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Cognitive Behavior Therapy: Basics and Beyond by Judith S. Beck.
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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.

  • e.g. “I’m afraid that people will think my project proposal is stupid.”

Evaluate the thought with these questions:

  • What is the evidence that your thought is true? What is the evidence on the other side?
  • What is an alternative way of viewing this situation? What else could explain the person’s behavior/the outcome?
  • Outcome analysis
    • What’s the worst that could happen? How would you cope with this situation?
    • What’s the best that could happen?
    • What’s the most realistic outcome of this situation? (especially if you tend to catastrophize)
  • What is the effect of believing your negative automatic thought? What could be the effect of changing your thinking to be more positive?
  • If your friend were in this situation and had the same automatic thought, what advice would you give him or her?
  • What should you do going forward? How likely are you to do this?

Patterns of cognitive distortions: These put a label to common ways that people distort reality in self-defeating ways.

  • Catastrophizing—imagining the worst possible thing that could happen
  • Selective bias/tunnel vision/discounting the positive —focusing and emphasizing negative evidence for, ignoring or de-emphasizing positive evidence against
  • All-or-nothing—either you get an A or you’re a total failure
  • Mind reading—assuming negative intent or belief of other people, without considering other possibilities
  • Emotional reasoning—because you feel it so strongly, it must be true
    • I feel like a failure all the time, so it must be true
  • Exaggeration, or overgeneralization
  • Should and must statements—a precise fixed idea of how people should behave. Overestimate how bad it is if these expectations are failed

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.

  • Realize that you can fall into a negative vicious cycle without intervention:
    • Stressful situation arises
      • Work asks you to work on a promising new project, but it risks failure. You get anxious.
    • Automatic thoughts arise that cause a maladaptive, self-defeating reaction
      • “I can’t succeed in this. If I fail, people will know and I’ll be ashamed.”
    • A negative outcome results, further strengthening patient’s negative core beliefs and aggravating the automatic thoughts
      • You don’t volunteer for the project. “I knew I wasn’t capable of signing up for this.”
    • Patient also withdraws from situations that might lead to positive data
      • You prevent yourself from volunteering for any future new projects, because the thought of doing so causes you too much anxiety.
  • Small bits of positive data will counteract the vicious cycle. When done repeatedly, it can build its own virtuous cycle.

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?”

  • Articulate your rules, assumptions, and attitudes.
  • Attitude: “It’s terrible to fail.”
  • Rule: “If a challenge seems too great, don’t even try it.”
  • Assumption: “If I try to do something difficult, I’ll fail. If I avoid doing it, I’ll be OK.”

Generally, dysfunctional core beliefs fall into three categories:

  • Helplessness: “I want to achieve more, but I’m not capable of it.”
  • Unlovableness: “I’m not worthy of being loved by others. I’m undesirable.”
  • Worthlessness: “I’m bad. I’m fundamentally not worthy of good things.”

For beliefs, consider the following interventions:

  • Phrase the rule/belief as an assumption—this makes it easier to spot the logical fallacy.
    • “If I ask for help, I’ll be seen as weak.” vs “Don’t ask for help.”
  • Present more functional beliefs, that are more qualified versions of the old belief
    • “If I don’t get an A, I’m a failure.” -> “If I don’t get an A, I’m just human, and I still tried hard. It’s better than 0%.”
    • “I can’t do anything right.” -> “I can do most things right, and there’s a good reason for when I get something wrong.” NOT “I can do everything right.”
  • Behavior experiment
    • Act “as if” the belief weren’t true.
    • Act as if you assume the positive outcome will be true.
  • Imagine counseling someone else with the same issue, or pretend your child has the same belief.
  • Look...

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Cognitive Behavior Therapy: Basics and Beyond Summary Principles of Mental Disorders

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.

  • Example: A patient wants to try something new. She thinks, “you’re definitely going to fail, you’re not good at anything.” → Anxious about failing, the patient declines to try the new activity. → She then thinks, “I told you, you can’t get anything right—you’re worthless.”

