Midterm 2 (Final) Flashcards

Question

Describe the "includes “Action Plans” (therapy homework)" basic principle of CBT

Answer 1

- Historically we would call this homework but people often don't have great memories associated with the term homework -> action plan is the new term - Action plan: what we're going to do in between sessions - 50 mins/week isn't enough for a patient to make sustained change - You have to be doing these things and practicing these skills in between sessions - You have all these other hours of the week where you could be continuing the same patterns - Important to build new patterns/habits - Anything we want the client to remember should be recorded - Should be written down so that the client remembers what they're supposed to do and the types of processes they're supposed to go through

Answer 2

* Not just cognitive strategies are used * There are other strategies incorporated into CBT that are more of the behavioural or mindfulness * These got borrowed from other treatments but have been shown to be really helpful * The therapist can pull techniques from other treatment approaches -> very common way for therapists to practice

Answer 3

- Student with depression in the UK - Trying to deconstruct the problems that she's having with the CBT model - Therapist focused in on a particular situation, rather than taking all of the times that the client doesn't go to lecture, so that Lucy can remember what that experience was like - Going through the thoughts (cognitions), which are typically, especially with someone with depression, "I" statements that are negative and reflect badly on the person - The therapist had to differentiate for the client the difference between thoughts and emotions (common) -> emotions are typically one word and are often reflected on the face - The therapist asks about physiology - The therapist added what happens afterwards (behaviour)? How do you feel afterwards? - This is to motivate people to see that what they've been doing (behaviour) hasn't been helping, it's not making them feel better - This was the first session: they went through information gathering and now the therapist is able to introduce the client to this cognitive model, write it down and then give it to the client to take home to think about more and build on this in future sessions

Answer 4

- Assessing current problem - Identify triggers and modifying factors - Consequences - Maintaining processes - Past history and problem development

Answer 5

* When conducting an assessment in CBT the main thing we're interested in is the current problem * A common start to the 1st session is "what brought you to therapy right now?" * A lot of people have been struggling with their mental health for a long time but we're interested in what brought the person through the door right now * Want to get a good picture of what's happening right now to understand how to intervene * Involves structured questions to obtain detailed information * Ask a lot about the current problems * Ask clients to detail a recent occasion when the problem occurred and problem symptoms were experienced * Trying to get all the little details and types of things that you would then put into the cognitive conceptualization (ex: what happened before, in the middle, after (antecedents, behaviours, consequences)) * Break presenting problems into 4 internal systems (cognitions, emotions, behaviour, physiology) and the environment * Breaking the problem into the pieces that are part of the cognitive model (either the situation, the automatic thoughts, the emotions, the behaviours, the physiology) * What was happening in the environment? What's the larger context for when this problem occurs? * When we want to figure out how to help the person right now and what they're going through right now, then this is going to be the more relevant source of info (how is this problem being maintained?) * We want to break that ongoing cycle

Answer 6

- Identify antecedent factors (triggers and modifying factors) - Triggers: what factors make the problem more or less likely to occur - Ex: things in the environment, internal things (thoughts or emotions) that prompt the behaviour - Modifiers: contextual factors that impact how severe the problem is when it occurs - Ex: for someone who has problems with alcohol: - A trigger might be walking past a bar which makes the problem more likely to occur - A modifier might be whether or not they're with other people (ex: someone with a problem with alcohol may be less likely to enter the bar if they're with other people who know they have a problem and need to cut down on their drinking, but if they're by themselves they may be more likely to go in and drink more)

Answer 7

- What has happened/is happening as a result of current problems? - What happens immediately after the current problem? - When the problem does occur, what are the consequences in terms of emotions, behaviour, physiology, relationships, interactions with other people - Interested in consequences because these are what give us a clue about the maintaining processes (the function) - All of our behaviours despite how maladaptive they might be serve a function and we want to figure out what that function is to see if we can get it served in another way

Answer 8

- It's the maintenance processes that we're trying to break in therapy - Even though we care about what's happened earlier in life, that's not necessarily relevant to why the client is struggling still or right now - The vicious cycles that keep the problem going - Different disorders have different common maintaining processes, but assessment must be individualized to client - Ex: escape/avoidance, reduction in activity, short-term reward

Answer 9

- Escape and avoidance: common with anxiety disorders, people don't like to feel the physiological sensation of anxiety and are trying to escape or avoid it from happening in the first place, this only reinforces that anxiety is something that needs to be avoided and needs to not be experienced rather than seeing it as a normal experience that everyone has from time to time - Reduction in activity: relevant for depression, the more someone withdraws from their environment, the less that they have the opportunity to experience pleasurable events and emotions which reinforces the depression and then the more they want to continue to withdraw - Short-term reward: seen in more addictive disorders (ex: substance-use and binge eating) where taking the substance or the food or gambling is pleasurable (there's a dopamine and opioid release in the brain when people are engaging in the experience) but in the long term it's maladaptive and people are seeking that short-term reward without considering the longer term consequences

Answer 10

- We care about past history to some extent and how the problem initially developed - Consider vulnerability factors, precipitants, and modifiers

Answer 11

- Things that set the stage for a problem to develop, but are neither necessary nor sufficient - In the diathesis-stress model, these would be the diatheses - The things that put someone at risk for developing a mental health problem - Ex: family history of a mental health problem or particular personality or coping style - Diathesis-stress model -> in the absence of any major stressful event, it may be that the diathesis never gets expressed, it's sort of latent - Why mental health problems run in families but aren't necessarily present in every generation -> they can skip a generation

Answer 12

- Things that come more directly before the problem is expressed - Events or situations that provoke the onset of symptoms - Ex: stressors or major life events, which don't have to be traumatic events (can be normal life events, like starting a new university or moving to a new town, which are generally seen as positive or have the potential to be positive but are stressful nonetheless) - These can activate some of the diatheses - Ex: the breakup of a relationship in someone who has had negative views about themselves, which really activates those views and brings them to the forefront and leads to depression - Likely that these event(s) activate a pre-existing vulnerability belief - These vulnerability beliefs may have come from early life experiences around family, friendships, or romantic relationships and then they get activated or reactivated in the case of people who might have multiple episodes of depression

Answer 13

* These could be changes to life circumstances that affect the severity of the problem * For someone who's generally an anxious person and has had a longstanding history with anxiety, you're interested in why they're coming to therapy now, what brought them in now? * It's possible that there's something that could've been present that's contributing to their anxiety symptoms and is the result for initially presenting to therapy or returning to therapy (for people who have done it before, why are they coming back? What just happened to increase the severity of their problems?)

