CBT and REBT

● Cognitive behaviour therapies refer to the umbrella term for all approaches which combine both
cognitive and behavioural methods in the short-term treatment approach.
● In some books CBT = Beck’s Cognitive Therapy (CT). behavioural component can’t be ignored to
beck and Ellis both added it.
● Common features
○ Collaborative relationship
○ A present-centred, time-limited focus; structured
○ More psychoeducational than other therapies - an educational treatment focusing on
specific and structured target problems
● Therapeutic approaches
○ REBT
○ RBT (Maultsby) - variant of REBT
○ CT
○ RT (Glasser) -- reality therapy
○ ACT - acceptance
○ MBCT - mindfulness based cognitive therapy
○ DBT (Linehan)
○ SFBT
● History
○ 1950s: Albert Ellis developed RT/RET/REBT/RECBT
■ He was practiced and trained in psychoanalysis - on couples having marital and
sexual problems
■ He noticed that clients were changing when their
thought process was changing → changes behaviour
■ The original approach was more directive / confrontative
○ Ellis’ method and a few others, eg. Glasser…
○ The term CBT came into usage around the early 1990s, initially used by behaviourists to
describe behaviour therapy with a cognitive flavour. In more recent years …
● Cognitive Conceptualisation
○ Precipitating, perpetuating, predisposing maintaining
factors, etc. → understanding/case conceptualisation
○ This can modify over time with sessions, as more information is gained.
○ Clear in Beck’s therapy
● Interpretation / Cognition
○ (usual / cognitive way)

