1-Page Summary

While Cognitive Behavior Therapy is a text to train psychiatry practitioners, many of the techniques can be applicable to daily life. Even if you aren’t formally diagnosed with a mental health disorder, you likely face situations that evoke more negative emotions than you’d like—nervousness talking to your boss, road rage, anxiety in social situations, stress that you won’t get everything done, or fear of failure in trying something new.

This summary focuses on the key CBT interventions to change your dysfunctional automatic thoughts and behaviors. These are generally applicable for all readers, not just those aiming to practice CBT for patients.

When you feel dysphoria (negative emotion), think the cardinal question: “What was just going through my head?” Articulate the thought explicitly.

• e.g. “I’m afraid that people will think my project proposal is stupid.”

Evaluate the thought with these questions:

• What is the evidence that your thought is true? What is the evidence on the other side?
• What is an alternative way of viewing this situation? What else could explain the person’s behavior/the outcome?
• Outcome analysis
  • What’s the worst that could happen? How would you cope with this situation?
  • What’s the best that could happen?
  • What’s the most realistic outcome of this situation? (especially if you tend to catastrophize)
• What is the effect of believing your negative automatic thought? What could be the effect of changing your thinking to be more positive?
• If your friend were in this situation and had the same automatic thought, what advice would you give him or her?
• What should you do going forward? How likely are you to do this?

Patterns of cognitive distortions: These put a label to common ways that people distort reality in self-defeating ways.

• Catastrophizing—imagining the worst possible thing that could happen
• Selective bias/tunnel vision/discounting the positive —focusing and emphasizing negative evidence for, ignoring or de-emphasizing positive evidence against
• All-or-nothing—either you get an A or you’re a total failure
• Mind reading—assuming negative intent or belief of other people, without considering other possibilities
• Emotional reasoning—because you feel it so strongly, it must be true
  • I feel like a failure all the time, so it must be true
• Exaggeration, or overgeneralization
• Should and must statements—a precise fixed idea of how people should behave. Overestimate how bad it is if these expectations are failed

Conduct behavioral experiments to push yourself to do what is uncomfortable. This will give you new data, to find a mismatch between your prediction and reality.

• Realize that you can fall into a negative vicious cycle without intervention:
  • Stressful situation arises
    • Work asks you to work on a promising new project, but it risks failure. You get anxious.
  • Automatic thoughts arise that cause a maladaptive, self-defeating reaction
    • “I can’t succeed in this. If I fail, people will know and I’ll be ashamed.”
  • A negative outcome results, further strengthening patient’s negative core beliefs and aggravating the automatic thoughts
    • You don’t volunteer for the project. “I knew I wasn’t capable of signing up for this.”
  • Patient also withdraws from situations that might lead to positive data
    • You prevent yourself from volunteering for any future new projects, because the thought of doing so causes you too much anxiety.
• Small bits of positive data will counteract the vicious cycle. When done repeatedly, it can build its own virtuous cycle.

To uncover your deeper beliefs, keep asking yourself questions about the situation or the automatic thought. “What does it mean to me if X happens? What does it mean about me?”

• Articulate your rules, assumptions, and attitudes.
• Attitude: “It’s terrible to fail.”
• Rule: “If a challenge seems too great, don’t even try it.”
• Assumption: “If I try to do something difficult, I’ll fail. If I avoid doing it, I’ll be OK.”

Generally, dysfunctional core beliefs fall into three categories:

• Helplessness: “I want to achieve more, but I’m not capable of it.”
• Unlovableness: “I’m not worthy of being loved by others. I’m undesirable.”
• Worthlessness: “I’m bad. I’m fundamentally not worthy of good things.”

For beliefs, consider the following interventions:

• Phrase the rule/belief as an assumption—this makes it easier to spot the logical fallacy.
  • “If I ask for help, I’ll be seen as weak.” vs “Don’t ask for help.”
• Present more functional beliefs, that are more qualified versions of the old belief
  • “If I don’t get an A, I’m a failure.” -> “If I don’t get an A, I’m just human, and I still tried hard. It’s better than 0%.”
  • “I can’t do anything right.” -> “I can do most things right, and there’s a good reason for when I get something wrong.” NOT “I can do everything right.”
• Behavior experiment
  • Act “as if” the belief weren’t true.
  • Act as if you assume the positive outcome will be true.
• Imagine counseling someone else with the same issue, or pretend your child has the same belief.
• Look back on major periods of patient’s life to find evidence that supports and contradicts the core belief
• Role playing an early traumatic experience. Play an older version of yourself, counseling your younger self on why the situation should be interpreted more optimistically.
• Make a list of advantages and disadvantages of each option. Score each entry to help make the ultimate decision.
• Continue imagining beyond the near future—weeks, months, years after whatever is causing dysphoria. Likely will find (inferring from past experience) that things will resolve satisfactorily.

Principles of Mental Disorders

The cognitive model proposes that dysfunctional thinking is common to all psychological disturbances. In this way, mental illnesses such as depression and anxiety may be considered thinking disorders. The patient has automatic dysfunctional self-talk that influences behavior negatively; the behavior is then interpreted in a negatively biased way, leading to worse thinking. This reinforces itself into a vicious cycle.

• Example: A patient wants to try something new. She thinks, “you’re definitely going to fail, you’re not good at anything.” → Anxious about failing, the patient declines to try the new activity. → She then thinks, “I told you, you can’t get anything right—you’re worthless.”

The negative thinking extends to the core of a patient’s beliefs about herself, the world, and other people, as well as intermediate levels of attitudes, rules, and assumptions the patient holds.

It’s not just the situation itself that makes a person feel a certain way, but also how they construe it, what lens they use to view it.

• Cyclical downfalls can be triggered by precipitating factors, such as a sudden provocation in stress.
• The patient may have had key developmental events earlier in life that predispose her to the condition.
• The patient may have developed coping mechanisms (adaptive and maladaptive) for the dysfunctional beliefs.

The key point of cognitive behavior therapy is that these dysfunctional beliefs can be unlearned.

Cognitive Conceptualization

The patient’s cognitive conceptualization exists on 3 levels: 1) core beliefs, 2) intermediate attitudes, rules and assumptions, and 3) automatic thoughts.

Core Beliefs

These are fundamental understandings regarded as absolute truths—just the way things are. Example: “I’m incompetent.”

They are often not explicitly articulated by the patient consciously.

Early experiences may have developed these—by parents, early authority figures; by a traumatic event; by apparent negative treatment by others (accurate or not).

These generally fall into three categories: “I’m helpless.” “I’m unlovable.” “I’m worthless”

Intermediate Attitudes, Rules, and Assumptions

Attitudes are judgments about a particular outcome or situation. Example: “It’s terrible to fail.”

Rules are prescriptions for behavior for the patient to follow in certain situations. Example: “If a challenge seems too great, don’t even try it.”

Assumptions are predictions about how things will go based on the patient’s behavior. Example: “If I try to do something difficult, I’ll fail. If I avoid doing it, I’ll be OK.”

Generally, the patient’s logic works like this: “If I engage in my [maladaptive coping strategy], then [my core belief] won’t come true and I’ll be OK.” And the inverse of this: “If I don’t engage in my [maladaptive coping strategy], then [my core belief] will come true and I’ll be hurt.”

(Note the patient may also have positive inversions, which arise when the patient’s mood is better. For example, a positive assumption may arise: “If I work hard, I can overcome my shortcomings.”)

Automatic Thoughts

Automatic thoughts arise unconsciously, often in response to a situation and sometimes unprompted. For example, someone who has a core belief that she’s incompetent may be told that her manager wants to meet with her. Her automatic thought may be, “My boss probably thinks I’m doing a terrible job. I’m finally going to be found out and fired.”

Patients are often more aware of the emotion they feel than the thought itself. Automatic thoughts may come in the form of verbal thoughts or images.

