Cognitive behavior therapy – CBT – summary – Master UU CP
Chapter 1:
- Description of Abe and Maria.
What is CBT?
Aaron Beck developed a form of psychotherapy in 1960/70 named cognitive therapy, also known as cognitive behavior therapy (CBT).
In all forms of CBT that are derived from Beck’s model, clinicians base treatment on a cognitive formulation: the maladaptive beliefs, behavioral
strategies, and maintaining factors that characterize a specific disorder. You will also base treatment on your conceptualization, or
understanding, of individual clients and their specific underlying beliefs and patterns of behavior.
Since Beck developed CBT, a stream of different CBT originated, varying in formulations and emphases in treatment. These include rational
emotional behavior therapy, dialectical behavior therapy, problem-solving therapy, acceptance and commitment therapy, exposure therapy,
cognitive processing therapy, cognitive behavioral analysis system of psychotherapy, behavioral activation,cognitive behavior modification, and
others. CBT has been adapted for clients with diverse levels of education and income as well as a variety of cultures and ages, from young
children to older adults. It is now used in hospitals and clinics, schools, vocational programs, prisons, and many other settings. It is used in group,
couple, and family formats. While the treatment described in this book focuses on individual 45- to 50-minute sessions with outpatients,
therapeutic interactions can be briefer.
The CBT theoretical model.
The cognitive model proposes that dysfunctional thinking (which influences the client’s mood and behavior) is common to all psychological
disturbances. When people learn to evaluate their thinking in a more realistic and adaptive way, they experience a decrease in negative emotion
and maladaptive behavior. For example, if you were quite depressed and had difficulty concentrating and paying your bills, you might have an
automatic thought, an idea (in words or images) that just seemed to pop up in your mind.
In traditional CBT, your therapist would likely help you examine the validity of this thought, and you might conclude that you had overgeneralized
and, in fact, you still do many things well, despite your depression. Looking at your experience from this new perspective would probably
decrease your dysphoria and you might engage in more functional behavior (start paying bills). In a recovery-oriented approach, your therapist
would help you evaluate your automatic thoughts. But the focus would be less on cognitions that have already arisen and more on cognitions
that are likely to arise in the coming week that could interfere with your taking steps to achieve a specific goal.
- Cognitions (both adaptive and maladaptive) occur at three levels. Automatic thoughts (e.g., “I’m too tired to do anything”) are at the
most superficial level. You also have intermediate beliefs, such as underlying assumptions (e.g., “If I try to initiate relationships, I’ll get
rejected”). At the deepest level are your core beliefs about yourself, others, and the world (e.g., “I’m helpless”; “Other people will hurt
me”; “The world is dangerous”). For lasting improvement in clients’ mood and behavior, you will work at all three levels. Modifying
both automatic thoughts and underlying dysfunctional beliefs produces enduring change.
CBT research.
CBT has been tested since the first published outcome study in 1977. Studies have demonstrated the efficacy of CBT for a wide range of
psychiatric disorders, psychological problems / components. CBT also helps prevent or reduce the severity of future episodes.
The development of Beck’s CBT.
In the late 1950s, Dr. Beck was a certified psychoanalyst; his clients free-associated on a couch while he made interpretations. Beck wanted to
experimentally validated psychoanalysis. In the early 1960s, Beck decided to test the psychoanalytic concept that depression is the result of
hostility turned inward toward the self. He investigated the dreams of depressed clients, which, he predicted, would manifest greater themes of
hostility. To his surprise, he found that the dreams of depressed clients contained fewer themes of hostility and far greater themes of
defectiveness, deprivation, and loss. He recognized that these themes paralleled his clients’ thinking when they were awake. As Dr. Beck listened
to his clients on the couch, he realized that they occasionally reported two types of thinking: a free-association stream and a stream of quick,
evaluative thoughts, especially about themselves. Dr. Beck recognized that clients experienced “automatic” negative thoughts that were closely
tied to their emotions. He began to help his clients identify, evaluate, and respond to their unrealistic and maladaptive thinking, and they rapidly
improved.
Beck than tested CBT in comparison with medication and found CBT to be as effective as medication and more effective in preventing relapse.
After this many studies followed and CBT is now the most practiced therapy in the world.
