Cognitive Behavioural Therapy

Question 1

Give a brief overview of CBT

Answer 1

CBT is a structured, time-limited, problem-focused and
goal oriented form of psychotherapy. CBT helps people learn to identify, question and change how their thoughts, attitudes and beliefs relate to the emotional and behavioural reactions that cause them difficulty

Question 2

who is associated with CBT?

Answer 2

Albert Ellis

Aaron Beck

Donald Meichenbaum

Question 3

What are the key concepts of CBT?

Answer 3

A structured, time-limited, problem-focused
and goal oriented form of psychotherapy. CBT helps people
learn to identify, question and change how their thoughts,
attitudes and beliefs relate to the emotional an
d behavioural reactions that cause them difficulty.

Question 4

What is the view of human nature in CBT?

Answer 4

The way human beingsmake sense of situations influences how we behave emotionally

Assumes that beliefs, behaviours, emotions, and physical reactions are all reciprocally linked.
o Changes in one area often will lead to changes in the other areas.
o A change in beliefs is not the only target of therapy, but enduring changes usually requires a change in beliefs.

Question 5

What is the focus of CBT?

Answer 5

Being able to process behavioral changes and to see the result
of these changes in their own lives

Changing cognitions to produce desired changes in affect and behaviour.

Question 6

What are the goals of CBT?

Answer 6

1. To help clients identify unhelpful thoughtprocesses and to learn newways of thinking
2. To minimize emotional disturbances and self-defeating behaviours by acquiring a more realistic, workable, and compassionate philosophy of life.
3. The creation of a collaborative effort between therapist and client to choose realistic and life-enhancing therapeutic goals.
4. Help clients to differentiate between realistic and unrealistic goals and between self-defeating and life-enhancing goals.
5. Have clients learn how to change their dysfunctional emotions and behaviours into healthier one’s.
6. Learn how to achieve unconditional self-acceptance (USA), unconditional other acceptance (UOA), and unconditional life acceptance (ULA).
7. To think in a mindful manner.

Question 7

What is the role of the therapist in CBT?

Answer 7

1. The therapist’s role is tolisten, teach, and encourage
2. Therapists apply behavioural techniques such as operant conditioning, modelling, and behavioural rehearsal to the more subjective processes of thinking and internal dialogue.
3. Therapists teach clients to actively rest their beliefs in therapy, on paper, and through behavioural experimentation.
4. To show clients how they have incorporated irrational absolute shoulds, ought’s, and musts into their thinking.
5. To dispute clients’ irrational beliefs and encourage them to engage in activities that will counter their self-defeating beliefs by replacing their rigid musts with preferences.
6. To demonstrate how clients are keeping their emotional disturbances active by continuing to think illogically and unrealistically.
   - Reminds clients that they are responsible for their own emotional destiny.
7. To help clients change their thinking and minimize irrational ideas.
   - While we may not be able to eliminate the tendency to think irrationally, we can make an ongoing effort to reduce the frequency of such thinking.
8. Encourages clients to identify the irrational beliefs they have accepted.
   - Demonstrates how they continue to indoctrinate themselves with such beliefs and remind them that change is possible.
9. Encourage clients to develop a rational philosophy.
10. Do their best to model REBT principles, including that of unconditional other acceptance (UOA)

Question 8

What is the client experience in CBT?

Answer 8

1. The clients role is to disclose private thoughts, learn new
   ways of thinking and implement that learning into daily life
2. Process behavioral changes and see the result of these changes in their own lives

Question 9

What is the client therapist relationship in CBT?

Answer 9

Therapist listens empathically while the client
discloses their thoughts and feelings

Therapists teach clients to actively rest their beliefs in therapy, on paper, and through behavioural experimentation.

Question 10

What are the methods, techniques and procedures of CBT?

Answer 10

Therapists apply behavioural techniques such as
operant conditioning, modelling, and behavioural rehearsal
to the more subjective processes of thinking and internal dialogue.

Question 11

What are the strengths and limitations of CBT from a diversity perspecitve?

Answer 11

Therapists apply behavioural techniques such as
operant conditioning, modelling, and behavioural rehearsal
to the more subjective processes of thinking and internal dialogue.

