1	Cognitive Behavioural Therapy (CBT) John Cook, Ph.D. Registered Psychologist
2	Agenda Overview CBT, CBT as practiced at Aegis over the last 10 years, and a proposal for future services Topics Introduction to CBT The CBT attitude and approach CBT programs offered at Aegis A proposed program of group CBT for people in the early stages schizophrenia
3	Introduction to CBT Definition: CBT is a therapeutic approach to helping resolve emotional and behavioural disturbance in patients by working with the their physical-sensory, cognitive and behavioural responses to internal and external events.
4	The CBT Model
5	Introduction to CBT Definition: CBT is a therapeutic approach to helping resolve emotional and behavioural disturbance in patients by working with the their physical-sensory, cognitive and behavioural responses to internal and external events. Assumptions: 1. These three components of experience are inter-dependent and synchronous. 2. Emotional experiences arise from cognitive ones. 3. Emotional and behavioural disturbance is the result of negative cognitive distortions. 4. These cognitive distortions and the resultant disturbance can be treated with CBT.
6	The CBT Model
7	Levels of Cognitive Distortion
8	Example
9	Cognitive Distortions 1. All-or-Nothing Thinking 2. Overgeneralization 3. Mental Filter 4. Disqualifying the Positive 5. Mind Reading 6. Fortune - Teller Error
10	Cognitive Distortions 1. All - or - Nothing Thinking: You see things in black and white categories. If your performance falls short of perfect, you see yourself as a total failure. 2. Overgeneralization: You see a single negative event as a never-ending pattern. Often signaled by use of words "never" or "always". 3 . Mental Filter: You pick out a single negative detail and dwell on it exclusively, so that you vision of all reality becomes darkened.
11	Cognitive Distortions 4. Disqualifying the Positive: You reject a positive experience by insisting it "doesn't count" for some reason or other, and in so maintain your negative belief. 5 . Mind Reading. You arbitrarily conclude that someone is reacting negatively to you, without bothering to check it out. 6. The Fortune - Teller Error. You anticipate that things will turn out badly, and behave as though this is an established fact.
12	Cognitive Distortions 7. Magnification/Minimization: You exaggerate the importance of your goof-ups while diminishing the importance of your accomplishments. Also called the "binocular trick." 8. Catastrophizing: You attribute extreme and horrible consequences to the outcomes of events, making them seem unmanageable or interminable. 9. Emotional Reasoning: You assume that your negative emotions necessarily reflect the way things really are: "I feel it, therefore it must be true."
13	Cognitive Distortions 10. “Should” Statements: You try to motive yourself with “shoulds” and “shouldn'ts”, as if you need to be whipped or punished. 11. Labeling and Mislabeling: This is an extreme form of overgeneralization where you attach a negative label to yourself or describe an event in a negative way. 12. Personalization: You see negative events as indicative of some negative characteristic of yourself or you take responsibility for events that were not your doing.
14	Cognitive Distortions 13. Maladaptive Thoughts: Unlike other thoughts on the list, these may be quite rational and accurate, but are harmful to dwell on none-the-less.
15	Example
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18	The CBT Attitude and Approach Attitude What is it in the way a CBT therapist approaches a patient that distinguishes this from other approaches? Approach What are the steps in common to most if not all CBT interventions?
19	The CBT Attitude
20	The CBT Attitude
21	The CBT Attitude
22	The CBT Attitude
23	The CBT Attitude
24	The CBT Attitude
25	The CBT Attitude
26	The CBT Attitude
27	The CBT Attitude
28	The CBT Approach Attend to arousal level Analyze experiences: (a) emotional responses (b) activating events (c) physical-sensory, cognitive, and behavioural components Match technique(s) to the appropriate components Teach the techniques in a time limited fashion Assign self-report forms and behavioural experiments for homework Evaluate and revise approach as needed
29	Existing Group CBT Programs Target: Men and women, 13 years of age or older; with Panic Disorder, Generalized Anxiety Disorder or Social Phobia Goals: 1. master techniques appropriate to each component
30	Existing Group CBT Programs Goals (Continued): 2. desensitize to the dominant response 3. learn to accommodate by “letting go” Format: 12, weekly, 2-hour sessions with J.C. and client manual
31	A Proposed Group CBT Program Target: young men and women in the prodrome or following their first psychotic break Goals: 1. reduce positive and negative symptoms 2. minimize transition into active phase or relapse 3. increase GAF Format: 16, weekly, 2-hour sessions with 2 co-therapists Structure: 1. check in and homework review 2. presentation of new concepts 3. break with munchies at half time 4. practice and consolidation of skills 5. assignment of homework
32	Functional, Symptom-Focused CBT Functional: interventions are linked to client life goals identified in pre-group interview in order to enhance motivation and engagement. Symptom-focused: program is made up of units that accommodate a variety of symptom profiles such as predominantly positive/negative symptoms, attention problems, affective disregulation, and social communication difficulties.
