Northumberland, Tyne and Wear
NHS Foundation Trust
Foundation in Cognitive
Behaviour Therapy
Newcastle Cognitive and Behavioural
Therapies Centre
Dr. Sally Standart
MRCPsych 2011
1
Aims of the Course
• To ask - What is CBT?
– This is an introduction to CBT; we won’t be covering all aspects of
treatment using CBT
– Is CBT for me?” How well does it fit my needs, aspirations etc?
• To get to know the model by reflecting on our own
reactions in thoughts, feelings, behaviour
• To get a taster of the basics of CBT theory
• What kind of conversation goes on in CBT?
– An introduction to Socratic dialogue.
• How to socialise the client to the session structure
2
Your objectives for the course…
• What would you like to get out of the next 2 afternoons?
• Are there any particular questions you would like us to
try and address?
– Let’s see if we can collaboratively address them…
3
What is CBT?
• It may be more accurate & helpful to think of “the C & B
T’s”
– No one single set of interventions; A family of theories and
practices
– A mixed marriage of two fundamentally different theory sets:
• Behaviourism – theory built on observable environment–organism
interactions
• “Cognitivism” – theory built on the understanding that people
perpetually interpret their environment & feel & act accordingly
– This workshop is going to major on this second side of the
“family” – group members going on in CBT training should
become well acquainted with Behavioural theory and practice
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The basic theory
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What is CBT?
“We are what we think. All that we are arises
with our thoughts. With our thoughts we
make the world.”
GAUTAMA BUDDHA, Dhammapada
Agree? Disagree? What did he mean?
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Exercise
• Spotting our own automatic thoughts:
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Exercise……..
• What was going through your mind when you knew what
the exercise was?
–
–
–
–
Words…
Pictures…
Sounds…
Memories…
• How did you feel physically?
• Did you do anything to prepare for the noise?
• Take some time and write down your responses-there is
no right or wrong answer
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Discussion…………..
• What were you focussing on most?
• Did you have any urges to act?
–
–
–
–
leave the room,
move away
Interrupt the exercise
Laugh it off
• If yes, what were you trying to achieve (e.g. Were you concerned
about how you might react in front of the group?)
• Did the way you were your thinking change?
–
–
–
–
Speed up?
Get less clear?
Go round in circles?
Shift to the future?
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Observations
• In response to being told the balloon would pop – we
reacted
• Our immediate thoughts were instant – not thought out
or considered
• We experienced physical changes
• Emotions altered
• We had the urge to do something
• Our attention was focussed on the balloon, or ourselves,
or the rest of the group
• Our memory accessed previous similar experiences
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Emotions and Actions
• When we feel a certain way we tend to act accordingly.
• E.g. - It’s been a long, tiring, stressful week. We might
put off going out with friends and stay home on our own
with a few drinks instead
• We tend to notice our emotions and what we do before
our thoughts
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Exercise 2
• Think about a time recently when you felt a bit
down, stressed or tired.
• Can you recall:
– What you did as a result?
– What you were thinking at the time?
• Is one easier to recall than the other?
• When you pause to reflect now, does anything
come to mind more clearly?
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How does this relate to CBT?
• The way we think can affect how we feel emotionally,
physically and what we do.
• When distressed our thinking tends to change.
• Thoughts can become extreme, worsening how we feel.
• We may then behave in a way that prolongs their
distress
• Psychological ailments can be understood as persistent
stuck patterns of thinking, feeling and acting that obstruct
an individual’s need to change
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So what does CBT do?
• …helps clients recognise their own thoughts, feelings
and ways of coping with everyday situations that have
become problematic
• …helps clients understand the links between thoughts,
feelings and reactions
• …helps clients find and test out new, more helpful ways
of thinking and doing for themselves
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“models” in CBT
• Because CBT seeks to treat a range of different
problems, there are many disorder-specific models.
–
–
–
–
–
–
Depression
Panic, Social Anxiety, OCD, GAD, PTSD
Eating Disorders
Delusions
Voices
Personality disorders
• In this workshop we’re focussing on the generic model
underpinning these, derived from the work of Aaron T.
Beck
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What do we mean by “Cognitive”?
situation
What I
notice
Cognition
What I think
about it
How I think
about it
How I
remember
What I
remember
How I react
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An illustration of the Cognitive Behavioural Model
situation
“thinking”
Behaviour
emotions
Physical
reactions
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An illustration of the Cognitive Behavioural Model
Balloon Exercise
“What if I make a fool of
myself”?
Heart rate
changes, get a
bit hot…
nervous
Hunch
shoulders, hold
breath
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Automatic Thoughts: What do we
mean?
• Raw, immediate, “the first thing that comes into my
mind” “gut reactions”, “hot” thoughts
• Emotion-laden
• Behaviour-driving
• More limited in scope than assumptions and beliefs
• So how does a CBTist help a client get hold of this
stuff?
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Exercise 3
• Think of someone you’ve been working with
recently
• Think of particular instance of raised emotion or
unhelpful behaviour
• Get specific – think about minutes rather than
days
• Can you put it together as per the previous
slides?
