Summary of Cognitive Behavior Therapy, Basics and Beyond by Beck - 3rd edition

This chapter will discuss the CBT principles of treatment.

CBT is tailored as much as possible to each individual client, but there are certain principles that apply to most clients. There are 14 principles:

• Principle 1: An ever-evolving cognitive conceptualization is the basis for CBT treatment plans. These conceptualizations are based on the data clients provide at the evaluation, informed by the cognitive formulation. From the start, you can incorporate the client's strengths, resources and posivite qualities into the conceptualization too. The conceptualization will be refined throughout the therapy as additional data will be given. The following factors are of importance and should be identified:
  - Cognitive obstacles.
  - Behavioral obstacles.
  - Precipitating factors.
  - Key developmental events.
  - Enduring patterns of interpreting key events.
• Principle 2: A sound therapeutic relationship is needed for CBT. Clients differ in the degree to which they are able to develop a good therapeutic relationship and how much time and effort is needed to develop a good enough relationship.
• Principle 3: During CBT, the client's progress is continually monitored. When both therapists and clients receive feedback on how clients are progessing, client outcome enhances.
• Principle 4: CBT is culturally adapted and tailors treatment to the individual. When clients' cultures are different from your own, you may need to improve your cultural competency. The clients may differ from you in other ways as well. Educate yourself on these differences and anticipate how this might be relevant to treatment. Be aware that you still need to conceptualize the individual client and refrain from assuming that you will need to vary treatment for a given individual.
• Principle 5: The positive is emphasized in CBT. Research shows that it is important to emphasize positive emotion and cognition in treating depression. It is also important to inspire hope.
• Principle 6: Collaboration and active participation are emphasized in CBT. Encourage the client to see therapy as teamwork.
• Principle 7: CBT is values based, aspirational and goal oriented. During the first session, you should ask the client about their values, aspirations and their specific goals for treatment.
• Principle 8: CBT is mostly about emphasizing the here and now. The therapy focuses strongly on the skills clients need to improve their mood and their lives. In the following three cases can it be wise to shift the focus to the past:
  - The client shows a strong desire to do so.
  - When there is insufficient change after working toward current problems and future aspirations.
  - When it is important for the client to know how and when their key dysfunctional ideas and coping strategies started and became maintained.
  After discussing and understanding the past, you will discuss how clients can make use of their new understanding in the coming week.
• Principle 9: CBT is educative. It is very important to make the process of therapy understandable. Psychoeducation has a big part during treatment too, as well as learning the client helpful techniques.
• Principle 10: CBT is time sensitive, because a therapist should try to make treatment as short as possible while fulfilling the objectives.
• Principle 11: The sessions of CBT are structured. Therapists try to treat clients as efficiently as possible to help them feel better as soon as possible.These objectives are more easliy reached by using a standard format.
• Principle 12: Guided discovery is used in CBT and teaches clients to respond to their dysfunctional cognitions.
• Principle 13: Therapy homework (action plans) is included in the therapy. This usually consits of:
  - Identifying and evaluating automatic thoughts that are obstacles to clients' goals.
  - Implementing solutions to obstacles that may arise in the next week.
  - Practicing behavioral skills learned in session.
  Record anything that the client should remember, because clients tend to forget a lot of what happened during sessions and that tends to lead to poorer outcomes.
• Principle 14: A lot of different techniques can be used to change mood, thinking and behavior.

This chapter will explain the importance of a therapeutic relationship through subquestions.

When Judith Beck teaches her psychiatric residents about establishing a good therapeutic relationship, she gives them four essential guidelines to remember:

• At every session, aim to treat every client the way you would like to be treated as a client.
• Be nice and create a safe environment.
• Clients are in therapy for a reason and will therefor pose challenges.
• Make sure that the expectations for my client and yourself stay reasonable.

These four guidelines are essential to start building a good relationship with your clients from your first contact with them. A good relationship is important because it is correlated with positive treatment outcomes. Spend time on this, but make sure that you have enough times to help clients reach their goals. Research demonstrates that the relationship strengthens when clients perceive improvement.

The focus should lie more heavily on the relationship, when you treat clients with serious mental health conditions. These clients, more often than not, have strong negative beliefs about themselves and others. They may assume that you will view them negatively, until extremely proven otherwise.

What are effective counseling skills?

Effective counseling skills are the Rogerian counseling skills. Empathy, genuineness and positive regards are most important. It is necessary to keep showing your commitment to and understanding of the client. This can be done by empathic statements, tone of voice, facial expressions, choice of words and body language. The most important basic counseling skills are:

• Positive reinforcement.
• Empathy.
• Encouragement.
• Acceptance of client.
• Caring.
• Validation.
• Positive regard.
• Accurate understanding.
• Interest.
• Inspiring hope.
• Genuine warmth.
• Humor.
• Offering a positive view of the client.
• Compassion.

