Introduction to

Cognitive Behaviour Therapy

Epictetus 55 - 135 AD
Men are disturbed, not by
things, but by the principles
and notions which they form
concerning things

Roman (Greek-born) slave & Stoic philosopher

Cognitive Therapy is a system of
psychotherapy that attempts to reduce
excessive emotional reactions and self-
defeating behaviour, by modifying the
faulty or erroneous thinking and
maladaptive beliefs that underlie these
reactions
Beck et al 1976, 1979, 1993
The approach is:
Collaborative (builds trust)
Active
Based on open-ended questioning
Highly structured and focused
 ‘Common Sense’ Model

Event Emotion

Cognitive Model

Meaning
Event we give Emotion
the event
You’re walking down the High
Street, and someone you know
walks by without acknowledging
you…
 4 interpretations – 4 emotions
I don’t want her to see me, I won’t know what to say – she’ll think I’m stupid &
boring

•Nobody wants to talk to me, no-one likes me

•She’s got a nerve being so snooty!
•She’s probably still hung over from that
party last night!
Cognitive principle – it is interpretations of
events, not events themselves, which are
crucial.
Behavioural principle – what we do has a
powerful influence on our thoughts and
emotions
The continuum principle – mental health
problems are best conceptualised as
exaggerations of normal processes
‘Here and now’ principle – it is usually more fruitful to focus on current
processes rather than the past
Interacting systems principle – it is helpful to look at problems as interactions
between thoughts, emotions, behaviour and physiology and the environment
in which the person operates
 Padesky’s 5 Aspects Model (1986)

ENVIRONMENT

THOUGHTS

BIOLOGY MOOD /
FEELINGS

BEHAVIOUR
 ENVIRONMENT
On Plane
Turbulence

THOUGHTS
We might crash

BIOLOGY
Heart racing MOOD / FEELINGS
Palpitations
Anxious 90%
Rapid breathing
Difficult to breathe –
choking sensation

BEHAVIOUR
Reassurance
seeking
Feelings & commonly associated thoughts
 Groups
Think of a recent situation or event which resulted in a negative mood shift
– Anxiety
– Sadness
– Anger

Groups: therapist / client / observer

– Identify:
◦ thoughts / feelings / behaviours
Identify a recent significant shift in mood (emotion)
What was the situation?
How did you feel? (emotion/physiology)
What was going through your mind at the time? (thoughts)
What did you do? (behaviours)
What were the consequences?
Cognitive Internal / External Trigger

Model of Turbulent flight

Panic Perceived Threat

We might crash
I’m going to die

Anxiety / Panic 90%

Catastrophic Physical / Cognitive

Interpretation of Symptoms
Symptoms Heart racing
Breathless
I’ll suffocate and die Difficulty breathing –
Avoidance & Safety Behaviours choking sensation
Reassurance seeking: Shaking
Ask companion Sweating
Look at faces of other travellers
Ask cabin crew
Avoid flying!
 Early Experiences

Cognitive Model
Core Beliefs &
of Depression Assumptions
Beck (1979)

Critical Incident

Negative Automatic
Thoughts (NATS)

Behaviour Feelings
Negative Automatic Thoughts

Assumptions

Core
beliefs
Negative Automatic Thoughts
Stream of thoughts that we can notice if we try to
pay attention to them (automatic)
Negatively tinged appraisals or interpretations –
meanings we take from what happens around us or
within us
Specific thoughts about specific events or
situations
Brief, frequent, habitual – often not heard
Plausible and taken as obviously true, especially
when emotions are strong
Identifying NATs
Shifts in Affect
Distinguish between thoughts and emotion and behaviour
Check for images
Cognitive Model of Depression
Negative cognitive triad
–Biased views of
◦ Oneself
– I am bad, useless, unlovable, worthless, a failure
◦ The world in general
– Nothing good happens, life is just a series of trials
◦ The future
– It will always be like this, nothing I can do will make any difference, what’s the point of anything?