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.

  • Cyclical downfalls can be triggered by precipitating factors, such as a sudden provocation in stress.
  • The patient may have had key developmental events earlier in life that predispose her to the condition.
  • The patient may have developed coping mechanisms (adaptive and maladaptive) for the dysfunctional beliefs.

The key point of cognitive behavior therapy is that these dysfunctional beliefs can be unlearned.

Cognitive Conceptualization

The patient’s cognitive conceptualization exists on 3 levels: 1) core beliefs, 2) intermediate attitudes, rules and assumptions, and 3) automatic thoughts.

Core Beliefs

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”

Intermediate Attitudes, Rules, and Assumptions

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

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:

  • External events
    • “A friend didn’t pick up my call.”
  • Stream of thoughts
    • A patient thinks about an exam and how much is being tested, then continues thinking about how important her grades are and a cavalcade of other thoughts.
  • Cognition: a thought, image, memory, or daydream
    • A patient thinks of a violent image.
    • A patient has a flashback of a traumatic event.
  • Emotion
    • A patient feels anger, then reflects on that anger. “I shouldn’t be angry at him. I’m such a bad person.”
  • Behavior
    • A patient binge eats despite promising herself she wouldn’t. “I’m so weak. I can’t even get my eating under control.”
  • Physiological
    • A patient feels her rapid heartbeat. “Why is my heart racing so fast? There’s something seriously wrong with me.”
  • Mental experience
    • A patient feels a sense of unreality. “I’m going crazy.”

These automatic thoughts then lead to emotions. The two are distinct.

  • Emotions are one word: sad, anxious, angry, jealous, ashamed, hurt, suspicious, disappointed.
  • Automatic thoughts are expressed as more than one word.

The Patient’s Reaction

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:

  • A patient tries to be perfect, or, on the other end of the spectrum, tries to appear purposely incompetent
  • A patient seeks intimacy aggressively, or she avoids intimacy absolutely.
  • A patient tries to control situations, or she abdicates control.

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:

  • The patient selectively pays attention to negative...

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Shortform Exercise: Consider Your Automatic Thoughts

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?

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Cognitive Behavior Therapy: Basics and Beyond Summary Principles of Treatment

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:

  • Recognize the negative thoughts that are happening automatically.
  • Recognize the biased interpretations of their experiences.
  • Examine the evidence of a situation. View their experiences from a more realistic and objective perspective.
    • Example: Instead of thinking “I can’t do anything right,” patients are led to think, “I’m not good at this specific task. But I’m good at others.”
  • Experiment with exposure to situations they fear to test their negative predictions.
  • Reflect on their experiments to adjust their beliefs.

The cardinal question of CBT: “What was just going through my mind?

CBT treatment has 6 characteristics.

1) CBT is Collaborative

  • The therapist and patient work together on the session agenda and after-session homework. As the patient improves, the patient takes more initiative.
  • The therapist shares the conceptualization to ensure it “rings true,” rather than forcing her understanding on the patient.
  • The therapist provides rationales for intervention and elicits approval.
  • The therapist constantly ends suggestions with “is that OK? Does that sound right?”
  • The therapist asks for feedback at the end of each session.
  • The pair uses guided discovery, Socratic questioning, and empiricism to explore the validity of automatic thought and test new situations.

2) CBT is Time-bound. Straightforward patients are empowered to be self-sufficient after 6-14 sessions, followed by periodic booster sessions.

  • After each session, the patient takes home therapy notes to review.
  • The patient carries coping cards with written statements that are important to remember.
  • As the therapist demonstrates techniques like problem-solving, she teaches the patient how to apply those techniques alone.
  • The patient learns to conduct her own CBT sessions.

3) CBT is Customized to the disorder and to the patient.

