Behaviour Therapy
&
Cognitive-Behaviour Therapy
An Introduction for Psychiatric Registrars
Frank McDonald
Consultation-Liaison Psychologist
www.fmcdonald.com
The Townsville Hospital
June 2002
Web V.02.6.22
Aims
1.
2.
3.
4.
5.
Introduce theoretical premises of Behaviour Therapy & CognitiveBehaviour Therapy
Describe behavioural case formulations - how they flow from a
complete Behavioural Analysis & their value
Describe a range of Behavioural & CBT treatments - ‘nuts & bolts’
of some psychological techniques
Provide supplementary material
a.
b.
c.
therapist & pt written info material
videos of strategies for mx of panic & depression (not on Web version)
self-help & professional literature & Web references
Check transfer of learning - discussion of medical practice case
vignettes in which knowledge of strategies from learning theory
based therapy may be helpful
2
BT & CBT Overview
Click action button to advance to section
1.
2.
3.
4.
5.
Paradigmatic bases of CBT & BT
Distinguishing characteristics of CBT & BT
Suitable disorders and problems
Behavioural analysis – the etiological inquiry
Survey of strategies for common conditions
3
BT & CBT Overview
6. Examples of specific behavioural strategies
a.
b.
c.
d.
e.
f.
Exposure therapy for anxiety disorders
Behavioural responses to panic symptoms
Activity scheduling for depression
Behavioural management of chronic pain
Behavioural marital counselling
Token economies for children
4
BT & CBT Overview
7. Examples of cognitive-behavioural strategies
a. Anxiety
b. Depression
c. Pain
8. Your comment on how CBT & Behaviour
Therapy may help with pt problems in some
psychiatric practice scenarios
9. References & Resource materials
10. Credits
5
1. Theory And Paradigm Bases
•
Both therapies derived from Learning Theory and
share some premises Pt’s problems are, at least in part,
I. causally related to antecedent events,
II. a result of reinforcing consequences,
III. a result of dysfunctional thoughts or behavioural
deficits.
IV. And a pt’s condition is, at least in part, treatable by
specific cognitive or behavioural techniques
(Sperry et al., 1992)
6
1. Theory And Paradigm Bases
• Both BT & CBT aim to modify or eliminate maladaptive
•
•
thoughts, feelings and behaviours
However their paths to this same goal differ (i.e.
different therapeutic targets and rx strategies)
Reflects differing paradigmatic bases
7
1. Theory And Paradigm Bases
• Behaviourists say “change behaviour (&/or environment)
•
- changes in thoughts & feelings follow”
Cognitivists say “change thoughts, images, etc
(cognitions) - changes in feelings & behaviour follow”
8
1. Theory And Paradigm Bases
1. Conditioning paradigm – “experiences & action”
Two subclasses
Classical conditioning
Operant conditioning
2. Cognitive-behavioural paradigm – “internal representation”
For further discussion & examples see separate notes.
Click here
(Document links require a PDF reader.)
9
2. Characteristics of CBT &
Behaviour Therapy
What distinguishes Learning Theory based
therapies?
I.
II.
III.
IV.
V.
Psycho-educational format
Systematic measurement
Individually-tailored, structured treatment
‘Home assignments’
Ultimate aim of self-management and self-control
10
3. Some conditions suitable for
BT & CBT
• Anxiety disorders
•
•
•
•
•
•
•
•
•
•
(PD +/- A, OCD, GAD, PTSD, Social & Specific Phobias)
Depression
Chronic pain
Social skills deficits
Marital/relationship problems
Sexual problems
Children’s behaviour problems
Eating disorders
Habit disorders (e.g. sleep disturbances, smoking)
Abnormal grief reactions
Anger problems
11
4. Behavioural Analysis –
The Etiological Inquiry
• BT & CBT not just a bunch of routinely applied
•
procedures such as response prevention, exposure
therapy, cognitive restructuring etc
Good BT & CBT rests on thorough Behavioural Analysis
of how problem began & why continues
12
4. Behavioural Analysis –
The Etiological Inquiry
• Behavioural Analysis – a search for all relevant
•
antecedents (recent & remote), concomitants &
consequences – the ‘before, during & after’
contingencies
More specifically, stimulus-response links – both
personal (cognitions, autonomic & behavioural
responses) & environmental – associated with problem.