Be alert for your clients' emotional reactions troughout the session. Address the issue right away, when you recognize that clients are experiencing increased distress. Positive reinforce expressed negative thoughts about themselves, the proces or you. It is wise to then conecptualize the problem and plan a strategy to resolve it. When the negative feedback of a client is not addressed, it may cause problems later on. 

The skills named above are important, but so is your ability to assess and adjust the degree to which you use these skills with every individual client. Most clients will react positively, but do not overdo or underdo it. The right balance is different per client. Emotional reactions give a clue to wether or not you should adjust yourself.

Different characteristics of the client can influence the therapeutic relationship:

• Age.
• Gender.
• Ethnicity.
• Socioeconomic status.
• Disability.
• Sexual orientation.

Remember that your own background and culture exert an influence on your values and beliefs and on how you perceive, behave to and speak toward clients. Being aware of this can help you react to your clients in a culturally sensitive way.

Should a therapist use self-disclosure?

In CBT, it is advised not to be a blank screen as a therapist, and thus use self-disclosure. Clients should perceive you as a warm, authentic person who wants to help them. Of course, self-disclosure should have a definite purpose. It is important to pay attention to yout clients' verbal and nonverbal reactions to your self-disclosures. Timing is everything. 

What causes difficulties to arise in the relationship with some clients and not with others?

Clients bring their general beliefs about themselves, other people, and relationships to the therapy session, as well as their characteristic behavioral coping strategies. These beliefs navigate their behavior, percepions and reactions in therapy. 

Problems in the relationship can arise, because you made a mistake. Common mistakes are:

• Misunderstanding what the client said.
• Being too directive or too nondirective.
• Interrupting too much.

If you have not made a mistake, the problem is likely to be related to your client's inaccurate cognitions. When clients have an incorrect view of you, they may very well have a similarly incorrect view of others. If this is the case, you can help them draw a conclusion about your relationship and then test it in the context of other relationships.

Your client and you influence each other. You, as a therapist, will likely bring your general beliefs about yourself, other people, relationships and your characteristic behavioral coping strategies. You may react in an unhelpful way if your negative core beliefs get triggered. Your client then may engage in an unhelpful coping strategy. Be aware of this and try to anticipate.

This chapter will discuss the first session and what is important.

What are the goals for the first therapy session?

The goals for a therapist for the first therapy session are:

• To establish rapport and trust with the client, normalize their difficulties and instill hope.

• Socialize clients into treatment by educating them about their disorder, the cognitive model and the process of therapy.

• Collect additional data to help conceptualize the client.

• Develop a goal list.

• Start solving a problem important to the client.

How can these goals be accomplished?

To accomplish these goals, the following format is used:

1. Initial part of session 1

   • Set the agenda. By setting the agenda the client knows what to expect. The therapist must make sure that the client agrees with the topics he/she set on the agenda. The therapist must explain the rational for why the agenda is set at the beginning of the session. In this way the client will collaborate more actively and the session will be more productive.

   • Do a mood check. The therapist asks the client for a brief narrative report of their mood since the last time they saw each other. This can be in the form of a question during the session, but a client could also fill out a form before the session starts.

   • Obtain an update. The therapist asks the client if there are any important problems or issues that might not yet have been discovered. The therapist can decide which problems are urgent to discuss by asking how distressed a client is by the problem. Long-term, or chronic issues can usually postponed to future sessions. After this, the therapist asks if anything positive happened last week, this will help clients see the reality more clearly.

   • Discuss the client’s diagnosis and do psycho education. Most clients want to know their diagnosis, and to establish that the therapist should emphasize that they are not abnormal or strange. For personality disorders it is better not to label it, but describe it. It is also desirable to give clients some initial information about their condition, so they can start attributing some of their problems to their disorder, instead of to their character. The therapist will explain what their disorder is about and can eventually give homework to read a chapter about their diagnosis at home.

2. Middle part of session 1

   • Identify problems and set goals. The therapist helps the client to turn their problems into therapy goals. The client can write these goals down, so that he/she will remember them during therapy. It is also good to create one general goal for therapy in behavioral terms. It is important to also identify aspirations and values of the client. Values are long-standing beliefs about what is most important in life. It shapes the choices and behavior of people. When people perceive they are not living up to their values, they often become distressed.
     Besides the clients' aspirations and experience, the meaning that clients put on aspirations and experiences is also important. 

   • Educate the client about the cognitive model. The therapist will help clients understand how their thoughts have an influence on their behavior. The therapist can explain this model using the clients’ own examples. Also do activity scheduling here or work on an issue. The therapist will try to show the client that there are different ways of viewing the issue and the therapist can provide the client with concrete steps in solving problems. This will instill hope in the client that the therapy might work.

   • Set a new Action Plan together and check on likelihood of completion.

3. End of session 1

   • Provide or elicit a summary.

