Samenvatting Cognitive Behavior Therapy, Third Edition - Introduction to cognitive behavioural therapies (PSB3E-KP07)
Short summary of Beck's 'Cognitive Behavioral Therapy' book for the CBT course
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Universiteit Utrecht (UU)
Clinical Psychology
Cognitive Behavior Therapy
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Inhalt
Lecture 1 Cognitive Behavior Therapy + Case formulation ................................................................... 2
The Why and What of CBT .................................................................................................................. 2
Functional Analysis .............................................................................................................................. 4
Topographical Analysis ........................................................................................................................ 8
Chapter 5: Linking assessment to treatment [Page, & Stritzke] ........................................................... 9
Behavioral case formulation: functional analysis................................................................................ 9
Cognitive behavioral case formulation................................................................................................ 9
Chapter 10: Case management [Page, & Stritzke]............................................................................... 10
Maintaining confidentiality ............................................................................................................... 10
Chapter 1: Introduction to CBT [Book by Beck] ................................................................................... 10
What is CBT?...................................................................................................................................... 10
The CBT Theoretical model ............................................................................................................... 10
Recovery-oriented cognitive therapy ................................................................................................ 10
Chapter 2: Overview of treatment [Book, Beck] ................................................................................. 11
Principles of CBT treatments ............................................................................................................. 11
Chapter 4: The Therapeutic Relationship [Book, Beck] ....................................................................... 13
Four essential guidelines ................................................................................................................... 13
Demonstrating good counseling skills ............................................................................................... 14
Monitoring client’s affect and eliciting feedback .............................................................................. 14
Collaborating with clients .................................................................................................................. 14
Using self-disclosure .......................................................................................................................... 14
Repairing ruptures ............................................................................................................................. 14
Managing negative reactions toward clients .................................................................................... 15
Chapter 5: The Evaluation Session [Book, Beck] ................................................................................. 15
Objectives for the evaluation session ............................................................................................... 15
Structure of the evaluation session................................................................................................... 15
Part 1: Starting the evaluation session .......................................................................................... 15
Part 2: Conducting the assessment ............................................................................................... 16
Part 3: Relating your diagnostic impressions, setting broad goals and relating your general
treatment plan .............................................................................................................................. 17
Part 4: Setting the action plan ....................................................................................................... 18
Part 5: Establishing expectations for treatment ........................................................................... 18
Part 6: Summarizing and eliciting feedback .................................................................................. 18
,Lecture 1 Cognitive Behavior Therapy + Case formulation
The Why and What of CBT
Basic principles of CBT
→Cognitive behavioral therapy is a systematic, action-oriented psychological treatment to improve
mental health.
→CBT focuses on challenging and changing unhelpful cognitions (e.g. thoughts, beliefs, and
attitudes), behaviors, and emotions.
→It can be seen as a very broad umbrella term; that encompasses several types of treatments,
including the more cognitive focused variant by Beck, but also exposure, behavioral activation (BA),
and is related to EMDR, Mindfulness, ACT, EFT etc.
→CBT is evidence-based treatment for many disorders, including depression, anxiety, PTSD, OCD,
tics, substance abuse, and also for example psychotic disorders.
Cognitions, Behaviors and Emotions/Physiology are interconnected
→Behavior techniques can change cognition
→Cognition: What you think → Emotion: How you feel → Behavior: What you do or do not
➔ They are all interconnected and influence each other
The Case Formulation approach
-no direct link between problem patient presented
and the treatment (treatment plan)
-focus on understanding why(detective work!)
-why continue drinking despite the many
negative consequences (divorce,
unemployment, health issues)
-why so much fighting, while the couple
also loves each other dearly
-develop hypotheses (see also Book Beck)
-based on individual analyses
-information gathering
→how, what happened before/after
→sometimes no answer: register the situation
to get a better understanding of the factors.
EXAMPLE for aggression you can use a
registration assignment to know more about
he or she see this situation eg smn bumps into
him and how does the patient receive this
situation hence interpretation bias? thus get
more detail into the problem
-link to theoretical models
,Case Formualtion approach EXAMPLE
→maybe addiction treatment (hence focus on the drinking problem)
→James Reason is a coping mechanism against traumatic events and Pete does it do socialize better
→in this case you see that james needs trauma therapy or eye movement therapy
and pete would need social skills
Case Formulation approach: testing your hypotheses
→During treatment and the evaluation phase: you test your hypotheses
➔ Effective intervention?
➔ Reduction of symptoms?
→if the answers are No
➔ Responsibility of therapist to go back to the induvial analyses/hypotheses; might they be
incorrect?
➔ Also should different therapeutical methos be used?
→SUM UP: link the outcome of the evaluation with information gathering and individual analyses
→With complex problems: Individual analyses = Better treatment effects
Different types of case formulations
→Behavioral case formulation (Page Ch5)
→Cognitive conceptualization case formulation (Beck Ch3)
→Cognitive Behavior case formulation (Page Ch5)
SUMMARY
,Functional Analysis
Individual Analyses and Conditioning Models
→During the individual analyses you are doing a functional analysis to understand the client better
➔ EXAMPLES
o Why ….. does a couple who have a too early born child in the hospital feel very
anxious when smelling sanitisers?
o Why ….. is a woman always sitting on a chair at the end of a row in the cinema, and
not in the middle?