Answer 14

With the assessment, we're trying to put the info into our cognitive model or cognitive conceptualization

Answer 15

- Situation/event (ex: bad grade on test) -> automatic thought (ex: all my studying was useless!) -> reaction (emotional, behavioural, physiological) (ex: feel sad and hopeless, not motivated to study next time, don't study next time and confirm this thought)

Answer 16

With CBT, we always start at the level of the automatic thoughts because these are the things that are the most accessible to the person and easiest to change as they're specific to a situation as opposed to being more global

Answer 17

* Using the simple thought record * Has columns for situation (who, what, when, where?), feelings (what did you feel? Rate your emotion 0-100%), thoughts (what was going through your mind as you started to feel this way? Thoughts or images) * The columns for feelings and thoughts are switched * Although the order or the way we think this happens is that there's a situation which leads to interpretation of the situation which leads to a reaction (technically the thought should be in the middle), people have an easier time, in terms of noticing when they have an emotional change or a change in their body * We tell people that once they experience that change, they have to tap into what they were thinking (what was going through your mind as you started to feel this way?) * Helping people to get to the thoughts * Easier to do if they pay attention to their feelings (emotional or physical or behavioural) * This type of simple thought record is the basis of cognitive restructuring but we do use it in the course of an assessment in those early sessions

Answer 18

- To get people familiar with the process of completing these types of records outside of sessions - To get more data to inform our case conceptualization (we may have initial ideas about people's automatic thoughts and basic beliefs) but this allows us to have more confidence in what we think are those core beliefs

Answer 19

- Enduring cognitive phenomena that are deeply rooted - Develop early-on based on our early life experiences - Hard to access especially early-on in therapy - Idea that people focus selectively on information that confirms core beliefs, and disregard information that doesn’t - This doesn't always happen - Everyone has core beliefs, not everyone has negative core beliefs but many do - They may not be activated or come up unless there's situations that activate them or unless someone's in the midst of a mental health problem Ex: if they're in a current depressive episode or they're in a place where they have increased anxiety -> going to be more likely to go through this process where in terms of what they view in the world, they're selectively attending to those events that confirm the view of themselves and disregarding the other info - In CBT, we pay attention to everything and not just the things that confirm our negative views of ourselves - Global (can apply to lots of different situations), rigid (hard to change), overgeneralized

Answer 20

- 3 categories: attitudes, rules, and assumptions - Attitudes: general beliefs about outcomes - They apply generally to the world or to people, not really "I" statements - Believed to be true for everyone and true in all situations - Rules: often involves a "should" statement - Something that you're applying to yourself that you think you should do - Assumptions: often involves an "if…then…" statement - Assumption about the workings of the world and what's going to happen - Intermediate beliefs fall in between core beliefs and automatic thoughts - The rule, attitude, assumption distinction isn't all that important and it's kind of confusing to clients - Main thing is that the assumption is the easiest to work with because it has this "if…then…" statement which is an implied causality or that this is always going to be the case - These things are easier to work with than the rules and the attitudes - Often what happens is that if people are providing these types of beliefs as rules or attitudes, you're kind of reworking them as assumptions to be able to work on that together

Answer 21

Core beliefs (ex: I'm incompetent -> this is global and not specific to a situation, very general. If you believe that you're incompetent, this is going to be a hard thing to easily change) -> intermediate beliefs (ex: attitude -> it's terrible to fail, rule -> I should give up if something is too hard, assumption -> if I try something difficult, I'll fail) -> automatic thoughts (applying general beliefs about failure to specific situations) (ex: all of my studying was useless!)

Answer 22

- Incompetent: - Generally achievement related - Ex: work, school, hobbies, etc. - More internal (ex: "I'm stupid", "I can’t do anything right", "I don't measure up", "I'm a failure") - Unlovable: - Related to interpersonal and connection with other people - Ex: "I'm unlovable", "I'm different", "I'm bound to be abandoned/rejected", "I'm defective; others will not love me" - Worthless: - Especially seen in people with suicidal ideation - Worthlessness is important to assess in terms of considering suicidal ideation - Ex: "I'm worthless", "I'm bad", "I'm evil", "I'm a waste", "I don't deserve anything good" - More of a severe belief - Initially it was thought that incompetent and unlovable were the 2 main core belief categories, but then as people worked more with clients with depression, there was a 3rd category added (worthless) - It's possible to have all of these or to feel both incompetent and unlovable - Some clients might present more with one than the other or one might be more relevant to the current situation and the current problem

Answer 23

* Intermediate beliefs are going to follow the core beliefs * Helpless (associated with incompetence): * Rule: I should never ask others for help * Attitude: it doesn't matter if I ask for help or my friend asks for help, anyone who asks for help is considered weak * Assumption: if I ask for help, others will think I'm weak or if I ask for help, people will think I can’t do it * Unlovable: * Rule: I should leave people before they leave me * Attitude: a break-up is crushing for anyone * Assumption: if I get close to someone, they will hurt me, leave me, or reject me * Worthless: * Rule: I should accept my fate * Attitude: people get what they deserve in life and if your belief is that you're worthless then the idea is that you don't deserve to get any good things * Assumption: if I get better, something bad will happen to me again (what's the point?)

Answer 24

- Often the best way to identify these is to have people fill out thought records or to get them to talk about situations in their everyday life and look at the pattern of their automatic thoughts and see what that pattern is - Does it have more to do with incompetence, does it have more to do with the relationships, does it have more to do with this worthless belief - What's the pattern there? -> that's really the clue - Downward Arrow Technique

Answer 25

* Ask client about meaning of key automatic thoughts that you suspect stem from core beliefs * If the thought is true... * What does that mean? * What is the worst part about the situation? * What is so bad about that? * What does that mean about you? (tied to core belief) * Ex: "all my studying was useless" -> what's the meaning of that?

Answer 26

* Considered to be the road map to therapy * We develop a treatment plan based on our conceptualization * We have general conceptualizations for different disorders and based on the model that you're working from * The conceptualization has to be individualized and personalized based on the info you're getting in the assessment * Based on this conceptualization, you're developing a treatment plan to target those maintaining factors * In the context of a CBT intervention, those maintaining factors are often going to be those negative automatic thoughts * Series of hypotheses about client that are refined based on incoming data * This is developed in the first few sessions but it's not done and isn't taken as fact and it can change as more info comes in * You could be wrong in the initial sessions or there could be stuff that the client is keeping to themselves that when it gets revealed, you have more info for your conceptualization * Once you're done with the assessment phase, there's often some form of feedback, where you're sitting down with your client and you're talking to them about doing sessions where you're gathering info and you might share a diagnosis (depending on how much info you have and if you feel confident to do this) and you're presenting the conceptualization * You want to see from the client's perspective -> does it align with their understanding of themselves * In CBT, we say that the client is the expert of themselves and they're teaching you about themselves and you're sharing your knowledge about therapy and the therapy process and techniques but you're working together on this * Will present conceptualization to client to see if it “rings true” for them and if they have any feedback, to alter it in some way * Often, especially in training clinics, you're going to write a report after those first few sessions, that talks about diagnosis and past history and conceptualization * You're not giving the client this report but you're presenting the conceptualization often using diagrams * Diagrams are good at showing those maintenance processes because there's a lot of arrows going back into one another * Modify conceptualization based on client feedback

