Cognitive behavioral therapy (CBT) is an evidence-based talk therapy that is effective in treating many psychiatric conditions. It is based on the theory that dysfunctional thoughts, emotions, and behaviors interact and can be modified. CBT uses techniques like cognitive restructuring, exposure therapy, and behavioral activation to help patients identify and change maladaptive patterns. It has a strong evidence base from randomized controlled trials and is recommended as an important component of treatment for many disorders.

1. Theory and Practice of Cognitive
Behavioral Therapy
By
Dr. Sumaya Batool

2. What is CBT?
• Set of ‘talk’ psychotherapies that treat psychiatric
conditions.
• Short-term focused treatment.
• Strong empirical support with randomized clinical
trials.
• As effective as psychiatric medications.
• Recommended as critical component of treatment,
particularly when medications are contraindicated
or ineffective.

3. Why So Popular?
• Clear treatment approach for patients
• Assumptions make sense to patients
• Based on patient’s experience
• Encourages practice and compliance
• Patients have a sense of control
• CBT works!

4. Definition of Cognitive Therapy
• CT is a focused form of psychotherapy based on a
model stipulating that psychiatric disorders involve
dysfunctional thinking.
• Dysfunctional/distorted thinking arises from both
biological and psychological influences
• Individuals’ emotional, behavioral, and
physiological reactions are influenced by the way
they structure their environment.
J. Beck, 1995

5. Definition of CT (continued…)
• Modifying dysfunctional thinking and behavior
leads to improvement in symptoms.
• Modifying dysfunctional beliefs which underlie
dysfunctional thinking leads to more durable
improvement

6. Definition of CT (continued…)
• Cognitive therapy is defined by a cognitive
formulation of the disorder and a cognitive
conceptualization of the particular patient.
• Cognitive therapy is not defined by the use of
exclusively cognitive techniques. Techniques from
many modalities are used.
• CT also often referred to as Cognitive-Behavior
Therapy (CBT).

7. Rationale for CBT
• Negative emotions are elicited by cognitive
processes developed through influences of
learning and temperament.
• Adverse life events elicit automatic processing,
which is viewed as the causal factor.
• Cognitive triad: Negative automatic thoughts
center around our understanding of:
• Ourselves
• Others (the world)
• Future
• Focus on examination of cognitive beliefs and
developing rational responses to negative
automatic thoughts.
Beck et al., 1979

8. Cognitive Specificity Hypothesis
• Distorted appraisals follow themes relevant to the
specific psychiatric condition.
• Psychological disorders are characterized by a
different psychological profile.
• Depression: Negative view of self, others, and future.
Core beliefs associated with helplessness, failure,
incompetence, and unlovability.
• Anxiety: Overestimation of physical and psychological
threats. Core beliefs linked with risk, dangerousness, and
uncontrollability.

9. Cognitive Specificity
• Negative Triad Associated with Depression
• Self “I am incompetent/unlovable”
• Others “People do not care about me”
• Future “The future is bleak”
• Negative Triad Associated with Anxiety
• Self “I am unable to protect myself”
• Others “People will humiliate me”
• Future “It’s a matter of time before I am embarrassed”

10. Targeted Cognitions for Different
Disorders
• OCD: appraisals of obsessive cognitions
• Anorexia: control, worth, perfection
• Panic: catastrophic misinterpretation of physical
sensations
• Paranoia: trust, vulnerability

11. Cognitive Model
Triggering Event
Bill goes to work
Appraisal
“I can never do
anything right…”
Behavior
Avoidance; withdrawal
Bodily Sensations
Low energy, disruption of
sleep, increased fatigue
Behavioral Inclination
“I don’t want to deal with it”
“It’s too stressful to think
about it”
Thase et al., 1998

12. Working Model of CBT
Event
Appraisal
Maladaptive
Behavior
Affective and
Biological Arousal
Behavioral
Inclination
Thase et al., 1998

13. What are Automatic Thoughts?
What was going through your mind?
• Happen spontaneously in response to situation
• Occur in shorthand: words or images
• Do not arise from reasoning
• No logical sequence
• Hard to turn off
• May be hard to articulate
Stressful
Situation
Automatic Thoughts
Negative
Emotions

