CBT for Therapists

Good short video "What is CBT?" by Robert Leahy

2012-02-11T14:21:00.001Z

CBT and Behavioural Experiments

2012-02-05T18:29:00.002Z

According to the bible of Behavioural Experiments, the Oxford Guide to Behavioural Experiments in Cognitive Therapy,

"Behavioural experiments are amongst the most powerful methods for bringing change in cognitive therapy".

In this article I will

- Answer the question "What is a behavioural experiment?"

- Explain why and when to use behavioural experiments

- Give an example of a good behavioural experiment

- Advise on some Dos and Don'ts for setting up effective behavioural experiments

- Provide further resources on behavioural experiments in CBT, including handouts and record sheets.

What is a Behavioural Experiment?

Behavioural Experiments are planned activities , based on experimentation or observation, undertaken by clients in session or between sessions. They test existing beliefs and/or help test more adaptive beliefs. Their design is derived from the formulation.
Put most simply

A behavioural experiment is when the client gets to test something out.

Why Why use Behavioural Experiments?

Inece

WO Many novice practitioners associate CBT with thought records , with just about trying to help clients think about things differently. Whilst its true that the thought record can be a powerful method, it's rarely sufficient on its own. The thought record allows the client to become more aware of their thinking and patterns of behaviour, and even to come up with alternatives. But they still may not be fully convinced that the alternatives are true. This is where behavioural experiments come in. Behavioural experiments can

• Test client’s old, negative and unhelpful existing beliefs

• Test client's ne and more helpful beliefs

• Enable experiential learning - "learning by doing"

• Increase the chances that clients will say they "feel it in my heart" as well as "know it in my head"

An example of a good behavioural experiment

For example, let's consider Julie, who has come for CBT because of difficulties with social anxiety, especially with making presentations which she has to do at work. She has already done a thought record where she has identified the following belief

When I give a presentation it is obvious I am very nervous and everybody thinks I am a terrible presenter

Julie believes this is true with a certainty of 90%.

A thought record gives her the alternative perspective that this may be mind-reading and extreme thinking.
She constructs an alternative belief

Although I am very nervous it may be that not everyone notices this and maybe some people think this I am an OK presenter

After consideration she says she believes this 25% and the original belief goes down to 75%. As a result her anxiety is somewhat reduced.Whilst this represents some progress, notice that Julie still doesn't really believe the second belief very strongly.

Julie needs to test out which belief is true - she needs to do a behavioural experiment.
Her therapist and her design the following behavioural experiment. Julie will design a survey to give to colleagues after she does her next presentation. The survey asks for two questions to be answered honestly
1. On a scale of 0-10 (10 very nervous) how nervous do I look when presenting?
2. On a scale of 0-10 (10 very good) how good am I at presenting?

Julie predicts she will score 9 out of 10 for nervousness and 2 out of 10 for being good at presenting.

She is amazed when she gets the feedback forms back from her survey and discovers she scores 4 out of 10 for nervousness and 6 out of 10 for being good at presenting. Notice that her colleagues don't say that she is completely nerveless or that she is a fantastic presenter - but they say enough to disprove her extreme thinking.

When asked to re-rate her original beliefs she now says rerates the positive belief at 75% and the more negative belief only 25%

As if often the case, a behavioural experiment has made a much greater impact that thethought record.

Some Dos and Don'ts for setting up effective behavioural experiments

* Plan experiments thoroughly don't just say "why don't you try it out"?

* Find out what beliefs are being tested, and how much the client believes them now

* Be specific about what the client will do, where and when

* Think about what problems are likely to be encountered and how to deal with them

* Set up experiments to be “no-lose” – we learn whatever happens

* After the experiment, explore the outcome – what happened, which beliefs were vindicated, what the client has learnt – how much their beliefs have changed

* Be enthusiastic and positive about the clients efforts and stay curious

* Finish by asking "what's the next step?"

