Introduction to Cognitive Behavioural Therapy (CBT)
“Men are disturbed not by things but by the views which they take of them”
The same event may lead to a range of emotions for different people depending on how the event is interpreted and evaluated. It is, therefore, not events that produce bad feelings but the way these events are appraised. When people hold unrealistic and negative beliefs about themselves or their experiences, an emotional upset will result. If this negative thinking is extreme or persistent, it may lead to an emotional disorder.
“We find either that individuals live creatively and feel that life is worth living or else that they cannot live creatively and are doubtful about the value of living. This variable in human beings is directly related to the quality and quantity of environmental provision at the beginning of each baby’s living experience”.(1974  : 83)
Following the work of John Bowlby, it appears that children, who have experienced
satisfactory bonding to primary care-givers, will develop a basic set of rules or core
beliefs which say “People can generally be trusted” (Bowlby 1969). Those who have not experienced satisfactory bonding can have an over-generalised response which says “You cannot trust anyone”. Unwilling separation and loss give rise to many forms of emotional distress and personality disturbance, including anxiety, anger, depression and emotional detachment. Attachment behaviour is held to characterise human beings from the cradle to the grave.
Cognitive psychologists take the individual’s early experiences as the starting point of many adult distortions of reality. They have revolutionised our knowledge of how we perceive the world and the situations we are in. Negative experiences, upsets, and the prevailing emotional attitudes of the carers, predispose the child to certain problems.
Someone with a parent or parents who are hard to please may grow up believing that they must always do well if they are to win approval. Such a person will tend to avoid situations in which they fear failure. In this way, they limit their own options. The difficulty may be dormant until life, refusing to play by the distorted rules of the individual, presents realities that cannot be accommodated, either by avoidance or by perfection e.g. making a marriage work, rearing children or progressing in a company.
Cognitive Behavioural Therapy
Cognitive-Behavioural Therapy, devised by A.T. Beck and Albert Ellis, did not gain
acceptance until the late 1970s. Beck gives the name “automatic thoughts” to thoughts and images occurring involuntarily in the stream of consciousness (Beck, 1976). He has described how the type of emotional disorder produced will depend upon the content of the thought. If a person’s automatic thought centres around danger or threat, then anxiety may be produced. If loss is the dominant theme of a person’s thought, depression will result.
Albert Ellis emphasises the role of “irrational beliefs” in emotional disorders
(Ellis, 1962). Irrational beliefs are evaluative beliefs such as: “I should be perfect”,
“If I make a mistake that proves how useless I am”. Such a belief would be extremely harmful because the client would be extremely upset every time he made a mistake and he might, for example, blame other people in order to avoid admitting to it.
Cognitive-Behavioural Therapy theory asserts that thoughts and beliefs are hypotheses which can be shown to be true or false by logic or evidence. The practice follows directly from the theory and involves helping the client to gather evidence that will disprove unrealistic and self-defeating thinking and thereby change it.
The Cognitive-Behavioural Therapy view is that people are not disturbed so much by past events as by the way that these events are viewed in the present. Take, for example, the case of a depressed person who believes that she is worthless. Her depression is not produced by a childhood experience such as her mother telling her that she was useless, but by the fact that she continues to think and believe this.
Ellis and the ABC Model
Ellis (1977) put forward an easily remembered model which explains the relationship between thinking and emotion. It is called the ABC Model:
A = Activating Event
B = Beliefs, thoughts
C = Emotional and behavioural consequences
What this means is that emotional distress and problematic behaviour, C, are the
consequences, not of the events themselves, A, but of the negative inferences and
evaluations of the events, B.
People, who have distorted images of themselves, have an A-C formula, in which A, the bad event, directly causes C, the emotional distress. One task of Cognitive Behavioural Therapy is to persuade the client that it is the bad evaluation B, “negative automatic thought” (NATS) that produces the C.
A young student teacher, who was in charge of a class of 25 children for a number of months, became very depressed because she was finding it very hard to control them. She felt that she was not in control and that she would make a useless teacher. She became so depressed that she started missing days. When the therapist asked her about the children in the class, it transpired that two of the children, in particular, were causing the disruption.
