CBT skills

What I know about CBT!This might help your patients.

Posted by Philip Kinsella Wed, December 14, 2016 11:54:27

What I know about CBT.

  • It works well.
  • Persistent behavioural change is the most important element.
  • You need a good relationship with the patient particularly to ensure they return.
  • Challenging thoughts works better than defusing from thoughts.
  • Patients will keep things from you.
  • Set lots of homework to be successful
  • Be efficient in the session
  • Trans-diagnostic approaches are probably better than protocols.
  • The patient needs to be his own therapist.
  • The therapist needs to be his own therapist
  • Techniques that the patient learns well are probably more important than formulations.
  • It is too ‘talky’ and benefits from experiential elements like imagery.
  • Most people aren’t good at some things in their lives
  • If you’re not good at some things you focus on the things you’re good at, so CBT should accept that.
  • If don’t memorise a workshop and put it into practice you’ll forget it very quickly.
  • CBT therapists are biased to focus on the research that supports their existing view.
  • Therapists believe the research that is in line with their existing views.
  • We are good with straightforward cases.
  • We are bad with complex cases.


What I know about CBT!This might help your patients.

Posted by Philip Kinsella Wed, December 14, 2016 11:52:45

What I know about CBT.

  • It works well.
  • Persistent behavioural change is the most important element.
  • You need a good relationship with the patient particularly to ensure they return.
  • Challenging thoughts works better than defusing from thoughts.
  • Patients will keep things from you.
  • Set lots of homework to be successful
  • Be efficient in the session
  • Trans-diagnostic approaches are probably better than protocols.
  • The patient needs to be his own therapist.
  • The therapist needs to be his own therapist
  • Techniques that the patient learns well are probably more important than formulations.
  • It is too ‘talky’ and benefits from experiential elements like imagery.
  • Most people aren’t good at some things in their lives
  • If you’re not good at some things you focus on the things you’re good at, so CBT should accept that.
  • If don’t memorise a workshop and put it into practice you’ll forget it very quickly.
  • CBT therapists are biased to focus on the research that supports their existing view.
  • Therapists believe the research that is in line with their existing views.
  • We are good with straightforward cases.
  • We are bad with complex cases.


Summary of James Bergo ‘Why do I do that’ This might help your patients.

Posted by Philip Kinsella Thu, November 17, 2016 09:52:59

Summary of James Bergo ‘Why do I do that’ (New Rise press)

This book explains the classic defense mechanisms as understood from psychodynamic perspective. These protect us from emotional pain, but may get in the way of growth and development. They are too painful to bear, may conflict with our morality, or undermine our self-image. They can be habitual. They may sometimes be useful. I have made a note as to what the CBT equivalent may be.

List of defenses:

Repression

Denial

Displacement

Reaction formation

Splitting

Idealisation

Projection

Control

Thinking

Repression: (when an uncomfortable feeling is pushed from awareness). Example, feelings of annoyance at child pushed out of awareness.

CBT equivalent: avoidance;

Denial (we deny that an uncomfortable fact is true). Example ‘There’s no way that I made that mistake’.

These mechanisms may be associated with anger.

CBT equivalent: avoidance of thoughts, thought suppression?

Displacement: (when a feeling such as anger is transferred to some other object e.g. kicking the cat instead of boss, anger at baby for crying, taken out on husband!).

CBT equivalent: ?

Reaction formation (turning a feeling into its exact opposite). This is associated with shame. Person who is gay starts a campaign against gays. The reformed ‘born again’ smoker.

CBT equivalent: over-compensatory rule, schema over -compensation.

Splitting: is a response to ambivalence, and strong feelings of hatred, serving to simplify the former and eliminate awareness of the latter. So when we are ambivalent/uncertain, there is a pull to resolve this. It is more comfortable to align ourselves with one, and completely reject the other.

CBT equivalent: black and white thinking/intolerance of uncertainty. Donald Trumpism!

Idealisation: (Seeing somebody as perfect to avoid uncomfortable feelings about them). Common in romantic relationships. Possibly in Bipolar disorder?? Idealizing ourselves to avoid uncomfortable feelings about self is common in Narcissism. Can be associated with splitting.

CBT equivalent: cognitive avoidance? Over-compensatory rule. Schema overcompensation.

Projection: Getting rid of a feeling and transferring it to some one else. ‘It’s not me that’s difficult it’s her’. May be associated with guilt. May be associated with splitting.

CBT equivalent: cognitive avoidance??

