GENERAL CONCEPTS OF CBT AND Intensive Short Term Psychodynamic Psychotherapy (ISTPDP)

Core beliefs are the most fundamental level of belief; they are global, rigid, and overgeneralized.

Automatic thoughts, the actual words or images that go through a persons mind, are situation specific and may
be considered the most superficial level of cognition.

Intermediate beliefs that exists between the two are- Attitudes, Rules & Assumptions.

Attitude: Its terrible to fail.- how do you evaluate failing

Rule: Give up if a challenge seems too great.- what should be the mode of action in the event of that mishap.

Assumptions: If I try to do something difficult, Ill fail. If I avoid doing it, Ill be okay.- as true for Aslam

( more clarification needed on the difference between these various components)

When patients beliefs are entrenched, you can lose credibility and endanger the therapeutic alliance if you
question the validity of core beliefs too early-its like you need to differentiate between the client and the
defenses he uses. A premature attempt to challenge the defense, might make the client feel you are attacking
him.

So you need to first point out how his defenses are the way he copes with challenges and its not who he is. Only
when he is aware of his defenses can he challenge them. Use wordings like-there is a self critical mechanism/ a
system in your mind which turns this projection inwards, instead of saying you turn this projection inwards.

As per ISTPDP these attitudes, negative thoughts, beliefs can be seen as defenses. If they are heavily
entrenched then they are like character defenses. Also they might vary in terms of insight-

A client can be aware of how much he criticises himself and say something like- I hate myself (NAT)

Someone who cant differentiate between himself and his defenses might say something like- Iam despicable.
(core belief)

Core beliefs-Intermediate beliefs (rules, attitudes, assumptions)-Situation- Automatic thoughts - Reaction

(emotional, behavioral, physiological)

Unconscious beliefs formulated through childhood experience, the stronger these beliefs the more likely is the
absence of insight, the absence of differentiation bw ones agency and defenses and the more likely is the client
to use character defenses.

A More Complex Cognitive Model

Thinking, mood, behavior, physiology, and the environment all can affect one another. Triggering situations
can be:

Discrete events (such a s getting a low mark on a paper).

A stream of thoughts (such as thinking about doing schoolwork or intrusive thoughts).
A memory (such as getting a poor grade in the past).
An image (such as the disapproving face of a professor).
An emotion (such as noticing how intense ones dysphoria is).
 A behavior (such as staying in bed).
A physiological or mental experience (such as noticing ones rapid heartbeat or slowed-down thinking).
Session Three and Beyond:

As therapy progresses, there is a gradual shift in responsibility. Toward the end of therapy, patients themselves
tend to identify their distorted thinking, devise their own homework assignments, and summarize the session.

Another gradual shift is from an emphasis on automatic thoughts to a focus on both automatic thoughts and
underlying beliefs.

As therapy moves into the final phase, there is another shift: preparing the patient for termination and relapse
prevention.

In Session 3, my goals for Sally (though not necessarily for all depressed patients) are to begin teaching her in a
structured way to evaluate her automatic thoughts and to continue to schedule pleasurable activities. In Session
4, I aim to help Sally do some problem solving about finding a part-time job and continue to respond to her
dysfunctional thoughts.

IDENTIFYING EMOTIONS

We need to differentiate between the clients thoughts and emotions, so we can point out if there is any
disparity between the two. Also we evaluate the thoughts (Defenses), not the emotions ( feelings)

Example: Therapist: So when you had the thoughts, He doesnt really want to talk. He doesnt really care that I called, how
did you feel emotionally? Sad? Angry? Something else?

Therapist: Feelings are what you feel emotionallyusually theyre one word, such as sadness, anger, anxiety, and so on. (pause)
Thoughts are ideas that you have; you think them either in words or in pictures or images. (pause) Do you see what I mean?

You will investigate further when patients report an emotion that does not seem to match the content of their automatic
thoughts, as in the transcript below:

Therapist: How did you feel when your mother didnt call you back right away?
Patient: I was sad.
Therapist: What was going through your mind?
Patient: I was thinking, What if something happened to her? Maybe theres something wrong.
Therapist: And you felt sad?
Patient: Yes.
Therapist: Im a little confused because those sound more like anxious thoughts. Was there anything else going through your
mind?
Patient: Im not sure.
Therapist: How about if we have you imagine the scene? [helping the patient vividly recall the scene in imagery form] You said
you were sitting by the phone, waiting for her call?
Patient: And then I thought, What if something happened? Maybe theres something wrong.
Therapist: What happens next?
Patient: Im looking at the phone, and I get teary.
Therapist: Whats going through your mind?
Patient: If anything happened to Mom, there would be no one left who cares.
Therapist: There would be no one left who cares. How does that thought make you feel?
Patient: Sad. Real sad.

