2013-11-24
CBT Made Easy
Dr. Mark Weiss MD
Medical Director Bellwood Health Services
[email protected]
Copyright ©2013 Dr. Mark Weiss
CFPC CoI Templates: Slide 1
Faculty/Presenter Disclosure
Faculty: Dr. Mark Weiss
Relationships with commercial interests:
Grants/Research Support: None
Speakers Bureau/Honoraria: None
Consulting Fees: None.
Other: Medical Director at Bellwood Health Services.
CFPC CoI Templates: Slide 2
Disclosure of Commercial
Support
This program has not received financial or inkind support.
Potential for conflict(s) of interest: None
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2013-11-24
Mitigating Potential Bias
None
CBT Theory
Perception
Events
Emotions
Thoughts
Behaviour
Copyright ©2013 Dr. Mark Weiss
Boss does not
acknowledge me
He must be upset
with me. What
did I do wrong?
Stay home
and cancel visits
with friends
because I just
don’t feel like it.
Sad
Copyright ©2013 Dr. Mark Weiss
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2013-11-24
Boss does not
acknowledge me
He must be upset
with me. What
did I do wrong?
Stay home
and cancel visits
with friends
because you just
don’t feel like it.
Sad
Copyright ©2013 Dr. Mark Weiss
Cognitive Behavioral Therapy
Evaluate thoughts to effect a change in perspective
which in turn effects change in mood  behavior.
Change behavior to effect change in mood.
Copyright ©2013 Dr. Mark Weiss
Outline
1) Simple Techniques for working with behavior
Identifying goals
Turning goals into action steps
2) Identifying NATs ( Negative Automatic Thoughts)
3) Simple techniques for reframing NATs into PATs
(Positive Automatic Thoughts) or EATs (Effective
Automatic Thoughts)
EMPATHY = Relating to the experience of another
Copyright ©2013 Dr. Mark Weiss
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Empathy
Without empathy all psychotherapeutic techniques
fail
The number one predictor of outcomes in
psychotherapy is the connection between therapist
an client
Two Basic Human Needs...
To feel connected
To feel competent
- Andrus Angyal
Tool
Task
Reflective Listening
Help client feel connected (
cultivate empathy)
Goals
Action Steps
NATs  PATs / EATs
Competence
Copyright ©2013 Dr. Mark Weiss
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What might empathy look
like.
How to practice empathy through reflective listening.
Case ?
23 year old male client tells me that his father had died.
My response:
“I am so sorry to hear about the death of your father”
Client ++ angry response:
“Why are you sorry, he deserved to die,
he was an asshole”.
Copyright ©2013 Dr. Mark Weiss
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What should you I say next ?
A) “Why did you get so angry at me ?”
B) Change the topic to something else.
C) “I can see that you are angry at me now. Lets talk about
this later.”?”
D) “I did not mean to upset you by telling you, “I was
sorry to hear about the death of your father. I can see that
it made you very angry. Would you like to talk about how
you are feeling about his passing.”
Copyright ©2013 Dr. Mark Weiss
Doctor: (Reflect) “I did not mean to upset you by telling
you, “I was sorry to hear about the death of your father. I
can see that it made you very angry. (Ask Listen) Would you
like to talk about how you are feeling about his passing”
Patient: I don’t really care, he was an f…….. asshole
(Reflect) Doctor: It sounds like you had a very difficult
relationship with your father. (Ask, Listen) Would you
like to tell me more about this?
Patient: ………………(Client discusses history of abuse)
Doctor: (Reflect) I can see why you are so angry at your
father. (Ask, Listen) How are you coping with this
anger ?
Copyright ©2013 Dr. Mark Weiss
Reflective Listening (ALRS)
A= Ask about (SEE)
Situation: Please tell me more about the …..
Emotions: How are you feeling……
Effect: How are you coping / How has this affected
you..
Listen = Understanding the meaning this has for the
client (not Judging or Fixing)
Reflect (Summarize)= Let the client know you heard
them.
“ I can see how frustrated you are and appreciate
that this is very difficult for you “
S=Support to the extent that you can
Copyright ©2013 Dr. Mark Weiss
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Reflecting (ALRS)
‘I can see that your husband’s memory loss has been very
difficult for you to cope with.’