Control: try to gain complete control of things to ward off anxiety.

CBT equivalent: rule about control.

Thinking/Rationalising/intellectualising: repeatedly thinking about something as a way to avoid the discomfort of it. Thinking can have good or bad effects

CBT equivalent: Worry/rumination etc.

Defenses against shame (awareness of a serious defect in self): defenses are usually narcissism; blaming; contempt.



Functional analytical psychotherapyThis might help your patients.

Posted by Philip Kinsella Wed, May 11, 2016 10:09:16

FAP focused on helping with relationships (based on an online workshop with Jonathan Kanter).

FAP is a therapy based on behavioural therapy traditions. In session CRB2’s are observed, evoked and reinforced. CRB1’s would be observed but not reinforced.

CRB2’s are clinically relevant behaviours such as opening up to the therapist, showing emotion, being courageous in facing a fear and so on. It is a very experiential therapy in which these positive behaviours are modeled in the therapy, in order to deepen the relationship with the patient.

The patient would be assessed using a format such as this:

FAP assessment questions (based on quick ACL assessment)

Awareness

1. How aware are you of your feelings as they happen?

2. How aware are you of your needs and values in the interaction?

3. How aware are you and accepting of the other person’s needs, values and interactions?

Courage

1. Are you able to show vulnerable feelings?

2. How are you at authentically sharing?

3. What are you like at asking for what you need?

Love

1. When others are emotional and vulnerable with you how are you at making them feel safe and accepted?

2. What are you like at expressing empathy when others share?

3. Can you sensitively give others what they need, when they ask?

4. How are you at expressing appreciation when others do loving things for you?

5. How much are you able to express feeling close and connected when others do loving things for you?

Self-love

1. How are you at accepting yourself and whatever you may be feeling?

2. What are you like at accepting love and appreciation from others?

(When not in an interaction:)

1. How are you at self- care and soothing yourself?

The philosophy of the patient is to use behavioural principals to encourage:

Awareness

Courage

Love

In (oneself and in) one’s patients to help them deal with their relational and other problems



Update on exposure. Michel Craske lectureThis might help your patients.

Posted by Philip Kinsella Wed, February 03, 2016 16:00:04

https://www.youtube.com/watch?v=pKPgFVKVFLA

She has done a lot of research on mechanisms of fear reduction

Fear will return over time. The fear is not eradicated after exposure, but there is a competing memory based on the safety that has been learnt during the exposure.

If a distressing unexpected trigger occurs later then the fear will occur.

Anxious people are not good at inhibiting fear i.e. in the amygdala.

Extinction learning unlike original fear learning, is context specific, so can easily return in adifferent context.

Maximizing exposure:

Duration of exposure is not so important.

Need to violate expectancies e.g. ask the patient what they need to do for the bad thing to happen, then do exposure.

Add extra triggers during exposure. E.g. add interceptive to driving exposure, add in social rejections to social exposure.

Cognitive restructuring is not good before exposure as it is shifting expectancy: should be done afterwards.

Variability is good e.g. triggering object and duration:different spiders, different height situations. this is a slight effect.

Good to enhance tolerance of fear.

Throw in many contexts in exposure: familiar/unfamiliar, accompanied/not, on or off medication.

New rules of exposure:

Mixed in level of difficulty not graded (if possible), does not have to be prolonged, add in extra stimuli, repeated exposure especially to a variety of triggers, ensure focused attention to stimuli, cognitive restructuring after exposure.Can try to enhance positive mood towards stimuli. Use affect labeling ‘I’m feeling anxious…’

Behavioural experiments:

BE do not focus on duration and they do focus on violating experiments, so this is good. BE needs to be better at facing a more variable range of exposures. BE need to ensure patient is focused on stimuli. Do CT afterwards not before. Can try to enhance positive mood towards stimuli. Use affect labeling ‘I’m feeling anxious…’



Ian Evans ‘How and why thoughts change’ book reviewThis might help your patients.

Posted by Philip Kinsella Tue, November 17, 2015 23:56:04

Ian Evans

‘How and why thoughts change’

This is a tremendous book looking in detail at a common treatment strategy for CBT therapists. It is interesting and humorous. I would have liked a little more on how emotion influences thinking, and perhaps more guidance on choice points about which approach or technique to use at a particular moment


Here is a rough summary of relevant content:

Thoughts are real and relate to actions. Thoughts have the potential to influence moods, and vice versa. We can have meta-cognitions, thoughts about thoughts e.g. ‘My mind is out of control.’