Question 12

Give a description of behaviour therapy

Answer 12

Cognitive behaviour therapy has enjoyed a rather popular acceptance due in part to the dynamic and enthusiastic leadership provided by Dr. Albert Ellis, and in part to the appeal of the ideas he presented. Ellis traces his theoretical ancestry back to the Stoic philosophers, particularly Epictetus. Ellis wanted an approach in which the therapist could be more active and more directive. He found that people exhibited maladaptive behaviours because they continually reindoctrinated themselves with irrational beliefs. Therapy must therefore consist of convincing people that they must stop indoctrinating themselves with old, irrational ideas and teaching them to think rationally about themselves and the world around them. The focus of this lesson is on Ellis’s Rational Emotive Behaviour Therapy (REBT), although Beck’s and Meichenbaum’s work will also be addressed. The introduction of cognitive constructs in behaviour therapy was nothing short of a ‘cognitive revolution’ in psychology. The original formulation of classical conditioning was based on the Stimulus-Response model (S-R), while operant conditioning was represented by the model: Stimulus-Response-Consequence (S-R-C). Within the shift to a cognitive-behavioural orientation, that model was expanded to include the mediating role of the organism to: Stimulus-Organism-Response-Consequence (S-O-R-C) (Goldfried, 2003). Donald Meichenbaum (1993) identified three directions in current cognitive therapy (‘cognitive behaviour modification’):
Conditioning: the technology of behaviour therapy (modelling, mental rehearsal, contingency manipulations) can be used to alter not only clients’ overt behaviour, but also their thoughts and feelings.
Information Processing: people are viewed as ‘architects’ of their experiences, influencing the data they are creating and collecting. Cognitive-behavioural therapists have developed intervention programs that are designed to help clients become aware of these processes and teach them how to notice, catch, monitor, and interrupt the cognitive-affective-behavioural chains and to produce more adaptive coping responses.
Constructive Narrative: Humans actively construct their personal realities and create their own representational models of the world. The therapist is viewed as a co-constructivist helping clients normalize their reactions, alter their stories, reframe stressful events, identify previous instances of effective coping.

Question 13

Upon completion of the lesson you should be able to:
describe the key concepts of the cognitive behavioural approach;
describe the aspects of the theory as they pertain to the general descriptors listed in Lesson 1;
outline the therapeutic process regarding the therapist, the client, and the relationship between the two;
evaluate the degree to which the theory behind the cognitive behavioural approach is consistent with your theoretical notions of a counsellor.
Required Readings

The text reading for this lesson are Chapters 10 and 13 of Corey’s Theory and Practice of Counselling and Psychotherapy. Read the chapter before you begin to do the work in the lesson to get an overview of the theory. Supplement the textbook information by reading the article by Weinrach et al. (2001).

Question 14

What are the basic concepts of behaviour therapy?

Answer 14

Irrational beliefs
Cognitive schema
A-B-C theory of personality
Cognitive restructuring
Socratic dialogue
Self-blaming process
Stress inoculation
Constructivism

Question 15

What are the basic assumptions of behaviour therapy?

Answer 15

What we believe determines how we behave. Emotions stem from our beliefs, evaluations (appraisals), and reactions to life situations. Human beings have the potential to generate both rational and irrational beliefs. Therapy is a process of re-education. By changing thoughts, we change feelings and actions. In his notoriously clear and emphatic manner, Ellis (2000) captures the most salient aspects of his approach in the following paragraph:

REBT is a cognitive-emotive-behavioural method of psychotherapy uniquely designed to enable people to observe, understand, and persistently dispute their irrational, grandiose, perfectionistic shoulds, oughts, and musts, and their awfulizing. It employs the logico-empirical method of science to encourage people to surrender magic, absolutes, and damnation; to acknowledge that nothing is sacred or all-important (although many things are exceptionally unpleasant and inconvenient); and to gradually teach themselves and to practice the philosophy of desiring rather than demanding and of working at changing what they can change and gracefully putting up with what they cannot.” (p. 201)

Question 16

What is the heredity in CBT?

Answer 16

Heredity/Environment: While Ellis accepts the existence of genetic factors, he does not directly address the concept of heredity. He claims that humans have the capacity to think both rationally and irrationally. Human behaviour is determined by people’s internal belief systems, in constant adaptive interplay with the environment. We are partly conditioned by the environment, by the types and quality of early and on-going relationships. At the same time, we have the capacity to become purposeful agents in our life. There is a reciprocal interaction between the person and the environment.

Question 17

What are cognitions in CBT?

Answer 17

Cognitions: What we believe or think, determines how we feel and how we act. When we perceive an event, object, or situation, we think about (appraise) it, we experience a feeling toward it, and we act or react in accordance with our appraisals and feelings. Human thinking often assumes the form of self-talk.

Question 18

What are the motivations in CBT?

Answer 18

Motivation: Irrational/rational beliefs motivate people. We act in accordance with our beliefs. Motivation is based on the assumption that we naturally prize and pursue pleasure and joy, creativity, and freedom. We are rewarded when we minimize pain and maximize pleasure.

Question 19

What is the time orientation of CBT?

Answer 19

Past experiences and people’s perceptions of them can create irrational beliefs and misinterpretations of events. Irrational beliefs could also be passed along from one generation to the next. However, the focus in cognitive therapy is on the person’s current belief system. It is not so much the event or the situation that produces psychological distress, but the person’s view or perception of that event or situation. By teaching clients to dispute their own irrational beliefs, this approach also increases their ability to generate adaptive responses based on rational beliefs in the future.

