In this section, you will learn about:
- The key concepts of cognitive behavioural therapy.
- The key techniques and processes of cognitive behavioural therapy.
- The role of the counsellor and client in CBT.
Supplementary materials relevant to this section:
- Reading A – An Introduction to Cognitive Behavioural Therapy
- Reading B – Cognitive Conceptualisations
- Reading C – The CBT Model
- Reading D – Cognitive Restructuring
- Reading E – The Central Pillars of CBT
You will learn more about cognitive behavioural therapy (CBT) in this module. It is important to note that the theoretical concepts, processes, and skills presented in this module provide only a brief overview of the approach. Suppose you would like to achieve mastery of CBT. In that case, you must seek more in-depth knowledge through further reading, attendance at professional development courses, and supervised practice.
Reflect
As you progress through this module, take time to reflect upon your comfort level with the core concepts, underpinning principles and techniques of CBT.
Do they match your values and beliefs? Would you be comfortable working within the principles of this model? Are you willing to apply the techniques of CBT?
Cognitive behavioural therapy (CBT) is a widely used counselling approach focusing on cognitive and behavioural strategies as the central components of therapeutic change. Clients often seek counselling as they are distressed and having difficulty managing their emotions or behaviour. CBT's basic premise is that emotions result from problematic thoughts and behaviours. As emotions are difficult to change directly, CBT aims to target distressing emotions by using cognitive and behavioural therapeutic strategies to change the thoughts and behaviours underlying them (Cully et al., 2020).
Read
Reading A – An Introduction to CBT provides an overview of cognitive behavioural therapy, including a brief history, some basic principles, levels of cognition, underlying assumptions, and how CBT is used to understand and explain the development of mental health issues. You will also read briefly about the empirical evidence about cognitive behavioural therapy.
There is no single ‘cognitive behavioural therapy’. Instead, CBT refers to any therapy that emphasises the general principles of the cognitive behavioural approach. As such, we offer the following as a broad definition of CBT:
Cognitive behavioural therapy is a form of counselling/therapy based upon the underpinning concept that maladaptive thinking patterns cause maladaptive behaviours, which, in turn, cause interference, dysfunction, and counter-productive impacts on everyday living. It is a time-limited, action-orientated, client-inclusive practice of changing thought patterns to change behaviour and feelings/emotions.
CBT is generally used as a short-term counselling style (often between six and twenty sessions depending upon the client’s issue or needs), and it uses a practical and goal-oriented approach to help the client.
What is Cognitive Behavioural Therapy?
This video describes how CBT is an evidence-based treatment that can help people with depression, anxiety, panic attacks, hard relationships, and many other problems.
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Check your understanding of the content so far!
The basic principles of CBT are taken from the two theoretical backgrounds of cognitive psychology and behavioural psychology. According to CBT principles, people develop patterns of thinking and behaviour in response to events that occur in their lives. These responses may initially be appropriate and functional in a particular context, however, they may become problematic when they become a general, unconscious pattern of behaviour. CBT works by identifying and addressing how a person’s thoughts and behaviours interact to create problematic issues. The thinking behind CBT is that much of how a person feels depends on what they think and how they behave. To help you better understand this, let’s explore the underlying cognitive and behavioural principles.
The difference between the Principles and Cognitive Behavioural Therapy
Before we go any further, think about the importance of not trying to influence a client's thinking.
In this video, Erika Bugbee talks about the difference between The Principles and Cognitive Behavioural Therapy and provides examples from her experiences.
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Cognitive Principles
Most clients will attribute the emotional distress that has brought them to counselling to a certain event or situation. The following formula can explain this tendency:
For example, Mary consults a counsellor because she feels highly anxious when she thinks about or is exposed to social situations that involve speaking to people. This has resulted in Mary avoiding social situations (such as parties) and has affected her work opportunities. Mary is likely to say that her problem is that socialising with people makes her feel anxious and makes her avoid such situations. So, Mary believes that a particular event (socialising with people) activates a certain emotional response (anxiety) as well as a behavioural response (avoidance). This is depicted in the following diagram:
However, the underlying premise of CBT is that there is an intermediate stage between an event happening and how a person responds emotionally or behaviourally. How a person perceives an activating event will influence the emotional or behavioural consequence. This makes a lot of sense when we consider that people may react differently to the same situation because of how they perceive it. Ultimately, different perceptions of a situation can elicit different emotions and behaviours.
Let’s look at a simple example of this process. Suppose you are walking down the street and see someone you know coming the other way, but she does not seem to notice you.
Here are a number of possible thoughts about this event – note how the possible emotional responses arising from those interpretations vary:
- ‘I can’t think of anything to say to her, she’ll think I'm really boring and stupid.’ [Leading to anxiety]
- ‘Nobody would ever want to talk to me anyway, no one seems to like me.’ [Causing depression]
- ‘She’s got a nerve being so snooty, I’ve not done anything wrong.’ [Triggering anger]
- ‘She’s probably still hung over from that party last night!’ [Resulting in amusement]
This illustrates the fundamental cognitive principle, that different cognitions give rise to different emotions.
