LECUTE 1 CBT
Why and what of CBT Conditioning models
- CBT is a systematic, action-oriented psychological - Conditioning models help understanding behavior:
treatment to improve mental health both adaptive and maladaptive
- CBT focuses on challenging and changing unhelpful 1. Classical conditioning: Why... does a couple who
cognitions, behaviors and emotions have a too early born child in the hospital feel very
- It can be seen as a very broad umbrella term that anxious when smelling sanitizers?
encompasses several types of treatments 2. Operant conditioning: Why... is a woman always
- CBT is evidence-based treatment for many disorders sitting on a chair at the end of a row in the cinema,
and not in the middle?
Interconnected
Cognitions, behaviors and emotions are interconnected, 1. Classical conditioning
it activates each other - Food UCS à drooling, UCR
- Idea: if you change one thing, you change the others - Sound CS, neutral
as well - Pairing those together will lead to: Sound (CS) à
food (CS) à drooling (UCR)
The case formulation approach
Is a formulation about your specific patient how different - Sound (CS) à Drooling (CR)
symptoms are related and are maintained
-> Based on this formulation you develop a specific 2. Operant conditioning
treatment - Reinforcement increases behavior (+S+ get
something positive and -S- remove something
Important with case formulation negative)
- Focus on understanding WHY - Punishment decreases behavior (+S- get something
- Develop hypotheses based on the individual negative and -S+ remove something positive)
analyses (N = 1), information gathering and - Positive (addition of stimulus) and negative (removal
theoretical model of stimulus) have the same meaning in reinforcement
and punishment
During treatment and the evaluation phase
Testing your hypotheses Functional analyses
- Effective intervention? - Focus on the function of the problem (Behavior à
- Reduction symptoms? Consequences)
If not -> it is the responsibility of the therapist to go back - Links to operant conditioning: a learning process
to the individual analyses/hypotheses: might they be through which the strength of a behavior is modified
incorrect? And should different therapeutical methods be by reinforcement or punishment
used? - Focus on when does it happen? Always or in certain
situations? (Antecedents, also called Discriminating
Complex problems stimulus)
With complex problems a individual analyses has better - There is always a positive and a negative
treatment effects (Hayes et al., 1997) consequence
Types of case formulations
1. Behavioural case formulation (Page & Stritzke, Ch 5)
2. Cognitive conceptualization/case formulation (Beck,
Ch 3)
3. Cognitive Behavioural case formulation (Page &
Stritzke, Ch 5)
Summary: case formulation approach
- It guides treatment
- Makes numerous, complex problems more
manageable in the case of multiple disorders
- Guides the selection, focus, and sequence of
interventions
- Identifies client strengths and suggests ways to build
client resilience
- Helps understand non-response in therapy and
suggests alternative routes for change
- Promotes client engagement
1
,Functional analysis
Discriminating Respondent (R) - Reinforcing consequences (increase beh) = Sr
Stimulus (Sd) - Punishment consequences (decrease beh)
Julia Social situations Dominant and Sr: to prevent to be bullied
With unknown aggressive Neg con: many conflicts
people behavior
Pam Social situations Very quiet and Sr: to prevent to be bullied
With unknown submissive Neg con: loneliness
people behavior
Positive stimuli/situations (S+) Negative stimuli/situations (S-)
Increase (+S) +S+ +S-
Reward: positive reinforcement Punishment: positive punishment
Increase of something positive Increase of something negative
Decrease (-S) -S+ -S-
Punishment: negative punishment Reward: negative reinforcement
Decrease of something positive Decrease of something negative
Not happening (while ~S+ ~S-
expected (~S) Punishment: negative punishment Reward: negative reinforcement
Not happening of something positive Not happening of something negative
that was anticipated that was anticipated
Behavior will increase (reinforcements)
• The high after drug use (+S+)
• Self-harming to erase unpleasant memories, taking a pill for panic (-S-)
• Reducing boredom (-S-)
• Evading a supposed panic attack by avoiding shops, aggressive behavior to avoid feeling humiliated (~S-)
Behavior will decrease (punishments)
• Getting arguments about smoking (+S-)
• Time out (leave the pleasant situation) (-S+)
• Not getting the expected promotion (~S+)
• First sign (sign before the S): what happened? (increase, decrease, prevent) Second sign (after the S): valence of
the stimuli / situations (positive or negative)
