2. Learning Objectives
1. To develop a basic knowledge of the importance of CBT in
clinical practice and the conditions for which it can be
used
2. To understand the key principles of CBT and the
Activating Event – Belief – Consequence concept
3. To develop the ability to perceive thinking errors in
oneself and others
4. To understand the basic techniques that are used for
various conditions
5. To be able to set Specific, Positive, Observable, Realistic
and Timed goals for oneself and others
3. Lesson Overview
1. Introduction to CBT
2. Principles of CBT
3. *Task 1*
4. Thinking errors
5. CBT in practice
6. *Task 2*
7. Case discussion
8. *Task 3*
9. Discussion and conclusion
4.
5. What is CBT?
Cognitive Behavioural Therapy is based on the idea that our
emotions are governed by our thoughts
At face value the majority of what CBT teaches is common
sense
CBT aims to encourage people to have a more objective
view of events by developing more healthy emotions
“Men are disturbed not by things, but by the view which
they take of them” (Epictetus in The Enchiridion)
6. What can it be used for?
Conditions for which NICE has
issued guidance for the use of
CBT:
Schizophrenia
Eating disorders
Self-harm
Anxiety
Depression
Bipolar disorder
Depression in children
Dementia
Obsessive-Compulsive
Disorder (OCD)
Post Traumatic Stress
Disorder (PTSD)
Disturbed (violent) behaviour
Other conditions for which CBT
may prove beneficial:
Addiction
Chronic fatigue syndrome
Chronic pain
Personality disorders
Phobias
Relationship problems
Psychotic disorders
7. Where’s the evidence?
CBT has one of the strongest evidence bases of
all psychotherapies.
The vast majority of this research related to the
implementation of CBT for the treatment of
anxiety and depression
Many randomised controlled trials have shown
CBT to be more effective or equivalent to
medication for their management
To take the example of depression, a one-year
follow up of a recent trial indicates that patients
undergoing CBT were less likely to relapse than
patients taking antidepressants alone.
9. People are different
Many people assume that an event makes them
feel a certain way e.g. someone who treats them
inconsiderately makes them feel angry.
Some people may even say that this makes them
behave in a certain way.
However, many people will react differently to the
same event
This is because different people will have had
different thought processes at the time
It is these thought processes which determine
how we act
10. Example
Imagine someone close to you treats you inconsiderately. How do
you feel?
Person 1: Angry “That idiot has no right to treat me that way”
Person 2: Depressed “This lack of consideration means they don’t love
me”
Person 3: Jealous “This means they care more about someone else”
Person 4: Hurt “I don’t deserve to be treated poorly because I am
always considerate”
Person 5: Guilty “I must have done something to upset them”
Person 6: Anxious “This must mean they’re losing interest in me”
Person 7: Happy “Great now I can use this as an excuse to end our
relationship”
Person 8: Annoyed “I’m not prepared to put up with this behaviour”
Person 9: Disappointed “I wish they had been more considerate”
Person 10: Ashamed “They must have found out something about me”
11. Learning your ABCs
A is the Activating event:
It may refer to a real external event, an external event
that is anticipated to happen in the future or an internal
event in the subject’s own mind (e.g. image, memory,
dream)
B refers to the Beliefs of the subject:
These include thoughts, personal expectations of
yourself, the world and other people and the meanings
attached to events
C refers to the Consequences:
These include emotions, behaviours and the physical
sensations related to certain emotions.
12.
13. Dispute and Effect
CBT encourages people to think about
what thoughts and beliefs they attach to
events
They are then encouraged to question
these beliefs and generate new healthy
alternatives
This is often done by filling in “ABCDE”
forms where D stands for Dispute and E
stands for Effect
14. *Task 1*
Write down on a slip of paper the last time that
you felt angry
Now write down the last time that you felt upset
Now, for each of these, write down your thoughts
at the time of the incident
Many people find that the times that they felt
angry they criticised the actions of other people,
whereas the times that they felt upset they
criticised themselves
Was this also what you found?
15. Thinking errors
These are errors in thinking that we all make from time to time i.e. they are normal
However, it is these thinking errors that prevent us from thinking rationally about our situation
By working out which thinking errors people are prone to, we can work out how to
prevent/correct this:
1. Catastrophising: Taking a relatively minor negative event and imagining disasters resulting
from this one event.
