Introduction of Cognitive Behavioural Therapy Skills

Connections

CBT is a five area assesment... Understanding the connections in CBT is like joining the dots!!!!!!!!


CBT claims that when we are distressed or facing problems, there are five areas in our lives that are connected. We are usually in a situation and we have thoughts about this situation and then we are feelings things, which makes us do things and then our body physically reacts also. There is no order to these responses, but all five are happening and are all connected.

All five areas are interconnected. Each area influences the other. A change in behaviour can effect how I feel, both emotionally and physically in my body. It can have an effect on the situation. It can lead to changes in present relationships, and it can effect how I view past relationships and events. Or, changes in thinking can affect how I feel or how my body reacts. It can affect the way I behave and can lead to changes in my situation.

Changing perspectives

Look at a married couple. Do you know the STATUS of their Relationship?

To understand it you have to get information from a lot of areas....

Friends, family , foe, neighbours etc....

CBT is exactly like this.

“We have to walk around together and see the whole picture to understand how things really are.”

Challenge!

“We cannot change the events that happen in our lives, but we can change the way we think about them and what we do about them.”

CBT focuses on two main areas:

1) Helping people to change what they are thinking

2) Helping people change behaviours that are unhelpful or harmful to them

That is why it is called Cognitive Behavioural Therapy. It examines the thoughts (cognitions) and behaviours of people.

CBT claims that most of our worries or anxieties, our depression or anger, come from the way we are thinking and looking at a situation. And, because of how we react and behave.

CBT, therefore, is all about identifying what we are thinking or doing which is not helpful to us or others and then challenging them and changing them.

It is not simply changing negative thoughts into positive thoughts. It is about seeing things as they really are. It is about being realistic. For example, someone who is anxious about failing an exam and thinks that life is not worth living if they fail, would benefit from challenging their beliefs and become more realistic by thinking things like ‘I can try my hardest and if I fail I can re-sit the exam.’ Or, ‘I am good at other subjects. Even if I fail this one it won’t be so bad.’ Or, ‘I have done well in the past, this worrying isn’t helping me concentrate.’

Sometimes CBT helps people to challenge unhelpful behaviours also. For example, people who get depressed often stop doing what they enjoy and stop seeing friends. A simple CBT challenge for people in these circumstances is to change that behaviour; to make themselves go out and continue to do things they enjoyed before, even if they don’t feel like doing it now.

CBT is about change. The change happens when people challenge how they think and do things. It is about beating the negative thoughts and habits that pull people down a downward spiral. It is saying ‘no’ to what is not helpful in life.

“The challenge is your choice!”

CBT gives the power:

• To manage mood swings.
• To manage behaviour that is harmful and self-defeating.
• To choose better ways of responding.
• To control negative thinking and negative moods.
• To change - the choice is yours!!

“It’s like breaking the chains that bind us.”

Identifying the Therapy

The first step in understanding a problem is to make an assessment. Sometimes problems are overwhelming and can be better understood if we break the problem down into five parts and understand these five areas first. This means becoming aware of how the five areas in a person’s life are connected and influencing each other.

Sometimes people have specific isolated problems, which may not necessarily lead to a mental illness. CBT offers tools that can help people to make an assessment of these also.

The aim of assessment is to understand a person’s story and to understand the context of that story and the precipitating factors (that is, those things which keep the problem going).

An assessment is helpful, not only for gaining a sense of awareness and understanding, but it helps to identify where the problem lies and what interventions can be made where. It is like a doctor hearing a story of symptoms and then being able to prescribe the right medicine. In CBT terms, we need to understand these five areas of thoughts, behaviours, feelings, physical reactions and environment, in order to identify where the problems areas are and where specifically change can be made – so that the chain can be broken.

For a general overview of a person’s life history, the following can be used.

You can begin to understand your own problem by defining what you are experiencing in these five areas of your life. Describe any recent changes or long-term problems you have experienced in each of these areas. You can use the Questions below to guide you.

Environmental changes/life situations: Have I experienced any recent changes ? What have been the most stressful events for me in the past 3 years ? 5 years ? In childhood? Do I experience any long-term or ongoing difficulties (including discrimination or harassment by others ?)

Physical Reactions : Do I experience any physical symptoms that trouble me, such as changes in energy, appetite, and sleep, as well as specific symptoms, such as heart rate fluctuations, stomach aches, sweating, dizziness, breathing difficulties, or pain ?

Moods: What single words describe my moods (sad, nervous, angry, ashamed)?

Behaviours: What things do I do that I would like to change or improve ? At work ? At home ? With friends ? By myself ? Do I avoid situations or people when it might be to my advantage to be involved ?

