Behaviour Therapy Behaviour Therapy & &

Cognitive-Behaviour TherapyCognitive-Behaviour TherapyAn Introduction for Psychiatric RegistrarsAn Introduction for Psychiatric Registrars

Frank McDonaldFrank McDonaldConsultation-Liaison PsychologistConsultation-Liaison Psychologist

www.fmcdonald.comwww.fmcdonald.com

The Townsville HospitalThe Townsville HospitalJune 2002 June 2002

Web V.02.6.22Web V.02.6.22

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AimsAims

1.1. Introduce theoretical premises of Behaviour Therapy & Introduce theoretical premises of Behaviour Therapy & Cognitive-Behaviour TherapyCognitive-Behaviour Therapy

2.2. Describe behavioural case formulations - how they flow Describe behavioural case formulations - how they flow from a complete Behavioural Analysis & their valuefrom a complete Behavioural Analysis & their value

3.3. Describe a range of Behavioural & CBT treatments - ‘nuts Describe a range of Behavioural & CBT treatments - ‘nuts & bolts’ of some psychological techniques& bolts’ of some psychological techniques

4.4. Provide supplementary material Provide supplementary material a.a. therapist & pt written info materialtherapist & pt written info materialb.b. videos of strategies for mx of panic & depression (not on Web videos of strategies for mx of panic & depression (not on Web

version)version)c.c. self-help & professional literature & Web references self-help & professional literature & Web references

5.5. Check transfer of learning - discussion of medical practice Check transfer of learning - discussion of medical practice case vignettes in which knowledge of strategies from case vignettes in which knowledge of strategies from learning theory based therapy may be helpfullearning theory based therapy may be helpful

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BT & CBT Overview BT & CBT Overview Click action button to advance to sectionClick action button to advance to section

1.1. Paradigmatic bases of CBT & BTParadigmatic bases of CBT & BT

2.2. Distinguishing characteristics of CBT & BTDistinguishing characteristics of CBT & BT

3.3. Suitable disorders and problemsSuitable disorders and problems

4.4. Behavioural analysis – the etiological Behavioural analysis – the etiological inquiryinquiry

5.5. Survey of strategies for common conditionsSurvey of strategies for common conditions

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BT & CBT OverviewBT & CBT Overview

6.6. Examples of specific behavioural Examples of specific behavioural strategiesstrategies

a.a. Exposure therapy for anxiety disordersExposure therapy for anxiety disorders

b.b. Behavioural responses to panic symptomsBehavioural responses to panic symptoms

c.c. Activity scheduling for depressionActivity scheduling for depression

d.d. Behavioural management of chronic painBehavioural management of chronic pain

e.e. Behavioural marital counsellingBehavioural marital counselling

f.f. Token economies for children Token economies for children

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BT & CBT OverviewBT & CBT Overview

7.7. Examples of cognitive-behavioural Examples of cognitive-behavioural strategiesstrategies

a.a. AnxietyAnxiety

b.b. DepressionDepression

c.c. PainPain

8.8. Your comment on how CBT & Behaviour Your comment on how CBT & Behaviour Therapy may help with pt problems in Therapy may help with pt problems in some psychiatric practice scenarios some psychiatric practice scenarios

9.9. References & Resource materials References & Resource materials

10.10.CreditsCredits

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1. Theory And Paradigm 1. Theory And Paradigm BasesBases• Both therapies derived from Learning Theory Both therapies derived from Learning Theory

and share some premises -and share some premises - Pt’s problems are, at least in part, Pt’s problems are, at least in part,

I.I. causally related to antecedent events,causally related to antecedent events,II.II. a result of reinforcing consequences, a result of reinforcing consequences, III.III. a result of dysfunctional thoughts or a result of dysfunctional thoughts or

behavioural deficits.behavioural deficits.IV.IV. And a pt’s condition is, at least in part, And a pt’s condition is, at least in part,

treatable by specific cognitive or behavioural treatable by specific cognitive or behavioural techniques techniques

(Sperry et al., 1992)(Sperry et al., 1992)

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1. Theory And Paradigm 1. Theory And Paradigm BasesBases• Both BT & CBT aim to modify or eliminate Both BT & CBT aim to modify or eliminate

maladaptive thoughts, feelings and maladaptive thoughts, feelings and behavioursbehaviours

• However their paths to this same goal differ (i.e. However their paths to this same goal differ (i.e. different therapeutic targets and rx strategies) different therapeutic targets and rx strategies)

• Reflects Reflects differing differing paradigmatic basesparadigmatic bases

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1. Theory And Paradigm 1. Theory And Paradigm BasesBases• Behaviourists say “change behaviour (&/or Behaviourists say “change behaviour (&/or

environment) - changes in thoughts & feelings environment) - changes in thoughts & feelings follow”follow”

• Cognitivists say “change thoughts, images, etc Cognitivists say “change thoughts, images, etc (cognitions) - changes in feelings & behaviour (cognitions) - changes in feelings & behaviour follow”follow”

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1. Theory And Paradigm 1. Theory And Paradigm BasesBases

1.1. Conditioning paradigm – “experiences & action”Conditioning paradigm – “experiences & action” Two subclassesTwo subclasses

Classical conditioning Classical conditioning Operant conditioningOperant conditioning

2.2. Cognitive-behavioural paradigm – “internal Cognitive-behavioural paradigm – “internal representation”representation”

For further discussion & examples see separate For further discussion & examples see separate notes. notes.