REBT
● Developed first. Ellis is known to be the grandfather for CBT. Beck is more popular though.
● REBT vs CBT
○ Beck’s cognitive therapy is more popular because more empirical research work is done
there. REBT was more concerned with having a change in the client’s life.
○ They are both equally used, however Beck’s therapy is more researched.
● Ellis was influenced by stoic philosophers.
● Brief History
○ Developed by Albert Ellis (RT → RBT → REBT → RECBT)
[considered grandfather of CBT] in 1955 in USA
○ Initially called RT
 ○ 1962: RET; …
● (quote)
○ Criticises approaches that focus on conventional insight (like psychoanalysis)
● Basics of REBT
○ REBT is an action…
○ It’s not just a psychotherapy, it is a healthy and and upl
○ Ultimate goal → Unconditional self acceptance, unconditional
other acceptance, unconditional life acceptance
○ ABC
■ A = activating event / adversity [person was insulted by the boss]
■ B = irrational belief
● “For me to be happy, people must like me” →
demandingness [root of other irrational beliefs]
● ^ not the case in Beck’s approach
■ C = consequence (behavioural/emotional) [client will come to T with the
consequence - isolation from others, anxiety etc. T has to identify and reach the
current C. “What is the most distressing thing? What is the problem that you
want to work on?” client tells problem → consequence is evident]
■ Exploring CAB (in that order). Then T forms the B-C connection.
○ Unhealthy negative emotions
■ Depression, anxiety, anger, hurt, shame, guilt, jealousy, envy
○ Healthy negative emotions
■ Sadness, concern, healthy anger, disappointment (for hurt & shame),
remorse/regret, healthy jealousy, healthy envy
○ Goal of T is to convert unhealthy negative emotions → healthy
negative emotions (more realistic given the situation).
○ The critical aspect of A
■ This should be uncovered. [the most distressing part of the event]. The actual
thing that is distressing someone more could not be what is told by the client.
■ Eg. when a person loses his job, the event is more about being insulted in front of
everyone and losing one’s image.
○ Primary and secondary A
■ Identifying the A will take some time.
■ Ask the client → “On which emotion do you want to work
on? What is most distressing for you?”
■ T asks C to rate the primary and secondary emotion on 1-10.
■ Critical A could be the perceived aspect of the A.
○ Understanding the B to C connection
■ A to C connection is faulty, it is actually the B to C connection that exists.
■ How B leads to C
○ REBT Wisdom
■ Other people or the world or life doesn’t cause distress… or negative emotions.
■ We have emotional buttons but the keyboard with buttons is ours and we allow
others to push them.
■ We upset ourselves and we make ourselves miserable.
■ All human beings are irrational and fallible…
■ Elegant vs Inelegant solution
 ● REBT focuses on elegant solution. CBT can sometimes take the
inelegant route.
● Inelegant = more practical. “What is the evidence of cheating?”
● Elegant = “even if he/she is cheating, how can I
deal with that?” In terms of thought patterns →
how I am able to live a more rational /
fulfilling life.
○ Usually for things one can’t change
○ Irrational beliefs
■ Rigid, absolute, unbending
■ Not logical
■ Not logical
■ Not consistent with reality
■ Doesn’t help in achieving goals
■ Leads to unhealthy emotions
○ Rational beliefs
■ Flexible
■ Logical
■ Leads to health (positive/negative) beliefs
○ Types of irrational beliefs
■ Demandingness
● Eliciting demandingness in one’s own life: “I must succeed” “I must pass
this test”
● Shoulds are of 2 types: preferential [i should wake up early in the
morning]; absolutionistice [hidden behind the should is a must, this is
the should REBT focuses on]
■ Awfulisation
●
■ Frustration tolerance
● Think of a situation / person / behaviour which you extremely dislike /
can’t tolerate
■ Global evaluation of human worth
● Self downing - “I am weak, vulnerable, worthless.”
● “Which self downing thoughts come to your mind
● Other downing - “They are a rotten person.”
■ Not necessary to reach at the core beliefs. These beliefs can be worked on directly
without reaching the core belief.
○ Types of irrational thoughts
■ Evident in one’s language
■ “Shoulds, musts, ought tos”
○ Types of disputation
■ Functional disputes - questioning whether the belief helps accomplish desired
goals.
■ Empirical disputes - questioning whether the “facts” are accurate
● Done in both REBT & CBT
■ Logical disputes - questioning the logic of thinking processes
● Done in both REBT & CBT
 ■ Philosophical disputes / Rational alternative - questioning whether despite
dissatisfactions, if some pleasure can be derived from life anyway.
● Related to developing a new belief system in the C
○ Disputing styles
■ Didactic - educative / instructive
■ Socratic - probing / asking questions
■ Metaphor - asking questions using a metaphor
■ Humour
○ Disputing strategy - combination of disputation types and styles.
○ Examples of disputation
■ Will having this belief help me or hurt me? - functional
■ Where is it getting
○ E = Effective new belief system
■ This replaces the irrational beliefs
○ F = Functional healing developing from the E
● Misconceptions about REBT
○ REBT does not say that all emotions are to be eliminated
○ Rational thoughts lead to negative functional emotions while irrational beliefs will lead to
negative dysfunctional emotions
○ When people experience no emotion or extreme, behavioural efficiency is lost
○ REBT → helps people become in charge of their emotions and
not let outside events push their buttons.
● Steps
○ Establish rapport with the client
○ Gain necessary information (can be done through filling questionnaires / form also)
○ Therapeutic aspects:
○ Exploring what problem the client would like to work on? Setting the session goal.
○ Exploring primary and secondary emotional disturbance (related to critical aspect of A) if
any and finalising the consequence to work on.
■ Can present the client with a list of emotions
○ Done before starting the therapy
○ Explore A
■ Rational emotive imagery - take them to the event / visualising the event / what
they felt during the event
○ Clarifying A - learn about critical aspects of A
○ Agreeing on goal emotion (New C)
○ Discovering B (socratic questioning, inference chaining/DAT)
■ Rational emotive imagery - to explore what thoughts arose in a particular
situation by having them immerse themselves in the situation.
■ DAT : Thought → “what does it mean to you / about you?”
○ Looking for the apparent or hidden ‘musts’, ‘shoulds’...
○ If the hypothesis is confirmed…
■ If the client becomes emotionally charged and starts catharsis, it is good
○ Ask the client to rehearse the new C → confirm with the
client that this new E leads to the C.
○ Set homework
○ Summarise, give and take feedback; fix new appointment
 ● Cognitive techniques - cost benefit analysis, double standard dispute, catastrophe scale (generally
used for awfulisation and anxiety), devil’s advocate, bibliotherapy / psychoeducational
assignments, disputation, role playing
● Emotive techniques - rational emotive imagery, time projection, role play / reverse role play
[emotional catharsis can take place here], practicing new strong beliefs / forceful coping
statements / disputing, shame attacking exercise
● Behavioural techniques - shame attacking exercise [logic behind it should be there, will it suit the
problem of the client, the client should be willing to do it], using humor, modelling, risk taking,
homework, using reinforcement, systematic desensitisation, modelling
● Downward arrow technique

