Information

CBT approach and why we generate unrealistic thoughts

CBT approach and why we generate unrealistic thoughts



We are searching data for your request:

Forums and discussions:
Manuals and reference books:
Data from registers:
Wait the end of the search in all databases.
Upon completion, a link will appear to access the found materials.

On reading about Cognitive-Behavioural Therapy (CBT) I encounter

But, if you feel sad after a friend cancels your lunch plans and you begin to think there's obviously something seriously wrong with you and no one likes you, this is problematic because this thought is extreme and not based on reality.

This makes sense because concluding that none likes you from canceling lunch is overestimation.

But my question is different: how or why are we generating these unrealistic thoughts in the first place? Especially given that after some challenging these thoughts, we can correct them ourselves. So if we can correct them ourselves after challenging them, why do we generate these unrealistic thoughts in the first place, and not the correct ones?


Another way to phrase these questions would be:

  • Why do humans feel fear and anxiety?
  • Why are humans particularly sensitive to potential losses See: https://en.wikipedia.org/wiki/Loss_aversion

In the broadest terms, the answer is that we evolved to have these mental characteristics because they probably gave our ancestors a survival and/or reproductive edge over their contemporaries. In the past, humans needed to be socially accepted in a small tribe; exclusion meant actual death as it was too hard to survive alone. Hence, we evolved to be hyper-sensitive to signs of social exclusion.

Your final question might be:

  • How come we can't control our feelings with our thoughts?

See the first point above. It didn't help us survive to be calm and at peace.


Abstract

La terapia cognitiva-conductual (TCC), como una forma de terapia, es más que una mera �ja de herramientas”. La TCC permite una mejor comprension de como funciona la mente humana ya que se basa en las neurociencias y en la psicolog໚ experimental y cientໟica. El Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM) inicialmente fue 𠇊teórico”, pero actualmente (la versión más reciente, el DSM 5) se basa cada vez más en paradigmas de TCC (con la inserción de importantes nociones tales como cognitiones y conductas). Este reporte breve presenta el conocimiento actual sobre el trastorno de ansiedad generalizada (TAG) y cómo puede ser tratada esta condición a través de medios no farmacológicos. En los últimos años, las teor໚s del TAG han evolucionado, Ilegando a ser más precisas acerca del funcionamiento cognitivo de quienes lo padecen. En este artໜulo se revisan los modelos teóricos actuales y las principales tຜnicas de manejo terapéutico, como también los avances en la investigación sobre el proceso “transdiagnóstico” y el TAG en la ni༞z. La TCC es un tratamiento efectivo para el TAG y lo característico es que reduzca las preocupaciones. Un estudio ha mostrado que dicha terapia es equivalente al tratamiento farmacológico y más efectiva a los seis meses de haber completado el estudio.


CBT History Timeline

CBT suggests that if we can challenge irrational thoughts with the evidence we can overcome our negative emotions.

Founded by Zeno of Citium around 2,000 years ago, Stoicism suggested that negative emotions were generated by errors of thinking.

Zeno asserted that ‘man conquers the world by conquering himself’. This idea forms the basis of what we now call ‘resilience’ in CBT.

Another Stoic philosopher, Marcus Aurelius – this time a Roman – is reported to have said: ‘Very little is needed to make a happy life it is all within yourself, in your way of thinking.’

We see that CBT history can be traced back to those early thinkers

Evolution of CBT

Drawing upon Stoicism, US psychologist Albert Ellis (1913–2007) developed rational emotive behavioural therapy (REBT) – the earliest form of cognitive-based psychotherapy – in the 1950s.

This philosophy gave Ellis the idea that humans have a tendency to think irrationally, based on self-defeating beliefs that lead to problematic cycles of behaviour.

Ellis held both an MA and a PhD in clinical psychology from Columbia University. He was apparently a sickly child who lacked self-confidence, and he struggled as a young man to talk to women of his own age.

Wanting to find a partner, he decided to try to tackle his shyness by going to Central Park in New York and making himself talk to 100 women. Although he didn’t get a date from this, he became more confident about talking to women and managed to alter what he saw as his irrational fear.

Ellis viewed helping people to think more rationally as the best route to improving their emotional and behavioural functioning.

REBT belongs to the behavioural school of therapy and is closely related to CBT. It is an active-directive therapy based on challenging faulty beliefs (replacing irrational thinking with rational thinking) to resolve emotional and behavioural problems.

Believing that we can think our way out of distress, Ellis developed the ABCDE model, named after the five stages that it involves:

  • Activating event (for example, you crash your car)
  • Belief system (this leads you to believe that you are a bad driver)
  • Consequences (emotional and behavioural: you stop driving because you fear you will have another accident)
  • Disputing irrational beliefs (the counsellor disputes that you are a bad driver, and points out that most people have at least one accident in their driving career)
  • Effects (cognitive and emotional) of revising your beliefs (now known as ‘cognitive restructuring’).

Ellis believed that the therapist was primarily a teacher, and so did not put any focus on the therapeutic relationship.

REBT is considered highly directional and sometimes confrontational, and is based around the personality of the client. Ellis would interrupt, swear and shout as a way of drawing attention to the client’s irrational thinking.

Aaron Beck, the creator of CBT theory

Feltham & Dryden (1993: 31) define CBT as ‘an umbrella term for those approaches based on, related to, or developing from behaviour therapy and cognitive therapy’.

It is a psychological therapy that emphasises thoughts, originally developed as ‘cognitive therapy’ in the 1960s by US psychiatrist Aaron Temkin Beck, who was born on 18 July 1921 and studied at Yale University.

Beck studied and practised Freudian psychoanalysis when he designed and carried out several experiments to test the effectiveness of psychoanalysis for depression, he was surprised to find that this therapy was not effective.

This led him to look into developing an alternative approach. He noticed that counselling clients often had an internal dialogue that was negative and self-defeating.

In contrast to Ellis, Beck took a new approach in terms of stressing that a therapeutic relationship is integral to the therapy being successful, that clients need to discover their own ‘faulty’ thinking, and that it is the client’s disorder rather than the personality that is important.

The work of George Kelly on personal constructs psychology was also important to the development of the history of cognitive therapy. Kelly held that every individual uses their own set of personal constructs to make sense of their experiences.

CBT is a model of ‘faulty’ (irrational) thinking. The thoughts, emotions and behaviours that arise following a person’s perception of a situation can then form a vicious circle, with the unhelpful behaviour then triggering further negative thoughts . CBT aims to break the vicious cycle through changing either the thoughts or the behaviours – and so to turn it into a virtuous cycle.

In the 1970s, behavioural psychologists and educators started to develop new approaches focusing on acquiring cognitive and behavioural skills so people could self-manage their psychological problems.

Donald Meichenbaum worked on cognitive-behavioural modification, identifying dysfunctional self-talk to change unwanted behaviours.

Moving into the 1980s, multi-modal behaviour therapy was developed by Arnold Lazarus this technically eclectic modality is ‘heavily based on a systematic assessment of the way in which clients function’ (Feltham & Dryden, 1993: 116).