(Kennerley et al., 2017, pp. 4-5)
For many people, socialising may result in emotional responses such as excitement or enjoyment; however, for Mary, this triggers anxiety. Mary may assume that people will find her boring or that she will embarrass or humiliate herself somehow. In Mary’s case, the formulation of the problem can be depicted as:
This interaction between thoughts, feelings, and behaviours is central to CBT and needs to be explained to clients. One visual tool that can assist in this process is the following diagram from Simmons and Griffiths (2017).
Read
Reading B – Cognitive Conceptualisation elaborates on how the cognitive principles we have just explored are used in CBT to understand clients and their circumstances and provides a framework for therapy.
How Does Cognitive Behavioural Therapy Work?
This video provides examples on how Cognitive behavioural therapy is an evidence-based treatment option for people with mental illness. It focuses on the relationship between thoughts, feelings, beliefs, and behaviours.
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Essentially, the cognitive component of the CBT model emphasises that it is not the situation that causes the emotional distress that an individual experiences. Cognitive behavioural therapists argue that the individual’s interpretation or view of that event or situation causes the emotional distress. According to the CBT model, differing interpretations are the result of internal cognitive processes occurring at three layers of cognitive functioning – automatic thoughts, intermediate beliefs, and core beliefs, as depicted in the following extract:
Automatic thoughts are immediate internal reactions that occur in response to situations and/or events. We are often unaware of automatic thoughts because of their almost instantaneous nature. Sometimes automatic thoughts are helpful, as they help us navigate our environments. However, automatic thoughts become unhelpful when they are attached to symptoms of psychopathology (e.g., social isolation, depression, anxiety, etc.) and negatively impact people's quality of life. One way that we gain insight about these automatic thoughts is by understanding our emotional reactions to them.
Intermediate beliefs are attitudes or rules that a person follows in life that typically apply across situations (not situation specific as with automatic thoughts). Intermediate beliefs can often be stated as conditional rules: “If x, then y.” For example, “If I am thin, then I will be loved by others.” Individuals create these assumptions by categorizing the information they receive from the world around them. These rules guide thoughts and subsequently influence behaviors.
Core beliefs drive rules and automatic thoughts. For example, the belief, “I am unlovable,” may be driving the conditional rule, If I am thin, then I will be loved by others, which may drive obsessive thinking about one’s appearance, excessive exercise, or disordered eating habits. Core beliefs are often formed in childhood and solidified over time as a result of one’s perceptions of experiences. Because individuals with psychological disorders tend to store information consistent with negative beliefs but ignore evidence that contradicts them, core beliefs tend to be rigid and pervasive. Although automatic thoughts are often tied to a specific situational trigger, intermediate and core beliefs are more global and cut across domains. Individuals tend to have core beliefs that involve either interpersonal (“I’m unlovable”) or achievement issues (“I’m incompetent”).
(Adapted from Cully et al., 2020, pp. 71-72)
Reflect
Before reading on, reflect upon each of these concepts. Can you see how an individual’s core beliefs influence intermediate beliefs and automatic thoughts?
What differences would there be in the intermediate beliefs and automatic thoughts of a person who held positive core beliefs about themselves versus a person who held negative core beliefs about themselves?
Check your understanding of the content so far!
To help you understand these concepts, let’s look at a couple of examples.
Example 1
Imagine two women, Susan and Dianna. Both of them are studying for a Diploma of Counselling and are currently working on this module.
The following table outlines both Susan and Dianna’s core beliefs, automatic thoughts, emotions, and resultant behaviour:
| Susan | Dianna | |
|---|---|---|
| Core Belief ↓ |
Susan has a core belief that she is incompetent and that she will fail no matter how hard she tries. | Dianna has a core belief that she is competent and that she will succeed at whatever she tries with enough effort. |
| Automatic Though ↓ |
As Susan reads through the material in this module, she thinks, “I don’t get this! I knew I was stupid!” | As Dianna reads through the material in this module, she thinks, “I don’t get this! I might need to review the material some more.” |
| Emotion ↓ |
Susan begins to feel frustration and anger. | Dianna begins to feel determined and enthusiastic. |
| Behaviour | As a result of her thinking, Susan decides to walk away from the module and never completes it. | As a result of her thinking, Dianna revises the material and starts to make sense of the concepts and theories. |
The women in the scenario do the same thing (completing this module) but feel and behave very differently. Cognitive behaviour therapists suggest that these students are motivated by their thoughts, which are triggered by their core beliefs about themselves.
Let’s look at another example.
Example 2
Imagine a friend calling to cancel his attendance at a dinner party you arranged for this evening.
