Unique file 15

General Survey ofGeneral Survey of
Cognitive-BehavioralCognitive-Behavioral
Therapy StrategiesTherapy Strategies
The Model and The TechniquesThe Model and The Techniques
Kevin D. Arnold, Ph.D., ABPPKevin D. Arnold, Ph.D., ABPP
Director, The Center for Cognitive andDirector, The Center for Cognitive and
Behavioral Therapy of Greater ColumbusBehavioral Therapy of Greater Columbus
614.459.4490614.459.4490

Theory Behind CBTTheory Behind CBT
 Barlow’s Theory of Emotional DisordersBarlow’s Theory of Emotional Disorders

Barlow (1991) & Moses and Barlow (2006)Barlow (1991) & Moses and Barlow (2006)
 Key ConceptsKey Concepts

Emotional RegulationEmotional Regulation

Emotional MemoryEmotional Memory

Antecedent Cognitive AppraisalsAntecedent Cognitive Appraisals

Emotionally Driven Behaviors (EDBs)Emotionally Driven Behaviors (EDBs)

AvoidanceAvoidance

 Emotional Regulation: Key Strategies*Emotional Regulation: Key Strategies*

Situational ControlSituational Control
• Situation SelectionSituation Selection

Predictive Model of Emotional Arousal Features and LikelihoodsPredictive Model of Emotional Arousal Features and Likelihoods

Costs and Benefits Assessment of Regulation vs. ExperienceCosts and Benefits Assessment of Regulation vs. Experience
• Situation ModificationSituation Modification

Modification of the Physical, External EnvironmentModification of the Physical, External Environment

AttentionAttention
• Attention DeploymentAttention Deployment

Distraction to Other Situational Features or Away CompletelyDistraction to Other Situational Features or Away Completely

Concentration on Emotional Experience, Situational Factors, orConcentration on Emotional Experience, Situational Factors, or
PredictionsPredictions
*Gross & Thompson, 2007

 Emotional Regulation: Key Strategies*Emotional Regulation: Key Strategies*

AppraisalAppraisal
• Cognitive AppraisalCognitive Appraisal

Modification of Appraisal (e.g., threat value, label ofModification of Appraisal (e.g., threat value, label of
event)event)

ResponseResponse
• Response ModulationResponse Modulation

Relaxation StrategiesRelaxation Strategies

Expression of Emotion (Behavioral, Verbal)Expression of Emotion (Behavioral, Verbal)

Adaptive Response AlternativesAdaptive Response Alternatives
*Gross & Thompson, 2007

 Emotional Memory* and AnxietyEmotional Memory* and Anxiety

Disclaimer—Not a NeuropsychologistDisclaimer—Not a Neuropsychologist

Role of Amygdala and Prefrontal Cortex in AnxietyRole of Amygdala and Prefrontal Cortex in Anxiety
• Amygdala Stores Stress Arousal as Nondeclarative MemoryAmygdala Stores Stress Arousal as Nondeclarative Memory
• In Contrast, Hippocampus Stores Declarative MemoryIn Contrast, Hippocampus Stores Declarative Memory
• PFC Necessary to Habituate to AnxietyPFC Necessary to Habituate to Anxiety

Habituation is New Learning Allowing PFC to ModulateHabituation is New Learning Allowing PFC to Modulate
Amygdala Arousal and Enhance Declarative Recall ThroughAmygdala Arousal and Enhance Declarative Recall Through
HippocampusHippocampus
• PFC can also “prevent the acquisition of fear conditioning” orPFC can also “prevent the acquisition of fear conditioning” or
“excite the amygdala and increase fear.” (pp. 36-37)“excite the amygdala and increase fear.” (pp. 36-37)
*Quirk, 2007

 Emotional Memory* and DepressionEmotional Memory* and Depression

Disclaimer—Not a NeuropsychologistDisclaimer—Not a Neuropsychologist

Role of Amygdala and Prefrontal Cortex inRole of Amygdala and Prefrontal Cortex in
DepressionDepression
• PFC Activation Levels Needed to be Higher inPFC Activation Levels Needed to be Higher in
Depressed Patients For Working MemoryDepressed Patients For Working Memory
PerformancePerformance
• Predisposition to Serotonin Based AbnormalitiesPredisposition to Serotonin Based Abnormalities
Associated with Increased Activity in AmygdalaAssociated with Increased Activity in Amygdala
and with Abnormalities in Connection of Prefrontaland with Abnormalities in Connection of Prefrontal
Cortex and Amygdala.Cortex and Amygdala.
*Davidson, Fox & Kalin, 2007

