Cognitive Behavior Therapy

COGNITIVE
BEHAVIOR THERAPY
- Pragya
Clinical Psychologist

What is CBT ?
◦ Process of teaching , coaching and reinforcing positive behaviors
◦ Focuses on: challenging and changing unhelpful cognitive distortions & behavior,
improving emotional regulation and develop coping strategies
◦ Helps to identify thoughts and emotions that are linked with behaviors
◦ Based on an assumption that psychiatric disorders or psychological problems arises
because of dysfunctional thinking

Assumptions of CBT
1. Cognitive processes impacts behavior
2. Cognitive processes can be monitored and changed
3. Behavior can be modified by modifying cognitions/thoughts

Goals of CBT
◦ To change the way clients think and behave
◦ To identify core beliefs and help in restructuring
◦ Encourage/help clients to gather evidences in support as well as against of their
beliefs or thinking
◦ To increase self-awareness and self-understanding
◦ To improve self-control

What determine our emotional response?
◦ It is not the event per se that determine our feelings but the meaning that we attach
to these events
◦ In order to understand a person’s emotional response to particular life events, it is
important to discover the meaning S/he attaches to these events, i.e., the subjective
construction of reality
◦ Person’s emotional problems are the impact of adverse events can be greatly
exacerbated by the person’s unhelpful thoughts and beliefs that interfere with the
ability to cope constructively with such events

Experience of emotional distress
◦ Cognitive theory is based on information-processing model
◦ During psychological distress, a person’s thinking or incoming information becomes
more rigid and distorted, judgments become overgeneralized and absolute
◦ Distorted thinking underlies all psychological disorder and these distortions usually
stem from deeper dysfunctional beliefs that are activated during emotional distress

Interaction of five elements
◦ Cognition/ thoughts in CBT interacts with behavior, physiology and emotions and
these system interacts with the wider context of their environment
◦ Understanding how these five aspects of person’s life are interconnected can help
the client to understand the problem better

Emotion in continuum
◦ CBT suggests there is continuity between normal emotional reactions to life events
and excessive or extreme emotional reactions found in psychopathology
◦ Normal emotional reactions are mature and flexible (you can’t please everyone)
◦ Extreme emotional reactions are primitive and absolute (I’m thoroughly unlikeable)

Specific cognitive content
◦ Emotional disorder have a specific cognitive content or theme running through them
(Content Specificity Hypothesis)
◦ These concepts of the personal domains (anything that the person considers
important in their life)
◦ The nature of person’s emotional disturbance depends on whether he perceive
events as adding to, subtracting from, endangering, or impringing upon

Cognitive vulnerability
◦ Vulnerability means an endogenous, stable characteristics that remains latent until
activated by a precipitating event
◦ Cognitive theory is a stress-diathesis model where diathesis is cognitive vulnerability
(maladaptive beliefs) and the stress is current adverse life events (precipitating
factors)

◦ The cognitive model was first put forward by Beck (1976) which possess the emotional
problem could be driven by patterns of negative thinking and problem could be
alleviated by changing thinking process
◦ It focuses on four key elements of psychological distress: thoughts, feelings, physical
sensation and behavior as well as the relationship between them
Thoughts
Feelings
Feelings (physical
sensations)
Behavior

Three levels of cognition
Negative Automatic Thoughts (NATs):
◦ Situation specific thoughts or images
◦ Involuntary pop into a person’s mind when in emotional distress
◦ Appear plausible to the person and difficult to turn-off
◦ Lies outside the immediate awareness but can be quickly brought to the attention
◦ Can be triggered by external or internal events
◦ Client’s tend not to notice that it effects their mood (either positive or negative
way)

Assumptions and rules (intermediate beliefs):
◦ Guide behavior and set standards
◦ Unarticulated and difficult to detect
◦ Usually identified by their ‘if…then’ or ‘unless…then’ and usually expressed in ‘must’
and ‘should’ statements
◦ Trouble is when standards are not met or rules are violated which activate the
negative core beliefs from its dormant state
◦ Focus on three major issues: acceptance (I’m nothing unless I’m loved),
Competence (I’m what I accomplish) and control (I can’t ask for help)
◦ Cross-sectional and lie between NATs and core beliefs

Core beliefs:
◦ Deepest level of cognition which may be latent
◦ Global and absolute beliefs
◦ Usually formed through early learning experience
◦ Dormant until activated by relevant life events. Once activated, they process
information in biased way
◦ It can be about self, others and the world

STRUCTURE OF THERAPY
AND SESSIONS

Length of therapy:
◦ 12-20 sessions, depending upon the nature, severity and complexity of the
problems
◦ CBT is time-limited, skills based therapy and requires active participation by the
clients
Frequency of sessions:
◦ Weekly or fortnightly
◦ This allows enough time for practice, experimentation and reflection between
sessions without running the risk of losing momentum
◦ Frequency of sessions can be adjusted as therapy progresses

Session Length:
◦ 45-60 minutes
◦ Shorter session length is needed when,
1. Client starts to appear restless or fidgety
2. Client is unable to reflect back an understanding of what has been discussed
3. Client is socially anxious
Regular reviews:
◦ Every six sessions
◦ Help to identify difficulties in engagement of client

