Skills in Cognitive Behaviour Therapy

Frank Wills, Author

• Publisher: SAGE Publications Ltd
• Year: 2014
• Print ISBN: 9781446274842, 9781446274835
• eBook ISBN: 9781473911215
• Edition: 2
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

This step-by-step guide to the core skills and techniques of the cognitive behaviour approach is suitable for those with little or no prior experience in CBT. The author uses case examples from a variety of settings to illustrate the skills needed at each stage of the therapeutic process, and brings the therapeutic relationship to the foreground to show you how to build and maintain a successful working alliance with your clients.

 

This second edition includes new content on:

- the historical foundations of CBT
- common presenting issues, such as depression and anxiety

- third wave CBT

- IAPT
- insights from other approaches, relevant to trainees in other modalities with an interest in CBT

 

Accompanied by a new companion website,  which includes additional case studies, template forms, PowerPoint presentations for each chapter, and a wealth of material for further reading, this is an essential text for anyone wishing to hone their therapeutic skills in CBT.

Appendix 1 : Resources for CBT Measures

As described within the text, a defining feature of CBT practice has been the use of psychological measures to assess problems and monitor client progress – classically using quantitative measures such as inventories to gauge the strengths of symptoms in anxiety and depressive disorders. The Internet has revolutionised access to such measures, many of which can be downloaded without any charge from various websites. Some measures, however, such as the Beck measures (see below), still require registration and payment – so users need to access some caution that they are legally using a measure that they come across.

Pearson Clinical (www.pearsonclinical.co.uk)

Therapists need to register so that they can purchase the following measures:

• ◆ Beck Depression Inventory II (BDI)
• ◆ Beck Anxiety Inventory (BAI)
• ◆ Beck Hopelessness Scale (BHS)
• ◆ Beck Obsessive & Compulsive Scale (BOCS).

These are also available as measures especially adapted for children and young people.

Free Downloadable Measures

It is now difficult to cover all the many available websites, and in any case they can be found via relatively straightforward searches by the use of key terms. One good starting point for aspirant CBT therapists is via the website of the Oxford Cognitive Therapy Centre (OCTC) where measures are downloadable without charge for a wide variety of problems that readers of this book are likely to be interested in: www.OCTC.co.uk/resources

Appendix 2 : Other Cognitive Methods using Cost Benefit Analysis and Pie Charts

It is sometimes said that there are three main ways of challenging negative thoughts:

• ◆ reality testing (‘What is the evidence?’)
• ◆ pragmatic testing (‘Is that thinking justified when it makes you feel that way?’)
• ◆ logic testing (‘Does that way of thinking really make sense?’).

Quite often a CBT practitioner will deploy all these three ways and then see which seems to be the most helpful to the individual client. Clients obviously have different ways of doing things within their own heads, and some ways of challenging thoughts will chime with their internal processes better than others. There is, however, usually no sounder way of finding this out other than by ‘suck it and see’. It is probably also often a case of ‘all hands to the pump’ and ‘we’ll use whatever works’. From my experience with clients, however, I would say that, for most clients, logical challenges often have limited effects. Reality-testing challenges can work well but often they are helpfully reinforced by pragmatic challenges. Pragmatic challenges are often the ones that bring a commitment to thinking about things in a different way, because, the client might say, they really work against me. The CBA technique is probably the clearest and most parsimonious of the pragmatic challenges.

Cost Benefit Analysis (CBA)

CBA shows a subtle acceptance of the fact that sometimes the client’s negative thinking may have some subtle pay-offs. Readers can probably all remember that before an exam, many examinees will be heard loudly declaring that they haven’t done ‘any revision at all!’ Isn’t it amazing how many then go on to pass? Similarly, some people who declare ‘I’m such a failure’ may be partly concerned to lower the expectations of others and also avoid later negative labelling by getting in first themselves. CBA helps to acknowledge these ‘benefits’ yet also set them against the context of their disadvantages:

Problems with CBA can sometimes arise if clients are not willing to acknowledge that there are any advantages to negative thinking so we end up with a one-sided battle and an unsatisfying victory for the positive rational side. Clients can sometimes be helped to acknowledge ‘benefits’ by distinguishing between ‘short term’ and ‘long term’ cost and benefits. The advantages of negative thinking are heavily weighted towards short-term coping and against longer-term life development. It is probably easier to own a flawed coping mechanism as a way of coping in the short term, until a more positive longer-term strategy can be devised and implemented. Leahy (2003) suggests that the simple CBA above can also be used to review positive alternative thoughts. The CBA is really a form of problem solving and can be adapted to decision making. When problems with decisions arise they frequently involve other people, therefore it is useful to consider the costs and benefits for others as well as for oneself so that the matrix now looks like this:

Pie Charts

When we discussed cognitive distortions in Chapter 4, we noted that one of the main ‘serial offenders’ was ‘making over-statements’. These types of statements seem to result from negative attention bias – but they also reinforce it. It may well be that there is a form of ‘special pleading’ going on here. Special pleading is a well-known device to secure advantage by a selective review of the facts of the case. Here they seem to relate to securing disadvantage – unless we consider the case for ‘subtle pay-off’ made above.

The cognitive tactic is usually to get the client to see that their review of relevant factors is restricted and to explore whether a wider consideration of the facts may be helpful.

A flagrant distortion was immediately evident to me when one of my clients blamed herself for the fact that her husband had left her. It turned out that her husband had a gambling addiction and had over the years persuaded her to sign away all their joint money and assets to him, so that when he went away with another woman, my client lost everything including the roof over her head. We drew one circle in which she was attributed 100% of the responsibility for the break-up – ‘If I had been a better wife, he wouldn’t have got into gambling in the first place.’ Then we listed some other factors that might have been involved so that a new ‘pie chart’ circle could be drawn. Leahy (2001) is spot on in suggesting adding ‘bad luck’ to the list – a more potent factor than most of us allow! The resulting list looked like this:

• ◆ My husband’s gambling:  60%
• ◆ My husband’s drinking:  20%
• ◆ The other woman:  10%
• ◆ The gambling and drinks industries:  5%
• ◆ Bad luck:  4%
• ◆ Not being a super wife:  1%

Figure A.1 Pie chart (based on above percentages)

Pie charts can have very powerful effects but, like all methods, sometimes run into problems. Therapists can sometimes feel a bit manipulative when they do the kind of pie chart described above – especially knowing that leaving the client’s responsibilities until last virtually guarantees that only a tiny percentage of responsibility will be left by then. In the above example, we had to keep readjusting the previous figures to allow any percentage at all for the last few items. It can also be important for people to retain some responsibility, sometimes as a moral issue but also sometimes to be a player of some account. It strikes me in retrospect that this latter point was particularly true for this client after such a thorough ‘disempowerment’ by her husband. I wish I could record that I had registered this at the time – perhaps next time, eh?

Further reading

Burns, D.D. (2001) Ten ways to untwist your thinking. In The feeling good handbook. Harmondsworth: Penguin.

Leahy, R.L. (2001) Cognitive therapy techniques: a practitioner’s guide. New York: Guilford. (Chapters 2 and 6)

References

APA (2000) Diagnostic and statistical manual IV-TR. Washington: American Psychiatric Association.

Anchin, J.C., & Kiesler, D. (1982) Handbook of interpersonal psychotherapy. New York: Pergamon Press.

Aristotle (2012) Nicomachean ethics. Chicago: University of Chicago Press.

Arnow, B.A., Steidman, D., Blasey, C., Mender, R., Klein, D.N., Rothbaum, B.O. et al. (2013) The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic de...

Table of contents

• Cover
• Table of Contents
• Half Title
• Acknowledgements
• Title Page
• Copyright Page
• Illustration List
• Table List
• About The Author
• Acknowledgements
• Companion Website
• Introduction
• Practising CBT Skills within their Knowledge Base
• Skills for Assessing, Formulating and Starting CBT
• Skills for Developing the Relationship in CBT
• Skills for Working with Negative Thinking
• Skills for Working on Changing Behaviour
• Skills for Working with Emotions
• Skills for Working with Enduring Life Patterns
• Maintaining and Developing CBT Skills
• Appendix 1 : Resources for CBT Measures
• Appendix 2 : Other Cognitive Methods using Cost Benefit Analysis and Pie Charts
• References
• Index