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CBT Final Exam 154 Questions with Verified Answers
Gold Standards for Tx Outcome Studies (Foa & Meadows, 1997) - CORRECT ANSWER 1. Clearly defined target sxs
- Reliable and valid measures
- Use of blind evaluators
- Assessor Training
- Manualized, replicable, specific treatment programs
- Unbiased assignment to tx
- Tx adherence (fidelity) Bhardwaj 2016 Diversity - CORRECT ANSWER 1. Diversity and cultural identity go beyond race and ethnicity
- 25% US population is a minority <-> only 5% of clinical psychologists Horrell, 2008 Diversity - CORRECT ANSWER 1. White males from West developed most psychotherapies -> samples are predominantly white European
- Many assessments also developed on white, European or US population -> just translating is not enough Hays, 2014 Diversity - CORRECT ANSWER 1. POC make up <15% of healthcare providers and psychology faculty
- Past 15 yrs <4% of articles focus on race, ethnicity, diversity in top clinical journals Intersectionality - CORRECT ANSWER - There is an intersectionality within different aspects of diversity.
- awareness of intersectionality can benefit psychotherapy Addressing Model - CORRECT ANSWER A - age and generational D - developmental disability D - disability (applied) R - religion
E - ethnicity S - social status S - sexual orientation I - indigenous heritage N - national origin G - gender Diversity and CBT - CORRECT ANSWER - maybe noted in language preference
- collaborative approach: ct has an active role in tx planning -> facilitates effectiveness across cultures
- consider unique aspects of ct's cultural identity
- allows for exploration of sig. life events within the framework of their own cultural values
- non-Western cultures often prefer the behavioral aspects and problem solving Limitations to CBT - CORRECT ANSWER - no exclusive focus on BIPOC individuals in study samples
- less focus on the past -> limits therapist knowledge of childhood cultural factors
- focus on future goals may alienate cultures with not so linear timeline
- Euro-American middle-class values not relevant to all groups
- India: study reported potential conflict of CBT principles and their family values Limits to Older Adults - CORRECT ANSWER Successfully applied to older adults tho some indications that improvements may not be maintained as well as in younger adults (Thorp et al) CBT and Sexual Minorities - CORRECT ANSWER - viewed as psychosexual disorders
- profound need for mental health services
- heterosexual therapists may assume their clients are also heterosexual
- MOGAI individuals may not share their identity with others -> isolation Cultural Recommendations - CORRECT ANSWER - treat each client as unique
- assess CT's level of involvement in their culture -> don't assume
- non-adapted versions of tx should be tested first
- framing tx culturally appropriate
- prioritize reducing barriers to EBPP
- identifying values
- avoid labeling "distorted cognitions" regarding cultural beliefs
- educate self about MOGAI and systematic bias
- awareness of stimulus value Helpful actions in CBT: CLASS (Hays, 2019) - CORRECT ANSWER C - Change something in the environment L - Learn a new skill A - Assert yourself or communicate S - Social Support S - Self-care focus Iwamasa and Hays (2019) - CORRECT ANSWER - stimulus value matters but it doesn't tell the whole story
- nearly all clients suffer from invisible disabilities: mental illness
- avoidance is common to nearly all psychological disorders
- asking about culture is a form of validation and respect
- client empowerment, intervention tailoring, role of environment on emotions
- focus on logic undervalues spirituality
- examine both own and ct's diversity and privilege
- humble in your understanding of culture and related stressors Contact Hypothesis (Allport, 1954) - CORRECT ANSWER Contact between groups under optimal conditions could effectively reduce intergroup prejudice Personalized Self Care - CORRECT ANSWER - be cautious about numbing or binging
- make a list of Things to do: such as hobbies Things to think about: that make you happy Supportive ppl to connect with Places to go to improve your mood Recovery Culture (Onken et al., 2002) - CORRECT ANSWER A recovery-enhancing system is person-oriented and respects people's lived experience and expertise. It promotes choice-making and self-responsibility. It addresses basic needs and problems in living. It empowers people to move towards self-management of their condition. The orientation is one of hope with an emphasis on positive
mental health and wellness. A recovery-oriented system assists people to connect through mutual self-help. It focuses on positive functioning in a variety of roles and building or rebuilding positive relationships. Ways to Foster a Culture of Recovery - CORRECT ANSWER - assume recovery from many mental health problems is possible
- act to support environments that are safe and open
- advocate for clients capacity and responsibility for recovery
- show solidarity with people in recovery
- offer formal services that can aid recovery
- use person-first language Recovery in CBT - CORRECT ANSWER - clinicians work to instill hope -> hope grounded in empirical evidence
- collect data to show what's working or not -> continually assess progress Poor treatment gain is viewed as: - CORRECT ANSWER - problem with the treatment
- problem with the timing for the individual NOT the individual themselves!! Recovery-Oriented Cognitive Therapy (CT-R) - CORRECT ANSWER - greater emphasis on adaptive beliefs and behaviors rather than sxs and psychopathology
- more discussion of strengths, personal qualities, skills, resources, aspirations, and values Techniques - CORRECT ANSWER Cognitive Techniques Behavioral Technique Differentiating Thoughts from Feelings - CORRECT ANSWER - Cognitive techniques: goal is to monitor and challenge thoughts that lead to unhelpful mood or actions
- No challanging feelings or questions
- Feeling are one word - thoughts are more than one word
Questioning Thoughts - CORRECT ANSWER - Take the stance of a curious scientist! "I wonder.."
