Workshop on :An Introduction to

CBT- 14th & 15th June 2013

Nisha Sachdeva

Consultant Clinical Psychologist,

NHI
• CBT stands for Cognitive Behaviour Therapy

• Combines 2 effective kinds of psychotherapy : cognitive

therapy (CT) and behavior therapy(BT)

• BT helps you weaken the connections between

troublesome situations and your habitual reactions to
them. Reactions such as fear, depression or rage. It also
teaches you how to calm your mind and body, so you can
feel better, think more clearly, and make better
decisions.
• CT teaches you how certain thinking patterns
are causing your symptoms — by giving you a
distorted picture of what's going on in your life,
and making you feel anxious, depressed or
angry, or provoking you into ill-chosen actions.
• Research on depression in the 1960s conducted by Aaron
Beck, served as the foundation of cognitive therapy.

• Like Albert Ellis, Aaron Beck also turned his back on

psychoanalytical techniques.

Aaron Beck
• Beck found his clients illustrated evidence of
irrational thinking that he called systematic
distortions. The basic premise of Beck's
Cognitive-Behavioral Therapy concerns these
distortions.

• It is not a thing that makes us unhappy, but how

we view things that make us unhappy.
What is CBT ?
• Utilizes a directive, action-oriented approach,
that teaches a person to explore, identify, and
analyze dysfunctional patterns of thinking and
behaving.

• Once these counterproductive patterns are

identified, the therapist aids the client
how to challenge and restructure their
thinking and behaviour.
Guiding Principles of CBT
• A goal oriented and problem focused
therapy
• Focuses initially on the present
• Short-term, time limited format
• Sessions are structured
• Requires a sound therapeutic alliance
• Based on Cognitive Theory
• CBT is educative, aims to teach the pt. to be ones
own therapist and emphasizes relapse
prevention
• Homework is a central feature
• Requires Collaboration and active participation
• Uses a variety of techniques to change/modify
thinking, mood and behaviour after identifying
maladaptive thoughts and beliefs
Typical problems that CBT addresses
• Depression • OCD
• Anxiety • PTSD
• Panic Disorder • Personality Disorders
• Social Phobia • Chronic Pain
• Substance Abuse • Hypochondriasis
• Eating Disorder • Schizophrenia
• Marital/Couples • Has been modified for
problems group therapy as well as
family therapy
The Cognitive Model
• CBT is based on the cognitive model, which says
that people’s emotions and behaviours are
influenced by their perception of the event.

• It is not the situation itself that determines what

people feel but rather the way in which they
perceive/construe the situation

• E.g Friend goes by without saying hi.

Hierarchy of Beliefs (Beck’s conception
of the mind)
Core Beliefs

Intermediate Beliefs
(Rules, Attitudes,
Assumptions)

Automatic Thoughts
Core Beliefs
• Beginning childhood ppl. develop certain beliefs about
themselves, other people and their worlds.

• The deepest and most fundamental understandings which

they may not be able express even to themselves.

• These ideas are regarded by the person as absolute truth.

• They drive the intermediate beliefs and ultimately ATs

• For most of their lives ppl may have positive core beliefs.
However, negative core beliefs may surface in times of
distress. E.g. “I am unlovable”, “I am Incompetent”, “I am a
failure”
• When a negative core belief is activated a person may
interpret situations through it lens and selectively focus
on information which confirms this belief.

• A person in a depressed state would only focus on things

that support the belief of unlovable and would
discount/ignore situations which are contrary to the
belief. E.g. A person has recently gone through a break
up ( Unlovable)

• Thus core beliefs are the most difficult to change bec. of

being rigid, global and overgeneralised in nature
Intermediate Beliefs
• Core beliefs influence the devpt. of an
intermediate class of beliefs i.e. attitudes,
assumptions and rules. These are usually
unarticulated.

• These in turn influence how a person views a

situation and thus how he/she thinks, feels and
behaves.

