1
Introduction to Cognitive Behavioral
Therapies
Inhoud
Lecture 1: Introduction to cognitive behavioural therapies: An overview, the process and
applications ........................................................................................................................2
Lecture 2: Classical conditioning and exposure.....................................................................6
Lecture 3: Exposure in Practice.............................................................................................9
Lecture 4: PTSD and EMDR ................................................................................................. 12
Lecture 5: Behavioural Activation ....................................................................................... 16
Lecture 6: Behavioral interventions in eating disorders ........................................................ 21
Lecture 7: Parent training: Analyzing and observing behaviour/antecedent and consequent
interventions ..................................................................................................................... 27
Lecture 8: Psychosis .......................................................................................................... 35
Lecture 9: Cognitive interventions: Analyzing & modifying cognitions ................................... 41
Lecture 10: Behavioural Experiments .................................................................................. 46
Lecture 11: Mindfulness ..................................................................................................... 50
Lecture 12: Intro to CBT: Acceptance and commitment therapy (ACT) .................................. 54
Lecture 13: Schema (focused) therapy ................................................................................ 60
,2
Lecture 1: Introduction to cognitive behavioural therapies: An overview,
the process and applications
What is CBT?
- Based on theoretical models of learning and information processing
- Empirically support
- Standardized protocols
History of CBT
- Late 1950’s – 1960’s (1st gen)
o Behavioural therapy
▪ Learning models
▪ Classical (Pavlov) and operant conditioning (Thorndike & Skinner)
▪ Observable behaviour
▪ Exposure therapy
- Early 1970’s – 1980’s (2nd gen)
o Cognitive therapy (Beck)
▪ Information processing
▪ Negative automatic thoughts
▪ Cognitive restructuring
▪ Socratic dialogue
- Integrated during 80’s into
o Cognitive- behavioural therapy
- 2000’s onward (3rd gen)
o Mindfulness Based Cognitive Therapy
o Acceptance and Commitment Therapy
o Dialectical Behaviour Therapy
New generation: Emotions, language, values, and interpersonal relationships
- 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 disorder, skills training in
autism, etc.)
- Attractive, because short-term, complaint-driven and measurable effects
Effectiveness CBT
- Strong evidence for efficacy in anxiety disorders
o Social anxiety disorder & panic disorder (medium)
o Somatoform disorders (illness anxiety and BDD; medium-large)
- PTSD (medium) & OSD (large)
- Schizophrenia and other psychotic disorders > positive symptoms
- Bulimia Nervosa, Insomnia & Personality disorders > More effective than other therapies
- Depressive disorder (major/persistent) > mixed, as effective as ADM
- Bipolar disorder > not as a standalone intervention
- Substance use disorder > cannabis and nicotine, not for opioids and alcohol
Negative attitudes towards manuals
- Disagreement
- Unfamiliarity
- Labor intensive
- Unique clients (comorbidity)
- Confidence in own clinical judgements
- Overemphasis general factors
o Dod-bird verdict (1980): “Everybody has won, and all must have prices”
,3
CBT is not perfect
- 50-60% who start treatment, reach recovery (dependent on disorder)
o Efficacy; ideal (how big effect in research setting)
o Effectiveness; real (how big effect in real world setting (less control))
- Therapist drift
Therapists’ beliefs and attitudes
Some research finding that might upset you
- We rarely use treatment manuals and dislike them
o Despite better treatment outcomes
o Many clinicians have no idea what a manual is (50%)
- We overestimate the importance of therapeutic alliance
o How much of the treatment outcome is associated with alliance?
▪ Clinicians: 32%
▪ Evidence: 4-5%
- Does therapeutic alliance drive treatment outcome?
o Not in CBT
o Early behavioural change better predictor
Why does this matter?
- CBT not perfect
- But when we drift, we underperform on what it could deliver to clients
o And that means people could suffer
The good news
- Best indicator of therapist drift:
o Experience?
- Shapiro & Shapiro (1982) told us something very scary
Characteristics of CBT
- Focus on present
- Question is: why does the problem persist? … and how can we change it?