- Explore other possibilities! "could be that, but what else could it be?" Unhelpful Thoughts - CORRECT ANSWER 1. All or nothing Thinking
- Mental Filter
- Negative/Distorted Filtering
- Catastrophizing
- Emotional Reasoning
- Labeling or Judging
- Mind Reading
- Overgeneralization
- Fortunetelling & Jumping to Conclusions
- Personalization
- "Should" and "Must" statements All or Nothing Thinking - CORRECT ANSWER - aka Dichotomous or Black-and- White Thinking
- Look for: "never," "every," "all," and "always" Mental Filter - CORRECT ANSWER Confirmatory or preservation bias Negative/Distorted Filtering - CORRECT ANSWER - Magnifying or exaggerating the negative (making "mountains out of molehills")
- Minimizing or discounting the positive Catastrophizing - CORRECT ANSWER It will be "unbearable"; "I totally lost it" Emotional Reasoning - CORRECT ANSWER "I feel sad; therefore, this relationship is hopeless." "I feel hopeless, so I am hopeless and things will never improve" Lableing or Judging - CORRECT ANSWER Assigning global negative traits to oneself or others; Unfair, Wrong, Bad, Stupid: "I'm ugly" or "He's rotten" Mind Reading - CORRECT ANSWER Assuming someone's thoughts: "She thinks I'm lazy for quitting the class"
Overgeneralization - CORRECT ANSWER Applying a few experiences to all events; "See? I knew that would happen. I always ruin everything" Fortunetelling & Jumping to Conclusions - CORRECT ANSWER Predicting a negative future Personalization - CORRECT ANSWER Assigning 100% blame to oneself, not seeing other people or events as factors; taking things personally "Should" and "Must" statements - CORRECT ANSWER Not accepting of reality - focusing on how one perceives the world should be rather than how it is; "I should really work out more." "I must get this done by Friday." "I should do well - If I don't then I'm a failure." Thoughts - CORRECT ANSWER - tens of thousands of thoughts per day
- many of them repetitive from day to day
- many are negative about oneself or the world Thought records help bring awareness to the thought process so that some unhelpful thoughts can be modified Three Levels of Thoughts - CORRECT ANSWER 1. Automatic Thoughts
- Intermediate Beliefs
- Core Beliefs
- Automatic Thoughts - CORRECT ANSWER Ideas, words, or images that seem to just pop into one's mind, and are the most superficial
- occur after events (outside the client or an internal event like pain) but before an emotional response
- often occur outside of awareness because they are habitual, believable and fast
- therapist works to elicit automatic thoughts through questioning, imagery, and role playing so the client can identify thoughts that precede emotions
- If the therapist notices mood changes during sessions ("affect shift"), they should help the client identify the automatic thoughts they had just prior to the mood change
- After clients have learned to identify automatic thoughts, they can start keeping thought records
- Intermediate Beliefs - CORRECT ANSWER Reflect underlying assumptions, rules, attitudes, and assumptions ("If I try new things, I will get embarrassed. I'll get rejected.")
