Cognitive Behaviour Therapy (CBT)

- its application to Depression

& Low Self-esteem
Frank McDonald
Consultation-Liaison Psychologist
The Townsville Hospital
for JCU Med School Year 5 Mental Health Rotation
www.fmcdonald.com
Overview

• What is CBT?
• Suitable Conditions for CBT
• Preparatory Steps
• Central Concepts of Cognitive Therapy: 3 levels of thinking
• Core Beliefs
• Schema
• Automatic Negative Thoughts (ANT’s)
• ‘How to’ of Cognitive Therapy
• Assessment
• Managing ANT’s
• Referring on option
• Class Exercise: Cognitive Therapy case study formulation of
depression & low self-esteem
• Patient & Therapist Resources
What is CBT ?

Any significant mental

health problem involves
Biological
on-going interactions
amongst
• Biological factors
genes, current biological Mental Health
state
• Psychological factors
cognitions (thoughts &
schemas), affect (feelings Psychological Social
& moods), overt
behaviours
• Social factors
immediate social
environment & culture
What is CBT ?
• Cognitive Behaviour
Therapy is one approach to
addressing Psychological
contribution to mental
health issues
• Based on idea that
thoughts create moods,
influence behaviour &
alter physiological state

Feelings & behaviour depend

on interpretation of events
What is CBT ?
• In CBT pt’s learn that we
all have inherent
tendencies to certain
specific thoughts,
schemas & core beliefs
(more generalised ways
of thinking) that can
evoke unhappiness &
disturbance
• We can learn to spot
negative thoughts as they
come up & then challenge
& re-think them
 What is CBT ?
• Cognitive Therapy usually
combined with behavioural
techniques or ‘experiments’
• These help pts act on their
new ideas. Disconfirm their
original conclusions & confirm
alternative beliefs e.g.
asserting self usually does not
end in hostility but engenders
respect
• They also address behavioural
excesses (e.g. avoidance) &
deficits (e.g. problem-solving) Confronting fear of heights
• When combined, termed consolidates new ideas about fear
Cognitive Behaviour Therapy
CBT empirically supported for
• ADHD
• Conduct disorder
• Dementia
• Substance abuse (including
alcohol)
• Schizophrenia
• Depression
• Bipolar disorder
• Panic disorder
• Phobias (eg Social Phobia)
• Generalised anxiety disorder
• Obsessive-compulsive disorder
• Posttraumatic stress disorder
• Somatoform & factitious
disorders
• Dissociative disorder
• Sexual disorders
• Eating disorders
• Some sleep disorders
• Personality disorders
• Marital, family and parenting
problems
• Pain
• Health-related behaviours

In these diagnostic groups CBT has increasingly become

the treatment of choice or a significant adjunct to
pharmacological management
Preparatory steps
1. Is there evidence of CBT’s
effectiveness with presenting
problem?
2. Explain relationship between thinking
& feeling via basic CBT model of
distress e.g. Ellis’s ABC model (click
link). Does pt accept it? (Many do. It’s
the easiest of all psychotherapies for
people to understand & apply.)
3. Is pt willing & able to identify &
regularly work on specific problems
via self-help assignments? e.g. keep
written record of re-evaluations of
Automatic Negative Thoughts
(ANT’s)?
4. Willing to read suggested material
(‘bibliotherapy’) to facilitate self-help?
Central concepts
• Within Beck’s model of
Cognitive Therapy pt
interpretation of events
analysed at 3 levels of thinking
• 1. Core Beliefs about self,
others, the world/life e.g. “I am
a failure, others are always
ready to attack me. The world
is full of bullies, life is not fair”
• Most fundamental but least
conscious influence on our
perceptions of events.
Develop from early
experience
Central concepts
• Such beliefs potentially could
produce state of extreme &
continuous distress. But next,
more intermediate level (its
assumptions & rules),
acts as buffer around core beliefs
in engagements with self, others,
& world
• Unconditional & absolutist. They
consist of most sensitive view of
self (vulnerable, helpless, inept,
loveless, worthless) & most
primitive view of others (rejecting,
hostile, demeaning). “I’m
worthless” “I’m unlovable” “I’m a
failure” “The world is hostile”
“Other people hate me”
 Central concepts
• 2. Schemas (mental structures that
organise info), assumptions & rules
that allow pt to function, even if not
optimally
• Often expressed as conditional
‘if-then’ statements
• Also may adopt rules for life - ‘shoulds’,
‘musts’ ‘oughts’ ‘needs’ - to cope
• e.g. “If I show my weaknesses, then others
will reject me. If I’m good then good things will
happen. Everyone should approve of me. I
must try to excel, others will like me & then
I don’t have to face my feelings of failure as a
person. I need to have others’ approval,
attention or affection (like air, water, shelter vs.
prefer )”
Central concepts
• 3. Automatic negative thoughts (ANT’s) or ‘self-talk’
• Most accessible level of cognition
• These repetitive internal words, phrases, images,
meanings drive our ‘here & now’ experiences &
emotional responses
e.g. “I can’t face the day. Why get up? There’s nothing to
live for!”
Central concepts

