Cognitive Behavior Therapy

 Elements Of CBT
 Therapeutic Goals
 Therapist’s Function And Role
 Relationship Between Therapist And Client
 Client’s Experience In Therapy
 The Therapeutic Process
 Therapeutic Techniques and Procedures
notes
Elements of CBT
• ACTIVE
-The client must be involved in the therapeutic process not as an observer or as an occasional
visitor, but as a core and key participant.
• MOTIVATIONAL
-The therapist needs to take responsibility for helping to motivate the client toward a change in
behavior, affect, or thinking. The therapist must be able to set up the format, and rationale for
the client to consider change of value.
• DIRECTIVE
-The therapist must be able to develop a treatment plan and then to help the client to
understand, contribute to, and see the treatment plan as a template for change.
• STRUCTURED
-Sessions have identifiable beginning, middle and end.
• COLLABORATIVE
-CBT is a collaborative effort between the therapist and the client.
Client role - define goals, express concerns, learn
& implement learning
Therapist role - help client define goals, listen,
teach, encourage.
• BRIEF AND TIME-LIMITED
- Each therapy session should, ideally , stand alone. A time-limited focus is not a number of
sessions, but rather way of looking at therapy.
• SOLUTION-FOCUSED
- The CBT therapists works with the client on generating solutions not simply gaining insight
into the problem.

• Therapy does, however, vary considerably according to individual patients, the nature of their
difficulties, and their stage of life, as well as their developmental and intellectual level, gender,
and cultural background.
• Treatment also varies depending on patients’ goals, their ability to form a strong therapeutic
bond, their motivation to change, their previous experience with therapy, and their preferences
for treatment, among other factors.
• The emphasis in treatment also depends on the patient’s particular disorder(s).

Rational Emotive Behavior Therapy

Therapeutic Goals
1. Basic goal is to teach clients how to change their dysfunctional emotions and behaviors into
health ones.
2. Two main goals of REBT are to assist clients to achieving unconditional self-acceptance and
unconditional other acceptance.
3. As clients become more able to accept themselves, they are more likely to unconditionally
accept others.

Therapist’s Function And Role

1. Encouraging clients to discover their irrational beliefs and ideas
2. Making connection of how these irrational beliefs lead to emotional disturbances.
3. Challenging clients to modify or abandon their irrational beliefs.
4. Dispute the irrational beliefs and substitute rational beliefs and behaviors.

Relationship Between Therapist And Client

• Intensive therapeutic relationship is not required. But, REBT unconditionally accept all clients
and teach them to unconditionally accept others and themselves. (accept them as persons but
confront their faulty thinking and self-destructive behaviors)
• Ellis believes that too much warmth and understanding can be counter-productive, foster a
sense of dependence for approval from the therapist.
• Therapists shows great faith in their clients’ ability to change themselves.
• Open and direct in disclosing their own beliefs and values
• Transference is not encouraged, when it occur, the therapist is likely to confront it (e.g., clients
believe that they must be liked and loved by their therapists.)

Client’s Experience In Therapy

• A learner---learn how to apply logical thoughts, experiential exercises, and behavioral
homework to problem solving and emotional change.
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 • Focus on here-and-now experiences
• Not spend much time to exploring clients’ early history and connecting present and past
• Expect to actively work outside the therapy sessions.

SITUATION: Lara receives a negative evaluation at work.\

The Therapeutic Process

• Therapy is seen as an educational process
Clients learn:
• To identify and dispute irrational beliefs
• To replace ineffective ways of thinking with effective and rational cognitions
• To stop absolutistic thinking, blaming, and repeating false beliefs

1. Detecting irrational beliefs

• The counsellor’s foremost role in the process of disputing irrational beliefs is firstly to assist
clients in detecting them. Irrational beliefs can be detected through the examination of activating
events (A) and consequences (C).
2. Discriminating between rational and irrational beliefs
• The second step in disputing irrational beliefs is deciding whether the belief is irrational or not.
• A clue to the rationality of a belief is the use of terms such as should, must and ought.
• Use of such terms often indicates that a belief is irrational.
3. Debating irrational beliefs
Debating irrational beliefs is a large part of REBT. There are many techniques that can be used
to debate irrational beliefs.
• Socratic debate
The counsellor draws attention to the incongruence or inconsistency in the client’s beliefs. The
goal is to enable clients to critically examine their beliefs and not simply accept the counsellor’s
perception.

