While Cognitive Behavior Therapy is a text to train psychiatry practitioners, many of the techniques can be applicable to daily life. Even if you aren’t formally diagnosed with a mental health disorder, you likely face situations that evoke more negative emotions than you’d like—nervousness talking to your boss, road rage, anxiety in social situations, stress that you won’t get everything done, or fear of failure in trying something new.
This summary focuses on the key CBT interventions to change your dysfunctional automatic thoughts and behaviors. These are generally applicable for all readers, not just those aiming to practice CBT for patients.
When you feel dysphoria (negative emotion), think the cardinal question: “What was just going through my head?” Articulate the thought explicitly.
Evaluate the thought with these questions:
Patterns of cognitive distortions: These put a label to common ways that people distort reality in self-defeating ways.
Conduct behavioral experiments to push yourself to do what is uncomfortable. This will give you new data, to find a mismatch between your prediction and reality.
To uncover your deeper beliefs, keep asking yourself questions about the situation or the automatic thought. “What does it mean to me if X happens? What does it mean about me?”
Generally, dysfunctional core beliefs fall into three categories:
For beliefs, consider the following interventions:
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The cognitive model proposes that dysfunctional thinking is common to all psychological disturbances. In this way, mental illnesses such as depression and anxiety may be considered thinking disorders. The patient has automatic dysfunctional self-talk that influences behavior negatively; the behavior is then interpreted in a negatively biased way, leading to worse thinking. This reinforces itself into a vicious cycle.
The negative thinking extends to the core of a patient’s beliefs about herself, the world, and other people, as well as intermediate levels of attitudes, rules, and assumptions the patient holds.
It’s not just the situation itself that makes a person feel a certain way, but also how they construe it, what lens they use to view it.
The key point of cognitive behavior therapy is that these dysfunctional beliefs can be unlearned.
The patient’s cognitive conceptualization exists on 3 levels: 1) core beliefs, 2) intermediate attitudes, rules and assumptions, and 3) automatic thoughts.
These are fundamental understandings regarded as absolute truths—just the way things are. Example: “I’m incompetent.”
They are often not explicitly articulated by the patient consciously.
Early experiences may have developed these—by parents, early authority figures; by a traumatic event; by apparent negative treatment by others (accurate or not).
These generally fall into three categories: “I’m helpless.” “I’m unlovable.” “I’m worthless”
Attitudes are judgments about a particular outcome or situation. Example: “It’s terrible to fail.”
Rules are prescriptions for behavior for the patient to follow in certain situations. Example: “If a challenge seems too great, don’t even try it.”
Assumptions are predictions about how things will go based on the patient’s behavior. Example: “If I try to do something difficult, I’ll fail. If I avoid doing it, I’ll be OK.”
Generally, the patient’s logic works like this: “If I engage in my [maladaptive coping strategy], then [my core belief] won’t come true and I’ll be OK.” And the inverse of this: “If I don’t engage in my [maladaptive coping strategy], then [my core belief] will come true and I’ll be hurt.”
(Note the patient may also have positive inversions, which arise when the patient’s mood is better. For example, a positive assumption may arise: “If I work hard, I can overcome my shortcomings.”)
Automatic thoughts arise unconsciously, often in response to a situation and sometimes unprompted. For example, someone who has a core belief that she’s incompetent may be told that her manager wants to meet with her. Her automatic thought may be, “My boss probably thinks I’m doing a terrible job. I’m finally going to be found out and fired.”
Patients are often more aware of the emotion they feel than the thought itself. Automatic thoughts may come in the form of verbal thoughts or images.
A wide variety of situations can evoke automatic thoughts:
These automatic thoughts then lead to emotions. The two are distinct.
A patient’s cognitive conceptualization shapes the patient’s reaction, which is composed of emotional, physiological, and behavioral components.
