The theory behind Cognitive-Behavioral Therapy (CBT) is that the way that people perceive situations is more closely connected to their reaction than the situation itself. When people are in psychological distress, they often are not seeing situations very clearly. Simply put, a therapist’s job when using CBT is to help clients identify the thoughts that pop up into their minds, evaluate, and respond to them. The assumption is that when clients are able to do this, they feel better and can act in accordance with their goals.
One critical component underlying all aspects of CBT is that just because you think something doesn’t necessarily mean it’s true. Clients cannot progress beyond the basics of CBT without accepting this.
According to the Beck Institute for Cognitive-Behavioral Therapy, “CBT uses a variety of cognitive and behavioral techniques, but it isn’t defined by its use of these strategies.” This allows for the use of other treatment modalities, such as Acceptance & Commitment Therapy, Mindfulness-Based Cognitive Therapy, and Dialectical Behavioral Therapy, as a part of CBT.
To be an effective with Cognitive-Behavioral Therapy, you have to continuously conceptualize clients’ experiences in order to understand what their problem is and to decide how you should best assist them. This can include evaluating their thoughts, identifying and modifying their beliefs, doing problem solving, and teaching them skills to regulate their emotions, change their behavior, or decrease their physiological arousal. Or maybe there’s nothing to be done about a problem and clients need to work toward acceptance of the problem and changing their focus toward valued action.
How Does CBT Work with Different Mental Health Disorders?
- For Major Depressive Disorder, a therapist focuses on the automatic thoughts that have to do with the self, the world, the future.
- For Panic Disorder, we focus on the automatic thoughts that have to do with the catastrophe that the client is afraid will happen if a symptom gets worse.
- With Obsessive-Compulsive Disorder, a CBT therapist doesn’t focus on automatic thoughts; rather, the focus is on the beliefs that clients have about their obsessive thinking and about their ritualistic behavior.
Initially, your work with a client will focus on evaluating and modifying their thoughts and/or beliefs. As sessions progress, you might begin to focus on clients’ deeply held beliefs, which are referred to as Core Beliefs. Core beliefs prevent you from gathering evidence to contradict your analysis of a situation. You can identify these beliefs as they are always active (24 hours a day, 7 days a week) and act as a “lens” where whatever happens to you gets filtered through it. There are three primary categories of Core Beliefs:
- Helplessness (being ineffective in getting things done, in protecting themselves, or as compared to other people)
- Worthlessness (a belief that you are morally bad)
Using what CBT therapists refer to as the “downward arrow approach”, you identify a core belief through automatic thoughts by asking, “If your automatic thought were true, what would that mean? And especially, what would that mean about you?” This can be time consuming and challenging as clients often express their core beliefs as an automatic thought. You can also explore how the client has coped with these core beliefs all their life, examine what kind behavioral strategies they have developed to get along with in life, and identify some consistent patterns of behavior that are, at times, dysfunctional.
Core beliefs can’t be worked on during the initial steps of therapy until the client is in agreement with the critical concept above (thoughts are not necessarily true). Also, questioning one’s core beliefs questions a client’s core self, which can be very uncomfortable; this requires trust in the therapeutic relationship to be solid and established.
People cope with their Core Beliefs by using Assumptions or “Rules for Living”, regardless of whether they create more problems than they solve. Coping Strategies are the characteristic ways that clients behave in order to protect themselves from the activation of their core beliefs. Most of these take the form of an “if…/then…” format. For example, “If I don’t trust people, then I’m going to be ok. But if I do trust them, I’m going to be hurt, and therefore proven unloveable.” Therapists help clients evaluate these conditional assumptions by exploring both the positive assumption that helped them cope with their core belief, as well as any negative counterparts to their assumptions.
Responding to Dysfunctional Cognitions
The errors we make in our thinking are referred to as Cognitive Distortions. It’s not essential to label the cognitive distortion, but it can be helpful to give clients some distance from their emotionally charged thoughts. Cognitive-Behavioral therapists tend to challenge these thinking errors using a variety of techniques, including Socratic Questioning, Behavioral Experiments, Labeling of Cognitive Distortions, Cognitive Challenging/Refocusing/Reframing, Exploration of Coping Patterns, Exploration of Thoughts and Emotions, Interactive Feedback, Role-Play/Behavioral Rehearsal, and using Analogies and Metaphors.
Of these, the most important is Socratic Questioning, where clients learn how to evaluate thoughts and beliefs by gathering evidence, developing alternative explanations, de-catastrophizing, and using other Socratic questions, such as:
- What’s the evidence?
- What’s the evidence on the other side?
- What’s another way of looking at this situation?
- If the worst happens, how could you cope?
- What’s the best outcome?
- What’s the most realistic outcome?
- What’s the effect of changing (or not changing) your thinking about this?
- What would you tell a friend who was in the same situation?
- Given all of this, what do you think you should do now?
Therapists should proceed with caution until a client is able to demonstrate that they really believe the cognitive model (that thinking influences how they feel and what they do) and that by evaluating their thinking, they can feel and act better. Clients should also be able to demonstrate to you that they can use the list of socratic questions and have filled out any related worksheets with you during/in-session. Otherwise, any assignments you give will be half-believed, half-accomplished, and will be unlikely to make any material change in cognition between sessions.
Practicing New Skills
It’s just not enough to come in and talk for 45-50 minutes a week. The way that people get better is by making small changes in their thinking and behavior every day. In order to best accomplish this, CBT relies on assignments between sessions (also called “Action Plans” and “Homework”). Research shows that CBT that includes assignments is more effective than CBT that doesn’t. Assignments entail some kind of responding to the client’s negative thinking and behavioral change. If in doubt, you can ask your client, “What do you think is most important to remember this week? What would you like to do about it? What would you like to remember?” Regardless of the assignment, have them write it down using a Therapy Summary Worksheet.
Assignments can include reading therapy notes every day, implementing solutions to problems, monitoring experiences to notice important automatic thoughts, responding to their negative cognitions, reading coping cards or therapy notes, using worksheets, and practicing new behavioral skills. Behavioral skills often involve activity scheduling (social activities; self-care activities; exercise; activities that can bring a sense of pleasure or achievement; exposure techniques; bibliotherapy; interpersonal skills; social skills; communication skills; assertiveness skills; emotional regulation techniques; mindfulness/relaxation) or using techniques to solve specific problems, such as improving sleep, regulating eating, or decreasing the use of harmful substances.
The single most important question to ask your clients at the end of each session is, “How LIKELY are you to do the assignments on this action plan this week?” If they respond with 90-100%, your work is done. If they say 75%, they will do some of it, but just before the session just to please you. If they say 50%, they’re not going to do it, but they don’t want to tell you. To reach 90%, make certain the action plans are easier, or make parts of the action plan optional. You can ask the client, “What are the practical problems that will get in the way?” or “What are the automatic thoughts that will get in the way?” Once you’ve addressed these and revised the action plan, you can then ask the client, “NOW how likely are you to do the action plan this week?”