1

Cognitive Behavioural Therapy

workshop

Sydney campus

10am – 1pm

January 12 2017

Dr Vicki Hutton (vicki.hutton@acap.edu.au)

CONTENTS

1. COGNITIVE BEHAVIOURAL THERAPY: AN EVIDENCE-BASED

PSYCHOLOGICAL INTERVENTION …..2

2. OTHER THERAPIES RELATED TO CBT …..3

3. DEFINING AND DESCRIBING CBT …..4

4. ROLE OF THERAPIST …..5

5. ROLE OF CLIENT …..6

6. STRUCTURE (including INTERVENTIONS) …..7

7. GROUP THERAPY …..23

8. APPENDIX – SAMPLE WORKSHEETS …..28

2

1. COGNITIVE BEHAVIOURAL THERAPY: AN EVIDENCE-BASED

PSYCHOLOGICAL INTERVENTION

Cognitive Behavioural Therapy (CBT) has made a massive contribution to mental health care,

but it is a broad tradition with some practitioners at the cognitive end and some at the

behavioural end. CBT has also evolved over the years.

APS definition:

Cognitive Behaviour Therapy (CBT) is a focused approach based on the premise that cognitions

influence feelings and behaviours and, that subsequent behaviours and emotions can influence

cognitions. The therapist helps individuals identify unhelpful thoughts, emotions and

behaviours. CBT has two aspects: behaviour therapy and cognitive therapy. Behaviour therapy

is based on the theory that behaviour is learned and therefore can be changed. Examples of

behavioural techniques include exposure, activity scheduling, relaxation, and behaviour

modification. Cognitive therapy is based on the theory that distressing emotions and

maladaptive behaviours are the result of faulty patterns of thinking. Therefore, therapeutic

interventions, such as cognitive restructuring and self-instructional training are aimed at

replacing such dysfunctional thoughts with more helpful cognitions, which leads to an

alleviation of problem thoughts, emotions and behaviour. Skills training (e.g., stress

management, social skills training, parent training, and anger management), is another

important component of CBT.

Evidence-based Psychological Interventions in the Treatment of Mental Disorders: A Literature

Review third edition (Copyright © 2010 The Australian Psychological Society Ltd.)

Why is CBT so popular?

CBT has the most research evidence of effectiveness for a wide range of mental health

disorders. (Mental disorder is a term used to describe a range of clinically diagnosable

disorders that significantly interfere with an individual’s cognitive, emotional or social

functioning.)

(Better Access to Mental Health Care initiative, 2007)

CBT is used in some of our placement agencies for clients experiencing a range of conditions,

including:

Mood/anxiety disorders

PTSD

Personality disorders

Self-esteem issues

Eating disorders

Self-injury

Suicidal ideation

3

2. OTHER THERAPIES RELATED TO CBT

Behavioural activation (BA): a method that recognises that individuals with depression may

choose inactivity rather than activities they previously enjoyed. Methods such as positive

reinforcement are used to increase the person’s activities. (See ‘Behavioural Activation’

worksheet in the Appendix).

Rational emotive behaviour therapy (REBT) (Albert Ellis): first of the cognitive behaviour

therapies. It is based on the assumption that cognitions, emotions and behaviours interact

significantly and have a reciprocal cause-and-effect relationship (A-B-C-D-E model – Activating

event emotional or behavioural Consequence/reaction. Beliefs about A create C. Disputing

new Effective philosophy).

Cognitive therapy (CT) (Aaron Beck): CT is active, directive, time-limited, present-centred,

problem-oriented, collaborative, structured, and empirical. There are three theoretical

assumptions: (1) people’s thought processes are accessible to introspection; (2) people’s

beliefs have highly personal meanings; (3) people can discover these meanings themselves

rather than being taught or having them interpreted by the therapist.

Cognitive-behaviour modification (Donald Meichenbaum): Focus on changing self-talk, but

not as direct and confrontational in uncovering and disputing irrational thoughts as REBT.

Cognitive narrative approach to CBT: Focus on plots, characters and themes in the stories

people tell about themselves and others regarding significant events in their lives.

Schema-Focused Therapy: Focus on identifying and changing maladaptive schemas and their

associated ineffective coping strategies through cognitive and experiential work.

