Introduction to Cognitive Behavioural Therapies – Lectures
Lecture 1 – overview, process, and application
Theory behind CBT
Empirically based form of treatment departing from theoretical models on learning
and information processing (several types of biases)
History of CBT
Late 1950’s-1960’s onwards – 1st generation
o Behaviour therapy (observable behaviours; classical and operant
conditioning, behavioural interventions like exposure)
1970’s-1980’s
o Cognitive therapy (information processing; negative automatic thoughts,
Socratic dialogue, cognitive restructuring)
1980’s (Aaron and Julie Beck)
o Integrated into cognitive behavioural therapy
2000’s onwards
o Mindfulness based cognitive therapy
o Acceptance and commitment therapy
o Dialectical behavioural therapy
Nowadays referred to as CBT
Practice of CBT
Characteristics
Focus on the present
Why does the problem persist
Focus on thought, behaviours, and emotions
Time limited (depends on where, but around 12-16 sessions)
Goal oriented (work toward a goal set with patient)
Problem-solving approach (teaching patient to be their own therapist)
Building on theoretical and clinical research
Focus on THINK, FEEL and BEHAVE (all related)
Structure of CBT
1. Validation of patient complaints
2. Building therapeutic relationship/ engagement
3. Explain general treatment rationale
4. Cognitive and behavioural assessment
5. Formulating realistic goals (not “I want to be happy again”, but more specific)
6. Designing a treatment plan
7. Carrying out the treatment plan
8. Broadening to other areas of dysfunctioning
9. Relapse prevention
Aim
To investigate the exact nature of the patients thought and behaviours
Initial approach
formal assessment using interview, self-monitoring
,Maintenance
Assess the nature and impact of cognitions and behaviours continuously during
treatment phase and also in interaction with the patient
Definitions
Behavioural therapy – applying experimentally verified learning principles
Behaviour – a logical response to a meaningful situation; result of a complex information
system with antecedent and consequent factors (ABC)
Learning – acquiring knowledge about the connection between evens (=expectations) can
result in a behavioural change
Levels of knowledge
Learning model – abnormal behaviour is achieved by the same learning processes as normal
behaviour: the ways of developing, maintaining, and changing behaviour are the same
Normal of Abnormal – deficit or excess (frequency, intensity, duration, inappropriate
situations)?
Norm: general norm, impairment, health-related risk, illegal
www.samenmindersuicide.nl
Conclusions of CBT
Importance of
o Clear procedure
o Established effectiveness
o Empirical evidence of supposed mechanism of change (CBT: embedded in
learning theory or in information processing, etc)
Status of CBT
First line of treatment for disorders: affective disorders (anxiety/ depression)
www.ggzrichtlijnen.nl
Attractive because it is short-term, complaint-driven and has measurable effects.
CBT is not perfect
o According to the disorder, about 50-60% who start the treatment reach
recovery
In well-conducted studies
Efficacy and effectiveness
o So how might we improve our empirically supported treatments?
Develop new therapies?
Deliver the existing ones appropriately?
