COGNITIVE BEHAVIOUR THERAPY

WHAT IS COGNITIVE BEHAVIORAL THERAPY?

• Cognitive Behavioral Therapy can be defined as the intentional combination of

demonstrated readiness and methodological rigor of behavioral procedures with
the cognitive-behavioral processes that influence adjustment. In other words, CBT
is utilizing the accurate understanding of our thoughts to purposefully change
reactions and behaviors.
• Our internal thoughts are viewed as mechanisms for change. This type of therapy
is a short-term, goal oriented form of treatment that can be thought of as a
combination of behavioral therapy and psychotherapy.
• The treatment takes a hands-on, practical approach to problem-solving.
• Psychotherapy focuses on the personal meaning of thought patterns that are
believed to have developed in childhood.
• Behavioral therapy emphasizes the close relationship between personal problems,
behavior, and thoughts.

• CBT is a way of focusing on the cognitive processes that produce feelings. The
approach helps by changing people’s behavior and attitudes with a deeper
understanding of thoughts, images, beliefs, and attitudes.

• The treatment is customized for each patient with regard to differences in

personalities and specific needs. CBT can be viewed as an umbrella term for many
different forms of therapies aimed at correcting dysfunctional cognition and
maladaptive behaviors.

Attitudes grooved in neural pathways during childhood become automatic thoughts. The
thoughts resulting in disruption in daily life are negative thoughts around situations that
created them.

CBT allows patients to interrupt these thoughts with a deeper understanding of the errors
or distortions in the perception of these automatic thoughts. This type of therapy helps
patients to correct misinterpretations of the thoughts that have caused disruption in their
daily lives.
Cognitive Behavioral Therapy is utilized in treating multiple types of psychiatric problems.
The treatment is typically done between 3 and 6 months, depending on the problem. The
following is a list of psychological problems where CBT has been utilized.

• depression
• anxiety
• eating disorders
• anger management
• marital crisis
• obsessive-compulsive disorder
• schizophrenia
• post-traumatic stress disorder
• chronic pain

There are 5 five areas that are believed to be interconnected and affecting one another.
For instance, how one feels about a certain situation can cause physical and emotional
feelings, resulting in varying behaviors in response.

• situations
• thoughts
• emotions
• physical feelings
• behaviors

CBT breaks problems down into smaller pieces to give detailed attention to each part.
The techniques aid patients in disrupting negative, automatic thoughts, and replacing
them with more helpful ones. The overall goal is to teach the skill of breaking down
negative thought patterns and changing them into a more helpful approach to handling
daily life.
 HISTORY OF CBT

A Closer Look at Aaron Beck

Dr. Aaron T Beck is given the title of Father of Cognitive Behavior Therapy. He was also
named one of the top 5 most influential psychotherapists of all time. Beck is also named
as an American in history that shaped the history of psychiatry.

Dr. Beck has published over 600 articles. He has authored or co-authored 25 books. The
work he did in developing various scales for measuring depression is still in use today.

His work in cognitive behavioral therapy grew from the work of other psychologists like
George Kelly and the vocabulary of Frederic Bartlett and Jean Piaget. The cognitive
constructs theory of Kelly and the vocabulary created by Bartlett around the theories of
schemas and the vocabulary of Piaget’s theory of cognitive development were very
influential in Beck’s initial work in CBT.

As a clinical psychologist, Dr. Beck was noticing a remission of patients’ symptoms. With
this realization, came the understanding that his patients were presenting with repeated
stories around activating events that he later labeled automatic negative thoughts.

Through his work with depressed patients, Dr. Beck developed the Negative Cognitive
Triad. He found 3 types of dysfunctional beliefs, or thoughts, that depressed people were
experiencing. His findings suggested that these types of thoughts dominated the thinking
of people with depression.

1. “I am defective or inadequate.”
2. “All of my experiences result in defeats or failure.”
3. “The future is hopeless.”

Dr. Beck believed that a close, personal relationship with the patient was crucial. The
development of a trusting relationship was necessary to allow for the exploration of
automatic negative thoughts. The mere admission of these thoughts was unsettling for
some of his patients. The reframing of these thoughts through work with Dr. Beck
resulted in significant numbers of patients’ self-reported improvement.

