Behaviour Modification

UNIT 2 COGNITIVE BEHAVIOUR Techniques

THERAPIES (INCLUDING
RATIONAL EMOTIVE THERAPY)

Structure
2.0 Introduction
2.1 Objectives
2.2 History of Cognitive Behaviour Therapy
2.3 Theory of Causation
2.3.1 ABC Model
2.4 Dysfunctional Thinking
2.4.1 The Three Levels of Thinking
2.4.2 Two Types of Disturbance
2.4.3 Seven Inferential Distortions
2.4.4 Evaluations
2.4.5 Core Beliefs
2.5 Steps in Cognitive Behaviour Therapy
2.6 The Process of Cognitive Behaviour Therapy
2.6.1 Engage Client
2.6.2 Assess the Problem, Person and Situation
2.6.3 Prepare the Client for Therapy
2.6.4 Implement the Treatment Programme
2.6.5 Evaluate Progress
2.6.6 Prepare the Client for Termination
2.7 The Treatment Principles of CBT
2.8 Cognitive Behavioural Techniques
2.8.1 Cognitive Techniques
2.8.2 Imagery Techniques
2.8.3 Behavioural Techniques
2.8.4 Other Strategies
2.9 Applications of CBT
2.10 Limitations and Contraindications
2.11 Let Us Sum Up
2.12 Unit End Questions
2.13 Suggested Readings
2.14 Answers to Self Assessment Questions

2.0 INTRODUCTION
Cognitive-Behaviour Therapy (CBT) is based on the concept that emotions and
behaviours result (primarily, though not exclusively) from cognitive processes;
and that it is possible for human beings to modify such processes to achieve
different ways of feeling and behaving. There are a number of ‘cognitive-
behavioural’ therapies, which, although developed separately, have many
31
Cognitive and Behaviour similarities. This unit will present an approach that combines Rational emotive
Therapies
behaviour therapy (REBT) and Cognitive therapy (CT); incorporating elements
of some other approaches as well. The first half of the unit will cover the history
of cognitive behaviour therapy, the theory of cognitive behaviour therapy,
explanation of dysfunctional thinking and the second half will deal with the
steps, process, practice principles and techniques of cognitive behaviour therapy.
Lastly we will cover the applications and limitations of cognitive behaviour
therapy.

2.1 OBJECTIVES
After reading this unit, you should be able to:
• Know the history and theory and core ideas of cognitive behaviour therapy;
• Discuss the steps, process and treatment principles of cognitive behaviour
therapy;
• Describe the different techniques of cognitive behaviour therapy; and
• Describe the applications and limitations of cognitive behaviour therapy.

2.2 HISTORY OF COGNITIVE BEHAVIOUR

THERAPY
The ‘cognitive’ psychotherapies can be said to have begun with Alfred Adler,
one of Freud’s close associate. Adler disagreed with Freud’s idea that the cause
of human emotionality was ‘unconscious conflicts’, arguing that thinking was a
more significant factor. Cognitive Behaviour Therapy has its modern origins in
the mid 1950’s with the work of Albert Ellis, a clinical psychologist. Ellis
originally trained in psychoanalysis, but became disillusioned with the slow
progress of his clients. He observed that they tended to get better when they
changed their ways of thinking about themselves, their problems, and the world.
Ellis reasoned that therapy would progress faster if the focus was directly on the
client’s beliefs, and developed a method now known as Rational Emotive
Behaviour Therapy (REBT). Ellis’ method and a few others, for example Glasser’s
‘Reality Therapy’ and Berne’s ‘Transactional Analysis’, were initially categorised
under the heading of ‘Cognitive Psychotherapies’.

The second major cognitive psychotherapy was developed in the 1960’s by

psychiatrist Aaron Beck; who, like Ellis, was previously a psychoanalyst. Beck
called his approach Cognitive Therapy (CT). (Note that because the term
‘Cognitive Therapy’ is also used to refer to the category of cognitive therapies,
which includes REBT and other approaches, it is sometimes necessary to check
whether the user is alluding to the general category or to Beck’s specific variation).

Since the pioneering work of Ellis and Beck, a number of other cognitive
approaches have developed, many as offshoots of REBT or CT. The term
‘Cognitive Behaviour Therapy’ came into usage around the early 1990’s, initially
used by behaviourists to describe behaviour therapy with a cognitive flavour. In
more recent years, ‘CBT’ has evolved into a generic term to include the whole
range of cognitively oriented psychotherapies. REBT and CT have been joined
by such developments as Rational Behaviour Therapy (Maxie Maultsby),
32
Multimodal Therapy (Arnold Lazarus), Dialectical Behaviour Therapy (Marsha Cognitive Behaviour
Therapies (Including
Linehan), Schema Therapy (Jeffrey Young) and expanded by the work of such Rational Emotive Therapy)
theorists as Ray DiGiuseppe, Michael Mahoney, Donald Meichenbaum, Paul
Salkovskis and many others.

