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0:00
hi this is dr. Diane Gayheart and this is my lecture on cognitive behavioral therapy and counseling it's just an introductory one that kind of covers the basics because this is a broad area but it is designed to go with my textbooks case documentation counseling and psychotherapy as well as theory and treatment planning in counseling and psychotherapy which go into much more depth than I can do in this one online video and there are also many other free
0:29
resources you can find at mastering competencies dot com so giving a lay of the land of cognitive behavioral or CBT as most people refer to it in the field it's not easy actually because there are different versions of how it evolved or what's what so I'm gonna primarily the behaviorists have one way of kind of this finding the different phases and the cognitive folks have a different way of doing it so but basically CBTs
1:00
were first this very broad range of therapeutic models that are grounded on some very basic behavioral concepts as well as cognitive concepts and so originally these as you may may be obvious maybe not they originally evolved as separate approaches but most people will use these together not always but and also depending on the problem they might use more behavioral versus cognitive for example phobias and such seemed were often respond very well
1:40
to a more behavioral and cognitive types of approaches so the behavioral approaches evolved out of you know research such as classical conditioning those are Pavlov's dogs and you know you're ringing a bell dog salivates by pairing a different stimuli operant conditioning which are the Skinner boxes so you know you slowly reinforce steps towards a desired behavior to encourage to train or teacher learning behavior and also like social learning
2:16
theories also under the umbrella behavioral approaches how we you know watch others and learn behavior that way so that's one of the early schools and I they began in labs kind of psychology labs and that what they'll the principles they learn from those laboratory experiments got translated into a therapeutic approach and then similarly the cognitive approaches evolved out of cognitive theories in psychology and then it evolved into
2:50
therapeutic model that and you know early pioneers in this area like Aaron Beck we used a purely cognitive model and like I said though most people today do a blend of these two the cognitive behavioral it's probably the most frequently cited therapy model it it is favored often by insurance companies and HMOs because it follows a medical model it's based a very it has very strong evidence base to it because these approaches actually you know emerge from
3:25
a modern scientific method and so it's very natural and congruent to be doing kind of evidence-based studies on these approaches and they lend themselves well to they're very easy to study compared to something like existential therapy that is dealing with much more philosophical concepts that are just hard to operationalize in the beginning where you know behavioral therapy emerged directly out of psychological experiments so they naturally translate
3:55
to that environment and they also just make sense they make a logical sense and so I think that's also why a lot of people use this that said I don't think a lot of people do CBT all that well and so even though many people will sign it they they're referring to mostly doing psycho education where I think especially when you start working with cognitive therapy delivering that well and doing that well I think takes a lot of skill and some more subtle than one
4:26
might more some then maybe the intervention of psychoeducation so I encourage you if you are interested in this approach to really develop some of the finer skills because there is an art to it I think when it's done particularly well and it's also useful to mention I think I go into this in the book but I'm not gonna do a whole lot up on this in this particular online lecture although I have other online lectures of mindfulness it's a particular area of interest and expertise of mine but
4:57
there's a whole new wave of mindfulness informed and mindfulness-based therapies and within the behavioral tradition they call it the third way that behavioral ISM I don't know if the say be calm or CBT people call it that but what's interesting about mindfulness is that it is it involves especially the mind practice of mindfulness involves watching your breath your quieting the mind and learning to observe what is going on without trying to change this
5:30
and this is really counter cultural - if you're gonna use the behavioral world the first two waves of behavioral ISM where it's you know identify the problem behavior you know and and fix it you know identify the irrational thought and correct it so CBT has always been very corrective and mindfulness is the opposite of that is paradoxical in some ways in that by simply observing your mind and by accepting what is your relationship to it changes and so your
6:03
experience around it changes so it's got this paradoxical element of change to it but mindfulness is being broadly used in in conjunction with CBT therapies nowadays and other therapies and it did actually emerge out of behavioral medicine in a hospital setting working with clients who had chronic pain with Jon Kabat syns mindfulness based stress reduction at the University of Massachusetts so this is kind of the third wave and it's often added or
6:36
complements other CBT approaches again it's very easily studied the evidence base for it is rapidly emerging unlike really anything I think I've ever seen in my career in terms of watching a particular approach be studied but again it lends itself so nicely to its it's a very concrete intervention and so it's relatively easy to measure the outcomes of those interventions so this is and then you know there are multiple forms of CBT