Lazarus was originally trained in behaviour therapy but – realising its limitations – ‘began to incorporate cognitive and other strategies into his work’ (Seligman, 2006: 447).

In the modern era, Christine Padesky – joint author with Dennis Greenberger of Mind Over Mood (voted by BABCP as the best-selling client self-help manual) – has made significant contributions to CBT methodology, as recognised in receiving the Aaron Beck award in 2007.

It was Padesky (1995: 4) who first coined the ‘hot-cross-bun model’, which diagrammatically shows how thoughts, emotions, physical feelings and behaviours all interact with each other, within a situation (see below).


9 Things You Should Know About Cognitive Behavioral Therapy

You’ve probably heard of cognitive behavioral therapy (CBT), the evidence-based psychotherapy treatment method focused on changing negative thoughts and behaviors. It seems to be mentioned in nearly every self-help article online: Sleep problems? Try CBT. Childhood trauma? CBT may help. Anxiety, depression, low self-esteem, fear of flying, hangnails? CBT is the answer for you.

Basically, there's a good chance you’ve either received CBT or know someone who has. So what is it? Does it really alleviate psychological distress, and if so, how? How much does it cost, and can you just use the techniques on your own? These kinds of details can be a mystery to the general public. Lucky for you, I’m a clinical psychologist who uses CBT in my practice, so I should be able to answer most of the questions you have about it. Let’s dig into them one at a time.

CBT is one of scores of treatment methods used in psychotherapy. It’s based on the assumption that many of life’s problems stem from faulty thoughts (that’s where “cognitive” comes from) and behaviors. By intentionally shifting them toward healthier, more productive goals, we can alleviate distress. In practice, cognitive behavioral therapy generally consists of identifying the problematic thoughts and behaviors and replacing them with healthier responses.

For example, say Jane Doe is anxious in social situations and has started to avoid gatherings in favor of isolating evenings at home. A CBT therapist may educate her about the fear response that is being irrationally triggered, teach her how to shift her thoughts and relax her body, and develop an action plan to help her remain calm while engaging in the party this weekend. Next week, they’ll evaluate what worked and what didn’t, and tweak their methods until Jane can comfortably socialize.

CBT is used for anything from phobias, anxiety, depression, trauma, self-esteem issues, and ADHD, to relational problems like poor communication or unrealistic expectations of your partner. Basically, if it’s an issue that involves thoughts and behaviors (which covers a lot of ground), CBT has a treatment approach for that.

Is it right for you? That’s a difficult question. Do your problems concern how you think and behave? For example, are you ruminating about a past breakup or finding yourself mindlessly shopping online? If so, then yes, you could probably benefit from CBT. If you are more concerned about your purpose or meaning in life, or about what moments from your past color who you are today, there may be other approaches that fit better for you (and we'll get to that in question #9).

One of the reasons CBT is so well-known and widely used is because it has been studied so extensively. It is a good modality to study because it emphasizes brief, direct, solution-oriented interventions. In other words, the aim is to produce clear, measurable changes in thoughts and behaviors, which is a goldmine for researchers. It also means you get to see quick results.

I asked Martin Hsia, Psy.D., a certified CBT psychologist in Glendale, California about how he uses it in his practice. “Since a high percentage of people we see in our practice are dealing with some form of anxiety (social anxiety, health or illness anxiety, OCD, panic, etc.), being able to gently challenge people to face their fears and develop new ways of relating to their own thoughts is a central part of the work,” he says. “CBT gives us the tools to encourage people to do something highly unpleasant: confront the things they have been avoiding.”

CBT is a form of psychotherapy, so you can expect the early sessions to be what you would see in any initial therapy sessions: discussing payment information and the cancellation policy, your goals for therapy, your history, and a review of your problems. After that, you’ll talk about the struggles you encounter and try to formulate the most effective response together.

Essentially, the client brings in the problems they’d like to overcome or the situations they find stressful, and the therapist and client work together to create an action plan. An action plan means they identify the problematic thoughts or behaviors, find a way to change them, and develop a strategy to implement this change in the coming week. This is where “homework” comes in.

CBT is focused on providing a quick (8 to 12 sessions, which is quick by therapy standards) and effective reduction of symptoms, which is best done by applying the techniques throughout the week, not just during the therapy session. Typical homework might include relaxation exercises, keeping a journal of thoughts and emotions throughout the week, using worksheets that target a specific area of growth, reading a book that applies to your issues, or seeking out situations to apply your new approach. For example, Jane may want to keep an eye out for meet-up events that challenge her to overcome her fears while she applies her new relaxation techniques.

Another example: Let’s say a major factor in John Doe’s depression is his negative internal self-talk—he constantly belittles and berates himself on a loop. John and his CBT therapist may discuss a technique called “thought stopping” where he abruptly disrupts the flow of negative thoughts by yelling (in his mind) “Stop!” as he redirects his thoughts to something more positive like an affirmation or a meditation app. Homework may involve practicing this technique at least once every day until the next session. John and his therapist will debrief in the next session, evaluate what worked and what didn’t, and tweak the process for the following week.

One of the highlights of CBT is that it is focused on eliminating symptoms as quickly as possible, typically in a few weeks to a few months. Of course, people rarely have only a single issue to work on in therapy, so this length depends on the number and severity of the issues, but brevity is key to this approach.

This brings up one of the major differences between CBT and many other forms of therapy. According to Donald Meichenbaum, one of the founders of CBT, “[We ask] what and how questions. Why questions are not very productive.” While other treatment approaches spend a great deal of time digging deep and asking why you feel depressed, anxious, or have low self-esteem, CBT sticks to the current thoughts and behaviors. Rather than examining why you are afraid of snakes, CBT focuses on helping you reduce your fear. While some people are content with reducing their symptoms, others want to know why they exist in the first place. For them, deeper approaches like psychodynamic therapy may be more satisfying.

Have you ever kept a gratitude journal? What about monitoring your donut intake? Have you tracked your daily steps or monitored your sleep? Then you’re already applying some of the principles of CBT in your everyday life. You can find many of CBT’s techniques in books like David Burns’s Feeling Good or Edmund Bourne’s Anxiety and Phobia Workbook, online, or in popular apps like Headspace and Happify. But for a course of CBT tailored to you and your issues, a period of time in structured therapy is still the best approach.

CBT is psychotherapy, so if your insurance covers psychotherapy or behavioral medicine, it should cover most, if not all, of your CBT therapy. If you’re paying out of pocket, CBT costs range from free or on a sliding scaled at some community clinics, to $200+ per session in a private practice. Again, the length of time someone spends in treatment is generally less than other treatment approaches, so it may be cheaper in the long run. You can search for a therapist who practices CBT and fits your budget on a therapist finder website like Psychology Today or GoodTherapy.

Some clients may feel that they want therapy to be a place where they come and process their experiences with some gentle facilitation by their therapist. Their main goal may not be dealing with a specific symptom or problematic habit, but more about general growth and a long-term relationship with a therapist. Maybe they want to explore their memories, dreams, and early relationships with guidance from their therapist. Given that CBT can be a more direct and practical style of therapy, it may not feel helpful for someone seeking that kind of deep, relational work. Having said that, many skilled therapists who practice CBT are very flexible with their approach, and can adjust to meet the needs of a variety of clients.

