Cognitive Behavior therapy

1. M R . C H E TA N S H A R M A
M . P H I L . P S Y C H I AT R I C S O C I A L W O R K S C H O L A R
I N S T I T U T E O F M E N TA L H E A LT H
P T. B . D . S H A R M A U H S R O H TA K
COGNITIVE BEHAVIOR
THERAPY

2. INTRODUCTION
• Cognitive behaviour therapy (CBT), a common form
of psychotherapy used to help people become aware of and to
change their inaccurate or negative patterns of thinking.
• Unlike many traditional psychotherapies, cognitive behavior
therapy is not directed at uncovering the origins of a person’s
particular problem.

3. • CBT is based on the idea that how we think (cognition), how
we feel (emotion) and how we act (behavior) all interact
together.
• Specifically, out thoughts determine our feelings and our
behavior.
• Therefore, negative and unrealistic thoughts can cause a
person distress and result in problems.

5. HISTORICAL DEVELOPMENT OF CBT
• The fundamentals of Cognitive behavior therapy have been
around since ancient Greeks.
• Cognitive Behavioural Theories evolved from bi-directional
movements in the existing fields of cognitive psychology and
behavioural science.
• The evolution of CBT took place in 3 stages.

6. PHASE I- BEHAVIOR THERAPY ROOTS
• Groundbreaking work of behaviorism began with John B.
Watson and Roasalie Rayner’s Studies of conditioning in
1920.
• Behaviorally-centered therapeutic approaches appeared as
early as 1924 with Mary Cover Jones work dedicated to the
unlearning of fears in children.
• These were the antecedents of the development of Joseph
Wolpe’s behavioral therapy in the 1950s.

7. • It was the work of Wolpe and Watson, which was based
on Ivan Pavlov's work on learning and conditioning, that
influenced Hans Eysenck and Arnold Lazarus to develop new
behavioral therapy techniques based on classical conditioning.
• Julian Rotter in 1954 and Albert Bandura in 1969 contributed
behavior therapy with their respective work on social learning
theory by demonstrating the effects of cognition on learning
and behavior modification,
• (Wikipedia).

8. PHASE II- COGNITIVE THERAPY ROOTS
• One of the first therapists to address cognition in
psychotherapy was Alfred Adler (1870–1937), notably with his
idea of basic mistakes and how they contributed to creation of
unhealthy or useless behavioral and life goals.
• Adler and Low influenced the work of Albert Ellis, who
developed the earliest cognitive-based psychotherapy called
rational emotive therapy (contemporarily known as rational
emotive behavioral therapy, or REBT).
• The first version was announced to the public in 1956

9. • In the late 1950s, Aaron T. Beck was conducting free association
sessions in his psychoanalytic practice.
• During these sessions, Beck noticed that thoughts were not as
unconscious as Freud had previously theorized, and that certain
types of thinking may be the culprits of emotional distress.
• It was from this hypothesis that Beck developed cognitive therapy,
and called these thoughts “automatic thoughts”.

10. PHASE III- BEHAVIOR AND COGNITIVE
THERAPIES MERGE
• In initial studies, cognitive therapy was often contrasted with
behavioral treatments to see which was most effective. During
the 1980s and 1990s, cognitive and behavioral techniques
were merged into cognitive behavioral therapy.
• Pivotal to this merging was the successful development of
treatments for panic disorder by David M. Clark in the UK
and David H. Barlow in the US.

11. • Over time, cognitive behavior therapy came to be known not
only as a therapy, but as an umbrella term for all cognitive-
based psychotherapies.
• These therapies include, but are not limited to, rational
emotive behavior therapy (REBT), cognitive
therapy, acceptance and commitment therapy, dialectical
behavior therapy, metacognitive therapy, metacognitive
training, cognitive processing therapy, EMDR,
and multimodal therapy

12. PRINCIPLES OF CBT
• Principle no. 1- Cognitive behavior therapy is based on an
ever-evolving formulation of patients’ problems and an
individual conceptualization of each patient in cognitive terms.
• Principle no. 2- CBT requires a sound therapeutic alliance
• Principle no. 3- CBT emphasizes collaboration and active
participation

13. • Principle no. 4- CBT is goal-oriented and problem-focused.
• Principle no. 5- CBT initially emphasizes the present.
• Principle no.6- CBT is educative, aims to teach the patient to
be their own therapist, and emphasizes relapse prevention
•
• Principle no.7- CBT aims to be time-limited