   • Review homework assignment. The therapist makes sure the patent knows what to do. If the client seems to doubt if he/she will be able to do all the exercises, the therapist should offer to change it. It is important that the client will feel successful in making the homework; otherwise it can contribute to their low self-worth.

   • Elicit feedback. What did the client think about the session and the therapist? This feedback can be given in verbal or written form by filling out a form. Shows that the therapist cares about what the client thinks, this strengthens rapport.

This chapter will discuss the important of action plans and how to use them during treatment.

Clients who carry out action plans (homework assignments) progress better in therapy than those who do not. Good action plans provide opportunities for clients to educate themselves further, to collect data, to test their thoughts and beliefs, to modify their thinking, to practice cognitive and behavioral tools, and to experiment with new behaviors. Action plans need to be tailored to the individual.  Not only the type of action plans is important, but also the amount of it. It is therefore important to predict potential difficulties before assigning action plans. The action plans should err on the side of being too easy as opposed to too difficult, clients should not feel like a failure.

In the beginning the therapist will suggest action plans, but as soon as possible the client should try to devise their own action plans. Typical action plans are:

• Behavioral activation, getting active, and scheduling activities.

• Reading the therapy notes. Make the client summarize what they think is most important for them te remember and to do after discussing an issue with you.

• Monitoring automatic thoughts. Clients should ask themselves: ‘What is going through my mind right now?’ when they notice their mood is changing and remind themselves that this thinking may or may not be true.

• Evaluating and responding to automatic thoughts. The therapist will help clients modify their inaccurate and dysfunctional thoughts and write down their new way of thinking. An essential action plans is to have them read these therapy notes on a regular basis. Clients will also learn to evaluate their own thinking and practice doing so between sessions.

• Doing behavioral experiments. It is often important to design eperiments together that clients can do between sessions to test the validity of negative predictions.

• Disengaging from thoughts that are part of an unhelpful thought process. 

• Implementing steps towards the goals of the client.

• Participating in activities that lift affect.

• Clients can write a list of the things they did throughout the day that were a little difficult or more.

• Practicing behavioral skills. Clients might have to learn new skills to effectively solve their problems.

• Bibliotherapy: Important concepts you are discussing in session can be greatly reinforced when clients read about them in books or magazines.

• Preparing for the next session by thinking about what is important to discuss.

How can action plans adherence be increased?

Although some clients easily do the suggested assignments, action plans are more problematic for others. Implementation of the following guidelines increases the likelihood that clients will be successful withaction plans and experience an elevation in mood:

• Tailor the assignment to the individual. (Be 90–100% sure the client can and will do the assignment.)

• Provide a rationale as to how and why the assignment might help. Clients are more likely to comply with action plans if they understand the reason for doing them. This is called providing a rationale. The therapist will provide a brief rationale initially; later in treatment, the therapist will encourage clients to think about the purpose of an assignment.

• Think of action plans together. The therapist seeks the clien’s input and agreement.

• Make action plans a no-lose proposition. Tell the client that it would be good if he/she gets it done, but that it is okay if the client has trouble finishing it. The client should not feel like a failure.

• Give the client explicit instruction on how to do the action plans.

• Begin the assignment in session. This motivates clients to complete the assignment.

• Help set up systems for remembering to do the assignment. What will help the client remember to do the homework?

• Ask clients to imagine completing an item on the action plan. Clients are more likely to complete their action plans if they visualize a positive outcome.

Why should the therapist anticipate and prevent problems with executing the action plans?

Clients who complete action plans between sessions have better treatment outcomes than clients who do no complete the action plans. It is therefore important to predict the types of obstacles that can arise for clients to complete their action plans. To increase the chance clients will actually do their action plans, the therapist can do several things:

• Estimate the likelihood of completion.

• Anticipate possible problems: The therapist should ask the clients how likely he/she is to carry out the assignment (0-100%). If the client is less than 90% confident the therapist can engage in the following strategies: 

  • Covert rehearsal uses induced imagery to uncover and solve potential homework-related problems. Which practical obstacles and dysfunctional cognitions may hinder the completion of homework?

• Be alert for possible negative reactions of the client toward an action plan.

• Talk about the disadvantages and advantages of the action plan toegether.

• Modify the action plan if a client is unsure about completing it.

• Make the plan easy.

Why conceptualizing difficulties?

When clients experience difficulty with completing their action plan, conceptualize why the problems arose.

The first questions that should be asked is: Why did the problem arise, and what was it related to?

Types of problems that may occur:

• A practical problem. A practical problem can often be avoided if the assignment is carefully set. 

• Cogntitions that interfere with doing the items on the action plan.

• A psychological problem masked as a practical problem. Some clients believe that a practical issue is preventing them from doing the action plan, but there may actually be a thought or belief that is inferring. This belief has to be discussed before moving on to solving the practical issue.