CBT is not without its critiques, as even Dr. Hsia admits. “Fair criticisms of CBT highlight its ‘one-size-fits-all’ assumptions about what helps people get better,” he says. Again, CBT focuses on symptoms instead of those symptoms’ deeper roots, and some psychologists who feel the deeper roots are essential would consider CBT short-sighted. In the end, you need to find out what works best for you, and that might take some trial and error.

You may find it most helpful to talk to your therapist (or potential therapist) about what you’re seeking help for and ask them how they would approach the treatment. Whether you receive CBT treatment or another method, the most important thing is that you feel a safe, trusting connection with your therapist and that the treatment makes sense to you.

Ryan Howes, Ph.D., ABPP, is a licensed clinical therapist who practices in Pasadena, California.

You May Also Like: 7 Easy Ways to Improve Your Mental Health


Dr. Beck began helping patients identify and evaluate these automatic thoughts. He found that by doing so, patients were able to think more realistically. As a result, they felt better emotionally and were able to behave more functionally. When patients changed their underlying beliefs about themselves, their world and other people, therapy resulted in long-lasting change. Dr. Beck called this approach “cognitive therapy.” It has also become known as “cognitive behavior therapy,” or “CBT.”

In the years since its introduction, CBT has been studied and demonstrated to be effective in treating a wide variety of disorders. More than 2,000 studies have demonstrated its efficacy for psychiatric disorders, psychological problems and medical problems with a psychiatric component.

At Beck Institute, we continually study, practice, and teach the latest innovations in CBT. We established the Beck Institute Center for Recovery-Oriented Cognitive Therapy in 2019 to extend the impact of the field to individuals given a diagnosis of a serious mental health condition.


Theory

CBT works by identifying and addressing how a person's thoughts and behaviors interact to create anxiety. Therapists work with clients to recognize how negative thought patterns influence a person's feelings and behaviors. Here's an example of how two different people can react to a situation differently based upon their thoughts:

Situation: You are required to give a presentation in front of a large group.
ThoughtEmotionBehavior
I'll practice and do great!confident, anticipatoryPractices and completes the presentation without problem
I bet I make a fool of myself in front of everyone.anxious, worried, scaredPuts off practicing, attempts to get out of doing the presentation.

With CBT, a therapist attempts to intervene by changing negative thought patterns, teaching relaxation skills, and changing behaviors that lead to the problem worsening. To help provide motivation for treatment and get a client on board, providing psychoeducation about anxiety is the first step of treatment.


1. Make sure that the thought is phrased correctly as a statement of fact

When examining the evidence for and against a negative automatic thought it is essential that the thought be in the form of a statement that the client believes to be true. Other types of thoughts are not amenable to thought records, or may initially be phrased in unhelpful ways that require reformulation. Phrasings that may prove problematic for the successful completion of thought records include:

  • Thoughts in the form of a question
  • “What if … ?” thoughts
  • Thoughts referring to feelings
  • Truisms

Thoughts in the form of a question such as “Why am I so useless?” are not a statement which the client believes to be true. Exploring the evidence for a thought phrased in this format has the potential to invite more questions than it provides answers. Thoughts in the form of a question can be more productively phrased as a statement, changing “Why am I so useless?” to “I am useless”, to which the client can assign a belief rating. A straightforward way of responding to negative thoughts in the form of a question is to simply ask your patient “How about if we rephrase that question as a statement?”, or “If we rephrased that as ‘I am useless’ how much would you have agreed with it in that moment?”.

Similarly, thoughts that begin with the phrase “What if … ?” indicate doubt that a patient may not actually hold. Statements such as “What if I need to leave and embarrass myself?” can be rephrased as statements of fact: the prediction “I will need to leave and embarrass myself” is more suitable for a thought record. Clinicians should also consider that when working with predictions shifting to experiential techniques such as behavioral experiments is often more productive than persisting with purely cognitive approaches.

If a thought just refers to feelings – for example “I feel angry / upset / sad” – then the patient will validly assign this statement a high conviction rating. There is unlikely to be convincing evidence that they don’t feel this way because if a person feels something then they feel it! (As an aside, this is a great reason why stating what another person’s behavior makes us feel is a great assertiveness technique – it’s hard to argue with a feeling). When a patient expresses a thought about how they feel it is best not to work with that thought directly, but instead to unpack the reason why the individual feels that way ¬– this unpacking can result in a testable thought. For example, when a friend failed to phone her, one patient recorded “I feel so sad, anxious, and disappointed” in her thought record. When her therapist explored this further she described how this friend’s actions often made her feel as though she were unimportant and likely to be excluded from the group. She described having an image of an event from childhood when she was excluded from a group of friends which, to her, meant “It’s happening all over again”. Once this painful and anxiety-provoking prediction had been unpacked she was able to work through this difficulty in a helpful way.

Finally, it is helpful for the therapist to consider whether a statement is a truism – could this thought conceivably be true for everyone? A statement like “Perhaps I might fail” could be true in so many situations that it is fairly meaningless. If your client expresses a thought that is so widely applicable to everyone then it is worth attempting to explore whether there is a more specific prediction that they are making.

Lesson: When helping patients to complete a thought record make sure that the thought to be tested is a statement of fact which they believe to be true. Don’t be afraid to explore further or to ask the patient’s permission to rephrase their thought.


What is Cognitive Behavior Therapy (CBT)?

Cognitive Behavior Therapy (CBT) is a psychotherapy that has been shown to be effective in over 2,000 research studies. It is a time-sensitive, structured, present-oriented psychotherapy that helps individuals identify goals that are most important to them and overcome obstacles that get in the way. CBT helps people get better and stay better.

CBT is based on the cognitive model: the way that individuals perceive a situation is more closely connected to their reaction than the situation itself.

One important part of CBT is helping clients figure out what they most want from life and move toward achieving their vision. They learn skills to change thinking and behavior to achieve lasting improvement in mood and functioning and sense of well-being.

CBT uses a variety of cognitive and behavioral techniques, but it isn’t defined by its use of these strategies. We do lots of problem solving and we borrow from many psychotherapeutic modalities, including dialectical behavior therapy, acceptance and commitment therapy, Gestalt therapy, compassion focused therapy, mindfulness, solution focused therapy, motivational interviewing, positive psychology, interpersonal psychotherapy, and when it comes to personality disorders, psychodynamic psychotherapy.

Illustration of the Cognitive Model

Key Terms

Cognitive formulation – the beliefs and behavioral strategies that characterize a specific disorder

Conceptualization – understanding of individual clients and their specific beliefs or patterns of behavior

Cognitive model –the way that individuals perceive a situation is more closely connected to their reaction than the situation itself

Automatic thoughts – an idea that seems to pop up in your mind


Case Formulation in Cognitive-Behavioral Therapy: A Principle-Driven Approach

Cognitive-behavioral treatments are often described in step-by-step manuals. They provide strategies for treating a specific psychological disorder or diagnosis as opposed to addressing the specific problems and symptoms of a particular person.