Question 20

What is the view of human nature in CBT?

Answer 20

People respond to life events through a combination of cognitive, affective, motivational, and behavioural reactions. Underlying all of them is a cognitive system that deals with the way in which individuals perceive, interpret, and assign meanings to events. Sometimes responses are maladaptive because of misperceptions (erroneous idiosyncratic interpretations) of situations. Cognitive therapy aims to adjust information-processing and initiate positive changes in all systems by acting through the cognitive system.

Question 21

Does CBT use Holistic/Atomistic explanations?

Answer 21

Holistic/Atomistic: As the name of his approach suggests, Ellis considers REBT as a holistic form of therapy that takes into consideration all aspects of human functioning: thinking, feeling, and behaving. In its earlier formulation, the theory was called Rational Emotive Therapy. Later on, Ellis decided to make the behavioural component explicit in the title as well, in order to better reflect the comprehensive nature of his approach.

Question 22

Does CBT use External/Internal: explanations?

Answer 22

External/Internal: People respond to life events according to their belief system. They create their own worlds and they tend to view those worlds phenomenologically and subjectively.

Question 23

Does CBT use Nomothetic/Idiographi explanations?

Answer 23

Nomothetic/Idiographic: Ellis recognizes the individual’s uniqueness. We have the resources and the ability to assert and express a unique approach to dealing with the circumstances we create and encounter in life. While the focus in Ellis’s approach is on the individual’s subjective worldview, the mechanisms by which people generate rational or irrational beliefs are considered to be universal. In Ellis’s (2000) own words, “These irrational ideologies are not infinitely varied or hard to discover. They can be listed under a few major headings and, once understood, quickly uncovered by REBT analysis” (p. 174).

Question 24

Does CBT use Longitudinal/Cross Sectional: explanations?

Answer 24

Longitudinal/Cross Sectional: REBT does not consider developmental, maturational factors to be responsible for the generation of rational or irrational beliefs. Rather, people of all ages can avoid psychological distress by learning how to subject their own misperceptions and misinterpretations to rational analysis.

Question 25

Does CBT use Tension Production/Reduction: explanations?

Answer 25

Tension Production/Reduction: Cognitive therapy in general and REBT in particular is based on the assumption that we naturally prize and pursue pleasure and joy, creativity and freedom. We are rewarded when we minimize pain and maximize pleasure. This approach therefore follows a tension reduction model.

Question 26

What is the observer frame of reference for CBT?

Answer 26

While the REBT therapist, in collaboration with the client, examines the client’s internal, subjective belief system and cognitive schemas, the theory does suggest that rational, therefore, objective analysis is the most effective way to treat psychological distress. However, Ellis’s construct of irrational beliefs has been criticized by other theorists (including Aaron Beck) for imposing an external (objective and rational) set of criteria on the definition of adaptive functioning.

Question 27

What is the basis for inference for CBT?

Answer 27

The REBT theory does predict that a person can live a more rewarding and productive life if he or she learns how to subject his or her perceptions and beliefs to logical analysis, very much along the lines of a scientist’s endeavour: develop and empirically test hypotheses.

Question 28

What is the basis for psychopathology for CBT?

Answer 28

Psychopathology originates with irrational beliefs and distorted perceptions. As cognitive schemas (meaning structures) are based on past experiences, sometimes they may no longer be relevant to our current situation. When that happens, individuals start to develop psychological problems. The cognitive theory of depression, for example, is based essentially on an information-processing model. A pronounced and prolonged negative biasing of this process is manifest in the characteristic thinking disorder in depression (selective abstraction, overgeneralization, negative self-attributions).
Walden, DiGiuseppe, and Dryden (cited in Weinrach, et al., 2001) classified the various types of irrational beliefs described by Ellis into four categories, which they called “core irrational beliefs”: demands, awfulizing, low frustration tolerance, and global evaluations of human worth.

Question 29

What is the basis for a healthy personality for CBT?

Answer 29

Healthy people are able to change and rely on their own potential and cognitive resources for their continued growth and development. Healthy individuals have learned how to recognize potentially irrational beliefs and reconstruct them into adaptive and testable interpretations of themselves and the world.

Question 30

What is the role of the therapist for CBT?

Answer 30

The cognitive therapist generally takes an active, directive, persuasive, and disputational stance. He or she is actively involved in helping clients think rationally. The cognitive therapist also emphasizes the collaborative effort, whereby together with the client they reframe the client’s conclusions in the form of testable hypotheses.

Question 31

What are the implications for the helping relationship in CBT?

Answer 31

This is a relatively brief form of therapy used on clients that can be helped through logical analysis and cognitive reconstructing. It is relatively easy to train counsellors to use REBT. The approach also has a strong psycho-educational component.