Guides therapy
13
4. Behavioural Analysis –
The Etiological Inquiry
• Analysis & therapy lie in the context of a supportive
•
relationship
Despite apparent technical nature of BT & CBT, research
says ‘warm’ therapists get significantly better results
than ‘cold’ therapists. Even in more mechanical
treatments like graded exposure therapy for phobias
14
4. Behavioural Analysis –
The Etiological Inquiry
• Irrespective of paradigm, behavioural analysis a sine qua
non of learning theory based therapies
• Hypotheses formulated about precise variables
•
controlling problem so as to suggest treatment.
Reduces chances of ‘trial & error’ therapy
Hypotheses tested by outcomes – reformulated if
unsupported, loop-fashion, until success
15
4. Behavioural Analysis –
The Etiological Inquiry
• Treatment targets are specified in strict operational,
•
•
measurable terms – not vague language like “less anxious”
– a hallmark of behaviour therapies
Treatment target options: change causes, change
responses, change both or environment
Changing environment often produces quickest, most
efficient improvement in feelings
16
4. Behavioural Analysis –
The Etiological Inquiry
• Treatment is basically hypothesis testing of testable
•
constructs
Click on links for ‘Behavioural Analysis’ notes for
expansion and for example matrix to guide assessment
17
5. Survey of BT & CBT Techniques
for Common Conditions
• Anxiety
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–
–
–
–
–
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Breathing retraining
Relaxation training
Graded exposure therapy
Flooding (rarely used)
Response prevention (extinction)
Cognitive restructuring strategies
Structured problem solving
18
5. Survey of BT & CBT Techniques
for Common Conditions
• Anxiety (cont’d)
•
– Meditation
– Assertiveness Training / Social Skills Training
– Stimulus control
– Eye Movement Desensitisation Reprocessing
– Thought stopping
To see how anxiety disorders are treated using
psychological strategies on a disorder by disorder basis
click here
19
5. Survey of BT & CBT Techniques
for Common Conditions
• Depression
– Cognitive Therapy for ways of thinking common to
depression (e.g. 3 P’s – ‘permanent, pervasive &
personal’)
– Activity scheduling – gradually increasing pleasurable
and achievement events
– Structured Problem Solving
– Social skills training/Assertiveness training to
increase social rewards
– Consider involving family/partner in therapy
20
5. Survey of BT & CBT Techniques
for Common Conditions
• Habit Disorders/Addictive behaviours
(e.g. Primary Insomnia, smoking)
–
–
–
–
–
–
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Stimulus control
Relaxation/ imagery/ autosuggestion
Environmental changes
Self-reward
Self-monitoring
Aversion therapy
Saturation (extinction)
21
5. Survey of BT & CBT Techniques
for Common Conditions
• Social Skills Deficits
–
–
–
–
–
–
–
Behaviour modelling
Covert modelling
Behaviour rehearsal
Role playing
Assertiveness Training
Social Skills Training (e.g. conversational skills)
Communication Skills Training (e.g. listening,
negotiation, conflict resolution)
22
5. Survey of BT & CBT Techniques
for Common Conditions
• Chronic Pain
–
–
–
–
–
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Goal setting
Self-monitoring
Pacing
Graded physical conditioning
Relaxation for any tension component
Emotion defusing strategies (for frustration, anxiety
etc)
23
5. Survey of BT & CBT Techniques
for Common Conditions
• Chronic Pain (cont’d)
–
–
–
–
–
Autosuggestion/self-hypnosis
Structured problem solving
Distraction (more suited to acute pain)
Meditation
Assertiveness Training (e.g. making/refusing requests
given physical limitations)
– Depression management strategies
24
5. Survey of BT & CBT Techniques
for Common Conditions
• Relationship Difficulties
– Communication Skills training
• Basic –
Listening, validating, levelling
• Intermediate – Assertiveness training
• Advanced –
Negotiation skills (win/win)
Conflict resolution skills
• Reciprocity counselling (quid pro quo agreements)
• Miscellaneous
– Token economies
– Behavioural exchange contracts
25
6. Behavioural Strategies
• A. Exposure therapy for
Fear
anxiety (used in OCD,
PTSD, PD+A, Specific and
Social Phobia)
– Exposure to anxiety in
graded fashion. Identify
specific goals and break
them into smaller,
manageable steps
Relax
STOP
Relax
Relax
Relax
Relax
STOP
STOP
STOP
STOP
Relax
STOP
The Principle of Exposure Therapy
26
6. Behavioural Strategies
– Learn to master
situations that cause
mild, then gradually
greater, anxiety. Teach
& test a relaxation
strategy before to
reduce distress/panic
during exposure
– Aim is to achieve
relative relaxation
before next step
Fear
Relax
STOP
Relax
Relax
Relax
Relax
STOP
STOP
STOP
STOP
Relax
STOP
The Principle of Exposure Therapy
27
6. Behavioural Strategies
•
– Principle: best way to overcome fear is to face it, but
in ways research says are more likely to succeed
– Emphasise habituation to anxiety in each exposure
