CBT Free Workshop

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[00:00:00]accommodate uh more than 100 candidates because there was an issue with the uh Google meet and perhaps we will have to also change the link in between if the technical issue gets resolved and we are able to help other members to join. Uh so good evening everyone welcome to the CBT webinar and uh today we are not just going to talk about the cognitive distortions but we are also going to learn how to gently outrich these cognitive distortions with our clients with our patients and maybe with ourselves too.

[00:00:34]uh we'll try to keep this webinar focused as much possible on the practical tools because our goal is to help you learn uh better tools and techniques and uh hopefully you all leave better equipped with the CBT principles and techniques uh and without needing a 100page or a 500page book or a manual by your side. Um this webinar is a collaborative initiative by sole space which is my organization and uh Sophiana loca which is led by Ashish Ashish she's also there today amongst all of us and uh we are delighted to bring this learning experience to all of you and let's get started uh so this is about me I am Dr. Tanuja Koshell I'm a clinical psychologist and I have over 10 years of work experience u in the field of clinical psychology. I completed my studies from GMC, Chandigar and as New Delhi and I feel that uh CBD I use regularly and I feel that this is one of the most effective and one of the most evidence-based practices for wide range of emotional issues and it's quite flexible and it uh it's very valuable tool across different disorders and I feel that if you understand CBT well it becomes very easy to understand ACT acceptance commitment therapy in electrical behavioral therapy and other third wave therapies. So CBD acts more like a base you know um and I hope that my experience helps add value to your understanding of CBD. Moving on, we also have Mha G with us today. Mega, would you like to introduce yourself, please?

[00:02:33]>> Uh, am I audible?

[00:02:35]>> Yes.

[00:02:36]>> Uh, hello everyone. My name is Meag Girl. I'm a counseling psychologist and today I'm also with you to learn and also I help you to understand the CBT concepts in a deeper way. So I'm practicing psychologist from last 2.5 years and I'm currently associated with tanuja mam surace and uh basically we used CBT and I love CBT a lot. So today let's learn grow together and know more about CBT. Thank you.

[00:03:04]>> Absolutely. I think Miga always brings up CBT across different clients and she's so much inclined towards this uh technique this approach that every now and then whenever she's managing a patient she always comes up with a CBT conceptualization and CBT focused goals.

[00:03:23]Uh so let's start uh the next slide tells a little bit about what CBT is.

[00:03:29]I'll try to put it simply. CBT is basically a type of therapy which helps people recognize and change negative and unhelpful thoughts so that they can feel better and cope with life in a more effective way. Now we'll understand this with the help of an example. Imagine that you are uh your thoughts they are like a pair of glasses that you're wearing and sometimes you know these glasses they get smudged with negative or distorted views and because of that smudged glasses it makes everything look worse than it really is and CBT is like how to clean those glasses. CBT helps you spot spot those smudges or those negative thoughts and it also helps you to replace uh those smudges or those negative thoughts with more realistic ones.

[00:04:24]By changing how you see things, you start to feel better and make healthier choices. So I always tell my clients that with CBT we are not trying to make you more positive or we are not not trying to make your thoughts get more positive. What we are trying to do here in CBT through CBT is we're trying to make your thoughts more balanced. We are trying to make your thoughts more rational rather than being toxic may uh positive. Right? So it is about reframing negative thoughts into more balanced thoughts not reframing the negative thoughts into positive thoughts necessarily. This is the heart of CBT.

[00:05:04]Now this triangle CVT triangle I want all of you to please pay full attention to this CBT triangle because every now and then we uh introduce this triangle to our clients during the psycho education process as well and for you to practice CBT it's very important that you understand this core um idea this very important idea of CBT triangle it shows how our thoughts our feelings and behaviors are interrelated and one affects the What we think affects how we feel and how we feel influence how we behave and by changing how we think we can improve how we feel and thus our actions get changed.

[00:05:49]It's basically about fixing one part or modifying one part of the triangle to help the whole thing get better.

[00:05:57]Um one example of uh this triangle we can take an example to better understand this. Uh imagine that you have to give a big presentation just like I am giving this big presentation. Imagine you have to give a big presentation at school or at your work and sometimes we all would get those thoughts or I'm going to mess it up and everyone will laugh at me. Now because of this thought you really start to feel anxious and nervous. This is a feeling. Thought is I'm going to mess it up. People will laugh at me. Feeling is because of this thought I start to feel nervous and anxious and as a result I might not appear for this presentation.

[00:06:38]I may avoid practicing for for the presentation or sometimes one may even skip the presentation because of anxiety and fear. In CBT what do we learn? What do we do in CBT? We learn to spot the negative thoughts and we challenge them.

[00:06:55]So instead of thinking I'll mess it up, we'll try to think okay I've prepared well and I can try and do my best. Now this new thought it helps you feel more calmer, more in control, more confident and uh you're likely to practice and then do well. So you see how negative thought leads to negative feeling and negative behavior and how a rational thought which says that okay I am well prepared. I'll do try to do my best. It leads to a more balanced feeling and thus a balanced or a practical reasonable behavior which is appearing for your presentation.

[00:07:34]Uh next is uh these are three very important concepts guys that you should all know before you practice CBT. One is negative automatic thoughts and uh second is core beliefs and third is thoughts. So I have tried to put it in a in a onion analogy.

[00:07:51]You think of your mind as an onion with three layers. The outer layer is the thoughts. Thoughts are you know what we observe on day-to-day basis like say for example it's the weather is sunny today or I have to do a lot of work today.