• A problem related to the therapist’s cognitions. Therapists can have dysfunctional thoughts about assigning homework or exploring why a client has not done items on the action plan. The therapist should be aware that he is not doing his clients a favor by allowing them to skip items.

Other problems that may occur are:

• Doing the action plan at the last minute.

• Forgetting the rationale for an assignment.

• Difficulty with an item on the action plan.

• Overestimating the demands of an assignment. The client may overestimate the effort, energy and time an assignment will cost.

• Depressed clients often procrastinate and avoid doing things.

There is also a problem related to negative predictions. Clients may have negative predictions about doing the items on the action plan such as: ‘I shouldn’t have to put forth so much effort to feel better’ or ‘I am incompetent. These predictions stand in the way of completing the action plan. It can be helpful to have the client test these predictions. The therapist should prepare the client for their reaction to a possible negative outcome through Socratic questioning. The therapist should make the usefulness of the assignment clear, but has to acknowledge that the outcome of an assignment is never a given to avoid disappointment.

This chapter will discuss structuring sessions.

The therapist must plan the sessions around the issues and goals of the client and the therapeutic objectives. Sessions can be divided into three parts. Each part can be structured on its own.

What's the start of the session like?

The therapist can structure the first part of the session as follows:

• Do a mood check. The therapist will ask the client to compare how they are feeling now to how they did last week. The therapist compares the subjective description from clients (what they are telling the therapist) to the objective test scores (from a chart the client filled in before the session started). The mood check is not just about this day, but also about the time between the two sessions. A mood check is usually quick. As a therapist you should be careful that clients don’t attribute mood changes to external factors. The client should understand that their mood depends on their thinking patterns. Clients should feel that they have some control over how they feel. If clients state that nothing can improve their mood, it can be helpful write down ‘things that make me feel better’ and ‘things that make me feel worse’. This can give them insight in the fact that a more active lifestyle makes them feel less depressed. If clients are taking medication, the therapist should ask about any difficulties. As a psychologist you cannot change the medication, but you can help the client respond to eventual cognition that interfere with them taking medication.

• Set the agenda. This also is a very brief part of the session in which the therapist asks clients what they want to discuss in the current session. If clients engage in a lengthy description of the problem the therapist should interrupt and direct the topic back to setting the agenda. Lengthy descriptions of the problem are part of a later part of the session. The client can choose which topic on the agenda has priority. Sometimes the therapist can suggest the first agenda item himself if he thinks that a specific problem is the most important for now. The priority topics are the ones that are discussed first. If there is not enough time, less important issues can be moved to future sessions. It is important to note that you need not always adhere to the agenda. When deviating from the agenda, the change should be made explicit and the change can only take place with the client’s agreement. If the client drifts off to a topic that is not on the agenda, the therapist can interrupt the client and ask if he or she wants to deviate from the agenda.

• Obtain an update of the week. The therapist tries to get a general idea of how the client’s week went. This is a bridge between the previous session and the new one. The therapist should not only ask about problems, but should also emphasize positive experiences the client might have had. This will make the client realize that their week had some positive points and that they didn’t feel the same level of sadness the whole week.

• Review action plans. If a therapist doesn’t engage in this part, the client will eventually stop doing the action plan. Therefore it is an important part of the session. The previous action plan is discussed and new action plan is created for next week.

What's the middle of the session like?

The therapist can structure the middle part of the session as follows:

• Work on a specific problem and teach cognitive behavior therapy skills in that context. The therapist continues to reinforce the cognitive model and continues teaching about automatic thoughts. The therapist can provide some symptom relief through helping clients respond to their anxious thoughts.

• Follow-up discussion with relevant, collaboratively set action plans.

• Work on the next problem, till the time is up.

What's the end of the session like?

The therapist can structure the end part of the session as follows:

• Summarize session. The therapist can summarize the discussed content in the client’s words. If the therapist uses his/her own words it could seem to clients that the therapist didn’t understand them right. The therapist could also ask the client to summarize what they discussed and eventually add things the client forgot.

• Discuss new action plans.

• Elicit feedback. If clients didn’t fully express their reaction to the session, the therapist can ask them to complete a therapy report. If clients have negative feedback the therapist should positively reinforce them and try to solve the problem together with the client. Negative feedback is usually because the therapeutic alliance isn’t optimal.

As in the assessment and first therapy session it is still important that the therapist and the client have a good working relationship. If clients are starting to feel better, the therapist can begin to start working on relapse prevention.

This chapter will discuss identifying automatic thoughts.

