Cognitive Behavior Theory

Introduction
• Cognetive Behaviour therapy (C.B.T) which is
a form of pschycotherapy and also called
cognetive therapy was formed by Aaron Beck.

• Treatment is based on a conceptualization , or

understanding of individual patients.
• CBT is a psycho-social intervention.
•  It aims to improve mental health.
• CBT focuses on challenging and changing
unhelpful cognitive distortions (e.g. thoughts, beliefs,
and attitudes) and behaviors, improving emotional
regulation.
• Helps in the development of personal coping
strategies  that target solving current problems.
 Overview

• The CBT model is based on the combination of the

basic principles from behavioral and cognitive
psychology.
• CBT is a "problem-focused" and "action-oriented"
form of therapy, meaning it is used to treat specific
problems related to a diagnosed mental disorder.
• The therapist's role is to assist the client in finding and
practicing effective strategies to address the identified
goals and decrease symptoms of the disorder.
•CBT is recommended as the first line of treatment
for majority of psychological disorders.

•The goal of CBT is to allow a client to take control of

their problems and manage their life.

•CBT values and empowers the individual to take

control of their life through psycho education.

•It uses the vast array of techniques specific to

individual diagnosis in a health adaptive way.
 Overview

• The cognitive model emphesizes that people’s

thoughts and feelings are not determined by
the situation but   by their interpretation and
construction of that situation.
• CBT seeks to modify the dysfunctional core
beliefs that result in automatic thoughts 
 Principles
Basics and Beyond by Judy Beck (1995).

• CBT is based on an ever-evolving formulation of

the client and their problems in cognitive terms.
• CBT requires a good client-therapist relationship.
• CBT emphasizes collaboration and active
participation.
• CBT is goal-oriented and problem focused.
• CBT initially emphasizes the present.
• CBT is educative; it aims to teach the client to be
his/her own therapist, and emphasizes relapse
prevention.
• CBT aims to be time limited.
• CBT sessions are structured.
• CBT teaches patients to identify, evaluate, and
respond to their dysfunctional thoughts and
beliefs.
• CBT uses a variety of techniques to change
thinking, mood, and behavior.
 Structure of the Assessment Session

•Greet the client

• Collaboratively decide with the client whether a
family member should attend all, part, or none of the
session.
• Set the agenda and convey appropriate expectations
for the session.
• Conduct the assessment.
• Set initial broad goals.
• Elicit feedback from the client
 Goals of the Assessment Session
• Formulate the case and create an initial
cognitive conceptualization
of the client.
• Determine whether you will be an
appropriate therapist.
• Determine whether you can provide the
appropriate “dose” of
• therapy (e.g., if you are able to provide
only weekly therapy but the client
requires a day program).
• Determine whether adjunctive treatment or
services (such as medication) may be indicated.

• Initiate a therapeutic alliance with the client(and

with family members, if relevant).

