1 cbt An Introduction to CBT


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A Simple Introduction to Cognitive Behavioural Therapy

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1 cbt An Introduction to CBT

  1. 1. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukCOGNITIVE BEHAVIOURAL THERAPY (CBT)A Brief IntroductionINTRODUCTIONThere are many ideas, theories and strategies in counselling. There are those whocontend that it is a skilled process, those who feel it has a mainly theoretical base, thosewho consider it is all about relationship and being and those who feel it combines all orelements of the first three. However, there is considerable agreement that broadlyspeaking therapeutic approaches can be divided into four main schools. These are:-• Psychodynamic Approaches - concerned with the mind , psyche ,instincts and drives.This is often referred to as ‘working with the presenting past’ .• Cognitive –Behavioral Approaches — concerned with the mind ,its thoughts feelingsand behaviors and mainly how to assist clients to live in the present and look for apreferred future.• Humanistic and Existential Approaches - concerned with relationship and being.• There is the development of the 4thwave. This includes approaches such asSolution Focused Brief Therapy and a variety of eclectic (e.g. Egan’s Skilled HelperModel) and integrative approaches (e.g. Culley’s Integrative Helping Model) . TheEclectic and integrative models combine aspects of some or all of the first three.This development in integration and eclecticism is particularly relevant to models ofhelping for those who use counseling skills and for those who wish to combine severaltheoretical approaches e.g. CBT with aspects of Humanistic Therapy ( see Nelson-Jones2002). McLeod (1998) suggests that ‘eclecticism’ is a model where the counsellor selectsor chooses the best or appropriate concepts and techniques from a broad range oftheories. Whereas integration usually uses no more than 3 models He further suggeststhat some of the main differences between an eclectic and integrative approach are:ECLECTIC INTEGRATIVETechnical TheoreticalFocus on differences Focus on commonalitiesChoosing from many theories Combining many (normally 3 max)Applying what is Creating new approachesTable 1 : Adapted & Summarised from McLeod(1998)These notes are designed mainly to provide a backdrop to a presentation and experientialexercises on CBT. They will look at its background, roots and some of the main conceptswhich underpin this approach to helping and outline several exercises designed tofacilitate a greater understanding of this popular and effective approach to therapy.
  2. 2. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukCognitive Behavior Therapy (CBT)Cognitive Behavioural Therapy (CBT) is a combination of cognitive therapy, (whose majorexponent was Aaron Beck) -, behaviour modification therapy (of which Joseph Wolpe wasa well known expert) and Rational Emotive Behaviour Therapy (REBT) (whose mainexponent and founder was Arthur Ellis). Ellis, in particular, formed his theory as a directalternative to psychoanalysis, the then dominant force in therapy. This seemed toemphasise the irrational aspect of people, caught in a struggle between the irrational IDand the over-moralising, controlling, parental super-ego. Like many others, he felt that anapproach that acknowledged the connection between thinking and feeling, and the abilityof people to change patterns in the present, was important. Thus the cognitive andbehavioural approach to therapy was born and this eventually led to CBT. Each of theseterms is now briefly defined.Cognitive is a process such as mental thinking. It refers to everything in the mind, suchas thoughts, dreams, memories, images etc.Behaviour is everything we do. What we say, do, act or avoid and do not say, do,act or avoid.Therapy, comes from the Greek word ‘to heal’ and it is how the concepts and strategiesof CBT are used in a helping relationship.This (very short history) is important because it describes the antecedents and basicpremise of this important and widely accepted form of therapy. It is a therapy that can bereadily ‘adapted’ or ‘integrated’ within other approachesMore About CBT. CBT is based on the assumption that most unwanted thinking patternsand emotional and behavioural reactions are learned over a long period of time. The aim isto identify the thinking that is causing unwanted feelings and behaviours and to learn toreplace this thinking with positive thoughts. This can result in behaviours that are morepositive. The therapy does not focus on the events from the past (such as childhood) butfocuses on current difficulties in the here and now. CBT aims to teach new skills and newways of reacting.Strategies. It uses cognitive techniques (such as challenging negative thoughts) alliedwith behavioural techniques (such as exposure therapy that gradually desensitises aperson to ,say, phobia and also techniques such as relaxation, breath awareness etc.This combination is designed to help challenge negative thoughts, beliefs and behaviour.Research Research indicates that CBT is particularly useful in the treatment of a widevariety of presenting problems and particularly, anxiety, panic attacks, depression, OCDsand phobias. It is designed to combine elements of cognitive therapy that assist clients tomodify or eliminate unwanted thoughts and beliefs-, and behavioural therapy, which canhelp to change behaviour in response to those thoughts.So in short CBT could be said to rest on the following seemingly simplistic saying; ‘Youfeel the way you think and/or you think the way you feel’ It offers an approach that isdesigned to work with unhelpful thoughts and thus change how we feel. In this way it setsout to assist people; to avoid and/or eliminate unhelpful behaviours. Like other approachesit proposes that we are ultimately responsible for our choices and our ABC’s
