Tuesday, December 9, 2008

Introduction of Cognitive Behavioural Therapy Skills


CBT is a five area assesment... Understanding the connections in CBT is like joining the dots!!!!!!!!

CBT claims that when we are distressed or facing problems, there are five areas in our lives that are connected. We are usually in a situation and we have thoughts about this situation and then we are feelings things, which makes us do things and then our body physically reacts also. There is no order to these responses, but all five are happening and are all connected.

All five areas are interconnected. Each area influences the other. A change in behaviour can effect how I feel, both emotionally and physically in my body. It can have an effect on the situation. It can lead to changes in present relationships, and it can effect how I view past relationships and events. Or, changes in thinking can affect how I feel or how my body reacts. It can affect the way I behave and can lead to changes in my situation.

Changing perspectives

Look at a married couple. Do you know the STATUS of their Relationship?

To understand it you have to get information from a lot of areas....

Friends, family , foe, neighbours etc....

CBT is exactly like this.

“We have to walk around together and see the whole picture to understand how things really are.”


“We cannot change the events that happen in our lives, but we can change the way we think about them and what we do about them.”

CBT focuses on two main areas:

1) Helping people to change what they are thinking

2) Helping people change behaviours that are unhelpful or harmful to them

That is why it is called Cognitive Behavioural Therapy. It examines the thoughts (cognitions) and behaviours of people.

CBT claims that most of our worries or anxieties, our depression or anger, come from the way we are thinking and looking at a situation. And, because of how we react and behave.

CBT, therefore, is all about identifying what we are thinking or doing which is not helpful to us or others and then challenging them and changing them.

It is not simply changing negative thoughts into positive thoughts. It is about seeing things as they really are. It is about being realistic. For example, someone who is anxious about failing an exam and thinks that life is not worth living if they fail, would benefit from challenging their beliefs and become more realistic by thinking things like ‘I can try my hardest and if I fail I can re-sit the exam.’ Or, ‘I am good at other subjects. Even if I fail this one it won’t be so bad.’ Or, ‘I have done well in the past, this worrying isn’t helping me concentrate.’

Sometimes CBT helps people to challenge unhelpful behaviours also. For example, people who get depressed often stop doing what they enjoy and stop seeing friends. A simple CBT challenge for people in these circumstances is to change that behaviour; to make themselves go out and continue to do things they enjoyed before, even if they don’t feel like doing it now.

CBT is about change. The change happens when people challenge how they think and do things. It is about beating the negative thoughts and habits that pull people down a downward spiral. It is saying ‘no’ to what is not helpful in life.

“The challenge is your choice!”

CBT gives the power:

  • To manage mood swings.
  • To manage behaviour that is harmful and self-defeating.
  • To choose better ways of responding.
  • To control negative thinking and negative moods.
  • To change - the choice is yours!!

It’s like breaking the chains that bind us.”

Identifying the Therapy

The first step in understanding a problem is to make an assessment. Sometimes problems are overwhelming and can be better understood if we break the problem down into five parts and understand these five areas first. This means becoming aware of how the five areas in a person’s life are connected and influencing each other.

Sometimes people have specific isolated problems, which may not necessarily lead to a mental illness. CBT offers tools that can help people to make an assessment of these also.

The aim of assessment is to understand a person’s story and to understand the context of that story and the precipitating factors (that is, those things which keep the problem going).

An assessment is helpful, not only for gaining a sense of aware
ness and understanding, but it helps to identify where the problem lies and what interventions can be made where. It is like a doctor hearing a story of symptoms and then being able to prescribe the right medicine. In CBT terms, we need to understand these five areas of thoughts, behaviours, feelings, physical reactions and environment, in order to identify where the problems areas are and where specifically change can be made – so that the chain can be broken.

For a general overview of a person’s life history, the following can be used.
You can begin to understand your own problem by defining what you are experiencing in these five areas of your life. Describe any recent changes or long-term problems you have experienced in each of these areas. You can use the Questions below to guide you.

Environmental changes/life situations: Have I experienced any recent changes ? What have been the most stressful events for me in the past 3 years ? 5 years ? In childhood? Do I experience any long-term or ongoing difficulties (including discrimination or harassment by others ?)

Physical Reactions : Do I experience any physical symptoms that trouble me, such as changes in energy, appetite, and sleep, as well as specific symptoms, such as heart rate fluctuations, stomach aches, sweating, dizziness, breathing difficulties, or pain ?

