Cognitive Behaviour Therapy

100 Key Points and Techniques

Michael Neenan, Windy Dryden

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781000332995
• Edition: 3
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

Cognitive Behaviour Therapy: 100 Key Points and Techniques is a crisp, concise elaboration of the 100 main features of the very popular and evidence-based CBT approach within the field of psychotherapy.

In recent decades CBT has been applied to an ever-increasing number of problems (including anxiety disorders, substance abuse and eating disorders) and populations (children, adolescents and older people). With newly incorporated material on supervision, this extensively revised and updated third edition covers CBT theory and practice. Divided into helpful sections, the topics covered include:

• Misconceptions about CBT
• Teaching the cognitive model
• Assessment?case conceptualization?treatment planning
• Ways of detecting and answering negative automatic thoughts (NATs)
• Homework (between-session assignments)
• Conducting behavioural experiments
• Uncovering and restructuring intermediate and core beliefs
• Relapse management
• Resistance
• Supervision
• Third wave CBT

This compact, usable book is an essential guide for psychotherapists and counsellors, both trainee and qualified, who need to ensure they are entirely familiar with the key features of CBT as part of a general introduction to the current major psychotherapies.

Part 1

CBT THEORY

1

IT IS NOT EVENTS PER SE THAT DETERMINE OUR FEELINGS BUT THE MEANINGS THAT WE ATTACH TO THESE EVENTS

‘At the very heart of the C[B]‌T model is the view that the human mind is not a passive receptacle of environmental and biological influences and sensations, but rather that individuals are actively involved in constructing their reality’ (Clark, 1995: 156). In order to understand a person’s emotional response to particular life events, it’s important to discover the meaning they attach to these events: their subjective construction of reality. For example, a person whose partner has left him believes he cannot be happy or cope on his own and becomes depressed; another person whose partner has departed feels relieved that she has been freed from a ‘stifling relationship’; a third person feels guilty as he views his bad behaviour as the reason for her departure – the same event for each person, but not the same emotional reaction to it as each reaction is mediated by the person’s view of the event. In order to change the way we feel about events we need to change the way we think about them. Searching for the meaning attached to each emotion would be the same if the person had a range of emotions to a single event or continually changing emotions as events unfold over the short or longer term (see Point 6).

This conceptual cornerstone of cognitive behaviour therapy (CBT) derives from ancient Stoic philosophers such as Epictetus and Marcus Aurelius and their views on mental control, i.e. our thoughts and beliefs are within our control whereas many things that happen to us in life are outside of our control; therefore, we can choose how we respond to events – events themselves do not cause or dictate our emotional reactions. For example, losing your job in a recession is outside of your control but losing your self-respect as well is a judgement you have made about being jobless (for a fascinating discussion on the links between Stoic philosophy and CBT, see Robertson, 2020).

CBT does not argue that a person’s emotional problems are simply created in her head but that the impact of adverse events (e.g. being burgled) can be greatly exacerbated by the person’s unhelpful thoughts and beliefs that interfere with her ability to cope constructively with such events (e.g. ‘I can never ever feel safe again in my own home no matter how many locks I put on the doors and windows’). CBT helps clients to develop alternative and adaptive viewpoints in order to tackle their problems:

If I keep things in perspective, I know that the increased security measures will help to keep me safe in my home and my mind, but I realize and accept, without liking it, that there can be no guarantee I won’t be burgled again.

Developing alternative viewpoints underscores the CBT principle that there’s always more than one way of seeing things, no matter how unpleasant these things are. Even in the unspeakable horrors of Auschwitz, Viktor Frankl (1905–1997), a famous psychiatrist, observed that ‘everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way’ (1946 [1985]: 86).

As here, the Frankl quote is frequently found in the CBT literature to emphasize our inner freedom to choose but this view of life in the Nazi camps doesn’t go uncontested (an alternative viewpoint). For example, the Holocaust scholar Lawrence Langer (2014: xiv) insists that ‘the role of chance far outweighed the role of choice in the fate of the survivors’; and the barbaric ‘events they endured rudely dispel as misconception the idea that choice is purely an internal matter, immune to circumstance and chance’ (Langer, 1991: xii). Primo Levi (1919–1987), who survived Auschwitz, stated: ‘I insist there was no general rule [for survival] … luck dominated’ (1947[1996]: 180).

