[SAGE VIDEO TUTORIALS][COGNITIVE BEHAVIORAL THERAPY]

MARK PFEFFER: My name is Mark Pfeffer.I'm a licensed psychotherapist and directorof the Panic Anxiety Recovery Center.

BECCA BARISH: Hi.My name is Becca Barish.I'm a licensed social worker, and I'm the program coordinatorfor the Panic Anxiety Recovery Center.

MARK PFEFFER: In this tutorial, we'llbe explaining to you the basic model of CBT,the components, which are the cognitive componentsand the behavioral components, some of the ways you can applythe model in real life, and the variationsof modern cognitive behavioral therapy.[WHAT IS CBT?]So what is cognitive behavioral therapy?

MARK PFEFFER [continued]: Cognitive behavioral therapy is a form of psychotherapythat is empirically based.It's focused on problems and examines the relationshipamong thoughts, feelings, and behavior.Cognitive behavioral therapy is concernedwith testing the reality of thought.

MARK PFEFFER [continued]: [DEMONSTRATION PART 1]In order to describe the model of CBT to you,we thought we'd start off with a brief demonstration.What I have in my hand here is a Chinese handcuff,and this Chinese handcuff is, for our purposes,going to demonstrate what someone feels like when theyfeel stuck or trapped, and see if wecan apply the basic model of CBT to how someone would figure outa way to get out of this trap.

MARK PFEFFER [continued]: So Becca has got the Chinese handcuff,and she's going to, first of all, be trapped.

BECCA BARISH: Oh no.I'm trapped.My fingers are stuck in this handcuff.

MARK PFEFFER: What's the core belief?

BECCA BARISH: I'm never going to get out of this handcuff.I'm not the type of person that could possiblyget my fingers out of this handcuff.

MARK PFEFFER: And could you thinkof also another automatic thought?

BECCA BARISH: I'll never be able to get out of this handcuffbecause I'm not strong enough to do it.

MARK PFEFFER: OK.How about physical symptoms?

BECCA BARISH: I'm sweating.My hands are starting to shake a little bit, my heart's racing,and I'm getting very uncomfortable.

MARK PFEFFER: And if I asked you to get out this trapthe most expedient way you can because you have to do itat all costs, what is the behavior?Wow.Great job if you want to destroy something,but what we're trying to demonstrate in this modelis this concept of letting go to get control.

MARK PFEFFER [continued]: And later on in the tutorial, we'llbe showing Becca again dealing with this feeling of beingtrapped in a very different way.[CBT MODEL EXPLAINED]So when we look at the model of CBT,it really starts off with a trigger,and as Becca demonstrated, the trigger for herwas being stuck in a trap.

MARK PFEFFER [continued]: Contributing to the process is maladaptive beliefs.These are longstanding beliefs that peoplehold about who they are and about their fears.And Becca said that she's not the kind of personwho can handle being stuck.So these are the kind of maladaptive beliefsthat contribute to developing a maladaptive cognitiveappraisal, and that's really an automatic negative thought.

MARK PFEFFER [continued]: As Becca said, I'm never going to get out of this trap.Now, once you have that automatic negative thought,it really creates physiological responses-- emotionsof fear, sweating, rapid heartbeat,physiological symptoms.

MARK PFEFFER [continued]: And of course, the behavioral responseis running away, avoiding.In Becca's case she broke out of that trap.So this is how day in, day out, people, in our case, whohave anxiety disorders, really relate to a simple trigger,and how it really ends up in a behavioral response, emotions,and physiological combinations that really prevent peoplefrom doing what they want to do.

MARK PFEFFER [continued]: So it's a symphony of components that are happening all at once,and this typically happens in a very quick order,even though we're spending a few minutesto talk about this basic model.

BECCA BARISH: Oftentimes when people feel scared,they go into the fight, flight, freeze response.So a behavioral response is the waythat someone can respond to a trigger.Sometimes it's by freezing in place,sometimes it's by getting out of there as quickly as possible,and sometimes it might be by lashing out or overreactingto that situation.So the behavioral response is how we react in those momentswhen we feel high levels of stress and anxiety.

BECCA BARISH [continued]: [EXPOSURE WORK]

MARK PFEFFER: We put people on what we call an exposure plan.So instead of fight, flight, freeze response,we really try to get people to face their fear incrementally.So the plan would get people gradually to do the very thingthey think they cannot do.So if it's riding a roller coaster,the first thing we may do with someone riding a roller coasteris to try to get them to watch a rollercoaster up front and personal, and then graduallyget them to do some very specific things thatwould simulate being on a roller coaster,and then actually being on a roller coaster.

BECCA BARISH: So when we're talkingabout behavioral reconstruction, we'retalking about exposure work, and what that meansis we break it down into three parts.We think about the frequency, intensity, and duration.So it means that we have people engaging in activitiesthey might typically not feel comfortabledoing by doing it more often, giving it more intensely,and perhaps spending more time doing itso that it becomes part of their routinerather than something that feels very unattainable.

