10) Cognitive Therapy: Techniques and applications

Question 1

What does CT look like across sessions? Describe what happens at each stage (4; 4; 3)

Answer 1

Early stages
* First 1-3 sessions
* Cognitive assessment: identify thoughts, beliefs, assumptions and how it leads to development and maintenance of behaviours
* Techniques: psychoeducation
* Develop a collaborative relationship

Middle stages
* Bulk of sessions (e.g., 50-70%)
* Intervention: effecting change
* Cognitive restructing of ATs, assumptions, sometimes core belief
* Techniques: Socratic dialogue + variety of other techniques

Late stages
* Consolidating change and relapse prevention
* Cognitive restructuring: tell clients how core beliefs can maintain and increase relapse
* Establish supports/early intervention

Question 2

What is the structure of a typical CT session? (6)

Answer 2

• Check in: sometimes something happens during the week etc.
  o Quick
• Agenda setting
  o Quick
• Review/Discussion of learning tasks (HW)
  o Extended
• Cognitive restructuring
  o Extended
• Setting new learning tasks (HW)
  o Intermediate
• Closure
  o Quick

Question 3

What are the 3 key components in cognitive restructuring? (3)

Answer 3

• Identifying automatic thoughts and their effects
• Identifying and facilitating change of thinking biases
• Identifying and facilitating change of assumptions & core beliefs

Question 4

List some methods of identifying automatic thoughts and thinking biases:
* Within session (5)
* Outside of session (2)
* More generally (2)

Answer 4

Within session
* Listening skills - clients offer rich information during their descriptions (e.g., during CBA)
* Recall of HOT (high affect) thoughts a/w frustrating, depressing, anxiety-generating events o Imagery of problem situations e.g., imaginal desensitisation
* Role play interpersonal situations that provoke negative affect (challenging social situation in SAD, discussion of binge in BN)
* Self-monitoring diaries (thought records)
* Provoke experiences e.g., ask client to touch the carpet (scared of contamination)
 Automatic thoughts can flood through

Outside of sessions
* Behavioural experiments
* Self-monitoring diaries (thought records)
 Especially important for depression – slowed down psychic activity so often not a lot of thoughts during sessions. Thought records for homework can elicit more thoughts to discuss at the next session

More generally
* Use of metaphors and analogies
* Visual methods – pictures
 E.g., doing therapy: minefield vs. sailing

Question 5

How do we go about appraising automatic thoughts? (8)

Answer 5

• Be clear about the objective
  o Assessment vs. education vs. intervention – enhancing alliance vs intervention – reappraisal
• Assessment: identify and label
• Education
  o Link ATs to negative feelings
  o Explore thinking biases/beliefs that may underlie these self-statements
  o Identify subsequent coping and consequences
• Enhancing alliance
  o Acknowledge distress, other listening skills
  o Explore impact, validate, stay with experience

Question 6

How do we go about re-appraising ATs and thinking biases? (3)

Answer 6

• use thought records
• explore motivation to change these
• Facilitate change through one or more strategies of cognitive restructuring including the identification of alternative (functional) thinking patterns

Question 7

List some strategies for identifying conditional assumptions and core beliefs. (3)

Answer 7

• Downward arrow technique
• Identify common themes associated with client distress or intense affects
  o problem situations
  o painful memories
• Identify biases in thinking/unhelpful attributional styles often reflect/couch schemas

Question 8

Identify and describe the 4 stages within cognitive restructuring (4; 3; 3; 3)

Answer 8

1) Prep
* Understanding client’s belief structures
* Overcoming resistance: validation responses
* Highlighting need for change (a la motivational interviewing)
* Identifying NATs, thinking biases, beliefs

2) Prep
* Select beliefs amenable to change (manuals may help)
* Building a case for change (e.g., gathering evidence that supports a reappraisal)
* Select one or more CT techniques worth trialling

3) Effect change
* Socratic questions directed at the specific assumption/belief targeted for change
* Allow time for emotional processing
* Review effects, If necessary, change approach/technique/method

4) Consolidate change
* If effective, use techniques to consolidate change
* Use multiple approaches and methods that converge on same belief
* Tailor technique to what is most effective for client

Question 9

Identify Padesky’s 4 components of Socratic Dialogue

Answer 9

• Ask informational questions
• Listening
• Summarising (regularly)
• Ask synthesising and analytical questions

Question 10

Outline how Padesky’s 4-component Socratic Dialogue can be mapped onto a cognitive restructuring template

Answer 10

• SD Informational questions (Stage 1 & 2 of CR - prep)
• SD Empathic Listening (Stage 1 and 2 of CR - prep)
• SD Summarising responses (Stage 1 and 2 of CR - prep)
• SD Synthesising questions: (Stage 3 of CR - effecting change)

Further steps (Stage 4 of CR - consolidate change)
* Series of Socratic questions that converge on a specific belief
* Focus on review, re-appraise and re-write beliefs

Question 11

Identify some methods to reappraise/change assumptions and core belief. (5)

Answer 11

• Socratic dialogue in therapy situation
• Role-play and post-reflection/discussion
  o E.g., dating - Self and significant other
  o Different aspects of oneself (child-adult; emotion- reason)
• Imagery, analysis, and discussion
• Behavioural experiments
• Learning/discovery tasks (HW) directed at cognitive restructuring

Question 12

List some CT techniques from Leahy. (10)

Answer 12

• Eliciting thoughts
• evaluating and testing thoughts
• evaluating assumptions and rules
• examining information-processing and logical errors
• modifying decision making
• responding to and evaluating intrusive thoughts
• modifying worry and rumination
• putting things in perspective
• identifying and modifying schemas
• emtoional regulation techniques

Question 13

What are some CT techniques? (7)

Answer 13

• Reviewing and testing the evidence
• Cost-benefit or Pros-Cons analyses
• Thought records
  o Identifying NATs, biases, assumptions, beliefs
  o Alternative explanations
  o Developing new perspectives
  o Re-scripting beliefs
• Downward arrow (vertical descent)
• Reviewing and testing probability estimations
• Step-wise approach to “unmanageable” problems - breaking it down
• Behavioural experiments

Question 14

Why would you use downward arrow technique in…
Assessment?
Therapy?