• Begin to socialize the patient into the structure and

process of therapy.
• Identify important problems and set broad goals.
 The Assessment Phase
• client demographics.
• Chief complaints and current problems.
• History of present illness and precipitating events.
• Coping strategies (adaptive and maladaptive), current and
historical.
• Psychiatric history, including kinds of psychosocial
treatments (and perceived helpfulness of these
treatments), hospitalizations, medication, suicide
attempts, and current status.
• Substance use history and current status.
• Medical history and current status.
• Family psychiatric history and current status.
• Developmental history.
• General family history and current status.
• Social history and current status.
• Educational history and current status.
• Vocational history and current status.
• Religious/spiritual history and current status.
• Strengths, values, and adaptive coping strategies.
 Structure of Sessions
• First Session and other Sessions
• Standard cognitive behavior therapy sessions
last for about 45–50 minutes, but the first one
often takes an hour.
• First Session
– The most important and often the most difficult.
– Therapist must address several areas to begin.
– establish the structure for the remaining sessions
• Goals for the first session are:
– Establish rapport and trust with patients,
– Socialize patients into treatment by educating them
about their disorder(s), the cognitive model, and
the process of therapy.
– Collect additional data to help therapist
conceptualize the patient.
– Develop a goal list.
– Start solving a problem important to the patient
• Initial Part of Session 1
– Set the agenda.
– Do a mood check.
– Obtain an update (since the evaluation).
– Discuss the patient’s diagnosis and do psycho education.
• Middle Part of Session 1
– Identify problems and set goals.
– Educate the patient about the cognitive model.
– Discuss a problem.
• End of Session 1
– Provide or elicit a summary.
– Review homework assignment.
– Elicit feedback.
• Setting the Agenda
– Deciding what to be talking in today’s session
– Done at beginning of every session
– Initially, therapist will be more active in setting the
agenda as the client often don’t have many ideas as to
where to start
– As instance the therapist might say , “I have a list of
things I'd like to go over today and then I'll ask you
what you'd like to add is that ok? “
– make sure the patient agrees with the topics you
propose
– Always provide rationale to the client for setting the
agenda
– it is ideally quick into the point
• Doing a mood check
– Brief in nature
– therapists ask the client for brief narrative
report on the mood as an instance, “how
have you been doing this week?”
– guide the client just using one or two
sentences for time sake and quickly
review the symptoms s/he filled out just
prior to the session
• Obtaining an Update
– discover any important problems and issues of the
client that they have not mentioned yet in
evaluation that they could take priority in the
session
– the therapist could ask what happen between the
time period of evaluation and now and see if the
response is something important
– client may at this stage only reports the negative
experiences and therapist have to ask specifically
what kinds of positive things had happened so that
the client see reality more clearly.
• Diagnosis and Psycho education
– usually patient is seeking for just a general
understanding of their diagnosis
– therapist helps the client change how to see their
problems and be more correlated with their
disorders instead of their character
– Educate the client that with the help of cognitive
behavior therapy many people with the same
diagnosis have been able to overcome their mental
illnesses.
– it is very important to help to instill help that
actively participating in therapy on the client's part
will have a better outcome in therapy .
• Identifying Problems and Setting Goal
• start focusing more specifically now on the
client's problems
• Therapists need to listen closely to their
responses and be empathetic when it's needed
• the main goal of identifying the problem is to help
the client pinpoint their goals.
• Goals should be ‘SMART’ (Specific, measurable,
achievable, realistic and time frame)
• Make sure the client is being active in the goal
making process
Educate the patient about the cognitive model.
• Educate client about how their thinking affects
their reactions
• It is preferable to use their own examples. For
instance, “Can we talk for a few minutes about
how you're thinking and how you're thinking
affects your mood?”
• Helps the client realize that the theory is
focused on the relationship among trigger
situations of automatic thoughts or images and
reactions
• Discuss a problem
• if there is a time the therapist might start
• discussing a specific problem that could be
very significant to the patient and develop
alternate ways of viewing the problem
• talk about the concrete steps that they can take
to solve the problem
• Provide or elicit a summary.
– tie all the threads of the session together
– reinforce the important things that are covered
– the therapist might ask the client to review
highlights that client deem to see
• Review and Reminder of the homework
• what is the goals of this assignment and will this
assignment be helpful for this particular client
• Make sure the client will actually go through and
do the homework
• Review helps the client to get a plan of when they
will fit the homework into their day
• Therapist might even suggest that they set alarms
or put notes and places that they are more likely to
see them going over
• Elicit feedback.
• Most patients feel positively about the
therapist in the therapy
• it's also a part of the session in which the client
gets a chance to express and you to resolve
any misunderstandings that they might have.
• Second Session and Beyond:
– Goals:
• to help patients identify important problems on
which to work and,
• teach patients relevant skills, especially
identifying and responding to automatic
thoughts and, for most depressed patients,
scheduling activities.
• The First Part of the Session
Goals of The First Part of the Session
•  Reestablish rapport.
• Elicit the names of problems patients want help in
solving.
• Collect data that may indicate other important
problem areas to discuss.
• Review homework.
• Prioritize the problems on the agenda.
• Mood Check
• Overview of their mood for the past week
• It helps both the party keep track of how they are
progressing.
• examine whether patients have additional problems that
they may not report verbally, such as suicidal ideation,
feeling worthless and so on.
• Make a quick comparison between the objective scores
of the previous session and the present objective scores
• If there is a discrepancy between the test scores and the
self-report, elicit a subjective description from patients
and match it with objective test scores.
• Set the agenda.
• The purpose is to set an initial agenda.
• Elicit the names of problems they want help in solving
from the client.
• Rather than asking, “What do you want to talk about
today?” or What do you want to put on the
agenda?”(which can lead to less productive
discussions), you phrase the question in a problem-
solving way (until patients are socialized to setting the
agenda in this way). For instance: “What problem or
problems do you want my help in solving today? Can
you just tell me the names of the problems?”
• Obtain an update.
• Helps therapist make a bridge between the
previous session and the current one.
• It includes a brief update of the patient’s week,
during which therapist will remain alert for
potential problems that could be important for the
agenda.
• Next therapist will elicit positive experiences
which therapist may use later in the session or in
future sessions.
• Review Homework.
• Homework review should always be included in the agenda
of the subsequent session.
• Reviewing the patient’s homework is critical. If therapist do
not, patients invariably stop doing it.
• Therapist find out which behavioral assignments they did
and what they learned from them.
• Discuss which assignments would be helpful for them to
continue in the coming week.
• If any homework items requires lengthy discussion (or if
there are any assignments they failed to do), therapist can
collaboratively decide to discuss them later in the session,
so therapist can quickly review the rest of the assignments.
• Prioritize the agenda.
• Short list of topics that therapist and patient agree
to make the focus of that session.
• If there are too many agenda items, therapist and
the patient will collaboratively prioritize items
and agree to move the discussion of less important
problems to a future session
• Can include new topics, continuation of previous
topics
• Usually, homework for the coming week is not on
the agenda
• The Middle Part of the Session
• list the names of the problems on the prioritized agenda and ask
patients which problem they want to work on first.
• when therapist judge that a particular problem is the most
important, may take the lead in suggesting an agenda item with
which to start
• therapist will collect data about the problem, conceptualize the
patients’ difficulties according to the cognitive model, and
collaboratively decide on which part of the cognitive model
therapist will begin working (solving the problem situation,
evaluating automatic thoughts, reducing patients’ immediate
distress.
• While discussing problems on the agenda, therapist will be teaching
patients skills and setting new homework.
• therapist will also make periodic summaries, if needed,
to help therapist and the patient recall what therapist
have been doing in this part of the session.
• In this second session, the therapist seek not only to
help client do some problem solving, but also to:
– Reinforce the cognitive model.
– Continue teaching client to identify her automatic thoughts.
– Provide some symptom relief through helping client
respond to his/her thoughts
– maintain and build rapport through accurate understanding.
• Final Summary and Feedback
• Offer a summary of what happened during the
session
• Summary can be brief and follow a timeline of the
session
– Get patient feedback
– Can you give me some feedback about our session
today?
– Was there anything that was particularly helpful or
anything that was a waste of time?
– Was there anything I did or said that rubbed you the
wrong way?
 Problems with Structuring the Therapy
Session
• Therapist Cognitions : interfering cognitions about
structure, interrupting patients, and implementing the
standard structure.
• Interrupting the Patient (for effective structure
sessions)
• Socializing the Patients.
• Strengthening the Therapeutic Alliance
• Mood Check
• Bridge between Sessions (too little or too much
information)
• Discussion of Agenda Items(Unfocused Discussions)
 EMOTIONS AND THOUGHTS