  • Different disorders require different approaches.
    • Panic disorder involves testing catastrophic misinterpretations of bodily/mental sensations.
    • Anorexia requires modifying beliefs about personal worth and control.
    • Substance abuse focuses on beliefs about the self and permission-granting beliefs about substance abuse.
  • Each patient has different thinking patterns, beliefs, and developmental events.

4) CBT is Present-focused. CBT is goal-oriented, current problem-focused.

  • Contrast this to Freudian psychoanalysis, which tends to focus on unconscious conflicts and past events.
  • Strategies are devised to overcome current problems. This often consists of evaluating the evidence of the situation, creating incremental solutions to experiment with the situation, changing beliefs.
  • Attention can shift to the past when patients get stuck in their thinking, or when examining childhood roots modifies their rigid ideas. (“With that experience, it’s no wonder you feel that way. Can you see how almost any child who had the same experiences would grow up feeling the same way you do?”)

5) CBT is Built on Trust, which arises with the therapist’s warmth, empathy, genuine regard, and competence.

  • Treat patients the way you would like to be treated.
  • Accurately summarize the patient’s thoughts and feelings. The patient will feel understood.
  • Your previous successes will make the patient feel optimistic about chances of recovery. “I’ve helped other patients much like you.”

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:

  • Introduction: Mood check, reviewing the week, setting an agenda.
  • Middle: Reviewing homework, discussing problems on the agenda, strategy setting, setting new homework, summarizing.
  • Final: Eliciting feedback.

To build collaboration, trust, and structure, use a standard communication approach during a session:

  • Tell the patient what you are about to do, why, and say you will invite feedback.
  • Do what you said.
  • Ask, “Does this ring true? How does that sound?”

Developing the Therapeutic Relationship

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:

  • Share your conceptualization with the patient constantly, asking whether it “rings true.”
    • “OK, I want to make sure I understand. The situation was [this], and your automatic thought was [this]. This thought made you feel [this emotion], so you acted by doing [this]. Did I get that right?”
  • When noticing dysphoria during the session (the patient could be remembering something or reacting to the session itself), address it: “You look upset. What was going through your mind?”
  • Positively reinforce patients for providing feedback. “It’s great that you recognized your thinking.”
  • Positively reinforce patients for making strides in their therapy. For example, when the patient notices automatic thoughts, suggests new solutions, or does homework.
  • Highlight evidence of improvement makes the patient more optimistic that the method is working. Improve the patient’s mood during the session and create a plan to feel better during the week.
  • Emphasize the positive.
    • Elicit patient strengths.
    • Elicit positive data from the preceding week. “What positive things happened since I saw you last?”
    • Elicit data contrary to their negative thoughts.
    • Ask what positive data means about the patient.
    • Give positive feedback on adaptive coping mechanisms: “What a good idea.”
  • Don’t attack the core beliefs too early—this can endanger the alliance....

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Cognitive Behavior Therapy: Basics and Beyond Summary The CBT Session Structure

Each CBT session consists of a regular structure. Here we’ll go over the structure for three types of sessions:

  • The evaluation session, which aims to build a cognitive conceptualization of the patient
  • The first therapy session, where treatment and problem-solving will begin
  • Each therapy session afterward, where treatment continues and the patient progresses toward self-sufficiency

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 Evaluation Session

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.

  • Check that the patient has had a recent medical check-up—an organic issue like hypothyroidism may be misdiagnosed as depression.

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.

  • “This is an evaluation session. I’ll ask a lot of questions to determine the diagnosis. A number of questions may not be relevant. Is that OK?”
  • “I’d like to find out about symptoms you’ve been experiencing and how you’ve been functioning lately. I’ll ask you to tell me anything else you think I should know. Then we’ll set broad goals, I’ll share initial impressions, and what we should focus on in treatment. At the end I’ll see whether you have other questions. Does that sound OK?”
  • “Is there anything else you want to cover today?”

Conduct the assessment.