The following table demonstrates two possible scenarios of how you may interpret and react to this situation due to differences in core beliefs:
| Scenario A | Scenario B | |
|---|---|---|
| Core Belief ↓ |
In Scenario A, imagine you have a core belief that you are worthless. | In Scenario B, imagine you have a core belief that you are worthwhile. |
| Automatic Thought ↓ |
You might think, “I can’t believe he’s not coming! I knew I didn’t mean anything to him.” | You might think, “Oh well, that’s a shame. I was looking forward to catching up.” |
| Emotion ↓ |
You may begin to feel depressed. | You might feel disappointed but eager to make time to catch up with him sometime soon. |
| Behaviour | You abruptly dismiss your friend’s apology and proceed to cancel the evening. | You make a new time to catch up with your friend and continue to plan the menu for tonight’s party. |
From the examples, you can see the impact an individual’s belief system and thought processes can have on their actions.
Stress Management Using Cognitive Therapy
Licensed Clinical Social Worker Thomas Moore, explains how to manage stress using CBT and shows how becoming more aware of our thoughts, perceptions and beliefs, we can better manage stress.
Watch
Reflect
Can you think of any recent situations in which you reacted negatively? Can you break that situation down into a core belief → automatic thought → emotion → behaviour?
Many people have cognition processes that result in overall unhelpful thinking styles that they tend to apply globally across situations and which may result in emotional distress (such as depression or anxiety) or unhelpful behaviours (such as anger or avoidance). Some of the most problematic thinking styles are listed in the following extract:
(Centre for Clinical Interventions, n.d., as cited by, Healthy WA, n.d.)
Consistently using these thinking styles may result in considerable emotional distress and problematic behaviour. CBT focuses on helping clients identify these unhelpful thoughts and beliefs and to challenge them. You will learn more about the strategies and techniques used by CBT therapists to address unhelpful patterns later in this section of the module.
Behavioural Principles
While the cognitive model focuses on how thoughts impact emotions and behaviour, the behavioural model focuses on the role of behaviour. You should recall learning about key behavioural principles in CHCCSL005 Research and apply learning theories in counselling. CBT uses these principles to understand how behaviour influences mood and perceptions.
Behavioural principles suggest that behaviour influences a person's emotions and cognitions. For example, if a client suffers from low self-confidence, they might avoid public speaking. This behaviour (avoidance) is caused by low self-confidence. However, avoiding public speaking reinforces this low self-confidence and impacts emotions and mood.
Let’s consider another example. Martha has been experiencing low mood and bouts of tearfulness over three months. She has gradually stopped doing the hobbies she previously enjoyed and now tends to spend most of the day at home watching television. In this case, there is a reinforcing interaction between Martha’s low mood and her behavioural responses. The lower her mood, the less she feels like doing anything and the worse she is likely to feel, creating a vicious cycle of low mood. A central goal of counselling here would be to apply behavioural strategies aimed at changing her unhelpful behaviour (you will learn more about such strategies later in this module).
Reflect
Reflect upon the impact of behaviours in reinforcing particular thoughts and emotions. Can you think of recent situations in which your behaviours reinforced your thoughts and emotions?
Interaction of Principles
CBT combines the key principles from cognitive and behavioural models to facilitate client change. Cognitive behavioural therapists focus on the interaction between an individual’s thoughts/cognitions, their emotions, their behaviours, their physiological reactions, and the environment that they operate in (Kennerley et al., 2017). They believe that each system has an influence over the others and that targeting the system (or systems) that is problematic for the client will result in overall change. The following diagram depicts these systems and how they interact:
To help you better understand this concept, let’s return to the example of Mary, the client experiencing social anxiety. Her issues can be understood by identifying the four components activated in response to the event of ‘socialising’.
In Mary’s case, a cognitive behavioural therapist would help Mary change her thoughts and behavioural responses, which would, in turn, change her emotional and physiological responses.
HOW TO BE THE BEST COGNITIVE BEHAVIOuRAL THERAPIST: Apply these 10 Principles
This video uses the book Cognitive Behavioural Therapy: Basics and Beyond by Dr. Judith Beck to outline CBT and its 10 core principles.
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Check your understanding of the content so far!
Read
Reading C – The CBT model - Before moving on, take some time to review the CBT model and principles . This reading defines the elements of the CBT model and strategies for sharing these with clients.
Since the cognitive behavioural model attributes client issues to problematic thoughts or behaviours, changing these forms the basis of cognitive behavioural therapy. Cognitive strategies aim to help clients identify and challenge unhelpful thoughts and
perceptions that may create distress, while behavioural strategies target unhelpful behaviours. Cognitive behavioural therapists may use various techniques depending on the client’s difficulty, including techniques that focus on a client’s thoughts, behaviours, relationships, work/home/social environment, biological circumstances, or support/lack of support. The techniques used will depend upon the client’s goals, how the client’s issues are understood at the current time, and how the issues may change in the future.
Structure of a CBT Session
This video outlines a good structure that is not only good for a CBT session but for all therapy sessions. Session structure allows both the client and therapist to be on the same page and maintain the flow from session to session.