Answer 27

- How did patient develop this disorder? What were the vulnerability factors? - What were significant life events, experiences? What were the stressors/precipitants? - What are patient’s basic beliefs about themselves, the world, and others? (Beck's cognitive triad, he believed people with depression had problems with all 3 of these types of beliefs) - What are patients’ attitudes, rules, and assumptions? (intermediate beliefs) - What strategies has patient used to cope with beliefs? What are their (often) maladaptive coping skills that are maybe some of the problems that they brought to therapy? - What automatic thoughts, images, and behaviors maintain disorder? (what you're working on in CBT intervention) - How did beliefs interact with life events to make patient vulnerable to disorder? - What is happening in patient’s life right now that's contributing to the disorder and what are patient’s perceptions of this? (one of the most important)

Answer 28

- They come in verbal form (most common), visual form (ex: imagining the worst case scenario or imagining a picture of something that may happen), or both - Often embedded within a broader statement or phrased as a question because the person doesn't necessarily want to admit that they're thinking this or that they believe this and so they phrase it as a question – have to work to identify thought and re-phrase as simple statement - A simple statement, often involving "i" - It's on the part of the therapist to search through what the client is saying and pull out the most important info and potentially ask the client if what they found is consistent with what the client is thinking - Basic question that we want clients to ask themselves: “What was going through my mind just then?” - Ask when: - Notice a change in emotion - Notice a change in mind/body (physiological change) - Feel the urge to engage in a dysfunctional way

Answer 29

- We work with these different types of automatic thoughts slightly differently - Thought is distorted: occurring despite objective evidence to the contrary - Not a lot of evidence to support it - Ex: “I am going to fail this exam” despite being an A student - Thought is accurate, but conclusion is distorted - "Because of this then this is going to happen" -> that last part is distorted - Ex: “I didn’t meet the deadline; thus, I am a horrible student” - May be true that the student didn't meet a deadline but the conclusion about being a horrible student for missing, let's say, one deadline for the first time ever is not accurate (that part is distorted) - Thought is accurate, but not helpful - It's not helping you to achieve the goals that you want - Ex: “It is going to take me hours to finish this assignment. I will be up all night!” - If you left an assignment to the last minute, then it may take you hours to finish it and you may stay up much later than you were hoping but thinking in that way isn't going to help you achieve your goal of finishing the assignment - In those cases, it's about thinking in a different way or letting go of the thought

Answer 30

- This is going to differ depending on the different types of automatic thoughts - Reviewing evidence for and against the thought - Worst case, best case, most realistic case - Advantages and disadvantages of having the thought? - Distancing self from thought - Problem-solving - Assess outcome of automatic thought evaluation process

Answer 31

- What evidence supports the thought? What evidence does not support the thought? What is a more balanced way of looking at things? - Most common way that we generally start with - Most people who have depression are thinking in a very negative way and are viewing the world through this lens of depression - A lot of their thoughts are going to be distorted and this is a process that will work for a lot of those types of thoughts What evidence supports the thought? - Always start with this to recognize that there may be some valid evidence that the person thinks a certain way (there's a reason they're thinking this way) - You want to validate that and see what it is that they believe supports this negative thought - You ask them to give as much evidence as they can provide What evidence doesn't support this thought? - We try and have this evidence be as objective as possible - Once you have the evidence for and the evidence against the thought, you can then look at the 2 columns and see where things stand, what's a more balanced way of thinking about this? - You don't want to totally dismiss the evidence that the client thinks supports the thought -> this is valid and part of their experience - What you're looking at is a more balanced way so it's not this completely negative or completely black and white situation

Answer 32

- What is the worst that could happen? If that happened, how would I cope? - These are situations in particular with people who have GAD who tend to catastrophize and worry a lot about the future - This tends to be a good approach for that - What's the worst thing that could happen in this situation? How would I cope -> a lot of people, even if there's a very small % chance that the worst case scenario would happen, that's still something they worry about

Answer 33

- This is helpful for those thoughts that are accurate - Thought may be true, but not helpful - We can't talk about evidence for and against if our impression is that the thought is accurate - What are the effects of believing vs not believing your thought? How do you behave in response to the thought? - Ex: if you're overwhelmed with all of the work you have to do for your assignment, it's likely going to be too much and you might engage in escape behaviour and that's not going to help you achieve your goal - Coming up with a different way of thinking about it to help you actually move forward

Answer 34

- What would you tell a friend or family member in this situation? - Another strategy for types of thoughts that are accurate but not helpful - This is helpful too for thoughts that are distorted because we tend to generally be kinder to other people in our lives than we are with ourselves - It's easier for us to be more compassionate and more balanced in our way of approaching our thoughts when we project them onto other people

Answer 35

- What can you do in this situation? What could you do differently next time? - Good for thoughts like "I didn't prepare enough for my exam" or "I didn't start my assignment in time" - There's no getting away from the situation you're in right now so what can you do differently next time

Answer 36

- After you go through this process of evaluating automatic thoughts, it's important to assess the outcome of automatic thought evaluation process - To what degree does the person believe their initial automatic thought after it has been evaluated and looked at in a microscope - We often get people to give a rating and look for change in their emotional state or their urge to act in a dysfunctional way or whatever it was that led them to identify the automatic thought in the first place - How does that change after the process of evaluation?

Answer 37

- Situation (describe what was happening who, what, when, where - antecedent, context) - Emotion or Feeling (emotions can be described with one word, ex: angry, sad, scared, rate 0-100% - the thing that we notice changes) -> want to see what are the most prominent emotions in response to this situation - Negative automatic thought (identify one thought to work on: what thoughts were going through your mind? What memories or images were in my mind?) - Evidence that supports the thought (what facts support the truthfulness of this thought or image) - Evidence that doesn't support the thought (what experiences indicate that this thought is not always completely true? Looking for small ways in which the thought might be distorted or unhelpful. If my best friend had this thought, what would I tell them? Are there any small experiences which contradict this thought?) - Alternative thought (write a new thought which takes into account the evidence for and against the original thought) - Emotion or feeling (how do you feel about the situation now? Rate 0 - 100%) -> after going through this process, re-rate those same emotions to see if you have had any improvements

Answer 38

* Shows the catastrophizing process that characterizes anxiety * Therapist engaging in modifying automatic thoughts * Client with anxiety and panic attacks and has a fear of driving * Client brought in a log of some of the thoughts that she had before and during the event (driving) * The therapist first asks the client to explain what happened and also asks about when these thoughts in her log occurred * The therapist asks what were the anxiety ratings associated with particular thoughts * The therapist asks the client which one of the thoughts she would prefer to start working with * The therapist analyzes the accuracy/probability of the client's thoughts with her * Ex: what do you think was the likelihood that the event in this thought you were having would actually occur? * He illustrates the math surrounding the event and the likelihood of it actually occurring * Ex: client thinks odds of it happening are 90% but therapist does the math and it has happened 0% of the time * Therapist then asks client to reassess the likelihood of event actually happening * Client went from 90% probability to 5% * Therapist explains to client the overestimation of risk that occurs in people with anxiety and how the point is not to think there's no risk for anything but to think more realistically about it which can help manage the anxiety * Therapist also explains to client how having experienced panic attacks may be influencing the way she sees things