session. Biggest trap is to flee a step at height of fear
(re-forges association of situation & fear)
– Confront fears regularly and frequently
See ‘Exposure Therapy’ notes
Click here for pt notes
Click here for therapist notes
28
6. Behavioural Strategies
• Example of graded exposure hierarchy for
Agoraphobia or Social Phobia
– Goal: To travel alone by bus to the city and back
1.Travelling
2.Travelling
3.Travelling
4.Travelling
5.Travelling
6.Travelling
7.Travelling
one stop, quiet time of day (anxiety level 4/10)
two stops, quiet time of day
two stops, rush hour (anxiety level 6/10)
five stops, quiet time of day
five stops, rush hour (anxiety level 8/10)
all the way, quiet time of day
all the way, rush hour (anxiety level 10/10)
29
6. Behavioural Strategies
• Some pts with Social Phobia may need assistance with
•
•
developing social skills
Click here for Conversational Skills material
Click here for pt introduction to Assertiveness Training
Click here for list of Assertiveness Techniques
Click here for Conflict Resolution strategies
Model & role play to aid generalisation (role play practice
the core element of any social skill development)
30
6. Behavioural Strategies
• B. Teaching behavioural responses to early symptoms of
panic
– After education about panic, pt’s breathing is retrained
– Slow, steady breathing is central to controlling panic.
Regular daily practice set up
– Strategies applied at earliest symptom in selfmonitoring framework
– Prof. Gavin Andrews on hyperventilation control.
See References to purchase CD-ROM video via
CRUfAD Web address
– See pt guide ‘Panic Attacks!’ Click here
31
6. Behavioural Strategies
•
1.
2.
3.
4.
5.
•
Videos below (Andrews & Hunt, 1998) on mx of panic in
General Practice, demonstrate a learning theory
framework & psychological research on the issue
Patient presentation
Assessing antecedents and consequences
Psycho-educational phase
Breathing retraining discussion & ‘homework’ assignment
Behaviour rehearsal & real-world generalisation
Videos not available on Web.
See References for purchase details of complete clinical
skills program on CD-ROM available via CRUfAD Web
address in References
32
6. Behavioural Strategies
• C. Behavioural management of depression
Main psychological approaches
– Cognitive Therapy (see CBT section)
– Structured problem solving (see CBT section)
– Activity Scheduling
• Ask pt about recent frequency of activities that
gave sense of pleasure or achievement – either
or both often unusually low in depressed pts
• Encourage achievable, gradual increases each
day.
• See list of suggested Pleasant Activities
Click here
33
6. Behavioural Strategies
• D. Behavioural management of Chronic Pain
– Set specific adjustment goals. For suggestions on goal
planning click here. Blank goal sheet - click here
– Increase behaviours associated with adjustment to
chronic pain. For guidelines click here and for more
comprehensive guidelines on targets & rx’s click here
– Baseline activity levels via pain diary. Raise or lower
these according to principles of pacing. Click links for
initial pain diary cover and follow-up diary cover and
blanks for each day & evening of the baseline periods
34
6. Behavioural Strategies
– Build stamina with appropriate exercise. Behaviourists
start exercise below current capacities to avoid
association with pain before habits established
– Click links for movement guidelines & movement diary
35
6. Behavioural Strategies
• E. Behavioural Marital Counselling
– Reciprocity Counselling focuses on couples forming
quid pro quo agreements about highly specific
desirable changes by partner
– Reciprocal agreements prevent either partner feeling
any unfairness about change
– Click links for guidelines & home monitoring sheets
36
6. Behavioural Strategies
• F. Token Economy
– Mainly for children & young adolescents
– Makes a game of home discipline. Reduces emotionality
of parents. Adds objectivity to task. Reciprocal control in
that child can manage parent. Gets around imbalance of
power problem in some behavioural programs
– Fade to more natural contingencies as habits established
– See example
– Can be adapted to closed institutional settings i.e. where
access to privileges outside closed system difficult
See example
37
7. Cognitive-Behavioural Strategies
• A. Cognitive Therapy for Anxiety
– Explain cognitive restructuring to pts who potentially
can ‘think about their thinking’ - role of specific
thoughts, thinking styles & core beliefs. Supplement
with info sheets / recommended reading
Click here for samples
– Teach strategies
• Diary disputation / self-challenge of troublesome
cognitions. Better than therapist persuasion, direct
argument. Variation on role reversal strategy
espoused by social psychologists for modifying
attitudes. Model examples first using ‘thinking out
loud’
38
7. Cognitive-Behavioural Strategies
• Click here for disputing tips, example & blank ‘Daily
Stress & Tension Log’.