More good free resources on Behavioural Experiments in Cognitive Therapy
Introductory chapter (Historical and conceptual underpinnings) from Bennett-Levy, Butler, Fennell, Hackmann, Mueller & Westbrook Oxford Guide to Behavioural Experiments in Cognitive Therapy

Chapter on Behavioural Experiments for Depression by Fennell, Bennett-Levy & Westbrook from their book Oxford Guide to Behavioural Experiments in Cognitive Therapy (Chapter 10)

Good handout on behavioural experiments to give to clients

Good powerpoint presentation on Behavioural Experiments

Behavioural Experiment Worksheet

Another behavioural experiment worksheet from Good Medicine (recommended site)

Good Behavioural Experiments FAQ

Video demonstration of setting up a behavioural experiment

Manual including behavioural experiments for Chronic Fatigue Syndrome (CFS) and ME

Systematic review suggesting some evidence that behavioural experiments may be more effective than exposure alone

Who Influenced Dr. Aaron Beck's Work? (Students Ask Dr. Beck - PART TWO)

2012-01-14T17:22:00.000Z

2011-12-27T12:59:00.000Z

Quick CBT (Cognitive Therapy) Quiz: How much do you know about GAD (Generalised Anxiety Disorder)?

Generalised Anxiety Disorder (GAD) is one of the most common problems you are likely to encounter as a Cognitive Therapist. Take this quick quiz to test your knowledge of it and how to treat it.

Which of these is most characteristic of GAD.

Who says that the tolerance of uncertainty is the most central feature of GAD?

The main idea behind the worry decision tree (Butler & Hope) is

Adrian Wells's metacognitive approach to GAD would include

Which answer below best gives rationale for "worry time".

Which statement about GAD is most accurate

Thank you for completing the quiz. Click Grade me to see your score out of a possible 60.

How to Stop Worrying: Self-Help for Anxiety Relief

2011-11-20T23:41:00.000Z

How to Stop Worrying: Self-Help for Anxiety Relief
Very useful self-help resource to help with Generalised anxiety disorder

The Politics of Well-Being: A blueprint for 'Philosophical CBT'

2011-11-15T20:50:00.000Z

The Politics of Well-Being: A blueprint for 'Philosophical CBT': Imagine being able to practice philosophy through the NHS. The idea is not as far-fetched as it sounds. In fact, therapists and counselors ...

The Politics of Well-Being: Tim LeBon on Philosophical CBT

2011-11-15T20:49:00.000Z

The Politics of Well-Being: Tim LeBon on Philosophical CBT: Tim LeBon is a cognitive therapist and philosophical counselor, and the author of the book Wise Therapy . He's one of a handful of people ...

The Politics of Well-Being: An interview by Jules Evans with Aaron Beck on CBT

2011-10-27T17:44:00.002+01:00

The Politics of Well-Being: An interview with Aaron Beck on CBT:
This is an interesting interview journalist and practical philosophy expert Jules Evans did with Aaron Beck, the inventor of Cognitive Behavioural Therapy (CBT), back in 2007. Of particular interest is how Beck differentiates CT from REBT and also the tips he gives on CBT for schizophrenia. It's also noteworthy if not surprising that Beck endorses Seligman's work with children (I wonder what he thinks of positive psychology?) and , as Evans observes, how Beck is very reluctant to go beyond the facts ....

Borkovec et al. article on GAD

2011-10-22T08:33:00.001+01:00

There are a lot of free resources written by leading experts and here's one I found that I wanted to share with you.
http://focus.psychiatryonline.org/cgi/content/full/2/3/392

It's called

Cognitive-Behavioral Therapy for Generalized Anxiety Disorder With Integrations From Interpersonal and Experiential Therapies

and it's written by Tom Borkovec, Michelle Newman and Louis Castonguay.

This is the abstract

After providing background information on the definition andnature of generalized anxiety disorder, this article describescognitive-behavioral therapy (CBT) methods that have been empiricallysupported in the treatment of this disorder. Subsequent to thisdescription, relevant outcome literature is briefly reviewed,along with evidence that the addition of other techniques beyondtraditional CBT methods may be necessary to maximize clinicaloutcome. A description is then provided of an integrated interpersonal/emotionalprocessing therapy that the authors have recently added to theirCBT protocol. CBT with and without this integrated treatmentis currently being evaluated in an experimental trial.

The article is now a little out of date, but does include a good survey of CBT for GAD as understood in 2004 - for example it mentions but does not go into detail about Dugas' model focussing on intolerance of uncertainty and does not mention Wells' metacognitive approach. It does, however, go into some detail about Borkovec's own theory that worry is a form of avoidance i.e. one of the functions of worry is to avoid experiencing anxiety - a strategy that backfires and is addressed by facing the anxieties. The article also introduces the idea of integrating interpersonal concerns into CBT, a useful idea given the recent interest in Interpersonal Therapy.

