body and welcome. My name is Neil Sidman, and I'm a member of the Public Education Committee for ADAA, that's the Anxiety and Depression Association of America. We're really excited to present this webinar. This is the first of our series, and the topic is Cognitive Behavioral Therapy for Anxiety and Depression. Our presenter is Dr. Dennis Greenberger. We're going to be recording the webinar, and you'll be able to see it again at a later time on the ADAA website. If you have questions during the webinar, you can type them in. So, on the right side of your screen, you should see a Q&A panel, and there's a little field at the bottom of that panel. When you click in it, you can type in a question, then either hit your enter key or click the icon. We're going to try to get to as many of your questions as we can at the end of the presentation. Also, keep in mind other participants in the webinar cannot see your question; only myself and Dr. Greenberger will be able to see your

question now. Before we begin, I'd like to tell you just a little about ADAA, the Anxiety and Depression Association of America. ADAA was started in 1979, and today it's the leading nonprofit organization in the field of anxiety disorders and depression. Our mission is to improve diagnosis and promote the prevention, treatment, and cure of anxiety, depression, and stress-related disorders through education, like today's webinar, practice, and research. We fight to really end stigma, and we promote the message that these conditions are real, serious, and treatable. Now, I want to invite you to visit the ADAA website. It's really a fabulous resource, so you should make a note. It's adaa.org. On the website, there's a great section called Find a Therapist. It's a searchable database of treatment providers. Also on the website, you'll get free educational information and resources, self-tests, information about self-help groups and clinical trials, and just a lot of other great information. So, it's really worth visiting the

website, and also you can support Ada by making a charitable donation on the website. Okay, so I'm really happy to introduce our presenter, Dr. Dennis Greenberger, who is a clinical psychologist practicing in Newport Beach, California. He's the founder and director of the Anxiety and Depression Center. Dr. Greenberger is the co-author, along with Christine Pesi, Ph.D., of Mind Over Mood and The Clinician's Guide to Mind Over Mood. Mind Over Mood was awarded the most influential cognitive behavioral therapy book by the prestigious British Association of Cognitive and Behavioral Therapies. Mind Over Mood has been translated into 21 languages and sold over a million copies. It's one of the most widely read cognitive therapy books ever written. So, let me turn it over now to Dr. Greenberger, and remember, you can type in a question anytime. Uh, well, thank you, Neil, for the kind introduction. I appreciate it. Uh, I, before beginning, I also would like to thank ADAA for asking me to do this webinar. I've been a member of ADAA for

many years and have always been impressed by the tireless work that they do. Um, it's a wonderful organization that has really done an immeasurable amount in promoting awareness of anxiety and depressive disorders. And I'm honored to be the first person asked to participate in these webinar series. So, in today's webinar, I hope to provide an introduction to cognitive behavior therapy, or CBT, and explain why and how it may be helpful for people with mood disorders such as anxiety and depression. I hope by the end of the webinar that you'll better understand anxiety and depression and the cognitive behavioral model, uh, how CBT works, and understand why major medical and psychological and governmental organizations label CBT as an empirically or research-validated treatment for depressive and anxiety disorders. Um, also, I hope that at the end of the webinar, that if you're motivated to do further research on CBT, uh, to help you better understand if it may be helpful for you or someone that you care

about you may have heard about cognitive therapy or CBT, um, but not be fully appreciative of what it is. CBT is an active and structured and focused form of psychotherapy, uh, that rests on the idea that the way we think and perceive events and the way we act or behave as an important influence on the way we feel. So, it's really a very simple premise. Let me, let me repeat it though because it's really the crux of what CBT is all about. It rests on the idea that the way we think and the way we behave affects the way we feel. And if we can understand and modify our thoughts and our behaviors, there's a very good chance that we can feel differently. So, if we modify how we think or behave, we can often reduce or overcome the symptoms of depression and anxiety and lead more meaningful lives. One of the unique features of CBT is that it's been extensively researched, and very sophisticated research consistently demonstrates that CBT is a very effective treatment for anxiety and