- Problem solving approach
- Goal oriented
- Time limited
- Focus on thoughts, behaviours, emotions
◄Think ◄►◄► Behave ◄► Feel ►
- Change feelings is difficult
- More difficult than someone’s thinking and behaviour
Structure of CBT
1. Validation of clients complaints
2. Building therapeutic relationship / engagement
3. Explaining general treatment rationale
4. Cognitive and behavioural assessment
, 4
5. Formulating realistic goals
6. Designing treatment plan
7. Carrying out treatment plan
8. Broadening to other areas of dysfunction
9. Relapse prevention
Cognitive and behavioural assessment
- Aim:
To investigate the exact nature of this client’s thoughts and behaviours
- Initial approach:
Formal assessment using interview, self-monitoring, observations, etc.
- Maintenance:
Assess the nature of cognitions and behaviours continuously during treatment phase and also
in interaction with the client
- Assessment in CBT never stops
Definitions
- Behavioural therapy:
Applying experimentally verified learning principles
- Learning:
Acquiring knowledge about the connection between events (= expectations) can result in a
behavioural change
- Behaviour:
A logical response to a meaningful situation
- 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
- Problematic behaviour:
Deficit or excess (frequency, intensity, duration, inappropriate situation)?
- Norm: general norm, impairment, health-related risk, illegal
Behavioural therapy (BT)
Basic principles of BT
- Behaviour is produced by the interaction of person with his/her environment
- Behaviour is maintained by its consequences
o Antecedents of behaviour – conditions or stimuli that set the occasion for behaviour to
occur
▪ Discriminate stimuli (Sd)
▪ Establishing operations (EO)
o Behaviour – anything a person does (or not does)
o Consequences – effect that behaviour produces
▪ Immediate
▪ Delayed
➢ May differ
Antecedents
- Discriminative stimuli (Sd):
o Events or situations that elicit the behaviour and predict reinforcement or punishment
Dit zijn gebeurtenissen of situaties die bepaald gedrag uitlokken en die aangeven dat
er een beloning (of straf) kan volgen. Bijvoorbeeld: als een stoplicht groen is, dan
weet je dat je mag doorrijden.
- 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
Dit zijn factoren die invloed hebben op hoe aantrekkelijk of onaantrekkelijk iets wordt
als beloning of straf. Ze kunnen ervoor zorgen dat je sterker gemotiveerd bent om iets
Introduction to Cognitive Behavioral
Therapies
Inhoud
Lecture 1: Introduction to cognitive behavioural therapies: An overview, the process and
applications ........................................................................................................................2
Lecture 2: Classical conditioning and exposure.....................................................................6
Lecture 3: Exposure in Practice.............................................................................................9
Lecture 4: PTSD and EMDR ................................................................................................. 12
Lecture 5: Behavioural Activation ....................................................................................... 16
Lecture 6: Behavioral interventions in eating disorders ........................................................ 21
Lecture 7: Parent training: Analyzing and observing behaviour/antecedent and consequent
interventions ..................................................................................................................... 27
Lecture 8: Psychosis .......................................................................................................... 35
Lecture 9: Cognitive interventions: Analyzing & modifying cognitions ................................... 41
Lecture 10: Behavioural Experiments .................................................................................. 46
Lecture 11: Mindfulness ..................................................................................................... 50
Lecture 12: Intro to CBT: Acceptance and commitment therapy (ACT) .................................. 54
Lecture 13: Schema (focused) therapy ................................................................................ 60
,2
Lecture 1: Introduction to cognitive behavioural therapies: An overview,
the process and applications
What is CBT?
- Based on theoretical models of learning and information processing
- Empirically support
- Standardized protocols
History of CBT
- Late 1950’s – 1960’s (1st gen)
o Behavioural therapy
▪ Learning models
▪ Classical (Pavlov) and operant conditioning (Thorndike & Skinner)
▪ Observable behaviour
▪ Exposure therapy
- Early 1970’s – 1980’s (2nd gen)
o Cognitive therapy (Beck)
▪ Information processing
▪ Negative automatic thoughts
▪ Cognitive restructuring
▪ Socratic dialogue
- Integrated during 80’s into
o Cognitive- behavioural therapy
- 2000’s onward (3rd gen)
o Mindfulness Based Cognitive Therapy
o Acceptance and Commitment Therapy
o Dialectical Behaviour Therapy
New generation: Emotions, language, values, and interpersonal relationships
- 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 disorder, skills training in
autism, etc.)