In addition, the third wave of CBT includes holistic, reflexive and experiential themes:

Dialectical behaviour therapy (DBT): The overall goal is the reduction of ineffective action

tendencies linked with deregulated emotions. It is delivered in four modes of therapy:

(1) Traditional didactic relationship with the therapist;

(2) Skills training, which involves teaching the four basic DBT skills of mindfulness, distress

tolerance, emotion regulation and interpersonal effectiveness;

(3) Skills generalisation in which the focus is on helping the individual integrate the skills

learnt into real-life situations;

(4) Team consultation.

Acceptance and commitment therapy (ACT): ACT helps individuals increase their acceptance

of the full range of subjective experiences, including distressing thoughts, beliefs, sensations,

and feelings, in an effort to promote desired behaviour change that will lead to improved

quality of life. ACT reframes symptoms as ‘difficult thoughts and feelings’ and advocates for

people to perceive these thoughts and feelings as harmless and transient.

Mindfulness-based cognitive therapy (MBCT): Group treatment that emphasises mindfulness

meditation as the primary therapeutic technique. In MBCT, the emphasis is on changing the

relationship to thoughts, rather than challenging them.

4

3. DEFINING AND DESCRIBING CBT

CBT is a therapy that helps people look at the different situations that they find themselves in,

and to understand their thoughts, emotions and behaviours.

The CBT model proposes that it is not the situation that causes the emotional distress that an

individual experiences. Rather, it is the individual’s interpretation or view of that event or

situation which causes the emotional distress.

Key therapeutic principles underpinning CBT:

Therapy is regarded as a collaborative project between client and counsellor

The work is problem-focused and structured

Therapy is time-limited

Practice is informed by research

Westbrook, D., Kennerley, H., & Kirk, J. (2001). An introduction to Cognitive Behaviour Therapy:

Skills and applications (2nd ed.). London: Sage.

5

4. ROLE OF THE THERAPIST

Percentage (%) of total psychotherapy outcome variance attributable to therapeutic factors.

*Unexplained variance: expectancy, extra-therapeutic change and more

Norcross, J.C. (2011, p.13) Psychotherapy relationships that work: Evidence-based responsiveness Oxford Scholarship On-line

One of the fundamental principles of CBT is that there needs to be a collaborative relationship between the client and therapist. This collaboration takes the form of a therapeutic alliance in which the therapist and client work together to fight a common enemy: the client's distress.

To establish a collaborative relationship, the therapist needs to strike a balance between being directive and imposing structure on the one hand, and allowing the client to make choices and take responsibility on the other. This balance involves deciding when to talk and when to listen; when to confront and when to back off; when to offer suggestions and when to wait for the client to make their own suggestions.

Beck Institute for Cognitive Behavior Therapy: Cognitive Therapy and the Emotional Disorders, pp. 220-221; Cognitive Therapy of Depression, pp. 50-54

6

According to Dryden (2015), general therapeutic goals at the outset of therapy include:

Develop an effective working alliance

Provide a safe place for clients to discuss what is important

Help clients see that they can effectively address concerns

Show clients you are genuine with them, understand them from their frame of reference,

accept them

Establish a communication forum where you both talk freely about mutual experiences of

therapy (i.e. establish meta-therapy dialogue)

Dryden, W. (2015). How to help your clients get the most out of CBT: A therapist’s guide. New York, NY: Routledge.

5. ROLE OF THE CLIENT

The client’s role in CBT includes:

Speak openly about their problems

Be active in the therapeutic process, speak up, giving their opinion about therapy

Undertake to carry out agreed tasks in the service of goals

Dryden, W. (2015). How to help your clients get the most out of CBT: A therapist’s guide. New York, NY: Routledge.

Clients who are suitable for the CBT approach to therapy:

Can recognise automatic thoughts or images

Can recognise and distinguish changes in affect or emotions

Can recognise helpful and unhelpful behaviour in self or in others

Have some optimism regarding therapy

Accept both responsibility and the need for change

Are willing to carry out homework assignments

Are able to concentrate and focus on an agreed agenda

Corrie, S., Townend, M., & Cockx, A. (2016). Assessment and case formulation in Cognitive

Behavioural Therapy. London: Sage Publications Ltd.