14. Cognitive Distortions
• Patients tend to make consistent errors in their
thinking
• Often, there is a systematic negative bias in the
cognitive processing of patients suffering from
psychiatric disorders
• Help patient identify the cognitive errors s/he is
most likely to make

15. Types of Cognitive Distortions
• Emotional reasoning Feelings are facts
• Anticipating negative outcomes The worst will happen
• All-or-nothing thinking All good or all bad
• Mind-reading Knowing what others are thinking
• Personalization Excess responsibility
• Mental filter Ignoring the positive

16. Examples
•Cognitive Distortions
• Emotional Reasoning: “I feel incompetent, so I
know I’ll fail”
• Catastrophizing: “It is going to be terrible”
• Personalization: “It’s always my fault”
• Black or white thinking: “If it isn’t perfect,
it’s no good at all.”

17. Core Beliefs
• Core beliefs underlie and produce automatic
thoughts.
• These assumptions influence information
processing and organize understanding about
ourselves, others, and the future.
• These core beliefs remain dormant until
activated by stress or negative life events.
• Categories of core beliefs (helpless, worthless,
unlovable)
Automatic Thoughts
Core Beliefs

18. Examples of Core Beliefs
• Helpless core beliefs
• I am inadequate, ineffective, incompetent, can’t cope
• I am powerless, out of control, trapped
• I am vulnerable, weak, needy, a victim, likely to be hurt
• I am inferior, a failure, a loser, defective, not good enough, don’t measure up
• Unlovable core beliefs
• I am unlikable, unwanted, will be rejected or abandoned, always be alone
• I am undesirable, ugly, unattractive, boring, have nothing to offer
• I am different, flawed, defective, not good enough to be loved by others
• Worthless core beliefs
• I am worthless, unacceptable, bad, crazy, broken, nothing, a waste
• I am hurtful, dangerous, toxic, evil
• I don’t deserve to live

19. Cognitive Conceptualization
Current
Situation
Automatic Thoughts
About self, world
And others
Physiology
Feelings
Behavior
Childhood
And Early
Life Events
Underlying Assumptions
and Core Beliefs
Compensatory
Strategies

20. Example 1
Situation
Partner says:
“I need time to
be with my friends”
Automatic Thoughts
Automatic response:
“Oh no, he’s losing interest
and is going to break up
with me….”
Physiology
Heart racing
Lump in throat
Feelings
Sadness
Worry
Anger
Behavior
Seek reassurance
Withdraw
Cry
Childhood
Experiences
Parental neglect
and criticism
Underlying Assumptions &
Core Beliefs
“I’m flawed in numerous ways,
which means I’m not worthy of
consistent attention and care.
People only care when they want
something.”
Compensatory
Strategies
Be independent and
you’ll be safe.
Watch out – people
are careless with you.

21. Example 2
Situation
Disappointing
exam result
Automatic Thoughts
“I am not going to get
through this program -
I’m not as smart
as everyone else.
People will
discover this and I
will be humiliated.”
Physiology
Pit in stomach
Dry mouth
Feelings
Worry, shame,
Disappointment
Humiliation.
Behavior
Use alcohol,
Procrastinate
with homework
Childhood
Adversities
Parental standards
reinforce academic
achievement
Underlying Assumptions
“If I don’t excel in school, I’m a
total failure”
Compensatory
Strategies
Work extra hard
to offset
incompetence.

22. Responding to Negative Thoughts
• Define Situation
• Clarify meaning of cognitive appraisal
• What was going through your mind just then?
• What did the situation mean for you?
• Evaluate interpretation
• Evidence: For and against this belief?
• Alternatives: Any other explanation(s)?
• Implications: So what….?

23. Evaluating Negative Thoughts
• What is the effect of telling myself this thought?
• What could be the effect of changing my thinking?
• What would I tell ___ (a friend/family member) if
s/he viewed this situation in this way?
• What can I do now?