7:09
that I do go into much more detail in the book but again it's a very broad area and so I encourage you to do more reading you can start with one of my texts but there's there many yeah there's a lot of reading to be done here so this is just an introductory overview of the world of CBT and so here forward and we'll prime I'll be talking about you know the more traditional if you want to call the first and second waves of you know behavioral techniques cognitive and then kind of the combined CBTs
7:41
in a nutshell the least you need to know so as the name implies and as I've already mentioned CBT combines behavioral techniques and interventions with cognitive so the behavioral piece of CBT focuses on analyzing how the symptoms are being reinforced in the person's day-to-day life and then you identify ways to either shape or reinforce desired behaviors instead and so in the case of you know working with anxieties and phobias you would look at you know what's reinforcing you know the
8:20
anxiety or phobia and then you would identify what kind of strategies can we use to address this you could do something and we'll talk about some of those you know graduated exposure so you know a little bit of exposure at a time to whatever the feared object is a spider or a snake or whatever that might be so those are the behavioral and there's a hide range of behavioral interventions on the cognitive side the cognitive elements of the approach are
8:49
doing is you're looking at what you might call distorted or dysfunctional thinking or a rash thinking and look at how that is creating whatever the problematic symptom is it might be depression invite the anxiety it might be a phobia and so or even an eating disorder a relationship problem I mean whatever it is so you would analyze where is the distorted thinking or problematic thinking that is related to the symptom so maybe in with depression you might have someone who just went through a
9:22
broke up and breakup and they feel like their life is over so um it's probably an over-exaggeration of the situation and so you would look at that their beliefs that are creating the depression due to the break-up so so that's the basis of it um in terms of the role of the counselors compared to for example many other therapists likes like a dynamic or humanistic or substantial they have a much more educational and expert position that they typically that
9:55
you know CBT therapists typically take in relationship to their clients and so that is different within the different schools you in comparison to other schools and so there is a little bit more of an expertise and a hierarchy and a sense of being educational kind of helping to fix the problem for their client rather than simply for example in the humanistic approach there the therapist is creating a particular process and this process through this
10:27
process the client you know self actualizes and so the focus is really on just facilitating a process it's not that the therapist necessarily has this expertise that they're teaching to the client so it is a particular type of relationship role over the is you may imagine in the beginning since many of these theories you know developed out of a laboratory culture the counselors and therapists tended to have a very detached attitude with clients or
11:01
relationship with clients and over the years there has been a greater introduction of war than empathy into the therapeutic relationship and that's more typical of contemporary 21st century CBT so now I want to highlight the Jews for the significant one of them there are many significant contributions but what I think is one of the more significant contributions to the field my CBT therapist so I'm going to talk about
11:35
Alice's ABC theory of change and it is a cognitive model but it also is there's a version of this and all the different schools but the basic idea here is that most of us you know have an experience a life experience which both they're calling an activating event and then there's a consequence we experience a mood or behavior or and and so and normally what therapists are looking at our CBT therapist is analyzing is you know we come in you know my girlfriend
12:12
broke up with me and then the consequences I'm sad and I'm angry and I'm hurt so and that's often when you're in it and you're experiencing it that's what it feels like she broke up with me and that's why I'm depressed what we don't realize and what is not I would say natural for most of us at least is that in between what mediates that is a belief and that belief we can have conscious control over and we can change our consequent are the undesired
12:50
consequences like sadness or you know bad behavior on our part whatever it might be by changing the belief and this is often just put out there you know the ABC theory and it's when you actually when this sinks in that and you begin to see that all of your internal world can be navigated this way this is a really profound insight and it can be a difficult one at first think most of us don't want to hear in the beginning that oh no no no no she
13:24
did not cause your depression you know your belief about her actions is what's causing your depression most of us really don't want to hear it especially when you're depressed sad feeling you know wronged it's very it's it's not fun to explore that but once you begin to really buy into this idea that you know thing there is this event and it's our beliefs about it our assumptions about how things should be different is what's causing our suffering not the event
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itself and when you truly get that insight it really changes your whole life it's quite profound I don't and it really changes how you engage all aspects of your life and so although this seems very simplistic and often you can put it up on a cute little bored you can diagram it out but I think there's another layer here that is a very profound insight in life and that can really change how one relates to all of life and so this whole idea that