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We will now explore some of the most commonly used CBT techniques used in structuring a session.
Cognitive Restructuring
The primary objective of cognitive restructuring is to change distorted, unhelpful thoughts to more balanced, realistic thoughts. It is typically achieved via a structured process (which we will explore shortly) facilitated by Socratic questioning. Socratic questioning involves the counsellor asking questions that allow clients to explore underlying assumptions and logical contradictions in their statements. Socratic questioning has two aims:
- To help the client make connections between thoughts and the behavioural consequences of those thoughts.
- To help the client identify different ways of thinking and new possibilities for action.
McLeod (2019, p. 129) provides the following examples of Socratic questions:
- How much do you believe what you say about yourself?
- What evidence is there to support this belief?
- What evidence is there that contradicts your conclusions?
- What is the worst thing that could happen?
- What would happen if you were to ...?
- What would you advise someone else to do in this situation?
Cognitive Restructuring in CBT with Dr. Beck
Dr. Aaron Beck reviews cognitive restructuring with a depressed client during a recent Beck Institute Workshop. Dr. Beck describes how he helped the client evaluate evidence for and against his thoughts and his belief that he was a failure. He also explains how cognitive restructuring helps depressed clients access rational thinking that is typically blocked by their cognitive distortions.
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The cognitive restructuring process involves three key steps:
- Identifying the key negative thoughts or beliefs. These are the thoughts and beliefs that influence the problem behaviour. This process should be a collaboration between the client and counsellor.
- Testing them for evidence, accuracy and value. Counsellors will encourage the client to start questioning the legitimacy of their thoughts and beliefs.
- Modifying or replacing the key negative thoughts or beliefs with more balanced and realistic thoughts.
Let’s take a closer look at how each of these steps can be done.
Identifying Unhelpful Thoughts or Beliefs
The first step is to help the client identify negative automatic thoughts in and out of the session. Automatic thoughts tend to:
- Be short and specific.
- Occur extremely quickly after the event.
- Occur as words or images.
- Not arise from careful or logical thought but seem reasonable at the time.
Examples of negative automatic thoughts include, “Nobody likes me”, “Everything always goes wrong for me”, “They think I’m stupid”, “If I’m late for work, I will lose my job”. Although most clients may realise, on some level, that these negative thoughts are not true, individuals suffering from anxiety or low mood tend to take these negative thoughts as fact, which reinforces their distress.
Within counselling sessions, counsellors may be able to track and bring automatic thoughts to a client’s attention by observing the client’s language and changes in the client’s emotions or mood.
To identify which automatic thoughts are “hot” [i.e., automatic thoughts that occur in combination with a change in emotion or mood; often associated with unhelpful core beliefs], listen for verbal cues, such as the language used in the thought […], and watches nonverbal cues, such as increased volume of speech or fidgeting. Changes in facial expression, shifts in position, or hand movements can be helpful in determining whether a patient is experiencing an automatic hot thought. Listening to tone, pitch, volume, and the pace of a patient’s speech is also beneficial. When you notice these actions, this is an opportune time to bring it to the patient’s attention and assist them in identifying an automatic thought associated with the shift in emotions. In these instances, you are simply an observer of the behavior and make a note of your observation to the patient (“You are speaking more loudly; what is going through your mind right now?”). The patient then provides an explanation of the behavior.
(Adapted from Cully et al., 2020, pp. 75-76)
Case Example
| Client: | My boss reprimanded me again yesterday. (sighs heavily) |
| Counsellor: | Tell me more. |
| Client: | Well, we were at a meeting; and I had just made my presentation, and he said he had expected a better product for the client. (Voice gets softer, begins wringing hands) |
| Counsellor: | Your voice changed slightly when you said that; tell me what is going through your mind right now. |
| Client: | I just feel like a failure at everything. My work has always been the one thing I was good at, and now I am failing at that, too. |
| Counsellor: | Let’s look at that line of thinking and the feelings it creates. It seems that when that thought entered your mind, your mood changed very quickly. Did you notice that? |
| Client: | Yeah, I guess it did upset me pretty fast. |
(Adapted from Cully et al., 2020, p. 76)
By listening carefully in this way, counsellors may begin to identify patterns of distorted thinking that can point to underlying dysfunctional intermediate and core beliefs:
Case Example (Cont’d)
| Counsellor: | I’ve heard you say several times that you either didn’t do a good job or that someone else put in more time and energy. It seems to me that you feel inadequate a lot of the time. Is that right? |
(Cully et al., 2020, p. 79)
Some counsellors might then explore childhood experiences consistent with the belief. Although not strictly necessary for CBT to be effective, this may help the client understand how this belief has come about (Cully et al., 2020).