depressive disorders. CBT has been shown to alleviate depression, generalized anxiety disorder, panic disorder, social anxiety disorder, health anxiety, obsessive-compulsive disorder, or OCD, and post-traumatic stress disorder. The appeal for many people of CBT, both patients, is that it's practical in terms of skill building, it's powerful in terms of getting results, and it creates permanent and durable changes in people's lives. So, today's webinar is not intended to summarize the extensive CBT research that has been done, but if you're interested in the research database, I encourage you to explore this after the webinar. So, CBT rests on a warm and supportive and trusting relationship between the client and the therapist. The therapist and the client work together in a collaborative way to address mutually agreed-upon therapy goals. CBT begins like most therapies with a very thorough history-taking and an assessment of the problem that the client wants to overcome. The therapist is likely to ask

a lot of questions about the symptoms that you're having, how long the symptoms have been present, how frequent and severe the symptoms are. The therapist will want to know if there are certain situations in which your symptoms are more likely or less likely to occur, and your therapist is probably going to want to understand your strength as well as your symptoms to be able to come to a diagnosis and develop a treatment plan that's designed for you and based on your particular history. In the first session or two, you and your therapist together will decide upon what the therapy goals are, decide on a way of measuring progress, and decide on the frequency of the session. Your therapist may be able to give you an estimate of how many sessions he or she thinks it will take you to get better, but for many problems, including many depressive and anxiety disorders, a full course of CBT can be completed in 20 sessions or less. There's a lot of research that demonstrates that CBT can be effective in

a relatively brief period of time for many mood and behavior problems. Many people get better and stay better with relatively brief CBT treatment. In the beginning of treatment and periodically throughout the treatment, your therapist is likely to have you take some paper and pencil tests in order to establish a baseline of the symptoms of your symptoms and in order to measure your progress as the treatment proceeds. These tests can help quantify the frequency and severity of the symptoms that you're having, measure your progress as the treatment moves along, and identify symptoms that may need additional work as the treatment progresses. It's very important that after the first or second session, you have a sense of comfort and trust with your therapist and you have a sense that you can get better with the therapist and with the treatment that they're providing. Trust and comfort are particularly important in Psychotherapy and turn out to be highly predictive of successful treatment outcomes. Now, it's also important to understand that most CBT treatment involves between-session homework.

assignments on the client's part, and usually, the more homework that's done between sessions, the faster the treatment gets completed. So, as a client, it's important to be prepared to devote time to learning and practicing new coping skills and experimenting with new ways of thinking and behaving. Most people just enter psychotherapy on only one or two occasions in their lives, so you really want to recognize it as an important opportunity to make the most of it that you possibly can in the treatment. The therapist and the patient are working collaboratively in the context of this warm and trusting relationship to look at the thoughts and behaviors that occur along with the anxious or depressed feelings. In its simplest form, the idea is that if we can identify and change the thoughts and behaviors associated with anxiety and depression, then there's a good chance that the anxiety and depression will be significantly alleviated. Now, to make sure that we're on the same page in terms of what we're talking about, behaviors are simply things that we do. There are actions. Behaviors are

observable, and they're subject to change. There's clear and demonstrable behavior changes that happen when we're depressed and anxious, and if we can understand and alter the behaviors, it's one step in improving the mood problem. Now, cognitions is cognition is just a fancy word for the way we think. More generally, cognition refers to thoughts and beliefs and perceptions, but it really refers to our self-talk. It's the way we understand experiences and the way we attach meaning to events that happen in our lives. On its most basic level, cognition refers to the way we talk to ourselves. It's the monologue or dialogue that takes place in our minds throughout our lives. Now, these thoughts aren't observable from the outside, but they're very visible from the inside. With a little bit of training, one of the early steps in CBT is to become a good observer and documenter of your behaviors and your thoughts. Now, the cognitive behavioral model is represented in this diagram. As you can see, there's four components to

the model. There's thinking, there's behavior, there's mood, and there's physical functioning. The arrows in between the four areas suggest that each one of the areas affects the others in a system. And when there's a change or alteration in any one of these areas, the other three areas, as part of the system, are going to be altered as well. So, as an example of the effect of thoughts on our moods or our physical functioning, consider the scenario of you sitting at home and your phone ringing. Before you answer the phone, the first thought that may go through your head is that someone's calling to tell you that a relative is hurt or has been in an accident or something terrible has happened. If that's your thought, you're likely to feel afraid, anxious, nervous, and fearful. You may notice your heart beginning to race and your breathing change. If you pick up the phone and find out, though, that it was the wrong number, you're likely to feel relieved in the

