CBT Techniques

Question 1

What is the structure of a CBT session?

Answer 1

Beginning:

• Greet client + establish the relationship
• Collect information to establish the agenda for this particular session

Middle:

• Select one of the topics from the agenda + collect more data on it (specifically relating to the processes in the cognitive model)
• Plan a strategy
• Implement a strategy
• Evaluate effectiveness of chosen strategy
• Ask client to summarise what they have planned/learned - make sure client gets down in writing
• Create an action plan of things collaboratively with client - that they want to do/achieve between this session and the next

End:

• Ask for feedback (e.g. are you happy with the tasks, felt listened to and like the therapist understands your values etc.)
• Make sure the client has a good summary of the session
• Check on homework

Question 2

What do you do if a client changes the agenda midway through the session?

Answer 2

This is acceptable - but needs to be made clear with the client that this is what has happened/bring it to their awareness that they’ve changed topics
e.g. “I notice we were talking about X but now we’re talking about Y… Which is more important to you?”

The therapist can also change the direction of the consultation too should they feel it more beneficial to discuss one problem over another

Question 3

What 4 things should you do at the beginning of the session?

Answer 3

Check on clients mood

Make a bridge

Set the agenda

Review the clients action plan

Question 4

How should you check the clients mood?

Answer 4

Subjective and objective measures e.g. using a depression or anxiety inventory + asking how they feel; allows you to keep track of data/concrete examples of change

Question 5

How do you make a bridge?

Answer 5

Link previous session with current - “what happened between last session and this one that is important for me to know?”
- Often these responses are negative

Followed up with “can you tell me anything that has happened between the sessions that was more positive for you?”

Should also link to the next session - “is there anything coming up in between this session and the next that I should know about?”

Question 6

How do you set the agenda?

Answer 6

Will likely be dictated by the content of the bridge i.e. what has happened in the previous week that was challenging, or what is coming up in the week to come that might also be more challenging and warrants actioning

Question you ask needs to be specific, else client can ramble about unrelated things:

“what problem or problems would you like my help in solving today?”

Therapist can also ask to include an item on the agenda that they think would be useful for the client; needs to be okayed by client

Question 7

How do you review the clients action plan?

Answer 7

3 questions:

• “what did you get done?”
• “what did you learn from that?”
• “is there anything you’ve done this week that would be helpful to continue doing?”

Question 8

How do you manage a client who just keeps talking and gets off task?

Answer 8

As simple as it sounds:

“Oh Judith can I just interrupt you a second?”

This can feel quite uncomfortable, but stops the session being derailed and unproductive

One way of managing your fears about upsetting a client is to raise this as a likelihood at the beginning of a session:

“I think what you’ll find is I’ll be interrupting you periodically to really get the information I need…. If this becomes a problem, please do let me know”

Question 9

How do you manage a client who gets annoyed/upset at you interrupting?

Answer 9

You will pick up on this in the session e.g. from their body language or they might tell you directly, you can ask:

“so what was going through your mind right there?” - to encourage that awareness - validate their response

Then you can suggest that for the next period of the session, that you wont interrupt them at all and see if they’d appreciate it

Question 10

What are the fundamentals of the therapeutic alliance/relationship?

Answer 10

Empathy

Warm, genuine and human interactions

Verbal and non-verbal validation/interest demonstration

Showing you understand e.g. by referring to what you have learned about how their minds work (“given your high expectations you place on yourself, I can see why you now feel disappointed with your grade”)

“what would you like to work on TOGETHER” etc - emphasising that the process is a collaborative one

When you give them something that works

Sometimes a small degree of self-disclosure e.g. “I think that way too sometimes”

Asking for and acting on feedback

The therapeutic relationship is the anaesthesia to surgery - it allows someone to apply specific techniques (Beck)

Question 11

Why is goal setting important and how should it be done?

Answer 11

Important as it gives a clear outcome for what is hoped to be achieved by the end of the therapy course - will (hopefully) be realistic and achievable, but may need to be reassessed throughout the process as other things emerge or are solved

Should be done in the first session

Often based on “core values”: e.g.

• Relationships
• Family
• Work
• Home
• Physical health
• Mental health
• Spirituality
• Finances
• Other interests/hobbies
• Social justice

Question 12

How do you use the cognitive model?

Answer 12

Should be applied to any situation your client brings to you; take one at a time and work through the situation

Questions: IN THIS ORDER 
What was the situation? Or what were you thinking about (remembering, experiencing, predicting)?
What went through your mind? 
What was your reaction? 
How did you feel emotionally?
Did your body react? If so, how?
What did you do?

Can literally draw out a diagram in session demonstrating the relationships, can share with client

Question 13

How do you identify an automatic thought?

Answer 13

Watch for a change in your reaction:
Maybe you start doing a certain set of behaviours
Maybe you’re avoiding doing something
Maybe you notice a strong emotion
Maybe you notice some change in your body

When you notice one of these changes, ask:
“what was just going through my mind?”