Clients should also be encouraged to continue this process outside of the counselling sessions. This can be facilitated using a ‘thought record’ or diary, such as the following.
| Thought Diary (example) | |
|---|---|
|
A. Activating Event This may be either: An actual event or a situation, a thought, a mental picture or recollection "At my brother's place and a friend of his drops by. He starts talking to me." |
B. Beliefs
"I wish he wouldn't talk to me. He would notice that I look like a nervous wreck. I will sound stupid if I talk to him." Thought discovery question "...and what does this mean? He will think I'm an idiot (85) |
|
C. Consequences
Anxious (70) Irritated (40)
Heart pounding, sweating, fast breathing Avoided eye contact |
|
Testing Thoughts for Evidence, Accuracy and Value
Once dysfunctional automatic thoughts and possible core beliefs have been identified along with the accompanying emotion they evoke, the next step is to challenge them by generating evidence for and against them. Building evidence may be facilitated by asking questions such as (Cully et al., 2020, p. 85):
- What evidence is there that this thought is true?
- What evidence is there that this thought is not true?”
- What would I tell someone I loved if they were in this situation and had these thoughts?
- If my automatic thought is true, what is the worst that could happen?
- If my automatic thought is true, what is the best thing that could happen?
This testing process may be introduced to the client in the following way:
We have identified a thought that is very powerful for you. You rated this thought as 90 out of 100 for sadness. Before spending a lot of time and energy on this thought, I want to know whether or not it is true. Often when people are depressed or anxious, they take thoughts like this at face value, without first asking whether they are true. Accepting thoughts like this as true would certainly lead to the symptoms you’ve been struggling with. If I thought, “I am worthless and can’t do anything right,” I wouldn’t want to get out of bed in the morning either, and I would probably feel pretty hopeless and sad. When we test a thought like this, we are going to generate evidence for and against the thought. It is as though the thought were on trial, and you were a lawyer for the case. Remember, you have to be able to prove the evidence you are generating. So, now let’s see how your thought stands up....
(Cully et al., 2020, p. 85)
After such an introduction, the counsellor would work with the client to help them test their automatic thoughts using questions such as those previously outlined. This process usually reveals the client’s negative automatic thoughts are unrealistic or unbalanced.
Modify or Replace the Key Negative Thoughts or Beliefs with More Balanced and Realistic Thoughts
The last step in cognitive restructuring involves replacing negative thoughts with more realistic, balanced ones. This does not involve creating random positive or opposite thoughts but rather identifying more balanced thoughts that consider factual, realistic information rather than relying on subjective emotion.
Thought records can be used to help test the validity of thoughts and then modify these thoughts. For example, a student who states, “I am useless at this subject. My marks are really bad,” could be invited to record thoughts posed by the following questions:
- In what way are you useless?
- What sort of things do you feel that you cannot accomplish?
- What sort of things can you achieve?
- How do you assess your success?
The counsellor would then engage with the client to compare the evidence that supports and contradicts their negative thoughts. They would then encourage them to recognise a more functional, balanced thought. It could be, “My mark is in the top 10 in the class,” or “I put most of my time into studying for another subject. I did get good marks in that.” The client is then encouraged to re-evaluate his or her emotion in light of this revision. This process is shown in the following thought record example:
|
Negative thought = "I am a failure" (strength of belief 90%) Anxiety 80% |
|||
| Evidence For | Evidence Against | Evidence Based Thought | Revised Emotion |
| Consider the evidence. What balanced thought would be more helpful? |
What do you feel now? How intense? 0-100% |
||
| I failed the exam |
I got 49%. I did get some of the exam right. I have passed all my other exams. I was sick for two weeks before the exam. |
I'm not a failure. I failed one exam. All this means is that I need to spend more time studying before retaking the exam |
Anxiety 60% Strength of belief 60% |
Read
Reading D – Cognitive Restructuring provides an overview of the cognitive restructuring process and relevant techniques, including Socratic questioning, de-catastrophising, and ‘putting thoughts on trial’. You will also find a range of useful worksheets that assist with explaining and implementing these techniques with clients.
Cognitive restructuring targets the thought component of a client’s presenting difficulty by helping the client identify, challenge, and replace negative automatic thoughts and beliefs that drive emotional states. However, the cognitive component is only one piece of the puzzle. Cognitive behavioural therapists also use various behavioural strategies designed to address the behavioural and physical components related to a client’s difficulty. The CBT model emphasises that the relationship between cognition and behaviour is bi-directional (i.e., they influence each other). Cognitive restructuring is likely to affect behaviour positively, and positive behavioural changes are typically associated with an improved outlook.
Most behavioral techniques used in CBT are designed to help people 1) increase participation in activities that improve mood, 2) change patterns of avoidance or helplessness, 3) gradually face feared situations, 4) build coping skills, and 5) reduce painful emotions or autonomic arousal.
(Wright et al., 2017, p. 22)
Cognitive Restructuring Techniques
This video talks about how to change your thoughts with cognitive restructuring techniques.
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Check your understanding of the content so far!