2. All-or-nothing thinking: Extreme thinking that can lead to extreme emotions.
3. Fortune telling: Trying to predict what might happen in the future.
4. Mind-reading: Assuming that other people have negative thoughts.
5. Emotional reasoning: Relying too heavily on our feelings as a guide to our thoughts.
6. Overgeneralising: Drawing global conclusions from events (“always”, “never”, “people are …”,
“the world is ….”).
7. Labelling: Globally rating things that are too complex for a definitive label.
8. Making demands: Thoughts and beliefs that contains words like “must”, “should”, “need”,
“ought”, “got to” and “have to”.
9. Mental filtering: Acknowledging only information that fits with your particular belief system.
10. Disqualifying the positive: Transforming a positive event into a neutral or negative event in
your mind.
11. Low frustration tolerance: Magnifying discomfort and not tolerating it even temporarily.
12. Personalising: Interpreting events as relating to you personally.
16. Thinking errors - examples
1. "Nobody likes me."
2. "I'm the worst student in the world."
3. "I missed the bus, I'm such an incapable person."
4. "I should study longer."
5. "I'm causing problems for a lot of people."
6. "I didn't remember to get a Christmas present for Cassandra's
kid, hence I'm useless (even though I remembered presents for
all others)."
7. "I'll never get a job."
8. "I'm a jerk."
9. "It's always my fault."
10. "I must get a Distinction in my exam or else I'm worthless."
11. "So I scored the goal that won the match, anyone could do it."
12. "If I haven't had sex by the time I'm 20 I may as well give up
thoughts of intimate relationships forever."
13. "Although I got high distinctions in all my subjects, I failed PE,
hence I'm a failure."
14. "I'm angry, so somebody must be trying to take advantage of
me."
15. "I failed to put out the garbage bins again, the world will end."
16. "So I got the University Medal in physics, anyone could do it."
17. "I should do better at my work."
18. "I'm miserable so I must be a miserable person."
19. "So what if David said he was proud of me, he doesn't mean it."
20. "I'm so fat I could never succeed in life."
1. Mind-reading
2. Labelling
3. All-or-nothing thinking
4. Making demands
5. Personalising
6. Mental filtering
7. Fortune telling
8. Labelling
9. Personalising
10. Making demands
11. Disqualifying the positive
12. Fortune telling
13. Mental filtering
14. Emotional reasoning
15. Catastrophising
16. Disqualifying the positive
17. Making demands
18. Emotional reasoning
19. Disqualifying the positive
20. All-or-nothing thinking
19. Anxiety
FEAR = Face Everything And Recover
Exposure/desensitisation – facing up to
anxiety
Habituation – becoming accustomed to
anxiety
Wait until anxiety reduced by half before
ending the exposure
20.
21. Depression
CBT encourages depressed people to do the exact
opposite of what their depression makes them
feel like doing
This may seem enormously hard, but CBT
encourages people to take small steps towards a
greater goal
Many people find that, although they do not
enjoy activities as much as they would have done
before becoming depressed, they are glad to
have done something
CBT also helps depressed individuals to recognise
their depressed thoughts and prevent rumination
22. OCD
Experiment – reduce/increase compulsions
and see how this affects their obsessions
Patients normally find that they become
more preoccupied with their obsessions,
the more they carry out the compulsions
(and vice versa), thus proving that there is
a plausible link between the two
Patients are also encouraged to create
“responsibility pie charts” to help them see
that they are not entirely responsible for
the outcome of events
23. Example – woman who is obsessed about harm coming to her children from
poisonous substances (believes she herself would be entirely to blame if
something were to happen)
Responsibility pie chart
The children
Other people for keeping
things clean and
uncontaminated
My partner sharing
responsibility for the
children's well-being
Government and Council
for protecting us from
toxis substances
Me
toxic substances
Responsibility pie chart
The children
Other people for keeping
things clean and
uncontaminated
My partner sharing
responsibility for the
children's well-being
Government and Council
for protecting us from
toxis substances
Me
toxic substances
24. *Task 2*
You can save this task for later if you want!
Grab a partner and sit back to back
Ask your partner to tell you a story for one minute
Now recall as many points from the story as you can
Now ask them to tell you a story again, but this time,
deliberately distract yourself and refocus your attention
Now again, recall as many points from the story as you can
It is likely that you will find that you remembered a lot less
the second time, but with practice, you can train yourself to
refocus successfully
This technique can be very useful in day-to-day activities
when you find yourself distracted
26. Case scenarios
For the following 3 cases, attempt to
answer the following questions:
What is the condition is this patient likely to be
suffering from?
