Cognitive Behavioural Therapy in the 
Mood and Anxiety Disorders
Eilenna Denisoff , Ph.D., C. Psych.
Katy Kamkar, Ph.D., C. Psych.
Work, Stress and Health Program /  Psychological Trauma Program 
Centre for Addiction and Mental Health, Toronto

What is Cognitive-Behavioural 
Therapy (CBT)?
•	A problem-oriented therapy 
•	Focus on present and future
•	Short-term format
•	Sessions are structured
•	Involves a strong working alliance
•	Homework is a central feature
•	Based on Cognitive Theory
•	Requires Collaborative Empiricism

Evidence-Based Therapy
•	“Evidence-based” means that there is a body of research literature that supports an approach in terms of there having been a demonstration of effectiveness using the scientific method of investigation. 

•	CBT is one of the most extensively researched of the psychotherapies. 
•	Currently, there are over 325 published outcome studies on cognitive-behavioural interventions.  

	 (From Butler, Chapman, Forman, & Beck, 2006)

Evidence-Based Therapy
•	CBT has been successfully applied to the treatment of a wide range of psychiatric disorders such as depression, anxiety disorders, substance abuse, and eating disorders. 

•	It has also been shown that CBT tends to yield more durable effects than medications once they are discontinued (e.g., Butler et al., 2006; Marks et al., 1993; Barlow & Lehman, 1996; Barlow et al., 2000; Nadiga et al., 2003). 

What is Cognitive-Behavioural 
Therapy (CBT)?
•	Utilizes a directive, action-oriented approach, that teaches a person to explore, identify, and analyze dysfunctional patterns of thinking and behaving.  
•	Once these counterproductive patterns are identified, the therapist instructs the client how to challenge and restructure their thinking and behaviour. 

Effectiveness of CBT for Depression
•	CBT has become one of the most often practiced treatments for depression and it has been found to be an effective treatment of depression in most efficacy studies.  
•	It aims to alleviate depression through the direct modification of the clients' irrational and negative beliefs. 
Core Symptoms of Depression
•	Sad or low mood for greater than two weeks
•	or
•	Loss of interest or pleasure for greater than two weeks
•	+
•	appetite/weight changes
•	sleep problems
•	agitation or retardation
•	fatigue
•	worthlessness/guilt
•	concentration difficulties
•	thoughts of dying

Theory of Depression
Cognitive Model
Beck’s Negative Cognitive Triad
Negative Thoughts about Self
•	“I must be worthless for all of these awful 
•	things to have happened to me.”
•	“If I were a good person, I wouldn’t have been abused.”

•	The core belief underlying each of these thoughts is worthlessness.
•	Such thoughts can have a detrimental impact by contributing to low self-esteem, low self-confidence, interpersonal relationship problems, and interfering with willingness to actively become better. 

Negative Thoughts about the World
•	Negative thinking about the world is a pattern of thinking in which an individual tends to notice and recall negative aspects of experiences more readily than positive or neutral events. 
Negative Thoughts about the Future
•	“Nobody will like me.”
•	“I won’t be good at it.”
•	“What’s the use in trying? I’ll never get any better.”

•	When depressed, individuals typically imagine the future as being completely negative. This anticipation of events turning out negatively is called hopelessness. 
The “C” in CBT
•	CT emphasizes techniques designed to to help people detect, evaluate, and modify their inner thoughts, particularly those associated with emotional symptoms such as depression, anxiety, and anger. 

Emotions
•	Identifying Emotions
•	Generally one descriptive word.
•	Noticing body changes (e.g. tension or heaviness) might signal a mood.
•	Try to identify 3 different moods in a day.
•	Pick a mood and identify a situation where you felt each mood.
•	Important to distinguish from thoughts.
The “B” in CBT
•	Depression: Behavioural Activation
•	Monitoring daily activities
•	Assessment of pleasure and mastery
•	Graded task assignments
•	Cognitive rehearsal and problem solving around tasks
•	Social skills (assertion, communication)

The “B” in CBT
•	Actions are connected to the way we feel.
•	When a client tracks feelings of depression they may discover that when they are depressed they are: 
•	more passive;
•	less active; and
•	often stop pleasurable activities
•	As an initial step toward treating depression, it can be very helpful to increase activities – especially pleasurable activities or activities that create a sense of accomplishment.  