  3. 3. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukLearning Your ABCsA major aid in cognitive therapy is what Albert Ellis called the ABC Technique or systemof Irrational Beliefs. This ‘system’ attempts to bring together the feeling-thinking link andthe meaning you attach to this with the resulting consequences and behaviours. Thesebehaviours are normally acted out and this ‘acting out’ comes in three main forms:Self- Destructive Behaviours - addictions & self harmIsolating and moody Behaviours - depressionAvoidance Behaviours – leading to phobias and Obsessive CompulsiveDisorders (OCDs)Before examining the thinking-feeling link in greater detail, each of the components of theABC concept will be outlined.A - Activating Event or objective situation. We live in an ‘environment’ or world iseventful. An outline of this, including some typical events is shown below.:A = Activating EventOur EventfulWorldThe Activating Event – oftenreferred to as a ‘Trigger’ iscaused by one of these :• A real external event• An anticipated event• An internal event in themind – thoughts, image ,memory dreamEVENTSThe WorldOther people- relationshipsPersonal ExperiencesPersonal HistoryFuture ( thoughts & feelings)SelfNoteThis activating event is an ‘objective ‘ situation that ultimately leads either to some sortof emotional response and/or possible irrational thinking.
  4. 4. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukB – BELIEFS. We live in this eventful world with a set of beliefs . These include rules,demands and thoughts that we connect to events. In problematic and negative issuesthese can be irrational and lead to negative consequences.B = BELIEFSBeliefsThese include the :thoughts, rules,demands , meaningsthat we attach to events & theworld :**** THOUGHTS lead toAttitudesRulesDemandsBeliefsImagesMeaningsNoteThese beliefs, which lead to negative thoughts and feelings and behaviours, are the link orbridge between the Activating Event and the Consequences.*** Very often people find it difficult to identify the thoughts linked to the belief( More on this later when we explore how to complete an ABC Table)C – The CONSEQUENCES So we live in this eventful world with a set of beliefs whicheffect our thoughts and lead to consequences for us, others and our ‘world’C = the CONSEQUENCESConsequences includeemotions,behavioursand physical sensationscaused by A and BEMOTIONSHealthy feelingsUnhealthy feelingsPhysical SensationsBEHAVIOURSConstructive ActionDestructive ActionNoteThe thoughts caused by the ‘belief’ leads to the emotions and resulting behaviour. Theseemotions could be anger, anxiety, distress etc .These are often referred to as the Mad, Sad, Bad, Glad range of emotions. Beforemoving on, it can be useful to look at the ‘volcano of felt experiences’
  5. 5. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukTHE VOLCANO OF FELT EXPERIENCESWe are all aware of the term ‘emotion’ but it is important to understand where these ‘riseup’ from. The following diagram shows the Volcano of Felt ExperiencesFOUR LEVELS OF FELT EXPERIENCEAll feelings and emotions (of which we are more aware) rise up through us like lava in avolcano. They rise up from a Raw or Primitive Basic Life Energy. This ‘courses up’through the Felt Senses (see Gendlin and Existential Therapy) and up to the Feelings& Emotions levels.Feelings are more easily recognised than the Felt Sense. Emotions are more intensethan feelings . e.g. irritation and rage. Emotions totally DOMINATE our attention,whereas feelings are more subtle and fluid than emotionsUnderstanding the levels of felt experience helps us to decide how we can use thetherapeutic relationship to assist clients to control , explore and manage theseexperiences.In general the deeper the level of felt experience the more existential is the issue .Therefore CBT can help at the feelings/emotions level, but if these are rooted inexistential questions, then approaches that are more humanistic/existential , and candeal with the ‘spiritual’ are more appropriate. This can assist in deciding how and whento integrate aspects of CBT into our practice.As feelings are thoughts can be linked, we now move on to errors in thinking that cangive rise to inappropriate and often unhealthy feelingsRaw or Basic Life EnergyFelt SensesFeelingsEmotionsRise of Emotions.Note the Intensityincreases as the‘Cone’ widthdecreases