Structure of therapy:
EARLY STAGE
Focus on engagement
and assessment
Education about the
CBT model
Development of CBT
formulation
MIDDLE STAGE
Practice and review of
the CBT techniques
Reformulation
LATER STAGE
Relapse management
Coping with set backs
Review of summary,
formulation and skills/
techniques learned

Issues (must consider)
Clinical issues Therapy structure considerations
Clients find it difficult to express feelings
or communicate problems
• Spend time on engagement
• Non-problem focused talk
Client seems confused or may lack insight • Lengthened formulation period
• The formulation should be revisited
frequently
Client is uncertain about psychological
treatment of their problem
• Spend time on formulation and
education about CBT model

Client has fixed NATs or limited capacity to
see things from alternate viewpoints
• Start with behavioral intervention/task
• after success in behavioral task,
introduce cognitive task
Client is anxious about completing
behavioral goals
• Spend time in planning behavioral
• Plan very small goals
• Challenge negative beliefs about
completing goals

Clients find it difficult to identify thoughts,
feelings and behavior
• Spend time on education of CBT model
• Educate about difference between
thoughts, feelings and behavior
• Spend time on cognitive tasks

Overview of a session
Setting the agenda
(5 minutes)
Update (5 minutes)
Homework review
(5-10 minutes)
Specific CBT
strategies (20-25
minutes)
Setting homework
task (5 minutes)
Reflection of session
(5 minutes)

◦ The first few sessions are used to gather information in order to developing a
hypothesis and treatment plan
◦ It tends to be an explanation rather than label
◦ It contains essentially:
Predisposing
factors
Information
about past
history and
covers
childhood or
teenage years
Precipitating
factors
Events or
circumstances
contributed to
development of
symptoms
Protective
factors
Help the client
to cope
Triggers
Issues that sets
off the
symptoms on
regular basis
Symptoms
Under four
main
categories:
physical,
thoughts,
feelings and
behavior
Maintenance
cycle
All the above
information fit
together

Socratic questioning (guiding discovery)
◦ Used throughout each stage of therapy
◦ Used to gain information about the client’s lives and explore the alternatives
together
◦ Gives the client an opportunity to be more active in the therapeutic process
◦ It involves asking questions about:
1. Client has knowledge to answer
2. Draw attention to information that are relevant but outside the client’s focus
3. To move from concrete to abstract
4. Construct a new idea

• Asking relevant questions to which client is not
aware
Asking informational
questions
• Therapist actively listens to the answers of clients
• Discovery of new information
Listening
• To check if they think along the same lines
• Reflect back the gained information
Summarizing
• Use the new information from the client and apply
it to client’s concern/belief
Synthesizing/analytical
questions
Four main stages of
Socratic Questioning
approach

Interview
Initial stage:
◦ Educate the purpose of assessment is to get an overview of the client’s difficulties
◦ Rapport building
◦ Explain about the confidentiality and the process during this time and do not get
into details

Initial problem list, onset and course:
◦ Main problem/ issues
◦ Information regarding how the problems have been developed over time
◦ Why is the client presented now?
Triggers:
◦ Situations, thoughts or feelings that sets the symptoms off on daily basis
◦ Identify whether its internal or external

Symptoms (maintaining factors)
◦ Thoughts (what runs through your mind?)
◦ Feelings (when you have thoughts like that how do you feel?)
◦ Physiological (what does your body feel like when you experience this problem?)
◦ Behavior (what do you do to cope in these situations?)
◦ Avoidance (what things have you stopped doing since you’ve experienced these
difficulties?)

Ways of coping:
◦ Assess how has the client has been coping with the problem
◦ Sometimes person indulge in behavior which is helpful in short term, which is not
beneficial in long term. Identify those behavior
◦ Identify avoidance or safety behavior
Precipitating factors:
◦ Find out what was happening at the time when person developed problem
◦ Do not lost in details
◦ Ask questions that is relevant to the problem

Predisposing factors:
◦ Information regarding client’s background, which would make them vulnerable to
develop the problem
Protective factors:
◦ Gain information about the person’s strength
OTHER ASSESSMENT TOOLS
1. Self monitoring
2. Self-report questionnaires

Note
◦ Depressed people have often experienced trauma at some time in their lives or their
need not being met in some way and may developed negative beliefs based on
these experiences
◦ Guilt and shame can be important emotion
◦ It is important to ask about whether they have ever thought of harming themselves
and identify whether the self harm as a coping strategy or with suicidal intent
◦ As a coping strategy, it is helpful for short-term but in long term it may lead to
scarring (leads to lower self esteem) or in case of overdosing (serious health
problem)

Case conceptualization
◦ The CBT formulation or case conceptualization provides the overall picture of the
development and maintenance of the client’s problems
◦ It explain how and why the client’s problem developed and why the problems are
persisting through patterns of thinking, feelings and behaving

Functions
1. Developing a shared understanding with the client
2. increasing hope
3. Prioritization of problems for treatment
4. Overcoming therapist bias
5. Communication tool among professionals or family members
6. Individualization of treatment
7. Predicting difficulty

Precipitating factors Precipitating factors Protective factors
Core beliefs
Assumptions
Trigger situations/critical incidents
Problems
Thoughts Emotions Physical sensations Behaviors