14. • Principle no. 8- CBT sessions are structured
• Principle no. 9- CBT teaches patients to identify, evaluate, and
respond to their dysfunctional thoughts and beliefs
• Principle no. 10- CBT uses a variety of techniques to change
thinking, mood, and behavior

15. BASIC ASSUMPTIONS OF CBT
• Beck (1979) provides a list of general assumptions that
underlie the theory.
1. Perception and experiencing in general are active processes
which involve both inspective and introspective data.
2. The patient’s cognitions represent a synthesis of internal and
external stimuli.
3. How a person appraises a situation is generally evident in his
cognitions (thoughts and visual images).

16. 4. These cognitions constitute the person’s “stream of
consciousness” or phenomenal field, which reflects the
person’s configuration of himself, his world, his past and
future.
5. Alterations in the content of the person’s underlying
cognitive structures affect his or her affective state and
behavioral pattern.

17. 6. Through psychological therapy a patient can become aware
of his cognitive distortions.
7. Corrections of these faulty dysfunctional constructs can lead
to clinical improvement.

18. BASIC CONCEPTS OF CBT
• Fundamental to the cognitive model is the way in which
cognition (the way we think about things and the content of
these thoughts) is conceptualized.
• Beck outlined three level of cognition:
1. Core beliefs
2. Dysfunctional assumptions
3. Negative automatic thoughts

19. CORE BELIEFS
• Core beliefs, or schemas, are deeply held beliefs
about self, others and the world.
• Core beliefs are generally learned early in life and are
influenced by childhood experiences and seen as
absolute.

20. COGNITIVE TRIAD OF NEGATIVE CORE
BELIEFS
Negative views
about the world
”everybody hates
me because I am
worthless”
Negative views about
the future “ I’ll never
be good at anything
because everybody
hates me”
Negative views
about oneself
“I’m worthless”

21. DYSFUNCTIONAL ASSUMPTIONS
• Dysfunctional assumptions are rigid, conditional
‘rules for living’ that people adopt.
• These may be unrealistic and therefore maladaptive.
• For example, one may live by the rule that ‘It’s better
not to try than to risk failing’.

22. NEGATIVE AUTOMATIC THOUGHTS
• NATs are thoughts that are involuntarily activated in
certain situations.
• In depression, NATs typically centre on themes of
negative, low self-esteem and uselessness.
• For example, when facing a task, a NAT may be ‘I’m
going to fail’. In anxiety disorders, automatic
thoughts often include overestimations of risk and
underestimations of ability to cope.

23. WHAT ARE THE KEY ELEMENTS OF
CBT?
• CBT ultimately aims to teach patients to be their own
therapist, by helping them to understand their current ways of
thinking and behaving, and by equipping them with the tools
to change their maladaptive cognitive and behavioural
patterns.
• The key elements of CBT may be grouped into those that help
foster an environment of collaborative empiricism and those
that support the structured, problem-orientated focus of
CBT.

24. • Collaborative empiricism is based upon the establishment of a
collaborative therapeutic relationship in which the therapist
and patient work together as a team to identify maladaptive
cognitions and behaviour, test their validity, and make
revisions if needed.
• CBT also relies on the non-specific elements of the therapeutic
relationship, such as rapport, genuineness, understanding and
empathy.

25. • The focus of CBT is problem-oriented, with an emphasis on
the present.
• Unlike some of the other talking treatments, it focuses on ‘here
and now’ problems and difficulties. Instead of focusing on the
causes of distress or symptoms in the past, it looks for ways to
improve a patient’s current state of mind.
• CBT involves mutually agreed goal setting.

26. • Goals should be ‘SMART’
• S- SPECIFIC
• M- MEASURABLE
• A- ACHIEVABLE
• R- REALISTIC
• T- TIME-LIMITED

27. TYPES OF CBT
Acceptance and commitment therapy
Cognitive therapy
Dialectical behavior therapy.
Schema therapy
Rational emotive behavior therapy
Mindfulness.

28. RATIONAL EMOTIVE BEHAVIOR
THERAPY
• “People are disturbed not by things, but by the view they take of
them”- Epictetus, Greek Philosopher
• Rational Emotive Behavior Therapy (REBT) is the first form of
cognitive behavior therapy (CBT) and was created by Dr. Albert
Ellis in 1955
• According to REBT, our attitudes, our belief, our thoughts- the way
we think about events and the meanings we give to them, directly
affect how we feel and behave.
• REBT is also the only cognitive-behavioral therapy that encourages
people to examine their philosophy of life- their goals, values, etc.,
and how their philosophy affects their self- help efforts.

