Psychology
COGNITIVE BEHAVIORAL THERAPY
July 07, 2012.Christine E. Reilly, PhD, RN,
Educational Objectives
The goal of this program is to improve treatment of psychiatric disorders through an understanding of cognitive behavioral therapy and its principles. After hearing and assimilating this program, the clinician will be better able to:
1. Describe the cognitive model and how it is applied in psychotherapy sessions.
2. Identify common cognitive errors.
3. Identify elements of a thought record and use it to identify, evaluate, and reframe automatic thoughts and cognitive errors.
4. Use the cognitive model to facilitate adherence to medication.
5. Implement cognitive therapy techniques in primary care and community settings.
Summary
Overview of cognitive behavioral therapy (CBT): fundamentals of CBT include identification of automatic thoughts, utilization of mood and thought logs, and cognitive reframing; many clinicians fail to do cognitive therapy basics; basic techniques for depression now used across many other areas; clinician should conceptualize patient’s words through cognitive model
Cognitive model: help patients identify their thoughts during upsetting situations and write them down; identify and evaluate data for those thoughts; develop alternative thoughts; postulate how alternative thoughts would change feelings associated with situations; by retrospectively putting patients back into situations with new automatic thoughts, they begin to feel better
Introduction to CBT: structured, skill-enhancing model requiring monitoring of moods, behaviors, and outcomes by patient; structured — patient and therapist work collaboratively toward common goal; patient’s monitoring of own moods, behaviors, and outcomes ensures goal-directed work; clinician should have patients keep therapy notebook to use in session and at home; clinician should be flexible and use modifications when necessary; patients should have some amount of insight and understand their diagnosis; self-monitoring — patients often believe they are always thinking about their diagnosis, but this is not true; patient should monitor own negative automatic thoughts using severity scales and logs; patient’s ability to realistically assess beliefs surrounding situation invaluable; thought monitoring helps patients see their own distorted beliefs; educative — clinician should share conceptualization of problem with patient; also share therapy notes to ensure patient correctly understood; goal oriented — vague goals mean vague therapy and vague outcomes; have clearly defined goals and review goals with patient every session to ensure patient has not shifted goals; collaborative — CBT not hierarchical; patients take lead
Clinician’s role: patients unload data in sessions; data complicated and intertwined; clinician must listen, itemize, and conceptualize patient’s information through cognitive model; clinician must help patient realize that thoughts, rather than situations, create negative feelings; clinician must help patient identify automatic thoughts that cause anxiety and change those thoughts; patient able to return to reality automatically, except when depressed and anxious; depression and anxiety prevent patients from reframing their ideas to create positive feelings
Identifying automatic thoughts: cognitive therapy provides template for patients to rethink ideas when agitated, angry, depressed, or sad; this ability present from childhood, but lost in presence of anxiety and/or depression; clinician should ask patient to identify what was in mind in particular scenario to illicit automatic thought; helpful to give patients multiple choice selection of automatic thoughts that cause negative feelings; often patients unable to identify thoughts and only identify their negative feelings
Reframing automatic thoughts: once patients identify negative automatic thoughts, they must reframe them by providing data for and against, then provide alternative thoughts for situation; clinician then places patient back in original situation with new, more functional thoughts to reassess feelings; patients realize they would have felt less upset had they used reframed thoughts rather than original negative automatic thought; using new thoughts changes patient’s affect and response