2

INFORMATION PROCESSING BECOMES DISTORTED WHEN WE EXPERIENCE EMOTIONAL DISTRESS

Cognitive theory is based on an information-processing model ‘which posits that during psychological distress a person’s thinking becomes more rigid and distorted, judgements become overgeneralized and absolute, and the person’s basic beliefs about the self and the world become fixed’ (Weishaar, 1996: 188). In an undisturbed frame of mind, a person is likely to check her impressions and appraisals of events in order to obtain accurate information. When emotionally upset, the person will usually distort incoming information by introducing a consistently negative bias into her thinking so that it becomes rigid and overgeneralized, e.g. she’s upset when not invited to a friend’s party because she interprets the lack of an invitation as meaning that she’s an unlikeable person. Instead of ascertaining the reasons for not being invited, or keeping an open mind about it, she dwells on her supposed unlikeability, lowering her mood in the process. We all, at times, engage in distorting incoming information so we get trapped in, for example, all-or-nothing thinking or emotional reasoning (see below).

Distorted thinking underlies all psychological disorders (Ledley et al., 2010). These distortions usually stem from deeper dysfunctional beliefs that are activated during emotional distress, e.g. a person experiencing depression after the breakup of his relationship insists ‘I’ll always be alone’ (fortune-telling) because he believes he is unattractive (core belief). Common information-processing errors or biases found in emotional distress include:

•All-or-nothing thinking: situations and individuals are viewed in either/or terms, e.g. ‘You’re either trustworthy or not. It’s as simple as that.’

•Jumping to conclusions: judgements are rushed rather than considered, e.g. a client says after the first session ‘Therapy isn’t helping me’ (her problem is a long-standing one).

•Confirmation bias: seeking evidence to confirm existing beliefs and ignoring or discrediting disconfirming evidence, e.g. a depressed client looking back over his life says ‘I’ve never had any real friends because I’m so unlikeable. Those few that said they were my friends were only feeling sorry for me or playing games with me.’ As Shermer (2020: 317) remarks, ‘The confirmation bias is succinctly articulated in the biblical idiom: “seek and ye shall find”.’

•Mind-reading: discerning the thoughts of others without any accompanying evidence to support such claims, e.g. ‘My boss didn’t smile at me this morning, so that means she is unhappy with my work’ (she praised his work previously without smiling at him).

•Labelling: attaching global negative labels to oneself, others or the world, e.g. ‘I didn’t understand what she said unlike others in the group, so this must mean that I’m stupid’ (he is also mind-reading in assuming that everyone else in the group understood what was said).

•Emotional reasoning: assuming that feelings are facts, e.g. ‘I feel incompetent, so it must be true’ (‘incompetent’ is a belief, not a feeling – see Point 48).

Teaching clients how to identify and correct these errors or biases shifts their thinking from reflexive (automatic) to reflective (deliberative) information processing thereby slowing it down in order to improve problem solving and decision making. This shift is also known as metacognitive awareness, i.e. thinking about thinking (incidentally, a definition of philosophy), e.g. ‘I can see now how much of my overreactions to setbacks are shaped by this emotional reasoning I’ve learnt about.’ In the example in the opening paragraph, the person discovers that her friend had invited her but ‘My mother forgot to pass on the message. If I hadn’t got so upset, then I wouldn’t have jumped to conclusions, as I do far too often.’ If she hadn’t been invited and it was expected that she would be, then she needs to contact her friend to find out why she has been excluded from the invitation list. Even if her friend deliberately excluded her, this doesn’t mean she’s an unlikeable person, but a person not immune from her friendships ending and having to learn to adapt to this unwelcome reality.

A development in CBT called ‘third wave’ therapies (see Point 100) uses metacognitive awareness to change one’s relationship to upsetting thoughts by learning to detach from and accept them, thereby mitigating their unpleasant impact, instead of trying to change these thoughts by arguing with, avoiding or suppressing them.

3

AN EMOTIONAL DISORDER IS USUALLY UNDERSTOOD BY EXAMINING THREE LEVELS OF THINKING

These three levels of thinking are: negative automatic thoughts (NATs), underlying assumptions/rules, and core beliefs.