A wide variety of situations can evoke automatic thoughts:

• External events
  • “A friend didn’t pick up my call.”
• Stream of thoughts
  • A patient thinks about an exam and how much is being tested, then continues thinking about how important her grades are and a cavalcade of other thoughts.
• Cognition: a thought, image, memory, or daydream
  • A patient thinks of a violent image.
  • A patient has a flashback of a traumatic event.
• Emotion
  • A patient feels anger, then reflects on that anger. “I shouldn’t be angry at him. I’m such a bad person.”
• Behavior
  • A patient binge eats despite promising herself she wouldn’t. “I’m so weak. I can’t even get my eating under control.”
• Physiological
  • A patient feels her rapid heartbeat. “Why is my heart racing so fast? There’s something seriously wrong with me.”
• Mental experience
  • A patient feels a sense of unreality. “I’m going crazy.”

These automatic thoughts then lead to emotions. The two are distinct.

• Emotions are one word: sad, anxious, angry, jealous, ashamed, hurt, suspicious, disappointed.
• Automatic thoughts are expressed as more than one word.

The Patient’s Reaction

A patient’s cognitive conceptualization shapes the patient’s reaction, which is composed of emotional, physiological, and behavioral components.

To cope with negative beliefs and a cognitive conceptualization, patients often use a variety of coping mechanisms. Generally, a coping mechanism is often an extreme implementation of a behavior, or an extreme absence of the behavior. Examples:

• A patient tries to be perfect, or, on the other end of the spectrum, tries to appear purposely incompetent
• A patient seeks intimacy aggressively, or she avoids intimacy absolutely.
• A patient tries to control situations, or she abdicates control.

If the response is maladaptive, the patient progressively worsens her situation, because the behavior causes further problems, which further worsens the patient’s cognitive conceptualization.

Over time, the patient can be locked into a negative vicious cycle, where the patient’s biased information-processing model reinforces negative beliefs. Reinforcement can happen when:

• The patient selectively pays attention to negative data.
• The patient discounts positive data, even turning positive into negative data
  • A patient may get an A on a test, then discount the grade with, “That test was too easy to mean anything.”
  • A patient may get praise, then discount the praise with, “I don’t deserve it, my boss is wrong.”
• The patient may ignore positive or neutral data altogether.
  • A patient who struggles at a task may not consider that other capable people have failed at the task, or that the task has poor instructions.

The negative vicious cycle works like this:

• A stressful situation arises.
• Automatic thoughts arise that cause a maladaptive, self-defeating reaction.
• A negative outcome results, further strengthening patient’s negative core beliefs and aggravating the automatic thoughts.
• The patient also withdraws from situations that might lead to positive data.
• All this is interpreted by the patient not as a mental disorder, but rather that something is wrong with the patient. This worsens dysphoria.

Importantly, the maladaptive response may offer some short-term relief to the patient but be destructive over the long-term.

• For example, a patient feels anxious about taking a test. She stays in bed to calm her heart rate, but this causes her to arrive late to the test and get a poor grade. This aggravates her future anxieties.

As a clinician, your understanding of the patient’s cognitive conceptualization begins with first contact, and is refined over more sessions and gathering more data with the patient.

Example patient:

• Sally was criticized as a child by her mother. She was often compared unfavorably to her more successful brother. This led to core beliefs about her inadequacy.
• She developed attitudes and rules about always doing the best, being great at everything she tried. In depressed states, she focused on her deficiencies and became afraid of never amounting to anything.
• Her coping strategies include having high standards, overpreparing for tests, looking for weaknesses and addressing them, and not asking for help.
• Sally received new experiences leading to negative thoughts: her classmates had far more AP credits than she did; she didn’t make the school athletic team.
• Sally developed automatic thoughts: “I’m no good. I won’t be able to do this. I’ll probably fail and drop out of college.” She did not question her automatic thoughts.
• These automatic thoughts aggravated into meta-thoughts about her emotions and thought patterns: “What’s wrong with me? Why am I so down? I’m just hopeless.”
• These thoughts led to self-defeating behaviors, like withdrawing from her friends, discontinuing activities that used to give her positive accomplishment, and not concentrating during studying.

Here’s an example of a cognitive model sequence, where a situation prompts automatic thoughts:

• Situation: Sally feels exhausted (physiological trigger) when she wakes.
  • Automatic thought: I’m too tired to get up. There’s no use getting out of bed.
  • Reaction: Emotionally, she feels sad. Physiologically, she feels heavy. Behaviorally she stays in bed.
• Automatic thoughts: “What if my professor gives a pop quiz? What if this counts against my grade? What if I fail the class?”
  • Reaction: Emotionally, she feels anxious. Physiologically, she feels her heart rate rise.
• Situation: Sally notices her rapid heartbeat.
  • Automatic thought: “What’s wrong with me? Why am I getting worked up over nothing?
  • Reaction: Emotionally, she feels more anxious.
• Automatic thought: “I’d better just stay in bed, I can’t do anything right now.”
  • Reaction: Emotionally, she feels relief. Physiologically, she feels her heart rate slow. Behaviorally, she stays in bed longer.

Correcting Automatic Thoughts

Patients misconstrue neutral or even positive situations as negative through their automatic thoughts. Further, they tend to not examine their automatic thoughts critically and take them for granted. However, through the process of CBT, by examining their automatic thoughts and correcting errors, they often feel better.

Automatic thoughts can be examined on the basis of their validity and utility.

Validity: the thought is not supported by the evidence. Or, the conclusion drawn may be distorted.

• Example: The patient looks at evidence of failure and thinks, “I didn’t do what I promised,” which leads her to conclude, “I’m a bad person.” The patient can learn to recognize that the conclusion is incomplete and not supported by all available evidence.

Utility: the thought may be valid, but dysfunctional.

• Example: “It’ll take an all-nighter to finish this assignment.” While true, this increases the patient’s anxiety, which decreases concentration and causes worse performance. Therefore, this thought is dysfunctional.
• A better thought is, “I’ve finished assignments in this situation before. Dwelling on how long it’ll take makes me feel bad, and I won’t concentrate. It’ll take me longer to finish. Better to concentrate on one part at a time, and give myself credit for finishing.”

Exercise: Consider Your Automatic Thoughts

Automatic thoughts can arise for all people. Think about what automatic thoughts you have and how they affect your emotion.

• Think about the last time you felt an automatic negative emotion in response to a situation. What was the situation? What were you feeling?

• Picture the situation vividly. What thoughts do you remember thinking at the time?

• Did more thoughts continue to pile onto the original negative thought? What were these thoughts?

Principles of Treatment

Cognitive Behavioral Therapy (CBT) is directed toward solving current problems and modifying dysfunctional thinking and behavior. Changing the underlying belief system leads to enduring behavior change.

CBT encourages the patient to:

• Recognize the negative thoughts that are happening automatically.
• Recognize the biased interpretations of their experiences.
• Examine the evidence of a situation. View their experiences from a more realistic and objective perspective.
  • Example: Instead of thinking “I can’t do anything right,” patients are led to think, “I’m not good at this specific task. But I’m good at others.”
• Experiment with exposure to situations they fear to test their negative predictions.
• Reflect on their experiments to adjust their beliefs.

The cardinal question of CBT: “What was just going through my mind?”

CBT treatment has 6 characteristics.

1) CBT is Collaborative

• The therapist and patient work together on the session agenda and after-session homework. As the patient improves, the patient takes more initiative.
• The therapist shares the conceptualization to ensure it “rings true,” rather than forcing her understanding on the patient.
• The therapist provides rationales for intervention and elicits approval.
• The therapist constantly ends suggestions with “is that OK? Does that sound right?”
• The therapist asks for feedback at the end of each session.
• The pair uses guided discovery, Socratic questioning, and empiricism to explore the validity of automatic thought and test new situations.

2) CBT is Time-bound. Straightforward patients are empowered to be self-sufficient after 6-14 sessions, followed by periodic booster sessions.

• After each session, the patient takes home therapy notes to review.
• The patient carries coping cards with written statements that are important to remember.
• As the therapist demonstrates techniques like problem-solving, she teaches the patient how to apply those techniques alone.
• The patient learns to conduct her own CBT sessions.

3) CBT is Customized to the disorder and to the patient.

• Different disorders require different approaches.
  • Panic disorder involves testing catastrophic misinterpretations of bodily/mental sensations.
  • Anorexia requires modifying beliefs about personal worth and control.
  • Substance abuse focuses on beliefs about the self and permission-granting beliefs about substance abuse.
• Each patient has different thinking patterns, beliefs, and developmental events.