◦ First sheet, historical information about client and list identified thoughts, emotions,
physical sensations and behaviors
◦ Second sheet, thoughts, thoughts, emotions, physical sensations and behaviors as a
maintenance cycle
◦ Bottom sheet, current/cross-sectional information regarding the problem
◦ Purpose:
1. Top part- help the client understand why they develop a certain core belief or
automatic thoughts
2. Bottom part- practically used in therapy to start with

Developing the formulation
Predisposing factors:
◦ Personal predisposing factors- genetics, birth & developmental problems, disability,
personality, coping styles, social skills, self-esteem and intelligence
◦ Contextual predisposing factors- parenting & attachment style, family & school
experiences, early trauma and societal or cultural issues

Precipitating factors:
◦ Personal precipitating factors- illness, hormonal changes, pain and the activation of
genetic vulnerabilities
◦ Contextual precipitating factors- life changes, job stress, financial pressure,
unemployment, housing problems, relationship problems and loss of social support
◦ Exploration of what prevented the person from seeking help in the past, gives an
about apprehensions, fears or misinterpretations the person which may be a barrier

Protective factors:
◦ Personal protective factors- personality, intelligence, social skills, coping skills, sense
of humor, motivation and help seeking
◦ Contextual protective factors- positive & supportive relationships, employment and
access to help
Trigger factors:
◦ Things that set off the problems
◦ Identification is difficult in long term illness, due to avoidance behavior

Core beliefs:
◦ Global and deepest level of cognition
◦ Negative core beliefs generate many NATs
◦ Not apparent at the start of the therapy
◦ Identified at later stage through various techniques such as “downward arrow
technique”
Assumptions:
◦ Rules for living, serve the function of protecting people from negative core beliefs

Thoughts (NATs):
◦ Constant judgments or running commentary on person’s experience that run
a person’s mind
◦ Can be about self, others and world
◦ Includes words or images
Emotions:
◦ Dominant emotional states experienced by a person

Physical sensations:
◦ Emotional states usually have physiological correlates which client see them as a
separate physical issue
Behaviors:
◦ Either to cope with or to eliminate unpleasant emotional/physical feelings
◦ Can be overt (subtle), may include avoidance of situations or covert, may include
repeating over an over in mind

Reformulation
◦ Process of modifying a formulation
◦ Adding new information, that have been learnt in therapy process
◦ After discussing the maintenance cycle with the client, its helpful to draw potential
CBT intervention and go through the cycle again
◦ Replacing the negative thoughts with positive one
◦ Behavioral task, replace one behavior with a different one in order to break a
negative cycle

Challenges
1. Lack of collaboration:
◦ Arise because of the expectation of client or therapist or both
2. Client has medical model of illness:
◦ Depending upon health belief model, avoid debate whether the problems are
physical or psychological
◦ As per CBT model physical and emotional feelings affect each others

3. Client does not want to discuss the past:
◦ If client is reluctant, work on maintenance cycle without past history
◦ Current NATs are all that is needed
4. Formulation does not help in developing treatment plan:
◦ Client might be not ready to divulge certain information or even unaware of certain
things
◦ Spend more time on formulation stage

5. Formulation is either too complex or too simple:
◦ It needs to be detailed enough to hypothesize about development and
maintenance of problems without being unnecessarily complex
◦ Testing a formulation, if it
- Makes theoretical sense
- Fit with the evidence
- Account for predisposing, precipitating or maintenance factors
- Predict future difficulties
- Fit past history
- Predict treatment progress

◦ Helping the client to identify the coping strategies is most useful place to start once
formulation has been discussed and goals have been identified
◦ It is helpful with client to identify their own coping strategies before teaching new
strategies
◦ Strategies work more effectively if client practices them in relaxed state or feeling in a
reasonable mood as they will not able to use learnt strategies under stress until they
get used to of them under relaxed condition

Psycho-education
◦ Educating clients about CBT, psychology and symptoms, recognizing symptoms and
realizing what is happening to their body can act as a coping strategy
◦ Clients sometimes do not realize impact of psychological problem on their body,
thus find these symptoms very frightening
◦ Educating them about the relationship between these two and teach techniques to
help clients to control over some of the physical sensations such as breathing
exercises and progressive muscle relaxation

Breathing techniques
◦ When people feel stressed or anxious, they tend to breathe too quickly which may
leads to panic attack or breathing too fast and deeply may leads to physical
discomfort
◦ It helps to control their breathing when required
◦ The main task is to slow down the breathing and allow it to be controlled and
relaxed
◦ Clients are asked to practice the breathing once a day for 5-10 minutes

Relaxation techniques
◦ Involves lying down, closing the eyes and imagining a really lovely or safe place and
using all the senses to give reality to the scene
◦ Some task involves tensing and relaxing various parts of their body like feet, calves,
thighs, buttocks, stomach, biceps, forearms, hands, neck and face

Grounding techniques
◦ When people get very anxious they can feel numb and losing contact with their
environment
◦ It can help to bring the anxiety level down and helps the person to get in contact
with environment again
◦ Recognizing anxious feelings and then start to ground yourself:
1. Stamp your feet
2. Use breathing/relaxation exercises

4. Use a grounding/comforting object that you carry around and squeeze when you
feel stressed
5. Make contact with yourself, notice how body parts feel or touching the body
parts
6. Develop a grounding image, rehearse a calming image which makes you feel
relaxed
7. Develop a grounding phrase, to remind you that you are surviving in the present
◦ Make contact with environment, use each of the senses (sight, hearing, touch, taste,
smell) to get in contact with environment around you

