6a) Cognitive Therapy techniques

Question 1

What are the factors that determine how significant CT plays in a therapist’s treatment? (3)

Answer 1

• Personal preference
• Client’s symptoms and,
• Client’s ability to engage in this approach

Question 2

What are the factors that determine how significant CT plays in a therapist’s treatment? (3)

Answer 2

• Personal preference
• Client’s symptoms and,
• Client’s ability to engage in this approach

Question 3

Who came up with the CT model?

What did they believe? (3)

Answer 3

Beck (1960s)

• maladaptive states are underpinned and/or maintained by biased ways of thinking
• How we think affects how we feel and act, NOT the situation
• The same event can elicit different interpretations from different people

Question 4

What does the CT model posit?

Answer 4

The way we think determines how we feel, and not the situation we are in

Question 5

What is the role of the therapist in the CT model? (4)

Answer 5

• help client to identify and modify these maladaptive thoughts
• Encourage Client to engage in scientific and rational thinking
• Ask client what thoughts led them to this maladaptive state
• Collect evidence to examine validity of the thoughts > examine the thought > examine the meaning behind the thought

Question 6

What does CT provide?

What approach does it take?

What type of thinking does it strive for?

Answer 6

• a method for testing thoughts against reality
• Constructivist approach = Probability rather than certainty (as client will never gain certainty)
• Scientific thinking achieved through disconfirmation or falsification

Question 7

Drawbacks to CT?

Answer 7

• Rational analysis may not be enough to facilitate change
• Might need other techniques: evoking emotions, motivational enhancement, behavioural changes

Question 8

What does CT aim to do? (2)

Answer 8

• develop realistic thoughts, not positive thoughts
• Client to develop a pragmatic way of thinking

Question 9

Identify, define, and describe the 3 levels of cognition. (5; 6; 8)

Answer 9

• Most immediate level = automatic thoughts
  o Occur spontaneously
  o Appear valid to individual
  o Associated with emotional and behavioural disturbances
  o Not all thoughts are problematic, but many are irrational and unhelpful
  o Negative automatic thoughts (NATs) = Usually characterised by bias or distortion
  o E.g., that person doesn’t like me
• Assumptions = results in the vulnerability to experience NATs
  o Typically rigid
  o Over-inclusive
  o Unrealistic to attain
  o Not easily accessed or verbalised
  o Makes an individual more vulnerable to experiencing emotional disturbance
  o E.g., I have to act a certain way to get people to like me
• Schemas (or core beliefs) = assumptions are a consequence of schemas
  o Enduring, stable, very rigid
  o Over-inclusive
  o Unrealistic
  o Very hard to change
  o E.g., I’m unloved
  o All experiences are filtered through and evaluated by these underlying assumptions and core beliefs
   Often done so in a very biased and selective way
   Means individual is more likely to interpret an event and recall information in such a way that only serves to reinforce the core belief

Question 10

Draw a diagram of Panic Disorder under the CT model.

What is the core maintaining factor for PD?

How do cognitive therapists intervene here?

Answer 10

• Trigger stimulus (internal or external) -> perceived threat -> apprehension -> body sensation -> catastrophic misinterpretation of bodily sensations
• Core maintaining factor is a catastrophic misinterpretation of bodily sensations
• We intervene cognitively by helping clients to re-appraise the symptoms as non-threatening

Question 11

What are the 6 main cognitive biases in OCD that maintain symptoms?

How do CTs intervene? How does that help? (2)

Answer 11

• Inflated responsibility
• Over importance of thoughts
• Over importance of controlling one’s thoughts
• Over-estimation of threat
• Intolerance of uncertainty
• Perfectionism
• We intervene cognitively by helping clients to re-appraise these biases
• By helping to re-interpret, the stressors associated with these biases can be reduced and the prevention of engagement in a compulsion can occur

Question 12

What are the 4 main cognitive biases in Social Anxiety that maintain symptoms?