14:29
whatever symptom we're experiencing is not due to a set of life circumstances but our beliefs about those life circumstances which generally in a nutshell are things shouldn't be that way and yet they are and so if you can revise your belief you will have different consequences so um so this is I think a really profound idea that's really the underpinnings of the cognitive piece of this approach and that when this really sinks in it's a
15:09
very profound insight and it's I think I also think it's important to be careful to not take this in a direction because I can have undertones of blaming you know the victim blaming the client you know you're the one parading your own depression stop you know believing that and then you won't you know so that's also the wrong way to work with these ideas and you have to be careful that that you don't have engage you know present these ideas to clients
15:36
in such a way that they begin to feel blamed instead you know having a compassionate stands for this kind of I think at least according to this theory our default way of engaging life the only time we need to sit back and examine those beliefs is when we're having undesirable you know symptoms sad dance or you know becoming angry or rageful or whatever it might be that's when we need to go and examine these beliefs but it is something to do and
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it's important to do this whole process in a way that doesn't belittle or blame the client for whatever might be going on so now I want to talk about the big picture and looking at the an overview of the counseling process in CBT so if you look at the four basic steps or phases of CBT um the first one is assessment and so whether it's more behavioral or cognitive so if it's a behavioral assessment we're going to talk about case conceptualization in a
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moment here you'll be you know analyzing you know what comes before or after the sim you know the symptom was reinforcing the symptoms are the problems in a cognitive approach you'd be focusing more on what are the the beliefs or schemas that are creating the problems so first you assess what's not working what's not right and then step two is you target specific behaviors or thoughts for change and so often this targeting is very concrete and specific
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and typically the targeting would be you know wanting to reduce you know the frequency they might use you know frequency count you know so no more than you know one panic attack or you know no panic you know the goal is that you know not have panic for three months and then therapy is over and so you would you know develop these behavioral targets and I talked more about that in my treatment planning lectures and you know in the book I go
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into a lot of detail about how to do that and in many ways I guess I should jump in here and say that you know the CBT way particularly behavioral part of that the behavioral measure four goals and treatment targets is very much required by insurance payers and such so it's pretty much the approach standard approach for writing goals although if you're familiar with my textbooks my textbooks talk about how to you know use all that various you
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know counseling theories family therapy theories and to write the goals from the therapeutic perspective and then link it to some of these behavioral targets that is what the third parties are wanting so then step three you have to educate clients and what that involves is you know setting up a new reinforcement schedule for the desired behaviors and or you know finding ways to change the beliefs that are related to the problems and then yeah and then finally step four
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is the replacing and the retraining so in step three I get your educating them about how to do this and then step four you are replacing or retraining or you know doing new pairing of stimuli and such to correct whatever the problem is so it's a very kind of has a technical feel it came out of the laboratory environment you can kind of see that very concrete step by step logical problem-solving so I think a lot of people that kind of naturally default to
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this because this is a very logical way to solve problems and at least in a Western cultural context making connection developing the therapeutic and counseling relationship in CBT so as I mentioned earlier one of the kind of signature elements of the therapeutic relationship and CBT is that the therapist or counselor takes on much more of an educator or expert role you know might go up to a whiteboard and draw the ABC you know on the thing on
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the board and you know analyze the clients particular situation they would probably do you know sign thought records we'll talk about those in a moment so sign homework tasks and have clients you know go through their week and you know lysing but using teaching them to use tools outside of the session and so there is this educator and expert role that the therapist or takes on and and actually this can work well with diverse
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clients especially those who come from cultural backgrounds that kind of see doctors as experts and they there is this they they want the doctor to be an expert actually and so that can actually be comfortable with certain clients from diverse backgrounds and we'll talk a little bit more about that at the end of this lecture but again you have to be careful because this approach is loaded with a lot of Western cultural assumptions about how to solve problems