Manualized treatments may fall short as they tend to adopt a general approach to treatment versus creating a specific approach tailored to each client.

While manualized treatments may be useful under certain circumstances—for example when individuals with a specific diagnosis have highly overlapping symptoms and problems—there are circumstances that call for a more flexible, individualized approach.

Here, we will focus on this specialized method known as a case formulation.

What is case formulation and when is it useful?

A case formulation is a hypothesis about the psychological mechanisms that cause and maintain an individual’s symptoms and problems (Kuyken et al., 2009 Persons, 2008).

It’s a principle-driven approach that targets mechanisms grounded in basic psychological theories—such as cognitive theory, classical and operant conditioning.

As outlined by Persons (2008), a case formulation can be useful when:

  • A client has several disorders or problems.
  • No treatment manual exists for a particular disorder or problem.
  • A client has numerous treatment providers.
  • Problems arise that are not addressed in a manual—nonadherence or therapeutic relationship ruptures.

Steps in Case Formulation

The case formulation should be developed in collaboration with the client to ensure engagement and increase commitment to treatment.

To develop a strong case formulation, the following steps are recommended (Persons, 2008):

  1. Conduct a thorough assessment to determine the presence of specific diagnoses, symptoms, and problems. It’s important to create a list of all of the client’s presenting symptoms and problems in various areas and life domains (i.e., panic attacks, excessive worry, low mood, poor academic performance, relationship difficulties).
  2. Develop an initial case formulation based on tentative or “working” hypotheses about:
    • Factors that predisposed the client to develop the symptoms and problems
    • Factors that precipitated the most recent episode
    • Maintaining factors
    • Protective factors
  3. Set up experiments to test out the initial case formulation. The results of these tests will confirm or disprove hypotheses about factors that cause or maintain the client’s symptoms and problems. For example, a therapist may use a thought record to test out whether a client’s procrastination stems from perfectionistic beliefs, which may reveal that procrastination or difficulty initiating tasks is instead due to thoughts of hopelessness. The case formulation should be revised based on the results.
  4. The case formulation should continue to be tested and revised throughout treatment with the goal of targeting mechanisms involved in the onset and maintenance of the client’s symptoms and problems. With ongoing consent of the client, it should be used as a guide for treatment planning and clinical decision making.

Components of Case Formulation

A case formulation should provide a coherent summary and explanation of a client’s symptoms and problems. It should include the following components (Persons, 2008):

  1. Problems: Psychological symptoms and features of a disorder, and related problems in various areas of life—social, interpersonal, academic, occupational.
  2. Mechanisms: Psychological factors—cognitive, behavioral—that cause or maintain the client’s problems. Mechanisms are the primary treatment targets.
  3. Origins: Distal factors or processes that lead to the mechanisms and thereby predispose the client to developing certain psychological symptoms and problems.
  4. Precipitants: Proximal factors that trigger or worsen the client’s symptoms and problems. Precipitants can be internal—physiological symptoms that trigger a panic attack—or external—a stressful life event that triggers a depressive episode.

The following is an example of a case formulation, based on recommendations by Persons (2008). It illustrates how a case formulation approach provides a parsimonious description of the cognitive and behavioral mechanisms underlying a client’s myriad of symptoms and problems.

When Rachel was in elementary school, her classmates laughed at her during her class presentations and teased her because of her stutter (ORIGINS).

This led Rachel to develop the core schemas “I am socially awkward,” and “People are overly critical.” (COGNITIVE MECHANISMS).

As an adult, she was preparing for a presentation at work (PRECIPITANT), and thought to herself, “I am going to humiliate myself in front of my colleagues.” (COGNITIVE MECHANISM).

This lead to feelings of anxiety (PROBLEM).

As a result, she called in sick the day of her presentation (BEHAVIORAL MECHANISM) and thought “I am a failure” (COGNITIVE MECHANISM) which lead to feelings of sadness and shame (PROBLEMS).

She stayed in bed all day (PROBLEM) to avoid these feelings (BEHAVIORAL MECHANISM).

A case formulation is an invaluable tool for highlighting how a client’s problems and symptoms are related. It aids the therapist in accurately identifying and targeting underlying psychological mechanisms with increased efficiency, leading to improved therapeutic outcomes

Recommended Readings

Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. New York, NY: Guilford Press.

Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. New York, NY: Guilford Press.


Behavior Therapy: How Does it Work?

Meet Miriam. She is smart, ambitious, creative, and full of energy. She is studying at a university, majoring in business. During the next few years, after she graduates, she wants to live in interesting places and get solid training and experience with a good corporation. Her dream is to start her own company, to be her own boss, and to do things that she can take pride in. For her, financial success and doing something worthwhile must go hand-in-hand.

But Miriam has a secret. She is terrified of speaking in front of people who are not her close friends. She has fought these fears for a long time, but she has never been able to conquer them. She is also aware of the fact that she will need to be able to speak to strangers comfortably and convincingly if she is going to meet her goals in business.

Now that you and your client have agreed upon your goals, it is time to choose a particular technique for the therapy. As a behavioral therapist, you are looking for a method to allow Miriam to learn a new response to the thought of public speaking. Now the idea terrifies her. After therapy is over, she should no longer be terrified and she may even look forward to the opportunity to speak in front of other people.

You know that everyone is not the same and different problems may call for different approaches to therapy. For these reasons, you have been trained in a variety of techniques that you can use to customize Miriam’s therapy to meet her particular needs. It is time to decide how you are going to help Miriam.

Try It

Systematic desensitization works by gradually—step-by-step—exposing the person to situations that are increasingly more anxiety-producing. This is called “progressive exposure.” By learning to cope with anxiety with less-threatening situations first, the person is better prepared to handle the more-threatening situations. Even more important for treatment, the mind learns that nothing horrible happens. This retraining of the subconscious mind means that the situation actually becomes less threatening.

The first steps in systematic desensitization is the development of a “hierarchy of fears.” This simply means that you must help your Miriam create a list of situations related to her fear of public speaking. Then you create a hierarchy. This means that you have her organize the situations from the least frightening to the most frightening.

For the next step in this exercise, you will need to take on Miriam’s role as the client. Imagine that you have developed a list of frightening situations, from ones that make you only slightly uncomfortable to ones that nearly make you sick with anxiety.

Try It

Remember that systematic desensitization works by putting the person in a series of situations. The early ones are not threatening or are only mildly threatening. However, as soon as your client learns to cope with each situation, you start working on the next most frightening situation.

So we’re ready to start, right? Wrong!

Behavioral therapy teaches the client to cope with an anxiety-producing situation by replacing fear with an alternative response. A common alternative response is relaxation. This idea is that fear and anxiety cannot coexist with relaxation—if you are relaxed, you can’t be fully afraid.

However, most people are not very good at relaxing on command. So the behavioral therapist will teach the client how to relax effectively. The techniques are ones often used in meditation—slow breathing and focus on positive thoughts. Psychologist Kevin Arnold explains a deep breathing technique in this video.


