Introduction to Cognitive Behavioural therapy

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Introduction to Cognitive Behavioural therapy Powered By Docstoc
					 Identifying and Monitoring
Negative Automatic Thoughts
      and Behaviours
    15th November 2010

    Louise Payne and Rita Woo
     Workshop Objectives

• Understanding the rationale for
  identifying negative automatic thoughts
  (NATs) and related behaviours
• Understanding key techniques for
  eliciting, clarifying, and monitoring ATs
• Understanding common pitfalls in the
  identification of NATs
Identifying thoughts and behaviours -
    some basic principles of CBT

•   Cognitive principle
•   Behavioural principle
•   Interacting systems principle
•   Levels of cognition
        The Cognitive Principle
The “naïve”/common sense model
Event                     Emotion
e.g.    Loss of job                 Anger or

The cognitive model:
Event    Interpretation             Emotion
Loss of job           (cognition)   Anger or
               Example of interpretation
                – you fail a piece of coursework
Possible thought                        Possible emotion

I‟m a failure – they made a mistake
to accept me onto the IAPT course

I won‟t be able to cope with the work

How dare they fail me! My work is

I can learn from this,
and will do better next time
    Implications of the Cognitive Model

• It is not events in themselves that matter, but
  the meaning of these events to the individual
• The „same‟ event can have different
  emotional consequences depending on the
• When an emotional reaction seems out of
  proportion to an event, the idiosyncratic
  meaning explains the reaction - “if I thought
  like that would I feel that bad?”
   Implications of the Cognitive Model

• To understand people‟s distress, we
  have to understand their cognitions, i.e.
  their individual way of perceiving the
• We may be able to reduce distress by
  helping people to change their
• Hence: cognitive therapy

• Role play setting up homework task in
  front of group
• Randomly selected participants
• Competence rated by facilitators and
  The Behavioural Principle
• What we do can influence how we think
  and feel
• Behaviours designed to “cope” with
  problems may have a key role in
  maintaining them
• CBT suggests that changing what you
  do is a powerful way of changing
  thoughts and emotions
                Thoughts and Behaviours
                        – you fail a piece of coursework

I’m a failure; they made a   Sadness / shame
mistake to accept me

I won’t be able to cope      Anxiety
with the work

How dare they fail me        Anger

I can learn from this and    Nervous but positive
ask for more help
 Interacting Systems Principle

• Cognitive factors viewed as mediators
  with causation not claimed.
“The cognitive model does not postulate a
  sequential unidirectional relationship in
  which cognition always precedes
  emotion, but assumes that cognition,
  emotion, and behaviour are reciprocally
  determining and interactive constructs”
  (Clark and Steer, 1996)
Interacting Systems Principle - The cognitive model of
emotional disorder (Padesky and Greenberger, 1995)
                   Thinking                    ENVT.

   Affect                             Behaviour

            Levels of Cognition

• Within CBT we assume that there are
  different „levels‟ of cognition
• These levels differ in terms of their of their
  accessibility, specificity, and ease of change

• These levels include:
   – Negative Automatic Thoughts
   – Assumptions
   – Core Beliefs / Schemas
  Negative Automatic Thoughts
• Automatic stream of thoughts about
  events; appraisals, interpretations
  – Are, or can easily become, conscious
  – But habitual, so often not „heard‟ – out of
    focus of awareness
  – May be in “shorthand” (“this is awful” / “not again”)
    and need expanding
  – Plausible & often taken as obviously true,
    especially when emotions are strong
  – May be suppressed or avoided or diluted –
    content is distressing
  – May be images or verbal, including
       Negative Automatic Thoughts
• Highly specific to situations / events
• Idiosyncratic content but shared themes
  across disorders
• Emotions are logically connected to
  content of key “hot” automatic thoughts
• Usually tackled early on in therapy
• Relatively easy to identify and change
• Variability in ease that people will learn
  how to ID NATs – need specific explanations,
  examples, diagrams, handouts
“dysfunctional” / “irrational” thoughts
• “Non rational thinking is highly prevalent
  and… even when people know their thinking
  is irrational, they often find it more compelling
  than their rational reasoning”
                          – Seymour Epstein 1994