4) CBT is Present-focused. CBT is goal-oriented, current problem-focused.

• Contrast this to Freudian psychoanalysis, which tends to focus on unconscious conflicts and past events.
• Strategies are devised to overcome current problems. This often consists of evaluating the evidence of the situation, creating incremental solutions to experiment with the situation, changing beliefs.
• Attention can shift to the past when patients get stuck in their thinking, or when examining childhood roots modifies their rigid ideas. (“With that experience, it’s no wonder you feel that way. Can you see how almost any child who had the same experiences would grow up feeling the same way you do?”)

5) CBT is Built on Trust, which arises with the therapist’s warmth, empathy, genuine regard, and competence.

• Treat patients the way you would like to be treated.
• Accurately summarize the patient’s thoughts and feelings. The patient will feel understood.
• Your previous successes will make the patient feel optimistic about chances of recovery. “I’ve helped other patients much like you.”

6) CBT is Structured. This Makes the session more understandable and empowers the patient to do self-therapy. Each CBT session consists of three parts:

• Introduction: Mood check, reviewing the week, setting an agenda.
• Middle: Reviewing homework, discussing problems on the agenda, strategy setting, setting new homework, summarizing.
• Final: Eliciting feedback.

To build collaboration, trust, and structure, use a standard communication approach during a session:

• Tell the patient what you are about to do, why, and say you will invite feedback.
• Do what you said.
• Ask, “Does this ring true? How does that sound?”

Developing the Therapeutic Relationship

A therapeutic relationship that is trusting, empathetic, and collaborative is critical to patient improvement. Here are pointers on how to build a strong therapeutic relationship:

• Share your conceptualization with the patient constantly, asking whether it “rings true.”
  • “OK, I want to make sure I understand. The situation was [this], and your automatic thought was [this]. This thought made you feel [this emotion], so you acted by doing [this]. Did I get that right?”
• When noticing dysphoria during the session (the patient could be remembering something or reacting to the session itself), address it: “You look upset. What was going through your mind?”
• Positively reinforce patients for providing feedback. “It’s great that you recognized your thinking.”
• Positively reinforce patients for making strides in their therapy. For example, when the patient notices automatic thoughts, suggests new solutions, or does homework.
• Highlight evidence of improvement makes the patient more optimistic that the method is working. Improve the patient’s mood during the session and create a plan to feel better during the week.
• Emphasize the positive.
  • Elicit patient strengths.
  • Elicit positive data from the preceding week. “What positive things happened since I saw you last?”
  • Elicit data contrary to their negative thoughts.
  • Ask what positive data means about the patient.
  • Give positive feedback on adaptive coping mechanisms: “What a good idea.”
• Don’t attack the core beliefs too early—this can endanger the alliance. Instead, identify the cognitions that are closest to conscious awareness, then work your way down into core beliefs over time.

Planning Treatment and Structuring Sessions

Most patients feel more comfortable when they know what to expect from therapy and what they are expected to do. CBT sessions are designed to be structured and follow a predictable format each time.

Session agenda at a high level:

1. Reestablish the therapeutic alliance and collect data. Set and prioritize the agenda together.
2. Discuss the problems on the agenda. Engage in problem-solving and thereby teach cognitive skills.
3. Review the session and provide homework.

During the session, maintain the structure of the session:

• Elicit the most important points of the session and make sure those are written down.
• If the patient gets off track, interrupt gently to guide the patient on the most helpful agenda items.

The CBT Session Structure

Each CBT session consists of a regular structure. Here we’ll go over the structure for three types of sessions:

• The evaluation session, which aims to build a cognitive conceptualization of the patient
• The first therapy session, where treatment and problem-solving will begin
• Each therapy session afterward, where treatment continues and the patient progresses toward self-sufficiency

The session structures will refer to tasks such as problem-solving, identifying beliefs, and assigning homework. We’ll cover those items in the next chapters.

The Evaluation Session

The goal in the evaluation session is to start building a cognitive conceptualization of the patient. Treatment and problem-solving should NOT be done until the first therapy session.

Prepare by gathering all the notes available, including previous psychiatry work.

• Check that the patient has had a recent medical check-up—an organic issue like hypothyroidism may be misdiagnosed as depression.

Invite a family member or friend to attend, but start the meeting alone with the patient and discuss when to bring the other person in on the session.

Set the agenda and convey expectations for the session.

• “This is an evaluation session. I’ll ask a lot of questions to determine the diagnosis. A number of questions may not be relevant. Is that OK?”
• “I’d like to find out about symptoms you’ve been experiencing and how you’ve been functioning lately. I’ll ask you to tell me anything else you think I should know. Then we’ll set broad goals, I’ll share initial impressions, and what we should focus on in treatment. At the end I’ll see whether you have other questions. Does that sound OK?”
• “Is there anything else you want to cover today?”

Conduct the assessment.

• Get a full medical and social history.
• Ask patients to describe their typical day. Look for variations in mood; how they interact with other people; how they function at home and work; how they spend free time.
• Pinpoint difficulties in their daily life to address (for example, difficulty sleeping, social isolation, limited opportunities for mastery, or falling behind in schoolwork).
• Ask about positive experiences (“what are the better parts of the day?”)
• Ask about coping strategies (“even though you were tired, how did you get yourself to go to class?”)
• Structure the questions to get what you need: “For these next questions, I just need a yes or no.”
• End with: “Is there anything you’re reluctant to tell me? You don’t have to tell me what it is. I just need to know if there’s more to tell.”

Discuss bringing the guest into the session, and ask if there’s anything the patient wants to guard from the guest.

• Ask the guest what is most important for you to know.
• If the guest focuses on the negative, ask about the patients’ positive qualities and strengths.

Relate your impressions.

• “I’ll need time to review my notes to establish the diagnosis. But my impressions so far are [these].”

Set initial broad goals.

• “We’ll set more specific goals, but broadly should we say our goals are: reduce depression, do better at school, get back to socializing?”
• “In the future we’ll find problems to solve and engage in problem solving, examine your depressed thinking and the evidence, and come up with solutions.” Elaborate on what this means.
• “We’ll plan to meet every X weeks, then with less frequency later. My guess for how many sessions we need is between 8 to 14. We’ll decide together what’s best.”

Elicit feedback from the patient.

• How does that sound? Does this sound OK? Do you want to come back next week?

Look for indications the patient is unsure about committing to treatment.

• Positively reinforce their expression of skepticism. “It’s perfectly understandable that you think this won’t work. Thanks for sharing that.”
• Ask, “what makes you think I can’t help, or that this treatment won’t work?”
• “I can’t give you a 100% guarantee. But there’s nothing you’ve told me that makes me think it won’t work.”
• If the patient says it hasn’t worked in the past: “did your last therapist set agendas; write down what to remember; ask for feedback?” and so on, covering your usual procedure. If not, then “It sounds like our treatment here will be different. If it were exactly the same as your past experiences, I’d be less hopeful.”
• If yes, then you will need to find out precisely what occurred in the past and how the treatment failed.

After the session, develop your hypothesis of the cognitive model and treatment plan.

• Focus first on fixing immediate short-term problems, then working more on core beliefs in the middle.
• You may not be sure yet whether to focus on historic antecedents, or about other dysfunctional beliefs that were not mentioned.

Create goals other than what the patient has articulated.

• Investigate dysfunctional beliefs about X.
• Identify and respond to automatic thoughts.

Initial Therapy Session

The first therapy session is when you can begin problem-solving and treating the patient.

As always, describe the agenda, ask if that sounds OK, and ask if the patient would like to add anything.

• Rationale: “We’ll do this at the beginning of every session so we make sure we have time to cover what’s most important to you.”
• Language: “in a few minutes, we’ll discuss your diagnosis and how that affects your thoughts.” This signals that the agenda setting is not yet complete.
• Chronic problems (such as arguments with family) can usually be postponed to a future session.

Do a mood check.

• “Tell me in a sentence or two how you felt for most of the week?”
• Ideally the patient fills out a questionnaire beforehand.
• If this is difficult for the patient, simplify the question—”what was your mood, on a scale of 0 to 10?”

Get an update.

• Ask if anything significant has happened since the evaluation session.
• For a reported problem, ask how upsetting or significant it was, then prioritize according to the severity.