  6. 6. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukErrors in Thinking Before exploring both how the ABC ‘model’ could be appliedand at some examples of its use, it is useful to look at how ‘beliefs’ can lead to faultythinking. Now, CBT is based on the proposition that feelings and emotions are directlylinked to thinking. Therefore, we can develop ‘thinking errors’ and these lead to unhealthyemotions with subsequent destructive action. Consequently, it is important to begin torecognise and then challenge faulty or irrational thinking. These irrational thoughts areoften rooted in what can be termed the ‘Three Bad Witches’ or the ‘3 Dunnerby Sisters!I SHOULDADone or BeI AUGHTADone or BeI MUSTADone or BeThese ‘witches’ are often at the root of many of the following typical irrational/faultythinking errors.‘With ME It’s ALL or NOTHING Very often our beliefs lead to extremes of ‘either : or’ i.e.love: hate: ; right: wrong etc. This ‘all or nothing’ type of thinking can then lead to extremesin emotions. In short we either take full responsibility or blame for an event or else takenone. Very often it is better to have a more balanced view and to be open to ‘both: and’type of thinking.‘ Gonna Build a Mountain’ Awfulising This form of thinking error turns a relativelyminor event into a major catastrophe . Everything is ‘awfulised’ and a minor ‘crisis’ isturned into a major drama. An example could be that somebody turns down your invitationto have a coffee and you assume ‘ They hate me’ or ‘ I’ll never speak to them again’ !‘It can never be or it always will be ’ Thinking Very often we can over-predict thefuture. We can in a sense be ‘prophets of doom’ and decide that bad experiences fromthe past will. certainly happen in the future. In this way we can often cause unhealthyemotions and actions.Another form of this thinking is that we ‘guess’ the future and predict that all our guessesmust be right. This nearly always extends into ‘mind reading’ others and deciding youknow what they are thinking and feeling. These ‘guesses are virtually always negative andvery often incorrect. We can so easily ignore the facts, get in touch with the negativefeelings and their link with our ‘it can never be or always will be’ forms of thinking.’!‘Feelings are facts’ Thinking Being totally ruled by your feelings and subsequentthoughts; in other words, taking your feelings at their face value. Whilst feelings areauthentic and deserve to be ‘heard’ they are also part of a complex emotional system, withdeepening layers that often reach back into our past. This is often referred to as the‘Volcano of Emotions’ with at least 4 layers of consciousness. Thus feelings are not onlycomplex but they form only one part of the true meaning of incidents and events.
  7. 7. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukOther Possible Errors Some other possible ways of faulty thinking are based on thefollowing :The ‘Perfect’ World Remember, seeking perfectionism is a lost cause. Thereis difference and diversity and not ‘perfection’ Attempting to find the ‘perfect’ in lifeleads to disappointment and mental stress.Over-generalising – Remember, one swallow does not necessarily make aSummer. Beware of any tendency to form general ‘rules’ for particular eventsOver-Personalising whilst taking responsibility and personalising events can behelpful, we need to remember that we are not the centre of the world and thuseverything does not ‘rotate’ or ‘relate’ to myself.Labelling Needlessly labelling yourself or others, This is often connected withall or nothing thinkingOnly seeing the negative Failing to see ,or filtering out , positives, this is oftenConnected with ‘awfulising’There are many other possible faults in thinking that can lead to unhealthy emotions anddestructive actions. Individuals can benefit from identifying their faulty thoughts and thendeveloping strategies to challenge and change these.PAUSE FOR EXERCISEExploring irrational / faulty thinkingPutting the ABC’s Together Returning to the simple ABC model . It can be seen thatan Activating event can trigger a Belief with consequential thoughts and these can giverise to Consequences. This can this can lead either to Unhealthy/Destructive or Healthy/Constructive Action. An example of each of these is shown in the following two ABCTables.EXAMPLE 1 – Unhealthy / Destructive Action ‘ Vicious Cycle’A – The Event B : - The Beliefs C : - The ConsequencesYou get a C Grade in yourAssignment on a courseYou expect an A. Youthink “ I’m useless, Ishould have done better” ‘This means I’m going tofail the Course ’You experience feeling of panicand anxiety (emotions)feel sick ( physical sensation)and stay in bed next day anddon’t attend the School/University ( behaviour)