•   Conflicts between head and heart
•   Fiction vs. documentary
•   Irrational fears
•   Superstitious beliefs
•   Statistics vs. vivid instances
              Key Messages

The way we think has an important role to
play in understanding how we feel – “it‟s no
wonder you feel x, given you are thinking y”

Thoughts best seen as opinions not facts,
that are open to investigation and evaluation

In CBT, aim is to identify – and later critically
evaluate – ATs that are distressing and
interfere with functioning
 NATs and other levels of cognition
                 Core beliefs / Schemas
                  I am unlovable / I am defective

                 Rules and Assumptions
   If people get to know me they will find out how useless I am &
                                reject me
 If I don‟t get close to anyone, my uselessness will remain hidden

                    Automatic Thoughts
I am being boring / I can‟t think of anything worthwhile to say / they
          don‟t like me / I am a failure / this will never work
                   Rules and Assumptions
• Guidelines for living, standards, rules which guide daily actions
  and expectations.

• Evolve from core beliefs about self and the world, provide the
  soil from which NATs sprout

   – Not as obvious as NATs, may not be verbal
   – Often have to infer them from actions
   – Usually conditional: „If…. then…‟ or „Should / must… otherwise…‟
   – Problematic when rigid

• Moderately accessible, may be somewhat difficult to change
  and may be less specific than NATs

• Usually tackled later in Tx – linked with relapse prevention (Beck
  et al, 1979)
                  Core Beliefs
• Absolute statements, e.g. “I am unlovable / bad / stupid
  / defective…”
   – Generally learned early on in life, but may develop
     or change later, e.g. effects of trauma
• May be difficult to access, can be difficult to
  change, and are highly general
• Generally not tackled in short term therapy for
  focal problems (but may change anyway)
• May be more important for chronic problems
       Levels of cognition
        More specific More accessible     Easier
NATS                                    to change


        More general    Less             Harder
                       accessible       to change
CBT: levels of cognition
     Automatic Thoughts
       Rules and

      Core
   Identifying NATs – a recap
NATs are part of an interacting system
 that operates to maintain people‟s
NATs can take a variety of forms - words,
 meanings / metaphors, images, memories
NATs and associated behaviours are key
 targets of change within CBT
NATs - and associated emotions / behaviours -
 need to be clarified in detail before
 challenging them
     Presenting the rationale for identifying NATs
Distressed response          Response learned in


                                              Aha!! (understanding the
                                              patterns/sequences so far

Affect, behaviour, bodily reactions etc

                                     search for alternatives

                                     Reduce distress
                                     Coping/ adaptive behaviour
 Presenting the Rationale for Identifying NATs

   –   Clear explanation
   –   Emphasise collaboration
   –   Link the explanation back to the formulation
   –   Use analogies, stories, metaphors (e.g. dog mess
       story, being ignored in the street)

• Be open about possible impact (may be upsetting

• Emphasise method of skill acquisition:
   – In session teaching  independent practice  skill
   – Analogies may help (e.g. playing piano/tennis, new
 Role Play: Introducing the rationale for NATs

• Ask about a recent example to review the cognitive
  model and introduce the rationale for identifying

   – Goal is to illustrate that problems are maintained
     as a vicious circle (thinking, mood, behaviour,
     body state)
   – Highlight the role of thoughts
   – Meta-message - there is something that you can
   – Check out - does your client understand the
     rationale for identifying their thoughts?
   – Explore any objections that they may have
          Role-play debrief

• What was the experience like for the
• What was the experience like for the client?
• What was helpful / less helpful?
• What would you have done differently if you
  were doing this again?
  Identifying NATs: Main Methods

1. Identifying in-session ATs / “hot

2. Identifying and monitoring ATs in
    recalled problem situations
  –   Recall
  –   Imagery
  –   Role play
  –   Behavioural experiments
          In-session „Hot Cognitions‟