Moods: What single words describe my moods (sad, nervous, angry, ashamed)?

Behaviours: What things do I do that I would like to change or improve ? At work ? At home ? With friends ? By myself ? Do I avoid situations or people when it might be to my advantage to be involved ?

Thoughts : When I have strong moods, what thoughts do I have about myself ? Other people? My future ? What thoughts interfere with doing the things I would like to do or think I should do ? What images or memories come into mind ?

From Mind Over Mood by Dennis Greenberger and Christine Padesky.1995 The Guildford Press

CBT Model of Assessment

Aaron Beck, the founder of CBT, developed his theory when researching depressive illness.

This is the ‘Classic Model’ of CBT. The model shows that causes of depression come from different influences in a persons’ life. It shows how depression often develops from childhood experiences and is eventually recognized by symptoms in the adult’s later life.

Explanation of the Model:

The first box shows that there may be ‘early childhood experiences’ that affected a person. People as early as childhood can develop ‘core beliefs’. A ‘core belief’ is when a person perceives themselves in a certain way. That is, they believe certain things about themselves. For example a person may think “because my mother left us, I must be unlovable”. Or “I am worthless”. Usually ‘core beliefs’ are the ‘I’ statements we make about ourselves. [NOTE: Core beliefs commonly develop from childhood, but can develop from any other life event later in life.]

The second box shows how these experiences develop ‘dysfunctional assumptions’. This means for example if a person grows up with a bullying father, they may develop thinking patterns like “I must keep quiet, or I will make my father angry” or, “the only way to survive is to fight back”. From such experiences and changes in thinking, people then develop ‘dysfunctional assumptions’. Assumptions are like rules or standards. People make up rules to survive. In the case of the previous example, the client may develop the rule “If I keep quiet, then I won’t get hurt.” . These rules are usually expressed with a ‘if…..then…’sentence structure.

The third box shows that, as happens in most people’s lives there, are other ‘critical incidents’ that influence us. These are usually important or decisive events which influence us. For example, a marriage break down, the death of a loved one, the tsunami, or a bombing.

The fourth box shows how depression develops when the earlier dysfunctional assumptions and core beliefs then become activated by these events. That means, when what we learnt negatively about earlier events, we then use to make sense of other present events. ‘Assumptions are activated.’ For example, if a lady used to compare herself negatively to her sister in childhood, or was always compared to her sister and made to feel bad, she may develop core beliefs like ‘I am not as good as my sister’ or ‘I am inferior’. This means vulnerability is established here that she grows up feeling inferior and second best. If in her later life her marriage breaks down, because of these earlier experiences, she may then blame herself for the marriage breakdown because she believes she wasn’t a good enough wife – inferior. So, the previous assumptions about being inferior repeat themselves and become activated again in a new situation.

The fifth box shows Negative Automatic Thoughts. ‘Automatic thoughts’ are the everyday thoughts we have in the present. They are the thoughts going through our mind. They are the things we say to ourselves. For example, if I go into a room and see a nice plant I may say to myself ‘that is a beautiful plant.’ ‘Negative Automatic thoughts’ are thoughts that go through our mind because of the way we interpret events negatively or feel negatively about them. For example, if I arranged to meet someone at a shop and they are late, I may feel worried or impatient and my negative automatic thoughts might be ‘maybe she had an accident’ or ‘maybe she missed a bus’ or ‘she’s always late’. Negative Automatic thoughts are the thoughts we have about the present, but they have a link with our deeper assumptions and core beliefs. People have described them as the thoughts we have at the ‘tip of the iceberg’, but which are connected to the deeper assumptions and core beliefs ‘under the water.

A Critical incident may therefore activate old assumptions, create new ones and develop all kinds of negative automatic thoughts.

Finally, the sixth box show how depression is then maintained by these thoughts and experiences. It becomes an illness when it goes on to develop symptoms. The ‘Symptoms’ are signs or warning signs that a person has got stuck and that their life is changing negatively and that this is beginning to affect their behaviour, their level of motivation, the way they feel (moods) and their thinking and their physical reactions.

Cognitive Model of Depression

The Cognitive Model of Depression

Early Experience: Develop Core Beliefs

Vulnerability Stage
Dysfunctional Assumptions: (based on core beliefs)

Critical Incident

Activating Stage

Assumptions activated

Beliefs Develop

Negative Automatic Thoughts:


Behavioural: Eg, Lowered activity levels, social withdrawal.