Therapeutic Techniques and Procedures

Cognitive Methods
• Disputing Irrational Beliefs
• Doing Cognitive Homework
• Bibliotherapy
• Cost-benefit Analysis.
• Changing One’s Language
• Psychoeducational Methods
Emotive Techniques
• Rational Emotive Imagery (REI)
• Humor
• Role Playing
• Shame Attacking Exercises
Behavioral Techniques
• Standard Behavior Therapy
• Operant Conditioning (Reinforcements & Penalities)
• Systematic Desentization
• Relaxation Techniques
• Modeling
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Therapeutic Techniques and Procedures

COGNITIVE METHOD - 1. DISPUTING IRRATIONAL BELIEFS
• Challenging the client to see irrational beliefs as unrealistic and encouraging them to replace
these with more rational, realistic versions
• The aim is to replace long-standing false beliefs with a client driven flexible belief system in
order to help them become less disturbed.
• “If I don’t get what I want, it is not at the end of the world “

5 WAYS OF DISPUTING IRRATIONAL BELIEFS

1. Rigidity Versus Flexibility

1. Classic all or nothing thinking,
Example: I must, I should and when not, my world will end.
“I must be a good mother to my son , if not it would break my heart.”
2. Therapists can challenge this thinking, making it more flexible meaning having strong desires but
being prepared for setbacks.

2. Extremism Versus Non-Extremism

Associating failures and setbacks with a generalized view that this setback proves the irrational
thoughts around worthlessness and hopelessness correct.
Non-extremism accepts that these failures make things more difficult but they are not life-
threatening.

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 Irrational Thought: I’m stupid, I can’t do Rational Thought: “ I guess I didn’t work hard
anything right. Because I’m stupid. I bet I enough – I’ll have to come up with a better plan for
would be fired because of this. next time.:

Behavior: Lara avoids her boss because she Behavior: Lara seeks out her boss to talk about
believes she’s in trouble. She feels nervous how she can improve. She approaches her next
the next time she’s confronted with task as a challenge and gradually improves.
challenging work and perform poorly.

3. Logical Disputing
This form of disputing is aimed at showing the client that feelings are not facts.
Example:
“I feel terrible so I must be terrible. “
“I feel ugly today, so I must be ugly”
The goal is to show the client that there is no logical reason for these kind of thoughts by
questioning the evidence for it.

4. Empirical Disputing
Ask “where is the proof that this belief is true?” With this question, one is looking for the
scientific evidence of the irrational belief’s validity. Use of Socratic questioning

5. The Functional Dispute

Ask “is my irrational belief helping me or does it make things worse for me?” In other words,
does the belief work to help achieve basic goals? Is this belief helping happiness or hurting it? Use of
Socratic questioning

Questioning irrational thoughts

1. What is the evidence?
What is the evidence that supports this idea?
What is the evidence against this idea?
2. Is there an alternative explanation?
3. What’s the worst that could happen? Could I live through it?
What is the best that could happen?
What is the most realistic outcome?
4. What is the effect of my believing the irrational thought?
What could be the effect of changing my thinking?
5. What should I do about it?
6. What would I tell________(a friend) if he or she were in the same situation?

Therapeutic Techniques and Procedures

COGNITIVE METHOD – 2. DOING COGNITIVE HOMEWORK
• Clients are expected to make lists of their problems, look for their absolutist beliefs, and dispute
these beliefs.

Therapeutic Techniques and Procedures

COGNITIVE METHOD – 3. Cost-Benefit Analysis.
This method is particularly helpful for individuals who have addictions and/or low frustration
tolerance.
Individuals who are addicted to smoking may be asked to make lists of the advantages of
stopping smoking and the disadvantages of continuing smoking. They are then instructed to think
seriously about these advantages and disadvantages 10 or 20 times a day. This activity gives them good
reasons for overcoming the addiction

ACTION/ACTIVITY ADVANTAGES DISADVANTAGES

1.

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Therapeutic Techniques and Procedures
COGNITIVE METHOD – 4. Bibliotherapy

• A therapeutic approach that uses literature to support good mental health, is a versatile and
cost-effective treatment option often adapted or used to supplement other types of therapy.
• Both individual and group therapy may utilize this method, which is considered appropriate for
children, adolescents, and adults.
• Mental health professionals may encourage those in therapy and those who are waiting for
therapy to read for guidance or self-help, developmental purposes, to learn about mental health
concerns, and for the therapeutic benefits of imaginative literature.

