Introduction to Cognitive Behavioural therapy2011327212936

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					   Identifying and Monitoring
Negative Automatic Thoughts
              and Behaviours
               20th January 2011

          Tracy Chotoo 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 interpretation
 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 world
We may be able to reduce distress by
 helping people to change their cognitions
Hence: cognitive therapy

Role play setting up a homework task in
 front of the group
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
mistake to accept me

I won’t be able to cope
with the work

How dare they fail me

I can learn from this and
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
   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 memories
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
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
   (compensatory function), 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…‟ statements
     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

 Present rationale
   Clear explanation
   Emphasise collaboration
   Link the explanation back to the formulation
   Use analogies, stories, metaphors (e.g. being ignored in
     the street, noise in the middle of the night)

 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
   Highlight the role of thoughts
   Meta-message - there is something that you can do
   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 therapist?
 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 shift
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?”
 “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 client
The Role of 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 appraisals”

                              Butler et al, 2007
Usefulness of Identifying Emotions

 Changing the way we feel is a key aim of CBT
 Avoidance of emotions is common across clinical
  presentations, and is shown to have a role in maintaining
  them (Harvey et al, 2004)
 Common therapist error – to over emphasise cognition at
  the expense of acknowledging and talking about
 Important to clarify mood states:
  - goal setting for emotional change and track progress
  - choose actions targeted towards particular moods
Identifying Affect

 Paying attention to them and reflecting on them
 Look for markers of emotional arousal/lack of
 Ask about physical sensations
 Mood monitoring diary
 Develop a language to talk about affect e.g.
  feeling words and metaphors, model talking
  about feelings etc…
 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)…………………………………………..
  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 am worthless
I feel 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?
 What does this say about you?
 What does this mean about you? Your life?
  Your future?
 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
* NB These questions are listed on the Mind Over Mood DTR
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!” “”I was thinking
  negatively again”)
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)

Differentiate relevant thoughts – do they
 fit with the feeling(s) identified?
What is the most distressing / “hot”
Top Tips when Identifying Cognitions

    Identify cognitions as close to their time of activation
     as possible
    Identify the specific moment at which the client was
     most upset (likely to be linked to the “hot” cognition)
    Guided discovery: curiosity, open questions (“how?”,
     “what?”) The $64,000 question… “what is running
     through your mind right now” not “what are you
    Write it down – word for word, not reported speech
    Try to turn any questions into statements
     “How could you answer that?”
     “What if that did happen?”
    Expand exclamations, turn images into descriptions
    Get belief ratings – “how much do you believe that?”
Padesky DVD – Identifying NATs
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/helpful questions that she used?
  How does Padesky approach collaboration?
  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)

  Therapist‟s task is to begin to help the client
  identify their NATs
 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 –
 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
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 / image
    Ask about images – “Is there something that
     represents how you felt?” (Hackmann, 2004)
Client intellectualizes responses and avoids emotions (Moore and
Garland, 2003)

       Turn up the heat – i.e. imagery to try to
        recreate the situation
       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

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: normalise reactions, allow client
    to disclose thoughts at their own pace.
 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 too
 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., & Hackmann, A (2008).
  Cogntive Behavioural 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.