CLINICAL MASTERS - Cognitive behavior therapy course, Utrecht University, 2021
LECTURE 1
1. CBT Basic principles
- Cognitive-behavioral therapy is a systematic, action-oriented psychological
treatment to improve mental health.
- CBT focuses on challenging and changing unhelpful cognitions (e.g. thoughts,
beliefs,
and attitudes), behaviors, and emotions.
- It can be seen as a very broad umbrella term; that encompasses several types of
treatments, including the more cognitive focused variant by Beck, but also exposure,
behavioral activation (BA), and is related to EMDR, Mindfulness, ACT, EFT, etc.
- CBT is an evidence-based treatment for many disorders, including depression,
anxiety, PTSD, OCD, tics, substance abuse, and also example psychotic disorders.
- Patients desperate with symptoms if not treated effectively -> comorbidity
- CBT: what you think influences how you feel and how you behave, all
interconnected. Not only what you do, but also what you fail to do, what you not to
do, avoidance behavior is also behavior. If you change one thing-> other aspects will
change as well. Conceptualize negative thoughts-> cognitive interventions to
change, but also behavioral techniques will help to change cognitions. Strong
evidence of BA.
- Body behaviors: useful information eg. depression, social anxiety
2. The Case Formulation approach
Info gathering & Individual analysis
DSM, the way it’s labeled is a general cluster of symptoms,
same disorder-> act differently, differences: sex, culture, age,
maintaining factors, comorbidity. Knowing diagnosis is not
enough, need to know how symptoms are maintained-> need
case formulation -> treatment, combine individuals, everyone
is different
Model:
- No direct link between the problem the patient presented and
the treatment (treatment plan)
- Ask how things are related before afterward, use what client tells you helpful to
registration assignment-> to get a better understanding of the processes
- focus on understanding why: why continue drinking despite the many negative
consequences (divorce, unemployment, health issues) they would stop you would
assume
- why so much fighting, while the couple also loves each other dearly -> focus on
individual analysis -> develop hypotheses
- based on individual analyses
- information gathering -link to theoretical models (always use them)
- E.g. in aggression: use registration assignment you wanna know how he sees these
situations e.g. when someone bump intro them how they see this interpretation bias
-> more info on these details on the problems
,In drinking, there are differences, focus on different treatment James-> trauma-focused
treatments e.g. exposure exercises, EMDR, not for Pete-> for Pete using social anxiety and
negative interpretation
● 97% of therapists agreed with the statement: “Two people could have the same
problem, but the analyses could direct to totally different treatments” (Hermans et al.,
2004)
During treatment and the Evaluation phase -> testing of your hypotheses
- Always monitor the treatment
- Effective intervention?
- Reduction symptoms? No? Why not? Responsibility of therapist to go back to the
individual analyses/hypotheses; might they be incorrect? Did I miss something, invite
a partner to get a better perspective
- Should different therapeutical methods be used?
With complex problems:
- Individual analyses = Better treatment effects
- Different types of case formulations: Behavioural case formulation Vs Cognitive
conceptualization/case formulation Vs Cognitive Behavioural case formulation
Summary: Case formulation approach
- Synthesises client experience, CBT theory, and research
- 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
- It helps understand non-response in therapy and suggest alternative routes for
change
- Promotes client engagement
- E.g. women, baby 6 months, a mixture of symptoms worry she would hurt her baby,
choke the baby, pillow on his face, saw a knife and afraid she would choose him
3. Functional analysis:
, - Conditioning models helps understanding behavior: both adaptive as well as
maladaptive behavior
- Learning is a long term change in behavior based on experience
Classical conditioning/ Pavlov Operant conditioning/ Skinners
dogs->bell->food (US) Bell (CS)-> salivate Reinforcement increases the behavior
(UR) Positive = addition of the stimulus (e.g.
human-> same way getting a hug when you did something+S+)
shot-> pain-> dentist “this won’t hurt a bit” Negative = removal of the stimulus e.g.
became a stimulus able to turn off the electrical shock-S-
Why ….. does a couple who have a too Punishment decreases behavior:
early born child in the hospital feel very positive (added )or negative (removed)
anxious when smelling sanitizers? punishment: both have the same meaning
in reinforcement and punishment.