Distraction techniques
◦ It is helpful but not when its only coping strategy as if someone is constantly
distracting themselves in order to save them from anxiety, it will be difficult for them
to be in present. Thus, it needs to be in moderation
1. Counting
2. Counting any thing
3. Visualization
4. Remembering a pleasant memory
5. Focusing on breathing slowly

Mindfulness
◦ Paying attention in particular way, in the moment and non-judgmentally
◦ It is about being in the moment, using the senses to become aware of what is
happening right now
◦ NATs might pop into the head on a regular basis but the aim is to notice them and
then turn the attention back to be in the moment
◦ Also helpful in the early stage of therapy

◦ Mindfulness exercises:
1. Observing the colors in a room
2. Listening to the sounds
3. Listening to a piece of music
4. Observing one’s breathing
5. Touching a piece of material
◦ Gaining benefits from the exercises may take time and clients have to practice it on a
daily basis

Behavioral intervention
◦ Strategies which help clients to target the behaviors that might be keeping the
maintenance cycle going
◦ Behavioral exposures are helpful in anxiety disorders such as OCD
◦ Active scheduling or behavioral activation are helpful in depression

Behavioral exposure
◦ It helps to the client to face up to situations they have been avoiding, usually
because of anxiety
◦ Used in anxiety disorders especially phobias, OCD and may be helpful in case of
depression where client use avoidance as a way of coping
◦ Educate the client and review the maintenance cycle
◦ Reminds the client that avoidance maintains the problem and discuss the ways to
reduce it

◦ Identify all things has been avoiding and graded hierarchy is prepared based on that
list
◦ Easiest, placed at bottom depending on client (must be manageable enough without
difficulty)
◦ Each goal should be given rating from 0-10 and needs to be specific
◦ Each goal on hierarchy needs to be slightly more difficult than last one
◦ Client educated to practice each goal until they feel comfortable before moving on
next one
◦ Client can be given practice diary to note down their goals on daily basis

Exposure with response prevention (ERP)
◦ Client with Obsessive problems may be exposed to anxiety and cutting down on
avoidance, reduce checking behaviors and reassurance seeking
◦ Client must educated or warned before treatment procedure
◦ Sometimes clients ritualize by using covert rituals (saying rhymes, repeating phrases),
they can be dealt in same way as behavioral or overt rituals
◦ Record sheets may not be useful for all clients with obsessional problems as they
might use it as an additional rituals

Behavioral experiments
◦ Client sets themselves goal but sees it as an experiment rather than goal, despite of
their success
◦ With this, leaving situations does not mean failure; it means an opportunity to learn
and do things differently next time
◦ It is useful especially at beginning of the therapy
◦ It gives the clients an opportunity to test out ideas and to realize that their feared
situations may not be as bad as they were imagining

Activity monitoring and scheduling
◦ Useful in patients with depression, to help them monitor their activities and plan the
schedule
◦ Main symptoms of depression include: tiredness, lack of energy, low motivation;
patient trapped in a vicious cycle
◦ Feeling overwhelmed by small tasks and then criticize themselves for not doing
Anything, which makes them feel guilty and worthless leading to further lethargic
feelings

Feel low
Don’t feel like doing
anything,
so don’t do anything
Thoughts “I am useless”
Feelings: guilt, anxiety
Feel like doing even less
Thoughts “I am
worthless”

Start to do
something
Feel pleased
with self
Mood increases as
feel as sense of
achievements
Feel more
energetic
Start doing
another activity
Feel low and
depressed
Positive activity cycle

◦ Educate clients about positive activity cycle and then monitor current level of activity
◦ For each hour client has to make an entry and rate each activity for amount of mastery
and pleasure
◦ Also warn them, not to worry if rating is very low but try to differentiate amount of
pleasure for each activity
◦ After that, help client to add in or schedule activities for next week that are fairly
achievable
◦ This must happen slowly, as adding in too many activities can leave them feeling
pressurized and may make them feel worse

Psycho-education: Thoughts and beliefs
Difference between thoughts and fact:
◦ Human nature is to believe that our beliefs are true
◦ Patient with depression, anxiety or obsessional problem are prone to have rigid and
fixed beliefs
◦ Spend time exploring nature of thoughts and beliefs with client before identifying
and evaluating thoughts
◦ Discuss with client about difference between believing something to be true and
something actually being true. Important point to come out of this work is that
thought does not necessarily imply fact

Function of thoughts and beliefs:
◦ In order to function effectively, we make assumptions to predict what will happen in
given situation
◦ If we wont, then we treat each new situation naively as if it were first time and we
couldn’t generalize from other similar situation that we previously encountered-
extremely tedious and time consuming
◦ While we develop assumptions, we sometimes get them wrong
◦ Aim of CBT is not to remove them but to remove negative bias in these thoughts,
assumptions and beliefs

What get in the way of thoughts and reality?
◦ Discuss with client, how our thoughts are influenced by our interpretations of an
or situation and meaning that we attach to them
◦ As they are automatic, we are not usually aware of this process
Situation ThoughtsInterpretation