• Directly influence Automatic Thoughts (ATs)

Examples
• Attitude: “It’s terrible to be incompetent”
• Rules: “ I must work as hard as I can all the
time”
• Assumptions: “If I impress people, they will like
me. If people get to know me, they’ll think I’m a
loser.”
“If I don’t have someone to help me, then I won’t
survive. I won’t be able to support myself”
Automatic Thoughts
• Actual words or images that go through a
person’s mind
• Situation specific
• Not the result of deliberation or reasoning
• Spring up automatically. Rapid and brief
• Most superficial level of cognition
• Possible to identify them.
• E.g. of NAT: I’ll never understand this, What if
the therapy doesn’t work?, I won’t be able to do
this, Image of self going through homework and
unable to understand (feels distressed)

• People usually accept ATs as true w/o reflection

or evaluation

• NAT can be modified which may lead to change

in negative emotions to more positive ones
• One of the most important clues that ATs might be
occurring is the presence of strong emotions.

• Clients are often more aware of the emotion they

feel as a result of the thought than the thought itself.
E.g. a patient maybe aware of feeling sad, anxious,
irritated, embarrassed but unaware of the ATs until
questioned by the therapist.

• A large part of the CB therapist is to identify and

modify NATs ( Cognitive Restructuring)
Thought v/s Feeling (Emotion)
• Misconceptions associated. People often mix the two.

• In CBT important to differentiate between them.

• Expressing a feeling: “I feel (or “I

am”)____________________.”
sad
happy
angry, irritated
scared, afraid
depressed
confused
disgust
• Expressing a Thought (unwittingly) disguised
as a Feeling: “I feel like you always try to get
your point ”

• Same sentence as a Feeling: “I feel scared when

you raise your voice.

• Expressing a Thought: “In my perception you

shout more often than not when you get angry.”
Cognitive Model (Pictorial depiction)
(Adapted from Judith Beck’s Cognitive Therapy: Basics and Beyond)

Situation Emotion
Cognitive Model

Automatic
Situation Emotion
Thoughts
Cognitive Model

Situation Automatic
Emotion
Thoughts

Intermediate Beliefs
 Cognitive Model

Situation Automatic
Emotion
Thoughts

Intermediate Beliefs

Core Beliefs
Example
jjjj Situation Automatic Thoughts Reactions
Student reading text This is too hard. I’ll never
book understand this
Emotional
Sadness
Intermediate Belief
If I don’t understand
something perfectly, then I’m Behavioral
dumb
Closes book

Core Belief
Physiological
I’m Incompetent
Heaviness in abdomen
Activity
Three aspects to Beck’s approach
I. The Cognitive Triad
Negative view of self
- Worthlessness

Negative view of Negative view of

future- Hopelessness world-Helplessness
II. Underlying assumptions & beliefs:
interpretive rules developed from early
experiences which give rise to everyday thoughts
or cognitions. They evolve from the messages we
receive from parents, friends, schoolteachers and
other significant people in our lives. May lead to
certain biases in thinking .

• Egs. of beliefs which make a person vulnerable to

depression:
1. “ I must get people’s approval”

▫ Challenging Statement: "It feels good to be

praised for what I do, but it is impossible to
please everyone all the time. It is therefore
important to judge for myself what I think is best
and then be prepared to take the consequences."
2. "I must prove my worth through my
achievements"

▫ Challenging Statement: "My worth as person

does not depend on my achievements. I am
worthwhile because I exist."
3. "I must do things perfectly or not at all“

▫ Challenging Statement: "Setting unrealistic

standards only leads to procrastination and
anxiety. I do not need to do things at 100% to get
satisfaction and enjoyment.”
4. "I must be valued by others or my life
has no meaning”

▫ Challenging Statement: "I may prefer to be in

a loving relationship, but if I am not, it does not
make me less-worthwhile. I do not need other
people to feel good about myself."
5. "The world must always be just and
fair"