The cognitive model states that the interpretation of a situation (rather than the situation itself), often expressed in automatic thoughts, influences one’s subsequent emotion, behavior, and physiological response. Of course some events are upsetting for everyone, but people with psychological disorders often misconstrue positive or neutral events. This means that their automatic thoughts are biased. Automatic thoughts are a stream of thinking that coexists with a bigger stream of thoughts. Everyone has automatic thoughts. People often are more aware of the emotion they feel as a result of their thoughts than of the thoughts themselves, but with a little training these thoughts can be conscious. When they are conscious most of us will do a reality check of these thoughts, but people with psychological disorders don’t question these thoughts and just accept them. Automatic thoughts are often in short hand form. For example: a client might think ‘damn’ and this means ‘ I was stupid to leave my cellphone at home’.

How can automatic thoughts be categorized?

Automatic thoughts can be evaluated according to their validity and their utility. The most common type of automatic thought is distorted in some way and occurs despite objective evidence to the contrary. A second type of automatic thought is accurate, but the conclusion the client draws may be distorted. A third type of automatic thought is also valid, but decidedly dysfunctional. Identifying and responding to automatic thoughts is usually helpful to a client and may produce a positive shift in affect. The automatic thoughts can be identified during a session while discussing a problem the client is experiencing. It is important that the therapist checks again at the end of the session to ascertain how well the client understands the cognitive model.

How can automatic thoughts be evaluated?

An action plan in identifying these automatic thoughts is to simply ask oneself: ‘What was going through my mind?’ when clients mood starts getting worse. As a therapist you will ask this question when clients describe a problematic situation that arose or when you notice a shift to negative affect during a session. In this latter situation it is often important to be alert to both verbal and nonverbal cues from the client, so as to be able to elicit their hot cognitions that is, important automatic thoughts and images that arise in the therapy session itself, and are associated with a change or increase in emotion. These hot cognitions can be about the client him/herself, the therapist, or the subject under discussion. They may interfere with the client’s concentration, motivation, feelings of worth, or the therapeutic relationship. If clients are unable to answer the question: ‘What was just going through your mind?’ the therapist can ask them how they are feeling and where in their body they experienced the emotion (this will heighten the emotional level during the session and the client might remember what it felt like to be in the situation again), elicit a detailed description of the situation, request that the client visualizes the distressing situation, suggest that the client and the therapist engage in role play, elicit an image, supply thoughts opposite to the ones you hypothesize actually went through their minds, ask for the meaning of the situation for them, or phrase the question differently. These are all techniques that may help clients in identifying their automatic thoughts. If clients are still unable to identify their automatic thoughts, the therapist should move on to another subject in order to not let the client feel as a failure.

What other problems may occur when treating automatic thoughts?

Clients may have other automatic thoughts about their (emotional or behavioral) reaction to the situation they had automatic thoughts about. Clients can have automatic thoughts before a situation, during a situation, or after a situation. Therapists should discover which thoughts were most distressing to a client.

If a client worries about many problems and can’t say which one is most important to him/her, the therapist might ask the client to hypothetically eliminate one problem, and determine how much relief the client feels if this problem wouldn’t be there. The problem the client feels most relieved about when eliminated is likely to be the most troublesome to the client. When the most troublesome problem is discovered the focus can be on identifying automatic thoughts and problem solving.

When you ask for clients’ automatic thoughts, you are seeking the actual words or images that have gone through their mind. Until they have learned to recognize these thoughts, many clients report interpretations, which may or may not reflect their actual thoughts. For example: The interpretation: ‘I couldn’t get myself to start reading’, actual automatic thought: ‘I can’t do this’. These interpretations should be changed into the real automatic thought to evaluate them effectively. Clients also sometimes report thoughts that are not fully spelled out, e.g. ‘Uh-oh”, the therapist guides the client to express the thought more fully.

External and internal stimuli can give rise to automatic thoughts. Clients can have automatic thoughts about their cognitions, their emotions, their behavior, or their physiological or mental experiences. Identifying automatic thoughts is a skill that comes naturally to some clients and is more difficult for others. Therapists need to listen closely to ensure that clients report actual thoughts, and may need to vary their questioning if clients do not readily identify their thoughts. Techniques that can be used are discussed in this chapter.

This chapter discusses way to evaluate automatic thoughts.

What are some ways to address the thoughts a client has?

Clients can have a thousand thoughts a day. In therapy there is no time to evaluate them all, and you will only address a few of them per session. Selecting key automatic thoughts is paramount to addressing them. To determine if an automatic thought is an important one the therapist needs to answer the following questions: Is the automatic thought (still currently) distressing to the client? Is the client likely to have this kind of thought again? There may also be situations in which an automatic thought seems to be important, but the therapist will decide not to discuss it. For example a reason could be that there is an even more important problem to discuss or that the client’s level of distress is too high to evaluate his thinking.