Evaluating automatic thoughts: playing out worst-case scenario indicated for anxiogenic thoughts; evaluating advantages, disadvantages, and impact of particular thoughts indicated for hopeless patients who are stuck but not suicidal; negative automatic thoughts about therapy — clinician should help patients evaluate attitudes toward treatment; clinician should encourage patient to shift negative attitudes and beliefs about efficacy of therapy in order to improve patient’s follow-through and therapeutic outcomes; clinician should assess patient’s attitude toward treatment and impact of that attitude; clinician should encourage very depressed patients to act as if therapy will help; another way to reframe automatic thoughts — have patient consider what he or she would tell friend or family member in same situation; clinician should record new insights and attitudes on index cards for patients to refer to later (coping cards)
Cognitive errors: David Burns offers list of 10 common thinking errors; useful in inpatient settings and for groups; useful for staff to reference these errors; catastrophizing — thinking worst-case scenario; emotional reasoning — patients evaluate truth based on severity of emotions; situation horrible because patient feels horrible; jumping to conclusions; overgeneralizing; all-or-nothing, black and white thinking; dichotomous thinking occurs when people under stress; clinician must slow patients down to reduce dichotomous thinking
Thought records: useful teaching model, but can overwhelm patients; clinician should consider using thought record in concept; consists of situation, automatic thought, accompanying emotions, alternative response, and reframing questions
Employing thought records: start with two columns and add; clinician should have patient record upsetting situations in therapy notebook for homework; next, patient must identify automatic thoughts that occurred during upsetting situation; patient should keep track of first thing that goes through his or her head in upsetting situation; clinician should structure sessions around upsetting situations listed in notebook; identify problematic themes with patient
Clinician’s automatic thoughts and cognitive distortions: to improve ability to help patients, clinicians should practice skills themselves, ie, keep mood log, journal, and record of automatic thoughts and cognitive distortions; difficult to ask patients to do something that clinician has not done; clinician might feel nervous and frustrated with process; clinicians’ automatic thought that they don’t know what they are doing, and using cognitive model just means more work; these negative thoughts reduce likelihood that clinician will use cognitive model with patients; cognitive model helps with patient satisfaction in primary care settings once physicians overcome negative automatic thoughts about using cognitive model
Collaborative approach: recognize patient’s strengths; maintain same goals; encourage patient to share; clinician should recognize he or she cannot fix everything, due to inherent complexity of life; therapeutic to acknowledge to patient impossibility of addressing all issues in one day; patients want to be heard and understood; clinician should be mindful that patients know what clinician wants to hear and may not communicate how they actually feel; clinician should give patient permission to share true feelings; do not ask dichotomous questions; rather, ask questions that allow patient to disclose difficulties and noncompliance; clinician should take care not to validate non-goal-oriented behaviors while remaining collaborative; best to directly address difficulties and obstacles
Sessions: structured patient interaction; set agenda for session; start with mood check, review goal, plan remainder of session, problem solve, and assign homework; setting agendas helps maintain focus; homework — not afterthought at end of session; consider how content of session helpful to and useful in patient’s life; homework assignments could present in beginning of session; summarize — summarize throughout session, especially when clinician unfocused, distracted, or confused; good way to regroup and ensure patient understands skills being taught
CBT Techniques
Activity schedules: functional analysis of patient’s daily behaviors and moods; 24-hr retrospective activity monitoring; clinician should have patient record activities hour-by-hour, 3 or 4 times per day as homework;
Depression: patient should keep mastery and pleasure rating scale to track enjoyment and accomplishment level; difficult to treat depression without activity monitoring; offers information on which daily activities reduce depression