All of these approaches are characterised by their view that cognition is a key
determining factor in how human beings feel and behave, and that modifying
cognition through the use of cognitive and behavioural techniques can lead to
productive change in dysfunctional emotions and behaviours.

Though the various versions or ‘brands’ of cognitive behavioural therapy (CBT)

can be distinguished in terms of certain aspects of the client therapist relationship,
the cognitive target for change, the assessment of change, the degree of emphasis
placed on the client’s self-control, and the degree to which cognitive or
behavioural change is the focus, treatment principles common to all cognitive
behavioural therapies can be identified.

2.3 THEORY OF CAUSATION

CBT is not just a set of techniques. It also contains comprehensive theories of
human behaviour. CBT proposes a ‘biopsychosocial’ explanation as to how human
beings come to feel and act as they do that is, that a combination of biological,
psychological, and social factors are involved. The most basic premise is that
almost all human emotions and behaviours are the result of what people think,
assume or believe (about themselves, other people, and the world in general). It
is what people believe about situations they face not the situations themselves
that determine how they feel and behave.

Both REBT and CT, however, argue that a person’s biology also affects their
feelings and behaviours which is an important point, as it is a reminder to the
therapist that there are some limitations on how far a person can change.

2.3.1 ABC Model

A useful way to illustrate the role of cognition is with the ‘ABC’ model. (Originally
developed by Albert Ellis, the ABC model has been adapted for more general
CBT use). In this framework ‘A’ represents an event or experience, ‘B’ represents
the beliefs about the A, and ‘C’ represents the emotions and behaviours that
follow from those beliefs. Here is an example of an ‘emotional episode’, as
experienced by a person prone to depression who tends to misinterpret the actions
of other people:
A) Activating event: Friend passed me in the street without acknowledging
me.
B) Beliefs about A: He’s ignoring me. He doesn’t like me.
I’m unacceptable as a friend – so I must be worthless as a person.
For me to be happy and feel worthwhile, people must like me.
C) Consequence: Emotions: hurt, depressed.
Behaviours: avoiding people generally.
Note that ‘A’ doesn’t cause ‘C’: ‘A’ triggers off ‘B’; ‘B’ then causes ‘C’. Also,
ABC episodes do not stand alone: they run in chains, with a ‘C’ often becoming
33
Cognitive and Behaviour the ‘A’ of another episode – we observe our own emotions and behaviours, and
Therapies
react to them. For instance, the person in the example above could observe their
avoidance of other people (‘A’), interpret this as weak (‘B’), and engage in self-
downing (‘C’).

Note, too, that most beliefs are outside conscious awareness. They are habitual
or automatic, often consisting of underlying ‘rules’ about how the world and life
should be. With practice, though, people can learn to uncover such subconscious
beliefs.

2.4 DYSFUNCTIONAL THINKING

We have seen that what people think determines how they feel. But what types
of thinking are problematical for human beings?

To describe a belief as ‘irrational’ is to say that:

It blocks a person from achieving their goals, creates extreme emotions that
persist and which distress and immobilise, and leads to behaviours that harm
oneself, others, and one’s life in general.

It distorts reality (it is a misinterpretation of what is happening and is not supported

by the available evidence);

It contains illogical ways of evaluating oneself, others, and the world.

2.4.1 The Three Levels of Thinking

Human beings appear to think at three levels:
1) Inferences;
2) Evaluations; and
3) Core beliefs.
Every individual has a set of general ‘core beliefs’ usually subconscious, that
determines how they react to life. When an event triggers off a train of thought,
what someone consciously thinks depends on the core beliefs they subconsciously
apply to the event.

Let’s say that a person holds the core belief:

‘For me to be happy, my life must be safe and predictable.’ Such a belief will
lead them to be hypersensitive to any possibility of danger and overestimate the
likelihood of things going wrong. Suppose they hear a noise in the night. Their
hypersensitivity to danger leads them to infer that there is an intruder in the
house. They then evaluate this possibility as catastrophic and unbearable, which
creates feelings of panic.

Here is an example (using the ABC model) to show how it all works:
Your friend phones and asks if you will help her for a project for the rest of the
day. You had already planned to catch up with some reading.

You infer that: ‘If I say no, she will think badly of me.’ You evaluate your inference:
‘I couldn’t stand to have her disapprove of me and see me as selfish.’ Your
34
inference and the evaluation that follows are the result of holding the underlying Cognitive Behaviour
Therapies (Including
core belief: ‘To feel OK about myself, I need to be liked, so I must avoid Rational Emotive Therapy)
disapproval from any source.’

You feel anxious and say yes.

Cognitive Therapy focuses mainly on inferential-type thinking, helping the client
to check out the reality of their beliefs, and has some sophisticated techniques to
achieve this empirical aim.

REBT emphasises dealing with evaluative type thinking (in fact, in REBT, the
client’s inferences are regarded as part of the ‘A’ rather than the ‘B’).

