2017-MBB2-Clinical-Lecture-6

1、Psychological Treatment: Cognitive Behaviour TherapyDr Christopher GrootMelbourne School of Psychological SciencesUniversity of Melbourne Basic premise: There is in interaction between how individuals feel, think, and act and how they understand their world, themselves, and their prospects for the f

2、uture. These patterns cause and maintain many psychological disorders What is Cognitive Behaviour Therapy? CBT is a relatively short-term therapy that is active, directive, and collaborative. The goal of CBT is to assist patients in changing their maladaptive thinking patterns and overt behaviour by

3、 acquiring more adaptive ways of responding within themselves and with others.What is Cognitive Behaviour Therapy?CBT as an empirically-validated therapy.Review Chambless and Ollendick, 2001 for lists or well-established, probably efficacious, and promising therapies.Some CBT therapies that are on t

4、he lists are for: Anxiety disorders-panic, agoraphobia, GAD Depression Eating disorders Chronic pain Smoking cessation Geriatric sleep disorders Marital discord Childrens phobia, abdominal pain, anxietyCommon Principles of Cognitive-Behavioural Therapies Formation of patients and their problems in c

5、ognitive terms. Thinking, perceiving, believing, attitudes Express concepts in operational terms. E.g. measure thinking Specify treatment in operational terms. Manualised therapy Empirical validation of treatment. Measure outcomes Use of reliable and objective measures.Common Principles of Cognitive

6、-Behavioural Therapiescontinued Problem-focused and goal-oriented. Treatment emphasizes the “here and now.” Therapist and patient collaborate to identify problems and plan treatments. Therapist as teacher who educates the patient to identify, evaluate, and respond to thoughts and beliefs, and to pro

7、blem-solve and make decisions more effectively in order to bring about desired change.Common Principles of Cognitive-Behavioural Therapiescontinued Create opportunities for new learning in therapy. = learning new skills change. Generalize changes outside of therapy situations. Principles are made ex

8、plicit to the client. Therapist as teacher model Therapy is structured and time limited.Core BeliefIntermediate BeliefSituationAutomaticThoughtsReactionsEmotionalBehaviouralPhysicalCore Beliefs (Beck, 1995) Are developed in order to understand ones place in the world. Begin in childhood. Are global,

9、 rigid, and overgeneralized. Are viewed as truths.Example: I must be a good person.Problems?Intermediate Beliefs, i.e., attitudes, rules, and assumptions:Attitudes, Rules and Assumptionsexist between core beliefs and automatic thoughts.are often articulated as automatic thoughts.Examples:Attitude: I

10、ts unacceptable to not be good.Rule: I must try as hard as I can to be good.Assumption: If I am not good, then I am bad and probably even evil.Situation Automatic Thoughts Reactions Situation Automatic Thoughts ReactionsOnes underlying core and intermediate beliefs influence ones perspective of curr

11、ent situations.Example:Situation: Becoming angry when babysitting the grandchildren.Situation Automatic Thoughts ReactionsAutomatic Thoughts: I should not ever be angry at my grandchildren. If I was a good grandmother, then I would not get angry with my grandchildren. I must be evil if Im angry at m

12、y grandchildren.Reaction: Emotion: depressed, self-hatred Behavioural: say nothing, withdraw when possible Physical: nausea, flush, hyped up CBT for Depression Thorough assessment (includes symptom set, severity and suicidality). Phases of Therapy: First phase: Treatment often includes a concentrati

13、on on psychoeducation and non-cognitive (behaviour) techniques Relatively straightforward/structured and easier to achieve successes (people who are depressed experience difficulty initiating change). Second phase: Treatment focuses on cognitive techniques and problem-solving. Third phase: Generaliz

14、ation and Relapse Prevention.Stimulus Control Common Initial Technique: Stimulus Control Covert and overt behaviours often occur in the presence of specific triggers, meaning that the behaviors are under “stimulus control.” Example: Beck video client and lonely Saturdays ABC assessment will often id

15、entify triggers, however, if a behavior is resistant to change look further for additional triggers, and problem-solve removal of those triggers if possible. Utilize stimulus control for therapy purposes by developing new stimuli to trigger more adaptive behavior (examples: signs, symbols, notebooks

