Students, externs and interns often are asked to “conceptualize a case” using a specific therapeutic technique; suggest treatment goals; and describe concrete interventions. What follows is a brief guide for cognitive behavioral therapy. If you learn this, you’ll pass your final/comprehensive examination with no trouble. If you don’t know what these words mean, then you need to do some more studying.
Case conceptualization components:
1. Events/triggers don’t cause behavior, rather they are moderated by thoughts/beliefs. Thus how one thinks largely determines how one feels and behaves. A more typical cycle is event/trigger – alarms (feelings, somatic and physiological markers) – belief (thoughts) – coping strategies (behavior). E.g. depressing event – negative thoughts/fear about future – behavior deactivation – withdrawal.
2. Once the client has become aware of/gotten insight to her/his thoughts/thinking patterns, then she/he can be “cognitively restructured.” This is different than pure behavior therapy such as classical conditioning (Pavlov) or operant conditioning (Skinner).
3. There are a series of feedback loops between alarms, beliefs and behavior. Changing one’s thinking (through the process of cognitive restructuring) reduces incidence of maladaptive behavior, e.g. substance abuse, self-harm, anger. Maladaptive behaviors are ineffective as coping strategies because they don’t reduce alarm sensitivity or incidence of dysfunctional beliefs. If anything they instill a false sense of optimism because the client may think she/he’s problem-solved, but she/he really hasn’t. Adaptive behaviors on the other hand degrade alarm sensitivity, resulting in greater incidence of functional beliefs, resulting in adaptive coping strategies.
Specific treatment outcome goals:
1. Give the client tools to reduce symptomatology of depression or anxiety (typical clinical presentations). CBT is problem-focused and goal-oriented. For example with depression, use cognitive restructuring to eliminate automatic negative thoughts; client then will interpret interpersonal interactions and the environment in a more positive and realistic way; resulting in behavior change. For anxiety, develop more adaptive responses to fear/panic using exposure therapy.
2. Reduce alarm sensitivity – increase distress tolerance, reduce subjective personal distress.
3. Change thought patterns, which in turn will up-regulate positively-valenced beliefs.
4. Decrease incidence of maladaptive behavior – change behavior patterns – increase coping skills.
Intervention strategies and techniques:
Cognitive behavior therapy involves both a “cognitive” and a “behavior” component, so there are intervention strategies addressing both.
1. Identify automatic negative thoughts, intermediate beliefs, core beliefs (fears). This formulation is from Beck; another commonly used one is the “cognitive triad” of beliefs about self, future and world.
a. Have client keep a thought log/record/journal to record automatic negative thoughts several times per day. This will demonstrate how dysfunctional beliefs contribute to symptomatology.
b. Use mindfulness exercises.
c. Develop lists of problems to solve; concrete treatment plans; identify treatment obstacles.
d. Assign homework.
e. Use the downward arrow technique to move from automatic negative thoughts to core beliefs and excavate characteristic modes of thought that are creating cognitive distortions (Beck) or irrational thinking (Ellis). Examples: overgeneralization; catastrophizing; mislabeling; negative attribution bias.
2. Change beliefs by cognitive restructuring.
a. Challenge automatic thoughts – search for discrepant evidence to disconfirm pathogenic cognitions; lower the subjective probability belief is true.
b. This will reduce reactivity to triggers and sensitivity to alarms.
c. Replace negative thought patterns – raise the cognitive accessibility of alternative belief formulations. This is the main point of CBT.
d. Use psychoeducation.
e. Use skills training (Linehan – DBT).
f. Focus on a valued ideal (Hayes – ACT).
g. Engage in role plays, role modeling, behavioral rehearsal.
3. Conduct behavioral experiments to disrupt symptoms, identify alternative coping strategies. More adaptive behavior in turn will change dysfunctional beliefs. The client must be convinced of this link in order for CBT to work.
a. Chain analysis – uncover links and characteristic thought patterns leading to problematic behavior.
b. The problem with maladaptive behavior such as escape avoidance isn’t that it’s bad per se. It may work for the client, temporarily; the client might think it works. It isn’t effective, though, on a long-term basis. The client might think they’ve dealt with the problem, whereas in fact they haven’t. Example: client solves fear of freeways by taking surface streets. What if client is forced on freeway when surface streets close? A better behavioral strategy is exposure/response prevention; construct SUDS scale; use progressive exposure/systematic desensitization to confront client’s fear (e.g. one on-ramp/off-ramp at a time).
c. Shake things up – try something else – break pairing or association between depression/anxiety and client’s environment. Behavioral activation often is all that’s necessary to change maladaptive coping strategies into adaptive ones. This will down-regulate alarm sensitivity and up-regulate functional beliefs. Examples: client is depressed whenever listens to music by the Grateful Dead, which she/he associates with happy younger years. Solution: stop listening to Grateful Dead. Client is depressed because she/he can’t find a boyfriend/girlfriend. Client stays at home all day. Solution: get client out of the house.
d. Supply response-contingent positive reinforcement/validation.