A range of psychotherapies tries to influence thoughts, including CBT. However, it may be that CBTs do not work by changing thoughts, but by other processes in the therapy e.g. the relationship, or behavioural change. Therapy can both target the way information is processed e.g. worrying cycles, and how thoughts are retrieved from memory (problematic in PTSD), and the overt conscious thoughts that arise from such processes (‘no one at this party likes me’). The processes can be addressed by bias training e.g. the person who thinks no one likes him can be trained to focus on friendlier people, perhaps through a computer programme.

Schemas, more ingrained mental structures, e.g. about your mother, may be a mixture of expectations, assumptions and emotional connections. These may not be clearly articulated, and be out of awareness, or only articulated when specific questions are asked (‘how did you get on with your mother?). Beliefs and schemas have a degree of inertia, and won’t change easily.

Thoughts are kept in memory, of which there are three stages: encoding, storage and retrieval. Implicit, explicit and autobiographical memories are important.

External cues, internal search strategies, motivation, mood, and associations will access thoughts and memories. Thinking involves problem-solving, decision-making reasoning and creativity.

There are two thinking systems: fast and slow described in Daniel Kahneman’s book. System one functions automatically to notice and allow rapid reactions to day-to-day urgent problems. System two functions with mental effort (so is less likely to be used), and is the conscious reasoning self. System two can take over from system one, but there may have to be a decision for this to happen.

Thinking can be influenced by mood, personality traits and social influences.

Thoughts that depressed patients may utter such as ‘I’m a terrible person’ may function to elicit sympathy and support.

Rumination, brooding and worry can be a problem.

There can be distorted thoughts, delusions and dissociation, also obsessional thinking.

Kahneman identified judgment heuristics. Number one is representativeness, taking one thing to represent the general. Number two is availability; this means how easily examples can be brought to mind. Number three is anchoring, the initial base rate influences the final estimate.

Do thoughts influenced mood or vice versa? Both are true. Words can become associated with feelings so the word ‘fail’ may become associated with low mood and easily evoke it.

State dependent retention is important and means recall of an event is better if during recall one reinstates the mood one was in during their original learning. Also there is the mood congruity effect: people are more likely to attend to events that match their emotional state of the time (p137).

Emotions can be seen as providing information.

There are basic emotions: fear, anger, sadness, and happiness. Some emotions are more complex and are influenced by cognitive appraisal e.g. jealousy and embarrassment.

It is simplistic to separate thoughts, feelings and behaviours as they interact together.

There are general principles of how and why thoughts change:

This can be external influences e.g. psychotherapy or friends or information, or internal, something the person does for themselves (‘I’ll challenge my thoughts’).

Therapeutic change is influenced by the quality of the relationship, also by changes the therapist recommends to the patient.

Therapists ask specific questions to challenge the patient’s thoughts. New experiences that can be planned with the therapist (exposure or behavioural experiments) reinforce this. Sometimes an epiphany happens that brings about a profound change; this could be an event or something that’s said.

It is important to remember that specific thoughts occur in triggering social situations.

Metacognition is an important perspective. ‘Thoughts don’t matter, but your response to them does’.


Ideas to enhance CBT practice:

Try to enhance positive affect at an earlier stage to increase cognitive flexibility.

Also increase motivation to do the work.Improving your therapeutic relationship encourages change. Patients and therapists may have dysfunctional schemas about therapy that need exploring. Could explain the idea of fast to slow thinking.

Therapists should use Socratic Discovery rather than arguments.

Use a thought record.

Evaluate the function of thoughts: thoughts may be a type of behaviour “If I say I’m sad he’ll be more supportive’.

Be aware thoughts can be general, for example ‘I’m unattractive’ or more specific ‘if I put on weight I’m unattractive’.

Sometimes listening and reflecting works better than challenging.

Consider closed-mindedness-this may be to protect the patient from emotional threats. ‘A man convinced against his will, is of the same opinion still’. Patients may have beliefs that make them reluctant to consider alternative opinions.

Good question is ‘what would you say to a person who said…’

Help the patient see that her narrative of her life is unhelpful

Help the patient change harsh words to neutral words for example ‘I’m weird’ to ‘I’m a character’.

Help the patient to be self compassionate and accept their flaws: this could be a compassionate image, or they could write a compassionate letter to themself.

You can change a thought by changing the frequency of its occurrence (manage triggers); changing the content; change its value: ‘I don’t mind this’; changing the process of reaching a conclusion (just because I’ve done poorly in this job does not mean I’m a failure; change the relationship with the reinforcer.

