cognitive behavioral therapy

1. Introduction to Cognitive
Behavioral Therapy
Dr Nastaran Otared

2. Scenario 1: Job Interview Rejection
Alex, a recent graduate, feels nervous and excited about their first job interview.
Despite preparing thoroughly, they worry about making a good impression and
competing against more experienced candidates. Alex hopes this job will be the start of
a successful career.
Negative Automatic Thoughts:
1."I'm not good enough for any job."
2."Everyone else is better than me."
3."I'll never succeed in my career."
4."I'm a failure."
5."No one will ever hire me."
6."I messed up and it's all my fault."
7."There's something wrong with me."
8."This rejection proves I'm not capable."

3. Scenario 2: Receiving Criticism from a Friend
Description of Someone: Jamie, who values their close friendships deeply, feels
sensitive about maintaining these relationships. After a misunderstanding leads to
criticism from a friend, Jamie starts to doubt their self-worth and fears the impact
this incident may have on their friendship.
Negative Automatic Thoughts:
1."My friend hates me."
2."I'm a bad friend."
3."I always say the wrong thing."
4."No one likes spending time with me."
5."I'm unworthy of love or friendship."
6."I can never do anything right."
7."This criticism means I'm a terrible person."
8."Everyone must be talking about how awful I am."

4. Think about the last time you felt depressed or
anxious and write your negative thoughts.

5. WHAT IS COGNITIVE BEHAVIORAL THERAPY?
CognitiveTherapy+BehavioralTherapy=CognitiveBehavioralTherapy
Cognitive Model:
The cognitive model focuses on thinkingand how our thoughts are connected
to our mood, physiological responses, and behaviors
Cognitivetherapy will teach you to change your thoughts, beliefs,and attitudes
that contributeto yourproblems.
Two people can be faced with similar situations, but because they think about those
situations in different ways,theyhave different reactions to them.

7. Example 1
Situation: You send a message to a friend
and they don't reply for several hours.
Automatic Thought: "They're ignoring me
because they don't like me anymore."
Reaction:
•Emotional: You feel sad, rejected, and
anxious.
•Behavioral: You might avoid contacting
other friends for fear of being ignored
again, or you might obsessively check your
phone for a reply.
•Physical: You could experience stomach
aches or headaches due to the stress and
anxiety from these thoughts.

8. Example 2
Situation: You receive a lower grade
than expected on a project at work.
Automatic Thought: "I'm incompetent
and I'm going to lose my job."
Reaction:
•Emotional: You feel embarrassed,
disappointed in yourself, and fearful
about your job security.
•Behavioral: You might work late hours
to compensate, avoid taking on new
projects for fear of failure, or not ask for
feedback to avoid further criticism.
•Physical: You may have trouble
sleeping, lose appetite, or experience
increased stress levels.

9. BEHAVIORAL MODEL
“Depressedindividualsdo not get enough positive reinforcementfrom interactionswith
their environment to maintain happy,adaptive behavior.
Two behavioral patterns associated with depression:
 Low levelof positive feelings from engagingin life activities
 No longer participating in enjoyableactivities
 Not getting as much enjoyment in activities as in the past
 No longer enjoying socializing with others
 High rate of negative consequences
 Frequently noticing things are not working out
 Feeling a lack of support and understanding from
 others

10. History of CBT

11. COGNITIVE BEHAVIORAL MODEL
Wenzel, A., Brown, G. K., & Karlin, B. E. (2011). Cognitive Behavioral Therapy for Depression in Veterans and Military
Servicemembers: Therapy Manual. Washington, DC: U.S. Department of Veteran Affairs.

12.  CBT is evidence based. CBT has been well tested in research studies and has
been provento be effectiveintreating mental health problems.
 CBT is structured. You should expect to have a good idea of where you’re
going and how to get there. So, we will set clear goals to create a roadmap that
will help us find the best way to improve your symptoms. During each session
we will set an agenda for what we want to discuss, we will discuss last week’s
practice assignment, discuss agenda items, and then assignnewhomework.
 CBT is psychoeducational. The entire program is skill based and involves
you enhancing your skill set. You will learn different “tools” to help cope with
your current problems that you will be able to take with you when treatment is
over.
 CBT is goal oriented. We will work together to identify and achieve specific
treatmentgoals. We will trackyourprogresson yourgoals and problemsolveways
to reach them.
 CBTis time limited. Treatment is usually 8-20weeks.

