Saturday, November 14, 2015

Crisis Intervention with Cognitive Behavioral Therapy

Major Paper: Crisis Intervention with Cognitive Behavioral Therapy
Jennifer Greene
Advanced Micro
Dr. Jane Phillips
November 10, 2015

With any therapy approach that you choice for treatment it is first imperative that we have an understanding of our client, the issues that are most important to them and basic understanding of the different therapy options out there to treat your particular client and circumstances. The same can be said of Cognitive Behavioral Therapy or CBT. As with any therapy there are controversies that surround CBT, and those who feel it is the “go to therapy” for the majority of clients.  CBT is still a developing therapy. It is evidence-based, collaborative, educational, short-term, structured, yet adaptable. Cognitive Behavioral Therapy is founded in a focus on the combination on behavioral therapy and cognitive therapy. It is a form of psychotherapy which focuses on modifying overt behaviors, beliefs, attitudes, expectations and cognitive styles (Galeazzi & Meazzini, 2004).

Historical Foundations
 Cognitive Behavioral Therapy (CBT), is a psychological therapy treatment option that aims to modify an individual’s dysfunctional thinking and convert them into positive emotions that change the individuals overall mental states and wellbeing (Richard House & Del Loewenthal, 2008). CBT is a collaborative treatment of both cognitive therapy and behavioral therapy. With theories and models from Pavlov, Skinner, Ellis, and Beck, CBT works to take an approach that benefits individuals on both the cognitive and behavioral. CBT holds that if you can alter the way a person evaluate or thinks about a situation: then they can alter their negative feelings, emotions and behaviors into more realistic, healthy views, even if the situation itself cannot be altered (Greene, 2015).

Historically, cognitive researchers such as Beck(2015) have learned that people operate from both overt and covert behaviors and that a person’s thoughts and beliefs about their particular situation, weather logical or illogical, shape their cognitive reality and how they process information (Beck Institute for Cognitive Behavior Therapy, 2015). Beck described overt behaviors to be behaviors that can be outwardly observed, such as the way a person walks, the tone and affliction in someone’s speech, acts of aggression, etc(Greene, 2015). While he describes covert behaviors are thoughts, feelings, perceptions, or things that cannot be openly displayed or acknowledged. Both however are learned through modeling someone that we feel a close connection to such as a parent or other trusted loved one, classical conditioning and/or operant conditioning. Beck’s research found that we learn these modeling behaviors through reinforcement, either positive or negative (Cobb, 2008)

On the behavioral theory side work from Pavlov discovered a connection between positive and negative stimuli and a person’s conditioned reactions (Watson, J. B. & Rayner, R. (1920). Conditional learning can be both positive and negative in nature, such as with phobias. Skinner furthered this research by describing 5 behavioral principals: positive/negative reinforcement, punishment, extinction and response cost, that describe how operant behavior is learned and changed. The basic principal is in order to change/decrease a negative or unwanted behavior the negative reinforcement must be greater than the positive reinforcement or reward received. The key is the stimulus that follows the behavior. In extinction you work to eliminate the behavior but without the stimuli.  For instance, with children throwing tantrums, ignoring the behavior is the best way to stop it since the child will take either positive or negative stimuli as reinforcement for the behavior. In other words your positive or negative response is the reinforcement for the child’s negative or unwanted behavior, thus the parent has conditioned the child that if they act in this way, they will get their parents attention. By refusing to acknowledge the behavior at all, either in a positive or negative light, you recondition your child that this behavior will not provide them with any parental interaction (Greene, 2015).