This will identify the automatic thought, you’ll know when you think it if it actually was an automatic thought or something else/a distraction

Question 14

What is the ‘opposite technique’ for identifying automatic thoughts?

Answer 14

A technique for identifying automatic thoughts when you can’t figure out what was going through your mind

Try posing a question to yourself about something that could be the opposite of what you are thinking e.g.
“are you thinking that you are really going to enjoy spending time with your friends?”

This should prompt some kind of aversive reaction in you and you will know that the opposite is actually true

Question 15

How do you identify a core belief?

Answer 15

The downward arrow technique:
“If your automatic thought were true, what would that mean/what would that mean about who you are?”
- This should point to how they feel about themselves

Formulation:
After hearing a number of situations be talked through/after you’v identified a number of automatic thoughts, you may start to see a theme emerging about how they feel about themselves; look for identifiers of helplessness, unlovabiltiy, worthlessness

Core belief as automatic thought:
Sometimes, some automatic thoughts might be independent of situation e.g. “I’m incompetent” as opposed to “I’m incompetent because of X situational factors”

Question 16

How do you identify coping strategies?

Answer 16

Formulation:
How has the client coped with their core beliefs throughout their life?
What kind of behavioural strategies have they developed?
What are some consistent patterns of behaviour that are dysfunctional, at least at times?

Ask directly:
“How have you coped throughout life?”

Question 17

How do you identify assumptions?

Answer 17

Working on coping strategies:
Once you’ve identified coping strategies, you can work backwards to an - “If X then Y” statement e.g.
If I trust people then I get hurt - If I don’t trust/avoid people then I don’t get hurt

Formulation:
Some assumptions are situation specific e.g. “if I talk to my friends about how I’m feeling then they won’t listen to me” - but this relates to the broader assumption mentioned above about trust, therefore if multiple situations yield similar situation-specific assumptions, this might point to an overarching assumption

Provide part of the assumption:
e.g. “How would you fill in this blank? If I were to try something that could be hard for me then _____”

Hypothesise:
“It seems to me that you have some idea about X, do you think that could be true? Do you think that could be something to do with the reason you do Y (examples of behaviours)?”

Question 18

What are Socratic questions? Why are they used?

Answer 18

Questions with the intent of getting the client to check the evidence for and utility of their automatic thoughts that arise in response to given environmental stimuli

They are important tools because:

• to simply give advice isn’t as powerful as collaboratively working on a solution - its less integrated/believed by the client (violates the principle of collaborative empiricism)
• any advice given might be on the basis of very little evidence if its from your point of view, might falsely reassure/guide
• also teaching someone how to employ the Socratic method themselves allows further development outside of session

“ASK DON’T TELL”

Question 19

What are some examples of Socratic questions addressing the evidence for a given automatic thought?

Answer 19

What evidence do you have that your thought is true?

Do you have any evidence of the other side?

Is there another way of looking at this situation?

If the worst thing your imagining did happen, how would you cope with that?

Question 20

What are some examples of Socratic questions addressing alternative possibilities to the automatic thought?

Answer 20

What is the best thing that could happen?

What is the most realistic outcome?

Question 21

What are some examples of Socratic questions addressing the outcome of an automatic thought?

Answer 21

What is the effect of telling yourself that X?” e.g. ‘people will be critical’

What could be the effect of changing your thinking?

Question 22

What are some other Socratic questions you might ask?

Answer 22

What would you tell a friend in the same situation?

(finally) Is there any action you wish to take? What would you like to do about it? (or if you want to include an imperative, what should you do next?”

Question 23

What are behavioural experiments?

Answer 23

Experiences that you help clients set up in session or between, to test the automatic thoughts they have that take the form of negative predictions e.g. if I do X then bad thing Y will happen

Before the experiment, we have to introduce the possibility that it might not go as expected + ask them:
“What would you like to be able to tell yourself if the experiment doesn’t go well?” - get them to write it down, read before, and after experiment if necessary

After the experiment is over, we get clients to write down their conclusions

Can help clients change thinking at both intellectual and emotional levels

Question 24

What is a credit list?

Answer 24

Getting the client to keep a list of all the small successes they accomplish during the day, in spite of their negative core beliefs

Question 25

What other techniques are there?

Answer 25

Self disclosure - limited acknowledgement of having been in a similar situation and what was beneficial; not always appropriate

Normalisation - reassurance that what the individual is experiencing is common and it doesn’t make them odd (only necessary really if they have anxieties that they are different, else might just be minimising)

Use of analogy/metaphor - to get client to think in a different kind of way, offering an alternative way to integrate the teaching

Exploration of expectations - get clients to verbalise these expectations then co-create alternatives

Look to past successes - are there any similar situations in the clients past where they have overcome things? How did you get better then? Can we apply the same now? Using yourself as a model

Role models - is there anyone you look up to? Exploring the idea that this person wasn’t born as they are and had to overcome things to get where they are; How would they manage this? How can you modify your behaviour to look more like theirs?

