COGNITIVE-

BEHAVIORAL
PSYCHOTHERAPY
#4 – Cognitive techniques
The cognitive model - revision
◦ Cognition (thoughts, the meaning we give to events) mediates the relationship between
experienced events and emotional/behavioral relations, e.g., panic attacks are catastrophic
cognitive interpretations of normal physiological phenomena.
◦ Automatic thoughts – a near-constant stream of thoughts that is not usually in our awareness
and that we usually accept without reflection and uncritically.

“Although automatic thoughts seem to pop up spontaneously, they become fairly predicable once
the patient’s underlying beliefs are identified.”
“Dysfunctional thoughts are almost always negative.”
“Automatic thoughts are usually quite brief, and patients are often more aware of the emotion they
feel as the result of their thoughts than of the thoughts themselves.”
Identifying automatic thoughts
Situation/stimulus Example Automatic thought
An external event A friend ignores you. “He must hate me.”
Stream of thoughts Thinking about a past social “I am an idiot.”
situation
Memory or flashback PTSD memory “I’ll never get over it.”
Emotion Anxiety “I’m such a coward. What is
wrong with me?”
Behavior Not wanting to make a phone “I’m so stupid. Everyone would
call. have done it already.”
Physiological sensation. Increased heartbeat “Something’s wrong.”
Cognitive interventions in CBT
◦ Cognitive interventions refer to all techniques used in collaboration between therapist and client
that address the client’s thinking.
◦ Psychoeducation
◦ Identifying automatic thoughts.
◦ Cognitive restructuring – evaluating automatic thoughts (true/false) and modifying them - making them
more flexible.
◦ Cognitive defusion – making the thoughts less distressing.
Psychoeducation
◦ Giving the client scientific information about their own disorder and about the principles of
CBT.
◦ The information should be tailored to the client – accessible.
◦ The information should be built around the client’s own experience – from the general to the specific.

◦ Psychoeducation makes the client feel safe: they know what is going on and why.
◦ Psychoeducation makes the client feel better: they know they are not “crazy.”
◦ Psychoeducation makes the client feel stronger: they get more control.
◦ Psychoeducation builds the relationship between therapist and client as partners.
Identifying automatic thoughts
◦ Identifying automatic thoughts is a skill that requires practice. It is a necessary skill, because we
cannot fully control the situations that happen to us and we cannot fully control our emotions,
but we have a great degree of control over the ways we relate to ourselves, our lives, other
people, the world, etc.
◦ Beck (2011):
◦ What was running through your mind in that situation?
◦ What would you guess had been running through your mind in that situation?
◦ If [a family member or friend] were in that situation, what might run through his or her mind?
◦ Did you experience a mental image of a future catastrophe? or a bad memory from the past?
◦ Might you have been thinking _________________ [supply a thought that seems appropriate for the
situation and the client’s emotional distress] or _________________ [supply a thought that seems to be
the opposite of that which would be expected for the situation and the client’s emotional distress]?
◦ What did that situation mean to you? or mean about you?
Identifying automatic thoughts
◦ When the client has trouble identifying their automatic thoughts, in general, a good idea is to try
to get the client emotionally engaged in the situation in question:
◦ Focus on the emotional and physiological reaction.
◦ Ask about the situation, ask the client to visualize it again.
◦ Role-play the situation with the client.
◦ Give a suggestion of the opposite thought, e.g., “Were you thinking that’s perfect?”
Evaluating automatic thoughts
◦ Once clients have recognized the thoughts and beliefs that have the potential to exacerbate
emotional distress, they can begin to consider the accuracy and helpfulness of their thinking, as
well as the degree to which they are attaching excessive significance to their thinking.
◦ Having elicited an automatic thought, determined that it is important and distressing, and
identified its accompanying reactions (emotional, physiological, and behavioral), you may
collaboratively decide with the patient to evaluate it. You would rarely directly challenge the
automatic thought, however, for three reasons.
◦ 1. You usually do not know in advance the degree to which any given automatic thought is
distorted.
◦ 2. A direct challenge can lead patients to feel invalidated.
◦ 3. Challenging a cognition violates a fundamental principal of cognitive behavior therapy, that of
collaborative empiricism: You and the patient together examine the automatic thought, test its
validity and/or utility, and develop a more adaptive response.
Evaluating automatic thoughts
◦ Socratic dialogue is the chief cognitive intervention for evaluating automatic thoughts.
◦ It involves tentatively accepting the automatic thought and then asking the client questions that
examine whether the thought is (a) true and (b) useful to the client.

◦ What is the evidence for/against this question?

◦ What does the thought mean about you?
◦ How does the thought make you feel, and is that helpful or not?
◦ Uncovering cognitive distortions: how often does the expected negative outcome happen? Has it
happened? How have you usually coped with it when it happened? How else do you think you could
cope with it?
Evaluating automatic thoughts
Evaluating automatic thoughts
◦ Socratic dialogue can be challenging for the client. It is important to:
◦ Make the questions not sound like an interrogation: express curiosity, but do not demand explanations.
◦ Offer frequent summaries and reflections – make sure you understand the client right.
◦ Ask the client for summaries and their opinion – are they following along? How do they feel?
◦ Reinforce the client for working – praise and support!