- Core Beliefs (aka 'schema') - CORRECT ANSWER The deepest beliefs about oneself, others, and the world ("I'm a failure. I'm worthless. I'm incompetent. I'm helpless. Other people will try to hurt me. The world is a dangerous place"). - These often begin as negative, extreme, rigid, and global Thought Record to Link Thoughts and Feelings - CORRECT ANSWER 1.Use Basic Thought Record: "Date," "Event," "Automatic Thoughts," and "Emotions" (next slide) 2.Instruct the client to choose meaningful events, but they can be positive or negative 3.Teach the client to write down the automatic thought and label and rate emotion intensity (0-100) Evaluating Automatic Thoughts - CORRECT ANSWER - Do not directly challenge the thought ("That's not true" - at least not initially); Use collaborative empiricism
- Collaborate to test the thought's validity or usefulness, but don't question it too early - make sure you understand the context and the automatic thought
- Collaboratively develop an alternative or adaptive response Socratic Questioning - CORRECT ANSWER - the process of asking questions of a speaker focused on the responses to previous questions; its ultimate goal is to uncover the truth
- Socratic questions are perceived as more helpful and more supportive of autonomy and engagement than didactic presentations
- neutral, collaborative, empathic, and curious -> no judgmental or evaluative comments
- not helpful to pressure clients to change their thoughts; instead, ask more questions Revealing the Issue - CORRECT ANSWER "What evidence supports this idea? What evidence is against its being true?"
Conceiving Reasonable Alternatives - CORRECT ANSWER "What might be another explanation or viewpoint of the situation? Why else did it happen?" Examining various potential consequences - CORRECT ANSWER "What are the worst, best, bearable and most realistic outcomes?" Evaluate the potential Consequences - CORRECT ANSWER "What's the effect of thinking or believing this? What could be the effect of thinking differently and no longer holding onto this belief?" Distancing - CORRECT ANSWER "Imagine a specific friend/family member in the same situation; if they viewed the situation this way, what would you tell them?" Advanced Thought Record - CORRECT ANSWER Situation -> Automatic Thoughts -
Emotion -> Alternative Response -> Outcome Alternative Reponses (thought rec) - CORRECT ANSWER - What is the mistake in thinking?
- What is the evidence for/against this idea?
- Is there an alternative explanation of the situation?
- How much do you believe this thought? (0-100%)
- What is the effect of you believeing this thought?
- What should you do about it? Ambiguous Situations (thought rec) - CORRECT ANSWER Generate a number of plausible responses to ambiguous situations to understand Ct's thought processes and help them relaize alternatives. Outcome (thought rec) - CORRECT ANSWER - What emotions do you feel now?
- How intense are the emotions? (0-100)
- Do the alternativethoughts change your belief in the original thought?
- Do the alternative thoughts change your feelings and/or actions? What do you plan to do? ABCDEF Thought Records - CORRECT ANSWER A = Activating Event (What happened?) B = Belief or thought you are having
C = Consequence (feeling or behavior that results from your belief) D = Dispute, challenge, or "talk back" to your thoughts; use evidence to develop your disputes E = Evaluate (did the dispute change your feeling about the event? -> sometimes Effective New Belief F = Functional consequence (what did you do?) The 3 Cs: Correcting Automatic Thoughts - CORRECT ANSWER Catch It:
- What is the automatic thought?
- What was going through your mind? Check It:
- What is the evidence for/against it?
- What would you say to a friend with that thought?
- Is this a mistake in thinking? (eg.: 'jumping to conclusions', 'all or nothing') Change It:
- What is an alternative? Another possibility?
- Does the new thought help you reach your goal? Core beliefs (schema) - CORRECT ANSWER Cognitive networks that help orient to, categorize, and interpret experiences Core belief collaboration (Cognitive Technique) - CORRECT ANSWER - Automatic thoughts may reflect core beliefs, which are the target of change in CBT.
- Get feedback from Cts about possible core beliefs as they are identified
- Adress core beliefs through thought records, the downward arrow technique, behavioral experiments, and alternative beliefs
- Chart (and mention) fluctuations in conviction over sessions and weeks
- Modify case conceptualization as needed and seek feedback Downward Arrow Technique or 'Vertical Descent' (Cognitive Technique) - CORRECT ANSWER - Identify a key automatic thought
- Ask: What does it mean to you?
- Use if-then questions: If .... what does that tell us about you?