Another method is to use Socratic questioning. When an important automatic thought is identified, the therapist should collaboratively decide with the client to evaluate it. The automatic thought should not be directly challenged, because as a therapist you don’t know if an automatic thought is true, a direct challenge may lead clients to feel invalidated and challenging a cognition violates a fundamental principal of CBT, that of collaborative empiricism: the client should get the chance to test the automatic thought’s validity. Socratic questions help clients evaluate their thinking and involve a dialectical discussion. In CBT this dialectical discussion needs to be structured in order to discuss the thoughts in depth. There a different kinds of questions that can be asked in evaluating an automatic thought:

• The ‘evidence’ questions. Because automatic thoughts usually contain a degree of truth, clients usually do have some evidence that supports their accuracy, but they often fail to recognize evidence to the contrary:

  • For example: "What is the evidence that supports this idea?"

• The ‘alternative explanation’ question:

  • For example: "Is there an alternative explanation or viewpoint?"

What other sorts of questions could be asked in order to address a client's issues?

In addition to the aforementioned, there are specific categories of questions that could be used to help a client assess their automatic thoughts. A few examples are:

• The ‘decatastrophizing’ questions:

  • Many clients predict a worst-case scenario, but that almost never happens. The therapist can lead them to realizing that and help them think of more realistic outcomes. The therapist can also let the client see that even if the worst would happen; the client would be able to cope. For example: "What is the worst that could happen?"

• The ‘impact of automatic thought’ questions:

  • The therapist helps the client assess the consequences of responding and not responding to his/her distorted thinking. For example: "What could be the effect of changing my thinking?"

• The ‘distancing’ questions:

  • Clients often benefit from getting some distance from their thoughts by imagining what they would tell a close friend or family member in a similar situation. For example: "What would I tell a friend if he or she was in my situation?"

• The ‘problem solving’ questions:

  • The therapist and client think of ways to solve the problem and come up with a behavioral plan. For example: "What should I do?" The therapist helps the client devise an alternative explanation for what has happened.

Asking all of these questions takes too long and might make the process too burdensome for a client. Therefore the therapist should choose one or two that they think are most relevant. The process will get shorter the longer the client already is in therapy. The client will eventually know what is expected of them and will only need minor encouragements from the therapist.

What are some follow-up steps a therapist should take?

Therapists need to assess the outcome of the evaluation process. In this phase the therapist checks how much the client still believes the automatic thought. In addition, they also need to conceptualize when evaluation is ineffective. If the client still believes the automatic thought, the therapist needs to conceptualize why the cognitive restructuring has not been sufficiently effective. Reasons why the restructuring might have been ineffective could be that: there are other more central automatic thoughts left unevaluated, the evaluation of the automatic thought is superficial or inadequate, the client has not sufficiently expressed the evidence that he or she believes supports the automatic thought, the automatic thought itself is also a core belief or the client understands intellectually that the automatic thought is distorted, but does not believe it on an emotional level.

Some other methods may be to use alternate methods of questioning and responding to automatic thoughts.

In addition to using Socratic questions you could also:

• Vary the questions.

• Identify the cognitive distortion. Clients tend to make consistent errors in their thinking. Often there is a systematic negative bias in the cognitive processing of clients who suffer from a psychiatric disorder. The most common errors are:

  • All or nothing thinking: clients view a situation in only two categories instead of on a continuum.

  • Catastrophizing: clients predict the future negatively without considering other, more likely outcomes.

  • Disqualifying or discounting the positive: clients unreasonably tell themselves that positive experiences, deeds, or qualities do not count.

  • Emotional reasoning: clients think something must be true, because they feel it so strongly.

  • Labeling: clients put a fixed, global label on themself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion.

  • Magnification/minimization: When clients evaluate themselves, another person, or a situation, they unreasonably magnify the negative and minimize the positive.

  • Mental filter: clients pay too much attention to one negative detail instead of seeing the whole picture.

  • Mind reading: clients believe they know what others are thinking, failing to consider more likely possibilities.

  • Overgeneralization: clients make a sweeping negative conclusion that goes far beyond the current situation.

  • Personalization: clients believe others are behaving negatively, because of them, without considering more plausible explanations for their behavior.

  • ‘Should’ and ‘must’ statements: clients have a fixed idea of how they or others should behave, and they overestimate how bad it is if these expectations are not met.

  • Tunnel vision: clients only see the negative aspects of a situation.

• It often helps to label distortions and to teach clients to do the same. A therapist may also provide clients with a list of all the distortions.

• Use self-disclosure. The therapist tells the client a relevant example of his/her own life to show the client that the therapist also sometimes had those thoughts and was able to change them.

• Respond when automatic thoughts are true. When automatic thoughts are true the therapist should focus on problem solving, investigate whether the c;ient has drawn a valid conclusion, or work on acceptance of the problem.

• Teach clients to evaluate their automatic thoughts. This will take place at the end of therapy, when clients know what is expected of them.

This chapter will explain what mindfulness is and how to integrate it into CBT.

Mindfulness refers to maintaining attention on immediate experience while taking an orientation of openness, acceptance, and curiosity. It teaches to focus on what is happening right now, either externally or internally. It also teaches you to being willing to experience the now in a nonjudgmental way.