  8. 8. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukEXAMPLE 2:- Healthy/Constructive Action ‘ Virtuous Cycle’A – The Event B : - The Beliefs C : - The ConsequencesPeter ( 17) fails his drivingtestPeter thinks ‘Too bad Ifailed the test. Practicemakes perfect. I’ll have totake more lessons’Peter feels regret andirritation.( emotion)A slight ‘sinking feeling’( physical)Decides to take more lessonsand re-take the test as soonas possible.( behaviour)Initially, therapists often use a simple ABC Table to assist clients to ‘map out’ the whole oftheir ABC process. Once this has been done, a more complex Table is used to further theprocess. The latter will be looked at in greater detail later on in this note.If we were to look at the simple examples of the ABC Table shown above, it is reasonableto suppose that clients are often readily aware of the Consequences and then can moveon to identify the Activating event. The bridge or link between these (the A and the C ) isthe Belief that lead to Unhealthy/Destructive or Healthy /Constructive Action. However,many clients find it difficult to readily identify these and the ensuing faulty thoughts.Therefore, when working to explore and identify an ABC ‘pattern’ it is important to reach apoint where the ‘thinking’ rooted in the Belief is identified. Then, if it leads toUnhealthy/Destructive Action ( C ) strategies can be devised to counter-act thefaulty/irrational thoughts thus leading to a more healthy/constructive cycle.Most people can more readily access the Consequences and this is probably the beststarting point in identifying an ABC pattern. Some points on this are to be found in the nextsection.Format for a simple ABC Table There are many formats for an ABC table. But asimplified version is shown below. The five steps are an indication of the order that canbe used to complete the Table for a given event.A – The EventThe ‘Trigger’B : - The Beliefs C : - The Consequences3.Record ‘trigger’- whatstarted emotions4Record thoughts & beliefsthat occurred5.Try to identify ‘fault orerror in thinking1.Record Emotions2.Record Behaviour/Action
  9. 9. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukStep 1. Record the emotions that have arisen (concerning the event)’Step 2 Record the resulting behaviour and action (also any physical sensations)Step 3 Record and explore the ‘trigger’ event that gave rise to Steps 1 and 2.Step 4. Record the thoughts and beliefs (and explore) that occurred with Steps 1 to3. These are the link or bridge between the Consequences and the Activating event.The Helper/Therapist can either do this during the session with the client and/or encouragethe client to maintain their own ABC log or set of tables.Before moving on to explore how to adapt the simple ABC Table and begin to challengeand change the faulty or irrational thinking, we need to pause for an experiential exercisethat uses the simple ABC Table.PAUSE FOR EXERCISEEstablishing the ABC link Part 1Taking it Forward – Challenge and ChangeOnce the simplified ABC Table has been explored and the irrational thought(s) identified,then it is possible to begin to deepen the exploration, understanding and action towardschallenging and changing unhealthy/destructive patterns.This requires two extra components to be added to the basic ABC scheme. These areoften referred to as Disputing irrational thoughts and the Effect of alternativeaction/changes. This leads to an A B C D E Table,Both of these extra components ( D and E ) will be briefly explored, sub-steps for eachproposed and then the complete ABCDE Table will be outlined
  10. 10. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukDisputing Irrational Thoughts The obvious first step is to begin to challenge theirrational thoughts which are based on a ‘faulty’ understanding that is fed by unhealthybeliefs. This requires two new steps, steps 6 and 7 , that follow Steps 1 to 5..Step 6 Identify and Challenge Identify the ‘thinking error’ and also record achallenge to this. This can best be achieved by a much closer examination of the negativethought(s). Some ways of doing this are to explore the following areas and questions.a. Is the thinking ‘rigid’ or ‘flexible’? Very often, ‘rigid’ thinking leads tonegativity.b. Are these thoughts logical, sensible and can they be checked out withfriends and others?c. Are emotions ‘flooding’ and swamping the thoughts?.Step 7 Generate Alternatives Once errors have been identified, it is importantto begin to generate alternative thoughts for the Beliefs. This can be helped by asking thefollowing questions;a. What do I do differently when I’m either not feeling so bad or feeling OK?b. What ‘coping strategies’ have I adopted in the past either for this or similarsituations ?c. How can I think in a more flexible and balanced way?d. If I were to advice my best friend about this situation, what one thing might Irecommend that could improve the situation?These are many other strategies and questions that could be asked in order to assist inSteps 6 and 7. Now to move on the E where alternative thoughts, beliefs, emotions andbehaviours are explored and implemented as an Experiment and Evaluated.Effects on Emotions and Behaviour of Alternative Thoughts and proposed ActionOnce Steps 1 to 5 ( initial ABC Table) and Steps 6 and 7 ( challenging negative thoughtsand proposing alternatives) has been achieved, it is now time to reflect on this and to trysomething different. This will require a further step which has two main partsStep 8 : - Effect of Alternative Having decided how you ( wish or think) will feel andbehave differently :a. Assess any (predicted) healthy emotions on a scale of either 0 to 10 or 0 to100, with the higher number being the bestb. Outline your ‘new’ or ‘modified’ behaviour or actionThe final stage is to implement and act on Step 8b and assess its effects.