The Beck Institute for Cognitive Behavior Therapy was founded to further investigate the
usage of his ground breaking theory in helping people suffering from various
psychological disorders. The institute was founded with his daughter, Dr. Judith Beck, to
further investigate and serve a worldwide resource for CBT.

KEY CONCEPTS AND PRINCIPLES OF THE APPROACH

The patient’s active participation in therapy is a key principle in CBT. Without it, this goal-
oriented and problem focused approach would not be effective. Sessions in CBT are well
structured and the client’s better understanding of the role of cognition in correcting
behavioral dysfunctions is paramount to their success. This educative approach allows the
client-therapist relationship to deepen, which is also an important principle in this
therapy.

CBT is a time limited approach, and work outside of the therapy office is vital to success.
While this approach is initially present focused, an emphasis on adaptive thinking allows
for relapse prevention. It allows the patient to be taught techniques to change their
thinking, mood, and behavior with the understanding that they will be utilized in their
future.

In cognitive behavior therapy, psychological problems are believed to develop through

the use of cognitive distortions. Aaron Beck’s work suggests that by correcting these
distortions, a more accurate experience of events is created. Through this work, a patient
is better able to develop skills to properly process exposure to life events.
 COGNITIVE DISTORTIONS

Nine of these are described here: all-or-nothing thinking, selective abstraction,

mind reading, negative prediction, catastrophizing, overgeneralization, labeling
and mislabeling, magnification or minimization, and personalization.
1. All-or-nothing thinking. By thinking that something has to be either exactly as
we want it or it is a failure, we are engaging in all-or-nothing, or dichotomous,
thinking. A student who says, “Unless I get an A on the exam, I have failed” is
engaging in all-or-nothing thinking. Grades of A– and B then become failures
and are seen as unsatisfactory.
2. Selective abstraction. Sometimes individuals pick out an idea or fact from an
event to support their depressed or negative thinking. For example, a baseball
player who has had several hits and successful fielding plays may focus on an
error he has made and dwell on it. Thus, the ballplayer has selectively abstracted
one event from a series of events to draw negative conclusions and to feel
depressed.
3. Mind reading. This refers to the idea that we know what another person is
thinking about us. For example, a man may conclude that his friend no longer
likes him because he will not go shopping with him. In fact, the friend may
have many reasons, such as other commitments, not to go shopping.
4. Negative prediction. When an individual believes that something bad is going to
happen, and there is no evidence to support this, this is a negative prediction. A
person may predict that she may fail an exam, even though she has done well on
exams before and is prepared for the upcoming exam. In this case, the inference
about failure—the negative prediction—is not supported by the facts.
5. Catastrophizing. In this cognitive distortion, individuals take one event they are
concerned about and exaggerate it so that they become fearful. Thus, “I know when I
meet the regional manager, I’m going to say something stupid that
will jeopardize my job. I know I will say something that will make her not want
to consider me for advancement” turns an important meeting into a possible
catastrophe.
6. Overgeneralization. Making a rule based on a few negative events, individuals
distort their thinking through overgeneralization. For example, a high school
sophomore may conclude: “Because I do poorly in math, I am not a good
student.” Another example would be the person who thinks because “Alfred
and Bertha were angry at me, my friends won’t like me, and won’t want to
have anything to do with me.” Thus, a negative experience with a few events
can be generalized into a rule that can affect future behavior.
7. Labeling and mislabeling. A negative view of oneself is created by self-labeling
based on some errors or mistakes. A person who has had some awkward incidents
with acquaintances might conclude, “I’m unpopular. I’m a loser” rather than “I felt
awkward talking to Harriet.” In labeling and mislabeling in this way, individuals can
create an inaccurate sense of themselves or their identity. Basically, labeling or
mislabeling is an example of overgeneralizing to such a degree that one’s view of
oneself is affected.

8. Magnification or minimization. Cognitive distortions can occur when individuals

magnify imperfections or minimize good points. They lead to conclusions that
support a belief of inferiority and a feeling of depression. An example of
magnification is the athlete who suffers a muscle pull and thinks, “I won’t be
able to play in the game today. My athletic career is probably over.” In contrast,
an example of minimization would be the athlete who would think, “Even
though I had a good day playing today, it’s not good enough. It’s not up to my
standards.” In either magnification or minimization, the athlete is likely to feel
depressed.

