Beck Institute Webinar CBT For FrontLine Medical Professionals Delivered On 4.4.20

CBT for Front-Line Medical
Professionals: Brief Interventions

During a Time of Crisis
ALLEN R. MILLER, PH.D., M.B.A.
Director, CBT Programs

Beck Institute for Cognitive Behavior Therapy
April 4, 2020
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©2020 Beck Institute for Cognitive Behavior Therapy
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Any unauthorized use or circulation is strictly prohibited.
Dr. Aaron T. Beck developed CBT at the
University of Pennsylvania in the 1960s. In
1994, Dr. Beck and his daughter, Dr. Judith
Beck, established Beck Institute.
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international source for training,
therapy, and resources in Cognitive
Behavior Therapy (CBT).
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©2020 Beck Institute for Cognitive Behavior Therapy 2
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worldwide through excellence
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Agenda
• The Situation • Distress Tolerance
• Values clarification • Emotional Regulation
• Sleep Hygiene
• CBT Model
• Activity Monitoring and
• Cognitive Planning
Conceptualization • Breathing and Mindfulness
-Depression • Interpersonal Effectiveness
-Anxiety • CBT-Hopelessness
-Anger • Action Plans
-Coping Cards
• Cost-Benefit Analysis
-Imagery
• Socratic Questions -Behavioral Experiments
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The Situation
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Mental health during COVID-19: AMA
During a crisis such as the COVID-19 pandemic, it is
common for everyone to experience increased levels
of distress and anxiety, particularly as a result of social
isolation. Physicians and other frontline health care
professionals are particularly vulnerable to negative
mental health effects as they strive to balance the duty
of caring for patients with concerns about their own
well-being and that of their family and friends.
THE ETHICIST: By Kwame Anthony Appiah
Values Clarification: https://www.nytimes.com/2020/03/30/magazine/coro

navirus-medical-
ethics.html?campaign_id=52&emc=edit_ma_20200403
&instance_id=17294&nl=the-new-york-times-
magazine&regi_id=71289774&segment_id=23739&te=1
&user_id=2049670c30aa042ad5a6b2ff8a46379d
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Stressors
• Volumes and acuity
• Possibility of infection
• Long shifts
• Inability to save all patients
• Shortness of supplies
• Under-preparedness
• Separation from partners/children/other
family/friends
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Normal Adjustment Issues
• Overwhelmed by • Exhausted
volumes and acuity • Depression
• Fear of infection • Anxiety
• Guilt over inability to • Insomnia
save all • Stress
• Frustration over lack • Substance use
of supplies • Feel lonely
• Anger about under- • Miss social activities
preparedness • Miss hobbies
• Miss partners/children • Bored
https://www.inquirer.com/health/coronavirus/coronavirus-covid19-mental-health-doctors-
20200327.html
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763229
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Common Goals
• Get control ( https://beckinstitute.org/using-cbt-to-respond-
to-covid-19/ )
• Resolve ethical concerns: Work vs family

• Reduce Fear: Regarding exposure
• Lower anxiety: Worry less
• Improve mood: More pleasure, competence
• Limit anger: Towards, pandemic, employer,
government, self, others
• Healthy lifestyle: Eat, sleep, exercise
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CBT Model for Crisis Intervention
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Crisis Intervention (Not linear)
• First Aid: Physical needs, Safety, Social
connections
• Conceptualization: Cause, maintenance
• Prioritize needs: Values, Priorities, Problem

solve, Goals
• Coping Strategies: For what I cannot change
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Crisis Intervention (Not linear)
• Change Efforts: For what I can control
• Challenges: How do I (colleague)get in the

way
• Acceptance: It is what it is
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CBT Values
• Demonstrate Understanding: Listen,
empathize
• Interpersonal Effectiveness:
Unconditional acceptance
• Conceptualization
• Focus on one issue
• Collaboration
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CBT Techniques for Crisis Intervention
• Socratic Questions • Mindfulness
• Cognitive • Distress Tolerance
Restructuring • Emotion Regulation
• Behavioral Activation • Acceptance
• Cost-Benefit Analysis • Value Identification
• Role Play • Motivation
• Imagery • Coping Cards
• Feedback
• Relaxation
• Action Plans
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Cognitive Conceptualizations
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Situation
Automatic Thoughts
and Images
Reaction
Emotional Behavioral Physiological
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Depression
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Cognitive Model for Depression
Situation Automatic Reactions

