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Cognitive-Behaviour Therapy

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  • 1. A Brief Introduction To Cognitive-Behaviour Therapy By Wayne Froggatt This version: Feb-2006Cognitive-Behaviour Therapy (CBT) is based on the concept that emotions and behaviours result (primarily,though not exclusively) from cognitive processes; and that it is possible for human beings to modify suchprocesses to achieve different ways of feeling and behaving. There are a number of ‘cognitive-behavioural’therapies, which, although developed separately, have many similarities.Some history cognitive flavour. In more recent years, ‘CBT’ has evolved into a generic term to include theThe ‘cognitive’ psychotherapies can be said to whole range of cognitively-oriented psychothera-have begun with Alfred Adler, one of Freud’s in- pies. REBT and CT have been joined by such de-ner circle. Adler disagreed with Freud’s idea that velopments as Rational Behaviour Therapythe cause of human emotionality was ‘uncon- (Maxie Maultsby), Multimodal Therapy (Arnoldscious conflicts’, arguing that thinking was a Lazarus), Dialectical Behaviour Therapy (Marshamore significant factor. Linehan), Schema Therapy (Jeffrey Young) and Cognitive Behaviour Therapy has its modern expanded by the work of such theorists as Rayorigins in the mid 1950’s with the work of Albert DiGiuseppe, Michael Mahoney, Donald Mei-Ellis, a clinical psychologist. Ellis originally chenbaum, Paul Salkovskis and many others.trained in psychoanalysis, but became disillu- All of these approaches are characterised bysioned with the slow progress of his clients. He their view that cognition is a key determining fac-observed that they tended to get better when they tor in how human beings feel and behave, and thatchanged their ways of thinking about themselves, modifying cognition through the use of cognitivetheir problems, and the world. Ellis reasoned that and behavioural techniques can lead to productivetherapy would progress faster if the focus was change in dysfunctional emotions and behaviours.directly on the client’s beliefs, and developed a By now it will be seen that ‘CBT’ is a genericmethod now known as Rational Emotive Behav- term that encompasses not one but a number ofiour Therapy (REBT). Ellis’ method and a few approaches. When reading articles or texts onothers, for example Glasser’s ‘Reality Therapy’ CBT, it is helpful to identify the theoretical per-and Berne’s ‘Transactional Analysis’, were ini- spective involved. Often they are saying the sametially categorised under the heading of ‘Cognitive thing, but using different words. Being aware ofPsychotherapies’. the terminological differences will help the reader The second major cognitive psychotherapy understand and, hopefully, integrate the variouswas developed in the 1960’s by psychiatrist approaches. This article will present an approachAaron Beck; who, like Ellis, was previously a that combines REBT and CT, incorporating ele-psychoanalyst. Beck called his approach Cogni- ments of some other approaches as well.tive Therapy (CT). (Note that because the term‘Cognitive Therapy’ is also used to refer to thecategory of cognitive therapies, which includes Theory of causationREBT and other approaches, it is sometimes nec- CBT is not just a set of techniques – it also con-essary to check whether the user is alluding to the tains comprehensive theories of human behaviour.general category or to Beck’s specific variation). CBT proposes a ‘biopsychosocial’ explanation Since the pioneering work of Ellis and Beck, a as to how human beings come to feel and act asnumber of other cognitive approaches have devel- they do – i.e. that a combination of biological,oped, many as offshoots of REBT or CT. The psychological, and social factors are involved.term ‘Cognitive Behaviour Therapy’ came into The most basic premise is that almost all hu-usage around the early 1990’s, initially used by man emotions and behaviours are the result ofbehaviourists to describe behaviour therapy with a what people think, assume or believe (about
  • 2. themselves, other people, and the world in gen- behaviours that harm oneself, others, and one’seral). It is what people believe about situations life in general.they face – not the situations themselves – that 2. It distorts reality (it is a misinterpretation ofdetermines how they feel and behave. what is happening and is not supported by the Both REBT & CT, however, argue that a per- available evidence);son’s biology also affects their feelings and be- 3. It contains illogical ways of evaluating oneself,haviours – an important point, as it is a reminder others, and the world.to the therapist that there are some limitations onhow far a person can change. The Three Levels of Thinking A useful way to illustrate the role of cognition is Human beings appear to think at three levels: (1)with the ‘ABC’ model. (originally developed by Inferences; (2) Evaluations; and (3) Core beliefs.Albert Ellis, the ABC model has been adapted for Every individual has a set of general ‘core be-more general CBT use). In this framework ‘A’ liefs’ – usually subconscious – that determinesrepresents an event or experience, ‘B’ represents how they react to life. When an event triggers offthe beliefs about the A, and ‘C’ represents the emo- a train of thought, what someone consciouslytions and behaviours that follow from those beliefs. thinks depends on the core beliefs they subcon- Here is an example of an ‘emotional episode’, as sciously apply to the event.experienced by a person prone to depression who Let’s say that a person holds the core belief:tends to misinterpret the actions of other people: ‘For me to be happy, my life must be safe andA. Activating event: predictable.’ Such a belief will lead them to be Friend passed me in the street without ac- hypersensitive to any possibility of danger and knowledging me. overestimate the likelihood of things going wrong. Suppose they hear a noise in the night.B. Beliefs about A: Their hypersensitivity to danger leads them to He’s ignoring me. He doesn’t like me. infer that there is an intruder in the house. They I’m unacceptable as a friend – so I must be then evaluate this possibility as catastrophic and worthless as a person. unbearable, which creates feelings of panic. For me to be happy and feel worthwhile, peo- Here is an example (using the ABC model) to ple must like me. show how it all works:C. Consequence: A. Your neighbour phones and asks if you will Emotions: hurt, depressed. baby-sit for the rest of the day. You had already Behaviours: avoiding people generally. planned to catch up with some gardening. Note that ‘A’ doesn’t cause ‘C’: ‘A’ triggers B. You infer that: ‘If I say no, she will thinkoff ‘B’; ‘B’ then causes ‘C’. Also, ABC episodes badly of me.’do not stand alone: they run in chains, with a ‘C’ You evaluate your inference: ‘I couldn’t standoften becoming the ‘A’ of another episode – we to have her disapprove of me and see me asobserve our own emotions and behaviours, and selfish.’react to them. For instance, the person in the ex- Your inference and the evaluation that fol-ample above could observe their avoidance of lows are the result of holding the underlyingother people (‘A’), interpret this as weak (‘B’), core belief: ‘To feel OK about myself, I needand engage in self-downing (‘C’). to be liked, so I must avoid disapproval from Note, too, that most beliefs are outside con- any source.’scious awareness. They are habitual or automatic, C. You feel anxious and say yes.often consisting of underlying ‘rules’ about howthe world and life should be. With practice, In summary, people view themselves and thethough, people can learn to uncover such subcon- world around them at three levels: (1) inferences,scious beliefs. (2) evaluations, and (3) core beliefs. The therapist’s main objective is to deal with the underlying, semi- permanent, general ‘core beliefs’ that are the con-What is dysfunctional thinking? tinuing cause of the client’s unwanted reactions.We have seen that what people think determines CT focuses mainly on inferential-type think-how they feel. But what types of thinking are ing, helping the client to check out the reality ofproblematical for human beings? their beliefs, and has some sophisticated tech-A definition niques to achieve this empirical aim. REBT emphasises dealing with evaluative-To describe a belief as ‘irrational’ is to say that: type thinking (in fact, in REBT, the client’s infer-1. It blocks a person from achieving their goals, ences are regarded as part of the ‘A’ rather than creates extreme emotions that persist and the ‘B’). When helping clients explore their think- which distress and immobilise, and leads to Page 2 of 12
  • 3. ing, REBT practitioners would tend to use strate- mere predictions, for example: ‘I’ll be de-gies that examine the logic behind beliefs (rather pressed forever’, ‘Things can only get worse’.than query their empirical validity). • Emotional reasoning: thinking that because What REBT and CT do share, though, is an ul- we feel a certain way, this is how it really is: ‘Itimate concern with underlying core beliefs. feel like a failure, so I must be one’, ‘If I’mTwo Types of Disturbance angry, you must have done something to makeKnowing that there are different levels of thinking me so’, and the like.does not tell us much about the actual content of • Personalising: assuming, without evidence,that thinking. The various types of CBT have dif- that one is responsible for things that happen:ferent ideas of what content is important to focus ‘I caused the team to fail’, ‘It must have beenon (though the differences are sometimes a matter me that made her feel bad’, and so on.of terminology more than anything else). One way of looking at the content issue that I The seven types of inferential thinking de-find helpful comes from REBT, which suggests scribed above have been outlined by Aaron Beckthat human beings defeat or ‘disturb’ themselves and his associates (see, for example: Burns, 1980).in two main ways: (1) by holding irrational beliefs Evaluationsabout their ‘self’ (ego disturbance) or (2) by hold- As well as making inferences about things that hap-ing irrational beliefs about their emotional or pen, we go beyond the ‘facts’ to evaluate them inphysical comfort (discomfort disturbance). Fre- terms of what they mean to us. Evaluations arequently, the two go together – people may think sometimes conscious, sometimes beneath aware-irrationally about both their ‘selves’ and their cir- ness. According to REBT, irrational evaluationscumstances – though one or the other will usually consist of one or more of the following four types:be predominant. • Demandingness. Described colourfully bySeven inferential distortions Ellis as ‘musturbation’, demandingness refersIn everyday life, events and circumstances trigger to the way people use unconditional shouldsoff two levels of thinking: inferring and evaluat- and absolutistic musts – believing that certaining. At the first level, we make guesses or infer- things must or must not happen, and that cer-ences about what is ‘going on’ – what we think tain conditions (for example success, love, orhas happened, is happening, or will be happening. approval) are absolute necessities. Demand-Inferences are statements of ‘fact’ (or at least ingness implies certain ‘Laws of the Universe’what we think are the facts – they can be true or that must be adhered to. Demands can be di-false). Inferences that are irrational usually con-sist of ‘distortions of reality’ like the following: rected either toward oneself or others. Some REBT theorists see demandingness as the• Black and white thinking: seeing things in ex- ‘core’ type of irrational thinking, suggesting tremes, with no middle ground – good or bad, that the other three types derive from it perfect versus useless, success or failure, right against wrong, moral versus immoral, and so • Awfulising. Exaggerating the consequences of on. Also known as all-or-nothing thinking. past, present or future events; seeing some- thing as awful, terrible, horrible – the worst• Filtering: seeing all that is wrong with oneself that could happen. or the world, while ignoring any positives. • Discomfort intolerance (often referred to as• Over-generalisation: building up one thing ‘can’t-stand-it-itis’). This is based on the idea about oneself or one’s circumstances and end- that one cannot bear some circumstance or ing up thinking that it represents the whole event. It often follows awfulising, and leads to situation. For example: ‘Everything’s going demands that certain things not happen. wrong’, ‘Because of this mistake, I’m a total failure’. Or, similarly, believing that something • People-Rating. People-rating refers to the which has happened once or twice is happening process of evaluating one’s entire self (or all the time, or that it will be a never-ending pat- someone else’s). In other words, trying to de- tern: ‘I’ll always be a failure’, ‘No-one will ever termine the total value of a person or judging want to love me’, and the like. their worth. It represents an overgeneralisa- tion. The person evaluates a specific trait, be-• Mind-reading: making guesses about what haviour or action according to some standard other people are thinking, such as: ‘She ig- of desirability or worth. Then they apply the nored me on purpose’, or ‘He’s mad with me’. evaluation to their total person – eg. ‘I did a• Fortune-telling: treating beliefs about the future bad thing, therefore I am a bad person.’ Peo- as though they were actual realities rather than ple-rating can lead to reactions like self- downing, depression, defensiveness, grandios- Page 3 of 12