 Impact on the HPA AxisImpact on the HPA Axis

The HPA Axis is the Hypothalamus-Pituitary-AdrenalThe HPA Axis is the Hypothalamus-Pituitary-Adrenal
AxisAxis

Changes in HPA Axis Functioning Have Been FoundChanges in HPA Axis Functioning Have Been Found
in Early Developmental Exposure to Trauma*in Early Developmental Exposure to Trauma*
• Predisposes to later MDD and PTSD VulnerabilityPredisposes to later MDD and PTSD Vulnerability

Early Trauma has been Shown to ReduceEarly Trauma has been Shown to Reduce
Hypothalamic MassHypothalamic Mass

In utero Exposure to Stress Reveals Changes inIn utero Exposure to Stress Reveals Changes in
Fetus and Infant Dysregulation of the HPA SystemFetus and Infant Dysregulation of the HPA System
Leading to Greater Degrees of Stress and AnxietyLeading to Greater Degrees of Stress and Anxiety
*Shea, Walsh, MacMillan & Steiner (2006)

 Antecedent Cognitive AppraisalsAntecedent Cognitive Appraisals

Early Learning During Parenting Interactions orEarly Learning During Parenting Interactions or
Traumas Regarding Self-Efficacy or ThreatsTraumas Regarding Self-Efficacy or Threats

Appraisal of Likelihood of Negative Event OccurrenceAppraisal of Likelihood of Negative Event Occurrence

Appraisal of Catastrophic OutcomeAppraisal of Catastrophic Outcome

Appraisal of Incapacity to Effect Outcomes or ManageAppraisal of Incapacity to Effect Outcomes or Manage
OutcomesOutcomes

Appraisal of Others as Harsh (Punitive Parenting) orAppraisal of Others as Harsh (Punitive Parenting) or
Unsupportive (Dismissive Parenting)Unsupportive (Dismissive Parenting)

Overall Situational Appraisal & Development ofOverall Situational Appraisal & Development of
Assumptive SchemasAssumptive Schemas

 Emotionally Driven Behaviors (EDBs)Emotionally Driven Behaviors (EDBs)

Behavioral Response ProbabilitiesBehavioral Response Probabilities

Activation of Learned, Adaptive Responses toActivation of Learned, Adaptive Responses to
Over-generalized and InappropriateOver-generalized and Inappropriate
Emotional RecallEmotional Recall

Reduce Emotional ArousalReduce Emotional Arousal
• Negative ReinforcementNegative Reinforcement

When EDBs Lead to Unhealthy OutcomesWhen EDBs Lead to Unhealthy Outcomes
• Social Isolation, Avoidance of Adaptive Situations,Social Isolation, Avoidance of Adaptive Situations,
Reduction in Relationship ConnectionsReduction in Relationship Connections

 AvoidanceAvoidance

Escape is an EDB to Exit to Reduce ArousalEscape is an EDB to Exit to Reduce Arousal

Avoidance is to Prevent Arousal or Full ArousalAvoidance is to Prevent Arousal or Full Arousal

Forms of AvoidanceForms of Avoidance
• Subtle Behavioral AvoidanceSubtle Behavioral Avoidance

Avoiding Eye Contact, ProcrastinationAvoiding Eye Contact, Procrastination
• Cognitive AvoidanceCognitive Avoidance

Distraction, Stonewalling, Mental Rituals, Thought StoppingDistraction, Stonewalling, Mental Rituals, Thought Stopping
• Safety SignalsSafety Signals

Shaking Medicine Bottles, Keeping Positive AssociationShaking Medicine Bottles, Keeping Positive Association
Objects Handy, Good Luck Charms, Carrying CleanersObjects Handy, Good Luck Charms, Carrying Cleaners

 Examples from Moses & Barlow (2006)Examples from Moses & Barlow (2006)
Behavioral AvoidanceBehavioral Avoidance Avoid Eye ContactAvoid Eye Contact Social PhobiaSocial Phobia
Avoiding PhysiologicalAvoiding Physiological
ArousalArousal
Panic/DepressionPanic/Depression
ProcrastinationProcrastination Generalized AnxietyGeneralized Anxiety
Cognitive AvoidanceCognitive Avoidance Forced Positive Self TalkForced Positive Self Talk DepressionDepression
DistractionDistraction Panic/DepressionPanic/Depression
WorryingWorrying Generalized AnxietyGeneralized Anxiety
Safety SignalsSafety Signals Good Luck CharmsGood Luck Charms OCDOCD
Carrying Good FeelingCarrying Good Feeling
ObjectsObjects
Depression/GADDepression/GAD
Carrying Items to Hide FaceCarrying Items to Hide Face
or Bodily Reactionsor Bodily Reactions
Social PhobiaSocial Phobia

