Cognitive Behavior

Therapy
Dr. Halima S. Qureshi
Assistant Professor | Clinical Psychologist
National University of Modern Languages (NUML)
Setting Up Therapy & Initial
Sessions
• Establishing Rapport and Psychoeducation
• The therapeutic relationship is the foundation of effective CBT.
• Use active listening, empathy, and validation to build trust.
• Provide psychoeducation on CBT principles: how thoughts, emotions,
and behaviors interact.
• Introduce the collaborative approach: therapy as a partnership, not
an expert-driven process.
Structuring Sessions (Agenda
Setting, Progress Tracking)
• A structured session helps maintain focus and efficiency.
• Typical CBT session structure:
• Check-in: Mood, thoughts, progress from the last session.
• Set agenda: Prioritize topics for discussion.
• Work on agenda items: Cognitive restructuring, skill training, problem-
solving.
• Assign homework: Practice outside of sessions.
• Feedback & review: What worked, what needs adjustment.
Case Formulation Using Beck’s
Cognitive Model
• Helps in understanding how a client’s thoughts shape emotions and
behaviors through a structured approach.
• Identify automatic thoughts, intermediate beliefs, and core beliefs using
thought records and guided discovery.
• Use Socratic questioning to explore how thoughts influence emotions and
behaviors.
• Develop a case formulation template incorporating life experiences,
triggers, and cognitive patterns to track thought distortions and behavioral
responses.
• Apply downward arrow technique to uncover underlying core beliefs
systematically.
Identifying Automatic Thoughts

• What are automatic thoughts?

These are immediate, unfiltered thoughts that pop into the mind in response to a
situation. They are often negative, irrational, or exaggerated.
• How to do it?
• Ask your client: "What went through your mind just before you felt that way?"
• Encourage them to write it down in a thought record:
• Situation: What happened? (e.g., "I made a mistake in my presentation.")
• Automatic Thought: What did you think at that moment? (e.g., "I’m so stupid.")
• Emotion: What did you feel? (e.g., Anxiety, shame)
• Behavior: What did you do? (e.g., "I avoided eye contact, spoke less.")
• Validate their thoughts by saying, "These thoughts are common, let’s examine if
they’re 100% true."
Identifying Intermediate Beliefs (Rules &
Assumptions)
• What are Intermediate Beliefs?
These are underlying rules and assumptions that shape automatic thoughts. They usually follow a pattern like:
• Rules: "I must always be perfect, or I’m a failure."
• Assumptions: "If I make a mistake, people will reject me."
• How to do it?
• Look for patterns in thought records (e.g., multiple automatic thoughts about being a failure).
• Ask questions to uncover the rule or assumption:
• "What does it mean if this thought is true?"
• "Is there a rule you feel you need to follow to be accepted?"
• "What would happen if you broke that rule?"
• Example Conversation:
• Client: "I made a mistake, so I must be incompetent."
• Therapist: "If that’s true, what does it mean about you?"
• Client: "It means I can’t afford to make mistakes."
• Therapist: "Why not?"
• Client: "Because if I do, people won’t respect me."
• Intermediate belief: “If I make mistakes, I am worthless.”
Identifying Core Beliefs (Deep-Rooted Self-
Perceptions)
• What are Core Beliefs?
These are deeply ingrained, absolute ideas about oneself, others, or the world. They usually sound like:
• "I am unlovable."
• "I am not good enough."
• "The world is unsafe."
• How to do it?
• Use the Downward Arrow Technique:
• Ask, "If this were true, what would it say about you?"
• Keep asking "And if that’s true, what does it mean?" until you reach a deeper belief.
• Example Conversation:
• Client: "If I make a mistake, I’ll be embarrassed."
• Therapist: "And if that happens, what does it mean?"
• Client: "It means people will judge me."
• Therapist: "And if people judge you, what does it say about you?"
• Client: "It means I’m a failure." (→ Core Belief: "I am a failure.")
Using Socratic Questioning to Challenge
Thoughts
• What is Socratic Questioning?
It is a structured way to challenge irrational thoughts and help clients see alternative perspectives.
• Ask for evidence
• "What evidence do you have that this thought is true?"
• "What evidence suggests it’s not completely true?"
• Consider alternative explanations
• "Is there another way to look at this situation?"
• "If your friend were in the same situation, what would you tell them?"
• Evaluate the consequences
• "What’s the worst that could happen? How likely is it?"
• "What’s the best that could happen?"
• "What’s the most realistic outcome?"
• Reframe the thought
• "If you weren’t thinking this way, how would you feel instead?"
• "What would be a more balanced way to think about this?"
Key Differences Between Automatic
Thoughts, Intermediate Beliefs & Core
Beliefs
Concept Definition Example

Instant thoughts in reaction to "I messed up the meeting. I’m

Automatic Thoughts
situations useless."
Rules & assumptions guiding "If I fail, I am not worthy of
Intermediate Beliefs
behavior respect."