7

6. STRUCTURE (Individual therapy)

CBT is a structured stage-by-stage programme, in which the problem behaviour that has been

troubling the client is identified and then modified in a systematic, step-by-step manner. The

following stages are fundamental to CBT:

a. Therapeutic relationship

b. Assessment

c. Case formulation

d. Intervention

e. Monitoring

f. Relapse

a. Therapeutic relationship

Establishing rapport and creating a working alliance

Socialisation of the client to the cognitive-behavioural model

Warmth, genuineness and congruence

Being accepting, respectful and non-judgmental

Attentiveness to the client

Accurate empathy

Notion of client-counsellor collaboration - sharing responsibility for defining problems and

solutions

McLeod, J. (2013). An introduction to counselling (5th ed.). Maidenhead, Berkshire: Open

University Press.

b. Assessment

The assessment is not a list of questions, asked in rigid succession. It is a task around which

client and therapist work collaboratively and begin to develop a relationship of understanding

and trust.

The therapist seeks information in four key domains:

COGNITIONS – what thoughts and images are occurring, and how is information processed;

what words, phrases, images are in the mind of the client when experiencing the problematic

situation?

EMOTIONS – different feeling states that occur around the manifestation of the problem.

BEHAVIOUR – what does the person do?

PHYSICAL – what physical sensations or reactions occur, what physiological or bodily

symptoms are associated with the problem?

8

IMPORTANT: You need to elicit information about specific events, not generalised accounts of

what usually happens.

Steps:

1. Invite the client to talk about problematic events and use these descriptions to find out as

much as possible about:

CONTENT that is present within each of the four domains;

INTENSITY of the experience;

SEQUENCING of elements or their re-occurrence in repeating cycles of dysfunctional

activity.

2. Construct an understanding of how cognitions, emotions, actions and physical states are

linked together.

Assessment phase sets the scene for case formulation, treatment planning and

implementation of interventions, but can be therapeutic in itself.

Corrie, S., Townend, M., & Cockx, A. (2016). Assessment and case formulation in Cognitive

Behavioural Therapy. London: Sage Publications Ltd.

ACTIVITY

The ‘Five Areas Assessment of Joan Smith, a 40-year old married woman’ provides an example

of how to include information from the four key domains in your assessment.

Please read the case study, Case 5.2 ‘Panic’ (DSM-5 Clinical Case studies. Anxiety disorders.

Retrieved from

http://dsm.psychiatryonline.org.ezproxy.navitas.com/doi/full/10.1176/appi.books.978158562

4836.jb05#x83514.8290309

Work in pairs or groups to develop a ‘five areas assessment’ for this case.

Note: The ‘Panic Assessment’ worksheet in the Appendix is also a handy tool to help with this

particular assessment.

9

Williams, C., & Garland, A. (2002). A cognitive-behavioural therapy assessment model for use

in everyday clinical practice. Advances in Psychiatric Treatment, 8, 172-179.

10

Life situation, relationships and practical problems

Altered thinking

Altered emotions

Altered physical symptoms/feelings

Altered behaviour or activity levels

11

Case 5.2 Panic

Carlo Faravelli, M.D.

Maria Greco was a 23-year-old single woman who was referred for psychiatric evaluation by

her cardiologist. In the prior 2 months, she had presented to the emergency room four times

for acute complaints of palpitations, shortness of breath, sweats, trembling, and the fear that

she was about to die. Each of these events had a rapid onset. The symptoms peaked within

minutes, leaving her scared, exhausted, and fully convinced that she had just experienced a

heart attack. Medical evaluations done right after these episodes yielded normal physical

exam findings, vital signs, lab results, toxicology screens, and electrocardiograms.

The patient reported a total of five such attacks in the prior 3 months, with the panic occurring

at work, at home, and while driving a car. She had developed a persistent fear of having other

attacks, which led her to take many days off work and to avoid exercise, driving, and coffee.

Her sleep quality declined, as did her mood. She avoided social relationships. She did not

accept the reassurance offered to her by friends and physicians, believing that the medical

workups were negative because they were performed after the resolution of the symptoms.

She continued to suspect that something was wrong with her heart and that without an

accurate diagnosis, she was going to die. When she had a panic attack while asleep in the

middle of the night, she finally agreed to see a psychiatrist.

Ms. Greco denied a history of previous psychiatric disorders except for a history of anxiety

during childhood that had been diagnosed as a “school phobia.”

The patient’s mother had committed suicide by overdose 4 years earlier in the context of a

recurrent major depression. At the time of the evaluation, the patient was living with her

father and two younger siblings. The patient had graduated from high school, was working as a

telephone operator, and was not dating anyone. Her family and social histories were otherwise

noncontributory.

On examination, the patient was an anxious-appearing, cooperative, coherent young woman.