When helping clients explore their thinking, REBT practitioners would tend to
use strategies that examine the logic behind beliefs (rather than query their
empirical validity).

What REBT and CT do share, though, is an ultimate concern with underlying

core beliefs.

2.4.2 Two Types of Disturbance

Knowing that there are different levels of thinking does not tell us much about
the actual content of that thinking. The various types of CBT have different
ideas of what content is important to focus on (though the differences are
sometimes a matter of terminology more than anything else).

One way of looking at the content issue that is helpful comes from REBT, which
suggests that human beings defeat or ‘disturb’ themselves in two main ways: (1)
by holding irrational beliefs about their ‘self’ (ego disturbance) and (2) by holding
irrational beliefs about their emotional or physical comfort (discomfort
disturbance). Frequently, the two go together – people may think irrationally
about both their ‘selves’ and their circumstances – though one or the other will
usually be predominant.

2.4.3 Seven Inferential Distortions

In everyday life, events and circumstances trigger off two levels of thinking:
inferring and evaluating. At the first level, we make guesses or inferences about
what is ‘going on’ – what we think has happened, is happening, or will be
happening. Inferences are statements of ‘fact’ (or at least what we think are the
facts – they can be true or false). Inferences that are irrational usually consist of
‘distortions of reality’ like the following:
1) Black and white thinking: This refers to seeing things in extremes, with
no middle ground that is either good or bad, perfect versus useless, success
or failure, right against wrong, moral versus immoral, and so on. This is
also known as all ornothing thinking.
2) Filtering: This refers to seeing all that is wrong with oneself or the world,
while ignoring any positives.
3) Over-generalisation: This refers to building up one thing about oneself or
one’s circumstances and ending up thinking that it represents the whole
situation. For example: ‘Everything’s going wrong’, ‘Because of this mistake,
35
Cognitive and Behaviour I’m a total failure’. Or, similarly, believing that something which has
Therapies
happened once or twice is happening all the time, or that it will be a never-
ending pattern: ‘I’ll always be a failure’, ‘No-one will ever want to love
me’, and the like.
4) Mind-reading: This involves making guesses about what other people are
thinking, such as: ‘She ignored me on purpose’, or ‘He’s mad with me’.
5) Fortune-telling: Here this refers to treating beliefs about the future as though
they were actual realities rather than mere predictions, for example: ‘I’ll be
depressed forever’, ‘Things can only get worse’.
6) Emotional reasoning: This refers to thinking that because we feel a certain
way, this is how it really is: ‘I feel like a failure, so I must be one’, ‘If I’m
angry, you must have done something to make me so’, and the like.
7) Personalising: This means assuming, without evidence, that one is
responsible for things that happen: ‘I caused the team to fail’, ‘It must have
been me that made her feel bad’, and so on.

The seven types of inferential thinking described above have been outlined by
Aaron Beck and his associates.

2.4.4 Evaluations
As well as making inferences about things that happen, we go beyond the ‘facts’
to evaluate them in terms of what they mean to us. Evaluations are sometimes
conscious, sometimes beneath awareness. According to REBT, irrational
evaluations consist of one or more of the following four types:
i) Demandingness
ii) Awfulising
iii) Discomfort Intolerance
iv) People rating
These four are being discussed below:
i) Demandingness: Described colourfully by Ellis as ‘musturbation’,
demandingness refers to the way people use unconditional should and
absolutistic musts, believing that certain things must or must not happen,
and that certain conditions (for example success, love, or approval) are
absolute necessities.

Demandingness implies certain ‘Laws of the Universe’ that must be adhered

to. Demands can be directed either toward oneself or others. Some REBT
theorists see demandingness as the ‘core’ type of irrational thinking,
suggesting that the other three types derive from it.

ii) Awfulising: Exaggerating the consequences of past, present or future events;

seeing something as awful, terrible, horrible, that is the worst that could
happen.

iii) Discomfort intolerance: This is often referred to as ‘can’t-stand-it-itis’:

This is based on the idea that one cannot bear some circumstance or event.
36
 It often follows awfulising, and leads to demands that certain things do not Cognitive Behaviour
Therapies (Including
happen. Rational Emotive Therapy)

iv) People Rating: People rating refers to the process of evaluating one’s entire
self (or someone else’s). In other words, trying to determine the total value
of a person or judging their worth. It represents an overgeneralisation. The
person evaluates a specific trait, behaviour or action according to some
standard of desirability or worth. Then they apply the evaluation to their
total person as for example, ‘I did a bad thing, therefore I am a bad person.’
People rating can lead to reactions like self downing, depression,
defensiveness, grandiosity, hostility, or over concern with approval and
disapproval.

