Holt Academy

Cognitive Behavioural Services

Cognitive Behaviour Therapy

CBT can be characterised in the following ways. It is;

• Problem orientated
• Structured
• Pro-active
• Empirically based
• Short term
• Collaborative
• Based on psychological methods of treatment

These characteristics have resulted in the development of certain clinical management principles and criteria for suitability for treatment:

Negotiation - Management issues are discussed openly, seeking the clients’ views directly and stating your own frankly. Endeavour to proceed in mutually agreed steps. Ultimately aim to make the client their own therapist.

Definitions - All problems, goals, interventions, measures, and outcomes are clearly and succinctly defined, using observable behaviour as the basis of definitions.

Goal orientation – Treatment goals are agreed at the beginning of therapy and worked towards systematically

Measurement - A variety of measurements, both broad and narrow are used and repeated at agreed stages through therapy. Involve the client and significant others in this process and give feedback.

Pragmatism - Management decisions should be made by results not theories. "Hunches" can and should be tested out practically and systematically.

Practice - Regular practice provides quicker and greater results. Graded, real life (in vivo) practice is the best, though role play and imagination can be helpful.(Marks 87)

Research has shown quite clearly (Marks 87) that patients who do not fulfil specific criteria prior to treatment are less likely to succeed. These criteria are;

• The client and therapist can agree in defining the problem in terms of observable behaviour.
• The behaviour is current and predictable.
• The client and therapist can agree on clear behavioural goals which relate to the problem.
• The following contra-indications are absent:
  • Severe depression
  • acute psychosis
  • Organic state
  • 5mg of diazepam or equivalent daily
  • Over 2 units of alcohol daily
• The client is motivated, and understands and agrees to therapy.

Which problems are suitable for CBT?

The "Health of the Nation" document (HMSO 92) estimated that up to 7% of the adult population experience anxiety disorders (phobias, obsessive compulsive disorder and panic). Also, a major community study in the USA estimated the prevalence of anxiety disorders at similar levels (Reiger et al 90). Since CBT is the treatment of choice for these problems and it has been shown to be effective in the treatment of other disorders it is possible to apply CBT in 13% of all psychiatric out-patients (Marks 86). Current research is also expanding its application to the management of chronic physical problems (e.g. pain and fatigue {CFS}) and chronic psychosis.

CBT is particularly effective in the management of the following;

• Phobic disorders (specific e.g. spiders, and complex agoraphobia and social)
• Panic
• Obsessive-compulsive disorders
• Sexual disorders
• Habit disorders e.g. tics and stammering
• Mild to moderate depression
• Condition management e.g. pain, fatigue and Fibromyalgia
• Post traumatic stress disorder

Also, by applying a systematic, problem solving approach to assessment and treatment based on empirically researched cognitive behavioural principles, the skills of the Cognitive Behaviour Therapist can be of benefit to clients with a wide variety of problems.

These include;

• Generalised anxiety states/stress
• Anger control problems
• Enuresis
• Eating disorders
• Substance abuse
• Personality disorder
• Panic disorder
• Social skills deficit
• Morbid grief
• Compulsive gambling
• Health anxiety
• Management of psychosis

It is not useful in the treatment of;

• Acute schizophrenia
• Severe depression
• Acute mania
• Organic illness

Treatment techniques used in Cognitive Behaviour Therapy

Treatment is tailored to the needs of individual clients’ and their circumstances, as is the pace of treatment. The clients’ progress is carefully monitored during treatment and evaluated at regular intervals through the use of client and therapist rated measures (Richards and McDonald 1990).

Approaches may be divided into those which;

Reduce anxiety linked behaviour (e.g. Phobias and OCD)

• Exposure in vivo
• Imaginable exposure
• Response prevention
• Cognitive restructuring
• Coping tactics/problem solving
• Modelling

Reduce impulsive behaviours (e.g. Gambling and Habit Disorders

• Self monitoring
• Competing response
• Covert sensitisation
• Satiation
• Aversive therapies
• Response cost

Develop new behaviours (e.g. Social Skills Deficits)

• Social skills training
• Sexual skills training
• Modelling
• Shaping
• Contracting
• Role rehearsal
• Education

Modify unhelpful thinking styles by challenging Automatic Negative Thoughts (ANTs)

• Recording Automatic Negative Thoughts
• Using a change in mood
• Writing them down and recording
  • Date
  • Emotions; what they feel, how bad it was, using a 0-8 scale
  • Situation; what they were doing when the thought popped in
  • Thoughts; what exactly were the thoughts and how much they believed them using a 0-8 scale.
• Counting the thoughts

Dealing With A.N.Ts by;

• Seeing them for what they are
• Recognising any unhelpful thinking style
• Challenging them by providing an objective, positive alternative to them

Four ways to challenge A.N.Ts

1. Question the evidence for the thought
   • Is the thought based on what you think or what you know.
2. Seek any alternative explanation
   • Would you have thought this if you weren’t anxious?
   • On a better day would you think this?
   • What would someone who's view you trusted think about this?
   • If someone came to you with this problem, what would you say to them?
3. Identify the effect of thinking negatively
   • Can you find alternatives which may be more helpful?
4. Identify any errors in the style of thinking such as,
   • Conclusion Jumping
   • Over-generalising
   • Responsibility Taking
   • “All or nothing”
   • Selective Thinking

Using the above techniques it is possible to challenge unhelpful thoughts and to see that things may not be quite as bad as they have seemed.

This response to the A.N.Ts is written down and the degree to which it is believed is rated and this rate compared the previous rating. Having challenged the ‘normal’ thoughts succesfully the client re-measures how they feel. Over time, and with practice, the ability to challenge negative thoughts becomes second nature and the client becomes their own therapist.