Question 32

What are the goals of helping for CBT?

Answer 32

The ultimate goals of cognitive behaviour therapy are: to help clients learn how to dispute their own irrational beliefs, how to stop using self-defeating behaviours, and how to acquire a more realistic, tolerant philosophy of life.

Question 33

What are the techniques and procedures for CBT?

Answer 33

Techniques and Procedures
Unconditional acceptance of the client as a person. The REBT counsellor shows clients that although they commit many mistakes, they are not contemptible for these errors, which minimizes the clients’ need for defensiveness. The role of empathy and the counsellor’s non-judgemental attitude is particularly stressed by Meichenbaum (1993).

Logical analysis. The counsellor teaches clients how to apply rational principles and empirically test their own hypotheses about the world and themselves.

Suggestion and autosuggestion. The counsellor encourages clients to practice the technique of disputing their self-defeating beliefs and replace them with rational and adaptive convictions.

Constructivist interventions: reflective listening, normalization, Socratic dialogue, cognitive reframing, imagery reconstruction of stressful experiences, highlighting indicators of narrative transformations (particularly in Meichenbaum’s approach).

Humour. The counsellor uses humour to gently poke fun at the client’s irrational beliefs, thus highlighting the irrational aspects while decreasing defensiveness.

Rational emotive imagery. Clients can imagine themselves having a rough time at something and not feeling terribly upset or having to ‘cop out’ of it.

Emotive-evocative methods, such as shame-attacking exercises. The counsellor assigns the client to behave in ways in which he or she might feel humiliated or shamed. By doing this, clients often come to the realization that others are not nearly as interested or critical of their behaviour as they had imagined.

Behavioural methods: role-playing, modelling, home assignments, self-monitoring, logs and journal keeping.

Assessment: Cognitive behaviour therapy favours a thorough and objective assessment of the client’s presenting concern. Aaron Beck developed a number of highly reliable and valid psychological assessment tools that are currently considered standard in clinical practice: Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS), and Beck Scale for Suicide Ideation (BSS).

Question 34

Counselling Situation
Mary, a very successful computer analyst, is 34 years old, single, with very limited dating experience. She would like to settle down and get married but is afraid to meet men because she feels they will make fun of her for her lack of social skills. Mary dreads the thought of being alone all her life; “nothing could be worse”, except perhaps being laughed at by someone she dates. She feels self-conscious because she is 15 pounds overweight. She believes a woman has to be attractive, outgoing, charming, and feminine. At the same time, she believes men are unfair in expecting all this of women and often feels very angry toward men. She attributes her shyness and lack of self-confidence to the fact that kids used to make fun of her in high school because she was overweight. She is considering quitting her job because most of her colleagues are mean and none has asked her out. This makes her feel worse. Mary wants help in deciding how to solve her ‘confidence problem’.

Apply the principles of Rational Emotive Behaviour Theory to Mary.
Identify Mary’s irrational beliefs.
How would you help Mary dispute her irrational beliefs?
Homework Assignment Exercise
The homework assignment is used extensively in cognitive behaviour therapy to assist clients in putting into practice new behaviours. Homework encourages clients to attack their irrational beliefs. In the following exercise, suggest an appropriate homework assignment for each situation.

Pat says she is depressed most of the time. She avoids anything that she thinks will make her feel more depressed. She wants to change but she is afraid of doing much, fearing another bout of depression.

The client would like to take a course in counselling but fears he has no ability to do this. He is afraid of failing and afraid of being told that he would never make it as a counsellor.

Jane, a third year university student, wants to overcome her shyness around boys. She doesn’t date but would very much like to. She just doesn’t know how to begin to change.

Diane feels she must please everyone. She is known as “Ms. Super-Nice” at the office because she will do anything to please. She never stands up to people, nor does she ever present her own views, for fear others may disapprove. She feels that if others disapprove, they will no longer like her. She would like to become more assertive because deep down inside she feels she has some good ideas but is afraid to present them.

Joe blames himself for the problems he is having with his wife. He has been working late at the office because of the new contract and is feeling terribly guilty. He feels he can’t be giving his wife enough attention because of the number of hours he has been putting into his job. His conflicting desire to do his best at work and at home is tearing him apart.

Self Reflections
Define the concept of irrational belief. What constitutes the irrational quality of a belief?
Do you agree or disagree with the assumption of REBT that the basis for emotional disturbance lies in irrational beliefs and thinking? Justify your position.
Based on your knowledge of the theories and the information presented by Altshuler and Rush (1984) compare and contrast cognitive therapy with psychoanalysis.
How does Beck’s cognitive therapy differ from Ellis’s REBT? What are the similarities?
What is Beck’s major contribution to psychotherapy?
What is Meichenbaum’s major contribution to psychotherapy?