‘I can appreciate how difficult it is for you to talk about
this.’
‘I can sense how angry you have been feeling about your
illness.’
‘I can see that you have been very upset by her behavior.’
‘I can understand that it must be frightening for you to
know the pain might keep coming back.
Copyright ©2013 Dr. Mark Weiss
Support
Point out anything positive you can. Reinforce strengths.
“I am so happy that you have come to see me about
this”, “It takes a lot of courage to …”
Offer what you can ( maintaining boundaries).
“ Would it be okay to talk about some options to help
you, feel better.”
I can see how difficult the circumstances are, and I only
wish I had a magic wand that could make this all go away. If
there is something you feel I might be able to help with,
please let me know.
Copyright ©2013 Dr. Mark Weiss
Example
23 year old female client who was in rehab, abstinent
from substance use. Hx of promiscuity comes to see
me.
Doctor: How are you ?
Patient: I am fine. I have to tell you something.
Doctor: Please go ahead, I am listening.
Patient: I prostituted myself twice since I last saw you.
Copyright ©2013 Dr. Mark Weiss
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What question would you ask next ?
1) Did you use protection?
2) That sounds concerning, I am worried about that?
3) Last visit we talked about respecting our bodies what
happened?
4)
How do you feel about what you just told me?
Copyright ©2013 Dr. Mark Weiss
How do you feel about ….?
Patient: Well actually it felt like a rush. I could not believe that
someone would find me attractive enough to pay me for sex.
Doctor: (Reflect ) I can see how being paid for sex might have made
you feel this way, but you seemed concerned when you told me this.
Longer discussion………….( Client expresses ambivalence and shame at
having experienced a rush from her actions.)
Patient: I am not ready to commit to not prostituting again. I kinda
liked how it made me feel.
Doctor: (Reflect ) You told me that you like how this made you feel so I
can understand why you might not be ready to change this. (Ask) Is
there some part of this that you don’t like or are concerned about ?
Patient: Well I did have some questions on STDs. Is it okay for me to
ask?
Copyright ©2013 Dr. Mark Weiss
Outcome
Client was able to commit to doing whatever she was going to
do in the safest way possible:
Telling anybody ahead of time that protection was a must.
Buy and bringing condoms with her.
Ensuring safety by letting a friend know where she was going.
Returning to talk about her behavior.
Beginning CBT: Client agreed that it would be helpful to
journal thoughts and feelings before and after any sexual
experience and bring this to our next session.
Copyright ©2013 Dr. Mark Weiss
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Thought Journaling
Situation
Mood
Thoughts
Take Home Message
Ask
Listen
Reflect
Support: Means supporting the client in changing what
they want to change or work on.
Copyright ©2013 Dr. Mark Weiss
The Order of Things
1) Client feels understood and heard.
2) Change
Behavior
Copyright ©2013 Dr. Mark Weiss
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A Problem
25 year old
Male in a group home
feels depressed.
Management wants to
kick me out unless I get
my room clear ! The
fire inspector thinks it’s
a hazard.
Behavioral Approach
Complaint
Action Steps
Copyright ©2013 Dr. Mark Weiss
Therapy in one (or two) sentence:
1) Desired Outcome: I can see how difficult this is for
you.
What is most important to you about this situation?
How would you like this to work out?
How would you like to feel ?
Copyright ©2013 Dr. Mark Weiss
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Therapy in one or two sentences
2) Goals: What do you think you might be able to do
between now and the next time we see each other that
might be helpful to you in achieving ………….. ?
If you could do one thing between now and the next time
we see each other what might that be.
3) Goals Sheets: Identify realistic achievable goals.
Write down action steps
Copyright ©2013 Dr. Mark Weiss
Behavioral Approach
Complaint
Client’s Desired Outcome
Goals
Action Steps
Copyright ©2013 Dr. Mark Weiss
Goal /
Action
Clean my
room so I
can stay in
my recovery
home.