20:43
I'm looking at you know it tends to look at emotionality in a very logical way so there are a lot of even gender culture assumptions kind of embedded that one needs to be aware of and careful with and working with the you know all clients actually not just all clients are diverse and everyone's got you know gender culture ethnicity and so all of that it's important to consider and as I mentioned increasingly their empathy is used on the part of the therapist often
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though it's it's used very differently than empathy is used in humanism and the humanistic approach the therapist uses empathy has a curative for lack of a better word it is the therapy price it is the intervention it is what's gonna promote change its curative it is it's it's what's doing the therapy that what's doing the chain what's promoting the change that is desired and CBT empathy is used to build rapport and make clients feel comfortable to make
21:53
clients feel understood so that they trust the therapist to allow and allows them to then be open to the education portion of it which is where they would say the real change comes from so it's a it's very different it's a it's used to build connection so that the therapy can happen whereas in humanism the empathy is the process for creating the change the desired change and so the more contemporary cbt idol alliance is it tends to be more
22:25
egalitarian tends to have more warmth in it than the traditional you know more lab thing the lab coat therapist but that's the you know that's the culture that this evolved out of and so it's very natural that that would be the relationship where this began and I think even within Western culture there has been a flattening of hierarchies in many ways and so on this kind of demand for more egalitarian more warmth caring it's just also you know CBT is evolving
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as the culture changes another unique thing about CBT is that many CBT therapists will actually use written contracts for how long the therapy will be how frequent they will meet what the goals are I mean with the clients are writing these contracts out and what interventions and the clients agreed to do the homework and such and so they make it a very formal relationship in that sense and so these contracts are used to help motivate clients to be
23:27
engaged in the process which often can demand quite a bit of outside homework and work compared to other approaches were you know humanism and/or psychodynamic or most of the transformational processes in the session so let's next move on to talk about case conceptualization and CBT so there are actually many ways to do case conceptualization and really the distinction between most schools of CBT would be in how exact precisely they
23:58
engage case conceptualization and so we're gonna cover these main ones there are there there are more out there but these are some of the main ones that you will see across the various specific approaches so looking at baseline functioning it's a behavioral approach looking at a the functional analysis of which has a strong element to it analyzing or identifying schemas and core beliefs identifying distorted cognitions looking at there are the
24:33
identifying irrational beliefs looking at the negative cognitive triad there is a whole system called the basic ed from multi modal therapy and we'll also talk a bit here about DSM diagnosis so one form of assessment would be doing a baseline functioning and so this creates um this is where you get a baseline so how frequent is the behavior how long is it what is the severity of it and often identifying and any antecedents so events that may have triggered the
25:07
symptoms as well as the consequences and so for example and this can be very useful because most of our eyewitness testimony in memory is is not so good so it's very helpful to ask clients to actually write even if it's you know for just a week to write down to get a baseline functioning so that what that would mean for example if a parent is reporting that a child is having Tantrums you would have the parent go home and keep a record of how often you
25:36
know where the Tantrums how long do they last how severe was each and to notice any antecedents and consequences from this and it can be very useful because often especially when parents and tantrums it it can they can either overestimate or underestimate the same thing with conflict with couples and even things like depression and panic it's very interesting I thought you can be very useful to actually get a baseline of depression because most
26:05
people come in saying oh I you know I'm feeling depressed and it's been like this for weeks or months and and often times though to get a baseline in terms of when are the depression symptoms most prominent because many people I've worked with when they go to work that they almost disappear or significantly less severe at work and then they're more severe in the morning and or at night when there's free time so that's a common pattern some people are more
26:33
depressed at work too so it's it's useful to just get a sense and I think it's very enlightening to actually especially depression alike with them to rate you know on a scale I give it a scale of one to ten you know and to see how it ebbs and flows across the week and I and across the days even you know in the morning it could be the worse or it's not too bad and it gets worse and even it's I think it's very eye-opening for many people and opens up
26:59
some new ways of looking at what's going on by getting the space line functioning so a similar but more elaborate version of baseline functioning is getting a cognitive behavioral functional analysis so a functional analysis goes a bit deeper than baseline and it involves a much more careful analysis of the antecedents and consequences of problem thoughts and/or behaviors because it will you can have them a person look at what they are doing and thinking and