  • 4. ity, hostility, or overconcern with approval and Helping people change disapproval. The steps involved in helping clients change canCore beliefs be broadly summarised as follows:Guiding a person’s inferences and evaluations are 1. Help the client understand that emotions andtheir core beliefs. Core beliefs are the underlying, behaviours are caused by beliefs and thinking.general assumptions and rules that guide how This may consist of a brief explanation fol-people react to events and circumstances in their lowed by assignment of some reading.lives. They are referred to in the CBT literature 2. Show how the relevant beliefs may be uncov-by various names: ‘schema’; ‘general rules’; ‘ma- ered. The ABC format is useful here. Using anjor beliefs’; ‘underlying philosophy’, etc. REBT episode from the client’s own recent experi-and CT both propose slightly different types of ence, the therapist notes the ‘C’, then the ‘A’.core belief. I find it convenient to refer to them as The client is asked to consider (at ‘B’): ‘What(1) assumptions and (2) rules. was I telling myself about ‘A’, to feel and be- Assumptions are a person’s beliefs about how have the way I did at ‘C’? As the client devel-the world is – how it works, what to watch out ops understanding of the nature of irrationalfor, etc. They reflect the ‘inferential’ type of thinking, this process of ‘filling in the gap’thinking. Here are some examples: will become easier. Such education may be• My unhappiness is caused by things that are achieved by reading, direct explanation, and outside my control – so there is little I can do by record-keeping with the therapist’s help and to feel any better. as homework between sessions.• Events in my past are the cause of my prob- 3. Teach the client how to dispute and change the lems – and they continue to influence my feel- irrational beliefs, replacing them with more ra- ings and behaviours now. tional alternatives. Again, education will aid the client. The ABC format is extended to in-• It is easier to avoid rather than face clude ‘D’ (Disputing irrational beliefs), ‘E’ responsibilities. (the desired new Effect – new ways of feeling Rules are more prescriptive – they go beyond and behaving), and ‘F’ (Further Action for thedescribing what is to emphasise what should be. client to take).They are ‘evaluative’ rather than inferential. Here 4. Help the client to get into action. Actingare some examples: against irrational beliefs is an essential com-• I need love and approval from those significant ponent of CBT. The client may, for example, to me – and I must avoid disapproval from any dispute the belief that disapproval is intoler- able by deliberately doing something to attract source. it, to discover that they in fact survive. CBT’s• To be worthwhile as a person I must achieve, emphasis on both rethinking and action makes succeed at whatever I do, and make no mis- it a powerful tool for change. The action part takes. is often carried out by the client as ‘home-• People should always do the right thing. When work’. they behave obnoxiously, unfairly or selfishly, they must be blamed and punished. The process of CBT therapy• Things must be the way I want them to be, oth- What follows is a summary of the main compo- erwise life will be unbearable. nents of an CBT intervention.• I must worry about things that could be dan- Engage client gerous, unpleasant or frightening – otherwise they might happen. The first step is to build a relationship with the client. This can be achieved using the core condi-• Because they are too much to bear, I must tions of empathy, warmth and respect. avoid life’s difficulties, unpleasantness, and Watch for any ‘secondary disturbances’ about responsibilities. coming for help: self-downing over having the• Everyone needs to depend on someone problem or needing assistance; and anxiety about stronger than themselves. coming to the interview.• I should become upset when other people have Finally, possibly the best way to engage a cli- problems, and feel unhappy when they’re sad. ent is to demonstrate to them at an early stage that change is possible and that CBT is able to assist• I shouldn’t have to feel discomfort and pain – I them to achieve this goal. can’t stand them and must avoid them at all costs.• Every problem should have an ideal solution – and it’s intolerable when one can’t be found. Page 4 of 12
  • 5. Assess the problem, person, and situation • Warn that relapse is likely for many mentalAssessment will vary from person to person, but health problems and ensure the client knowsfollowing are some of the most common areas that what to do when their symptoms return.will be assessed as part of an CBT intervention. • Discuss their views on asking for help if needed in the future. Deal with any irrational• Start with the client’s view of what is wrong beliefs about coming back, like: ‘I should be for them. cured for ever’, or: ‘The therapist would think• Determine the presence of any related clinical I was a failure if I came back for more help’. disorders.