Therapy worksheets related to CBT

Disclaimer: The resources available on Therapist Aid do not replace therapy, and are intended to be used by qualified professionals. Professionals who use the tools available on this website should not practice outside of their own areas of competency. These tools are intended to supplement treatment, and are not a replacement for appropriate training.

Copyright Notice: Therapist Aid LLC is the owner of the copyright for this website and all original materials/works that are included. Therapist Aid has the exclusive right to reproduce their original works, prepare derivative works, distribute copies of the works, and in the case of videos/sound recordings perform or display the work publicly. Anyone who violates the exclusive rights of the copyright owner is an infringer of the copyrights in violation of the US Copyright Act. For more information about how our resources may or may not be used, see our help page.

Therapist Aid has obtained permission to post the copyright protected works of other professionals in the community and has recognized the contributions from each author.


Theory

CBT works by identifying and addressing how a person's thoughts and behaviors interact to create anxiety. Therapists work with clients to recognize how negative thought patterns influence a person's feelings and behaviors. Here's an example of how two different people can react to a situation differently based upon their thoughts:

Situation: You are required to give a presentation in front of a large group.
ThoughtEmotionBehavior
I'll practice and do great!confident, anticipatoryPractices and completes the presentation without problem
I bet I make a fool of myself in front of everyone.anxious, worried, scaredPuts off practicing, attempts to get out of doing the presentation.

With CBT, a therapist attempts to intervene by changing negative thought patterns, teaching relaxation skills, and changing behaviors that lead to the problem worsening. To help provide motivation for treatment and get a client on board, providing psychoeducation about anxiety is the first step of treatment.


Dr. Beck began helping patients identify and evaluate these automatic thoughts. He found that by doing so, patients were able to think more realistically. As a result, they felt better emotionally and were able to behave more functionally. When patients changed their underlying beliefs about themselves, their world and other people, therapy resulted in long-lasting change. Dr. Beck called this approach “cognitive therapy.” It has also become known as “cognitive behavior therapy,” or “CBT.”

In the years since its introduction, CBT has been studied and demonstrated to be effective in treating a wide variety of disorders. More than 2,000 studies have demonstrated its efficacy for psychiatric disorders, psychological problems and medical problems with a psychiatric component.

At Beck Institute, we continually study, practice, and teach the latest innovations in CBT. We established the Beck Institute Center for Recovery-Oriented Cognitive Therapy in 2019 to extend the impact of the field to individuals given a diagnosis of a serious mental health condition.


9 Things You Should Know About Cognitive Behavioral Therapy

You’ve probably heard of cognitive behavioral therapy (CBT), the evidence-based psychotherapy treatment method focused on changing negative thoughts and behaviors. It seems to be mentioned in nearly every self-help article online: Sleep problems? Try CBT. Childhood trauma? CBT may help. Anxiety, depression, low self-esteem, fear of flying, hangnails? CBT is the answer for you.

Basically, there's a good chance you’ve either received CBT or know someone who has. So what is it? Does it really alleviate psychological distress, and if so, how? How much does it cost, and can you just use the techniques on your own? These kinds of details can be a mystery to the general public. Lucky for you, I’m a clinical psychologist who uses CBT in my practice, so I should be able to answer most of the questions you have about it. Let’s dig into them one at a time.

CBT is one of scores of treatment methods used in psychotherapy. It’s based on the assumption that many of life’s problems stem from faulty thoughts (that’s where “cognitive” comes from) and behaviors. By intentionally shifting them toward healthier, more productive goals, we can alleviate distress. In practice, cognitive behavioral therapy generally consists of identifying the problematic thoughts and behaviors and replacing them with healthier responses.

For example, say Jane Doe is anxious in social situations and has started to avoid gatherings in favor of isolating evenings at home. A CBT therapist may educate her about the fear response that is being irrationally triggered, teach her how to shift her thoughts and relax her body, and develop an action plan to help her remain calm while engaging in the party this weekend. Next week, they’ll evaluate what worked and what didn’t, and tweak their methods until Jane can comfortably socialize.

CBT is used for anything from phobias, anxiety, depression, trauma, self-esteem issues, and ADHD, to relational problems like poor communication or unrealistic expectations of your partner. Basically, if it’s an issue that involves thoughts and behaviors (which covers a lot of ground), CBT has a treatment approach for that.

Is it right for you? That’s a difficult question. Do your problems concern how you think and behave? For example, are you ruminating about a past breakup or finding yourself mindlessly shopping online? If so, then yes, you could probably benefit from CBT. If you are more concerned about your purpose or meaning in life, or about what moments from your past color who you are today, there may be other approaches that fit better for you (and we'll get to that in question #9).

One of the reasons CBT is so well-known and widely used is because it has been studied so extensively. It is a good modality to study because it emphasizes brief, direct, solution-oriented interventions. In other words, the aim is to produce clear, measurable changes in thoughts and behaviors, which is a goldmine for researchers. It also means you get to see quick results.

I asked Martin Hsia, Psy.D., a certified CBT psychologist in Glendale, California about how he uses it in his practice. “Since a high percentage of people we see in our practice are dealing with some form of anxiety (social anxiety, health or illness anxiety, OCD, panic, etc.), being able to gently challenge people to face their fears and develop new ways of relating to their own thoughts is a central part of the work,” he says. “CBT gives us the tools to encourage people to do something highly unpleasant: confront the things they have been avoiding.”

CBT is a form of psychotherapy, so you can expect the early sessions to be what you would see in any initial therapy sessions: discussing payment information and the cancellation policy, your goals for therapy, your history, and a review of your problems. After that, you’ll talk about the struggles you encounter and try to formulate the most effective response together.

Essentially, the client brings in the problems they’d like to overcome or the situations they find stressful, and the therapist and client work together to create an action plan. An action plan means they identify the problematic thoughts or behaviors, find a way to change them, and develop a strategy to implement this change in the coming week. This is where “homework” comes in.

CBT is focused on providing a quick (8 to 12 sessions, which is quick by therapy standards) and effective reduction of symptoms, which is best done by applying the techniques throughout the week, not just during the therapy session. Typical homework might include relaxation exercises, keeping a journal of thoughts and emotions throughout the week, using worksheets that target a specific area of growth, reading a book that applies to your issues, or seeking out situations to apply your new approach. For example, Jane may want to keep an eye out for meet-up events that challenge her to overcome her fears while she applies her new relaxation techniques.

Another example: Let’s say a major factor in John Doe’s depression is his negative internal self-talk—he constantly belittles and berates himself on a loop. John and his CBT therapist may discuss a technique called “thought stopping” where he abruptly disrupts the flow of negative thoughts by yelling (in his mind) “Stop!” as he redirects his thoughts to something more positive like an affirmation or a meditation app. Homework may involve practicing this technique at least once every day until the next session. John and his therapist will debrief in the next session, evaluate what worked and what didn’t, and tweak the process for the following week.

One of the highlights of CBT is that it is focused on eliminating symptoms as quickly as possible, typically in a few weeks to a few months. Of course, people rarely have only a single issue to work on in therapy, so this length depends on the number and severity of the issues, but brevity is key to this approach.