2.4.5 Core Beliefs

Guiding a person’s inferences and evaluations are their core beliefs. Core beliefs
are the underlying, general assumptions and rules that guide how people react to
events and circumstances in their lives. They are referred to in the CBT literature
by various names: ‘schema’; ‘general rules’; ‘major beliefs’; ‘underlying
philosophy’, etc. REBT and CT both propose slightly different types of core
belief. In this unit we would refer to them as assumptions and rules.
Assumptions are a person’s beliefs about how the world is – how it works, what
to watch out for, etc. They reflect the ‘inferential’ type of thinking. Here are
some examples:
My unhappiness is caused by things that are outside my control – so there is little
I can do to feel any better.
Events in my past are the cause of my problems – and they continue to influence
my feelings and behaviours now.
It is easier to avoid rather than face responsibilities.
Rules are more prescriptive – they go beyond describing what is to emphasise
what should be. They are ‘evaluative’ rather than inferential. Here are some
examples:
I need love and approval from those significant to me – and I must avoid
disapproval from any source.
To be worthwhile as a person I must achieve, succeed at whatever I do, and
make no mistakes.
People should always do the right thing. When they behave obnoxiously, unfairly
or selfishly, they must be blamed and punished.
Things must be the way I want them to be, otherwise life will be unbearable.
I must worry about things that could be dangerous, unpleasant or frightening –
otherwise they might happen.
Because they are too much to bear, I must avoid life’s difficulties, unpleasantness,
and responsibilities.
Everyone needs to depend on someone stronger than themselves.

37
Cognitive and Behaviour I should become upset when other people have problems, and feel unhappy when
Therapies
they’re sad.
I shouldn’t have to feel discomfort and pain – I can’t stand them and must avoid
them at all costs.
Every problem should have an ideal solution –and it’s intolerable when one
can’t be found.

2.5 STEPS IN COGNITIVE BEHAVIOUR THERAPY

The steps involved in helping clients change can be broadly summarised as
follows:

i) Help the client understand that emotions and behaviours are caused by beliefs
and thinking. This may consist of a brief explanation (Psychoeducation)
followed by assignment of some reading.

ii) Show how the relevant beliefs may be uncovered.

The ABC format is useful here. Using an episode from the client’s own
recent experience, the therapist notes the ‘C’, then the ‘A’. The client is
asked to consider (at ‘B’): ‘What was I telling myself about ‘A’, to feel and
behave the way I did at ‘C’? As the client develops understanding of the
nature of irrational thinking, this process of ‘filling in the gap’ will become
easier. Such education may be achieved by reading, direct explanation, and
by record-keeping with the therapist’s help and as homework between
sessions.

iii) Teach the client how to dispute and change the irrational beliefs, replacing
them with more rational alternatives.

Again, education will aid the client. The ABC format is extended to include
‘D’ (Disputing irrational beliefs), ‘E’ (the desired new Effect – new ways of
feeling and behaving), and ‘F’ (Further Action for the client to take). (Refer
to table below)

Table: Rational Self-Analysis

CBT emphasises teaching clients to be their own therapists. A useful
technique to aid this is Rational Self-Analysis (Froggatt, 2003) which
involves writing down an emotional episode in a structured fashion. Here
is an example of such an analysis using the case example described earlier:
A) Activating Event (what started things off):
Friend passed me in the street without acknowledging me.
C) Consequence (how I reacted):
Feelings: worthless, depressed. Behaviour: avoiding people generally.
B) Beliefs (what I thought about the ‘A’):
1) He’s ignoring me and doesn’t like me. (inference)
2) I could end up without friends for ever. (inference) This would be
terrible. (evaluation)
38
 Cognitive Behaviour
3) I’m not acceptable as a friend (inference)- so I must be worthless Therapies (Including
as a person. (evaluation) Rational Emotive Therapy)

4) To feel worthwhile and be happy, I must be liked and approved

by everyone significant to me. (core belief)
E) New Effect (how I would prefer to feel/behave):
Disappointed but not depressed.
D) Disputation (of old beliefs and developing new rational beliefs to
help me achieve the new reaction):
1) How do I know he ignored me on purpose? He may not have seen
me. Even if he did ignore me, this doesn’t prove he dislikes me –
he may have been in a hurry, or perhaps upset or worried in some
way.
2) Even if it were true that he disliked me, this doesn’t prove I’ll
never have friends again. And, even this unlikely possibility would
be unpleasant rather than a source of ‘terror’.
3) There’s no proof I’m not acceptable as a friend. But even if I
were, this proves nothing about the total ‘me’, or my
‘worthwhileness’. (And, anyway, what does ‘worthwhile’ mean?).
4) Love and approval are highly desirable. But, they are not absolute
necessities. Making them so is not only illogical, but actually
screws me up when I think they may not be forthcoming. Better I
keep them as preferences rather than demands.
F) Further Action (what I’ll do to avoid repeating the same irrational/
thoughts reactions):
1) Re-read material on catastrophising and self-rating.
2) Go and see my friend, check out how things really are (at the
same time, realistically accepting that I can’t be sure of the
outcome).
3) Challenge my irrational demand for approval by doing one thing
each day (for the next week) that I would normally avoid doing
because of fear it may lead to disapproval.
iv) Help the client to get into action.
Acting against irrational beliefs is an essential component of CBT. The client
may, for example, dispute the belief that disapproval is intolerable by deliberately
doing something to attract it, to discover that they in fact survive. CBT’s emphasis
on both rethinking and action makes it a powerful tool for change. The action
part is often carried out by the client as ‘homework’.