Why ….. is a woman always sitting on a
chair at the end of a row in the cinema, and
not in the middle? Anxious, sitting there
easier to leave the cinema, sense of
control, positive reinforcement, reduce
anxiety, negative reinforcement
• Functional analyses: focus on the function of the problem/behavior → Consequences
• directly linked to operant conditioning: a learning process through which the strength of a
behavior (voluntary behavior) is modified by reinforcement or punishment
• Focus on when does it happen. Always? Or in certain situations? What defines the context
where the maladaptive behavior is present vs absent?
→ Antecedents= Activating event (when does it happen) also called Discriminating
Stimulus = Sd (discriminate when does it happen)
- 3 elements Activating event – Behaviour – Consequences (ABC) (Page &
Stritzke)
, Match between activating behavior and consequence
Example situation:
• Jonathan, age 14, problems at school Teachers at school say he is a difficult boy. He
teases and also hits other children (Behaviour) because he likes that and gets attention
(positive reinforcing consequence, +S+). A psychologist is observing the boy for a few
days (gathering information) and notices that the problematic behavior is mainly occurring
in the theory classes (Activating event). The hypothesis is that Jonathan has difficulty
with theory and that he teases other children to reduce his boredom (negative
reinforcing consequence: -S-). → school test confirms mismatch Jonathan and current
school choice
• Different types of consequences:
➢ Reinforcing consequences -> increase
the likelihood of the behavior
➢Punishment consequences -> decrease
the likelihood of the behavior
• Different types within the Reinforcing
and Punishment consequences:
Positive and Negative
➢Reinforcement: “get something positive” or
“remove something negative”
➢Punishment: “get something negative” or
“remove something positive”
Summary:
a. The functional analysis is concerned
with the (perceived) association between
preceding stimuli, the behavior (R), and
the consequences. It is based on operant
conditioning
b. When analyzing the behavior of
patients; there is always a positive and a
negative consequence (always a reason
why it’s reinforced, +S+, and -S- otherwise
there is no reason to change) ->
hypothesis (registration assignment to test is and treat it)
c. The functional analysis is a hypothesis and it informs / guides treatment
• Antecedents and Consequences can be external events (e.g., a comment from your boss)
or internal events (e.g., depressed feelings).
• How to get input for a functional analysis:
- ask the client, for example using topographical analysis
- registration assignment for the client (also when not aware of antecedents and
consequences)
- use your clinical knowledge and scientific knowledge of common antecedents and
consequences of certain behaviors
LECTURE 1
1. CBT Basic principles
- Cognitive-behavioral therapy is a systematic, action-oriented psychological
treatment to improve mental health.
- CBT focuses on challenging and changing unhelpful cognitions (e.g. thoughts,
beliefs,
and attitudes), behaviors, and emotions.
- It can be seen as a very broad umbrella term; that encompasses several types of
treatments, including the more cognitive focused variant by Beck, but also exposure,
behavioral activation (BA), and is related to EMDR, Mindfulness, ACT, EFT, etc.
- CBT is an evidence-based treatment for many disorders, including depression,
anxiety, PTSD, OCD, tics, substance abuse, and also example psychotic disorders.
- Patients desperate with symptoms if not treated effectively -> comorbidity
- CBT: what you think influences how you feel and how you behave, all
interconnected. Not only what you do, but also what you fail to do, what you not to
do, avoidance behavior is also behavior. If you change one thing-> other aspects will
change as well. Conceptualize negative thoughts-> cognitive interventions to
change, but also behavioral techniques will help to change cognitions. Strong
evidence of BA.
- Body behaviors: useful information eg. depression, social anxiety
2. The Case Formulation approach
Info gathering & Individual analysis
DSM, the way it’s labeled is a general cluster of symptoms,
same disorder-> act differently, differences: sex, culture, age,
maintaining factors, comorbidity. Knowing diagnosis is not
enough, need to know how symptoms are maintained-> need
case formulation -> treatment, combine individuals, everyone
is different
Model:
- No direct link between the problem the patient presented and
the treatment (treatment plan)
- Ask how things are related before afterward, use what client tells you helpful to
registration assignment-> to get a better understanding of the processes
- focus on understanding why: why continue drinking despite the many negative
consequences (divorce, unemployment, health issues) they would stop you would
assume
- why so much fighting, while the couple also loves each other dearly -> focus on
individual analysis -> develop hypotheses
- based on individual analyses
- information gathering -link to theoretical models (always use them)
- E.g. in aggression: use registration assignment you wanna know how he sees these
situations e.g. when someone bump intro them how they see this interpretation bias
-> more info on these details on the problems
,In drinking, there are differences, focus on different treatment James-> trauma-focused
treatments e.g. exposure exercises, EMDR, not for Pete-> for Pete using social anxiety and
negative interpretation
● 97% of therapists agreed with the statement: “Two people could have the same
problem, but the analyses could direct to totally different treatments” (Hermans et al.,
2004)
During treatment and the Evaluation phase -> testing of your hypotheses
- Always monitor the treatment
- Effective intervention?