Experience common to us all.

Barely aware of these thoughts and a little training can easily bring these
thoughts into consciousness.
Do a reality check if we are not suffering from psychological
dysfunction.
If suffering from psychological dysfunction, may not engage in critical
examination.
Cognitive behavior therapy teaches them tools to evaluate their thoughts
in a conscious, structured way, especially when they are upset.
Explain automatic thoughts to patients.
Elicit and specify automatic thoughts.
Teach patients to identify automatic thoughts.
Although automatic thoughts seem to pop up spontaneously,
they become fairly predictable once the patient’s
underlying beliefs are identified. You are concerned with
identifying those thoughts that are dysfunctional—that is,
those that distort reality, are emotionally distressing,
and/or interfere with patients’ ability to reach their goals.

• Automatic thoughts are usually quite brief, and patients

are often more aware of the emotion they feel as a result
of their thoughts than of the thoughts themselves.

• The emotions patients feel are logically connected to the

content of their automatic thoughts.
• Automatic thoughts are often in “shorthand” form, but can be
easily spelled out when you ask for the meaning of the thought.
• Automatic thoughts may be in verbal form, visual form (images),
or both.
• Automatic thoughts can be evaluated according to their validity
and their utility.
• The most common type of automatic thought is distorted in some
way and occurs despite objective evidence to the contrary.
• A second type of automatic thought is accurate, but the conclusion
the patient draws may be distorted
 Characteristics of Automatic Thoughts

Automatic thoughts are stream of thinking that coexists with

a more manifest stream of thought (Beck, 1964).

Creates self awareness and motivation to identify

underlying thoughts and beliefs.

Automatic thoughts are usually quite brief, and patients are

often more aware of the emotion they feel as a result of their
thoughts than of the thoughts themselves.