▫ Challenging Statement: "It is frustrating

when things don't go the way I would like, but I
will get over it. I can accept, but not necessarily
like the tact, that life is unfair."
III. Information Processing: The cognitive
model also asserts that depressed people make
a number of distortions in the way they
interpret information. Their information
processing style leads to depression and
passivity.
Cognitive Distortions
• Inaccurate or irrational automatic thoughts which
are usually followed by negative affect.
• Beck came out with 11 cognitive distortions:

1. All-or-Nothing Thinking (Dichotomous

Thinking): Judgments about oneself, personal
experiences, or others are either all good or all bad,
a total success or a total failure, completely perfect
or completely flawed. Black and white thinking.
e.g. "I lost the game (i.e., tennis), therefore I'm a
total loser in everything.”
2. Overgeneralization: You see a single negative
event as a never-ending pattern that negative events
will keep happening to you.
e.g. “She turned me down for a date; now one will
ever want to go out with me now”

3. Mental Filter: You focus almost exclusively on

the one negative event and ignore all positives.
e.g. During an interview you wish you would have
said a particular point differently and now see the
entire interview as a disaster.
4. Discounting the Positive: Positive experiences are
rejected by insisting they "don't count" for some reason
or another. In this way, a negative belief can be
maintained.
e.g. "Those successes were easy, so they don't matter."

5. Jumping to Conclusions: A negative interpretation

is made even though there are no definite facts to
convincingly support this conclusion.
e.g. “He said he has to leave, he must have thought our
conversation was so boring that he made up an excuse
to leave.”
6. Magnification
(Catastrophizing)/Minimization: You
exaggerate the importance of things (such as when
you make a mistake), or you inappropriately shrink
things until they appear tiny (your own desirable
qualities). This is also called the ‘binocular trick.’

e.g.“I can’t believe I made a mistake during that

presentation, it ruined the entire thing!”
“The fact that I met that deadline was nothing
really, any idiot could have done it”.
7. Emotional reasoning: You let your feelings
guide your interpretation of reality. I feel therefore it
must be true.
e.g."I feel depressed, therefore my marriage is not
working out."

8. Shoulds: You interpret events in terms of how

things should be rather than simply focusing on
what is. "I should do well. If I don't, then I'm a
failure."
9. Labeling and Mislabeling: Labeling yourself or
others in a demeaning way. Name calling.
e.g. “I am worthless” or “He’s a total failure”

10. Personalization: Assuming personal

responsibility for something for which you are not
responsible. Attributing external events to oneself
without evidence supporting a causal connection is
termed Personalization.
e.g. sometimes seen in patients who have been
sexually or physically abused.
11. Self Worth: You make an arbitrary decision
that in order to accept yourself as worthy, okay,
or to simply, feel good about your- self, you have
to perform in a certain way; usually most or all
the time.
Exercise- Cognitive Distortions
1. "That's what wives are supposed to do—so it
doesn't count when she's nice to me”

Cognitive Error: Discounting the positive

2. "I get rejected by everyone”

Cognitive Error: Dichotomous thinking ( All or

none)
3. "My marriage ended because I failed.”

Cognitive Error: Personalization

4. “He didn’t come to my party that means he
doesn’t like me”

Cognitive Error: Jumping to conclusions

5. “I feel ugly, therefore I must be ugly”

Cognitive Error: Emotional Reasoning

Activity
How CT works
Recognize the NATs

Dispute the Automatic Thoughts

Develop alternative positive explanations

Distraction

Disputing the underlying beliefs

First Therapy Session
• Establishing trust and rapport
• Socializing pt. into therapy-setting agenda
• Mood check (inventories)
• Educating pt. about disorder, cognitive model & process
of therapy
• Eliciting pts. expectations for therapy
• More history which may help
• Developing a goal list: short term & long term
• Summary of session
• Eliciting Feedback
Structure of Subsequent Sessions
• Brief update
• Mood check
• Bridge from previous session
• Agenda setting
• Reviewing homework
• Discussion of issues on agenda
• Setting homework(if applicable)
• Summary and feedback
• Collaborative Empiricism
• Psychoeducation
• Cognitive Techniques
• Behavioural Techniques
• The usual course of treatment involves an initial emphasis on
ATs (cognitions closest to conscious awareness) where the
therapist teaches the pt. to identify, evaluate & modify
thoughts.