CBT for OCD (Obsessive Compulsive Disorder)

2011-09-28T14:28:00.001+01:00

Obsessive Compulsive Disorder (OCD) is one of the most disabling and at first sight puzzling of the anxiety disorders. Yet it is treatable, and CBT has the most impressive evidence base of all the treatments.

A new self-help book has just come out, Break Free from CBT. I went to a Paul Salkovskis workshop
at the recent BABCP conference at Guildford and was very impressed by his ideas.
The key idea to the CBT treatment for OCD can best be described in terms of Theory A and Theory B.
Theory A is what the client is already thinking. Its contents vary depending on the type of OCD, but basically it will be a varient of

Theory A: My problem is that I might get contaminated/harm someone/leave the house open. Because of this I need to avoid any contact with germs/avoid people/ repeatedly check that the door is locked.

The key insight of CBT for OCD is that theory A is the problem, and the compulsive behaviour that is meant to solve it (checking, avoidance) is also part of the problem. So we have Theory B, namely

Theory B: My problem is that I worry that I get contaminated/ I worry that I will harm someone/ I worry that I have left the door unlocked. Because of this I need to stop doing the checking/avoiding.

Of course it may take an OCD sufferer some time to be convinced of theory B, and the whole ethos of CBT isn't so much about convincing, more about examining the evidence. So the client will be asked to do a behavioural experiment to see which fits the data best, theory A or theory B. For example, if someone has thoughts they will harm someone, they will be asked "how often have you harmed someone before?" and "what is more likely, that you are the sort of person who harms someone, or the sort of person who has high moral standards and is worried they will harm someone?".
There is a lot more detail in the book featuring different case examples and a variety of other techniques (including ERP, exposure and response prevention, which is the more behavioural and less cognitive treatment for CBT).

In summary, OCD is treatable, and I'd thoroughly recommend this book for sufferers and therapists alike.

Read an extract from Break Free from OCD by Challacombe, Oldfield and Salkovskis

Buy Break Free from OCD from Amazon

OCD Resources for therapists
Book Review of Break Free From OCD
Salkovskis 1985 cognitive model of OCD& formulation sheet for OCD
Salkovskis et al vicious flowerformulation sheet for OCD
Presentation on benefit of guided self-help using CBT for OCD
OCD questionnaires including OCI and RAS
NICE guidelines on OCD

Self - help resources for OCD

OCDUK - lots of resources for those suffering from OCD and their families -especially strong on help for children with OCD
Institute of Psychiatry expert advice on OCD - includes further reading suggestions
OCD Thought Record form - Thought record sheet customised for OCD
ERP logging for OCD - to record exposure and its effects
OCD Rituals Diary
OCD and Beckham - helping to take some of the stigma from OCD from the OCD Closet
6 minute video on CBT and OCD featuring Paul Salkovskis
CBT techniques for OCD -self-help page
Introduction to Overcoming OCD by Lee Brosan - a very short, clear and inexpensive guide - a good place to start.
Overcoming OCD by David Veale and Rob Wilson - another good self-help guide

dealing with guilt

2011-05-03T08:14:00.002+01:00

Just published article on how to deal with guilt - getting the balance right
between challenging inappropriate or unhelpful guilt and paying heed to existential messages

http://blog.timlebon.com/2011/05/guilt-useful-or-useless-emotion.html

changing core beliefs using CBT

2010-10-11T12:20:00.000+01:00

Just published some notes on changing core beliefs using CBT
http://www.timlebon.com/corebeliefs.html

Recommended site for free resources

2010-10-11T11:41:00.000+01:00

Excellent CBT (cognitive therapy) worksheets for therapists and also
for Self-help at http://www.getselfhelp.co.uk/freedownloads2.htm

Two recent Judith Beck articles aimed at the general public about CBT

2010-07-18T16:02:00.001+01:00

Judith Beck dispels some misconceptions about CBT

Judith Beck on the the hows and whys of CBT

Three more good sites full of CBT resouces

2009-12-06T23:28:00.001Z

If you know where to look ,there are a lot of free resources for CBT therapists to use.