- Be supportive and empathic as core beliefs are revealed Core Belief Worksheet (CBW) - CORRECT ANSWER Therapist or client write down core maladaptive belief and a new adaptive belief -> hwk is to gather evidence:
- contradicts the maladaptive belief & supports the adaptive belief
- supports the maladaptive belief but with some sort of reframing Challenging Distorted Thoughts (Cognitive Technique) - CORRECT ANSWER - Thought records and naming distortions
- Asking for evidence and probabilities
- Looking for alternative explanations
- Client acting 'As if' they do not believe negative thoughts
- use humor to change the nature of maladaptive thoughts -> sparingly & after rapport established and nature of issue is understood
- Make the abstract concrete: aks client to define terms "Flip the Script" (Cognitive Technique) - CORRECT ANSWER Turn ANTs (automatic negatives thoughts) into PETs (positive empowering thoughts) through cognitive restructuring or "reframing" Cope Ahead (skill from DBT) (Cognitive Technique) - CORRECT ANSWER 1. Describe the problem situation
- Decide what skills to use
- Imagine the Situation
- Rehearse coping in your mind
- Relax after rehearsing Meta Cognition (Cognitive Technique) - CORRECT ANSWER - "thinking about thinking"
- Teaching clients to use the phrase "I'm having the thought that ... 'I'm worthless"
- allows to slow down the thought process and analayze it
- helps demonstrate that thoughts are not 'true' but just an activity in our mind Name it to Tame it (Cognitive Technique) - CORRECT ANSWER - Becoming mindful and labeling negatigve habitual patterns and thought processes can help bring them into consciousness to start the process of change.
- If you're aware of patterns, you can lean to coach yourself Other Cognitive Techniques - CORRECT ANSWER - ask the Ct how they can test out a thought
- distinguish thoughts form feelings
- distinguish actions from traits or ppl
- name your "thinker": 'thx Karen for your input, but I disagree'
- taking your mind for a walk (ACT)
- convert 'should' thoughts to 'I want to' or 'I need to' Cognitive Rehearsal (Cognitive Technique) - CORRECT ANSWER Imagining each step in sucesfully completing a task Covert Modeling (Cognitive Technique) - CORRECT ANSWER Visualizing successful confrontation of feared situation Continuum Technique (Cognitive Technique) - CORRECT ANSWER Place the situation on a 0 to 100 continuum of negative outcomes and describe what could be better and worse Double Standard (Cognitive Technique) - CORRECT ANSWER Would you apply the same standard to a loved one as you do to yourself? Positive "Reframe" (Cognitive Technique) - CORRECT ANSWER What is more positive (but accurate) view of a behavior or situation Possibility vs. Probability (Cognitive Technique) - CORRECT ANSWER Yes, you may have a heart attack if you're anxious, but what do you think of the true probability is? Progress vs. Perfection (Cognitive Technique) - CORRECT ANSWER - Progress = improvement + moving closer to your goal
- Practice makes progress
- Perfection is impossible: It's all or nothing thinking Role Model's Approach (Cognitive Technique) - CORRECT ANSWER Think of someone you admire greatly - how would they think and act in this situation? WWXD? "Pie" Technique (Cognitive Technique) - CORRECT ANSWER Have a client draw a "pie chart" and divide up responsibility for a situation
Challanging 20/20 Hindsight (Cognitive Technique) - CORRECT ANSWER - looking back at the context of the negative outcome and assigning too much self-blame
- encouraging Its to consider all potential reasosn for an event happening (or not happening) Inoculate/Manage the Worse Case (Cognitive Technique) - CORRECT ANSWER What are the worst things that could happen, and how would you deal with them? Future Self (Cognitive Technique) - CORRECT ANSWER When confronted with a difficult decision, try to think about it from the perspective of your future self Reframing (Cognitive Technique) - CORRECT ANSWER Reappraisal of past, current, or future situation to be realistic without common mistakes in thinking Cognitive Defusion (Cognitive Technique) - CORRECT ANSWER Many excersies including: Sing your unhelpful thoughts to the tune of Jingle Bells Distanced Self-Talk (Cognitive Technique) - CORRECT ANSWER Saying out loud the unhelpful thoughts - hearing it through your ears can be more powerful than just reframed thoughts Metaphores (Cognitive Technique) - CORRECT ANSWER Utilized to help illustrate concepts, connect ideas, and to enable more visual learners a different way to change ways of thinking Eg.:
- Watching scary movie 100x (exposure)
- Boy on the beach (exposure)
- File Cabinet (as schema)
- Leaves on a stream (mindfulness)
- man in a hole (ACT)
- skills as jacket (DBT) Self-Monitoring (Behavioral Technique) - CORRECT ANSWER Tracking one behavior to change, often over a week Eg.:
- thought record
- food diary
- sleep diary
- audio/video review
- diary cards
- exercise trackers
- notes on effort toward a goal With positive behaviors tracked they tend to increase - negative tracking tend to decrease
- helps with distancing
- learn toward their internal experiences rather than habitually running away
- enhances cognitive flexibility Chain Analysis (Behavioral Technique) - CORRECT ANSWER aka Functional Analysis/Three-term Contingency/ABC
- Activating/Antecedent Event
- Behavior
- Consequence Helps determine why a behavior occurred and why it may be maintained through moment-to-moment reviews Progressive Relaxation Training/Progressive Muscle Relaxation - CORRECT ANSWER - Rationale: relaxation results from the absence of muscle contractions - learned by tensing and releasing muscle groups
- Reciprocal inhibition and systematic desensitization - presenting an incimpatible response (relaxation) with gradually presented feared stimuli PRT Practice - CORRECT ANSWER - useful for distressed or anxious individuals
- notice tension and apply relaxation
- slow, diaphragmatic breathing
- loose closthing, close eyes, low light, soothing environment, helpful patter
- notes about sleep and sex traumas
- tense muscles for 5-7 seconds, release, become aware of pleasant sensation for 20-30 sec w/o moving or talking
Behavioral Activation - CORRECT ANSWER Eg.:
- pleasurable activities
- pleasant events
- self-reliance training
- in vivo exposure
- activity scheduling
- diversion techniques
- building mastery
- Getting clients moving an active will almost always result in mood improvement
- Isolating in bed nearly always leads to depression
- Ct should do behavioral activation BEFORE they feel like it or feel better Guidelines for Activity Scheduling - CORRECT ANSWER - Provide rationale for activity scheduling
- Use questioning to elicit collaboration/suggestions about how to schedule the activity
- start where the Ct is and not where they think they "should" be
- be specific and concrete
- plan for possible obstacles Environmental Control - CORRECT ANSWER Modifying the environment to modify the behavior = antecedent control
- stimulus control: a behavior is more likely to occur when a specific antecedent stimulus is present Changing Habits - CORRECT ANSWER - it can take 18 to 254 days (mean 66) to change a habit
- Steps to change habits:
- Decide to change
- focus awareness on the behavior
- Devisive strategies to help in stopping the habit
- Replace the habit with an alternative behavior
- Press by being consistent and tracking progress
- Expect and manage lapses
- Approach )add) works bettern than avoid (subtract something) - I'll cook from home v. I'll eat out less
- share goals - accountability makes it more likely
- celebrate milestones and small wins Communication and Assertiveness Training - CORRECT ANSWER - Differences between assertiveness and passivity, aggressiveness, and passive-aggressiveness
- teaching self-observation skills and awareness of preferences
- reinforcing 'I' statements
- using role-plays to practice skills Visualization (Behavioral Technique) - CORRECT ANSWER Imaginning a pleasant scene or situation to aid in relaxation Role Playing (Behavioral Technique) - CORRECT ANSWER Note automatic thoughts, practice new adaptive thoughtts, rehearse new behaviors, modeling, coaching Role Reversal (Behavioral Technique) - CORRECT ANSWER How would you talk to a friend who had a similar experience? Social Skills Training (Behavioral Technique) - CORRECT ANSWER Eg.:
- Introducing self
- Shaking hands
- Eye contact
- Smiling
- Speaking clearly Grounding or distraction or Self-soothing (Behavioral Technique) - CORRECT ANSWER Eg.: Awareness of all 5 senses Other Behvaioral Techniques - CORRECT ANSWER - graded task assignments (shaping)
- modeling
- problem solving (systematically)
- Rebreathing (to reduce hyperventilation) and breathing retraining (to induce relaxation)
- writing is therapeutic even if not shared Anxiety and Related Dos - CORRECT ANSWER - anxiety dos are the most prevalent class of mental disorders
- negatively impacts physicalo health, quality of life, relationships and disability status
- costly due to high comorbidity, lost productivity, and high healthcare costs
- anxiety systems are operating correctly just at the wrong time - little threat or danger -> causes the misperception and exaggeration of threat Context of Exposure Therapy - CORRECT ANSWER - most Cts don't receive efficacious tx -> median time to seek tx for PTSD is 12yrs after onset