She denied depression but did appear worried and was preoccupied with ideas of having heart

disease. She denied psychotic symptoms, confusion, and all suicidality. Her cognition was

intact, insight was limited, and judgment was fair.

Diagnosis: Panic disorder

12

c. Case formulation

Formulation is a psychologically-informed explanation of the client’s problems which can

provide the basis for how to approach the task (Corrie, Townend & Cockx, 2016).

For CBT therapists, the aim of developing a case formulation is to arrive at an individualised

theory of a client’s difficulties that is derived from cognitive and/or behavioural theory.

The case formulation is shared with the client, and the client’s response helps sharpen the

formulation.

Formulation allows the client to begin to learn about CBT concepts and become their own

therapist.

WHENEVER POSSIBLE, IT IS PREFERABLE TO BASE A FORMULATION ON AN ACTUAL INCIDENT

RATHER THAN WHAT GENERALLY HAPPENS WHEN THE CLIENT GETS CAUGHT UP IN THE

PROBLEM.

Some ways to approach case formulation:

1) The following elements can be included:

Problem list – itemising the client’s difficulties in terms of cognitive, behavioural and

emotional components (as identified in the case assessment)

Hypothesised mechanisms – one or two physiological mechanisms underlying the

client’s difficulties

Account/narrative of how the hypothesised mechanisms lead to the overt difficulties

Current precipitants – events or situations that are activating the client’s vulnerability

at this time

Origins of the underlying vulnerability (client history)

Treatment plan

Obstacles to treatment

Persons, J.B., & Tompkins, M.A. (2007). Cognitive-behavioral case formulation. In T.D. Eells

(ed.). Handbook of Psychotherapy Case Formulation, 2nd ed. New York: Guildford Press.

2) The five ‘Ps’ approach (Dudley & Kuyken 2006):

Presenting issues

Precipitating factors

Perpetuating factors

Predisposing factors

Protecting factors (person’s resilience, strengths, safety activities)

Dudley, R., & Kuyken, W. (2006). Formulation in cognitive-behavioural therapy. In L. Johnstone

and R. Dallos (eds). Formulation in Psychology and Psychotherapy: Making sense of people’s

problems. London: Routledge.

13

No matter what approach you take, it is important for the therapist to check continually to be

certain that the client understands the therapist's formulations. For example, clients who are

depressed often indicate understanding simply out of compliance (Beck Institute for Cognitive

Behavior Therapy, 2016).

ACTIVITY

Work in pairs or groups to complete a 5 p’s formulation for Case 5.2 ‘Panic’.

The formulation diagram ‘How did “the problem” develop?’ presents the 5 p's in an accessible way.

Note:

Based on the case formulation, therapy goals would be developed. Suggested goals for Panic

Disorder could be:

(a) Identification of catastrophic misinterpretations;

(b) Promoting the ability to generate alternative appraisals;

(c) Testing the validity of both catastrophic and non-catastrophic interpretations

Corrie, S., Townend, M., & Cockx, A. (2016). Assessment and case formulation in Cognitive

Behavioural Therapy. London: Sage Publications Ltd.

14

15

d. Intervention strategies

There are many different therapeutic tactics available to the CBT therapist. Without an overall

strategy for a given case, the therapy may become trial-and-error. The strategy for change

should follow logically from the case formulation.

The overall strategy for change generally incorporates techniques drawn from one or more of

three intervention categories: testing automatic thoughts, modifying assumptions, and

changing behaviours (Beck Institute for Cognitive Behavior Therapy, 2016).

TESTING AUTOMATIC THOUGHTS

Once a key automatic thought has been identified (see worksheet ‘Automatic Thoughts’ in the

Appendix), the therapist asks the client to temporarily suspend their conviction that the

thought is undeniably true and instead to view the thought as a hypothesis to be tested. The

therapist and client collaborate in gathering data, evaluating evidence, and drawing

conclusions.

There are several techniques for testing the validity of automatic thoughts:

The therapist asks the client to draw on his/her previous experiences to list the evidence

supporting and contradicting the hypothesis (see ‘Challenging Negative Thoughts’

worksheet in the Appendix). After weighing all available evidence, clients may reject their

automatic thoughts as false, inaccurate, or exaggerated.