2.6 THE PROCESS OF COGNITIVE BEHAVIOUR

THERAPY
This section of the unit will deal with the summary of the main components of
CBT intervention.

39
Cognitive and Behaviour 2.6.1 Engage Client
Therapies
The first step is to build a relationship with the client. This can be achieved
using the core conditions of empathy, warmth and respect. Watch for any
‘secondary disturbances’ about coming for help: self-downing over having the
problem or needing assistance; and anxiety about coming to the interview. Finally,
possibly the best way to engage a client is to demonstrate to them at an early
stage that change is possible and that CBT is able to assist them to achieve this
goal.

2.6.2 Assess the Problem, Person and Situation

Assessment will vary from person to person, but following are some of the most
common areas that will be assessed as part of a CBT intervention.
• Start with the client’s view of what is wrong for them.
• Determine the presence of any related clinical disorders.
• Obtain a personal and social history.
• Assess the severity of the problem.
• Note any relevant personality factors.
• Check for any secondary disturbance: How does the client feel about having
this problem?
• Check for any non-psychological causative factors: physical conditions;
medications; substance abuse; lifestyle/environmental factors.

2.6.3 Prepare the Client for Therapy

• Clarify treatment goals.
• Assess the client’s motivation to change.
• Introduce the basics of CBT, including the biopsychosocial model of
causation.
• Discuss approaches to be used and implications of treatment.
• Develop a contract.

2.6.4 Implement the Treatment Programme

Most of the sessions will occur in the implementation phase, using activities like
the following:
Analysing specific episodes where the target problems occur, ascertaining the
beliefs involved, changing them, and developing relevant homework (known as
‘thought recording’ or ‘rational analysis’).
Developing behavioural assignments to reduce fears or modify ways of behaving.
Supplementary strategies and techniques as appropriate, e.g. relaxation training,
interpersonal skills training, etc.

2.6.5 Evaluate Progress

Toward the end of the intervention it will be important to check whether
improvements are due to significant changes in the client’s thinking, or simply
to a fortuitous improvement in their external circumstances.
40
2.6.6 Prepare the Client for Termination Cognitive Behaviour
Therapies (Including
It is usually very important to prepare the client to cope with setbacks. Many Rational Emotive Therapy)
people, after a period of wellness, think they are ‘cured’ for life. Then, when
they slip back and discover their old problems are still present to some degree,
they tend to despair and are tempted to give up self-help work altogether.

Warn that relapse is likely for many mental health problems and ensure the client
knows what to do when their symptoms return.

Discuss their views on asking for help if needed in the future. Deal with any
irrational beliefs about coming back, like: ‘I should be cured for ever’, or: ‘The
therapist would think I was a failure if I came back for more help’.

2.7 THE TREATMENT PRINCIPLES OF CBT

The basic aim of CBT is to leave clients at the completion of therapy with freedom
to choose their emotions, behaviours and lifestyle (within physical, social and
economic restraints); and with a method of self observation and personal change
that will help them maintain their gains.

Not all unpleasant emotions are seen as dysfunctional. Nor are all pleasant
emotions functional. CBT aims not at ‘positive thinking’; but rather at realistic
thoughts, emotions and behaviours that are in proportion to the events and
circumstances an individual experiences.

Developing emotional control does not mean that people are encouraged to
become limited in what they feel – quite the opposite. Learning to use cognitive-
behavioural strategies helps oneself become open to a wider range of emotions
and experiences that in the past they may have been blocked from experiencing.

There is no ‘one way’ to practice CBT. It is ‘selectively eclectic’. Though it has

techniques of its own, it also borrows from other approaches and allows
practitioners to use their imagination. There are some basic assumptions and
principles, but otherwise it can be varied to suit one’s own style and client group.

CBT is educative and collaborative. Clients learn the therapy and how to use it
on themselves (rather than have it ‘done to them’). The therapist provides the
training – the client carries it out. There are no hidden agendas – all procedures
are clearly explained to the client. Therapist and client together design homework
assignments.

The relationship between therapist and client is seen as important, the therapist
showing empathy, unconditional acceptance, and encouragement toward the
client. In CBT, the relationship exists to facilitate therapeutic work – rather than
being the therapy itself. Consequently, the therapist is careful to avoid activities
that create dependency or strengthen any ‘needs’ for approval.

CBT is brief and time-limited. It commonly involves five to thirty sessions over
one to eighteen months. The pace of therapy is brisk. A minimum of time is
spent on acquiring background and historical information: it is task oriented and
focuses on problem-solving in the present.

41
Cognitive and Behaviour CBT tends to be anti-moralistic and scientific. Behaviour is viewed as functional
Therapies
or dysfunctional, rather than as good or evil. CBT is based on research and the
principles of logic and empiricism, and encourages scientific rather than ‘magical’
ways of thinking.