The emotions patients feel are logically connected to the

content of their automatic thoughts.
 Automatic thoughts are often in “shorthand” form,
but can be easily spelled out when you ask for the
meaning of the thought.
 Automatic thoughts may be in verbal form, visual
form (images), or both.
 Automatic thoughts can be evaluated according to
their validity and their utility.
 CBT teaches tools to evaluate thoughts in a
conscious and structured way during the upset
condition.
 EXAMPLES

A person has a thought of “I don’t understand this, and feel slightly

anxious”, may respond to the thought in a productive way, “I do
understand some of it, let me just reread this section.”

Sally, if reading economic chapter, has the same thought as the

reader, “I don’t understand this.”
I will never understand this” But after learning CBT,
EXPLAINING AUTOMATIC THOUGHTS TO
PATIENTS/CLIENTS
Situation: Looking at people at the park

Automatic Thought: I’ll never be like them

Emotion: Sad
 ELICITING AUTOMATIC THOUGHTS

“What was going through your mind”

When patients describe a problematic situation that arose, usually since your
previous session together.
When you notice a shift to, or intensification of, negative affect during a session.
 Difficulties in Eliciting Automatic Thoughts
If patients are unable to answer the question “what was just
going through your mind?” we can:
1. Ask them how they are/were feeling and where in their body they
experienced emotion.
2. Elicit a detailed description of the problematic situation.
3. Request that the patient visualize the distressing situation.
4. Suggest that the patient role-play the specific interaction with you (if the
distressing situation was interpersonal).
 Elicit an image.

 Supply thoughts opposite to the ones you

hypothesize actually went through their minds.

 Ask for the meaning of the situation.

 Phrase the question differently.

 DIFFERENTIATING BETWEEN AUTOMATIC
THOUGHTS AND INTERPRETATIONS

 Seeks actual words or images that have gone through their

minds.

 Patients may report of interpretation , which may or may

not reflect their actual thoughts.

First Session: When you saw that women, what went through
your mind?
“Denying my feelings”
“What were you actually thinking?”
Second Session: What emotion did you really feel?
“Denying my feelings”

Third Session: “What emotion did you feel?”

“What feelings were you denying?”

Fourth Session: “Did you feel happy or excited?”

“Can you picture that in your mind?
“I just walked away and talked to my friend”
 Specifying Automatic Thoughts Embedded in Discourse
People need to learn to specify the actual thoughts that are going through
their mind in order to evaluate them effectively
Embedded Expressions Actual Automatic Thoughts

I guess I was wondering if he likes me. Does he like me?

I don’t know if going to professor would It’ll probably a waste of time if I go.
be a waste of time.
I couldn’t get myself to start reading. I can’t do this

We gently lead clients to identify the actual

words that went through their minds.

Examples: Wearing a red dress and

entering into the classroom.
 CHANGING THE FORM OF TELEGRAPHIC OR QUESTION
THOUGHTS

Question Statement

“Will I be able to cope?” “I won’t be able to cope.”

“ Can I stand it if she leaves?” “I won’t be able to stand if she
leaves”
“What if I can’t do it.” “I’ll lose my job if I can’t do it”
“What if she gets mad at me” “She’ll hurt me if she gets mad at me”
“How will I get through it” “I won’t be able to get through it”
“What if I can’t change” “I’ll be miserable forever if I can’t
change”
“Why did this happen to me?” “This shouldn’t have happened to me”
 RECOGNIZING SITUATIONS THAT CAN EVOKE
AUTOMATIC THOUGHTS
A wide range of external stimuli and internal experiences can give rise to automatic
thoughts.
Situation/Stimulus Example Automatic Thoughts
External events Mother keeps How dare she is treating
(Series of events) hanging phone me like this?
Stream of Thoughts Thinking about exam I’ll never learn
this stuff
Cognition: Thought, Becomes aware of I must be crazy
Image, belief, day dream, violent image I’ll never get over this
Memory, Flashback Has a flashback of
traumatic events
Emotions Anger I shouldn’t be
angry at him. I am such a bad
person
Behavior Binge eats I am so weak..
Physiological or Mental Rapid Heart Beat What if there’s
something wrong
Experience
 INITIAL AND SECONDARY THOUGHTS AND REACTIONS

Situation Potential Additional

Automatic Thoughts

Initial Automatic Thoughts

Emotion
Emotion

Behavior
Behavior

Physiological Reaction
Physiological Reaction
 IDENTIFYING EMOTIONS
 Emotions are of primary importance in CBT.
 Intense negative emotion is painful and may be dysfunctional it interferes
with a patient’s capacity to think clearly, solve problems, act effectively, or
gain satisfaction.

