Cognitive Behavioural Therapy (CBT)

CBT is used as monotherapy or in combination with medication for major depressive disorder, generalized anxiety disorder, and eating disorders. If a patient has cognitive distortions and avoidance behaviour, this make them a good candidate for CBT.

CBT can be delivered in a wide variety of formats. Group and remote delivery (online or phone) CBT works as well as individual therapy.^[1]

CBT provides also provides stronger protection from relapse following treatment discontinuation compared to medications.^[2][3] When depression-specific psychotherapies are delivered in routine practice, recovery rates from depression are close to 50%.^[4]

Treatment is generally time-limited (approximately 12 sessions). Cognitive techniques include identifying distortions such as overgeneralization of negative events, catastrophizing, minimizing positive events, and maximizing negative events. Patients work with therapists to identify and change cognitive distortions and avoidance behaviours that cause their symptoms. This frequently involves keeping diaries or “thought records” outside of sessions and practicing behavioural strategies learned in sessions.

1. CBT is based on an ever-evolving formulation of patients’ problems and an individual conceptualization of each patient in cognitive terms.
2. CBT requires a good therapeutic alliance.
3. CBT focuses on collaboration and active participation;you should view therapy as teamwork; together the doctor and patient decide what to work on each session, how often to meet, and what to do between sessions for therapy homework. At first, the physician may be more active in suggesting a direction for therapy sessions and in summarizing what's discussed during a session
4. CBT is goal oriented and problem focused. You should ask in your first session for your patient to describe their problems and set specific goals so there is a shared understanding of what they are working towards.
5. Self-perception is amenable to change through CBT

Just like how CBT is a structured-form of therapy, your sessions with your patient should also be structured and modeled on that. A typical CBT session should be structured as follows:^[5]

It is important for the patient to have specific goals they want to achieve by the time they are finished the course of therapy.

It is also important to have goals between sessions, that are more attainable and realistic. The “SMART Goals” framework is one way of achieving that.

• S - Specific
• M - Measurable
• A - Attainable
• R - Realistic
• T - Time

Example of a SMART goal could be: “Add more structure to your day” – i.e. Make your bed, eat regular meals, have a regular sleep schedule, and make a regular schedule. Another SMART goal could be: “Have more social interaction by calling one friend each week.”

Homework is an integral part of CBT, and what makes CBT work. There are various types of homework assignments including:

• Behavioural activation
• Monitoring automatic thoughts
• Practicing new skills or implementing new solutions
• Reading assignments (like chapters in Mind Mover Mood)

You should ask yourself what is going through your mind when homework isn't being done. Remind yourself that you are not doing your patients any favours if you allow them to skip homework or don't encourage better compliance. The literature shows that patients who do homework assignments regularly have a better prognosis that paints who do not.^[6]

• Identify your patient's current feelings (“I’m a failure, I can’t do anything right, I’ll never be happy”)
• Identify the problematic behaviours (isolating herself, spending a great deal of unproductive time in her room, avoiding asking for help). These problematic behaviours both flow from and in turn reinforce Sally’s dysfunctional thinking.
• What the precipitating factors that in influenced your patient's perceptions at the onset of their depression? (e.g., being away from home for the first time and struggling in her studies contributed to her belief that she was incompetent)
• Third, I hypothesize about key developmental events and how the enduring patterns of interpreting these events that may have predisposed your to their symptoms (e.g., your patient has had a lifelong tendency to attribute personal strengths and achievement to luck, but views her weaknesses as a reflection of her “true” self).

• Do a scale to quantify symptoms
• Set the agenda
• Review the homework from last time
  • Thought records, behavioural activation
• Note any safety concerns
• Note any changes in therapeutic alliance, transference/countertransference

1. “What is the evidence that your thought is true? What is the evidence on the other side?”
2. “What is an alternative way of viewing this situation?”
3. “What is the worst that could happen, and how could you cope if it did? What’s the best that could happen? What’s the most realistic outcome of this situation?”
4. “What is the effect of believing your automatic thought, and what could be the effect of changing your thinking?”
5. “If your [friend or family member] were in this situation and had the same automatic thought, what advice would you give him or her?”
6. “What should you do?”

Sometimes a patients emotions and thoughts are very valid, the question is how well do they cope with these feelings?

When evaluating situations that your patient brings up, here are some helpful techniques:

Use a pie chart to assess the pie chart contribution of the situation

- “If you are a terrible student, then where are you on this continuum,” “Are you a 100% terrible student? 50%? or 0%? Why that percent?” - “If you feel like you are a failure or people don’t love you, “How much of that do you think is true? 100%, 50%?”

• Rate the feeling
• which thought matches the emotion - the hot thought
• how much you believe in each thought
• which thought is the most therapeutic
• evidence for and against

The goal of CBT is to help your patients correct the hot thought, by reaching balance thoughts such as:

• Even though [i’m behind on my rent], I can see that [I have a solution now/and a capable person], because [I have support from my family].

Beware though, of superficial and “fake” balance thoughts. For example, if a patient is constantly worried about having anxiety because their hot thought is: “I’m a terrible mom.” and her balanced thought is “but I’m an good wife.” Notice that this balanced thought doesn't actually relate to the hot thought. If the balance thought does not correspond with the hot thought, that’s a giant pit fall the therapist must identify!

Socratic questioning, or the socratic method, is a key technique in CBT. You help your patient understand themselves by asking questions about their thoughts, examples include:

• “What was going through your mind before you started to feel this way?”
• “What images or memories do you have of this situation?”
• “What does this thought mean about your future, and your life?”
• “What are you afraid might happen?”
• “What is the worst that could happen?”
• “What does this mean about how the other person thinks about you?”
• “What does this mean about the other person or people in general?”
• “Did you break rules, hurt others, or do something that you should not have done?”
• “What do you think about yourself about having done this, or thinking you did this?”

CBT uses lots of different terminologies, and it can be helpful to spell out exactly what they mean, so both you and your patients can be speaking the same language.

• Feelings are one word
• You're not a robot, you can't change feeling, but you can change thoughts and behaviours

• Thoughts are sentences
• Be skeptical of your thoughts!
  • Sometimes your thoughts are right, but sometimes they can be wrong too

Although some automatic thoughts are true, many are either untrue or have just a grain of truth. Patients need a structured method to evaluate their thinking; otherwise, their responses to automatic thoughts can be superficial and unconvincing and will fail to improve their mood or functioning. Typical mistakes in thinking include:

1. What is the evidence that supports this idea? What is the evidence against this idea?
2. Is there an alternative explanation or viewpoint?
3. What is the worst that could happen (if I’m not already thinking the worst)? If it happened, how could I cope? (What is the best that could happen? What is the most realistic outcome?)
4. What is the effect of my believing the automatic thought? What could be the effect of changing my thinking?
5. What would I tell [a specific friend or family member] if he or she were in the same situation?
6. What should I do?

It is often very hard to describe what exact situation occurred when your patient describes their automatic thought to you weeks after the event. By that time, the patient often has had several days to think about their actions-thoughts-behaviours, and it can be easily to over-rationalize those thoughts. To get a better sense of the exact automatic thought and behaviours, it can be helpful to ask your patient: “replay everything back to me like a movie, down to the specific words exchanged and the conversation if you can.” This helps ground the patient on the exact situation at that time, and helps you better understand their thought process.