29. R= Rational… Most people realize that when they think more
rationally and reasonably, their life goes better.
E= Emotive.. Most people understand that their emotions are affected
by what happens to them and how they think about those events.
B= Behavior.. Most people accept that what they do affects how they
think and feel.
T= Therapy.. it can also mean teaching or training.

30. ABC MODEL
Activating
event
Beliefs &
Thoughts
Consequences

31. MINDFULNESS
• Mindfulness is best thought of as a way of being rather than an
activity in and of itself.
• Originally associated with Buddhist psychology, the term
“mindfulness” comes from the Sanskrit word “Smriti” which
literally translates to “that which is remembered”

32. MINDFUL AWARENESS HAS THREE KEY
FEATURES
• Purpose- Mindfulness involves intentionally and purposefully
directing your attention rather than letting it wander.
• Presence- Mindfulness involves being fully engaged with and
attentive to the present moment.
• Acceptance- Mindfulness involves being non-judgmental
toward whatever arises in the moment.

33. COGNITIVE DISTORTIONS
• A cognitive distortion is an exaggerated or irrational thought
pattern involved in the onset or perpetuation of
psychopathological states, such as depression and anxiety.
• Cognitive distortions are thoughts that cause individuals to
perceive reality inaccurately.
• Individuals experience automatic thoughts in response to
events, which in turn lead to emotional and behavioral
responses.

34. 1. All-or-nothing thinking
2. Overgeneralization
3. Mental filter
4. Jumping to conclusions
5. Personalization
6. Emotional reasoning
7. Magnification or minimization
8. Disqualifying the positives

35. APPLICATION OF CBT TO VARIOUS
DISORDERS
• Depression
• Initially, CBT was considered a treatment of choice for mild to
moderate depression among psychological treatment options.
• CBT is efficacious in the acute treatment of depression and
may provide a viable alternative to antidepressant medications
for even more severely depressed unipolar patients when
implemented in competent fashion. (Driessen et., al. 2010)

36. • Anxiety disorders
• CBT is a first-line, empirically supported intervention for anxiety
disorders.
• Although cognitive restructuring exercises are indeed emphasized
throughout the treatment to target dysfunctional thoughts,
• Usually further cognitive treatments are included to address worry
behavior in addition to thought content. To target worrying as a
process, cognitive techniques, such as mindfulness, are emphasized.
(Curtiss et al., 2021)

37. • Psychotic conditions
• CBT is effective in dealing with persistent positive as well as
negative symptoms of schizophrenia and also it improve
medication adherence. CBT has also shown its effectiveness in
treatment of acute psychoses. (Agbor et., al. 2022)

38. • Obsessive-compulsive disorder
• CBT is considered as effective psychological treatment for
OCD, particularly in obsessional problems where intrusive
thoughts are considered as personal responsibility.
• CBT can change responsible beliefs and appraisals and thereby
reduce distress and neutralizing behaviors. (Allen, 2010)

39. • Personality disorders-
• Another illustration of the cognitive model is seen in
personality disorder, each of which is characterized
by a set of dysfunctional beliefs.
• Cognitive behavioral therapy deals with these
dysfunctional beliefs and helps the client in working
more efficiently.

40. • Eating disorder-
• Anorexia and bulimia are characterized by a
constellation of maladaptive beliefs that encourage
sufferers to continue their unhealthy eating patterns.
• While discouraging them from trying to modify their
eating behavior so as to make it more normative.

41. PROCESS OF CBT
1. Engage client
• The first step is to build a relationship with the client. This can
be achieved using the core conditions of empathy, warmth and
respect.

42. 2. Assess the problem, person and situation
• Start with the client’s view of what is wrong for them.
• Determine the presence of any related clinical disorders.
• Obtain a personal and social history.
• Assess the severity of the problem.
• Note any relevant personality factors.
• Check for any secondary disturbance: How does the client feel
about having this problem? Check for any non-psychological
causative factors: physical conditions; medications; substance
abuse; lifestyle/environmental factors.

43. 3. Prepare the client for therapy
• Clarify treatment goals.
• Assess the client’s motivation to change.
• Introduce the basics of CBT, including the Bio-psycho-social
model of causation.
• Discuss approaches to be used and implications of treatment.
• Develop a contract.