Click here Click here (Document links require a PDF reader. (Document links require a PDF reader. Click hereClick here to install one) to install one)

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2. Characteristics of CBT & 2. Characteristics of CBT & Behaviour TherapyBehaviour Therapy

What distinguishes Learning Theory based What distinguishes Learning Theory based therapies?therapies?

I.I. Psycho-educational formatPsycho-educational format

II.II. Systematic measurementSystematic measurement

III.III. Individually-tailored, structured treatmentIndividually-tailored, structured treatment

IV.IV. ‘‘Home assignments’Home assignments’

V.V. Ultimate aim of self-management and self-Ultimate aim of self-management and self-controlcontrol

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3. Some conditions suitable 3. Some conditions suitable for for BT & CBTBT & CBT• Anxiety disorders Anxiety disorders (PD +/- A, OCD, GAD, PTSD, Social & Specific Phobias) (PD +/- A, OCD, GAD, PTSD, Social & Specific Phobias) • DepressionDepression• Chronic painChronic pain• Social skills deficitsSocial skills deficits• Marital/relationship problemsMarital/relationship problems• Sexual problemsSexual problems• Children’s behaviour problemsChildren’s behaviour problems• Eating disordersEating disorders• Habit disorders (e.g. sleep disturbances, smoking)Habit disorders (e.g. sleep disturbances, smoking)• Abnormal grief reactionsAbnormal grief reactions• Anger problemsAnger problems

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4. Behavioural Analysis – 4. Behavioural Analysis – The Etiological InquiryThe Etiological Inquiry

• BT & CBT not just a bunch of routinely applied BT & CBT not just a bunch of routinely applied procedures such as response prevention, procedures such as response prevention, exposure therapy, cognitive restructuring etcexposure therapy, cognitive restructuring etc

• Good BT & CBT rests on thorough Behavioural Good BT & CBT rests on thorough Behavioural Analysis of how problem began & why continuesAnalysis of how problem began & why continues

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4. Behavioural Analysis – 4. Behavioural Analysis – The Etiological InquiryThe Etiological Inquiry

• Behavioural Analysis – a search for all relevant Behavioural Analysis – a search for all relevant antecedents (recent & remote), concomitants & antecedents (recent & remote), concomitants & consequences – the ‘before, during & after’ consequences – the ‘before, during & after’ contingencies contingencies

• More specifically, stimulus-response links – both More specifically, stimulus-response links – both personal (cognitions, autonomic & behavioural personal (cognitions, autonomic & behavioural responses) & environmental – associated with responses) & environmental – associated with problem. Guides therapyproblem. Guides therapy

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4. Behavioural Analysis – 4. Behavioural Analysis – The Etiological InquiryThe Etiological Inquiry

• Analysis & therapy lie in the context of a Analysis & therapy lie in the context of a supportive relationship supportive relationship

• Despite apparent technical nature of BT & CBT, Despite apparent technical nature of BT & CBT, research says ‘warm’ therapists get significantly research says ‘warm’ therapists get significantly better results than ‘cold’ therapists. Even in more better results than ‘cold’ therapists. Even in more mechanical treatments like graded exposure mechanical treatments like graded exposure therapy for phobiastherapy for phobias

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4. Behavioural Analysis – 4. Behavioural Analysis – The Etiological InquiryThe Etiological Inquiry

• Irrespective of paradigm, behavioural analysis a Irrespective of paradigm, behavioural analysis a sine qua nonsine qua non of learning theory based therapies of learning theory based therapies

• Hypotheses formulated about precise variables Hypotheses formulated about precise variables controlling problem so as to suggest treatment. controlling problem so as to suggest treatment. Reduces chances of ‘trial & error’ therapyReduces chances of ‘trial & error’ therapy

• Hypotheses tested by outcomes – reformulated if Hypotheses tested by outcomes – reformulated if unsupported, loop-fashion, until successunsupported, loop-fashion, until success

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4. Behavioural Analysis – 4. Behavioural Analysis – The Etiological InquiryThe Etiological Inquiry

• Treatment targets are specified in strict operational, Treatment targets are specified in strict operational, measurable terms – not vague language like “less measurable terms – not vague language like “less anxious” – a hallmark of behaviour therapiesanxious” – a hallmark of behaviour therapies

• Treatment target options: change causes, change Treatment target options: change causes, change responses, change both or environment responses, change both or environment