9. Personalization. Taking an event that is unrelated to the individual and mak-

ing it meaningful produces the cognitive distortion of personalization.

Examples include “It always rains when I am about to go for a picnic” and
“Whenever I go to the shopping center, there is always an incredible amount
of traffic.” People do not cause the rain or the traffic; these events are beyond
our control. Furthermore, when people are questioned, they are able to give
instances of how it does not always rain when they have planned an outdoor
function and that they do not always encounter the same level of traffic when
shopping. For example, traffic is usually heavier at certain times of day than at
others, and if one chooses to shop at a particular time, there will be more or less traffic.
If they occur frequently, such cognitive distortions can lead to psychological
distress or disorders. Making inferences and drawing conclusions from a behav-
ior are important parts of human functioning. Individuals must monitor what
they do and assess the likelihood of outcomes to make plans about their social
lives, romantic lives, and careers. When cognitive distortions are frequent,
individuals can no longer do this successfully and may experience depression,
anxiety, or other disturbances. Cognitive therapists look for cognitive distor-
tions and help their patients understand their mistakes and make changes in
their thinking.

COMMON THERAPY TECHNIQUES USED

There are many different techniques used in cognitive behavior therapy, which can be
practiced with the support of a therapist or individually. Some of the most common CBT
therapists will assign are highlighted here.
Albert Ellis developed the ABC technique that is still utilized in CBT today. The ABC
Technique of Irrational Beliefs analyzes the first three steps in which someone might
develop an irrational belief: A) Activating event B) Belief C) Consequences. Activating
Event. This is an event that would lead someone to a type of high emotional response,
and/ or negative dysfunctional thinking.

• Beliefs. The client would write down the negative thoughts that occurred to them
around the activating event.
• Consequences. These are the negative feelings and behaviors that occurred as a
result. The beliefs are to be viewed as a bridge to the negative feelings and
behaviors that occurred as a result of the activating event.

Ellis believed that it was not the activating event (A) that causes the negative beliefs and
consequences (C), but rather how the patient interprets or misinterprets the meaning of
the event (B) that helps cause the consequences (C). Helping a patient reinterpret their
irrational belief system helps to forge new ways for them to interpret their beliefs
resulting in alternative behaviors. A person can utilize this technique, even in the absence
of a therapist.

Journaling for the awareness of cognitive distortions is a powerful way to better

understand personal cognition. A person keeps track of their automatic thoughts and an
analysis of the presence of various distortions is detected.

Once better understood, a person can utilize different methods to reevaluate these
automatic thoughts with evidence. Well trained practitioners in CBT can aid someone
who has difficulty in unraveling these distortions.
Rescripting is a technique used to help patients suffering from nightmares. When the
emotion that is brought to the surface from the nightmare is exposed, a therapist can
help the patient to redefine the emotion desired and to develop a new image to elicit
that emotion.

Exposure therapy is used in OCD and anxiety phobias. Exposing yourself to the trigger
reduces the response to the trigger. Many therapists recommend mild exposure 3 times
daily. While this may be uncomfortable during the first exposures, the increase in
exposure reduces phobic reactions.

The Worst Case/ Best Case/Most Likely Case Scenario technique is used to help people
overcome fear or anxiety. Allowing the brain to ruminate to the point of ridiculousness
allows the person to “play out” the fear to an unrealistic end. Then the person is brought
to the best case and again allowed to let their thoughts “play out” to the ridiculous. Then,
a most likely scenario is explored with actionable steps attached, so that control over
behavior is realized.

A recent, popular technique being utilized in CBT is called Acceptance and Commitment
Therapy. It differs from traditional CBT in that it is not trying to teach people to better
control their thoughts around their activating events; instead this approach is teaching
people to “just notice,” accept and embrace the feelings around the activating events.
This approach utilizes techniques from CBT as well, but ACT focuses on freeing the
patient from the grip of the event itself.

Mindfulness techniques like deep breathing and Progressive Muscle Relaxation (PMR)play
a big role in CBT. These techniques allow the person to be present in the moment
and calmly soothe the unfocused mind. With the relaxation comes the stronger ability to
tune in and alter automatic negative thoughts.