Motivational: Eg, loss of interest and pleasure, everything is an effort, procrastination.

Affective: (Moods) Eg, Sadness, anxiety, guilt, shame.

Cognitive: Eg, poor concentration, indecisiveness, ruminations, self-criticism, suicidal thoughts.

Somatic: (Physical Reactions) Eg, loss of sleep, loss of appetite.

Obsession Compulsive Disorder (OCD).

Some anxiety problems can turn into OCD. It is known that after a traumatic event or after traumatic grief, or extreme stress, people can develop OCD.

‘Obsession’ means a person is thinking thoughts that he does not want. They are involuntary. They are intrusive thoughts. They are unwanted thoughts. The thoughts are usually repetitive in nature and are resisted by the person. These can be thoughts, images or impulses. They can be about violence, of a sexual nature or, about seeking reassurance and safety. The cognitions can be about fears of disaster, avoiding something, or seeking reassurance.

‘Compulsion’ is a type of behaviour that is irrational and excessive. There is a certain order in the behaviours. There are external compulsions that can be observed by others. There are also internal compulsions which others cannot see, like counting, or saying sentences over and over again.


Washing hands repeatedly.

Some people with OCD have obsessions without compulsions.

Having a Disorder usually means that people have lost control over their lives and can not function in society. In the case of OCD, people are so affected by their behaviours and thoughts that they can no longer work or develop meaningful relationships for example.


Again CBT is very effective for challenging people’s thoughts and behaviours in the cycle of OCD.

Treatment may involve:

  • Medication
  • Behavioural Therapy
  • Exposure Response Prevention (ERP), which is where a client is asked not to do the compulsions to learn that the distress, will decrease by itself.
  • Cognitively challenge the irrational obsessive thoughts. Thoughts can be challenged about how probable they are, or where responsibility lies. People are generally advised not to avoid thoughts but to confront them for example, by writing them down.
  • Family members need to be involved and trained to understand the OCD cycle.
  • After treatment relapse prevention is advised as OCD tendencies can re-emerge if the client comes under stress.


It is important to be able to describe what is going on inside us. Sometimes people have been avoiding their feelings for a long time, so they have become difficult to express. Sometimes people grow up in families where feelings are not allowed to be expressed in the family. It is often difficult to remember what feelings are like and what they are called when people are not used to expressing them. Here is a list of feelings to help to describe emotions. It is important to help clients to identify their feelings and be able to describe their inner experiences. Describing and naming feelings is an important part of healing.

Happy Sad Excited Angry Surprisedm Depressed Hysterical Furious Overjoyed Gloomy Panicky Annoyed Cheerful Dismayed Unsettled Irritated Buoyant Disappointed Anxious Tetchy Merry Deflated Curious Aggrieved Proud Ashamed Suspicious Jealous Satisfied Guilty Frustrate Defeated Content Lost Determined Mellow Helpless Vengeful Serene Grief-stricken Disgusted Light-hearted Miserable Afraid Light-headed Dejected Terrified Downcast Triumphan Disdainful Apprehensive Woeful CarefreeAloof Self-righteous Crushed Vindicated Foolish Loving Ridiculous Trapped Scornful Sympathetic WorriedColdblooded Relieved Mischievous Sullen Pained Silly Ecstatic Humiliated Humorous Confused Grateful Used Mortified Defiant Pleased Remorseful Bored Delighted Indifferent Peeved Amused ForgivingHostile Churlish Safe Critical InsecureSmug Lonely Impatient Intolerant Restless Unsafe Pathetic Secure

This is a helpful tool to help clients identify their feelings and thoughts:

Identifying your Feelings and the Thoughts behind them.

Try filling in the following to identify your feelings, which situations trigger different feelings and what thoughts lead to this emotion.


2.Describe the Events that Trigger This Emotion

3.What kinds of Thoughts lead to This Emotion ?


Everyday what we think makes us feel things and do things.

Thoughts lead to feelings, which lead to actions.


The first task in CBT is to try to identify what thoughts are behind the feelings we feel. Every feeling has a thought behind it. If I am sad, there must be a reason behind it and therefore a thought behind it. It is necessary to teach clients to pause and think what is going through their mind before they felt in a particular way.

One aim of CBT is to recognize and then to challenge these thoughts.