13.  CBT requires you to attend weekly sessions. Regular attendance is essential
to recovery. Sessions areapproximately 50 minutes long.
 CBT requires active participation. What you get out of treatment is a direct
result of the effort you put into it. Just showing up is not enough. We need you
to be anactivepartner in yourtreatment process.
 CBT has a home practice requirement. Treatment is challenging and takes
daily commitment from you to be successful. CBT is not a one time therapy. It
is not an instant change that you will immediately notice after one session.
Practice assignments help put your new skills to use.
 CBT focuses on the here and now. Treatment emphasizes how depression is
maintained in yourpresent life.
 CBT is collaborative. Although the therapist is the expert on CBT, you are the
experton yourself. We will worktogetherto tailoryourtreatment to yourneeds.

14. What is Cognitive-Behavioral Therapy (CBT)?
A PROBLEM-
ORIENTED THERAPY
FOCUS ON
PRESENTAND
FUTURE
SHORT-TERM
FORMAT
SESSIONSARE
STRUCTURED
INVOLVESA
STRONG WORKING
ALLIANCE
HOMEWORK IS A
CENTRAL FEATURE
BASED ON
COGNITIVE THEORY
REQUIRES
COLLABORATIVE
EMPIRICISM

16. Levels of thoughts

17. Core beliefs are like the big ideas we have
about ourselves, other people, and life.
They're the main thoughts that we believe
really deep down, even if we don't always
talk about them.
Core beliefs are formed through a variety
of experiences, including our upbringing,
cultural background, significant life events,
and relationships.

18. We can split core beliefs into three kinds:
1.About Ourselves: These are thoughts like
"I'm good at making friends" or "I'm bad at
sports." They're what we think about who we
are.
2.About Others: These beliefs might be like
"People are mostly kind" or "You can't trust
anyone." They're our ideas about what other
people are like.
3.About the World: These are big ideas like
"The world is a beautiful place" or "Life is
hard." They're what we think life in general is
like.
So, if someone grows up being told they're
smart and does well in school, they might
believe "I am smart." If they see people helping
each other, they might think "People are
helpful." And if they find fun things to do, they
might believe "The world is an exciting place."
These are examples of core beliefs.

19. Intermediate beliefs are the beliefs that lie
between core beliefs and automatic thoughts.
Core beliefs are deeply ingrained beliefs about
ourselves, others, and the world, while
automatic thoughts are the immediate thoughts
that pop into our minds in response to
situations.
Intermediate beliefs, are more specific than
core beliefs but more general than automatic
thoughts. They often reflect our attitudes, rules,
expectations, and assumptions about various
aspects of life. Intermediate beliefs can be
either helpful or unhelpful, and they play a
significant role in shaping our interpretations of
events and our emotional reactions to them

20. 1.Rules: These are rigid guidelines or principles that individuals feel
they must adhere to in order to feel safe, worthy, or in control. For
example, someone might have a rule that says, "I must always please
others," or "I should never make mistakes.“
2.Assumptions: Assumptions are underlying beliefs about how the
world works or how people should behave. They are often taken for
granted and can influence interpretations of events. An example of an
assumption might be, "If I fail at something, it means I'm incompetent,"
or "People will always disappoint me.“
3.Attitudes: Attitudes are general evaluations or feelings toward certain
people, objects, or situations. They can be positive, negative, or neutral
and influence how individuals approach various aspects of life. For
instance, someone might have a negative attitude toward authority
figures, believing that they are always trying to control others.

21. Automatic thoughts are rapid, reflexive streams
of thought that occur in response to situations.
They are often influenced by underlying beliefs
and past experiences, and can intensify or
alleviate emotions. These thoughts are
characterized by their speed, emotional impact,
and tendency to follow certain patterns or
themes. In cognitive-behavioral therapy,
individuals learn to identify and challenge
automatic thoughts to promote more balanced
thinking and reduce distress.