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Building our understanding
• Thus far we’ve only considered what happens in
the here-and-now
• But what do these here-and-now thoughts rest
on?
• In the examples from the previous, what is your
understanding of the background to the specific
episode?
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Purely here-and-now
Working
on essay
It’s no
good. I’ll
fail
Go back &
re-write
Miserable,
anxious
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A little background…
Working
on essay
Remember the
essays I messed
up
“It’s no good. Only
Worry
I’ll fail”
attend to about
mistakes failing
Go back &
re-write
Miserable,
anxious
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Balanced thinking & helpful action…
doing something
new
Limit rewriting
Working
on essay
Remember a range
of ok & poor essays
“It’s no good. Check
Worry
I’ll fail”
mistakes about
failing
& good
points
A bit miserable,
somewhat
anxious
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But if we have deeper-set ways of thinking…
Working on essay
Activates
assumption
I should do everything
well. Less than 100% =
failure
Appraises
performance
according to
rule
It’s no
good. I’ll
fail
Go back &
re-write
Miserable,
anxious
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& if we have yet deeper-set ways of thinking…
Working on essay
Fits with memory of
emotionally abusive
upbringing
Activates
assumption
“People are vicious”
I must do everything
perfectly or else
Appraises
performance
according to
belief
I’ll fail &
get
punished
Re-write?
Give up?
Miserable,
anxious
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Layers of cognition
• Automatic thoughts… tend to rest on assumptions &
rules… which tend to rest on our beliefs
• We tend not to notice our thoughts as readily as we
notice our emotions and actions
• Our rules, assumptions & beliefs tend to operate
implicitly rather than being explicitly voiced
• ATs are easier to access than underpinning assumptions
and beliefs
• CBT therefore typically deals with Behaviour and ATs
before deeper-set cognition
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Exercise 4
• Back to the previous example
• Can you suggest (you may know or need to hypothesize)
the rules, assumptions, beliefs underpinning the ATs?
• What do you know about the person’s life experience via
which these may have been learned?
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The basics of practice
CBT & Socratic Dialogue
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Role play demonstration
• Role play to demonstrate links between
thoughts, emotions, physical reactions and
behaviour.
• Look out for all of the above
• Does the information help make sense of the
client’s experience?
• What do you observe about the way the
therapist communicates?
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How the therapist helped the client
focus on ATs
• In the moment unhelpful behaviours are switching on
– E.g., “what were you thinking as you began to run away”?
• In the moment that you notice emotion rising
– E.g. “ What went through your mind in the moments you began
to feel scared”?
• In the moment of marked distressing physiological
changes
– E.g. “What were you most concerned about when you felt your
heart pounding”?
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The style of the dialogue
• What do you observe about the way the
therapist communicated?
32
What are Socratic Questions?
• Semi open (generally not “yes or no”
responses but directed to some extent)
•
•
•
•
•
•
•
What was happening just then?
What went through your mind?
What did that mean to you?
How did you feel?
What emotional impact did that have?
What physical symptoms did you have?
What did you do when you felt really upset?
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Questioning and Summaries
• CBT has a very distinctive style:
– An active, enquiring therapist
– Socratic questions.
– Frequent Summaries.
– Giving & getting Feedback.
– Building summaries into formulations as
dialogue progresses
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Feedback & Summaries
• Giving feedback…
•
– It sounds to me that…..
– Let me see if I have got this right….
– Have I understood this correctly?...
Getting Feedback…
– Have I missed anything important?
– How would you put that in your own words?
– Could you feed back your own understanding of what we’ve been
discussing?
– What things stand out as most important in our discussion so far?
– I’m not putting you on the spot, but I want to check that I’ve explained
things clearly, so could you summarise what’s been said so far?
• Putting it together
– Itt looks like things link up this way…
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Socratic questions
• Ask questions that the person is capable of answering
– Avoid “Why?” questions
– Ask sequences of simple questions rather than single
complex questions
• Summarise regularly (give and invite feedback)
– The longer the chain, the easier to get lost
– Don’t assume that client assent to your summary indicates
understanding
• Client should not feel interrogated by the therapist
– Take responsibility for the question your client can’t answer
– Remember your basic counselling & communication skills
– Focus on the problems you agree to tackle
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What’s useful about this style?
•
•
•
•
Collaborative
Specific
Promotes client-owned learning
Testing of hypotheses rather than
presuming you know
• Accesses theory without “fitting the patient
into boxes”
• Engages client, promotes shared
understanding
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Helping the client change
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Learning and Change
• CBT doesn’t simply seek understanding, but to change
– To open up stuck patterns of thought, feeling & behaviour
– To bring about new learning
– But people’s stuck patterns serve purposes (e.g. maintain a
sesne of sefety) so change can be anxiety provoking
• Goal orientation is therefore a key foundation to the
process
• Get your goals wrong & therapy has no sound
foundation
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Goals and Change
• Goals can be
– short-term (for this session),
– mid-term (for this course of sessions, this month…)
– Long-term (life)
• For therapy have a tangible, measured impact on the
client’s life goals need to be tangible, measurable &
achievable
• Well-set goals can
–
–
–
–
Guide learning
inspire hope
Build confidence
Establish teamwork
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Goal Setting
• Specific and achievable
• Designed to have a positive, consistent impact
on a client’s life
• Prepares the client for change through
consideration
• Allows for discussion of fears (often predictive
and testable)
• Informs a collaborative approach
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Role Play
• Observe therapist and client elicit,
formulate and set goals
• Discussion
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In Pairs
• Consider one or two specific goals that you
would like to set yourselves over the next week
– Avoid life-changers at this stage – we’re simply trying
to get at the way goals work
– Use previous slides as guide
– Phrase positively –i.e. what you want to achieve
– Can you come up with time settings?