Finally, the emphasis is on profound and lasting change in the underlying belief
system of the client, rather than simply eliminating the presenting symptoms.
The client is left with self-help techniques that enable coping in the long-term
future.

2.8 COGNITIVE BEHAVIOURAL TECHNIQUES

There are no techniques that are essential to CBT –one uses whatever works,
assuming that the strategy is compatible with CBT theory (the ‘selectively eclectic’
approach). However, the following are examples of procedures in common use.

2.8.1 Cognitive Techniques

Self-monitoring
Self-monitoring is an important assessment tool. The therapist instructs the patient
to observe and record her own behavioural and emotional reactions. As these
reactions are distributed throughout the patient’s daily life, self-monitoring tends
to be employed as a homework assignment. The therapist and patient
collaboratively select the target of monitoring (e.g., a symptom, behaviour, or
reaction) based upon the patient’s goals and presenting problem list. Self-
monitoring serves at least three purposes within a course of CBT:
1) it encourages and effectively trains the patient to observe her own reactions
in a more scientific manner;
2) it renders a concrete record of the target symptoms and problems; and
3) new problems can become apparent and targeted for future intervention.
Self-monitoring is especially useful in early sessions as a means of assessing the
severity or frequency of a particular problem or symptom. However, self-
monitoring is equally useful in later sessions as a means of tracking the patient’s
progress. Examples of self-monitoring include a record of daily activities and
corresponding mood; a frequency count of the number of panic attacks per day;
a record of the frequency and content of auditory hallucinations; and a food
diary in which time, quantity, and type of food eaten are recorded (J. S. Beck,
1995).

Rational analysis
This refers to the analyses of specific episodes to teach client how to uncover
and dispute irrational beliefs (as described above). These are usually done in-
session at first – as the client gets the idea, they can be done as homework.

Double-standard dispute
If the client is holding a ‘should’ or is self-downing about their behaviour, ask
whether they would globally rate another person (e.g. best friend, therapist, etc.)
for doing the same thing, or recommend that person hold their demanding core
belief. When they say ‘No’, help them see that they are holding a double-standard.
42
This is especially useful with resistant beliefs which the client finds hard to give Cognitive Behaviour
Therapies (Including
up. Rational Emotive Therapy)

Catastrophe scale
This is a useful technique to get awfulising into perspective. On a whiteboard or
sheet of paper, draw a line down one side. Put 100% at the top, 0% at the bottom,
and 10% intervals in between. Ask the client to rate whatever it is they are
catastrophising about, and insert that item into the chart in the appropriate place.
Then, fill in the other levels with items the client thinks apply to those levels.

You might, for example, put 0%: ‘Having a quiet cup of coffee at home’, 20%:
‘Having to do chores when the cricket is on television’, 70%: being burgled,
90%: being diagnosed with cancer, 100%: being burned alive, and so on. Finally,
have the client progressively alter the position of their feared item on the scale,
until it is in perspective in relation to the other items.

Devil’s advocate
This is a useful and effective technique (also known as reverse role-playing)
which is designed to get the client arguing against their own dysfunctional belief.
The therapist role-plays adopting the client’s belief and vigorously argues for it;
while the client tries to ‘convince’ the therapist that the belief is dysfunctional. It
is especially useful when the client now sees the irrationality of a belief, but
needs help to consolidate that understanding.

Reframing
This is another strategy for getting bad events into perspective is to re-evaluate
them as ‘disappointing’, ‘concerning’, or ‘uncomfortable’ rather than as ‘awful’
or ‘unbearable’. A variation of reframing is to help the client see that even negative
events almost always have a positive side to them, listing all the positives the
client can think of (Note this needs care so that it does not come across as
suggesting that a bad experience is really a ‘good’ one).

2.8.2 Imagery Techniques

Time projection
This technique is designed to show that one’s life and the world in general,
continue after a feared or unwanted event has come and gone. Ask the client to
visualise the unwanted event occurring, then imagine going forward in time a
week, then a month, then six months, then a year, two years, and so on, considering
how they will be feeling at each of these points in time. They will thus be able to
see that life will go on, even though they may need to make some adjustments.

The ‘worst-case’ technique

People often try to avoid thinking about worst possible scenarios in case doing
so makes them even more anxious. However, it is usually better to help the
client identify the worst that could happen. Facing the worst, while initially
increasing anxiety, usually leads to a longer-term reduction because
1) the person discovers that the ‘worst’ would be bearable if it happened, and
2) realises that as it probably won’t happen, the more likely consequences will
obviously be even more bearable; or
43
Cognitive and Behaviour 3) if it did happen, they would in most cases still have some control over how
Therapies
things turn out.
The ‘blow-up’ technique
This is a variation of ‘worst-case’ imagery, coupled with the use of humour to
provide a vivid and memorable experience for the client. It involves asking the
client to imagine whatever it is they fear happening, then blow it up out of all
proportion till they cannot help but be amused by it. Laughing at fears helps get
them under control.