anxiety and rapid heartbeat are going to disappear. So, this demonstrates the connection between a thought to a benign cue, which was the phone ringing. The thought was, Something terrible has happened, and the mood of anxiety or fear, and the physical reaction of the rapid heartbeat or the breathing change. Now, the process works in reverse as well, so it may start with a physical sensation rather than with the phone ringing. So, consider perhaps walking up a flight of stairs or three flights of stairs. If you do this, it's likely that your breathing is going to alter, your heart may start to race a little faster, and you may start to sweat. Now, if you're someone who's prone to panic attacks, you may interpret or misinterpret your rapid heartbeat as a heart attack, or you may interpret or misinterpret your dizziness as a stroke. Now, let's see how the four-part CBT model can help you better understand symptoms of anxiety and depression. Or here's depression, actually. Thoughts typically associated with depression are negative. So, when we're depressed, we tend to interpret or

misinterpret events in a negative way. Typical thoughts when we're depressed are I'm no good, no one likes me, I'm a failure, I'm never going to get any better. These negative thoughts exemplify the thinking component of the cognitive model of depression. In terms of mood, we often feel along with depressed, irritable, sad, perhaps angry. In terms of the physical functioning when we're depressed, physically we may feel lethargic or tired. We may sleep more or sometimes sleep less. We may eat more or eat less, and there's changes in our brain chemistry as well. So we analyze the different components of depression, the different dimensions in this model. These are the physical symptoms that we often see. Now the final component of the CBT model is the behaviors, and behaviorally when we're depressed, we tend to withdraw from other people. We tend to be more socially inactive. We do fewer activities, especially fewer activities that may

have given you a sense of mastery or control or meaning in your life in the past. Now, one of the things that many people like about this model is that it's a concise way of understanding symptoms and of understanding how all these different symptoms that you may be experiencing interact with one another. Additionally, this model is a way of pulling together what may appear to be separate, unconnected symptoms and provide a way of understanding that seemingly disparate symptoms may, in fact, all be part of the depressive episode. It also demonstrates that we as a science really don't fully understand the ultimate cause of mood problems, but what we do understand is that these four components all interact with one another, and as a system, if we can change any one of the areas, the other three areas will change as well. Now, let's look at whether or not the CBT model can help us understand anxiety in a way that was similar to the way that it helps us understand depression. So, you can see here that the model is identical. We're looking at the

four different components, um, and then we can break them out separately. So, thoughts associated with anxiety often begin with what if. Uh, if you suffer from an anxiety disorder or you know someone who does, this is not going to be any surprise to you. Uh, the what if sentence ends with a catastrophe or something going horribly wrong. So, there are thoughts that something bad is about to happen or that there's imminent danger of some sort. In panic or anxiety attacks, the thought may be that I'm dying, I'm going crazy, I'm having a heart attack, I'm having a stroke. Uh, phys or mood-wise, uh, along with those thoughts, we feel nervous and anxious, and we may have a panic attack. I think of anxiety on a continuum of severity, with uh, the low end being a little nervous, uh, anxiety being in the middle, and a panic attack at the most uh, severe end of the continuum. Uh, now physically, the physical symptoms associated with anxiety are an accelerated heart rate, uh, dry mouth, sweating not due to the heat, um, and as

in depression, changes in brain chemistry as well. This is really a fight or flight response and an acceleration of the autonomic nervous system. It's our body physically getting ready to respond to a threat or danger. The danger that's described earlier in the thinking component of this model. So, there's a thought or perception that something bad's about to happen, that there's some imminent danger, and in response to that perception, our bodies respond as they've been programmed to do with a fight or flight response. So, the body and mind's reaction makes perfect sense in response to the perceived danger, to the interpretation or misinterpretation that something bad is about to happen. Now, behaviorally, when we're anxious, we avoid what triggers our anxiety. We limit our activities, and we engage in safety behaviors. Again, this makes sense. If the perception of danger or of catastrophe is accurate, we're programmed really to avoid these dangerous situations. The most extreme example of avoidance behaviors would be phobias, where people

avoid public speaking or heights or closed spaces or airplanes or in the most severe situations, even leaving their homes or a room in their home because of fear. So, this CBT model has the advantage of being simple yet being able to accurately describe, I think, the experiences of anxiety and depression. Further, and as importantly, the model really serves as the basis for CBT treatment and suggests multiple areas for intervention that can help people develop practical thinking and behavioral skills that can help them to feel better and to help them overcome mood problems that they may be plagued by. So, it turns out that of the four components that you see there, it's only the mood component that we can't directly intervene with. We can intervene at the physical level with medication, and in CBT, we focus our interventions on thoughts and behaviors. But, like I said earlier, a change in any one of those areas is likely to have an impact on the mood as well. And what we found is that certain

