Cognitive Behavioral Therapy

Cognitive Behavioural
therapy – part 2
Presenter – Dr. Priyash Jain
Guided by – Dr. Abhay Paliwal Sir
Associate professor
Department of Psychiatry
MGM Medical College

Index
• Recap
• Cognitive behavioural therapy
• Depression
• OCD
• Anxiety Disorders
• Schizophrenia
• Summary

• Cognitive processing is given a central role in the cognitive
behavioural model because humans continually appraise the
significance of events in the environment around them and within
them,
• cognitions are often associated with emotional reactions.
A Quick Recap

CBT in depression
Developing the therapeutic relationship.
Planning treatment and structuring sessions.
Identifying and responding to dysfunctional cognitions.
Emphasizing the positive.
Facilitating cognitive and behavioral change between sessions
(homework).

• Demonstrate good counseling skills and accurate understanding.
• Share your conceptualization and treatment plan.
• Collaboratively make decisions.
• Seek feedback.
• Vary your style.
• Help patients solve their problems and alleviate their distress.

• Feel likable, when you are warm, friendly, and interested.
• Feel less alone, when you describe the process of working together as a team to
solve their problems and work toward their goals.
• Feel more optimistic, as you present yourself as realistically hopeful that
treatment will help.
• Feel a greater sense of self-efficacy, when you help them see how much credit
they deserve for solving problems, doing homework, and engaging in other
productive activities.

Planning Treatment and Structuring sessions
• Your goal in the first part of a therapy session is to establish the
therapeutic alliance and collect data so you and the patient can
collaboratively set and prioritize the agenda.
• In the second part of a session, you and the patient will discuss the
problems on the agenda.
• In the context of solving these problems, you will teach the patient
relevant cognitive, behavioral, problem-solving, and other skills.

Identifying And Responding To Dysfunctional
Cognitions
Guided Discovery
• Ascertain which cognition or cognitions are most upsetting to
patients,
• ask them a series of questions to help them gain distance (i.e., see
their cognitions as ideas, not necessarily as truths), evaluate the
validity and utility of their cognitions

Cognitions
Therapist: Okay, Sunita, you said you wanted to talk about a problem with
finding a part-time job?
Patient: [automatic thought] I won’t be able to handle a job.
Therapist: [labeling her idea as a thought and linking it to her mood] And how does
that thought make you feel?
Patient: [emotion] Sad. Really low.
Therapist: [beginning to evaluate the thought] What’s the evidence that you won’t
be able to work?
Patient: Well, I’m having trouble just getting through my classes.
Therapist: Okay. What else?
Patient: I don’t know . . . I’m still so tired. It’s hard to make myself even go and look
for a job, much less go to work every day.

Cognitions
Therapist: In a minute we’ll look at that. [suggesting an alternative
view] Maybe it’s actually harder for you at this point to go out and
investigate jobs than it would be for you to go to a job that you
already had. In any case, is there any other evidence that you
couldn’t handle a job, assuming that you can get one?
Patient: . . . No, not that I can think of.
Therapist: Any evidence on the other side? That you might be able
to handle a job?
Patient: I did work last year at a bookstore. And that was on top of
school and other activities. But this year . . . I just don’t know.

Cognitions
Therapist: And what’s the effect of changing your thinking, of
realizing that possibly you could work in the bookstore?
Patient: I’d feel better. I’d be more likely to apply for the job.
Therapist: So what do you want to do about this?
Patient: Go to the bookstore. I could go this afternoon.

Cognitions
Behavioral Experiments
Discussing the validity of patients’ ideas, as described above, can help
them change their thinking, but the change may be significantly more
profound if the cognition is amenable to a behavioral test, that is, if the
patient can have an experience that disconfirms its validity.

Cognitions
Behavioral Experiments
A depressed patient, for example, might have the automatic thought,
“If I try to read anything, I won’t be able to concentrate well enough to
understand it.”
You might ask the patient to read a short passage from a book in your
office to see to what degree this thought is valid.

Emphasizing THE POSITIVE
• Most patients, especially those with depression, tend to
focus unduly on the negative.
• When they are in a depressive mode, they automatically
(i.e., without conscious awareness) and selectively attend to
and put great emphasis on negative experiences, and they
either discount or fail to recognize more positive
experiences.