Answer 39

- All-or-nothing thinking (aka black and white thinking) - Ex: if I'm not perfect I have failed - Mental filter: only paying attention to certain types of evidence - Ex: noticing our failures but not noticing our successes - Jumping to conclusions (mind reading and fortune telling) - Emotional reasoning: assuming that because we feel a certain way what we think must be true - Ex: I feel embarrassed so I must be an idiot - Labelling: assigning labels to ourselves or other people - Ex: I'm a loser or they're such an idiot - Over-generalizing: seeing a pattern based upon a single event, or being overly broad in the conclusions we draw - Disqualifying the positive: discounting the good things that have happened or that you have done for some reason or another - Ex: "that doesn't count" - Magnification (catastrophizing) and minimization: blowing things out of proportion (catastrophizing), or inappropriately shrinking something to make it seem less important - Should and must thinking: using critical words like "should", "must", or "ought" can make us feel guilty, or like we have already failed - If we apply "shoulds" to other people the result is often frustration - Personalization: blaming yourself or taking responsibility for something that wasn't completely your fault or conversely blaming others for something that was your fault

Answer 40

* Unhelpful thinking styles that we all have to some extent * Some of them overlap with each other * In CBT, we think there's something going array or we think there's things that we can change regarding people's thinking * Automatic thoughts are specific to a particular situation * Cognitive distortions are patterns in our automatic thoughts * Ways in which we generally think that create these automatic thoughts * With a selection of automatic thoughts, we can likely understand cognitive distortions and then work on those and hope they'll generalize to all of the different situations

Answer 41

- Only seeing the extremes - It's either this way or this way and there's nothing in the middle - We hope to get people to be able to see the things in the middle - Identify the relevant extremes - Ex: what would be the worst case scenario and what would be the best case scenario - Explore the stages or steps between the extremes - Being explicit and pointing out to people that there are multiple things between those extremes and multiple places you could fall or you could aim to be between the black and the white area - Working with people and asking "where are you now?" "where do you want to be?"

Answer 42

- When scanning your environment, you're only perceiving evidence that fits with the way that you think about yourself - Ex: if someone's in a current depressive episode, they're only seeing the things that suggest that there's something wrong with them or that they're defective or incompetent - Pay attention to all instances of an event and note both good and bad - We try to be more like a scientist in this situation and actually pay attention to either every instance (if low frequency event) or a random sample of every 4th instance of something to have a more representative sample of information and not just be filtering in on the negatives

Answer 43

- 2 key types: - Mind reading: imagining we know what others are thinking - Fortune telling: predicting the future

Answer 44

* Developed in the 1950s by Joseph Wolpe * He developed systematic desensitization after being dissatisfied with existing treatments for PTSD, which were mostly psychoanalytic treatments * 1st form of exposure therapy was systematic desensitization * He found that when he would pair things that were distressing to people (particularly people from the military), with food, he noticed that the fear response was extinguished * This was based on the principal of reciprocal inhibition * Reciprocal inhibition: the experience of fear is incompatible with the experience of pleasure or relaxation so if you pair a fear stimulus with something else, it will bring the fear down * Eventually it became that he would pair exposure with relaxation techniques * He is also famous for developing the Subjective Units of Distress Scale (SUDS) which is something we use all the time when doing exposure therapy to measure people's ratings of their anxiety/distress during an exposure * Easy and quick way of communicating how they're feeling in the moment from a 0-100 rating

Answer 45

The experience of fear is incompatible with the experience of pleasure or relaxation so if you pair a fear stimulus with something else, it will bring the fear down

Answer 46

1. Neutral stimulus evokes fear response due to pairing * Avoidance/safety behaviours (ex: escape and avoidance conditioning) maintain the fear because people don't get to learn that the stimulus is neutral and not harmful 2. Trauma/bad experience * Generalize from one specific instance so that similar stimuli come to evoke fear (stimulus generalization response) * Ex: if you get bit by dog, you come to fear all dogs because there's been this generalization of the response * Benign stimuli associated with the event begin to evoke fear response * Ex: being totally fine with cars and after a car accident, learning to fear cars but also other things related to the accident (ex: the location, the individuals present…) * Stimulus generalization where you generalize few stimuli all associated with the car accident

Answer 47

On conditioning principles about how a fear develops

Answer 48

* Set of therapeutic techniques used to teach clients to approach feared stimuli and we pair this with something * Designed to undo conditioning processes (similar to Little Albert developing the fear and Little Peter deconditioning the fear) * May be paired with relaxation techniques (systematic desensitization) and/or prevention of compulsions or safety behaviours (important for treatment of OCD)

Answer 49

* Allow client to learn that fear response diminishes over time * Allow clients to experience the anxiety towards their feared stimulus and know that it'll dissipate overtime without engaging in any of these additional safety behaviours or compulsions * Help client learn corrective information about the feared stimulus * Ex: the idea that not all dogs are going to bite you (some dogs are friendly) so learning that one bad experience isn't necessarily going to generalize to all versions of the stimulus

Answer 50

Habituation: * Over time, physical sensations (ex: heart racing, sweating, mind racing) associated with fear response or anxiety naturally reduce/diminish overtime * Our bodies can't maintain such a high level of arousal for a long period of time so it does decrease Extinction: * Conditioning idea * Feared stimulus is no longer paired with escape/avoidance behaviour * Stimulus may be paired with relaxation or something else so that new association is learned * Ex: for people with OCD who have this fear-related thought and always engage in a compulsion to correct it, if they stop engaging in that compulsion, they'll no longer be pairing those 2 things in their mind -> they're allowing the anxiety to dissipate on its own which will help extinguish the fear response Learning of corrective info: * Over repeated trials, clients learn that feared outcome does not happen, or is very unlikely * More of a cognitive explanation * Idea that the more you do this the more you learn that the feared outcome will not happen or is unlikely to happen * You experience a change in your cognitive expectations for stimulus and something bad or negative happening Increased self-efficacy: * Even if fear response is not completely extinguished, client learns that they can handle feelings * They learn that it's not going to be too overwhelming for them or going to lead to some very bad outcome (ex: death) * The more we can work up the exposure hierarchy, the more the client feels self-efficacy that continues to motivate the client to do this

Answer 51

- Planned experiential activities undertaken to test validity of patient’s beliefs and construct more adaptive beliefs - Can be done in session or outside of session and is planned ahead of time - The client is interacting with other people rather than just the therapist - Hypothesis testing vs discovery (just gathering info) - Behavioural experiments can be hypothesis testing where we have a particular hypothesis that we're testing - How is this person going to react in this situation? - Ex: the client thinks that they're going to react negatively and that's what we're testing - Active vs observational: behavioural experiments can be active where the client actually has to speak to someone VS observational where the client just has to watch other people interact with one another - This resembles a bit more exposure but has a different purpose than exposure