Thoughts
Emotional
Intermediate
Belief
Behavioral
Core Belief
Physiological
Beck, J. (1995). Cognitive Therapy: Basics and Beyond. Guilford. New York.
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Common Thoughts of Depression
• Can’t do my job
• Can’t be in my house
• I miss my family/kids/grandchildren
• Can’t be a good partner in relationship
• No end in sight
• The situation is hopeless
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ANXIETY
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The Vicious Cycle
Anxiety
Cognitive Appraisal:
1. Danger
Flaws in performance
2. Inadequate skills
Negative audience
reaction
Beck, A.T. and Emery, G. (1985). Anxiety Disorders and Phobias. Basic Books. New York.
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Common Thoughts of Anxiety
• If might become infected
• I could get sick/die
• There are too many cases, I can’t handle
the work load
• The acuity is too high. I can’t give cases
the attention they need.
• My patient(s) might die
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ANGER
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Cognitive Model of Anger
Incident
Show of
Disrespect Hurt
Violation of a
Rule
Blameworthy Angry
Hostile Desire
to Punish
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Common Thoughts of Anger
• This isn’t fair, I don’t deserve this.
• They knew it was coming
• We don’t have enough PPE
• There are no ventilators
• We are running out of meds
• They lie to us
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Cost-Benefit Analysis
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Advantages-Disadvantages Analysis
• Useful when a client has important decisions
to make
• Useful if clients are having difficulty taking

steps towards a particular goal
• Helps client organize his or her thoughts

about an issue
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Advantages-Disadvantages Analysis
Advantages of… Disadvantages of…
Advantages of Not… Disadvantages of Not…
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ITCH for Problem-Solving
• Identify the Problem.
• Think about possible solutions.
• Choose a solution to implement.
• How well does it work?

Muñoz, R.F. Ippen, C.G. Rao, S. Le, H-N, Dwyer, E.V. (2000).Manual for group cognitive-
behavioral therapy of major depression. medschool2.ucsf.edu/latino/pdf/CBTDEN/overview.pdf
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Socratic Questions
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Socratic Questions for Guided
Discovery
• What is the evidence that my thought is true?
What is the evidence that my thought is not
true?
• What’s an alternative explanation or viewpoint?
• What’s the worst thing that could happen and
how would I cope if it did?
• What’s the best that could happen?
• What’s the most likely outcome?
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Socratic Questions for Guided
Discovery
• What is the effect of telling myself this
thought?
• What could be the effect of changing my
thinking?
• What would I tell someone else if he/she
viewed this situation in this way?
• What should I do now?
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DISTRESS TOLERANCE
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What is Acceptance?
• Acknowledgment of the facts of a situation
and realistic limitations
• Does not mean approval, resignation, or
passivity
• Is not anti-change: it is a prerequisite for
change!
• Similar to the Serenity Prayer
-Serenity to accept what I cannot change
-Courage to change the things I can
-Wisdom to know the difference
• Usually involves sadness or grief
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Wise Mind ACCEPTS
Distracting with…
Activities—engage in any tolerable exercise
Contributing—give something to another
Comparisons– compare self to others the same or
less fortunate than you
Emotions—do things that stimulate different
emotions,
Pushing away—leave the situation (mentally) for
awhile
Thoughts—count, focus attention elsewhere
Sensations—hold ice, squeeze ball, etc.
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Emotion Regulation
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Healthy Lifestyle
Eating
Exercise
Sleep
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Sleep Hygiene
• Avoid Caffeine, Alcohol, Nicotine, and Other
Chemicals that Interfere with Sleep
• Lighten Up on Evening Meals
• Exercise helps promote restful sleep if it is

done several hours before you go to bed.
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Sleep Hygiene
• Go to bed the same time every night. ...
• Get up at the same time every morning (7
days/week)
• A quiet place to sleep. ...
• Keep your bedroom dark and cool. ...
• Dedicate your bed to sleep and sex, and
nothing else. ...
• Turn off all screens 30 minutes before bed
• Turn phone off
• Limit your daytime naps
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Activity Monitoring & Planning
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Activity Monitoring
• Assess how patients spend their time.
• How do their prior beliefs about their
activity levels compare with the actual
measures?
• How well did they do certain activities
compared to their actual performance?
• How much pleasure did they experiences
when engaged in activities compared
with what they expected?
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Activity Monitoring
• Monitoring
• Track activities over the week
• Rate mood
• Review to notice patterns, high-risk