•NATs are situation-specific and involuntarily ‘pop’ into a person’s mind when he’s experiencing emotional distress such as depression or anxiety. They appear plausible to the person and are difficult to turn off. NATs often lie outside of immediate awareness but can be quickly brought to the client’s attention by asking standard CBT questions like: ‘What was going through your mind at that moment when you got to the meeting late?’ (Client’s reply: ‘I’m always late. I’m undisciplined, sloppy. My colleagues will look down on me.’) NATs can be triggered by external events and/or internal events (e.g. pounding heart: ‘I’m having a heart attack. Oh God! I’m dying!’). NATs can also occur as images, e.g. a person sees himself ‘dying of embarrassment’ if he makes a faux pas as best man at his friend’s wedding. Clients are usually more aware of how they feel than of the thoughts that prompted the feeling (J. S. Beck, 2011). NATs are usually the starting point for clinical investigation. The alternative to NATs are not PATs (positive automatic thoughts) as they can be equally distorted (e.g. ‘Once the problem is gone, it won’t reoccur’), but thoughts based on reason and evidence that provide a realistic and balanced view of events.

•Underlying assumptions (e.g. ‘If I impress others, then I should get ahead in life’) and rules (e.g. ‘I should not let people down’) guide behaviour and set standards. These assumptions and rules are often unarticulated and can be difficult for clients to detect. Underlying assumptions are usually identified by their ‘if … then’ or ‘unless … then’ construction, and rules are usually expressed in ‘must’ and ‘should’ statements. These assumptions and rules are the means by which individuals hope to avoid coming face to face with their negative core beliefs (e.g. ‘I’m incompetent’). The ‘truth’ of these core beliefs is not questioned and, therefore, assumptions and rules serve to maintain and reinforce them. Trouble looms for the person when behaviour is not what it should be, standards are not met or rules violated; ‘trouble’ is the activation of the negative core belief from its dormant state. Beck et al. (1985) suggest that maladaptive assumptions often focus on three major issues: acceptance (e.g. ‘I’m nothing unless I’m loved’), competence (e.g. ‘I am what I accomplish’) and control (e.g. ‘I can’t ask for help’). Assumptions and rules are cross-situational and are also known as intermediate beliefs because they lie between NATs and core beliefs (J. S. Beck, 2011).

•Core beliefs (also known as schemas; see below) are the third level of thought and the deepest. Negative core beliefs are overgeneralized and unconditional (e.g. ‘I’m hopeless’). They are usually formed through early learning experiences and lie dormant until activated by relevant life events (e.g. the client sees himself as thoroughly incompetent for not living up to his unrelenting standards of always being efficient, punctual and disciplined). Once activated, negative core beliefs process information in a biased way that confirms them and disconfirms contradictory information (e.g. ‘So what if I’m mostly on time for meetings?’). Core beliefs can be about the self (e.g. ‘I’m unloveable’), others (e.g. ‘I can’t trust anyone’), and/or the world (e.g. ‘Everything is against me’). Once the distress has passed, negative core beliefs become deactivated or return to their latent state and a more positive outlook is re-established (clients with personality disorders may have their negative core beliefs activated most of the time; see Davidson, 2008). Modifying core beliefs and schemas ‘is believed to result in the most generalizable change and the greatest prevention of relapse’ (Beck and Dozois, 2011).

How do these three levels interact? A person feels depressed when he fails to get A grades in his exams. His dormant core belief, ‘I’m a failure’, is activated by his inability to live up to his rigid rule of living that he must be the best at everything he does and his mind is flooded with NATs: ‘I can’t show my face at college. Run away and hide. The whole college is laughing at me.’ It’s important to point out that not every client problem will have or need this three-level examination, particularly in short-term CBT. Therapists, however, are often eager to move beyond the NATs (‘the superficial stuff’) and ‘get at’ these deeper beliefs because they see it as the ‘real work’ of CBT. For them, it may be sobering to learn that ‘pretty much all the research supporting the effectiveness of CBT [for most common mental health problems] is based on CBT that focused on NATs and sometimes DAs [dysfunctional assumptions], not CBs [core beliefs]’ (Westbrook, 2014: 20). Dobson and Dobson (2018) suggest that it’s quite likely that negative core beliefs change gradually without directly modifying them if clients continue to think and act differently over the longer term – an indirect process of ‘chipping away’ at core beliefs.

We would like to end this point on a technical note about schemas and core beliefs. Cognitive schemas ‘are organized structures of stored information that contain individuals’ perceptions of self and others, goals, expectations and memories’ (Beck and Dozois, 2011). Core beliefs (e.g. ‘I’m no good’ and ‘People cannot be trusted’) represent the content of the schemas. As these examples of...

Table of contents

• Cover
• Half Title
• Series Information
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Part 1 CBT Theory
• Part 2 Misconceptions About CBT
• Part 3 CBT Practice
• References
• Index