Behavioural Experiments
Behavioural experiments are activities designed to test existing (or alternative adaptive) beliefs. They allow the client to experience, in a safe situation, the difference they would have in their feelings if they changed their thoughts. Some of these may take place within the counselling session. For instance:
[A] client who has issues around personal boundaries in relationship may be invited to sit closer to the therapist, or further away. A client who experiences agoraphobic panic attacks may be encouraged to be in the therapy room with the door locked.
(McLeod, 2019, pp. 128-129)
Behavioural experiments may also take place out-of-session. For example, a client with social anxiety may believe that they must plan and censor what they will say in social situations. They may believe that if they say what they are truly thinking in the moment, the people they are talking to will not like them and will stop talking to them. Before the behavioural experiment, the client may believe this is true with 90% certainty. The counsellor may then suggest that for the next five social situations the client attends, they actively speak up and offer their opinions during conversations. During this experiment, the client may observe that people don’t seem to have an issue with them expressing their opinion and that no one discontinues a conversation because they have spoken. As such, after this experiment, the client may report that they are now only 30% sure of their initial belief. This experience has weakened the strength of the client’s automatic thought and taught them that the alternative behaviour of voicing their opinion does not always lead to negative reactions from those they are talking to.
Importantly, a strong alliance between the client and their counsellor must have been established before introducing any behavioural experiments. The situation or experiment should be carefully designed in collaboration with the client to make it more likely that the client will ‘give it a go’.
Behavioral Experiments in Cognitive Therapy
In this video, Dr. Aaron Beck discusses the use of behavioral experiments in cognitive therapy. He explains that behavioural experiments are more than just "getting the patient active". Instead, they are also used to help the client test and then modify inaccurate and unhelpful beliefs that impact healthy functioning.
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Reflect
Think about a belief you have. Can you think of a behavioural experiment that you could do to test this belief?
Developing a Behavioural Experiment (CBT Clinical Demonstration)
This video provides an example of a therapist and client collaboratively developing a behavioural experiment aimed at testing negative predictions about a situation. After watching the video, answer the questions that follow.
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Behavioural Activation
Behavioural activation involves “a set of procedures and techniques aimed at increasing [client]’s activity and access to reinforcing situations that improve mood and functioning” (Cully et al., 2020, p. 92). For example, let’s consider the example of a client feeling ‘down’ and tired, and so is generally staying in bed all day and avoiding doing anything productive. This behaviour is then reinforcing their reactions. Such interaction is depicted in the following diagram:
Low mood involves behavioural and physical components that maintain low mood and decrease the chance of adaptive functioning by increasing avoidance (i.e., staying in bed) (Cully et al., 2020). Behavioural activation targets the behaviour and physical components maintaining the client’s low mood by introducing pleasant activities that function to:
- Reverse avoidance.
- Increase physical activity.
- Increase self-confidence.
- Increase feelings of usefulness and purpose.
The following extract outlines the three steps involved in behavioural activation:
Step #1: Provide Client with Rationale for Behavior Activation
It is important to educate the patient as to what behavioral activation is and how it can be useful for improving depression and anxiety. Let [clients] know that feeling a little down or having a bad day and not feeling well physically can make it more likely that they will stop doing many activities that used to be pleasurable. When this happens, [clients] can get into the habit of avoiding pleasant activities that might actually help them feel better. It is also important for [clients] to understand the connection between what they do and how they feel, both mentally and physically. You are encouraged to explain to [clients] that increasing activity and/or taking action, even when we do not feel like it, help us to feel better physically, as well as decrease depression.
Step #2: Identifying Behaviours – Discuss Activities
Identification of potential activities begins by exploring with the [client] activities that would be most meaningful. This may begin by having a general discussion about values that are important to the [client] as well as goals that they may want to accomplish. Values clarification (i.e., identifying the most important things to patients) can help [clients] feel heard and convey the collaborative process of the therapeutic relationship. Explicitly identifying values may enhance a [client]’s motivation to change and guide the identification of behaviors that the [client] would be willing to engage in related to [their] values. Additionally, a [client]’s values can help identify therapeutic goals to incorporate into the treatment plan.
Exploring targets for behavioral activation may begin with asking [clients] about 1) the types of things they would like to do but have not been able to do, or 2) activities they already do but would like to do more often. It may be important to anchor these behaviors within the context of values or goals that are important to them. You might want to ask if there is something that they need to do that they have been unable to do or have been avoiding. Although you want [clients] to do activities that are purely pleasurable to elicit positive mood, some [clients] may want to accomplish something rather than focus on doing something pleasant.
Possible questions might include:
- "Can you think of any activities or hobbies that you used to enjoy doing but have now stopped doing?"
- "Can you think of any activities or hobbies that you would like to do but have never done?
- "Are there things in your life that you would like to change? If so, what would you like to do about these issues that you have previously not done?"