24. Sample Thought Log
Situation Thoughts Emotions Rational
Response
Outcome
Going on
vacation—Ask a
colleague to do
some work for
me
She’ll say no…
I’m not doing a
good job
The boss thinks I
take too much time
off
Anxiety
(70%)
Guilt (40%)
Sadness
(20%)
Cognitive
Distortions:
All/nothing
Mindreading
Fortune-
Telling
Over-
generalization
I haven’t taken
a day off in 6
months. We
work as a team,
so it’s also her
job to track the
samples.
Anxiety (10%)
Guilt (0%)
Relief (40%)

25. Common Components of CBT
• Establish good therapeutic relationship
• Educate patients - model, disorder, therapy
• Assess illness objectively, set goals
• Use evidence to guide treatment decisions
• Structure treatment sessions with agenda
• Limit treatment length
• Issue and review homework to generalize learning

26. Course of Treatment
1. Assessment
2. Provide rationale
3. Training in self-monitoring
4. Behavioral strategies
1. Monitor relationship between situation/action and mood.
2. Applying new coping strategies to larger issues.
5. Identifying beliefs and biases
6. Evaluating and changing beliefs
7. Core beliefs and assumptions
8. Relapse prevention and termination

27. Basic Principles
• Change mood states by using cognitive and behavioral strategies:
• Identifying/modifying automatic thoughts & core beliefs,
• Regulating routine, and
• Minimizing avoidance.
• Emphasis on ‘here and now’
• Preference for concrete examples
• Start with specific situation (complete thought log)
• Reliance on Socratic questioning
• Ask open-ended questions
• Empirical approach to test beliefs
• Challenge thoughts not based on evidence
• Cognitive restructuring
• Promote rapid symptom change

28. CBT
TECHNIQUES

29. Cognitive Rehearsal
• In this technique, the patient is asked to recall a
problematic situation from his/her past. The therapist
and patient work on the problem to find a solution for it.
The therapist asks the patient to rehearse positive
thoughts in his/her mind; rehearsing positive thoughts
helps in making appropriate changes to the patient's
thought processes. The power of imagination proves to
be of great help when you are doing such type of
exercises.
Validity Testing
• In this technique, validity of thoughts of the patient are
tested by the therapist; the patient is allowed to defend
his/her viewpoint with the help of an objective evidence.
The faulty nature or invalidity of beliefs held by the
patient is exposed if he/she is unable to produce any kind
of objective evidence.

30. Writing in a Journal
• It is a practice of maintaining a diary to keep an account of the
different situations encountered by patients in day-to-day life.
Thoughts associated with these situations and behavior
exhibited in response are also mentioned in the diary. The
therapist and patient review what all is written in the diary and
try to identify the patient's maladaptive thought patterns. The
discussion which takes place between patient and therapist is
helpful for finding the different ways in which behavior of the
patient gets affected.
Guided Discovery
• The purpose behind using this technique is to help patients to
understand their cognitive distortions. Patients are offered the
necessary assistance and guidance by therapists to understand
how they process information. It allows patients to alter the way
they process of information. Upon completion of this treatment,
the patient's perception of the world undergoes a profound
change and he/she starts seeing things with a new outlook. A
change in perception enables the patient to modify his/her
behavioral patterns.

31. Modeling
It is one of the important cognitive behavioral therapy
techniques wherein therapists perform role-playing
exercises. These cognitive behavioral therapy exercises
teach patients how to respond in difficult situations.
The patient sees the behavior of the therapist as a
model to overcome his/her own behavioral problems.
Homework
'Homework' is actually a set of assignments to be
completed by patients. During their sessions with
therapists, the patients are asked to take down notes,
review audiotapes of these sessions and read
articles/books related to this therapy.

32. Aversive Conditioning
• In this technique the appeal of maladaptive behavior is
lessened with the help of 'dissuasion'. The patient is exposed
to an unpleasant stimulus while he/she is engaged in a
particular behavior for which treatment is needed. The end
result of this exercise is that the patient learns to associates
the unpleasant stimulus with the maladaptive behavior in
question; he/she becomes averse to behaving in such a
manner.
Systematic Positive Reinforcement
• It is one of the CBT techniques in which a certain kind of
behavior (positive) is rewarded with positive reinforcement. A
reward system is used to reinforce the importance of positive
behavior in the minds of patients.