The Basic CBT ModelThe Basic CBT Model
 Beck & Other’s ApproachBeck & Other’s Approach

Psychopathology is bio-psycho-socialPsychopathology is bio-psycho-social

Feelings can be managed through addressingFeelings can be managed through addressing
cognitions and behaviorscognitions and behaviors

Psychopathology has deficits in behaviors andPsychopathology has deficits in behaviors and
maladaptive or distorted cognitionsmaladaptive or distorted cognitions

Underlying assumptions have been learned in an “if-Underlying assumptions have been learned in an “if-
then” formatthen” format

Schemas create a construction that is maladaptiveSchemas create a construction that is maladaptive
now, but not when first developednow, but not when first developed

Cognitive TriadCognitive Triad
 Cognitive TriadCognitive Triad

Distorted Thoughts are those that are moodDistorted Thoughts are those that are mood
congruent but not reflective of the evidence incongruent but not reflective of the evidence in
lifelife

These are sometimes referred to asThese are sometimes referred to as
Automatic ThoughtsAutomatic Thoughts

The thoughts fit basically into threeThe thoughts fit basically into three
categories: Self, Others/World, or Futurecategories: Self, Others/World, or Future

Cognitive BlockadeCognitive Blockade
 Cognitive BlockadeCognitive Blockade

Mood or other pathologic processes create aMood or other pathologic processes create a
filtering of information that is state-dependentfiltering of information that is state-dependent

Information, both internal and external, isInformation, both internal and external, is
filtered so that only mood congruentfiltered so that only mood congruent
information is a) perceived, or b) valued.information is a) perceived, or b) valued.

Overcoming the impact of the blockade is aOvercoming the impact of the blockade is a
major goal of CBTmajor goal of CBT

Treatment Method: GeneralTreatment Method: General
 IT IS AN APPROACH, NOT A MANUALIT IS AN APPROACH, NOT A MANUAL
 Cognitive Therapy is collaborative so that theCognitive Therapy is collaborative so that the
patient and therapist are a team working onpatient and therapist are a team working on
problems togetherproblems together
 Cognitive Therapy is active and engages theCognitive Therapy is active and engages the
patient through a treatment relationship thatpatient through a treatment relationship that
encourages but respects the patient throughencourages but respects the patient through
empathyempathy
 Cognitive Therapy uses the Socratic Method,Cognitive Therapy uses the Socratic Method,
using questions whenever possibleusing questions whenever possible

 Socratic MethodSocratic Method

Questions are used in CBT toQuestions are used in CBT to
• Help the patient become aware of thoughtsHelp the patient become aware of thoughts
• Examine thoughts to identify distortionsExamine thoughts to identify distortions
• Replace distortions with health and evidencedReplace distortions with health and evidenced
based ideasbased ideas
• Plan to develop new thinking patternsPlan to develop new thinking patterns
• Self-Awareness of EDBsSelf-Awareness of EDBs

 CollaborativeCollaborative

Therapy is guided by a team approach toTherapy is guided by a team approach to
problemsproblems
• The treatment conceptualization is createdThe treatment conceptualization is created
collaboratively as a basis for the treatmentcollaboratively as a basis for the treatment
methodsmethods
• The structure of the sessions is agreed upon as aThe structure of the sessions is agreed upon as a
way of keeping the collaborative work movingway of keeping the collaborative work moving
• Both agree on structure and directionBoth agree on structure and direction

 Structure and DirectionStructure and Direction

All sessions use the following templateAll sessions use the following template
• Setting an agendaSetting an agenda
• Bridging back to the previous sessionBridging back to the previous session
• Setting a target for the sessionSetting a target for the session
• Application of the CBT techniques to the targetApplication of the CBT techniques to the target
• Summarization of the sessionSummarization of the session
• Setting homeworkSetting homework
• Feedback on the sessionFeedback on the session

 Problem OrientationProblem Orientation

Conceptualization: Patients problems within aConceptualization: Patients problems within a
present, learning contextpresent, learning context

