COGNITIVE BEHAVIOUR

THERAPY (CBT)
 COGNITIVE BEHAVIOUR THERAPY (CBT)

• A form of psychotherapy based on behavior modification but aimed

at altering cognitive processes such as attitudes, beliefs,
expectations, and self image.

• Re-educative (relearning) form of therapy.

 HISTORICAL BACKGROUND

Behavior Therapy (1950s)

• Desensitization
• Behavior Modification
Cognitive Therapy (1950-60s)
• Beck’s Cognitive Therapy (CT)
• Rational-Emotive Therapy (RT) – Albert Ellis
Newer Approaches (1990s)
• Mindfulness Meditation
• Dialectical Behavior Therapy (DBT)
AARON BECK
(1921-2021)
Cognitive-Behavior Therapy

• Cognitions – thoughts, beliefs, and internal images that people

have about events in their lives.
• Cognitive counseling theories focus on mental processes and
their influences on mental health.
• A common premise is that how people think largely determines
how they feel and behave.
• Cognitive Therapy (CT) was developed by the American
Psychiatrist Aaron Beck in 1960s. The name was changed to
Cognitive Behaviour Therapy (CBT), as the behavioural therapy
techniques became part of it.
Cont..

• Cognitive Therapy was initially developed for depression. Soon

after its development it was adapted for other disorders
including
• OCD
• Phobias
• PTSD
• Eating Disorders
• Personality Disorders
 VIEW OF HUMAN NATURE/PERSONALITY

• Usually employed with individuals who suffer from:

• Dysfunctional automatic thoughts - involving content specific
to an event.
• Maladaptive schemas - general rules about themselves or the
world associated with an event.

• These individuals often engage in self-statements that affect

their behavior.
Automatic Thoughts (ATs)

• Negative thoughts about yourself, your world, or your future

• ATs are not given the same consideration as other thoughts but
rather they are assumed to be true
 THOUGHTS AND FEELINGS

• Reciprocal link between thoughts and feelings.

• Unhelpful thoughts are associated with adverse moods.

• Adverse moods are likely to generate more extreme and

unhelpful thoughts.
 BEHAVIOURS

• Extreme thoughts and feelings can affect positive/negative

activities.

• Increase activities that worsen the problem.

• Resulting behaviours may cause adverse long-term consequences

which perpetuate the problem.
CONCEPTUALIZATION OF PSYCHOLOGICAL
DISTURBANCE

• Information processing is biased in a negative distorted way:

people revert to more primitive thinking which prevents them
functioning as effective problem solver. (Beck 1979)
• Thinking errors or logical errors which characterize thinking in
psychological disorders.
• Quantity / Quality
• Negative bias
 12 COMMON THINKING ERRORS

1. All or Nothing, Black and White, Dichotomous

• “If I’m not a success, I’m a failure”.
2. Catastrophizing/Fortunetelling
• “I’ll be so upset, I won’t be able to function at all”.
3. Disqualifying the Positives
• “Sure I got a good mark, but I was just lucky”.
4. Emotional Reasoning
• “I feel it, therefore it must be true”.
5. Labeling
• “I’m a loser… I’m no good”; “He’s an idiot!”.
6. Minimization/Maximization
• “I only hit the target 3 times”.
7. Filtering/Selective Abstraction
• “I received one low mark…I’m doing a horrible job”.
8. Mind Reading
• “I know he hates my guts”; “she’s judging me”.
9. Overgeneralization
• “I never…”; “I always…”.
10. Personalization
• “He was short with me because I did something wrong”.
11. Should/Must Statements
• “They should be doing this for me!”; “You should change”;
“If she loves me, she will do this”.
12. Tunnel Vision
• “This smoke is going to be so good!”.
 THEORY OF COGNITIVE BIAS

• According to Beck depressed individuals feel depressed because

their thinking is biased toward negative interpretations.

NEGATIVE TRIAD  NEGATIVE SCHEMA OR BELIEF

 COGNITIVE BIAS (OR DISTORTIONS) 
DEPRESSION
 THE COGNITIVE TRIAD

• Negative view of the self (e.g., I’m unlovable, ineffective.).

• Negative view of the future (e.g., Nothing will work out.).

• Negative view of the world (e.g., World is hostile.).

PSYCHOLOGICAL HEALTH

• Ability to process information in a relatively accurate and flexible

manner.
• Psychological health requires us to be able to use the skills of
reality testing to solve personal problems as they occur.
• We have a slightly positive bias
 ASSESSMENT AND CASE
CONCEPTUALIZATION IN CBT
 INITIAL CONTACT AND ASSESSMENT

• Current issue or presenting complaint.

• History of presenting complaint.
• Appraisal of meaning of the given events is central in CBT.
• Subjective interpretation of stimuli made by an individual in the
environment.
• Appraisal and assessment starts from the initial contact with the
client.
• Formulation
 CLIENT SUITABILITY FOR CBT
Inclusion criteria:
•Can access thoughts and feelings.
•Accepts some responsibility for change.
•Understands a CBT rationale and basic formulations.
•Able to form a good relationship with therapist.
•A degree of optimism about therapy.