Answer 14

• Assessment: To identify the hierarchical structure of beliefs, thoughts, intermediate beliefs, core beliefs
• Therapy: To make client aware of a belief that underpins distress maintains NAT

Question 15

What are some potential responses to use when utilising the downward arrow technique? (5)

Answer 15

• What if that were true/the case?
• If that were true what would that mean?
• If that were the case, why should it bother you?
• And,…what would be so bad about that?
• If that were the case, what would it say about you/others/your past/your future?

Question 16

What do you need to take into consideration when utilising the downward arrow technique? (4)

Answer 16

• When you get close to the core beliefs, make sure you don’t sound disparaging
   Validation response
   Apologise for asking upsetting questions
   …prefix…Just so I understand you better,…
• Bail out of downward arrow in time
   When you arrive at the core belief
   When you arrive at the belief you want re-appraised.

Question 17

Outline and describe the 4 categories of CT competence (3; 2; 4; 3)

Answer 17

Attitudes (novice) - listed expert to novice
* Towards learning and discovery
 Collaborative empiricism
* Patience with self and client
 Change does not happen overnight

Knowledge (expert) - listed expert to novice
* CT principles – theory and procedures
* Repertoire of techniques and methods
* Conceptualise client’s response (including ambivalence, distrust) in CT terms

Technical skills (4) - listed expert to novice
* Promote active, collaborative engagement and empiricism
* SOCRATIC DIALOGUE
* Other CT skills
* Integrations skills (including timing and fluency)

Relational skills (3) - listed expert to novice
* Empathy skills
* Be sensitive to and pick out client ambivalence/resistance
* Relationship awareness of what works for client (tailoring techniques and methods to client)

Question 18

Define schemas

Answer 18

deeply ingrained habitual patterns of thinking and responding. They are often equated with core beliefs.

Question 19

What do depression schemas reflect (4)

Answer 19

failure, loss, rejection, depletion

Question 20

What do anxiety schemas reflect? (2)

Answer 20

threat, injury

Question 21

What do anger schemas reflect (2)

Answer 21

humiliation, domination

Question 22

What do personality disorder schemas reflect?

Answer 22

schemas are typical of each PD

Question 23

How can we test predictions of core beliefs?

Answer 23

behavioural experiments

Question 24

list methods to reappraise core beliefs (6)

Answer 24

• schema work (in schema therapy)
• behavioural experiments
• reviewing and rescripting exercises (e.g., in thought records)
• developing caveats/continuum charts
• historical tests of core beliefs
• researching and recording evidence that supports alternative belief structure

Question 25

what are some Qs to ask to help find evidence that does not support a hot thought?

Answer 25

• have I had any experience that show that this thought is not completely true all the time?
• If my best friend or someone I loved had this thought, what would I tell them?
• If my best friend or someone who loves me knew I was thinking this thought, what would they say to me? What evidence would they point out to me that would suggest that my thoughts were not 100% true?
• When I am not feeling this way, do I think about this type of situation any differently? How?
• When I have felt this way in the past, what did I think about that helped me feel better?
• Have I been in this situation before? What happened? is there anything different between this situation and previous ones? What have I learnt from prior experiences that could help me now? Are there any small things that contradict my thoughts that I might be discounting as not important?
• Five years from now, if I look back at this situation, will I look at it any differently? Will I focus on any different part of my experience?
• Are there any strengths or positives in me or the situation that I am ignoring?
• Am I jumping to any conclusions that are not completely justified by the evidence?
• Am I blaming myself for something over which I do no have complete control?

Question 26

List some questions that can facilitate reappraisal of unhelpful assumptions

Answer 26

• Is the assumption reasonable/fair/balanced?
  o what is the evidence?
  o in what way does it fail to reflect the reality of human experience?
  o would this be an assumption that the client would like to impart to others/one’s children?
• In what way is the assumption unhelpful?
  o advantages and disadvantages of maintaining these beliefs/assumptions?
  o cost in terms of goals, personal distress, thriving?
• Is your appraisal of these events balanced/fair/reasonable?
• Are you thinking in all or nothing terms?
• Are you being too hard/critical on/of yourself?
• Making unfair conclusions on the basis of a single event? [overgeneralising]
• Might you be amplifying your weaknesses and disregarding your strengths?
• Are you taking things personally/taking more than your fair share of responsibility for the event?
• Are you applying rigid/perfectionistic/unrealistic standards in judging yourself?
• Might you be using a double standard – one for yourself and another for others?
• Are you over-estimating the chances of a negative event/disaster?
• Are you exaggerating the importance of negative events?
• Are you assuming that nothing will/you can do nothing to change this situation?
• Are you predicting the future instead of working/coping with/trying to change the present?