• Changing environment often produces quickest, Changing environment often produces quickest,

most efficient improvement in feelingsmost efficient improvement in feelings

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4. Behavioural Analysis – 4. Behavioural Analysis – The Etiological InquiryThe Etiological Inquiry

• Treatment is basically hypothesis testing of Treatment is basically hypothesis testing of testable constructs testable constructs

• Click on links for Click on links for ‘Behavioural Analysis’ notes‘Behavioural Analysis’ notes for for expansion and for expansion and for example matrixexample matrix to guide to guide assessmentassessment

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5. Survey of BT & CBT 5. Survey of BT & CBT Techniques for Common Techniques for Common ConditionsConditions• AnxietyAnxiety

– Breathing retrainingBreathing retraining– Relaxation trainingRelaxation training– Graded exposure therapyGraded exposure therapy– Flooding (rarely used)Flooding (rarely used)– Response prevention (extinction)Response prevention (extinction)– Cognitive restructuring strategiesCognitive restructuring strategies– Structured problem solvingStructured problem solving

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5. Survey of BT & CBT 5. Survey of BT & CBT Techniques for Common Techniques for Common ConditionsConditions• Anxiety (cont’d)Anxiety (cont’d)

– MeditationMeditation– Assertiveness Training / Social Skills TrainingAssertiveness Training / Social Skills Training– Stimulus control Stimulus control – Eye Movement Desensitisation ReprocessingEye Movement Desensitisation Reprocessing– Thought stoppingThought stopping

• To see how anxiety disorders are treated using To see how anxiety disorders are treated using psychological strategies on a disorder by disorder psychological strategies on a disorder by disorder basis basis click here click here

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5. Survey of BT & CBT 5. Survey of BT & CBT Techniques for Common Techniques for Common ConditionsConditions• DepressionDepression

– Cognitive Therapy for ways of thinking Cognitive Therapy for ways of thinking common to depression (e.g. 3 P’s – common to depression (e.g. 3 P’s – ‘permanent, pervasive & personal’) ‘permanent, pervasive & personal’)

– Activity scheduling – gradually increasing Activity scheduling – gradually increasing pleasurable and achievement events pleasurable and achievement events

– Structured Problem SolvingStructured Problem Solving– Social skills training/Assertiveness training to Social skills training/Assertiveness training to

increase social rewardsincrease social rewards– Consider involving family/partner in therapyConsider involving family/partner in therapy

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5. Survey of BT & CBT 5. Survey of BT & CBT Techniques for Common Techniques for Common ConditionsConditions• Habit Disorders/Addictive behaviours Habit Disorders/Addictive behaviours

(e.g. Primary Insomnia, smoking)(e.g. Primary Insomnia, smoking)– Stimulus controlStimulus control – Relaxation/ imagery/ autosuggestion Relaxation/ imagery/ autosuggestion – Environmental changesEnvironmental changes– Self-rewardSelf-reward– Self-monitoringSelf-monitoring– Aversion therapy Aversion therapy – Saturation (extinction)Saturation (extinction)

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5. Survey of BT & CBT 5. Survey of BT & CBT Techniques for Common Techniques for Common ConditionsConditions• Social Skills DeficitsSocial Skills Deficits

– Behaviour modellingBehaviour modelling– Covert modellingCovert modelling– Behaviour rehearsalBehaviour rehearsal– Role playing Role playing – Assertiveness TrainingAssertiveness Training– Social Skills Training (e.g. conversational skills)Social Skills Training (e.g. conversational skills)– Communication Skills Training (e.g. listening, Communication Skills Training (e.g. listening,

negotiation, conflict resolution)negotiation, conflict resolution)

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5. Survey of BT & CBT 5. Survey of BT & CBT Techniques for Common Techniques for Common ConditionsConditions• Chronic PainChronic Pain

– Goal settingGoal setting– Self-monitoringSelf-monitoring– PacingPacing– Graded physical conditioningGraded physical conditioning– Relaxation for any tension componentRelaxation for any tension component– Emotion defusing strategies (for frustration, Emotion defusing strategies (for frustration,

anxiety etc)anxiety etc)

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5. Survey of BT & CBT 5. Survey of BT & CBT Techniques for Common Techniques for Common ConditionsConditions• Chronic Pain (cont’d)Chronic Pain (cont’d)

– Autosuggestion/self-hypnosis Autosuggestion/self-hypnosis – Structured problem solvingStructured problem solving– Distraction (more suited to acute pain)Distraction (more suited to acute pain)– MeditationMeditation– Assertiveness Training (e.g. making/refusing Assertiveness Training (e.g. making/refusing

requests given physical limitations)requests given physical limitations)– Depression management strategies Depression management strategies

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5. Survey of BT & CBT 5. Survey of BT & CBT Techniques for Common Techniques for Common ConditionsConditions• Relationship DifficultiesRelationship Difficulties