22. Situation: Giving a presentation at work. Automatic thought: "Everyone is
going to think I'm incompetent because I stumbled over my words."
Situation: Receiving a text message from a friend inviting you to a social
event. Automatic thought: "They only invited me out of pity; they
probably don't really want me there."

23. Scenario: Sarah is preparing for a job interview at a
prestigious company. As she reviews her qualifications and
prepares answers to potential interview questions, she begins
to feel increasingly anxious about the upcoming interview.
Core beliefs?
Intermediate beliefs?
Automatic beliefs?

24. Core Belief: Sarah's core belief might be "I am not good
enough." This deep-seated belief stems from past experiences
of feeling inadequate and unworthy, such as receiving criticism
from a former boss or comparing herself unfavorably to others.
Intermediate Beliefs: she might hold the rule "I must always
excel in everything I do" or the assumption "If I make a
mistake, it means I am a failure." These beliefs shape her
expectations and standards for herself, leading to heightened
anxiety about the interview.
Automatic Thoughts: She thinks, "They're going to see right
through me," "I'll never get this job," and "I'm going to
embarrass myself."

25. 1.Downward Arrow Technique
2.Thought Records
3.Socratic Questioning
4.Imagery-Based Techniques
5.Life History Timeline
6.Behavioral Experiments
7.Values Clarification
8.Core Belief Worksheet
9.Belief Driven Formulation
10.Dysfunctional Thought Record
11.ABC Model (Activating Event, Belief, Consequence)
12.Role-Playing
13.Chair Work
14.Pie Chart Technique
15.Continuum Techniques
16.Historical Test of Beliefs
17.Identifying Cognitive Distortions
18.The Two-Column Technique
19.Cost-Benefit Analysis (Decisional Balancing)
20.Perspective-Taking Exercises

26. Downward Arrow Technique
The Downward Arrow Technique is a cognitive-behavioral
therapy (CBT) tool used to uncover deeper, underlying core
beliefs from surface-level automatic thoughts. The process
involves repeatedly asking the client to consider what their
automatic thought says about them, leading to a deeper
exploration of their beliefs about themselves, others, and the
world. This technique helps reveal the core beliefs that fuel
emotional distress and dysfunctional behavior.

27. Situation: A client is upset because they were not selected for a
project at work.
Automatic Thought: "I was not chosen for the project because
I'm not good enough.“
Using the Downward Arrow Technique:
1.Therapist: "What does it mean about you that you weren't
chosen for the project?“
2.Client: "It means I'm not skilled enough.“
3.Therapist: "And if you're not skilled enough, what does that
say about you?“
4.Client: "That I'm incompetent."

28. 1.Therapist: "What does being incompetent mean to you on a
deeper level?“
2.Client: "That I'll never succeed in my career.“
3.Therapist: "And what would it mean about you if you never
succeed in your career?“
4.Client: "That I'm a failure.“
5.Therapist: "And if you're a failure, how does that make you feel
about yourself?“
6.Client: "That I'm worthless."

29. Situation: A client is extremely anxious about an upcoming public
speaking engagement.
Automatic Thought: "I'm going to embarrass myself in front of
everyone.“
1.Therapist: "What does it mean about you if you embarrass
yourself?“
2.Client: "It means I'm not capable of speaking in public.“
3.Therapist: "And if you're not capable of speaking in public, what
does that say about you?“
4.Client: "That I'm inadequate."

30. 1.Therapist: "What does being inadequate mean to you on a
deeper level?“
2.Client: "That I'm not as good as others.“
3.Therapist: "And what would it mean about you if you're not as
good as others?“
4.Client: "That I'm worthless."

31. Situation: A client feels anxious and insecure in their romantic
relationship.
Automatic Thought: "My partner is going to leave me."
1.Therapist: "What does it mean about you if your partner leaves you?"
2.Client: "It means I'm not lovable."
3.Therapist: "And if you're not lovable, what does that say about you?"
4.Client: "That there's something fundamentally wrong with me."
5.Therapist: "What does having something fundamentally wrong with
you mean on a deeper level?"
6.Client: "That I'm flawed and undeserving of love."
7.Therapist: "And if you're flawed and undeserving of love, how does
that make you feel about yourself?"
8.Client: "That I'm alone and always will be."