➔ Conditioning models helps understanding behavior: both adaptive as well as maladaptive
behavior
o Operant conditioning and Classical conditioning models
▪ Classical conditioning
• CS (bell) → US (steak) → UR (salvia) ; CS (bell) → CR (salvia)
▪ Operant conditioning
• The Skinner Box: Skinner’s operant conditioning chamber (Skinner’s
box) was designed to teach rats how to push a lever. This behavior is
not natural to rats so operant conditioning with positive and
negative reinforcement were performed in order to teach the
behavior
o Positive Reinforcement: Increase smth positive [+S+]
o Negative Reinforcement: Decrease smth negative [-S-]
• Reinforcements increases behavior and Punishment decreases the
behavior
Individual Analyses linked to conditioning models
→Why ….. does a couple who have a too early born child in the hospital feel very anxious when
smelling sanitisers? Link classical conditioning [CS (Sanitizers) → US (early born child) →
UR/CR(anxiety)]
→Why ….. is a woman always sitting on a chair at the end of a row in the cinema, and not in the
middle? Link operant conditioning
➔ Sitting at the end row will remove the feeling of anxiety because of the easy exit [-S-]
o Negative reinforcement
➔ Sitting at the end row will increase her control [+S+]
o Positive reinforcement
Functional Analyses – ABC
→Functional analyses: focus on the function of the behavior → Consequences of it
→Links to operant conditioning : a learning process through which the strength of a behavior
(voluntary behavior) is modified by reinforcement or punishment
→Focus on when does it happen. Always? Or in certain situations? What defines the context where
the maladaptive behaviour is present vs absent?
➔ Antecedents=Activating event also called Discriminating Stimulus = Sd
o can be external events (eg. a comment from your boss) or internal events (e.g.
depressed feelings)
3 Elements of Functional Analyses
➔ Antecedents/ Activating event (Sd) → Behavior (Response) → Consequences (C)
o ABC
,How to get input for a functional analysis
→ask the client, for example using topographical analysis
→registration assignment for client (when talking about the activating events and its nor clear)
→use your clinical knowledge and scientific knowledge of common antecedents and consequences
of certain behaviors
EXAMPLE Functional Analyses
EXAMPLE 2 Functional Analyses
→Jonathan, age 14, problems at school
➔ Teachers at school say it is a difficult boy. He teases and also hits other children (Behavior)
because he likes that and gets attention (positive reinforcing Consequence, +S+).
➔ Psychologist is observing the boy for a few days (gathering information) and notices that the
problematic behavior is mainly occurring in the theory classes (Activating event).
➔ The hypothesis is that Jonathan has difficulty with theory and that he teases other children
to reduce his boredom (negative reinforcing consequence: -S-). → school test confirms
mismatch Jonathan and current school choice
Functional Analyses – Consequence
→Different types of consequences
➔ Reinforcing consequences, that increase the likelihood of the behavior
➔ Punishment consequences, that decrease the likelihood of the behavior
→Different types within the Reinforcing and Punishment consequences: positive and negative
➔ Reinforcement: “get something positive (+S+)” or “remove something negative(-S-)”
➔ Punishment: “get something negative(+S-)” or “remove something positive(-S+)”
,Final step of functional analysis is to define the consequences
→First sign (sign before the S): what happened? (increase, decrease, prevent)
→Second sign (after the S): valence of the stimuli / situations (positive or negative)
→EXAMPLE see Jams and Pete and define their consequences!
→Anxiety related behaviors (like avoidance ) are generally -S- reinforced, and addictive behaviors are
generally +S+ reinforced
SUMMARY
1. The functional analysis is concerned with the (perceived) association between preceding stimuli
(Sd), the behavior (R), and the consequences . It is based on operant conditioning
2. When analysing behaviour of patients ; there is always a positive ánd a negative consequence
3. The functional analysis is a hypothesis and it informs / guides treatment (Page & Stritzke , Ch .5)
4.There should always be a reinfocment and punishment when dealing with client
,2 EXAMPLES OF FUNCTIONAL ANALYSES IN ONE
ANTECENT (Stimulus Sd)
Activating event:
Invitation to participate at master-activity. Fun-facts
Position myself in the last row and observing other people
POSITIVE CONSEQUENCES (Sr)
[+S+]
[-S-]
→decrease/ avoid the confrontation by the lack of your uniqueness or fun-facts
→ for the client this stands in the center
→no one is judging me in a negative way; monitoring others so when they look at me I can share
positivity (hence manipulating them not thinking negative about me)
NEGATIVE CONSEQUENCES
[+S-]
→increases the stress and guilty towards the teaching assistant
[-S+]
→missed the chance of having fun (decrease smth positive)
AUTOMATIC THOUGHTS
→There is nothing interesting about me
→I am the oldest; I think the others thinking what the old lady is doing in the dancehall
,Topographical Analysis
Topographical Analysis focuses on:
→Very detailed procedure where you talk about one event, and go through it step by
step.