Basic Assumptions
Having studied and practiced psychoanalysis, Dr. Beck designed and carried out several experiments to test psychoanalytic concepts of depression. As a result of his findings, Dr. Beck began to look for other ways of conceptualizing depression. He found that depressed patients experienced streams of negative thoughts that seemed to arise spontaneously. He called these cognition's “automatic thoughts.” He found that the patients’ automatic thoughts fell into three categories. The patients had negative ideas about themselves, the world and/or the future. He found that by doing so, patients were able to think more realistically. As a result, they felt better emotionally and were able to behave more functionally. When patients changed their underlying beliefs about themselves, their world and other people, therapy resulted in long-lasting change. Dr. Beck called this approach “cognitive therapy.” It has also become known as “cognitive behavior therapy (Beck Institute for Cognitive Behavior Therapy, 2015)”. 

The key features of CBT are found in the phases of help that consist of engagement, assessment, intervention, and evaluation and termination. Engagement deals with recognizing the client’s perspective and the ability for the therapist to view problems from a place of empathy, warmth, genuineness, and acceptance. This area also deals with empowering the clients to recognize what is and is not working for them. The assessment process recognizes that not all clients are able to express their feelings about the situations they are going through. Therapist work with identifying what behavior is and is not currently working for the client. Assessment continues throughout the entire therapy process to plan interventions and goals for behaviors the client wants to change.  Intervention is helping the clients learn the tools they need to make the changes to reach their goals. Using a variety of techniques from systematic desensitization and flooding, behavioral activation, contingency management techniques, response prevention, self-monitoring, psychoeducation, anxiety and stress management, cognitive reconstruction to self-talk and coping statements therapist can help equip clients for desired lasting change. Systematic desensitization is a technique used to help people overcome their phobias. The therapist would use relaxation techniques and then gradually expose the patient to their phobia to help reduce the reaction and fear the client has to anxiety-producing object. This is only done after the client has been exposed to relaxation therapy and can apply the technique during the desensitization. Flooding utilizes the same technique as systematic desensitization, except that the client is immersed into the anxiety-producing object or situation until they can realize that no harm or the dreaded consequences they thought would happen actually happen. Behavioral activation is a tool used to help the patient set activity goals and then hold the patient accountable to reaching those goals.  The main goal in behavioral activation is the help the client avoid behaviors by making their activity experiences enjoyable and rewarding. This technique is especially helpful for people who suffer with depression, and PTSD (Dahl, Stewart, Martell, & Kaplan 2014).  Contingency management technique is when patient’s behaviors are rewarded for adherence to treatment. This technique is most often used when treating those with chemical dependency problems or mental health problems such as retardation. This can be done by using a token system or voucher system, where the client receives a token or voucher for good behavior that they can later use for something else that had been agreed upon beforehand between the client and therapist (Silverman, Preston, Clone, Katz, Bigelow & Stitzer, 2000). 

Termination and evaluation starts early in the therapy process and is continuously reviewed. Termination is not something that is dreaded, but celebrated in the therapy process as a new beginning in the client’s life. Response prevention and self-monitoring may include utilizing tools such as the ABC Charts and keeping a diary. These tools are used to help you monitor your mood, and take control. Psychoeducation, anxiety and stress management, cognitive reconstruction, self-talk and coping statements are also useful tools used in CBT. Stress management and anxiety management uses a variety of techniques in CBT such as progressive muscle relaxation, diaphragmatic breathing, rational thinking, exposure therapy and desensitization.  The goal is to shift the focus and increase the client control over themselves, rather than focusing on changing their environment. Stress management and anxiety management also aims at helping the client develop a deep sense of competency in both professional and personal arenas by applying effective problem-solving techniques and learning to think rationally about situations and experiences (Hoffman, Asnaani, Sawyer & Fang 2012).

