Theory and Practice of

Cognitive
Shona N. Behavioral
Vas, Ph.D.
Therapy
Department
of Psychiatry &
Behavioral Neuroscience
Cognitive-Behavior Therapy
Program
MS-3 Clerkship 2008-2009

Outline
What

is Cognitive Behavior Therapy (CBT)?

What

are the basic principles of treatment?

What

is the course of treatment?

What

are some examples of interventions?

Who

is appropriate for CBT?

What is CBT?
Set

of talk psychotherapies that treat

psychiatric conditions.
Short-term focused treatment.
Strong empirical support with
randomized clinical trials.
As effective as psychiatric medications.
Recommended as critical component of
treatment, particularly when
medications are contraindicated or
ineffective.

Why So Popular?
Clear

treatment approach for patients

Assumptions make sense to patients
Based on patients experience
Encourages practice and compliance
Patients have a sense of control
CBT works!

Definition of Cognitive
Therapy

CT is a focused form of psychotherapy

based on a model stipulating that
psychiatric disorders involve dysfunctional
thinking.
Dysfunctional/distorted thinking arises from
both biological and psychological influences
Individuals emotional, behavioral, and
physiological reactions are influenced by
the way they structure their environment.
J. Beck, 1995

Definition of CT
(continued)
Modifying

dysfunctional thinking and

behavior leads to improvement in
symptoms.

Modifying

dysfunctional beliefs which

underlie dysfunctional thinking leads
to more durable improvement

Definition of CT
(continued)

Cognitive therapy is defined by a cognitive

formulation of the disorder and a cognitive
conceptualization of the particular patient.

Cognitive therapy is not defined by the use

of exclusively cognitive techniques.
Techniques from many modalities are
used.

CT also often referred to as CognitiveBehavior Therapy (CBT).

Rationale for CBT

Negative emotions are elicited by cognitive

processes developed through influences of
learning and temperament.
Adverse life events elicit automatic processing,
which is viewed as the causal factor.
Cognitive triad: Negative automatic thoughts
center around our understanding of:

Ourselves
Others (the world)
Future

Focus on examination of cognitive beliefs and

developing rational responses to negative
automatic thoughts.
Beck et al., 1979

Cognitive Specificity
Hypothesis

Distorted appraisals follow themes relevant

to the specific psychiatric condition.
Psychological disorders are characterized
by a different psychological profile.
Depression: Negative view of self, others, and
future. Core beliefs associated with
helplessness, failure, incompetence, and
unlovability.
Anxiety: Overestimation of physical and
psychological threats. Core beliefs linked with
risk, dangerousness, and uncontrollability.

Cognitive Specificity

Negative Triad Associated with Depression

Self I am incompetent/unlovable
Others People do not care about me
Future The future is bleak

Negative Triad Associated with Anxiety

Self I am unable to protect myself
Others People will humiliate me
Future Its a matter of time before I am
embarrassed

Targeted Cognitions for Different

Disorders
OCD:

appraisals of obsessive
cognitions
Anorexia: control, worth, perfection
Panic: catastrophic misinterpretation
of physical sensations
Paranoia: trust, vulnerability

Working Model of CBT

Event

Appraisal

Maladaptive
Behavior

Behavioral
Inclination

Affective and
Biological Arousal

Thase et al., 1998

Cognitive Model
Triggering Event
Bill goes to collection

Behavior

Appraisal
I can never do
anything right

Avoidance; withdrawal

Behavioral Inclination
I dont want to deal with it
Its too stressful to think
about it

Bodily Sensations
Low energy, disruption of
sleep, increased fatigue
Thase et al., 1998

What are Automatic

Thoughts?

What was going through your

Happen spontaneously
mind? in response to

situation
Occur in shorthand: words or images
Do not arise from reasoning
No logical sequence
Hard to turn off
May be hard to articulate

Stressful
Situation

Automatic Thoughts

Negative
Emotions

Cognitive Distortions
Patients

tend to make consistent

errors in their thinking
Often, there is a systematic negative
bias in the cognitive processing of
patients suffering from psychiatric
disorders
Help patient identify the cognitive
errors s/he is most likely to make

Types of Cognitive Distortions

Emotional reasoning
Feelings are facts
Anticipating negative outcomes
The worst will
happen
All-or-nothing thinking
All good or
all bad
Mind-reading
Knowing what others are
thinking
Personalization
Excess
responsibility
Mental filter
Ignoring the positive

Examples

Cognitive Distortions
Emotional Reasoning: I feel incompetent,
so I know Ill fail
Catastrophizing: It is going to be terrible
Personalization: Its always my fault
Black or white thinking: If it isnt perfect,
its
no good at all.

Core Beliefs
Core beliefs underlie and produce
automatic thoughts.
These assumptions influence information
processing and organize understanding
about ourselves, others, and the future.
These core beliefs remain dormant until
activated by stress or negative life
events.
Categories of core beliefs (helpless,
worthless, unlovable)

Core Beliefs

Automatic Thoughts

Examples of Core Beliefs

Helpless core beliefs

I am inadequate, ineffective, incompetent, cant cope

I am powerless, out of control, trapped
I am vulnerable, weak, needy, a victim, likely to be hurt
I am inferior, a failure, a loser, defective, not good enough, dont
measure up

Unlovable core beliefs

I am unlikable, unwanted, will be rejected or abandoned, always

be alone
I am undesirable, ugly, unattractive, boring, have nothing to offer
I am different, flawed, defective, not good enough to be loved by
others

Worthless core beliefs

I am worthless, unacceptable, bad, crazy, broken, nothing, a

waste
I am hurtful, dangerous, toxic, evil
I dont deserve to live

Cognitive Conceptualization
Current
Situation

Automatic Thoughts
About self, world
And others

Physiology
Feelings
Behavior

Childhood
And Early
Life Events

Underlying Assumptions
and Core Beliefs

Compensatory
Strategies

Example 1
Situation
Partner says:
I need time to
be with my friends

Automatic Thoughts
Automatic response:
Oh no, hes losing interest
and is going to break up
with me.