– Communication Skills trainingCommunication Skills training• Basic – Listening, validating, levellingBasic – Listening, validating, levelling

• Intermediate – Assertiveness trainingIntermediate – Assertiveness training

• Advanced – Negotiation skills (win/win) Advanced – Negotiation skills (win/win)

Conflict resolution skills Conflict resolution skills

• Reciprocity counselling (Reciprocity counselling (quid pro quoquid pro quo agreements) agreements)

• MiscellaneousMiscellaneous– Token economiesToken economies– Behavioural exchange contractsBehavioural exchange contracts

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6. Behavioural Strategies6. Behavioural Strategies

• A. Exposure therapy for A. Exposure therapy for anxietyanxiety (used in OCD, (used in OCD, PTSD, PD+A, Specific and PTSD, PD+A, Specific and Social Phobia)Social Phobia)– Exposure to anxiety in Exposure to anxiety in

graded fashion. Identify graded fashion. Identify specific goals and break specific goals and break them into smaller, them into smaller, manageable steps manageable steps

Fear

Relax

Relax

Relax

Relax

Relax

RelaxSTOP

STOP

STOP

STOP

STOP

STOP

The Principle of Exposure Therapy

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6. Behavioural Strategies6. Behavioural Strategies

– Learn to master Learn to master situations that cause situations that cause mild, then gradually mild, then gradually greater, anxiety. greater, anxiety. Teach & test a Teach & test a relaxation strategy relaxation strategy before to reduce before to reduce distress/panic during distress/panic during exposureexposure

– Aim is to achieve Aim is to achieve relative relaxation relative relaxation before next stepbefore next step

Fear

Relax

Relax

Relax

Relax

Relax

RelaxSTOP

STOP

STOP

STOP

STOP

STOP

The Principle of Exposure Therapy

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6. Behavioural Strategies6. Behavioural Strategies

– Principle: best way to overcome fear is to face it, Principle: best way to overcome fear is to face it, but in ways research says are more likely to but in ways research says are more likely to succeed succeed

– Emphasise habituation to anxiety in each exposure Emphasise habituation to anxiety in each exposure session. Biggest trap is to flee a step at height of session. Biggest trap is to flee a step at height of fear (re-forges association of situation & fear) fear (re-forges association of situation & fear)

– Confront fears regularly and frequentlyConfront fears regularly and frequently

• See ‘Exposure Therapy’ notes See ‘Exposure Therapy’ notes Click hereClick here for pt notes for pt notes Click hereClick here for therapist notes for therapist notes

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6. Behavioural Strategies6. Behavioural Strategies

• Example of graded exposure hierarchy for Example of graded exposure hierarchy for Agoraphobia or Social Phobia Agoraphobia or Social Phobia

– Goal:Goal: To travel alone by bus to the city and back To travel alone by bus to the city and back

1.1. Travelling one stop, quiet time of day (anxiety level Travelling one stop, quiet time of day (anxiety level 4/10) 4/10)

2.2. Travelling two stops, quiet time of day Travelling two stops, quiet time of day 3.3. Travelling two stops, rush hour (anxiety level 6/10) Travelling two stops, rush hour (anxiety level 6/10) 4.4. Travelling five stops, quiet time of day Travelling five stops, quiet time of day 5.5. Travelling five stops, rush hour (anxiety level 8/10) Travelling five stops, rush hour (anxiety level 8/10) 6.6. Travelling all the way, quiet time of day Travelling all the way, quiet time of day 7.7. Travelling all the way, rush hour (anxiety level Travelling all the way, rush hour (anxiety level

10/10)10/10)

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6. Behavioural Strategies6. Behavioural Strategies

• Some pts with Social Phobia may need assistance Some pts with Social Phobia may need assistance with developing social skills with developing social skills

• Click hereClick here for Conversational Skills material for Conversational Skills materialClick hereClick here for pt introduction to Assertiveness for pt introduction to Assertiveness Training Training Click hereClick here for list of Assertiveness for list of Assertiveness TechniquesTechniquesClick hereClick here for Conflict Resolution strategies for Conflict Resolution strategies

• Model & role play to aid generalisation (role play Model & role play to aid generalisation (role play practice practice thethe core element of any social skill core element of any social skill development)development)

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6. Behavioural Strategies6. Behavioural Strategies

• B. Teaching behavioural responses to early symptoms B. Teaching behavioural responses to early symptoms of panicof panic– After education about panic, pt’s breathing is re-After education about panic, pt’s breathing is re-

trainedtrained– Slow, steady breathing is central to controlling Slow, steady breathing is central to controlling

panic. Regular daily practice set uppanic. Regular daily practice set up– Strategies applied at earliest symptom in self-Strategies applied at earliest symptom in self-

monitoring frameworkmonitoring framework– Prof. Gavin Andrews on hyperventilation control. Prof. Gavin Andrews on hyperventilation control.