Negative filter
– Remembering events
– Interpreting current events / situations
– Overgeneralising from small negative event to broad negative conclusion
Goals of therapy
Help the client counteract negative cognitive
biases, and develop more balanced view of herself,
the world, and the future
Restore activity levels – especially those that give
sense of pleasure or achievement
Increase active engagement and problem solving
 Course of treatment
Identify specific problem list (& prioritise)
–Eg. Poor sleep, relationship difficulties etc
Introduce cognitive model – how it might apply to client
Goals (SMART)
Reduce symptoms through behavioural or simple
cognitive strategies
Identify and challenge NATs
Relapse prevention
Overview of a typical course of
therapy
Referral
Assessment: suitability, therapeutic relationship
Assessment (ongoing): problem analysis, wider
picture, measures
Problem list & prioritise
Goals for therapy (SMART)
Formulation (ongoing): Sharing model, maintaining
factors, predisposing factors, rationale for treatment
Overview of a typical course of
therapy
Assessment, Formulation
Treatment: start with symptom focused intervention
Review: every six sessions, repeat measures
Discharge: repeat measures, relapse prevention
Follow up / booster sessions:
◦ 1,3,6,12 month ?
Typical CBT treatment session
Set collaborative agenda
Review time since last session
Feedback on last session
Review homework
Focus on major topics for the session
Set homework
Potential problems with completing homework
Feedback on session
Therapy Skills
Engagement
Warmth and empathy
Collaboration
Guided discovery – socratic questioning
Feedback and summarising
Agenda setting – structure and focus
Open and closed questioning
Aims of Assessment
Initiate & develop therapeutic relationship
Establish suitability for CBT
Gather specific information re current difficulties
Elicit maintaining factors
Initial formulation
Socialise to CBT model
Establish joint understanding of the presenting
problem
Suitability for short term CBT
Ability to identify & describe negative thoughts
Awareness & differentiation of emotion
Compatibility with CBT rationale
Acceptance of personal responsibility for change
Alliance potential
Chronicity of problem
Security operations
Focality
Optimism/pessimism regarding therapy
Homework
Identify a recent significant shift in mood
What was the situation?
How did you feel?
What was going through your mind at the time?
What did you do?
What were the consequences?
Measures
The concept of measures is central to the CBT
approach, as it enables both client and practitioner
to evaluate the impact of interventions (Grant et al
2004)
They are important in the process of assessment and
aid the practitioner to develop a credible formulation
for the client, so that appropriate cognitive and
behavioural interventions can be used
Why Measures?
Assessment – to provide information
Baseline – subsequent measures will show extent of change
Effectiveness – helps to (objectively) demonstrate effectiveness of
therapy, and allow modification of treatment
Feedback
Knowledge - data collection & suggests areas for future research
What measures?
Standardised – developed for particular populations
and problems
–Eg. Beck Depression Inventory
–Beck Anxiety Inventory
–Agoraphobic Cognitions Questionnaire

• Individualised – allow for more specific

information for assessment and formulation.
– Eg. Problem definition, Targets of therapy, Diaries,
% Belief Ratings, Ratings of specific emotions
Cognitive Interventions
Restructuring thoughts and beliefs
– Guided discovery
– Thought diaries
– Challenging NATs (looking at evidence)
– Addressing thinking errors
– Responsibility Pie
– Cost/Benefit Analysis
– Downward Arrow technique
Cognitive Interventions
Education Eg. Written information on thinking errors, disorder specific info
Continuous use of formulation
Imagery techniques
Role play & role reversal
Action Plan
Education in Body systems (symptoms)
Behavioural Interventions
Very powerful method of bringing about change
Key component of CBT intervention
Borrowed and adapted from Behaviour Therapy
Incorporate different methodological approaches
Behavioural Experiments
Similar in BT / CBT, but fundamentally different
In BT, it is the end product, in CBT, a means to an end ie. Cognitive change
In BT – graduated, repeated and prolonged exposure
In CBT - New ideas are put to the test. Means of testing the validity
thoughts, perceptions, beliefs.
Examples
Hyperventilation to simulate panic
Activity monitoring and scheduling
Metaphors – South American tribe?
Consider experiment for client with OCD, believes something terrible will
happen to family if he doesn’t neutralise his thought by doing rituals for
up to an hour
Problem solving
Identify problem to be worked on
Think of as many solutions as possible
Consider each solution – pros & cons
Pick solution that appears best
Small steps
Action & review
Relapse Prevention
What have I learned?
What was most useful?
What can I continue to do?
When will I be at risk of this happening again?
What are the signs?
What could I do to avoid losing control?
What could I do if I did lose control?
Coping with Relapse
How can I make sense of this lapse?
What have I learnt from it?
With hindsight, what would I do differently?
Introduction to CBT
This presentation gives you an introduction to the rationale of CBT
It does not enable you to perform CBT
Using Cognitive Behavioural interventions may be helpful for your clients
CBT - Guided self-help?
 Summary
No formulation No CBT
Use CB techniques
–Bibliotherapy: e.g. Mind Over Mood
–Challenge negative thoughts
◦ Court Case
◦ Evidence
◦ More balanced/alternative thought
◦ Downward arrow
–Behavioural experiments / exposure
–Activity Diaries
–Relaxation?
More information & resources
www.get.gg
– Self help
– Workbooks
– online CBT programmes – printable forms etc
– Online
◦ Professional links
– CBT organisations
– Therapist manuals online
– Books
Bibliography
Certificate in Cognitive Behaviour Therapy.
– Salford Cognitive Therapy Training Centre. 2006
An introduction to Cognitive Behaviour Therapy: Skills
& Applications.
– Westbrook, Kennerley, Kirk, 2007. Sage.
Treatment Plans & Interventions for Depression &
Anxiety Disorders.
– Leahy. 2000. Guilford.
Cognitive Therapy of Anxiety Disorders.
– Wells. 1997. Wiley.
Mind Over Mood.
– Greenberger, Padesky. 1995. Guilford.