Recovery-oriented cognitive therapy.
CT-R, an adaptation of traditional CBT, maintains the theoretical foundation of the cognitive model in conceptualizing individuals and planning
and delivering treatment. But it adds an additional emphasis on the cognitive formulation of clients’ adaptive beliefs and behavioral strategies,
and factors that maintain a positive mood. Rather than emphasizing symptoms and psychopathology, CT-R emphasizes clients’ strengths,
personal qualities, skills, and resources.
One difference between traditional CBT and CT-R is the time orientation. In traditional CBT we tend to talk about problems that arose in the past
week and use CBT techniques to address them. In CT-R, we focus more on clients’ aspirations for the future, their values, and steps they can
take each week toward their goals. The usual CBT techniques are used in overcoming challenges or obstacles clients will face in taking these
steps.
A typical cognitive intervention.
- Excerpt of a therapy session with Abe. P. 8-9.
Becoming an effective CBT therapist.
- The book gives some advice for students reading the book. P. 9-12. To the untrained observer, CBT sometimes appears deceptively
simple. The cognitive model, the proposition that one’s thoughts influence one’s emotions and behavior (and sometimes physiology),
is quite straightforward. Experienced CBT therapists, however, seamlessly accomplish many tasks at once.
You can view the development of expertise as a CBT therapist in four stages. P. 11-12.
Making the best use of this book.
- Some directions on how to read the book.
- Reflection questions and practice exercise.
,Chapter 2
Principles of treatment:
1. CBT treatment plans are based on an ever-evolving cognitive conceptualization.
I base my conceptualization of clients on the data they provide at the evaluation, informed by the cognitive formulation (key cognitions,
behavioral strategies, and maintaining factors that characterize their disorder[s]). From the beginning, I incorporate their strengths,
positive qualities, and resources into my conceptualization too. I continue to refine this conceptualization throughout therapy as I
collect additional data, and I use the conceptualization to plan treatment. I conceptualize Abe’s difficulties in three time frames. From
the beginning, I identify current cognitions that are obstacles to his aspirations (“I’m a failure”; “I can’t do anything right”). I also
identify behavioral obstacles that serve to maintain his depression (isolating himself, inactivity). Second, I identify precipitating factors
that influenced Abe’s perceptions at the onset of his depression. He struggled at work and then lost his job; his wife became
increasingly critical and divorced him. These events led to his belief that he was incompetent. Third, I hypothesize about the key
developmental events and his enduring patterns of interpreting these kinds of events that may have predisposed him to depression.
2. CBT requires a sound therapeutic relationship.
In general, you spend enough time developing the therapeutic relationship to engage clients in working effectively with you as a team.
You use the relationship to provide evidence that clients’ negative beliefs, especially beliefs about the self (and sometimes about
others), are inaccurate and that more positive beliefs are valid. If the alliance is sound, you can maximize the time you spend helping
clients resolve obstacles they will face in the coming week.
3. CBT continually monitors client progress.
4. CBT is culturally adapted and tailors treatment to the individual.
CBT tends to emphasize rationality, the scientific method, and individualism. Clients from other cultures may hold different values and
preferences: for example, emotional reasoning, varying degrees of emotional expression, and collectivism or interdependence. When
clients’ cultures are different from your own, you may need to improve your cultural competency. You may, in fact, be largely unaware
of your own cultural biases. You may also be unaware of the extent of cultural bias some clients experience in their community,
especially if they are not part of the majority culture. Such biases and prejudice may play a significant role in your clients’ difficulties.
Your clients may differ from you in many ways, in addition to culture. These include age, religious or spiritual orientation, ethnicity,
socioeconomic status, disability, gender, sexual identity, and sexual orientation. Make sure to educate yourself about your clients’
characteristics and anticipate how these differences might be relevant to treatment.
5. CBT emphasizes the positive.
Recent research demonstrates the importance of emphasizing positive emotion and cognition in treating depression. You help clients
actively work toward cultivating positive moods and thinking. It is also very important to inspire hope.
6. CBT stresses collaboration and active participation.
Both therapists and clients are active.
7. CBT is aspirational, values based, and goal oriented.
your initial session with clients, you should ask them about their values (what is really important to them in life), their aspirations (how
they want to be, how they want their life to be), and their specific goals for treatment (what they want to accomplish as a result of
therapy).