Additional education for patients with obsessional problem:
◦ Clients with obsessional problem will need to know more about the thoughts that
their thoughts are unwanted, repetitive and intrusive
◦ These thoughts are distressing as content of thoughts is unacceptable or shocking to
the person
◦ As per theory, usually humans experience such thoughts as random alerts to
risk and threats in environment. Normally these thoughts are ignored as they are
irrelevant

◦ Patient with obsessional problem do not dismiss these thoughts as irrelevant
◦ It is thought about thoughts (metacognition) or appraisals that determines whether
or not experience of intrusive thoughts leads to distress and leads to OCD
◦ They assume that as they thought the thought (or seen image) must mean something
terrible about themselves
◦ Sometimes, person thinks that having a bad thought is as bad as having done that act:
THOUGHT-ACTION FUSION

Identify NATs
◦ Identification is an essential step to change thought pattern through cognitive
techniques
◦ Problem is when clients are asked to identify and record NATs, they will consciously
attending to NATs more than usual, focus on the negative is that client can start to
feel even more negative or hopeless
◦ Some techniques which can be used to help clients elicit NATs-

Discussion of recent situations:
◦ Client is asked to recall a specific recent difficult situation or event, which should be
focused on and described in as much detail as possible
◦ Client should asked about their emotional response to situation
Use of imagery:
◦ If client is having trouble accessing NATs verbally or if the negativity of thought
associated with situation does not seem in proportion to level of distress reported, it
is helpful to ask about mental images

Worst case scenario:
◦ Useful technique for eliciting negative component of automatic thought
◦ Sometimes client will describe thought that is not in itself negative. It is rather
meaning behind statement
◦ Ask: ”what is worst thing that could happen?” “what does it mean if this true?”
Role play:
◦ Useful when thoughts and emotions associated with specific situations are not
from memory
◦ Therapist and client enact a situation in session, at key points therapist stops to ask
“how they are feeling?” or “what they are thinking?”

Diary keeping:
◦ Harder to access thoughts and emotions connected with specific situations after
situations has passed
◦ Therapist should ask client to keep a diary or record sheet between sessions, so that
important events can be remembered and discussed in therapy
◦ Recording emotions, physical sensations and behaviors in addition to NATs is useful,
this information is used to illustrate maintenance cycle
◦ Therapist should complete the record sheets first with client in session before asking
client to use it as homework
◦ Helps to spot patterns in thinking

Date Situations Emotion(s) Thoughts or images
Where were you?
Who was there?
What were you doing? When?
What did you feel at that time?
How strongly did you feel it? (0-10)
How strongly do you believe
the thought? (0-10)
Date Situations Emotion(s) Thoughts or
images
Physical
sensations
Behavior
Where were you?
Who was there?
What were you
doing? When?
What did you feel at
that time?
How strongly did you
feel it? (0-10)
How strongly do
you believe the
thought? (0-10)
Did you notice any
changes in your
body at that time?
What did you do
after
the NATs?
Thought record sheet (Basic)
Thought record sheet (Detailed)

Date Situation Intrusive
thought/image
Appraisals Emotion(S)
sensations
Physical
sensations
Behavior
Where were
Who was there?
What were you
doing? When?
What was the
thought or image
that come into
mind?
What was your
thought about
intrusive
thought?
What did you
feel at that time?
How strongly
did you feel it?
(0-10)
Did you notice
any changes in
your body at
that time?
What did you
do after
experiencing
the NATs?
Thought record sheet (OCD)

Suggested questions:
1. what was going through your mind?
2. What does this say about you if its true?
3. What are you afraid might happen?
4. What would be the worst thing that could happen if its true?
5. What does this mean about what other person think about you?
6. What does this mean about the other person in general?
7. What image do you have about the situation?

Thinking errors
◦ Different people are prone to different thinking biases
◦ Most client easily recognize at least 2-3 thinking bias that are common in their own
thinking
◦ Identification of them can instigate a challenge to negative thought
◦ Discuss with clients about different thinking errors:

• When the worst possible outcome is predicted and magnifiedCatastrophizing
• Guessing another person’s thoughtMind-reading
• Predicting a bleak future, without any evidenceFortune-telling
• Only seeing extremes, being unable to see grey area
All-or-nothing (Black-and-white)
thinking
• When positives are viewed as worthless or meaninglessDiscounting the positive
• Single negative event is viewed as affecting everything, as a signal that everything
will go wrongOvergeneralization
• Feeling responsible when not at fault
Personalization

Evaluation of NATs
◦ Thought evaluation is a cognitive technique that aims to correct negative bias in
thought processes
◦ This leads to more positive thoughts and behavior
◦ Once the client has necessary skills, NATs can be recorded and evaluated as
homework practices

Decide which NATs to focus on
◦ As session is time limited, focus on NATs that are central to client’s problem
◦ If several NATs are elicited in conversation, need to decide which thoughts to focus
on in session. It is helpful to revisit the formulation, therapy goals and session
agenda
◦ Must consider few things, before deciding-
1. NAT would fit into CBT maintenance cycle
2. Thought relate to problem was identified during assessment and formulation, if not
then must be dealt in different stage of therapy or practical problem dealt with
other support systems like problem solving