◦ Do not give advice, do not preach. It is better if the client reaches conclusions on their own.
◦ Do not ignore positives, or moments when the client is telling the truth – sometimes things really are bad
and painful.
◦ Take your time.
Evaluating automatic thoughts
◦ What if the automatic thought is true?
◦ It is important for clinicians to recognize that not all automatic thoughts are negative and
inaccurate; in some instances, automatic thoughts represent a very real and difficult reality. In
these cases, it is contraindicated to ask guided questions to evaluate the accuracy of these
thoughts. Clinicians can, nevertheless, encourage clients to evaluate how helpful their thinking
is for their mood, for others, for problem solving, and for acceptance. Thus, clinicians might ask
Socratic questions like “What is the effect of focusing on this automatic thought?” or “What is
the effect of changing your thinking?” or “What are the advantages and disadvantages of
focusing on this thought?” Clients who consider the answers to these questions often realize
that rather than accepting stressful or disappointing life circumstances, their rumination is
exacerbating their emotional stress and keeping them stuck in a struggle against those
circumstances.
Evaluating automatic thoughts
◦ If the patient still believes the automatic thought to a significant degree and does not feel better
emotionally, you need to conceptualize why this initial attempt at cognitive restructuring has not
been sufficiently effective. Common reasons to consider include the following:
◦ 1. There are other, more central automatic thoughts and/ or images left unidentified or unevaluated.
◦ 2. The evaluation of the automatic thought is implausible, superficial, or inadequate.
◦ 3. The patient has not sufficiently expressed the evidence that he or she believes supports the automatic
thought.
◦ 4. The automatic thought itself is also a core belief.
◦ 5. The patient understands intellectually that the automatic thought is distorted, but does not believe it on
an emotional level.
Evaluating automatic thoughts
◦ The downward arrow technique: on the basis of an automatic thought, the client provides a
core belief.

“If this thought were true, what would it mean about you?”
“What does it say about you?”
“What does that mean?”
“What would be the worst thing about it?”
Modifying thoughts and beliefs
◦ If, after evaluating the accuracy and usefulness of their thinking, clients realize that it is
problematic, then one option is to move toward modifying it. Modified automatic thoughts are
often referred to as alternative responses, rational responses, adaptive responses, or balanced
responses.
◦ Clinicians encourage clients to craft balanced responses on the basis of the conclusions that
they drew from the guided evaluation. These balanced responses tend to be lengthier than the
original automatic thought. The reason for this is that automatic thoughts tend to be quick,
evaluative, and judgmental. Balanced responses take into account nuances, as most situations
that people face in life are multifaceted.
Modifying thoughts and beliefs
◦ Investigating a causal relationship: drawing a client’s rigid belief in the form of an X/Y graph
(e.g., hard-working/happy) and asking for examples of people fitting into various points on the
graph. This shows that reality is not as one-sided as the client may believe (e.g., there are
people who work hard and are unhappy, there are people who don’t work hard and are happy).

◦ Pie chart of responsibility: identifying factors which could have influenced an outcome in a
difficult/painful situation. Shows that everything is not the client’s fault, even though their actions
might have contributed a part.

◦ Analyzing costs and benefits of beliefs: allows the client to more rationally assess their
beliefs, motivates to further engagement in therapy. Especially useful in disorders which grant
some secondary benefits, e.g., social anxiety disorder, anorexia.
Modifying thoughts and beliefs
◦ Experiments: planning a behavioral experiment in order to test a thought, expectation, or
belief.
◦ Together with the client, the therapist plans a situation in which the client will be able to see
whether their feared outcome comes true. The goal is to collect data as if one were a scientist –
test a hypothesis.
◦ If I talk to a stranger, my mind will go completely blank and I won’t know what to say.
◦ If I stop worrying about my children, something bad will happen.
◦ If I don’t try to stop worrying about my children, I will go insane.
◦ Do other people usually notice when someone trips and falls outside?
◦ How many people are usually looking at you when you’re on the bus?
◦ How do other people usually initiate conversations?
Modifying thoughts and beliefs
◦ Imagery rescripting: especially useful with clients suffering from personality disorders. The
client identifies an especially painful, difficult, or significant memory. Together with the therapist,
the client creates a new scenario in their imagination (e.g., someone intervenes to stop the
trauma).
Cognitive defusion
◦ In some cases, it might be better not to engage with the automatic thoughts or try to prove them
wrong (e.g., intrusive thoughts in OCD).
◦ In these cases, a functional approach can be taken to make the thoughts less harmful and less
important.