This brings up one of the major differences between CBT and many other forms of therapy. According to Donald Meichenbaum, one of the founders of CBT, “[We ask] what and how questions. Why questions are not very productive.” While other treatment approaches spend a great deal of time digging deep and asking why you feel depressed, anxious, or have low self-esteem, CBT sticks to the current thoughts and behaviors. Rather than examining why you are afraid of snakes, CBT focuses on helping you reduce your fear. While some people are content with reducing their symptoms, others want to know why they exist in the first place. For them, deeper approaches like psychodynamic therapy may be more satisfying.

Have you ever kept a gratitude journal? What about monitoring your donut intake? Have you tracked your daily steps or monitored your sleep? Then you’re already applying some of the principles of CBT in your everyday life. You can find many of CBT’s techniques in books like David Burns’s Feeling Good or Edmund Bourne’s Anxiety and Phobia Workbook, online, or in popular apps like Headspace and Happify. But for a course of CBT tailored to you and your issues, a period of time in structured therapy is still the best approach.

CBT is psychotherapy, so if your insurance covers psychotherapy or behavioral medicine, it should cover most, if not all, of your CBT therapy. If you’re paying out of pocket, CBT costs range from free or on a sliding scaled at some community clinics, to $200+ per session in a private practice. Again, the length of time someone spends in treatment is generally less than other treatment approaches, so it may be cheaper in the long run. You can search for a therapist who practices CBT and fits your budget on a therapist finder website like Psychology Today or GoodTherapy.

Some clients may feel that they want therapy to be a place where they come and process their experiences with some gentle facilitation by their therapist. Their main goal may not be dealing with a specific symptom or problematic habit, but more about general growth and a long-term relationship with a therapist. Maybe they want to explore their memories, dreams, and early relationships with guidance from their therapist. Given that CBT can be a more direct and practical style of therapy, it may not feel helpful for someone seeking that kind of deep, relational work. Having said that, many skilled therapists who practice CBT are very flexible with their approach, and can adjust to meet the needs of a variety of clients.

CBT is not without its critiques, as even Dr. Hsia admits. “Fair criticisms of CBT highlight its ‘one-size-fits-all’ assumptions about what helps people get better,” he says. Again, CBT focuses on symptoms instead of those symptoms’ deeper roots, and some psychologists who feel the deeper roots are essential would consider CBT short-sighted. In the end, you need to find out what works best for you, and that might take some trial and error.

You may find it most helpful to talk to your therapist (or potential therapist) about what you’re seeking help for and ask them how they would approach the treatment. Whether you receive CBT treatment or another method, the most important thing is that you feel a safe, trusting connection with your therapist and that the treatment makes sense to you.

Ryan Howes, Ph.D., ABPP, is a licensed clinical therapist who practices in Pasadena, California.

You May Also Like: 7 Easy Ways to Improve Your Mental Health


What is Cognitive Behavior Therapy (CBT)?

Cognitive Behavior Therapy (CBT) is a psychotherapy that has been shown to be effective in over 2,000 research studies. It is a time-sensitive, structured, present-oriented psychotherapy that helps individuals identify goals that are most important to them and overcome obstacles that get in the way. CBT helps people get better and stay better.

CBT is based on the cognitive model: the way that individuals perceive a situation is more closely connected to their reaction than the situation itself.

One important part of CBT is helping clients figure out what they most want from life and move toward achieving their vision. They learn skills to change thinking and behavior to achieve lasting improvement in mood and functioning and sense of well-being.

CBT uses a variety of cognitive and behavioral techniques, but it isn’t defined by its use of these strategies. We do lots of problem solving and we borrow from many psychotherapeutic modalities, including dialectical behavior therapy, acceptance and commitment therapy, Gestalt therapy, compassion focused therapy, mindfulness, solution focused therapy, motivational interviewing, positive psychology, interpersonal psychotherapy, and when it comes to personality disorders, psychodynamic psychotherapy.

Illustration of the Cognitive Model

Key Terms

Cognitive formulation – the beliefs and behavioral strategies that characterize a specific disorder

Conceptualization – understanding of individual clients and their specific beliefs or patterns of behavior

Cognitive model –the way that individuals perceive a situation is more closely connected to their reaction than the situation itself

Automatic thoughts – an idea that seems to pop up in your mind


Case Formulation in Cognitive-Behavioral Therapy: A Principle-Driven Approach

Cognitive-behavioral treatments are often described in step-by-step manuals. They provide strategies for treating a specific psychological disorder or diagnosis as opposed to addressing the specific problems and symptoms of a particular person.

Manualized treatments may fall short as they tend to adopt a general approach to treatment versus creating a specific approach tailored to each client.

While manualized treatments may be useful under certain circumstances—for example when individuals with a specific diagnosis have highly overlapping symptoms and problems—there are circumstances that call for a more flexible, individualized approach.

Here, we will focus on this specialized method known as a case formulation.

What is case formulation and when is it useful?

A case formulation is a hypothesis about the psychological mechanisms that cause and maintain an individual’s symptoms and problems (Kuyken et al., 2009 Persons, 2008).

It’s a principle-driven approach that targets mechanisms grounded in basic psychological theories—such as cognitive theory, classical and operant conditioning.

As outlined by Persons (2008), a case formulation can be useful when:

  • A client has several disorders or problems.
  • No treatment manual exists for a particular disorder or problem.
  • A client has numerous treatment providers.
  • Problems arise that are not addressed in a manual—nonadherence or therapeutic relationship ruptures.

Steps in Case Formulation

The case formulation should be developed in collaboration with the client to ensure engagement and increase commitment to treatment.

To develop a strong case formulation, the following steps are recommended (Persons, 2008):

  1. Conduct a thorough assessment to determine the presence of specific diagnoses, symptoms, and problems. It’s important to create a list of all of the client’s presenting symptoms and problems in various areas and life domains (i.e., panic attacks, excessive worry, low mood, poor academic performance, relationship difficulties).
  2. Develop an initial case formulation based on tentative or “working” hypotheses about:
    • Factors that predisposed the client to develop the symptoms and problems
    • Factors that precipitated the most recent episode
    • Maintaining factors
    • Protective factors
  3. Set up experiments to test out the initial case formulation. The results of these tests will confirm or disprove hypotheses about factors that cause or maintain the client’s symptoms and problems. For example, a therapist may use a thought record to test out whether a client’s procrastination stems from perfectionistic beliefs, which may reveal that procrastination or difficulty initiating tasks is instead due to thoughts of hopelessness. The case formulation should be revised based on the results.
  4. The case formulation should continue to be tested and revised throughout treatment with the goal of targeting mechanisms involved in the onset and maintenance of the client’s symptoms and problems. With ongoing consent of the client, it should be used as a guide for treatment planning and clinical decision making.