3. Addressing thought helps you and client to meet the goals: usually it is impossible
to cover all the problems.
If thoughts does not related with agenda topics, remind clients about it
If thoughts are very important, alter agenda based on new issue
If thought seems less pressing, discuss and put it on the agenda for following
sessions
4. Thought might reflect reality but it would be abnormal (Distorted or Dysfunctional),
if thought is an accurate interpretation of reality yet causing distress work on
coping strategies and problem solving

5. Thought must cause emotional distress, also look for physical sign of an emotional
impact of thought such as changes in breathing, speech and facial expression
6. Clients believe their NATs as true, then it has more impact on emotions and
behavior
◦ In case of obsessive thoughts, it is the appraisal of intrusive thought that needs
evaluation

Thought challenging
◦ CBT does not aim to directly challenge thoughts, assuming they are wrong but it aims
to explore NATs to find out if they are biased
◦ If they are biased then alternative ways of thinking are developed
◦ Therapist take a non-judgmental stance rather than assuming that thoughts are
wrong or biased
◦ Evaluating NATs is to consider evidence both ‘for thoughts’ and ‘against thoughts’
◦ Only direct factual evidence should be used is evaluation

◦ Thought evaluation sheets are tools that are used for thought evaluation process
◦ These should be completed together with the client in session to start with and then
practice it as homework
◦ Discuss each column of the thought evaluation sheet with clients
Date Situations Emotion(S) Thoughts or
images
Evidences
for thought
Evidence
against
thought
Alternative
(balanced)
thought
Where were you?
Who was there?
What were you
doing? When?
What did you feel
at that time?
How strongly did
you feel it? (0-10)
How strongly do
you believe the
thought? (0-10)
What direct
evidence do
you have to
support it?
What direct
evidence d you
have against it?
Rate how
strongly you
believe this
alternatively?

Suggested questions
1. Am I only noticing ‘down’ side of things?
2. Am I expecting myself to be perfect?
3. What would I say if my friend would think like this?
4. What would one of my closest friend say about this?
5. Am I assuming that my way of looking at things is only way?
6. Am I assuming that my way of looking at things is right way?
7. Am I blaming myself for something that is not my fault?
8. Am I judging myself more harshly than I would judge others?

9. What are pros and cons of thinking this thought?
10. Am I feeling hopeless about possibility of changing things?
11. What are the evidences for this thought?
12. Am I making any thinking errors?
13. Do I often think like this when in a certain state of mind?
14. When I am feeling different, do I think differently about things?
15. Are there certain situations or times when I see things differently?
16. Are there any experience I have had that contradict this thought?

Variation in thought evaluation sheet:
Depression
◦ There is balance to strike when designing thought evaluation sheet, need to be simple
enough to be user friendly yet captures all required information
◦ In depression, client usually have entrenched negative thoughts and are likely to
attend selectively to negative information while filtering out positive things
◦ They can actually generate lots of ‘evidence for’ but very little ‘evidence against’ which
actually serve to strengthen beliefs
Date Situations Emotion(s) NATs or images Alternative
thoughts/images
Outcome
Where were you?
Who was there?
What were you doing?
When?
that time?
How strongly did you
feel it? (0-10)
How strongly do you
believe the thought?
(0-10)
What are your new
balanced thought or
images?
How strongly do you
believed them? (0-10)
Re-rate NAT?
Re-rate emotions?

Variation in thought evaluation sheet:
OCD
◦ Information is needed on the intrusive thought and appraisals of this thought
◦ Client with very strong beliefs can find it difficult to accept that their own thoughts or
beliefs do not reflect reality, do not argue if thoughts are true or false, instead focus
on if thought is helpful or not
◦ Illustrate impact that thinking can have subsequent emotions, physical sensation and
behavior
Date Situation Emotion(S)
sensations
Intrusive
thought/image
Appraisals Alternative
thoughts/images
Outcome
Where were you?
Who was there?
What were you
doing? When?
that time?
How strongly did
you feel it? (0-10)
What was the
thought or image
that come into your
mind?
How strongly do
you believe this
thought? (0-10)
What are your new
balanced thought or
images?
How strongly do you
believed them? (0-10)
Re-rate NAT?
Re-rate
emotions?

Generating alternative images
◦ Helpful for clients who tend to experience NATs in form of images
◦ Imagery work include:
1. Psycho-education about mental images: normalize the experience of having mental
images, explain images do not reflect reality or what will happen
2. Following images to completion: identify biggest fear of client (use like downward
arrow technique)
3. Imagining a different outcome: generating an image and then following it through,
deliberately changing it to create positive outcome

Strategies for OCD: Intrusive thought-habituation technique
◦ Intrusive thoughts often accompanied by strong negative emotions like anxiety and
fear
◦ Habituating to these thought means exposing to thoughts, Repeating a thought over
and over causes thought to lose its power and body therefore ceases to become over-
aroused
1. Written exposure: writing thought on paper until the anxiety drops to 2 or 3 out of
10
2. Loop tape exposure: record thoughts in a tape and listen to it over and over until
the anxiety drops to 2 or 3 out of 10. It is important to refrain from any rituals

Thought-stopping technique:
◦ Generating the intrusive thought and stop by shouting ‘shout’ out loud and then
replacing intrusive thought with more pleasant image
◦ Usually practiced in therapy sessions and then as homework assignment
◦ Next goal is to move from verbalizing ‘stop’ to thinking ‘stop’