• Obtain a personal and social history. The practice principles of CBT• Assess the severity of the problem. • The basic aim of CBT is to leave clients at the• Note any relevant personality factors. completion of therapy with freedom to choose• Check for any secondary disturbance: How their emotions, behaviours and lifestyle does the client feel about having this problem? (within physical, social and economic re- straints); and with a method of self-• Check for any non-psychological causative observation and personal change that will help factors: physical conditions; medications; sub- them maintain their gains. stance abuse; lifestyle/environmental factors. • Not all unpleasant emotions are seen as dys-Prepare the client for therapy functional. Nor are all pleasant emotions func- tional. CBT aims not at ‘positive thinking’; but• Clarify treatment goals. rather at realistic thoughts, emotions and be-• Assess the client’s motivation to change. haviours that are in proportion to the events• Introduce the basics of CBT, including the bi- and circumstances an individual experiences. opsychosocial model of causation. • Developing emotional control does not mean• Discuss approaches to be used and implica- that people are encouraged to become limited tions of treatment. in what they feel – quite the opposite. Learn- ing to use cognitive-behavioural strategies• Develop a contract. helps oneself become open to a wider range ofImplement the treatment programme emotions and experiences that in the past they may have been blocked from experiencing.Most of the sessions will occur in the implemen-tation phase, using activities like the following: • There is no ‘one way’ to practice CBT. It is ‘selectively eclectic’. Though it has techniques• Analysing specific episodes where the target of its own, it also borrows from other ap- problems occur, ascertaining the beliefs in- proaches and allows practitioners to use their volved, changing them, and developing rele- imagination. There are some basic assump- vant homework (known as ‘thought recording’ tions and principles, but otherwise it can be or ‘rational analysis’). varied to suit one’s own style and client group.• Developing behavioural assignments to reduce • CBT is educative and collaborative. Clients fears or modify ways of behaving. learn the therapy and how to use it on them-• Supplementary strategies & techniques as ap- selves (rather than have it ‘done to them’). The propriate, e.g. relaxation training, interper- therapist provides the training – the client car- sonal skills training, etc. ries it out. There are no hidden agendas – all procedures are clearly explained to the client.Evaluate progress Therapist and client together design homeworkToward the end of the intervention it will be im- assignments.portant to check whether improvements are due to • The relationship between therapist and clientsignificant changes in the client’s thinking, or is seen as important, the therapist showingsimply to a fortuitous improvement in their exter- empathy, unconditional acceptance, and en-nal circumstances. couragement toward the client. In CBT, the relationship exists to facilitate therapeuticPrepare the client for termination work – rather than being the therapy itself.It is usually very important to prepare the client to Consequently, the therapist is careful to avoidcope with setbacks. Many people, after a period activities that create dependency or strengthenof wellness, think they are ‘cured’ for life. Then, any ‘needs’ for approval.when they slip back and discover their old prob- • CBT is brief and time-limited. It commonly in-lems are still present to some degree, they tend to volves five to thirty sessions over one to eight-despair and are tempted to give up self-help work een months. The pace of therapy is brisk. Aaltogether. minimum of time is spent on acquiring back- ground and historical information: it is task- Page 5 of 12
  • 6. oriented and focuses on problem-solving in the that person hold their demanding core belief. present. When they say ‘No’, help them see that they• CBT tends to be anti-moralistic and scientific. are holding a double-standard. This is espe- Behaviour is viewed as functional or dysfunc- cially useful with resistant beliefs which the tional, rather than as good or evil. CBT is client finds hard to give up. based on research and the principles of logic • Catastrophe scale: this is a useful technique to and empiricism, and encourages scientific get awfulising into perspective. On a white- rather than ‘magical’ ways of thinking. board or sheet of paper, draw a line down one Finally, the emphasis is on profound and last- side. Put 100% at the top, 0% at the bottom, anding change in the underlying belief system of the 10% intervals in between. Ask the client to rateclient, rather than simply eliminating the present- whatever it is they are catastrophising about,ing symptoms. The client is left with self-help and insert that item into the chart in the appro-techniques that enable coping in the long-term priate place. Then, fill in the other levels withfuture. items the client thinks apply to those levels. You might, for example, put 0%: ‘Having aA typical CBT interview format quiet cup of coffee at home’, 20%: ‘Having toWhat happens in a typical CBT interview? Here is mow the lawns when the rugby is on television’,how a typical interview would progress: 70%: being burgled, 90%: being diagnosed with1. Review the previous session’s homework. Re- cancer, 100%: being burned alive, and so on. inforce gains and learning. If not completed, Finally, have the client progressively alter the help the client identify and deal with the position of their feared item on the scale, until it blocks involved. is in perspective in relation to the other items.2. Establish the target problem to work on in this • Devil’s advocate: this useful and effective session. technique (also known as reverse role-playing)3. Assess the emotion and/or behaviour: specifi- is designed to get the client arguing against cally what did the client feel and/or do? their own dysfunctional belief. The therapist4. Identify the thinking that lead to the unwanted role-plays adopting the client’s belief and vig- emotions or behaviours. orously argues for it; while the client tries to5. Help the client check out the evidence for ‘convince’ the therapist that the belief is dys- and/or logic behind their thinking, preferably functional. It is especially useful when the cli- using ‘Socratic questioning’ (‘What evidence ent now sees the irrationality of a belief, but are you using ... ?’ ‘How is it true that ... ?’ needs help to consolidate that understanding. etc. Replace beliefs that are agreed to be dys- (NB: as with all techniques, be sure to explain functional. it to the client before using it).6. Plan homework assignments to enable the cli- • Reframing: another strategy for getting bad ent to put new functional beliefs into practice. events into perspective is to re-evaluate them as ‘disappointing’, ‘concerning’, or ‘uncomfort-Techniques Used In CBT able’ rather than as ‘awful’ or ‘unbearable’. AThere are no techniques that are essential to CBT – variation of reframing is to help the client seeone uses whatever works, assuming that the strat- that even negative events almost always have aegy is compatible with CBT theory (the ‘selectively positive side to them, listing all the positives theeclectic’ approach). However, the following are client can think of (NB: this needs care so that itexamples of procedures in common use. does not come across as suggesting that a bad experience is really a ‘good’ one).Cognitive techniques• Rational analysis: analyses of specific episodes Imagery techniques to teach client how to uncover and dispute irra- • Time projection: this technique is designed to tional beliefs (as described above). These are show that one’s life, and the world in general, usually done in-session at first – as the client continue after a feared or unwanted event has gets the idea, they can be done as homework. come and gone. Ask the client to visualise the (There is an example at the end of this article). unwanted event occurring, then imagine going• Double-standard dispute: If the client is hold- forward in time a week, then a month, then six ing a ‘should’ or is self-downing about their months, then a year, two years, and so on, con- behaviour, ask whether they would globally sidering how they will be feeling at each of rate another person (e.g. best friend, therapist, these points in time. They will thus be able to etc.) for doing the same thing, or recommend Page 6 of 12
  • 7. see that life will go on, even though they may where there is a chance of failing or not match- need to make some adjustments. ing their expectations. Or a client who fears re-• The ‘worst-case’ technique: people often try to jection might talk to an attractive person at a avoid thinking about worst possible scenarios party or ask someone for a date. in case doing so makes them even more anx- • Stimulus control: sometimes behaviours be- ious. However, it is usually better to help the come conditioned to particular stimuli; for ex- client identify the worst that could happen. ample, difficulty sleeping can create a connec- Facing the worst, while initially increasing tion between being in bed and lying awake; or anxiety, usually leads to a longer-term reduc- the relief felt when a person vomits after binge- tion because (1) the person discovers that the ing on food can lead to a connection between ‘worst’ would be bearable if it happened, and bingeing and vomiting. Stimulus control is de- (2) realises that as it probably won’t happen, signed to lengthen the time between the stimu- the more likely consequences will obviously lus and the response, so as to weaken the con- be even more bearable; or (3) if it did happen, nection. For example, the person who tends to they would in most cases still have some con- lie in bed awake would get up if unable to sleep trol over how things turn out. for 20 minutes and stay up till tired. Or the per-• The ‘blow-up’ technique: this is a variation of son purging food would increase the time be- ‘worst-case’ imagery, coupled with the use of tween a binge and the subsequent purging. humour to provide a vivid and memorable ex- • Paradoxical behaviour: when a client wishes perience for the client. It involves asking the to change a dysfunctional tendency, encourage client to imagine whatever it is they fear hap- them to deliberately behave in a way contra- pening, then blow it up out of all proportion till dictory to the tendency. Emphasise the impor- they cannot help but be amused by it. Laughing tance of not waiting until they ‘feel like’ doing at fears helps get them under control. it: practising the new behaviour – even though it is not spontaneous – will gradually internal-Behavioural techniques ise the new habit.One of the best ways to check out and modify a • Stepping out of character: is one common type ofbelief is to act. Clients can be encouraged tocheck out the evidence for their fears and to act in paradoxical behaviour. For example, a perfec-ways that disprove them. tionistic person could deliberately do some things to less than their usual standard; or someone who• Exposure: possibly the most common behav- believes that to care for oneself is ‘selfish’ could ioural strategy used in CBT involves clients indulge in a personal treat each day for a week. entering feared situations they would normally avoid. Such ‘exposure’ is deliberate, planned • Postponing gratification is commonly used to and carried out using cognitive and other cop- combat low frustration-tolerance by deliber- ing skills. The purposes are to (1) test the va- ately delaying smoking, eating sweets, using lidity of one’s fears (e.g. that rejection could alcohol, sexual activity, etc. not be survived); (2) de-awfulise them (by see- Other strategies ing that catastrophe does not ensue); (3) de- • Skills training, e.g. relaxation, social skills. velop confidence in one’s ability to cope (by successfully managing one’s reactions); and • Reading (self re-education). (4) increase tolerance for discomfort (by pro- • Tape recording of interviews for the client to gressively discovering that it is bearable). replay at home.• Hypothesis testing: with this variation of ex- Probably the most important CBT strategy is posure, the client (1) writes down what they homework. This includes reading, self-help exer- fear will happen, including the negative con- cises such as thought recording, and experiential sequences they anticipate, then (2) for home- activities. Therapy sessions can be seen as ‘train- work, carries out assignments where they act ing sessions’, between which the client tries out in the ways they fear will lead to these conse- and uses what they have learned. At the end of quences (to see whether they do in fact occur). this article there is an example of a homework format which clients can use to analyse specific• Risk-taking: the purpose is to challenge beliefs episodes where they feel or behave in the ways that certain behaviours are too dangerous to they are trying to change. risk, when reason says that while the outcome is not guaranteed they are worth the chance. For example, if the client has trouble with perfec- tionism or fear of failure, they might start tasks Page 7 of 12
