals

:

1. Likelihood Estimations

2. Lack of Control

3. ImminenceSlide21

Generalized Anxiety Disorder

Anxiety and Depression

Attending to the “negative” or unpleasant

Stimuli viewed as negative, dangerous, impending

Self viewed as helpless or hopeless

Sense of stimuli gaining velocity and gathering momentum (unfolding, changing, advancing)

Self protectiveSlide22

Generalized Anxiety Disorder

Worry

A chain of thoughts and anticipatory processes

A repetitive habitual means of verbal thoughts regarding potential or possible threatening events

Paradoxical: actually lessens autonomic system arousal, reduces the somatic component

Helps avoid aversive imagery

Believed (by the client) to be a coping mechanism

Beliefs regarding thoroughly considering all the possible outcomes and being able to mentally manipulate circumstances

Fears are all-encompassing network and even include “neutral” stimuliSlide23

GAD versus OCD (Fergus, Wu, 2010)

Intolerance of Uncertainty

(can’t deal w/ambiguity)

GAD-worry, OCD- compulsions

Perfectionism

OCD-a way to decrease anxiety about the uncertainty of the future

Negative Problem Orientation

GAD-Higher negative problem orientation (

attentional

bias)

Responsibility and Threat Estimation

Related to anxiety in general

Importance of and Control of Thoughts

Central to OCDSlide24

Obsessive-Compulsive Disorder

Obsessions & Compulsions

Obsessions

- Upsetting thoughts, images, or urges that intrude, unbidden into the person’s stream of consciousness

Compulsions

- behaviors or mental acts that the person feels compelled to perform, usually with a desire to resist; are connected to what they are intended to prevent

(e.g. checking, washing, hoarding, ordering or memory compulsions, cognitive

restructuring, neutralizing rituals, themed rituals- religious, sexual, aggressive)

Dysfunctional Beliefs

(Taylor, Coles, Abramowitz, Wu,

Olatunji

,

Timpano

, McKay, Kim,

Cramin

, &

Tolin

, 2010)

:

1)

Inflated personal responsibility-

belief that the client has the power to cause, and the duty to prevent, negative outcomes

2)

Over-estimation of threat

(negative events are likely to occur and their occurrence would be terrible)

3)

Over-importance of thoughts

(belief that control over one’s thoughts is entirely possible)

4)

Perfectionism

- belief that mistakes and imperfection are unacceptable

5)

intolerance of uncertainty-

belief that it is necessary and plausible to be completely certain that negative outcomes will not occurSlide25

Obsessive-Compulsive Disorder

Three Aspects of Perfectionism

(Ashby, Rice, & Martin, 2006):

Self-oriented- high standards for self

Socially Prescribed Perfectionism- belief that others set high standards for you

Other-oriented Perfectionism- setting high standards for othersSlide26

Post-Traumatic Stress Disorder

Witnessing an event perceived as traumatic

Traumatic to self or other

Event causing distress

Could be either: a) Restrictions experiencing emotion/emotional

responsivity

(emotional numbing) OR b) intense arousal

Belief that risk of bodily injury or death

Horror

Re-experiencing (nightmares, intrusive memories, flashbacks)

Hyperarousal

(disturbed sleep, irritability, being easily startled)

Hypoarousal

(avoidance)

The past invading the present, short term stuck in long term memory: moved to limbic system of the brainSlide27

PTSD (Cont.)

More numbing predicts worse outcomes.

More emotional “outbursts” predict better prognosis.Slide28

PTSD (cont.)

Proposed domains to address

Biology

(developmental problems, increased medical problems)

Cognitive

- difficulties in attention, information processing, learning

Dissociation

- depersonalization,

derealization

, impaired memory

Affect regulation-

poor emotional self-regulation, difficulty labeling emotions

Attachment

- social isolation, difficulty with perspective taking

Behavioral control

- poor impulse control, aggression, oppositional behavior

Self-concept

- low self-esteem shame and guilt, lack of sense of selfSlide29

Social Phobia

Marked and persistent fear of social situations

Concerns about possible scrutiny by others

Presumptions of judgment and rejection

Anticipating incompetence on part of self

Avoidance behaviors

Ignoring social cues which may be helpful

Cognitive Biases (

e.g

“I will mess up.”, “They will see how bad I am at this.”)Slide30

Panic Disorder

Negative interpretations limited to self- different explanations regarding such symptoms in others