Steps
Tell
manager
about my
intention
and plan
Ask sister
if I can
borrow. file
boxes
Go to
dollar
store buy
garbage
bages
Budget
time for
organizing
Mon
Tues
Wed
Thurs
Friday
Sat
Sun
Call 9am
9am
10 am
10 am to
11 am
or
One bag
of
garbage
per day.
2-3 pm
Fill one
file box
with
papers.
Copyright ©2013 Dr. Mark Weiss
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Positive experiences = TEFLON
Negative Experiences are like
VELCRO.
Copyright ©2013 Dr. Mark Weiss
Pleasure Mastery Worksheet
Task
How did it feel ?
Note any thoughts that
came to mind.
Called
Manager
Felt nervous at first.
Felt okay after.
He was more supportive
than I expected
Called my
sister.
Thought she could help
but she said she was to
busy.
I am disappointed.
Got 5 bags
of garbage Felt hopeful.
out.
Manager smiled at me
when he saw my garbage
bags on the curb. I can
do this over time.
Suggesting a Desired Outcome
Patient repeatedly is stuck on complaining about how they feel.
For example, “ I am depressed, so depressed ……..”
Doctor: Is it okay for me to suggest something that I think
might be helpful
Patient: Okay
Doctor: It sounds like you feel depressed but you want to feel
happy. Is this correct ?
Patient: Yes, I am fed up feeling this way, and I would like to be
happy.
Doctor: I can see your desire for change, and I would like to
help.
Patient: What can I do ?
Copyright ©2013 Dr. Mark Weiss
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Goalification ( Greg Dubord)
Based on the principle of moving clients away from their
complaints but suggesting antonyms to the clients
complaint.
Complaint
Antonym (Goal)
Depression
Happiness, Satisfaction
Anxiety
Calm
I don’t like
myself
Confidence
Suggesting a Desired Outcome
Patient: Stuck on complaint of feeling depressed and being
kicked out:
Doctor: Would it be okay for me to suggest something.
Patient: Yes
Doctor: It sounds to me like you want to feel calm and
happy and that if your room was more organized you
would feel better. Is this correct.
Patient: Yes, I would feel better, but I have no idea where
to start. It feels overwhelming.
Doctor: Identify baby steps
Copyright ©2013 Dr. Mark Weiss
Behavioral Approach
Complaint
Client identifies
UNrealistic
Realistic
and
Achievable
Client’s Desired Outcome
Goals
Client unable to
identify
Suggest
Action Steps
Copyright ©2013 Dr. Mark Weiss
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Tug of War Metaphor
Two people are engaged in a tug of war.
Pit of Suffering
So who do you think is likely to end up in the pit of
suffering? – The big guy or the small guy…
Copyright ©2013 Dr. Mark Weiss
Tug of War Metaphor
(Cont’d)
Everything that is bigger than
you in life.
I am free to move on?
Pit of Suffering
Copyright ©2013 Dr. Mark Weiss
Tug of War Metaphor
(Cont’d)
“I brought this up because the big guy is like all
of those things in our lives that might be unfair
but bigger than us and that we cannot change or
control.”
Think of a story you can tell to demonstrate this
“And or demonstrate with client. You want this
piece of paper tug of war.”
Copyright ©2013 Dr. Mark Weiss
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Pen to Gold Metaphor
Here is another way to think about this.
“Please take the pen and hold it for a moment. Now
concentrate really really hard and turn this pen into
gold……….Okay try a little harder…….Okay so if I
continued to ask you to turn this into gold how would you
feel…….How is your situation similar to the experiment we
just did.”
Copyright ©2013 Dr. Mark Weiss
Message
If you want something that can’t happen
who hurts?
Copyright ©2013 Dr. Mark Weiss
Maladaptive Thoughts
Complaint
Client identifies
UNrealistic
Realistic
and
Achievable
Client’s Desired Outcome
Goals
Client unable to
identify
Suggest
Action Steps
Copyright ©2013 Dr. Mark Weiss
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When our thoughts get in the way !
They just don’t like me and are
going to kick me out !
Elicit Maladaptive Thoughts (3 questions)
What is going through you mind when you recall the event?
What does this mean about you / others.
What do you think might happen.
Evaluate the Thought ( 4 questions)
If you play this thought in you mind what do feel or want to do?