  • 8. Applications of CBT • Child or adolescent behaviour disorders • Relationship and family problemsCBT has been successfully used to help peoplewith a range of clinical and non-clinical problems, Modalitiesusing a variety of modalities. Typical clinical ap- The most common use of CBT is with individualplications include: clients, but this is followed closely by group• Depression work, for which CBT is eminently suited. CBT is• Anxiety disorders, including obsessive- also frequently used with couples, and increas- compulsive disorder, agoraphobia, specific ingly with families. phobias, generalised anxiety, posttraumatic stress disorder, etc. Learning to use CBT• Eating disorders To practise CBT it is important to have a good• Addictions understanding of dysfunctional thinking. This can• Hypochondriasis be gained by a critical reading of the substantial• Sexual dysfunction literature available.• Anger management The use of CBT in the interview situation is• Impulse control disorders best learned by attending a training course It can• Antisocial behaviour also be observed by reading verbatim records of• Jealousy interviews or from audio or video tapes of inter-• Sexual abuse recovery views conducted by CBT practitioners.• Personality disorders The most effective way you can learn how to• Adjustment to chronic health problem, physi- help clients uncover and dispute irrational beliefs cal disability, or mental disorder is to practice CBT on oneself, for example by us- ing written ‘self-analysis’ exercises (see the last• Pain management page of this article).• General stress management___________________________________________________________________________________ READING LISTThere are many hundreds of books and articles based on CBT. Here is a small selection of what is available.Self-Help Books duction Workbook. Oakland, CA: New Harbinger Publications.Beck, A. (1988). Love Is Never Enough. New Dryden, Windy. (1997). Overcoming Shame.York: Harper & Row. London: Sheldon Press.Birkedahl, Nonie. (1990). The Habit Control Dumont, R. (1997). The Sky Is Falling: Under-Workbook. Oakland, CA: New Harbinger Publica- standing & coping with phobias, panic, and ob-tions. sessive-compulsive disorders. New York: Norton.Bourne, Edmund J. (1995). The Anxiety & Phobia Ellis, Albert & Abrams, Michael. (1994). How toWorkbook (Second Edition). Oakland, CA: New Cope With a Fatal Illness: the rational manage-Harbinger Publications. ment of death and dying. New York: BarricadeBurns, David M. (1980). Feeling Good: The New Books, Inc.Mood Therapy. New York: Signet, New Ameri- Ellis, Albert & Harper, Robert A. (1975). A Newcan Library. Guide to Rational Living. Hollywood: WilshireCalabro, Louis E. (1990) Living with Disability. Book Company.New York: Institute for Rational-Emotive Ther- Ellis, Albert. (1997). Anger – How to Live With andapy. Without It. New York: Carol Publishing Group.Cooper, C.L. & Palmer, S. (2000). Conquer Your Ellis, T.T. & Newman, C.F. (1996). Choosing toStress. London: Chartered Institute of Personnel Live: How to defeat suicide through cognitiveand Development. therapy. Oakland: New Harbinger Publications.Copeland, Mary Ellen. (1998). The Worry Control Fanning, Patrick & McKay, Matthew. (1993).Workbook. Oakland, CA: New Harbinger Publica- Being a Man: A guide to the new masculinity,tions. Oakland, CA: New Harbinger Publications.Davis, Martha. Eshelman, Elizabeth R. & McKay, Froggatt, W. (1997). GoodStress: The life thatMatthew. (1988). The Relaxation and Stress Re- can be yours. Auckland: HarperCollins. Page 8 of 12
  • 9. Froggatt, W. (2003). Choose to be Happy: Your Beck, J.S. (1995). Cognitive Therapy: Basics andstep-by-step guide (Second Edition). Auckland: beyond. New York: Guilford PressHarperCollins. Bond, F.W. & Dryden, W. (2002). Handbook ofFroggatt, W. (2003). FearLess: Your guide to Brief Cognitive Behaviour Therapy. Chichester:overcoming anxiety. Auckland. HarperCollins John Wiley & Sons Ltd.Froggatt, W. (in press, June 2006). Taking Con- Borcherdt, B. (2002). Humor and its contributionstrol: Managing stress to get the most out of life. to mental health. Journal of Rational-Emotive &Auckland: HarperCollins. Cognitive-Behaviour Therapy. 20:3/4, 247-257Hauck, Paul. (1983). How to Love and be Loved. Bouman, T.K. & Visser, S. (1998). Cognitive andLondon: Sheldon Press. Behavioural Treatment of Hypochondriasis. Psy- chotherapy and Psychosomatics. 67, 214-221Jakubowski, P., & Lange, A.J. (1978). The Asser-tive Option: Your Rights & Responsibilities. Chadwick, P. Birchwood, M. & Trower, P.Champaign, Il: Research Press. (1996). Cognitive Therapy for Delusions, Voices and Paranoia. Chichester: Wiley.Oliver, Rose & Bock, Fran. (1987). Coping withAlzheimers: A Caregivers Emotional Survival Cigno, K. & Bourn, D. (Eds.). (1998). Cognitive-Guide. North Hollywood: Wilshire Book Com- Behavioural Social Work in Practice. Aldershot:pany. Ashgate Publishing Group.Robb, H.B. (1988). How to Stop Driving Yourself Ellis, A. (1971). Growth Through Reason. Holly-Crazy With Help From the Bible. New York: In- wood: Wilshire Book Co.stitute for Rational-Emotive Therapy. Ellis, A. (1976). The biological basis of humanRobin, Mitchell W. & Balter, Rochelle. (1995). irrationality. Journal of Individual Psychology.Performance Anxiety. Holbrook, Massachusetts: 32, 145-168Adams Publishing. Ellis, A. (1985). Overcoming Resistance: Ra-Sandbek, Terence J. (1993). The Deadly Diet: tional-Emotive Therapy With Difficult Clients.Recovering From Anorexia & Bulimia.. Oakland, New York: Springer.Ca: New Harbinger Publications. Ellis, A. (1986). Fanaticism That May Lead To ASeligman, Martin E.P. (1994). What You Can Nuclear Holocaust. J. Of Counselling & Devel-Change and What You Cant: The complete guide opment. 65, 146-151to successful self-improvement. Sydney: Random Ellis, A. (1987). A Sadly Neglected CognitiveHouse. Element in Depression. Cognitive Therapy & Re-Steketee, Gail & White, Kerrin. (1990). When search. 11, 121-146Once Is Not Enough: Help for obsessive- Ellis, A. (1991). The Revised ABCs of Rational-compulsives. Oakland, CA: New Harbinger Publi- Emotive Therapy. Journal of Rational-Emotive &cations. Cognitive-Behavior Therapy. 