For [clients] who have difficulty identifying activities, you can introduce a behavioral activity checklist [...]. Before completing the next steps (e.g., setting a plan), it is important to discuss the potential importance of the behavior with the [client]. If [they report] low importance, encourage the client to find another, more meaningful activity.
Step #3: Setting an Action Plan
Once the [client] has identified a meaningful activity to engage in, help shape this work into a meaningful therapeutic goal. Action plans are one mechanism for creating meaningful behavioral goals for therapy. Action plans in their most basic form stipulate the specific goal to be accomplished, defined in terms of observable and measurable characteristics and a timeframe for monitoring progress.
Example:
Goal: To read at least three times per week (a minimum of 30 minutes per reading session).
Timeframe: Client will complete three reading sessions over the next week.
(Cully et al., 2020, pp. 93-96)
Reflect
Can you think of any activities or things in life that behavioural activation may help? For instance, many students engaged in self-paced learning find it useful to develop action plans with clear study goals and timeframes to reduce avoidance and interference.
Behavioural Activation (CBT Clinical Demonstration)
This video illustrates how weekly activity monitoring can be introduced and set up for homework with a client. After watching the video answer the questions that follow.
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Graded Exposure and Relaxation
One way in which negative mood states are maintained is by avoidance behaviours. Exposure strategies combined with relaxation strategies, such as systematic desensitisation, aim to gradually expose the client to those situations that create feelings of anxiety to replace the anxiety response with a learned relaxation response (McLeod, 2019).
Graded Exposure in CBT
This video explains how this CBT technique work for phobias, panic, and anxiety in general.
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This process must be discussed and planned carefully with the client. Graded exposure involves the following steps:
- Training the client in relaxation strategies. Counsellors can use various relaxation techniques, including progressive muscle relaxation, breathing techniques, and guided relaxation exercises. One of the simplest and most effective methods is mindful breathing.
- Construction of an anxiety hierarchy. The counsellor and client draw up a list of the client’s fears, ranking them from least to most anxiety provoking.
- Exposing the client to the stimuli in the hierarchy. Beginning with the object that causes the least anxiety, the counsellor uses imagining or ‘in-vivo’ techniques to expose the client to anxiety-provoking situations while simultaneously engaging in relaxation strategies. This is then repeated with higher levels of anxiety-provoking situations until no anxiety is experienced and continued until the most anxiety-provoking situation does not trigger anxiety. This process is depicted in the following diagram:
Exposure Therapy for Phobias Video with Reid Wilson
Expert Reid Wilson shows you how exposure therapy is done, he conducts two remarkable sessions with a woman suffering from claustrophobia. Watch the video and answer the questions that follow.
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Role-Plays
Role-plays are another technique that can elicit a situation without having to experience it. A role-play can be used within a counselling session to help a client practice newly learned skills or additional techniques to be used in the ‘real world’. A client could also use cognitive rehearsal, a similar technique that requires the client to imagine the steps needed to complete a task. This process helps the client identify any obstacles that may arise during a task and prepare in advance for overcoming them.
Homework
Homework is an important tool for many CBT therapists. The main aim of CBT is to provide skills that the client can apply to their own life. Therefore, practising these skills outside of sessions is an important aspect of CBT-based counselling.
Homework assignments in CBT involve the practice of new behaviours and cognitive strategies, engagement in behavioural experiments, and collection of self-monitoring data between therapy sessions.... Homework activity in CBT is firmly based in basic principles of beahvioural psychology: a new behaviour may be acquired in one situation (i.e. elicited by a specific set of stimuli), but will rapidly be extinguished if it does not generalize to (i.e. be reinforced in) a range of other situations.
(McLeod, 2019, p. 130)
Despite the usefulness of homework tasks, many clients will not comply with completing them – this is a common occurrence. This may be due to homework tasks being overwhelming or not specific enough, incompatible with the client’s therapy goals, or the client does not accept or perceive the benefits of homework. It was also suggested that the skill of the therapist in reviewing and assigning homework, and more broadly, the interaction between the therapist and the client, can affect the effectiveness and completion of homework (Kazantzis, 2021). If a counsellor observes that their client is not completing homework tasks, it is important not to get frustrated; this should be addressed gently. Kazantzis et al. (2005, cited in McLeod, 2019) suggests the following strategies for encouraging homework completion:
- Provide a rationale for homework assignments in the first session.
- Set homework tasks that align with the client’s goals and existing coping strategies.
- Make sure tasks are specific and not vague.
- Check the client’s understanding of what’s expected of them.
- Provide written instructions for homework tasks.
- If the client is highly distressed, do not discuss the assignment.
- Discuss the outcome of a homework task in the following session.
‘Homework’
The term ‘homework’ can have negative connotations for some clients, which may further discourage them from completing the tasks. As such, many therapists will use the terms ‘practice’, ‘action plan’, or ‘experiment’ instead.
CBT Session Demo: Homework & Action Plan
The counsellor in this video gives a demo of excellent questioning to invite client to set their homework. Answer the questions that follow.