interventions can have a profound and life-changing effect on the way that you feel now. Automatic thoughts are what are described on this slide, and in CBT, one of the skills that hopefully you'll develop is to identify on an ongoing basis your internal dialogue, your self-talk. Automatic thoughts are those words and images that come into our mind spontaneously throughout the day. Whenever we have a strong mood, there's going to be a thought that's present, and that thought can provide clues in understanding our emotional reaction. One key in CBT is learning to identify the thoughts that occur along with the mood problems that you're having, to identify the thoughts. You may want to ask yourself or learn to ask yourself on a routine basis, What was going through your mind and what you were thinking about whenever you have a strong mood? These thoughts can then be worked with and hopefully altered in the course of CBT. Now, the thoughts can be either verbal, they can be words, or they can be

images. Uh, what we found very often with depression, the thoughts are more, uh, verbal, more words. And when we're anxious, the thoughts, um, more often, uh, tend to be images. A lot of attention in CBT is focused on slowing down problematic experiences that you have and learning to analyze the four components in the CBT model. Uh, at the end of CBT, you should be an expert at identifying and altering your thought processes or altering your behaviors and your thoughts in a way that improves your life. Uh, in CBT, I think you learn to act and behave in a new way, and you learn to think differently, to have different thought content, but also to be able to view your thoughts in a different way, perhaps from a different perspective. One fascinating discovery was the fact that anxiety and depression are characterized by very specific types of thinking that are distinct from each other in terms of content. Anxious thoughts are characterized by themes of danger and vulnerability and threat and catastrophic expectations of the future. Uh, depressed thoughts, on the other hand.

are characterized by negativity in three areas. We're negative towards ourselves, uh, we're negative towards um the future or have a hopeless attitude, and we tend to be negative about ongoing experiences. It's as if we have a voice in the back of our head uh that comments in a negative way about our lives. This is sometimes referred to as the negative cognitive triad, uh, negative thinking about ourselves, uh, the future, and ongoing experiences. You may have heard the phrase of cognitive distortions or thought distortions. This refers to the idea that the way we perceive ourselves or the world or experiences uh may not accurately match the way things actually are. Uh, the idea is somewhat analogous to looking into a funhouse or a distorted mirror. Uh, we know when we look in the mirror that the image that we're viewing doesn't actually match the way we actually are. Uh, so similarly, when we're depressed and anxious, our minds distort what we see in a similar fashion. Uh, when we're anxious, we over-perceive danger or threat or our own

vulnerability, uh, and when we're depressed, we're overly negative, overly self-critical, and overly hopeless about the future. We may see the world and ourselves in the future, and really our ongoing experiences in this distorted manner, uh, so clearing up the distortions in the funhouse mirror or clearing up the distortion in our minds can go a long way to seeing things more clearly and may help us to feel uh less depressed and less anxious. Now cognitive behavioral therapy for depression often involves learning to identify and evaluate and alter the automatic thoughts that occur along with the depressive episodes. So in order to learn to do this with the CBT therapist may use what's called a thought record or a thought log in which the client learns to um monitor and identify the automatic thoughts that they have in the midst of being depressed. Uh CBT treatments for anxiety are likely to begin by focusing on more in behavior rather than thoughts, uh, so they may not uh formally utilize thought records, uh, but the behavioral interventions may

ultimately work because of creating these durable changes in the underlying thoughts or the underlying catastrophic predictions. The thought records I think can be real illustrative in the process of learning to separate out and distinguish the different parts of the CBT model. So, if you learn to record your experiences in a way that changes in this kind of way, it lays the groundwork for being able to make the kind of changes that you may desire to make. The thought records can be thought of as a psychological microscope, and what we're putting under the microscope is a slice of your experience, a moment of your life. And as we look through the microscope, what we're separating out are the different factors of the experiences. As I talked about earlier in the CBT model, we want to describe your thoughts, your mood, your behavior, your physical reaction, and our hope is that once we separate out these components, we can teach you to put them back together in a way that's more adaptive. So, this is an example of a