BECCA BARISH [continued]: Many people have unhelpful thinkingstyles that can get in the way of thinking about thingsin a way that's productive.So for example, if someone is the thought of nobody likes me,that could be an example of over generalizing, feelingthat nobody likes you, or even mind reading, thinkingthat you know what other people are thinking.So one of the components of CBT isto get in touch with those cognitionsand to help somebody understand that there might be other waysto think of it.

BECCA BARISH [continued]: What about, maybe perhaps some peoplemight like me, or to even think of examples when people haveliked you in the past in order to showthe fact that those cognitions might not actually be valid.

MARK PFEFFER: In addition to identifying these thinkingerrors, like mind reading, catastrophic thinking,emotional reasoning, we also havepeople do homework that will help them practicechanging some of their thinking.So we could have people do somethingthat I refer to as just a rational dialogue.So it would be irrational self-- what if I can't get outof this situation-- and then rational self.

MARK PFEFFER [continued]: Well, maybe I can think of the alternativesand figure out a way, as Becca was describing.So if people, while they're waiting on lineor sitting on a bus, can start thinking about someof their irrational thoughts, theycan start practicing by themselves.We also have people write down their thoughts during what wecall a worry time, where people wouldspend maybe a half an hour or so reallywriting all the thoughts and irrational thoughts and worriesthat they have, and then respond to them based on someof the teachings that we just discussedof trying to have more rational responsesthan these irrational thoughts.

MARK PFEFFER [continued]: So the more exposure work people do,the more the brain will start signalingthat I can do this very thing that previously Ididn't think I could do.And so the step by step process of desensitization,habituation works.[MODERNIZATION]As cognitive behavioral therapy is evolving,we've gone through our infancy and our adolescence.

MARK PFEFFER [continued]: Now we're kind of in our adulthoodand there's some changes that have been happeningin the field that I just thought I'dbring to the attention of some of the viewers.And that is that the notion of trying to dispute our thoughtshave come with some controversy.

MARK PFEFFER [continued]: So of course, we want to change our thinking,but instead of having to take every thought we haveand trying to provide surgery on every thought,the theory today is to try to practicemore acceptance and mindfulness, that I accept the fact that Ihave the thought that I'm stuck or trappedand I can't get out of it as giving usa little buffer and a way to control our emotions.

MARK PFEFFER [continued]: The other difference between more traditionalcognitive behavioral therapy and modern cognitive behavioraltherapy these days is there's a movement towards getting awayfrom doing exposures for every single fear that someone has.So the idea is to get away from the specific content of doingexposure work and instead start training people in general,what I call uncertainty training.

MARK PFEFFER [continued]: [DEMONSTRATION PART 2]So now that you've learned the basic model of CBT,we thought we'd re-demonstrate the scenariowhere Becca was stuck.Now that she's been able to change some of her thinking,perhaps she can have a different outcomein terms of escaping from the Chinese handcuff.So Becca, if you would please administer the trigger.

MARK PFEFFER [continued]: And now that you've had some cognitive behavioral therapy,you're stuck.You're still stuck as you were before,but what would your maladaptive belief be now?

BECCA BARISH: My fingers are stuck,but perhaps there's a possibilitythat I might still be able to get my fingers outof this trap.

MARK PFEFFER: And how about the automatic thought?

BECCA BARISH: Maybe there's a possibilitythat I could get my fingers out of this trap.

MARK PFEFFER: OK.Still somewhat anxious, I guess, but doyou have any physical symptoms?

BECCA BARISH: My heart rate is stillgetting a little higher because I'm nervous,but because I'm telling myself that there's a possibility,I don't feel as anxious as I did before.

MARK PFEFFER: Any emotions?

BECCA BARISH: I feel a little bit nervousbut I also feel hopeful.

MARK PFEFFER: Now, let's see the behavioral response.Before, you broke out of it.Let's see what your behavior could be now.

BECCA BARISH: So now that I'm not freaking out and justtrying to get out of it at any cost,I'm going to try different options of how I could get out.So this isn't working, but perhaps if I try thisand pushing in, now I can get myself out of it.

MARK PFEFFER: What a great client.This is the concept of the model of CBT.And furthermore, it's a principlethat we like our clients to understand,this letting go to get control, and this Chinese handcuffis a great way to demonstrate that.[KEY POINTS]So in this tutorial today, you hopefullylearned about the basic model of cognitive behavioral therapy,the components, the behavioral componentsand the cognitive components.

BECCA BARISH: You also learned about treatment strategiesin order to conduct cognitive behavioral therapy, as wellas modern CBT variations that exist in today's world.

MARK PFEFFER: For young therapists reallyinterested in getting out of the boxand looking at cognitive behavioral therapy,one of the things you have to understandis this is very different than traditional therapy,from assessment to treatment, and you alsohave to look at yourself.Am I the kind of person who could handle making my clientsfeel uncomfortable, putting them into situations?

MARK PFEFFER [continued]: So it's very important to look at yourself,realize your capabilities, but certainlyunderstand that cognitive behavioral therapy is hereto stay, and figure out a way to use itbased on your own strengths and needs.