[00:08:09]These are normal thoughts on the surface layer. What we can observe on the inner layer are negative automatic thoughts. Now the these negative automatic thoughts which we all also call NADs they are like very quick automatic autopilot they pop out of nowhere without warning and they can be negative for example if I make a mistake I automatically think oh I'm terrible at this like u my I can tell you about my negative automatic thought so I I'm you know expecting a lot of psychology students there and we all know how our relation relationship is with statistics. So whenever I make a mistake in stats, I'm always like, "Oh, I can never do maths right. I can never do stats right." So that's my negative automatic thought which comes out of nowhere, it pops in my head, right? And uh this is how nities are. And then we further if we go a little further in the onion layer in the core of mind at the very core are core beliefs. Now core beliefs they are deep rooted and usually longheld ideas long-held meaning we have been holding them for a pretty long time usually since childhood or adolescent years and these ideas are about yourself or about the world around you. Uh simply put core beliefs are guiding principles of our life. Now these guiding principles can be balanced or they can be super negative. Usually the core beliefs they are absolute and very global. For example, common core beliefs which we find in psychological disturbances is people cannot be trusted. Now this is a very global and an absolute core belief or I'm not a good person. I'm not good enough. This is also a core belief like a positive core belief which I carry with myself is that I deserve respect or I deserve to be loved. This is a core belief. It's a positive example. A negative example can be people cannot be trusted or I'm not good enough. In CBT we start by noticing quick negative automatic thoughts because they are easier to spot and also slightly easier to change. thoughts are easier negative automatic thoughts. Yes. Easier. And the right way to address the negative thinking is identify spot or change.

[00:10:41]Uh and these negative automatic thoughts sometimes they come from deeper core beliefs which we work upon over a period of time. we reach core beliefs like uh through strategies like downward arrow technique and we can work on the deeper core beliefs also in the uh further course of CBT but we start with entities and understanding these layers of onion or mind they help us know how to make real and lasting changes. Uh now next is um uh so in order to make CPT easier to understand and apply we have divided the process of CPT into three clear phases and uh this structure will help you to know what to focus on during the each phase of therapy. The first phase is initial phase which usually lasts from first to four sessions. And during the initial phase of CBT, we build rapper with the client. We understand their concerns, their complaints. We explain what is CBT, what is that heart of CBT, the triangle and we also try to start identifying the negative automatic thoughts. Now this is what we do the in the initial phase. In the middle phase which lasts roughly around five to eight sessions, we go deeper now and we start challenging the unhelpful thoughts. We introduce cognitive and behavioral techniques. For example, evidence testing, probability testing, in behavioral techniques. We can talk about activity scheduling, deep breathing exercises. So we do the real work in the middle phase and we begin to change the patterns. The last phase usually from roughly from 9 to 12 sessions. This is about consolidation.

[00:12:28]Consolidation phase meaning strengthening the newly learned skill.

[00:12:33]So whatever the client has learned, we try to strengthen that and we work on preventing the relapse. Plus we help the client to become a become their own therapist. Um, somebody has their mic switched on by the name of RR emotion.

[00:12:52]Can you please switch off your mic?

[00:12:54]Thank you so much. Thanks. All right.

[00:12:56]So, this is the structure. Now, moving on.

[00:13:01]Okay. Uh, so we are talking about initial phase. Can we have the next slide please?

[00:13:07]Right. So, making a start strong start in therapy. Okay. What do you do in the let's talk about first session. What what do you do in first session? I'll tell you simply put starting a first session, you usually have quite a a fixed kind of a script for the first session.

[00:13:28]And how it goes is when you when the client is entering your room first of all try to be warm and little friendly but while maintaining the boundaries you give a smile welcome them make them sit down and uh after that you ask them that okay this is your name and u and u maybe you tell them that I am Dr. Tanuja and I have been practicing in this field for so many years or this is my background my work X and then you tell them that uh you talk about this this confidentiality you tell them that whatever we are going to discuss in this session is going to be confidential it is going to be between the two of us unless until I feel that there is a threat to your life if there are some life-threatening thoughts ideas or behaviors in that case I can reach out to your treating psychiatrist or your immediate family member. Rest of the information is between the two of us. This is how you tell them about confidentiality about rapper building. Simple questions you can ask. Which series are you watching these days? You can discuss about the actors. You can discuss about the movies that the client like you can discuss about the kind of genre that the client reads or maybe the kind of music that the client likes or the sports that he's or she's playing.

[00:14:47]That's how you build rapo. Rapo building simply put RAPO is the feeling of trust and safety the connection which the client is able to feel with you and the client will be able to feel that connection only if they are able to relate with you that's why we focus a lot on you know reading improving your awareness networking watching u um things online or on in movies so that you have some content to talk about and build that uh connection or that rapper with the client.

[00:15:19]Um so rapper is basically you know the client if the client feels that I feel safe talking to you you have a good rapper. So how do we do it? We use a warm soft body language. We show genuine interest and empathy. We listen more than we speak especially in the initial sessions. Avoid judgment. Avoid rushing to fix things. Please allow your client to speak. You know it is said that when your client is speaking listen to the client because they're telling you their diagnosis or they're actually telling you what are the things that you need to work on.

[00:15:58]Um we also ask in the first session that okay we are here what is the concern what are you here for simply you ask the chief complaints.

[00:16:09]So this is what we usually do in the first session. Usually you know it is said that therapy is highly tailor made which I 100% agree. Same kind of structure cannot be applied with every uh client but during the f the first uh session is more or less similar similar in the sense the kind of things that you have to say to the client right um we can move to the next slide. Okay this is very important therapeutic alliance. Now if you think of um uh therapy maybe ma can we move to the next slide?