  • Get a full medical and social history.
  • Ask patients to describe their typical day. Look for variations in mood; how they interact with other people; how they function at home and work; how they spend free time.
  • Pinpoint difficulties in their daily life to address (for example, difficulty sleeping, social isolation, limited opportunities for mastery, or falling behind in schoolwork).
  • Ask about positive experiences (“what are the better parts of the day?”)
  • Ask about coping strategies (“even though you were tired, how did you get yourself to go to class?”)
  • Structure the questions to get what you need: “For these next questions, I just need a yes or no.”
  • End with: “Is there anything you’re reluctant to tell me? You don’t have to tell me what it is. I just need to know if there’s more to tell.”

Discuss bringing the guest into the session, and ask if there’s anything the patient wants to guard from the guest.

  • Ask the guest what is most important for you to know.
  • If the guest focuses on the negative, ask about the patients’ positive qualities and strengths.

Relate your impressions.

  • “I’ll need time to review my notes to establish the diagnosis. But my impressions so far are [these].”

Set initial broad goals.

  • “We’ll set more specific goals, but broadly should we say our goals are: reduce depression, do better at school, get back to socializing?”
  • “In the future we’ll find problems to solve and engage in problem solving, examine your depressed thinking and the evidence, and come up with solutions.” Elaborate on what this means.
  • “We’ll plan to meet every X weeks, then with less frequency later. My guess for how many sessions we need is between 8 to 14. We’ll decide together what’s best.”

Elicit feedback from the patient.

  • How does that sound? Does this sound OK? Do you want to come back next week?

Look for indications the patient is unsure about committing to treatment.

  • Positively reinforce their expression of skepticism. “It’s perfectly understandable that you think this won’t work. Thanks for sharing that.”
  • Ask, “what makes you think I can’t help, or that this treatment won’t work?”
  • “I can’t give you a 100% guarantee. But there’s nothing you’ve told me that makes me think it won’t work.”
  • If the patient says it hasn’t worked in the past: “did your last therapist set agendas; write down what to remember; ask for feedback?” and so on, covering your usual procedure. If not, then “It sounds like our treatment here will be different. If it were exactly the same as your past experiences, I’d be less hopeful.”
  • If yes, then you will need to find out precisely what occurred in the past and how the treatment failed.

After the session, develop your hypothesis of the cognitive model and treatment plan.

  • Focus first on fixing immediate short-term problems, then working more on core beliefs in the middle.
  • You may not be sure yet whether to focus on historic antecedents, or about other dysfunctional beliefs that were not mentioned.

Create goals other than what the patient has articulated.

  • Investigate dysfunctional beliefs about X.
  • Identify and respond to automatic thoughts.

Initial Therapy Session

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.

  • Rationale: “We’ll do this at the beginning of every session so we make sure we have time to cover what’s most important to you.”
  • Language: “in a few minutes, we’ll discuss your diagnosis and how that affects your thoughts.” This signals that the agenda setting is not yet complete.
  • Chronic problems (such as arguments with family) can usually be postponed to a future session.

Do a mood check.

  • “Tell me in a sentence or two how you felt for most of the week?”
  • Ideally the patient fills out a questionnaire beforehand.
  • If this is difficult for the patient, simplify the question—”what was your mood, on a scale of 0 to 10?”

Get an update.

  • Ask if anything significant...

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Cognitive Behavior Therapy: Basics and Beyond Summary Identifying Automatic Thoughts and Problem Solving

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:

  • Articulating the automatic thought explicitly.
  • Evaluating the automatic thought for validity and utility.
  • Constructing behavioral experiments to highlight the discrepancy between the patient’s automatic thoughts and reality.

We’ll cover each component in a dedicated section.

Identifying Automatic Thoughts

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:

  • Paint a vivid picture. Ask the patient to imagine the situation, picture the time, and revisit exactly what the patient was doing.
  • Ask for a description of the physical sensation of the emotion.
    • “Where did you feel the anxiety?”
  • Turn the reflection into present tense—past tense obscures the emotional response.
  • Ask the opposite of what you think the thought was. “Did you think you were going to ace the test?”
  • Role play the situation with the patient.
  • If the patient is unresponsive, ask what the patient thought would have been the worst that could have happened.
  • “Were you imagining something that might happen or remembering something that did?”