Cognitive restructuring is a CBT technique that helps people examine their unhelpful
thinking. It helps them to redevelop ways to react in situations that have in the past
proven problematic. Keeping a daily record of the automatic negative thoughts creates a
way to find the patterns in these thoughts. With an identified pattern, alternative
reactions and adaptive thoughts can be forged.

Treating thoughts as guesses is a technique that helps to gather evidence to combat

automatic negative thoughts. When a person takes their thoughts to “court” proof of
truth must be found for the thought to be held as accurate. If any proof against the
thought is found, it must be tossed and replaced with a more accurate thought.

Activity Scheduling is a powerful technique in CBT. It helps people engage in activities that
they are not normally used to doing. It presents as a way to slowly reintroduce rewarding
behavior that has been excluded from people’s routines. The technique is helpful in
increasing positive emotion when performed incrementally.

Graded exposure is a technique used to help expose anxiety sufferers to contact with
what is feared. The underlying theory is that people who avoid situations that induce fear
or anxiety will increase the anxiety. The slowly increased exposure aids to decrease that
fear.

ASSESSMENT IN CBT

Careful attention is paid to assessment of client problems and cognitions, both at

the beginning of therapy and throughout the entire process, so that the therapist
may clearly conceptualize and diagnose the client’s problems. As assessment
proceeds, it focuses not only on the client’s specific thoughts, feelings, and behav-
iors but also on the effectiveness of therapeutic techniques as they affect these
thoughts, feelings, and behaviors.
There are some ways in which cognitive therapists use assessment techniques, including
client interviews, self-monitoring, thought sampling, the assessment of beliefs and
assumptions, and self-report questionnaires.

1. Interviews.
In the initial evaluation, the cognitive therapist may wish to get an
overview of a variety of topics while at the same time creating a good working
relationship with the client. The topics covered are similar to those assessed by
many other therapists and include the presenting problem, a developmental his-
tory (including family, school, career, and social relationships), past traumatic
experiences, medical and psychiatric history, and client goals. Therapists may
use previously developed structured interviews or nonstructured interviews.
They caution against asking biased questions such as “Didn’t you want to go to work?”
and suggest instead “What happened when you did not get to work?” In assessing
thoughts, therapists may need to train their clients to differentiate between thoughts and
feelings and to report observations rather than make inferences about the observations.
Accuracy of recall is encouraged (although clients are not expected to remember all
details) and is preferred to guesses about past events.

2. Self-monitoring.
Another method used to assess client thoughts, emotions, and behaviors outside the
therapist’s office is self-monitoring. Basically, clients keep a record of events, feelings,
and/or thoughts. This could be done in a diary, on an audiotape, or by filling out a
questionnaire. One of the most common methods is the Dysfunctional Thought Record
(DTR). Sometimes called a thought sheet, the DTR has one column in which the client
describes the situation, a second in which the client rates and identifies an emotion, and
a third to record her automatic thoughts. Clients may practice using the DTR in therapy so
that they get used to recording automatic thoughts and rating the intensity of feelings.
Use of the DTR provides material for discussion in the next session and an opportunity for
clients to learn about their automatic thoughts.

3. Thought sampling.
Another method for obtaining information about cognitions is thought sampling. Having a
tone sound at a random interval at home and then recording thoughts is one way to get a
sample of cognitive patterns. Clients may then record their thoughts in a tape recorder or
notebook.
Thought sampling can be useful in getting data that is related to specific
situations, such as work and school. However, thought sampling can interrupt
the client’s activity and may become irritating. Also, thoughts irrelevant to the
client’s problems may be recorded.

4. Self-report Questionnaire
In addition to these techniques, previously developed self-report questionnaires or rating
scales can be used to assess irrational beliefs, self-statements, or cognitive distortions.
Structured questionnaires have been developed for specific purposes, such as the Beck
Depression Inventory, the Scale for Suicide Ideation, the Dysfunctional
Attitude Scale, and the Schema Questionnaire.
Questionnaires such as these are usually brief and can be administered at various points
in therapy to monitor progress. For example, the Beck Depression Inventory consists of
21 items, with each containing four choices expressing degrees of sadness, dislike, guilt,
crying, worthlessness, and similar items. Each choice is brief, with most being less than
eight words long.