- exposure therapy is underutilized by practitioners and difficult for clients to access History of Exposure Therapy - CORRECT ANSWER o 100 yrs ago: Counterconditioning - Mary Cover Jones o 55 yrs ago: Systematic Desensitization - Joseph Wolpe o 40 yrs ago: Emotional Processing Theory - For & Kozak o 35 yrs ago: Emotional Processing Theory - David Barlow o 30 yrs ago: Dr. Thorp+Exposure Therapy o 20 yrs ago: Dr. Thorp+Prolonged Exposure Therapy (PE) for PTSD Responses to Fear - CORRECT ANSWER 2 options: Avoidance: Forget Everything And Run Therapeutic Exposure: Face Everything And Rise
- many avoidant behaviors are reinforced through negative reinforcement - specifically the sense of relief a person feels when they avoid a situation reinforces that avoidance or escape behavior
Exposure Therapy - CORRECT ANSWER - one form of CBT that is evidence-based practice
- avoidance of, or escape from, a feared (but safe) stimulus means that the individual never learns that it's safe
- exposure is the opposite of avoidance = entails facing of fears What is Exposure Therapy? - CORRECT ANSWER Defined by temporary and repeated confrontation of stimuli that are objectively safe but feared by the client, to reach the client's long-term goals -> can be done in the physical world or in imagination It is a natural way for clients to build distress tolerance and emotion regulation skills Evidence for Exposure Therapy - CORRECT ANSWER - exposure to a feared stimuli is an empirically supported mechanism of change for pathological anxiety
- many studies demonstrate effectiveness of exposure-based CBT for anxiety disorders
- works well in individual and group settings
- first-line tx recommended for OCD, PTSD, panic disorder, GAD, specific phobia Guidelines for Exposure Therapy - CORRECT ANSWER - no exposure to dangerous things
- never force Ct to do anything, never assign anything we'd be unwilling to do ourselves
- don't ask Cts of what they want to do exposure to -> ask about activities they've avoided but wish they could do comfortably
- typically go beyond "normal" activities for in vivo exposure aka have Ct "overshoot" = occasional reinforced extinction How long for Exposure? - CORRECT ANSWER General guidline: 30 minutes or more -> allows emotions to crest and fall Loved Ones and Exposure Therapy - CORRECT ANSWER Often included during the psychoeducational phase or sometimes in helping the client with exposure themselves
Self-Report Measures in Exposure Therapy - CORRECT ANSWER - administered at the start of every session Subjective Units of Distress (SUDs) - CORRECT ANSWER - teach Clients the SUDs scale (0-100), then anchors
- Anchors should be unlikely to change after treatment 3 Types of Exposure Therapy - CORRECT ANSWER - In Vivo (in life) Exposure
- Imaginal Exposure
- Interoceptive Exposure In Vivo (in life) Exposure - CORRECT ANSWER Feared but relatively safe activities or situations, sometimes with the therapist Imaginal Exposure - CORRECT ANSWER A narrative of an upsetting memory or fictional future event Interoceptive Exposure - CORRECT ANSWER Exposure to internal cues, physiology, or bodily sensations through induction exercises; primarily for treating panic do What's in a Name? Exposure Therapies - CORRECT ANSWER PE: for PTSD = In Vivo+Imaginal Exposures NET: for PTSD = uses narrative for all major life events + Imaginal Exposure WET: for PTSD = written form of Imaginal Exposure, 5x30min sessions TF-CBT: for chidlren w/ PTSD = including loved ones ERP: for OCD = discouragement of compulsive behaviors Formats of Exposure Therapy - CORRECT ANSWER - Videoconferencing Psychotherapy Exposure
- Virtual Exposure
- Apps Goals for Exposure Therapy - CORRECT ANSWER - emotions do not last forever or stay at the same high levels of intensity
- experience temporary distress for longer term benefit - physiological arousal is desired during exposure tx as an indicator of emotional engagement
- tolerate challanging but safe situations or memories
- memories, temporary distress, and physiological responses can be unpleasant but not dangerous
- improve confidence and discriminative skills
- change the meaning of traumatic events (in PTSD)
- facilitate linear memories in PTSD Advantages of Exposure - CORRECT ANSWER - works for most clients
- reduced intensity that is long-lasting after just a few months
- often decreases sis of depression as well Limitations of Exposure Therapy - CORRECT ANSWER - many therapists are reluctant to try it
- typically done in individual sessions
- may be difficult to schedule 90-120 minute sessions Candidates for Exposure - CORRECT ANSWER - clients w/ PSTD following all types of trauma
- Cts w/ clear, episodic memory of the traumatic event
- high comorbid dissociative and depressive sis are fine + anxiety, substance use, anger and guilt Guideline for Imaginal Exposure - CORRECT ANSWER - done aloud by narrating a memory or feared scenario
- therapist keeps track of time and occasionally checks in about SUDs