TYPES OF BIBLIOTHERAPY
• Prescriptive Bibliotherapy- which is also referred to as self-help, involves the use of specific
reading materials and workbooks to address a variety of mental health concerns. Self-help may
be conducted with or without the guidance of a therapist.

• Books On Prescription- is a program where reading materials targeting specific mental health
needs are "prescribed" by mental health professionals, who might use resources such as the
Bibliotherapy Education Project to find the appropriate books. Most libraries in the United States
carry a set of books from the approved list for this purpose, often providing as a book list on
their website. The Carnegie Library of Pittsburg is one such library. Their website also lists
books for children, which cover topics like adoption, self-esteem, grief, divorce, and more.

• Creative bibliotherapy -utilizes imaginative literature—novels, short stories, poetry, plays, and
biographies—to improve psychological well-being. Through the incorporation of carefully
selected literary works, therapists can often guide people in treatment on a journey of self-
discovery. This method is most beneficial when people are able to identify with a character,
experience an emotional catharsis as a result of this identification, and then gain insight about
their own life experiences.

Therapeutic Techniques and Procedures

COGNITIVE METHOD – 5. Changing One’s Language

• Precision of Language = REBT rests on the premise that imprecise language is one of the
cause of distorted thinking process;
• Clients learn that “musts”, “ought's”, and absolute “shoulds” can be replaced with preferences.
• Instead of saying “It would be absolutely awful if….” , they learn to say “ It
would be inconvenient if…”
• Clients who use language patterns that reflect helplessness and self-
condemnation can learn new self-statements which help them think and
behave differently.

Therapeutic Techniques and Procedures

COGNITIVE METHOD – 6. Psychoeducational Methods
• Introduce clients to various educational materials.
• Therapists educate clients about the nature of their problems and how treatment is likely to
proceed.
• Clients are more likely to cooperate with a treatment program if they
understand how the therapy process works and if they understand why
particular techniques are being used (Ledley, Marx, & Heimberg, 2010).

Therapeutic Techniques and Procedures

EMOTIVE TECHNIQUES- 1. Rational-Emotional Imagery

Using the technique of rational emotive imagery (REI), clients are asked to vividly imagine
one of the worst things that might happen to them. They imagine themselves in specific situations where
they experience disturbing feelings. Then they are shown how to train themselves to develop healthy
emotions in place of disruptive ones.
For example, a man may vividly imagine that, if he is rejected by a woman he wishes to date, he
will be terribly depressed afterward, be unable to think about anything else, and be very angry at himself.
The therapist then would have him keep the same negative image and work on feeling the
healthy emotions—disappointment and regret about the woman’s wish not to go out with him—without
feeling depressed and angry at himself. Imagining asking the woman for a date, being turned down,
and working on experiencing healthy rather than unhealthy negative emotions can help reduce
depression and feelings of inadequacy. Preferably, such techniques should be practiced once a day for
several weeks

Therapeutic Techniques and Procedures

EMOTIVE TECHNIQUES- 2. Forceful Self-Statements
Statements that combat “musturbating” beliefs in a strong and forceful manner can be helpful in
replacing irrational beliefs with rational beliefs. If a client has told himself that it is awful and terrible to get
a C on an examination, this self-statement can be replaced by a forceful and more suitable statement
such as “I want to get an A, but I don’t have to!” Ellis often uses obscenities as a way of providing more
force to a statement

Therapeutic Techniques and Procedures

EMOTIVE TECHNIQUES- 3. Forceful self-dialogue.
In addition to single self-statements, a dialogue with oneself, somewhat similar to the Socratic
dialogue, can be quite helpful.
Arguing strongly and vigorously against an irrational belief has an advantage over therapist–client

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dialogue in that all of the material comes from the client. Taping such dialogues, listening to them over
and over again, and letting listeners determine if one’s disputing is really powerful can help clients
impress themselves with their own power

Therapeutic Techniques and Procedures

EMOTIVE TECHNIQUES- 4. HUMOR.
• Emotional disturbances come from being too serious so humor is used to put life in
perspective

Therapeutic Techniques and Procedures

EMOTIVE TECHNIQUES- 5. ROLE PLAY
• The therapist asks the patient to rehearse certain behaviors to bring out what they feel in a
situation. The focus is on working through the underlying irrational beliefs that are related to
unpleasant feelings and make appropriate changes to the latter's thought processes.
For example:
Dawson may put off applying to a graduate school because of his fears of not being accepted.