The book’s conclusion is addressing thoughts is valid in therapy. It is not certain which the best techniques are, this may have to be judged at the time of the interaction, bearing in mind evidence based protocols. The devil may be in the detail of the technique!



BABCP conference-educationThis might help your patients.

Posted by Philip Kinsella Wed, August 05, 2015 14:17:44

Competence in a CBT programme research by Dr Kate Sherrat.

Survey of trying to understand what is really helpful for the trainees

  1. At the start of the course most trainees desired more personal and professional confidence: want to believe in self and be less hard on self, compare the self less to others.
  2. CBT training is not the best choice if you want to be more confident in self: they have more NATS and less confidence!! ( at middle of course). Move from clear models to idiosyncratic approaches is difficult. Generally this confidence is better by end of course. Reflecting and rating tapes can undermine confidence.
  3. Students did report changes in a wide range of qualities, mostly knowledge; skills; self reflection etc. important skills were formulation, guided discovery and reflection.
  4. Supervision is biggest change agent. Tapes difficult but helpful. Learning from supervisors was important.
  5. During training students can experience altered thinking and perception; being more curious and thoughtful. Thinking about multiple things at same time.
  6. Trainees use training and self reflection in the therapy room. Self understanding can increase. CBT from inside good.


Integrated behavioural couples therapy.This might help your patients.

Posted by Philip Kinsella Mon, May 04, 2015 17:04:26

Integrative behavioural couple therapy. Andrew Christensen. April 2015.

This was an interesting two-day workshop from an experienced American academic.

There are several brands of couple therapy, the one presented here is an adaption of pure behavioural couples therapy: it has been evaluated in a trial, was effective, but not more so than the original therapy.

The therapy has a ‘dyadic’, conceptualization at its heart, working hard not to see either party at fault. Incidents are brought alive in the session, and emotion driven maladaptive behaviour is modified. Private emotion driven behaviours, such as poor sexual engagement, is brought to the surface, and explored. Effective communication is encouraged, and strengths and positive behaviour is prompted.

Therapy goals can be to change things, or to accept things.

Homework exercises are based on encouraging naturally reinforcing behaviours rather than prescribing rule governed behaviours. For example’ what would have to happen that you would enjoy a date at the cinema’, rather than ‘I will to to the cinema with my wife’ on Tuesday.

Key idea is DEEP analysis.

Differences in libido, desire for closeness, interests cause problems

Emotional sensitivities are considered. As are,

External stressors. Which lead to,

Patterns of problematic interaction: moving away and against, hanging on, and moving against with others

In therapy an example of the problem is identified and subject to a DEEP analysis. Acceptance is encouraged for differences and sensitivities. Acceptance and change for external stressors. And change for problematic behaviours.

Couples cannot be treated if they are not living together, or one or both are not committed.

The structure of the therapy is 1 joint, and 2 individual sessions for assessment, 1 joint session for feedback, multiple treatment sessions and a relapse prevention plan.

In the assessment there is a focus on letting each speak, a neutral position, and the impact of the other’s actions; the relationship history is traced, measures are taken and a self help book is given out. If there is a current affair it must be ended, or the person must tell their partner. Feedback session is a DEEP analysis.

The homework is a weekly questionnaire, tracking progress and issues that come up.

The 3 main strategies are: CAB

Affective change-‘empathic joining’

Cognitive change-‘unified detachment’

Behavioural change ‘new coping’

Empathic joining is where therapist encourages shared feelings, and validation is encouraged.

Unified detachment is more of an intellectual discussion of a difficult experience describing the pattern using antecedent, behaviour and consequence analysis to encourage understanding and a shared perspective.

Direct change is where the therapist coaches new behaviours in the session and out, often focused on better communication, initially building on the skills the couple have got.

Additional strategies are increasing positive behaviours, (joint) problem solving, and communication training.

Can terminate when significant progress made and /or couples request it: can include follow-ups.

Reflection: my thoughts are that there is a need for couples therapy where I work in Nottingham. There are logistic problems in having two patients rather than one, and I felt doing the role-play that this was quite challenging work, like herding angry cats!

It is not advisable to do couple therapy if you have already been treating one partner, as there will be bias.

I would like to offer this approach, I need to advertise that if one patient’s problems is driven by couple discord this could be an intervention I could offer.

There is a very funny video about couple communication that could be used clinically and in training. http://youtube.com/watch?v=q6sMnQsv7Hk