Mindfulness can help to get a different relationship with your thoughts. The goal would not be to eliminate the unhelpful thought or eliminate distressing internal stimuli, but to nonjudgmentally observe and accept your internal experiences - without evaluating them or trying to change them.

Different types of mindfulness exist. Here are three of them:

• Mindfulness of thoughts.
• Mindfulness of internal stimuli.
• Mindfulness for self-compassion.

There are formal mindfulness practices and informal mindfulness practices. In a formal mindfulness meditation, you set aside a period of time, go to a quiet place and focus your attention on a particular experience. You notice when your attention has wandered from the specified experience and nonjudgmentally bring it back to the experience.

Informal mindfulness practices refers to applying the principles of mindfulness to your day-to-day experiences.

It may be a good idea to practice mindfulness yourself for the following three reasons:

• It may reduce stress and enhance your sense of well-being.
• It can help you understand and describe it to clients.
• It might motivate clients to practice it when you have told them about your experiences.

It seems that integrating mindfulness into CBT treatment is much more effective for clients than teaching mindfulness as a standalone skill. You should encourage your clients to use either formal or informal mindfulness exercises when they find themselves stuck in an unhelpful thought process or caught up in an uncomfortable internal experience.

What is the AWARE technique?

The AWARE technique is a mindfulness technique developed to be used when clients worry excessively and / or experience a lot of anxiety. The steps are:

1. Accept the emotion. Accept the emotion as natural and normal. The sensations are a normal part of the emotion.
2. Watch it from a distance. Look at it without judgment. Be detached.
3. Act constructively with it. Act as if you do not feel the emotion. Whatever you can do without anxiety, you can do with it.
4. Repeat the steps. Continue to accept, watch and act constructively.
5. Expect the best. Most of the time, what you fear most does not happen. If you practice the steps often, you will gain confidence that anxiety always decreases. And your difficulties with anxiety will decrease once you stop fighting it or trying to avoid or control it.

This chapter discusses how to modify beliefs.

When clients are in a maladaptive mode, it is important to:

• Develop and strengthen realistcally positive beliefs to activate the adaptive mode.
• Modify the unrealistic, negative beliefs to deactivate the depressive mode.

During treatment, it is important to reinforce the more positive beliefs by helping clients to engage in activities that could bring a sense of mastery, pleasure, connection and empowerment. Other important strategies are:

• Eliciting positive information and inferring helpful conclusions about their experiences.
• Eliciting the advantages of believing adaptive beliefs.
• Pointing out the meaning of positive data.
• Referencing other people.
• Using a chart to collect evidence.
• Inducing imagies of current and historical experiences.
• Acting 'as if'.

What are some techniques to modify maladaptive core beliefs?

Techniques to modify core beliefs are: Socratic questioning, examining advantages and disadvantages, intellectual-emotional role plays, acting ‘as if’, behavioral experiments, cognitive continuum, self disclosure, core belief worksheet, extreme contrasts, stories and metaphors, historical tests, restructuring early memories and coping cards. The first 7 were already discussed in previous chapters, the remaining are additional techniques and will be explained.

In the core belief worksheet clients monitor the operation of their beliefs and reframe evidence that seemed to support the old belief. Clients have to recognize positive data. Clients might find this difficult and the therapist might use some techniques to make it easier, such as making clients think about what they would say to another person or what another person would say about them.

Using extreme contrasts to modify core beliefs is another technique to modify core beliefs. It can be helpful for clients to compare themselves with someone, either real or imagined, who is at the negative extreme of the quality related to their core belief. Using stories, movies and metaphors can help clients develop a different idea about themselves by encouraging them to reflect on their view of characters or people who share the same negative core belief.

‘Historical tests of the core belief’ is another technique. With this technique clients try to discover where their belief started. Clients record memories that may have contributed to the establishment or maintenance of the core belief; this can be continued in homework assignments. A second step in this process is to search for evidence in memory that supports the new, positive belief. The third step is to reframe each piece of negative evidence.

In the fourth and last step clients summarize their memories. For many Axis I clients the intellectual techniques discussed above are sufficient to modify their core belief. For others, special emotional techniques, in which clients’ affect is aroused, are also indicated. One such technique is restructuring an earlier traumatic experience. The therapist and client can engage in role-play to reenact and reinterpret an earlier experience. They stop when the client reports that the younger-self is feeling less sad or anxious.

This chapter will discuss imagery.

What sort of techniques are there to explain and deal with mental imagery?

Many clients experience automatic thoughts not only as unspoken words, but also in the form of mental pictures or images. Failure to identify and respond to upsetting images may result in continued distress for the client. The word image may not be clear to the client. The therapist can then use synonyms, such as mental picture or daydream. Some clients may not report their mental images, because they find them too distressing and don’t want to re-experience it. The therapist can teach them about these images and normalize them.