The therapist asks the client to design an experiment to test the hypothesis. Once the

experiment has been planned, the client predicts what the outcome will be, then gathers

data. Frequently the data contradicts the client's prediction, and the client can reject the

automatic thoughts

REATTRIBUTION

When clients unrealistically blame themselves for unpleasant events, the therapist and client

can review the situation to find other factors that may explain what happened other than, or

in addition to, the client's behaviour.

MODIFYING UNDERLYING ASSUMPTIONS

The cognitive therapist emphasizes questioning in the modification of underlying assumptions.

After an assumption has been identified, the therapist asks the client a series of questions to

demonstrate the contradictions or problems inherent in the assumption (see Socratic

Questioning).

Another strategy for testing assumptions is for the therapist and client to generate lists of the

advantages and disadvantages of changing an assumption. Once the lists have been

completed, the therapist and client can discuss and weigh the competing considerations.

16

According to Corrie, Townend and Cockx (2016), underlying assumptions are often based on

the following cognitive distortions:

Dichotomous thinking: seeing things in ‘all-or-nothing’ categories

o ‘I’m a failure because I didn’t get the new job’

Overgeneralisations: seeing a single negative event as a never-ending pattern of defeat

o ‘I’m going to be single for the rest of my life because I just got dumped’

Mental filter: picking out a single negative detail and dwelling on it to the exclusion of

others

o ‘I’ve been so tired lately. I’m never going to get on in the world.’

Disqualifying the positive: rejecting positive experiences by insisting they don’t count

o Most of your friends like your new hair colour, but you can’t stop thinking about

the one person who didn’t.

Jumping to conclusions; mind reading: arbitrarily making conclusions about what others

are thinking (see also fortune telling: predicting that things will turn out badly)

o ‘My partner doesn’t love me because they don’t tell me every day.’

Magnification (catastrophising)/minimisation: exaggerating or shrinking the importance

of events inappropriately

o See the ‘candy’ excerpt below.

Emotional reasoning: thinking that negative emotions reflect the way that things really

are, thus basing decisions on emotions alone

o After a really bad day, you don’t go out with friends because you assume they’re

just asking you to be polite.

Should statements: criticising oneself and others using unfair rules and standards

o ‘I should be married and have a well-paying job at my age.’

Labelling: calling oneself names in response to events

o ‘I’m stupid because I didn’t pass my driving test first go.’

Personalisation: blaming oneself or others for something without accounting for other

factors that were involved

o ‘Some people didn’t come to my party so I’m a failure.’

Corrie, S., Townend, M., & Cockx, A. (2016). Assessment and case formulation in Cognitive

Behavioural Therapy. London: Sage Publications Ltd.

SOCRATIC QUESTIONING

Socratic questioning is often used during assessment and throughout the course of therapy to

identify irrational beliefs, automatic thoughts, negative self-statements, dichotomous thinking,

and other forms of cognitive processing associated with the emotional and relational

difficulties being experienced by the client.

McLeod, J. (2013). An introduction to counselling (5th ed.). Maidenhead, Berkshire: Open

University Press.

17

IMPORTANT POINTS:

Socratic questioning requires genuine curiosity, empathy and sensitivity to avoid any sense of

patronising the client. The purpose is NOT to change the client’s mind, but to GUIDE

DISCOVERY.

Socratic questioning involves asking the client questions which:

(a) The client has the knowledge to answer;

E.g. A client who is completely unaware of their emotions may not be able to answer

“what are you feeling now?”, but can answer “Are you aware of any tension or changes in

your body as we talk about your father?”

(b) Draw the client’s attention to information that is relevant to the issue being discussed and

that may be outside of the client’s present focus;

E.g. When depressed, there is a tendency to recall depressing memories. Memories

contradictory to the current mood can be retrieved with a stimulus (i.e. good Socratic

questions.

(c) Generally move from the concrete to the more abstract;

Concrete questions that narrow the client’s concern (e.g. “I’m no good”) to a specific

example ensure client and therapist are talking about the same thing. Questions can then

help the client learn something from the example which then becomes applicable to the

abstract.

(d) Allow the client to eventually apply the new information to either re-evaluate a previous

conclusion, or construct a new idea.