Components of Case Formulation

A case formulation should provide a coherent summary and explanation of a client’s symptoms and problems. It should include the following components (Persons, 2008):

  1. Problems: Psychological symptoms and features of a disorder, and related problems in various areas of life—social, interpersonal, academic, occupational.
  2. Mechanisms: Psychological factors—cognitive, behavioral—that cause or maintain the client’s problems. Mechanisms are the primary treatment targets.
  3. Origins: Distal factors or processes that lead to the mechanisms and thereby predispose the client to developing certain psychological symptoms and problems.
  4. Precipitants: Proximal factors that trigger or worsen the client’s symptoms and problems. Precipitants can be internal—physiological symptoms that trigger a panic attack—or external—a stressful life event that triggers a depressive episode.

The following is an example of a case formulation, based on recommendations by Persons (2008). It illustrates how a case formulation approach provides a parsimonious description of the cognitive and behavioral mechanisms underlying a client’s myriad of symptoms and problems.

When Rachel was in elementary school, her classmates laughed at her during her class presentations and teased her because of her stutter (ORIGINS).

This led Rachel to develop the core schemas “I am socially awkward,” and “People are overly critical.” (COGNITIVE MECHANISMS).

As an adult, she was preparing for a presentation at work (PRECIPITANT), and thought to herself, “I am going to humiliate myself in front of my colleagues.” (COGNITIVE MECHANISM).

This lead to feelings of anxiety (PROBLEM).

As a result, she called in sick the day of her presentation (BEHAVIORAL MECHANISM) and thought “I am a failure” (COGNITIVE MECHANISM) which lead to feelings of sadness and shame (PROBLEMS).

She stayed in bed all day (PROBLEM) to avoid these feelings (BEHAVIORAL MECHANISM).

A case formulation is an invaluable tool for highlighting how a client’s problems and symptoms are related. It aids the therapist in accurately identifying and targeting underlying psychological mechanisms with increased efficiency, leading to improved therapeutic outcomes

Recommended Readings

Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. New York, NY: Guilford Press.

Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. New York, NY: Guilford Press.


Abstract

La terapia cognitiva-conductual (TCC), como una forma de terapia, es más que una mera �ja de herramientas”. La TCC permite una mejor comprension de como funciona la mente humana ya que se basa en las neurociencias y en la psicolog໚ experimental y cientໟica. El Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM) inicialmente fue 𠇊teórico”, pero actualmente (la versión más reciente, el DSM 5) se basa cada vez más en paradigmas de TCC (con la inserción de importantes nociones tales como cognitiones y conductas). Este reporte breve presenta el conocimiento actual sobre el trastorno de ansiedad generalizada (TAG) y cómo puede ser tratada esta condición a través de medios no farmacológicos. En los últimos años, las teor໚s del TAG han evolucionado, Ilegando a ser más precisas acerca del funcionamiento cognitivo de quienes lo padecen. En este artໜulo se revisan los modelos teóricos actuales y las principales tຜnicas de manejo terapéutico, como también los avances en la investigación sobre el proceso “transdiagnóstico” y el TAG en la ni༞z. La TCC es un tratamiento efectivo para el TAG y lo característico es que reduzca las preocupaciones. Un estudio ha mostrado que dicha terapia es equivalente al tratamiento farmacológico y más efectiva a los seis meses de haber completado el estudio.


CBT History Timeline

CBT suggests that if we can challenge irrational thoughts with the evidence we can overcome our negative emotions.

Founded by Zeno of Citium around 2,000 years ago, Stoicism suggested that negative emotions were generated by errors of thinking.

Zeno asserted that ‘man conquers the world by conquering himself’. This idea forms the basis of what we now call ‘resilience’ in CBT.

Another Stoic philosopher, Marcus Aurelius – this time a Roman – is reported to have said: ‘Very little is needed to make a happy life it is all within yourself, in your way of thinking.’

We see that CBT history can be traced back to those early thinkers

Evolution of CBT

Drawing upon Stoicism, US psychologist Albert Ellis (1913–2007) developed rational emotive behavioural therapy (REBT) – the earliest form of cognitive-based psychotherapy – in the 1950s.

This philosophy gave Ellis the idea that humans have a tendency to think irrationally, based on self-defeating beliefs that lead to problematic cycles of behaviour.

Ellis held both an MA and a PhD in clinical psychology from Columbia University. He was apparently a sickly child who lacked self-confidence, and he struggled as a young man to talk to women of his own age.

Wanting to find a partner, he decided to try to tackle his shyness by going to Central Park in New York and making himself talk to 100 women. Although he didn’t get a date from this, he became more confident about talking to women and managed to alter what he saw as his irrational fear.

Ellis viewed helping people to think more rationally as the best route to improving their emotional and behavioural functioning.

REBT belongs to the behavioural school of therapy and is closely related to CBT. It is an active-directive therapy based on challenging faulty beliefs (replacing irrational thinking with rational thinking) to resolve emotional and behavioural problems.

Believing that we can think our way out of distress, Ellis developed the ABCDE model, named after the five stages that it involves:

  • Activating event (for example, you crash your car)
  • Belief system (this leads you to believe that you are a bad driver)
  • Consequences (emotional and behavioural: you stop driving because you fear you will have another accident)
  • Disputing irrational beliefs (the counsellor disputes that you are a bad driver, and points out that most people have at least one accident in their driving career)
  • Effects (cognitive and emotional) of revising your beliefs (now known as ‘cognitive restructuring’).

Ellis believed that the therapist was primarily a teacher, and so did not put any focus on the therapeutic relationship.

REBT is considered highly directional and sometimes confrontational, and is based around the personality of the client. Ellis would interrupt, swear and shout as a way of drawing attention to the client’s irrational thinking.

Aaron Beck, the creator of CBT theory

Feltham & Dryden (1993: 31) define CBT as ‘an umbrella term for those approaches based on, related to, or developing from behaviour therapy and cognitive therapy’.

It is a psychological therapy that emphasises thoughts, originally developed as ‘cognitive therapy’ in the 1960s by US psychiatrist Aaron Temkin Beck, who was born on 18 July 1921 and studied at Yale University.

Beck studied and practised Freudian psychoanalysis when he designed and carried out several experiments to test the effectiveness of psychoanalysis for depression, he was surprised to find that this therapy was not effective.

This led him to look into developing an alternative approach. He noticed that counselling clients often had an internal dialogue that was negative and self-defeating.

In contrast to Ellis, Beck took a new approach in terms of stressing that a therapeutic relationship is integral to the therapy being successful, that clients need to discover their own ‘faulty’ thinking, and that it is the client’s disorder rather than the personality that is important.

The work of George Kelly on personal constructs psychology was also important to the development of the history of cognitive therapy. Kelly held that every individual uses their own set of personal constructs to make sense of their experiences.

CBT is a model of ‘faulty’ (irrational) thinking. The thoughts, emotions and behaviours that arise following a person’s perception of a situation can then form a vicious circle, with the unhelpful behaviour then triggering further negative thoughts . CBT aims to break the vicious cycle through changing either the thoughts or the behaviours – and so to turn it into a virtuous cycle.

In the 1970s, behavioural psychologists and educators started to develop new approaches focusing on acquiring cognitive and behavioural skills so people could self-manage their psychological problems.

Donald Meichenbaum worked on cognitive-behavioural modification, identifying dysfunctional self-talk to change unwanted behaviours.