• Then the beliefs that underlie the dysfunctional ATs and are
valid across situations become the focus (intermediate and
core beliefs) and are modified

• Deeper modification of beliefs makes pt. less likely to relapse

• Early in treatment a cognitive therapist may rely more on

behavioral techniques whereas later in treatment the focus
shifts towards cognitive techniques
Collaborative Empiricism
• Therapeutic stance of-high collaboration & scientific
attitude in testing cognitions & behaviors.

• Function like an investigative team to develop

hypothesis about cog .& beh. patterns ,examine data &
explore alternate ways of cognition & behaviour

• Individual differences are important.

• Therapist general attitude influences the outcome

• Adjust therapist activity level to match severity of illness

& phase of treatment.
Psychoeducation
• Information about disorder

• Info. about cognitive model- automatic

thoughts, emotions (diff. between them)

• Socializing into CT
Cognitive Techniques
• Identifying & modifying ATs.

• Identifying & modifying Schemas ( intermediate

and core beliefs)
Identifying and Modifying ATs
1. Basic Question: What was going through your
mind just then?
• When therapist sees changes in affect during session (through
verbal as well as non-verbal cues)

• Describe problematic situation/time during which shift in

affect was felt by pt.

• Imagery to describe situation and time in detail then ask ques.

• Role play with therapist

If pt still cannot answer then try asking questions
like:
 Do you think you were thinking of _____________?

 If someone else was in the situation what do you think

they might have been thinking?

 Were you imagining something that might happen or

remembering something that did?
Example
T: I just noticed a change in your eyes. What just went through your
mind? ( therapist has noticed a shift in affect during session)
P: I am not sure
T: How are you feeling right now? (emotions are easier to articulate)
P: Don’t know. Sad, I guess
T: Where do you feel the sadness?
P: In my chest and behind my eyes (physiological response)
T: So when I asked “ How’s school going?” you felt sad. Any idea
what you were thinking of?
P: I think it was about my Maths class. I was thinking of getting back
my test papers
T: What were you thinking? Or did you imagine something?
P: Ya I pictured a “C” at the top, in red ink.
 2. Daily record of dysfunctional thoughts:
• To identify unpleasant emotions
• To identify the situation in which they occur
• To identify associated NATs and cognitive
distortions
• To generate rational alternatives
• The idea is to elicit alternatives from the pt.
rather than supplying them through lecturing
3. Socratic Questioning: disciplined & systematic
questioning to pursue thoughts in many directions &
for many purposes (exploring deeper ,uncover
assumptions, to open up issues). In CT used to
examine and refute pts. dysfunctional thoughts

▫ What is the evidence to support your belief?

▫ What is the evidence against it?
▫ Could there be an alternative explanation?
▫ What is the worst thing that could happen? Could
I live through it ?
▫ What is the best thing that could happen?
▫ What is a more 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/she were in the
same situation?
Example
P: I am a complete failure at everything
T: You look defeated when you say that. Do you feel
defeated?
P: Yes I am no good
T: you say I am no good. Is it true that you haven’t done
anything good?
P:Nothing of importance
T: How about you children this week did you care for
them at all?
P: Of course I helped my wife put them to bed and took
them for their swimming lessons
T:Do you think that was important to them?
P: umm I suppose so
T: And did you do anything to make your wife happy
this week?
P: well, she liked the fact the I came home from work
on time
T: would a “complete failure” be able to make his wife
happy in such a way?
P: I guess not
T: so is it accurate to say you are a complete failure
in every way?
P: I suppose not
T: so how do you feel now?
P: Guess a little better
4. Decatastrophizing: hypothetically make the
client confront his/her most dreaded
catastrophe.