Here are three I was recently told about by a colleague (thanks, Ann)

http://www.cci.health.wa.gov.au/resources/mhp.cfm

From the Australian Centre for Clinical Interventions

Good information sheets (http://www.cci.health.wa.gov.au/resources/minipax.cfm?mini_ID=8)

including Behavourial Activation Core Beliefs

http://www.ntw.nhs.uk/pic/leaflet.php?s=selfhelp

Northumberland Trust self-help booklets
Good resources include Controlling Anger Shyness and Social Anxiety

http://www.westsuffolkcbt.com/professionals.aspx

West Suffolk CBT Service
Many good informatio sheets and workshop handouts including Formulation Template New System versus Old System Flashcard

CBT Formulation (case conceptualisation)

2009-10-04T08:54:00.000+01:00

CBT formulation (or case conceptualiation) is the keystone of CBT. It is the blueprint to help you and the client figure out what is going on.
Many versions of CBT formulation have been advocated, including the following (overlapping) elements

Getting a list of problems, issues and goals
Diagnosis
Key core beliefs (global statements about self, world and future)
Key dysfunctional assumptions (life rules, shoulds, musts)
Vicious cycles and maintaining factors (things that keep the problem going, safety behaviours, compensatory strategies)
Triggers (things that set the problem off now)
Modifiers (things that make it better or worse)
Vulnerability factors (childhood experiences, genetic factors)
Critical Incidents (what started the big problem recently)
Treatment Plan
Alternative core beliefs, assumptions and policies
Typical cycle of event, thought, mood, physiology and behaviour

Formulations are often done in diagram form, preferably in collaboration with the client.

Some free internet resources

Will Kuyken's Evidence-based case formulation chapter (pdf)

Workshop on CBT Formulation (pdf)

Eoin Stephen's paper on A Case Formulation Approach to CBT (pdf)

Chris Allen's articles on case conceptualisation part 1 and part 2

Clients’ experience of case formulation in cognitive behaviour therapy for psychosis ,

Recommended Reading
Needleman, L. Cognitive Case Conceptualisatin: A Guidebook for Practitioners
Persons, J Cognitive Therapy in Practice: A case Formulation Approach
Beck, J Cognitive Therapy: Basics and Beyond
Kuyken, W, Padesky, C, Dudley, R Cognitive Case Conceptualisation
Padesky, C - Audio cd on case conceptualisation available from www.padesky.com

Two free measures that can help with CBT

2009-10-03T19:52:00.000+01:00

There are a wealth of measurements available in CBT, such as the Beck Depression Inventory (BDI), but most are copyrighted (ie you have to pay for them). Furthermore many of them take a long time to complete, which means you might only want to administer them once a month or so.

Whilst it is worth getting hold of and using these measures, you and your clients might also benefit from using two quick to use and free measures that are currently used in the IAPT services in the UK.
These are the GAD-7 (for anxiety) and PHQ-9 (for depression)

You can find the measures and guides to using them here
They take a couple of minutes to administer so, when appropriate, can be used every week as a quick gauge of where clients are at and also a measure of progress.

Giving a rationale for CBT

2009-09-27T07:13:00.001+01:00

Some clients (or patients) may come to CBT (cognitive behavioural therapy) knowing exactly what CBT is and how it will benefit them. However the majority probably won't - they may be ambivalent about the therapy and start with misconceptions about CBT.

If they understand the potential of CBT for them it will not only increase their motivation but also give them a better opportunity to engage fully in the collaborative CBT process. So it's a good idea to provide a rationale for CBT, and explain how it works, early on in the first session.

So how best to do this?

Here are some alternative ways to present CBT to the client in the first session
1) Give a handout on CBT for the client to read after the session
2) Explain the CBT rationale in session using short case vignettes and a diagram
3) Use similes and metaphors to tell the client what CBT is like.
4) Use a "naturally occuring moment" to link the client's own situation to how CBT can help them.

Imagine you were a CBT client, which would you prefer?

In my view, all of these have a place, but as you'll see I do have a view as to which is usually preferable.