The first step in overcoming negative thinking is to become aware of our thoughts and of their effects on us.

Negative thoughts make us feel bad – anxious, sad, depressed, hopeless, guilty and angry. Instead of being overwhelmed by these feelings, we can learn to use tools to do something about these. When our mood changes for the worse, we can look back and ask ourselves what was running through our mind at that moment; what were we thinking about? If we can stop ourselves being carried away by our feelings and ask ourselves instead what we are thinking, then we can become more aware of our negative thoughts. Then, over the course of a few days, we will become more sensitive to changes in our feelings and to the thoughts that spark them off. We may find that the same negative thoughts occur again and again.

There are various ways to challenge thoughts.

ABC Diary

The ABC Model:

It is important to understand what A, B, C,stand for before people use an ABC diary.

A =Activating Events this may be an actual incident, external event, or, a memory, a thought about a future event or an emotion

B =Beliefs this is people’s interpretation of the events, (of A). These are their thoughts about the events. Either inferred thoughts or thoughts where they evaluate.

C =Consequence

  • consequent feelings - how the event/thoughts (A and B) make people feel.
  • consequent behaviours - how the event/thoughts (A and B) lead people to do certain action or, behave in a certain way.

ABC DIARY: How to do it

The best way to become aware of negative thoughts is to write them down as soon as they occur. You can do this using the first three columns of the ABC Diary.

A – Activating event

In the first column, write down the activating event or trigger for the situation that contributed to your upset. What were you doing? What sensations did you feel? Or what was happening around you?

B – Beliefs

In the second column, write down the beliefs (or thoughts) that you had at the time. Try to record what went through your mind as precisely as you can. Some of your beliefs may take the form of images or memories, rather than words. You might for example be reminded of the past by a present trigger or, project into the future and imagine yourself being unable to cope with a situation in the future. In this case write down what you saw in your mind’s eye.

There may be times when you cannot identify what went thought your mind. In this case, ask yourself what the meaning of the situation is to you. What does it tell you about yourself, or about the future?

Also in this column, rate how much you believe what went through your mind, on a scale between
0 – 10. Ten means that you are totally convinced by what you thought and 0 means you do not believe it at all. You can rate the strength of your beliefs anywhere between 0 – 10.

C – Consequences

In the third column, write down the consequences of what you were thinking.

The consequences include how you felt and acted. Rate how strongly you felt these feelings on a scale from 0 – 10. Write down what you did, or how you acted as a result of feeling in a certain way. You will often find it easier to write down the consequences before you try to identify the beliefs.


Is a way to challenge thoughts is to use the Flashcard.

This falshcard is easy to use as people answer the questions one at a time. It is like filling in a form.

Flashcard: How to do it

This tool is a more straight forward way to challenge our thoughts as people take time to answer one question at a time, rather than filling in columns. It is quicker and may be ideal when people want to challenge a thought right away. It is also a very good tool to stop people from giving in to negative urges. It gives enough time to pause and think again whether they want to carry out a negative behaviour or not.

How to answer the questions

1. I hold the belief that.

Write down what your negative thought is.

2. It is understandable that I hold this belief because…

Give the reason why you hold the belief.

Give evidence for the belief. Facts not feelings!

3. However, the belief is unreasonable because….

Give reasons why this belief is not true.

Give evidence against the belief.

4. It is also unhelpful because…

Describe why this won’t help you in the long term. Will this really help you to feel better?

5. Reformulation. A better belief for me would be…

Think of another belief that would be more helpful and more realistic.

6. Since I have held this belief for so long, it will take time to change. What I need to do now is…

Think of something you can do to help yourself cope better now and for the future.

Daily Mood Log

This is another effective tool to challenge our thinking. It focuses on trying to make people aware of which thinking errors they are making in their thinking and helps them to establish new and more helpful thoughts.

Describe your Upsetting event

This is the same as column A of the ABC diaries. Write down the situation or event you are in when the upset started. Again pay attention to triggers and sensations.

Record Your negative Feelings

Here you list feelings again with one word and rate how strongly your feel them.

The triple Column Technique

In the first column write down a list of thoughts that were going on in your mind when you were feeling like this and were in this situation. This tool is helpful to untwist your thinking. Often when you are overwhelmed or feel like your head is all muddled, this tool will help you put one thought at a time on paper so you can see them in black and white and begin to challenge them, rather than let them overwhelm you.