See References to purchase CD-ROM video via See References to purchase CD-ROM video via CRUfAD Web addressCRUfAD Web address

– See pt guide ‘Panic Attacks!’ See pt guide ‘Panic Attacks!’ Click here Click here

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6. Behavioural Strategies6. Behavioural Strategies

• Videos below (Andrews & Hunt, 1998) on mx of panic in Videos below (Andrews & Hunt, 1998) on mx of panic in General Practice, demonstrate a learning theory General Practice, demonstrate a learning theory framework & psychological research on the issueframework & psychological research on the issue

1.1. Patient presentationPatient presentation2.2. Assessing antecedents and consequencesAssessing antecedents and consequences3.3. Psycho-educational phasePsycho-educational phase4.4. Breathing retraining discussion & ‘homework’ Breathing retraining discussion & ‘homework’

assignmentassignment5.5. Behaviour rehearsal & real-world generalisationBehaviour rehearsal & real-world generalisation

• Videos not available on Web. Videos not available on Web. See References for purchase details of complete clinical See References for purchase details of complete clinical skills program on CD-ROM available via CRUfAD Web skills program on CD-ROM available via CRUfAD Web address in References address in References

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6. Behavioural Strategies6. Behavioural Strategies

• C. Behavioural management of depressionC. Behavioural management of depression

Main psychological approaches Main psychological approaches – Cognitive Therapy (see CBT section)Cognitive Therapy (see CBT section)– Structured problem solving (see CBT section)Structured problem solving (see CBT section)– Activity Scheduling Activity Scheduling

• Ask pt about recent frequency of activities Ask pt about recent frequency of activities that gave sense of pleasure or achievement that gave sense of pleasure or achievement – either or both often unusually low in – either or both often unusually low in depressed ptsdepressed pts

• Encourage achievable, gradual increases Encourage achievable, gradual increases each day. each day.

• See list of suggested Pleasant Activities See list of suggested Pleasant Activities Click hereClick here

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6. Behavioural Strategies6. Behavioural Strategies

• D. Behavioural management of Chronic PainD. Behavioural management of Chronic Pain– Set specific adjustment goals. For suggestions on goal Set specific adjustment goals. For suggestions on goal

planning planning click here.click here. Blank goal sheet - click here Blank goal sheet - click here– Increase behaviours associated with adjustment to Increase behaviours associated with adjustment to

chronic pain. For guidelines chronic pain. For guidelines click hereclick here and for more and for more comprehensive guidelines on targets & rx’s click herecomprehensive guidelines on targets & rx’s click here

– Baseline activity levels via pain diary. Raise or lower Baseline activity levels via pain diary. Raise or lower these according to principles of pacing. Click links for these according to principles of pacing. Click links for initial pain diary cover initial pain diary cover and and follow-up diary coverfollow-up diary cover and and blanksblanks for each day & evening of the baseline periods for each day & evening of the baseline periods

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6. Behavioural Strategies6. Behavioural Strategies

– Build stamina with appropriate exercise. Build stamina with appropriate exercise. Behaviourists start exercise below current Behaviourists start exercise below current capacities to avoid association with pain before capacities to avoid association with pain before habits establishedhabits established

– Click links for Click links for movement guidelinesmovement guidelines & & movement diarymovement diary

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6. Behavioural Strategies6. Behavioural Strategies

• E.E. Behavioural Marital CounsellingBehavioural Marital Counselling– Reciprocity Counselling focuses on couples Reciprocity Counselling focuses on couples

forming forming quid pro quoquid pro quo agreements about highly agreements about highly specific desirable changes by partner specific desirable changes by partner

– Reciprocal agreements prevent either partner Reciprocal agreements prevent either partner feeling any unfairness about change feeling any unfairness about change

– Click links for Click links for guidelinesguidelines & & home monitoring sheetshome monitoring sheets

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6. Behavioural Strategies6. Behavioural Strategies

• F. Token EconomyF. Token Economy– Mainly for children & young adolescents Mainly for children & young adolescents – Makes a game of home discipline. Reduces emotionality Makes a game of home discipline. Reduces emotionality

of parents. Adds objectivity to task. Reciprocal control in of parents. Adds objectivity to task. Reciprocal control in that child can manage parent. Gets around imbalance of that child can manage parent. Gets around imbalance of power problem in some behavioural programs power problem in some behavioural programs

– Fade to more natural contingencies as habits established Fade to more natural contingencies as habits established – See exampleSee example– Can be adapted to closed institutional settings i.e. where Can be adapted to closed institutional settings i.e. where

access to privileges outside closed system difficultaccess to privileges outside closed system difficultSee exampleSee example

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies• A. Cognitive Therapy for AnxietyA. Cognitive Therapy for Anxiety