Activity scheduling: depression marked by lack of motivation, which contributes to isolation and ultimately more depression; helps depressed patients understand relationship between action and motivation; action comes before motivation; patient should plan next day’s activities; use patient’s family and support network to help with activity scheduling; more isolated patients should text clinician completed activity schedule for following day
Other techniques: positive self-statement and credit logs; identifying and modifying automatic thoughts; problem solving; skills training; exposure hierarchies; graded task assignments (reducing large tasks into smaller ones); identifying and responding to images; cognitive rehearsal (patient imagines more assertive responses); role playing; coping cards; exploring advantages and disadvantages of choices (clinician and patient evaluate pros and cons of making and not making particular choices); relaxation; mindfulness training; time management; physical exercise helps depression and anxiety; reviewing therapy tapes and notebooks to anchor new skills
Adherence to medication: educate patient on psychotropic medications; address patient’s beliefs and challenge automatic thoughts that taking medication means weakness or will lead to dependence; set up behavioral experiments to track medication’s effectiveness; assess patient’s belief that medication will help; elicit patient’s and family’s concerns about taking medications
Practical problems: assess whether patient can afford medications; consider whether patient will remember to take medications; assess patient’s organization level; consider whether patient has backup medications
Cognitive problems: address patient’s perceived advantages and disadvantages of medication use; embellish and elaborate on advantages, summarize and condense disadvantages; draw conclusions and address automatic thoughts
Behavior change: insight does not mean behavioral change; address assertiveness levels to foster change
Homework: must facilitate behavioral change once session over; clinician should structure what patient will do differently; anticipate automatic thoughts and worst-case scenario of behavioral change; identify and challenge cognitive obstacles to behavioral change
Worry time: address rumination by writing out worries; thinking processed in temporal lobe, writing processed in occipital lobe; writing causes cognitive shift; have rumination time at same time daily, no more than 10 min; patient should dismiss ruminations and intrusive thoughts until designated times
12-step programs: offer wisdom and support that can motivate and integrate patient through social connection, thereby facilitating change
When is it CBT? cognitive interaction with patient successfully done in primary care and community centers; set agenda — after data dump, quickly itemize and summarize topics presented; ask patient which topic most important to talk about during current session; mood check; identification of automatic thoughts — use skills cards with automatic thought on one side, questions for reframing thought on other side, eg, what is worst-case scenario? what is data? what is alternative? homework — write to-do list on wellness pad to encourage compliance
Acknowledgements
Dr. Reilly was recorded at Fourth Annual Mental and Behavioral Health Symposium, presented by Baptist Health South Florida Continuing Medical Education, held March 3, 2012, in Miami, FL, and sponsored by Baptist Health South Florida. The Audio-Digest Foundation thanks Dr. Reilly and Baptist Health South Florida Continuing Medical Education for their cooperation in the production of this program. For information on the Fifth Annual Mental and Behavioral Health Symposium, visit, http://cme.baptisthealth.net/MHS/Pages/index.aspx
Suggested Reading
Beck AT et al: Cognitive therapy: current status and future directions. Annu Rev Med 62:397-409, 2011; Beck AT: The evolution of the cognitive model of depression and its neurobiological correlates. Am J Psychiatry 165:8, 2008; Boden MT et al: The role of maladaptive beliefs in cognitive-behavioral therapy: Evidence from social anxiety disorder. Behav Res Ther 50:5, 2012; Burns DD (1989). The Feeling Good Handbook. New York: William Morrow and Co; Chu BC et al: Disorder-specific effects of CBT for anxious and depressed youth: a meta-analysis of candidate mediators of change. Clin Child Fam Psychol Rev 10:4, 2007; Clark DA et al: Cognitive theory and therapy of anxiety and depression: convergence with neurobiological findings. Trends Cogn Sci 14:9, 2010; Cuijpers P et al: Efficacy of cognitive-behavioural therapy and other psychological treatments for adult depression: meta-analytic study of publication bias. Br