•   In-session cognitions very important as
    they may be about therapy (“this will never
    work”), the therapist (“they don’t understand
    me”), or the client (“I shouldn’t be feeling like
    this – I’m pathetic”)
•   In-session cognitions crucial in
    conceptualisation and in managing
    ruptures in the relationship
•   Opportunity for modelling and coaching
    key skills
            In-session „Hot Cognitions‟
When? Look out for non-verbal and verbal cues of affect
How? I just noticed a change in your expression
 (describe it).
 - What is running through your mind right now? / What
 did you just say to yourself? / If I was inside your
 head, what would I be hearing?
 - How are you feeling? / Is there anywhere in your
 body that you notice that?
Remain curious:
 “is there anything else?”
 “what about images? / Memories of things that have
 happened before?”
   Recalled shifts in emotion in real life
- Describe a recent, specific time when feeling
  distressed / mood shifted – how were they feeling?
  Establish a rating of distress (0 – 100). Write it

- What was going through your mind just then?
  (thoughts, images, memories). Try and ID point
  that client was most upset (before, during, afterward)
  and elicit cognitions at this time

- Is there anywhere in your body that you notice that?

- What did you do when feeling like that?

- Write it down (thought record)
Situation              Emotion(s)              Automatic Thoughts               Behaviours
Where were you?        What did you feel?      What went through your mind –    What did you do?
What were you doing?   How much did you feel   words/ images?
What happened just     this (0 – 100)?         How much did you believe this
before you felt this                           thought at the time (0 – 100)?
Situation                   Emotion(s)              Automatic Thoughts
Where were you?             What did you feel?      What went through your mind
What were you doing?        How much did you feel   – words/ images?
What happened just          this (0 - 100)?         How much did you believe this
before you felt this way?                           thought at the time (0 – 100)
 Monitoring thoughts and behaviours
• Simplicity – think about stage of therapy,
  challenges of observing and recording
• Consider measures in more than one system
• Is what you are monitoring relevant to the
  problem focus?
• Specific, clearly defined targets
• Clear, simple instructions – always write it
• Think about methods of recording
• Provide in-session training on monitoring
  before doing it outside of therapy room –
  anticipate problems with the client
         Identifying emotions

• “emotional disturbance is triggered by
  appraisals accessible via the contents
  of consciousness, which includes
  thoughts and images. Affect is
  considered an important “marker” that
  indicates the presence of relevant

                    -Butler et al, 2007
            Identifying Emotions
• Changing the way we feel is a key aim of
• Avoidance of feelings is common across
  clinical disorders, and shown to have a role in
  maintaining them (Harvey et al, 2004)
• Common therapist error – to over-focus on
  cognition, at expense of acknowledging and
  talking about feelings that are present
• Important to clarify mood states because:
  – allows you to set goals for emotional change and
    track progress
  – Choose actions targeted towards particular moods
     Identifying and expressing affect
• Listen for feelings, notice them and reflect
  them back
• Look for markers of emotional arousal
• Ask about physical sensations
• Ask about feelings – metaphors may be
  easier to use
• Comment on these – “you sound a bit
  hopeless” “that sounds like a real worry”
• Provide a language to talk about affect –
  feeling words and metaphors, model talking
  comfortably about feelings
• Warmth and empathy
            Identifying emotions
• Check physiology – what changes do you notice in
  your body?

• Notice 3 different moods states / day

• Provide a checklist of mood states, and link with

• Keep a diary of situations and emotions (see
  Greenberger and Padesky, Ch 3)

MOODS (+ rating)…………………………………………..
      Example mood monitoring diary
• Date
• Situation
• Emotion 0 – 100

angry               anxious           apprehensive
sad                 miserable         depressed
frightened          worried           irritated
pleased             frustrated        calm
contented           happy             bored

Thinking: what was running through my mind?

How much do I believe each of these thoughts?
     Quiz: Identifying thoughts and feelings

I‟ve got to get out of here
Things will never get better
I shouldn‟t have done that…
I‟m worthless
I feel so stupid
Really wound up
Here we go again…
             Questions to Elicit NATs
             Padesky and Greenberger (1995)

• What was going through your mind just before you
  started to feel this way?
• If I was inside your head, what would I be hearing
  right now?
• What does this say about you?
• What does this mean about you? Your life? Your
• What are you afraid might happen?
• What‟s the worst that could happen?
• What does this mean about what the other person
  thinks about you?
• What images or memories do you have in this
Identifying NATs - more useful questions
                   (Beck 1995)