The “B” in CBT
•	By tracking activities, we can discover how they affect our mood. 
•	By scheduling and completing activities that are enjoyable or create a sense of accomplishment, your client will be making behavioural changes that can lead to improved mood. 
•	Activity scheduling allows you to measure how much your client feels a sense of pleasure and/or accomplishment from the activities they partake in. 
The “B” in CBT:
•	Activity Scheduling -
•	Focuses on activity assessment and increasing mastery and pleasure.  
•	Since depressed clients tend to underreport positive experiences and emphasize negative experiences, self-reports may not be as accurate as a log of weekly activities.
•	Clients are encouraged to document the actual activities they engaged in and the amount of time spent doing each activity. 
The “B” in CBT: Behavioural Activation
•	Activity Scheduling -
•	Using a scale, such as 0-10, clients are asked to rate mastery and pleasure of each activity, where 0 suggests there was no experience of accomplishment or pleasure and 10 indicates a great sense of accomplishment or pleasure for the activity. 
The “B” in CBT: Behavioural Activation
•	Activity Scheduling -
•	If there is a lack of experiences of mastery or pleasure in your client’s day-to-day life, you can schedule activities that will make him or her feel better about themselves. 
•	Generate a list of activities high in pleasure and mastery.  Evaluate negative automatic thoughts that may interfere with client’s ability to follow the activity schedule as planned.  And assign the new schedule for the upcoming week. 
The “B” in CBT: Behavioural Activation
•	Examples of Pleasurable Activities:
•	Listening to music
•	Drawing/painting
•	Yoga/meditation
•	Going to a sporting event
•	Going to a restaurant
•	Visiting/telephoning a friend
The “B” in CBT: Behavioural Activation
•	EXERCISE: 

•	First, choose a mood that is troublesome for you.
•	MOOD: _______________________

•	During this week, you will be rating this mood on a 0-100 point scale. 
•	1----------20---------------50--------------80--------100
•	Not 	   A little	     Medium	      A lot	  Most I’ve 
•	at all					                     ever felt

The “B” in CBT: Behavioural Activation
•	Example Activity Schedule
The “B” in CBT: Behavioural Activation
•	Learning from the Activity Schedule:

•	Did my mood change during the week? How? What patterns do I notice? 
•	Did my activities affect my mood? If so, how?
•	What activities helped me feel better? Why? Are these activities in my best long-term interest?
•	What other activities could I do that might also make me feel better?

The “B” in CBT: Behavioural Activation
•	Learning from the Activity Schedule:

•	What activities helped me feel worse? Why? Are these activities in my best interest to do?
•	Were there certain times of the day (e.g., mornings) or week (e.g., weekends) when I felt worse?
•	Can I think of anything I could do to feel better during these times?
The “B” in CBT: Behavioural Activation
•	Learning from the Activity Schedule:

•	Were there certain times of the day or week when I felt better?
•	What activities can I plan in the coming week to increase the chances that I will feel better this week? Over the next few months?
The “B” in CBT: Behavioural Activation
•	Another common behavioural technique is graded task assignment. To help clients initiate activities for mastery and pleasure, activities can be broken down into smaller, more manageable steps, and are accomplished one at a time. 
•	The client is encouraged to list the behaviours that he or she used to engage in prior to becoming depressed.  They then assign these activities to themselves beginning with the least threatening changes and progressing to the most difficult behaviours. 
The “B” in CBT: Behavioural Activation
•	Cognitive Rehearsal & Problem-Solving - 
•	Depression tends to impair problem-solving ability.  Depressed individuals often struggle to find good solutions to problems and express low confidence in their solutions. 
•	Sometimes individuals with depression have never learned problem-solving skills, or have developed poor strategies for solving problems. 
•	Deficits in problem-solving ability may impair one’s ability to cope with stressors related to depression. 
The “B” in CBT: Behavioural Activation
•	Cognitive Rehearsal & Problem-Solving -
•	Problem Solving Steps…
•	1. Define the problem 
•	2. Generate range of solutions
•	3. Evaluate and decide on solution 
•	4. Implement and evaluate solution 
The “B” in CBT: Behavioural Activation
•	Assertiveness Training - 
•	Techniques such as assertiveness training are used to target behavioural symptoms of depression.  
•	An assertive person is one who acts in his/her own best interests, stands up for self, expresses feelings honestly, is in charge of self in interpersonal relations, and chooses for self. 
•	Assertive behaviour is positive and will bring results in one’s dealings with others.  Not being assertive is one way to cultivate low confidence, self esteem, and worse.

The “B” in CBT: Behavioural Activation
•	Assertiveness training can assist clients in:
•		1. expressing themselves in a balanced 		    	    manner;
•		2. standing up for their rights;
•		3. making decisions more easily; 
•		4. being more able to refuse requests;
•		5. giving and receiving compliments; and
•		6. expressing anger more constructively. 
Theory of Depression
The “C” in CBT
•	Therapist helps clients recognize and change pathological thinking at two levels of information processing: automatic thoughts and schemas.
•			Automatic Thoughts – 
•	Cognitions that stream rapidly through our minds when we are in the midst of a situation or recalling events. 
•			Schemas – 
•	Core beliefs that act as a template or underlying rule for assessing information.
The “C” in CBT
•	Automatic Thoughts: 
•	These “pop” into one’s head, and usually not even aware of them; however, we can learn to bring these thoughts into consciousness.
•	These thoughts can become predictable when underlying beliefs are identified.

The “C” in CBT
•	They can be words (e.g., “I’ll be fired”), images or mental pictures (e.g., “seen” herself as a homeless person pushing a shopping cart down the street), or memories (e.g., the memory of being hit on the hand with a ruler by her fifth-grade teacher when she made a mistake).
•	One of the most important clues that automatic thoughts might be occurring is the presence of strong emotions (“hot thoughts”). 
–	Clients are often more aware of the emotion they feel as a result of the thought than of the thought itself. 
The “C” in CBT
•	To identify automatic thoughts, clients are asked to notice what goes through their mind when they have a strong feeling or reaction to something. 

–	What was going through my mind just before I started to feel this way?
–	What does this say about me if it is true?
–	What does this mean about me, my life, my future?
–	What am I afraid might happen?

The “C” in CBT
–	What is the worst thing that could happen if it is true?
–	What does this mean about how the other person(s) feel(s)/think(s) about me?
–	What does this mean about the other person(s) or people in general?
–	What images or memories do I have in this situation?

The “C” in CBT
•	Cognitive Restructuring - 
•	A large portion of treatment in CBT is dedicated to working with automatic thoughts.  This is typically done in two phases: 
•			1) identifying automatic thoughts; and
•			2) modifying negative automatic thoughts.
The “C” in CBT
•	Cognitive Errors: These are inaccurate or irrational automatic thoughts.

•	All-or-Nothing Thinking: Judgments about oneself, personal experiences, or other are all good or all bad, a total success or a total failure, completely perfect or completely flawed. 

–	One condemns themself based on a single negative comparison such as, "I lost the game (i.e., tennis), therefore I'm a total loser in everything," or "I couldn't operate the new piece of equipment therefore I'm completely useless".

The “C” in CBT
•	Overgeneralization: You see a single negative event as a never-ending pattern that negative events will keep happening to you. 

–	In this type of thinking, the person usually makes negative predictions for the future based on a single negative event such as, "He turned me down for a date; no one will ever want to go out with me now," or  "I can't tolerate running and playing soccer with my son, therefore I'll never be able to be involved in his life." 

