Cognitive Behaviour Therapy

Cognitive-behaviour therapy involves a specific focus on cognitive strategies such as identification and modification of maladaptive cognitive errors and restructuring of core beliefs and/or representations of the self. Further focus is on behavioural strategies that are designed to activate clients in the environment with a view to effect desired behaviour change.

Distinctive features of CBT:

  • Use of homework and outside-of-session activities
  • Direction of session activities
  • Teaching of skills used by clients to cope with problems
  • Emphasis on clients’ future experiences
  • Providing clients with information about the course of treatment
  • An intrapersonal/cognitive focus

Albert Ellis

Ellis was born in Pittsburg (1913). He spent most of his life in New York. A natural counsellor, Ellis studied psychoanalysis and was supervised by a training analyst. Ellis, however grew increasingly frustrated by psychoanalysis which he concluded was unscientific and superficial (Corey, 2005).

In the early 1950s, Ellis experimented with other treatment frameworks, from humanism to behaviour therapy. From such experimentation, Ellis founded what is now referred to as Rational Emotive Behaviour Therapy (or REBT).

Aaron Beck

Beck, born in 1921, Providence, Rohde Island, was initially attracted to the study of neurology. It wasn’t long, however, before he discovered psychiatry was a more fitting interest for him. Beck struggled with numerous fears throughout his life, including a fear of public speaking and anxiety about his health. Beck used these fears to help him understand himself and others which ultimately provided the basis on which he developed his cognitive theory (Corey, 2005).

Through his research, Beck discovered that people who are suffering from depression often reported thinking that was characterised by errors in logic. These errors, Beck called, ‘cognitive distortions’.

Ellis’ Rational Emotive Behaviour Therapy (REBT)

Essential to Ellis’s theory is the A-B-C sequence. This sequence describes the relationship between experience, beliefs and reactions.

Consider the model below:
 
A (Activating Event) — B (Belief) — C (Consequence)

According to Ellis, we experience Activating Events (A) everyday that prompts us to look at, interpret, or otherwise think about what is occurring.  Our interpretation of these events results in specific Beliefs (B) about the event, the world and our role in the event.  Once we develop this belief, we experience Consequences (C) based solely on our belief.

Example 1 – Mel & Toni
Mel and Toni are work colleagues. Over coffee they begin discussing the project they are working on together. On completion of the project they are required to present their proposal to the board of directors. Mel hates doing presentations so Toni decides to volunteer to do the presentation on her own. But when Toni announces that she is going to do the presentation alone – Mel becomes upset.

Here’s why:

  • (A) The activating event was Toni announcing to Mel that she will do the presentation for the board of directors
  • (B) Mel has a belief that she is unworthy. She feels as though she always looks scruffy, stumbles on her words and is therefore not fit to associate with figures of authority.
  • (C) The consequence is that Mel becomes upset because Toni (unknowingly) reinforced Mel’s belief that she is unworthy. Although Mel would prefer not to do the presentation – she is upset because she believes Toni thinks she is not worthy to do such a presentation.

The role of the counsellor is to dispute the irrational belief (B). Disputing has three parts: detecting, discriminating and debating irrational beliefs.

Disputing irrational beliefs

Detecting irrational beliefs: The counsellor’s foremost role in the process of disputing irrational beliefs is firstly to assist clients in detecting them. Irrational beliefs can be detected through the examination of activating events (A) and consequences (C).

Discriminating between rational and irrational beliefs: The second step in disputing irrational beliefs is deciding whether the belief is irrational or not. A clue to the rationality of a belief is the use of terms such as should, must and ought. Use of such terms often indicates that a belief is irrational.

Debating irrational beliefs: Debating irrational beliefs is a large part of REBT. There are many techniques that can be used to debate irrational beliefs. Some of these include:

Socratic debate: The counsellor draws attention to the incongruence or inconsistency in the client’s beliefs. The goal is to enable clients to critically examine their beliefs and not simply accept the counsellor’s perception.

Humour and creativity: Stories and metaphors can help clients gain new insight or a fresh perspective on their beliefs.

Developing new rational beliefs: There are numerous methods for assisting clients in developing new rational beliefs. Some of these include:

Coping self-statement: Coping statements can strengthen newly formed rational beliefs. “For example, an individual who is afraid of public speaking may write down and repeat to himself several times a day statements such as “I want to speak flawlessly, but it’s alright if I don’t,” “No one is killed for giving a poor speech,” and “I’m an articulate person.” (Sharf, 2004, 336).

Cost-benefit analysis: This is the process of comparing the costs and the benefits of holding a particular belief or set of beliefs. Clients are encouraged to think about the advantages and disadvantages on a regular basis.

Psycho educational methods: Self-help books, audio CDs and other learning tools may supplement counselling sessions and serve as a reminder of strategies learnt in counselling.

Teaching others: Clients are encouraged to teach others to dispute their irrational beliefs. This serves as a learning tool and a reinforcer of strategies learnt in counselling.