Discuss the patient’s diagnosis.

• Use human language: “The evaluation shows that you have a moderate depression. I want you to know that it’s a real illness. It’s not the same as people saying, ‘oh, I’m so depressed.’” Avoid using the label of a personality disorder diagnosis.
• Make it real: “I know that because you have the symptoms in this diagnostic manual (DSM). The manual lists the symptoms for each mental health disorder, just like a neurology manual would list the symptoms of a migraine.”
• Normalize the situation: “It’s very common for people with depression to feel this way.” “Most depressed people start criticizing themselves for not being the same.” “Sometimes it’s hard to figure out these thoughts.”
• Connect the patient’s reactions to the condition: “The thoughts you’ve been having are a result of your depression. There isn’t anything wrong with you.“
• Give optimism to avoid a crushing feeling of diagnosis: “Fortunately, cognitive behavior therapy is effective in helping people overcome depression. I’ve seen a lot of patients improve through the course of therapy.”
• Analogy: “For everyone with depression, it’s as though they’re seeing themselves and the world through eyeglasses covered with black paint (pantomime this). These make everything look dark and hopeless. What we’ll do in therapy is to scrape off the black paint (pantomime) so you see things more realistically. Is that clear?”

Identify problems and set goals.

• “Let’s review the problems you’ve been having.” “It sounds like you have these major problems right now: [list the problems]. Are there any others?”
• “Would you like to write them down, or should I?”
• Invert the reported problems into goals, then turn them into homework items.
  • Problem: “I don’t feel like I hang out with friends anymore.”
  • Goal: “Have an active social life.”
  • Homework: “Call Jessica this week to have lunch.”
• Elicit a response instead of dictating: “Would it help if you answered back the thought? What could you remind yourself?”
• Make broad goals more specific.
  • Patient: “I’d like to be happier.”
  • Therapist: “If you were happier, what would you be doing?”
• Make the goal something they have control over.
  • Less control: “I’d like my boss to stop pressuring me.”
  • More control: “Learn new ways of talking to my boss.”
• For depressed patients, try to discuss the problem of inactivity. Overcoming passivity and experiencing pleasure and master is essential. (Shortform note: More generally, find the common problem that, if fixed, will yield short-term results.)

Educate the patient on the cognitive model.

• “Can we talk about how your thinking affects your mood? Can you think of a time when you noticed your mood change? What were you thinking?”
• “So you had the thought “X.” How did those thoughts make you feel emotionally?”
• “You just gave a good example of how your thoughts influence your emotion.” (Show a diagram of Situation → Automatic Thoughts → Reaction.)
• Make sure the patient can verbalize an understanding of the model. “Can you tell me in your own words about the connection between thoughts and feelings?”
• “We’ll start evaluating your thoughts to see if they’re 100% true, 0% true, or somewhere in between. For example, you may find that instead of (this automatic thought), the reality is (an alternative explanation).”
• If the patient balks that she has real problems, not just bad thoughts, respond “I do believe you have real problems—I didn’t mean to imply you don’t. We’re going to solve those problems together.”

Start working on a problem with the patient (see next chapter for details). The goal is to discuss a situation in which the patient struggled or felt dysphoric, and to create a solution together.

Set homework. (We’ll have more on homework assignments in a later chapter.)

• Write the homework tasks on a paper.
• Common tasks include:
  • Remind yourself of the disorder and positive thoughts. “If I start thinking I’m lazy and no good, remind myself that I have a real illness, called depression, that makes it harder for me to do things. As my treatment starts to work, my depression will lift, and things will get easier.”
  • Identify automatic thoughts.
  • Review the goals list.
• Patients in dysphoria overestimate the work it takes. With the patient, estimate the time needed for each item with the patient.
• Collaborate to find a way to review the homework regularly at multiple touchpoints per day. An alarm helps.
• If the patient balks at a task, suggest making it optional or crossing it off altogether, and ask the patient what she’d like to do.

Summarize at the end of a session.

• “Can you tell me what you think is most important for you to remember this week?”

Elicit feedback.

• Give two chances for feedback—once live at the end of the session, and after the session in a written Therapy Report.
• “What did you think of today’s session?”
• “Was there anything about this session that bothered you? Anything I got wrong?”
• “Is there anything you’d like us to do differently next session?”
• Here are questions to include in a Therapy Report:
  • What did we cover today that’s important to you to remember?
  • How much did you feel you could trust your therapist today?
  • Was there anything that bothered you about therapy today? If so, what was it?
  • How much homework had you done for therapy today? How likely are you to do the new homework?
  • What do you want to make sure to cover at the next session?

Each Session Thereafter

Each session after the initial therapy session is similar in structure, save for these gradual changes:

• Over time the problem solving will extend beyond automatic thoughts to underlying beliefs.
• As the patient feels better, start work on preventing relapses and anticipating setbacks, as the patient feels better.
• Over time the patient will play a more active role in setting the agenda.

Prepare for the session yourself.

• What is your conceptualization of the patient’s difficulties?
• What progress have we made so far? In mood? Behavioral changes? Deepening of the cognitive level?
• How strong is our therapeutic alliance? What do I need to do today to strengthen it?
• Have any dysfunctional ideas hindered therapy?

The patient precedes the session by filling out a Preparing for Therapy Worksheet. Questions include:

• What did we talk about last session that was important? What do my therapy notes say?
• What has my mood been like, compared to other weeks?
• What happened (positive and negative) this week that my therapist should know?
• What problems do I want help in solving? What is a short name for each of these problems?
• What homework did I do? What did I learn? If I didn’t do it, what got in the way?

Check on mood and medication.

• “How are you feeling? Were you thinking about the whole week, or just today?”
• Elicit attribution for the change.
  • “Why do you think you’re a little less depressed?”
  • “Can you see how your thinking and what you did affected how you felt, in a positive way?”
  • If the patient points to an external source, like medication, say, “I’m sure that helped, but did you also find yourself thinking differently or doing anything different?”
• If the patient does not identify anything to improve mood, make a list of:
  • Things that make me feel better
  • Things that make me feel worse
• When asking about medication, ask not a binary question of whether they took medicine, but more, “how many times this week did you take your medication?”

Set the agenda.

• Reduce the patient’s suggested problems to clear, simple names, like “applying for a job.” Interrupt if they get too long.
• Ask for when in the past week they felt the worst.
• Think about which problem is most important; which is most solvable; and which is most likely to bring about symptom relief.

Get an update on the week.

• “Did anything else happen this week?”
• For each problem mentioned by the patient, ask if it’s a problem we need to talk about today.
• Ask when they felt the best this week, or what happened that was positive.
  • This helps patients realize they didn’t feel distressed the entire week.

Review homework. This is critical for the patient to continue doing homework.

• The patient reads aloud the assignment from the previous week.
• Rate how much they believe the adaptive statements and beliefs they’ve written down as part of homework.
• Ask, “Did you do the assignment? What did you learn from it?”
• “Which of these assignments are helpful to continue in the coming week?”
• Consider: how much did the patient agree with each statement in the therapy notes from last week?

Prioritize the agenda.

• List the named problems. Ask if there’s any other problem that is even more important than those you named.
• If the patient is unsure how to prioritize, ask “Let’s say we can eliminate each of these problems one by one. Which one would make you feel better?”
  • If this tactic is effective, teach the patient to do this herself.
• “If we run out of time, are there things we can put off until next week?”
• Alternatively, ask, “what 1 or 2 problems are most important to talk about?”
• Avoid any problems the patient can resolve alone or at another session.

Problem solving.

• List the important problems and ask which one to work on first. This gives them active responsibility in their treatment.
• The goals of problem-solving are:
  • Collect data to understand the situation clearly
  • Investigate other situations the problem arose, and which one the patient felt most upset in.
  • Evaluate the patient’s automatic thoughts (evidence for and against)
  • Solve the problem situation. Ask, “What would I do if I were in the patient’s position?”
    • For example, if you were anxious about an upcoming interview and felt unprepared, how would you try to become more prepared or feel less anxious?
  • Reduce patient distress and create symptom relief in the moment.
  • Suggest behavioral changes to apply in the future.
  • Teach the patient new skills and reinforce the cognitive model.
  • Set new homework.
  • Assess new patient mood after problem solving.
• If the patient is fuzzy on details of the problem, paint a vivid picture of the scenario and ask the patient to imagine it.
• If you can’t solve a problem, ask the patient to name a person who could have the same problem, and what advice she would give him.
• Ask, “Do I need to do anything to reestablish rapport?”