The patient should be led to describe the specific thought as it occurred, NOT speculating on its intent.

  • Not “I must be sabotaging myself.” Rather “I was thinking, “I’m going to fail the test.”
  • Not “I couldn’t get myself to start reading.” Rather “I can’t do this.”
  • Not “how will I get through it?” Rather “I can’t get through this.”

Probe if secondary automatic thoughts may have surfaced.

  • Automatic thoughts about their reactions (emotion, behavior, or physiology) can cause a vicious cycle.
    • For example, the first thought may be “I’m going to fail the test.” This may provoke anxiety, leading to a physiological response and rapid heart rate. This may then provoke another automatic thought: “Why is my heart beating so fast? What’s wrong with me?”
  • Ask, “what else went through your mind?” Then ask, “which of these thoughts was most upsetting?”

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.

  • “How did that thought make you feel?”
  • “What does that emotion make you want to do?”
  • “What would happen if you had the opposite thought? How would you feel?”
  • The patient should understand the difference between thought and emotion. Emotions are one word.

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:

  • “My mom didn’t pick up the phone and I thought ‘what if something happened to her?’ I felt sad.” This doesn’t quite match—wondering if something happened to your mother would typically provoke worry or anxiety.
  • Probe further—“so the ring tone stops. What happens next?” Patient: “I get teary.” Therapist: “What is going through your head?” Patient: “What if something happens to her? Then there’s no one left to care about me.” That’s the real underlying thought that matches the emotion of sadness.

Rate the intensity of the emotion to triage problems and gauge improvement in mood.

  • “Let’s try to rate the emotion on a scale of 0 to 100%. 0 is no sadness at all, and 100% is the saddest you have ever felt.”
  • Make a ruler of emotions with the patient. “Let’s make a scale of when you felt sad in the past. When did you feel just a little bit sad? The saddest you’ve ever felt? And in between? Now, how did you feel in this situation?”
  • If the patient is reviewing a past event: “How much did you feel [the negative emotion] then? How much do you feel it now?”
  • Situations that are minor in emotional intensity might not be worth exploring further.

Evaluating Automatic Thoughts

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.

  • “What is the evidence that your thought is true? What is the evidence on the other side?”
  • “What is an alternative way of viewing this situation? What else could explain the person’s behavior/the outcome?”
  • “What’s the worst that could happen? How would you cope with this situation?” (You can give solutions to help the thinking.)
  • “What’s the best that could happen? What’s the most realistic outcome of this situation?” (This is especially useful if the patient has a catastrophic view.)
  • “What is the effect of believing your automatic thought? What could be the effect of changing your thinking?”
  • If your friend were in this situation and had the same automatic thought, what advice would you give him or her?”
  • “What should you do going forward? How likely are you to do this?”

For more advanced patients, you can vary the questions.

  • “Is it true that [your extreme assumption] always has to be true?”
    • For example, “does it always have to be true that you need to make your mom happy at all times?”
  • “Is it reasonable to expect that sometimes [the situation] will happen?”
  • “Is it desirable to have [this extreme goal]?”

Cognitive distortions tend to fit one or more of these patterns:

  • Catastrophizing—imagining the worst possible thing that could happen
  • Selective bias/tunnel vision/discounting the positive —focusing and emphasizing negative evidence for the thought. Alternatively, ignoring or de-emphasizing positive evidence against the thought.
  • All-or-nothing—”either I get an A...

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Shortform Exercise: Question Your Own Automatic Thoughts

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?

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Cognitive Behavior Therapy: Basics and Beyond Summary Identifying Deeper Beliefs

After the first session, you can begin building a cognitive conceptualization of the patient, linking the whole pathway of

  • Formative experiences
  • To core beliefs
  • To intermediate rules, assumptions, and beliefs
  • To coping strategies
  • To automatic thoughts and reactions

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.