Moving into the 1980s, multi-modal behaviour therapy was developed by Arnold Lazarus this technically eclectic modality is ‘heavily based on a systematic assessment of the way in which clients function’ (Feltham & Dryden, 1993: 116).

Lazarus was originally trained in behaviour therapy but – realising its limitations – ‘began to incorporate cognitive and other strategies into his work’ (Seligman, 2006: 447).

In the modern era, Christine Padesky – joint author with Dennis Greenberger of Mind Over Mood (voted by BABCP as the best-selling client self-help manual) – has made significant contributions to CBT methodology, as recognised in receiving the Aaron Beck award in 2007.

It was Padesky (1995: 4) who first coined the ‘hot-cross-bun model’, which diagrammatically shows how thoughts, emotions, physical feelings and behaviours all interact with each other, within a situation (see below).


Behavior Therapy: How Does it Work?

Meet Miriam. She is smart, ambitious, creative, and full of energy. She is studying at a university, majoring in business. During the next few years, after she graduates, she wants to live in interesting places and get solid training and experience with a good corporation. Her dream is to start her own company, to be her own boss, and to do things that she can take pride in. For her, financial success and doing something worthwhile must go hand-in-hand.

But Miriam has a secret. She is terrified of speaking in front of people who are not her close friends. She has fought these fears for a long time, but she has never been able to conquer them. She is also aware of the fact that she will need to be able to speak to strangers comfortably and convincingly if she is going to meet her goals in business.

Now that you and your client have agreed upon your goals, it is time to choose a particular technique for the therapy. As a behavioral therapist, you are looking for a method to allow Miriam to learn a new response to the thought of public speaking. Now the idea terrifies her. After therapy is over, she should no longer be terrified and she may even look forward to the opportunity to speak in front of other people.

You know that everyone is not the same and different problems may call for different approaches to therapy. For these reasons, you have been trained in a variety of techniques that you can use to customize Miriam’s therapy to meet her particular needs. It is time to decide how you are going to help Miriam.

Try It

Systematic desensitization works by gradually—step-by-step—exposing the person to situations that are increasingly more anxiety-producing. This is called “progressive exposure.” By learning to cope with anxiety with less-threatening situations first, the person is better prepared to handle the more-threatening situations. Even more important for treatment, the mind learns that nothing horrible happens. This retraining of the subconscious mind means that the situation actually becomes less threatening.

The first steps in systematic desensitization is the development of a “hierarchy of fears.” This simply means that you must help your Miriam create a list of situations related to her fear of public speaking. Then you create a hierarchy. This means that you have her organize the situations from the least frightening to the most frightening.

For the next step in this exercise, you will need to take on Miriam’s role as the client. Imagine that you have developed a list of frightening situations, from ones that make you only slightly uncomfortable to ones that nearly make you sick with anxiety.

Try It

Remember that systematic desensitization works by putting the person in a series of situations. The early ones are not threatening or are only mildly threatening. However, as soon as your client learns to cope with each situation, you start working on the next most frightening situation.

So we’re ready to start, right? Wrong!

Behavioral therapy teaches the client to cope with an anxiety-producing situation by replacing fear with an alternative response. A common alternative response is relaxation. This idea is that fear and anxiety cannot coexist with relaxation—if you are relaxed, you can’t be fully afraid.

However, most people are not very good at relaxing on command. So the behavioral therapist will teach the client how to relax effectively. The techniques are ones often used in meditation—slow breathing and focus on positive thoughts. Psychologist Kevin Arnold explains a deep breathing technique in this video.


1. Make sure that the thought is phrased correctly as a statement of fact

When examining the evidence for and against a negative automatic thought it is essential that the thought be in the form of a statement that the client believes to be true. Other types of thoughts are not amenable to thought records, or may initially be phrased in unhelpful ways that require reformulation. Phrasings that may prove problematic for the successful completion of thought records include:

  • Thoughts in the form of a question
  • “What if … ?” thoughts
  • Thoughts referring to feelings
  • Truisms

Thoughts in the form of a question such as “Why am I so useless?” are not a statement which the client believes to be true. Exploring the evidence for a thought phrased in this format has the potential to invite more questions than it provides answers. Thoughts in the form of a question can be more productively phrased as a statement, changing “Why am I so useless?” to “I am useless”, to which the client can assign a belief rating. A straightforward way of responding to negative thoughts in the form of a question is to simply ask your patient “How about if we rephrase that question as a statement?”, or “If we rephrased that as ‘I am useless’ how much would you have agreed with it in that moment?”.

Similarly, thoughts that begin with the phrase “What if … ?” indicate doubt that a patient may not actually hold. Statements such as “What if I need to leave and embarrass myself?” can be rephrased as statements of fact: the prediction “I will need to leave and embarrass myself” is more suitable for a thought record. Clinicians should also consider that when working with predictions shifting to experiential techniques such as behavioral experiments is often more productive than persisting with purely cognitive approaches.

If a thought just refers to feelings – for example “I feel angry / upset / sad” – then the patient will validly assign this statement a high conviction rating. There is unlikely to be convincing evidence that they don’t feel this way because if a person feels something then they feel it! (As an aside, this is a great reason why stating what another person’s behavior makes us feel is a great assertiveness technique – it’s hard to argue with a feeling). When a patient expresses a thought about how they feel it is best not to work with that thought directly, but instead to unpack the reason why the individual feels that way ¬– this unpacking can result in a testable thought. For example, when a friend failed to phone her, one patient recorded “I feel so sad, anxious, and disappointed” in her thought record. When her therapist explored this further she described how this friend’s actions often made her feel as though she were unimportant and likely to be excluded from the group. She described having an image of an event from childhood when she was excluded from a group of friends which, to her, meant “It’s happening all over again”. Once this painful and anxiety-provoking prediction had been unpacked she was able to work through this difficulty in a helpful way.

Finally, it is helpful for the therapist to consider whether a statement is a truism – could this thought conceivably be true for everyone? A statement like “Perhaps I might fail” could be true in so many situations that it is fairly meaningless. If your client expresses a thought that is so widely applicable to everyone then it is worth attempting to explore whether there is a more specific prediction that they are making.

Lesson: When helping patients to complete a thought record make sure that the thought to be tested is a statement of fact which they believe to be true. Don’t be afraid to explore further or to ask the patient’s permission to rephrase their thought.


Therapy worksheets related to CBT

Disclaimer: The resources available on Therapist Aid do not replace therapy, and are intended to be used by qualified professionals. Professionals who use the tools available on this website should not practice outside of their own areas of competency. These tools are intended to supplement treatment, and are not a replacement for appropriate training.

Copyright Notice: Therapist Aid LLC is the owner of the copyright for this website and all original materials/works that are included. Therapist Aid has the exclusive right to reproduce their original works, prepare derivative works, distribute copies of the works, and in the case of videos/sound recordings perform or display the work publicly. Anyone who violates the exclusive rights of the copyright owner is an infringer of the copyrights in violation of the US Copyright Act. For more information about how our resources may or may not be used, see our help page.

Therapist Aid has obtained permission to post the copyright protected works of other professionals in the community and has recognized the contributions from each author.