Thoughts : When I have strong moods, what thoughts do I have about myself ? Other people? My future ? What thoughts interfere with doing the things I would like to do or think I should do ? What images or memories come into mind ?

From Mind Over Mood by Dennis Greenberger and Christine Padesky.1995 The Guildford Press

CBT Model of Assessment

Aaron Beck, the founder of CBT, developed his theory when researching depressive illness.

This is the ‘Classic Model’ of CBT. The model shows that causes of depression come from different influences in a persons’ life. It shows how depression often develops from childhood experiences and is eventually recognized by symptoms in the adult’s later life.

Explanation of the Model:

The first box shows that there may be ‘early childhood experiences’ that affected a person. People as early as childhood can develop ‘core beliefs’. A ‘core belief’ is when a person perceives themselves in a certain way. That is, they believe certain things about themselves. For example a person may think “because my mother left us, I must be unlovable”. Or “I am worthless”. Usually ‘core beliefs’ are the ‘I’ statements we make about ourselves. [NOTE: Core beliefs commonly develop from childhood, but can develop from any other life event later in life.]

The second box shows how these experiences develop ‘dysfunctional assumptions’. This means for example if a person grows up with a bullying father, they may develop thinking patterns like “I must keep quiet, or I will make my father angry” or, “the only way to survive is to fight back”. From such experiences and changes in thinking, people then develop ‘dysfunctional assumptions’. Assumptions are like rules or standards. People make up rules to survive. In the case of the previous example, the client may develop the rule “If I keep quiet, then I won’t get hurt.” . These rules are usually expressed with a ‘if…..then…’sentence structure.

The third box shows that, as happens in most people’s lives there, are other ‘critical incidents’ that influence us. These are usually important or decisive events which influence us. For example, a marriage break down, the death of a loved one, the tsunami, or a bombing.

The fourth box shows how depression develops when the earlier dysfunctional assumptions and core beliefs then become activated by these events. That means, when what we learnt negatively about earlier events, we then use to make sense of other present events. ‘Assumptions are activated.’ For example, if a lady used to compare herself negatively to her sister in childhood, or was always compared to her sister and made to feel bad, she may develop core beliefs like ‘I am not as good as my sister’ or ‘I am inferior’. This means vulnerability is established here that she grows up feeling inferior and second best. If in her later life her marriage breaks down, because of these earlier experiences, she may then blame herself for the marriage breakdown because she believes she wasn’t a good enough wife – inferior. So, the previous assumptions about being inferior repeat themselves and become activated again in a new situation.

The fifth box shows Negative Automatic Thoughts. ‘Automatic thoughts’ are the everyday thoughts we have in the present. They are the thoughts going through our mind. They are the things we say to ourselves. For example, if I go into a room and see a nice plant I may say to myself ‘that is a beautiful plant.’ ‘Negative Automatic thoughts’ are thoughts that go through our mind because of the way we interpret events negatively or feel negatively about them. For example, if I arranged to meet someone at a shop and they are late, I may feel worried or impatient and my negative automatic thoughts might be ‘maybe she had an accident’ or ‘maybe she missed a bus’ or ‘she’s always late’. Negative Automatic thoughts are the thoughts we have about the present, but they have a link with our deeper assumptions and core beliefs. People have described them as the thoughts we have at the ‘tip of the iceberg’, but which are connected to the deeper assumptions and core beliefs ‘under the water.

A Critical incident may therefore activate old assumptions, create new ones and develop all kinds of negative automatic thoughts.

Finally, the sixth box show how depression is then maintained by these thoughts and experiences. It becomes an illness when it goes on to develop symptoms. The ‘Symptoms’ are signs or warning signs that a person has got stuck and that their life is changing negatively and that this is beginning to affect their behaviour, their level of motivation, the way they feel (moods) and their thinking and their physical reactions.

Cognitive Model of Depression

The Cognitive Model of Depression

Early Experience: Develop Core Beliefs

Vulnerability Stage
Dysfunctional Assumptions: (based on core beliefs)

Critical Incident

Activating Stage

Assumptions activated

Beliefs Develop

Negative Automatic Thoughts:

Symptoms:

Behavioural: Eg, Lowered activity levels, social withdrawal.

Motivational: Eg, loss of interest and pleasure, everything is an effort, procrastination.

Affective: (Moods) Eg, Sadness, anxiety, guilt, shame.

Cognitive: Eg, poor concentration, indecisiveness, ruminations, self-criticism, suicidal thoughts.

Somatic: (Physical Reactions) Eg, loss of sleep, loss of appetite.