Beck’s Cognitive Therapy

Beck’s Cognitive therapy teaches clients to identify faulty patterns of thinking. Clients are introduced to intervention strategies that assist in changing thought patterns and consequently changing behaviour. Cognitive therapy is founded on the notion that our core-beliefs, thoughts, emotions and behaviours are all inter-connected.

Example – David & James
Imagine two men – David and James. Both of these men have bought a new self-assemble bookshelf and are trying to build it from the brief instructions enclosed. Read through the table below as it outlines the different thought processes David and James may go through as they complete this building project.

David vs James

Core Belief:

  • David has a core belief that he is unlikely to succeed at anything.
  • James has a core belief that says with effort he can accomplish anything. 

Automatic Thought:

  • As David reads through the instructions, he thinks, “I don’t get it! I never understand this stuff.” 
  • As James reads through the instructions, he thinks “I don’t get this! Where am I going wrong?”

Emotion:

  • David begins to feel frustration and anger.
  • James begins to feel determined to find answers.

Behaviour:

  • As a result of his thinking David decides to walk away from the half-assembled bookshelf and never completes it.
  • As a result of his thinking James revises the instructions and finally completes the assembly of the bookshelf.

Both men in the above scenario are doing the same thing (assembling a bookshelf from brief instructions) yet they behave very differently. The Cognitive Behaviour approach suggests that these men were motivated by their thoughts which were triggered by the core beliefs they hold about themselves.

From the example outlined above, the impact people’s belief system and thought processes could have on their actions was obvious. It is the role of the Cognitive Behavioural therapist to assist clients in identifying core beliefs or thoughts that are interfering with their life and then teach them strategies to change the pattern.

Cognitive Distortions

Beck labelled information processing errors, cognitive distortions. They are often logical, but they are not rational. They can create real difficulty with one’s thinking. Below is a list of some of the most common cognitive distortions. 
 
All-or-nothing thinking: You see things in black and white categories. If your performance falls short of perfect, you see yourself as a total failure. 
 
Overgeneralization: You see a single negative event as a never-ending pattern of defeat.

Mental filter: You pick out a single negative detail and dwell on it exclusively so that your vision of all reality becomes darkened, like the drop of ink that discolours the entire beaker of water. 
 
Disqualifying the positive: You reject positive experiences by insisting they “don’t count” for some reason or other. You maintain a negative belief that is contradicted by your everyday experiences. 
 
Jumping to conclusions: You make a negative interpretation even though there are no definite facts that convincingly support your conclusion.

Mind reading: You arbitrarily conclude that someone is reacting negatively to you and don’t bother to check it out.
The Fortune Teller Error: You anticipate that things will turn out badly and feel convinced that your prediction is an already-established fact. 
 
Magnification (catastrophizing) or minimization: You exaggerate the importance of things (such as your goof-up or someone else’s achievement), or you inappropriately shrink things until they appear tiny (your own desirable qualities or the other fellow’s imperfections). This is also called the “binocular trick.” 
 
Emotional reasoning: You assume that your negative emotions necessarily reflect the way things really are: “I feel it, therefore it must be true.” 
 
Should statements: You try to motivate yourself with shoulds and shouldn’ts, as if you had to be whipped and punished before you could be expected to do anything. “Musts” and “oughts” are also offenders. The emotional consequence is guilt. When you direct should statements toward others, you feel anger, frustration, and resentment. 
 
Labelling and mislabelling: This is an extreme form of overgeneralization. Instead of describing your error, you attach a negative label to yourself: “I’m a loser.” When someone else’s behaviour rubs you the wrong way, you attach a negative label to him, “He’s a damn louse.” Mislabelling involves describing an event with language that is highly coloured and emotionally loaded. 
 
Personalization: You see yourself as the cause of some negative external event for which, in fact, you were not primarily responsible. 

Source: Burns, D.D. (1989). The Feeling Good Handbook. New York: William Morrow.

Regularly occurring cognitive distortions can create psychological distress and may lead to depression, anxiety or other difficulties. An examination of cognitive distortions is used in cognitive counselling to assist client in identifying and modifying their maladaptive thought patterns.

The process of cognitive therapy is briefly outlined in the figure below.

  1. Identify a client’s automatic thinking
  2. Evaluate the automatic thought in terms of: The feeling/emotion it generates; Its validity (Is it true?)
  3. Apply strategies to modify the thinking pattern 

A counsellor may ask a number of questions in order to evaluate a client’s automatic thoughts (step 2). Some questions a counsellor may ask are listed below.

Questioning automatic thoughts

What is the evidence?

  • What is the evidence that supports this idea?
  • What is the evidence against this idea?

Is there an alternative explanation?

What’s the worst that could happen? Could I live through it?

  • What is the best that could happen?
  • What is the most realistic outcome?

What is the effect of my believing the automatic thought?

  • What could be the effect of changing my thinking?

What should I do about it?

What would I tell________(a friend)  if he or she were in the same situation?

Source: Beck, J. (1995). Cognitive therapy: Basics and beyond. New York, NY: Guilford Publications.