33	Unit Outline Unit 1: Introduction to CBT Unit 2: Positive and Negative Symptoms Unit 3: Attention and Affect Regulation Unit 4: Social Communication
34	Unit 1: Introduction to CBT Week 1: Schizophrenia Symptoms Program rationale Adjunctive treatments Pitfalls e.g., street drugs Week 2: Life Goals Areas of dissatisfaction Positive alternatives Personal strength profile From goals to steps
35	Unit 1: Introduction to CBT Week 3: The CBT Model Component analysis Automatic thoughts (ATs) Cognitive distortions Challenging vs. accommodating Week 4: Stress Management Diathesis-stress Let it go vs. try harder Relaxation techniques Practice
36	Unit 2: Positive and Negative Symptoms Week 5: Delusions Continuum of beliefs Evidence for and against Cognitive restructuring Behavioural experiments Week 6: Hallucinations Voices as activating events Exploring alternative beliefs Behavioural experiments Coping skills
37	Unit 2: Positive and Negative Symptoms Week 7: Getting Going Congruent positive symptoms Alternative coping appraisals Stress management Goal setting Week 8: Getting Social Social skills training Role play Real-life practice
38	Unit 3: Attention and Affect Regulation Week 9: Attention Role of attention Behaviours that help/hinder Behavioural goal-setting Week 10: Activation Recognizing mood CBT model for depression Activation Weekly activity schedule
39	Unit 3: Attention and Affect Regulation Week 11: Cognitive Restructuring Recognizing depressive thoughts Identifying cognitive distortions Disputing and replacing Automatic thought (AT) form Week 12: Cognitive Restructuring Restructuring of ATs from homework Using a restructuring form Activity schedule review
40	Unit 4: Social Communication Week 13: Nonverbal Communication Learning the language Observation and role play Week 14: Social Anxiety Fear and avoidance hierarchy Role play Behavioural goals
41	Unit 4: Social Communication Week 15: Social Anxiety Real-life exposure Further role-plays Behavioural assignments Week 16: Relapse Prevention Self-monitoring techniques Stress management revisited Review of weeks 1 - 15 Graduation ceremony
42	Summary Use of CBT to modify feelings and behaviours by challenging thinking Collaborative attitude and analytic, graduated approach of CBT illustrated CBT programs offered at Aegis A proposed program of group CBT for people in the early stages schizophrenia
43	References -- Aegis Programs Barlow, D. and Craske, M. (2000). Mastery of Your Anxiety and Panic, 3^rd Ed. New York: Oxford University Press. Craske, M. and Barlow, D. (2006). Mastery of Your Anxiety and Worry, 2^nd Ed. New York: Oxford University Press. Heimberg, R. and Becker, R. (2002). Cognitive-Behavioral Group Therapy for Social Phobia. New York: Guilford Press.
44	References -- Proposed Program Articles: Cather, C. (2005). Functional cognitive-behavioural therapy: A brief, individual treatment for functional impairments resulting from psychotic symptoms in schizophrenia. Canadian Journal of Psychiatry, 50(5), 258-263. Lecomte, T., Leclerc, C., Wykes, T. and Lecomte, J. (2003). Group CBT for clients with a first episode of schizophrenia. Journal of Cognitive Psychotherapy, 17(4), 375-383.
45	References -- Proposed Program Books: Chadwick, P., Birchwood, M. and Trower, P. (1996). Cognitive therapy for delusions, voices and paranoia. Chichester, UK: John Wiley & Sons, Ltd. Kingdon, D. and Turkington, D. (2005). Cognitive therapy of schizophrenia. New York: Guilford Press. Nelson, H. (1997). Cognitive behavioural therapy with schizophrenia. Cheltenham, UK: Nelson Thornes Ltd.
46	Cognitive Behavioural Therapy (CBT) PowerPoint reprints available: http://www.PsycServ.com/events/archives/CBT_powerpoint.pdf http://www.PsycServ.com/CBT_powerpoint.htm