[00:16:42]Yeah. Uh so if you think of therapy like a boat you and the client are in the same boat together. The client is holding a map because they know what they want out of therapy. They have their goals in their mind. And the therapist they help in paddling.

[00:16:59]They offer support. As a therapist you offer tools, techniques and direction.

[00:17:05]But in order to move forward the board to move forward therapist and client they both need trust and they both need teamwork and that's the bond. So three things are important in therapeutic uh alliance. One is you have clarity of goals. How do we set goals? You simply ask the client very simple question in first session. What are your expectations from therapy? What are you looking forward to or how can I help you? So you ask them clearly what is their expectation. So number one thing in therapeutic alliance is goals. Number two is tasks. Tasks man uh the things that you do the techniques that you apply. You're doing deep breathing with them or um you are doing downward arrow technique with them or you are uh doing uh cognitive restructuring with them or you are identifying cognitive distortions and modifying them. So second is task and third is the bond.

[00:18:01]Bond is again the connection that you share with your client.

[00:18:07]And uh again for good therapeutic uh alliance you have to listen properly.

[00:18:11]You have to be empathetic. You have to work collaboratively. You have to be consistent meaning showing up for your client. Avoid unnecessary cancellations uh prescheduling rescheduling and be consistent may also mean following up with your client and be reliable. simple language should be used and what is the difference between RAPO and therapeutic alliance I would say RAPO is making the client feel relaxed and safe in the therapy room and therapeutic alliance is working with the client it's a working rel relationship collaborative effort okay moving on I hope we are on time okay uh assessment okay so CBT assessment used to understand the client's current psychological functioning. Now, this is very very important CB with the assessment because this is uh on on the basis of assessment, you're going to set your goals and you're also going to more or less decide that what kind of techniques you're going to apply. Uh initial step here, we need to get a very clear picture of client's current emotional, cognitive, behavioral and physical symptoms.

[00:19:26]What do we focus on in this session? We focus on severity like how intense the symptom is. This can simply be done based on a rating scale. You can like ask your client that u um on a scale of 0 to 10 where is your mood? Zero being crying spells the mood is very bad and 10 being related very happy. So how would you rate your mood correctly?

[00:19:50]Frequency meaning how often does it occur? So say for example it's a client with the chicotilomania. they have hair cooling issue. So you ask them that okay on an average how many episodes are happening every day or how many cigarettes are you smoking in a day if you're dealing with a smoking case or over the week if not if it's not happening every day. Duration. If you're managing alcohol consumption then what is the duration of one single episode of drinking?

[00:20:25]uh or if you are managing OCD, what is the duration of one single episode of hand washing?

[00:20:31]Then we also ask them what how this issue is impacting their life. How much does the problem affect their daily functioning?

[00:20:47]relationship.

[00:20:55]So how it is impacting your functioning is the impact during the assessment period. We can also use rating scales to establish baselines.

[00:21:07]The baseline is very important because if you don't know where your client is functioning today, you won't be able to assess if CBT has been helpful to them or not over the p over the next five sessions or 10 sessions. So extremely important to establish a baseline and ask these questions. Maybe you can administer some rating scales like BDI, BAI, HAMD. Uh some structured scales can be conduct can be administered or you can interview the client simply and ask about the severity, frequency, duration and in fact. Now for example for anxiety you can ask on a scale of 0 to 10 how anxious do you feel on an average on on daily basis or today how how are you feeling today? uh or for headaches you can ask that can you rate the intensity of headache from 0 to 10 or uh expenditure is another issue which can be uh for which we can establish a baseline like how much money do you typically spend during the each shopping uh stream for overeating for obesity management how much how often do you find yourself eating more than intended um as I said that establishing baseline is very important because you know where exactly the client is and you set very realistic and clear therapy goals based on this plus you are able to track changes throughout the progress of therapy.

[00:22:32]This uh can we have the next slide?

[00:22:34]Okay. So smart goals is a very simple technique. SMART is basically an acronym and um for every alphabet stands for a terms S means specific. Be clear about what you want out of therapy. Measurable is you track progress. So rating scale is a wonderful way to you know quantify the improvement. Measurable and A is achievable. The goal should be realistic. It should not be beyond the resources of a client. The client is not able to get out of the bed because of sadness and you are asking them to go to a gym. It's not achievable. So the goal should be realistic. Relevant meaning choose what matters to the client. not something irrelevant like the client wants to work upon um uh smoking management and you are giving him absolutely unrelated uh goals say for example I'm not able to think of anything which is not related to smoking at all maybe you are you are asking them to do puja and the person is not at all spiritual or religious so it does not align with their value system this is completely unrelated to who they are or what they want to work towards Time bound means you have to set a deadline that okay we'll try to manage this particular problem over the next two weeks. We'll try to reduce the levels of anxiety right today if the anxiety score is uh 20 we'll try to bring it to 15 over the next four weeks or five weeks. Um okay so um now you think of this is again an example um this is a 22 year old college student experiencing moderate mild to moderate depression and he reports staying in bed most of the day avoiding classes feeling unmotivated and engaging not able to engage in activities he used to enjoy. So now in this case how do we uh structure smart rules? Can we have the next slide?

[00:24:37]So specific I will attend my my morning online psychology class from my study desk instead of my bed. Now this is a quite a specific goal and uh not unrealistic as well. Measurable at least four times a week. So you have set how many times a day it becomes measurable.