○
● Words of wisdom inferred from REBT
○ Unconditional self, other and life acceptance
○ Mindfulness of one’s irrational thoughts
○ Gratitude and compassion for others - in more modern REBT
○ ‘Right’ and ‘wrong’ are just labels which humans have made
○ All humans are naturally irrational and fallible

Beck’s Cognitive Therapy

● Understanding negative automatic thoughts, hidden cognitive schemas, core beliefs (cognitive
triad); how these lead to maladaptive behaviour
● Terminology and concepts
○ NATs, assumptions/rules and core beliefs (negative beliefs about self, others/world,
future)
■ NATs are explored first and can be noticed in one’s speech
■ Core beliefs → rules/assumptions → NATs
○ Cognitive triad
○ Cognitive errors/distortions
■ These make thought patterns illogical, self-defeating
○ Behavioural activation
■ Activity schedule, relaxation techniques, guided imagery technique, behavioural
assignment,
○ Behavioural skills / relaxation skills
■ Problem focused, emotion focused coping skills, assertiveness training
● Type of Cognitions - Beck
 ○ Automatic thoughts is the initial thought that comes into a person’s mind. Eg. other
people will think I am strange
○ The assumptions and rules (behind the NAT). These are the intermediate beliefs. Eg.
other people should not think I am strange, other people should approve of me.
■ Assumptions → if/then statements
■ Rules represent the demandingness / awfulisation / discomfort intolerance
○ Core evaluations, belief or schemas
■ Schema is a general structure. One can have a schema about what they think
about things like their family, healthy life, illness, covid, etc.
■ If someone has health anxiety, their core belief/schema about health should be
explored.
■ If others do not approve of me, I am not good, I am hopeless and worthless.
● Levels of cognition
○ NATs
○ Dysfunctional assumptions
○ Core beliefs (guide assumptions → leading to NATs)
■ Takes time to identify since it is below the surface of conscious awareness.
○

● NATs Characteristics
○ They just happen automatically …
● Cognitive errors
○ All or none - either it is totally good or totally bad.
○ Minimisation - many bad things are happening, but because of the core beliefs the
achievements are minimised.
○ Catastrophizing - also called awfulising
○ Mind reading - my friend did not smile at me, so she doesn’t like me. When we think about
what other people might be thinking which causes an emotional disturbance in us.
○ Overgeneralization -
○ Emotional reasoning - because i am feeling bad, the person is actually bad. Because i am
feeling anxious, the situation is actually terrible.
 ○ Exploring the use of shoulds, musts, oughts
○ Selective abstraction - selectively choosing, highlighting and generalising negative things
○ Arbitrary generalisation - drawing out a global arbitrary inference from limited
information
○

● Process of assessment
○ More focus of assessment in CBT than in REBT
○ Case history, MSE, develop a hypothesis, tentative cognitive conceptualisation of the case
[this is a flexible conceptualisation] the hypothesis can be discussed with the client
○

● Structure of the first therapy session

○ (by Aaron Beck’s daughter - Judith Beck)
 ○

● Structure of the second session

○

○ The session agenda should be realistic

○ Make them hopeful (inspirational stories/quotes), establish rapport
○ Exploring the problem/NATs
● CBT Sequence
○ Identify the problem situation
○ Identify the feeling or negative emotion
○ evaluate/rate the negative feeling
○ evaluate/rate the presence of secondary emotions / %
■ Critical E - “What is the most disturbing thing about this situation?”
 ■ Magical question - “If I have the power to do so, which factor should I take away
so that you would feel better about the situation?”
■ How do you feel about feeling depressed/anxious
■ Rate all the feelings one is feeling (depression, anxiety, etc) - which one they
would like to work on that day
○ Explore physical sensations
■ People may not be aware about their emotions and may misjudge the emotions as
something else.
■ If someone says they are anxious -- they are likely to have sweaty palms, nausea,
etc.
■ Info on physical sensations helps clarify the emotion experienced
○ Eliciting the beliefs and thoughts (B) by exploring NATs, rules, assumptions and core
beliefs
○ Ask for the strength of the thought/belief (%): optional
■ If the belief is ‘nobody likes me’, how much do you believe in it?
○ Explore and challenge the unhelpful belief
■ Disputing (and its styles), socratic questioning
○ Develop helpful beliefs
■ Behavioural assignments
○ Ask for the strength of the helpful beliefs
■ Emotional consequences
○ Set homework
● Eliciting the B