Ben, who was a 65-year-old man, was depressed, and he was preparing to go to his daughter's house for a Thanksgiving dinner. It's 11:00 in the morning. The first column is just a situation where you want to answer who, what, when, and where. His mood was sad and remorseful, and the thoughts were, Thanksgiving is such a sad time. I have two grown children who live out of town with their families. I don't get to see them nearly as often as I would like. Thanksgiving's the beginning of the season when families should be complete and together. We'll never be a family like that again, and my life will never be as good as it once was. You can see the negativity that's involved in Ben's thinking at this moment. Now, similarly with anxiety, this is an example of how an anxious experience would appear on a thought record. This is an example of Judy, a patient with panic disorder. So with Judy, her situation again who, what

when and where it's 2:30 in the afternoon. I'm alone at the mall where I've been shopping for 45 minutes. Uh, the mood at that moment was fear and panic rated at 100%. And you can read the thoughts and see the catastrophic nature of them where she's thinking she's going to die. She needs to get to a hospital and having an image of herself lying on the floor, uh, unable to breathe. What I want you to notice here, if you would, is how the two experiences were dissected and the different components of the experience are articulated in the different columns. So, the ability to understand your experiences in this fashion sets up the foundation on which to more closely look at and maybe alter the thoughts and the behaviors that maintain the psychological distress that you're experiencing. Now, with depression, CBT would typically involve um, mastering the first three sections of the thought record. Uh, the treatment would then proceed to the second half of the thought record which teaches you to

look more closely at the automatic thought and learn to gather evidence or facts or data that supports or doesn't fully support the automatic thought that you've identified in the first half of the thought record. So, given our time limitations today, I'm not going to go into the nuts and bolts of the second half of the thought record, but the essential skill that your CBT therapist is likely to be teaching you is to answer the questions: Where's the evidence that supports the automatic thought that I identified? Is there any evidence that doesn't fully support the automatic thought? And based on the evidence, is there another way of thinking about the situation that I'm in now? This final question is important because what we're hoping is that your new, more adaptive way of thinking will be based on evidence or data, factual information or experiences, rather than on fears and low self-esteem or depression or a sense of hopelessness. We hope that the thought record can help you develop these new, healthier, and more adaptive ways of

thinking and really develop a foundation on which to base the new thinking, which should help you to feel better. So, um, the thought records can be boiled down to a set of three questions. It's essentially: what am I thinking? Where is the evidence that supports or doesn't support the thought? And based on the evidence, is there another way of thinking about this? I consider this the Cliff Notes version of cognitive therapy. Now, for anxious people, there's a different set of three questions, and that's um: what's the worst that could happen? What's the best that could happen? And in all likelihood, what's going to happen? Now, identifying and altering a single thought is not going to make you better for the long haul. What we're doing is teaching a skill that hopefully will fundamentally alter the ongoing self-talk, uh, the thousands of thoughts that you have in any given day, in a way that ultimately will help you to get better, stay better, and live better. Uh, the hope is that with consistent practice over a short period of time

most people can learn new ways of thinking that will fundamentally alter these thought patterns, the self-talk, the self-perception, the view of the future, and will clear up the distortions I was talking about earlier in the Funhouse mirror. So, depending on the problem that you come into treatment for, your CBT therapist may decide to begin with behavioral interventions for your depression and anxiety. When we're depressed, we tend to be less active, more lethargic, and have a harder time getting going. Your CBT therapist is likely to suggest what we call a behavioral experiment. The experiment is maybe to track the activities that you do throughout the day and just notice whether or not there's a relationship between what you do and how you feel. After keeping track of your daily activities for some time, you may want to ask the following questions: So, is there a relationship between what I do and how I feel? Did my activities affect my mood? What activities help me

to feel better or worse. Were there certain times of the day when I felt worse? Can I think of anything I could do to feel better during these times, uh, with certain times of the day or week when I felt better? And then, in looking at my answers, uh, especially to questions three and four, what can I plan in the coming week to increase the chances that I'm going to feel better over the next week or over the next month? What we want to do is to try to plan in activities that give you a sense of mastery or control or meaning or pleasure and enjoyment in your life to see if that has an impact on the way you're feeling. Now, with um, this slide, uh, demonstrates some of the similarities between the different anxiety disorders. Um, what I want you to notice is uh, each anxiety disorder is listed in the first column, and then typical thought content is in the second column. The beliefs with anxiety uh, across the disorders are always danger and vulnerability and threat. Uh, what I want to draw your