• Cards with anti-worry statements / self-directions
referred to regularly (principle of overlearning).
Click here for example - ‘Coping with Worrying
Thoughts’ and other ‘Managing Worry’ strategies
• Reframing (alternative perspective taking). Examples:
– “How would a reasonable person view same
situation?”
– Relate emotional reaction to point on a
‘Catastrophe Scale.’ Click here for pt info sheet
39
7. Cognitive-Behavioural Strategies
• Thought stopping. Click here for description. Use
with other ‘Managing Worry’ strategies
• Powerful, brief coping self-statements pt believes
to be true. Rapid, abbreviated form of earlier,
more complex disputation e.g. “Feelings are not
facts!” “Shit happens!” “Shouldhood is shithood!”
“I’m musterbating again!” “I am a fallible human
being who can therefore make mistakes, & some
of them, big ones!”
Click here for pt info sheet
40
7. Cognitive-Behavioural Strategies
• Meditation (conditions switching off “what if?”
thinking in GAD, “futurising” type problems)
– Start with a one minute meditation exercise.
Model out loud own multisensory awarenesses,
moment to moment, free from any positive or
negative judgments / adjectival speech
– Pt tries same for similar period out loud initially
& gradually increases time during repeated
home assignments e.g. eventually long enough
for hypnogogic phase of sleep to start
41
7. Cognitive-Behavioural Strategies
• Guided Imagery. Used for relaxation, enhancing
performance or imaginal confronting of avoided
stimuli, obsessional cues, trauma recollections often in graded exposure fashion e.g. sees self
extending travel radii from home
– Can be intensified in hypnotic state or with
associated cues e.g. vehicle crashes or aircraft
sound effects recordings. Search Web for these
42
7. Cognitive-Behavioural Strategies
– In confrontive applications, cognitive & somatic
counter-conditioning imperative before pt
leaves session. Otherwise in vitro exposure
resensitises rather than desensitises
– See Sleeping Better pt notes for example of
relaxing Guided Imagery technique (‘Counting
Down to Sleep’)
43
7. Cognitive-Behavioural Strategies
• Distraction (GAD, acute pain etc not when
extinction needed e.g. specific phobias, P.D.+A.,
PTSD)
• Rational emotive imagery. Maultsby’s technique pts simply instructed to “push” themselves to feel
better over a minute or so then articulate how they
did it. (Usually with more rational thinking that
provides starting point for further practice)
44
7. Cognitive-Behavioural Strategies
• Structured problem solving (common skill deficit in
worriers). Applied common sense. New variation
on old “Think, judge, act” rule of conduct. Again
see ‘Managing Worry’ pt info sheets pp. 5-6
• See Video examples (Andrews & Hunt, 1998) of
structured problem solving with anxious pts on CDROM available via CRUfAD Web address in
References
45
7. Cognitive-Behavioural Strategies
• B. Cognitive Therapy for Depression
– As for CBT for anxiety, explain cognitive restructuring
for depression to pt. Role of specific thoughts,
thinking styles & core beliefs.
– Perhaps start with examples of common thinking
styles seen in those more prone to depression e.g.
Seligman’s 3P’s of adversity “permanent, personal &
pervasive” as they apply to the cognitive triad of
depression – future, self & the world
46
7. Cognitive-Behavioural Strategies
– Supplement with info sheets / recommended reading.
Click here for pt. info sheet on Ellis’s ABC model.
