Cognitive Behavioural

Therapy: A Basic Overview

Carly WelchUniversity of Birmingham

Learning Objectives1. 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

Lesson Overview1. Introduction to CBT2. Principles of CBT3. *Task 1*4. Thinking errors5. CBT in practice6. *Task 2* 7. Case discussion8. *Task 3*9. Discussion and conclusion

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)

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

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.

Principles of CBT

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

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”

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.

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

*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?

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.

Thinking errors - examples1. "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-reading2. Labelling3. All-or-nothing thinking4. Making demands5. Personalising6. Mental filtering

7. Fortune telling8. Labelling9. Personalising10. Making demands11. Disqualifying the positive12. Fortune telling

13. Mental filtering

14. Emotional reasoning15. Catastrophising16. Disqualifying the positive17. Making demands18. Emotional reasoning19. Disqualifying the positive20. All-or-nothing thinking

CBT in practice

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

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

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

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 keepingthings clean anduncontaminatedMy partner sharingresponsibility for thechildren's well-beingGovernment and Councilfor protecting us fromtoxis substancesMetoxic substances

Responsibility pie chart

The children

Other people for keepingthings clean anduncontaminatedMy partner sharingresponsibility for thechildren's well-beingGovernment and Councilfor protecting us fromtoxis substancesMetoxic substances

*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

Case scenarios

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?

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”.

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”.

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”.

*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

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

References:1. Wilson R & Branch R. Cognitive Behavioural Therapy for Dummies,

John Riley & Sons, Edition 1, 20052. 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