Cognitive Behavioural Therapy.
Lecture & Literature Summary.
Cognitive Behavioural Therapy (CBT) – Lecture 1
This lecture consists of three parts:
1) Introduction to CBT & Case Conceptualisation.
2) Functional Analysis.
3) Topographical Analysis.
Introduction to CBT.
Basic Principles of CBT:
CBT is a systematic, action-oriented psychological treatment to improve mental
health.
CBT focuses on challenging and changing unhelpful cognitions, behaviours, and
emotions.
o Cognitions: thoughts, beliefs, and attitudes.
CBT is a broad umbrella term encompassing several treatments; such as the more
cognitive focused variant (Beck), exposure, behavioural activation (BA), and is
related to EMDR, mindfulness, ACT, EFT, etc.
CBT is an evidence-based treatment method and is the first treatment choice for
many disorders including depression, anxiety, OCD, tics, substance use, and
psychotic disorders.
o We support clients best by using evidence-based, tested, treatment methods.
Note. Some professionals view CBT as a specific method (e.g., Beck), however, others
believe it shares characteristics and relations with other methods such as EMDR, ACT etc.
If a patient does not receive successful treatment, they become demoralised and the chance
of starting a new treatment is much lower, comorbidity may increase, as well as the
mortality rate.
Mortality rate: suicide & death.
The basic principles of CBT Cognitions, Behaviours, and Emotions/Physiology are all
interconnected.
What you think influences how you feel, which influences what you do, which
again, influences what you think. The points are all so interconnected that they
activate one another.
^ It can be useful to explain this model to clients.
1
,Cognitive Behavioural Therapy.
Lecture & Literature Summary.
What you Think:
If you conceptualise negative thoughts, you can use different interventions to change
them.
o Conceptualising negative thoughts can drive different symptoms.
What you Do:
It is not only about what you do but also what you do not do, e.g., not going to a
party due to anxiety.
Avoidance behaviour is also behaviour.
Behaviour, and body posture, are relevant to your mood, which can be detected by a
therapist.
The Case Formulation Approach.
Here we can see that different treatment methods are necessary for the same symptoms,
hence, individual analysis (IA) is necessary, as is our focus on the ‘why’.
The model described by a patient is not always the main focus of treatment – there is no
direct link.
Gathering information from the client is important.
What happened, how did it happen, how are things related?
The client might not always have answers to your questions, hence, assign
homework.
Registration assignment: register when things happen to understand
factors and processes.
Focus on understanding why someone engages in a problem, e.g., why would someone
continue to drink despite the negative consequences? – To dampen the trauma.
Develop hypotheses based on an individual analysis.
An individual analysis comes from information gathering.
Link the gathered information to theoretical models for the bigger picture.
Note. Trying to understand why something happened is how we build our hypotheses.
The treatment method is a way of testing your hypotheses, which are based on an
individual analysis.
If there is an effective intervention and symptom reduction, the hypotheses are likely correct.
If there is no effective intervention and no symptom reduction, then, it is the responsibility of
the therapist to go back to the individual analysis/hypotheses. Also, consider if a different
theoretical model should be used.
2
,Cognitive Behavioural Therapy.
Lecture & Literature Summary.
A therapist must always continue to monitor the treatment method and
improvements (including the lack of) made.
Sometimes, the hypothesis is ‘correct’, however, the chosen treatment method does
not suit the client and hence, fails to work.
In the case of complex problems, an individual analysis can lead to better treatment effects.
Types of Case Formulations:
Behavioural case formulation.
Cognitive conceptualisation/case formulation.
Cognitive behavioural case formulation.
Note. Differences between these will not be exam material.
Case Formulation Summary:
Synthesizes the client’s experience, CBT theory and research.
Guides treatment.
Makes multiple, complex problems more manageable in the case of multiple
disorders.
Guides the selection, focus, and sequence of interventions.
Identifies the client’s strengths and suggests ways to build client resilience.
Helps to understand non-response in therapy and suggests alternative routes for
change.
Promotes client engagement.
Functional Analysis
Functional analysis focuses on the function of the problem/behaviour.
Why an Individual Analysis is Important:
DSM disorder names are general descriptions of clustered symptoms.
Two individuals with the same disorder can have very different symptoms due to
personality, age, background, comorbidity, behaviour, etc.
o Each diagnosis calls for a unique treatment, i.e., a person diagnosed with
depression receives CBT and a person diagnosed with PTSD receives CBT but
the treatment method varies due to the diagnosis.
A diagnosis alone is not enough for treatment, you need to know how different factors
are related and how symptoms are maintained.
o The treatment needs to be tailored to the individual as a person.
Thus, this all contributes to case formulation.
o Case Formulation: analysing how different symptoms are maintained and
related, and based on that, you develop a specific treatment.
A functional analysis = an individual analysis.