Intervention Examples
            Cognitive Behavioral Therapy (CBT) has been effectively used as treatment option for a wide variety of disorders including, but are not limited to: Psychiatric disorders such as eating disorders, depression, schizophrenia, bipolar disorders, substance abuse and personality disorders, Attention-deficit / hyperactivity disorder (ADHD);Psychological problems such as relationship difficulties, impulse control, identity issues, anger, eating disorders, and compulsive gambling, low self-esteem, stress, grief and loss and work related problems; Medical disorders such as obesity sleep disorders, sexual difficulties, chronic fatigue syndrome and chronic/acute pain (Westbrook, Kennerley, & Kirk, 2011, pp. 1-22). CBT is also effective with other psychiatric disorders such as anxiety disorders that include social phobias, obsessive-compulsive disorder, PTSD, and panic disorder (Hamid-Balma, 2009)

Typically, those who are wishing to undergo therapy using the CBT approach would meet face-to-face with a therapist for a total of 10-20 sessions between 45 minutes to an hour each.  These sessions would take place normally once a week for the first few sessions and then move to once every other week. Afterwards, the client might continue to come in for “booster sessions: after the therapy has been over for one month and then again at the third month (NACBT, 2014)

CBT techniques consist of cognitive rehearsal, validity testing, writing in a journal, guided discovery, modeling, homework, aversive conditioning, and systematic positive reinforcement (Beck, 2011, pp. 17-27).  Cognitive Rehearsal is finding certain ways that a problem can be handled by “rehearsing” different ways of dealing with a particular situation so the patient will be better equipped to handle the situation when it arises. Sometimes this is referred to as role playing.  Validity testing is when the therapist asks the client to defend their thought process or thinking. If the client is not able to do this, the therapist then points out the errors in the clients thinking.  Journal writing is used to help the therapist find any maladaptive thinking patterns with the client as they daily record interactions they have had and how they reacted to the situation.  Modeling is the process of showing the client healthy behavior, patterns and ways to interact and respond to different situations that the patient can model in their own life. Homework is used in a variety of ways from journaling, to recordings. The purpose of homework is to identify distorted thinking and behaviors the client currently has and apply new coping skills and/or strategies instead of what they currently are using (Smith, 2009). Guided discovery is a process in which the therapist uses to help the client reflect on how they process information and their feelings. This helps form the client’s blueprint for changing how they think and behave (Manning, 2011). Aversive conditioning is using a unwanted stimuli to correct or eliminate an unwanted behavior. An example of this is a person who wants to stop sucking their thumb may apply a horrible tasting liquid to their thumb as negative stimuli to stop the unwanted behavior of thumb sucking. Systematic positive reinforcement is simply rewarding the good behavior that is desired (Beck, 2011, pgs 17-27). 

 Cognitive behavioral therapy holds an emphasis on measuring changes in both the cognition and behavior of an individual. It obtains these goals by a variety of methods including “homework” or practice exercises.  These assignments/exercises are crafted together for the client to bring to the next session. They should include a short list of the client’s broad goals that are put into order of importance that the client wants to work toward. Incorporate these goals into planning the homework assignments.  These assignments are a necessary part of CBT because it shows the clients willingness to change and set outside their comfort zone or normal way of handling a situation (Shirk, S. R., Crisostomo, P. S., Jungbluth, N., & Gudmundsen, G. R., 2013). A homework assignment for someone suffering with depression or anxiety might be something as simple as attending a social event that is small, documenting daily activities and emotional appraisals, to something a little harder such as approaching someone new to talk to them.  What is important during this time is the collaboration between therapist and client on the   homework assignment and the follow through and perseverance on the client’s part to complete it ( Bauer, Wilansky-Traynor, & Rector, 2012).The completion or lack thereof allows the therapist to gauge what treatment steps are most logically needed based upon the patient’s compliance. This compliance is linked to the therapeutic alliance between therapist and the person seeking help and/or assistance (Freeman, 2007)

Overall Impression of CBT
            I personally really enjoy CBT. It has a wide range of use from trauma-focused cognitive behavioral therapy, to working with children, adults, to medical uses for treatment of schizophrenia, psychosis and other mental health illness. With roots in philosophy, behavior therapy and cognition it’s a wide encompassing tool that focuses on the here and now. It can be brief or long standing depending upon the issue and it is collaborative between the client and therapist. What I like about the techniques is that it does not tell people how they should feel or why, but rather encourages the client using the Socratic Method (NACBT, 2014). I like the inclusion of having the client give concrete examples for the problems they have. Then relating back any feelings, thoughts or behaviors to those examples helps the client explore their perceptions of the problems and how to fix them, while at the same time exploring the frequency, duration and intensity of the problem (Sattler, 1998)