2.8.3 Behavioural Techniques

One of the best ways to check out and modify a belief is to act. Clients can be
encouraged to check out the evidence for their fears and to act in ways that
disprove them.

Exposure
This is possibly the most common behavioural strategy used in CBT involves
clients entering feared situations they would normally avoid. Such ‘exposure’ is
deliberate, planned and carried out using cognitive and other coping skills.

The purposes are to

1) test the validity of one’s fears (e.g. that rejection could not be survived);
2) deawfulise them (by seeing that catastrophe does not ensue);
3) develop confidence in one’s ability to cope (by successfully managing one’s
reactions); and
4) increase tolerance for discomfort (by progressively discovering that it is
bearable).
Hypothesis testing
In this, there is a variation of exposure, the client
1) writes down what they fear will happen, including the negative consequences
they anticipate, then
2) for homework, carries out assignments where they act in the ways they fear
will lead to these consequences (to see whether they do in fact occur).
Risk-taking
The purpose is to challenge beliefs that certain behaviours are too dangerous to
risk, when reason says that while the outcome is not guaranteed they are worth
the chance. For example, if the client has trouble with perfectionism or fear of
failure, they might start tasks where there is a chance of failing or not matching
their expectations. Or a client who fears rejection might talk to an attractive
person at a party or ask someone for a date.

Stimulus control
Sometimes behaviours become conditioned to particular stimuli; for example,
difficulty sleeping can create a connection between being in bed and lying awake;
or the relief felt when a person vomits after bingeing on food can lead to a
connection between bingeing and vomiting. Stimulus control is designed to
lengthen the time between the stimulus and the response, so as to weaken the
44
connection. For example, the person who tends to lie in bed awake would get up Cognitive Behaviour
Therapies (Including
if unable to sleep for 20 minutes and stay up till tired. Or the person purging food Rational Emotive Therapy)
would increase the time between a binge and the subsequent purging.

Paradoxical behaviour
When a client wishes to change a dysfunctional tendency, encourage them to
deliberately behave in a way contradictory to the tendency. Emphasise the
importance of not waiting until they ‘feel like’ doing it: practising the new
behaviour – even though it is not spontaneous – will gradually internalise the
new habit.

Stepping out of character

This is one common type of paradoxical behaviour. For example, a perfectionist
person could deliberately do some things to less than their usual standard; or
someone who believes that to care for one self is ‘selfish’ could indulge in a
personal treat each day for a week.

Postponing gratification
This is commonly used to combat low frustration tolerance by deliberately
delaying smoking, eating sweets, using alcohol, etc.

2.8.4 Other Strategies

Problem solving
Activity Scheduling
Skills training, e.g. relaxation, social skills.
Reading (self re-education).
Tape recording of interviews for the client to replay at home.
Probably the most important CBT strategy is homework. This includes reading,
self-help exercises such as thought recording, and experiential activities. Therapy
sessions can be seen as ‘training sessions’, between which the client tries out
and uses what they have learned.

2.9 APPLICATIONS OF CBT

CBT has been successfully used to help people with a range of clinical and non-
clinical problems, using a variety of modalities. Typical clinical applications
include:
• Depression
• Anxiety disorders, including obsessive compulsive disorder, agoraphobia,
specific phobias, generalised anxiety, posttraumatic stress disorder, etc.
• Eating disorders
• Addictions
• Hypochondriasis
• Sexual dysfunction
• Anger management
45
Cognitive and Behaviour • Impulse control disorders
Therapies
• Antisocial behaviour
• Jealousy
• Sexual abuse recovery
• Personality disorders
• Adjustment to chronic health problem, physical disability, or mental disorder
• Pain management
• General stress management
• Child or adolescent behaviour disorders
• Relationship and family problems
The most common use of CBT is with individual clients, but this is followed
closely by group work, for which CBT is eminently suited. CBT is also frequently
used with couples, and increasingly with families.

2.10 LIMITATIONS AND CONTRAINDICATIONS

It is safe to say that CBT has proved quite versatile, having been successfully
applied to a wide spectrum of psychological difficulty. The limits of cognitive
therapy have yet to be empirically established. However, several factors may
make the cognitive-behavioural approach less effective; in fact, these factors
may interfere with the efficacy of any psychotherapeutic approach. Low patient
motivation, unless appropriately addressed, can impede progress, especially
among patients who hold beliefs that they will suffer significant adverse
consequences if they comply with treatment. Patients who have positive beliefs
about dysfunctional aspects of their disorder likewise need special intervention.
Examples include the schizophrenic patient’s grandiose delusion (e.g., one who
believes he is being persecuted because he is a great deity) and the anorexic
patient’s social beliefs (e.g., she is superior to others).