• Involves imagining worst possible outcome and

then objectively judging its severity.

• Esp. useful in anxiety disorders like GAD, panic

disorder, OCD where catastrophizing is central.
5. Cognitive Rehearsal: The patient imagines a
difficult situation and the therapist guides him
through the step-by-step process of facing and
successfully dealing with it. The patient then
works on practicing, or rehearsing, these steps
mentally.
Identifying & Modifying Schemas
1. Recognizing when a belief is expressed
like an AT
T: What went on through your mind when you
got your results?
P: I should have done better. I can’t do anything
right. I’m so inadequate (core belief)
2. Directly eliciting a rule or attitude
3. Downward arrow technique
▫ The therapist identifies a key AT which he
suspects might be stemming from a dysfunctional
belief. Then the pt. is asked regarding the meaning
of the cognition for him.
▫ Asking what the thought means to him often
elicits intermediate belief
▫ Asking what it means about the pt may uncover
core belief
Example1 (Downward arrow to access
underlying assumptions in a pt. with OCD)
P: I can’t control bad thoughts
T: What’s so bad about not being able to control them?
P: It’s not normal to have uncontrollable thoughts
T: Supposing it’s not normal: what would that mean?
P: I’ve got to get them under control otherwise I would
lose control of my mind and do something awful
T: Supposing you did lose control, what would be bad
about that?
P: I couldn’t live with the idea that I harmed someone
when I could have prevented it
T: If you had harmed someone and could have prevented
it, what would be bad about that?
P: I’d have to kill myself
Example 2 (Depression)

• Situation: Therapist took session with pt. who

reported feeling no better at the end
• Emotion (of therapist): guilty, anxious,
depressed
• Thought: That was a terrible session we didn’t
get anywhere
That was a terrible session we didn’t get anywhere(AT)

Supposing that was true, what would that mean to you?

The pt. wont get better

Supposing he didn’t what would that mean to you?

That I had done a bad job

And supposing you had, what would that mean to you?

 That I was a lousy therapist

Supposing you were a lousy therapist, what then?

Sooner or later I’d be found out

And what does “found out” mean?

That every one would know I was no good and despise me.
It would prove that my success up to now is pure luck
Maladaptive Belief: To think well of myself and
to have others think well of me, I have to succeed
at every single thing I do.
4. Examining pts ATs & looking for
common themes
T: In a no. of situations you seem to have the
thought “I can’t do it” or “It’s too hard” I wonder
if you have a belief that you are somehow
incompetent or inadequate?
P: Yes I think I do. I do think I’m inadequate (core
belief)
5. Advantages & disadvantages of beliefs
T: What are the advantages of believing if you
don’t do your best you are a failure?
P: Well it might make me work harder
T: What are the disadvantages of the same?
P: Well I feel miserable when I don’t do well in an
exam. .I get nervous before a presentation..I
spend so much time studying that I don’t get
time to other things I like.
Modifying Beliefs
1. Socratic questioning to modify beliefs:
Belief: If I ask for help it’s a sign of weakness
T: so you believe about 90% that if you ask for help it means you
are inadequate?
P: yes
T: could there be another way of viewing it?
P: not sure
T: take therapy for e.g. are you inadequate bec you came for
help here?
P: maybe
T: that’s interesting bec. I usually view it in the opposite way. Is
it possible that its actually a sign of strength and adequacy
that you came for therapy?
P: not sure
T: ok lets say we have 2 depressed college students. I
seeks treatment while the other doesn’t & continues
to struggle with depressive symptoms which one of
the do you consider more adequate?
P: the one who goes for help?
T: are you sure?
P: ya its not a sign a of adequacy to struggle if you
could get help an do better
T: How much do you believe that?
P:pretty much. Maybe 80%
T: lets have you write something down about
this..lets called the 1st idea ‘old belief’. Now what
was it?
P: If I ask for help I am inadequate
T: Lets see, you believed it 90% before. put 90%
next to it & how much do you believe it now?
P: less. Maybe 40%
T: ok write 40% next to 90%. Now write new
belief. How would you put that?
P: if I ask for help I am not inadequate?
T: lets put it this way, if I ask for help when its
reasonable, it’s a sign of adequacy and strength
P:ok
T: how much do believe the new belief now?
P: A lot. Maybe 70-80%
2. Behavioural Experiments:
Directly test the validity of the pts. thoughts or assumptions &
are an important evaluative technique.