Answer 52

- When planning behavioural experiments, it's possible that they can be spontaneous - Ex: if you have been talking about particular things in session and the client takes an example from their life and brings it (ex: "I tried to talk to this person and this was the result") and it wasn't planned - Spontaneous can be good - If you are planning the experiments, you want the client to be able to push themselves but you also want to avoid setbacks - Similar to exposure, you don't want to go too far too fast, you want to take steps working your way up - Design experiment so that you learn something either way - Once you're interacting with people outside of the therapy room, you can't predict what's going to happen and it's possible that the experiment will not go the way that you, as a therapist, hope it's going to go - You want the client to be able to learn something either way and you want to save time for processing to be able to go through it if it doesn't work out the way that you were expecting - Prepare for challenges ahead of time -> you want to set the client up for as much success as possible

Answer 53

- Exposure is designed to put people in a situation that'll provoke anxiety and have them learn that the anxiety will decrease - Much more behavioural in nature and focused on conditioning - Behavioural experiments are more about trying to develop more adaptive or realistic beliefs

Answer 54

- Client needs to be fully engaged rather than “go through motions” or else they can come up with excuses (ex: "it’s because I wasn't being my true self" or for a client with social anxiety "it's because I didn't really care/it wasn't really a real thing so I didn't actually get anxious so people didn't notice my signs of anxiety and therefore they didn't reject me") - Post-talk explanations that are going to mean that the experiment wasn't going to be as helpful as it could be - Important for people to monitor their thoughts/feelings throughout -> especially if they're on their own, they're bringing this back to their therapist - Be flexible and respond to the unexpected

Answer 55

- If it's done within the context of a therapy session, you want to save time to debrief -> you would never want to end without talking about it - What actually happened? How did outcome fit with predictions? Did the outcome fit with the predictions or how was it different? - Regardless of what the outcome was, what did client learn? What might you do differently next time based on results?

Answer 56

Making decisions: - If someone is having trouble making decisions - Advantages and disadvantages analysis - Getting them to systematically note the advantages and disadvantages of the different options - Weigh the advantages and disadvantages of both options, and rate importance of each from 1-10 - You want to consider both options and not think that every advantage or disadvantage that you list is of equal importance to you -> some could be much more minor and others could be much more major - You want to rate the weight of all of these things and then this can be reviewed together with your therapist Refocusing: - Evaluating automatic thoughts is not always desirable or feasible - Ex: There are times, let's say you're in the middle of an exam, or you're in the middle of a presentation, where you're not able to take the time to evaluate an automatic thought that might be happening - You can instead label the automatic thought - Recognize what it is (ex: if giving a presentation, this is a thought that I'm having that's consistent with my social anxiety) - Then deliberately refocus attention on task at hand (deliberately let this thought go and refocus on what you're doing) - Related to the thought not being helpful in terms of what you're trying to accomplish in this situation Graded task assignments: - If you feel like you have a big thing to do and it's overwhelming in terms of where to start - Break the goal down into smaller pieces and focus on one step at a time - Success encourages further action Pie technique: - Can be useful for a variety of different situations - Useful for setting goals or determining relative responsibility - Use pie graph - Can be seen in treatment for eating disorders where we're trying to understand how people evaluate themselves as a person Self-comparisons and credit lists: - When you're being tough on yourself, one question to ask is are you comparing yourself to you at your best or your worst? - A lot of times we're comparing ourselves to when we're functioning at our best but if we're in the midst of a mental health problem (ex: a depressive episode or a worsening of anxiety) it's not fair to compare ourselves to our best - Especially if trying to monitor treatment progress, people will say that they're not back to how they were - Important to note how they're doing compared to when they started treatment, have they made improvement? -> what we're trying to look at rather than are they back to where they were when they didn't have these mental health problems? - Give yourself credit when its due (credit lists) - Credit lists: taking time everyday to give yourself credit for the things that you did today - Ex: for someone who's working their way out of a depressive episode, these can be simple things like getting dressed, getting out of bed, taking a shower - Don't have to be major accomplishments - This is to recognize that despite feeling like they didn't do anything all day, people still did things that are important to recognize

Answer 57

Depression

Answer 58

They came out of the behaviour therapy era where behaviour therapy and behaviourism were the dominant modes of thinking

Answer 59

- Idea of these models is that depression is associated with a particular behaviour- environment relationship that evolves over time and maintains depression - These are maintenance models because maintenance models are what are generally driving our treatment models - Focused on “if-then” contingencies – what are the consequences of the behaviour for the person? - Less about the behaviour itself and about what the person is doing/not doing, and more about what are the effects of that? - As with functional behavioural assessment, what are the consequences that are maintaining the behaviours? - Ferster and Lewinsohn

Answer 60

- Ferster was one of the early people who talked about behavioural models of depression - He believed that what's happening is that there's less reinforcement from the environment which then feeds into the depressive symptoms - Decreased rates of response-contingent reinforcement lead to: 1) “Turning inward”: If you're not getting a lot of what you need from you environment then you're going to withdraw from that environment and are going to turn inward towards yourself 2) “Doing nothing”: not engaging in the environment 3) Escape and avoidance: negative reinforcement, things that negatively reinforce the depressive symptoms - We talk a lot about these with anxiety but these are also a component of maintenance in depression

Answer 61

- Social avoidance core to depression - He felt that although avoidance and these processes are happening, what's really core to depression is social avoidance - Social avoidance: idea that people are no longer engaging in their social world and social relationships and therefore aren't getting the reinforcement that most people get from social relationships - Why this pandemic has been so hard for people

Answer 62

- The environment is the setting in which the behaviour occurs and the responses that can come from the environment - Reciprocal association between the person with depression's actions and behaviour and the environment in which that occurs in and the responses from that environment (often responses from other people in the environment)

Answer 63

- Behavioural responses towards environment reduce ability to experience positive reward from environment - Treatment focuses on activation and processes that inhibit activation, such as escape and avoidance behaviours (negative reinforcement processes) and ruminative thinking - Although depression is a disorder that can be characterized by high negative affect (ex: crying, lots of sadness), behavioural activation model is more about the lack of positive affect (or the lack of reward) that's characterized in one's life - If you're not experiencing positive rewards from your environment that'll lead you to withdraw and reduce your behaviour - The model is that you're feeling depressed and that leads to behaviours such as staying inside, withdrawing from friends and family, stopping activities that you previously may have enjoyed (ex: hobbies), thinking about your problems (ex: in rumination), procrastinating/putting things off - All of these types of responses to the feelings of depression are going to feed into more depression - If you're withdrawing and not doing your normal routine, you're going to have less opportunity to receive that reinforcement from the environment and therefore aren't going to experience those highs that those of us who are not depressed tend to experience when we do something we enjoy - Vicious cycle - In this treatment we try to break the cycle