Padesky, C.A. (1993). Socratic Questioning: Changing minds or guiding discovery? Keynote

address delivered at the European Congress of Behavioural and Cognitive Therapies, London,

September 24, 1993

There are three categories of questions (Westbrook et al., 2011):

1. Questions aimed at uncovering evidence (e.g. evidence for and against a specific cognition)

2. Questions aimed at identifying alternative perspectives (e.g. other ways of viewing the

event or situation; how the client thinks another person may view the situation)

3. Questions relating to consequences (e.g. the implications, emotionally, behaviourally and

interpersonally, of having a particular thought or belief, including what is helpful and

unhelpful in holding a particular view)

Westbrook, D., Kennerley, H., & Kirk, J. (2011). An introduction to Cognitive Behaviour Therapy:

Skills and applications (2nd ed.). London: Sage.

18

Some examples of Socratic Dialogue Questions

What do you mean when you say….?

Has something happened to lead you to this conclusion?

Have you ever been in similar circumstances before?

What did you do? How did that turn out?

What things would you do differently if….?

What do you know now that you didn’t know then?

Why would someone make this assumption?

Do you have any evidence to support that conclusion?

Can someone else give evidence to support that response?

What would you advise a friend who told you something similar?

This case study from Beck Institute for Cognitive Behavior Therapy (2016) demonstrates how a

client was selectively focusing on only negative information in drawing conclusions. In the

following excerpt, the therapist uses Socratic dialogue to explore how the depressed client was

disgusted with herself for eating candy when she was on a diet.

Patient: I don't have any self-control at all.

Therapist: On what basis do you say that?

Patient: Somebody offered me candy and I couldn't refuse it.

Therapist: Were you eating candy every day?

Patient: No, I ate it just this once.

Therapist: Did you do anything constructive during the past week to adhere to your diet?

Patient: Well, I didn't give in to the temptation to buy candy every time I saw it at the

store...Also, I did not eat any candy except the one time it was offered to me and I felt I

couldn't refuse it.

Therapist: If you counted up the number of times you controlled yourself versus the number

of times you gave in, what ratio would you get?

Patient: About 100 to 1.

Therapist: So if you controlled yourself 100 times and did not control yourself just once, would

that be a sign that you are weak through and through?

Patient: I guess not -- not through and through (smiles).

(Retrieved from www.beckinstitute.org )

ACTIVITY

Select one of the cognitive distortions that may be applicable to you. Working in triads, advise

your ‘counsellor’ of your cognitive distortion. Your counsellor will then use Socratic questions

to explore the cognitive distortion with you. (The worksheet ‘Challenging Negative Thoughts’

in the Appendix may also help with this activity.)

19

BEHAVIOURAL TECHNIQUES FOR MODIFYING UNDERLYING ASSUMPTIONS In contrast to strictly cognitive techniques, behavioural techniques focus more on how to act or cope than on how to view or interpret events. One of the principle goals of behavioural techniques is to modify dysfunctional cognitions. For example, the client who believes "I can't enjoy anything anymore" often modifies this automatic thought after completing a series of behavioural assignments designed to increase the number and variety of pleasurable activities they engage in. Thus behavioural change is often used as evidence to bring about cognitive change (Beck Institute of Cognitive Behavior Therapy, 2016).

MINDFULNESS

Emphasis on not forcing change to take place, but on promoting awareness and acceptance.

BEHAVIOUR EXPERIMENTS

Behaviour experiments may be enacting sequences of behaviour in the therapy room or out.

These may be opportunities for the client to practice new skills and ways of coping (e.g. in a

group setting); or involve confronting (rather than avoiding) feared situations and stimuli.

ASSERTIVENESS AND SOCIAL SKILLS TRAINING

People can develop psychological problems because they are not very good at engaging in

micro-level social interaction sequences.

EXPOSURE TECHNIQUES

Graded hierarchy of fear-eliciting situations that have been planned and discussed in advance.

IMAGERY RESCRIPTING

Following a phase of reflection on the event, client is asked to ‘rescript’ the event by imagining

what would need to happen to have made the original event less distressing.

HOMEWORK

Practice new behaviours and cognitive strategies, engagement in behavioural experiments and

collection of self-monitoring data between therapy sessions.

Kazantzis et al. (2005) suggest the following principles for successful use of homework

assignments in therapy:

Rationale for homework assignments provided in first session

Relevant to the client’s goals and aligned with existing coping strategies

Specific rather than vague

20

Check the client has understood what is expected

Written instructions provided

Assignment not discussed if client is highly distressed

Outcome discussed at following session

Kazantzis, N., McEwan, J., & Dattilio, F.M. (2005). A guiding model for practice. In N. Kazantzis,

F.P. Deane, K.R. Ronan, & L. L’Abate (eds). Using homework assignments in Cognitive Behavior

Therapy. London: Routledge.