Examples: Sally feeling guilty and sad for cancelling social event with her
friend
and at the same time, feeling anxious to meet her professor for
help.
 Evaluating Automatic Thoughts

• Select automatic (habitual or regular) thoughts.

• Use Socratic questioning to evaluate automatic thoughts.
• Assess the outcome of the evaluation process.
• Conceptualize when evaluation is ineffective.
• Use alternate methods of questioning and responding to automatic
thoughts.
• Respond when automatic thoughts are true.
• Teach clients to evaluate their automatic thoughts.
 How One Feels in Different Situations

Angry Sad Anxious

Brother cancels plan Mom does not return Seeing low my bank
with me my call account is
Friend does not Not enough money to Hearing that we
return my gym bag go away on vacation might have tornado
Driver plays music Nothing to do on Finding a bump on
too loudly Saturday my neck
 RATING DEGREES OF EMOTION
 It is sometimes to important not only to identify the emotions, but also to
quantify the degree of emotion they are experiencing.
 Helps in learning to rate the intensity of emotions in testing the experiencing
beliefs.
 It also helps to assess whether questioning and adaptively responding to a
thought or belief have been effective or not for further intervention.
 Helps clients/patients to judge the intensity of an emotion fairly and easily.

Not sad at all A little sad Medium Sad Very sad

Completely Sad
 CHAPTER 11
Evaluating Automatic Thoughts: This chapter describes how to:
 Select key automatic thoughts.
 Use Socratic questioning to evaluate automatic thoughts.
 Assess the outcome of the evaluation process.
 Conceptualize when evaluation is effective.
 Use alternative methods of questioning and responding to automatic
thoughts.
 Respond when automatic thoughts are true.
 Teach patients to evaluate their own automatic thoughts.
INTRODUCTION OF CBT
(Cognitive Behaviour Theory )

Aaron Beck
 CBT:
• founder- psychiatrist named Aaron Beck.

• CBT is a form of psychotherapy that treats

problems and boosts happiness  by modifying
dysfunctional thoughts, emotions and behaviors.
( thoughts influence feelings and behaviors)

• effective for treating less severe forms of depression

and anxiety, posttraumatic stress disorder (PTSD),
substance abuse , eating disorders and obsessive-
compulsive disorder.
• CBT umbrella, including

1. cognitive therapy,
2. problem-solving therapy,
3. dialectical behavior therapy,
4. meta-cognitive therapy,
5. rational-emotive behavior therapy,
6. cognitive processing therapy,
7. mindfulness-based cognitive
therapy,
8. cognitive-behavioral analysis system
of psychotherapy &
9. schema-focused therapy 
• CBT helps clients identify, evaluate and respond to
their dysfunctional thoughts or beliefs. This is
accomplished using a wide variety of techniques.
• Components of CBT:
1. Core beliefs : +ve ( I am competent) & -ve (I am
helpless)
2. Automatic thoughts: quite brief and most people are
usually more aware of the emotion that goes along with
the thought rather than the thought itself.

• approach that requires both the therapist and the client

to be invested in the process and willing to actively
participate

 
 Example:
• Ellie grew up with a mother who was overly cautious
and distrustful of the world around her. Ellie, now
age 20, also thinks that she is never safe from others.
This causes her immense anxiety on a daily basis in
many areas of her life. Ellie has begun to avoid going
out, afraid that she will be robbed or raped. Ellie
finally decides to visit a therapist who is trained in
cognitive behavioral therapy to help cure her
negative thinking patterns and anxiety.
• Definition of CBT using the example of Ellie:

i. Ellie's negative thoughts = ''The world is a scary

place. I cannot trust anyone. I am in danger. I will get
robbed or raped if I go out.''
ii. Ellie's resulting negative emotions = ''Intense
anxiety''
iii.Ellie's maladaptive behaviors = ''Avoidance (in this
case it's avoidance of social interaction or going
outside her home).''

This is maladaptive because it causes Ellie to be socially

isolated, which is a risk factor for major depression.
• not designed for lifelong participation but focuses
more on helping clients meet their  goals in the near
future.

• Since CBT is present-focused, current problems are

discussed. While there may be some mention of past
behaviors or thoughts, therapy takes place with a focus
on the here and now.