- often recording the Cts narration, so Ct can listen to it daily Safety Behaviors - CORRECT ANSWER - behaviors that make the Ct feel better or safer but undermine the benefit of exposure cuz they reinforce "conditional safety" Response Prevention: Discouraging Cts form using safety behaviors both during tx and after termination Termination of Exposure Therapy - CORRECT ANSWER - determine when tx is complete based on: self-report measures, completion of all items of the fear hierarchy
- compare SUDs ratings from earlier sessions to ffinal sessions to assess progress
- Booster session: if needed add a few sessions
- Relapse Prevention: normalizing fluctuation in sxs and determining if and when tehrapy may be needed again Pro Tips - CORRECT ANSWER - starts with SUDs in the 30 range: "sweet spot" = challanging but not too threatening so Ct would stop
- reassuring Cts that whaterver reaction is okay and not life-threatening Dealing with Avoidance - CORRECT ANSWER - validates fears and urges to avoid
- review rationale for tx
- review reasons Ct sought tx
- review progress Ct has made
- offer support and encouragement
- problem-solve around obstacles
- assess for safety behaviors Dealing w/ Under-engagement in Exposure Therapy - CORRECT ANSWER - signs: emotionally disconnected, rushes through narrative, low SUDs in early sessions
- common, about 20% of Cts
- reiterate the rationale
- explore fears about engagement w/ memoy
- validate, noting distress is unpleasant but not dangerous
- model the procedure if needed Dealing w/ Over-engagement in exposure Therapy - CORRECT ANSWER - signs: high SUDs that remain high, visibly distressed
- very uncommon - about 1%
- use common grounding techniques
- reiterate rationale
- during narrative imaginal exposure: use past tense, yese open, breathing, more convo style
- could have Ct write narrative rather than verbalize it Diversity and Exposure Therapy - CORRECT ANSWER Age: succesful w/ kids as young as preschool age & older adults too
Ethnicity & International: supported for BIPOC & non-Western cultures Gender & Trauma type: proven accross many Progression of Prolonged Exposure - CORRECT ANSWER Phase 1: Tx Overview & Psychoeducation Phase 2: Intro to & Engagement w/ In Vivo Exposure Phase 3: Intro to & Engagement w/ Imaginal Exposure Phase 4: Intro to & Engagement w/ 'Hot Spots' Phase 5: Termination & relapse Prevention Exposophobia (myths why therapists are afraid of Exposure Therapy) - CORRECT ANSWER - exposure will cause intolerable anxiety
- will increase co-occurring problems like substance abuse, depression, or other anxiety
- shouldn't be used for PTSD, complex PTSD or chidlhood sexual abuse
- exposure w/ children should be avoided
- Cts don't want or can't tolerate it
- must follow extensive coping skill training CBT for Suicide Prevention (CBT-SP) - CORRECT ANSWER - therapeutic relationship/rapport
- risk assessment
- crisis intervention
- safety planning
- hope box
- means & safety counseling
- treatment planning & goals
- review and consolidation of skills & relapse prevention
- constructing a timeline of the suicidal crisis
- behavioral & cognitive coping startegies
- review of recent suicidal crisis with skills & planning for future crisis
- losing a patient to suicide - impact on providers CBT and Depression - CORRECT ANSWER - joint determination of goals, problem definition, and prioritization
- collaborative empiricism
- self-monitoring
- regular feedback (rationale, checking understanding, summaries)
- scheduling activities, cognitive rehearsal, role playing
- eliciting & questioning automatic thoughts (cog restructuring)
- engaging in behavioral activation to combat lack of environmental reinforcement
- assigning & reviewing hwk CBT & Anxiety - CORRECT ANSWER - change cognition (threat)
- exposure to feared situations
- response prevention- worrying is a human thing - "what if?" and imagineing the worst scenario Specific Phobia & CBT - CORRECT ANSWER - Exposure Therapy: start w/ fear hierarchy of thought, images, objects, people, and situations
- imaginal + in vivo exposure + prevention + cognitive restructuring -> get SUDs every 5min OCD & CBT - CORRECT ANSWER - Exposure Therapy: start w/ fear hierarchy
- imaginal + in vivo exposure + prevention + cognitive restructuring -> get SUDs every 5min
- 15, 2hrs/week or twice-weekly sessions typical
- behavioral avoidance is problematic GAD & CBT - CORRECT ANSWER - relaxation and cognitive restructuring
- inhibit checking, reassurance seeking
- worry time (typically an hour set aside each day)
- traditional CBT for GAD doesn't work as well for older adults but ACT appears to Panic Disorder & CBT - CORRECT ANSWER - describe sxs (diff ct present diff)
- start w/ fear hierarchy
- begin in vivo exposures - therapist may initially join client during initial exposure