In addition to the questioning techniques listed above, there are a number of additional strategies to assist clients in challenging their thought patterns. Some of these include:

Challenging absolutes

When clients use language such as, everyone, always, never, no one, always, counsellors challenge these absolute statements. For example:

Client:  Everyone is getting better grades than me.
Counsellor: Everyone?
Client:  Well, maybe not. There are some people, I suppose, whose grades I don’t know.
Counsellor: Whose grades do you know?
Client: Jillian’s and Petra’s.
Counsellor: Notice how we went from everyone having better grades to only two people with better grades.
Client: I guess, it’s just those girls. They are always doing so well.

Reattribution

This is a techniques counsellors use to more fairly distribute the responsibility of an event as clients often heavily blame themselves. For example:

Client: I stuffed up! I let my daughter down. I said I would be there to watch her swimming race and I missed it.
Counsellor: Weren’t you running late because of a meeting that ran well past schedule?
Client: Yes.
Counsellor: Were you in control of the time the meeting would end?
Client: No. But I told my daughter I would be there.
Counsellor: So there were other factors involved in your schedule?
Client: Yes, I guess so.

Listing the advantages and disadvantages

By considering the advantages and disadvantages of a particular thought, clients can be encouraged to assess the thought in terms of its usefulness. For example: A client might think, “I must earn a promotion.” Some advantages and disadvantages of this thought may include:

  • Advantages
  • May generate motivation to achieve
  • Inspires optimism
  • Disadvantages
  • May create undue pressure
  • May impact negatively on performance in current role

Listing the advantages and disadvantages may help clients to moderate their thinking from an all-or-nothing approach to a more balanced perspective on the matter at hand. 

Applications

Cognitive approaches have been applied as means of treatment across a variety of presenting concerns and psychological conditions. Cognitive approaches emphasise the role of thought in the development and maintenance of unhelpful or distressing patterns of emotion or behaviour. 

Beck originally applied his cognitive approach to the treatment of depression. Cognitive therapy has also been successfully used to treat such conditions as anxiety disorders, obsessive disorders, substance abuse, post-traumatic stress, eating disorders, dissociative identity disorder, chronic pain and many other clinical conditions. In addition, it has been widely utilised to assist clients in enhancing their coping skills and moderating extremes in unhelpful thinking. 

Challenges of CBT

(1) When the client has difficulty identifying emotions and thoughts
It is common for clients to experience emotion prior to any conscious recognition of their preceding thought(s). This can make it difficult to ascertain the actual thought(s) that activated the emotional response.

To assist clients in identifying their thoughts, counsellors may need to use specific questioning techniques to isolate thoughts. Such as, “What were you telling yourself at the time?” or “What was going through your mind?” In addition, role playing the situation and stopping the scene at crucial (emotional) times in the sequence may help clients recall their thinking.

(2) When clients agree with the principles but can’t seem to alter their thinking
Frequently, clients report an understanding of the principles of cognitive therapy on an intellectual level, but cannot seem to apply that understanding in a way that promotes real change (Sanders & Wills, 2005). Reinforcing that change takes time and even pre-empting the difficulty of shifting from “the head level to the gut feelings” can be helpful ways of preparing clients to stick with the strategies (p. 167). It may simply be a matter of repetition and practice for clients working through change from the ‘head’ through to the ‘heart’. 

(3) Clients have limited motivation for change
For clients that are not attending counselling of their own free will, it is essential that counsellors establish motivating factors for the client in the initial stages of therapy. Client may, for example, be attending counselling to keep harmony in a significant relationship or to elicit help to get someone ‘off their back’. Whatever the reason for attendance, counsellors should focus on the possible benefits an individual may receive by being involved in the counselling process. 

Strengths

  • Well supported by scientific research    
  • Wide application      
    Has been used successfully with personality and mood disorders 
  • Provides a structured plan and sequence for therapy  

Weaknesses

  • Requires clients to be attuned to nuances in mood or attentive to previously unconscious thoughts
  • Can be overly prescriptive and ignore individual factors
  • Requires the ability to think abstractly (ie. to think about thinking)
  • May not be as depth orientated as some clients may prefer or see as necessary for change

Conclusion

All counselling approaches have both their merits and their limitations. Cognitive behaviour therapies are popular for their broad application, scientific validation and the structure they can create for counselling. Cognitive behavioural approaches teach clients the skills of evaluating their own thought patterns, and as such, this approach can be successfully transferred to situations outside of the counselling room.

Effective application of cognitive behavioural counselling requires not only a comprehensive understanding of cognitive concepts but also an appreciation for the time it can take to alter thought patterns and an awareness of the fact that clients may need much practice before realising the benefits of cognitive strategies.

References

  • Beck, J. (1995). Cognitive therapy: Basics and beyond. New York, NY: Guilford Publications.
  • Burns, D. D. (1989). The feeling good handbook. New York: William Morrow.
  • Corey, G. (2005). Theory and practice of counselling and psychotherapy. (7th ed.). Belmont, CA: Brooks/Cole.
  • Sanders, D., & Wills, F. (2005). Cognitive therapy: An introduction. (2nd ed.). London: Sage.
  • Sharf, R. (2004). Theories of psychotherapy and counseling: Concepts and cases. (3rd ed.). Pacific Grove, CA: Brooks/Cole.