The “C” in CBT
•	Mental Filter: A conclusion is drawn after looking at only a small portion of the available information.  Salient data is ignored in order to confirm the person’s biased view of the situation. 

–	For example: I didn’t get all of my work done today, I’ll never be good at anything.

The “C” in CBT
•	Disqualifying the Positive: Positive experiences are rejected by insisting they "don't count" for some reason or another.  In this way, a negative belief can be maintained. 

–	For example: 
–	A client completes tasks on the activity schedule and then decides it was pathetic to set that task as a goal. 

The “C” in CBT
•	Jumping to Conclusions: A negative interpretation is made even though there are no definite facts to convincingly support this conclusion. 

–	For example:
–	“He said he has to leave, he must have thought our conversation was so boring that he made up an excuse to leave.” 

The “C” in CBT
•	Magnification/Minimization: The significance of an attribute, event, or sensation is exaggerated or minimized. 

•	For example: 
•	“I can’t believe I made a mistake during that presentation, it ruined the entire thing!”

•	“The fact that I met that deadline was nothing really, any idiot could have done it”.
The “C” in CBT
•	Catastrophizing: Focus is on the most extreme negative consequences of a given situation.

•	For example: 
•	Getting called into the bosses office is interpreted as “I’m going to be fired”

The “C” in CBT
•	Emotional Reasoning: What someone feels determines what they think.  It is assumed that negative emotions reflect what the way things really are. 

–	For example: 
–	"I feel really sad therefore the world must be a miserable place”

The “C” in CBT
•	“Must,” “Should,” or “Never” Statements: These are inflexible rules for behaviour that are learned, or are expectations that one must live up to. 
–	For example:
–	"I never do anything right," or "I should be better by now," or "I should be able to handle this, and "I must be weak."

The “C” in CBT
•	Personalization: Excessive responsibility or blame is taken for negative events. 

–	For example:
–	“The family dinner was a disaster because I felt down so nobody was able to enjoy themselves."

The “C” in CBT
•	Schemas:
•	The basic templates or rules for information-processing that underlie the more superficial layer of automatic thoughts.
•	These beliefs are also related to emotions and behaviours that are maladaptive
•	These start to take shape in childhood and are influenced by a multitude of life experiences.

The “C” in CBT
–	Core Beliefs
–	Global and absolute rules for interpreting information related to self-esteem
–	The deeper cognitive structures, which aren’t directly as observable as automatic thoughts.
–	Typically deduced rather than identified explicitly
–	Drive both the intermediate beliefs and compensatory strategies
–	Most difficult to change, and require devoted attention; global, rigid, and over-generalized
–	(e.g., “I’m unlovable”)

The “C” in CBT
The “C” in CBT
•	Socratic Questioning - 
•	The style of questioning used in CBT to change dysfunctional thinking.
•	One of the more difficult aspects of CBT for practitioners to master. 
The “C” in CBT
CBT – Anxiety Disorders
•	Anxiety Disorders - Panic, Social Phobia
•	Principles of CBT
•	Relationships among thoughts, emotions, and behaviours
•	Behavioural Model
•	Functions of Anxiety
•	Developing a hierarchy
•	Examining Thoughts
•	Automatic thoughts, cognitive errors, evidence
The Anxiety Disorders
•	Panic Disorder with Agoraphobia
•	Panic Disorder without Agoraphobia
•	Agoraphobia without Hx of Panic Disorder
•	Specific Phobia
•	Social Phobia
•	Obsessive-Compulsive Disorder
•	Post-traumatic Stress Disorder
The Anxiety Disorders (cont.)
•	Acute Stress Disorder
•	Generalized Anxiety Disorder
•	Anxiety Disorder Due to a General Medical Condition
•	Substance-Induced Anxiety Disorder
•	Anxiety Disorder NOS
Cognitive-Behavioural Therapy
•	Principles of CBT 
•	Thoughts, emotions, behaviours
•	Functions of anxiety
•	Behavioural Strategies 
  -Developing a Hierarchy
•	Cognitive Strategies
   -Examining Thoughts
3-components of Anxiety
•	Physiological
•	based on central and autonomic nervous system arousal
•	Cognitive
•	consists of thoughts, beliefs, self-statements or images associated with perceived danger or uncontrollability
•	Behavioural
•	manifested as escape, or avoidance (including procrastination) and checking/safety behaviour
Panic Example
(Physical Sensations)	Thoughts 
		“Something is terribly wrong with me”
		“This is serious, I’m having a heart attack”