The therapist may tell about an image he/she gets while the client is telling him/her something. In this way the client will be better able to understand what the therapist means by a mental image. There are several techniques to teach a client to respond to their mental images:

• Following images to completion. The therapist will encourage clients to continue visualizing a spontaneous image until the client imagines getting through a crisis and feels better, or the client imagines a final catastrophe, such as death. In the first scenario the client can be convinced of a realistic outcome quite easily and the therapist can help the client with creating a new, more positive image. In the second case the client cuts of the image at the worst point. The client should imagine what would happen after the worst point. The therapist can also help the client induce a coping image.

• Jumping ahead in time. For example: The client is really struggling with a paper he has to make. When the therapist asks to complete the image the client only gets more anxious and keeps imagining more obstacles. In this case it is a good technique to suggest that the client imagines himself in the near future, while finishing his paper and sending it to his professor. This could make the client feel relieved and feel better and more confident about the future.

• Coping in the image. In this technique the therapist guides clients so they can imagine they are coping with a difficult situation they have spontaneously envisioned.

• Changing the image. The therapist teaches clients to reimagine a spontaneous image, changing the ending to alleviate their distress.

• Reality testing the image, just as is done with verbal automatic thoughts. It is better though to use an imagery technique for dealing with images.

• Repeating the image. The therapist suggests that clients keep imagining the original image over and over again, paying attention to whether their level of distress change. Some clients seem to do an automatic reality check, and make their image more realistic.

• Substituting images

What sort of techniques are there to induce imagery?

Sometimes the therapist will induce an image to help a client respond to a spontaneous image. Some techniques used to induce images:

• Covert rehearsal.

• Rehearsal of coping techniques. Clients continually imagine themselves realistically coping with the situation in detail. They practice using coping strategies in imagination.

• Distancing helps clients see their problems in greater perspective. The therapist shows clients that difficulties are likely to be time-limited. The therapist and client will look into the future and see how bad things really are.

• Reduction of perceived threat. The client views a situation with a more realistic assessment of actual threat. For example: imagining the encouraging faces of their friends when they have to do a presentation.

This chapter discusses problems that might arise during treatment.

What are the key steps to identifying a problem?

Problems in therapy arise almost with every client; they provide insight into problems the client experiences outside the office. Problems can be uncovered in a number of ways: By listening to clients’ unsolicited feedback, by directly soliciting clients’ feedback, whether or not they have provided verbal or nonverbal signals of a problem, by reviewing recordings of therapy sessions alone or with a colleague or supervisor and rating the tape on the Cognitive Therapy Rating Scale or by tracking progress according to objective tests and the client’s subjective report of symptom relief.

Having identified a problem, a therapist should be aware of automatic thoughts blaming the client. The problem can have different causes and ideally the therapist can show recordings of the session to a colleague to evaluate the cause of the problem together. Problems can occur in one or more of the following categories: diagnosis, therapeutic alliance, structure of the session, socialization of the client, dealing with automatic thoughts, accomplishing therapeutic goals across sessions and clients’ processing of the session content. At times, clients may feel better during individual sessions but fail to make progress over the course of several sessions. The experienced therapist, in lieu of the preceding questions, may first wish to rule in or rule out five key problem areas:

• Do the client and I have a solid therapeutic alliance?
• Do we both have a clear idea of the client’s goals for therapy? Is he committed to working toward his goals?
• Does the client truly believe the cognitive model—that his thinking influences his mood and behavior, that his thinking at times is dysfunctional, and that evaluating and responding to dysfunctional thinking positively affect how he feels emotionally and how he behaves?
• Is the client socialized to cognitive behavior therapy—does he contribute to the agenda, collaboratively work toward solving problems, do homework, provide feedback?
• Is the client’s biology (e.g., illness, medication side effects, or inadequate level of medication) or his external environment e.g., an abusive partner, an extremely demanding job, or an intolerable level of poverty or crime in his environment) interfering with your work together?

When a therapist identified a problem and depending on what kind of problem, he or she may consider the advisability of one or more of the following:

• Giving the client a more in-depth diagnostic evaluation.
• Arranging a medical or neuropsychological examination for the client.
• Adjusting your conceptualization and checking it out with the client.
• Learning more about the treatment of the disorder of the cient.
• Asking more specific feedback from the client about her experience of you and of the treatment.
• Reestablishing the client's aspirations, values and goals for treatment.
• Talk about the cognitive model with the client again.
• Going over the treatment plan with the client again. Finding out if there are concerns or doubts.
• Assessing the expectations of the client for how he is going to get better.
• Be clear about the importance of setting and reviewing action plans during sessions and accomplishing action plans throughout the week.
• Keep working on automatic thoughts, beliefs and behaviors.
• Make sure to check what the client understood from the session content and record the most important points.
• If necessary, change the structure of the session.