44. 4. Implement the Treatment Programme
• Most of the sessions will occur in the implementation phase,
using activities like the following:
• Analyzing specific episodes where the target problems occur,
ascertaining the beliefs involved, changing them, and
developing relevant homework (known as ‘thought recording’
or ‘rational analysis’)

45. 5. Evaluate Progress
• Toward the end of the intervention it will be important to
check whether improvements are due to significant changes in
the client’s thinking, or simply to a fortuitous improvement in
their external circumstances.

46. 6. Prepare the client for termination
• Many people, after a period of wellness, think they are ‘cured’
for life.
• Warn that relapse is likely for many mental health problems
and ensure the client knows what to do when their symptoms
return.

47. Techniques of CBT

48. COGNITIVE TECHNIQUES
• Self-Monitoring
• The therapist instructs the patient to observe and record her
own behavioral and emotional reactions.
• After listing the problem the therapist and patient
collaboratively select the target monitoring.
• Rational Analysis
• It focuses on analysis of specific episodes to teach client how
to uncover and dispute irrational beliefs.

49. • Double-standard dispute
• If the client is holding a ‘should’ or is self-downing about their
behaviour, ask whether they would globally rate another
person (e.g. best friend, therapist, etc.) for doing the same
thing, or recommend that person hold their demanding core
belief.
• When they say ‘No’, help them see that they are holding a
double-standard.

50. • Catastrophe Scale
• On a whiteboard or sheet of paper, draw a line down one side.
Put 100% at the top, 0% at the bottom, and 10% intervals in
between.
• Ask the client to rate whatever it is they are catastrophising
about, and insert that item into the chart in the appropriate
place. Then, fill in the other levels with items the client thinks
apply to those levels.

51. • Devil’s Advocate
• It is designed to get the client arguing against their own
dysfunctional belief.
• The therapist role-plays adopting the client’s belief and
vigorously argues for it.
• While the client tries to ‘convince’ the therapist that the belief
is dysfunctional.

52. BEHAVIORAL TECHNIQUES
• Exposure
• It involves client entering feared situations they would normally avoid.
• Such exposure is deliberate, planned and carried out using cognitive and
other coping skills.
• Hypothesis testing
• In this, there is a variation of exposure, the client
1. writes down what they fear will happen, including the negative
consequences they anticipate, then
2. for homework, carries out assignments where they act in the ways they
fear will lead to these consequences (to see whether they do in fact occur).

53. • Stimulus control
• Sometimes behaviors become conditioned to particular
stimuli; for example, difficulty sleeping can create a
connection between being in bed and lying awake;
• Or the relief felt when a person vomits after bingeing on food
can lead to a connection between bingeing and vomiting.
• Stimulus control is designed to lengthen the time between the
stimulus and the response, so as to weaken the connection

54. • Paradoxical behavior
• When a client wishes to change a dysfunctional tendency,
encourage them to deliberately behave in a way contradictory
to the tendency.
• Emphasize the importance of not waiting until they ‘feel like’
doing it: practicing the new behaviour – even though it is not
spontaneous – will gradually internalize the new habit.

55. IMAGERY TECHNIQUES
• Time projection
• This technique is designed to show that one’s life and the world in
general, continue after a feared or unwanted event has come and
gone.
• Ask the client to visualize the unwanted event occurring, then
imagine going forward in time a week, then a month, then six
months, then a year, two years, and so on,
• Considering how they will be feeling at each of these points in time.
They will thus be able to see that life will go on, even though they
may need to make some adjustments.

56. • The ‘worst-case’ technique
• People often try to avoid thinking about worst possible
scenarios in case doing so makes them even more anxious.
• However, it is usually better to help the client identify the
worst that could happen.
• Facing the worst, while initially increasing anxiety, usually
leads to a longer-term reduction.