• Just the thought of not being accepted to the school of his choice brings out intense feelings of
“being stupid.”
• Dawson role-plays an interview with the dean of graduate students, notes his anxiety and the
specific beliefs leading to it, and challenges his conviction that he absolutely must be accepted
and that not gaining such acceptance means that he is a stupid and incompetent person.

Therapeutic Techniques and Procedures

EMOTIVE TECHNIQUES- 6. SHAME-ATTACKING EXERCISES
• The exercises are aimed at increasing self-acceptance and mature responsibility, as well as
helping clients see that much of what they think of as being shameful has to do with the way
they define reality for themselves.
• Ellis asserts that we can stubbornly refuse to feel ashamed by telling
ourselves that it is not catastrophic if someone thinks we are foolish.
For example:
Clients may wear “loud” clothes designed to attract attention, sing loudly, ask a silly question at
a lecture.
By carrying out such assignments, clients are likely to find out that other people are not really
that interested in their behavior. They work on themselves so that they do not feel ashamed or
humiliated, even when they acknowledge that some of their acts will lead to judgments by others.
They continue practicing these exercises until they realize that their feelings of shame are self-
created and until they are able to behave in less inhibited ways. Clients eventually learn that they often
have no reason for continuing to let others’ reactions or possible disapproval stop them from doing the
things they would like to do.

Therapeutic Techniques and Procedures

BEHAVIOR TECHNIQUES
Behavioral homework assignments to be carried out in real-life situations are particularly
important.
These assignments are done systematically and are recorded and analyzed on a form.
Homework gives clients opportunities to practice new skills outside of the therapy session, which may be
even more valuable for clients than work done during the therapy hour.

Therapeutic Techniques and Procedures

BEHAVIOR TECHNIQUES Systematic Desentization

Clients can be encouraged to desensitize themselves gradually but also, at times, to perform the very
things they dread doing implosively.
For example,
A person with a fear of elevators may decrease this fear by going up and down in an elevator
20 or 30 times in a day. Clients actually do new and difficult things, and in this way they put their insights
to use in the form of concrete action. By acting differently, they also tend to incorporate functional beliefs.
For example:
“an individual who is afraid of public speaking may write down and repeat to himself several times a day
statements such as “I want to speak flawlessly, but it’s alright if I don’t,” “No one is killed for giving a poor
speech,” and “I’m an articulate person.”

Therapeutic Techniques and Procedures

BEHAVIOR TECHNIQUES -Reinforcements and penalties.
When people accomplish a task, it is useful for them to reward themselves.

For example, a shy person who has an extended conversation with three sales clerks may reward
himself by reading a favorite magazine.
Individuals who fail to attempt a task may penalize themselves. Ellis gives the example of burning a $100
bill. Such a self-penalty can quickly encourage clients to complete agreed-upon assignments.

CREATE A LIST OF ACTIVITIES YOU’D LIKE TO DO AND RATE EACH ACTIVITY ACCORDINGLY,
REWARD IF DONE EASILY AND PENALIZE WHEN ACTIVITY IS UNDONE.

ACTIVITY EASE (1-10) REWARD PENALTY

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Applications of REBT to Various Settings
• Individual Clients
• Self/ Personal Growth
• Groups
• Marriage / relationships
• Family
• Workplace
• Varying Intellectual ability/learning impairments
CAUTION: Cognitive therapies do not appear to work as well with those who are cognitively impaired.

Application of REBT as a Brief Therapy

Ellis originally developed REBT to try to make psychotherapy shorter and more efficient than most
other systems of therapy, and it is often used as a brief therapy. Ellis has always maintained that the
best therapy is efficient, quickly teaching clients how to tackle practical problems of living

Application to Group Counseling

• REBT is also suitable for group therapy because the members are taught to apply its principles
to one another in the group setting.
• This form of group therapy focuses on specific techniques for changing a client’s self defeating
• thoughts in various concrete situations. In addition to modifying beliefs, this approach helps
group members see how their beliefs influence what they feel and what they do.
• Tailored for specific diagnoses such as anxiety, panic, eating disorders, obesity,dissociative
disorders, and phobias
• This approach to groups is effective for treating a wide range of emotional and behavioral
problems.