[00:24:56]It becomes quantifiable achievable. I have done it before and I can prepare by setting up my laptop and water bottle the night before so that it doesn't become overwhelming for the client to do 10 things at once. So next day morning you just have to go and sit on the table and open your laptop. R is relevant.

[00:25:15]This will help me reestablish a routine and feel more engaged in academics which matters to the client. Now this is most important. Relevant mean it matters to the client. Time bound. I will follow this goal for the next two weeks and then review my progress in the next session.

[00:25:34]Okay. Now we come to case conceptualization. Okay. Con this is very very important. Again case conceptualization is like creating a map a road map to understand someone's problem. It helps u in understanding or seeing what kind of thoughts, feelings and behaviors are connected and what keeps the problem going on.

[00:25:58]What what do we do in case conceptualization? We identify the main problem. We look at the thoughts and beliefs uh related to it and uh we notice how the feelings and behaviors respond to these thoughts. We also consider past experiences and then based on all of this information we help the client understand and work on the problem. Uh so how the client is basically what thought is leading to which feeling and which behavior and what is the vicious cycle like for example somebody with the uh complaint of social anxiety.

[00:26:36]Now because the client is thinking that if I go out people are going to judge me, they are going to make fun of me.

[00:26:44]Now this thought is making me so anxious, so worried. I'm highly nervous.

[00:26:49]Thus I stay inside my house. I stay indoors. Okay, this is the behavior that I'm staying indoor. There is completely avoidance. This is the triangle. How?

[00:26:58]Now this strangle is keeping me stuck because when I'm staying indoor I have no opportunity to experiment that what will happen if I go out and thus to break this false belief this false thought irrational thought that if I go out people are going to make fun of me so unless until I don't go I don't do behavioral experiment which is again a great CBT technique if I don't do behavioral experiments this illusion will not get broken in my head in fact if I continue to stay indoor. What is the message which I'm giving to my brain? The message is that I am safe and secure because I'm staying indoors. If I go out something catastrophic will happen.

[00:27:41]So this is the the uh you know this is how you utilize that triangle and you understand the vicious cycle in which the client is stuck and this is exactly how you describe the problem the case conceptualization to the client. You discuss that you know this is my understanding of of your problem. Are you able to resonate with this? Are you able to relate with this? The client may or may not be. If the client is not able to relate to your conceptualization, it's all right. You understand the problem better and you take your client's help in coming up with a with a better and a more relatable case conceptualization.

[00:28:21]Uh so this is about the conceptualization from here on I think MA would like to uh take it up MA do you want to proceed and I also will be joining you guys again I'll be coming back uh to talk about some more aspects of CBT but I think from here on Bingha can take Some of the middle phase is going to be covered by Mega. Mega are you there?

[00:28:54]Okay.

[00:28:56]She's working on it.

[00:29:01]Uh I think there is some issue. So maybe I can continue from here and uh once Bega is able to some technical issue is there once she's able to resolve that then she can take it up. Okay. So this is also part of case conceptualization presenting problem is the main issue what your client is coming and telling you that doctor I have headache doctor I'm not able to sleep at night or I get a lot of anxiety I have overthinking so many thoughts are jumbled up in my head so what the client is coming and presenting to you the main issue is the presenting problem precipitating factor is the event which triggered it so maybe my anxiety got triggered uh after an accident which I met or uh the the OCD got triggered after uh joining an office where the boss was very toxic. So any reason any event any situation can act as a precipitating factor but it is important to identify what has been the triggering factor in your client's case.

[00:30:02]Predisposing factors are already existing pre-existing factors which makes the person more likely to face mental health issues. So predisposing factor can be you know people unfortunately you know if somebody is coming from a broken family or uh somebody coming from an unfortunate background uh unprivileged not very privileged background so those kind of factors may be there poverty may be there and lack of awareness can be there some stigma could be there or um you know these kind of if there are issues which have already been existing in the family or in the background of the individual which make them more prone to develop velment of uh in psychological issues. Perpetuating factors are the ones which maintain now the example that I quoted social anxiety was the perpetuating factor is that the client is staying indoors. Um and the protective factors are the strengths and resources that the client has. So for example, somebody who is having depression which is of moderate level moderate level depression but the person is somehow able to do their workout regularly. Now in this case this is a protective factor and we are hypothesizing we are assuming hypothesizing would be a better term. We are hypothesizing that uh if the client was not what not was not working out the depression would have been at a severe level may happen at a severe level. So working out is a protective factor or somebody who has a good social support system who have a nice supportive understanding family good set of friends who they can talk to. So those are the protective factors. We can move on. I think we need to hurry up a little.

[00:31:47]Psycho education. So psycho education one you tell them what is CBT just the way I told you and introduce the triangle. Give them examples to understand. Use a lot of analogies.

[00:32:00]Emphasize on skill building. You tell them in advance that this is a a lifestyle change. This is a skill building process. During the process of CBT, I'm going to tell you about certain techniques and tools which we will learn together and you will slowly start to implement them on your in your daily life. Explain the structure of session in advance. You tell them about the initial phase, middle phase and the termination phase. Tell them that this is a collaborative effort. This is a joint effort. We both are working on the same goal towards the same goal. And introduce the idea of small homework tasks throughout the therapy. Next please.

[00:32:40]Okay. So I think we have discussed this that we tell the client that what what will be the structure of a session like we can move on. All right. So from here on I think Mega if the technical issue is sorted you can take it up.

[00:32:59]I will also be joining you guys after a few slides. again.