I)Structure of the Assessment Session

In this session, you will:
Greet the patient.
Set the agenda and convey appropriate expectations for the session.
Conduct the assessment. establishing the intrapsychic conflict in terms of Feelings(wish), anxiety and
defenses (NAT, behavior)
 Set initial broad goals. the intrapsychic task establishment and positive goals. In addition the goals will be
redefined in each session by the client. what is it that you would like to talk about today?
Elicit feedback from the patient.-seeking willingness and commitment to therapy, setting goals together

Formulating the case: Not just in terms of diagnosis, but also chart out the defenses the client uses in every
session, wish fear and defense analysis should be done constantly to give you a better idea about the clients
psyche and its functioning.

II) CASE HISTORY TAKING

A case history should include all of the following:

Patient demographics.
Chief complaints and current problems.
History of present illness and precipitating events.
Coping strategies (adaptive and maladaptive), current and historical.
Psychiatric history, including kinds of psychosocial treatments (and perceived helpfulness of these
treatments), hospitalizations, medication, suicide attempts, and current status.
Substance use history and current status.
Medical history and current status.
Family psychiatric history and current status.
Developmental history.

General family history and current status.

Social history and current status.

Educational history and current status.
Vocational history and current status.
Religious/spiritual history and current status.
Strengths, values, and adaptive coping strategies.

III) What is a typical day like in the life of the client: Another important part of the evaluation is asking how
patients spend their time. Asking patients to describe their typical day gives you additional insight into their
daily experience and facilitates setting specific goals at the first treatment session. As they describe a typical
day, look for:
Variations in their mood.
Whether and how they interact with family, friends, and people at work.
How they are generally functioning at home, work,and elsewhere.
How they spend their free time.

You will also probe for what they are not doing and what they are actively avoiding.

IV)Your goals for the first session are to:

Establish rapport and trust with patients,

normalize their difficulties, and instil hope.
Socialize patients into treatment by educating them about their disorder(s), the cognitive model,( or the
triad model) and the process of therapy. Ask the client to explain the model in his words once you are
done explaining.
Collect additional data to help you conceptualize the patient.
Develop a goal list.
V) REVISITING THE GOALS IN EACH SESSION: Starting next week, were going to work toward your
goals. At every session, Ill ask you what problems you want my help in solving. For example, next week you
might say, Im still having trouble getting my schoolwork done, which relates to your goal of doing better at
school. Then well do some problem solving. We might figure out ways to improve your concentration, to get
yourself on a study schedule, and to get help from other people if you need it. (pause) Does that sound okay?

Problem solving would be done along with exploring the internal hindrances-that is identify the pattern to the
clients problem, what are the intrapsychic conflicts which are distancing him from his goals.

VI) You will hypothesize about the development of the patients disorder.( for the therapist)

Were there important early life events that led to the development of negative core beliefs?
What are the patients automatic thoughts, and what beliefs did they spring from?
The trigger could be emotional, physiological, cognitive- for example if you feel tired on getting up(
physiological), this might trigger your automatic thoughts
What precipitated the disorder?
Did the patient put an adverse construction on certain precipitating events?
How do the patients thinking and behavior contribute to the maintenance of the disorder?

VII) OFFERING PERIODIC SUMMARIES:. Patients often describe a problem with many details. You will
summarize what they have said in the form of the cognitive model (or the triad model) to ensure that you have
correctly identified what is most troublesome to patients, and to present it in a way that is more concise and
clear.

Also ask the client to relate back to you what has he understood.

VIII) ENDING THE SESSION Miss X our time is up. Can you tell me what you think is most important for
you to remember this week? Anything that you didnt like about the therapy?

CBT techniques:

Evidence seeking- what is the evidence that you are failure? Can you think of any contrary evidence
which tells you, you are not a failure?
Can you think back over the past week? If 0 means not depressed at all, and 10 means the most
depressed youve ever been, what has your depression been like for most of the week? Or you can ask
patients, Can you tell me about your depression this week? Would you say it was mild, moderate, or
severe? How did your mood compare to other weeks?

Challenging negative thoughts. Begin by monitoring what you say to yourself during periods of stress.
Some negative thought patterns /cognitive distortions which heighten our stress and which we should
identify are as follows:

Catastrophizing : Giving greater weight to the worst possible outcome, however unlikely, or
experiencing a situation as unbearable or impossible when it is just uncomfortable. Eg. Its bound
to all go wrong for me. Because we believe something will go wrong, we make it go wrong.
Filtering: that is, focusing entirely on negative elements of a situation, to the exclusion of the
positive ones. E.g. I know he [my boss] said most of my submission was great but he also said
there were a number of mistakes that had to be correctedhe must think Im really hopeless.
Should Statements: Using should, ought, or must statements can set up unrealistic
expectations of yourself and others. It involves operating by rigid rules and not allowing for
flexibility. E.g. I shouldnt get angry. People should be nice to me all the time.
 Personalising: Taking responsibility for something thats not your fault. E.g. Priyas in a terrible
mood. It must have been something I did. Its obvious she doesnt like me, otherwise she wouldve
said hello.
Magnification/Minimisation: A tendency to exaggerate the importance of negative information or
experiences, while trivialising or reducing the significance of positive information or experiences. E.g.
Supporting my friend when her mother died still doesnt make up for that time I got angry at her last
year
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