Interpretation bias

Cognitive errors: double messages- self and others- note inconsistencies

A number of people with panic disorder were found to have strongly influencing and significant life events which predisposed them to panic (loss separation, bereavement, health related concerns starting in childhood or young adulthood, major separation from significant

caregivers)

Associated and correlated with neuroticism- low perception of pleasantness, perceived control, goal achievement and higher sense of moral violationSlide31

Cognitive Behavioral Cycle

Using proven REBT- Rational Emotive Behavior Therapy (Albert Ellis) but incorporating client belief systems and spiritual

worldview

Compared to baselineSlide32

Dealing With the FeelingsSlide33

Cognitive Behavioral Principles

Early life experiences

Maintained throughout time

Maintained by behaviors that may not be useful

Maintained by looking for thoughts and behaviors that keep the cycle goingSlide34

Cognitive Behavioral Principles

Continuing to elicit negative thoughts and

record more

helpful ways of thinking about

situations, self

and others to influence emotion positively.

Reviewing

thoughts, particularly

expectations for

self and ‘

shoulds

’ rather than ‘wants’.

Identifying rules for living and

examining their

helpfulness.

Identifying

unhelpful thinking styles that

lower mood

. Encouraging the client to

analyze thoughts

and then step back from them.

Reviewing

alternative explanations for

negative automatic thoughts.

Conducting behavioral

experiments to

help increase

believability of alternative thoughts.

Listing

goals with an emphasis on own

needs and

expectations.Slide35

Thinking Error Types

1)

Awfulizing

/Catastrophizing

- Predicting only negative outcomes for the future: “

____ is awful, terrible, catastrophic or as bad as it could possibly

be”, “If ___ happens my life is over.”

2)

Disqualifying/Discounting

- Overlooking the positive and only seeing the negative, believing that good things don’t count: “I am sure even when my family complimented me they had to because they are my relatives. They had to be nice.”

3)

All or nothing

- Viewing the situation on one end of extremes: “If my boss corrects me I must be the worst employee”, “If my child does something wrong I failed as a parent”, “If I didn’t pass one exam I am an unsuccessful student.”

4

Low

Frustration Tolerance

-

Belief that things should not be inconvenient: “I

can’t stand

_____” ; “_____

is too much and is intolerable or unbearable

.”Slide36

Thinking Error Types

5)

Self Downing

- Self deprecating thoughts: “I am no good, worthless, useless, and utter failure, beyond hope or help, devoid of value.”

6)

Other downing

- Derogatory beliefs about others: “You are no good, worthless, useless, an utter failure, beyond hope, of no

value.”

7)

Emotional reasoning

- Letting emotions totally overrule facts to the contrary: “I feel as if everyone is talking about me.”

8)

Labeling

- Giving a label or stereotype without testing beliefs out:” All of them are like that.”

9)

Mind reading

- Trying to predict things based on limited aspects of a situation: “ I know they will think I’m poor because I can’t afford the latest clothes.”Slide37

Thinking Error Types

10)

Overgeneralization

- Making broad conclusions about an event based on limited information: “My husband doesn’t love me because he is always busy when I am around.”

11)

Personalization

- Assuming that others behaviors are all about you: “My wife is quiet. Something must be on her mind.”

12)

Shoulds

/musts

- Having an absolute concrete standard about how things ought to be: “ Successful people in life only get As in school.”Slide38

Cognitions Related To Anxiety

Cognitions Supporting Worry:

(

Dugas

&

Koerner

, 2005)

“Worrying is helpful.”

“Worrying, thinking about possible outcomes can help me deter or change events.”

“Worry can prevent negative outcomes.

“Worry is a sign of a caring concerned person.”

“Worrying is a positive personality trait.”

“Worrying aids in problem solving and helps me plan.”

“Worrying motivates me.”Slide39

Cognitions Related To Anxiety

“I am losing control.”