J Psychiatry 196:3, 2010; Ekers D et al: A meta-analysis of randomized trials of behavioural treatment of depression. Psychol Med 38:5, 2008; Gibbons CJ et al: The clinical effectiveness of cognitive therapy for depression in an outpatient clinic. J Affect Disord 125:1-3, 2010; Goldberg JF et al: Dysfunctional attitudes and cognitive schemas in bipolar manic and unipolar depressed outpatients: implications for cognitively based psychotherapeutics. J Nerv Ment Dis 196:3, 2008; Gould RL et al: Efficacy of cognitive behavioral therapy for anxiety disorders in older people: a meta-analysis and meta-regression of randomized controlled trials. J Am Geriatr Soc 60:2, 2012; Hofmann SG el al: Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry 69:4, 2008; Jansen M et al: Effectiveness of a cognitive-behavioral therapy (CBT) manualized program for clinically anxious children: study protocol of a randomized controlled trial. BMC Psychiatry 12:16, 2012; Jones C et al: Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia. Cochrane Database Syst Rev 18:4, 2012; Otte C: Cognitive behavioral therapy in anxiety disorders: current state of the evidence. Dialogues Clin Neurosci 13:4, 2011; Ridgway N et al: Cognitive behavioural therapy self-help for depression: an overview. J Ment Health 20:6, 2011; Spielmans GI et al: What are the active ingredients in cognitive and behavioral psychotherapy for anxious and depressed children? A meta-analytic review. Clin Psychol Rev 27:5, 2007; Stirman SW et al: Clinicians' perspectives on cognitive therapy in community mental health settings: implications for training and implementation. Adm Policy Ment Health March 18, 2012; Sudak DM: Cognitive behavioral therapy for depression. Psychiatr Clin North Am 35:1, 2012
Readings
Beck AT et al: Cognitive therapy: current status and future directions. Annu Rev Med 62:397-409, 2011; Beck AT: The evolution of the cognitive model of depression and its neurobiological correlates. Am J Psychiatry 165:8, 2008; Boden MT et al: The role of maladaptive beliefs in cognitive-behavioral therapy: Evidence from social anxiety disorder. Behav Res Ther 50:5, 2012; Burns DD (1989). The Feeling Good Handbook. New York: William Morrow and Co; Chu BC et al: Disorder-specific effects of CBT for anxious and depressed youth: a meta-analysis of candidate mediators of change. Clin Child Fam Psychol Rev 10:4, 2007; Clark DA et al: Cognitive theory and therapy of anxiety and depression: convergence with neurobiological findings. Trends Cogn Sci 14:9, 2010; Cuijpers P et al: Efficacy of cognitive-behavioural therapy and other psychological treatments for adult depression: meta-analytic study of publication bias. Br J Psychiatry 196:3, 2010; Ekers D et al: A meta-analysis of randomized trials of behavioural treatment of depression. Psychol Med 38:5, 2008; Gibbons CJ et al: The clinical effectiveness of cognitive therapy for depression in an outpatient clinic. J Affect Disord 125:1-3, 2010; Goldberg JF et al: Dysfunctional attitudes and cognitive schemas in bipolar manic and unipolar depressed outpatients: implications for cognitively based psychotherapeutics. J Nerv Ment Dis 196:3, 2008; Gould RL et al: Efficacy of cognitive behavioral therapy for anxiety disorders in older people: a meta-analysis and meta-regression of randomized controlled trials. J Am Geriatr Soc 60:2, 2012; Hofmann SG el al: Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry 69:4, 2008; Jansen M et al: Effectiveness of a cognitive-behavioral therapy (CBT) manualized program for clinically anxious children: study protocol of a randomized controlled trial. BMC Psychiatry 12:16, 2012; Jones C et al: Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia. Cochrane Database Syst Rev 18:4, 2012; Otte C: Cognitive behavioral therapy in anxiety disorders: current state of the evidence. Dialogues Clin Neurosci 13:4, 2011; Ridgway N et al: Cognitive behavioural therapy self-help for depression: an overview. J Ment Health 20:6, 2011; Spielmans GI et al: What are the active ingredients in cognitive and behavioral psychotherapy for anxious and depressed children? A meta-analytic review. Clin Psychol Rev 27:5, 2007; Stirman SW et al: Clinicians' perspectives on cognitive therapy in community mental health settings: implications for training and implementation. Adm Policy Ment Health March 18, 2012; Sudak DM: Cognitive behavioral therapy for depression. Psychiatr Clin North Am 35:1, 2012
Disclosures
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Reilly and the planning committee reported nothing to disclose.
