This is the second course I’ve been taking from The Great Courses. It is Cognitive Behavioral Therapy: Techniques for Retraining Your Brain by Professor Jason M. Satterfield. Since CBT principles are what SMART Recovery is based on I thought it would behoove me to take the course. This first entry will have 4 out of the 24 lectures in the course. It gives the basics of CBT including the “Third-Wave” of CBT. The next several lectures deal with specific diagnosis and how CBT deals with them. For a list of the lectures click here.
I found the topic as presented difficult to understand. Professor Satterfield shifted between didactic teaching and case presentations. Although, with effort, by the end of the fourth lecture I had a clear understanding of what CBT is and how it differs from traditional psychotherapy. I hope this summery is helpful.
Cognitive Behavioral Therapy: Techniques for Retraining Your Brain
Course by Professor Jason M. Satterfield
University of California, San Francisco
Course in 24 lectures
Lecture 1: Cognitive Behavioral Foundations
The Professor introduces the course with stating the goals. The goal of the course is to present the science of how we change. If there are things we can’t change we can learn things to lessen suffering and improve the quality of your life. Another goal is to give the student a toolbox of evidence based strategies you can use whenever you need them.
He also introduces us to three people who will be his case study subjects in the lectures.
1) Carol, 30 year old woman who has anxiety, especially in social situations. This impacts her personal and work life in a negative manner.
2) Michael, 50 year old male, normally kind but prone to angry outbursts.
3) Maria, 70 year old woman. Under a lot of stress due to taking care of a husband with dementia. The stress has led to depression and anxiety.
The lecture goes on talking about change. What can and cannot be changed. For instance, our degree of introversion versus extroversion may be difficult or impossible to change but we can all be taught to improve our social skills. He mentions a study that compared functional MRI (fMRI) of the brain for treating depression. One treatment used Cognitive Behavioral Therapy (CBT) and another used Paxil psychopharmacology. Both groups had improvement in their depression but the CBT group showed changes in their hippocampus and the Paxil group showed changes in their prefrontal cortex. Why they had different responses is unclear but the main point is that CBT can change your brain.
So we can say that therapy can change your brain in positive ways. There are some non specific factors such as empathy from the therapist and the therapeutic alliance. Social support from groups can help also. Even SMART Recovery groups can help!
Introduction to Cognitive Behavioral Therapy
Cognition – All our mental activity.
Top of triangle – Thoughts
Other 2 corners are Behavior and Emotions
The 3 corners of the triangle all influence each other. The emotion anxiety will influence thoughts, like I’m afraid of social situations and your behavior such as I’m staying home instead of going to a party. If you accept some discomfort and get out of your comfort zone and go to the party your behavior may eventually effect your emotions by getting less anxious in social situations.
Special Features of the Cognitive Behavioral Therapy process
1) CBT is collaborative and transparent. Collaborative in that the patient and therapist work together in a partnership. They collect data on what their problems are. They agree on a formulation of the problems and develop a treatment plan. Transparent in that it’s all done above board. No hidden agendas.
2) CBT is empirical. A hypothesis is developed about why you may be anxious or depressed but that can change as therapy progresses and new things are learned.
3) CBT is time limited. Depending on individual but usually 12 to 24 sessions.
4) Skills focused. Teach behaviors that address the problems.
5) Symptom focused. Monitor how changing your behavior impacts your original symptoms.
6) Focused on the present. Delving into the past generally not done extensively.
Since this is recorded and a Q and A session at the end of the lecture isn’t available Dr Satterfield offers the FAQs. Questions that he’s frequently asked when presenting this material.
FAQ 1 – It sounds like you are asking us to not go with our gut, or to downplay our emotions.
Answer 1 – CBT asks you to have more of a balance. We need our passions and emotions but when things get out of balance and our lives are getting out of control we may need to appeal to our rational mind to get us back in control. An out of control life can result in great emotional suffering.
FAQ 2 – Why did you become a CBT therapist?
Answer 2 – I started in the neurosciences at MIT. I later got hooked on how the neurosciences impacted people and decided to go the psychology route.
FAQ 3 – The CBT triangle seems too simple.
Answer 3 – The triangle is simplistic but it is just scratching the surface of psychological behaviors.
Lecture 2: Quantified Self-Assessment for Therapy
Lecture starts with a little history. Aaron T. Beck is the father of CBT. In the 1960s he became frustrated with psychoanalysis in a group of depressed patients he was treating.
There were some roots of CBT in ancient philosophy. Socratic questioning, in which the person is not told the answer but asked a series of questions to arrive at the answer themselves. Epictetus postulated that “Men are disturbed, not by things, but by the principles and notions which they form concerning things.”
Albert Ellis was already writing about REBT, Rational Emotive Behavior Therapy. This was very influential to Beck. CBT formally started when Beck and others published Cognitive Therapy of Depression in 1979.
Theory of CBT.
How does CBT explain emotions, suffering, mental illness? How does CBT explain individual variations? Does the theory hold for everyone? To answer these questions remember we are looking at 3 key variables, the CBT triangle, cognition, behavior, emotions. We want to engage these 3 variables in 3 ways.
1) Detection, data gathering
2) Analysis and evaluation
3) Challenging or changing those cognitions, behaviors and emotions.
This is just the surface of the therapy. The job of the CBT therapist is to delve deeper into the reasons and motivations of the client. Classic psychotherapy starts at the bottom, looking at early development, unconscious motivations etc. and works it’s way up. Hopefully these insights will help the client improve their behavior. CBT is the opposite. It starts at the top, focusing on current problematic behaviors and setting behavioral goals to strive for. Eventually deeper insights are gained as therapy progresses.