“I cannot handle this anymore.”

“My life is falling apart.”

“Everyone knows how socially inept I am.”

“I can’t deal with this stress anymore. It is absolutely overwhelming and immobilizing.”

“I know I will absolutely fail.”

“This is bound to happen again.”Slide40

Cognitions Related To Anxiety

“Something bad is going to happen to me.”

“I must be having a heart attack or other serious health issue if I am having these symptoms. Next thing I know I’ll die.”Slide41

Anxiety Versus Depression- Self Statements(Safren,

Heimberg

, Lerner,

Henin

,

Warman

, Kendall, 2000)

Inability to cope

I can’t take it anymore.

I can’t stand it.

I wish I could escape.

I don’t want to feel this way.

I cant cope.

I can’t get through this

Something has to change.

Uncertainty About the Future

How will I handle myself?

Can I overcome the uncertainties?

What will happen to me?

Will I make it?

Can

I make it?

Am I going to make it?

What am I going to do with my life?

I want to fight back but I’m afraid to do so.Slide42

Anxiety Versus Depression- Self Statements(Safren,

Heimberg

, Lerner,

Henin

,

Warman

, Kendall, 2000)

I don’t feel good.

I don’t feel very happy.

I am not safe warm, comfortable.

I am not sure that I can accomplish this.

I don’t feel so good about myself/my life.

I hate myself.

I feel like a loser.

I’m worthless/a failure.

Something is wrong with me.

No one understands me.

I

don’t

think I can go on.

I wish I could die.

I’m against the world.

I can’t get started.

I’ll

never make it.

I’m no good.Slide43

Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005

)

Relationships, Entitlements, Achievements

If

people

criticize

me, I

am not

a worthwhile person.

Other

people’s approval is very important to me.

I

can make everyone like me if I just try hard enough.

The

most important thing in the world to me

is to

be accepted by other people.

I

find it impossible to go against other people’s wishes.

Unless

I get constant praise I feel that I

am not

worthwhile

.Slide44

Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)

LOVE

Life

is unbearable unless I

am loved

by my family.

If

I

am not

loved it is because I

am unlovable

.

If

I love somebody who doesn’t love me, I must be

inadequate.

I

need to be constantly told I’m loved to feel secure.

If

I were a better person then somebody would love me.

In

order to be happy, I need someone to really love me. Slide45

Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)

Influence

I

can prevent people being upset by thinking about

what they

might need.

If

I have a fight with my friends, it must be my fault.

I

should be able to please everybody

.

I am responsible

for other people’s happiness.

If

people are uncomfortable around me it is my fault.

If

the people around me are upset, I usually worry

that I

have upset them.Slide46

Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)

Success

I

can’t feel equal to others unless I’m really good

at something

.

I

only feel valued if I achieve my goals.

My

success in life defines my goals.

I

need to be successful in all areas that are

important to

me.

Life

is pointless if I don’t have goals to chase.

Without

success in life, it is impossible to be happy.Slide47

Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)

Perfection

I

see no point in doing anything unless it can be

done perfectly

.

There

are no second prizes in

life.

Things

must be done to certain standards, otherwise

there

is no point in doing them.

If

I make mistakes

then

others will think less of

me.

If

I don’t do something perfectly

then I

don’t like myself very much.

I

never seem to be able to reach my own high standards.Slide48

Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)

External

I

can only be happy if I have the good things in life.

Unless

I have expensive possessions,

people won’t approve of me.

If

I were rewarded for the goals I achieve, know I could

be happy

.

If

my friends are unhappy, then I cannot be happy.

Everything

has to be going well in order for me to be

happy.

My

happiness depends on others. Slide49

Cognitions Related To DepressionParslow, R.A., Christensen, H., Griffiths, K.M., Groves, C. (2005)

Rights

If

obstacles are placed in my path, it is natural

that I

would get angry.

Things

should always go right for me.

If

I do the right things people should acknowledge it

.

If

I feel that I deserve something, I should get

it.

If

I go out of my way to help others, they

should do

the same for me when I need it.