Summarize often.

• Summarize the content of a problem. Use the patients’ words as much as possible, because paraphrasing lessens the intensity of the automatic thought.
• Summarize the session at the end. “Do you think that about covers it?”
• As the patient makes progress, ask the patient to summarize. “What do you think is most important for you to remember this week?

Obtain feedback from the patient.

• “What did you think about the session?”
• “Is there anything I got wrong?”
• “Is there anything we should talk about next time, or do differently?”

Take notes after the session.

• Therapist objectives
• Problems discussed
• Dysfunctional thoughts and beliefs, written verbatim
• Interventions made in session
• Newly restructured thoughts and beliefs
• Assigned homework
• Agenda items for future sessions
• Refinements to conceptualization of patient

With the structure of all CBT sessions covered, we’ll next dive into the specifics of treatment, including identifying automatic thoughts, problem-solving, and assigning homework.

Identifying Automatic Thoughts and Problem Solving

A key part of treating mood disorders is identifying the patient’s automatic thoughts and guiding the patient to evaluate them and overcome them. This is done by:

• Articulating the automatic thought explicitly.
• Evaluating the automatic thought for validity and utility.
• Constructing behavioral experiments to highlight the discrepancy between the patient’s automatic thoughts and reality.

We’ll cover each component in a dedicated section.

Identifying Automatic Thoughts

The key question of identifying automatic thoughts is: “What is going through your mind right now?”

To elicit the automatic thought, try a range of techniques:

• Paint a vivid picture. Ask the patient to imagine the situation, picture the time, and revisit exactly what the patient was doing.
• Ask for a description of the physical sensation of the emotion.
  • “Where did you feel the anxiety?”
• Turn the reflection into present tense—past tense obscures the emotional response.
• Ask the opposite of what you think the thought was. “Did you think you were going to ace the test?”
• Role play the situation with the patient.
• If the patient is unresponsive, ask what the patient thought would have been the worst that could have happened.
• “Were you imagining something that might happen or remembering something that did?”

The patient should be led to describe the specific thought as it occurred, NOT speculating on its intent.

• Not “I must be sabotaging myself.” Rather “I was thinking, “I’m going to fail the test.”
• Not “I couldn’t get myself to start reading.” Rather “I can’t do this.”
• Not “how will I get through it?” Rather “I can’t get through this.”

Probe if secondary automatic thoughts may have surfaced.

• Automatic thoughts about their reactions (emotion, behavior, or physiology) can cause a vicious cycle.
  • For example, the first thought may be “I’m going to fail the test.” This may provoke anxiety, leading to a physiological response and rapid heart rate. This may then provoke another automatic thought: “Why is my heart beating so fast? What’s wrong with me?”
• Ask, “what else went through your mind?” Then ask, “which of these thoughts was most upsetting?”

Frame the thought as an idea, not as a truth or fact. It will be evaluated later.

Make clear the impact the thought has on emotion and behavior.

• “How did that thought make you feel?”
• “What does that emotion make you want to do?”
• “What would happen if you had the opposite thought? How would you feel?”
• The patient should understand the difference between thought and emotion. Emotions are one word.

If the emotion doesn’t match the thought, then probe further—you may not be at the root of the situation. Here’s an example:

• “My mom didn’t pick up the phone and I thought ‘what if something happened to her?’ I felt sad.” This doesn’t quite match—wondering if something happened to your mother would typically provoke worry or anxiety.
• Probe further—“so the ring tone stops. What happens next?” Patient: “I get teary.” Therapist: “What is going through your head?” Patient: “What if something happens to her? Then there’s no one left to care about me.” That’s the real underlying thought that matches the emotion of sadness.

Rate the intensity of the emotion to triage problems and gauge improvement in mood.

• “Let’s try to rate the emotion on a scale of 0 to 100%. 0 is no sadness at all, and 100% is the saddest you have ever felt.”
• Make a ruler of emotions with the patient. “Let’s make a scale of when you felt sad in the past. When did you feel just a little bit sad? The saddest you’ve ever felt? And in between? Now, how did you feel in this situation?”
• If the patient is reviewing a past event: “How much did you feel [the negative emotion] then? How much do you feel it now?”
• Situations that are minor in emotional intensity might not be worth exploring further.

Evaluating Automatic Thoughts

Automatic thoughts can be examined on the basis of their validity and utility. Invalid thoughts are not supported by the evidence. Or, the thought may be valid, but dysfunctional.

Never challenge a patient’s thought or belief. This violates the collaborative empiricism of CBT. You are to guide the patient to examining her own thought.

Ask Socratic questions to help them gain distance.

• “What is the evidence that your thought is true? What is the evidence on the other side?”
• “What is an alternative way of viewing this situation? What else could explain the person’s behavior/the outcome?”
• “What’s the worst that could happen? How would you cope with this situation?” (You can give solutions to help the thinking.)
• “What’s the best that could happen? What’s the most realistic outcome of this situation?” (This is especially useful if the patient has a catastrophic view.)
• “What is the effect of believing your automatic thought? What could be the effect of changing your thinking?”
• “If your friend were in this situation and had the same automatic thought, what advice would you give him or her?”
• “What should you do going forward? How likely are you to do this?”

For more advanced patients, you can vary the questions.

• “Is it true that [your extreme assumption] always has to be true?”
  • For example, “does it always have to be true that you need to make your mom happy at all times?”
• “Is it reasonable to expect that sometimes [the situation] will happen?”
• “Is it desirable to have [this extreme goal]?”

Cognitive distortions tend to fit one or more of these patterns:

• Catastrophizing—imagining the worst possible thing that could happen
• Selective bias/tunnel vision/discounting the positive —focusing and emphasizing negative evidence for the thought. Alternatively, ignoring or de-emphasizing positive evidence against the thought.
• All-or-nothing—”either I get an A or you’re a total failure.”
• Mind reading—assuming negative intent or negative beliefs about other people, without considering other possibilities.
• Emotional reasoning—because you feel it so strongly, it must be true
  • “I feel like a failure all the time, so it must be true.”
• Exaggeration, or overgeneralization.
• Should and must statements—a precise fixed idea of how people should behave. The patient overestimates how bad it is if these expectations are failed.

When automatic thoughts are true:

• Focus on problem solving.
• Investigate whether the patient has drawn an invalid conclusion.
• Work on acceptance.

Comforting lines to say:

• “We’ll keep practicing this until it becomes easy.”
• (If the patient finds it difficult to get thoughts) “Sometimes these thoughts are hard to catch. No big deal.”

Ask about the patient’s current mood and how much they believe the automatic thought.

If after examination, there is no mood improvement, a deeper root issue may be at hand.

• The automatic thought may be too superficial. Other thoughts, images, or assumptions remain.
  • “I was thinking that I would fail the test” may be incomplete. On further examination, the patient says, “I was thinking I can’t do anything right. I saw my parents laughing at me.”
• Evaluation of the automatic thought is implausible, superficial, or inadequate.
  • “Yes, my automatic thought was silly. I’ll get my work done for sure.”
• The patient has not sufficiently expressed the evidence in support of the automatic thought.
  • Don’t skip ahead after one response. Ask if there’s any other evidence in support of the thought, or against the thought.
• The person believes the new thought rationally, but doesn’t feel it emotionally.This is often because of an underlying belief, which needs more intervention to change.

Teach the patient to examine thoughts herself. Often 1-2 particular questions will work better for a patient than other questions.

• Patients can keep a Thought Record or “Testing your Thoughts” worksheet, which goes through the whole Socratic questioning above. Components include:
  • Date/Time
  • Situation—”What event or stream of thoughts led to the unpleasant emotion? What distressing physical sensations did you have?”
  • Automatic thoughts—”What thoughts or images went through your mind? How much did you believe each at the time?”
  • Emotions—”What emotion(s) did you feel at the time? How intense was the emotion?”
  • Adaptive response—”What cognitive distortion did you make? Use (Socratic) questions at bottom to compose a response to the automatic thought. How much do you believe each response?”
  • Outcome—”How much do you now believe each automatic thought? What emotion do you feel now? How intense is the emotion? What will you do/what did you do?”
  • Note to the patient that this is a general tool, that it may not work all the time, and that relieving the emotion by 10% is worth it.
• For some people, consider audio recordings of the main points, rather than written notes.