• The pt. expresses a negative prediction: the therapist proposes

that the pt. test it during the following week

• Collaboratively they decide how, when, where the pt. will test it.
The therapist suggests changes to maximize the likelihood of
success

• The therapist asks the pt. how she will react if the experiment
does confirm the pts. fears so they can devise a response in
advance.
E.g. of assumptions which can be tested using beh.
experiment.
• If I go to the professor he wont help me
• If I try to read this chapter I wont understand it
• If I go to the party Saturday night I’ll have a
terrible time.
3. Rational –Emotional role play:

• Also known as point counterpoint.

• Usually employed after other techniques have been
tried out.
• The therapist first provides the rationale for asking the
pt. to play the ‘emotional’ part of the mind that
strongly endorses the dysfunctional belief. While he
(therapist) plays the rational part.
• In the 2nd segment they switch roles
• Both use the word “I” i.e. they are playing the pt.
P: “ I am inadequate bec. I didn’t get all A’s”
T: No I am not. I have belief that I am inadequate, but
I am reasonably adequate most of the time
P: No I am not. If I were truly adequate I would have
gotten all A’s
T: Adequacy doesn’t equal total academic perfection
P: I got a C in chemistry that proves that I am
inadequate.
T: that’s not right either. If I had failed in chemistry
that could perhaps indicate that I wasn’t adequate in
chemistry. Even then it doesn’t make me inadequate
in everything. Moreover could have failed chemistry
for other reasons. E.g. I was depressed and couldn’t
concentrate much on studies.
P: but a truly adequate person wouldn’t become
depressed in the 1st place
T: actually even truly adequate people get depressed.
There is no connection & when they their
concentration & motivation definitely suffer. So they
don’t perform as well as usual.
T: it doesn’t mean they are inadequate in all
respects
P: maybe you are right. They are just depressed
T: you are right any more evidence that you re
completely inadequate?
P: I guess not
T: how about we trade roles now and this time you
be the rational part who disputes my emotional
part and I’ll use your arguments.
4. Using others as reference point in belief
modification:
When pts. other persons belief, they often get
psychological distance from their own
dysfunctional belief they begin to see an
inconsistency bet. What they believe is true for
themselves and what they more objectively is
true for other people.
T: You mentioned last week that your cousin has a
different belief about having to everything perfectly.
Could you elaborate?
P: she thinks that she doesn’t have to everything
perfectly. She's an ok person no matter what.
T: do you believe she’s right? That she doesn’t have to
be great at everything to be an ok person?
P: oh yes
T: Do see her as completely inadequate?
P: Oh no. she might get good marks might not get
good marks but she’s certainly adequate.
T: I wonder if her belief could apply to you as well.
5. Using extreme contrasts:
At times its helpful for pts to compare themselves to
someone who is at a negative extreme of the quality
related to the pts core belief.
T: I wonder do you know anyone at school who truly is
inadequate?
P: there is one guy in my class who hardly attends
classes or does homework. He just seems to party all
the time. I think he’s failing
T: ok so compared to him how inadequate are you?
P: not very
T: if you were truly an inadequate person what would
you be doing differently?
P: I guess I’ll sit around all day not do anything
worthwhile, not have any friends, drop out of school
T: how close are you to that now?
P: not at all I guess
T: so how accurate would you say it is to label yourself
as truly inadequate?
P:I guess its really not accurate
6. Developing Metaphors: e.g. cinderella