Orientation to the Present/Here and NowOrientation to the Present/Here and Now

Selection of strategies and techniquesSelection of strategies and techniques

Assess the effectiveness of the CBT on theAssess the effectiveness of the CBT on the
problem within its contextproblem within its context

Common Strategies in CBTCommon Strategies in CBT
 SimplifySimplify
 Do it nowDo it now
 You can’t know unless youYou can’t know unless you
experimentexperiment
 If you are off track, do theIf you are off track, do the
oppositeopposite
 Persistence will producePersistence will produce
changechange
 Break it down and take oneBreak it down and take one
thing at a timething at a time
 Do that which you don’t expectDo that which you don’t expect
yourself to doyourself to do
 Pull, don’t push/FlowPull, don’t push/Flow

 EducateEducate

CBT educates patients to be their ownCBT educates patients to be their own
therapiststherapists
• Help the patient to learn how to learnHelp the patient to learn how to learn

It’s not resistance, it’s reluctanceIt’s not resistance, it’s reluctance

It’s not resistance, it’s slownessIt’s not resistance, it’s slowness
• Patients learn inductivelyPatients learn inductively

Beliefs are hypothesisBeliefs are hypothesis

Testing them can provide insight or new ways of thinkingTesting them can provide insight or new ways of thinking

 Key ElementsKey Elements

Behavioral ExperimentationBehavioral Experimentation

Daily Activity RecordsDaily Activity Records

Activity SchedulingActivity Scheduling

Pleasure SchedulingPleasure Scheduling

Identify Distortions through Self-Monitoring (3Identify Distortions through Self-Monitoring (3
Column) and Labeling Automatic ThoughtsColumn) and Labeling Automatic Thoughts

Test the EvidenceTest the Evidence

Challenge and Create New Thoughts (5 Column)Challenge and Create New Thoughts (5 Column)

Cognitive DistortionsCognitive Distortions
 Related to MoodRelated to Mood
 Don’t represent evidence or have goneDon’t represent evidence or have gone
unchallengedunchallenged
 Have not been evaluated, insteadHave not been evaluated, instead
assumed to be trueassumed to be true
 Learned based on historyLearned based on history
 See HandoutSee Handout

 Assessing the Automatic ThoughtsAssessing the Automatic Thoughts

Question, Question, QuestionQuestion, Question, Question

Listen, Listen, ListenListen, Listen, Listen

Downward ArrowDownward Arrow

Imaging a SituationImaging a Situation

Noticing Affect and Calling Out the ThoughtsNoticing Affect and Calling Out the Thoughts

 Strategies for Challenging and Restructuring Cognitive DistortionsStrategies for Challenging and Restructuring Cognitive Distortions

Defining TermsDefining Terms 

Cost-Benefit Analysis of Idea or BeliefCost-Benefit Analysis of Idea or Belief 

Modified 5-Column/Testing the EvidenceModified 5-Column/Testing the Evidence 

Testing the Utility of the EvidenceTesting the Utility of the Evidence 

Evaluating LabelsEvaluating Labels 

Changing Behavior to Test IdeasChanging Behavior to Test Ideas 

Examining Should StatementsExamining Should Statements 

Articulating Values and Changing ThemArticulating Values and Changing Them 

Progress not PerfectionProgress not Perfection 

Old Rules, New RulesOld Rules, New Rules 

New Bill of RightsNew Bill of Rights 

Monitor Feelings/Ideas and Label DistortionsMonitor Feelings/Ideas and Label Distortions 

Downward Arrow/Vertical DecentDownward Arrow/Vertical Decent 
Loosely Based on Leahy, 2003

 Cognitive DistortionsCognitive Distortions

Mind ReadingMind Reading: Assuming you know what others are thinking: Assuming you know what others are thinking

Future PredictingFuture Predicting: Appraisal of future events: Appraisal of future events

CatastrophizingCatastrophizing: Predicting the worst possible outcome: Predicting the worst possible outcome

LabelingLabeling: Using global labels to describe yourself or others: Using global labels to describe yourself or others

Black-White ReasoningBlack-White Reasoning: Thinking in all or none terms not shades of gray: Thinking in all or none terms not shades of gray

Regret OrientationRegret Orientation: Looking back and not living in the moment of the: Looking back and not living in the moment of the
nownow

Arbitrary InferencesArbitrary Inferences: Drawing conclusions from little or no evidence: Drawing conclusions from little or no evidence

FilteringFiltering: Noticing only the things that confirm your ideas: Noticing only the things that confirm your ideas