Therapists beliefs and attitudes
We rarely use manuals, and we dislike them
o Even though using them results in better outcome for patients
o Many clinicians have no idea what a manual is
, We believe the therapeutic alliance will do lots of work for us
o 1. How much of the clinical outcome is associated with the alliance
Clinician beliefs = 32%
The evidence = 4-5%
o 2. Does the alliance drive therapy outcome
Not in CBT
Important to focus on early behavioural change
But when we drift, we underperform on what it could deliver to our patients and that means
people suffer
Basic principles of BT – ABC
Interaction of a person with his/her environment
Antecedent
o Conditions or stimuli that set the occasion for behaviour to occur
Behaviour
o Anything a person does (or not does)
Consequence
o Effect that behaviour produces (immediate & delayed)
behaviour 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 (typical in CT)
Functional analysis
Functional analysis – antecedents
Discriminative stimuli
o Events of situations that elicit the behaviour and predict reinforcement/
punishment
Establishing operations
o Factors changing the reinforcing or punishing properties of other
environmental events
o E.g., hunger, thirst, craving, negative mood, thoughts, rules
o Motivational
factors
S delta
o Situations or
circumstances
in which the
behaviour
does NOT take
place
Example functional analysis
, Basic principles CT
Thoughts or cognitions give meaning to a neutral stimulus and determine feelings
and behaviours
Beliefs or schemas are developed through (childhood) experiences and form a filter
Identify thoughts
o Distinguish between automatic thoughts and core beliefs
o Challenge and change these thoughts
Analysis of CBT on different levels
Most specific (movie-like)
o Topographical analysis (chain of behaviours)
On the level of problem behaviour
o Functional analysis in BT behaviour – describing antecedents (Sd/EO) –
behaviour – positive and negative consequences
o Cognitive conceptualisations in CT (core beliefs, beliefs, situation, automatic
thoughts, reactions (emotional, physiological, behavioural)
New developments in CBT
Mindfulness/ acceptance and commitment therapy
o Mindfulness-based cognitive therapy (MBCT)
Non-judgemental observation of present experiences. Thoughts can
be observed. Meditation.
o Acceptance and commitment therapy (ACT)
Acceptance: willingness to stay in contact with aversive experiences
Commitment to life values and goals
Cognitive diffusion: not change content of the thoughts, but the
relation with the thoughts
o Dialectic Behaviour Therapy (DBT)
Lecture 2 – Exposure in practice
Effectiveness of exposure therapy
Mean effect sizes for exposure-based therapy of anxiety disorders
o Overview of treatments protocols that contain exposure to anxiety provoking
stimuli as a central component of treatment
What is being avoided?
Situations (e.g., social interaction)
Emotions (e.g., fear)
Bodily sensations (e.g., palpitations)
Cognitive contents (e.g., memories)
This is a key question in treatment design
Classical conditioning
Thorndike
1800s
Represented the original S-R framework
Learning is the result of associations forming between stimuli and responses
Lecture 1 – overview, process, and application
Theory behind CBT
Empirically based form of treatment departing from theoretical models on learning
and information processing (several types of biases)
History of CBT
Late 1950’s-1960’s onwards – 1st generation
o Behaviour therapy (observable behaviours; classical and operant
conditioning, behavioural interventions like exposure)
1970’s-1980’s
o Cognitive therapy (information processing; negative automatic thoughts,
Socratic dialogue, cognitive restructuring)
1980’s (Aaron and Julie Beck)
o Integrated into cognitive behavioural therapy
2000’s onwards
o Mindfulness based cognitive therapy
o Acceptance and commitment therapy
o Dialectical behavioural therapy
Nowadays referred to as CBT
Practice of CBT
Characteristics
Focus on the present
Why does the problem persist
Focus on thought, behaviours, and emotions
Time limited (depends on where, but around 12-16 sessions)
Goal oriented (work toward a goal set with patient)
Problem-solving approach (teaching patient to be their own therapist)
Building on theoretical and clinical research
Focus on THINK, FEEL and BEHAVE (all related)
Structure of CBT
1. Validation of patient complaints
2. Building therapeutic relationship/ engagement
3. Explain general treatment rationale
4. Cognitive and behavioural assessment
5. Formulating realistic goals (not “I want to be happy again”, but more specific)
6. Designing a treatment plan
7. Carrying out the treatment plan
8. Broadening to other areas of dysfunctioning
9. Relapse prevention
Aim
To investigate the exact nature of the patients thought and behaviours
Initial approach
formal assessment using interview, self-monitoring
,Maintenance
Assess the nature and impact of cognitions and behaviours continuously during
treatment phase and also in interaction with the patient
Definitions
Behavioural therapy – applying experimentally verified learning principles
Behaviour – a logical response to a meaningful situation; result of a complex information
system with antecedent and consequent factors (ABC)
Learning – acquiring knowledge about the connection between evens (=expectations) can
result in a behavioural change
Levels of knowledge
Learning model – abnormal behaviour is achieved by the same learning processes as normal
behaviour: the ways of developing, maintaining, and changing behaviour are the same
Normal of Abnormal – deficit or excess (frequency, intensity, duration, inappropriate
situations)?