8. CBT initially emphasizes the present.
The treatment of most clients involves a strong focus on the skills they need to improve their mood (and their lives). Clients who use
these skills consistently (during and after treatment) have better outcomes than those who don’t. You shift the focus to the past in
three circumstances: 1. When the client expresses a strong desire to do so, 2. When work directed toward current problems and future
aspirations produces insufficient change, or 3. When you judge that it’s important for you and clients to understand how and when
their key dysfunctional ideas and behavioral coping strategies originated and became maintained.
9. CBT is educative.
A major goal of treatment is to make the process of therapy understandable.
10. CBT is time sensitive.
We try to make treatment as short term as possible while still fulfilling our objectives: to help clients recover from their disorder(s);
work toward fulfilling their aspirations, values, and goals; resolve their most pressing issues; promote satisfaction and enjoyment in
life; and learn skills to promote resilience and avoid relapse. Some clients need considerably more treatment over a longer period of
time.
11. CBT sessions are structured.
12. CBT uses guided discovery and teaches clients to respond to their dysfunctional cognitions.
13. CBT includes Action Plans (therapy homework).
Action Plans usually consist of • identifying and evaluating automatic thoughts that are obstacles to clients’ goals, • implementing
solutions to problems and obstacles that could arise in the coming week, and/or • practicing behavioral skills learned in session. Clients
tend to forget much of what occurs in therapy sessions, and when they do, they tend to have poorer outcomes. So here’s our rule of
thumb: Anything we want clients to remember is recorded.
14. CBT uses a variety of techniques to change thinking, mood, and behavior.
Chapter 4
Four essential guidelines.
The book says to write down 4 ideas on a card o n how to establish a good therapeutic relationship. It’s essential to start building trust and
rapport with your clients from your first contact with them. Research demonstrates that positive alliances are correlated with positive
treatment outcomes. Your objective is to make your clients feel safe, respected, understood, and cared for. Spend enough time on the
relationship to make that happen, but ensure that you have sufficient time to help clients reach their goals, alleviate their distress, and
enhance their functioning and positive mood. Research has demonstrated that the therapeutic alliance becomes strengthened when clients
perceive improvement from one session to the next.
, - You will need to focus more heavily on the relationship when you treat clients with strong, dysfunctional personality traits or serious
mental health conditions. They tend to bring the same extreme negative beliefs about themselves and others to treatment—and may
assume, until strongly demonstrated otherwise, that you will view them negatively. A good case conceptualization will help avoid this.
Demonstrating good counselling skills.
Norcross and Lambert (2018) have reviewed the research and drawn the following conclusions about the therapeutic relationship:
• Collaboration, goal consensus, empathy, positive regard and affirmation, and collecting and delivering client feedback are effective.
• Congruence/genuineness, emotional expression, cultivating positive expectations, promoting treatment credibility, managing
countertransference, and repairing ruptures are probably effective.
• Self-disclosure and immediacy are promising but have not yet been sufficiently researched.
• Therapist humor, self-doubt/humility, and deliberate practice also lack sufficient research.
In CBT, the Rogerian counseling skills of empathy, genuineness, and positive regard are especially important. You will continuously demonstrate
your commitment to and understanding of clients through your empathic statements, choice of words, tone of voice, facial expressions, and
body language. You will try to impart the following implicit (and sometimes explicit) messages, when you genuinely endorse them: “I care about
you and value you.” “I want to understand what you are experiencing and help you.” “I’m confident we can work well together and that CBT will
help.” “I’m not overwhelmed by your problems, even though you might be.” “I’ve helped other clients with issues like yours.”
- If you cannot endorse these 3 messages, you may need help with that. Some examples are on P. 59-60.
Using the right amount at the right times, can help clients
• feel likeable, when you are warm, friendly, and interested;
• feel less alone, when you describe the process of working together as a team to resolve their issues and work toward their goals;
• feel more optimistic, as you present yourself as realistically hopeful that treatment will help; and
• feel a greater sense of self-efficacy, when you help them see how much credit they deserve for solving problems, completing Action
Plans, and engaging in other productive activities.