            CBT is not without its limitations though. It may not be suitable for those with learning difficulties, since the focus is on the client’s ability to bring about change in his/her life and certain learning disabilities may hinder that expectation and leave the therapist needing to chose a different therapy option. Other limitations may be found in the clients preferences themselves. The client might want a therapy that is more long term or less structured with no homework assignments. Therapy geared toward focusing on both the past and the here and now, and not geared toward building the client/therapist relationship. In those cases selecting psychodynamic counseling might be a better fit (Judith S. Beck,Donald Meichenbaum, Glen O. Gabbard and Ryan Howes, 2015). Others may feel that with CBT, you are not validating their emotions, but instead are only interested in trying to change them to fit into your label. Other limitations are found with using CBT either alone or in combination with antidepressant medication for the treatment of “co-occurring depression and substance use issues” ( Hides, Samet & Lubman, 2010). CBT has also been viewed by some in the field as rigid and mechanical, focusing on education and goals planning. While ignoring how aspects of the past have influenced and carried over current issues that need to be treated as well (Hamid-Balma, 2009). CBT has also been known to work best with children over the age of 14, since their cognitive functioning is more developed then their younger counterparts. I will say that there have been cases of CBT being used with children as young as 7(Royal College of Psychiatrists, 2015).
            However, CBT is designed to foster relationships and independence at the same time. While CBT is not a cookie cutter approach. It focuses on the prevailing values and attitudes within a culture. Because of this, CBT can be tweaked or adapted to fit American culture, Chinese, Haitian, etc., to adopt the values that are important to that specific group, making the client less resistant to CBT (Hamid-Balma, 2009).There have been over 548 evidenced based studies conducted on CBT from 1958 to 202, including evaluations of intervention policies, practices and programs. These clinical trials have approached a broad range of conditions and populations including, but not limited to marital problems, criminal behavior, sexual dysfunction, depression, mood disorders and substance abuse, which have successfully addressed many issues children and adults face (Clark, 2011)

Some strength’s of CBT is that it is collaborative, structured and educational. At the center of CBT is the client/therapist relationship. Therapists need to show empathy, connect with the client, be honest, forthcoming and engaged without being condescending, or becoming attached. This exchange acts as a catalyst for recovery and change for the clients.  Clients seek out a therapist that they feel are kind, genuine, wise, and respectful and will not judge. It is imperative that therapists possess these qualities for CBT to be at its most effective.  The reason behind the therapist-client relationship is so the therapist can uncover any underlying beliefs, and automatic thoughts the client might behaving that could point to emotional and/or behavioral disorders (Ameli M, Dattilio, Hanna MA, 2012)

            Roberta Williams is a 34 year old female, who works in a predominantly male occupation. Roberta is concerned with her ability to maintain a healthy, lasting romantic relationship and friendships. She often times feels depressed, isolated, unworthy, insecure and lonely in her day to day life. She reports that her work life and home life both leave her feeling incomplete and dissatisfied. She self-reports anxiety issues, and referred herself to counseling. 

            While reading this case file there were several things that immediately stood out to me that I would explore further with Roberta. The first is the level of alcohol use as what appears to be a coping mechanism in her life. She reports that she drinks alone, in groups, uses alcohol to fall asleep and to cope with her days. She self-reports drinking on average 4-6 drinks, 3-4 times per week. According to the DSM-V, Alcohol Use Disorder diagnosis criteria, with the information already available she meets the criteria for at least mild alcohol use disorder (American Psychiatric Association, 2013). Regarding this specific problem I would want to gather some more information regarding if she has ever tried to reduce her drinking habits and the outcomes, if there is any history of alcohol abuse in her family, if she suffers from withdraws on the days she does not drink, and if her drinking has ever interfered with her relationships or work life. 