– Explain cognitive restructuring to pts who potentially Explain cognitive restructuring to pts who potentially can ‘think about their thinking’ - role of specific can ‘think about their thinking’ - role of specific thoughts, thinking styles & core beliefs. Supplement thoughts, thinking styles & core beliefs. Supplement with info sheets / recommended reading with info sheets / recommended reading Click here Click here for samplesfor samples

– Teach strategiesTeach strategies•Diary disputation / self-challenge of troublesome Diary disputation / self-challenge of troublesome

cognitions. Better than therapist persuasion, direct cognitions. Better than therapist persuasion, direct argument. Variation on role reversal strategy argument. Variation on role reversal strategy espoused by social psychologists for modifying espoused by social psychologists for modifying attitudes. Model examples first using ‘thinking out attitudes. Model examples first using ‘thinking out loud’loud’

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

•Click hereClick here for disputing tips, example & blank for disputing tips, example & blank ‘Daily Stress & Tension Log’. ‘Daily Stress & Tension Log’.

•Cards with anti-worry statements / self-directions Cards with anti-worry statements / self-directions referred to regularly (principle of overlearning). referred to regularly (principle of overlearning). Click here for example - ‘Coping with Worrying Click here for example - ‘Coping with Worrying Thoughts’ and other ‘Managing Worry’ strategiesThoughts’ and other ‘Managing Worry’ strategies

•Reframing (alternative perspective taking). Reframing (alternative perspective taking). Examples: Examples:

– ““How would a reasonable person view same How would a reasonable person view same situation?”situation?”

– Relate emotional reaction to point on a Relate emotional reaction to point on a ‘Catastrophe Scale.’ Click here for pt info sheet‘Catastrophe Scale.’ Click here for pt info sheet

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

•Thought stopping. Click here for description. Thought stopping. Click here for description. Use with other ‘Managing Worry’ strategiesUse with other ‘Managing Worry’ strategies

•Powerful, brief coping self-statements pt Powerful, brief coping self-statements pt believes to be true. Rapid, abbreviated form believes to be true. Rapid, abbreviated form of earlier, more complex disputation e.g. of earlier, more complex disputation e.g. “Feelings are not facts!” “Shit happens!” “Feelings are not facts!” “Shit happens!” “Shouldhood is shithood!” “I’m musterbating “Shouldhood is shithood!” “I’m musterbating again!” “I am a fallible human being who again!” “I am a fallible human being who can therefore make mistakes, & some of can therefore make mistakes, & some of them, big ones!”them, big ones!”

Click here for pt info sheetClick here for pt info sheet

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

•Meditation (conditions switching off “what if?” Meditation (conditions switching off “what if?” thinking in GAD, “futurising” type problems)thinking in GAD, “futurising” type problems)

– Start with a one minute meditation exercise. Start with a one minute meditation exercise. Model out loud own multisensory awarenesses, Model out loud own multisensory awarenesses, moment to moment, free from any positive or moment to moment, free from any positive or negative judgments / adjectival speechnegative judgments / adjectival speech

– Pt tries same for similar period out loud Pt tries same for similar period out loud initially & gradually increases time during initially & gradually increases time during repeated home assignments e.g. eventually repeated home assignments e.g. eventually long enough for hypnogogic phase of sleep to long enough for hypnogogic phase of sleep to startstart

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

•Guided Imagery. Used for relaxation, Guided Imagery. Used for relaxation, enhancing performance or imaginal enhancing performance or imaginal confronting of avoided stimuli, obsessional confronting of avoided stimuli, obsessional cues, trauma recollections - often in graded cues, trauma recollections - often in graded exposure fashion e.g. sees self extending exposure fashion e.g. sees self extending travel radii from home travel radii from home

– Can be intensified in hypnotic state or Can be intensified in hypnotic state or with associated cues e.g. vehicle crashes with associated cues e.g. vehicle crashes or aircraft sound effects recordings. or aircraft sound effects recordings. Search Web for theseSearch Web for these

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

– In confrontive applications, cognitive & In confrontive applications, cognitive & somatic counter-conditioning imperative somatic counter-conditioning imperative before pt leaves session. Otherwise before pt leaves session. Otherwise in in vitrovitro exposure resensitises rather than exposure resensitises rather than desensitisesdesensitises

– See Sleeping Better pt notes for example See Sleeping Better pt notes for example of relaxing Guided Imagery technique of relaxing Guided Imagery technique (‘Counting Down to Sleep’)(‘Counting Down to Sleep’)

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

•Distraction (GAD, acute pain etc Distraction (GAD, acute pain etc notnot when when extinction needed e.g. specific phobias, P.D.extinction needed e.g. specific phobias, P.D.+A., PTSD)+A., PTSD)

•Rational emotive imagery. Maultsby’s Rational emotive imagery. Maultsby’s technique - pts simply instructed to “push” technique - pts simply instructed to “push” themselves to feel better over a minute or themselves to feel better over a minute or so then articulate how they did it. (Usually so then articulate how they did it. (Usually with more rational thinking that provides with more rational thinking that provides starting point for further practice)starting point for further practice)