‘Act as if’ - e.g. ‘if you were to act as if this wasn’t too much to learn, how would your behaviour be different?’ If you can act as if you don’t believe in the outcome of a thought, you can test it for yourself

Question 26

What is a core belief worksheet?

Answer 26

Identify old core belief

Ask person how much they believe in it from 0-100% right now

Over the past week, what is the most you believed in this belief? What is the least? (identifies any variation - what times are triggering and alleviating?)

What is a more reasonable core belief?
- Doesn’t have to be overly positive, as not necessarily believable - something like “I am generally competent”

Identify evidence that:

• Disproves the old core belief
• Affirms the new core belief
• Evidences the old core belief - then try and find ways to reframe it

Re-assess credence in old belief:

• Did the process change the degree of belief in the old core belief?
• Assess on an intellectual and emotional level (do you really feel differently about this core belief now? Intellectual level usually changes before gut level)

Question 27

How else do you address core beliefs?

Answer 27

Historical antecedents:

• Ask about past experiences that might have lead to the development of certain core beliefs
• Address these experiences with fresh eyes as an adult - just because they believed it then, doesn’t mean that it was 100% even then and there were other explanations/ways of looking at it
• Use imagery - pretending they are the younger child/adolescent going through the experience (emotional level, still believes strongly the core belief) - do cognitive model on the younger patient - once feeling safe, can invite current patient (intellectual level, more adaptive appreciation of experience) into situation to have a dialogue with younger

Advantages/disadvantages of core beliefs:

• Are there any benefits or drawbacks to holding on to the beliefs?
• Can we retain benefits without having drawbacks?

Cognitive continuum:

• Draw a line from 0-100 labelled at each end, then mark yourself off on this continuum with regards to how much you believe in your core belief
• Anchor points - what does someone look like who is a 0 on this scale? And a 100? 50, 25, 75? Can use real world examples of people they know
• Maybe readjusting their own initial mark according to what these key points they have decided involve

Intellectual-emotional role play:

• Encourage and facilitate a (symbolic) dialogue between the head and the heart/gut
• Can write a dialogue/script
• Client plays both roles or therapist can play intellectual role and client emotional

Question 28

How do you follow up to a clients response about their cognitions/beliefs?

Answer 28

Help client draw a conclusion from what they have been reflecting on:

• “What do you conclude about all this?” - “Can you summarise what we’ve just talked about?”
• “What do you want to remember?”
• “What would be important to remind yourself of this week?”
• “What do you want to do this week?”
• Get them to write it down/create an audio recording of the conclusion - about 40-70% of what people hear is forgotten

Question 29

How do you respond if a client gives you an inadequate summary of what you’ve just talked about?

Answer 29

Sometimes the summary may be inaccurate:
“I think that’s close, but I wonder if it would be more helpful to remember it this way…”

Sometimes the summary may be too brief:
- “Do you think you might also want to remember…”

• In both cases, you can supply a summary and then ask if the client agrees with it

Then you get them to write this summary down

Question 30

How do you help clients to respond to automatic thoughts in between sessions?

Answer 30

Providing clients with a full list of Socratic questions
- Gives them the opportunity to fully explore any given automatic thought, rather than simply shrugging it off without proper in-depth, cognition changing analysis

Can also give worksheets:

• Testing your thoughts
• The thought record

Need to fulfil 2x criteria before using these tasks at home:

• Clients must really believe the cognitive model - that thinking impacts how we feel and what we do; and that they have the power to change both by changing how they think
• Clients must have demonstrated they can use these lists of questions/worksheets with you in session

Question 31

When should we not encourage clients to evaluate their automatic thoughts? Why shouldn’t we at those times? What should we do instead?

Answer 31

When a thought is patently, 100% true

• e.g. being depressed and so tired, and wanting to stay in bed - the thought that you are tired is probably very true, and some socratic questions e.g. “what is the evidence that you don’t want to get out of bed” don’t make any sense, and following the thought behaviourally isn’t going to change things
• We also don’t examine the obsessions in OCD, the content isn’t the pathology, its the functioning of the thought itself + the anxiety/beliefs around the thought (e.g. “I’m out of control”) + how you relate to the thought
• At this point, focusing on the impact of the thought or a behavioural intervention might be more effective

Focusing on the process of the thinking itself e.g. the ruminant aspects of thinking

• Tackling the content of each thought isn’t necessary, but the process of the thinking that is maladaptive is important to look at
• Sometimes behavioural activation i.e. getting up and doing something rather than thinking about it, may provide a different way of relating to the processes going on

States of hypo or hyper-arousal/emotions

• Hypo - instead of focusing on what is felt - people might not have words for how they feel - instead focus on what is happening in their body, have them describe it - removing the formal thought aspect
• Hyper - breathing/grounding exercises to help with distress tolerance; re-framing the arousal as e.g. energy/excitement rather than anxiety, fatigue rather than sadness