Probably easiest of cognitive therapies for pts to
understand. Info sheet focus: understanding &
modifying specific thoughts associated with
depression
– Visit Albert Ellis Institute for more on Ellis’s Rational
Emotive Behaviour Therapy
– Work thru structured program material with pt. Keep
demands low at first because of problems with
concentration, lethargy etc.
47
7. Cognitive-Behavioural Strategies
– Pt material on raising activity levels & modifying
depressive cognitions from Oxford University
Psychology Dept click here (Melanie Fennell in
Hawton et al., 1989)
• Structured problem solving for depression
– Click here for single sheet description of technique.
Present sheet to pt in session to aid application
48
7. Cognitive-Behavioural Strategies
• C. Cognitive Therapy for Chronic Pain
– Click here to see list of common thoughts
& associated feelings that can worsen pain
– Click here to see some suggested disputations of
thoughts that can worsen pain
49
7. Cognitive-Behavioural Strategies
– Cognitive therapy for self-defeating thoughts relies on
usual strategies such as ‘diarying’ & disputation
– Hypnotherapy (perhaps the oldest cognitive therapy)
seen by many pts as useful. A daily ½ hour selfhypnosis session can provide a welcome break from
constancy of pain
Click here for list that includes other cognitive (&
behavioural) pain mx strategies
Click here for more details on cognitive treatment,
targets, strategies & their rationales (go to page 6 for
cognitive treatments etc)
50
8. Psychiatric Practice Scenarios:
How Can Behaviour Therapy & CBT
Help?
• 1. As a psychiatric
registrar you see many
patients whose primary
complaint is that they are
"unable to sleep." Discuss
the most common
reasons for this
presentation. How would
you evaluate such a
problem and how might
you treat it using learning
theory principles?
(exclude ‘therapist
modelling’ as per pic)
51
8. How Can Behaviour Therapy &
CBT Help?
• 2. Ms A is a 45 year old woman who presents at mid-
morning to Emergency Dept. complaining of nausea and
anxiety. She had been unable to sleep the previous
night because she had run out of her usual sleeping
tablets (Temazepam). She has been taking up to 4
tablets (10mg) nightly for several months as her
insomnia had worsened. She had increased the dose
herself as her doctor had refused to do so and she had
resorted to visiting more than one doctor. She admits to
being somewhat anxious and depressed in mood at
times and to having difficulty concentrating on her work.
She denies taking any other drugs.
52
8. How Can Behaviour Therapy &
CBT Help?
• 3. Describe and discuss the various treatments that are
currently used in the treatment of Panic Disorder with
Agoraphobia.
53
8. How Can Behaviour Therapy &
CBT Help?
• 4. You are treating a 45 year old man with chronic low
back pain. He is requiring increasingly frequent
pethidine injections and appears depressed and tearful.
He says he can no longer cope with the pain. How do
you approach this problem?
54
8. How Can Behaviour Therapy &
CBT Help?
•
5. A rather shy and introverted Engineering Student
attends your outpatient clinic and tells you that he
can't present his assignments in front of his seminar
group. How can you as his psychiatric registrar help
him?
55
9. Reference Material
• Andrews, G. and Hunt, C. (1998) Counselling and Management Skills
in Clinical Practice. (CD-ROM) Clinical Unit for Research of Anxiety
Disorders (Web link next page for purchase), UNSW Psychiatry – St.
Vincent’s Hospital, Sydney, NSW, Australia
• Hawton, K., Salkovskis,P. et al.(1989) Cognitive Behaviour Therapy
for Psychiatric Problems: A Practical Guide. Oxford University Press.
• Sperry, L. et al. (1992) Chapter 4 ‘Behavioral Formulations’ in
Psychiatric Case Formulations. American Psychiatric Press,
Washington
• Treatment Protocol Project (1997) Management of Mental Disorders.
WHO Collaborating Centre for Mental Health and Substance Abuse,
Darlinghurst, NSW, Australia 2010
56
9. Reference Material
• Clinical Research Unit for Anxiety Disorders (CRUfAD) Website
A UNSW site with excellent anxiety resources for pts and
professionals. Free treatment manuals, CBT teaching resources,
assessment protocols, self-test, CD-ROM, videos, links etc
http://www.crufad.com/homepage.htm
• MoodGym
Excellent self-paced web program for behavioural & CBT of
depression (mainly) and anxiety. Downloadable relaxation
instructions and music http://moodgym.anu.edu.au/
57