- Attractive, because short-term, complaint-driven and measurable effects
Effectiveness CBT
- Strong evidence for efficacy in anxiety disorders
o Social anxiety disorder & panic disorder (medium)
o Somatoform disorders (illness anxiety and BDD; medium-large)
- PTSD (medium) & OSD (large)
- Schizophrenia and other psychotic disorders > positive symptoms
- Bulimia Nervosa, Insomnia & Personality disorders > More effective than other therapies
- Depressive disorder (major/persistent) > mixed, as effective as ADM
- Bipolar disorder > not as a standalone intervention
- Substance use disorder > cannabis and nicotine, not for opioids and alcohol
Negative attitudes towards manuals
- Disagreement
- Unfamiliarity
- Labor intensive
- Unique clients (comorbidity)
- Confidence in own clinical judgements
- Overemphasis general factors
o Dod-bird verdict (1980): “Everybody has won, and all must have prices”
,3
CBT is not perfect
- 50-60% who start treatment, reach recovery (dependent on disorder)
o Efficacy; ideal (how big effect in research setting)
o Effectiveness; real (how big effect in real world setting (less control))
- Therapist drift
Therapists’ beliefs and attitudes
Some research finding that might upset you
- We rarely use treatment manuals and dislike them
o Despite better treatment outcomes
o Many clinicians have no idea what a manual is (50%)
- We overestimate the importance of therapeutic alliance
o How much of the treatment outcome is associated with alliance?
▪ Clinicians: 32%
▪ Evidence: 4-5%
- Does therapeutic alliance drive treatment outcome?
o Not in CBT
o Early behavioural change better predictor
Why does this matter?
- CBT not perfect
- But when we drift, we underperform on what it could deliver to clients
o And that means people could suffer
The good news
- Best indicator of therapist drift:
o Experience?
- Shapiro & Shapiro (1982) told us something very scary
Characteristics of CBT
- Focus on present
- Question is: why does the problem persist? … and how can we change it?
- Problem solving approach
- Goal oriented
- Time limited
- Focus on thoughts, behaviours, emotions
◄Think ◄►◄► Behave ◄► Feel ►
- Change feelings is difficult
- More difficult than someone’s thinking and behaviour
Structure of CBT
1. Validation of clients complaints
2. Building therapeutic relationship / engagement
3. Explaining general treatment rationale
4. Cognitive and behavioural assessment
, 4
5. Formulating realistic goals
6. Designing treatment plan
7. Carrying out treatment plan
8. Broadening to other areas of dysfunction
9. Relapse prevention
Cognitive and behavioural assessment
- Aim:
To investigate the exact nature of this client’s thoughts and behaviours
- Initial approach:
Formal assessment using interview, self-monitoring, observations, etc.
- Maintenance:
Assess the nature of cognitions and behaviours continuously during treatment phase and also
in interaction with the client
- Assessment in CBT never stops
Definitions
- Behavioural therapy:
Applying experimentally verified learning principles
- Learning:
Acquiring knowledge about the connection between events (= expectations) can result in a
behavioural change
- Behaviour:
A logical response to a meaningful situation
- 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
- Problematic behaviour:
Deficit or excess (frequency, intensity, duration, inappropriate situation)?
- Norm: general norm, impairment, health-related risk, illegal
Behavioural therapy (BT)
Basic principles of BT
- Behaviour is produced by the interaction of person with his/her environment
- Behaviour is maintained by its consequences
o Antecedents of behaviour – conditions or stimuli that set the occasion for behaviour to
occur
▪ Discriminate stimuli (Sd)
▪ Establishing operations (EO)
o Behaviour – anything a person does (or not does)
o Consequences – effect that behaviour produces
▪ Immediate
▪ Delayed
➢ May differ
Antecedents
- Discriminative stimuli (Sd):
o Events or situations that elicit the behaviour and predict reinforcement or punishment
Dit zijn gebeurtenissen of situaties die bepaald gedrag uitlokken en die aangeven dat
er een beloning (of straf) kan volgen. Bijvoorbeeld: als een stoplicht groen is, dan
weet je dat je mag doorrijden.
- 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
Dit zijn factoren die invloed hebben op hoe aantrekkelijk of onaantrekkelijk iets wordt
als beloning of straf. Ze kunnen ervoor zorgen dat je sterker gemotiveerd bent om iets