27:30
what was going on in the environment before the symptom and then you know what happened afterwards and so that is a lot more detailed in terms of of analyzing multiple layers around the you know an occurrence of the symptoms so this is another assessment option when working from a CBT perspective and again it would you would depend on what the problem is whether you would do more of a baseline or functional analysis you can obviously do both ones almost an
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extension of the other for example you know with childhood very concrete behaviors often a baseline is sufficient especially with child behaviors yeah with younger children in particular not so much the teens you might want to do it more in the functional analysis a little more complex that adds in the awfulness psychological piece and so if there's more psychological elements to it you would probably want to add this functional CBT analysis so another
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approach to assessment from a cognitive approach is assessing schemas and core beliefs and this comes out of the original work of Aaron Beck who talked about we have these automatic thoughts kind of like these knee-jerk reactions a distressing situation so you know you know we were talking about the girlfriend breaks up with me and you know that's not fair that's wrong this is terrible this is horrible so that's the first layer
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there's intermediate beliefs that are kind of between these automatic beliefs and the lower levels of core beliefs and schemas and so then I more intermediate belief is that you know it's breakups are bad and then you can go down to this d1 level deeper is kind of core beliefs these are more global but often very absolutist and they're usually about ourselves you know such as I'm worthless I'm not good enough you know I'm a bad person somehow and so this breakup could
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be triggering you know I'll never be good enough you know I'm not good enough for anyone no one will ever love me and then schemas are the deepest level and this cognitive approach of Beck which is it's a very fundamental kind of cognitive framework that really organizes and shapes many thoughts feelings and behaviors and so and so this is when you get into again the you know I am fundamentally worthless I'm unlovable no one will ever love me but
30:11
very core schemas that kind of color a lot of how we see life and so um the assessment process or conceptualization process is going to be identifying the core beliefs and/or schemas that are underlying the symptoms so in this case breakup you know results in a depressed mood and so you're gonna look at the core beliefs and schemas that were triggered that the break-up triggered your beliefs about that and what you you know believe that says about you life
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your future your values you know what life is about so anyway this is the a way of cognitively assessing what's going on and then those become targeted for treatment and for change so another cognitive conceptualization approach is to identify distorted cognitions and cognitive therapists have you know lists of areas this is a list on by Aaron Beck the types are common forms of cognitive distortions that we all like to indulge in that often create
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anxiety depression inspire you know eating disorders or substance use disorders so um you know so these are some of the common things such as magnification or minimization so magnifying certain focusing on certain things and exaggerating it in our minds or minimizing in our minds personalization so you're personalizing you know maybe your partner just doesn't like country music and you take it as a very personal statement about your
31:57
partner not liking you and so because you like country music and so that's you know so they're looking for these habits of mind that we all indulge in to a certain degree to and they start identifying these to help identify the underlying core beliefs and schemas these are habits that tend to be pretty readily identified I would say this is some of the the first cognitive stuff you'll notice as people talk Albert Ellis talks about identifying irrational
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beliefs and he identified the three basic mus and these he abused a rational beliefs are typically flagged by words such as should ask ought to must you know I must do these things so and he talked about three basic categories and again this can be as a way as you're listening to clients talk about their problems you can listen for these themes so one is perfection based worth like if I don't you know if I'm not perfect at work and recognized at work are always
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at the top at work or at school or my you know relationships I'm not perfect if everything's not going right I'm worthless and so this is a very common in Western culture in particular to have your self-worth based on your achievements and that normally is not a very stable way to develop your identity and you're likely to experience either anxiety or depression when you are unable to sustain you know a level of perfect you
33:31
know performance another one if you don't know LS he is a bit on the snarky side so justice for me and so this is one where you kind of have the assumption that everyone on the planet needs to be nice to me and appropriate with me all the time no one else gonna have a bad day when they're interacting with me and everything should always be fair for me and so this is another really common one you will see again it's one very common in Western culture