• What do you guess you were thinking about?
• Do you think you may have been thinking X?
• Were you imagining something that might
  happen, or remembering something that did?
• What did that situation mean to you? What
  did that say about you? About him/her/them?
• Were you thinking ….. (provide a guess of the
  likely opposite of the thought)
    Persisting with identifying NATs
• Differentiate between actual thoughts and
  interpretations of thoughts / summaries of
  thoughts (“oh no!” “this is a nightmare”)
• Additional questioning often needed – clients
  often have secondary ATs (“I need to get out here”)
  in response to primary ATs (I’m going to vomit and
  people will be disgusted by me)
• Differentiate relevant thoughts – do they fit
  with the feeling?
• What is the most distressing / “hot” cognition?
                     Top Tips
•   ID NATs as close to their time of activation
      as possible
•   ID the specific moment at which the client was
    most upset (likely to be linked to the “hot”
•   Guided discovery: curious, open questions
    (“how?”, “what?”)      $64,000 question…
    “what is running through your mind right now”
    not “what are you thinking?”)
               Top Tips
• Write it down – word for word, not
  reported speech
• Try to turn any questions into
   – “How could you answer that?”
   – “What if that did happen?”
• Expand exclamations, turn images into
• Get belief ratings – “how much do you
  believe that?”
   The downward arrow               (Leahy, „03, Westbrook et al, „07)

Technique designed to help clients unpack or further analyse
the meaning of unhelpful cognitions

Can help ID client‟s fundamental belief system – the “bottom
line” (Fennell, 1999) or “bottom triangle” (Westbrook et al)

Beware „psycho-bulldozing‟ (Westbrook et al., 2007)
 “Is it alright for me to continue with these questions?”
 “Do you need a bit of a break?”

Tone is very important
Model the compassionate voice
 “This may sound like a silly question, but….”
 Try not to plough straight in with too much disputation

Death may not be the bottom – beware premature ending
               Downward arrow
T – What was going through your mind before going to the
P – I‟ll become anxious before talking to people
T – And if you did feel anxious, what could happen?
P – People wouldn‟t want to talk to me
T – And what would that mean?
P – That I‟m not worth talking to
T – What sort of a person is not worth talking to?
P – A loser
T – If you‟re a loser then that means….?
P – I‟ll never find anybody
T – And if that were to happen?
P – I‟ll always be alone and miserable
Downward arrow: some helpful questions
      (see Burns, 1989; Leahy, 2003; Westbrook, 2007)

• I wonder what seems so bad about that?
• In your view, what does that mean?
• What does that say about you / others / the
• What would that mean about your life / your
• What would others think of you?
• How would you label that?
• Can you describe the worst that could
  happen? If that was true…
 Exercise in pairs: Downward arrow

• In pairs, each person to take turn as therapist
  and client (either John or Jenny)
• Both therapist and client to read general info,
  then therapist to enquire about a recent
• Use downward arrow questions to clarify the
  cognitions they report

• As a client, what was helpful about
  being asked these questions? Anything
  that you found difficult? (Be specific)
• As a therapist, what did you find useful /
  more difficult?
• What do you feel you need to work on?
Padesky DVD – Identifying NATs

          (20 mins)
       Review of Padesky
• In small groups discuss:
  – What struck you about Padesky‟s
    approach to identifying NATs?
  – Was there anything that you thought she
    did well?
  – Anything you would have done differently?
   Identifying NATS – exercise in pairs

 Consider a problem that is concerning you
 right now, and think of a recent example e.g.
 the course, work etc. Identify a “hot” issue –
 (e.g. one that causes you some distress – not too

 Therapist‟s task is to begin to help the client
 identify their NATs

• 20 minutes each way
            Identifying NATs: Therapist‟s guide
- Establish a general description of the problem

- Using a recent example, describe:
        - The specific trigger situation:- When? Where? Who with?
          What doing? - “action replay”
        – Identify emotions, body sensations, rate intensity (0 –100)

• Identify thoughts (words, images, meanings)
    -      NB, word for word, “fit”.
    -      Write it down on a diary sheet
    -      Anything else?
    -      What is the “hot cognition”?

