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

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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...

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• 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...

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• 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...

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*   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...

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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...

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• 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...

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*   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.

Imagery

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...

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• 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 motivate the patient to do homework in between.
• It reduces anxiety about being on their own.
• Assign questions to answer before booster sessions about what work has done in between, and how problems were handled.