9(3), 139-172Wolfe, Janet. (1992). What to Do When He Has a Ellis, A. (1994). Reason and Emotion inHeadache: How to rekindle your mans desire. Psychotherapy (Rev.Ed.). New York: CarolLondon: Thorsons. Publishing Group. Ellis, A. (1999). Early theories and practices ofProfessional Literature Rational Emotive Behaviour Therapy and how they have been augmented and revised during theAltrows, Irwin F. (2002). Rational Emotive and last three decades. Journal of Rational-EmotiveCognitive Behavior Therapy with Adult Male Of- and Cognitive-Behavior Therapy. 17(2), 69-93fenders. Journal of Rational-Emotive & Cogni- Ellis, A. (1999). Rational Emotive Behaviourtive-Behaviour Therapy. 20:3/4, 201-222 Therapy and Cognitive-Behaviour Therapy forAndrews, G., Creamer, M., Crino, R., Hunt, C., Elderly People. Journal of Rational-Emotive &Lampe, L. & Page, A. (2003). The Treatment of Cognitive-Behaviour Therapy. 17(1), 5-18Anxiety Disorders: Clnician guides and patient Ellis, A. (2003). Discomfort Anxiety: A Newmanuals. Cambridge: Cambridge University Press. Cognitive-Behavioral Construct. Journal of Ra-Beck, A. T., Emery, G. & Greenberg, R. L. tional-Emotive & Cognitive-Behaviour Therapy.(1985). Anxiety Disorders and Phobias. New 21:3/4, 183-202York: Basic Books Ellis, A. (2003). Reasons why Rational EmotiveBeck, A.T., Freeman, A., Davis D.D. & Associ- Behavior Therapy is relatively neglected in theates. (2003). Cognitive Therapy of Personality professional and scientific literature. Journal ofDisorders (2nd Edition). New York: Guilford. Rational-Emotive & Cognitive-Behaviour Ther-Wright, Thase, Beck & Ludgate. (1993). Cogni- apy. 21,3/4: 245-252tive Therapy With Inpatients : Developing a Cog- Ellis, A. (2004). Why Rational Emotive Behaviournitive Milieu. New York: Guilford Press Therapy is the most comprehensive and effective form Page 9 of 12
  • 10. of behaviour therapy. Journal of Rational-Emotive & behavioural therapy for schizophrenia. Journal ofCognitive-Behaviour Therapy. 22:2, 85-92 Rational-Emotive and Cognitive-Behavior Ther-Ellis, A. & Abrams, M. (1994). How to Cope With apy. 18(4), 247-261a Fatal Illness: the rational management of death Graham, P. (Ed.). (1998). Cognitive Behaviourand dying. New York: Barricade Books, Inc. Therapy for Children and Families. Cambridge:Ellis, A. & Bernard, M.E. (Eds.). (1985). Clinical Cambridge University Press.Applications of Rational-Emotive Therapy. New Haddock, G. & Slade, P. D. (1996). Cognitive-York: Plenum. Behavioural Interventions with Psychotic Disor-Ellis, A. & Dryden, W. (1990). The Essential Al- ders. London: Routledge.bert Ellis. New York: Springer. Hays, P.A. (1995). Multicultural applications ofEllis, A. & Dryden, W. (1991). A Dialogue With cognitive-behavior therapy. Professional Psy-Albert Ellis. Stony Stratford, England: Open Uni- chology: Research and Practice. 26, 309-315versity Press. Hawton, K., Salkovskis, P.M., Kirk, J. & Clark,Ellis, A. & Greiger, R. (Eds.). (1977). Handbook D.M. (1989). Cognitive-Behaviour Therapy for Psy-Of Rational-Emotive Therapy (vol 1). New York: chiatric Problems. Oxford: Oxford University Press.Springer. Horvath, A.T. & Velten, E. (2000). Smart Recovery:Ellis, A. & Greiger, R. (Eds.). (1986). Handbook Addiction recovery from a cognitive-behaviouralOf Rational-Emotive Therapy (vol 2). New York: perspective. Journal of Rational-Emotive and Cogni-Springer. tive-Behavior Therapy. 18(3), 181-191Ellis, A., McInerney, J., DiGiuseppe,R. & Jensen, L.H. & Kane, C.F. (1996). CognitiveYeager,R. (1988). Rational-Emotive Therapy Theory Applied to the Treatment of Delusions ofWith Alcoholics And Substance Abusers. New Schizophrenia. Archives of Psychiatric Nursing.York: Pergamon Press. X(6), 335-341Ellis, A., Sichel, J., Yeager, R., DiMattia, D., & Johnson, M. & Kazantzis, N. (2004). CognitiveDiGiuseppe, R. (1989). Rational-Emotive Cou- Behavioral Therapy for Chronic Pain: Strategiesples Therapy. New York: Pergamon. for the Successful Use of Homework Assign-Ellis, A., Young, J. & Lockwood, G. (1987). Cog- ments. Journal of Rational-Emotive & Cognitive-nitive Therapy and Rational-Emotive Therapy: A Behaviour Therapy. 22:3, 189-218Dialogue. J. of Cognitive Psychotherapy. 1(4) Kiehn, B. & Swales, M.A. (1995). An OverviewEllis, Gordon, Neenan & Palmer. (1997). Stress of Dialectical Behaviour Therapy in the Treat-Counselling: A Rational Emotive Behavioural ment of Borderline Personality Disorder.Approach. London: Cassell. http://www.priory.com/dbt.htm. Internet: Psychia- try Online.Fava, G.A., Rafanelli, C., Grandi, S., Conti, S. &Belluardo, P. (1998). Prevention of recurrent depres- Kingdon, D., Turkington, D. & John, C. (1998).sion with cognitive behavioral therapy: preliminary Cognitive-Behaviour Therapy of Schizophrenia.findings. Arch Gen Psychiatry. 55(9), 816-20 British Journal of Psychiatry. Pp 581-587France, R. & Robson, M. (1997). Cognitive Be- Kinsella, P. (2002). Food for thought: REBT andhavioural Therapy in Primary Care. London: Jes- other approaches to obesity. The Rational Emo-sica Kingsley Publishers. tive Behaviour Therapist. 10(1), 37-44Free, M. L. (1999). Cognitive Therapy in Groups: Kush, F. R. (2000). An Innovative Approach toGuidelines and resources for practice. Chiches- Short-Term Group Cognitive Therapy in theter, England: John Wiley & Sons Ltd. Combined Treatment of Anxiety and Depression. Group Dynamics: Theory, Research, and Prac-Friedberg, R. D., Crosby, L. E., Friedberg, B.A., tice. 4(2), 176-183Rutter, J. G., & Knight, K. R. (2000). Making cog-nitive behavioral therapy user friendly to children. Laidlaw, K., Thompson, L.W., Dick-Siskin, L. &Cognitive and Behavioral Practice. 6, 189-200 Gallagher-Thompson, D. (2003). Cognitive Be- haviour Therapy with Older People. Chichester:Froggatt, W. (2002). The Rational Treatment of John Wiley & Sons Ltd.Anxiety: An outline for cognitive-behavioural in-tervention with clinical anxiety disorders. Hast- Lam, D.H., Hayward, P. & Bright, J.A. (1999).ings. Rational Training Resources. Cognitive Therapy for Bipolar Disorder: A thera- pists guide to concepts, methods and practice.Gibbs, J. C., Potter, G.B. & Goldstein, A. P. Chichester: Wiley.(1995). The Equip Program: Teaching youth tothink and act responsibly through a peer-helping Lawton, B. & Feltham, C. (2000). Taking Super-approach. Champaign, Illinois: Research Press. vision Forward: Enquiries and Trends in Coun- selling and Psychotherapy. London: Sage.Glaser, N.M., Kazantzis, N., Deane, F.P. andOades, L.G. (2000). Critical issues in using Lear, G. (1995). Pain relief in children. New Zea-homework assignments within cognitive- land Practice Nurse. Feb, 40-42 Page 10 of 12