What is the thinking error discussed?
What different techniques might be useful for
this patient?
27. Case 1
Mrs. Olivia Catherine Denton has been feeling “on
edge” and anxious for some time. You see her at
home, and she says that she constantly thinks
about the possibility of her house burning down
and feels the need to check and re-check various
electrical appliances and has to come home from
work several times each day just to check it’s still
there. When asked further about the most recent
time she felt on edge (not long before this
consultation), she describes how her husband put
some toast on and she had to stand and watch it.
She says she thought “If I look away for a split
second there will be a fire, which will spread to
the rest of the house, and it will all be my fault”.
28. Case 2
Mr. B. Down has been feeling particularly
low for some time. He spends most of his
time in bed, and when he does get up, he
does not feel he has the energy to do
anything. He tells you that he was feeling
particularly “low” this morning when his
wife informed him that she was taking the
children out for the day. He said that he
thought “She didn’t bother to invite me.
I’m a useless pathetic failure and my wife
and kids agree”.
29. Case 3
Ms. Ann X has an immense fear of social
situations, particularly events such as large
parties involving lots of people. She says that she
was invited to an event last weekend but was
unable to go. She says she imagined herself
making a fool of herself (e.g. falling over and
exposing herself) in front of everyone and being
ridiculed by the other guests. This gave her an
overwhelming sense of fear that manifested as a
fast heart rate, wobbly knees, dry throat and
butterflies in the stomach. She said she thought
“If I go to this party, then I am bound to draw
attention to myself and be hugely embarrassed”.
30. *Task 3*
The best goals use a “SPORT” format
This means that they are Specific,
Positive, Observable, Realistic and Timed
Use this format to set yourself your own
goal – it can be anything that you want to
achieve
Remember this format for the future when
setting yourself goals and objectives
31. Conclusion
CBT is an evidence-based therapy that has been
shown to be useful in the management of many
psychological conditions including depression,
anxiety and OCD
The main principle of CBT is that our thoughts
control our emotions and how we react to events
(Activating event – Beliefs – Consequences)
CBT encourages people to recognise errors in
their thinking, in order to help them to react
healthily to events
32.
33. References:
1. Wilson R & Branch R. Cognitive Behavioural Therapy for
Dummies, John Riley & Sons, Edition 1, 2005
2. National Association of Cognitive-Behavioral Therapists. History of
Cognitive-Behavioural Therapy. Available via URL:
http://www.nacbt.org/historyofcbt.htm [Accessed 8 Nov 2009]
3. Dimidjian, S., Hollon, S.D., Dobson, K.S., et al. (2006)
Randomized trial of behavioral activation, cognitive therapy, and
antidepressant medication in the acute treatment of adults with
major depression. Journal of Consulting & Clinical Psychology, 74,
658-670.
4. Fava, G.A., Ruini, C., Rafanelli, C., et al. (2004) Six-year outcome
of cognitive behavior therapy for prevention of recurrent
depression. The American Journal of Psychiatry, 161, 1872-1876.
5. Nice Guidelines. CG90 Depression in adults 28 Oct 2009
6. Willson R & Branch R. Cognitive Behavioural Therapy For
Dummies. Wiley Publishing 2006
Editor's Notes
This presentation provides a basic overview of the principles behind cognitive behavioural therapy and its clinical uses. In order to gain the most out of this presentation, I suggest you access the written document entitled “Cognitive Behavioural Therapy: A basic overview”, which accompanies this presentation.
These are the learning objectives that you should expect to have achieved by the end of this presentation.
I will begin by introducing the concept of CBT and the basic principles that surround it. I will then move on to discuss thinking errors in more detail. I will then discuss the clinical use of CBT and work through some clinical scenarios. Throughout this presentation, I will set tasks that will help you to further your understanding of CBT.
So to start of with – what is CBT? Well firstly, CBT stands for “cognitive behavioural therapy”. It is based on the idea that our emotions are governed by our thoughts. In fact, a lot of what CBT teaches can in fact be considered to be common sense; but I’m sure even the most intelligent individual would agree how easy it is to forget our own common sense. CBT simply teaches individuals to rationalise their thoughts and to view events from an objective viewpoint. The quote shown provides a useful summary of the viewpoint of CBT; that men are disturbed not by things, but by the view which they take of them.