Aaron Beck’s
Cognitive Therapy (CT)

• Relationship Between Therapist And Client

• Cognitive therapists are continuously active and deliberately interactive with clients, helping
clients frame their conclusions in the form of testable hypotheses.
• Therapists engage clients’ active participation and collaboration throughout all phases of therapy,
including deciding how often to meet, how long therapy should last, what problems to explore,
and setting an agenda for each therapy session
• Therapeutic relationship is necessary, but not sufficient, to produce therapeutic effect.
A therapeutic alliance is a necessary first step in Cognitive therapy. - “warm, empathic
relationships with clients while at the same time effectively using cognitive therapy
techniques that will enable clients to create change in their thinking, feeling, and
behaving”
• Encourage clients to take an active role in self-discovery.
• Aim to teach client how to be their own therapist, educate clients about the nature of
their problem, about the process of cognitive therapy, and how thoughts influence their
emotions and behaviors.
• Use homework to test their beliefs in daily-life situations
• The Therapeutic Process
The process of cognitive therapy
Step 1: Identify a client’s automatic thinking
Step 2: Evaluate the automatic thought in terms of:
􀂃 The feeling/emotion it generates
􀂃 Its validity (Is it true?)
Step 3: Apply strategies to modify the thinking pattern

Therapeutic Process
GUIDED DISCOVERY.
Sometimes called Socratic dialogue, guided discovery helps clients change maladaptive beliefs and
assumptions. The therapist guides the client in discovering new ways of thinking and behaving by asking
a series of questions that make use of existing information to challenge beliefs.

[Client:] I’ve been afraid that when I report to my new job on Monday, people
will think I can’t do the work.
[Therapist:] What does that tell you about the assumptions that you are making?
[Client:] Like I’m mind reading, like I know in advance what’s going to happen.
[Therapist:] And what assumptions are you making?
[Client:] That I know what my new colleagues will think of me.

Therapeutic Process
THE THREE-QUESTION TECHNIQUE.
A specific form of the Socratic method, the three question technique consists of a series of three
questions designed to help clients revise negative thinking. Each question presents a way of inquiring
further into negative beliefs and bringing about more objective thinking.
1. What is the evidence for the belief?
2. How else can you interpret the situation?
3. If it is true, what are the implications?

Therapeutic Process
HOMEWORK.
Much work in cognitive therapy takes place between sessions so that skills can be applied to real-life
settings, not just the office. Specific assignments are given to help the client collect data, test cognitive

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and behavior changes, and work on material developed in previous sessions. If the client does not
complete the homework, this fact can be useful in examining problems in the relationship between client
and therapist or dysfunctional beliefs about doing homework assignments (J. S. Beck, 2005).
Generally, homework assignments are discussed and new ones developed in each session.

Therapeutic Process
SESSION FORMAT.
Although therapists may have their own format that they adapt for different client problems,
there are certain topics to be dealt with in the therapy session (J. S. Beck, 1995). The therapist checks
on the client’s mood and how he is feeling. Usually, the therapist and client agree on an agenda for the
therapy session based, in part, on a review of events of the past week and on pressing problems that
may have emerged. Also, the therapist asks for feedback about the previous session and concerns or
problems that the client may have about issues that have occurred since the last meeting.
The therapist and client review homework and collaborate to see how the client could get more
out of it.
Usually, the major focus of the session is on the concerns the client raised at the beginning of
the therapy hour. Having dealt with specific items, new homework is assigned relevant to the client’s
chief concerns. Feedback from the client about the session is an important element of the collaborative
relationship between therapist and client.

Therapeutic Process
TERMINATION.
As early as the first session, termination may be planned. Throughout treatment, therapists
encourage patients to monitor their thoughts or behaviors, report them, and measure progress toward
their goals. In the termination phase, the therapist and client discuss how the client can do this without
the therapist. Essentially, clients become their own therapists. Just as clients may have had
difficulties in accomplishing tasks and may have relapsed into old thought patterns or behaviors, they
work on how to deal with similar issues and events after therapy has ended. Commonly, the frequency of
therapy sessions tapers off, and client and therapist may meet every 2 weeks or once a month.