  11. 11. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukFormat for a Complete ABC Table The final Table is outlined below with all 8 StepsSteps 1 to 5A – The EventThe ‘Trigger’B : - The Beliefs C : - The Consequences3.Record ‘trigger’- whatstarted emotions4Record thoughts & beliefsthat occurred5.Try to identify ‘fault orerror in thinking1Record Emotions2Record Behaviour/ActionSteps 6 to 8D = Dispute / Challenge E = Effect of Alternative Thought6.Identify and challenge faulty thoughts andbeliefs7Find alternatives to those that arechallenged8Rate the effects of 7 on your emotionsOutline your new or modified behaviour /actionThe Helper/Therapist can initially do the simple ABC Table with clients. Once that hasbeen done , then the ABCDE Table can be explored and completed either during thesession with the client and/or the client can be encouraged and asked to maintain theirown ABC/ ABCDE log or set of tables. This may take more than one session.PAUSE FOR EXERCISEEstablishing the ABC link Part 2The aim of the CBT therapy is to assist clients to create more Healthy/ ConstructiveConsequences, like example 2. of the ABC Model shown earlier.
  12. 12. © Peter Creagh, Trainer, Supervisor , UKCP Independent and BACP Registered Counselloremail : - peadar@satsang.freeserve.co.ukConclusionsThis short introduction to CBT outlined the background and some of the main concepts ofthis approach. It defined the terms of CBT and the underlying concept of the link betweenthoughts, feelings and behaviours. It looked at the ABC Table of activating event or trigger,the consequences for feelings and behaviours of this trigger and the underlying beliefs thatunderpin the thoughts that generate these emotions and behaviours.IT outlined how this ABC link could result in either healthy/Constructive or Unhealthy/Destructive emotions or actions. The latter were fuelled by irrational or faulty thinking.Some of the more common types of thinking errors were outlined. Finally, it looked at howthese thinking errors could be challenged and alternatives found and put into action.All of the above were brought together in a complete ABCDE Table and three exercisesfacilitated an experiential understanding of these important but introductory concepts ofCBT. There is much more to this approach to therapy and change. It is highly effective intreating the triad of neurosis (depression, aggression and addiction) and has a range ofadvanced concepts and strategies. These are not the subject of this brief note.However, the basics of CBT have been covered. These involve exploring andunderstanding the Thinking – Feeling – Behaviour cycle. Only when understanding isgained can people decide to and plan goals and actions that change vicious negativecycles into virtuous positive cycles.BIBLIOGRAPHYBurns, D (1999) Feeling Good – The New Mood Therapy Avon Books, New YorkCarkhuff, R (2000) The Art of Helping Human Resources Press MassachusettsCulley,S ( 1999) Integrative Counselling Skills in Action SAGE LondonEgan, G ( 1998) The Skilled Helper Brooks/Cole Pacific Grove Ca,USAFrankl,V ( 1984) Man’s Search for Meaning Washington Square PressGendlin, E (Greenberger, D & Padesky, C (1995) Mind Over mood Guilford Press New YorkHough, M ( 2002) A Practical Approach to Counselling LongmanMay,R (1978 ) Art of Counselling Abingdon PressMcLeod,J ( 1998) An Introduction to Counselling OU PressNelson-Jones ,R (2002) Essential Therapy & Counselling Skills SAGE LondonRogers,C ( 1951) Client Centered Therapy Constable, LondonRogers,C ( 1961) On Becoming a Person Constable, LondonSanders,P (1994) First Steps in Counselling PCCS Ross on Wye