Norm: general norm, impairment, health-related risk, illegal
www.samenmindersuicide.nl
Conclusions of CBT
Importance of
o Clear procedure
o Established effectiveness
o Empirical evidence of supposed mechanism of change (CBT: embedded in
learning theory or in information processing, etc)
Status of CBT
First line of treatment for disorders: affective disorders (anxiety/ depression)
www.ggzrichtlijnen.nl
Attractive because it is short-term, complaint-driven and has measurable effects.
CBT is not perfect
o According to the disorder, about 50-60% who start the treatment reach
recovery
In well-conducted studies
Efficacy and effectiveness
o So how might we improve our empirically supported treatments?
Develop new therapies?
Deliver the existing ones appropriately?
Therapists beliefs and attitudes
We rarely use manuals, and we dislike them
o Even though using them results in better outcome for patients
o Many clinicians have no idea what a manual is
, We believe the therapeutic alliance will do lots of work for us
o 1. How much of the clinical outcome is associated with the alliance
Clinician beliefs = 32%
The evidence = 4-5%
o 2. Does the alliance drive therapy outcome
Not in CBT
Important to focus on early behavioural change
But when we drift, we underperform on what it could deliver to our patients and that means
people suffer
Basic principles of BT – ABC
Interaction of a person with his/her environment
Antecedent
o Conditions or stimuli that set the occasion for behaviour to occur
Behaviour
o Anything a person does (or not does)
Consequence
o Effect that behaviour produces (immediate & delayed)
behaviour 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 (typical in CT)
Functional analysis
Functional analysis – antecedents
Discriminative stimuli
o Events of situations that elicit the behaviour and predict reinforcement/
punishment
Establishing operations
o Factors changing the reinforcing or punishing properties of other
environmental events
o E.g., hunger, thirst, craving, negative mood, thoughts, rules
o Motivational
factors
S delta
o Situations or
circumstances
in which the
behaviour
does NOT take
place
Example functional analysis
, Basic principles CT
Thoughts or cognitions give meaning to a neutral stimulus and determine feelings
and behaviours
Beliefs or schemas are developed through (childhood) experiences and form a filter
Identify thoughts
o Distinguish between automatic thoughts and core beliefs
o Challenge and change these thoughts
Analysis of CBT on different levels
Most specific (movie-like)
o Topographical analysis (chain of behaviours)
On the level of problem behaviour
o Functional analysis in BT behaviour – describing antecedents (Sd/EO) –
behaviour – positive and negative consequences
o Cognitive conceptualisations in CT (core beliefs, beliefs, situation, automatic
thoughts, reactions (emotional, physiological, behavioural)
New developments in CBT
Mindfulness/ acceptance and commitment therapy
o Mindfulness-based cognitive therapy (MBCT)
Non-judgemental observation of present experiences. Thoughts can
be observed. Meditation.
o Acceptance and commitment therapy (ACT)
Acceptance: willingness to stay in contact with aversive experiences
Commitment to life values and goals
Cognitive diffusion: not change content of the thoughts, but the
relation with the thoughts
o Dialectic Behaviour Therapy (DBT)
Lecture 2 – Exposure in practice
Effectiveness of exposure therapy
Mean effect sizes for exposure-based therapy of anxiety disorders
o Overview of treatments protocols that contain exposure to anxiety provoking
stimuli as a central component of treatment
What is being avoided?
Situations (e.g., social interaction)
Emotions (e.g., fear)
Bodily sensations (e.g., palpitations)
Cognitive contents (e.g., memories)
This is a key question in treatment design
Classical conditioning
Thorndike
1800s
Represented the original S-R framework
Learning is the result of associations forming between stimuli and responses