I

shouldn’t have to work so hard to get the things I want. Slide50

Behaviors Related To Anxiety

Attending to the disturbing stimulus to the neglect of additional environmental information

Intolerance of uncertainty- the tendency to react negatively on an emotional, cognitive, and behavioral level to uncertain situations and

events

Maladaptive schemas related to earlier life: disconnection and rejection, impaired performance, impaired limits, etc.Slide51

Overcoming Depression and Anxiety

“You can look at what happened to you; it was truly horrible, but it is not unthinkable or

unfaceable

. You do not have to run from it day and night, and you do not need to totally curtail your life for fear of a recurrence. You can live in a world where this once happened and where there is a remote chance that it could happen again. Moreover, you MUST look at it. You must face it down, because what is happening now is what happens when you don’t.”

(Bergner, 2009)Slide52

Essential Elements

Cognitive Restructuring

(Hope, Burns, Hayes, Herbert, Warner, 2010)

Identify and change dysfunctional cognitive beliefs/automatic thoughts

Replace anxiety producing thoughts with more socially adaptable ones

Through Socratic questioning

Challenge the voracity of assumptions regarding social situations

Living in new attitudes about self and others by applying new rational rebuttals to the irrational beliefs and behaviors

Targets 3 areas: 1. experiencing anxiety, 2. negative self evaluation, 3. fear of negative evaluation

Use a hierarchy of thoughts- surface to core (keep asking “what would that mean?” until 4-6

th

= core)

Exposure

Reducing disabling behaviors

Finding exceptions

Systematically facing feared situations in context they feared

Redirecting attentionSlide53

Essential Elements

Social Reappraisal Therapy

(Hoffman &

Scepkowski

, 2006)

Factors which influence formation=social apprehension, high social standards and goals, increased self attention (50-60%), high estimated social cost, perceived poor social skills, low perceived control, post event rumination

Create at least one social mishap per week

Switch focus on environment rather than inwardly- see the genuine observer’s perspective rather than the client’s own perspective

Realistically appraise the social cost

Reframe to increase sense of emotional controlSlide54

Essential Elements

Cognitive-Behavioral Treatment: Key Aspects

(

Lamplugh

,

Bele

Milicevic

, &

Starcevic

, 2008)

Understanding anxiety and the flight or fight response

Understanding the role of

hypervigilence

Promoting a sense of ‘riding out the wave’ of anxiety in an accepting manner instead of trying to control symptoms

Realistic appraisal of body sensations

Acknowledgment of physical feelings rather than distraction away from those feelings

Rating the intensity of physical feelings rather than anticipating the worst

Abandoning anxiety

Acknowledgement that catastrophic misinterpretations of physical feelings are problematic, not the physical feelings themselves

Cessation of maladaptive behaviors that maintain the problemSlide55

Essential Elements

Collaboration, cooperation between therapist and client

Clinician skills in CBT

Ability to

psychoeducational

foundation regarding thoughts, feelings, and behaviors

Ability of client to have insight and awareness

Desire of client to modify thoughts and behaviors

Homework and exercises for applications for client outside of session

4-6, 6-8 sessionsSlide56

Essential ElementsForsyth, D.M., Poppe

, K., Nash, V., Alarcon, R.D., & Kung,

S

(

October 2010

)

Gains in positivity are more closely related to emotional healing from depression and anxiety than loss of negativity.Slide57

Who Might Benefit?

Anxiety

Depression

Assertiveness Building

Diet and Health

I

ssues

Social

I

solation

Medical concerns

Grief

Alcohol Dependence

PTSD

Divorce

Life stressorsSlide58

Video Clips: Cognitions and Behaviors

Identify the thought patterns and toxic behavior choices in the video clips.Slide59

Problem Orientation

positive problem

orientation

a

protective

factor that facilitates the initiation

of proactive

problem-solution skills to manage

or minimize

early signs or symptoms of

psychological distress

n

egative problem orientation

-

a

serious

threat to

their well-being, respond with strong

negative emotions

(e.g., anxiety and/or depression

), and

avoid or postpone dealing with a

problemSlide60

Depression and Anxiety

Transdiagnostic

Approach

(Clark, 2009; McManus,

Shafran

, & Cooper, 2010)

Moving away from diagnosis specific treatments

Symptoms overlap between similar disorders

“A therapy that is made available to individuals with a wide rage of diagnoses, and does not rely on knowledge of thee diagnoses to operate effectively.”