Identifying Intermediate Beliefs

Given the same core belief, people may have different intermediate beliefs.

  • Say two patients have the same core belief, “I’m not good enough to accomplish my goals.” One patient may have the intermediate belief, “I should work as hard as I can at all times.” Another patient may have a very different belief, “I should lower my goals so I don’t get disappointed.”
  • Why do different intermediate beliefs arise? This can be because of genetic predisposition or environmental cues early in life.

How to identify intermediate beliefs:

  • The patient may voice the belief, as an automatic thought or when directly asked about intermediate beliefs.
  • Provide the first part of an assumption, and the patient fills it in.
    • “If I don’t get an A, then ___.”
  • Spot patterns to automatic thoughts—an intermediate thought may drive many of these automatic thoughts.
  • Use the downward arrow technique: Ask what the automatic thought means to the person. (Asking what the thought means about the person tends to show the core belief.)
    • Example questions: “If that’s true, so what?” “What’s so bad about…” “What’s the worst part about…”
  • Use questionnaires like the Dysfunctional Attitude Scale or Personality Belief Questionnaire.

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:

  • Show the patient how beliefs are learned and can be changed.
    • Ask the patient to think about someone who has different beliefs. Clearly the other person learned different beliefs, and so they’re not absolute rules. Also, clearly the other person isn’t a failure (or whatever the extreme belief would lead the patient to believe about herself).
  • Examine the advantages and disadvantages of beliefs.
  • Ask if this is an idea the patient would like to change.

Modifying Intermediate 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:

  • Phrase the rule/belief as an if-then assumption—this makes it easier to spot the logical fallacy.
    • “If I ask for help, I’ll be seen as weak.” vs “Don’t ask for help.”
  • Present more functional beliefs, that are more qualified versions of the old belief
    • “If I don’t get an A, I’m a failure.” can be turned into “If I don’t get an A, I’m just human, and I still tried hard. It’s better than 0%.”
  • Use Socratic questioning.
    • “Let’s say there are 2 people with the same problem. One does [the maladaptive behavior] and feels worse. The other does [a functional behavior] and feels better. Who’s the more competent person?”
  • Set up a behavior experiment.
    • Act “as if” the belief weren’t true. Then reflect on how that behavior makes the person feel.
  • Role play as the patient’s intellectual side and emotional side, with each of you taking a side and swapping turns. As the intellectual side, you explain the rational approach to the situation. As the emotional side, you convey the emotional reaction and automatic thoughts.
    • Explain the rationale to the patient that this will let you see what’s really maintaining the belief.
    • Be the intellectual side first, to give an example of rational reasoning for the patient. The patient will start as the emotional side.
    • After the role play, switch sides. The patient will voice the more functional intellectual thoughts. As you play the emotional side, use the patient’s own words—this will help highlight the dysfunction of the patient’s emotional thoughts.
  • Cognitive continuum—establish that the situation isn’t binary, and the patient is likely better on the scale than absolute zero.
    • Ask where she is on the scale. Then ask whether there is someone who is worse, and what that person would be doing. Keep drilling until it’s someone who’s at absolute zero. (For example, if the patient is worried she’s an academic failure, absolute zero may be someone who goes to zero classes. The patient can see that she’s better than this person.)
    • This technique is useful for patients with “all or nothing” cognitive distortions.
  • Ask the patient to imagine another person with a different belief. Then if the patient respects that other person, help her model that belief for herself.
  • Ask the patient to counsel someone else in her situation, such as:
    • Someone she knows who has the same issue
    • Imagining if their child had the issue
  • Self-disclosure—you’ve gone through a similar situation before and came up with a solution.

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.

Identifying Core Beliefs

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...