-   Summarise and ask for feedback: Have you
     Role play: debrief in pairs

What was helpful / difficult about identifying
NATs? For the client? Therapist?
What could have been done differently? (Try
and be specific)

Wider group – what might this experience be
like when working with a client?
What do you think you need to work on /
  Other strategies for eliciting NATs

- “What if you were to….?” (predictions)
- Induced imagery (“imagine yourself in
  that situation…”)
- Role play
- Behavioural experiments
- Self- observation and self-monitoring
  (records of thoughts and behaviours)
 Monitoring behaviours and thoughts
• Simplicity – think about stage of therapy,
  challenges of observing and recording
• Consider measures in more than one system
• Is what you are monitoring relevant to the
  problem focus?
• Specific, clearly defined targets
• Clear, simple instructions – always write it
• Think about methods of recording
• Provide in-session training on monitoring
  before doing it outside of therapy room –
  anticipate problems with client
 Identifying NATs – common
problems and how to deal with
Client cannot access key thoughts / images

- Effective and well-practised safety
  behaviours in operation?
- Use recent e.g. to evoke emotional state
  related to likely cognitions (incl. imagery /
  role play) – state dependent recall.
- Agree a behavioural experiment to remove
  SBs (example - traffic lights metaphor)
The client‟s thoughts are fleeting – difficult to
“pin down” and remember (Westbrook et al., 2007)

– Attend to shifts in mood within session –
  helping client to access thoughts/images
  can help clarify homework tasks
– Encourage client to carry DTR with them,
  or other methods of recording (mobile,
  envelope, small notebook etc.)
– Encourage recording as close to mood
  shift as possible
The client avoids distressing thoughts – focuses on
               feelings (Westbrook et al., 2007)
– Consider therapeutic relationship – what would help
  client to feel safe?
– Consider previous experience of other therapies –
  return to the model and clear rationale for exploring
  thoughts. Encourage exploration of affect and/or
– Clarify difference between thoughts and feelings
– Be wary for minimisation / invalidation /
  intellectualisation of thoughts – acknowledge this
  and explore fears about staying with thought /
– Ask about images – “Is there something that
  represents how you felt?” (Hackmann, 2004)
Client intellectualizes responses and avoids
    emotions (Moore and Garland, 2003)

 – Try and recreate the situation – i.e.
   imagery, more detailed description
 – Slow the therapy when you notice
   emotions in session
 – Behavioural experiments to test fears
   about emotional expression
      “Superficial” thoughts identified

• Test: if I thought x – and believed it -
  would I be feeling y?
• Secondary vs. “primary” NATs (Wells
• Use downward arrow to expand and
  explore meanings
• Be gentle but persistent…
  The client writes pages and pages of
          thoughts and musings

• Remind the client to be specific – record
  the moment emotions shift and write
  down specific thoughts
• Model diary completing within session
• Suggest recording a limited number of
    The client avoids discussing upsetting
       situations (Moore and Garland, 2003)

  – Identify thoughts about talking about
    upsetting events
  – Pros and cons of talking
  – Graded exposure to upsetting discussions
• Client fears therapist responses
  – Spend constructing safety within the
    relationship: normalize reactions, allow
    client to disclose thoughts at their own
• Think of a time recently when you felt
  irritated / upset / anxious – when you
  noticed a change in how your felt. NOT a
  major problem area for you
• Record your feelings / physical responses,
  and rate intensity (0 – 100)
• What went through your mind? – (in words
  or images, memories of past events)
• Consider recording behavioural response
• Any difficulties you may foresee? How
  might you overcome these difficulties?
         Identifying NATs – key reading

• Beck, J. (1995). Cognitive therapy: basics and
  beyond. New York: Guilford.
• Butler, G., Fennell, M., and Hackmann, A. (2008).
  Cognitive behaviour therapy for anxiety disorders:
  mastering clinical challenges. The Guildford Press
• Leahy, R.L. (2003). Cognitive therapy techniques: A
  practitioners guide. New York, Guildford.
• Wells, A. (1997). Cognitive Therapy of Anxiety
  Disorders. Chichester: Wiley.
• Westbrook, D., Kennerley, H., and Kirk, J. (2007). An
  introduction to cognitive behavioural therapy: Skills
  and applications. London: Sage.