• Applying Cognitive Techniques

**Cognitive techniques focus on identifying and examining a client’s beliefs, exploring the
origins of these beliefs, and modifying them if the client cannot support these beliefs.
Example
Your professor does not call on you during a particular class session. You feel depressed.
Cognitively, you are telling yourself: “My professor thinks I’m stupid and that I really don’t have much of
value to offer the class. Furthermore, she’s right, because everyone else is brighter and more articulate
than I am. It’s been this way most of my life!”
**The therapist would have you become aware of the distortions in your thinking patterns by
examining your automatic thoughts. The therapist would ask you to look at your inferences, which may
be faulty, and may investigate whether these inferences can be traced back to earlier experiences in
your life. Then the therapist would help you see how you sometimes come to a conclusion (your decision
that you are stupid, with little of value to offer) when evidence for such a conclusion is either lacking or
based on distorted information from the past.
**The client in cognitive therapy, would also learn about the process of magnification or
minimization of thinking, which involves either exaggerating the
meaning of an event (you believe the professor thinks you are stupid because she did not acknowledge
you on this one occasion) or minimizing it (you belittle your value as a student in the class).
**From the previous example , some possible alternative interpretations are that the professor
wants to include others in the discussion, that she is short on time and wants to move ahead, that she
already knows your views, or that she believes you are self-conscious about being singled out or called
on.

• Therapeutic Techniques and Procedures

Table 1 – Questioning irrational thoughts

1. What is the evidence?

What is the evidence that supports this idea?
What is the evidence against this idea?

2. Is there an alternative explanation?

3. What’s the worst that could happen? Could I live through it?
What is the best that could happen?
What is the most realistic outcome?

4. What is the effect of my believing the irrational thought?

What could be the effect of changing my thinking?

5. What should I do about it?

6. What would I tell________(a friend) if he or she were in the same

situation?

Source: Beck, J. (1995). Cognitive therapy: Basics and beyond. New York, NY: Guilford Publications.

Therapeutic Techniques and Procedures

CHALLENGING ABSOLUTES

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 When clients use language such as, everyone, always, never, no one, always , counsellors
challenge these absolute statements.
For example:
Client: Everyone is getting better grades than me.
Counsellor: Everyone?
Client: Well, maybe not. There are some people, I suppose, whose grades I don’t know.
Counsellor: Whose grades do you know?
Client: Jillian’s and Petra’s.
Counsellor: Notice how we went from everyone having better grades to only two people with better
grades.
Client: I guess, it’s just those girls. They are always doing so well.

Therapeutic Techniques and Procedures

REATTRIBUTION
This is a techniques counsellors use to more fairly distribute the responsibility of an event as
clients often heavily blame themselves.
For example:
Lara: I’m an irresponsible mother. My son got bitten by our cat because I wasn’t watching over him
playing with our cat.
Counselor: Weren’t you still cooking your son’s meal when that happened?
Lara: Yes.
Counselor: Were you in control of the moment ?
Lara: No. But I was just meters away from my son and my cat.
Counselor: So there were other factors involved in your schedule?
Client: Yes, I guess so.

Therapeutic Techniques and Procedures

LISTING THE ADVANTAGES AND DISADVANTAGES
By considering the advantages and disadvantages of a particular thought, clients can be
encouraged to assess the thought in terms of its usefulness.
For example:
A client might think, “I must earn a promotion.”
Some advantages and disadvantages of this thought may include:
Advantages
May generate motivation to achieve
Inspires optimism
Disadvantages
May create undue pressure
May impact negatively on performance in current role
**Listing the advantages and disadvantages may help clients to moderate their thinking from an all-or-
nothing approach to a more balanced perspective on the matter at hand.

Therapeutic Techniques and Procedures

DECATASTROPHIZING.
Clients may be very afraid of an outcome that is unlikely to happen. A technique that often works with
this fear is the “what-if” technique. It is particularly appropriate when clients overreact to a possible
outcome, as in this case:
[Client:] If I don’t make dean’s list this semester, things will be over for me. I’ll be a mess; I’ll never get
into law school.
[Therapist:] And if you don’t make dean’s list, what would happen?
[Client:] Well, it would be terrible, I don’t know what I would do.
[Therapist:] Well, what would happen if you didn’t make dean’s list?
[Client:] I guess it would depend on what my grades would be. There’s a big difference between getting
all B’s and not making dean’s list and getting all C’s.
[Therapist:] And if you got all B’s?
[Client:] I guess it wouldn’t be so bad, I could do better the next semester.
[Therapist:] And if you got all C’s?
[Client:] That’s really not likely, I’m doing much better in my classes. It might hurt my chances for law
school, but I might be able to recover.