The therapist then helped her to dispute the logic of her thinking by asking, for example, “How does it follow that you are useless and not in control when it is only 2 out of 25 children that are disruptive? The therapist got the client to carry out tasks to test out or contradict her beliefs by finding out from other teachers if they were having problems also. She discovered that they were and she also learned that the children were both going through a difficult time at home. This client, who was emotionally upset as a result of the event, was able to identify, through Cognitive-Behavioural Therapy:
i) her maladaptive thinking and beliefs
ii) realise the connections between thinking, emotions and behaviour
iii) test out maladaptive thinking and beliefs by examining the evidence
iv) substitute her NATS with more realistic thinking
There are many examples from everyday life which highlight our cognitive distortions:
- All-or-Nothing Thinking: If I don’t do it perfectly, there is no point in doing it at all.
- ‘Should’ Statements: If I respect others, they ‘should’ respect me.
- Over-generalisation: I never get anything right.
- Discounting the positive: OK so I did well at the exam, so what?
- It’s only what is expected of me.
- Jumping to conclusions: I’m no fun, nobody would want me around.
- Magnification This situation is awful. There is nothing I can do about it.
- Personalization/Blaming: The evening didn’t go well. It was my fault.
- I ‘should’ have been more entertaining.
By learning ways in which to correct distorted beliefs, neurotic states can be
corrected and a healthy psychological state can come about. Ways in which clients
learn to challenge their negative thinking is through role-play within the therapy session or as a homework exercise using the ‘triple column technique’.
Negative thought: I’m useless, I never get anything right.
Discounting the positive
Rational Response: I’m human. I’m not useless.
I have achieved very well many times
Cognitive therapy has become an effective treatment for people with emotional
difficulties, psychological problems and personality problems and important advances in both theory and practice have been made (Clark & Fairburn, 1996). For example, it appears that panic sufferers attribute catastrophic interpretations to relatively normal bodily symptoms (Clark, 1986). People who are socially phobic exaggerate the way they perceive others perception of them, based on internal rather than external cues (Clark & wells, 1995) and people with obsessional & compulsive disorders interpret their own thoughts as evidence that they are bad people or responsible for bad things happening (Salkovskis 1985).
Aims of CBT
One of the aims in Cognitive-Behavioural Therapy is to look at the meaning the client is giving to situations, emotions or biology expressed as the clients ‘negative automatic thoughts’. The concept is that there is a link between particular types of appraising thoughts and particular types of emotions and the influence that they have over our behaviour.
The appraisal danger for example, raises anxiety and primes us for evasive, defensive or other reaction. Loss is likely to invoke sadness and mourning behaviour and unfair is likely to arouse anger and a possible ‘fight’ response. The responses to our appraisals are not necessarily problematic and are often functional i.e. thinking of the dangers of driving can make us better, more careful drivers but when our appraisals become more exaggerated and we begin to see ourselves having an accident, then our emotion of slight functional anxiety becomes one of panic.
The essence of the model is that emotional difficulties begin when the way we see events gets exaggerated beyond the available evidence. These exaggerated ways of
seeing things tend to have negative influences on our feelings and behaviour, in a vicious circle. The cognitive therapist aims to understand, in a highly individualised way, why the client is appraising events in particular ways and why he/she feels the way that they do.
Given that the clients thoughts and emotions about an event may appear “irrational” his/her core beliefs or schemata may show the response as entirely rational.
The Therapeutic Relationship
In cognitive work, the relationship between the therapist and the client is collaborative. They work together as a team to bring about change. There is a mistaken belief that the approach lacks warmth and is therefore not appropriate in a true counselling situation.
However, it is usually therapists who are genuinely concerned to meet the many and
diverse needs of clients who use cognitive behavioural techniques when they feel that the client will benefit from such an approach. This sensitivity to clients needs is at the very heart of good counselling practice so the notion that it lacks warmth is certainly open to argument.
