Dr. Manu Sharma
“If psychiatrists are not trained in CBT, it
leaves them therapeutically impotent, and
therefore less able to lead a
CBTs represent a large portion of empirically
cognitions or thoughts can influence
emotions and behaviors across a variety of
Panic disorder- Clark (1986, UK) and Barlow
“enactive, performance-based procedures as
well as cognitive interventions to produce
changes in thinking, feeling and behavior”
Adapting CBT for children
Extrapolate from findings with adults
As with adult CBT, the therapy model
continues to evolve and is beginning to be
Pacing the content and speed of therapy
Limitations in metacognition and ineptitude
in labelling feelings
Major deficits in social skills or interpersonal
Higher use of behavioral techniques
Modes of Assessment
Information from other people
Direct observation of behavior in clinical
Initial analysis of the problem situation:
Clarification of the problem
Coping, avoidance, beliefs
At the moment you were feeling anxious, what
was going through your mind?
What were you thinking to yourself?
What were you saying to yourself?
Did you have an image in your mind at the time?
Did you see anything in particular?
What were you afraid might happen?
What was the worst thing you thought might
Requires the patient to collect information on
their problems between sessions
Needs to be specific with clearly defined
What to collect: Frequency, intensity &
duration of the targets
Provide patients with a record form
Keep it as simple as possible
Record information as soon possible after the
The content of the cognition may be typical
of the disorder or mood.
“no one will love me, I will be alone”; “it will be
a disaster”; “it’s not fair”
Cognitive distortions: emotional disorders,
OCD, depression, somatization, PTSD
Cognitive deficit of social skills and problemsolving: Conduct disorder, ADHD
The cognitive model of
Parents quarrel and separate
Father leaves home
Formation of dysfunctional core beliefs
“I always drive people away”,
“I’m no good”, “I’m worthless”
Development of dysfunctional
“Unless I always please people, they’ll reject
“If people get to know me, they’ll see I’m no
The cognitive model of
Boyfriend goes out with another girl
Negative automatic thoughts
“It’s my fault”, “I’ll never have another friend”,
“No one loves me”, “I’ll be alone forever”,
CBT for depression
Setting the agenda for the session,
Review of ‘homework’ from the previous session,
Goal setting of tasks for the session and practising
tasks in the session.
Homework is agreed, which may involve tasks practised
in the session and problem-solving to anticipate
Frequent summarizing with feedback.
Making a problem list not only clarifies things, but also
enables the young person to experience CBT as
collaborative, in that the therapist is trying to understand
the young person’s perspective and priorities.
CBT for depression
1. Self-control skills, self-consequation
(reinforcing themselves more, punishing themselves
less), self-monitoring (paying attention to positive
things they do), self-evaluation (setting less
perfectionistic standards for their performance) and
2. Social skills, including methods of initiating
interactions, maintaining interactions, handling
conflict, and using relaxation and imagery;
3. Cognitive restructuring, involving confronting
children about the lack of evidence for their
underestimate of the coping resources and
the likely rescue factors from the feared
Negatively distorted cognitive appraisal,
where the child is likely to be obsessively selffocused, hypercritical, concerned about
Physiological alerting and arousal leading to
somatic sensations--behavioral avoidance-
A modified thought diary
Subjective units of distress scale
The aim is to enable the child to recognize triggers
and early signs of anxious arousal.
The child is then taught anxiety management
skills such as applied relaxation and positive
The catastrophising cognitions may be challenged
Positive self-talk is developed-- “If I just sit still
and get on with my work, I will begin to feel
FEAR-a 16-session programme (Kendall et al, 1990)
Feeling frightened? (Awareness of bodily cues,
identifying anxiety and learning to relax)
Expecting bad things to happen? (Identifying
and correcting maladaptive self-talk by using
Attitudes and actions that can help. (Coping
and problem-solving strategies)
Results and rewards. (Self-evaluation and
coping with failure)
Family Anxiety Management (FAM) (Barratt et
This teaches parents contingency
management (rewarding appropriate coping
behaviour and extinguishing avoidance
Coping Cat/Koala program
The belief that thinking something is the
same as doing it – thought–action fusion;
undue sensitivity to responsibility for
omission (“If I don't remove every speck of
dirt, someone might become contaminated”).
The aim is to enable the child to appreciate
that anyone can have odd thoughts and
the way to deal with them is to ignore
Trying to avoid, suppress or neutralize the
thoughts will only cause them to return more
strongly than before.
The therapist might use stories about habits
and intrusive thoughts and the effects of
Tend to attribute hostility to others and
underestimate their own aggression in any
When upset they anticipate fewer feelings of
fear or sadness, interpreting strong feelings as
anger and react aggressively.
They value aggression as effective in
problem-solving and enhancing their selfesteem.
Children with conduct disorders find it hard to
generate verbal assertive (negotiating)
solutions to IP problems.
And resort to action-oriented and aggressive
Anger management programmes help
adolescents to identify their aggressive
behaviour and the conditions that provoke
and maintain it.
CBT must be part of a multi-modal approach
Rewarding prosocial behaviour ,
supplemented by instruction, discussion,
modelling strategies, rehearsal, prompting
Role-play and the use of videotape feedback.
Problem-solving skills training
Concepts of fairness, safety and what the
other person feels
Self-instructional progs--Core problems of
inattentiveness, impulsivity and restless
(the inability to ‘stop, look, listen and think’).
Results have been variable and disappointing.
The training has frequently been too short,
unrelated to clinical need
1 Watching a trainer model and talk through a
task, including planning and talking through
possible difficulties (cognitive modelling)
2 Carrying out the task, prompted by a trainer
3 Carrying out the task, prompting themselves
4 Carrying out the task, prompting themselves
5 Carrying out the task silently using covert
Behavioral: contracting, time out, modelling,
Cognitive: Relaxation, distraction, imagery,
coping skills, social skills
Child sexual abuse
“ I am being hurt physically (sexually) by this
Either I am bad or this adult is.
But adults do things for your good.
This is called punishment.
That’s what this adult told me, that I was being
punished for being bad.
So its my fault and I must deserve this.
Therefore I am as bad as whatever is done to
If I am hurt often, it means I must be very bad.”
Child sexual abuse
Loving and hating; wanting & fearing
Experiencing trust & betrayal together
Living with distorted IP boundaries
Child sexual abuse
Therapy focuses on:
Self-empowerment (did the best you could as
The younger the child, the more the parents
will need to be included in the therapy
Avoiding reassurance for a child with OCD
and using positive reinforcement for
compliance with a child with a conduct
Family's structure and its belief system
Complementary behavioral input for parentsODD, CD
Engaging the child or adolescent
Advantages of CBT
Educative and instructive
Emphasizes getting better rather than feeling
Can be researched and the psychotherapy
with max evidence
Cognitive maturity of children
Inept in labelling feelings, thoughts
C-B therapists need the ability to engage their
patients and create a collaborative working
C-B treatments are generally specific for
A psychoeducational element of giving info by
discussion supplemented with fact-sheets is
Cited as generally more effective for children
than non C-B interventions.