Giving a handout on CBT means you have more time to work on an assessment in the first session, and also means the client can read about CBT in their own time and at their own pace. You could base such a handout on the information given in Tim LeBon's CBT website.
But the disadvantages of just giving a handout are many. How many handouts have you been given and haven't actually read? What if the client misunderstands the material or has lots of questions it? Worse still, what if the client decides in the first session that CBT isn't for them, because they haven't understood CBT and its rationale properly - so they never bother to read the handout. For these reasons, I would recommend using handouts as a supplement rather than as the main way to explain CBT's rationale. I wonder if the same applies to use of handouts and readings in general - use them as a helpful extra that will be of benefit to the more motivated client, but don't rely on them.

What about using case vignettes and pre-prepared diagrams to help explain CBT in the first session? Again, this can be a useful approach. Have a look here for a good example of material to base this on and here is another, shorter explanation of CBT. You can present the "hot cross bun" model from Mind over Mood or perhaps an ABC account. The ABC account states that the activating event (A) doesn't lead directly to the behavioural and emotional consequences (C) - the beliefs (B) come in between them. Changing your beliefs provide scope for changing the consequences, whatever the event. These can be made more vivid if you have a store of case vignettes to show how ABC and the hot cross bun works, preferably choosing a case close to the client's presentation.
In my view presenting the CBT model and brief cases is preferable to just giving a handout, but presents different risks. Most obviously, it can turn the first CBT session into a lecture - not good for any form of counselling, even less so for CBT which emphasies teamwork and collaboration. So any "mini-lectures" needs to be done in a simple and concise manner, checking out that it makes sense to the client at regular intervals. It also really does need to be "mini" - no more than five minutes, preferably less.
But what if the client objects to some of the ideas you present? Instead of getting defensive, welcome these objections as signs of client engagement. Get the client interested in testing out their ideas empirically - it could even lead to an early behavioural experiment.
A third, more imaginative, way to help the client understand CBT is for you to provide similes and metaphors for CBT in the first session. So you say to the client "Getting CBT is like going to a yoga class in some ways - you learn skills but to get the main benefit you have to practice them outside." This can be particularly important if the client expects CBT to be either like going to the doctors - where you take away a prescription and don't need to do any work outside sessions - or client-centred counselling and psychoanalysis, where the work happens mainly in the sessions rather than outside them.
Can you think of other good analogies for good CBT ? Here are some to start to you off.
Good CBT is like

learning to drive
learning to cook
going to a yoga class
having golf lessons

Post a comment if you can think of any other good analogies for CBT.

The ideas to convey are that a CBT session involves learning skills and practising outside sessions. You can also use similes and metaphors to help get across the rationale for CBT - for example "CBT is like a mind gym" or "Cognitive therapy is a workout for the brain". Using similes is certainly a good idea, and might help persuade the client -but way not be sufficient on its own, as it doesnt explain the 5 part model or the link between thoughts and their consequences.

The fourth - and in my view best- way to provide an explanation and rationale for CBT in the first session with a client is to use "naturally occuring moments" to link the client's own situation to how CBT can help them. Here is one way this might work out
Therapist: Thanks for coming today. As you know, we are going to be using an approach called cognitive behavioural therapy (or CBT) to help with your problems. Would you like to hear a little about this approach and how it works?
Client: By all means.
Therapist: The basic idea in CBT is that how we think affects how we feel -and also what we do - and vice-versa. Does that make sense?
Client: I'm not sure. What do you mean exactly?
Therapist: Well, let's start with how we think affecting how we feel. What are you thinking at the moment?
Client: Well, to be honest I'm a bit sceptical about CBT! Will it work for me? Can you really think your way to happiness?
Therapist: And what emotion are you experiencing when you think "CBT might not work for me?"
Client: Rather down, a bit hopeless, I guess.
Therapist: And what emotion might another client be experiencing if they were thinking "CBT makes a lot of sense"
Client: Probably more hopeful.
Therapist: So here we have the same situation - a client coming for CBT for first time, two different thoughts "CBT might not work for me" and "CBT makes sense" and two different emotions.
Does the idea that how and what you think affects what you feel make more sense now?
Client: Yes, it does actually. I do see how my thinking affected my feelings today.
Therapist: And what are you feeling now?
Client: Rather more hopeful, actually!
Therapist: That's a great start then. Now shall we see how this might help with the problems you'd like help with ....

You can then move on to working on the assessment and formuation, with the client's interest in how the cognitive model might apply to them being ignited in a way that might be missing from the other three approaches.

Whichever method or combination of methods you use, hopefully this post provides some ideas about how best to share some information and a rationale for CBT in the first session with a client.