Investigators (Rogers, 1951; Truax 1963) have found that if the therapist shows the following characteristics, a successful outcome is facilitated: genuine warmth,
acceptance and accurate empathy (Beck,1976, p221). Other characteristics in the
relationship which make for a warm encounter are listening, summarizing and reflecting. Such qualities also enable the client and therapist to work together to challenge thoughts and beliefs which are problematic to the client, to enable such challenging work to take place. Cognitive therapy also allows adaptation of the core conditions to maximise their helpfulness to the individual client, for example too much empathy or warmth may be perceived as threatening to, say, a very depressed client, who believes ‘I do not deserve such caring’ or ‘No-one understands me, why is she pretending?’ Hence, the value of a good conceptualisation of the client’s needs, is being able to modify the core conditions accordingly.
The job of the therapist is essentially one of re-parenting i.e. providing a ‘secure base’ where reflection and debate can occur and where one’s most cherished rules can be revised. What is important is that the Cognitive Therapist formulates a useful conceptualisation of the client’s core beliefs or schemata, formed as a result of past experiences, and that they are clearly identified, to allow them to be re-evaluated from the perspective of a free thinking adult, who is now supported within the therapeutic relationship.
Cognitive Behavioural Therapy helps the client to come to terms with the manageability of the “worst case” scenarios and the realistic expectation that it is unlikely to happen anyway, for example, many people with panic disorder engage, at times, in “catastrophic thinking” i.e. imagining that the worst is about to happen. In anxiety-provoking situations, they often focus on their physical sensations and may become convinced, not only that a panic attack will occur but, that it will lead to a heart attack.
A panic attack is usually triggered by a negative thought or a frightening daydream.
Once a panic attack develops, your thoughts, feelings and physical symptoms feed each other in a vicious cycle.
A businessman named Bob spent thousands of pounds having tests. Whenever he felt upset, he’d obsess about some ache or pain, notice a tightness in his chest and become convinced he was dying of heart failure. The results of the tests always proved to be normal. He struggled unsuccessfully for years before he went for Cognitive-Behavioural Therapy.
Bob was asked to put his fear to the test by jogging up and down the hall. In the process he experienced instantaneous relief and agreed to try this at home instead of running to the doctor the next time he felt he was having a heart attack. Several days later, Bob got anxious and felt chest pain but he became so petrified he
couldn’t get out of the chair for fear the slightest movement would trigger a heart attack. Bob’s resistance to testing his fear illustrates how enormously convincing negative thoughts can be, even when they’re absolutely unrealistic. As a way of getting around Bob’s resistance, the therapist suggested that he try very
minimal exercises the next time he felt he was having a heart attack and then try some that were increasingly more demanding.
Between sessions, when he became anxious and felt convinced he was having a heart attack, he took deep breaths, stood up and sat down, walked back and forth across the room, touched his knees, toes and floor, etc. It became clear that he wasn’t having a heart attack. His chest pain and his anxiety vanished. Distorted thoughts, not realistic ones, cause anxiety. It is important at times of stress to look at the normality of one’s feelings and stop adding fear to the feeling, as it is only when one adds fear to their feelings that panic takes over.
Shame and Embarrassment
Shame and embarrassment are particularly prominent in people who suffer from social anxiety and panic attacks, as they are particularly sensitive about what people think about them. When a person is feeling ashamed or embarrassed, he usually experiences an intense desire to remove himself from the public view. This way of thinking, for example, “I could never face them again” leads to avoidance and further difficulties. The sufferer can become agoraphobic i.e. afraid of being in situations from which escape might be difficult or in which help might be unavailable if you suddenly had a panic attack.
In Cognitive-Behavioural Therapy, shame and embarrassment can be tackled in
the same way as other emotional problems by verbally disputing the logicality of the
client’s self-devaluation and by setting up behavioural experiments to test out the clients beliefs.