PersonalizingPersonalizing: Thinking that everything is your fault or that others are: Thinking that everything is your fault or that others are
targeting you specificallytargeting you specifically

OvergeneralizingOvergeneralizing: Using evidence from a specific context and applying a: Using evidence from a specific context and applying a
“rule” to many other contexts“rule” to many other contexts

Should/Would/CouldShould/Would/Could: Thinking in terms of morals or shoulds, rather than: Thinking in terms of morals or shoulds, rather than
the actual evidence in the situationthe actual evidence in the situation
Loosely Based on Leahy, 2003

Behavioral ActivationBehavioral Activation
 Behavioral Activation is Designing ActionsBehavioral Activation is Designing Actions
into a Patient’s Behavioral Repertoireinto a Patient’s Behavioral Repertoire


Pleasure SchedulingPleasure Scheduling

Functional Behavior Analysis in the SessionFunctional Behavior Analysis in the Session
 Reward Erosion and Mood ProblemsReward Erosion and Mood Problems

++ + -+ -

 Activity SchedulingActivity Scheduling

Activity Monitoring and RecordingActivity Monitoring and Recording
• MasteryMastery
• PleasurePleasure
• Hour Blocks vs. Sections of the DayHour Blocks vs. Sections of the Day

• Designing RoutinesDesigning Routines
• Increasing High Ms and PsIncreasing High Ms and Ps

 Pleasure SchedulingPleasure Scheduling

InventoriesInventories
• PastPast
• PresentPresent
• WishesWishes

Scheduling the PleasureScheduling the Pleasure
• Behavioral ExperimentsBehavioral Experiments
• Self-MonitoringSelf-Monitoring
• Foot in the Door FirstFoot in the Door First

 Application of Functional AnalysisApplication of Functional Analysis

Use of the Therapy Relationship to Differentially DeliverUse of the Therapy Relationship to Differentially Deliver
Reinforcement or PunishmentReinforcement or Punishment

Identification of Clinically Relevant BehaviorsIdentification of Clinically Relevant Behaviors
• CRB1: Those to DecreaseCRB1: Those to Decrease
• CRB2: Those to IncreaseCRB2: Those to Increase

Observe CRBsObserve CRBs

Elicit CRBsElicit CRBs
• Develop Alternate Behaviors to CRB1sDevelop Alternate Behaviors to CRB1s

Differentially Apply RewardsDifferentially Apply Rewards

Design Generalization invivoDesign Generalization invivo
 Cuijpers, van Straten, and Warmerdam (2007) showedCuijpers, van Straten, and Warmerdam (2007) showed
in meta-analysis that Behavioral Activation was Effectivein meta-analysis that Behavioral Activation was Effective
See Kanter, Manos, Busch, and Rusch, 2008

 Self-DeterminationSelf-Determination

Development of Personal GoalsDevelopment of Personal Goals

Identification of Stimuli to Old BehaviorsIdentification of Stimuli to Old Behaviors

Modification of Stimuli ExposureModification of Stimuli Exposure

Training New Behaviors to Stimuli (Self-Training New Behaviors to Stimuli (Self-
Regulation of Natural Prompts)Regulation of Natural Prompts)

Relaxation TherapyRelaxation Therapy
 Controlled BreathingControlled Breathing

ConcentrationConcentration
• RhythmRhythm
• SensationsSensations

Suggestive RelaxationSuggestive Relaxation

16 Muscle Group PMR16 Muscle Group PMR

Practice 2x per dayPractice 2x per day
Dm200119.wma

Relaxation TherapyRelaxation Therapy
 Uses of Relaxation TherapyUses of Relaxation Therapy

Cued Affect ManagementCued Affect Management

Counter-conditioningCounter-conditioning

Management of Physiologic StimuliManagement of Physiologic Stimuli

Overcoming “Resistance”Overcoming “Resistance”
 Use of Socratic MethodsUse of Socratic Methods

How Likely to Do?How Likely to Do?

Reasons Not To?Reasons Not To?