Not every thought needs to be examined. It might be more helpful to focus on a more distressing thought, teach other parts of the cognitive model, or avoid distress in the moment.

With experience, the patient can skip some of the examining questions, going directly to examining alternatives and forming an adaptive response.

Behavioral Experiments and Behavioral Activation

Main Ideas

Negative cognitions are linked to patients’ negative predictions of what will happen. The goal of behavioral experiments is to show that the patient’s negative prediction doesn’t often match the reality of the outcome.

For example, if a patient is anxious about being socially rejected, a behavioral experiment might consist of calling one of her close friends and reflecting on how the outcome matched her prediction.

Depressed people often have inactivity as a core problem. They deprive themselves of opportunities for pleasure or mastery, and they engage in dysphoric activities (such as sleeping or lying in bed) that may offer short-term relief from their negative automatic thoughts. Even when they do pleasurable activities, their automatic thoughts may make it displeasurable. (“I’m doing a terrible job. I can’t do this as well as I used to.”) Behavioral experiments try to reverse the vicious cycle and create situations for positive thoughts.

Tactics

Use the patient’s daily schedule as an opportunity to spot positive things that the patient isn’t doing, or negative things the patient does too much of. Strive for a good balance between pleasure and mastery.

• Ask how the activities make them feel (probably bad). Then normalize the activity for the patient: “Most depressed people think they’ll feel better in bed. But usually they find that doing anything else is better.”

Suggest experiments that are within the capability of the patient. Find the version of the behavior that is easiest—finding the right friend to ask out, the easiest physical activity to resume.

If applicable, try to achieve results within the session—collaboratively design experiments that patients can conduct right in the session itself.

• A depressed patient might have the automatic thought, “I won’t be able to concentrate on reading anything.” The experiment could be to read a passage from a book and summarize it for you, to see what degree the thought is valid.

Teach the patient to give herself credit when she does a good behavior or detects an automatic thought.

• The patient can tell herself, “Good. I did it.”
• If the patient is skeptical about this, say, “Even if these behaviors used to be easy in the past, being depressed makes it harder. So you deserve credit. When you’re over the depression, you don’t have to give yourself credit.”

Anticipate barriers to executing the experiment.

• If you sense hesitation from the patient, ask what automatic thought crossed her mind.
  • If she doesn’t offer one, say the opposite: “were you thinking about what a good time you’d have?”
  • Confront the automatic thought by asking what evidence she has to support it, and what evidence she has to disagree with it.
• Reduce the time delay to conducting the experiment—schedule an action today.
• If the behavior is too imposing, find an easier behavior to start with. Ask what activity takes less energy.
• Preempt negative feelings if the experiment fails: “what would you feel if your friends said no to hanging out?”
• If the patient has no ideas on what’s enjoyable, give a list of 5-10 activities and ask which sound the most enjoyable.

Use an hourly activity chart to plan out the day. Plan in rest sessions.

• The patient should write the activities into the chart herself.

Rate the sense of mastery and pleasure the person gets.

• Create a scale of 0, 5, and 10 for pleasure and mastery.
• Ask the patient to rate activities the patient has previously done, and to predict her ratings of future activities to come.
• Ideally, the real ratings contradict their predictions. For example, the patient may predict an activity is a 2 in pleasure, then find out later it’s a 6.

Example Discussion

This example dialogue pieces together the three steps of identifying automatic thoughts, evaluating them, and creating a behavioral experiment.

• Therapist: OK, Sally, you wanted to talk about getting a part-time job?
• Patient: Yeah, I need to work for the money, but...I don’t know.
• Therapist: [noticing Sally’s dysphoria] What’s going through your mind right now?
• Patient: [automatic thought] I can’t handle a job.
• Therapist: [labeling the idea as a thought and linking to her mood] And how does that thought make you feel?
• Patient: [emotion] Really sad. Hopeless.
• Therapist: [beginning to evaluate the thought] What’s the evidence that you can’t handle a job?
• Patient: Well, I’m already having trouble getting through my classes, so how can I handle a job?
• Therapist: Is there anything else?
• Patient: I feel so tired everyday. It’s already hard to just look for a job—how can I actually go to work everyday?
• Therapist: In a minute we’ll look at that. [suggesting an alternative view] It’s possible that looking for a new job is the harder part, and that once you have a job, keeping it is easier. Is there any other evidence that you couldn’t handle a job, assuming you can get one?
• Patient: No, nothing comes to mind.
• Therapist: [evidence on other side] Is there any evidence on the other side, that you might be able to handle a job?
• Patient: I did keep my part-time job last year, and I was able to do OK in school too. But this year...I don’t know.
• Therapist: Is there any other evidence you could handle it?
• Patient: It’s possible if the job didn’t take that much time and wasn’t so hard, I could keep it up.
• Therapist: What kind of job might that be?
• Patient: Maybe working in a store, like what I did last year.
• Therapist: [helping build concrete solutions] Are there any places like that where you could find a job?
• Patient: Maybe the college bookstore. I saw they were hiring in an email.
• Therapist: OK. And what would be the worst that could happen if you got a job there?
• Patient: I’d get overwhelmed and fail.
• Therapist: If that happened, how would you cope?
• Patient: I guess I’d quit.
• Therapist: What would be the best that could happen if you got a job there?
• Patient: I guess it’d be easy like last year and I could do it.
• Therapist: What’s the most realistic outcome?
• Patient: It probably won’t be easy at first, but I might be able to handle that and school at the same time.
• Therapist: Sally, what’s the effect of believing your automatic thought, “I can’t handle a job?”
• Patient: It makes me feel sad. It makes me stop wanting to try.
• Therapist: And what’s the effect of changing your thinking, of realizing that you realistically could work in the bookstore?
• Patient: I’d feel better. I’d apply for the job.
• Therapist: So what do you want to do about this?
• Patient: I want to go to the bookstore and apply for the job.
• Therapist: When will you go?
• Patient: I guess this afternoon.
• Therapist: How likely are you to go?
• Patient: Pretty likely. I’ll go.
• Therapist: How do you feel now?
• Patient: Better. A little nervous. But I’m hopeful.

Here, Sally can write a coping card that prepares a response to the situation: “If I’m afraid to go to the bookstore, remind myself that I probably could handle a job there and, in the worst case, I could quit. Even then, it’s not a big deal.”

Exercise: Question Your Own Automatic Thoughts

Reflect on automatic thoughts you have and how they might be improved.

• Think about a time in the past day or so where you felt a negative emotion about yourself (like self-doubt, anxiety, or sadness). What was going through your mind just then?

• How did that thought make you feel?

• What’s the evidence that your thought is true? What’s the evidence on the other side?

• What’s an alternative way of viewing this situation? What’s the worst that could happen?

Identifying Deeper Beliefs

After the first session, you can begin building a cognitive conceptualization of the patient, linking the whole pathway of

• Formative experiences
• To core beliefs
• To intermediate rules, assumptions, and beliefs
• To coping strategies
• To automatic thoughts and reactions

As you develop your understanding of this, share them merely as hypotheses. Avoid making the patient feel categorized or put in a box.

We’ll discuss investigating both intermediate beliefs and core beliefs.

Identifying Intermediate Beliefs

Given the same core belief, people may have different intermediate beliefs.

• Say two patients have the same core belief, “I’m not good enough to accomplish my goals.” One patient may have the intermediate belief, “I should work as hard as I can at all times.” Another patient may have a very different belief, “I should lower my goals so I don’t get disappointed.”
• Why do different intermediate beliefs arise? This can be because of genetic predisposition or environmental cues early in life.