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Psychoeducation
CBT aims to help clients become ‘their own counsellors’, and part of this involves helping clients to understand what processes underlie and maintain their current situations. Sometimes, just understanding what is happening to them physically and psychologically is enough to give clients a sense of control and reduce their symptoms of distress.
Psychoeducation about the cognitive behavioral approach
This video demonstrates the initial stage of therapy, providing a psycho-educational explanation to parents or children about the cognitive behavioral approach.
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A central part of psychoeducation involves the counsellor explaining to clients what cognitive, physical, and behavioural components underlie their emotional and behavioural responses and providing a rationale for the type of intervention subsequently used.
Psychoeducation on the CBT Model
This demonstration provides an excellent example on how to elicit automatic thoughts from a client and mapping them to the CBT Model. Answer the questions that follow.
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CBT Exposure Techniques for Anxiety Disorders
In this video, Dr. Judith Beck and Dr. Aaron Beck discuss exposure techniques for anxiety disorders. Using a patient example, Dr. Aaron Beck illustrates in-vivo exposure with a patient with a bridge phobia.
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Case study clinical example: First session with a client with symptoms of social anxiety (CBT model)
Following is an example of a counsellor using CBT techniques with a client with social anxiety, the role-play begins after the initial contracting for the sessions. Once you have watched the video, answer the questions that follow.
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Read
Before moving on, take some time to review Reading E – The Central Pillars of CBT, which discusses the core framework of CBT, and various strategies and techniques used with clients to support them in the change process.
Check your understanding of the content so far!
In CBT, the counsellor is usually viewed as the expert who assists the client in becoming aware of faulty thought patterns/negative automatic beliefs and the behavioural patterns that reinforce the client’s distorted thinking (Simmons & Griffiths, 2017).
What makes a good therapeutic relationship?
This video discusses the key factors for a good therapeutic relationship.
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The counsellor typically teaches the client how to identify distorted cognitions and then helps them to decide on suitable changes to resolve the problem. However, this is a collaborative process – counsellors respect the client’s wishes and work on the issues that the client states are important to them. According to Kennerly, Kirk and Westbrook (2017), the therapist’s role is as “a guide and mentor rather than as an instructor” (p. 46):
You are ‘walking alongside’ your client as he explores new options for feeling and behaving, and your role is to open up new opportunities for exploration, by asking questions or giving information that may lead him into previously unexplored areas. You need to have a good understanding of his current bearings in order to do this, so you need to adopt an open-minded curiosity and respect about your client’s beliefs, emotions and behaviours, and not to assume that you know how he feels or thinks.
(Kennerley et al., 2017, p. 46-47)
Through this process, counsellors also provide the client with hypotheses about their problems and experiences (Kennerley et al., 2017). The counsellor and client work together to test the hypotheses and problem-solve. However, it is important to remember that the counsellor does not have all the answers. Instead, the counsellor’s role is to make suggestions and guide clients in exploring their issues.
The client’s role is participating in the process and working with the counsellor. The client must be responsible for communicating their concerns, giving feedback, experimenting, practising, completing assigned homework, and implementing plans for change. For this collaborative process to succeed both the client and counsellor must take responsibility and be respectful and active in their therapeutic roles.
The Evolution of the Therapeutic Relationship
In this video, Dr. Aaron Beck discusses the evolution of the therapeutic relationship in CBT. He compares and contrasts old view of the therapeutic alliance in psychoanalysis to the modern approach used in CBT today.
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Check your understanding of the content so far!
This section of the module explored the theoretical underpinnings and key techniques of cognitive behavioural therapy. It is important for any counsellor who intends to use cognitive behavioural techniques to understand these concepts because theoretical understanding is vital for the effective practice of CBT. You will learn more about how counsellors implement cognitive behavioural therapy in the next section of this module.
- Cully, J. A., Dawson, D. B., Hamer, J., & Tharp, A. L. (2020). A provider’s guide to brief cognitive behavioral therapy. Department of Veterans Affairs South Central MIRECC. https://www.mirecc.va.gov/visn16/docs/therapists_guide_to_brief_cbtmanual.pdf
- Healthy WA. (n.d.). Unhealthy thinking styles. Retrieved April 11, 2022, from https://www.healthywa.wa.gov.au/Articles/U_Z/Unhelpful-thinking-styles
- Kennerley, H., Kirk, J., & Westbrook, D. (2017). An introduction to cognitive behaviour therapy skills and applications (3rd ed.). SAGE.
- McLeod, J. (2019). An introduction to counselling and psychotherapy: Theory, research and practice (6th ed.). McGraw Hill.
- Simmons, J., & Griffiths, R. (2017). CBT for beginners (3rd ed.). Sage.
- Wright, J. H., Brown, G. K., Ramirez Basco, M., & Thase, M. E. (2017). Learning cognitive-behavior therapy: An illustrated guide (2nd ed.). American Psychiatric Publishing.