Functional Analysis ABC:
Activate.
Behaviour.
Consequence.
Example of an Individual Analysis:
3
, Cognitive Behavioural Therapy.
Lecture & Literature Summary.
Why does a couple who have an early-born child in the hospital feel anxious when
smelling sanitisers?
Why is a woman always sitting on a chair at the end of a row in the cinema and not in
the middle?
Understanding ‘why’ helps treatment.
Conditioning models help to understand irrational behaviour, there is both adaptive and
maladaptive behaviour. Conditioning models examine learning and conditioning experiences
from the past which can make behaviour more understandable and logical.
Most behaviour is a logical response to stimuli, there is always a reason why a
patient does something, e.g., a positive consequence or the removal of a negative
consequence.
Classical conditioning: unconditioned stimulus + neutral stimulus = conditioned response.
Pavlov.
Operant/Instrumental Conditioning: consequences lead to changes in voluntary behaviour.
Operant conditioning is the focus of functional analysis.
Skinner.
There are two types of consequences to operant/instrumental conditioning:
1. Reinforcement increases behaviour.
a. It can be positive or negative reinforcement.
b. Positive reinforcement = addition of a stimulus. (+S+)
i. E.g., a rat is rewarded with food when it presses a lever.
c. Negative reinforcement = removal of a stimulus. (-S-)
i. E.g., a rat turns off an electric shock when it presses a lever.
2. Punishment decreases behaviour.
a. It can be positive or negative punishment.
b. Positive punishment = addition of a stimulus. (+S-)
c. Negative punishment = removal of a stimulus. (-S+)
Positive stimuli (S+) Negative Stimuli (S-)
+S+ +S-
Increase (+S) Reward: positive reinforcement Punishment: positive punishment
Increase of sth. positive Increase of sth. negative
-S+ -S-
Decrease (-S) Punishment: negative punishment Reward: Negative reinforcement
Decrease of sth. positive Decrease of sth. negative
~S+ ~S-
Not happening (while Punishment: negative punishment Reward: negative reinforcement
expected) (~S) Not happening of sth. positive that Not happening of sth. negative that
was anticipated was anticipated
Individual Analyses & The Link to Conditioning Models:
Why does a couple who have an early-born child in the hospital feel very anxious
when smelling sanitisers?
o Classical conditioning.
Why is a woman always sitting on a chair at the end of a row in the cinema and not in
the middle?
o Operant conditioning.
4
Lecture & Literature Summary.
Cognitive Behavioural Therapy (CBT) – Lecture 1
This lecture consists of three parts:
1) Introduction to CBT & Case Conceptualisation.
2) Functional Analysis.
3) Topographical Analysis.
Introduction to CBT.
Basic Principles of CBT:
CBT is a systematic, action-oriented psychological treatment to improve mental
health.
CBT focuses on challenging and changing unhelpful cognitions, behaviours, and
emotions.
o Cognitions: thoughts, beliefs, and attitudes.
CBT is a broad umbrella term encompassing several treatments; such as the more
cognitive focused variant (Beck), exposure, behavioural activation (BA), and is
related to EMDR, mindfulness, ACT, EFT, etc.
CBT is an evidence-based treatment method and is the first treatment choice for
many disorders including depression, anxiety, OCD, tics, substance use, and
psychotic disorders.
o We support clients best by using evidence-based, tested, treatment methods.
Note. Some professionals view CBT as a specific method (e.g., Beck), however, others
believe it shares characteristics and relations with other methods such as EMDR, ACT etc.
If a patient does not receive successful treatment, they become demoralised and the chance
of starting a new treatment is much lower, comorbidity may increase, as well as the
mortality rate.
Mortality rate: suicide & death.
The basic principles of CBT Cognitions, Behaviours, and Emotions/Physiology are all
interconnected.
What you think influences how you feel, which influences what you do, which
again, influences what you think. The points are all so interconnected that they
activate one another.
^ It can be useful to explain this model to clients.
1
,Cognitive Behavioural Therapy.
Lecture & Literature Summary.
What you Think:
If you conceptualise negative thoughts, you can use different interventions to change
them.
o Conceptualising negative thoughts can drive different symptoms.
What you Do:
It is not only about what you do but also what you do not do, e.g., not going to a
party due to anxiety.
Avoidance behaviour is also behaviour.
Behaviour, and body posture, are relevant to your mood, which can be detected by a
therapist.
The Case Formulation Approach.
Here we can see that different treatment methods are necessary for the same symptoms,
hence, individual analysis (IA) is necessary, as is our focus on the ‘why’.
The model described by a patient is not always the main focus of treatment – there is no
direct link.
Gathering information from the client is important.
What happened, how did it happen, how are things related?
The client might not always have answers to your questions, hence, assign
homework.
Registration assignment: register when things happen to understand
factors and processes.