SELF-HELP LEARNING MATERIALS

Information sheets and worksheets that enable client to learn how to apply CBT ideas and use

CBT methods to make changes in their lives.

GRADED TASK ASSIGNMENT

The therapist may break down an activity into subtasks, ranging from the simplest part of the task to the most complex and taxing. These graded tasks provide the immediate and unambiguous feedback that they can succeed.

COGNITIVE REHEARSAL

Technique of asking the client to imagine each step leading to the completion of the task. This rehearsal imagery helps focus attention on the task, and also permits the therapist to identify potential obstacles that may make the assignment more difficult for a particular patient.

ROLE PLAYING

Role-playing may be used to elicit automatic thoughts in specific interpersonal situations; to practice new cognitive responses in social encounters that had previously been problematic for the client; and to rehearse new behaviours in order to function more effectively with other people. Role-reversal is often effective in guiding clients to "reality test" how other people would probably view their behaviour, and thus allow clients to view themselves more sympathetically. Role-playing can also be used as part of assertiveness training. Role-playing frequently is accompanied by modelling and coaching procedures.

21

e. Monitoring

Measuring client improvement is an important part of an evidence-based modality like CBT.

Monitoring is also reassuring to remind the client of progress when they may be feeling

insecure due to loss of their usual coping strategies.

This can be done using SUDS – subjective units of distress scale – where the client rates their

level of anxiety or panic on a scale of 0-10 or 100; or the use of standardised measurement

instruments for specific diagnoses.

McLeod, J. (2013). An introduction to counselling (5th ed.). Maidenhead, Berkshire: Open

University Press.

f. Relapse prevention

Relapse may happen when the client is faced with a crisis; therefore it is necessary in CBT to

prepare for this and provide the client with skills and strategies for dealing with relapse events.

Three common types of experience:

Downers (feeling depressed)

Rows (interpersonal conflict)

Joining the club (pressure from others to resume behaviour)

22

TROUBLE SHOOTING

Some of the most common mistakes for new cognitive therapists include:

1. Failure to agree on specific problems to focus on;

2. Selection of peripheral problem to attack rather than a central concern;

3. Tendency to skip from problem to problem across sessions rather than persistently seek a

satisfactory solution to one or two problems at a time.

Other common sources of lack of progress include:

Problems in the working alliance/Poor therapeutic bond

Therapeutic bond is too good

Therapist lacks general therapeutic skills

Therapist lacks CBT-specific skills

Client believes change isn’t possible

Client has doubts about therapy but doesn’t disclose this

Client thinks intellectual insight is sufficient (doesn’t work on behaviour)

Client is not prepared to work for change

Client is intolerant of discomfort and unfamiliarity of change

Dryden, W. (2015). How to help your clients get the most out of CBT: A therapist’s guide. New York, NY: Routledge.

23

7. GROUP THERAPY

Once clients have the basic cognitive model down, they are often placed in group therapy to

further refine and practice the philosophy that they are applying to their problems.

Groups serve as a microcosm of the larger world in which clients can practice reacting to

criticism, rejection, or pleasure in more rational ways. They can also practice new behaviours

such as assertiveness. The focus is on the application of cognitive therapy methods.

Prochaska, J.O., & Norcross, J.C. (2014). Systems of Psychotherapy: A transtheoretical analysis

(8th ed.). Stamford, CT: Cengage Learning.

Benefits of CBT group therapy:

Cost effective

Members profit by hearing other members talk about their problems

Members are able to identify cognitive distortions

Sense of belonging and a safe environment

Conditional beliefs rise to surface and allow identification, testing and revising in safe

environment

Learn problem solving techniques from other members, especially adaptive responses

Social modelling and learning

Practice in a real life approximation of society

NOTE: Knowledge and ability to conduct individual CBT sessions is important before

conducting groups, due to the complex demands involved in tracking and facilitating group

process issues.

Corey, G. (2013). Theory and practice of counselling and psychotherapy (10th ed.). Boston, MA:

Cengage Learning.

Steps in CBT group work:

Step 1:

Therapeutic alliance - Group leader combines empathy and sensitivity with technical

competence in establishing their relationship with members.

Step 2:

Cognitive conceptualisation of cases – Group leader needs to be creative and active, and able

to engage clients through Socratic questioning and other cognitive and behavioural strategies.