• Initial Cognitive Therapy focus on ANT’s

• Scratch the surface of almost any mood problem, like
depression, & you’ll find associated self-talk e.g. “Life is
such a struggle. I’ve run out of fight. I can’t face another
day!”
• Whether cause or effect of depressed mood, such self-talk
will make depression, due to whatever cause, worse
‘How to’: Assessment
• Therapy begins (& often continues) with some form of
assessment to reveal presence of any of 3 cognitive factors
above
Can include:
Clinical interview
Self-monitoring (diaries). Central to Cognitive Therapy
Self-report questionnaires (e.g. Irrational Values Scale;
John Young’s Schema Questionnaire)
Structured interview (e.g. Functional Analysis of who,
what, when, where, thoughts & feelings, antecedents
(recent & remote) & consequences, purpose
served/payoffs for maintaining problem)
Observation (e.g. ‘think aloud’ technique)
Clinical records (e.g. referral notes, hospital observations)
‘How to’: Managing ANT’s
• ANT’s are usually first focus of Cognitive Therapy. Become obvious
from assessments & as listen to pt’s experiences & concerns
• This ‘5 Steps’ handout quickly shows pts how to identify & manage
ANT’s. Supplement with following handouts. Pt reading is previously
agreed requirement of most Cognitive Therapy to augment therapy
sessions
1. Cognitive_therapy_intro_for_pts.pdf Comprehensive intro to ‘cognitive
restructuring’ starting with contrasting case examples
2. Diary disputing pages 32-34.pdf Useful leads for questioning ANT’s &
diary/log example
3. Examples_of_unhelpful_thoughts.pdf Thinking styles that cause
distress
4. coping_statements.pdf Shortcuts to disputation
5. Managing_Unhelpful_Thoughts.pdf More tips on self-mx of ANT’s
6. disputing irrational thoughts.pdf Step by step self-mx example using
Ellis’s ABC model
‘How to’: Managing ANT’s
• CBT is not teaching pts what to think
or insisting logical/positive
/rational/helpful thoughts always be
sought out
• It does not usually address normal
sadness or distress associated with
unpleasant situations e.g. anxiety
while awaiting cancer test results
• Rather, stages of therapy reflect
objectives:
i) to help pts see relationship
between thinking & feeling thru
identifying specific ANT’s & then
ii) to help pts consider possibility of
alternative ways of seeing situation.
Simply inviting them. There are
numerous ways to achieve this goal
‘How to’: Managing ANT’s