times/situations, relationship
between mood and activities
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Activity Planning
• Scheduling
• Plan for the week ahead, scheduling
health activities
• Plan new activities to fill time voids
• Maximize activities that create a sense of
mastery and accomplishment.
• Utilize activities that involve enjoyment
• Review/troubleshoot
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Breathing and Mindfulness
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Benefits of Relaxation
• Helpful in managing stress
• Helpful in managing depression and anxiety
• May help to retrain the brain to respond
thoughtfully to stress, rather than reacting
impulsively
• Helpful to people maintain gains
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One Minute Breathing Exercise
• Breathe in deeply through your nose
(Four seconds)
• Fill lungs with air—hold for a few seconds
(Two seconds)
• Exhale slowly through your mouth (Six
seconds)
• Repeat four times
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Mindfulness
• Definition: “Paying attention in a particular
way, on purpose, in the present moment,
non-judgmentally” (Kabat-Zinn, 1995)
• Core component of ACT, MBCT, and DBT

and other Mindfulness or Acceptance-based
approaches
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Mindfulness: What is it?
• Training in Attentional control (e.g. focusing
exercises)
• Observing facts vs interpretations
• Non-Judgmental Stance
• Acknowledgment/Acceptance of what is
• The opposite of multi-tasking
• Can be used with positive and negative
emotions: helps us experience positive
emotions more fully and navigate negative
emotions more skillfully
• Can bring mindfulness to any activity
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Cognitive Defusion Exercise
• “Leaves on a Stream” provides an excellent cognitive defusion exercise used in
Acceptance & Commitment Therapy:
• (1) Sit in a comfortable position and either close your eyes or rest them gently
on a fixed spot in the room.
• (2) Visualize yourself sitting beside a gently flowing stream with leaves floating
along the surface of the water. Pause 10 seconds.
• (3) For the next few minutes, take each thought that enters your mind and
place it on a leaf… let it float by. Do this with each thought – pleasurable,
painful, or neutral. Even if you have joyous or enthusiastic thoughts, place them
on a leaf and let them float by.
• (4) If your thoughts momentarily stop, continue to watch the stream. Sooner or
later, your thoughts will start up again. Pause 20 seconds.
• (5) Allow the stream to flow at its own pace. Don’t try to speed it up and rush
your thoughts along. You’re not trying to rush the leaves along or “get rid” of
your thoughts. You are allowing them to come and go at their own pace.
Cognitive Defusion Exercise Russ Harris (2009)
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Cognitive Defusion Exercise
(continued)
• (6) If your mind says “This is dumb,” “I’m bored,” or “I’m not doing this right”
place those thoughts on leaves, too, and let them pass. Pause 20 seconds.
• (7) If a leaf gets stuck, allow it to hang around until it’s ready to float by. If the
thought comes up again, watch it float by another time. Pause 20 seconds.
• (8) If a difficult or painful feeling arises, simply acknowledge it. Say to yourself, “I
notice myself having a feeling of boredom/impatience/frustration.” Place
those thoughts on leaves and allow them float along.
• (9) From time to time, your thoughts may hook you and distract you from being
fully present in this exercise. This is normal. As soon as you realize that you have
become sidetracked, gently bring your attention back to the visualization
excercise
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INTERPERSONAL EFFECTIVENESS
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Interpersonal Effectiveness
• Obtaining your legitimate rights
• Refusing unwanted or unreasonable

requests
• Resolving interpersonal conflict
• “DEAR MAN”
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“DEAR MAN”
• Describe— the situation
• Express—feelings and opinions about the situation
• Assert—by asking for what you want and saying “no”
to what you don’t want
• Reinforce—the other person in advance
• Mindful—stay focused on your objectives

• Appear Confident—incudes tone of voice, eye
contact, posture, etc
• Negotiate—be willing to give to get
Dialectic Behavior Therapy, Marsha Linehan, 1993
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CBT-Hopelessness
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Safety Plan
• Warning signs
• Internal coping strategies: Things I can do on
my own to take my mind off my problems
• People and social settings that provide
distraction
• People whom I can ask for help
• Professionals I can contact during a crisis
• Making the environment safe
Stanley & Brown, 2008)
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Hope Box
• Letters or printed emails that mean a lot to you
• Photos of special times you have had – or of special
times you hope to have
• Photos of loved ones
• Inspirational quotes
• Spiritual or religious verses
• Articles or columns that you find meaningful
• Jokes that make you laugh
• Anything else that reminds you of reasons to stay
alive
https://www.speakingofsuicide.com/2013/05/16/hope-box/
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Action Plans
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Action Plan: Rationale
• A way of encouraging clients to practice