Mindfulness techniques:
◦ Involve labelling thoughts as ‘intrusive’ thought and then turning attention back to
task of being in moment
◦ Psycho-education about intrusive thought and normalization of experience of
intrusive thought
◦ Psycho-education about intrusive thought and subsequent appraisal, cognitive
techniques aimed to challenge appraisals
◦ Behavioral strategies target subsequent rituals that are helpful in targeting obsessions

Responsibility chart
◦ Over-valued ideas of responsibility are often a feature of OCD
◦ Often make ‘personalization’ thinking bias, behaving that they are to blame for events
that they did not have any control over
◦ Compulsive behavior can temporarily reduce feelings of guilt and shame as well as
anxiety by increasing person’s sense of control over feared event
◦ Responsibility chart is useful to challenge NATs related with responsibility and blame,
which introduce the idea that there are several factors contributing to an event or
situation

◦ Client is asked to think about all the people, circumstances or aspects which have
contributed to it then make a list of that on a paper
◦ Client is then asked to divide the circle into segments with each listed person/
circumstances/aspects, which represents its importance in contributing to the
situation
◦ Client’s own contribution should be assigned last
Responsibility thoughts
Contributing factors

Working with Assumptions and core beliefs
◦ It occurs later in therapy approach, after the more straightforward strategies
◦ Work on core beliefs/assumptions work is conducted in following situations:
1. When there is clear trauma emerging from early or previous experiences
2. When deeper theme emerging in client’s material
3. When early attempts to achieve symptom relief have definitely not worked
4. When client request some long-term therapy focused on early experience
◦ It require more therapeutic skills as: beliefs at deeper level are more ingrained,
therefore more difficult to change and clients with more negative core beliefs are
more complex to work with

Techniques
1. Spotting core beliefs and assumptions:
◦ During the course of therapy while working with NATs & behavioral intervention,
therapist needs to be vigilant for information that might gives clues as to client’s
rule/assumptions and core beliefs
◦ If client has kept thought diaries or records over time, recurrent thoughts may give
indications as to core beliefs and assumptions
2. Downward-arrow technique:
◦ Once NATs are identified, downward-arrow technique can be used to follow rules
and beliefs underlying negative thoughts
◦ One cannot get right beliefs instantly, may take lot of gentle exploration

3. Imagery:
◦ Sometimes people find it difficult to verbalize, important to help them make some
sense of images they are experiencing
◦ Suggested questions:
I. What is bad about events in images?
II. What does that mean about you, others and world?
III. What is the worst could happen?
IV. How do you feel now and in image?
V. What is going through your mind in image?
VI. Does that image remind you of something earlier in life?
VII. If so, when? How old were you? What was happening? What does it say about you now?

4. Challenging assumptions:
◦ Behavioral experiments, once a rule has been identified then prepare a suitable
experiment to test out that rule
◦ An experiment cannot fail, whatever happens there is a chance of learning
◦ Experiments have to be devised in collaboration with client so they feel supported
and comfortable enough to take risk
◦ Rules and assumptions have been with clients for a long time and have had
opportunity to grow, become ingrained and strengthened. Thus, behavioral
experiment may need to be prepared on an ongoing basis in order to have an
effect
◦ Discuss with client and ask questions about their rules/assumptions they hold and
how they affect them

Changing core beliefs
General discussion with client over time:
◦ Informal way of challenging and works by asking questions about belief and what
they feel other people might believe in their situation
◦ This is enough to get them thinking about beliefs they hold

List evidence that supports and does not support the core beliefs:
◦ Writing each negative core belief and then write evidence that supports belief and
evidence that does not
◦ Client can feel invalidated if ‘evidences support belief’ does not happen before
‘evidence does not support’
◦ It helps to enable client to look back their lives for information, which include
achievements, compliments, comments from other people and qualities client
recognize for themselves

Identifying new core belief:
◦ After writing evidences that does not support belief, develop a new core belief
which is realistic (not just opposite of negative beliefs)
◦ One way is to review all information gathered over time that does not support the
core belief
◦ Can be difficult for client, they need to be supported and helped so they do not
discount positive information

◦ Often client experience real trauma and life events during course of therapy which is
not appropriate to deal with thought challenging and behavioral intervention
◦ Using these strategies would be invalidating for clients and for difficulties they are
facing
◦ It helps in identifying problems and then create potential solutions
◦ Following range of problems helps through this approach:
1. Threatened or actual loss
2. Conflicts
3. Marital and relationship problem
4. Work difficulties
5. Study problems
6. Coping with boredom
7. Difficulty concerning child care
8. Dealing with handicap resulting from
physical/mental illness

Problems/difficulty
1. Client’s problem/difficulties need to be specific and definable
2. Client’s goal need to be realistic
3. Absence of severe acute psychiatric illness
4. Clear contract regarding nature, aims and extent of problem-solving

Assessment
Identifying problem:
◦ Jointly draw up a written problem list, with each problem clearly specified and
described
◦ People get symptoms like anxiety, ask them to rate anxiety (0-10) throughout day and
notice pattern between anxiety and issues that occur
◦ Ask client to rate their current mood (0-10) and let them think what would need to do
to raise their mood
◦ Solution-focused approach is used

Identify client’s resources:
◦ Helps client to identify the resources and coping strategies they already use and
potentially develop new coping resources
◦ Suggested questions:
1. How have you coped with past difficulties?
2. Can you think of any possible solutions?
3. What could you do o get over this problem?
4. Do you sometimes use coping strategies that help in short-term but cause problems in
long-term?
5. Do you have any close friend whom you can share your problems?
6. Do you have any professional involvement which may be helpful?
7. Can changes be made to your environment?