CBT is recognised by the National Institute of Health and Clinical Excellence as an appropriate management technique for various conditions including depression, anxiety and OCD. However, there is evidence that suggests that CBT may in fact be beneficial for further conditions including addiction, chronic fatigue syndrome or perhaps even personality disorders.
CBT has been around for many years and, therefore, has one of the strongest evidence bases of all psychotherapies. The majority of this research relates to its use in the management of anxiety and depression. In terms of the management of depression, it is generally accepted that CBT is as effective or, if not, more effective than treatment with medication alone.
One of the first things that CBT teaches is that people are different and that people think and react differently to events to other people. Many people often say that an event “made” them feel a certain way and some people would go so far as to say that this “made” them behave in a certain way. Realising that it was in fact their own thought process that led to their emotion or behaviour is key to the concepts behind CBT.
Imagine someone close to you treats you inconsiderately. How would you feel in this situation? It is likely that you thought of just one emotion, but as you can see, many different people would have different reactions to this same scenario. Some people might be angry, others might be anxious, whilst another person might feel depressed. We all have different thought processes, meaning that we are all likely to feel different emotions.
The principles behind CBT are often thought of in an “ABC” format, where “A” stands for the “Activating event”, “B” stands for the “Beliefs” of the individual and “C” stands for the “Consequences”. The activating event is the thing that triggers the thought process and this can be both external and internal. An external event is a real event that has happened or that is anticipated to happen, whereas an internal event is an image created in the individual’s own mind. The beliefs of the individual include their thoughts, their personal expectations and the meanings that they attach to events. Consequences include emotions, behaviours and in some circumstances, physical sensations.
This diagram shows the ABC concept more clearly. Additionally, this diagram shows how the three areas have a lot of interplay between each other and can lead to a vicious cycle. Identification of the existence of this cycle can help the individual to break it.
In order to help break the ABC cycle individuals are encouraged to question their thoughts an beliefs and to generate new healthy alternatives. One way of doing this is to fill in an “ABCDE” form, where D stands for Dispute, and E stands for effect. After identifying their own detrimental beliefs, they are encouraged to question it – which is the dispute. The effect of this is the impact that is has upon them. This might be feeling a different emotion, or it might be feeling the same emotion, but to a lesser extent.
This is the first task that I would like you to complete. Grab a pen and a slip of paper. Firstly, write down the last time that you felt angry. Now, write down the last time that you felt upset. Now, for each of these, write down your thoughts at the time of the incident. Pause this presentation at this point if you would like time to think. Many people find that the times that they felt angry they criticised the actions of other people, whereas the times that they felt upset, they criticised themselves. Was this also what you found?
Thinking errors are a key principle in CBT – they are the sorts of thoughts that prevent people from thinking and reacting rationally about a situation. However, thinking errors are normal, in that, everyone experiences from time to time, it’s just that some people experience them more than others or put too much emphasis on them. Certain people are more prone to certain types of thinking errors. By identifying these thinking errors, people can work out hoe to prevent or correct this. There are 12 main types of thinking errors, as shown above. The first of these is catastrophising, which fits with the saying of “making mountains out of mole-hills” – that is turning something minor into something more serious. The second of these is all-or-nothing thinking; this is where an individual thinks that if something isn’t true or hasn’t been achieved, then the opposite must be true. Fortune telling is when people try to make assumptions about the future. Mind-reading is when people make assumptions about other people’s thoughts. Emotional reasoning applies to situations where individuals rely too heavily on their emotions as a guide to their thoughts. That is, they think that if they feel in a certain way, then a certain idea must be true. The 6th thinking error is overgeneralising. Here, people use phrases such as “always” or “never” – anyone who has ever sat a medicine mcq should know that these types of phrases are “never” the right answer! Labelling means assuming that things with certain features are all the same. The thinking error of making demands applies to any belief that uses words such a must, should or need. Mental filtering is a process by which individuals ignore any information that does not fit with their own belief system. Disqualifying the positive is similar and involves transforming a positive event into a neutral or negative event. The 11th thinking error is having a low frustration tolerance. Finally, the last thinking error is personalising, where an individual interprets an event as relating to them personally.