◦ Cognitive defusion refers to the process of reducing the automatic emotional and behavioral
functions of thoughts by increasing awareness of the process of thinking over and above the
content or literal meaning of thought.
◦ Both defusion strategies and traditional cognitive restructuring rest on the assumption that thoughts
can serve as barriers to effective action and lead to potentially problematic emotional reactions.
However, more traditional cognitive perspectives (e.g., Beck, 1976) emphasize the importance of
changing cognitive content in order for emotional and behavioral change to occur (see chapter 21),
whereas defusion, decentering, or metacognitive awareness place greater emphasis on a person’s
relationship to his or her own thinking— that is, on the context in which thoughts are experienced.
Cognitive defusion
◦ The word repetition exercise: The therapist asks the client to condense a core distressing thought
to one or two words (e.g., a person who thinks she is a bad person might have that thought
condensed down to “I’m bad”). The therapist might ask the client to say that word or phrase out loud
once, and to notice the various feelings, thoughts, and sensations that show up. Then, the client
repeats the words out loud, fast, for about thirty seconds, and again the therapist asks the client to
notice what experiences and sensations show up. Typically, clients will have a significantly different
experience with the word or phrase by the end of this time period. The intensity of the affect
associated with it may diminish somewhat, and they may take the thought less seriously, or at least
see how odd or suspect the word is, and so on.

◦ “Having” thoughts. The “thought” language convention discussed above can be made more
explicit. When a client is fused with a distressing or counterproductive narrative, asking her to speak
the phrase “I’m having the thought that…” in advance of each thought in that narrative can often help
her defuse from those thoughts. This technique may likely facilitate defusion for at least two reasons.
First, it explicitly labels each thought as a “thought,” something not done when a person takes
language literally. Second, the somewhat laborious repetition of the phrase before every thought in
the narrative slows things down, reducing the relatively quick train of thoughts
Cognitive interventions for worry
◦ Intriguing empirical findings suggest that worry actually inhibits the physiological arousal of
unpleasant feelings, resulting in both the incubation of worrisome thoughts that rebound later
and the apparent short-term reinforcement of worry as a means of emotional suppression
(Wells & Papageorgiou, 1995; York, Borkovec, Vasey, & Stern, 1987). Worry is generally
experienced in abstract or linguistic form, further “neutralizing” emotional content and inhibiting
habituation, since the emotional or arousal component of “worry schemas” is not activated
during the process of worrying (Borkovec & Inz, 1990; Wells & Papageorgiou, 1995). Moreover,
worriers believe that worry protects against, prepares them for, and prevents negatives, on one
hand, while, on the other hand, also believing that worry will result in negative consequences,
such as illness or insanity, and that worrying must be controlled or eliminated (Wells, 2000a,
2002).
Cognitive interventions for worry
◦ Testing negative predictions in order to see how often worry comes true – helps examine the
function of worry, shows that having a thought does not necessarily make it true.
◦ Examining past worries – trying to see how many worries came true in the past. Helps
weaken the belief about the helpful role of worry.
◦ Reviewing coping strategies – if any worries have come true, ask clients how they coped with
these problems. Helps build a sense of agency and control.
◦ Imagining better outcomes – coming up with the worst, best, and most likely outcome to
facilitate greater flexibility in thinking.
◦ Experiment: Worry Time – limiting worry only to a certain period of time (e.g., an hour in the
evening) to show that (a) worry can be controlled and (b) it doesn’t actually help with anything
when you do it on purpose.
Cognitive interventions for intrusive thoughts
◦ These are thoughts or images that occur spontaneously, have some plausibility from the
perspective of the individual, and are experienced as unwanted. In OCD, the individual
experiences intrusive thoughts, such as fears of contamination or beliefs about making
mistakes; these thoughts are viewed as intolerable, as a signal that something bad will happen
and that the thought must be neutralized through actions such as washing or checking. People
with OCD often endorse a belief that a thought and an action (or a thought and “reality”) are
equivalent— that is, “If I have the thought that I might stab someone, then it will become a
reality unless I neutralize the thought or avoid the feared target.” This “thought– action fusion”
underpins a considerable range of OCD beliefs and behaviors, such as the belief that thoughts
are dangerous, need to be controlled, and cannot be tolerated.
Cognitive interventions for intrusive thoughts
◦ Mindful detachment – a form of cognitive defusion. Mindful detachment is a technique that
allows one to stand back, observing, while not engaging in any control, suppression, or
judgment about the validity or importance of a thought. This can involve noticing that a thought
occurs, imagining the thought as a cloud that passes, viewing the thought as a telemarketing
call to which one does not respond, or imagining the thought as a series of trains coming into
and departing the station, as one merely watches them pass. Mindful detachment is an
illustration that the most valuable approach to a thought is often to do nothing.
◦ Relinquishing control of thoughts – the belief that a thought will lead to some change in
reality (even when unrelated to one’s action) is an example of the fusion of thoughts with reality.
With this technique of relinquishing control, the patient is instructed to examine his or her beliefs
that thoughts are dangerous and need to be suppressed. Next, the individual is instructed to
allow the unwanted thoughts to simply occur. Finally, the individual is asked to repeat, “I want
this [event] to happen.” The question is, “Does letting go of control and repeating the feared
thought lead to a negative outcome?”