Monitoring clients ’affect and eliciting feedback.
You will be continuously alert for your clients’ emotional reactions throughout the session. You’ll observe their facial expressions and body
language, their choice of words, and tone of voice. When you recognize or infer that clients are experiencing increased distress, you will often
address the issue right at the moment—for example: “You’re looking a little upset. [or ‘How are you feeling right now?’] What was just going
through your mind?” Clients often express negative thoughts about themselves, the process of therapy, or you. When they do, make sure to
positively reinforce them. “It’s good you told me that.” Then conceptualize the problem and plan a strategy to resolve it.
- Even when you discern that your alliance with clients is strong, elicit feedback from them at the end of sessions. For the first few
sessions, you might ask, “What did you think about the session? Was there anything that bothered you, or you thought I
misunderstood? Is there anything you want to do differently next time?” After several sessions, when you believe clients will give you
honest feedback, you can just ask, “What did you think of the session?” Asking these questions can strengthen the alliance significantly.
Collaborating with clients.
Collaboration is a hallmark of CBT. Throughout treatment, you will foster collaboration in many ways. For example, you and your client will jointly
make decisions such as
• which goals to work toward during a session;
• how much time to spend on various goals and obstacles;
• which automatic thoughts, emotions, behaviors, or physiological responses to target;
• which interventions to try;
• which self-help activities to do at home;
• how often to meet; and
• when to start tapering sessions and ending treatment.
You’ll explain to clients in the first session that you and they will act as a team. You’ll be transparent and ask for feedback about your goals, the
process of therapy, the structure of sessions, and your conceptualization and treatment plan. Examples will be given throughout this book.
Tailoring the therapeutic relationship to the individual.
While the counseling skills we discussed earlier are essential, so is your ability to assess and adjust the degree to which you use these skills with
each client. Watching for clients’ emotional reactions in the session can alert you to a problem so you can change how you present yourself and
help the client feel more comfortable working with you. Your clients’ cultures and other characteristics (such as age, gender, ethnicity,
socioeconomic status, disability, gender, and sexual orientation) can influence the therapeutic relationship. Clients may differ in the way they
view you, your role, and their role.
It’s important to recognize that your own background and culture exert an influence on your beliefs and values and on how you perceive, speak
to, and behave toward your clients. Understanding the impact of your cultural biases helps you respond to clients in a culturally sensitive way.
Using self-disclosure.
In CBT, you don’t want to be a blank screen. You want clients to accurately perceive you as a warm, authentic person who wants, and is capable,
of helping them. Judicious self-disclosure can go a long way in fortifying this perception. Of course, self-disclosure should have a definite purpose,
for example, strengthening the therapeutic relationship, normalizing the clients’ difficulties, demonstrating how CBT techniques can help,
modeling a skill, or serving as a role model.
- Examples from the book: I tend to use some self-disclosure in most sessions with most of my clients. For example, when clients are
perfectionistic, I often tell them that I keep a sticky note on my desk that says, “Good enough.” When they are overly responsible and
say yes too often, I tell them about my sticky note that says, “Just say no.”
- Example with Abe P. 63-64.
As with any technique, pay attention to your clients’ verbal and nonverbal reactions to your self-disclosures. For example, many clients with
narcissistic personality disorder do not particularly appreciate hearing anything about me. Finally, be judicious in revealing your own automatic
thoughts and reactions. Timing is everything! Saying something like “It makes me feel sad when I hear about what your father did when you
were a child” may be inappropriate at the first session, before the client trusts your genuineness. Your clients may also benefit from your
reactions to their unhelpful behaviors. Here’s something nonpejorative you can say when an angry client has calmed down a little. “When you
get really passionate about something and yell, it makes it harder for us to figure out what to do about the problem we’ve been discussing.”
Repairing ruptures.
Clients bring their general beliefs about themselves, other people, and relationships to the therapy session, as well as their behavioral coping
strategies. If they believe that other people will hurt them , they tend to be vulnerable and on guard as therapy starts. A problem obviously
, exists when clients give you negative feedback (e.g., “I don’t think you understand what I’m saying). Many clients, however, allude indirectly to
a problem, sometimes taking responsibility themselves, for example, saying, “Maybe I’m not expressing myself clearly” when they really mean,
“You’re not understanding me.”