Homework is a central part of CBT and assignments are often given throughout the course of treatment. When assigning homework I know that it is important to keep in mind the level of commitment from the client as well as their reading and cognitive abilities. Roberta has already stated she loses attention during reading, so for this topic I would assign homework to her that required no reading and was more tailored around her observations and documentation.

Since Robert does not feel she has a drinking problem, I would not want to approach the homework from this angle. Instead, I would talk to her about keeping a journal throughout the week of her feelings, what was the trigger, how did her body react, what did she do, and documenting how difficult the trigger was for her to handle. This was I can see if her go to response is to drink, or if she has another normal response she is unaware of. Plus, this will allow me deeper insight into understanding Roberta’s insecurities and dissatisfaction in different arenas in her life, including her anxiety. I would make sure to include Roberta in this process asking her along the way if she feels the homework is reasonable, if she would want to change anything and also do an example with her.  

Roberta has quite a bit of automatic negative thoughts built around her relationships, work, and self. I would want to work at identifying those automatic thoughts, her cognitive distortions and replacing them with rational responses. An example of this was when she was offered a promotion at her job and her first response was to deny it because it would mean more paperwork. The cognitive distortion here is jumping to conclusions. A more rational response might be a promotion might make my job less boring and give me the ability to connect with the employees. Other automatic thoughts I would want to work with is Roberta’s thought process that she is unattractive, unworthy, and desperate.  Working through a CBT thought record, even together since she dislikes paperwork and reading would shed some light on her emotions and feelings related to her negative automatic thoughts when she has to give evidence that supports and contradicts those automatic thoughts. Plus, helping her build some alternative thoughts to her negative ones would be beneficial in her healing. 

I would want to work with Roberta through her depression and anxiety, by working through her negative thinking using the Thought Record and then associating the thinking style that goes along with her thoughts and feelings so we could re balance her thinking. An example of this would be with Roberta’s self-labeling. I would point out how that is negative thinking and challenge her to look for evidence that supports this idea and consider some positive affirmations. One example of this is that Roberta feels her co-workers know about her anxiety and her promotion was offered with this knowledge. I would want Roberta to assign the negative thought, find evidence that supports Roberta’s way of thinking, have Roberta determine if her co-workers would agree with her thoughts, have Roberta offer some alternative explanations such as a strong work ethic, think about what the worst possible case scenario could come from the situation and also have her think about what advice she would offer her friends if they were experience this. I would then help Roberta set up an experiment to test the validity of her thoughts. For example, if her thought is she is only appealing, happy and energized when she is with a romantic partner, I would have her write down every time she has any of these feelings throughout her day. Such as “was happy to get to a call from my friend today,” “was feeling energized at work when I was completing my job,” or “felt sexy when the stranger on the road turned to look at me when I passed by.”  Having Roberta keep a record of times that contradict her negative thoughts will help her see that she can be satisfied outside a romantic relationship. 

            Although Roberta has several different presenting concerns at the moment, applying the basic principles of CBT I believe can alter the way she thinks about her situations and therefore how she will respond in the future. A huge part of this process will be determined by Roberta’s willingness to do her homework assignments and step outside of her comfort zone. With Roberta, she has a strong motivation for change. She is able to identify some of her current stressors and shows a willingness to stand back and think about the root cause, even if her thinking is negative. She stated she made A’s and B’s throughout high school and had formal testing done regarding her reading that came out “normal,”  which shows she has the ability to think cognitively. Since her work seems to be independent in nature, at least to some degree, she is more likely to be able to fulfill her homework assignments, if the reading is kept to a minimum and I can use more outside the box assignments.  Another consideration would be my ability to establish a strong working relationship quickly with Roberta to show her I am there for her in an attentive way; I am knowledgeable; will be non-judgmental and willing to work with her. 

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