CBT will start with a Case Formulation and Assessment. Data can be gathered by interview, questionnaires, diaries, social and medical histories etc.
The lecturer then goes into an example with Maria, the elderly woman caring for her husband. She filled out several questionnaires. He points out that repeating these questionnaires later in therapy can give us a measure to show progress. This assessment shows she is at the border between moderate and severe depression. She has physical symptoms like anorexia, insomnia fatigue, aches and pains. She is also on the lower end of the moderately anxious. He points out that treatment of depression and anxiety will be part of the goals set up for her.
For an alternate perspective on Case Formulation he turned to Michael as an example. Michael is prone to anger outbursts and for him self monitoring, diary keeping were more helpful. He is asked to keep a diary noting emotions throughout the day.
He now talks to Carol about setting some SMART goals. Carol has difficulty with sleep, shyness and relationships. SMART Goals are Specific, Measurable, Attainable, Relevant, Timely. Carol uses the example of poor sleeping.
Specific – Go from 5 hours of sleep a night to 7 hours.
Measurable – She’ll do a sleep diary
Attainable – She thinks this is possible
Relevant – Definitely a goal she want to achieve
Timely – Needed for her increase the quality of her life.
Lecture 3: Setting Therapeutic Goals
In lecture two we described how we get a case formulation based on the data we’ve collected. Case formulation is defined as an individualized theory that explains a particular patients symptoms and problems. It serves as a basis for an individuals treatment plan and guides the therapy process. A formulation is always a work in progress. It can change as new data is taken in and as therapy progresses. The formulation is always transparent between patient and therapist.
Key Elements of a Case Formulation
1) First we need a problem list or diagnosis.
2) Second we’ll develop a working hypothesis. Four elements needed for a working hypothesis.
- a) Cognition and deeper cognitive structures. (Beck’s cognitive model.)
- b) Behaviors with attendant punishments and rewards.
- c) Origins – Early learning, family issues.
- d) Lastly – Tie it all together and create a summary to tell a story.
3) Third key is to focus on the patient’s strengths and weaknesses.
4) Fourth is to create a treatment plan based on our hypothesis, strengths and weaknesses and goals.
Now lets look at our patients: Maria has a problem list that includes problems with relationships with her husband and daughters, emotional issues like depression, stress, anxiety and some physical symptoms like aches and pains. She has a working diagnosis of major depression. Michael has conflicts with his wife and son. Also conflicts with coworkers, some friends and neighbors. He also has hypertension and high cholesterol. Emotionally he has anger outbursts. No formal psychiatric diagnosis.
Next we are going to work on developing a working diagnosis. At this point we need to understand Beck’s cognitive model. Activating events can cause automatic thoughts. However, different people have different automatic thoughts for the same event. Beck believed people follow scripts or schemas based on our core beliefs. These scripts give rise to our automatic thoughts.
Interviewing Michael Dr Satterfield determines he has strong beliefs of fairness and personal responsibility. He’s a hard working perfectionist and wants to control situations around him. Next we will evaluate his behavior based on these beliefs. He is quick to anger when he perceives others are being unfair or irresponsible. We will also consider where he learned these beliefs from his past.
Lecture 4: Third-Wave Cognitive Behavioral Therapy
A little history: First wave is early Freudian psychology. Looking at the subconscious, dream interpretation etc. Therapists are always looking for deeper meanings in what is said and how we behave. Second wave is cognitive model or CBT as presented thus far in this course. We react to events or have automatic thoughts that are provoked.
Cognitive model assumes we are not very rational. We often misinterpret events. We minimize or awfulize. All or none thinking. Mind reading, assuming what other people are thinking. Fortune telling. Example, if you’re depressed you are probably assuming bad outcomes. Over-personalize “I know it’s about me.”
He then goes through an example of use of the ABCs to unpack an event with Marie, who went out to do errands and left her husband with a caretaker. The Activating event is going out to do errands. The Beliefs are she was dwelling on feeling guilty for not taking care of her husband. The caretaker doesn’t understand him. Something might happen to him while she’s gone. Consequences are guilt, depression and she skipped a trip to Starbucks where she wanted to get a treat. To Dispute the belief that something might happen to him he asks her to bring up an example of what would she tell a friend she was out with who was worried about a daughter. She reminds herself that he is with a caretaker.
Third-wave therapy distinguishes itself from the other two by focusing on the process of cognition rather than the content of cognition. Acceptance and Commitment Therapy, ACT, teaches people to accept their thoughts rather than trying to control them. He then throws out the acronym FEAR to highlight our negative reactions to events.
Fusion with your thoughts. Our irrational thinking is our identity.
Evaluation of experience in the negative filters of our irrational beliefs.
Avoidance of experience. Our dysfunctional reaction to the experience.
Reason or rationalization for your dysfunctional behavior.
The healthy alternative is to, you guessed it, another acronym, ACT.
Accept your reactions.
Choose a valued or appropriate direction.
Take action to go towards your appropriate behavior.
ACT has six core principles.
1) Cognitive diffusion. Learning methods to reduce the tendency to think our thoughts are our identity.
2) Acceptance of our thoughts and letting them come and go without struggling with them.
3) Contact with the here and now. Don’t struggle with thoughts of the past and future. Mindfulness.
4) Accessing the transcendent self. The core of who you are despite surrounding events and the jumble of thoughts coming and going.
5) Values. Keeping aware of what values are important to you and your identity.
6) Committed action. Setting goals according to values and carrying them out responsibly.
The lecturer then makes a brief mention of MBCT. Mindfulness Based Cognitive Therapy. There are times to let the thought storm blow in and be accepted and then let it go without struggle. He discusses the problem with Michael who has anger outbursts. A useful strategy may be to let the anger thought storm come and go without acting on it.