Assumptions

:

General cognitive-behavioral processes which are shared

Absence of diagnostic assessment

Adoption of a convergent or integrative scientific approach

Commonalities

:

1) Altering incorrect or faulty appraisals based on emotions about self or other

2) Prevention of avoidance

3)

Psychoeducation

4)Behavior modificationSlide61

Challenging Thought Patterns

Shoulds

“Why?”

“if only ____, then _____”

Have

tos

_____ “enough”

Absolutes

: always/never

Right/wrong

Good/bad _____Slide62

Challenging Thought Patterns

Cognitive

distortions

- the

different

types of

distorted cognitive processes that produce

automatic negative

thoughts, which in turn,

evoke or

strengthen early symptoms of

psychological distress

and emotional

and/or

behavioral

disordersSlide63

Cognitive Reframing

Instead of “if he/she would…….”

Use:

“If I could just get a grip on _____ then we’d finally be happy.”

Watch where you put your BUTs:

__________ BUT __________. Slide64

Who Does Cognitive-Behavioral Therapy Work For?

Strong Motivation To Change

Time Commitment

Cognitive Functioning/Educational Level

Observant People

Insightful People

Those who will do work outside of sessionSlide65

Conceptualizing The Problem

Antecedents

What happened before?

Something triggered

t

his

Not Out of The Blue

(e.g. Boy throwing cars around the room- Is it a behavior issue really?)Slide66

Conceptualizing The ProblemSlide67

Conceptualizing The Problem

Antecedents

:

What happened right before that? (Affective)

What happens to you physically before this happens? Do you feel sick? (Somatic)

How do you normally act right before this happens? (Behavioral)

What thoughts go through your head before this happens? (Cognitive)

Where and when does this usually happen? (Contextual)

Do you do this with everyone or just when you are around certain people? (Relational)Slide68

Conceptualizing The Problem

Behaviors

What the client does in response

Examples

:

I avoiding going out of the house.

I stomped off my job.

I yelled at the kids.

I cried and staying in my room.Slide69

Exercise: Responses to The Antecedent

Antecedent

Behavior Reaction

Feeling Reaction

I was playing with my child but had to leave to get the laundry.

I expected to get the job but found out it was offered to someone else.

I

had a flashback of a trauma from my childhood.

I discovered my boyfriend was cheating.Slide70

Exercise: Responses to The Antecedent

Antecedent

Behavioral Response

Feelings

Response

The doctor told me I have cancer.

I got a pay cut.

My child failed school.

I do not look the way I want.Slide71

What Could the Antecedent Be?

Antecedent

Behavioral Response

Feelings Response

My son threw his crayons across the room

My son cried and kicked.

I covered my eyes and shook.

I stayed in bed all day.

I felt disappointed

in myself, unhappy with my life.Slide72

What Could The Antecedent Be?

Antecedent

Behavioral Response

Feelings Response

I slammed the phone down.

The teenager put the music on as loud as possible.

My spouse drove away.

I left the busy concert.Slide73

What Could The Antecedent Be?

Antecedent

Behavioral response

Feelings

response

I felt like throwing up as my heart raced and I experienced panic.

I resolved not to try anything again because “nothing ever works for me.”

I tried again – “next time could be better.”Slide74

Challenging Attributions

1) Am

I ascribing something like “This situation happened because

______?”

2)Am

I making a judgment about another person’s personality because of this event? What am I telling myself about what this means? (Because this happened, it means-

--)

3) Am I using adjectives to describe the other person’s personality, intentions rather than simply describing the behavior? (e.g. “You are always so lazy. You never care about our house.” versus “I am concerned about the amount of cleaning we still have to do. I realize we have busy tiring jobs but I am wondering how we plan to get the dishes done and get our things set up for tomorrow plus help the kids to finish their homework. How do we plan to get to divide these things up- any ideas?”)Slide75

Challenging Attributions

4) Is the way I’m thinking about this definitely 100% a fact?