Deep-seated, absolute beliefs about

Core Beliefs "I am unworthy."
self/world
Identifying & Restructuring
Automatic Thoughts
• Thought Monitoring (ABC Model, Thought Records)
• A (Activating Event) → B (Beliefs/Thoughts) → C (Consequences:
Emotional & Behavioral)
• Thought records help clients track and analyze patterns.
• Example:
• A: "I made a mistake at work."
• B: "I’m incompetent."
• C: Anxiety, avoidance.
Identifying & Restructuring
Automatic Thoughts
• Cognitive Distortions – How to Recognize & Challenge Them
• Common cognitive distortions:
• All-or-Nothing Thinking: "If I don’t succeed fully, I’ve failed."
• Overgeneralization: "I always mess up."
• Mind Reading: "They think I’m stupid."
• Catastrophizing: "This is the worst thing ever."
• Techniques to challenge distortions:
• Use Socratic questioning: "What’s the evidence?"
• Create a balanced thought alternative.
CBT Session Structure
Phase Duration Main Focus
Rapport, symptom tracking,
Opening & Mood Check 5–10 min
homework review
Agenda Setting 5 min Plan session collaboratively
Thought records, cognitive
Automatic Thoughts Identification 15–20 min
distortions
Socratic questioning, belief
Exploring Core Beliefs 15–20 min
modification
Case Conceptualization &
10–15 min CBT model, identify patterns
Formulation

Homework Assignment 5 min Practical application

Review, feedback, emotional check-
Session Closure 5 min
out
Core Principles of Cognitive
Therapy
• Cognitive Distortions and Maladaptive Beliefs
• Psychological issues arise due to exaggerated or distorted thinking patterns.
• Common distortions include overgeneralization, black-and-white thinking, catastrophizing, and
personalization.
• Cognitive Restructuring
• CT teaches individuals to challenge and modify irrational beliefs and replace them with realistic
thoughts.
• Example: A student who fails one test might think, “I am a complete failure.” CT helps the student
recognize this as a distortion and replace it with, “This was one test; I can improve with more
effort.”
• Present-Focused Therapy
• CT primarily focuses on current thought patterns rather than past experiences.
• However, understanding how core dysfunctional beliefs developed in childhood can sometimes
be useful.
Core Principles of Cognitive
Therapy
• Collaborative Empiricism
• Definition: A method where the therapist and client work together to test the validity of the
client’s beliefs through structured questioning and behavioral experiments.
• Example: A client believes, “Nobody likes me.” The therapist and client design a social experiment
where the client interacts with colleagues and records responses. If responses are generally
positive, the client realizes that their belief may be inaccurate.
• Socratic Questioning and Guided Discovery
• Therapists use open-ended questions to encourage self-reflection and insight.
• Example: Instead of saying, “Your belief is wrong,” the therapist might ask, “What evidence
supports this belief? What evidence contradicts it?”
• Behavioral Experiments and Homework Assignments
• Clients are assigned tasks outside therapy sessions to test their thoughts in real-life situations.
• Example: A socially anxious client may be asked to initiate small conversations and observe the
responses.
Goals of Cognitive Therapy
• Identify and modify dysfunctional thoughts.
• Teach problem-solving and coping strategies.
• Provide symptom relief and prevent relapse.
• Promote long-term emotional resilience.
Comparison: Cognitive Therapy vs.
REBT

Rational Emotive Behavior Therapy

Feature Cognitive Therapy (CT)
(REBT)
Focus Present thought patterns Irrational beliefs
Collaborative (uses Socratic
Therapist’s Role Directive and persuasive
questioning)
Clients test beliefs through
Change Mechanism Clients dispute irrational beliefs
experiments
Cognitive errors causing faulty
View of Distortions Irrational and rigid beliefs
interpretations
Case Examples
• Example 1: Managing Anxiety
• A client experiences severe anxiety before public speaking, thinking, “I
will embarrass myself, and everyone will laugh at me.”
• CT Strategy: The therapist helps the client challenge this thought by
asking, “Has this happened before? What is the evidence for and
against this belief?”
• The client performs a behavioral experiment where they give a small
presentation to a trusted friend and observe their reaction.
Case Examples
• Example 2: Overcoming Depression
• A young professional feels demotivated after a job rejection, thinking,
“I will never succeed.”
• CT Strategy: The therapist uses Socratic questioning to explore
alternative explanations and encourages the client to apply to other
jobs while tracking their progress.