Overview of cognitive behavioral therapy (CBT): fundamentals of CBT include identification of automatic thoughts, utilization of mood and thought logs, and cognitive reframing; many clinicians fail to do cognitive therapy basics; basic techniques for depression now used across many other areas; clinician should conceptualize patient’s words through cognitive model
Cognitive model: help patients identify their thoughts during upsetting situations and write them down; identify and evaluate data for those thoughts; develop alternative thoughts; postulate how alternative thoughts would change feelings associated with situations; by retrospectively putting patients back into situations with new automatic thoughts, they begin to feel better
Introduction to CBT: structured, skill-enhancing model requiring monitoring of moods, behaviors, and outcomes by patient; structured — patient and therapist work collaboratively toward common goal; patient’s monitoring of own moods, behaviors, and outcomes ensures goal-directed work; clinician should have patients keep therapy notebook to use in session and at home; clinician should be flexible and use modifications when necessary; patients should have some amount of insight and understand their diagnosis; self-monitoring — patients often believe they are always thinking about their diagnosis, but this is not true; patient should monitor own negative automatic thoughts using severity scales and logs; patient’s ability to realistically assess beliefs surrounding situation invaluable; thought monitoring helps patients see their own distorted beliefs; educative — clinician should share conceptualization of problem with patient; also share therapy notes to ensure patient correctly understood; goal oriented — vague goals mean vague therapy and vague outcomes; have clearly defined goals and review goals with patient every session to ensure patient has not shifted goals; collaborative — CBT not hierarchical; patients take lead
Clinician’s role: patients unload data in sessions; data complicated and intertwined; clinician must listen, itemize, and conceptualize patient’s information through cognitive model; clinician must help patient realize that thoughts, rather than situations, create negative feelings; clinician must help patient identify automatic thoughts that cause anxiety and change those thoughts; patient able to return to reality automatically, except when depressed and anxious; depression and anxiety prevent patients from reframing their ideas to create positive feelings
Identifying automatic thoughts: cognitive therapy provides template for patients to rethink ideas when agitated, angry, depressed, or sad; this ability present from childhood, but lost in presence of anxiety and/or depression; clinician should ask patient to identify what was in mind in particular scenario to illicit automatic thought; helpful to give patients multiple choice selection of automatic thoughts that cause negative feelings; often patients unable to identify thoughts and only identify their negative feelings
Reframing automatic thoughts: once patients identify negative automatic thoughts, they must reframe them by providing data for and against, then provide alternative thoughts for situation; clinician then places patient back in original situation with new, more functional thoughts to reassess feelings; patients realize they would have felt less upset had they used reframed thoughts rather than original negative automatic thought; using new thoughts changes patient’s affect and response
Evaluating automatic thoughts: playing out worst-case scenario indicated for anxiogenic thoughts; evaluating advantages, disadvantages, and impact of particular thoughts indicated for hopeless patients who are stuck but not suicidal; negative automatic thoughts about therapy — clinician should help patients evaluate attitudes toward treatment; clinician should encourage patient to shift negative attitudes and beliefs about efficacy of therapy in order to improve patient’s follow-through and therapeutic outcomes; clinician should assess patient’s attitude toward treatment and impact of that attitude; clinician should encourage very depressed patients to act as if therapy will help; another way to reframe automatic thoughts — have patient consider what he or she would tell friend or family member in same situation; clinician should record new insights and attitudes on index cards for patients to refer to later (coping cards)
Cognitive errors: David Burns offers list of 10 common thinking errors; useful in inpatient settings and for groups; useful for staff to reference these errors; catastrophizing — thinking worst-case scenario; emotional reasoning — patients evaluate truth based on severity of emotions; situation horrible because patient feels horrible; jumping to conclusions; overgeneralizing; all-or-nothing, black and white thinking; dichotomous thinking occurs when people under stress; clinician must slow patients down to reduce dichotomous thinking
Thought records: useful teaching model, but can overwhelm patients; clinician should consider using thought record in concept; consists of situation, automatic thought, accompanying emotions, alternative response, and reframing questions
Employing thought records: start with two columns and add; clinician should have patient record upsetting situations in therapy notebook for homework; next, patient must identify automatic thoughts that occurred during upsetting situation; patient should keep track of first thing that goes through his or her head in upsetting situation; clinician should structure sessions around upsetting situations listed in notebook; identify problematic themes with patient
Clinician’s automatic thoughts and cognitive distortions: to improve ability to help patients, clinicians should practice skills themselves, ie, keep mood log, journal, and record of automatic thoughts and cognitive distortions; difficult to ask patients to do something that clinician has not done; clinician might feel nervous and frustrated with process; clinicians’ automatic thought that they don’t know what they are doing, and using cognitive model just means more work; these negative thoughts reduce likelihood that clinician will use cognitive model with patients; cognitive model helps with patient satisfaction in primary care settings once physicians overcome negative automatic thoughts about using cognitive model