THE THERAPEUTIC PROCESS IN CBT

More so than many other theories of therapy, cognitive therapy is structured in

its approach. The initial session or sessions deal with assessment of the problem,
development of a collaborative relationship, and case conceptualization. As therapy
progresses, a guided discovery approach is used to help clients learn about
their inaccurate thinking. Other important aspects of the therapeutic process are
methods to identify automatic thoughts and the assignment of homework, which
is done throughout therapy. As clients reach their goals, termination is planned,
and clients work on how they will use what they have learned when therapy has
stopped. As therapeutic work progresses, clients move from developing insight
into their beliefs to moving toward change. Particularly with difficult and complex
problems, insight into the development of negative cognitive schemas is important.

1. Guided Discovery
Sometimes called Socratic dialogue, guided discovery helps
clients change maladaptive beliefs and assumptions. The therapist guides the
client in discovering new ways of thinking and behaving by asking a series of
questions that make use of existing information to challenge beliefs.
[Client:] I’ve been afraid that when I report to my new job on Monday, people
will think I can’t do the work.
[Therapist:] What does that tell you about the assumptions that you are making?
[Client:] Like I’m mind reading, like I know in advance what’s going to happen.
[Therapist:] And what assumptions are you making?
[Client:] That I know what my new colleagues will think of me.

2. The three-question technique.

A specific form of the Socratic method, the three-
question technique consists of a series of three questions designed to help clients
revise negative thinking. Each question presents a way of inquiring further into negative
beliefs and bringing about more objective thinking.
1. What is the evidence for the belief?
2. How else can you interpret the situation?
3. If it is true, what are the implications?
A brief example of this technique shows how it is an extension of the Socratic
method and how it can help individuals change their beliefs. Liese (1993) gives
an example of a physician using the three-question technique with a patient with
AIDS.
Dr.: Jim, you told me a few minutes ago that some people will scorn you
when they learn about your illness. (reflection) What is your evidence
for this belief?
Jim: I don’t have any evidence. I just feel that way.
Dr.: You “just feel that way.” (reflection) How else could you look at the
situation?
Jim: I guess my real friends wouldn’t abandon me.
Dr.: If some people did, in fact, abandon you, what would the implications be?
Jim: I guess it would be tolerable, as long as my real friends didn’t abandon
me.

3. Specifying automatic thoughts.

An important early intervention is to ask the
client to discuss and to record negative thoughts. Specifying thoughts using the
Dysfunctional Thought Record (Figure 10.3) and bringing them into the next
session can be helpful for work in future sessions. An example of automatic
thoughts and helping a patient understand them is given here.
During the first session, I had asked my client how often he thought that he had negative
thoughts. His response was that he had them at times, but only infrequently.
Given his Beck Depression Inventory of 38, my thinking was that he would have many,
many more. He estimated no more than two to three a day. As a homework assignment I
asked him to record as many of his thoughts as possible. I estimated that he probably had
several negative thoughts a day, and that by the end of the week he would probably have
50 thoughts recorded. He quickly responded: “I’ll never be able to do it. It would be too
hard for me. I’ll just fail.” My response was to indicate that he already had three and only
needed 47 more.

4. Homework. Much work in cognitive therapy takes place between sessions so that
skills can be applied to real-life settings, not just the office. Specific assignments
are given to help the client collect data, test cognitive and behavior changes, and
work on material developed in previous sessions. If the client does not complete
 the homework, this fact can be useful in examining problems in the relationship
between client and therapist or dysfunctional beliefs about doing homework
assignments. Generally, homework assignments are discussed and new ones
developed in each session.

5. Termination.
As early as the first session, termination may be planned.
Throughout treatment, therapists encourage patients to monitor their thoughts
or behaviors, report them, and measure progress toward their goals. In the termi-
nation phase, the therapist and client discuss how the client can do this without
the therapist. Essentially, clients become their own therapists. Just as clients may
have had difficulties in accomplishing tasks and may have relapsed into old
thought patterns or behaviors, they work on how to deal with similar issues and
events after therapy has ended. Commonly, the frequency of therapy sessions
tapers off, and client and therapist may meet every 2 weeks or once a month.
Although issues occur in therapy that may require changes in the therapeutic
process described here, the specificity of the therapeutic approach, the emphasis on
thoughts, and the use of homework are typical. Throughout the process of
therapy, a number of strategies are used to bring about changes in thoughts,
behaviors, and feelings.