5) Is there any other way of looking at the situation? Come up with at least three exceptions.

6) Have I assumed that because something is (

perceived

by me to be) such and such way that I am powerless over it? Slide76

Attributions Exercises

1) My spouse came home late two days this week. His clothes were a little disheveled looking- he must be having an affair.

2) My wife was supposed to meet me for the romantic dinner. She was ½ hour late and did not call me. When I saw her I had to yell at her because I knew she did not make our dinner a priority.

3) My coworker left a pile of unfinished work on her desk. It must be that she is lazy and planned to have me do all her dirty work.Slide77

Attributions Exercise

4) The group of popular people looked at me and smiled. I knew they were talking behind my back badly about me.

5) When I walked by they got quiet. I am sure they noticed my hand me down clothes compared to their name brand outfits.

6) Every time my mother comes over she helps me clean the house. I knew she always thought I was a slob and couldn’t do anything right.Slide78

Setting Behavioral Goals

Concrete

Specific

Manageable

Achievable

With accountability for follow

throughSlide79

Goal Setting ProcessSlide80

Setting Goals Exercises

Broad Goal

Specific Step

Outcome Desired

Feel less depressed

Get out of bed and get set for the day

Be

bathed, dressed and get out of the house for at least one hour per day

Stop fearing everyone’s reaction of me

Go to a public place three times per week for at least ½ hour and find out that the worst doesn’t happen.

Learn to talk to strangers without automatic belief and avoidance because I assume that everyone’s out to get me.Slide81

Setting Behavioral Goals

Broad Goal

Specific Goal

Desired Outcome

Feel more self confident

Have a better self concept, believe I have self worth

Try new things without fear of rejectionSlide82

Tips For Goal Setting

Tell what you want to happen rather than what you don’t want to happen.

State observations- what would you/others see?

What would be the benefits of such an action?

Use 1-100 scaling to identify priorities.

Behavioral outcomes should be inconsistent with the depression and anxiety symptomsSlide83

Tips For Goal Setting

Reintroduce prior successes

Reintroduce pleasant activities

Choose active helping (e.g. taking some proactive behavior action to relieve a stressor)

Don’t avoid.Slide84

Relaxation

Tension Reduction

Perceived control over stress

Progressive muscle relaxation- one by one relaxing and tensing various muscle groupsSlide85

Imagery

Imagining yourself as successful in identifying what that would take.

Involve as many senses as possible.

Strengths based- what would you like to see happen? When has this happened? How would you act if the new improved situation, feeling, behavior was going on?

Set aside time to ponder this.

Schedule a thinking time.Slide86

Typical Session OutlineSlide87

Questions For Ongoing CBT

What points did we come to since last session?

Anything you learned as you thought over things?

Anything you were uncomfortable with?

Things better or worse?

Treatment agenda- where are we? What to focus on today? What to amend?

Completed or not completed homework?Slide88

Setting Homework

Done collaboratively

Don’t assume follow up- ask. (e/g. couple I counseled re. communication interchanges)

Affirm the value of outside practices.

Highlight attempts and successes- build on

Start by modeling and practicing in session.

Inquire re. homework.

Anticipate problems.Slide89

Other Ways of Presenting Homework

Bibliotherapy

Progress

Tasks

Experiments

Observations

Exercises

Not about doing things “right”Slide90

When Thoughts are Hard to Determine

Observe behaviors

Observe body language

Observe positioning, tone, facial expressions, hand gestures.

Observe what emphasized more or less.Slide91

Mindfulness Approaches

Use decentering to switch from a judgmental problem focus which promotes negativity to a present here and now

nonjudmental

stance

Examples

:

What

did you notice in your thinking, emotions, or sensations?

D

id

you notice

the sense

of tightening or

tension

in any particular place in your body

?

So, these difficult thoughts and emotions were present in your awareness

.?

Key Components

:

Begin in

the initial assessment session. The participant is provided an opportunity to

describe his

or her experience of depression. Together, the therapist and participant explore ways

in which

MBCT may effectively reduce relapse risk.

T

he

therapist

enhances a

sense of mutuality and connection with participants.

