Hoorcolleges Introduction to cognitive behavioural therapies
Hoorcollege 1 – Introduction to cognitive behavioural therapies: an overview, the process and
applications
Theory behind CBT
What is CBT?
• Empirically based form of treatment, departing from theoretical models on learning and
information processing.
History of CBT (in short)
• Late 1950’s – 1960’s – onward: 1st generation
o Behaviour therapy (observable behaviours; classical and operant conditioning,
behavioural interventions like exposure)
• Early 1970’s – 1980’s – onward: 2nd generation
o Cognitive therapy (information processing; negative automatic thoughts, the socratic
dialogue, cognitive restructuring)
• Integrated during 80’s into
o Cognitive-behavioural therapy
• 2000’s onwards: 3rd generation
o Mindfulness Based Cognitive Therapy (MBCT)
o Acceptance and Commitment Therapy (ACT)
o Dialectical Behaviour Therapy (DBT)
• Nowadays often referred to as
o Cognitive- behavioural therapy
Practice of CBT
Characteristics of CBT
• Focus on present
• Question is: why does the problem persist?
• Focus on thought, behaviours, emotions
• Time-limited
• Goal oriented
• Problem solving approach
• Building on theoretical and clinical research
Basic of CBT
Structure of CBT
1. Validation of patients complaints
2. Building therapeutic relationship/engagement → evolves and grows during therapy
3. Explaining general treatment rationale
4. Cognitive and behavioural assessment
, 5. Formulating realistic goals
6. Designing treatment plan
7. Carrying out treatment plan → keep evaluating it all the time.
8. Broadening to other areas of dysfunctioning
9. Relapse prevention
Cognitive And Behavioural Assessment
• Aim
o To investigate the exact nature of this patient’s thoughts and behaviours.
• Initial approach
o Formal assessment using interview, self monitoring etc.
• Maintenance
o Assess the nature and impact of cognitions and behaviours continuously during
treatment phase and also in interaction with the patient (Assessment never stops).
Definitions
Behavioral therapy = applying experimentally verified learning principles.
Behaviour = behavior is a logical resons to a meaningful situation.
• Behavior is the result of a complex information system with antecedent and consequent
factors (ABC).
Learning = acquiring knowledge about the connection between events (= expectations) can result in
a behavioural change.
Learning model
• Abnormal behaviour is achieved by the same learning processes as normal behaviours: the
ways of developing, maintaining and changing behaviour are the same.
Normal or abnormal?
• Deficit or excess (frequency, intensity, duration, inappropriate situation)? Norm: general
norm, impairment, health-related risk, illegal.
EMDR
• Shapiro in the park
• Theory: cathalyses a rebalancing in the neurosystem, by shifting information that is locked up
in the central nervous system to the two hemispheres
• Procedure very clear.
• EMDR was effective in reducing PTSD symptoms (functional relationship clear).
• Empirical evidence for the supposed mechanism of change?
• Testing effectiveness and alternative explanations for effectiveness:
o Nonspecific effect? Attention?
o Experimental research!
,Working memory theory (with EMDR)
• Doordat je je ogen beweegt en moet nadenken over de situatie, heeft je werkgeheugen niet
genoeg ruimte over om ook nog na te denken over de emotie die je voelde in de situatie.
Hierdoor wordt de emotie steeds vager tot het uiteindelijk helemaal uitgedoofd is.
Conclusions for CBT interventions
• Importance of
o Clear procedure.
o Established effectiveness (functional relationship)
o Empirical evidence of supposed mechanism of change (CBT: embedded in learning
theory or in information processing, etc.)
Status of CBT
• Treatment of choice for many disorders (see Guidelines, for Mental Health)
• Important treatment option for many disorders (anxiety, depression, psychosis, somatoform
disorders, relation problems, work related problems, child disruptive disorders, skills training
in autism, etc.)
• Attractive, because short-term, complaint-driven and measurable effects.
CBT is not perfect
• According to the disorder, about 50%-60% who start the treatment reach recovery
o In well-conducted studies
o Efficacy and effectiveness
• So how might we improve our empirically-supported treatments?
Therapists’ beliefs and attitudes
• Warning: Some research findings that might upset you.
• We rarely use manuals and we dislike them.
o Even though using them results in better outcomes for patients.
o Many clinicians have no idea what a manual is.
• We believe the therapeutic alliance will do lots of the work for us.
1. How much of the clinical outcome is associated with the alliance?
▪ Clinician beliefs = 32%
▪ The evidence = 4-5%
2. Does the alliance drive therapy outcome?
▪ Not in CBT
▪ Important to focus on early behavioural change
So why does this matter?
• CBT is not perfect
• But when we drift, we underperform on what it could deliver to
our patients
o And that means that people suffer.
• What is the best thing that we could do right now?
o Develop new therapies?
o Deliver the existing ones appropriately?
o Let’s start with the red zone…
What is the best indicator of therapist drift?
• Our clinical outcomes in everyday practice.
• Shapiro & Shapiro told us something very scary.
, Behavioural thearpy (BT)
Basis principles of BT
• Interaction of person with his/her environment.
• ABC
o Antecedents of behaviour – conditions or stimuli that set the occasion for behaviour
to occur.
o Behaviour – anything a person does (or not does)
o Consequences – effect that behaviour produces (immediate & delayed)
• Behaviours is maintained by its consequences.
Assessment
• Intake evaluation: assessing problem behaviour (behavioural excesses/deficits). Coping
behaviour.
• Registration of problem behaviour and antecedents/consequences (typically in BT) or
thought records (typically in CT).
• Functional analysis.
Functional analysis – antecedents
• Discriminative stimuli (SD)
o Events or situations that elicit the behaviour and predict reinforcement or
punishment.
• Establishing operations (EO)
o Factors changing the reinforcing or punishing properties of other environmental
events.
o E.g.: hunger, thirst, craving, negative mood, thoughts, rules (e.g. if-then statements).
o Motivational factors.
• S-delta are situations or circumstances in which the behaviour does NOT take place.