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in the sense of you know life should always be fair and when it's not I'm gonna get angry and frustrated and beat or sad and depressed because I wasn't treated correctly and then the fourth third one here is effortless perfection is the belief comes from the belief that things in life should come easily you shouldn't have to work that hard to have all the you know good things in life um and yeah and so when things aren't going well or easily it feels like there's a
34:33
problem so again these are very common beliefs and Ellis's kind of categorizes to make the assessment easier the negative cognitive trial triad was developed by back in observing clients who come in with depression and so basically he said that they tend to have these negative thoughts and three areas negative thoughts about the self I'm worthless I'm not good enough negative thoughts about the world or life you know life is unfair people aren't you
35:07
know no one treats me right and then negative thoughts about the future things will never get better this is not gonna end and when you have this nice combination you tend it it's a nice it's the recipe for depression within his cognitive theory so if you're working with someone who's presenting with cognate depression you would want to identities three areas so multimode therapy it's a particular CBT approach and it's particular assessment includes
35:38
looking at all these different layers of functioning so you'd look at their behaviors their effect and mood sensations so physical sensory stuff what's going on imagery if there's images in their minds that are problems or in their dreams cognition is thoughts interpersonal relationships and then drugs and biology so what might be going on so they use these various areas they would assess all of these areas and the person's functioning in these areas and
36:06
then determine where to intervene based on that and so it's a very global assessment you know across all various areas of functioning and it's so that makes it a very client focused approach and it's they try to fit the treatment to the client so it might be more behavioural if that's where their problems are it might be more cognitive they might address you know the drugs or biology issues or might be more relationally focused and so they assess
36:36
across all these and then customize the treatment based on that so for all the psycho therapies and counseling models CBT is the most closely aligned with the Diagnostic DSM manual and so and it's very closely aligned with the medical model once the CBT conceptualizes within it you know you identify the syndrome that's you know the DSM diagnosis and you develop treatment around that and so naturally most of the evidence-based treatments which are treatments designed
37:07
for specific problem or many of them are CBT based because that is how the theory works and so there you know for example Beck has developed several specific cognitive approaches for working with depression and anxiety you know eating disorders substance abuse so they devalue it's very um it's very consistent with in the approach to be be developing almost like protocols for the various presenting problems and then this is why it's it's kind of the
37:39
preferred model speaks the medical language and so it tends to be the preferred model in by third-party payers because if you're accepting a whole bunch of you know you need to pay doctors and therapists and counselors you want to use a very similar system for me I'm managing all that paperwork in so in many ways you know this naturally fits in with what the rest of the healthcare industry is doing so now let's talk about setting goals in CBT so in many ways the goal-setting approach in CBT is
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kind of preferred by third party payers and often that the form that is required for exam for example in a government or county agency setting and you will see lots of examples in my text in my books about writing treatment plans especially in the theory and treatment planning book well as well as the case documentation book and so the CBT fits most naturally into this and I think as I mentioned earlier in this lecture you know my book will go through and also
38:46
show you how to take psychodynamic ideas and make them fit you know into the language that third party payers require while retaining the thinking of psychodynamic or postmodern or family systems retaining the logic of those intervention approaches so the goals are typically symptom and problem focused and basically reducing the symptom or the problem more so than increasing often they may use increasing language but it's often a deep emphasis on
39:19
decreasing something such as decreasing depressed mood decreasing anxiety it is based on also that the goals need to be behavioral and measurable and again this comes very much out of their scientific tradition that these approaches grew out of that they you know you need to be able to find a behavioral way how do you know that we've achieved our goal so you know there has only been one mild episode of depression you know in a month and so or whatever it might be no
39:53
more than you know one mild you know episode rather than and no panic attacks for a month maybe the goal or whatever it might be so again you need to make the in often clients are involved in discussing and setting these goals so now we're going to move on to talking about interventions and there are a lot and CBT they love interventions and they do really intervene creat interventions you know compared to more process oriented approaches so this really list
40:29
is endless and so we're going to touch on some of the more classic ones so one of the most common interventions is psychoeducation in CBT and it's actually hard to do this well because the goal it's easy as a therapist to get in there and just start talking about you know cognitions or behavioral this or that and the other and and as you do this you typically will give the clients far more information than they could possibly soak in and use to make a change in