How do CTs intervene? How does that help? (1)

Answer 12

• Preferential allocation of attentional resources (internal cues; external indicators of negative evaluation)
• mental representation of self as seen by audience
• compare this neg mental representation of self as seen by audience with an appraisal of audience’s expected standard
• judgement of probability and consequence of negative evaluation from audience

We intervene cognitively by helping clients to re-evaluate the probability and consequences of negative evaluation, and thus reduce the negative stressors associated with being in a social situation

Question 13

Provide evidence for the use of CT for
* MDD
* Panic Disorder
* OCD
* PTSD

Answer 13

MDD:
* 3 group RCT: CT vs antidepressant vs placebo
* 58% of both CT and antidepressant groups responded to treatment

Panic Disorder (Clark et al., 1994)
* 3 group RCT: CT vs Relaxation vs Control
* Post treatment:
* 82% of CT patients responded to CT intervention alone
* 68% of Relaxation patients met criteria for response
* 36% of control patients met criteria for response

OCD (Jones et al., 1998)
* o Compulsive washers
* o Response: CT > waitlist control

PTSD (Marks et al., 1998)
* o 4 groups RCT: ET vs CT vs Relaxation vs ET + CT
* o CT alone resulted in significant reductions in symptoms with large effect sizes

Question 14

Identify the steps in CT (5)

Answer 14

• 1) Provide education on thoughts
• 2) Teach clients to identify/elicit thoughts and assumptions
  o E.g., Identify cognitive distortions
• 3) Teach clients to evaluate and challenge automatic thoughts
• 4) Teach clients to evaluate and challenge underlying rules and assumptions
• 5) Teach clients to identify and challenge core beliefs (if required)

Question 15

Stage 1 of CT…
what are fundamental concepts of CT that must be taught to clients? (6)

Answer 15

Stage 1 = provide education on thoughts

Fundamental concept of CT = thoughts or our interpretations of an event, causes how we feel and act

Two key concepts that must be understood:
* o Thoughts and feelings are distinct phenomena
* o Thoughts create feelings and behaviours

It is imperative that individuals:
* o 1) understand the relationship between thoughts and feelings
* o 2) Learn to identify thoughts, assumptions and core beliefs
 Can be done using thought records as shown below, or through conversations with clients
 ABC charts are helpful in understanding these concepts

Clients must distinguish between thoughts and facts
* Important to explain to clients that just because we think something that does not make it true

Question 16

What approach should stage 1 of CT take?

Answer 16

collaboratively in session - ensures that clients understands

Question 17

stage 1 of CT

Why is a clear understanding of how thoughts, feelings, and behaviour interact important?

Answer 17

key to effective cognitive restructuring later on

Question 18

What is an essential technique in stage 2 of CT and why?

Answer 18

Thought monitoring - Without learning to monitor thoughts, they will be unable to challenge these thoughts later on

Question 19

How do we go about doing thought monitoring? What should we not do?

Answer 19

HW task = use ABC chart or thought monitoring record.

Retrospective self-report of thoughts are also notoriously unreliable

Question 20

What are the 5 steps to undertake when doing Stage 2 of CT?

Answer 20

Stage 2 of CT = identifying/eliciting thoughts and assumptions

1) Explain rationale for identifying thoughts

2) Practice identifying benign thoughts, feelings and behaviours
 In session, complete an ABC chart on paper or a whiteboard and work through an example together
 Use a benign example e.g., taking an exam (unless this is the context of the worry)
 Work through as many examples as is required until the client feels comfortable themselves
 At some point, they will need to do this for hw so make sure they can do it

3) Practice identifying** clients own** unhelpful thoughts
 Using the same ABC chart, work with clients to identify their own thoughts, feelings and behaviours during past situations

4) Ask the client to monitor thoughts for homework
 Discuss how frequently you want the client to do this
 They will most likely require tips on when or how to monitor their thoughts
 Could suggest doing this at particular time points – when certain events occur, or when they’re experiencing a particular emotion
 Maladaptive or negative automatic thoughts can be easily identified as they are those that cause an emotional response