attention to right now. Now is the fourth column, uh, which describes avoidance as one of the primary behaviors associated with anxiety. The reason I want to draw your attention here is that CBT of anxiety disorders often begins with a focus on the behavioral avoidance through a process we call exposure and response prevention. In the CBT model, exposure is the opposite of avoidance. Now, with anxiety disorders, uh, research and clinical experiences taught us that it may be most effective to initially focus on the behaviors rather than on the thoughts. Now, exposure and response prevention involves uh, exposure to either external cues such as germs or closed spaces or height, or maybe more importantly, it's exposure to the internal sensations of anxiety. In panic disorder, the exposure may be to the heartbeat or your dizziness or the shortness of breath that is feared. Uh, the exposure might be to a thought or to a physical sensation uh, that led you to believe you're having a heart attack, a stroke, or that you're dying. And during the therapeutic exposure exercise, your

CBT therapists may ask you to concentrate on your anxiety rather than on diverting your attention, and this is designed to enhance the potentially powerful and therapeutic effects of the exposure. Now, the response prevention component of this treatment means that we try not to engage in avoidance behaviors that are really designed just to reduce your anxiety. This is because anything that's done to reduce anxiety in the midst of the exposure is going to take away from the potentially beneficial and therapeutic aspect of the exposure. So, behaviors that may be targeted for response prevention include handwashing to get rid of germs or leaving social situations to avoid being negatively judged by other people, even distracting your attention when traumatic memories occur, or leaving a situation when panic begins. So, if the goal of exposure is to increase your anxiety, to expose you to anxiety, the goal of the response prevention is to not engage in any behavior that's going to reduce the anxiety. Now, this can be difficult and frightening and really requires a

solid and trusting therapeutic relationship, as well as courage and resolve on the client's part. Now, what we do with exposure is that we introduce a concept called subjective units of distress or SUDs. And what we like to do is develop a list of avoided situations, maybe 10 or 15 or 20 situations. We rate the intensity of the units of distress or the anxiety, and then we arrange those situations in a hierarchy according to the level of distress. The treatment or the homework begins at the bottom or the middle of the hierarchy, and the goal is to remain in the exposure situation until your anxiety decreases by about 50%. We want to stay in the anxiety-eliciting situation, and we want to remember the framework that this is really what the exposure and response prevention is. It's ultimately what can help you to get better. People become desensitized to the anxiety, is the hope. So, a typical fear ladder may look like this. This was from the patient I was describing.

earlier she had, uh, the most frightful thing for her was flying across country, uh, but she also had going to the shopping mall, the grocery store, bidden in the middle seat of a movie theater where she felt trapped, being in an elevator where she felt trapped, uh, being a long way from home or a long way from a hospital or driving by herself. Um, now exposure, uh, and response prevention, uh, simply U move up the fear ladder, and uh, many therapists will combine the exposure and response prevention with anxiety reduction strategy such as deep breathing or progressive muscle relaxation, uh, meditation, a non-judgmental observation of the thoughts and reactions that you're having, and from a practical perspective, learning and employing these anxiety management strategies enables people to more confidently engage in the exposure and response prevention. So if um exposure and exposure is really the opposite of anxiety reduction, they both can be beneficial, uh, ultimately it's the exposure to the uncomfortable situations or the uncomfortable Sensations that really, uh, probably has the greatest um

effect. So, uh, if we think back to the four-part CBT model that I described earlier, we remember that the exposure and response prevention, which are the behaviors, are going to be connected to important thoughts. So, when we engage in exposure and response prevention, we're really engaging in a behavioral experiment, testing out the thought I'm going to die or I can't tolerate this, I'm going to faint, I'm having a heart attack. And if at the end of the exposure and the response prevention, these dramatic effects didn't occur, uh, there should be a cognitive or thinking shift to account for the new and therapeutic experience that you just had. In other words, you may have just had an experience or a series of experiences that was inconsistent with your initial catastrophic belief, and the hope is that your belief will begin to loosen or change to account for the new experience. So, the exposure overcomes the avoidance behavior and hopefully provides evidence that supports or doesn't support the thought, uh, associated with the anxiety. So, in typically in panic, you