Emotions				Behaviour
Anxiety				Go to Emergency
						Check for signs and 						symptoms
Behavioural Model
			          Trigger
		    		
			    Interpretation

		    		           
				threat or danger!
		Neutral		           
		    		 increased anxiety
		no distress	           	
				Escape or Avoidance				           		
				   anxiety
				         
				*Negative 			 	      				 			Reinforcement
	 				 
				            
						
				*Strengthens the
				  Avoidance	

Functions of Anxiety
•	Anxiety is an emotion shared by all human beings
•	A moderate level of anxiety is adaptive and can be helpful (i.e. in performance situations)
•	Anxiety above optimal levels can begin to affect performance in a deleterious manner
Self-limiting nature of anxiety
•	Help clients to understand that high levels of anxiety are self-limiting

•	Encourage them to use exposure exercises to monitor their anxiety and learn about it
Habituation
•	Explain that with repeated exposures anxiety gradually decreases

•	Monitor both the level (SUDS) and duration (Minutes) of anxiety to help clients see the changes within sessions and across sessions
Subjective Units of Distress
•	Subjective Units of Discomfort (SUDS)
__________________________________
0				50			100%
Rating (Record at least one situation for each level)
0 Patient is totally relaxed, on the verge of sleep
25 Mild anxiety. Does not interfere with performance
50 Uncomfortable. Concentration is affected.
75 Increasingly uncomfortable. Patient becomes preoccupied with symptoms. Thinks about escaping the situation.
100 Highest anxiety the patient has ever experienced.
Behavioural Exposure Hierarchy
10.__Worst fear______
9._________________
8._________________
7._________________
6._________________
5._________________
4._________________
3._________________
2._________________
1.___Least worst_____

Developing a Hierarchy
•	Social Phobia (public speaking)
Worst Fear -giving a formal presentation, material is new and unfamiliar, large audience, boss present, standing
9. As #1 but more familiar, smaller audience
8. Giving a report at a staff meeting, supervisor present, coworker who had disagreed with patient in the past is also present
7. Same as #3, disagreeable coworker absent

Hierarchy (cont)
6. Formal presentation on familiar material, supervisor absent
5.  Disagreeing with coworker at a staff meeting
4.  Presenting a report at a staff meeting and answering questions about it
3.  Sitting at a conference table with coworkers, sharing opinions about a new project
2.  Giving a presentation to a group of sales people
1.  Expressing an opinion at a meeting of the PTA
Role of Cognitions
•	Association between Thoughts, Emotions, and Behaviour
•	Identifying Automatic Thoughts
•	Cognitive Errors
•	Examining the Evidence
•	The Rationale Response 
Examining the Evidence
•	Identify a “hot thought”

•	List “facts” that support the “hot thought”

•	List “facts” the do not support the hot thought

The Rationale Response 
•	Based on the evidence for and against 

•	A summary of all the evidence

•	If my hot thought is true what is the BEST, WORST, and MOST REALISTIC outcome?
Resources
•	On-Line
•	www.paniccenter.net
•	www.depressioncenter.net
•	www.camh.net (Centre for Addiction and Mental Health)
•	www.cmha.ca (Canadian Mental Health Association)
•	www.nimh.nih.gov (National Institute of Mental Health)