Answer 64

- Core cognitive process in depression where people spend a lot of time going over things in their head - Rumination often refers to past events - Ex: ruminating about early life events or even recent events that may have not gone the way that you wanted them to

Answer 65

- 1st phase of treatment: introduction to treatment - Explaining that events in your life, and how you respond, influence how you feel (standard CBT where we have a situation, a response, and an emotional response) -> much less concerned with thoughts because no cognitive component to behavioural activation treatment (purely behavioural) - Lives that provide too many problems and not enough rewards can lead to depression (explain to client how this is a natural response to the situation that they're in -> going to lead to an overall negative balance) - People pull away from the world when life is less rewarding (the whole idea of engaging with life is that it's benefiting you to some extent to be doing that and if you're not getting those benefits then you pull away - ex: in the pandemic where in general life became less rewarding for people and it caused a significant increase in mental health problems) - Pulling away can increase depression and make it hard to solve problems effectively partly because when you're depressed, you're not thinking clearly or thinking in a way that you would be otherwise so it's hard to figure out what to do and how to feel better - Treatment is not just “doing more” of anything but figuring out what activities would be most helpful (based on increasing activity/activation but you want to be thoughtful about it and want to figure out what's going to be most helpful to try and incorporate into client's routine based on their interests)

Answer 66

- As opposed to a thought record - Daily monitoring forms where people are recording what they're doing (activities) - Also use these forms for planning -> what's your plan for what you're going to do in a day? - We have clients rate 2 aspects of reward from 0-10 (mastery and pleasure) - The treatment thinks reward or positive affect isn't just one unitary construct but we can get reward in different ways - Mastery: we can get a feeling of mastery which comes from doing things that we feel are an accomplishment for us, like finishing a project - May not be that you're enjoying working on this in the moment, but you feel good once it's done - Pleasure: in the moment experience of enjoying what you're doing - Hedonic pleasure experience - Both of these (mastery and pleasure) are important components of reward - All the activities that people do, even if regular activities (ex: lying in bed or watching tv) are getting ratings of mastery or pleasure

Answer 67

- Use monitoring forms to schedule activities for the week - Help client maximize success: - Public commitment - Structure environment - Arbitrary reinforcers - Aversive contingencies - Record context and consequences of activation - Gather info about incomplete homework to understand barriers and avoidance patterns

Answer 68

- Targeting avoidance of tasks, emotions, interpersonal conflicts, etc. - A: assess whether the behaviour is approach or avoidance - C: choose to continue the behaviour, even if it's making you feel worse, or to try a new behaviour - T: try the behaviour chosen - I: integrate a new behaviour into your routine – give it a fair chance - O: observe the results – monitor the effects of the new behaviour - N: never give up! Change requires repeated efforts and attempts

Answer 69

Among moderate-to-severely depressed patients, BA was superior to cognitive therapy and equivalent to or superior than antidepressant medication

Answer 70

- Meta-analysis of 26 RCTs - Found that BA was superior to control conditions and to antidepressant medication

Answer 71

BA delivered by junior mental health workers was not inferior to CBT delivered by psychological therapists

Answer 72

Graded exposure: - Most common - Client slowly exposed to increasingly difficult stimuli - Often we're building a hierarchy (ex: a ladder) and we start at the bottom of it with things that aren't going to be too overwhelming for the person - They recognize they can do it and they can move up the ladder - Ex: fear of heights: start on 5th floor of building, move up to rooftop Systematic Desensitization: - Similar to graded exposure, but with the addition of relaxation techniques - Idea that you can't be relaxed and anxious at the same time - Example of relaxation technique: teaching client to do belly breathing (most of us naturally do chest breathing which doesn't help with relaxation) - Not everyone likes relaxation techniques (some may do better without the relaxation) Prolonged Exposure: - Specifically designed to treat PTSD - PTSD is more complicated than something like a phobia, it's not just a stimulus but there's a lot around the event that generally needs to be reprocessed - Repeated revisiting of traumatic event -> want people to revisit the event over and over again so that they don't experience the same kind of trauma response - Client recounts experience in great detail - Exposure to situations/objects/individuals that are reminders of the traumatic event, but that do not pose a threat - Ex: go back to the place where this event happened - Facilitates emotional processing of event - PTSD is more complex -> not just anxiety and fear, there's a lot of other emotional aspects of it One-session - This would be for standard phobias - One extended session (up to 3hrs) -> longer than regular session - Includes instruction on how to do this, modelling (therapist does the exposures), exposure, cognitive challenge - Shown to be efficacious in adult populations, some evidence supporting use in child/adolescent populations - You have to be well set up to do this, because you have to move up this hierarchy pretty quickly in this one session

Answer 73

In vivo: - Exposure to actual feared stimulus, or some approximation - You're confronting whatever it is - Sometimes requires creativity (ex: capturing a dead bee and bringing it to the sessions to expose client who has a phobia of bees to it) - Imaginal: - Client imagines feared stimulus when it isn’t feasible to do in vivo exposure -> when you can't recreate or you can't have the person expose themselves to the feared stimulus directly - Frequently used for PTSD, GAD, phobias of uncommon stimuli that you wouldn't necessarily cross in day-to-day life - PTSD: people are recounting the event -> can't necessarily go back and recreate it - GAD: people are fearing a lot of things in the future or the possibility of things happening (ex: getting in a car accident) - These are often recorded scripts that get more and more intense as you move up in the hierarchy and the therapist is often the one recording them to be able to give a lot of contextual features and to tap into the anxiety response - Not all clients will be able to engage in this – need to have good visualization skills - Issue: not all clients have good visualization skills, so listening to these recorded scripts, they may not be able to actually picture themselves in this situation and have the same level of anxiety elicited as if they were actually in this situation Virtual reality - Used when in vivo isn’t feasible - Good alternative to imaginal for clients who have difficulty with visualization because they can really put themselves in that situation - Becoming more accessible, but still not widely used -> availability of virtual reality technology now that is consumer grade and not too expensive - Limitation: comes down to the ability to create the worlds and things Interoceptive - Exposure to physical sensations of anxiety - Especially useful for panic disorder or for clients who find physical anxiety symptoms to be unacceptable - Clients learn that symptoms are not dangerous -> exposure to those physiological symptoms will help people recognize that these are not dangerous and that there's nothing wrong with them and that the sensations will dissipate soon after finishing the exposure - Ex: turning in an office chair to promote the sensation of dizziness, breathing through a straw to promote the sensation of shortness of breath, running in place to increase your heart rate Modelling - Not primary intervention – used as adjunct - Can help to ease client into exposure - Shows client that feared outcome is unlikely/impossible - Shouldn’t ask client to do anything that you wouldn’t do - With a hierarchy in exposure therapy therapist goes a bit past the reasonable so they're sure that this is going to stick - If you're going to ask your client to do something like that, then you should also be willing to do it or else it's not a reasonable ask - Sometimes this involves therapists having their own fears and having to work through those for their clients - When doing exposures, it's really important for the therapist to not demonstrate fear and anxiety to model to their client the type of response that they would want from them - Good idea to try out everything that clients will be doing, to know what their experience will be like