Step 3:

Group leader must remain continuously active, deliberately interactive with members, helping

them frame their conclusions in the form of testable hypotheses.

24

GROUP FEATURES:

Agenda

Feedback

Goal setting (both from therapist and group members)

Homework (behavioural experimentation)

Socratic questioning (clients begin to learn how to use this in their interactions with each

other)

CBT GROUP WORK DOES NOT INCLUDE:

Random self-disclosure

Emotional confrontation among group members

Straying into deeply affective expressions in the absence of a CBT strategy or technique

Client actively

working and benefiting

from group

Task (i.e. CBT and therapeutic activities)

Clients' involvement

Process (how members react and interact; dynamics tracked by

leader)

Group leader

25

SOME EXAMPLES OF CBT GROUP THERAPY:

Mosman Private Hospital

There is a clinical assessment, including providing information about group treatment, assessing whether suitable for the client, and determining client’s motivation.

Group-work includes: psycho-education about depression; self-assertion, interpersonal relationships, and social network; resources and pleasurable activities; the cognitive model of depression and cognitive restructuring; and relapse prevention and evaluation of treatment. A patient workbook is used during treatment.

Sessions have the following structure: 1) review of homework; 2) presentation of topic A; 3) exercise related to topic A - conducted individually, in pairs, or in groups; 4) break; 5) presentation of topic B; 6) exercise related to topic B - conducted individually, in pairs, or in groups; and 7) presentation of homework.

The Sydney Clinic - Anxiety Group Some topics covered include:

Managing physical sensations associated with anxiety

Increasing awareness of unhelpful thinking patterns with techniques to challenge and

change them

Exposure to situations associated with social anxiety

Building resilience

Mood and addictive disorders

Managing physical symptoms of stress and anxiety

Enhancing life management skills

Learning skills to improve sleep

Learning ways to combat worry

Increasing awareness of unhelpful thinking patterns, and learning techniques to challenge

them

Adopting assertive communication skills

Learning ways to address perfectionism

Identifying strengths

Relapse prevention

Dialectical Behaviour Therapy (DBT)

Skills training in: core mindfulness, interpersonal effectiveness, emotional regulation

Acceptance and Commitment Therapy (ACT)

Develop acceptance of unwanted experiences

Develop skills of mindfulness

Identify and align values

Work toward a valued and meaningful life using a committed approach

Learn to implement cognitive diffusion techniques – separating yourself from your

thoughts

26

The Hills Clinic - Mood and anxiety day programme

CBT based treatment designed to follow on from the inpatient programme.

Focuses on the here and now and teaches skills for thinking, feeling and acting in ways that

promote better mental health. Some topics covered during the mood and anxiety day patient

groups include:

Balanced life style

Goal setting

Problem solving

Core beliefs

Healthy thinking

Dealing with relapse

Mindfulness and acceptance

Relapse prevention

New Farm Clinic CBT approach to assist with skill development and facilitating behaviour change. Some topics covered include:

Understanding anxiety and depression

Relaxation techniques

Effective communication, active listening, assertiveness

Managing unhelpful thoughts

Managing stress

Self esteem

Toowong Private Hospital

CBT programme , with the following topics:

Understanding how thinking and behaviours affect feelings

Identifying negative and harmful thinking

Coping skills

Stress management

Relapse prevention

Perth Clinic

CBT programme, with the following topics:

Recognising and challenging unhelpful thinking

Identifying and exploring core beliefs which underpin unhelpful thinking

Goal setting/planning

Managing anxiety and panic attacks

Managing depression

Communication/assertion skills

27

Support networks

Self esteem

Stress management

Relaxation techniques

Healthy lifestyles

Medication information

*Programme is flexible and responsive to the needs of each group member. Most effective

when individuals work to apply skills to their own personal circumstances. Participants are

assigned active practice and homework tasks individually, taking into account their

circumstances and personal goals.

Belmont Private Hospital

CBT programme content:

Schemas

Lifestyle balancing

Goal setting

Mindfulness

Nutrition and medication

Mastering your worries

Emotional intelligence

Perfectionism

Improving self esteem

Healthy relationships

Cognitive distortions

Putting off procrastinating

Community support

Stress management

Managing anxiety

Understanding anger

28

8. APPENDIX – Sample worksheets

29

30

31

32

33

(CBT worksheets are available at http://www.therapistaid.com/therapy-worksheet/simple-

cbt-model/cbt/none )