can see right here that the Panic sequence will be may start with a rapid heartbeat or feeling faint. The thought might be I'm having a heart attack, I'm having a stroke. We begin to get the anxiety. It may escalate the panic, and then there's this behavioral avoidance, leaving the situation, perhaps winding up in a hospital emergency room. The exposure is going to be to the rapid heart, speak to the feeling faint, and to the thought that something terrible is occurring. So, my challenge today was to try to summarize the last 50 years of the development of CBT in 30 or 35 minutes, and I know I presented a lot of information. Thankfully, the slides in the webinar are going to be available if you care to listen again on the ADAA website. Also, I encourage you to do further research on CBT or on the treatment of anxiety and depressive disorders. The ADAA website contains a list of mental health professionals that specialize in CBT treatment, and it's likely that you can find someone in your

community that offers CBT treatment. Anxiety and depressive disorders are really the most treatable disorders. You can go to a psychotherapist for the outcome data. Consistently shows that the majority of people that complete a course of CBT get better, and the outcome data shows that those clients that have CBT as part of their treatment package have lower relapse rates and tend to get better and stay better. It's a practical and powerful and proven intervention that allows many people to make permanent and positive changes in their lives. So again, I'd like to thank ADAA for inviting me to provide this webinar, and I think we have time for some questions. Great, well thank you Dr. Greenberger for a wonderful presentation. And everyone, if you have a question, feel free to go ahead and type it in, and we'll see how many we can get to. So here's our first question. My son has major depressive disorder and severe anxiety and has been in CBT for over a

year but with little improvement. What should we do? Well, that's a good question. The first thing that I would do is to talk to the therapist and to find out what the treatment plan is and to find out if there is no progress from the therapist's perspective and from your son's perspective what the therapist's idea is about why there's an impact. There should be a conceptualization on the part of the therapist and an understanding of why things don't seem to be progressing. So, I think it's a totally legitimate question to ask the therapist. Depending on the age of your son and the laws in your state, you may be able to talk to the therapist directly, but I think it's a totally legitimate question to ask the therapist why there's no progress that's being made. You can certainly say that it's your understanding that CPT is generally short-term, although there are factors that do extend treatment. I should say that that

Although most people can get better in a, uh, a 20-session or less model, there are factors that do extend treatment. And so, if people have, uh, chronic maladaptive personality, uh, problems, if they have ongoing interpersonal problems, if they have co-occurring mental disorders, uh, if there's substance abuse that's involved, any, if there's a history of, um, trauma, uh, any of those factors, uh, potentially can extend, uh, the course of treatment. But I, I do think it's a legitimate question, and, and if there's no progress that's being made, I would, uh, certainly make inquiries about why that is. Great, great answer. Uh, okay, here's our next question. Uh, do you recommend flooding in exposure therapy, staying in a situation no matter how extreme or uncomfortable anxiety or panic becomes? Well, um, FL, the research evidence shows the flooding works. Um, one of the hallmark characteristics of cognitive behavior therapy is that it's collaborative, meaning that it's the therapist and, and the client who

together decide on the best course of treatment. So, um, my tendency, and I think many therapists' tendency, is to really leave that up to the client. Now, it's an uncomfortable decision to make, but it may be one that the client does decide to make because they want things to move along more rapidly. My view is that the client always has control over how rapidly the therapy proceeds, how rapidly the exposure proceeds. So, I do see some people who want to go through it as rapidly as possible, and other people, because of their hesitations and because of their life experiences, are not going to step fully on the accelerator. So, whether it's done in a systematic and gradual way or whether it's done in this more rapid fashion, um, either one will work, and it really becomes, in my mind, up to the client how rapidly they want to move along, right? Okay, here's another really good question. What are your feelings or thoughts on taking daily medication for anxiety? Well, that is a that's a very good question.