To cope with negative beliefs and a cognitive conceptualization, patients often use a variety of coping mechanisms. Generally, a coping mechanism is often an extreme implementation of a behavior, or an extreme absence of the behavior. Examples:
If the response is maladaptive, the patient progressively worsens her situation, because the behavior causes further problems, which further worsens the patient’s cognitive conceptualization.
Over time, the patient can be locked into a negative vicious cycle, where the patient’s biased information-processing model reinforces negative beliefs. Reinforcement can happen when:
Automatic thoughts can arise for all people. Think about what automatic thoughts you have and how they affect your emotion.
Think about the last time you felt an automatic negative emotion in response to a situation. What was the situation? What were you feeling?
Cognitive Behavioral Therapy (CBT) is directed toward solving current problems and modifying dysfunctional thinking and behavior. Changing the underlying belief system leads to enduring behavior change.
CBT encourages the patient to:
The cardinal question of CBT: “What was just going through my mind?”
CBT treatment has 6 characteristics.
1) CBT is Collaborative
2) CBT is Time-bound. Straightforward patients are empowered to be self-sufficient after 6-14 sessions, followed by periodic booster sessions.
3) CBT is Customized to the disorder and to the patient.
4) CBT is Present-focused. CBT is goal-oriented, current problem-focused.
5) CBT is Built on Trust, which arises with the therapist’s warmth, empathy, genuine regard, and competence.
6) CBT is Structured. This Makes the session more understandable and empowers the patient to do self-therapy. Each CBT session consists of three parts:
To build collaboration, trust, and structure, use a standard communication approach during a session:
A therapeutic relationship that is trusting, empathetic, and collaborative is critical to patient improvement. Here are pointers on how to build a strong therapeutic relationship:
Each CBT session consists of a regular structure. Here we’ll go over the structure for three types of sessions:
The session structures will refer to tasks such as problem-solving, identifying beliefs, and assigning homework. We’ll cover those items in the next chapters.
The goal in the evaluation session is to start building a cognitive conceptualization of the patient. Treatment and problem-solving should NOT be done until the first therapy session.
Prepare by gathering all the notes available, including previous psychiatry work.
Invite a family member or friend to attend, but start the meeting alone with the patient and discuss when to bring the other person in on the session.
Set the agenda and convey expectations for the session.
Conduct the assessment.
Discuss bringing the guest into the session, and ask if there’s anything the patient wants to guard from the guest.
Relate your impressions.
Set initial broad goals.
Elicit feedback from the patient.
Look for indications the patient is unsure about committing to treatment.
After the session, develop your hypothesis of the cognitive model and treatment plan.
Create goals other than what the patient has articulated.
The first therapy session is when you can begin problem-solving and treating the patient.
As always, describe the agenda, ask if that sounds OK, and ask if the patient would like to add anything.
Do a mood check.
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A key part of treating mood disorders is identifying the patient’s automatic thoughts and guiding the patient to evaluate them and overcome them. This is done by:
We’ll cover each component in a dedicated section.
The key question of identifying automatic thoughts is: “What is going through your mind right now?”
To elicit the automatic thought, try a range of techniques:
The patient should be led to describe the specific thought as it occurred, NOT speculating on its intent.
Probe if secondary automatic thoughts may have surfaced.
Frame the thought as an idea, not as a truth or fact. It will be evaluated later.
Make clear the impact the thought has on emotion and behavior.
If the emotion doesn’t match the thought, then probe further—you may not be at the root of the situation. Here’s an example:
Rate the intensity of the emotion to triage problems and gauge improvement in mood.
Automatic thoughts can be examined on the basis of their validity and utility. Invalid thoughts are not supported by the evidence. Or, the thought may be valid, but dysfunctional.
Never challenge a patient’s thought or belief. This violates the collaborative empiricism of CBT. You are to guide the patient to examining her own thought.
Ask Socratic questions to help them gain distance.
For more advanced patients, you can vary the questions.