16、.)Core Behavioural Technique: Activity Scheduling Goals: To increase behavior. To create and identify positive reinforcement. Rationale The therapist provide a rationale to the client about the “depression cycle.” Self-Monitoring The client records actual behavior for several days, including pleasur

17、e and mastery ratings. Patterns? Is everything really always bad? Activity Scheduling Planning ones day in advance. After showing competence at activity scheduling, develop a to-do list of practical tasks.Increasing Pleasurable Activities The treatment of depression often includes increasing pleasur

18、able activities, but this behaviour modification technique is often beneficial for clients with other diagnoses. The client is given a list of various pleasurable activities and is asked to review it and to incorporate a pleasurable activity into each day.Sleep Problems A behavioural assessment shou

19、ld include habits around sleeping, stimulant usage, and sleeping patterns. Explain the sleep cycle to clients. Interventions: The most effective intervention for sleep problems is getting up at the same time every day. Decrease stimulant use generally and avoid stimulant use completely after the eve

20、ning meal. Establish firm times for going to bed and getting up.Sleep Problems Interventionscontinued Bed should be reserved for sleeping activities, and other activities (e.g., reading, eating, watching TV) should be ceased. If a clients has not fallen to sleep within 30 minutes. They can engage in

21、 another activity in another room. At the first sign of drowsiness, the client should return to bed and discontinue the other activity until the morning. Firm getting up times must be adhered to each day not matter how tired the client may be. No napping during the day.Distraction Techniques Another

22、 simple behavioural technique for depression Example: interrupt negative rumination and inactivity Distraction Techniques can be established individually for each of your clients. The Pleasurable Activities list doubles as a distraction list.CBT Phase 2: Focus on thinkingCBT Steps re: Automatic Thou

23、ghts Identify automatic thoughts.Evaluate automatic thoughts. Evaluate the validity of the thought. E.G. “My boss hates me”. Does he? Evidence? Evaluate the utility of the thought. Is that thought useful to you?Respond to automatic thoughts.Do problem-solving if thoughts are true.Techniques to Ident

24、ify/Elicit Automatic Thoughts Ask the question: “What was going through your mind just then?” in the following circumstances: When the therapist notices a shift/intensification in mood. When the client is describing a situation in which s/he experienced an affect shift. While using imagery to enhanc

25、e the clients memory of the automatic thoughts. During a role-play of a specific interaction.Working with an Automatic Thought (Beck) Place the thought in the CBT/ABC model. Ask the client to rate their belief in the thought. Evaluate the thoughts validity/utility by questioning it. Some example que

26、stions: What evidence do you have to support this thought? Could there by another explanation? Is this thought helpful to you? What is the worst thing that could happen?ABC ModelAdvantages of using Diary SheetsDiary Sheet/Dysfunction Thoughts Record Objectifies the situation. Can be utilized by the

27、client outside of session, either by the client filling them out or reviewing a completed sheet about a similar situation. Saves time in therapy. Enhances generalization outside of therapy. Can be used to develop coping cards.Dysfunctional Thoughts RecordWorking with Intermediate and Core Beliefs Be

28、liefs sometimes appear as automatic thoughts. Noting the reoccurring automatic thoughts for commonalities can lead to beliefs. Work back from an automatic thought via the downward arrow technique (or is it “upwards”). Make hypotheses about beliefs and discuss them with the client.Downward Arrow Tech

29、niqueStrategies to Modify Thoughts and Beliefs Advantages and Disadvantages of Keeping the Belief Formulating a More Functional Belief Socratic Questioning interrogating thoughts/beliefs Example: A wife is necessary for happiness (Beck video) Behavioural Experiments Cognitive Continuum eg: Chocolate

30、 biscuits for breakfast = worst mother ever? Role-Play Example: Coping with lonely Saturdays (Beck video) Acting “As If” Example: AA “Fake it til you make it” confidence. Self-Disclosure Example: Blushing “I blush” badge.Phase 3: Relapse Prevention Preparation for relapse prevention occurs throughout therapy coping cards, homework sheets, hand-outs, etc. become the material for relapse prevention programs. The following enhance relapse prevention: Reinforcing client capabilities by attrib