• Anxiety-related behaviors (like avoidance) are generally –S- reinforced, and addictive behaviors are generally +S+
reinforced
Topographical analysis
2
, LECUTE 2 CBT Example 2
Automatic thought: “It’s too much for me… I’ll never get it
Cognitive Behavioral model done”
The cognitive model describes how people's thoughts Intermediate belief: “If I don’t excel, it will turn out very
and perceptions influence the way they feel and behave. bad for me. I’ll not make it through my masters… People
The cognitive model is at the core of CBT, and it plays a will reject me and I will be alone… I must be perfect to be
critical role in helping therapists conceptualize and treat accepted”
their clients' difficulties. Core belief: “I’m a total failure and incompetent”
Base of core belief: Parents only reinforced academic
Modifying targets in treatment achievements
- Cognitions - Learn how to recognize and change
anxiety thoughts Identifying automatic thoughts
- Emotions - Relaxation or imaginary to reduce Using mood shifts: “Before you start your shift, I would
anxious emotions love to know how you feel today (1-10)”
- Behaviors - Implement a step-by-step hierarchy to
break patterns or avoidance, build more social skills Guided discovery
1. Describe the [emotional] situation (what, where, with
Automatic thoughts whom’s)
Surface level of thinking - preconscious 2. Identify and give a score to intensity of feeling to be
- Words or images that come rapidly and investigated further. Pay attention to secondary
spontaneously to mind related to specific situations emotions [feeling angry [1] because feeling sad [2]!)
- Results into the core and intermediate beliefs 3. Describe automatic negative thoughts that link the
- These thoughts are biased, influences our reactions situations to the feeling “What thoughts were going
[feeling and behaviors] in situations through your head?” and “How did you feel when …
- Leads to presence of very strong emotions that are happened?”
not related to the event in case (depression, anxiety 4. Select most important automatic negative thought
disorder)
Hot thought
Intermediate beliefs The most important automatic negative thought
- Develops as the individual tries to make sense of the
world around them, it warns you Strategies for guided discovery
- Guide our behavior, set our standards and establish - Pursue lines of questioning that stimulates emotion
rules for living - Be specific
- “If…, then…” or “If I don’t…, then…” or “I - Focus on recent events (also with PTSD)
must/should/have to/always/never…, or else… - Stick with one line of questioning and one topic
- Dig deeper (what other thoughts did you have, try
Core beliefs staying in this situation a little longer)
Absolute fundamental convictions about yourself, the - Use your empathy skills
world and others - Ask for uncensored automatic thoughts
- These are based on experiences or unmet emotional - - Rely on case conceptualization for direction –
core needs as we grow up. differential diagnoses
- They are so grounded that they are regarded as
absolute underlying deeper truth and apply to Thought recording
situations in general . - Examples: Helpless, (G-schema)
worthless, unlovable, unsafe • Situation
• Automatic thoughts (believe 0-100%)
Core emotional needs • Emotions
These are needs to grow up (intense 0-100%)
- Need to belong [securely attached] • Challenging thought (believe 0-100%)
- Need for autonomy, identity, and competence • Alternative, more balanced, helpful thought
- Feeling free to express needs and emotions
- Need for spontaneity and play Identifying intermediate and core beliefs
- Need for realistic limits and control - Mood shifts
- Imagery
Example 1 - Role play
Automatic thought: “Oh no, he’s losing interest” - Guided discovery
Intermediate belief: “And is going to break up with me…
If I don’t please others, they will reject me. Be Conducting a life history
independent and you will be safe” Ask about…
Core belief: “I’m flawed on numerous ways, which - Influential people
means, I’m not worthy of consistent attention and care. - Core beliefs that may have been shaped by these
I’m unlovable” experiences
Base of core belief: Parental neglect and criticism, bullied - Cultural and social influences
- Transforming experiences
3
Why and what of CBT Conditioning models
- CBT is a systematic, action-oriented psychological - Conditioning models help understanding behavior:
treatment to improve mental health both adaptive and maladaptive
- CBT focuses on challenging and changing unhelpful 1. Classical conditioning: Why... does a couple who
cognitions, behaviors and emotions have a too early born child in the hospital feel very
- It can be seen as a very broad umbrella term that anxious when smelling sanitizers?
