Session # 5

Additional Strategies in
Cognitive-Behavioral
Therapy

SW 8350
Marla K. Ruhana
Wayne State University
School of Social Work

Additional Key Cognitive Strategies

Activity monitoring & scheduling

Advantages Disadvantages Inventory

Weigh pros and cons of available choices

Help resolve ambivalence

Graded task assignments (Beck, p.265) - Behavioral experiments

Role-play and reverse role-play
Relaxation (i.e. breathing, imagery, mindfulness)
PIE Technique (see J. Beck, 2011, p. 268-272)

Monitor & track the problem behavior

Schedule specific tasks, pleasurable/recreational activities

Set goals; determine relative responsibility; evaluate balance in ones life

Coping cards (with specific messages)

Thoughts-stopping

Homework (J. Beck, 2011, ch. 17)

Importance of homework assignments

Common types of homework

Behavioral activation
Behavioral experiments
Behavioral logs or thoughts records
Bibliotherapy

Increasing likelihood of homework completion

Develop assignment collaboratively get clients input.

Tailor assignment to the individual avoid generic assignments.
Provide a rationale for the assignment.
Use assignments with a good probability that they will get done.
Anticipate problems

Internal: lack of skills, lack of information/knowledge, perfectionism, etc.

External: environmental deficits: space, time, people, etc.

Reinforce work done; troubleshoot problems

Review homework (very important!!)

Termination

(J. Beck, 2011, ch. 18)

Start preparing clients for termination and relapse prevention at

the initial session. How??

Discuss the course of recovery.

Normalize relapse and occasional setbacks

Attribute progress to the clients own initiative and reinforce.

Gradually decrease the intensity of therapy.

At the end of every session underscore at least one significant outcome:

Is there one thing that you could take with you today to help you ?

Is there one thing that we have discussed here today that you can use
to...?

Elicit and address concerns about termination

Contingencies for aftercare

If inpatient or residential

Follow up with community-based referrals, treatment etc.

What is the client going do to maintain the therapeutic gains?

Support groups?
Will there be a follow-up?
Booster sessions?

Problems in cognitive therapy

(J. Beck, 2011, ch.20)

Uncovering problems

Elicit client feedback

Attend to clients non-verbal cues (e.g. affect, facial expressions,
etc.)

Domains where problems arise:

Assessment and conceptualization

Problem identification and definition
Treatment planning vague, abstract and no clear direction
Engagement and therapeutic alliance not engaging the client
collaboratively client not invested in the treatment process
Social worker & client are at different stages of change process
Client is no properly socialized to the cognitive model
Sessions lack adequate structure, planning and pace
Social worker not using CBT strategies skillfully
Social worker not explaining rationale for interventions/homework

Treatment Planning: A collaborative effort

Bio-Psycho-Social
Assessment

Case Conceptualization

Definition of the Problem

Treatment Plan

Goals

Objectives

Strategies

Cognitive Case Conceptualization (Beck, 2011, p. 199):

Relevant Background/Childhood Data
Core Beliefs (self, world, people/others)
(I am..., The world is... People are...

Conditional Assumptions

Rules

(If...then..)

(shoulds, musts, have to)

Compensatory (Behavioral) Strategies

Problematic Situation
Automatic Thoughts
(situation specific thoughts & images)

Maladaptive emotions

Meaning of
The A. T.

Maladaptive behaviors

Cognitive Case Conceptualization - Example:

Mother-highly critical, demanding, perfectionist; Father more supportive but rather passive.
Felt afraid of disappointing his parents. No overt abuse. Good student. Good health. No drug
or alcohol abuse.
I am incompetent; I am inadequate; The world is harsh; Others are critical

If I do not do things perfectly then I am

a failure; If I ask for help, I am weak

I should not make mistakesI must

always excel. I should work harder than
others.

Driven to work extra hard. Holds high expectations of herself. Hypervigilant

to possible mistakes. Quick to self-criticize.
Receives a major assignment at work for which he feels he does
not have adequate resources.
If I fail in this assignment others are going to be disappointed with me
I will be harshly criticized and they will think I am a failure; I should work harder

Anxious, sad, guilty (for not doing more)

Obsesses over details; perfectionist,

procrastinates; self-critical; works long hrs