Procedure
◦ Agree on agenda at beginning of each sessions
◦ Choose a problem to be focused on, preferably one that can be easy to solve in first
instance so client get sense of achievement
◦ Identify resources and goals together
◦ Goals then can be split into smaller steps which need to be realistic
◦ Methods used: brainstorming, list of pros and cons and thinking about consequences
of each task and any possible difficulties
◦ Provide information and advice client when required

Problem list?
Problem chosen?
Resources identified?
Goal identified?
Problem solving processes

◦ Preparatory work on emotions is recommended:
1. Client is unable to identify or distinguish between certain emotions
2. Client copes with difficult emotions in harmful ways (self harm; over/under eating; drug or
alcohol use; misuse of prescribed medicine; overworking; obsessional cognition/behavior)
◦ Either of the conditions can interfere with therapy and make it less effective
◦ If client is unable to identify emotional state, then they will not be able to see the link
between specific thoughts and emotional responses
◦ They will not be able to understand where emotions fit in maintenance cycle
◦ Cognitive interventions involve keeping records of emotional responses, which is
impossible if they do not have awareness of their emotional state

◦ CBT interventions are all about doing and thinking about things differently
◦ Interventions involve change, which is associated with experience of new or more
intense emotions
◦ Client is made aware of this possibility before process of change begins so they are
not frightened or confused when they experience changes in emotion

Psycho-education: Emotions
Purpose & function of emotions:
◦ Learning about roles of emotion can be useful for individual who fear experience of
certain emotions
◦ Emotions are normal part of human experience, they are not harmful though may be
experienced as unpleasant
◦ They have evolved in human beings to fulfill certain functions:
1. Helps to communicate how we are feeling to others, in order to influence their behavior
towards us
2. They are like signal to ourselves to provide information about what is going on around us
3. Motivate us to behave in certain way
4. Our emotion depends on how we interpret what is going on around us

How we learn about emotions and what it means:
◦ Children learn about emotions through experiencing them and labelled or responded
to by their caregivers
◦ They build their own understanding of emotions, what triggers them and how to cope
with them through this process
◦ If their emotions are not responded to appropriately or are dismissed as ‘wrong’, then
child can develop deficits in ability to label and cope with his/her own emotional state
◦ If caregivers do not validate (deny/neglect) their emotions, belief develops that
emotions are ‘bad’ and should be hidden away; which further leads to problem

Identify different emotional states in self and others:
◦ For clients who have difficulty in recognizing and distinguishing between different
emotional state in themselves and other people, then therapist should consider some
key points:
1. Discuss emotional language- list words used to describe same or similar emotions
2. Discuss bodily signs that emotions being experienced
3. Discuss common behavior associated with emotions
4. Discuss situation that are likely to trigger emotions
5. Discuss function of emotion

Exposure to feared/hidden emotional states
◦ Cognitive or behavioral intervention will result in client experiencing changes in
his/her emotional state
◦ Therapist and client can either role-play or imagine situation which induce certain
emotion
◦ Aim is to illustrate that emotion can come and go without disastrous consequences,
client will then feel more confident about his/her capacity to tolerate emotion in real
life

Beliefs about emotions
◦ Some people hold negative beliefs about experience or meaning of certain emotions
◦ Emotional changes produced by cognitive or behavioral interventions may be
experienced as very aversive
◦ Client may be less likely to complete homework tasks and might discontinue therapy
◦ Negative beliefs can be addressed by discussing functions of beliefs and by using
cognitive techniques to challenge unhelpful negative beliefs about emotions

Behavioral response to emotions
◦ Some clients experience certain strong emotions unbearable, so behaviors which help
clients to either avoid or deal with emotional pain naturally develop
◦ Coping strategy can have harmful side effects (drug and alcohol abuse; self-harm;
avoidance) and reinforce fear of emotions
◦ Problematic response to difficult emotional states can be identified and behavioral
intervention can be used to introduce different ways of responding to emotional
experience

Coping strategies
◦ Life circumstances (loss and bereavement; trauma)mean that difficult emotions are
experienced for prolonged periods
◦ Work on coping strategies, if you feel it would be appropriate for client to learn some
strategies before implementing cognitive and behavioral techniques
◦ Coping strategies are not used as a way of avoiding certain emotions as this is likely
to increase fear of emotion
◦ Therapist must assess fully your client’s experience of emotions and associated
behavior before suggesting this work

Using imagery and symbolism
◦ Clients who have difficulty in verbally expressing how they feel emotionally, imagery
and symbolism are used to explore emotions
◦ Client is ask, “if they have a name for emotion or if emotion were an ‘object’ or ‘thing’
what it would look like”
◦ For clients who are overwhelmed by their emotions is that it can give some separation
between person and emotion they are experiencing
◦ For clients who are very cut-off from their emotions, it can be useful way of exploring
their relationship with emotions

◦ Client can use color or image to represent how they are feeling about their emotion
◦ This techniques was borrowed from narrative therapy

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