If you are a mental health helper of almost any stripe: social worker, counsellor, psychologist, psychotherapist, or even psychiatrist, it would be surprising for you not to have heard of CBT (Cognitive Behaviour Therapy), such is its fame in the mental health professions. We can broadly define it as a combination of cognitive and behavioural therapeutic approaches used to help clients modify limiting, maladaptive thoughts and behaviours, ones that are often inconsistent with consensual reality (Beck, Rush, Shaw, & Emery, 1979). The basic premise of CBT is that emotions are difficult to change directly, so CBT targets emotions by changing the thoughts and behaviours that are contributing to the distressing emotions.

Generally considered a short-term therapy, CBT often consists of about 8 to 12 sessions in which client and therapist work collaboratively to identify problem thoughts and behaviours. The therapist then uses the troublesome thoughts and behaviours to furnish the client with tools and techniques to alter the way they think, feel, and behave in a given situation. The CBT-generated skill set enables the individual to be aware of thoughts and emotions; to identify how situations, thoughts, and behaviours influence emotions; and to improve feelings by changing dysfunctional thoughts and behaviours. Some have noted that “CBT” is an umbrella term and that there are a variety of CBT-based techniques used for different populations and different presenting issues.

The underlying principle of therapy, however, remains the same: there is collaborative CBT skill acquisition and “homework” in between sessions (components which set CBT apart from typical “talk” therapies) (Schmied & Tully, 2009; Gasper, n.d.; Grazebrook, Garland & the Board of BABCP, 2005).

In the beginning…

The work of Albert Ellis (1962) gave major impetus to the development of cognitive behaviour therapies through his Rational Emotive Behaviour Therapy (REBT), originally called Rational Emotive Therapy, or RET. Both Ellis and the founder of Cognitive Therapy, Aaron Beck, believed that people can consciously adopt reason. Both viewed the client’s underlying assumptions as targets of intervention. Both rejected their analytic training and replaced passive listening with active, direct dialogues with clients.

The ABC Paradigm

Ellis’ ABC Paradigm holds that when a person experiences a highly-charged emotional event – called a “C” or Consequent Emotion – following a significant activating event, or “A”, A does not cause C, although it may seem to. In fact, what happens is that emotional consequences are mostly created by “B”, the individual’s belief system. When an undesirable emotional consequence occurs, such as profound anxiety, it usually can be traced to the person’s irrational beliefs. When these beliefs are effectively disputed (at “D”) by challenging them rationally and behaviourally, the disturbed consequences are reduced. Because REBT has viewed cognition and emotion integratively (with thought, feeling, desires, and action interacting with each other), it is a comprehensive cognitive-affective behavioural theory and practice of psychotherapy (Ellis, 1995). But where Ellis confronted and persuaded clients that the philosophies they lived by were unrealistic, Beck regarded the client as a colleague who would research verifiable reality (Beck & Weishaar, 1995).

Beck’s collaborative empiricism

Beck’s Cognitive Therapy is based on a theory of personality which holds that how one thinks greatly determines how one feels and behaves. As noted, it is not just a therapy of collaborative empirical investigation, but also reality testing and problem solving between therapist and client. The client’s maladaptive interpretations and conclusions are treated as testable hypotheses. Both behavioural experiments and verbal procedures are used to examine alternative interpretations, generating contradictory evidence that supports more adaptive beliefs. These in turn lead to desired change (Beck & Weishaar, 1995).

CBT strategies

CBT is based on the idea that the processing of information is crucial for the survival of any organism, but in various psychopathological conditions – such as anxiety disorders, depression, mania, and paranoid states – a systematic bias has been introduced into the client’s information-processing system, causing interpersonal problems and possibly even threatening survival, at least indirectly. Thus, the selective bias of depressed clients leads them into themes of loss and defeat. Those with anxiety selectively and systematically interpret themes of danger, while paranoid clients lean toward attributing abuse or interference, even when there isn’t any. The overall strategies of CBT are, first, collaborative empiricism between therapist and client to explore dysfunctional interpretations and try to modify them. Then guided discovery attempts to discover what threads run through the client’s misperceptions and beliefs; these are linked where possible to analogous experiences of the past, creating a rich tapestry telling the story of the client’s disorder.

As clients tune into the nature of the “program” causing their information-processing glitches, a cognitive shift may occur in which clients realise how the data admitted, and the manner of integrating them, determined the behaviour (usually neurotic) which then resulted. The shift involves installing a new “program” which is more adaptive. A person suffering from an anxiety disorder, therefore, may realise that his or her “survival program” was causing selective attention to danger signals. Now, post-shift, attention can be turned to safety signals, with the “program” for “danger signals” being de-activated or at least turned down in “volume”. The shift to the neutral program (i.e., “there are some danger signals and some safety signals”) can be checked in the world. This feedback into the person’s system helps to reverse misinterpretations, catalysing readjustment (Beck & Weishaar, 1995).

CBT techniques, cognitive and behavioural

In CBT, verbal techniques are used to bring forth the client’s automatic thoughts, analyse the logic behind the thoughts, identify unhelpful assumptions, and examine the validity of the assumptions. Assumptions, once identified, are open to modification, which can occur by asking the client if the assumption seems reasonable, by having the client generate reasons for and against maintaining the assumption, and by presenting evidence contrary to the assumptions. Specific cognitive techniques include the following:

Decatastrophising: the “what-if” technique which helps clients prepare for feared consequences. This is helpful in decreasing avoidance.