- interoceptive exposure through induction excersises to elicit and maintain somatic sxs to help Cts learn they're not harmful
Panic Disorder: Interoceptive Exposure - CORRECT ANSWER - Respiratory System: shortness of breath -> deliberate hyperventilation like breathing rapidly for a minute/straw breathing/holding breath
- Cardiovascular/Circulatory System: Heart racing, sweating -> intense physical exercise like running in place
- Vestibular System: dizziness, imbalance -> shaking head from side to side
- Muscle Tone: muscle tightness, shaking, imbalance -> muscle tension/applied tension/doing pushups
- Psychological System: feelings of unreality -> staring into a mirror/staring at light then reading
- Nociceptive System: pain -> performing bending and lifting movements or dipping hand in ice water
- Various/Mixed System: heart racing, mind racing -> drinking caffeinated/energy drinks Social Anxiety & CBT - CORRECT ANSWER - responds well to CBT -> can address the cognitions and behaviors that are common
- start w/ fear hierarchy
- Ct can do behavioral experiments in session like giving a talk about X to the therapist -> ask about Ct's automatic thoughts and physical reactions -> provide feedback Social Anxiety Disorder & CBT Continued - CORRECT ANSWER Social Mishap/Bandwith Exposures
- behavioral experiments aimed at altering a Ct's perception of what is socially acceptable
- expand Ct's comfort zone
- Ct's will learn to tolerate "worst case scenario" situations
- if Ct habituate to the tasks further increase the bandwidth Addictive Behaviors & CBT - CORRECT ANSWER - can be effective for substance use disorders even with comorbid mental health issues
- behavioral chain analysis is used to identify triggers: External Triggers -> Internal Triggers (thoughts) -> Internal Triggers (feelings) -> Behaviors -> Consequences (immediate and longterm)
- break the chain with coping skills
Common Triggers for Addictive Behaviors - CORRECT ANSWER - cravings
- presence of stimuli
- offered the substance or activity
- negative thoughts
- interpersonal problems
- intense emotions (anger, boredom, loneliness, fear, anxiety, shame)
- celebration
- getting a case of "screw its" if things are bad Seemingly Irrelevant Decisions = Apparently Unimportant Decisions (Substance Abuse) - CORRECT ANSWER - small steps that lead to problematic behavior -> important for relapse prevention
- don't involve problematic behavior at the time, but each step bring you closer to such behavior: slippery slope Coping to "Break" the Chain (Substance Abuse) - CORRECT ANSWER - Motivational Interviewing
- "Surf" the urge (craving or emotion)
- cognitive restructuring (weigh the evidence, generate alternatives)
- positive self-talk
- stay in a stressful but safe until you habituate
- practice relaxation techniques (PMR, pleasant imagery)
- leave situation where substances are present
- "fake it 'til you make it" or "act as if" you are confident
- Role play and practice communication and refusal skills
- attend 12-step or other supportive meeting
- talk it out
- harm reduction and SMART recovery
- engage in an alternative distracting activity
- Contingency Management Motivational Interviewing (MI) - CORRECT ANSWER - communication method that focuses on acceptance without arguing or lecturing, and it emphasizes eliciting and shaping language of change
- main focus is on exploring and resolving ambivalence OARS (MI Skills) - CORRECT ANSWER Open-ended questions
Affirmations Reflective listening Summaries DARN CAT (MI Skills) - CORRECT ANSWER Desire: I want to.. Ability: I can.. Reason: It's important cuz.. Need: I should.. Commitment: I will.. Activation: I'm ready.. Taking Steps: I'm going to.. PTSD & CBT - CORRECT ANSWER - Stress Inoculation Training (coping)
- Prolonged Exposure (PE) Therapy: guiding the ct to address their fears through in vivo exposure and imaginal exposure
- Cognitive Processing Therapy/Cognitive Therapy Schizophrenia and Psychosis & CBT - CORRECT ANSWER - CBTp: conducted as an adjunct to antipsychotic meds and case management -> primarily addresses 'positive' sxs of schizophrenia
- starts w/ attention switching, modified self-statements, and reattribution
- awareness training, dearousing techniques, titrating social interactions, belied modification
- reality testing through behavioral experiments can be used w/ outcomes predicted and tested
- cognitive processes are modified first, then cognitive content is questioned after arousal and attention are more controlled Sleep & CBT - CORRECT ANSWER - Cognitive-Behavior Therapy for Insomnia (CBT- I): 6-8 50min sessions
- starts w/ subjective assessment of sleep through diagnostic interviews, questionnaires, functional analysis, and sleep diaries
- sleep diaries themselves may reduce anxiety and improve sleep
- starts with pychoeducation about sleep and circadian cycles