I’ve had many other counselors over the years and I chose you because of your focus on CBT (Cognitive-Behavioral Therapy). I really relate to your more analytical, organized, solution focused approach verses just letting me talk and you listen. It feels more pragmatic.– Client review
Cognitive-Behavioral Therapy (CBT) is one of the major tools used in psychotherapy. CBT assumes that the way that people perceive situations is more closely connected to their reaction than the situation itself.
Simply put, a therapist’s job when using CBT is to help clients identify the thoughts that pop up into their minds, evaluate, and respond to them. The assumption is that when clients are able to do this, they feel better and can act in accordance with their values and goals. One critical concept underlying all aspects of CBT is that just because you think something doesn’t necessarily mean it’s true.
CBT is evidence-based. This means that it is backed by research to be an effective treatment. However, it’s worth noting that any type of therapy (such as CBT) cannot be “evidenced based” without listing what disorder it is effective in treating. For example:
- CBT is an evidence based treatment for Major Depressive Disorder. The therapist focuses specifically on the automatic thoughts that have to do with the self, the world, the future.
- CBT is an evidence based treatment for Panic Disorder. The therapist focuses on the automatic thoughts that have to do with the catastrophe that the client is afraid will happen if a symptom gets worse.
- CBT is an evidence based treatment for Obsessive-Compulsive Disorder. Here, a CBT therapist doesn’t focus on automatic thoughts; rather, the focus is on the beliefs that the client has about their obsessive thinking and about their ritualistic behavior.
Where Therapists Get CBT Wrong
Many therapists jump into CBT without understanding the fundamental concepts and techniques, and apply a scattered “try, try again” approach with techniques. In fact, when working with clients it is critical to delay introducing CBT techniques until they have demonstrated two essential things first:
- That your client believes and “buy in” to the cognitive model (that “thinking influences how we feel and what we do”) and that by evaluating their thinking, they can feel and act better.
- Clients should also be able to demonstrate to you that they can use the list of socratic questions (see below) and have filled out any related worksheets with you during/in-session. Otherwise, any assignments you give will be half-believed, half-accomplished and will be unlikely to make any material change in their cognition between sessions.
Action Plans (“Assignments” or “Homework”)
It’s just not enough to come in and talk for 50 minutes a week. The way that people get better is by making small changes in their thinking and behavior every day. That’s why action plans are so crucial. Research consistently demonstrates that CBT which includes action plans is more effective than CBT that doesn’t.
Most people don’t like homework, so “assignments” or “action plans” are used instead. However, I’ve found that the following question helps to identify clients who are more likely to follow through with CBT assignments (i.e, those who don’t choose the third answer):
- How do you prefer to spend your time in-between sessions?
- I prefer reading assignments
- I prefer written assignments
- I prefer to just reflect and think on what was discussed in session.
Assignments entail some kind of responding to the client’s negative thinking and behavioral change. If in doubt, you can ask your client, “What do you think is most important to remember this week? What would you like to do about it? What would you like to remember?” At a minimum, clients should be assigned the following activities in-between sessions:
- Read coping cards or therapy notes everyday
- Implement solutions to problems
- Monitor experiences so that they can notice important automatic thoughts
- Respond to their negative cognitions
- Practice new behavioral skills
To be an effective therapist, you have to continuously conceptualize clients’ experiences. You must understand what the client’s specific problem is and decide on a treatment technique, such as:
- Evaluating their thoughts
- Identifying and modifying their beliefs
- Doing problem solving
- Teaching skills to regulate emotions
- Change their behavior
- Decrease their physiological arousal
- Acceptance of the problem and changing their focus
In the end, people’s reactions always make sense once you understand what they were thinking. That’s the hallmark of CBT.
Understanding Thoughts, Emotions and Behaviors
For example, think of a recent situation in which you felt at least a little distressed. Or where you engaged in an unhelpful behavior, or noticed a change in your body. With CBT, we ask ourselves:
- What was the situation? Or what were you thinking about, remembering, experiencing or predicting?
- What went through your mind? (Automatic Thoughts)
- How did you feel emotionally? What was your reaction? (Emotions)
- Did your body react? If so, how? (Physiological)
- What did you do? (Behavior / Coping strategy)
The resulting behaviors can tell us what kind of strategies a person has developed to survive in life. These patterns tend to be consistent and, at times, dysfunctional.
Understanding Core Beliefs
Initially, your work with a client will focus on evaluating and modifying their thoughts and/or beliefs. As sessions progress, you might begin to focus on clients’ deeply held beliefs, which are referred to as Core Beliefs. Core beliefs prevent you from gathering evidence to contradict your analysis of a situation. You can identify these beliefs as they are always active (24 hours a day, 7 days a week) and act as a “lens” where whatever happens to you gets filtered through it.