The

process of inquiry should be a genuine exchange

during which

the therapist uses

questions to

help the participant deepen awareness of his or her practice, while also embodying

the present-focused

, open, and warm attitudes of mindfulness.Slide92

Mindfulness

Choosing to control our focus of attention

Example: Washing dishes: instead of thinking of the stresses of the day and how much more to do- “Listen to the bubbles. They are fun!”

Just observe

Accepting things as they are rather than trying to always change them.

Stop thinking too much. Just let it be.Slide93

Cognitive Behavioral Overview

Increase insight and awareness then elicit more health positive outcomes

Note

negative thoughts and

record more

helpful ways of thinking about

situations, self

and others to influence emotion positively

.

Review thoughts

, particularly

expectations for

self and ‘

shoulds

’ rather than ‘wants

’. Identifying

rules for living and

examining their

helpfulness

.

Self monitor. Identify

unhelpful thinking styles that

lower mood

. Encouraging the client to

analyze her thoughts

and then step back from them.

Consider

alternative explanations

to negative automatic thoughts or behaviors.Slide94

Cognitive Behavioral Overview

Conducting behavioral experiments to help increase believability of alternative thoughts.

Analyze self-criticisms with focus on undoing negative automatic thoughts and behaviors.

List goals with an emphasis on own needs and expectations.Slide95

Patient Self Guided CBTRidgway, N., & Williams, C. (December 2011

)

General principles taught

Resources tailored to client

Audios, videos, workbooks

Bibliotherapy

May be computerized

Emphasis on homework

As effective with mild to moderate depression and anxiety as face to face therapist guided CBT Slide96

Patient Self Guided CBTRidgway

, N., & Williams, C. (December 2011).

Strengths

Many

people like to read

As

effective as

in person CBT

Can

teach key information and skills

Uses

a clear structure

Paper-based

tasks

and records

Ability to personalize

what

is read

Low

cost and can be copied

Can

incorporate many modalities, e.g. reading, listening, video, etc.

Interactive

learning

Automated

alerts can be used if deterioration or risk is recorded

Online

forums can provide added supportSlide97

Patient Self Guided CBTRidgway, N., & Williams, C. (December 2011)

Weaknesses

Text used can be difficult to understand if foundations not properly laid

Licensing

may make copying expensive

Need

online access or to travel to a fixed unit

Needs

flash and adobe reader plus adequate bandwidth and access to soundcard/speakers

Making

sure the client has proper equipment – E.g. Newer delivery mechanisms use MP3 or certain video formats

Audios

or videos are fun to

many people

Documentary

style may make people feel as if they are not alone

May

watch but not learn or apply

Needs

ways of helping people implement

what they

are learningSlide98

Evaluation Questions

Situational Questions

Feelings Questions

Thought Questions

What happened? What were you doing?

Who was there?

Who were you speaking to?

When was this?

What time of day was it?

Where were you?

How were you feeling before this happened?

How did you feel while this was happening?

What mood were you in after this happened?

Rate your mood: 1-100.

What was going through your mind before you started to feel this way?

What thoughts bothered you?

What are you afraid might happen?

What if what you think is true?

Are there other ways of thinking about things?Slide99

Thought Log

Event

Thought

Consequence

Alternate

ResponseSlide100

Anxiety Ladder

Rate 0-100, Systematically challenge one by one, pair with relaxationSlide101

Cognitive Debating Strategies

Is this a fact/strong opinion?

What evidence is there for this? Any evidence against this?

Alternative explanations that are more reasonable/possible?

Is there another way of feeling or thinking?

What would someone else make of this situation?

What advice would I give someone else?

Is this a type of unhelpful thinking habits?

Is this an automatic thought?Slide102

Cognitive Debating Strategies

What am I actually reacting to?

Am I getting anything out of proportion?

What harm has actually been done?

Am I overestimating the bad? The danger?

Am I underestimating my ability to cope?

Am I going to a negative automatic place?

How is pressuring myself or others helping me get through this?

Just because I feel bad is it really bad?

Are things really totally black or white- as clear cut as I am making them?