Emphasizing THE POSITIVE
From the first session on, you will elicit positive data from the
preceding week (“What positive things happened since I saw
you last? What positive things did you do?”). You will orient
sessions toward the positive, helping patients have a better
week.

Facilitating Cognitive And Behavioral Change
Between Sessions (Homework)
• Because patients tend to forget much of what occurs in
therapy sessions, it is important that anything you want
them to remember, be recorded so they can review it at
home.
• Either you or they should write down their self-help
assignments in a therapy notebook

Facilitating Cognitive And Behavioral Change
Between Sessions (Homework)
• Homework can be
• Behavioral changes as a result of problem solving and/or skills
training in session
• Identifying automatic thoughts and beliefs when patients notice a
dysfunctional change in affect, behavior, or physiology,

Cognitive Conceptualization
• “What is the patient’s diagnosis(es)?”
• “What are his current problems? How did these problems develop
and how are they maintained?”
• “What dysfunctional thoughts and beliefs are associated with the
problems? What reactions are associated with his thinking?”
• “How does the patient view himself, others, his personal world, his
future?”
• “What stressors contributed to the development of his current
psychological problems, or interfere with solving these problems?”

• Reader A thinks, “This really makes sense. finally, a book that will
really teach me to be a good therapist!”
• Reader A feels mildly excited and keeps reading.
• Reader B, on the other hand, thinks, “This approach is too simplistic.
It will never work.”
• Reader B feels disappointed and closes the book.
• Reader C has different thoughts: “This is just too hard. I’m so dumb.
I’ll never master this. I’ll never make it as a therapist.”
• Reader C feels sad and turns on the television.

• Reader C tends to focus selectively on information that confirms his
core belief, disregarding or discounting information to the contrary.
• For example, Reader C did not consider that other intelligent,
competent people might not fully understand the material in their
first reading. Nor did he entertain the possibility that the author had
not presented the material well. He did not recognize that his
difficulty in comprehension could be due to a lack of concentration,
rather than a lack of brainpower. He forgot that he often had
difficulty initially when presented with a body of new information,
but later had a good track record of mastery

• Core beliefs influence the development of an intermediate class of
beliefs, which consists of attitudes, rules, and assumptions.
• Reader C, for example, had the following intermediate beliefs:
• Attitude: “It’s terrible to fail.”
• Rule: “Give up if a challenge seems too great.”
• Assumptions: “If I try to do something difficult, I’ll fail. If I avoid doing
it, I’ll be okay.”

• How do core beliefs and intermediate beliefs arise?
• Reader C had difficult parenting. His parents were never content with
his grades no matter how good they were. He was always compared
to his sibling who was far better in academics then him. So growing
up in that kind of environment he started believing that he is
incompetent and dumb.

• When patients’ beliefs are entrenched, you can lose credibility and
endanger the therapeutic alliance if you question the validity of core
beliefs too early.
• The usual course of treatment in cognitive behavior therapy,
therefore, involves an initial emphasis on identifying and modifying
automatic thoughts that derive from the core beliefs.

Behavioral Activation
• One of the most important initial goals for depressed patients is
scheduling activities.
• Most have withdrawn from at least some activities that had
previously given them a sense of achievement or pleasure and lifted
their mood.
• And they frequently have increased certain behaviors (staying in bed,
watching television, sitting around) that maintain or increase their
current dysphoria.

• Situation: Thinking about initiating an activity
• [Common] Automatic thoughts: “I’m too tired. I won’t enjoy it. My
friends won’t want to spend time with me. I won’t be able to do it.
Nothing can help me feel better.”
• Behavioral Activation
• [Common] Emotional reactions: Sadness, anxiety, hopelessness
• [Common] Behavior: Remain inactive.

• Situation: Engaging in an activity
• [Common] Automatic thoughts: “I’m doing a terrible job. I should
have done this long ago. There’s still so much left to do. I can’t do this
as well as I used to. This used to be more fun. I don’t deserve to be
doing this.”
• [Common] Emotional reactions: Sadness, guilt, anger at self
• [Common] Behaviors: Stop the activity. Push self beyond a reasonable
point. Fail to repeat this activity in the future.