[00:33:03]Mega, if you can switch on your camera would be great if you're comfortable.

[00:33:06]Otherwise, it's all right.

[00:33:09]>> Uh, am I audible?

[00:33:11]>> Yes, you are. Can you switch on your camera or if you're not comfortable, that's all right?

[00:33:16]>> Actually, if I switch on my camera, the PP will not be visible.

[00:33:20]>> So, this is kind of a technical issue I was facing.

[00:33:23]>> No, no, you can please proceed.

[00:33:26]>> Okay. So, hello everyone. So, here we talk about the middle phase of therapy.

[00:33:30]As we discussed the initial phase as ma'am said like conceptualize.

[00:33:41]So even till now we have a lot of understanding about the client experiences current problems and uh a lot of things we know about the client till now. So now we talk about the middle phase. So uh just give me a second. Yeah. So first we talk about the structure of a typical middleace session. So basically exactly therapy work.

[00:34:11]Hello you actually uh your is not visible.

[00:34:21]>> Okay. So PP is not visible right?

[00:34:24]>> Ma I I am able to see your PP. Is anybody else experiencing this problem?

[00:34:29]Because the PP is visible to me.

[00:34:33]>> Okay.

[00:34:34]>> It's visible. I think >> invisible visible.

[00:34:37]>> You can proceed. Mega, it's visible.

[00:34:39]>> Okay. Okay. So, I was about I was talking that the real therapy work happens.

[00:34:53]So, structure exactly. So the first step is we begin the session. First of all after four to five sessions of the initial phase middle phase around fifth sessions start and five to 8 to 9 sess.

[00:35:10]So first step is begin the session.

[00:35:17]What was their past experiences in the last week?

[00:35:22]experiences and then after second step review homework sessions previous sessions homework.

[00:35:48]Example in the next session.

[00:36:10]So we will talk about all these things.

[00:36:13]So now the next thing is step three introduce skill building. This is a very important step in the middle phase. So after we identify that behavior patterns, so now we start talking about the practical skills to the clients skills thought discrimination, evidence gathering, activity scheduling, graded exposure, etc. So uh techniques.

[00:36:50]So first of all cognitive techniques and behavioral techniques. So cognitive techniques basically cognitive techniques focus mainly identify challengeful thoughts.

[00:37:12]techniques. So record Alternative thought hello present it in English since I don't know Hindi.

[00:37:54]>> Okay. Okay. Okay. Okay.

[00:37:56]>> Thank you.

[00:37:56]>> Okay. Yeah. So third is Socratic Krishna. In this soative questioning we try uh to the we try that in the same session client understand the understand their other beliefs also. We we basically try to questions that gently challenge the client and guide him to become actively involved in finding the answers. We kind we ask the kind of questions like what is evidence of this thought? What is evidence against of this thought? Uh is it what happens uh what do you say if the same situation happened with your friend? So we ask these type of questions so that client is able to evaluate or reframe his particular thoughts. So now the next is cognitive restructuring. In this we try and help we in in this we try keep the uh we try to climb to recognize and change the negative or unhelpful thought into a balanced and re realistic ones.

[00:38:52]And last is coh benefit analysis. We try to ask the client uh what are the pros and pro cons and pros of this situation.

[00:39:00]For example, uh the client says I don't want to go in office party. So we ask the client what are the pros of this situation? What are the cons of this situation?

[00:39:10]So this is an example of society questioning. Here the uh this is a conversation between a child and a therapist and child is asking therapist is asking what is evidence that nobody in the class likes you and the child says that nobody sits with me in class.

[00:39:28]So here therapist evaluate that that has this happened every time or just some days he just she she just try to evaluate that thought.

[00:39:38]Has someone ever smiled at you or asked to play? So now the child says yes last week a girl sat with me in class we ate lunch together and sometimes we play hide-and-seek during playtime. Uh in this way therapist help the child to evaluate their own thoughts and try to uh check if their thoughts are true or not. So the next thing the therapist asks could there be a diff different reason why no one sat with you today?

[00:40:09]So uh now the child says maybe I was late today and everyone has already sat down so I had to sit alone.

[00:40:17]So this is how the soleic cushioning done. So here is a video I want to show you video. Uh just give me a second.

[00:40:50]Tell Uh, excuse me.

[00:41:07]>> You're not able to hear the voice.

[00:41:09]>> Yeah. Mega, can you stop it? Can you just put a stop on the video?

[00:41:16]I think let the video get downloaded.

[00:41:19]Perhaps because of the internet speed we are not able to hear the video.

[00:41:28]You can just switch on the tab video tab and let it download for a few seconds and then try to uh switch it on again cuz the audio is not we are not able to hear the audio.

[00:41:41]You can try again otherwise uh if not possible that's all right just try once Uh I think we can show the video in the last.

[00:42:27]>> Okay. All right. So maybe you know uh Ashish can help us out in this and you can proceed with your slides Mega and at the end you can coordinate with Ashish.

[00:42:38]I've shared you have her his number with you and okay coordinate with him later.

[00:42:43]Please proceed with your slides.

[00:42:47]Yeah. So after cognitive techniques we talk about the behavior techniques. Am I audible?

[00:42:54]>> Yes, you are. But we can't see your slides. Can you share your screen again?

[00:43:08]Ma'am, is it possible uh uh to explain the step three because I had missed the step three in the middle phase.

[00:43:17]Uh so if we have time at the end we'll be happy to repeat the steps which have been missed by you.

[00:43:24]>> Thank you ma'am.