How do you know it is true
Is there any reason it might not be true
Advice you might receive or give.
Desired
Outcome:
(NAT)
Goals and Action
Reframe Perspective : Effective Thought
Copyright ©2013 Dr. Mark Weiss
Eliciting Thoughts
What is going through your mind when you recall the event?
Its my room.
I should be able to have a messy room.
What does this mean about you / others.
They don’t like me. They are mean.
What do you think might happen.
They want to kick me out.
Copyright ©2013 Dr. Mark Weiss
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Event
Feeling
Thoughts
Evaluate Thought
Un-helpful / Helpful
(Unhelpful thoughts
interferes with your
desired outcome)
Room
messy.
Eviction
threat.
Angry
Effective Thought and or
Behaviours
(Helpful thought
facilitates your desired
outcome.)
Its my room.
Depresse
d
I should be able to
have a messy
room.
They don’t like
me. They are
mean.
I don’t have another place to live so I want to be able to
live here until I get my own apartment.
Copyright ©2013 Dr. Mark Weiss
Desired Outcome:
Event
Feeling
Thoughts
Evaluate Thought
Un-helpful / Helpful
(Unhelpful thoughts
interferes with your
desired outcome)
Room
messy.
Eviction
threat.
Angry
Its my room.
Depresse
d
I should be able to
have a messy
room.
They don’t like
me. They are
mean.
Effective Thought and or
Behaviours
(Helpful thought
facilitates your desired
outcome.)
If you play this
thought in your mind
how will you feel or
what will you want to
do?
How do you know it is
true?
Is there any reason it
might not be true?
Advice you might
receive or give?
Desired Outcome: I don’t have another place to live so I want to be able to live here until I get
my own apartment.
Copyright ©2013 Dr. Mark Weiss
Situation Mood
Thoughts /
Behaviours
Un-helpful
/ Helpful
Effective Thought (EATs)
and or Behaviours
(Helpful thoughts help Effective = Getting your
you achieve your
desired outcome.
desired outcome)
Room
messy.
Angry
Its my room
Unhelpful
I should be able
to have a messy
room.
Unhelpful
Depressed
Eviction
threat.
They don’t like
me.
Unhelpful
Desired Outcome: I don’t have another place to live so I want to be able to live here until I get
my own apartment.
Copyright ©2013 Dr. Mark Weiss
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Event
Mood
Room
messy.
Angry
Current
Thoughts /
Behaviours
Un-helpful
/Helpful
Effective Thoughts and or
Behaviors
(Helpful thoughts
help you achieve
your desired
outcome.)
( Also called Dispute or Balanced
Thoughts)
Its my room
I only live in this room in a shared
home owned by St. Vincent’s.
Depressed I should be able
Eviction
to have a messy
threat.
room.
I may not care if my room is messy
but the fire inspector thinks it’s a
problem and I have no control.
They don’t like
me.
I don’t really know if the manager
likes me, and it may not matter. The
fire inspector does not know me
from a hole in the wall and the
manager is doing what he is told to
do.
.
Desired Outcome ( Achievable and Realistic):
able to live here until I get my own apartment.
I don’t have another place to live so I want to be
Copyright ©2013 Dr. Mark Weiss
Elicit Maladaptive Thoughts
What is going through you mind when you recall the event?
What does this mean about you / others.
What do you think might happen.
Evaluate the Thought ( 4 questions)
If you play this thought in you mind
How do you know it is true
Is there any reason it might not be true
Advice you might receive or give.
Desired Outcome:
Goals and Action
(NAT)
Reframe Perspective : Effective Thought
Copyright ©2013 Dr. Mark Weiss
YouTube.com
Search for “cognitive distortion-cbt”
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CBT
Practicing empathy by using Reflective Listening (ALRS)
Identifying a desired outcome of relevance to the client
Redirecting unrealistic expectations of goals by teaching
acceptance
Identifying goals of relevance to the client
Goals  Action Steps
Identifying maladaptive thinking
Turning NATs into EATs
Copyright ©2013 Dr. Mark Weiss
Suggestions
Mind Over Mood By Padesky
CAMH
Contact
[email protected]
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