5) Review homework next session
 Discuss the intention to review this homework at the next session and actually review the homework
 When reviewing HW, make sure to review together and clarify any parts you are unsure about
 Check that you understand the client’s meaning of any words that could be open to interpretation
 If a client is having trouble with this task, explore why and fix it
* If having trouble understanding what to do, means you need to revisit your education and examples
* If forgetting to do it, need to revisit the importance of this task.
o Alarms, notes to self ? that will serve to remind the client to complete it
* Tech-savvy people can complete this stuff on apps, or notes

Question 21

What needs to be considered when undertaking Step 4 of Stage 2 of CT? (4)

Answer 21

 Discuss how frequently you want the client to do this
 They will most likely require tips on when or how to monitor their thoughts
 Could suggest doing this at particular time points – when certain events occur, or when they’re experiencing a particular emotion
 Maladaptive or negative automatic thoughts can be easily identified as they are those that cause an emotional response

Question 22

What is involved in Step 5 of Stage 2 of CT? (3)

Answer 22

 Discuss the intention to review this homework at the next session and actually review the homework
 When reviewing HW, make sure to review together and clarify any parts you are unsure about
 Check that you understand the client’s meaning of any words that could be open to interpretation

Question 23

What happens if client is having trouble with homework?

have trouble understanding what to do…?

Forget to do it…?

Answer 23

Explore why and fix it
* If having trouble understanding what to do, means you need to revisit your education and examples
* If forgetting to do it, need to revisit the importance of this task.
o Alarms, notes to self ? that will serve to remind the client to complete it
* Tech-savvy people can complete this stuff on apps, or notes

Question 24

What is involved in an ABC Chart? (1; 2; 3)

Answer 24

A = activating / triggering event situation. Trigger may also be a feeling.
What was happening just before they started to feel this way?

B = beliefs. Involves thoughts and/or images running through their mind at the time.
Also the meanings and intrepretations they had about those thoughts/ images

C = consequences. Emotions, physical sensations, behaviours (actions and urges)

Question 25

What are some strategies to identifying/eliciting thoughts and assumptions? (7)

Answer 25

• thought monitoring
• recording thoughts
• review past experiences
• observing mood shifts
• thought checklists (there are some for specific disorders)
• taking a guess - although last resort
• therapist experience - also last resort
   “A lot of people who have similar symptoms to you say they think X, Y, and Z. Do any of those sound like thoughts you might have had?”
   Collaborative – if a client says no to your guess, do not challenge them.

Question 26

Define cognitive distortions

Answer 26

common errors in logic and thinking that people often engage in (Beck)

Question 27

Give examples of some cognitive distortions (9)

Answer 27

black and white all or nothing) thinking
 Personalising
 Blaming
 Mind reading
 Fortune telling
 Catastrophising
 Emotional reasoning
 Shoulds
 Labelling

Question 28

Why is identifying cognitive distortions helpful? (3)

Answer 28

o By helping clients to identify cognitive distortions that they typically engage in, they become familiar with their own maladaptive patterns, may be able to predict what situations and types of patterns they engage in, and may use this to challenge their thoughts

Question 29

What is helpful when reviewing cognitive distortions?

Answer 29

Often people will tend to experience the same kind of patterns and distortions

When reviewing these, it may be useful to provide clients with a handout that they can review and see which ones apply to them.

Question 30

How can we challenge unhelpful thoughts (2)

Answer 30

direct or indirect manner

Question 31

Identify one way of evaluating and challenging unhelpful thoughts. direct or indirect?