7. Restructuring early memories: involves

role playing, re-enacting an event to help the pt.
reinterpret an earlier traumatic experience.
Examples of Beliefs
Maladaptive beliefs More adaptive beliefs

• If I don’t do as well as others, • If I don’t do as well as others,

I’m a failure. I’m not a failure, just human
• If I ask for help, it’s a sign of • If I ask for help when I need it,
weakness I’m showing good problem
solving abilities (which is a
strength)
• I should be able to excel at • I shouldn’t be able to excel at
everything I try something unless I’m gifted in
that area & am willing to
devote time and effort to it at
the expense of other things
• I am defective • I am normal with both
strengths and weaknesses
Behaviour Techniques
• Behavioral Targets: Specific behaviors that
the patient wishes to modify. e.g.: number of
minutes of exercise, checking, hand
washing, homework done.

• Exposure: Confronting a feared stimulus.

Example: The OCD patient is asked to refrain
from washing his hands after he places his hands
in “dirty” water.
• Response/stimulus hierarchy: A list of most to
least feared responses or situations to be used in
exposure. E.g. The patient and therapist make a list
of situations or behaviors that the patient fears,
ranking them from least to most feared. The patient
afraid of elevators ranks “thinking of an elevator” as
least feared and “riding on the elevator to the top of
a tall building” as most feared.

• Modeling: Therapist demonstrates the desired

response. E.g. The therapist demonstrates in session
an appropriate assertive response that the patient
then imitates.
• Behavioral rehearsal: Patient enacts the
behavior which he plans to conduct outside of
therapy. E.g. The patient demonstrates in
session how he would assert himself with his
boss.

• Relaxation training Relaxing different muscle

groups in sequence; imagining relaxing images;
practicing slow breathing.
• Activity scheduling: Tracking activities
throughout the day and rating them for pleasure,
mastery, anxiety, sadness, fear, or other feelings
The patient may use an hourly schedule to track
his moods and activities.

• Mood Diary: The pt. rates his overall mood at

the end of each day and lists out the things
which made him feel good and the things that
made him feel bad.
• Assertiveness training: Instruction in how to
make legitimate requests that will enhance one’s
pleasure or self-esteem. The pt. practices assertive
responses in session then outside.

• Self-reward: Using self-praise or concrete

reinforcements to the self to increase desirable
behaviors. E.g. The patient may reward himself by
tangible positive consequences (food, a movie, a
present) or by positive self-statements (“I’m proud
of myself for trying”).
• Is an integral non optional part of CT.
• Good H/W assignments help the pt educate
himself further, to collect data, test beliefs,
modify thinking, practice and experiment with
new behaviours.
• Typical H/w egs. include:
▫ Behavioural activation
▫ Monitoring ATs
▫ Bibliotherapy
Increasing the likelihood of successful
homework
• Tailoring H/W to the individual
• Providing a rationale to it
• Setting H/W collaboratively
• Making H/W a no-lose proposition
• Starting H/W in the session
• Help pt. set cues to remember doing H/W
• Anticipating problems ( negative prediction,
overestimating the demands, perfectionism)
Near Termination Activities
• Responding to concerns about tapering sessions
• Responding to concerns about termination
• Reviewing what was learnt in theory
• Self therapy sessions
• Preparing for set backs after termination
• Booster Sessions
Indications & Contraindications-CBT
• Usually not attempted in organic brain disease.
• Indications: primary treatment for Axis I
disorders-Depression ,panic disorder , social
phobia , OCD , PTSD , GAD , Bulimia nervosa.

• Adjunctive in- bipolar disorder , schizophrenia

• Incorporating coping skills in substance abuse ,

personality disorders.