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their life and so my little rule typically is you know about two minutes of psycho ed and then 48 minutes of how do you apply this in your life and that's about the right recipe I have found for managing for doing cycle education and in my book I go into a nice long list of how to kind of move through this to either help to use psychoeducation effectively and clients often enjoy learning things you know but then applying it and using it to
41:32
actually you know address the issue is a whole different skill set and so you're gonna keep it brief and then you know break it down get the client's buy-in or buying maybe is one way to look at it or you know what their thoughts are do they think this is gonna work are they willing to try it and then how are you how would this look and then problem shooting how you know what are the problems that are likely to happen during the week and so it's a very
41:57
involved process and it's tempting to give way to more information that could be used on the Socratic method or guided discovery is used a lot in CBT and so this is where rather than telling a client that you're having an irrational thought or that's dysfunctional thinking you use questions to allow them to discover for themselves that what they're thinking is not that logical so you know things like what evidence do you have to support your
42:27
belief is there any evidence maybe to the contrary might there be I do think there's a more realistic middle ground what does person so-and-so say about your situation what are that what is the you know realistic likelihood that these things you know would really go so badly and that these are likely to have so you you use this kind of a Socratic method so the client is the one who begins to realize how their thinking and beliefs may not be all that realistic and
42:58
thereby reducing the effect that they're having in their lives the problems a more concrete way of addressing kind of dysfunctional thinking is the thought record and what this is you would have them maybe here what you're going to do and there are many very variations on this on a piece of paper you'd probably start on a whiteboard in the therapy room and have them do this as homework typically once you've done it a few times in the room you know you'd have an
43:28
identify a situation you know behaviorally you know what it may be there was a stressful situation at work then you identify what were the automatic thoughts you know my boss hates me you know cuz he you know cut me off the middle of a meeting and then what were your emotions so you might identify the emotions around that you know I felt angry if I'm humiliated I felt shamed you could you know so what did that lead to well I ate an extra
43:56
candy bar and I was short I avoided him the rest of the day I was didn't talk to anyone else for the rest of the day at the office I think a good work done and so then you you know what might have them identify what's a more adaptive a reasonable what are some other interpretations for why I got cut off in that meeting and you know what would be a more realistic belief to have all of this and so similarly similar processes facilitated and art you know the various schools of CBT can have
44:30
different forms in terms of there's a rational emotive therapists have the rebt self-help form which again they identify the activating event you know the irrational beliefs and then they have them dispute those are rational beliefs and identify more realistic beliefs and they're examples of these in the book there is also labeling cognitions and so you know identifying that you're personalizing minimizing and so once you've assessed those that we talked about early or the distorted cognition
45:06
patterns then you would teach clients about you know what personal personalizing and minimizing magnifying mind reading you know catastrophic thinking so you would have the clients learn to identify and then replace those with more realistic beliefs there's also um problem-solving and coping skills training so there's actual often this would be done in a group format it could be done in a one-on-one format too where you teach them just you
45:36
know how to a step by step you know solve problems develop coping skills so teaching them various skills to calm themselves down many ways the whole mindfulness based treatments are all a very specific coping skill that's being taught in those it's more than a coping skill but it's long it's the same idea how having clients identify negative inner talk and changing that negative self-talk and that's there's something often called um stress inoculation
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training so that means if you know it's you know a stressful event is coming it was stressful exam coming up you would have the client rehearse positive self-talk to not have so much anxiety related to the exam both and of course here the list continues and like I said it is truly endless but um cost-benefit analysis or what are their pros and cons of a particular different courses of action there's still classical conditioning
46:37
where you pair a relaxation response with a stressful situation or some variation of that there's still operant conditioning and reinforcement so this is Skinner's cats where you're going to reinforce you know steps in behaviors that go in the direction of the desired behavior there's systematic desensitization typically used more for phobias and anxieties where you systematically you know have the person you know exposed to
47:09