→Preferably a recent event (Did something happen last week that made you upset
→You can explain it to your patients as a procedure to really get to understand the
problems. It is like slowly playing a movie to see and understand every detail.
→Get information on antecedents (Sd), behavior (B), and the consequences (C)
Behavior
→The “B” (behavior) can take many forms
➔ 1)verbal responses; can be overt (open, public) and covert (hidden).
o Examples of overt response are yelling and complaining,
o and of covert responses are worrying, and cognitive rituals such as counting
➔ 2) psychophysiological responses; heart rate, sweating, dry mouth
➔ 3) motor responses; washing hands, hitting a person, tics
→Note that too much of a certain behaviour can be the problem, but also “too little’ or the
absence of certain behavior (e.g., lack of assertiveness, lack of social contact in psychosis)
Consequences
→The “C” (Consequences)
➔ can be short term, midterm or long term effects
o Example: a mom notices that giving in to the demands of her daughter is associated
with the direct ending of the whining (short term), but that the whining in general is
increasing (midterm) and that she fears that it will eventually negatively impact on
their relationship (long term)
Topographical Analysis: 5 Factors to focus on during the talk with the client
→Event → Thoughts/Cognitions → Emotions → Behavior → Consequences
Questions can be:
Antecedents
Where were you?
Who were with you?
What happened?
Behavior
How bad was it? (emotion)
What did you feel? (emotion)
What did you think at that
moment? (cognition)
What did you do? (behavior)
Guidelines during interview
→explain what you are going to do
→explain why such an analysis is important (increases motivation)
→it should aid your analyses
→take into account the analytical, and introspection level of your patient be aware that it might
elicit negative emotions
,EXAMPLE Topographical Analysis
Chapter 5: Linking assessment to treatment [Page, & Stritzke]
Behavioral case formulation: functional analysis
3 Main Elements of Functional Analysis
→Antecedents: proximal in time and distal in behvaior
→Behavior: described in terms of frequency, duration, intensity, and topography
➔ 3 variables important
o Positive reinforcement
o Negative reinforcement
o Automatic reinforcement
➔ Identify the function of behavior via 3 assessment
o Direct assessment
▪ Questioning the observer
o Analogue assessment
▪ Artificial conditions are constructed to test hypotheses about the
hypothesized reinforcers
o Naturalistic assessment
▪ Behavior is observed on its natural setting (EXAMPLE Jonathan in school)
→Consequences: four categories
➔ Positive reinforcement
➔ Negative reinforcement
➔ Punishment
➔ Response cost
Cognitive behavioral case formulation
Steps:
1. Obtain a comprehensive problem list (similar to ABC)
2. Consider a diagnosis
3. Research literature surrounding the diagnosis → searching for an evidence based treatment
a. Collecting infos on cognitive, behavioral, emotional and somatic aspects
4. Apply to client
5. Generate hypothesis
, a. To answer these: will look at the activating event/ antecedent within functional
analysis
Problem: this approach fails the link between hypothesis and treatment
Chapter 10: Case management [Page, & Stritzke]
Maintaining confidentiality
→Importance of confidentiality between client and therapist
→Parents of children who seek a therapist should also sign a confidentiality statement
→3 Examples forms:
➔ Requesting information from others
➔ Releasing information
➔ Exchanging information with others
Chapter 1: Introduction to CBT [Book by Beck]
What is CBT?
→Beck devised a structured, short-term, present-oriented psychotherapy for depression
The CBT Theoretical model
→the cognitive model proposes that dysfunctional thinking (which influences the client’s mood and
behavior) is common to all psychological disturbances
→When people learn to evaluate their thinking in a more realistic and adaptive way, they experience
a decrease in negative emotion and maladaptive behavior.
→EXAMPLE:
➔ You’re depressed and can’t concentrate to pay your bills
o Automatic thought: “I can’t do anything right”
▪ Consequence: feel sad (emotion) and goes to bed (behavior)
→When people learn to evaluate their thinking in a more realistic and adaptive way, they experience
a decrease in negative emotion and maladaptive behavior.
→Cognitions (both adaptive and maladaptive) occur at three levels.
➔ Automatic thoughts
o (e.g., “I’m too tired to do anything”) are at the most superficial level.
➔ You also have intermediate beliefs, such as underlying assumptions
o (e.g., “If I try to initiate relationships, I’ll get rejected”).
➔ At the deepest level are your core beliefs about yourself, others, and the world
o (e.g., “I’m helpless”; “Other people will hurt me”; “The world is dangerous”).
Recovery-oriented cognitive therapy
→CBT about we talk about problems tat arose the past week
➔ To overcome challenges client’s face
→CT-R focus on client’s aspirations for the future, their values and steps they can take each week
toward their goals
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