[00:43:26]>> Uh okay so now we talk about the behavioral techniques. So basically the main focus of the behavioral techniques is to modify the unhelpful behavior that maintain psychological distress. So what are the techniques in this? So the first one is uh graded exposure. So in graded exposure we systematically confronting the fearful situations. The second is activity scheduling. So in activity scheduling uh we basically simply schedule and plan some manageable activities like some enjoyable activities, some mastery task and some social activities like this is an example uh where four people are sitting together and watching a movie. This is like an activity scheduling to a client where we uh where we say to our client where we ask to the client to go and go for a movie with your friends. Uh kind of a enjoyable activity. So the next one is role play. In role play client practice new skills, confront difficult situation or explore unhelpful beliefs.

[00:44:30]Basically in role play the client and therapist sit together and therapist play a role of another person like a boss. Basically we can take an example the that the client is feeling very anxious speaking in front of a boss. So here uh the therapist play a role of a boss. So now therapist teach client how to be assertive in front of boss and also therapist also able to understand what are the other kind of beliefs of client hold about himself. So role play is a very effective technique in behavioral techniques uh which helps the client to learn diffic uh difficult um not difficult basically it helps the client to learn some skills to so that he can practice in the real world. The next one is behavioral experiment. Uh as ma'am said behavioral experiment basically tests the validity of the belief or prediction through real life experiences.

[00:45:31]Uh so how can they do in real life?

[00:45:34]Let's take an example.

[00:45:37]Uh this is a proper office kind of setup. Here is a girl. She's a client.

[00:45:42]She think that they will think I'm dumb if they see my PPT. So she she choose to not show her PPT in front of her colleagues. So now what therapist said to her? So uh therapist think that okay now so now do a behavioral experiment and check the validity of your thought is it true or not. So therapist give her a task to show a five slide presentation to other colleagues as a informal presentation type and uh then realize what other people are do is are reacting to it. So in this example the girl uh asked other colleagues that I want to show show you my five slide presentation. So are you interested? So in that manner she show her the five slide presentation and what happens everyone was very interested they feel very excited and also love that PPD. So this shows that her valid her thought was invalid because she was thinking that people will think I'm dumb if they see my PPD. But in real what happened was people feel very happy they was excited and also interested to show that PPD.

[00:46:58]So this was the proper step three where we talk about the in in step three basically we talk about all the techniques we try to teach all the techniques to the clients behavioral techniques cognitive techniques and uh so that clients learn all these things in the practical life. Now the fourth step is collaborative homework development. So basically homework is planned together by the therapist and client. Most of the times what we do is a mistake that we usually give the homework to the client and expect that they will do it in return but most 95% times clients will never complete their homework because they were not interested. They don't want to do that work. So uh basically in CBT homework should be in a collaborative homework is a collaborative work. Homework should be planned together where both client and therapist agree with a particular work which a client want has to do in the next week or in the next coming days where client actively participate in deciding the task which increase motivation and ownership. For example, this is a lady. She always uh shut herself in the room. She never likes to go outside but uh yeah so one what happened is that one time a uh her previous therapist told her you should go outside uh for a walk in the park for at least 30 minutes and she never did that. So when she ch when she changed her therapist, she gave her homework to at least go for a walk for 2 minutes with her pet and in the same balcony not outside of of her home but in the same balcony and she did that homework. So this is a very important thing at last she has to uh homework should be in a collaborative should be a collaborative work. So now this is a thought record exactly homework this homework is to given to the client so that they complete their work and this is the example of a client how they complete their homework the particular right situation the thought emotion behavior and the alternative thought.

[00:49:18]So now from uh this slide Tanuja ma'am will take over.

[00:49:38]All right. Uh so we coming to the last phase of therapy. Now just like the first phase, the last phase is uh equally or I would say sometimes the even more important than the first phase or the middle phase. This is a very sensitive phase of uh therapy because when you commit towards the last phase, the client may have developed some sort of dependency on you which you don't want.

[00:50:08]One of the aims, one of the goals, major goals of psychotherapy is to make the client independent and not overly dependent on yourself. Um, and this you you clarify once you start to come towards the termination of therapy. Of course during the initial phase also you you touch upon it because during the initial phase after you have done the history taking you has you have established the baseline. Uh by that time you know that uh approximately how many sessions the client would require and over the next how many weeks or months approximately your therapy will be going on. So you do inform that to the client.

[00:50:51]When you are conducting therapy and you are coming towards the end of the session, psycho education about about termination is reintroduced in a more structured way and this is done around uh if you talk about typical CBT structure which lasts up to 12 13 sessions. So this termination ideally should start around 9th session.

[00:51:12]Um so termination is introduced as a natural part of progress. uh and uh frame termination as a sign of growth and reinforce client's role and strength. Okay. So termination should not be perceived as abandonment by the client and it is um it it is just uh you know uh not the end but we are trying to foster independence and this is introduced as normal part of the CPT process.

[00:51:43]Um it's also important because it means that your client has made some progress and this is how you should present the idea to the client also that they have built the important skills and they have reached uh their goals to a great extent may not be completely and entirely but maybe you know uh if you have worked through your goals up to 70% then you can start to work towards termination.

[00:52:06]You can tell the client that now you are ready to move forward on your own and uh termination is not done suddenly that okay from tomorrow we are not going to meet. So you gently start to introduce the idea of termination.

[00:52:21]You plan ahead. You talk about it with your client. You understand that what is their readiness? Are they cognitively prepared to even talk about it?

[00:52:32]Um so basically it helps them cognitively get prepared uh for the process of termination and functioning independently.