• Most CBT treatment regimens last from 5 – 10

months, with one 50 to 60-minute session per week
depending on the severity of the client's or patient's
mental disorder.
4. Identifying & Modifying beliefs
Core Beliefs
 Core beliefs
• Core beliefs are those thoughts and assumptions that
we hold about ourselves, others, and the world around
us.
• It develops as we grow and lend direction to how we
think, act and feel.
• Positive and negative core beliefs.
- Positive-example
 “I am an okay person”
 “I can control my life to a certain degree”
 “I can achieve’’
 Cont.
- Negative- example
“I am not okay”
“I am not capable”
“I am not likeable”

•Aaron and Judith Beck (Beck,J,2005) has categories

core beliefs in three ways- helplessness, unlovability
and worthlessness.
Helpless core beliefs –
example – I am inadequate, I am incompetent, I
can’t cope, I am powerless, I am needy, I am weak, I
am inferior etc.
 Cont.

• Unlovable core beliefs

Example- I am unlikable, I am ugly, I am unloved,
neglected, rejected etc.
• Worthless core beliefs
Example- I am worthless, I am unacceptable, bad, I don’t
deserve to live etc.

• Core beliefs are one’s most central ideas about self.

• J.Beck- schema are cognitive structure within the mind and

the specific content of that are core beliefs.
 Identification & modification of core
beliefs
• Identify core belief and mentally hypothesize from
which category that core belief belongs to.

• Use Down arrow techniques

-Identify underlying assumptions and core beliefs
that drives the Negative Automatic Thoughts.
-this exercise elicit a core belief.
 Downward arrow technique: example
Automatic thoughts
“I don’t think Sarah likes me”
(What so bad about that?)

Assumptions
“whenever I get close to people, they end up disliking me”
(what does this say about you?)

“I will never have a close relationship”

what does this say about you

Core beliefs
“I am unlikable”
 Cont.
• Educate the client about their core beliefs in general
and their specific core beliefs.
• Helps client to specify and strengthen a new, more
adaptive core beliefs.
• Evaluate and modify the negative core beliefs with
the client.
• Use both “intellectual” and “emotional” or
experiential methods to decrease the strength of the
old core belief and to increase the strength of the new
core belief.
 Cont.

Use techniques to modify negative core

beliefs…
-Socratic questioning technique
-Cognitive continuum
-Core belief worksheets
-Extreme contrast
-Coping cards
-Stories and metaphors
Intermediate belief
 Intermediate belief
• Intermediate beliefs are defined as often unarticulated
attitudes, rules, expectations, or assumptions.
• Importantly, intermediate beliefs influence an
individual’s view of a situation, and ultimately, his or
her thinking, feelings and behavior.
• Both core beliefs and intermediate beliefs arise as a
result of people’s attempts to interpret and make
sense of their life experiences and environment. The
way in which they approach this interpretation
depends largely on the approaches to thinking they
learned earlier in their development.
 Cont.

• more under the surface but influence the direction our

automatic thoughts go in.

• different from core beliefs and encorporate rules,

attitudes and assumptions.

• It can help to explain that different people have

different beliefs because of different personalities and
experiences, and that they may make things hard for
us but that we can unlearn them.
 Examples
• Core Belief
I’m inadequate
Intermediate beliefs
1. Attitude: It’s terrible to inadequate.
2. Assumptions(positive) : If I work extra hard, I can do
okay.
Negative: If I don’t work hard, I’ll fail.
3. Rules: I should always do my best.
I should be great at everything I try.
Examples
Rule: I should do things myself

Attitude: it’s terrible to ask for help

Assumption: if I ask for help I’m incompetent

Key aspects of intermediate beliefs are
• Expectations and assumptions about ourselves,
relationships and situations around us.

• Rules and guidelines we follow.

• Attentional priorities and biases which influence what

we notice and the ways we think and respond to a
given situation.
 Identifying Intermediate belief
• Recognizing when a belief is expressed as an
automatic thought.
• Providing the first part of an assumption.
• Directly eliciting a rule or attitude.
• Using the downward arrow technique.
• Examining the patient’s automatic thoughts and
looking for common themes.
• Asking the patient directly.
• Reviewing a belief questionnaire completed by the
patient.
5. Importance of other techniques e.g.,
Imaginary & homework
 What Does CBT theory says?
• A person suffers because of the wrong interpretation of the
stimulus.
• Talks about the cognitive distortions.
• Cognitive Distortions means irrational thoughts pattern.
• Cognitive techniques helps to bring awareness on their type
of CD or in their harmful beliefs and helps in cognitive
restructuring.
• Long term goal is to change a person’s thinking and
behavioral patterns to healthier ones.
 Cognitive Techniques
• Journaling: Gathering data about your moods, their
source/intensity and your responses to them.
• Unravelling Cognitive Distortions: Making the client
aware of the distortions that they are likely to be
vulnerable of.
• Cognitive Restructuring: Challenging harmful or
destructive beliefs and restructuring them.
 What does Behavior Theory say?
• “We are the victim of our environment”
• A person is wrongly conditioned.
• Conditioning occurs with the interaction with the
environment.
• A person regardless of his/her background,
personality traits and internal thoughts can be trained
to act in a particular manner given the right
conditioning.
 Cognitive and Behavioral Techniques
• Graded Task Assignment
• Problem Solving and skills training
• Decision Making
• Relaxation( progressive muscle relaxation, imaginary, controlled
breathing)
• Credit List
• Role Playing
• Social Skills training
• Dance Movement Therapy or Exercising
• Imaginary techniques
• Systematic desensitization/ graduated exposure therapy
• Homework
 Graded Task Assignment