It’s important to use your conceptualization of the client to prevent or repair problems. Let’s say your client has given you negative feedback
(e.g., “This isn’t helping”) or you have inferred an affect shift and elicited an important automatic thought (e.g., “You don’t care about me”).
- First, you provide positive reinforcement (“It’s good you told me that” or the equivalent); then, you conceptualize the problem and
plan a strategy. The first question to ask yourself is “Is the client right?” If so, model good apologizing and discuss a solution.
Typical mistakes include introducing a worksheet that is confusing to your client, offering a suggestion that your client finds inappropriate,
proposing Action Plan items that are too difficult, misunderstanding what your client has said, or being too directive or too nondirective.
Another common problem is interrupting too much.
If you haven’t made a mistake, the problem is likely to be related to your client’s inaccurate cognitions. After positively reinforcing your client
for expressing the feedback, you might do the following: • Express empathy. • Ask for additional information in the context of the cognitive
model. • Seek agreement to test the validity of the thought. Example Maria P.65-67.
Helping clients generalize to other relationships.
When clients have an incorrect view of you, they may very well have a similarly incorrect view of other people. If so, you can help them draw a
conclusion about your relationship and then test it in the context of other relationships.
- Example Maria P.67- 68.
Managing negative reactions toward clients.
You and your clients have a reciprocal influence on each other. You will likely bring your general beliefs about yourself, other people, and
relationships to the therapy session, as well as your characteristic behavioral coping strategies. If your negative core beliefs get triggered
during a session, you may react in an unhelpful way and your client may then engage in an unhelpful coping strategy.
Ask yourself everyday: “Which clients do I wish would not come in today?”
Then use CBT techniques on yourself if any client comes to mind. Identify your cognitions about this client and do one or more of the
following:
• Evaluate and respond to your cognitions about the client; create a coping card to read.
• Check on your expectations for your clients. Work on accepting them and their values as they are.
• Check on your expectations for yourself. Make sure they’re realistic.
• Specify your concern and conceptualize: What might the client do or say (or not do or not say) in session (or between sessions) that
could be a problem? Which beliefs might underlie this behavior?
• Cultivate nondefensiveness and curiosity.
• Problem-solve by yourself or with a colleague/supervisor.
• Set appropriate limits with clients.
• Work on accepting your own emotional discomfort.
• Do good self-care throughout the day (e.g., deep breathing, taking a walk, calling a friend, doing a short mindfulness practice, eating
in a healthy way).
Chapter 5.
Effective CBT requires you to evaluate clients thoroughly, so you can accurately formulate the case, conceptualize the individual client, and
plan treatment. While there is overlap among treatments for various disorders, there are important variations as well, based on the cognitive
formulation—the key cognitions, behavioral strategies, and maintaining factors—of a particular disorder. Attention to the client’s presenting
problems, current functioning, symptoms, and history, along with their values, positive attributes, strengths, and skills, helps you develop an
initial conceptualization and formulate a general therapy plan. You hold the evaluation session before the first treatment session. Assessment
isn’t limited to the initial evaluation session though.
Objectives for the evaluation session.
Your objectives for the evaluation session are to..
• collect information (both positive and negative) to make an accurate diagnosis and create an initial cognitive conceptualization and
treatment plan,
• determine whether you will be an appropriate therapist and can provide the appropriate “dose” of therapy (level of care, frequency
of sessions, and duration of treatment),
• figure out whether adjunctive services or treatment (such as medication) may be indicated,
• initiate a therapeutic alliance with the client (and with family members, if relevant),
• educate the client about CBT, and;
• set up an easy Action Plan.
It’s desirable to collect as much information as possible before the evaluation session. Request that clients send, or arrange to have sent,
relevant reports from current and previous clinicians, including both mental health and health professionals. The evaluation session itself will
require less time if clients are able to fill out questionnaires and self-report forms beforehand. It’s especially important that clients have had a
recent medical checkup. It’s good practice to inform the client during the initial phone call that it’s often useful to have a family member,
partner, or trusted friend accompany the client to the evaluation session to provide additional information and/or to learn how he or she can
be helpful to the client.
Structure of the evaluation session.