• Perhaps the easiest and quickest way to get patients behaviorally
activated is to review their typical daily schedule

Graded task assignment
• Break down an activity into a series of smaller, more manageable
steps. The patient is encouraged to initially attempt to complete the
first step only. Once that step has been completed, the patient can
move on to the next step.
• Example: If the task is to prepare meal it can be divided into individual
steps like
• Step 1 – decide what to prepare
• Step 2 – buy groceries

Graded task assignment
• Step 3 – make the necessary preparations
• Step 4 – Prepare meal

Other techniques in CBT
Re-attribution
• A common cognitive pattern in depression involves incorrectly
assigning the blame or responsibility for adverse events to oneself.
Clients especially depressed patients are particularly prone to blaming
themselves.
• ‘Re-attribution’ can be used when a young person unrealistically
blames themselves for occurrences.

Diary Keeping
• records of cognitions are most likely to be accurate if they are made
at or near the time the thought occurs.
• The records can range from simply counting thoughts also.
• The client is encouraged to tune into relevant thoughts, stand back
from them and ultimately evaluate them.

Reality testing
• This involves examining the evidence for a thought or belief
• Reviewing the existing evidence of the predicted outcome
• Planning an appropriate experimental strategy to test out the validity
of the prediction.
• Noting and learning from the results
• Drawing specific conclusions from the experimentation.

• Behavioural Rehearsal:
• Any behavioural plan that the therapist can ask the patient to
complete outside therapy can first be rehearsed in a treatment
session to
• check on the patient’s ability to carry out the activity,
• practice behavioural skills,
• give feedback to the patient,
• spot potential roadblocks, and
• coach the patient on ways to ensure that the plan will have a positive
outcome.

Thought Stopping
It aims to stop the process of negative thinking and replace it with
more positive or adaptive thoughts. Procedures for thought stopping
are as follows:
• Recognize that a dysfunctional thought process is active.
• Give self-command to stop the thought – for example, tell yourself in
commanding tone, “Stop!” or “Quit thinking that way!” The
command can either be an internal thought or spoken aloud.

• Evoke a visual image to reinforce the command, such as a stop sign, a
red traffic light, or the gloved hand to the police officer directing
traffic.

• Switch the image from stop sign to a pleasant or relaxing scene. The
image should be something created in the mind such as a vacation
memory, the face of a pleasant person, or a photograph or painting
one has seen.

Setting up Sessions
The Evaluation Session
• Formulate the case and create an initial cognitive conceptualization of
the patient.
• Determine whether you will be an appropriate therapist.
• Determine whether you can provide the appropriate “dose” of
therapy (e.g., if you are able to provide only weekly therapy but the
patient requires a day program).

Setting up Sessions
• Determine whether adjunctive treatment or services (such as
medication) may be indicated.
• Initiate a therapeutic alliance with the patient (and with family
members, if relevant).
• Begin to socialize the patient into the structure and process of
therapy.
• Identify important problems and set broad goals.

Setting up Sessions
• Do a mood check.
• Set goals.
• Start working on a problem.
• Set homework.
• Elicit feedback.

Subsequent sessions
• Reestablish rapport.
• Mood Check
• Review homework.
• Elicit the names of problems patients want help in solving.
• Collect data that may indicate other important problem areas to
discuss.
• Prioritize the problems on the agenda.

CBT in OCD
• Cognitive models propose that intrusive thoughts, images, or urges
develop into obsessions when they are given excessive negative
importance.
• For instance, a woman has an image of dropping her baby and
believes,
• “(Having images of dropping my baby means) I’m a bad person and I
will lose control and do it.” These beliefs are referred to as fusion
beliefs.
• The aforementioned intrusion is a thought-action fusion as the
individual believes thinking about performing an action can cause the
action to occur.

CBT in OCD
• A related process is ‘moral thought–action fusion’, which is the belief
that thinking about a bad action is morally equivalent to doing it.
• Other fusion beliefs are thought-event fusion (thinking about an
event means it will or has already happened)
• Lastly, there is ‘thought–object fusion’, which is a belief that objects
can become contaminated by ‘catching’ memories or other people’s
experiences (Gwilliam et al, 2004).