Physiology
Heart racing
Lump in throat

Feelings
Sadness
Worry
Anger

Behavior
Seek reassurance
Withdraw
Cry

Childhood
Experiences
Parental neglect
and criticism

Underlying Assumptions &

Core Beliefs
Im flawed in numerous ways,
which means Im not worthy of
consistent attention and care.
People only care when they want
something.

Compensatory
Strategies
Be independent and
youll be safe.
Watch out people
are careless with you.

Example 2
Automatic Thoughts
Situation
Disappointing
exam result

I am not going to get

through this program Im not as smart
as everyone else.
People will
discover this and I
will be humiliated.

Physiology
Pit in stomach
Dry mouth

Feelings
Worry, shame,
Disappointment
Humiliation.

Behavior
Use alcohol,
Procrastinate
with homework

Childhood
Adversities
Parental standards
reinforce academic
achievement

Underlying Assumptions
If I dont excel in school, Im a
total failure

Compensatory
Strategies
Work extra hard
to offset
incompetence.

Responding to Negative
Thoughts

Define Situation

Clarify meaning of cognitive appraisal

What was going through your mind just then?
What did the situation mean for you?

Evaluate interpretation

Evidence: For and against this belief?

Alternatives: Any other explanation(s)?
Implications: So what.?

Evaluating Negative
Thoughts
What

is the effect of telling myself

this thought?
What could be the effect of changing
my thinking?
What would I tell ___ (a friend/family
member) if s/he viewed this situation
in this way?
What can I do now?

Sample Thought Log

Situation

Thoughts

Emotion
s

Rational
Response

Outcome

Going on
vacationAsk
a colleague to
do some work
for me

Shell say no
Im not doing a
good job
The boss thinks I
take too much
time off

Anxiety
(70%)
Guilt (40%)
Sadness
(20%)

I havent
taken a day
off in 6
months. We
work as a
team, so its
also her job to
track the
samples.

Anxiety (10%)
Guilt (0%)
Relief (40%)

Cognitive
Distortions:
All/nothing
Mindreadin
g
FortuneTelling
Overgeneralizatio
n

Common Components of CBT

Establish good therapeutic relationship

Educate patients - model, disorder, therapy
Assess illness objectively, set goals
Use evidence to guide treatment decisions
Structure treatment sessions with agenda
Limit treatment length
Issue and review homework to generalize
learning

Course of Treatment
1.
2.
3.
4.

Assessment
Provide rationale
Training in self-monitoring
Behavioral strategies
1.
2.

5.
6.
7.
8.

Monitor relationship between situation/action and

mood.
Applying new coping strategies to larger issues.

Identifying beliefs and biases

Evaluating and changing beliefs
Core beliefs and assumptions
Relapse prevention and termination

Basic Principles

Change mood states by using cognitive and behavioral

strategies:
Identifying/modifying automatic thoughts & core beliefs,
Regulating routine, and
Minimizing avoidance.

Emphasis on here and now

Preference for concrete examples

Start with specific situation (complete thought log)

Reliance on Socratic questioning

Ask open-ended questions

Empirical approach to test beliefs

Challenge thoughts not based on evidence

Cognitive restructuring

Promote rapid symptom change

Behavioral Interventions
Breathing

retraining
Relaxation
Behavioral activation
Interpersonal effectiveness training
Problem-solving skills
Exposure and response prevention
Social skills training
Graded task assignment

Cognitive Interventions
Monitor

automatic thoughts
Teach imagery techniques
Promote cognitive restructuring
Examine alternative evidence
Modify core beliefs
Generate rational alternatives

Efficacy
Cognitive

and behavioral
approaches are effective

Supported

by over 325 controlled

outcome studies

State-of-the-art

therapy, manualized

Applications of CBT
Mood

Disorders

Unipolar Depression (1979)

Bipolar Disorder (1996)
Dysthymia and Chronic MDD (2000)

Anxiety

Disorders

GAD (1985)
Social Phobia (1985)
Panic Disorder (1986)
OCD (1988)
PTSD (1991)

Emotional Disorders (2006)

Applications of CBT (Continued)

Eating Disorders (1981)

Marital Problems
Behavioral Medicine

Headaches (1985)
Insomnia (1987)
Chronic Pain (1988)
Smoking Cessation
Hypochondriasis
Body Dysmorphic Disorder

Controlled Outcome Studies

on CBT

Unipolar
Depression (~30)
Eating Disorders
Anorexia (~5)
Bulimia (~15)

Generalized
Anxiety Disorder
(~12)

Social Phobia (~14)

Panic Disorder (~10)
Borderline P.D. (2)
Schizophrenia (~45)
C/A Depression (8)
Chronic Depression
(1)

Conclusions
System

of psychotherapies
Unified theory of psychopathology
Short-term treatment
Objective assessment and
monitoring
Strong empirical support
As effective as pharmacotherapy

Questions?
Comments?
Dr. Shona Vas
(773) 702-1517
Psychiatry Department Office: A312
svas@yoda.bsd.uchicago.edu