Therapeutic Techniques and Procedures

COGNITIVE REHEARSAL.
Use of imagination in dealing with upcoming events can be helpful. A woman might have an image of
talking to her boss, asking for a raise, and then being told, “How dare you even talk to me about this
subject?” This destructive image can be replaced through cognitive rehearsal. The woman can imagine
herself talking to her boss and having a successful interview in which the boss listens to her request. The
cognitive rehearsal can be done so that the woman presents her request in an appropriate way, with the
boss not granting the request in one instance and the boss granting the request in another. The therapist
asks her to imagine the interview with the boss and then asks the patient questions about the imagined
interview.

Applications of Cognitive Therapy

Cognitive therapy has been successfully used to treat :

• phobias,
• Psychosomatic disorders,
• eating disorders,
• anger,
• panic disorders,

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 • generalized anxiety disorders
• posttraumatic stress disorder,
• suicidal behavior,
• borderline personality disorders,
• narcissistic personality disorders, and
• schizophrenic disorders
• personality disorders
• couples and families therapy
• Child abusers,
• divorce counseling,
• skills training,
• stress management
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Donald Meichenbaum’s
Cognitive Behavior Modification (CBM)

Meichenbaum’s cognitive behavioral approach combines some of the best elements of behavior
therapy and cognitive therapy.
According to Meichenbaum (1977), self-statements affect a person’s behavior in much the same
way as statements made by another person. A basic premise of CBM is that clients, as a prerequisite to
behavior change, must notice how they think, feel, and behave and the impact they have on others. For
change to occur, clients need to interrupt
the scripted nature of their behavior so that they can evaluate their behavior in various
situations.

• Self-instructional therapy focus:

• Trains clients to modify the instructions they give to themselves so that they can cope
• Emphasis is on acquiring practical coping skills
• Cognitive structure:
• The organizing aspect of thinking, which seems to monitor and direct the choice of
thoughts
• The “executive processor,” which “holds the blueprints of thinking” that determine
when to continue, interrupt, or change thinking
How Behavior Changes?
Meichenbaum (1977) proposes that “behavior change occurs through a sequence
of mediating processes involving the interaction of inner speech, cognitive structures,
and behaviors and their resultant outcomes” (p. 218). He describes a three phase
process of change in which those three aspects are interwoven. According to
him, focusing on only one aspect will probably prove insufficient.
3 Phases of Behavior Change
1. Self-observation
 Listen to themselves, realize they contribute to their depression through how they think, and
develop new cognitive structures
 This process involves an increased sensitivity to their thoughts, feelings, actions, physiological
reactions, and ways of reacting to others. If depressed clients hope to make constructive
changes,
for example
They must first realize that they are not “victims” of negative thoughts and feelings. Rather, they
are actually contributing to their depression through the things they tell themselves.
2. Starting a new internal dialogue
Clients learn to notice their maladaptive behaviors, and they begin to see opportunities for
adaptive behavioral alternatives.
Clients learn that psychological distress is a function of the interdependence of cognitions,
emotions, behaviors, and resultant consequences. In therapy, clients learn to change their internal
dialogue, which serves as a guide to new behavior.
3. Learning new skills
 Clients learn more effective coping skills, which are practiced in real-life situations
For example, clients who can’t cope with failure may avoid appealing activities for fear of not
succeeding at them.
Cognitive restructuring can help them change their negative view, thus making them more
willing to engage in desired activities. At the same time, clients continue to focus on telling themselves
new sentences and observing and assessing the outcomes.

THERAPUETIC TECHNIQUE
Coping Skills Programs
STRESS INOCULATION TRAINING
o teaching clients stress management techniques
o Stress inoculation training consists of a combination of information giving, Socratic discovery-
oriented inquiry, cognitive restructuring, problem solving, relaxation training, behavioral
rehearsals, self-monitoring, self-instruction, self-reinforcement, and modifying environmental
situations
THERAPEUTIC PROCESS
o SIT involves collaborative goal setting that nurtures hope, direct-action skills, and acceptance-
based coping skills. These coping skills are designed to be applied to both present problems
and future difficulties.
o Clients are assisted in generalizing what they learn in the training to daily living, and relapse
prevention strategies are taught. Meichenbaum describes stress inoculation training as a
complex, multifaceted cognitive behavioural intervention that is both a preventive and a
treatment approach.