Exclusion criteria:
•Impaired cognitive functioning.
•Chronic or severe problems.
•Unwilling to let go of avoidance behaviors.
•Unwilling to do homework.
•A pronounced pessimism about therapy.
 D
M
S
SE
M

• Some CBT therapists are diagnosticians and tend to make use of DSM.
• Labeling process
• Use of DSM
• Mental status examination : It focuses on any obvious sign that may
indicate anything about the client’s current state of mind that might
impact adversely or otherwise on therapy.
 ASSESSMENT (SANDERS & WILLS, 2005)

1. Current problem.
2. What keeps the problem going now?
3. How did the problem develop?
4. Developmental history.
5. General health issues.
6. Expectations of therapy and goals.
 CBT SESSION STRUCTURE (BECK, 1995)

1. Brief update and mood check (including use of measures).

2. Bridge from previous session.
3. Collaborative setting of the agenda.
4. Review of homework.
5. Main agenda items and periodic summaries.
6. Setting new homework.
7. Summary and feedback.
 COGNITIVE CONCEPTUALIZATION

Case conceptualization focuses on:

Vicious Cycle Linking

Thoughts And Emotions

Appraisal And Emotions

APPRAISAL:
The meaning the client gives to situations, emotions, or biology is
often expressed in the client’s negative thoughts.
 VICIOUS CYCLE

• Trigger

• Negative Automatic Thoughts (NATs)

• Emotions

• Behaviors
 CONCEPTUALIZATION

Levels of Cognition: (Pedesky, 1995)

Negative Automatic Thoughts

Dysfunctional Assumptions

Core Beliefs/Schemas
 CONCEPTUALIZATION

I don’t know what to say, I am making a mess of this. I am a failure, she

doesn’t like me.

If people get to know me, then they will find out how useless I am and
will reject me.

I am unlovable, I am defective.
 GOALS

• Primary goal is to teach clients ways to monitor their negative

automatic thoughts.

• Recognize the relationship between thoughts and emotions or

behavior.

• Compile evidence for and against the distorted automatic

thoughts.
 THERAPEUTIC RELATIONSHIP

• The cornerstone of cognitive behavioral therapy is collaborative

relationship, within which the client and therapist work to
identify and resolve the client’s difficulties.

• Therapeutic alliance promotes hope which is central to any

therapy.

• Core conditions or general characteristics of any therapy that

facilitate the application of cognitive therapy are included.
 IDENTIFYING ASSUMPTIONS AND
CORE BELIEFS

• “If…, then…” Statements

• Downward Arrow Technique

- If this thought is true, what’s so bad about that?

- What’s the worst part about that?

- What does it mean to you? About you?

 INTERVENTIONS USED BY BECK WITH
DEPRESSED PATIENTS

• Graduated tasks or activities.

• Activity schedule making.

• Mastery and pleasure.

 THOUGHT STOPPING

Four Phases:

1. Therapist’s interruption of overt thoughts.

2. Therapist’s interruption of covert thoughts.

3. Client’s overt interruption of covert thoughts.

4. Client’s covert interruption of covert thoughts.

 BEHAVIORAL TECHNIQUES

• Relaxation
• Systematic Desensitization
• Assertiveness Training
• Modeling
• Operant Conditioning
• Self-Controlling Procedures Including Biofeedback
• Extinction
• Aversive Conditioning
 IDENTIFYING EMOTIONS

• Diary of Emotions

Situation How Did I

Feel?
 IDENTIFYING THOUGHTS

• Diary of Emotions And Thoughts

Situation How Did I What Went

Feel? Through My
(0-100%) Mind?
(0-100%)
 SEVEN-COLUMN THOUGHT RECORD

TRIGGER EMOTION NAT EVIDENCE EVIDENCE ALTERN- OUTCOME

FOR NAT AGAINST ATIVE
NAT ADAPTIVE
THOUGHT
 TYPICAL CONTENT OF NATs IN DIFFERENT
DISORDERS
• Depression: Excessively negative view of the self, the world, and the
future.

• Anxiety: Over-estimation of threat in particular domains.

• Panic: Misinterpretation of anxiety, e.g., symptoms as indicating

imminent catastrophe (dying or going mad).

• Social Anxiety: Fear of negative evaluation by others.

• OCD: Responsibility for and need to prevent harm to self or others.

 SAMPLE
CASE CONCEPTUALIZATION
 CASE OF RUBY

• Intake and Clinical History

• Briefing

• Rapport Building

• Assessment and Diagnosis

• Vicious Cycle

• Goal Setting
• Tackle areas which are easier to modify at first.

• Homework tasks.

• Keeping a record of her negative thoughts and how she responded

to them.
• On other occasions, arranging plans to go out twice with friends.
• Or, go for a cycle ride every other day.
• Or, to make sure that she planned decent meals for herself, and
maybe invite someone else to eat with her.
• She was also encouraged to look at her negative beliefs and to ask
herself what evidence she actually had for those beliefs, or if there
were other ways of looking at her situation in a more realistic light
i.e. Thought Record Sheet as well as occupying the use of Downward
Arrow Technique.

• It is important to emphasize that CBT is not about looking at life

through rose-tinted spectacles, or thinking positively about sad or bad
things. It simply invites us to do a reality check, as we often get
caught in inaccurate and unhealthily negative belief systems about
our lives which compound real life challenges.
• Progress being monitored throughout the course of the sessions.

• She had got into a rhythm of exercise and social activity and found
that her sleep was less disturbed and that she felt less angry and
resentful.

• Although there were still practical challenges in her life, she had
developed the ability to recognize when she was engaging in
distorted thinking: catastrophizing, minimizing the positives,
maximizing the negatives, thinking in 'all-or-nothing' terms, and so
on.
• A year later, her therapist received an email to say that she had
started a degree in a local university which she was greatly
enjoying and even dipping her toes into socializing again.
THANK YOU!