Collaborative approach: recognize patient’s strengths; maintain same goals; encourage patient to share; clinician should recognize he or she cannot fix everything, due to inherent complexity of life; therapeutic to acknowledge to patient impossibility of addressing all issues in one day; patients want to be heard and understood; clinician should be mindful that patients know what clinician wants to hear and may not communicate how they actually feel; clinician should give patient permission to share true feelings; do not ask dichotomous questions; rather, ask questions that allow patient to disclose difficulties and noncompliance; clinician should take care not to validate non-goal-oriented behaviors while remaining collaborative; best to directly address difficulties and obstacles
Sessions: structured patient interaction; set agenda for session; start with mood check, review goal, plan remainder of session, problem solve, and assign homework; setting agendas helps maintain focus; homework — not afterthought at end of session; consider how content of session helpful to and useful in patient’s life; homework assignments could present in beginning of session; summarize — summarize throughout session, especially when clinician unfocused, distracted, or confused; good way to regroup and ensure patient understands skills being taught
CBT Techniques
Activity schedules: functional analysis of patient’s daily behaviors and moods; 24-hr retrospective activity monitoring; clinician should have patient record activities hour-by-hour, 3 or 4 times per day as homework;
Depression: patient should keep mastery and pleasure rating scale to track enjoyment and accomplishment level; difficult to treat depression without activity monitoring; offers information on which daily activities reduce depression
Activity scheduling: depression marked by lack of motivation, which contributes to isolation and ultimately more depression; helps depressed patients understand relationship between action and motivation; action comes before motivation; patient should plan next day’s activities; use patient’s family and support network to help with activity scheduling; more isolated patients should text clinician completed activity schedule for following day
Other techniques: positive self-statement and credit logs; identifying and modifying automatic thoughts; problem solving; skills training; exposure hierarchies; graded task assignments (reducing large tasks into smaller ones); identifying and responding to images; cognitive rehearsal (patient imagines more assertive responses); role playing; coping cards; exploring advantages and disadvantages of choices (clinician and patient evaluate pros and cons of making and not making particular choices); relaxation; mindfulness training; time management; physical exercise helps depression and anxiety; reviewing therapy tapes and notebooks to anchor new skills
Adherence to medication: educate patient on psychotropic medications; address patient’s beliefs and challenge automatic thoughts that taking medication means weakness or will lead to dependence; set up behavioral experiments to track medication’s effectiveness; assess patient’s belief that medication will help; elicit patient’s and family’s concerns about taking medications
Practical problems: assess whether patient can afford medications; consider whether patient will remember to take medications; assess patient’s organization level; consider whether patient has backup medications
Cognitive problems: address patient’s perceived advantages and disadvantages of medication use; embellish and elaborate on advantages, summarize and condense disadvantages; draw conclusions and address automatic thoughts
Behavior change: insight does not mean behavioral change; address assertiveness levels to foster change
Homework: must facilitate behavioral change once session over; clinician should structure what patient will do differently; anticipate automatic thoughts and worst-case scenario of behavioral change; identify and challenge cognitive obstacles to behavioral change
Worry time: address rumination by writing out worries; thinking processed in temporal lobe, writing processed in occipital lobe; writing causes cognitive shift; have rumination time at same time daily, no more than 10 min; patient should dismiss ruminations and intrusive thoughts until designated times
12-step programs: offer wisdom and support that can motivate and integrate patient through social connection, thereby facilitating change
When is it CBT? cognitive interaction with patient successfully done in primary care and community centers; set agenda — after data dump, quickly itemize and summarize topics presented; ask patient which topic most important to talk about during current session; mood check; identification of automatic thoughts — use skills cards with automatic thought on one side, questions for reframing thought on other side, eg, what is worst-case scenario? what is data? what is alternative? homework — write to-do list on wellness pad to encourage compliance
Acknowledgements
Dr. Reilly was recorded at Fourth Annual Mental and Behavioral Health Symposium, presented by Baptist Health South Florida Continuing Medical Education, held March 3, 2012, in Miami, FL, and sponsored by Baptist Health South Florida. The Audio-Digest Foundation thanks Dr. Reilly and Baptist Health South Florida Continuing Medical Education for their cooperation in the production of this program. For information on the Fifth Annual Mental and Behavioral Health Symposium, visit, http://cme.baptisthealth.net/MHS/Pages/index.aspx
CME/CE INFO
Accreditation:
Lecture ID:
PG011301
Qualifies for:
Expiration:
This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.
Instructions:
To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.
Estimated time to complete this CME/CE course:
Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.
More Details - Certification & Accreditation