43
How do we learn? Exercise…
• Consider some recent or pivotal learning in your own
experience
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Kolb’s Experiential Learning Theory
Concrete Experience:
doing/”hands-on” experience
Concrete
experience
Planning
Reflection
Reflection: standing back,
observing, reviewing the
experience
Conceptualisation: making
coherent sense of, coming to
conclusions from the experience
Planning: Trying a new/different
way of doing or thinking
Conceptualisation
Back to the next phase…
45
What kinds of learning happen in CBT?
• How current patterns are maintained, e.g.
– Via Safety-seeking behaviours that prevent us from checking out
the real level of risk
– Via mental behaviours (e.g. rumination) which take up vast
amounts of time & prevent us from getting new info into our
system
– Via depressive withdrawal & anxious avoidance
– Via reassurance-seeking rather than information-getting
– Via drugs alcohol etc
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What kinds of learning happen in CBT?
• How current thinking, feeling & acting is affected by
past experiences.
– Formulating to make sense
– Building client understanding & therapist empathy
– Helping to show how the present & the future can be different
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What kinds of learning happen in CBT?
• How to recognise what I am thinking
• How to recognise how I’m thinking
–
–
–
–
–
Overgeneralising
Catastrophising
Personalising
Ruminating
Worrying
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What kinds of learning happen in CBT?
• How to generate and use new thoughts and beliefs
– Thought diaries
– Data logs
– Re-evaluation methods
• How to work out new ways of thinking
– If I can spot rumination & worry, what alternatives can I employ?
– There I am personalising again, what’s a less personalised way
of looking at this?
• How to generate and practice new ways of behaving
– Reaction X doesn’t help; let’s try Y…
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Applying the theory in our work…
• Back to the examples we’ve used in our formulation
exercises…
• Based on the way we have formulated the person’s
problems what do they need to learn
– Re thoughts…
– Re behaviour…
• Try to frame their learning need as a goal
• Now consider the learning cycles they will need to go
through…
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Summary…
• CBT proposes that psychologically “stuck” states (illnesses, PD,
unhelpful habits, overly limited lifestyles, poor ways of managing
relationships…) can be understood in terms of enclosed cycles of
thinking, acting and feeling
• Depending on the severity, chronicity, complexity & breadth of these
states, the problem may be adequately explained in here-and-now
terms, or need a more “longitudinal” formulation
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Summary…
• Therapy works by
–
–
–
–
Forming an alliance based on shared goals
Exploring the client’s experience in Socratic terms
formulating the stuck state
Promoting learning that breaks unhelpful cycles and opens the client to
new learning
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How we organise therapy
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Structure
• Structure of both the sessions and the overall length of
treatment is informed by
–
–
–
–
–
Our goals
The learning methods we need to use
The learning speed of the client
The setting of therapy
The format of therapy
• If we forget that structure follows from the things we’re
trying to achieve, we’ll become rigid and rule-bound in
therapy
• Good structure can’t alone make good therapy, but bad
structure is a sure-fire way of ending up with bad therapy
54
Structure Exercise
• Observe the setting up of the discussion:
– How does the therapist get things started?
– How does this compare with how you tend to work at
present?
– What’s required of the client?
– What gets agreed?
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Structure -considerations
• Be clear about…
–
–
–
–
–
–
what are you and the client trying to achieve (be realistic!)
how long you have to work on it
what you’ll talk about
what you’ll do
the most important from the less important issues
(if you need to) allotting times for different items (to make sure
you work through things steadily)
• An agenda is not set in stone, so…
– Adjust as you need to & be clear about changes
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Structure continued….
• Session content is agreed collaboratively and will have discrete
junctures according to
– the needs & wishes of the client
– your goals in therapy
– your own professional know-how as a therapist
• Areas discussed will be likely to include
– a review of the week,
– mood check,
– homework review and new homework negotiation
– items that will follow naturally from the formulation
• Consider: how this might be used in your own service/role
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Conclusion
•
•
•
•
•
How well have we done in achieving our goals?
What have we learned about CBT?
About its application in your own work?
What attracts you to it (or not)?
Where you might go next…
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To consider…
• How has this helped inform you
knowledge about CBT?
• Would you like to take this curiosity
further?
• Has this aided your clinical work by
exploring processes?
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References
• Beck, Rush, Shaw, & Emery (1979)
Cognitive Therapy of Depression
• Kolb, D. A. (1984) Experiential Learning,
Englewood Cliffs, NJ.: Prentice Hall.
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