 It is a CBT technique for turning overwhelming tasks into

manageable achievements.
 Helps to see everything as step-by-step.
 This involves breaking a big goal into smaller goals that you
put in the most logical, achievable order.
 To reach a goal, it is usually necessary to accomplish a
number of steps along the way.
 Patients tend to become overwhelmed when they focus on
how far they are from a goal, instead of focusing on their
current step.
Example
 Decision Making
• Many patients, especially those who are depressed,
have difficulty making decisions.
• When patients want help in this area, a therapist will
ask them to list the advantages and disadvantages of
each option and then help them devise a system for
weighing each item and drawing a conclusion about
which option seems best.
Example
 Relaxation Techniques
• Progressive muscle relaxation.
• Controlled Breathing.
• Imaginary techniques.
• Patients can obtain commercially produced relaxation
tapes or they can follow a script and make a recording
for them during the session.
• Mindfulness techniques help patients non judgmentally
observe and accept their internal experiences, without
evaluating or trying to change them.
 Role playing
• Role playing between therapist and client.
• These cognitive behavioral therapy exercises teach
patients how to respond in difficult situations.
• The patient sees the behavior of the therapist as a
model to overcome his/her own behavioral problems.
• Role-playing is also useful in learning and practicing
social skills.
 Credit List
• Credit lists are simply daily lists (mental or written)
of positive things the patient is doing or items she
deserves credit for.
Example
 Imaginary Techniques
• Miracle question: Answer it and Change your Life
• Gives an idea on how the future will be different when the
problem is no longer present according to the client.
• "Suppose tonight, while you slept, a miracle occurred.
When you awake tomorrow, what would be some of the
things you would notice that would tell you life had
suddenly gotten better?"
• Added question "how would that make a difference?"
•  It can be used with individuals to set the course for
therapy, with couples, to clarify what each person
needs from each other and with families, who too
often see one person as the culprit.
Homework
 Homework in CBT
 is core mechanism to promote change in cognitive
behavioral therapy (CBT) used by clients to rehearse new
skills, practice coping strategies, and restructure destructive
beliefs.

 Between CBT sessions, clients may be assigned homework

like setting goals, reading assignments, listening to audio
tapes, practicing relaxation exercise and new behaviors and
implementing what was learned in session.
 On going homework assignments
Typical on-going homework assignments are discussed below.
1. Behavioural activation.

Getting inactive, depressed patients out of bed or off the

couch and helping them resume their normal activities (and

engage in new activities) is essential. Activity scheduling

benefits other patients as well.

2. Monitoring automatic thoughts.

From the first session forward, therapist will encourage to

notice their mood changing, and remind themselves that

their thinking may or may not be true. Also advice patients

that monitoring their automatic thoughts can lead them to

feel worse, if they accept them uncritically.

3. Evaluating and responding to automatic thoughts.

At virtually every session, you will help patients modify

their inaccurate and dysfunctional thoughts and write
down their new way of thinking. An essential homework
assignment is to have them read these therapy notes on a
regular basis. Patients will also learn to evaluate their
own thinking and practice doing so between sessions.
4. Problem solving.

At virtually every session, therapist will help patients develop

solutions to their problems, which they will implement
between sessions.

5. Behavioural skills.

To effectively solve their problems, patients may need to learn

new skills, which they will practice for homework. (example,
you might teach relaxation skills to anxious patients,
assertiveness skills to socially anxious patients,
or organizational and time management skills to patients
who would benefit from them.)
6. Behavioural experiments
Patients may need to directly test the validity of
automatic thoughts that seem misleading.
7. Bibliotherapy
Important concepts which are discussing in session
usually valuable to have patients both read and note
their reactions: what they agreed with, disagreed
with, and had questions about.
8. Preparing for the next therapy session
The beginning part of each therapy session can be
greatly speeded up if patients think about what is
important to tell you before they enter your office.
The Preparing for Therapy Worksheet can help
prepare them.
6. Challenges in CBT
 Challenges in CBT

• 1. CBT may not be effective for people with more

complex mental health issues or for those with
learning difficulties.