Here are 10 examples of different thinking errors. For each of these, have a think about what you think the thinking error being described is and click to find out if you are right. If you are incorrect, make sure you understand why the phrase applies to the thinking error being discussed. Under certain circumstances, certain phrases might include multiple thinking errors.
The next slides explain how CBT is used for some of the most common condition for which it is used.
The basic principle used behind the management of different types of anxiety is FEAR, which stands for face everything and recover. The basic idea behind this is to face up to the fear and realise that it is not as bad as they had thought it might be. Generally, this is not performed through flooding, but rather through a graded exposure desensitisation pattern and habituation. Individuals are often advised to face up to their fear and wait until their anxiety has reduced by half before ending the exposure. Ending the exposure too soon will not help the individual to overcome their anxiety.
This graph demonstrates more clearly the general principles behind the management of anxiety by CBT. At the first exposure, the anxiety is greatest and lasts longest but through continued exposure anxiety levels are reduced in both the period of time that they last and their intensity.
The principles behind the management of depression by CBT are actually fairly simple. Individuals are encouraged to do the exact opposite of what their depression makes them feel like doing. For instance, if they feel like they want to spend all day in bed, they are encouraged to get out of bed and do something. In a similar manner to the management of anxiety the individual is encouraged to take small steps so that each small step can be felt as an achievement. Normally individuals are glad to have done something, although they might not enjoy it as much as they did before they were depressed. Another way that CBT is used in the management of depression is to encourage individuals to recognise their negative thoughts and to break the cycle of rumination that often ensues. Rumination is the process of repetitively focussing on negative aspects of their life. They concentrate on their symptoms and the causes and consequences of these, which ultimately makes them feel worse.
Obsessive compulsive disorder is another condition where CBT is commonly employed. Individuals with CBT experience both compulsive behaviour and obsessive thoughts but they may not be aware of the link between the two. One way of demonstrating this to the individual is to perform an experiment. Ask them to reduce or increase their compulsions and see how this affects their obsessions. Normally, they will find that their obsessions increase if their compulsions are increased and their obsessions decrease if their compulsions decrease. The opposite of this is also true. Once the individual is aware of this link, a plan can then be made in the steps that can be taken to reduce both their compulsions and their obsessions. Again, this is likely to involve taking small steps towards their greater goal. Another technique that is particularly useful for OCD is to encourage individuals to create responsibility pie charts. This is shown more clearly on the next slide.
This is an example of a responsibility pie chart for a woman who is obsessed about harm coming to her children from poisonous substances. Before creating this pie chart, she felt that she would be entirely to blame if something were to happen. They are encouraged to think of other people or factors that might be responsible and to add these to the pie chart with an estimated distribution. They add their own responsibility in last. In this example, the individual has still given themselves the greatest responsibility but they can recognise that they would not be entirely to blame and that in fact they have attributed less than half of the responsibility to themselves.
This is the second task that I would like you to complete. You can save this task for later if you prefer! You will need a partner for the purpose of this task. Sit back to back with your partner and ask them to tell you a story for one minute. Now try to recall as many different points from the story as you can. Now ask them to tell you a story again, but this time, deliberately distract yourself and refocus your attention. Now again, recall as many points from the story as you can. It is likely that you will remember a lot less the second time, but with practice, you can train yourself to refocus successfully. This technique can be useful in day-to-day activities when you find yourself distracted.
I have created 3 case scenarios that I would like you to work through. I will not be narrating on these scenarios as I would like you to work through them in your own time. For each scenario, try to answer the following questions. Firstly, what is the condition this patient is likely to be suffering from? Secondly, what is the thinking error discussed in the case? Lastly, what different techniques might be useful for this patient?
This is the final task that I would like you to complete. It is purely for your own benefit. I would like you to think of something that you would like to achieve, however, big or small. Now I would like you to write this goal down but ensure that your goal is specific, positive, observable, realistic and timed. For instance, instead of saying “I don’t want to do badly in my exams” you could say “I would like to get above 60% in my end of year examinations”. Use this tool in the future when setting yourself goals and objectives.
The main points that I hope you take away from this presentation are that CBT is an evidence-based therapy that has been shown to be useful for many different conditions, that the main principle behind CBT is that our thoughts control our emotions and how we react to events and that CBT helps people to recognise errors in their thinking in order to help them react healthily to events. I hope that you have found this presentation useful. Please leave me feedback on what you enjoyed about this presentation and how you think it might be improved.