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Cognitive Behavior Therapy: Basics and Beyond Summary Homework Assignments

Homework gives the patient opportunities to practice new behaviors and thinking. Patients who regularly complete homework show better progress.

Principles of Homework

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.

  • If the patient didn’t complete the homework, you should take blame for assigning too difficult an assignment or not explaining it well enough.

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.

  • Ask the patient for their own estimation of how likely they are to complete, from 0-100%.
  • It’s better to remove an assignment than to set the habit of not completing an assignment.

Make homework no-lose—even if the patient doesn’t complete homework, she’ll discover thoughts that prevent her from making progress.

Homework Assignment Tasks

Homework assignments can take a variety of forms. Here are common tasks for patients:

  • Behavior activation—the patient just does activities, such as doing light exercise or making a phone call to a friend. For newer patients, this is often more useful to improve affect than more intellectual tasks.
  • Notice automatic thoughts.
  • Evaluate automatic thoughts.
  • Review therapy notes and read coping cards
    • Example of a coping card: “If I start to think that I can’t apply for a job, remind myself that I’m only going to do it for 10 minutes, that it may be difficult but probably won’t be impossible, and that the first minute will be hardest and then it’ll get easier.”
  • Problem solving—implement the solutions devised during sessions.
  • Conduct behavior experiments. Record data as evidence for or against negative thoughts.
  • Read other source material.
  • Prepare for the next therapy session.
  • Set reminders to read over homework multiple times per day.

As therapy progresses, the nature of homework may change:

  • The patient may start proposing homework and giving the rationale for the tasks.
  • The tasks can become more complex, diving deeper into the cognitive model.
  • Some regular tasks will still remain, like reviewing therapy notes daily.

Improving Homework Completion Rate

Here are techniques to increase homework completion rate:

  • Commitment devices
    • Daily checklists of tasks
    • Scheduling tasks in the patient’s calendar
    • Ask the patient to leave a voicemail with you whenever finishing a task
  • Find barriers for doing homework, and problem solve those barriers.
    • Rehearse the situation leading up to doing homework to find issues.
    • These may be practical barriers, such as lacking time in schedule or forgetting.
    • They may also be mental barriers, such as overestimating time or effort, overcoming the activation energy to get started, or believing it won’t work. ...

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Cognitive Behavior Therapy: Basics and Beyond Summary Additional Techniques and Troubleshooting

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:

  • When making decisions and choosing between options, ask the patient to make a list of advantages and disadvantages of each option. Score each entry to help make the ultimate decision.
  • Refocusing: when the patient’s attention veers to distracting automatic thoughts, rather than evaluating their automatic thoughts, instead refocus attention on the task at hand.
  • Distraction: get the patient’s mind off of automatic thoughts.
    • Ask what has worked in the past.
    • Suggestions: watch TV, go for a walk, email a friend, clean her desk, or browse the web.
  • Exposure: keep engaging the object of concern until the negative affect dissipates.
    • Patients often have safety behaviors, such as avoiding thinking about the subject to ward off anxiety, but which perpetuate the fundamental problem.
  • Graded task assignments: reaching the ultimate task (such as landing a new job) may be intimidating. Break the task into its constituent stepwise tasks to make each step seem less problematic (for example, prepare the resume, look at job postings, and so on).
    • Represent the steps visually with a staircase.
  • Role playing
    • Assume a positive outcome: “If you knew for sure the teaching assistant would be willing to talk to you, what would you say?”
  • Pie technique: visually represent something that causes distress. This can help the patient recognize the reality of a situation.
    • Time spent on different activities, with one pie chart showing actual time and another showing ideal time.
    • Attribution of causes for a situation. When shown on a pie chart, the most feared cause may be unlikely.
    • The likelihood of outcomes. When shown on a pie chart, the catastrophic one may be seen as unlikely.
  • Self-comparison: discuss the headwinds the patient has faced by applying them to a different person.
    • “We know that depression is a physiological issue. Would you expect someone who was infected with pneumonia to do everything flawlessly?”
  • Credit lists
    • Keep track of things that were positive or difficult to do.
    • This is a good stepping stone to the Core Belief Worksheet.