[00:52:41]Um we have to focus on the feelings of relief, pride. Sometimes clients may also exhibit sadness because they are not going to meet you on a regular basis. So maybe some transference issues if they are coming up. Maybe in some separate session we can talk about transference that could be there. Um in the end termination helps the client see how far they have come and it reminds them that uh now they have tools to keep going.

[00:53:10]Um next ma can we have the so it's this is basically an example which shows that you know uh like when you help a child learn a bicycle say for example maybe initially you hold the bicycle you hold the child and you don't just leave them on their own but gradually once the child has learned to uh ride a bicycle on their own to a to an extent you gently you know maybe let go of one hand and then gently you let go of the second hand but to continue to show the child that okay I am there I'm holding but actually you're not holding you're allowing the child to ride the cycle on their own so similarly the termination phase is such that initially you help the client you hold their hand you help them or guide them show them the direction but eventually once they start to practice those skills they have brought uh they have uh brought those lifestyle changes in their uh life in their routine you let go of them you make them independent and uh strengthen them empowered uh empower them to function independently without your support or guidance. So that was the analogy here. Next make a case. Okay. So spaced sessions this is a great technique when you're working towards termination.

[00:54:29]Space sessions they happen uh near the end of the therapy and the when the client is of course doing better. Um and this means that the sessions are not required to be scheduled on weekly basis. They can be more spaced meaning depending upon client's progress. You can schedule the next session after 10 days or 15 days or 20 days.

[00:54:52]When do we do it? We start the space sessions. Once you see that the client is reaching their goals and they're using their coping skills adequately, they are managing their life more independently.

[00:55:03]And uh how we do it I've already told you that instead of meeting once a week now you're meeting once in two weeks and then gradually you move to once in a month and every time you check with the client how they are doing. So for example if the if we have been work working on managing anxiety say for example and after several sessions they are using breathing techniques they are uh handling tough situations they are able to face their fears do exposure and prevent avoidance or prevent uh maybe compulsion. So you might say to your client that okay I observe that you have been doing really well. How would you feel about trying sessions once every two weeks so that you get some space to practice what you have learned independently.

[00:55:58]So this will help the client build confidence in a gradual manner uh rather than just feeling that suddenly I have been dropped off or uh I have been abandoned by the by the therapist. So termination also just like goal setting termination also has to be collaborative and very gentle. So this is space sessions and next please.

[00:56:23]Okay. So this is again an example of what you tell the client. you have been applying the tools well and managing more confidently. So we can shift to bi-weekly sessions to help you practice these skills independently while still checking it regularly. Right?

[00:56:40]Okay. So again this is very important that how you prevent relapse in therapy.

[00:56:44]This also you work towards relapse prevention towards the end of the therapy. Next uh we have some pointers in this um okay so as we move towards the end of therapy let's put up a plan together for what to do if old pattern starts to come back. So if you have worked with a client who has OCD who's dealing with OCD and they have managed to overcome a lot of their compulsions.

[00:57:10]Now if OCD tries to enter their life back, if OCD tries to tell them that okay maybe you can you know put this bottle properly.

[00:57:23]So this is the first thought which is trying to re-enter your mind after weeks of working on this thing. Whether you should act on this thought or no this is what we talk about in relapse prevention. So what if the disorder or the trouble or the anxiety or issues are trying to reenter your life in that case what you are supposed to do? This is relapse prevention. It helps you feel prepared, more confident so that you can handle it on your own. Please next.

[00:57:52]So you review and reinforce the skills in relapse prevention. You revise from beginning till now. What were the homeworks? Where are they in terms of each homework? Are they doing journaling? Journaling how often? How often have you prescribed and how often they are able to do? And is it adequate?

[00:58:12]Are they doing deep breathing? Are they doing regular behavioral experiments?

[00:58:16]Are they challenging their negative thoughts properly? To what extent? What are the barriers and how to overcome those barriers? So, you talk about the skills that you have taught them to what extent they are able to implement them in their day-to-day. Identify warning signs. Now you help them learn how to identify a red flag sign. So for example uh somebody with depression and you have really worked on behavioral activation.

[00:58:43]They were not able to get out of their room at all when you started therapy but now they are maintaining a decent schedule. They're going out making friends going for workout going for the dance class attending few classes. But now um over a period of time they start to observe that they have started to skip one meal. Out of three meals that they were taking they have started to skip meal one day, two day, third day. Okay, this is a sign. Fourth day this they took off from work without any apparent reason. Fifth day they did not go for the dance class. Okay, this is the red zone. Maybe in relapse prevention a lot of times I try to help my clients identify what is your green zone, what is your orange zone and what is your red zone. Usually I tell them that during the orange zone if you're able to identify that okay I'm going in the rel uh relapse is happening or my issues are reemerging during the orange zone if you're able to identify come to the therapist immediately. If you are identifying your signs in the red zone, go to your psychiatrist and therapist together. Uh so identify red flag signs then develop relapse prevention plan. So with them we help them that okay if this is happening this is what you have to do. You don't act upon the first thought itself which OCD is trying to again put in your head. You don't act on the first thought itself.

[01:00:08]Um secondly, if you are in the orange zone, try to restart doing activity scheduling. Activity scheduling is simply put, it's a timetable. So you're putting ticks and cross across the activities which you have been doing. So initially if activity scheduling was helpful to your client, you tell them if there's a relapse happening, you immediately restart doing your activity scheduling.

[01:00:31]We can also uh help them identify their own people, their supportive people like within their family who are the people that they can go and talk to, who are their maybe friends who are little psychologically minded, who can support them, help them during that period.