In the second column, list the distortions you are using. CBT has a list of cognitive distortions or ‘thinking errors’ which people make all the time, but which hold people imprisoned in their thoughts rather then allowing them to see things from another perspective. Use the list below to identify some of the distortions you might be making in your thinking.

In the third column, think of new thoughts that are more realistic and helpful which you could think instead or the next time you are in similar situations. Often, after having examined your thoughts with the thinking errors list, you come to more realistic thinking and can see for yourself what mistakes you are making in your thinking.

Column 1-Negative Thoughts

Write down the thoughts that make you upset and estimate your belief in each one

Column 2- Distortions

Use the Distorted Thinking List

Column 3- Positive Thoughts

Substitute more realistic thoughts and estimate your belief in each one

Thinking Errors

The following is a list of distorted thinking patterns people make. The list describes different thinking errors people make. These are useful for identifying negative thinking patterns. We all think along some of these ways.


Do you see things as either being black or white? Are you a total success a total failure? This could be called ‘all-or-nothing’ thinking. You must ask yourself ‘what is the evidence for saying that everything is wrong or nothing is right’. Some things may be wrong and not everything may be right.


If you make a mistake or fail at something, do you ever say to yourself ‘I never get anything right’? Just because you have failed at one thing doesn’t mean you will fail at everything. You are taking your feelings from one situation and colouring other situations in an equally bad way. Try to tell the difference between things which are really ‘bad’ or unpleasant, from those which you have coloured black, by ‘over-generalizing’.


Most of the events which take place in your life will be made up of good bits and bad bits. Do you find yourself concentrating on only the bad bits? This thinking error is like a mental filter, filtering out all the good bits and throwing them away, and keeping only the bad parts.


You may be convincing yourself that the good bits don’t count. This thinking error is a variation of the mental filter. If you recognize something which isn’t bad you discount it by saying that its not really good either. Remind yourself that filtering out good experiences and throwing them away only serves to deepen low mood. Discounting the positive is another way of focusing only on the bad experiences and another way to deepen depression.


Do you find yourself predicting that things will happen, even though you have little or no evidence to support it? This is a very common thinking error, which most of us are guilty of at some stage or other. The easiest way to challenge this error is to look for the evidence.

You may also conclude that someone is reacting negatively towards you without bothering to check this out (mind-reading).


Do you find yourself exaggerating the significance of your imperfections or undesirable events? ‘I made a mistake, my reputation is ruined’. Or do you minimize your strengths and your achievements? ‘I passed the exam but only got a B’. Thinking this way is guaranteed to make you feel inferior – check the evidence.


‘I feel guilty, therefore I must have done something wrong’. ’I feel fat, so I must be fat’. These are two examples of emotional reasoning – or ‘letting your heart rule your head’. Once more, to challenge this type of thinking error, look for the evidence – if you can’t find any you must realize that you are being emotional. Try to work out why you feel the way you do and then work out how you should be feeling.


If you ever say ‘I must pull myself together’ or ‘I should be enjoying this’, then you will make heavy demands on your emotions and may end up feeling like you failed if you are not living up to your high expectations of yourself. You simply tell yourself to stop trying to be perfect at all times.


If things go wrong, do you find yourself sticking labels on yourself? If you row with someone do you think that you are a rotten person? If you don’t manage something, do you consider yourself to be hopeless? Labeling suggests that you are completely rotten or hopeless in this case, and leaves no room for more positive descriptions of yourself. Check the evidence again.

If you feel that ‘everything bad always happens to me’ or ‘it’s my fault that my family is upset it must be something I have done’, this is personalization. Unless you can prove to yourself that you are to blame for something by finding substantiating evidence, then this is the thinking error or personalization.

Cost/Benefit Analysis

In Cost/Benefit Analysis yousimply write down the costs and benefits of thinking in negative ways. And when you analyze it by yourself you start to identify your weaknesses.

Cost/ Benefit Analysis


- Describe the advantages of feeling this way

- Describe the advantages of thinking this way


- Describe the advantages of feeling this way

-Describe the advantages of thinking this way

CBT Role Play

CBT can be used by challenging negative thoughts verbally, by working in pairs or in group.

How to do it?

· Make a list of your negative thoughts.

· Select a partner and face him or her.

· Tell your partner to read your negative thoughts, one by one, using the first person

· Talk to your partner in the same way you would talk to a friend who is upset, using the second person.

· If you get stuck, do a role reversal.