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

•Structured problem solving (common skill Structured problem solving (common skill deficit in worriers). Applied common sense. deficit in worriers). Applied common sense. New variation on old “Think, judge, act” rule New variation on old “Think, judge, act” rule of conduct. Again see ‘Managing Worry’ pt of conduct. Again see ‘Managing Worry’ pt info sheets pp. 5-6info sheets pp. 5-6

•See Video examples (Andrews & Hunt, 1998) See Video examples (Andrews & Hunt, 1998) of structured problem solving with anxious of structured problem solving with anxious pts on CD-ROM available via CRUfAD Web pts on CD-ROM available via CRUfAD Web address in References address in References

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

• B. Cognitive Therapy for DepressionB. Cognitive Therapy for Depression– As for CBT for anxiety, explain cognitive As for CBT for anxiety, explain cognitive

restructuring for depression to pt. Role of restructuring for depression to pt. Role of specific thoughts, thinking styles & core beliefs. specific thoughts, thinking styles & core beliefs.

– Perhaps start with examples of common Perhaps start with examples of common thinking styles seen in those more prone to thinking styles seen in those more prone to depression e.g. Seligman’s 3P’s of adversity depression e.g. Seligman’s 3P’s of adversity “permanent, personal & pervasive” as they “permanent, personal & pervasive” as they apply to the cognitive triad of depression – apply to the cognitive triad of depression – future, self & the worldfuture, self & the world

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

– Supplement with info sheets / recommended Supplement with info sheets / recommended reading.reading.

Click here for pt. info sheet on Ellis’s ABC model. Click here for pt. info sheet on Ellis’s ABC model. Probably easiest of cognitive therapies for pts to Probably easiest of cognitive therapies for pts to understand. Info sheet focus: understanding & understand. Info sheet focus: understanding & modifying specific thoughts associated with modifying specific thoughts associated with depressiondepression

– Visit Visit www.rebt.orgwww.rebt.org for more on Ellis’s Rational for more on Ellis’s Rational Emotive Behaviour Therapy. Emotive Behaviour Therapy.

– Work thru structured program material with pt. Work thru structured program material with pt. Keep demands low at first because of problems Keep demands low at first because of problems with concentration, lethargy etc.with concentration, lethargy etc.

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

– Pt material on raising activity levels & Pt material on raising activity levels & modifying depressive cognitions from Oxford modifying depressive cognitions from Oxford University Psychology Dept click here (Melanie University Psychology Dept click here (Melanie Fennell in Hawton et al., 1989)Fennell in Hawton et al., 1989)

• Structured problem solving for depressionStructured problem solving for depression– Click here for single sheet description of Click here for single sheet description of

technique. Present sheet to pt in session to aid technique. Present sheet to pt in session to aid application application

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

• C. Cognitive Therapy for Chronic PainC. Cognitive Therapy for Chronic Pain– Click here to see list of common thoughts Click here to see list of common thoughts

& associated feelings that can worsen pain& associated feelings that can worsen pain– Click here to see some suggested disputations Click here to see some suggested disputations

of thoughts that can worsen painof thoughts that can worsen pain

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7. Cognitive-Behavioural 7. Cognitive-Behavioural StrategiesStrategies

– Cognitive therapy for self-defeating thoughts relies Cognitive therapy for self-defeating thoughts relies on usual strategies such as ‘diarying’ & disputationon usual strategies such as ‘diarying’ & disputation

– Hypnotherapy (perhaps the oldest cognitive Hypnotherapy (perhaps the oldest cognitive therapy) seen by many pts as useful. A daily ½ therapy) seen by many pts as useful. A daily ½ hour self-hypnosis session can provide a welcome hour self-hypnosis session can provide a welcome break from constancy of painbreak from constancy of pain

Click here for list that includes other cognitive (& Click here for list that includes other cognitive (& behavioural) pain mx strategiesbehavioural) pain mx strategies

Click here for more details on cognitive treatment, Click here for more details on cognitive treatment, targets, strategies & their rationales (go to page 6 targets, strategies & their rationales (go to page 6 for cognitive treatments etc)for cognitive treatments etc)

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8. Psychiatric Practice 8. Psychiatric Practice Scenarios: How Can Behaviour Scenarios: How Can Behaviour Therapy & CBT Help?Therapy & CBT Help?• 1. As a psychiatric 1. As a psychiatric

registrar you see many registrar you see many patients whose primary patients whose primary complaint is that they complaint is that they are "unable to sleep." are "unable to sleep." Discuss the most Discuss the most common reasons for common reasons for this presentation. How this presentation. How would you evaluate would you evaluate such a problemsuch a problem and and how might you treat it how might you treat it using learning theory using learning theory principles? (exclude principles? (exclude ‘therapist modelling’ as ‘therapist modelling’ as per pic)per pic)