  • 11. Leahy, R.L. (2003). Cognitive Therapy Techniques: Tarrier, N., Wells, A. & Haddock, G. (1999).A practitioner’s guide. New York: Guilford. Treating Complex Cases: The cognitive behav-Marshall, W., Anderson, D. & Fernandez, Y.M. ioural therapy approach. Chichester: Wiley.(1999). Cognitive Behavioural Treatment of Sex- Treatment Protocol Project. (1997). Managementual Offenders. Chichester: Wiley. of Mental Disorders (Second Edition). Sydney:McMullin, R.E. (2000). The New Handbook of World Health Organisation.Cognitive Therapy Techniques. New York: W.W. White, C. A. (2001). Cognitive Behavior TherapyNorton & Company. for Chronic Medical Problems: A guide to as-Meichenbaum, D. (1997). Treating post- sessment and treatment in practice. Chichester:traumatic stress disorder: A handbook and prac- Wiley.tice manual for therapy. Brisbane. John Wiley. Woods, P.J. & Ellis, A. (1996). Supervision inMoore, R. & Garland, A. (2003). Cognitive Ther- Rational Emotive Behaviour Therapy. Journal ofapy for Chronic & Persistent Depression. Chich- Rational-Emotive & Cognitive-Behavior Therapy.ester: Wiley. 14(2), 135-151Moorey, Stirling & Greer, D. (2002). Cognitive Ziegler, D.J. (2002). Freud, Rogers, and Ellis: ABehaviour Therapy for People With Cancer (2nd comparative theoretical analysis. Journal of Ra-Edition). Oxford: Oxford University Press. tional-Emotive and Cognitive-Behavior Therapy. 20(2)Nelson, H. (1997). Cognitive-Behavioural Ther-apy with Schizophrenia: A practice manual. Chel-tenham. Stanley Thornes (Publishers) Ltd. How to obtain items on this listNelson-Jones, R. (1999). Towards Cognitive-Humanistic Counselling. Counselling. 10(1), 49- Library Interloan54 Many of the items listed are available through thePalmer. S. (2002). Cognitive and Organisational interloan system. You can ask your employingModels of Stress that are suitable for use within organisation’s librarian to order them for you, orWorkplace Stress Management/Prevention, send a request to the EIT library.Coaching, Training and Counselling Settings. The PurchaseRational Emotive Behaviour Therapist. 10(1), 15-21 To purchase any of the books: 1. Have your local bookseller order it from over-Reinecke, M.A., Dattilio, F.M. & Freeman, A. seas.(Eds.). (2003). Cognitive Therapy with Childrenand Adolescents: A casebook for clinical practice. 2. Order via the internet: go to the Centre forNew York: Guilford. Cognitive Behaviour Therapy’s website (www.rational.org.nz) and click on ‘Book-Rubin, R., Walen, S. R. & Ellis, A. (1990). Living Shop’.With Diabetes. Journal of Rational-Emotive & 3. Some of the books, especially those onCognitive-Behavior Therapy. 8(1), 21-39 REBT, can be obtained from the Albert EllisScott, M.J., Stradling, S.G. & Dryden, W. (1995). Institute (www.rebt.org).Developing Cognitive-Behavioural Counselling.London: Sage Publications. CBT on the InternetSecker, L., Kazantzis, N. & Pachana, N. (2004).Cognitive Behavior Therapy for Older Adults: There are numerous internet sites related to CBT.Practical Guidelines for Adapting Therapy Struc- A good place to start searching would be the Cen-ture. Journal of Rational-Emotive & Cognitive- tre for Cognitive Behaviour Therapy website at:Behaviour Therapy. 22:2, 93-110 http://www.rational.org.nz (as well as viewingShortall, T. (1996). Cognitive-behavioural treat- articles on that site, go to the ‘Links’ page for ref-ment of recurrent headache. The Rational Emotive erences to other sites).Behaviour Therapist. 4(1), 27-33 Page 11 of 12
  • 12. Rational Self-AnalysisCBT emphasises teaching clients to be their own therapists. A useful technique to aid this is Rational Self-Analysis (Froggatt, 2003) which involves writing down an emotional episode in a structured fashion. Here isan example of such an analysis using the case example described earlier:A. Activating Event (what started things off): Friend passed me in the street without acknowledging me.C. Consequence (how I reacted): Feelings: worthless, depressed. Behaviour: avoiding people generally.B. Beliefs (what I thought about the ‘A’): 1. He’s ignoring me and doesn’t like me. (inference) 2. I could end up without friends for ever. (inference) This would be terrible. (evaluation) 3. I’m not acceptable as a friend (inference)- so I must be worthless as a person. (evaluation) 4. To feel worthwhile and be happy, I must be liked and approved by everyone significant to me. (core belief)E. New Effect (how I would prefer to feel/behave): Disappointed but not depressed.D. Disputation (of old beliefs and developing new rational beliefs to help me achieve the new reaction): 1. How do I know he ignored me on purpose? He may not have seen me. Even if he did ignore me, this doesn’t prove he dislikes me – he may have been in a hurry, or perhaps upset or worried in some way. 2. Even if it were true that he disliked me, this doesn’t prove I’ll never have friends again. And, even this unlikely possibility would be unpleasant rather than a source of ‘terror’. 3. There’s no proof I’m not acceptable as a friend. But even if I were, this proves nothing about the total ‘me’, or my ‘worthwhileness’. (And, anyway, what does ‘worthwhile’ mean?). 4. Love and approval are highly desirable. But, they are not absolute necessities. Making them so is not only illogical, but actually screws me up when I think they may not be forthcoming. Better I keep them as preferences rather than demands.F. Further Action (what I’ll do to avoid repeating the same irrational/thoughts reactions): 1. Re-read material on catastrophising and self-rating. 2. Go and see my friend, check out how things really are (at the same time, realistically accepting that I can’t be sure of the outcome). 3. Challenge my irrational demand for approval by doing one thing each day (for the next week) that I would normally avoid doing because of fear it may lead to disapproval.Copyright Notice: This document is copyright © to the author (2001-6). Single copies (which must include this notice)may be made for therapeutic or training purposes. To use in any other way, contact: Wayne Froggatt, PO Box 2292,Stortford Lodge, New Zealand. Fax 64-6-870-9964. E-mail: wayne@rational.org.nz Comments are welcomed. Page 12 of 12