[01:00:49]Encourage continued practice. So you tell them the importance of u lifestyle change. So therapy is not a magic wand that you undergo 12 sessions and you overcome depression. Therapy is a lifestyle change. You identify your set of coping mechanisms. I strongly believe that we all have a set of coping mechanisms. If we continue to practice that set, we we are able to maintain our emotional equilibrium. If we let go any of us if we let go of that we our mental health will start to deteriorate. So I I have this one perspective that during therapy you also help the client to identify their set of coping mechanisms which till now they have not been able to identify. So you tell them the importance of continued practice that you have to continuously continue to practice the skills that you have learned in therapy. Normalize setbacks.

[01:01:39]You tell them that improvement is not uniform. There are there may be ups and downs in the process of improvement. So it's all right if you have some sad days. It's it's okay if you sometimes uh you know don't want to go to your gym, you want to take one day off, it's all right. It's okay to take breaks and it's okay to sometimes feel sad. We all all of us experience sadness in psychological disorders. A lot of time clients also get confused what is normal, what is not normal. So you help them identify on based on what indicators uh you can uh you know categorize or differentiate between what is normal what is not then offer booster sessions. So once you have terminated the therapy say after 12 sessions you have wrapped up therapy but still you give them some booster sessions in the sense tell them that okay now come after 1 month or 2 months 2 months mostly 1 month you give spaced also while termination. So after two months just come back and uh let's review how you are doing and during that booster session you can also revise the techniques tools talk to them or you can discuss if new issues are coming up so uh booster sessions they can go up to maybe u three to four booster sessions can be planned in CBT. Next please.

[01:03:00]Okay, this is basically we have developed a bas CBT cheat sheet uh so that it becomes easier for you that if this is the disorder these this should be your focus and these are the key CBT techniques which you can apply and we have also provided a sample thought frame. Uh you all can have a look at it.

[01:03:19]I think we have already discussed these techniques and uh sample thoughts. Can we proceed?

[01:03:27]This is another cheat sheet. This is for OCD, PTSD and panic disorder.

[01:03:35]All right. So, we are coming towards the end of uh today's webinar. But before you all leave, please uh stay back if you have stayed till now. We'll not take more than a few minutes uh from you. Uh so, our CBT practitioner course is coming up uh next month. It's a two-month uh course and uh I myself Dr. Tanuja and Mega Gar we both are going to facilitate this course over the uh over a period of two months and uh we going to have evening classes for this. Mega can we have the next slide?

[01:04:09]Uh so this is how it is going to be from 4th August to 30th September 3 days in a week Monday, Thursday and Friday 7 p.m.

[01:04:18]to 8:30 p.m. And this is uh the the facilitators are going to be myself and me gur. And uh this CBT practitioner course is again organized by sole space which is my organization and locana loca which is Ashish's uh organization and uh based on this uh CBT practitioner course we are offering two kind of certifications. One is level one which will be given to people who have completed their bachelors. So uh and level two which is uh provided to people who have completed their masters. The difference is that after masters you can of course after undergoing this course you can practice as a CBT practitioner but uh after uh bachelors you cannot practice but you will have better skills uh CBT skills and tools and techniques.

[01:05:08]That's the difference between level one and level two. And uh we are going to keep this um uh course practical like 50% practical and uh 50% theory is going to be there. Um apart from it I think um this is mostly it and let me just go through if anything anything is left from my end I'll just uh I think most of the things we have covered. Ashish, you have anything to say about the course or maybe if I'm skipping anything from my end.

[01:05:48]Yeah, absolutely. So, uh you can contact Ashish if you are interested in undergoing this course, pursuing this course. And uh before you all leave, I would also request um if you can drop a feedback about today's webinar uh to Ashish. And um also one picture would be great if you all can switch on your camera if you're comfortable. We can have one picture uh for uh uh today. I hope I'm not missing out anything.

[01:06:20]Ashish, I have covered most of the things right. And can we play the video?

[01:06:24]Ashish, is it possible to play the video?

[01:06:39]Uh Ashish has Mega shared a video with you?

[01:06:47]Not able to see. Okay. Actually, we had developed a video showing how to reframe the uh thoughts. Mika, any chances of showing the video?

[01:06:56]>> Uh Ashish, please check uh please check your WhatsApp.

[01:07:05]Uh yes, you both have each other numbers.

[01:07:24]>> Uh excuse me ma'am.

[01:07:25]>> Yes.

[01:07:26]>> Uh if possible could you please send the video on the group as well? Uh so sharing the video on the group won't be possible for us but we are just trying to play it here here only. Ashish is working on it.

[01:07:40]>> Okay ma'am sure >> meanwhile if anyone has any question we can take three four questions.

[01:07:50]Is that okay? Ashish can we take few questions?

[01:08:08]Yes, ma'am.

[01:08:10]Good evening, ma'am.

[01:08:13]>> Hello.

[01:08:14]>> Uh hello. Uh ma'am is busy right now. Uh she's on call. Uh please wait for a minute.

[01:08:20]>> Okay.

[01:08:22]Okay.

[01:08:24]>> Thank you.

[01:08:51]All right. So I have been informed that uh we are time and uh we cannot extend this any further. uh we are most welcome uh we'll be happy to have your uh uh have you join the upcoming course in the in the next month and u Ashish will be in touch with all of you on WhatsApp you can drop your feedback and queries there thank you so much everyone for joining today it was lovely talking to you all and uh all right bye-bye take