What is it? (3)

Answer 31

Socratic questioning. indirect approach to evaluating one’s thoughts

It’s a process of guided discovery. involves asking questions, and not about trying to prove client wrong, or manipulating client to therapist’s version of events

Question 32

What types of questions are asked in Socratic questioning (4)

Answer 32

1) The client can answer
* Asking questions that clients can’t answer will not help clients feel like it is a collaborative process

2) Draw attention to relevant information, but which may be outside the client’s current focus
* Draw attention to information that would be useful for clients to remember e.g., passing a test instead of focusing on all the tests that a client has failed

3) Move from the concrete to the abstract
* Client and therapist have a good understanding of the concern
* Can do this by asking specific questions about the thought, then move to more abstract questions that will identify more abstract information that can help the client evaluate the thought

4) The client can use to evaluate their own thoughts at a later time (without the presence of the therapist)
* All CT is most effective when it is client-led
* Goal should always be to help client identify thoughts, mood etc.
* If it is therapist-led, it will be unlikely to lead to long-term benefits – they will be reliant on therapist to change their thoughts

Question 33

Identify and describe the 4 stages of Socratic questioning. (1;1;5;2)

Answer 33

1) Asking informational questions
 To gather data
 Asking questions that client can answer that will bring relevant information to light in order to re-evaluate a thought

2) Listening
 So as to know what questions to ask next

3) Summarising
 Summarise often
 Helps client to know where you are going with questions, allows you to check understanding, shows information that has been given as a whole and helps to put all information together

4) Synthesising or asking analytical questions
 This help client to put this new information into original concern/thought/belief
 “How does this information fit with your original unhelpful thought?”

Question 34

Why is Socratic questioning useful?

Answer 34

Allows client to take a very active role in the process

Question 35

What is important no matter what cognitive restructuring technique you choose to use? (2)

Answer 35

always practice this together in session

Then provide for homework ONLY when you are confident they understand the technique and can do it themselves.

Question 36

What is the aim of cog restructuring?

Answer 36

Challenge unhelpful thoughts, and not simply to find the right thoughts

Question 37

What to NOT do during cog restructuring (4)

Answer 37

not about finding the ‘right’ thought

don’t argue with clients

never assume a client has the right answer

never force an answer

Question 38

Identify most commonly used CT techniques to challenge unhelpful thoughts (9)

Answer 38

o Examining the evidence
o Cost-benefit analysis
o Alternative explanations
o Likelihood/probability
o Defining the terms
o Reviewing past history
o Double standard
o Consequences
o Behavioural experiments

Question 39

Define ‘examining the evidence’.
Considerations? (4)

Answer 39

Definition = looking at the evidence for and against a thought

o Always ensure that you are examining the quality of the evidence.
o Can use a little humour when using this, but decide whether it’s appropriate based on your knowledge of the client
o Can use Socratic questioning within this technique in order to help the client elicit their own responses, but should never by an interrogation
o Use homework sheets

Question 40

Define ‘cost-benefit analysis’.
What is it often used in the goal of?

Answer 40

definition = identify the advantages and disadvantages of holding a particular thought

Often used to develop motivation to change the thought - Used especially if client is ambivalent

Question 41

Define ‘alternative explanations’ technique.
What are examples of some questions that can be asked? (2)

Answer 41

oEncourages clients to consider multiple perspectives, other thoughts or actions that might mitigate their current response
“are there any alternative explanations or other ways of thinking about this [that can reduce the distress associated with the thought]?”
“What are some different ways of viewing this situation?”

Question 42

Define ‘probability/likelihood’ technique.
How can we do this technique (2)?

Answer 42

encourages clients to consider how likely something is to occur - Very common for clients to overestimate the chances of something occurring

asking the question: “How likely do you think it is that the feared outcome will occur?”
Or can be done arithmetically, by breaking down the feared outcome into a series of smaller events in a chain and identifying the likelihood of each event

Question 43

Define ‘reviewing your history’ cog restructuring technique. (2)
What questions could you ask? (3)

Answer 43

This technique encourages clients to consider evidence from the individual’s own past experiences
They may find useful information that could be incorporated into challenging questions

“Do any of your past behaviours prove that the causal thought is wrong?”

“Has the feared outcome ever happened before?”

“What have you learned about the likelihood or severity of the feared outcome by reviewing your history?”