How to Overcome Not ToHow to Overcome Not To
 Framework of “No Choice” ListFramework of “No Choice” List
 Pros/ConsPros/Cons
 Application of Stages of ChangeApplication of Stages of Change

Overcoming “Resistance”Overcoming “Resistance”
 Stages of ChangeStages of Change

Pre-ContemplativePre-Contemplative
• Educate PatientEducate Patient

ContemplativeContemplative
• Strategies such as Pros-Cons or Cross-ExaminerStrategies such as Pros-Cons or Cross-Examiner

DecisionDecision
• Decision to/Decision not to, Pros-ConsDecision to/Decision not to, Pros-Cons

ActionAction
• Graduated Exposure StrategyGraduated Exposure Strategy
• Foot in the DoorFoot in the Door
• Noticing Action and its ImpactNoticing Action and its Impact

Anti-ContemplativeAnti-Contemplative
• A Different Day, A Different TimeA Different Day, A Different Time
• Push-Pull StrategyPush-Pull Strategy

Application to AnxietyApplication to Anxiety
 Retraining the Brain: HabituationRetraining the Brain: Habituation

Habituation is the result of extended exposure to an anxietyHabituation is the result of extended exposure to an anxiety
provoking stimulusprovoking stimulus
• Anxiety typically elevates beyond typical levels due to defeat ofAnxiety typically elevates beyond typical levels due to defeat of
avoidance or escapeavoidance or escape
• Anxiety begins to drop after extended exposureAnxiety begins to drop after extended exposure
• Anxiety usually flattens and persists at a reduced level for severalAnxiety usually flattens and persists at a reduced level for several
minutes during the exposureminutes during the exposure
• Over repeated exposure activities, anxiety ceases to elevateOver repeated exposure activities, anxiety ceases to elevate
clinically when the anxiety provoking stimulus is presentedclinically when the anxiety provoking stimulus is presented
• Habituation is seen inHabituation is seen in

Systematic Desensitization using Graduated ExposureSystematic Desensitization using Graduated Exposure

Exposure and Response Prevention (ExRP)Exposure and Response Prevention (ExRP)

Direct ExposureDirect Exposure

Narrative Story Telling InterventionsNarrative Story Telling Interventions

FloodingFlooding

 OCDOCD

OCD is conceptualized as an anxiety disorderOCD is conceptualized as an anxiety disorder
driven bydriven by
• mis-appraisal of the threat posed by intrusive,mis-appraisal of the threat posed by intrusive,
obsessive thoughtsobsessive thoughts
• use of ritualized behaviors or cognitive patterns touse of ritualized behaviors or cognitive patterns to
escape the anxietyescape the anxiety
• use of avoidance behaviors to end exposure touse of avoidance behaviors to end exposure to
triggers associated with the obsessive thoughtstriggers associated with the obsessive thoughts

 OCDOCD

Assessment in CBT is typically done with one ofAssessment in CBT is typically done with one of
several instruments, although usually it is the Yale-several instruments, although usually it is the Yale-
Brown Obsessive Compulsive Scale (YBOCS)Brown Obsessive Compulsive Scale (YBOCS)
• Identification of historical and current obsessions andIdentification of historical and current obsessions and
compulsionscompulsions
• Identification of target obsessions and compulsions, withIdentification of target obsessions and compulsions, with
SUDS ratings of each to create a hierarchySUDS ratings of each to create a hierarchy
• Identification of avoidance behaviorsIdentification of avoidance behaviors

SUDS = Subjective Units of Distress Scale using 0 to 100SUDS = Subjective Units of Distress Scale using 0 to 100

Must create behavioral anchors to ratings for patientMust create behavioral anchors to ratings for patient

 OCDOCD

Treatment with CBT is primarily Exposure andTreatment with CBT is primarily Exposure and
Response Prevention (ExRP) TherapyResponse Prevention (ExRP) Therapy
• ExposureExposure

Patient collection of obsessive thoughts per themePatient collection of obsessive thoughts per theme

Creation of Exposure Narrative—Often recordedCreation of Exposure Narrative—Often recorded

Design of 90 minute exposure to be done dailyDesign of 90 minute exposure to be done daily

Creation of SUDS tracking form throughout ExposureCreation of SUDS tracking form throughout Exposure
exerciseexercise

Safety plan for atypical NSEsSafety plan for atypical NSEs

 OCDOCD

Treatment with CBT is primarily Exposure andTreatment with CBT is primarily Exposure and
Response Prevention (ExRP) TherapyResponse Prevention (ExRP) Therapy
• Response PreventionResponse Prevention

Identification of Ritual Structure for each ObsessionIdentification of Ritual Structure for each Obsession

Identification of Avoidance PatternsIdentification of Avoidance Patterns

Creation of Behavioral Plan to stop Rituals and AvoidanceCreation of Behavioral Plan to stop Rituals and Avoidance