There are three primary categories of Core Beliefs:
- Ineffective in getting things done
- Ineffective in protecting ourselves
- Ineffective as compared to other people
- Worthlessness (belief that you are morally bad)
How Client Cope with their Core Beliefs
People cope with their Core Beliefs by using Assumptions or “Rules for Living”, regardless of whether they create more problems than they solve. Coping Strategies are the characteristic ways that clients behave in order to protect themselves from the activation of their core beliefs.
Most of these take the form of an “if…/then…” format. For example, “If I don’t trust people, then I’m going to be ok. But if I do trust them, I’m going to be hurt, and therefore proven unloveable.” Therapists help clients evaluate these conditional assumptions by exploring both the positive assumption that helped them cope with their core belief, as well as any negative counterparts to their assumptions.
Modifying Core Beliefs
Using what CBT therapists refer to as the “downward arrow approach”, you identify a core belief through automatic thoughts by asking, “If your automatic thought were true, what would that mean? And especially, what would that mean about you?” This can be time consuming and challenging as clients often express their core beliefs as an automatic thought. You can also explore how the client has coped with these core beliefs all their life, examine what kind behavioral strategies they have developed to get along with in life, and identify some consistent patterns of behavior that are, at times, dysfunctional.
Core beliefs can’t be worked on during the initial steps of therapy until the client is in agreement with the critical concept above (thoughts are not necessarily true). Also, questioning one’s core beliefs questions a client’s core self, which can be very uncomfortable; this requires trust in the therapeutic relationship to be solid and established.
Cognitive distortions are often the blueprint with which we explain and comprehend what happens to us in life. With CBT, it’s not essential to label the cognitive distortion, but it can be helpful to give clients some cognitive distance from their emotionally charged thoughts. Some common distortions include:
- All-or-Nothing Thinking: You see things only in two categories. Things are black or white, with no shades of grey. “I have to do a great job on everything.”
- Fortune-Telling: You make negative predictions about what will happen when other outcomes are more likely. “I’ll always have trouble figuring out my thoughts.”
- Labeling: You put a globally negative label on yourself. “I’m a failure for making a mistake.”
- Emotional reasoning: You believe something must be true because it “feels” true. “I must be incompetent.”
- Selective abstraction: You pay attention only to the negative aspects of situations instead of considering the entire experience. “I made so many mistakes”.
- Over-generalization: You draw a general conclusion on the basis of a small amount of evidence. “I do everything wrong.”
- Mind reading: You are sure you know what others are thinking. “They probably think I’m foolish.”
- Personalization: You take others’ actions personally when they actually have other intentions. “They did that to me on purpose.”
- Imperatives: You have an unreasonably rigid idea about how you or others should or must behave. “I should always do my absolute best.”
- Magnification and minimization: You magnify the negatives or minimize the positives. “I’m no good at figuring out what to do.” “It doesn’t matter that I have good common sense.”
Adapted from Cognitive Behavior Therapy: Basics and Beyond (J. Beck, 2011)
Responding to Dysfunctional Cognitions
Cognitive-Behavioral therapists tend to challenge these thinking errors using a variety of techniques, including Socratic Questioning, Behavioral Experiments, Labeling of Cognitive Distortions, Cognitive Challenging/Refocusing/Reframing, Exploration of Coping Patterns, Exploration of Thoughts and Emotions, Interactive Feedback, Role-Play/Behavioral Rehearsal, and using Analogies and Metaphors.
Of these, the most important is Socratic Questioning, where clients learn how to evaluate thoughts and beliefs by gathering evidence, developing alternative explanations, de-catastrophizing, and using other Socratic questions, such as:
- What’s the evidence?
- What’s the evidence on the other side?
- What’s another way of looking at this situation?
- If the worst happens, how could you cope?
- What’s the best outcome?
- What’s the most realistic outcome?
- What’s the effect of changing your thinking about this?
- What would you tell a friend who was in the same situation?
- What do you think you should do?
How to End every CBT Session
The single most important question to ask your client at the end of each CBT session is, “How likely are you to do your assignments (action plan) this week?”
- If your client responds saying 90-100%, you’re all set for success.
- If they say 75%, your client will do some of the assignment, but just before the session just to please you.
- If they say 50%, they’re not going to do it, but they don’t want to tell you.
To reach 90%, make certain the action plans are easier, or make parts of the action plan optional. You can ask yourself, “What are the practical problems (or automatic thoughts) that will get in my way?” Once you’ve addressed these and revised your action plan, you can then ask yourself, “NOW how likely am I to do the action plan this week?”