○
○ Ask a should question, so they are aware of the fact that it is a rule in their life
○ Inference chaining / downward arrow techniques: “What does that mean to you?”
● 3 Categories of Core Beliefs

○
● Behavioural aspect in CBT
○ Behavioural activation
 ○ Relaxation training
○ Problem focused coping skills
○ Emotion focused coping skills
○ Behavioural experiments
○ All behaviour therapy techniques
○ Monitoring NATs

Reality Therapy
● Falls under the CBT umbrella
● 1960s → Glasser developed his therapeutic approach called Reality
Therapy
● Later on Glasser studies control theory and adapted it and called it Choice theory [more solution
focused, exploring the choices available in one’s life]
● CT is based on the idea that conscious behaviours are chosen in an effort to satisfy one of 5 internal
basic human needs.
● Wubbolding extended the theory and practice of reality therapy with his conceptualisation of the
WDEP system.
● Glasser believes that all ‘patients’ have a common characteristic: they deny all the reality of the
world around them
● “Therapy will be successful when they are able to give up denying the world and recognise that
reality not only exists but that they must fulfill their needs within its framework.”
○ Unfulfilled needs → Problem
● “A therapy that leads patients towards reality, towards success, might accurately be called a therapy
towards reality or reality therapy.”
● Reality therapy is a client centred present-focused, directive therapeutic approach designed
to help individuals identify and satisfy their needs and wants more consistently and adaptively
● RT is founded on the principles of choice theory. Train (RT) and choice theory is the railway
track
● Part of CBT umbrella because:
○ It explores one’s cognitions
○ Core essence - related to client centred therapy.
○ Different from Rogerian approach. A little directive (confrontation) but not as directive as
CBT.
○ Influences: CBT, Rogerian approach, choice theory (foundation, adapted from Power’s
Control theory)
●
● 5 basic needs: love and belongingness, power [sense of accomplishment, people will consider
me worthy if I achieve], fun, survival, freedom

●
● Importance of therapist client relationship
○ Therapist should be capable of entering the client’s quality world

○
● Wubbolding believes that behavior is a language and that we send messages by what we are doing
○ Questions asked:
○ What message do you want others to get
○ What message are others getting whether or not you intended to send them
 ○ (used for understanding the cognition behind the behavior, confrontation, insight does
not develop)
● Characteristics

○
○ Do not focus on symptoms appearing and which disorder the person is having based on
DSM. Focus on the needs that are not being satisfied.

○
● Questions asked

○
● The WDEP system
○ Wants (exploring wants, needs, perceptions)
○ Direction and doing
○ Self evaluation
○ Planning and action
● Evaluation questions
 ○
○ Many times we feel that we have no control over situations - even though we really do
● Planning and Action

○
○ Positive course of action: Sometimes a course of action may be beneficial to the client but
may cause harm to others. The therapist types to promote a plan that is a win-win kind of
situation (for clients and other people).
○ Write the plan - make a plan which is positive, good for us and others, and should be
realistic and achievable, should consider the possibility of unforeseen factors, should
foresee possible failures.
○ Acceptance is the last option resulting from failure.
○ One more option after failure → trying again

Behaviour Therapy
● Pioneers: Watson, Skinner, Pavlov, Bandura
● Developed 1950s, early 1960s
● Behaviour therapists now use a variety of evidence-based techniques in their practices, including
CT, social skills training, relaxation training and mindfulness strategies
○ They also employ the cognitive model; but they have an essential behavioural component
● Classical vs operant conditioning
○ Reinforcements are used in operant conditioning
○ Conditioning (forming stimulus-response relationship)
○ In classical conditioning, the response is automatic / involuntary (salivation). In operant
conditioning the response is voluntary.
○ In classical conditioning the organism is in a relatively
passive role. Operant → organism is in active role.
 ○ In classical conditioning, the original stimulus (unconditioned stimulus) remains clear. In
operant conditioning, one can’t be sure of the first incidence that elicited response
(association is learned, but why the rat pressed the lever is not clear in later stages).