um and uh in general with let me address with depression first. What a lot of the research says is that the most efficient and effective treatment may be a combination of um anti-depressant medications and cognitive behavioral psychotherapy. And then at some point, the hope is that uh the client uh comes off of the anti-depressant medications. And what the research shows is those people who have gotten uh the cognitive behavioral therapy as part of the treatment package have a much lower relapse rate. Now with anxiety, what's interesting if you think what we're trying to do with CBT is that we're trying to have exposure-based experiences, which means that we're trying to have people be anxious, we're trying to trigger the anxiety. One of the counterproductive U mechanisms of the anti-anxiety medications is that it may actually interfere with the exposure. So um, you've got to, it's a, it's a fine line to walk between having the medication available and being able to do the exposure exercises. So one of the

things that I do in collaboration with whoever is prescribing the medication and the patient is when we're going to be doing the exposure exercises. We may delay taking the medication. We may decide along with the psychiatrist or the family doctor to take less of the medication. And for some people as they proceed along in the therapy, what we do say for example they're taking a Xanax or a Valium and they're just walking outside because that's part of the exposure exercise. They may carry the Xanax in their pocket to have it available just in case. And then some of the exposure may be to walk outside with the Xanax in the house. It's a little further away so we can gradually do the exposure with less of the safety mechanism of the anti-anxiety medication as part of the picture. So it requires a little bit more thoughtfulness with the anti-anxiety medications and perhaps with the anti-depressant medications. But I think

in combination with the CBT. We look at the anti-anxiety medication and how it plays into the larger picture. But certainly, a lot of people that I see are taking anti-anxiety medications, and we try to kind of wean from that as the therapy proceeds and as they're developing these cognitive and behavioral skills. Excellent. Okay, here's another. We're going to try to get to a couple more questions for everybody that has sent in a question that we won't have time for. We will make an effort to email you some resources, so hang in there. Here's a question. My daughter has PTSD and cognitive challenges. What type of therapist should I look for? Well, I'm not sure what kind of cognitive challenges we're talking about, but there are some very good cognitive therapies for PTSD and exposure cognitive and behavioral therapies for PTSD. So, the framework that I laid out earlier about what CBT does is definitely applicable to PTSD, and there's a lot of research.

that's taking place in the VA these days for people that are coming back from the Middle East with PTSD. There's been a whole lot of research on people that have suffered trauma, such as rape or being the victims of violent crimes of some sort. One of the treatments is called cognitive processing therapy, where the trauma is written out in excruciating detail. So remember, this is the exposure piece of cognitive behavioral therapy. We're exposing to memories. There tends to be an avoidance and an anxious avoidance of memories of the traumatic event, and so the CBT therapist is likely to try to expose to memories of the actual trauma again. This has to be done very delicately and very slowly and very collaboratively, but it's a matter of writing out in excruciating detail what the trauma was. So the sights, the sounds, the smells. You can go through the five senses of this, and this can be an ongoing process now.

the behavioral piece of it is to expose to external reminders of the traumatic event. So, now the piece that I'm not sure about because I don't know the details about is the cognitive challenges, but the whatever therapist that you have can take the cognitive challenges into account as they're doing the treatment planning and the deciding on the speed of the treatment as well. But the basic treatment should not change for the PTSD component of the disorder. Okay, great. Um, here's a great question. Uh, this is from a gentleman who is in his early 50s who had a very traumatic experience over 10 years ago, was attacked and stabbed for being gay. Um, and but here's his question. Uh, he says in the past years, uh, I've had uh, five jobs, currently unemployed, living off savings. I'm trying to get a job, but when I go for a job interview, how do I explain my job hopping without having to tell about my anxiety and depression? I tried telling the truth, but I feel that

I was not hired because of my anxiety and depression issues. Uh, well, that is a good question. What I've done with clients before is to really practice responses to those kinds of job interview questions. And so, we'll take a considerable amount of time to really write out a response. So, if you know that the question is likely to come about why there's been job hopping, um, you're going to really want to be able to come up with an answer that's truthful, um, but that you don't think is going to be ultimately harmful for you. And so, you might want to work on this with a friend or a family member or somebody that you trust so you can really practice the response um, that you're going to be giving in the interview. It's a likely question, and you want to feel comfortable with it when the um, uh, when the question comes. Yeah, uh, okay, that's all we have time for. For people that have emailed in questions that we didn't have time for, uh, please stay

connected, and we will make an effort to email you some resources. So again, thanks everybody for attending the webinar. We hope it was helpful and informative, and you should be getting an email to let you know when a recording of the webinar will be available on the Ada website. And please let friends and family know about our webinar series. Our next webinar is planned for January 9th at 7 pm eastern time, so I'm really looking forward to it. And finally, consider making a contribution to adaa so we can continue these kinds of programs and the many other activities of adaa. So bye for now, have a great holiday season, and we look forward to seeing you in the new year.

What Is Cognitive-Behavioral Therapy and How Is It Used to Treat Anxiety and Depression?

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