How to identify intermediate beliefs:

• The patient may voice the belief, as an automatic thought or when directly asked about intermediate beliefs.
• Provide the first part of an assumption, and the patient fills it in.
  • “If I don’t get an A, then ___.”
• Spot patterns to automatic thoughts—an intermediate thought may drive many of these automatic thoughts.
• Use the downward arrow technique: Ask what the automatic thought means to the person. (Asking what the thought means about the person tends to show the core belief.)
  • Example questions: “If that’s true, so what?” “What’s so bad about…” “What’s the worst part about…”
• Use questionnaires like the Dysfunctional Attitude Scale or Personality Belief Questionnaire.

Keep probing until you cause a negative affect in the patient, or the patient repeats her answer. This is about as deep as you can go.

Educate the patient about beliefs:

• Show the patient how beliefs are learned and can be changed.
  • Ask the patient to think about someone who has different beliefs. Clearly the other person learned different beliefs, and so they’re not absolute rules. Also, clearly the other person isn’t a failure (or whatever the extreme belief would lead the patient to believe about herself).
• Examine the advantages and disadvantages of beliefs.
• Ask if this is an idea the patient would like to change.

Modifying Intermediate Beliefs

In comparison to automatic thoughts, modifying intermediate beliefs may require more persuasion than just Socratic questioning. The key is to clarify the dissonance of the patient’s beliefs; deeper beliefs may require more visceral and narrative depictions.

Here are a range of techniques to use to try to modify the student’s intermediate beliefs:

• Phrase the rule/belief as an if-then assumption—this makes it easier to spot the logical fallacy.
  • “If I ask for help, I’ll be seen as weak.” vs “Don’t ask for help.”
• Present more functional beliefs, that are more qualified versions of the old belief
  • “If I don’t get an A, I’m a failure.” can be turned into “If I don’t get an A, I’m just human, and I still tried hard. It’s better than 0%.”
• Use Socratic questioning.
  • “Let’s say there are 2 people with the same problem. One does [the maladaptive behavior] and feels worse. The other does [a functional behavior] and feels better. Who’s the more competent person?”
• Set up a behavior experiment.
  • Act “as if” the belief weren’t true. Then reflect on how that behavior makes the person feel.
• Role play as the patient’s intellectual side and emotional side, with each of you taking a side and swapping turns. As the intellectual side, you explain the rational approach to the situation. As the emotional side, you convey the emotional reaction and automatic thoughts.
  • Explain the rationale to the patient that this will let you see what’s really maintaining the belief.
  • Be the intellectual side first, to give an example of rational reasoning for the patient. The patient will start as the emotional side.
  • After the role play, switch sides. The patient will voice the more functional intellectual thoughts. As you play the emotional side, use the patient’s own words—this will help highlight the dysfunction of the patient’s emotional thoughts.
• Cognitive continuum—establish that the situation isn’t binary, and the patient is likely better on the scale than absolute zero.
  • Ask where she is on the scale. Then ask whether there is someone who is worse, and what that person would be doing. Keep drilling until it’s someone who’s at absolute zero. (For example, if the patient is worried she’s an academic failure, absolute zero may be someone who goes to zero classes. The patient can see that she’s better than this person.)
  • This technique is useful for patients with “all or nothing” cognitive distortions.
• Ask the patient to imagine another person with a different belief. Then if the patient respects that other person, help her model that belief for herself.
• Ask the patient to counsel someone else in her situation, such as:
  • Someone she knows who has the same issue
  • Imagining if their child had the issue
• Self-disclosure—you’ve gone through a similar situation before and came up with a solution.

After developing a new, healthier belief, assign homework for the patient to look for situations to practice the new belief and behavior.

Don’t worry about extinguishing the bad behavior entirely. Reducing the belief level to 30% or below is usually sufficient.

Identifying Core Beliefs

Core beliefs are the central beliefs that people hold about themselves and the world. They are often formed at an early age. As with intermediate beliefs and automatic thoughts, they can be both positive and negative.

In mood disorders, negative core beliefs can be activated at all times, in contrast with “normally functioning” people, where negative core beliefs are activated only occasionally.

Core beliefs tend to be categorized into three types:

• Helplessness
  • “I want to achieve more, but I’m not capable of it.”
  • “I’m vulnerable.”
  • “I’m a victim.”
  • “I’m a failure.”
• Unlovableness
  • “I’m not worthy of being loved by others.”
  • “I’m undesirable.”
  • “I’m bound to be alone”
  • “I’m defective, therefore others won’t love me.”
• Worthlessness
  • “I’m bad. I’m fundamentally not worthy of good things.”
  • “I’m evil.”
  • “I don’t deserve to live.”

As you try to elucidate a patient’s core belief, try to categorize it into one of those three types. A statement that’s too general can be clarified to fit into the correct category.

• For example, the patient may offer the core belief, “I’m not good enough.” This can mean either “I’m not good enough to achieve more,” or “I’m not good enough to be loved.”

Core beliefs are often formed through early childhood experiences. To elucidate these experiences:

• When a patient recounts a recent situation that causes negative affect, ask her to vividly imagine the present situation to intensify the affect. Ask where she feels the affect in her body.
• Then ask when the earliest she can remember feeling this feeling in the past was.

Techniques to correct core beliefs

All the techniques used to address automatic thoughts and intermediate beliefs can also be applied to core beliefs.

In addition, here are techniques used particularly for core beliefs:

Set positively adjusted core beliefs, rather than extreme positive core beliefs.

• Turn “I can’t do anything right” into “I can do most things right, and there’s a good reason for when I get something wrong.”
• Do NOT turn it into “I can do everything right.”

Keep a Core Belief Worksheet with two columns:

• Evidence supporting new belief
  • The patient may struggle to volunteer evidence for this, so have her reflect on other people doing the behavior. If the patient sees someone else doing something positive, ask whether she’s also doing it herself and should give herself credit. Or visualize someone else doing what she’s doing, and ask if she’s doing something similar.
  • Any behavior that, if not done, would be negative data, belongs in positive data. For example, a struggling student might not consider going to class positive data, but if she didn’t go to class, she’d consider it negative data.
• Evidence that would have supported the old core belief, but a reframing makes it no longer as negative.
  • “I got a B on the test, BUT this isn’t a total failure. If I were really incompetent, I wouldn’t be here.”
  • “I didn’t understand something in class, BUT the teacher may not have explained it well, and I didn’t read about it.”

Historical tests of the Core Belief

• Look back on major periods of the patient’s life to find evidence that supports or contradicts the core belief.
• Summarize each major period, often with reframings of the core belief to be more qualified.
  • For example, “during high school, I was highly functioning. In college, I struggled more, but I still graduated and made it out.”

Role play an early childhood experience.

• Rationally discuss alternative explanations for the experience.
• For example, say a patient’s mother yelled at her for poor grades, because the mom was embarrassed among her peers.
  • The therapist role plays as the younger patient, but mounts a rational resistance against the traumatizer. The patient plays the role of the traumatizer (here, the parent). The roles switch.
  • The patient then role plays as an older version of herself sitting beside her younger self. “What does older Annie say to 7-year-old Annie?” “7-year-old Annie, do you believe her?”

Note that negative core beliefs of patients with personality disorders are usually more difficult to modify.

Homework Assignments

Homework gives the patient opportunities to practice new behaviors and thinking. Patients who regularly complete homework show better progress.

Principles of Homework

Explain the rationale of homework, often in terms of improving patient affect or in proven efficacy.

Sessions should typically begin with review of homework completion, outcomes from doing homework, and appropriateness of tasks for future homework.

• If the patient didn’t complete the homework, you should take blame for assigning too difficult an assignment or not explaining it well enough.

Set homework collaboratively. Get patient buy-in for homework assignment.

Lean toward making homework assignments easy and able to be completed than too hard. Aim for 90-100% likelihood of completion.

• Ask the patient for their own estimation of how likely they are to complete, from 0-100%.
• It’s better to remove an assignment than to set the habit of not completing an assignment.

Make homework no-lose—even if the patient doesn’t complete homework, she’ll discover thoughts that prevent her from making progress.

Homework Assignment Tasks

Homework assignments can take a variety of forms. Here are common tasks for patients:

• Behavior activation—the patient just does activities, such as doing light exercise or making a phone call to a friend. For newer patients, this is often more useful to improve affect than more intellectual tasks.
• Notice automatic thoughts.
• Evaluate automatic thoughts.
• Review therapy notes and read coping cards
  • Example of a coping card: “If I start to think that I can’t apply for a job, remind myself that I’m only going to do it for 10 minutes, that it may be difficult but probably won’t be impossible, and that the first minute will be hardest and then it’ll get easier.”
• Problem solving—implement the solutions devised during sessions.
• Conduct behavior experiments. Record data as evidence for or against negative thoughts.
• Read other source material.
• Prepare for the next therapy session.
• Set reminders to read over homework multiple times per day.