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:

  • Continue imagining beyond the image.
    • Often the patient stops at the most distressing part. Continuing past the image often shows how the patient will resolve the situation capably.
    • Picture what happens in the far future—weeks, months, years after the anxious image. Shows that things will likely be resolved satisfactorily.
  • Rework the image to include coping behaviors.
    • Ask leading questions to guide the adaptive behaviors that the patient could do in the situation.
    • This can include coping behaviors like reading coping cards during the stressful situation.
    • Assign homework to remember the positive image.
  • Rework the image to imagine a different outcome.
    • The outcome could be realistic and imagine likely outcomes. Then talk about behaviors that could push toward this outcome.
    • The outcome could also be magical. For example, a scary person could morph into a crying baby with a puff of smoke.
  • Imagine the image multiple times in succession. The severity of the image should decrease.

Use imagery as a therapeutic tool.

  • Induce an image of a situation. The patient then rehearses coping techniques.

Troubleshooting Sessions

Common Pitfalls to Sessions

As a therapist, you may run into the following shortcomings:

  • Failing to set patient expectations for therapy, and of her responsibilities.
  • Failing to emphasize key automatic thoughts
  • Failing to summarize frequently
  • Failing to summarize using patient’s own words
  • Failing to ask the patient for depth of understanding
  • Failing to provide rationale for agenda items or your direction
  • Failing to make a therapeutic intervention—just talking about problems without solving them or assigning homework
  • Failing to record therapy notes for patient to review

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.

Problems in Patient Engagement

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.

  • If the patient gives a neutral reaction, then it's a socialization problem.
  • If the patient is frustrated, then follow this standard procedure, 1) thank the patient for expressing her thoughts, 2) investigate automatic thoughts, 3) provide rationale for what you're doing. Directly tackling automatic thoughts can work, but sometimes it causes too much friction

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.

Interrupting During Sessions

To get the session on track...

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Cognitive Behavior Therapy: Basics and Beyond Summary Planning for Termination and Relapse Prevention

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.

  • The patient needs to develop confidence about her ability to solve her own problems.
  • The patient is the one who puts in the work, so the therapist should get only a portion of credit.

As sessions near the end, patients should anticipate setbacks and anticipate how they will respond.

  • Chart out the patient’s likely affect over time. This can look like the southern border of the US—Texas and Florida are troughs with lows.
  • Role play how the patient will feel during a setback. Ask how they predict they’d feel. In response, answer the thoughts and create coping cards.

Make a list of tools the patient has employed to deal with stressful situations:

  • Identifying, responding to automatic thoughts
  • Using thought records
  • Scheduling activities
  • Techniques for relaxation, distraction, and refocusing

Guide the patient to conduct self-therapy sessions, consisting of a template similar to normal therapy sessions. A template might include:

  • Review of past week, mood check
  • Review homework
  • Review current problems and engage in problem solving
  • Set new homework
  • Schedule next therapy session

Prepare for the taper off of sessions like any other stressful situation.

  • Elicit advantages and disadvantages of tapering therapy, with disadvantages reframed.
    • “I might relapse” can be turned to “If I’m going to relapse, it’s better for it to happen while I’m in therapy so I can learn how to handle it.”
  • Help respond to any distortions, such as catastrophizing a relapse.

Schedule booster sessions.

  • Having these pre-scheduled may...

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Table of Contents

  • 1-Page Summary
  • Principles of Mental Disorders
  • Exercise: Consider Your Automatic Thoughts
  • Principles of Treatment
  • The CBT Session Structure
  • Identifying Automatic Thoughts and Problem Solving
  • Exercise: Question Your Own Automatic Thoughts
  • Identifying Deeper Beliefs
  • Homework Assignments
  • Additional Techniques and Troubleshooting
  • Planning for Termination and Relapse Prevention