- Reduction symptoms? No? Why not? Responsibility of therapist to go back to the
individual analyses/hypotheses; might they be incorrect? Did I miss something, invite
a partner to get a better perspective
- Should different therapeutical methods be used?
With complex problems:
- Individual analyses = Better treatment effects
- Different types of case formulations: Behavioural case formulation Vs Cognitive
conceptualization/case formulation Vs Cognitive Behavioural case formulation
Summary: Case formulation approach
- Synthesises client experience, CBT theory, and research
- 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
- It helps understand non-response in therapy and suggest alternative routes for
change
- Promotes client engagement
- E.g. women, baby 6 months, a mixture of symptoms worry she would hurt her baby,
choke the baby, pillow on his face, saw a knife and afraid she would choose him
3. Functional analysis:
, - Conditioning models helps understanding behavior: both adaptive as well as
maladaptive behavior
- Learning is a long term change in behavior based on experience
Classical conditioning/ Pavlov Operant conditioning/ Skinners
dogs->bell->food (US) Bell (CS)-> salivate Reinforcement increases the behavior
(UR) Positive = addition of the stimulus (e.g.
human-> same way getting a hug when you did something+S+)
shot-> pain-> dentist “this won’t hurt a bit” Negative = removal of the stimulus e.g.
became a stimulus able to turn off the electrical shock-S-
Why ….. does a couple who have a too Punishment decreases behavior:
early born child in the hospital feel very positive (added )or negative (removed)
anxious when smelling sanitizers? punishment: both have the same meaning
in reinforcement and punishment.
Why ….. is a woman always sitting on a
chair at the end of a row in the cinema, and
not in the middle? Anxious, sitting there
easier to leave the cinema, sense of
control, positive reinforcement, reduce
anxiety, negative reinforcement
• Functional analyses: focus on the function of the problem/behavior → Consequences
• directly linked to operant conditioning: a learning process through which the strength of a
behavior (voluntary behavior) is modified by reinforcement or punishment
• Focus on when does it happen. Always? Or in certain situations? What defines the context
where the maladaptive behavior is present vs absent?
→ Antecedents= Activating event (when does it happen) also called Discriminating
Stimulus = Sd (discriminate when does it happen)
- 3 elements Activating event – Behaviour – Consequences (ABC) (Page &
Stritzke)
, Match between activating behavior and consequence
Example situation:
• Jonathan, age 14, problems at school Teachers at school say he is a difficult boy. He
teases and also hits other children (Behaviour) because he likes that and gets attention
(positive reinforcing consequence, +S+). A psychologist is observing the boy for a few
days (gathering information) and notices that the problematic behavior is mainly occurring
in the theory classes (Activating event). The hypothesis is that Jonathan has difficulty
with theory and that he teases other children to reduce his boredom (negative
reinforcing consequence: -S-). → school test confirms mismatch Jonathan and current
school choice
• Different types of consequences:
➢ Reinforcing consequences -> increase
the likelihood of the behavior
➢Punishment consequences -> decrease
the likelihood of the behavior
• Different types within the Reinforcing
and Punishment consequences:
Positive and Negative
➢Reinforcement: “get something positive” or
“remove something negative”
➢Punishment: “get something negative” or
“remove something positive”
Summary:
a. The functional analysis is concerned
with the (perceived) association between
preceding stimuli, the behavior (R), and
the consequences. It is based on operant
conditioning
b. When analyzing the behavior of
patients; there is always a positive and a
negative consequence (always a reason
why it’s reinforced, +S+, and -S- otherwise
there is no reason to change) ->
hypothesis (registration assignment to test is and treat it)
c. The functional analysis is a hypothesis and it informs / guides treatment
• Antecedents and Consequences can be external events (e.g., a comment from your boss)
or internal events (e.g., depressed feelings).
• How to get input for a functional analysis:
- ask the client, for example using topographical analysis
- registration assignment for the client (also when not aware of antecedents and
consequences)
- use your clinical knowledge and scientific knowledge of common antecedents and
consequences of certain behaviors