encompasses several types of treatments 2. Operant conditioning: Why... is a woman always
- CBT is evidence-based treatment for many disorders sitting on a chair at the end of a row in the cinema,
and not in the middle?
Interconnected
Cognitions, behaviors and emotions are interconnected, 1. Classical conditioning
it activates each other - Food UCS à drooling, UCR
- Idea: if you change one thing, you change the others - Sound CS, neutral
as well - Pairing those together will lead to: Sound (CS) à
food (CS) à drooling (UCR)
The case formulation approach
Is a formulation about your specific patient how different - Sound (CS) à Drooling (CR)
symptoms are related and are maintained
-> Based on this formulation you develop a specific 2. Operant conditioning
treatment - Reinforcement increases behavior (+S+ get
something positive and -S- remove something
Important with case formulation negative)
- Focus on understanding WHY - Punishment decreases behavior (+S- get something
- Develop hypotheses based on the individual negative and -S+ remove something positive)
analyses (N = 1), information gathering and - Positive (addition of stimulus) and negative (removal
theoretical model of stimulus) have the same meaning in reinforcement
and punishment
During treatment and the evaluation phase
Testing your hypotheses Functional analyses
- Effective intervention? - Focus on the function of the problem (Behavior à
- Reduction symptoms? Consequences)
If not -> it is the responsibility of the therapist to go back - Links to operant conditioning: a learning process
to the individual analyses/hypotheses: might they be through which the strength of a behavior is modified
incorrect? And should different therapeutical methods be by reinforcement or punishment
used? - Focus on when does it happen? Always or in certain
situations? (Antecedents, also called Discriminating
Complex problems stimulus)
With complex problems a individual analyses has better - There is always a positive and a negative
treatment effects (Hayes et al., 1997) consequence
Types of case formulations
1. Behavioural case formulation (Page & Stritzke, Ch 5)
2. Cognitive conceptualization/case formulation (Beck,
Ch 3)
3. Cognitive Behavioural case formulation (Page &
Stritzke, Ch 5)
Summary: case formulation approach
- It guides treatment
- Makes numerous, complex problems more
manageable in the case of multiple disorders
- Guides the selection, focus, and sequence of
interventions
- Identifies client strengths and suggests ways to build
client resilience
- Helps understand non-response in therapy and
suggests alternative routes for change
- Promotes client engagement
1
,Functional analysis
Discriminating Respondent (R) - Reinforcing consequences (increase beh) = Sr
Stimulus (Sd) - Punishment consequences (decrease beh)
Julia Social situations Dominant and Sr: to prevent to be bullied
With unknown aggressive Neg con: many conflicts
people behavior
Pam Social situations Very quiet and Sr: to prevent to be bullied
With unknown submissive Neg con: loneliness
people behavior
Positive stimuli/situations (S+) Negative stimuli/situations (S-)
Increase (+S) +S+ +S-
Reward: positive reinforcement Punishment: positive punishment
Increase of something positive Increase of something negative
Decrease (-S) -S+ -S-
Punishment: negative punishment Reward: negative reinforcement
Decrease of something positive Decrease of something negative
Not happening (while ~S+ ~S-
expected (~S) Punishment: negative punishment Reward: negative reinforcement
Not happening of something positive Not happening of something negative
that was anticipated that was anticipated
Behavior will increase (reinforcements)
• The high after drug use (+S+)
• Self-harming to erase unpleasant memories, taking a pill for panic (-S-)
• Reducing boredom (-S-)
• Evading a supposed panic attack by avoiding shops, aggressive behavior to avoid feeling humiliated (~S-)
Behavior will decrease (punishments)
• Getting arguments about smoking (+S-)
• Time out (leave the pleasant situation) (-S+)
• Not getting the expected promotion (~S+)
• First sign (sign before the S): what happened? (increase, decrease, prevent) Second sign (after the S): valence of
the stimuli / situations (positive or negative)