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The following procedures are designed to teach these coping skills:
• Expose clients to anxiety-provoking situations by means of role playing and imagery
• Require clients to evaluate their anxiety level
• Teach clients to become aware of the anxiety-provoking cognitions they experience
in stressful situations
• Help clients examine these thoughts by re-evaluating their self-statements
• Have clients note the level of anxiety following this re-evaluation

THE PHASES OF STRESS INOCULATION TRAINING

1. The conceptual phase

 Creating a working relationship with clients
 During the conceptual-educational phase, the primary focus is on creating a working
relationship and therapeutic alliance with clients. This is mainly done by helping them gain a
better understanding of the nature of stress and reconceptualising it in social-interactive terms.
The therapist enlists the client’s collaboration during this early phase and together they rethink
the nature of the problem or the individual’s stress concerns. Initially, clients are provided with a
conceptual framework in simple terms designed to educate them about ways of responding to a
variety of stressful situations. They learn about the role cognitions and emotions play in creating
and maintaining stress through didactic presentations, by curious questioning, and by a process
of guided self-discovery.

 Clients often begin treatment feeling that they are the victims of external circumstances,
thoughts, feelings, and behaviors over which they have no control. As a way to understand the
subjective world of clients, the therapist generally elicits stories that clients tell themselves.

 Training includes teaching clients to become aware of their own role in creating their stress and
their life stories. They acquire this awareness by systematically observing the statements they
make internally as well as by monitoring the maladaptive behaviors that flow from this inner
dialogue.

 Clients typically keep an open-ended diary in which they systematically monitor and record their
specific thoughts, feelings, and behaviors.

2. Skills acquisition and rehearsal phase

 Giving coping skills to apply to stressful situations
 the focus is on giving clients a variety of behavioral and cognitive coping skills to apply to
stressful situations.
 This phase involves direct actions, such as gathering information about their fears, learning
specifically what situations bring about stress, arranging for ways to lessen the stress by doing
something different, and learning methods of physical and psychological relaxation.
 The training involves cognitive coping; clients are taught that adaptive and maladaptive
behaviors are linked to their inner dialogue. Through this training, clients acquire and rehearse
a new set of self-statements
examples of coping statements that are rehearsed in this phase of SIT:
• “How can I prepare for a stressor?” (“What do I have to do? Can I develop a plan
to deal with the stress?”)
• “How can I confront and deal with what is stressing me?” (“What are some ways
I can handle a stressor? How can I meet this challenge?”)
• “How can I cope with feeling overwhelmed?” (“What can I do right now? How
can I keep my fears in check?”)
• “How can I make reinforcing self-statements?” (“How can I give myself credit?”)

3. Application and follow-through phase

 Transfer change to real world
 The focus is on carefully arranging for transfer and maintenance of change from the therapeutic
situation to everyday life.
 Clients practice their new self-statements and apply their new skills to everyday life.
 To consolidate the lessons learned in the training sessions, clients participate in a
variety of activities, including imagery and behavior rehearsal, role playing, modeling, and graded in vivo
exposure.
 Once clients have become proficient in cognitive and behavioral coping skills, they practice
behavioral assignments, which become increasingly demanding. They are asked to write down
the homework assignments they are willing to complete. The outcomes of these assignments
are carefully checked at subsequent meetings, and if clients do not follow through with them,
the therapist and the client collaboratively consider the reasons for the failure.

Relapse prevention, which consists of procedures for dealing with the inevitable
setbacks clients are likely to experience as they apply what they are learning to daily
life, is taught at this stage (Marlatt & Donovan, 2005). Part of relapse prevention
involves teaching clients to view any lapses that occur as “learning opportunities”
rather than “catastrophic failures.” Clients explore a variety of possible high-risk
stressful situations that they may reexperience.
Then they rehearse and practice in a collaborative fashion with the therapist, and with
other clients in a group, ways of applying skills they have learned in the training to
maintain the gains they have made. Follow-up and booster sessions typically take place

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at 3-, 6-, and 12-month periods as an incentive for clients to continue practicing and refi
ning their coping skills. SIT can be considered part of an ongoing stress management
program that extends the benefits of training into the future.

 Sharf, R. (2012). Theories of Psychotherapy and Counseling: Concepts and Cases (5th
Edition). Belmont , USA:Brooks/Cole, Cengage Learning

 Corey, G. (2013). Theory and Practice of Counseling and Psychotherapy (9th Edition).
USA:Thomson Brooks/Cole

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