Answer 74

* Obsessions about causing harm to others through ”bad energy” or through passing along illness * Engages in several compulsions to reduce her anxiety * Goals for ERP for OCD therapy: * Teach Caroline to face feared situations * Prevent her from engaging in compulsions * Work on her maladaptive thinking in relation to her OCD symptoms

Answer 75

* Almost all clients with OCD have this pairing of obsessions and some type of compulsions that they use to try and neutralize these obsessive thoughts about something that they're fearful of * It's important, for them to get the full benefit of exposure therapy, for there to be prevention of the compulsions * This makes this more challenging because sometimes the compulsions aren't behavioural in nature and are instead mental * Requires a lot of assessment early-on to figure out what are the compulsions that the person is engaging in and to be able to try to encourage them to some extent to not engage into those compulsions during the exposures

Answer 76

* Early sessions focus on assessment of symptoms and interference -> important because not uncommon that people with OCD have multiple forms of obsessions and compulsions, so you don't want to miss anything by the time that you start the exposure * Psychoeducation: * Core part of the beginning of any therapy * Describe nature of OCD * Explain how compulsions maintain anxiety (vicious cycle) * This could be presented in the form of figures (similar to the conceptualization in CBT) * Provide rationale for exposure: * Clients need to know why they're going to be asked to do the types of things that you’re going to ask them to do or else it feels random * Extinction: stop “feeding” obsessions by engaging in compulsions * Improvement will take time – will actually experience more distress in the short-term because you're not going to have those compulsions to rely on and fall back on (short-term worsening of symptoms) * Describe empirical findings that support the use of exposure (ERP has been shown to be extremely efficacious for OCD -> if clients engage in the treatment, it does wonders and is extremely efficacious and we see lots of success) * Can also use example from client’s life (ex: going on a first date with husband) * Introduce symptom monitoring and SUDS ratings: * What you're going to be doing with your sessions * Shows pattern of anxiety (ex: triggers, thoughts, distress, responses) * SUDS = Subjective Units of Distress Scale * Going to be using SUDS to monitor symptoms both while the client is doing work at home and in the context of exposures * Construct fear hierarchy: * Use SUDS ratings from monitoring to create hierarchy * Start with moderately easy items (SUDS <30), but not too easy and then move up the hierarchy over the course of treatment * Can take a while * Plan exposure exercises, prevention of rituals: * Create one for each obsession/compulsion combination * Build rapport: * Exposure will be difficult process for clients with OCD - important for client to trust therapist and feel comfortable with them * Important to establish a good rapport with the client and constantly explain the rationale and the hope that you have that this treatment process will help the person get better

Answer 77

In-session exposure: * The therapy is working up the hierarchy * Therapist-guided -> guiding the client up the hierarchy * Prevention of compulsions * Client asked for SUDS ratings throughout -> every time they're engaging in exposure exercises you want some ratings of the SUDS because you want to see how the SUDS are decreasing * Can graph to have visual representation of progress * Don't move up hierarchy until client can complete item with little effort and without engaging in compulsions * Repeating the steps of the hierarchy multiple times and you want the SUDS to decrease and you want the compulsions to decrease but mental compulsions can be hard and it can be hard to resist those compulsions early-on Homework: * Out-of-session exposure * Once something has been done in session and the client feels fairly comfortable with it, it should also be done outside of session * Idea that 1 or 2 sessions per week are not enough to break these patterns and people need to be engaging in activities outside of sessions * Helps with generalizability and self-efficacy * Continue symptom monitoring Modify as needed: * It's possible that when you created the hierarchy at the beginning it wasn't perfect * It's based on the client's report of their anxiety in various situations * Possible that steps need to be rearranged or the sequence of things needs to be changed * Need for flexibility * Adjust according to changes in symptoms, new behaviours, reactions to exposure exercises (ex: moving too fast), etc. * Provides opportunity for client to practice being own therapist -> want the client to practice and take on more responsibility over the course of treatment because ultimately they're going to be the one that'll need to continue some of this after the treatment is done * Periodically assess overall symptoms to track progress: * Not just on a day to day basis but using a self report measure or a clinician administered measure of OCD to see how the severity of symptoms is decreasing overtime (hopefully)

Answer 78

* Highly efficacious treatment for various problems * Most people get a lot better * Ex: OCD: 60-90% of individuals show a 50-80% reduction in symptoms * Often superior to pharmacological treatment -> we don't have a lot of good pharmacological treatments for OCD, the main first line treatment is a higher dose of an SSRI but ERP is considered a much better first line treatment * Relatively brief * Typically under 15 sessions (although some cases may require longer) * Important consideration in terms of cost * Can be done in a variety of different ways * Often done multiple times a week because you want to build momentum with the client but depends on the setting

Answer 79

* High dropout/refusal rate * Clients find it aversive, they really don't like it * It's hard to convince a client to try this at the beginning of treatment * Some therapists also find it aversive * They don't always like to push their clients to do things they don't want to do * They often find it aversive if they aren't well trained in it and haven't seen it work before * Several potential barriers to treatment: * Noncompliance * Subtle avoidance * Family involvement (families can often be key to the maintenance of the problem and reinforcing a lot of the rituals especially if someone has lived with OCD for a long time) * Comorbidities (treatment will work best for someone with just OCD)

Answer 80

- Manageable (client can do them) - Refrain from compulsions - Master one step before moving to next - Repeated (overtime)

Answer 81

- Current version of CBT for eating disorders - Transdiagnostic approach: - Many ED features present across different ED diagnoses (ex: weight/shape concerns, binge eating, purging, dietary restriction) - There's a lot of similarities across the diagnoses that suggest that the treatment could be similar - Categories of diagnoses for eating disorders aren't stable overtime - Most patients migrate across ED diagnoses over time - The diagnoses for EDs don't make much sense, so it makes sense to treat them as a whole - Over-evaluation of shape/weight is central maintenance factor of all eating disorders (considered the top target in CBT-E for eating disorders) - Precise form of applied treatment depends on the presentation of the individual person - Additional “enhanced” modules can be used to address symptoms external to core ED (perfectionism, low self-esteem, major interpersonal problems) - Level of intensity specific to weight status - BMI > 17.5 (low to normal range), 20 sessions over 20 weeks - BMI < 17.5 (low), 40 sessions over 40 weeks -> more intensive treatment because one of the main treatment goals is going to be for the person to gain weight and that takes time

Answer 82

Over-evaluation of shape/weight -> the extent to which your self-esteem or self-worth is dependent on your shape and your weight

Answer 83

- 1st phase - Engage the patient in treatment and change, increase motivation/commitment to treatment - Motivation to change is a place that can be hard when working with patients with EDs (usually greater motivation among binge eating ED but less motivation for those without binge eating and who are underweight) - Collaboratively create a personalized formulation to understand the person's symptoms -Psychoeducation about treatment and eating disorders and the consequences of different symptoms - Establish early in treatment: self-monitoring, weekly weighing, regular eating