Reattribution: a technique which tests automatic thoughts and assumptions by considering alternative causes of events. This particularly helps when clients perceive themselves as the cause of problem events.

Redefining: helps clients mobilise when they believe problems are beyond personal control; these techniques may make problems more concrete, stating them in terms of the client’s own behaviour.

Decentring: used chiefly to help clients who erroneously believe that they are the focus of everyone’s (usually negative) attention.

Behavioural techniques are also used to modify automatic thoughts and assumptions. These employ behavioural experiments designed to challenge specific maladaptive beliefs and promote new learning. A client might, for example, (1) predict that a certain outcome will obtain, based on automatic thoughts, (2) carry out the agreed behaviour, and then (3) evaluate the evidence in light of the new experience. Some of the chief behavioural techniques used to foster cognitive change are:

Homework: opportunities to apply CBT principles between sessions. Assignments typically focus on self-monitoring, structuring time effectively, and implementing procedures for dealing with actual situations.

Hypothesis testing: with both cognitive and behavioural components, this technique must make the hypothesis both specific and concrete.

Exposure therapy: thoughts, images, bodily symptoms, and levels of tension are experienced by, say, an anxious client. Exposure to the anxiety triggers provides data for the client, who can examine specific thoughts and images for distortions.

Behavioural rehearsal and roleplaying: used to practice skills or techniques which are later applied in real life. Role-playing may be taped in order to provide objective feedback with which to assess performance.

Diversion techniques: Activities such as social contact, work, play, visual imagery, and physical activity are used to reduce strong emotions and decrease negative thinking.

Activity scheduling: provides structure and encourages involvement. By rating, say, the degree of mastery and pleasure of an activity, depressed clients, for example, are able to see that they were not depressed at the same, unvarying level all day. They are able to contradict a belief that they cannot enjoy anything, and are further shown that activity takes some planning, so someone does not come to be an inert “couch potato” due to an inherent defect.

Graded task assignment: the client initiates an activity at a “safe” level and the therapist gradually increases the difficulty of assigned tasks (Beck & Weishaar, 1995).

Making it work in real life

Carrying out a program of CBT in real life presents certain challenges. Confidentiality is maintained, but occasionally audio- or videotaping needs to be conducted, so therapists must gain informed consent from clients. Some therapists give clients their home phone numbers in case of emergency. And therapists also – with client permission – bring significant others into a therapy session to review treatment goals and also to explore ways in which family members and others can assist in achieving them (this is especially true where some significant others may not understand the nature of the client’s disorder and/or are behaving in ways which are counterproductive to the therapy effort). Persons close to an individual can be invaluable in helping with reality testing and encouraging the client to complete the homework assignments.

Occasionally problems occur with clients misinterpreting – due to their automatic thoughts – what the therapist has said. Together, therapist and client can elicit these wrongly interpreted statements, looking for alternative interpretations (and if the therapist has made an error, of course, he or she accepts responsibility and corrects it). Nevertheless, problems can arise from unrealistic expectations about how quickly change should occur, from incorrect application of techniques, or – sometimes – from therapist automatic thoughts or logical distortions which prevent maximal effectiveness and problem-solving.

Beck and Emery (1979) issued guidelines for working with challenging clients and those who had already experienced “failure” of therapy:

• Avoid stereotyping the client as being the problem rather than having the problem
• Remain optimistic
• Identify and deal with your own dysfunctional cognitions
• Remain focused on the task instead of blaming the client
• Maintain a problem-solving attitude

Always, the therapist can provide a positive, powerful model for the client, showing that frustration does not necessarily lead to anger and despair (Beck & Weishaar, 1995).

© 2014 Mental Health Academy

This article was adapted from the upcoming Mental Health Academy CPD course “Using CBT with Social Anxiety Disorder”. Click here to learn more about MHA.

References

• Beck, A., Rush, A.J., Shaw, B.J., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. ISBN (cloth): 0-89862-0007; ISBN (paperback): 0-89862-919-5.
• Beck, A. T. & Emery, G. (1979). Cognitive therapy of anxiety and phobic disorders. Philadelphia: Center for Cognitive Therapy.
• Beck, A.T. & Weishaar, M.E. (1995). Cognitive Therapy. In Current Psychotherapies, 5th Ed., Corsini, & Wedding, Eds. Itasca, Illinois: F.E. Peacock Publishers, Inc.
• Gasper, P. (n.d.) Assessment & formulation in CBT. The Marian Centre. Retrieved on 30 June, 2014, from: hyperlink.
• Grazebrook, K., Garland, A., & the Board of BABCP (British Association of Behavioural and Cognitive Psychotherapies). (2005). What are cognitive and/or behavioural psychotherapies? International Institute for Cognitive Therapy. Retrieved on 25 June, 2014, from: hyperlink.
• Schmied, V. & Tully, L. (2009). Effective strategies and interventions for adolescents in a child protection context: Literature review. Ashfield, NSW: Centre for Parenting & Research, NSW Department of Community Services. Retrieved on 24 June, 2014, from: hyperlink.