Creation of tracking form for ritual and avoidance performanceCreation of tracking form for ritual and avoidance performance
• Behavioral DescriptionBehavioral Description
• Situational FactorsSituational Factors
• Emotional ExperiencesEmotional Experiences
• Outcome of Ritual or AvoidanceOutcome of Ritual or Avoidance
• Used to Create Better Response Prevention PlansUsed to Create Better Response Prevention Plans

 OCDOCD

Relapse Prevention and FadingRelapse Prevention and Fading
• Use of graphs to create evidenceUse of graphs to create evidence
• Cognitive Restructuring regarding beliefs about competencyCognitive Restructuring regarding beliefs about competency
to manage OCDto manage OCD
• Cognitive Restructuring to differentiate self from OCDCognitive Restructuring to differentiate self from OCD
• Fading the session length and frequency as habituationFading the session length and frequency as habituation
occursoccurs
• Development of plan should obsessions become moreDevelopment of plan should obsessions become more
controlling againcontrolling again
• Booster Sessions as a normative expectationBooster Sessions as a normative expectation

 OCDOCD

Case ExampleCase Example
• Exposure TapeExposure Tape 
• SUDS dataSUDS data


 Generalized Anxiety DisorderGeneralized Anxiety Disorder

Characterized by Uncontrollable WorrisomeCharacterized by Uncontrollable Worrisome
Thoughts that have several themesThoughts that have several themes

Anxiety Provocation is Based on the AppraisalAnxiety Provocation is Based on the Appraisal
of Risks in the Cognitions coupled withof Risks in the Cognitions coupled with
Estimates of Probability and BelievabilityEstimates of Probability and Believability

Anxiety is experienced as elevated but notAnxiety is experienced as elevated but not
panic-like, and occurs physically as well aspanic-like, and occurs physically as well as
subjectivelysubjectively


AssessmentAssessment
• Use of Scale like Beck Anxiety Scale or ZungUse of Scale like Beck Anxiety Scale or Zung
• Collect Diary of Worrisome ThoughtsCollect Diary of Worrisome Thoughts
• Develop SUDS for each ThemeDevelop SUDS for each Theme
• Identify Anxiety Components (e.g., subjectiveIdentify Anxiety Components (e.g., subjective
experience, physiologic arousal)experience, physiologic arousal)
• Identify Safety BehaviorsIdentify Safety Behaviors

Self vs. Other BehaviorsSelf vs. Other Behaviors
• Identify Magic Cognitions (Worry PreventsIdentify Magic Cognitions (Worry Prevents
Catastrophe)Catastrophe)


Treatment ComponentsTreatment Components
• Relaxation Therapy to Manage Anxiety ArousalRelaxation Therapy to Manage Anxiety Arousal
• Use of Theme-based Scripts for ExposureUse of Theme-based Scripts for Exposure
ExercisesExercises
• Cognitive Restructuring to Modify Estimates ofCognitive Restructuring to Modify Estimates of
Likelihood and BelievabilityLikelihood and Believability
• Modification of Safety Behaviors (e.g., callingModification of Safety Behaviors (e.g., calling
spouse to see if safe)spouse to see if safe)

Application to PTSDApplication to PTSD
 Rape TraumaRape Trauma

Direct Exposure TherapyDirect Exposure Therapy

Use of Cognitive ReprocessingUse of Cognitive Reprocessing
• Modification of View of SelfModification of View of Self
• Modification of Limited Event RecallModification of Limited Event Recall

Development of Realistic Risk AppraisalDevelopment of Realistic Risk Appraisal

Development of Personal Safety SkillsDevelopment of Personal Safety Skills
(Coping)(Coping)

Childhood TraumaChildhood Trauma

STAIRSTAIR
• Affect RegulationAffect Regulation

Development of Language of EmotionDevelopment of Language of Emotion

Development of Emotional Self-Soothing SkillsDevelopment of Emotional Self-Soothing Skills

Cognitive DistractionCognitive Distraction

Distress Tolerance & Behavioral Activation ofDistress Tolerance & Behavioral Activation of
Pleasurable ExperiencesPleasurable Experiences

Acceptance of Emotions and Reframing Emotions asAcceptance of Emotions and Reframing Emotions as
ValuedValued


STAIRSTAIR
• Interpersonal ConnectionInterpersonal Connection

Identification of Interpersonal Schemas & Common LifeIdentification of Interpersonal Schemas & Common Life
BehaviorsBehaviors