33. Cognitive Restructuring
• Cognitive restructuring is a cognitive behavioral therapy
exercise designed to help people examine unhelpful thinking
patterns and devise new ways of reacting to problematic
situations. Cognitive restructuring often involves keeping a
thought record, which is a way of tracking dysfunctional
automatic thoughts, and devising adaptive alternative
responses.
Activity Scheduling
• Activity scheduling is a cognitive behavioral therapy exercise
that helps people engage in behaviors they ordinarily would
not engage in. The intervention involves identifying a low
frequency behavior and finding time throughout the week to
schedule the behavior to increase its frequency. It is often
employed in treatment for depression, as a way of re-
introducing rewarding behaviors into people’s routines.

34. Graded Exposure
• Exposure is a cognitive behavioral therapy exercise designed to reduce anxiety
and fear through repeated contact with what is feared. This has been to shown
to be among the most effective treatments for any psychological problem. The
underlying theory has to do with avoidance of things that we fear resulting in
increased fear and anxiety. By systematically approaching what you might
normally avoid, a significant and lasting reduction in anxiety takes place.
Successive Approximation
• Successive approximation is a cognitive behavioral therapy exercise that helps
people tackle difficult or overwhelming goals. By systematically breaking large
tasks into smaller steps, or by performing a task similar to the goal, but less
difficult, people are able to gain mastery over the skills needed to achieve the
larger goal.
Mindfulness Meditation
• Mindfulness meditation is a cognitive behavioral therapy exercise that helps
people disengage from harmful ruminating or obsessing by learning to connect
to the present moment. Mindfulness comes from Buddhist meditation, and is
the subject of a significant amount of new research on effective treatment of
psychological problems.

35. Thought Replacement Exercise
• Catch the negative thought: Keep a journal, taking notes of the actual
thoughts you are thinking when you’re in a situation that upsets you
and ends in self-limiting and self-sabotaging behavior. Example: ‘It’s
going to be awful, I’m going to embarrass myself…’- (and then avoiding
an event).
• Thought Stopping: As you notice yourself saying these negative
automatic thoughts, you can stop them mid-stream by saying to
yourself “STOP”. You might also wear a rubber band or elastic bracelet
around your wrist, giving it a little twang each time you notice you are
allowing negative thinking to take over your head in a never-ending
loop. It will make you more aware of how often, and in what situation,
you are having the negative thoughts.
• Challenge the negative thought: Challenge the thoughts, examine
them to see if they’re valid. ‘Where’s the evidence for this? Is there
another way to look at it?’. Example: ‘Actually, that’s fortune telling, I
don’t actually know what’s going to happen, all I can do is my best,
maybe I’ll be a bit anxious, I can cope with that if it happens, and it
might not happen, I was okay last week at that other event even
though I tortured myself before it with this kind of thinking….’

36. Behavioral Interventions
• Breathing training
• Relaxation
• Behavioral activation
• Interpersonal effectiveness training
• Problem-solving skills
• Exposure and response prevention
• Social skills training
• Graded task assignment

37. Cognitive Interventions
• Monitor automatic thoughts
• Teach imagery techniques
• Promote cognitive restructuring
• Examine alternative evidence
• Modify core beliefs
• Generate rational alternatives

38. Efficacy
• Cognitive and behavioral approaches are
effective
• Supported by over 325 controlled
outcome studies
• State-of-the-art therapy, manualized

39. Applications of CBT
• Depression (1979)
• Bipolar Disorder (1996)
• Dysthymia and Chronic MDD (2000)
• GAD (1985)
• Social Phobia (1985)
• Panic Disorder (1986)
• OCD (1988)
• PTSD (1991)

40. Applications of CBT (Continued…)
• Eating Disorders (1981)
• Marital Problems
• Behavioral Medicine
• Headaches (1985)
• Insomnia (1987)
• Chronic Pain (1988)
• Smoking Cessation
• Hypochondriasis
• Body Dysmorphic Disorder

41. Conclusions
• System of psychotherapies
• Unified theory of psychopathology
• Short-term treatment
• Objective assessment and monitoring
• Strong empirical support
• As effective as pharmacotherapy