new skills between session.
• “Based on what we discussed today,

what is something you would like to work
on this week?”
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Common Action Plan Exercises
• Implement a coping skill to manage stress
• Evaluate thought-looking for evidence
• Use a coping card.
• Complete an activity log.
• Practice controlled breathing/mindfulness
• Call a family member or friend.
• Use communication skills.
• Implement a decision
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Generating Action Plans
• Tailor homework to the individual client.
• Provide a rationale.
• Design the assignment collaboratively.
• Consider starting the assignment in
session.
• Discuss a plan for completing the
assignment (e.g., where, when, visual
prompts or reminders).
• Anticipate problems.
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Coping Cards
Three Types:
 Automatic Thought-Adaptive Response
 Coping strategies
 Reminder-Why I am doing this (values)
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Imagery Directions
• Pick an appropriate time in the future: (e.g.
days, years, situation)
• Clearly state what you want to have happen
at that time/situation (e.g. demonstrate a skill,
experience a feeling, achieve a goal)
• Using all five senses, imagine yourself in the
future situation as if it were happening right
now (i.e. what do you see, hear, feel, smell,
taste?)
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Imagery
• Imagine yourself performing the skill/having
your desired experience in the way you
realistically hope to perform.
• Completely perform the skill/experience
through to the end and beyond
• Process how well the imagery process went
and discuss whether it needs to be tweaked.
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BEHAVIORAL
EXPERIMENTS
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Purpose of Behavioral Experiments
• Evaluating thoughts and beliefs through
experience
• Tends to be more powerful than standard
cognitive restructuring
• Helpful when clients “understand
intellectually” but “feel like it’s true”
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Behavioral Experiments
“The therapist helps the client identify a specific
cognition that the client needs to test, and then
uses activity as a way of testing, and usually
disconfirming, the hypothesis.”
Keeping in mind the case formulation,

collaboratively design behavioral experiments so
that the client can test the cognition.
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Behavioral Experiments
• Step 1: Present the Rationale
• Step 2: Develop a prediction
• Step 3: Set up the detailed experiment (with
coping plans for feared outcomes)
• Step 4: Record the Outcome
• Step 5: Review the outcome and summarize
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Assess Likelihood of Completion
• On a scale of 0-100% how likely is it that you
will complete the Plan?
• Anything less than 90% is in the questionable

category
• Redesign Plan until you receive a “90%”

response
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Summary
• Distress Tolerance
• The Situation
• Emotional Regulation
• Values clarification • Sleep Hygiene
• CBT Model • Activity Monitoring and
• Cognitive Conceptualization Planning
-Depression • Breathing and Mindfulness
• Interpersonal Effectiveness
-Anxiety
• CBT_Hopelessness
-Anger • Action Plans
• Cost-Benefit Analysis -Coping Cards
• Socratic Questions -Imagery
-Behavioral Experiments
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CBT Training through Beck Institute
• Workshops in Philadelphia
• Training for Organizations (at your location)
• Supervision
• Consultation
• Online Training (www.beckcbtonline.org)
• Live, interactive webinars
For more information email education@beckinstitute.org
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Get Beck Certified!

Learn more at
https://beckinstitute.org/certification/
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CBT for Front-Line Medical

Professionals: Brief Interventions

Director, CBT Programs

Beck Institute is a leading

Our mission is to improve lives

Sign up for the Beck Institute

Values Clarification: https://www.nytimes.com/2020/03/30/magazine/coro

• Resolve ethical concerns: Work vs family

• Conceptualization: Cause, maintenance

• Prioritize needs: Values, Priorities, Problem

• Coping Strategies: For what I cannot change

• Change Efforts: For what I can control

• Challenges: How do I (colleague)get in the

Emotional Behavioral Physiological

Situation Automatic Reactions

• Useful if clients are having difficulty taking

• Helps client organize his or her thoughts

Advantages of… Disadvantages of…

Advantages of Not… Disadvantages of Not…

• Think about possible solutions.

• Choose a solution to implement.

• How well does it work?

• Lighten Up on Evening Meals

• Exercise helps promote restful sleep if it is

• Review to notice patterns, high-risk

• Core component of ACT, MBCT, and DBT

• Refusing unwanted or unreasonable

• Resolving interpersonal conflict

• Mindful—stay focused on your objectives

Stanley & Brown, 2008)

• A way of encouraging clients to practice

• “Based on what we discussed today,

Keeping in mind the case formulation,

• Anything less than 90% is in the questionable

• Redesign Plan until you receive a “90%”

For more information email education@beckinstitute.org

Get Beck Certified!

Sign up for the Beck Institute newsletter

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