Focus on understanding why someone engages in a problem, e.g., why would someone
continue to drink despite the negative consequences? – To dampen the trauma.
Develop hypotheses based on an individual analysis.
An individual analysis comes from information gathering.
Link the gathered information to theoretical models for the bigger picture.
Note. Trying to understand why something happened is how we build our hypotheses.
The treatment method is a way of testing your hypotheses, which are based on an
individual analysis.
If there is an effective intervention and symptom reduction, the hypotheses are likely correct.
If there is no effective intervention and no symptom reduction, then, it is the responsibility of
the therapist to go back to the individual analysis/hypotheses. Also, consider if a different
theoretical model should be used.
2
,Cognitive Behavioural Therapy.
Lecture & Literature Summary.
A therapist must always continue to monitor the treatment method and
improvements (including the lack of) made.
Sometimes, the hypothesis is ‘correct’, however, the chosen treatment method does
not suit the client and hence, fails to work.
In the case of complex problems, an individual analysis can lead to better treatment effects.
Types of Case Formulations:
Behavioural case formulation.
Cognitive conceptualisation/case formulation.
Cognitive behavioural case formulation.
Note. Differences between these will not be exam material.
Case Formulation Summary:
Synthesizes the client’s experience, CBT theory and research.
Guides treatment.
Makes multiple, complex problems more manageable in the case of multiple
disorders.
Guides the selection, focus, and sequence of interventions.
Identifies the client’s strengths and suggests ways to build client resilience.
Helps to understand non-response in therapy and suggests alternative routes for
change.
Promotes client engagement.
Functional Analysis
Functional analysis focuses on the function of the problem/behaviour.
Why an Individual Analysis is Important:
DSM disorder names are general descriptions of clustered symptoms.
Two individuals with the same disorder can have very different symptoms due to
personality, age, background, comorbidity, behaviour, etc.
o Each diagnosis calls for a unique treatment, i.e., a person diagnosed with
depression receives CBT and a person diagnosed with PTSD receives CBT but
the treatment method varies due to the diagnosis.
A diagnosis alone is not enough for treatment, you need to know how different factors
are related and how symptoms are maintained.
o The treatment needs to be tailored to the individual as a person.
Thus, this all contributes to case formulation.
o Case Formulation: analysing how different symptoms are maintained and
related, and based on that, you develop a specific treatment.
A functional analysis = an individual analysis.
Functional Analysis ABC:
Activate.
Behaviour.
Consequence.
Example of an Individual Analysis:
3
, Cognitive Behavioural Therapy.
Lecture & Literature Summary.
Why does a couple who have an early-born child in the hospital feel anxious when
smelling sanitisers?
Why is a woman always sitting on a chair at the end of a row in the cinema and not in
the middle?
Understanding ‘why’ helps treatment.
Conditioning models help to understand irrational behaviour, there is both adaptive and
maladaptive behaviour. Conditioning models examine learning and conditioning experiences
from the past which can make behaviour more understandable and logical.
Most behaviour is a logical response to stimuli, there is always a reason why a
patient does something, e.g., a positive consequence or the removal of a negative
consequence.
Classical conditioning: unconditioned stimulus + neutral stimulus = conditioned response.
Pavlov.
Operant/Instrumental Conditioning: consequences lead to changes in voluntary behaviour.
Operant conditioning is the focus of functional analysis.
Skinner.
There are two types of consequences to operant/instrumental conditioning:
1. Reinforcement increases behaviour.
a. It can be positive or negative reinforcement.
b. Positive reinforcement = addition of a stimulus. (+S+)
i. E.g., a rat is rewarded with food when it presses a lever.
c. Negative reinforcement = removal of a stimulus. (-S-)
i. E.g., a rat turns off an electric shock when it presses a lever.
2. Punishment decreases behaviour.
a. It can be positive or negative punishment.
b. Positive punishment = addition of a stimulus. (+S-)
c. Negative punishment = removal of a stimulus. (-S+)
Positive stimuli (S+) Negative Stimuli (S-)
+S+ +S-
Increase (+S) Reward: positive reinforcement Punishment: positive punishment
Increase of sth. positive Increase of sth. negative
-S+ -S-
Decrease (-S) Punishment: negative punishment Reward: Negative reinforcement
Decrease of sth. positive Decrease of sth. negative
~S+ ~S-
Not happening (while Punishment: negative punishment Reward: negative reinforcement
expected) (~S) Not happening of sth. positive that Not happening of sth. negative that
was anticipated was anticipated
Individual Analyses & The Link to Conditioning Models:
Why does a couple who have an early-born child in the hospital feel very anxious
when smelling sanitisers?
o Classical conditioning.
Why is a woman always sitting on a chair at the end of a row in the cinema and not in
the middle?
o Operant conditioning.
4