• One method: ask pt to

consider questions on ‘diary
disputing’ h/o (#2) in relation
to a specific ANT they
identify
• By re-assessing, pt may
recognise alternative
explanations of events that
may be equally valid & lead
to more helpful response
• More methods: See ‘Pt and
Therapist Resources’ slide
‘How to’: Managing ANT’s
iii) Pts then to identify changes in mood or distress levels
& to record simultaneously what specific images &
thoughts they were aware of & new ratings of
endorsement of original beliefs after reflecting on new
perspectives (see diary example below)
Situation: Negative Thoughts Degree Alternative Degree
of Belief Thoughts of Belief
Waking up & not “I can’t face the day. 90 % “Stick to last night’s 40%
wanting to get out There’s nothing to get up plan. Once I’m up I
of bed for. I’ve got nothing to live usually feel better.
for.” Being more active will
lift my mood.”
At a friend’s house “I’m such boring company. I 85% “She did invite me to 25%
bet she wishes I’d just go come around. We’ve
home. I’m just making her been friends for a
feel bad too.” long time. She will
understand if I’m not
in top form.”
‘How to’: Managing ANT’s
• For many pts challenging
& changing ANT’s with
logic & evidence may be
sufficient
• May well positively effect
deeper levels of
maladaptive
thinking/assumptions
(schemas & core beliefs)
without direct attention to
these . . .

. . . or maybe not
‘How to’: Referring on
• If not, & distress or dysfunction remains high after
working on ANT’s, further work needed e.g. on
underlying Core Beliefs and/or Schema
• Such fundamental ways of thinking are long-established
& so usually require longer-term therapy that builds more
evidence for new ways of thinking against old patterns of
thought
‘How to’: Referring on
• Due to time factor, GP’s usually consider referring on to
Psychologists or other therapists trained in more
advanced forms of CBT eg schema focussed therapy or
dialectical behaviour therapy (DBT)
• Also, some therapists are more familiar with attributional
styles which most commonly occur in range of situations
within specific disorders. They can short-cut process of
identifying ANT’s & other beliefs & save therapy time

See Table next slide

Specific Disorders & Appraisal Style
Panic Disorder Enduring tendency to misinterpret physical symptoms
in catastrophic ways

Over-estimation of threat, intolerance of uncertainty,

Generalised Anxiety Disorder worry about worry

Depression Maladaptive schemata containing negative info about

self, future & the world

Post-traumatic Stress Perceived unpredictability & uncontrollability; loss of

belief in personal competency

Social phobia Assumed social incompetence, self-focus assessing

personal ineptitude

Eating Disorders Excessive need to control eating; belief that self-worth

solely related to shape & weight

Focus on intrusive thoughts; excessive responsibilty

OCD for harm; over-estimation of catastrophe
Case study formulation

Class Exercise
• Clinically depressed 25 y.o. with low self-esteem presents
for CBT after rejection by work colleague saying “I don’t
know how to interact successfully with people.” “Life is
such a struggle, I’ve run out of fight. I can’t face another
day.” “People don’t care about me. They are trying to
destroy me. I’ll never get better.”
• (These are her ANT’s - that stream spontaneously into her
consciousness unbidden but which seem very real &
plausible. These emerge early in Cognitive Therapy as
you ask pt to identify thoughts associated with her feelings
of low self-esteem & depression.)
Case study formulation
• Now, consistent with above, & starting from infancy,
childhood & adolescence let’s create a possible life history
of early experiences (critical events, deprivations, parental
personalities & peer relations, home, school & other
experiences that may have shaped core beliefs &
assumptions)
______________________________________________
______________________________________________
______________________________________________
_______________
• Suggest core beliefs about her self, others & life in general
that arose from those experiences
______________________________________________
______________________________________________
______________________________________________
Case study formulation
• Propose schema & basic assumptions, standards, values, rules,
guidelines for living that allow her to cope, despite core beliefs
(remember “ if…then”, “should”, “must”, “ought”, “need” self-
statements)
_______________________________________________________
_______________________________________________________
_______________________________________________________
__________________
• Then, these protective views of her self, world & others begin to
destabilise (rules are broken or assumptions are brought to fore),
increasing her vulnerability to dysfunction, as one or more distressing
situations develop, critical incidents occur, some repeated moderate
or singular major upsets, adversities or catastrophes strike - such as
_______________________________________________________
_______________________________________________________
_______________________________________________________
__________________
Case study formulation
• A specific precipitating event triggers underlying
maladaptive assumption or schema, or core belief & pt
decompensates. In this case the event was
_____________________________________________
_____________________________________________
____________
• Automatic negative thoughts – unwanted, intrusive,
unhelpful thoughts & meanings unconsciously rooted in
her core beliefs & schema then emerge uncontrollably,
propelling her into therapy. Any variations on presenting
ANT’s that might flow from our construction?
_____________________________________________
_____________________________________________
____________
Italicized headings above are drawn from Aaron T. Beck’s Cognitive
Therapy approach to case conceptualisation
Case study formulation
Early experiences