57. STRENGTHS AND LIMITATIONS OF CBT
Strengths Limitations
Well supported by scientific research Requires clients to be attuned to nuances
in mood or attentive to previously
unconscious thoughts
ƒ
Wide application ƒ
Can be overly prescriptive and ignore
individual factors
Has been used successfully with
personality and mood disorders
Requires the ability to think abstractly
(i.e. to think about thinking)
Provides a structured plan and sequence
for therapy
May not be as depth orientated as some
clients may prefer or see as necessary for
change

58. EFFICACY OF CBT
• A meta analysis showed that therapist-led CBT was more
efficacious than inactive and active comparisons in individuals
with bulimia nervosa and binge eating disorder. (Linardon et
al. 2017).
• A study conducted to discuss the usefulness of CBT for each
anxiety disorders. Overall findings showed that CBT appears
to be both efficacious and effective in the treatment of anxiety
disorders. (Kaczkurkin, 2015)

59. • A review of 269 meta-analytic studies examining the CBT for
SUD, anxiety disorders, somatoform disorders, eating
disorders, personality disorders, anger and aggression,
depression showed that maximum studies support CBT of
anxiety disorders, somatoform disorders, depression .
(Hoffman et al., 2018)
• CBT is an effective treatment modality for reducing symptoms
and enhancing functional outcomes among patients with
personality disorders, thereby making it a useful framework
for clinicians working with patients with PD symptomatology.
(Matusiewicz et al., 2010)

60. • CBT is effective in decreasing the relapse rate and improving
depressive symptoms, mania severity, and psychosocial
functioning, with a mild-to-moderate effect size. Subgroup
analyses indicated that improvements in depression or mania
are more potent with a CBT treatment duration of ≥90 min per
session, and the relapse rate is much lower among patients
with type I BD (Chiang et., al. 2017)

61. CASE VIGNETTE
• Mr. X is a 24 y/M college student on a full academic
scholarship. He belongs to a middle-socio economic status. He
visited the therapist to discuss his feelings of anxiety and
whether there is anything that can help him “calm his nerves.”
He said that he is used to getting anxious in certain situations,
but that it is starting to affect all areas of his life. He says that
he doesn’t have a friend because he gets “too freaked out” to
ask anyone on a date. He also says that his anxiety is starting
to affect his grades because he gets so nervous during exams
that he breaks into a cold sweat and cannot concentrate. He
wants to be able to control his anxiety but feels there is no
hope.

62. CASE CONCEPTUALIZATION
• Mr. X is experiencing cognitive and physiological anxiety in
response to evaluative situations.
• Therapy will focus on stress-management skills for his
physiological symptoms and identifying dysfunctional
thoughts or worries about his performance in academic and
social situations.
• Specifically, therapy will identify catastrophic thoughts he has
about failure.

63. • Goals:
• Relaxation
• Identifying Maladaptive thoughts/beliefs.
• Challenging Maladaptive thoughts/beliefs.

64. SESSION 1
• Establish relationship
• Identify the presenting problem
• Introduce CBT
• Describe problem in context of mode.
• Set Goals
• Receive feedback from him

65. SESSION 2
• Check Mood
• Introduce and practice progressive muscle relaxation.
• Set homework: Plan two times during week to practice
progressive muscle relaxation.
• Receive feedback from him.

66. SESSION 3
• Check Mood
• Review progressive muscle relaxation
• Introduce and practice imagery.
• Homework: 1 progressive muscle relaxation, 1 imagery exercise.
• Receive feedback from him.
• Session 4:
• Check mood
• Review imagery
• Introduce three-column thought record.
• Practice three-column with event from past week.
• Homework: 1 Relaxation technique, 1 three column thought record.

67. SESSION 5
• Check Mood
• Review homework and identify thought record.
• Discuss progress of therapy and termination.
• Introduce challenging thoughts and seven-column thought record.
• Receive feedback
• Session 6
• Check mood
• Review homework
• Complete seven-column in session
• Homework: 2 relaxation techniques 1 Seven column thought record.
• Receive feedback from him.

68. SESSION 7
• Check Mood
• Review homework
• Review progress of treatment
• Complete relapse prevention
• Introduce and schedule self-management sessions.
• Homework: self-management sessions.

71. CONCLUSION
• Cognitive behavior therapy is a type of psychotherapeutic
treatment that helps patients to understand the thoughts and
feelings that influence behaviors.
• Cognitive behavior therapy is generally short-term and focused
on helping clients deal with a very specific problem.
• During the course of treatment people learn how to identify
and change destructive or disturbing thought patterns that have
a negative influence on behavior.

72. • CBT has been used to treat people suffering from a wide range
of disorders, including anxiety, phobias, depression, addiction
and variety of maladaptive behaviors.
• CBT is one of the most researched types of therapy, in part
because treatment is focused on highly specific goal and
results can be measured easily.