CBT in OCD
• The content of intrusions usually violates patients’ deeply held values
and may be related to earlier experiences.
• For example, the woman who imagined herself dropping her baby
had taken care of a younger sibling when she grew up. Her mother
had frequently told her to be extremely careful when handling her
young sibling.

CBT in OCD
• Focus of attention is allocated toward intrusive thoughts as they are
assigned excessive importance.
• One of the core features of OCD is an overinflated sense of
responsibility for harm or its prevention. Responsibility is defined
here as: ‘The belief that one has power that is pivotal to bring about
or prevent subjectively crucial negative outcomes.

CBT in OCD
• Take the example of Sheela, a woman with OCD who has
intrusive thoughts of molesting a child.
• Therapist: ‘I want to see if we can build a better
understanding of what your problem is and therefore how to
solve it. It seems to me there are two explanations to test
out.

CBT in OCD
• The first explanation, which I will call theory A, is the one you
have been using for the past few years, that is, the problem
is that you are a paedophile.
• Theory B, which we would like to test out in therapy, is that
you are extremely worried about being a paedophile and in
your values care very deeply about children.

CBT in OCD
• theory A makes the worry and distress about being a
paedophile worse
• Would you be prepared to act as if it was theory B for at least
3 months and then review your progress?

CBT in Schizophrenia
• The negative symptoms of schizophrenia are mediated, at least in
part, by dysfunctional beliefs:
• “I’m helpless,”
• “I’m unlikeable,”
• “There’s no use in engaging with others because they’ll just reject me,”
• “If I try to be productive, I’ll just fail.”
• Individuals with this disorder tend to isolate themselves and avoid
tasks they view as challenging, even some fundamental activities of
daily living.

• Delusions are believed to develop, in part, due to information
processing biases, cognitive errors, and impaired reality testing.
• Individuals experiencing delusions tend to have a self-referential bias,
perceiving themselves to be the center and central focus of events,
while also interpreting their subjective experiences as having an
external causation.

• For example, an individual sees a commercial for cereal on television
and thinks that it was aired solely for him because he has eaten that
specific cereal in the past.
• He then stays up most of the night trying to figure out why the
commercial was aired, feels tired, and attributes being tired to
someone putting drugs in his food.

• Impaired reality testing, or the inability to distance oneself from
beliefs and interpretations to consider whether they are accurate, is
believed to be related to limited cognitive resources in these
individuals.
• Individuals may not fully accept their delusion as true initially, but
over time they selectively attend to information they believe confirms
the delusion and do not consider evidence that contradicts their
belief.

• A cognitive model of hallucinations describes factors that are
precursors to hallucinations, lead individuals to fixate on them, and
then maintain their occurrence.
• One predisposing factor is a low threshold for internal auditory and
visual imagining that seems real or almost real.
• This low threshold interacts with activated cognitive schemas that
produce cognitions related to the schema and not to reality

• For instance, an individual with a “failure” schema may have an
intrusive, automatic thought that is perceived as an auditory
hallucination saying, “You can’t do anything right.”
• The hallucination is perceived as coming from an external source due
to externalization bias, cognitive errors, and impaired reality testing.

Summary
• CBT focuses on challenging and changing cognitive distortions (e.g.
thoughts, beliefs, and attitudes) and behaviors, improving emotional
regulation, and the development of personal coping strategies that
target solving current problems.
• Though it was originally designed to treat depression, its uses have
been expanded to include the treatment of a number of mental
health conditions, including OCD, anxiety etc.

References
• Sadock B, Sadock V, Ruiz P. Kaplan & Saddocks comprehensive
textbook of psychiatry, volume 1 and 2. 10th ed. Philadelphia:
Lippincott Williams and Wilkins; 2009.
• Beck J, Beck A. Cognitive behavior therapy: basics and beyond.
• Colin Hughes, Stephen Herron and Joanne Younge, CBT for Mild to
Moderate Depression and Anxiety.
• Veale D. Cognitive–behavioural therapy for obsessive–compulsive
disorder. Advances in Psychiatric Treatment. 2007;13(6):438-446.

“The stronger person is not the
one making the most noise but
the one who can quietly direct
the conversation toward
defining and solving
problems.”
Aaron Beck
(uly 18, 1921 – November 1,
2021)
Thank You

Cognitive Behavioral Therapy

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