Formation of core beliefs about self, others, world & life in general

Formation of schema & basic assumptions

Critical incidents

Precipitating event

Automatic Negative Thoughts

Armed with formulation based on above, you can more fully engage
in Cognitive Therapy following steps outlined in slides 8 (Preparatory
steps) & 15 – 17 (Managing ANT’s)
Patient & Therapist Resources
• “Mind over Mood: a Cognitive Therapy Treatment Manual
for Clients”. Greenberger, D., Padesky, C.A. New York
Guilford Press 1995 (Workbook full of relevant exercises
to help pts work thru problematic emotions)
• “Reinventing your life: How to Break Free from Negative
Life Patterns”. Young, JE & Klosko, J. Dutton, New York,
1993 (Helps pts identify schema & provides guidance on
managing them)
• “Cognitive Therapy Techniques – a practitioner’s guide”.
Robert Leahy. NY Guilford Press 2003 (“A treasury of
cognitive therapy strategies & techniques. All the tools a
therapist needs . . .” Aaron T. Beck)
• “Cognitive Therapy for Challenging Problems – What to
do when the basics won’t work”. Beck, JS. NY Guilford
Press 2005. (Suits novice & mature therapists alike)
Suggested responses
• Now, consistent with above, & starting from infancy,
childhood & adolescence let’s create a possible life
history of early experiences (critical events, deprivations,
parental personalities & peer relations, home, school &
other experiences that may have shaped core beliefs &
assumptions)
• Distant father, suffers from depression, wanted son not daughter &
repeatedly tells her so for years
• Mother cold, aloof, can’t engage, so feelings of being unloved
• Striving for approval through hard work, academically very
successful & takes solace in that
• Bullied at school relentlessly, told ‘ugly’, feelings of insecurity, sees
world as hostile, demeaning, rejecting
• Isolation, need for self-reliance & control, but desperate for others
approval & sense of security
Suggested responses
• Suggest core beliefs about her self, others & life in
general that arose from those experiences.
(Remember - these are unconditional, absolutist core beliefs
developing from early experiences)
• “I am a failure, I am inadequate, I am worthless, I am unloved &
unlovable, I shouldn’t have been born”
• “I am alone, I am ugly & different from others. I cannot rely on others
for anything”
• “The world & others are hostile & they hate me”
Suggested responses
• Propose schema & basic assumptions, standards,
values, rules, guidelines for living that allow her to cope,
despite core beliefs (remember “ if…then”, “should”,
“must”, “ought”, “need” self-statements)
• “If I try hard enough, others will grow to like me. I will get more
affection. I need attention”
• “If I am successful I will be approved of”
• “If I show my inadequacies, others will reject me”
• “If I can’t cope I will be seen as weak & helpless. Dependency is a
sign of weakness”
• “ If I am not loved & accepted I will always be unhappy”
Suggested responses
• Then, these protective views of her self, world & others
begin to destabilise, (rules are broken or assumptions are
brought to fore) increasing her vulnerability to
dysfunction, as one or more distressing situations
develop, critical incidents occur, some repeated
moderate or singular major upsets, adversities or
catastrophes strike - such as
• Experiences of rejection or disapproval that have cumulative effect
• Bullying continues at university
• Relationships break up
• She has conflict with management at work about job conditions
Suggested responses
• A specific precipitating event triggers underlying
maladaptive assumption or schema, or core belief & pt
decompensates. In this case the event was

• Rejection by colleague at work

• Automatic negative thoughts – unwanted, intrusive,

unhelpful thoughts & meanings unconsciously rooted in
her core beliefs & schema then emerge uncontrollably,
propelling her into therapy. Any variations on presenting
ANT’s that might flow from our construction?

• As detailed in vignette

Q&A