Answer 84

- We would present this to the person and then use their own details about their symptoms and their maintaining factors to include in this - Philosophy: ED is vicious cycle maintained by interaction among thoughts, behaviours, and beliefs - Goal is to understand what factors and symptoms are relevant to the patient - Over-evaluation of control over eating and of shape and weight is thought to be the core maintaining factor that then influences the different behaviour - We would edit this for the individual person - The idea here, just like when we talk about a CBT formulation in general where automatic thoughts are at the bottom but that's what we start with, the same type of thing applies here - We start with the behaviours at the bottom and try to address them through regular eating and then work our way up to get to the top maintaining factors (over-evaluation of control over eating, shape or weight) that are a bit more cognitive in nature

Answer 85

- Gives us a better understanding of the processes maintaining the eating disorder (for therapist & patient) - We do this early-on in the assessment phase because this is going to inform our formulation and help the therapist to gain the bigger picture of what's going on with the person and then we continue this throughout treatment - Try as much as possible to get an accurate record of patient’s food intake (people are limited in their ability to retrospectively report things especially during binge eating episodes where they're likely to dissociate and purposefully don't want to keep track of how much they're eating, if you ask them a week later about their binge episode, they may not be able to tell you much about it, this is something they're supposed to do on an ongoing basis) - Highlights key behaviours, feelings, thoughts, and the contexts in which they occur - We can use these self-monitoring forms as specific examples to address in session - Therapeutic work between sessions - Increases patient self-awareness (for patients who binge eat -> end up decreasing the amounts that they eat during their binge eating episodes and the frequency of the episodes themselves) - Encourage self-monitoring in “real time” or as close in time as possible - Self-monitoring form includes columns for time, food consumed, place, meal/snack/binge/purge(V,L), exercise, and circumstances

Answer 86

* This is something you establish right at the beginning of treatment * Patients with eating disorders tend to fall into 2 groups when it comes to weighing behaviour: * Either they're completely avoiding getting on the scale, such that they may not own a scale and don't want to know what the number on the scale is, it's something fraught with a lot of emotions * Or they're obsessively weighing themselves to the point where they're doing it multiple times a day * Both are not good options * It's good for us to have some sense of how much we weigh on an ongoing basis but we definitely are not getting any helpful info by weighing ourselves multiple times a day * We show patients a graph that shows that there are normal fluctuations in weight throughout a week, throughout a day * There are a lot of different things that can determine our weight (ex: did we just eat a meal, did we just use the bathroom) * These are things that can change our weight by a few pounds * Misinterpreting numbers or inconsequential weight fluctuations is likely to result in some sort of negative behaviour (in terms of the goal of recovering from an ED) no matter what the reading is * If weight is up or the same, individuals feel motivation to diet even more and engage in even more weight control behaviours * If weight is down, dieting and other behaviours are reinforced and people feel like they "better keep it up" * Regardless of the outcome, it's probably going to be negative

Answer 87

- No weighing at home (transfer to at-home weighing late in treatment) - If we're doing weekly sessions, that means that patients are getting weighed once a week - For early sessions, people can bring in their scales or give it to a friend or family if they really feel like they'll be too tempted - Weigh patient jointly at the beginning of each weekly session - Joint plotting of weight graph -> plotting weight each week - From week-to-week, if the goal of treatment isn't for the person to gain weight, we should see relatively stable weight - Examination of trends over time - Motto: “One can’t interpret a single reading” -> because of all of those factors that can influence what that number is when we get on the scale, we want to look at trends overtime

Answer 88

- Core part of treatment for EDs - Prescribed pattern of regular eating - Food is medicine for treatment of EDs - 3 meals and 2-3 planned snacks - No more than 3-4 hours between meals/snacks (because hunger can be a trigger for binge eating episodes at least initially) - Mechanical, based on schedule, not hunger (because they don't have a good sense of their hunger and fullness cues) - Eating takes precedence over other activities - Initial emphasis on when the person is eating, later examine what - Some patients are going to have an urge to eat between meals and snacks -> problem solve, use incompatible behaviours, “surf the urge” (idea that comes from Dialectical Behaviour Therapy, where if you wait long enough, most likely any urge or craving or strong emotion is going to dissipate) - Regular eating is designed to get rid of binge-eating episodes and has been shown to be very effective at that

Answer 89

Vomiting: - Most common - Educate (psychoeducation) on ineffectiveness (only rid self of 30-50% calories consumed during a binge-eating episode) - Review consequences of vomiting (ex: dental health, electrolyte imbalance, vomiting is one of the most medically severe symptoms of EDs) - Delay (urge surfing, see what happens if you delay the urge to vomit, use behavioural experiment to evaluate urge) Laxatives and diuretics - Ineffective at preventing calorie absorption - Throw away supplies or plan a schedule of withdrawal (consult with physician) * We find that if regular eating is effective at reducing binge eating episodes then the reduction in compensatory behaviours follows naturally because most people are using compensatory behaviours directly in response to their binge eating episodes * There is a subset of people with an ED that is one of the ones under study, called purging disorder (people who don't eat large amounts of food in the sense that they don't have binge-eating episodes but they still engage in things like vomiting or laxative and diuretic use) * Treatment will be a little harder for them because we don’t have those binge eating episodes to start with * A lot of times they still are engaging in compensatory behaviours when they feel like they've eaten too much so if we can get on that regular eating pattern, that's helpful

Answer 90

- 7 trials (5 RCTs; 2 open trials) since January 2014 - 3 with a BN sample - 4 with a transdiagnostic sample - In RCTs, CBT-E performed better than interpersonal psychotherapy (IPT), psychoanalytic therapy, and no treatment - CBT-E was equivalent to integrative cognitive affective therapy; Broad and focused versions were equivalent - Remission rates varied highly from 22.2-67.6% due to differences in sample and operationalization of clinically significant change -> often an argument for why we need new treatments for EDs because the average is about 50% of people get better and 50% of people don't get better using the leading treatments

Answer 91

- CBT-Ten session protocol (CBT-T) - Taking the traditionally 20 session protocol and condensing it into 10 sessions making it much more scalable to be able to be delivered more broadly given its much shorter duration - Cohort comparison (not randomized) between patients treated with CBT-E versus CBT-T at same clinic - Differences in treatments: Focus on early parts of treatment protocol for CBT-E; include more exposure exercises; CBT-T delivered by “assistant psychologists” (ex: people with a Bachelor's degree) whereas CBT-E was still being administered by full licensed psychologists - Finding: change in eating disorder symptoms and clinical impairment was similar in CBT-E vs. CBT-T - Large decreases during treatment, with gains maintained at 6- month follow-up - Change in ED symptoms in terms of decreases in clinical impairment and they were very large during treatment and then the gains were maintained at a 6-month follow-up - Promising data in terms of not just being able to use an abbreviated treatment but being able to train people with a little less experience to provide this treatment potentially in community settings