Question 44

Define ‘double standards’ cog restructuring technique. (3)
What does the technique aim to do? (3)
What qs would you ask? (2)

Answer 44

o Clients are often harsher on themselves than other people
o Involves asking the client how they would see someone else in the same situation
o Helps clients to adjust expectations and treat themselves as they would everyone else

o Technique aims to highlight to clients these double standards, reflect on this, and encourage them to treat themselves as they would treat anyone else

 “What would you say to a friend in the same situation?”
 “Would you judge them as harshly?”

Question 45

Describe the ‘consequences’ cog restructuring technique.

What qs can you ask? (3)

What if some consequences are real? (2)

Answer 45

o Clients can overestimate the consequences of a feared situation/thought
o This technique asks clients to think about the feared consequence, and how bad it would actually be if it were to occur

 “If this thought were true, how bad would it be?”
 “What is the worst outcome?”
 “Would it matter in 5 years time?”

o Remember, some consequences are real.
 If a feared outcome is likely, think about whether the fear associated is proportionate to the situation and whether clinician should be doing cognitive restructuring

Question 46

Describe the ‘behavioural experiments’ cog restructuring technique. (2)

When does this technique work best?

Answer 46

o Involves testing out the thought/belief by creating an experiment
o This is considered a cognitive intervention, because a technique aims to create a change in unhelpful cognition
 But usually involves behavioural change
o Works best when unhelpful thoughts are phrased as an “if…then…” statement

Question 47

What is involved in a behavioural experiment? (4)

Answer 47

o Prior to conducting the experiment, it is important to have the client identify what they think will happen
o Then do the experiment
o Then client to note down what actually happened
o Work with the client to debrief and talk about how:
 What they thought was going to happen didn’t happen
 They could cope with any discomfort that they did face

Question 48

What are some types of behavioural experiments? (5)

Answer 48

 Doing the thing they fear and then observing the outcome
 Doing the opposite of their normal response and observing the outcome
 Taking a poll of friends
 Videotaping an interaction
 Doing research online

Question 49

What is the overall aim of cog restructuring? (2)

Answer 49

Generate alternative thoughts
Reframe/reappraise unhelpful thoughts in a more accurate/realistic way.

Question 50

Ideally, alternative thoughts naturally evolve from evidential review. What happens if they don’t? (3)

Answer 50

think about whether you have done enough cognitive restructuring,
whether the process was client-led, or
whether you need to try different cognitive restructuring techniques

Question 51

What should we be tracking over time when using CT? Why?

Answer 51

Track levels of conviction (out of 10 or as percentage)

When putting it altogether, always start and end by asking the client how strongly they believe the thought.

It is incredibly valuable for clients to see the reduction in belief or distress following thought challenging

Question 52

T/F: * Some thoughts may have to be challenged multiple times.

Why/why not?

Answer 52

• Some thoughts may have to be challenged multiple times
  o But always ask yourselves, why, in case there is something else that needs to be challenged e.g., an underlying need for certainty
  o No 2 people are the same – you may not be able to challenge the same thoughts experienced by people in the same ways
  o What you see as evidence against a thought may not be what a client sees as evidence

Question 53

T/F: Both within and between session practice for CT is imperative

Answer 53

o Need to explain to clients that for therapy to be effectives, clients must engage within and between session practice
 There are 168 hours in a week, but I only see you for 1 hour
 Their lives occur outside of the therapy room, so this is where they need to be practicing the skills they learn in therapy as much as possible
o CT sheets can be useful to provide for homework

Question 54

Why should CT always be client-led?

Answer 54

If it therapist led, it is unlikely to lead to long-term benefits.

A goal should always be to teach clients to evaluate their own thoughts, behaviours, mood etc

Question 55

Can you use CT with children?

Answer 55

• Research supports the use of CT with children
  o Simplified format with simplified language - Also applicable to adults e.g., using the word ‘thought’ instead of ‘cognitions’, ‘thought challenging’ rather than ‘cognitive restructuring’
  o E.g., Cool Kids Program