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8. How Can Behaviour Therapy 8. How Can Behaviour Therapy & CBT Help?& CBT Help?• 2. Ms A is a 45 year old woman who presents at 2. Ms A is a 45 year old woman who presents at

mid-morning to Emergency Dept. complaining of mid-morning to Emergency Dept. complaining of nausea and anxiety. She had been unable to sleep nausea and anxiety. She had been unable to sleep the previous night because she had run out of her the previous night because she had run out of her usual sleeping tablets (Temazepam). She has been usual sleeping tablets (Temazepam). She has been taking up to 4 tablets (10mg) nightly for several taking up to 4 tablets (10mg) nightly for several months as her insomnia had worsened. She had months as her insomnia had worsened. She had increased the dose herself as her doctor had increased the dose herself as her doctor had refused to do so and she had resorted to visiting refused to do so and she had resorted to visiting more than one doctor. She admits to being more than one doctor. She admits to being somewhat anxious and depressed in mood at times somewhat anxious and depressed in mood at times and to having difficulty concentrating on her work. and to having difficulty concentrating on her work. She denies taking any other drugs.She denies taking any other drugs.

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8. How Can Behaviour Therapy 8. How Can Behaviour Therapy & CBT Help?& CBT Help?

• 3. Describe and discuss the various treatments 3. Describe and discuss the various treatments that are currently used in the treatment of Panic that are currently used in the treatment of Panic Disorder with Agoraphobia.Disorder with Agoraphobia.

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8. How Can Behaviour Therapy 8. How Can Behaviour Therapy & CBT Help?& CBT Help?

• 4. You are treating a 45 year old man with chronic 4. You are treating a 45 year old man with chronic low back pain. He is requiring increasingly low back pain. He is requiring increasingly frequent pethidine injections and appears frequent pethidine injections and appears depressed and tearful. He says he can no longer depressed and tearful. He says he can no longer cope with the pain. How do you approach this cope with the pain. How do you approach this problem?problem?

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8. How Can Behaviour Therapy 8. How Can Behaviour Therapy & CBT Help?& CBT Help?

• 5. A rather shy and introverted Engineering 5. A rather shy and introverted Engineering Student attends your outpatient clinic and tells Student attends your outpatient clinic and tells you that he can't present his assignments in you that he can't present his assignments in front of his seminar group. How can you as his front of his seminar group. How can you as his psychiatric registrar help him?psychiatric registrar help him?

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9. Reference Material9. Reference Material

• Andrews, G. and Hunt, C. (1998) Counselling and Management Andrews, G. and Hunt, C. (1998) Counselling and Management Skills in Clinical Practice. (CD-ROM) Clinical Unit for Research of Skills in Clinical Practice. (CD-ROM) Clinical Unit for Research of Anxiety Disorders (Web link next page for purchase), UNSW Anxiety Disorders (Web link next page for purchase), UNSW Psychiatry – St. Vincent’s Hospital, Sydney, NSW, AustraliaPsychiatry – St. Vincent’s Hospital, Sydney, NSW, Australia

• Hawton, K., Salkovskis,P. et al.(1989) Cognitive Behaviour Hawton, K., Salkovskis,P. et al.(1989) Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide. Oxford Therapy for Psychiatric Problems: A Practical Guide. Oxford University Press.University Press.

• Sperry, L. et al. (1992) Chapter 4 ‘Behavioral Formulations’ Sperry, L. et al. (1992) Chapter 4 ‘Behavioral Formulations’ inin Psychiatric Case Formulations. American Psychiatric Press, Psychiatric Case Formulations. American Psychiatric Press, WashingtonWashington

• Treatment Protocol Project (1997) Management of Mental Treatment Protocol Project (1997) Management of Mental Disorders.Disorders.

WHO Collaborating Centre for Mental Health and Substance WHO Collaborating Centre for Mental Health and Substance Abuse, Darlinghurst, NSW, Australia 2010Abuse, Darlinghurst, NSW, Australia 2010

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9. Reference Material9. Reference Material

• Clinical Research Unit for Anxiety Disorders (CRUfAD)Clinical Research Unit for Anxiety Disorders (CRUfAD) WebsiteWebsiteA UNSW site with excellent anxiety resources for pts and A UNSW site with excellent anxiety resources for pts and professionals. Free treatment manuals, CBT teaching professionals. Free treatment manuals, CBT teaching resources, assessment protocols, self-test, CD-ROM, videos, resources, assessment protocols, self-test, CD-ROM, videos, links etc links etc http://www.crufad.com/homepage.htmhttp://www.crufad.com/homepage.htm

• MoodGym MoodGym Excellent self-paced web program for behavioural & CBT of Excellent self-paced web program for behavioural & CBT of depression (mainly) and anxiety. Downloadable relaxation depression (mainly) and anxiety. Downloadable relaxation instructions and music instructions and music http://http://moodgym.anu.edu.aumoodgym.anu.edu.au//