Therapy seeks to correct the original faulty interpretations and modify the assumption to free the patient to live more fully in the world of reality. According to cognitive theory, psychological disturbances, particularly depression, often begin with the faulty processing of information. This leads to assumptions which lead to irreconcilable and debilitating frustrations.
Kate came for therapy in a very depressed state after her husband had left her. She felt worthless and a failure. “I should have been able to make my marriage work”, she thought. She stopped going out and started to avoid any social gatherings for fear of negative evaluation by others. She had two sisters who, she felt, were better looking than her and always got more attention. She herself was a perfectionist and a high achiever. This gained her a lot of recognition. She was also a very independent, capable person and she viewed needing support as being incapable and weak. Her father always seemed so dependent on her mother, missing her if she went away for a few days, etc., and she thought becoming dependant on people can make you very unhappy. She was very confused. She did miss her husband but that made her feel weak. What was upsetting her the most was people seeing her as a failure.
During the course of therapy, it became evident, that due to Kate’s unique personal
experiences and life history, she interpreted missing someone, being lonely or needing support as being dependent. As a result of these core beliefs, she lost touch with her husband on an emotional level and, because she felt she was recognised only by her achievements, she feared failure. Her negative automatic thoughts were “I’m useless, I’m worthless”. Failure to make her marriage work made her realise her worst fear.
Depression is often perpetuated by a specific demand that some high standard of personal performance or approval by others must be achieved in order to feel happy. Kate became aware of how she was hurting herself by replaying her past, in other words, because of the way she viewed events. As a result of her core beliefs being clearly identified, she was able to re-evaluate them from the perspective of a free thinking adult, supported within the therapeutic relationship.
Recovery through CBT
Recovery may require new ways of solving practical problems: – goal-setting, problem-solving, assertiveness training and decision making are some of the skills that can be taught in a very structured way within the Cognitive-Behavioural approach but they require commitment and co-operation if they are to have any impact. The therapist works with clients to discover precisely what behaviours clients wish to change and to set specific goals for change. The approach offers a key to survival as much as an option for recovery.
The message throughout therapy is that the real work is a function of what goes on between sessions as well as within sessions, expressed as a concentration on homework and generalising therapeutic gains across different situations.
Beck Depression Inventory (BDI)
Beck Depression Inventory (B.D.I.) is a self-rating scale which can be given to the client to rate his/her own emotional, cognitive and physiological aspects of depression and, at the following session, the scoring can be assessed collaboratively with the therapist. It can be a source of encouragement and builds self-esteem for a client who views himself worse than he is. Research has shown that when a person is depressed they can interpret many situations incorrectly. His thoughts are distorted and not based on real fact.
Daily Mood Log
The Daily Mood Log is helpful in enabling clients make the link between their thoughts, feelings and behaviour. This form is structured to allow analysis of what occurs in response to specific upsetting events that happen between sessions. As clients monitor their typical coping behaviours, they become aware of positive strategies as well as self-damaging repetitive behaviours.
Cognitive therapists need to be thoroughly at home working with the emotion, for the emotion itself can be seen as a vital response to events in the world. “If you’re not working with the emotion you’re not where the action is” (Beck 1994).
Cognitive-Behavioural Therapy provides a comprehensive and effective approach to many emotional problems. It aims to help clients to become aware of what they have been unaware of, overlooking or avoiding e.g. “negative automatic thoughts” and “irrational beliefs” about themselves or their experiences. It transforms their perspectives on their concerns.
Beck, A.T. (1991) Cognitive Therapy and the Emotional Disorders
New York: Penguin
Boyne, E. (Edited by) (1995) Psychotherapy in Ireland (Revised Edition)
Dublin: The Columba Press.
Burns, D.D. (1999) The Feeling Good Handbook
New York: Plume
Casey, A., Dryden, W., Trower, P. (1999) Cognitive-Behavioural Counselling in
Action. London: Sage
Salkovskis, P.M. (1996) Frontiers of Cognitive Therapy
New York: The Guilford Press
Sanders, D., Wills, F. (2000) Cognitive Therapy – Transforming the Image London: Sage