Self-Awareness of Conflict between Trauma Emotions vs.Self-Awareness of Conflict between Trauma Emotions vs.
Goals for Interpersonal RelationshipsGoals for Interpersonal Relationships

Modification of Self-Defeating Behaviors Through Role PlayingModification of Self-Defeating Behaviors Through Role Playing
• Identification of Power and Control Issues in Role PlayingIdentification of Power and Control Issues in Role Playing
• Assertiveness Skills and Beliefs of Basic RightsAssertiveness Skills and Beliefs of Basic Rights
• Creation of Interpersonal Conflict Management SkillsCreation of Interpersonal Conflict Management Skills
• Fostering Flexibility Within Power-Differential RelationshipsFostering Flexibility Within Power-Differential Relationships


STAIRSTAIR
• Narrative Story Telling as ExposureNarrative Story Telling as Exposure

Creation of Memory TargetsCreation of Memory Targets

Assurance of Hope and Betterment of LifeAssurance of Hope and Betterment of Life
• Skills Using Emotional Management Strategies at end ofSkills Using Emotional Management Strategies at end of
Exposure & Staying in the PresentExposure & Staying in the Present
• Identification of Negative Emotions During NarrativeIdentification of Negative Emotions During Narrative
• Identification of Negative Interpersonal Schemas in theIdentification of Negative Interpersonal Schemas in the
NarrativeNarrative
• Contrasting Present Interpersonal Reality and New Skills toContrasting Present Interpersonal Reality and New Skills to
Learned SchemasLearned Schemas
• Applying Coping Skills to Real-Life Situations and HealthierApplying Coping Skills to Real-Life Situations and Healthier
Interpersonal Behaviors in Present RelationshipInterpersonal Behaviors in Present Relationship

Application to DepressionApplication to Depression
 Self-Monitoring of MoodSelf-Monitoring of Mood

Orientation to Descriptions of MoodOrientation to Descriptions of Mood

Mood LogsMood Logs

Three Column StrategyThree Column Strategy
 Behavioral Self-MonitoringBehavioral Self-Monitoring

Activity LogActivity Log

Cataloging Positive ExperiencesCataloging Positive Experiences

 Behavioral ActivationBehavioral Activation

Development of Three ListsDevelopment of Three Lists
• Current PleasureCurrent Pleasure
• Past PleasurePast Pleasure
• Hopes/Dreams PlanningHopes/Dreams Planning

Scheduling Daily Activities and StructureScheduling Daily Activities and Structure

Scheduling PleasureScheduling Pleasure

 Cognitive RestructuringCognitive Restructuring

Development of Evidence Testing Skills From Mood Logs andDevelopment of Evidence Testing Skills From Mood Logs and
Activity RecordsActivity Records

Understanding of Automatic and Distorted CognitionsUnderstanding of Automatic and Distorted Cognitions

Labeling Distorted CognitionsLabeling Distorted Cognitions

Modifying Distortions and Mood Through 5-ColumnModifying Distortions and Mood Through 5-Column

Using Pros/Cons and Other Cognitive Restructuring StrategiesUsing Pros/Cons and Other Cognitive Restructuring Strategies
 Stimulus ControlStimulus Control

Negative Mood Triggers and Management of ExposureNegative Mood Triggers and Management of Exposure

Development of Coping Mechanisms for Mood TriggersDevelopment of Coping Mechanisms for Mood Triggers
• Skills Enhancement (e.g., parenting skills, conflict management)Skills Enhancement (e.g., parenting skills, conflict management)

Applications to Other DisordersApplications to Other Disorders
 Mastery of Your ADHDMastery of Your ADHD
 Habit Reversal Therapy for Hair PullingHabit Reversal Therapy for Hair Pulling
 Anger Management Using StimulusAnger Management Using Stimulus
Control and Cognitive RestructuringControl and Cognitive Restructuring
 Weight Loss Protocol Developed by JudithWeight Loss Protocol Developed by Judith
BeckBeck
 Positive Parenting Program for ADHD andPositive Parenting Program for ADHD and
Modification of Parental IncompetenceModification of Parental Incompetence
DistortionsDistortions

What to DoWhat to Do
 Develop CBT competenciesDevelop CBT competencies
 Identify Useful Texts Like Leahy’s booksIdentify Useful Texts Like Leahy’s books
 Take Training from one of the CentersTake Training from one of the Centers
 Seek ABPP and/or ACT CertificationSeek ABPP and/or ACT Certification

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