●
○ Maladaptive behaviour pattern → fear response can be
conditioned classically and also counter conditioned, eg: Little Albert
experiment. Nausea,
○ Operant conditioning → studying for exams,
○ Social learning → modelling behaviour, aggression, bobo doll,
vicarious reinforcement,
● Behaviour Therapy Characteristics

○
● BT and FBA
 ○
○ Function of client behaviours → Identifying primary and
secondary gains of behaviour
○ Behaviours are sustained through the consequence of the behaviour

○
○ Motivational interviewing can be used to increase client’s motivation (to perform a
behaviour) - an active behavioural assignment
○ Today most BTists stress value of establishing a collaborative relationship with their clients
● Experiential therapy vs. BT
○ BT is more evidence based (empirical data, experimenting, checking post intervention
progress)
○ More empirical basis of BT → easy to assess progress of
clients
○ Experiential therapy is more subjective because of the uniqueness of experience of client
○ Some things like bad relationships/bad memory (an unresolved business) should be
approached using the experiential approach since they allow the client to experience
something in the moment, express it and allow catharsis better.
■ This lacks in CBT approaches. So a more eclectic approach can be applied.
●
● Techniques based on operant conditioning

○
■ Token economy - create a hierarchy of their needs and for every adaptive
behaviour they do, give them a token. This token can be used later on to choose
their reward.
■ Differential reinforcement - only specific adaptive behaviour is rewarded
■ Shaping and chaining - successive approximation of behaviour, one step forward
in direction of ultimate goal is reinforced. Chaining = sequence of actions (the
way one learn dancing - step by step and then later combining them)
■ Behavioral activation (for depression) - suggesting some behaviours in which they
move and ones which are pleasurable. Schedule the activity as a homework
assignment.
■ Biofeedback - changing breathing pattern / thinking pattern changes some
involuntary responses (heart rate, brain wave patterns). Works on operant
principles since it involves regulating involuntary bodily responses through
voluntary actions (controlling breathing, etc.). The feedback acts as a
reinforcement
○ Assertiveness training
 ■

■ Based on the observational learning, operant conditioning approach.

■ Confronting others, assertion - more rewarding for them
■

○ Social skills training …

■ Based on Observational learning
○ Multimodal therapy: Lazarus
 ■

■ 7 major areas (basic ID)

○
● Techniques based on classical conditioning

○
○ JPMR - Jacobson’s Progressive Muscle relaxation
■ In this the client must learn to relax through deep muscle relaxation training
■ Patients relax major muscle groups in a fixed order, beginning …
 ■

○ Systematic desensitisation
■

■ Deep relaxation is taught using imagery / JPMR. Then make a hierarchy of the
item which promotes most and least fear.
■ In vitro technique - done using imagination and visualisation. If they are able to
reach the highest level and able to relax themselves, it means that their anxiety and
fear is gone.
○ Graded exposure
 ■

■ ERP - Exposure and response related techniques (for OCD - for cleanliness
related anxiety)
○ In vivo exposure and flooding
■ Flooding - client is exposed to the most anxiety provoking stimulus suddenly; vivo
exposure
■

■ Assumption: because these situations are harmless, they can be exposed to the
most anxiety promoting stimulus
○ Implosive Therapy
■ Like flooding
 ■

■ In vitro technique
■ Important: client has to be taught to relax
○ Aversion therapy
■

■ The maladaptive behaviour has to be made aversive

○ Hypnotherapy, imagery, meditation, yoga - pleasurable state of trance is learnt through
constant practicing and the whole script need not be followed later on in order to achieve
that state. It gets easier to achieve trance state.
● Newer techniques
○ EMDR (Shapiro, 2001)
 ■

■ Eye movement: how we process images while we are dreaming

■

■ (The last point is controversial)

○ MBSR (Kabatt-Zinn)
 ■

■ Being aware of the present moment (body, breath, sounds

around us, etc) → and then integrating all of it.
○ MBCT
■
○

○ ACT (Hayes)
■
 ■

● ABA

DBT (Linehan)
● Very lengthy and less structured than CBT or REBT. lots of pain and efforts from the therapists’
side.
○ Client-therapist relationship/contract is different as compared to other forms of therapy.
○ Therapist is more accountable

●
● Very focused on mindfulness
● Used in the cases of: labile moods, ...