• Anxiety-related behaviors (like avoidance) are generally –S- reinforced, and addictive behaviors are generally +S+
reinforced
Topographical analysis
2
, LECUTE 2 CBT Example 2
Automatic thought: “It’s too much for me… I’ll never get it
Cognitive Behavioral model done”
The cognitive model describes how people's thoughts Intermediate belief: “If I don’t excel, it will turn out very
and perceptions influence the way they feel and behave. bad for me. I’ll not make it through my masters… People
The cognitive model is at the core of CBT, and it plays a will reject me and I will be alone… I must be perfect to be
critical role in helping therapists conceptualize and treat accepted”
their clients' difficulties. Core belief: “I’m a total failure and incompetent”
Base of core belief: Parents only reinforced academic
Modifying targets in treatment achievements
- Cognitions - Learn how to recognize and change
anxiety thoughts Identifying automatic thoughts
- Emotions - Relaxation or imaginary to reduce Using mood shifts: “Before you start your shift, I would
anxious emotions love to know how you feel today (1-10)”
- Behaviors - Implement a step-by-step hierarchy to
break patterns or avoidance, build more social skills Guided discovery
1. Describe the [emotional] situation (what, where, with
Automatic thoughts whom’s)
Surface level of thinking - preconscious 2. Identify and give a score to intensity of feeling to be
- Words or images that come rapidly and investigated further. Pay attention to secondary
spontaneously to mind related to specific situations emotions [feeling angry [1] because feeling sad [2]!)
- Results into the core and intermediate beliefs 3. Describe automatic negative thoughts that link the
- These thoughts are biased, influences our reactions situations to the feeling “What thoughts were going
[feeling and behaviors] in situations through your head?” and “How did you feel when …
- Leads to presence of very strong emotions that are happened?”
not related to the event in case (depression, anxiety 4. Select most important automatic negative thought
disorder)
Hot thought
Intermediate beliefs The most important automatic negative thought
- Develops as the individual tries to make sense of the
world around them, it warns you Strategies for guided discovery
- Guide our behavior, set our standards and establish - Pursue lines of questioning that stimulates emotion
rules for living - Be specific
- “If…, then…” or “If I don’t…, then…” or “I - Focus on recent events (also with PTSD)
must/should/have to/always/never…, or else… - Stick with one line of questioning and one topic
- Dig deeper (what other thoughts did you have, try
Core beliefs staying in this situation a little longer)
Absolute fundamental convictions about yourself, the - Use your empathy skills
world and others - Ask for uncensored automatic thoughts
- These are based on experiences or unmet emotional - - Rely on case conceptualization for direction –
core needs as we grow up. differential diagnoses
- They are so grounded that they are regarded as
absolute underlying deeper truth and apply to Thought recording
situations in general . - Examples: Helpless, (G-schema)
worthless, unlovable, unsafe • Situation
• Automatic thoughts (believe 0-100%)
Core emotional needs • Emotions
These are needs to grow up (intense 0-100%)
- Need to belong [securely attached] • Challenging thought (believe 0-100%)
- Need for autonomy, identity, and competence • Alternative, more balanced, helpful thought
- Feeling free to express needs and emotions
- Need for spontaneity and play Identifying intermediate and core beliefs
- Need for realistic limits and control - Mood shifts
- Imagery
Example 1 - Role play
Automatic thought: “Oh no, he’s losing interest” - Guided discovery
Intermediate belief: “And is going to break up with me…
If I don’t please others, they will reject me. Be Conducting a life history
independent and you will be safe” Ask about…
Core belief: “I’m flawed on numerous ways, which - Influential people
means, I’m not worthy of consistent attention and care. - Core beliefs that may have been shaped by these
I’m unlovable” experiences
Base of core belief: Parental neglect and criticism, bullied - Cultural and social influences
- Transforming experiences
3