• 2. Focus of CBT is always about the client and their

capacity to bring change to themselves. In this sense we
can say that it is too narrow focus and ignores too many
important issues like family, personal histories, and wider
emotional problems.
For these issue to be addressed a client would need
to turn to a different approach, perhaps along the lines of
psychodynamic counseling
• 3. When the client has difficulty identifying
emotions and thoughts: It is common for clients to
experience emotion prior to any conscious
recognition of their preceding thoughts. This can
make it difficult to ascertain the actual thoughts that
activated the emotional response.
To assist clients in identifying their
thoughts, counselors may need to use specific
questioning techniques to isolate thoughts. Such as,
“What were you telling yourself at the time?” or
“What was going through your mind?” In addition,
role playing the situation and stopping the scene at
crucial (emotional) times in the sequence may help
clients recall their thinking.
 4. When clients agree with the principles
but can’t seem to alter their thinking:

• Frequently, clients report an understanding of the principles

of cognitive therapy on an intellectual level, but cannot
seem to apply that understanding in a way that promotes
real change (Sanders & Wills, 2005).
Reinforcing that change takes time
and even preempting the difficulty of shifting from “the
head level to the gut feelings” can be helpful ways of
preparing clients to stick with the strategies. It may simply
be a matter of repetition and practice for clients working
through change from the ‘head’ through to the ‘heart’.
• 5. Clients have limited motivation for change
For clients that are not attending counseling of their
own free will, it is essential that counselors establish
motivating factors for the client in the initial stages of
therapy.
Client may, for example, be attending
counseling to keep harmony in a significant
relationship or to elicit help to get someone ‘off their
back’. Whatever the reason for attendance, counselors
should focus on the possible benefits an individual
may receive by being involved in the counseling
process.
Contd..

Strengths of CBT:

1. Model has great appeal because it focuses on human

thought. Human cognitive abilities have been
responsible for our many accomplishments so may also
be responsible for our problems.
2. Cognitive theories lend themselves to testing. When
experimental subjects are manipulated into adopting
unpleasant assumptions or thought they became more
anxious and depressed (Rimm & Litvak, 1969).
3. Many people with psychological disorders, particularly
depressive, anxiety, and sexual disorders have been
found to display maladaptive assumptions and thoughts
(Beck et al., 1983).
4. Cognitive therapy has been very effective for treating
depression (Hollon & Beck, 1994), and moderately
effective for anxiety problems (Beck, 1993).
 Contd..

Limitations of CBT:

1. The precise role of cognitive processes is yet to be

determined. It is not clear whether faulty cognitions are a
cause of the psychopathology or a consequence of it.
Lewinsohn (1981) studied a group of participants before
any of them became depressed, and found that those who
later became depressed were no more likely to have
negative thoughts than those who did not develop
depression. This suggests that hopeless and negative
thinking may be the result of depression, rather than the
cause of it. 
2. The cognitive model is narrow in scope - thinking is just
one part of human functioning, broader issues need to be
addressed.
3. Ethical issues: RET is a directive therapy aimed at changing
cognitions sometimes quite forcefully. For some, this may
be considered an unethical approach.
 CONCLUSION
• Cognitive behavioral therapy, also called CBT, is a
form of goal-oriented psychosocial therapy that
attempts to reverse a person's negative thinking
patterns in the interest of curing the negative
emotions and maladaptive behaviors that result from
those very thinking patterns by using numerous CBT
techniques. CBT used in number of disorders,
including addiction, anxiety, depression, and
obsessive-compulsive disorders.
 Reference
• “Cognitive Behavioral Therapy”-Psychology Today retrieved from
www.psychologytoday.com/us/basics/cognitive.

• Cognitive behavioral therapy retrieved from

https://en.wikipedia.org/wiki/Cognitive_behavioral_therapy
 
• "Positive Psychology Program" retrieved from
https://positivepsychologyprogram.com/cbt-cognitive-behavioral-therapy-techniques-workshe
ets/

•  Benefits and Limitations of Cognitive Behavioral Therapy (CBT) for Treating Anxiety “
retrieved from www.healthcentral.com/article/benefits-and..

• “CBT: APPLICATIONS AND CHALLENGES”, Counslling Connection, retrieved from

www.counsellingconnection.com/index.php/2009/10/13/.
THANK
YOU !