Even when motivation is present, the success of cognitive-behavioural methods

can be hampered by mental facility. Severely retarded individuals, for example,
might not be capable of the reasoning entailed in cognitive restructuring. Self-
monitoring might also prove to be too demanding a task for a person with severe
intellectual impairment. Behavioural methods may be more appropriate for these
individuals than cognitive strategies. Psychopaths (Lykken, 1995) might also
have difficulty with certain cognitive interventions; when performing a goal-
directed task, they may be less able to attend to peripheral information or to self-
regulate, especially under conditions of neutral motivation (Newman et al., 1997).

Finally, cultural differences may impact efficacy if therapists do not tailor the
therapy appropriately. Therapists must understand, for example, how these
differences may affect the building of a therapeutic alliance and how patients’
cultural beliefs affect their thinking and reactions. Different thinking styles and
stylistic preferences must often be accommodated for patients to progress.

46
 Cognitive Behaviour
Self Assessment Questions 1 Therapies (Including
Rational Emotive Therapy)
1) What does A, B, C represent in the ABC model used to explain the role
of cognitions?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

2) What are the two main ways in which human beings disturb themselves?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

3) What are core beliefs?

...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

4) Name the main components of CBT intervention?

...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

5) Explain the technique playing “Devil’s advocate’?

...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
47
Cognitive and Behaviour
Therapies 2.11 LET US SUM UP
Cognitive behaviour therapy (CBT) is a type of psychotherapeutic treatment
that helps patients to understand the thoughts and feelings that influence
behaviours. Cognitive behaviour therapy is generally short-term and focused on
helping clients deal with a very specific problem. During the course of treatment,
people learn how to identify and change destructive or disturbing thought patterns
that have a negative influence on behaviour.

The underlying concept behind CBT is that our thoughts and feelings play a
fundamental role in our behaviour. For example, a person who spends a lot of
time thinking about plane crashes, runway accidents and other air disasters may
find themselves avoiding air travel. The goal of cognitive behaviour therapy is
to teach patients that while they cannot control every aspect of the world around
them, they can take control of how they interpret and deal with things in their
environment. Cognitive behaviour therapy has become increasingly popular in
recent years with both mental health consumers and treatment professionals.
Because CBT is usually a short-term treatment option, it is often more affordable
than some other therapeutic options. CBT is also empirically supported and has
been shown to effectively help patients overcome a wide variety.

Cognitive and behavioural psychotherapies are a range of therapies based on

concepts and principles derived from psychological models of human emotion
and behaviour. They include a wide range of treatment approaches for emotional
disorders, along a continuum from structured individual psychotherapy to self
help material. There are a number of different approaches to CBT that are regularly
used by mental health professionals. These types include Rational Emotive
Therapy, Cognitive Therapy and Multimodal Therapy.

Cognitive behaviour therapy has been used to treat people suffering from a wide
range of disorders, including anxiety, phobias, depression, addiction and a variety
of maladaptive behaviours. CBT is one of the most researched types of therapy,
in part because treatment is focused on a highly specific goal and results can be
measured relatively easily. Cognitive behaviour therapy is well-suited for people
looking for a short-term treatment options that does not necessarily involve
pharmacological medication. One of the greatest benefits of CBT is that it helps
clients develop coping skills that can be useful both now and in the future.

2.12 UNIT END QUESTIONS

1) Discuss the history and theory of Cognitive behaviour therapy?

2) Discuss in detail dysfunctional thinking with examples?

3) Describe the steps and process of cognitive behaviour therapy?

4) What are the treatment principles of CBT?

5) Describe in detail the various cognitive and behavioural techniques in CBT?

6) Write about the applications and limitations of CBT?

48
 Cognitive Behaviour
2.13 SUGGESTED READINGS Therapies (Including
Rational Emotive Therapy)
Gabbard, Glen O., Beck, Judith S. and Holmes, Jeremy. (2005). Oxford Textbook
of Psychotherapy, 1st Edition. Oxford: Oxford University Press.

Gabbard, Glen O. (2009). Textbook of Psychotherapeutic Treatments. U.S.A:

American Psychiatric Publishing, Inc.

2.14 ANSWERS TO SELF ASSESSMENT

QUESTIONS
1) ‘A’ represents an event or experience, ‘B’ represents the beliefs about the A,
and ‘C’ represents the emotions and behaviours that follow from those
beliefs.
2) The human beings defeat or ‘disturb’ themselves in two main ways: by
holding irrational beliefs about their ‘self’ (ego disturbance) and by holding
irrational beliefs about their emotional or physical comfort (discomfort
disturbance).
3) Core beliefs are the underlying, general assumptions and rules that guide
how people react to events and circumstances in their lives.
4) The main components of CBT are engaging the client; assessing the problem,
person and situation; preparing the client for therapy; implementing the
treatment program; evaluating progress and lastly preparing the client for
termination.
5) Devil’s advocate is a useful and effective technique designed to get the client
arguing against their own dysfunctional belief. The therapist role-plays
adopting the client’s belief and vigorously argues for it; while the client
tries to ‘convince’ the therapist that the belief is dysfunctional.

49