maybe a picture of a spider the spider in the far corner of the room middle of the room you know hold a spider in vivo exposure and flooding is used for certain phobias and fears may respond well to just flooding which is like just go in there and you know get in you know jump in the back deep end of the pool metaphorically or maybe literally depending on the situation so that's what flevit flooding is it's just letting them experience it till they get
47:38
allowing them to become a customized to it there's also EMDR is a very specific form of this ID movement desensitization reprocessing it's a very specific trauma intervention that you can get certified in so there and goes on with the mindfulness of which I've talked about which I will talk about in other lectures is another kind of mindfulness based intervention that's an option that therapists may use or assign so it goes on forever in CBT but these are some of
48:11
the standard interventions in the field and like I said in my book I have examples of what some of these forms would actually look like they're one of the few therapy models that have forms and and outs that go home with clients and such and so next we're going to talk about research in the evidence-based related to CBT so as I mentioned throughout this lecture that research is very much part of the culture foundational assumptions of CBT CBT grew
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out of a very out of the laboratory environment and so you will when you go and read the National to mental health they have a list of evidence-based treatments CBT dominates it they really does because that's it's that's where that is therapeutic model that grew out of you know the scientific method so you will see there are lots of different you know the list is it goes on forever have a nice long list I think in the book too but you know integrated
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behavioral couples therapy trauma-focused CBT cognitive behavioral for panic for generalized anxiety for depression you know the list is quite long so there are many and such things that you will find so the evidence base is strong for CBT and finally wanna wrap up by talking a little bit about using CBT with diverse populations so CBT has been used successfully with a wide range of diverse populations and there has been even studied with some of these
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populations and the thing to remember that when working with culturally diverse clients is that you want to be careful in terms of looking at some of the embedded values that are part of CBT CBT you know very much embodies the Western you know scientific method and and it really privileges a very linear type of logic which is really not the only logic on the planet and because there's a more emotional forms of logic and it has within it also a very
50:20
individual kind of privileges a very individualistic set of values for just versus communal values then a lot of you know what may be logical and and our dysfunctional thinking you need to consider what your going to label irrational or dysfunctional thinking in terms of the broad in terms of the client's cultural and religious even socioeconomic class and so it I just the idea here is just to be cautious and mindful of that and to be mindful of the
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values and you know assumptions that are embedded in the approach that said as I think I mentioned earlier many diverse populations do want to view their counselor psychotherapist social worker psychologist psychiatrist as an expert and this stance I mean this particular approach you know encourages that stance and so there are many diverse clients who are comfortable with that relationship and into how they structure the relationship and the educational piece to this and
51:26
again it's just being mindful in terms of how you apply it so finally I also want to talk a little bit about working with LGBTQ clients I'm using CBT approach and the first thing to be mindful of here is that therapists want to begin by looking at their own core beliefs and schemas related to sexual orientation and gender and gender identity before working and trying to use these ideas with with diverse clients and one of the things too
51:59
there are several various models you can look at in terms of working with LGBTQ clients using CBT and so you want to look at identifying some of there are even some list of some common irrational beliefs of clients especially those who've experienced marginalization discrimination and how that can often kind of magnify some of the any core beliefs or scheme as a person might have about for example let's say their worth as a person and having repeated episodes
52:32
of discrimination and harassment certainly are going to magnify and intensify those and so also look at examining the role that social norms planned even stigma play in the development of the clients beliefs and schemas and working with them to find ways to develop more realistic or fair evaluations of themselves life others and in a way that helps them to kind of cope with what will be most likely ongoing discrimination in their life
53:04
and various forms and marginalization and so there is both you know extra work that needs to be done you know because of the discrimination typically experienced as well as extra work of developing extraordinary coping skills often to cope with it to cope with what's going to be an ongoing stressor of being different in their life so okay so that was introductory and a whirlwind tour of sorts of cognitive behavioral therapy again I have other lectures that
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relate to dialectical behavioral therapy specifically and trauma-focused CBT and mindfulness like I said it is a very CBT is a very broad class of theories although they do share some very basic common you know core underpinnings and assumptions and it's a widely used model and I encourage you to read far and wide and I hope you found this lecture very useful and helpful in your introduction to see
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