Can there be more than one solution to this problem?Slide103

Cognitive Debating Strategies

Is believing this life giving or death producing?

How important is this really?

How will things be in 1 week? 1 month? 6 months? 1 year? If I continue thinking or behaving this way?

What would happen if I tried to see this situation as an outside observer? How would things look? Would things have a different meaning?

What is the bigger picture?Slide104

The Helicopter View

What can I see in this situation as I look higher and higher?Slide105

Helping Kids

What is making you scared? Sad?

What are you expecting will happen?

Are you in a thinking trap?

Are you 100% sure this will happen?

Could there be any other ending to the story?Slide106

STOP

S Signs of anxiety or depression

T Thoughts of anxiety or depression

O Other better ways of thinking or feeling?

P Praise for new plan for next timeSlide107

Hindsight Bias

A type of memory distortion

“ I knew it all along phenomenon”

Needs to be confronted just like other distortions

Thinking that we knew more or could predict more than we couldSlide108

Old Versus New Systems

I am…

People are…

The world is…

I am…

People are…

The world is…

Old Rules that Protect Me:

New Rules that Protect

Me…Slide109

Positive Self Talk

I can be anxious/angry/sad and still deal with this.

I have done this before so I can do it again.

I don’t have to feel happy all the time to get through what I need to do in life.

These are just feelings. They won’t last forever.

I don’t need to rush. I can take things one by one.

I have gotten through things before. I will get through them again.Slide110

Generalizing Skills Outside Sessions

Ongoing homework

Planning for reassessing thoughts and behaviors often

Planning for alternatives to depression and anxiety: if/when ___ happens I will do ___.

Booster sessionsSlide111

Modified ABC Model

A

ctivating

Event

B

eliefs

C

onsequences

D

isputations of

Beliefs

E

ffective New BeliefsSlide112

Summary: Depression & Anxiety

Physical

Thought

Behs

.

Feelings

Anxious

Tense, shaky, worried, energized, HR increase, can’t concentrate

I’m in danger,

Have to get out, I can’t cope

Avoid, Fidget, Escape, Ruminate

Nervous, edgy, apprehensive, panicked, terrified

Depressed

Tired, lethargic, withdrawn, eating

or sleeping changes, loss of interest in hobbies, restlessness, poor ADLs

I’m worthless, Life’s awful, Bad things happen to me, It’s hopeless

Do less, talk less or quieter voice, Eat or sleep less or more, isolate

Sad, gloomy, unhappy, despairing, hopelessSlide113

Summary: Depression & Anxiety

New Thoughts

New Behaviors

Depression

Even if I feel sad I will get through, If I do something I will feel better, This is just my habitual gloomy way of thinking.

Do things anyway, Get out, talk to someone, Get dressed, Do an activity I used to enjoy, Relax, Focus attention elsewhere

Anxiety

Is this really a threat? I could be overestimating the threat, I have gotten through before even

when I was worried or panicked.

Problem solve, Don’t avoid or you’ll never find out that the worst doesn’t happen.Slide114

Changing Distortions

Type of thinking

Neg. impact

Replacement

All or nothing

Discouragement, no middle ground

Continuum thinking

Overgeneralization

Makes all problems last forever

Focus on the here and now

Negativity

Make the positive impossible

Appreciate the positives

Discounting positive

Eliminates real joy in the present

Purposely find and enjoy the positivesSlide115

Changing Distortions

Jumping to Conclusions

Anger, anxiety, depression

Consider all possibilities

Predictions

Dread,

disaster, panic

Stay in present

Mind

Reading

Anxiety, sadness, anger, assumptions

Clear communication

Magnification

Treating people unfairly

See strengths in self and others

Emotional reasoning

Upsetting judgments made without evidence

Listen to your head and heartSlide116

Changing Distortions

Shoulds

Discouragement at self,

Anger at others

Bring expectations in line with reality

Labeling

Discouragement at self,

Anger at others

Stick to specific circumstances

Blame

Discouragement at self,

Anger at others

Stick to specific circumstancesSlide117

Videos: Doing Treatment

Watch the videos and see how the irrational cognitions and unhealthy behavior choices are addressed.Slide118

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