As therapy progresses, the nature of homework may change:

• The patient may start proposing homework and giving the rationale for the tasks.
• The tasks can become more complex, diving deeper into the cognitive model.
• Some regular tasks will still remain, like reviewing therapy notes daily.

Improving Homework Completion Rate

Here are techniques to increase homework completion rate:

• Commitment devices
  • Daily checklists of tasks
  • Scheduling tasks in the patient’s calendar
  • Ask the patient to leave a voicemail with you whenever finishing a task
• Find barriers for doing homework, and problem solve those barriers.
  • Rehearse the situation leading up to doing homework to find issues.
  • These may be practical barriers, such as lacking time in schedule or forgetting.
  • They may also be mental barriers, such as overestimating time or effort, overcoming the activation energy to get started, or believing it won’t work.
    • Ask the patient what the worst that can happen is, and the best.
    • Remind the patient that they’re not aiming for perfection.
• Anticipate negative results of homework and address subsequent automatic thoughts
• Start homework in session, so that offline homework is merely continuation of the task rather than completion.

Additional Techniques and Troubleshooting

CBT is customized to the patient, and different techniques may have different efficacy between patients. Here are more techniques mentioned in the book to draw upon:

• When making decisions and choosing between options, ask the patient to make a list of advantages and disadvantages of each option. Score each entry to help make the ultimate decision.
• Refocusing: when the patient’s attention veers to distracting automatic thoughts, rather than evaluating their automatic thoughts, instead refocus attention on the task at hand.
• Distraction: get the patient’s mind off of automatic thoughts.
  • Ask what has worked in the past.
  • Suggestions: watch TV, go for a walk, email a friend, clean her desk, or browse the web.
• Exposure: keep engaging the object of concern until the negative affect dissipates.
  • Patients often have safety behaviors, such as avoiding thinking about the subject to ward off anxiety, but which perpetuate the fundamental problem.
• Graded task assignments: reaching the ultimate task (such as landing a new job) may be intimidating. Break the task into its constituent stepwise tasks to make each step seem less problematic (for example, prepare the resume, look at job postings, and so on).
  • Represent the steps visually with a staircase.
• Role playing
  • Assume a positive outcome: “If you knew for sure the teaching assistant would be willing to talk to you, what would you say?”
• Pie technique: visually represent something that causes distress. This can help the patient recognize the reality of a situation.
  • Time spent on different activities, with one pie chart showing actual time and another showing ideal time.
  • Attribution of causes for a situation. When shown on a pie chart, the most feared cause may be unlikely.
  • The likelihood of outcomes. When shown on a pie chart, the catastrophic one may be seen as unlikely.
• Self-comparison: discuss the headwinds the patient has faced by applying them to a different person.
  • “We know that depression is a physiological issue. Would you expect someone who was infected with pneumonia to do everything flawlessly?”
• Credit lists
  • Keep track of things that were positive or difficult to do.
  • This is a good stepping stone to the Core Belief Worksheet.

Imagery

Often specific vivid images are a primary source of patient distress. Elucidating the image is important for recovery.

Synonyms of imagery include mental picture, daydream, fantasy, or memory.

Techniques to improve imagery:

• Continue imagining beyond the image.
  • Often the patient stops at the most distressing part. Continuing past the image often shows how the patient will resolve the situation capably.
  • Picture what happens in the far future—weeks, months, years after the anxious image. Shows that things will likely be resolved satisfactorily.
• Rework the image to include coping behaviors.
  • Ask leading questions to guide the adaptive behaviors that the patient could do in the situation.
  • This can include coping behaviors like reading coping cards during the stressful situation.
  • Assign homework to remember the positive image.
• Rework the image to imagine a different outcome.
  • The outcome could be realistic and imagine likely outcomes. Then talk about behaviors that could push toward this outcome.
  • The outcome could also be magical. For example, a scary person could morph into a crying baby with a puff of smoke.
• Imagine the image multiple times in succession. The severity of the image should decrease.

Use imagery as a therapeutic tool.

• Induce an image of a situation. The patient then rehearses coping techniques.

Troubleshooting Sessions

Common Pitfalls to Sessions

As a therapist, you may run into the following shortcomings:

• Failing to set patient expectations for therapy, and of her responsibilities.
• Failing to emphasize key automatic thoughts
• Failing to summarize frequently
• Failing to summarize using patient’s own words
• Failing to ask the patient for depth of understanding
• Failing to provide rationale for agenda items or your direction
• Failing to make a therapeutic intervention—just talking about problems without solving them or assigning homework
• Failing to record therapy notes for patient to review

Getting feedback on your performance is helpful. Ask the patient if you can record their session, so you can review the session with a colleague.

Beware of your own negative automatic thoughts about the patient, therapy, or yourself. Not all sessions will go well. Instead of catastrophizing the problem and questioning your ability as a therapist, see it as an opportunity to refine your skills.

Problems in Patient Engagement

In general, problems in CBT sessions can be a result of one of two issues: 1) insufficient socialization (the patient lacks training on what to do) or 2) reluctance to comply (the patient knows what to do but doesn't want to do it).

Distinguish between the two by socializing the patient to the CBT model.

• If the patient gives a neutral reaction, then it's a socialization problem.
• If the patient is frustrated, then follow this standard procedure, 1) thank the patient for expressing her thoughts, 2) investigate automatic thoughts, 3) provide rationale for what you're doing. Directly tackling automatic thoughts can work, but sometimes it causes too much friction

Causes of reluctance to comply include a weak therapeutic alliance; ineffective structure or pace of session; unrealistic patient expectations; lack of patient understanding of cognitive model; or the patient’s biology or external environment.

Interrupting During Sessions

To get the session on track to cover the most helpful items, you will have to interrupt.

An effective way to do this is to:

1. Ask if you can interrupt
2. Ask for what you want, or summarize what you're hearing
3. Ask if that sounds right.

If the patient is upset at the interruption, follow the standard procedure from above. Also apologize for interrupting, and ask if they would like to continue and leave some topics behind, or to talk uninterrupted.

The Patient Feels Over-structured

If the patient’s automatic thoughts reveal feeling boxed in by the session, ask if the patient would like to begin the session without agenda setting but just talking at length.

Planning for Termination and Relapse Prevention

CBT is intended to be fixed in duration, teaching the patient to be her own therapist. Make this known to the patient at the beginning, to prepare for the expectation.

To help ease the transition, help the patient attribute positive changes to herself, not to the therapist or external causes.

• The patient needs to develop confidence about her ability to solve her own problems.
• The patient is the one who puts in the work, so the therapist should get only a portion of credit.

As sessions near the end, patients should anticipate setbacks and anticipate how they will respond.

• Chart out the patient’s likely affect over time. This can look like the southern border of the US—Texas and Florida are troughs with lows.
• Role play how the patient will feel during a setback. Ask how they predict they’d feel. In response, answer the thoughts and create coping cards.

Make a list of tools the patient has employed to deal with stressful situations:

• Identifying, responding to automatic thoughts
• Using thought records
• Scheduling activities
• Techniques for relaxation, distraction, and refocusing

Guide the patient to conduct self-therapy sessions, consisting of a template similar to normal therapy sessions. A template might include:

• Review of past week, mood check
• Review homework
• Review current problems and engage in problem solving
• Set new homework
• Schedule next therapy session

Prepare for the taper off of sessions like any other stressful situation.

• Elicit advantages and disadvantages of tapering therapy, with disadvantages reframed.
  • “I might relapse” can be turned to “If I’m going to relapse, it’s better for it to happen while I’m in therapy so I can learn how to handle it.”
• Help respond to any distortions, such as catastrophizing a relapse.

Schedule booster sessions.

• Having these pre-scheduled may motivate the patient to do homework in between.
• It reduces anxiety about being on their own.
• Assign questions to answer before booster sessions about what work has done in between, and how problems were handled.