Cognitive distortions tend to fit one or more of these patterns:
Reflect on automatic thoughts you have and how they might be improved.
Think about a time in the past day or so where you felt a negative emotion about yourself (like self-doubt, anxiety, or sadness). What was going through your mind just then?
After the first session, you can begin building a cognitive conceptualization of the patient, linking the whole pathway of
As you develop your understanding of this, share them merely as hypotheses. Avoid making the patient feel categorized or put in a box.
We’ll discuss investigating both intermediate beliefs and core beliefs.
Given the same core belief, people may have different intermediate beliefs.
How to identify intermediate beliefs:
Keep probing until you cause a negative affect in the patient, or the patient repeats her answer. This is about as deep as you can go.
Educate the patient about beliefs:
In comparison to automatic thoughts, modifying intermediate beliefs may require more persuasion than just Socratic questioning. The key is to clarify the dissonance of the patient’s beliefs; deeper beliefs may require more visceral and narrative depictions.
Here are a range of techniques to use to try to modify the student’s intermediate beliefs:
After developing a new, healthier belief, assign homework for the patient to look for situations to practice the new belief and behavior.
Don’t worry about extinguishing the bad behavior entirely. Reducing the belief level to 30% or below is usually sufficient.
Core beliefs are the central beliefs that people hold about themselves and the world. They are often formed at an early age. As with intermediate beliefs and automatic thoughts, they can be both positive and negative.
In mood disorders, negative core beliefs...
Homework gives the patient opportunities to practice new behaviors and thinking. Patients who regularly complete homework show better progress.
Explain the rationale of homework, often in terms of improving patient affect or in proven efficacy.
Sessions should typically begin with review of homework completion, outcomes from doing homework, and appropriateness of tasks for future homework.
Set homework collaboratively. Get patient buy-in for homework assignment.
Lean toward making homework assignments easy and able to be completed than too hard. Aim for 90-100% likelihood of completion.
Make homework no-lose—even if the patient doesn’t complete homework, she’ll discover thoughts that prevent her from making progress.
Homework assignments can take a variety of forms. Here are common tasks for patients:
As therapy progresses, the nature of homework may change:
Here are techniques to increase homework completion rate:
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CBT is customized to the patient, and different techniques may have different efficacy between patients. Here are more techniques mentioned in the book to draw upon:
Often specific vivid images are a primary source of patient distress. Elucidating the image is important for recovery.
Synonyms of imagery include mental picture, daydream, fantasy, or memory.
Techniques to improve imagery:
Use imagery as a therapeutic tool.
As a therapist, you may run into the following shortcomings:
Getting feedback on your performance is helpful. Ask the patient if you can record their session, so you can review the session with a colleague.
Beware of your own negative automatic thoughts about the patient, therapy, or yourself. Not all sessions will go well. Instead of catastrophizing the problem and questioning your ability as a therapist, see it as an opportunity to refine your skills.
In general, problems in CBT sessions can be a result of one of two issues: 1) insufficient socialization (the patient lacks training on what to do) or 2) reluctance to comply (the patient knows what to do but doesn't want to do it).
Distinguish between the two by socializing the patient to the CBT model.
Causes of reluctance to comply include a weak therapeutic alliance; ineffective structure or pace of session; unrealistic patient expectations; lack of patient understanding of cognitive model; or the patient’s biology or external environment.
To get the session on track...
CBT is intended to be fixed in duration, teaching the patient to be her own therapist. Make this known to the patient at the beginning, to prepare for the expectation.
To help ease the transition, help the patient attribute positive changes to herself, not to the therapist or external causes.
As sessions near the end, patients should anticipate setbacks and anticipate how they will respond.
Make a list of tools the patient has employed to deal with stressful situations:
Guide the patient to conduct self-therapy sessions, consisting of a template similar to normal therapy sessions. A template might include:
Prepare for the taper off of sessions like any other stressful situation.
Schedule booster sessions.