What is CBT?

Cognitive Behavioural Therapy has two fundamental elements:

  1. The cognitive element focuses on modifying dysfunctional thoughts and beliefs which underpin problematic feelings and behaviour

  2. The behavioural element focuses on generating behavioural experiments which may help to further challenge dysfunction beliefs and lead to long term behavioural change

There are a number of other things which are common across all types of CBT:

  1. CBT is time-limited - usually around 12-16 sessions for uncomplicated depression and anxiety. Personality disorders and other chronic disorders will take longer, maybe more than 1-2 years of treatment

  2. CBT is applied to specific problem or disorder

  3. CBT allows for client control by inviting the client to take an active part in his/her treatment

  4. CBT aims to educate the client about the therapeutic process. This means they learn how to prevent relapses - CBT clients become their own therapists

Automatic thoughts and schema

One of the key elements of cognitive therapy is identifying automatic thoughts. These are thoughts which occur spontaneously and rapidly, often unnoticed. They're usually a knee-jerk, immediate interpretation of a situation. They become habitual so we gradually get used to them and start to take their accuracy for granted.

These automatic thoughts are rooted in deeper thought structures called schema (also known as core beliefs). Schema are relatively stable cognitive structures of stored generic features of an experience or idea. They are formed from personal experiences and by the way we identify with significant others. A practical example would be that you'll have a restaurant schema which means that you know roughly what to do in different types of restaurant. A more abstract one would be a schema about how worthy of love you are.

Schema are really useful - they help us to organise new information in a meaningful way so that we can function in a complex world and they shape our expectations and thinking style. When our early experiences are constructive, the resulting schema help us to make sense of the world in a functional way. But if our early experiences and relationships are problematic, the resulting schema may well reflect this negativity. That may not be a problem in adulthood as schema can be present but be dormant, not affecting our thought processes. Where it becomes more of a problem is when a negative schema is activated by adult situations similar to the early experiences in which is was formed. That can then lead to distortions of reality because the schema act as filters through which current information and experience is processed.

For example, if one of your parents walked out on the family when you were young, you may have a schema regarding close relationships that says something along the lines of people I trust will let me down. As an adult you are able to live with this and it does not significantly affect the way you think. However, you then have a partner break up with you, triggering the people I trust will let me down schema. Complicating the matter further is the fact that there may be inter-locking assumptions such as, If I don’t have a loving husband I’m nothing as well as rules such as, A woman cannot be happy without a husband. These rules and assumptions are also triggered when the schema is activated. And this is when systematic cognitive distortions (e.g., catastrophizing, emotional reasoning, and selective abstraction) can occur.

As this happens, people may engage in cognitive and behavioural coping strategies strategies. For example, someone might tell themselves that men are not worth the trouble. These coping strategies might help lessen emotional pain in the short term but, in the long run, they can often reinforce and worsen dysfunctional beliefs.

Certain sets of belief constitute a vulnerability to certain emotional disorders:

  • vulnerability to thinking about loss and failure leads to emotions such as sadness, and behaviours such as social withdrawal

  • vulnerability to danger-oriented beliefs, will lead to emotions such as anxiety, and dysfunctional 'safety' behaviours to avoid the risk of perceived rejection, embarrassment or death

  • vulnerability to themes of humiliation, unfairness, etc leads to emotions such as anger and resulting behavioural responses might include aggressive retaliation perceived as self-defence

Collaborative Empiricism

In order to uncover problematic thoughts and schema in CBT, the client and therapist work together, like a team of scientists, evaluating the client’s beliefs, testing them out to see whether they are accurate or not, and modifying them according to reality. This is known as collaborative empiricism.

This is achieved through a process called guided discovery which uses Socratic questioning to guide the client in a mindful discussion that will enable them to gain insight over their distorted thinking.

Specifically, this process aims to help the client:

  1. monitor and identify automatic thoughts

  2. recognise the relationships between cognition, affect, and behaviour

  3. test the validity of automatic thoughts and core beliefs (sometimes with behavioural experiments)

  4. correct biased conceptualisations by replacing distorted thoughts with more realistic ones

  5. identify and alter beliefs, assumptions, or schema that underlie faulty thinking patterns

This active, collaborative approach extends to the treatment plan for the whole therapy and the agenda for each session which are discussed with the client. Feedback of the client’s thoughts about the ongoing session and the whole treatment is routinely asked in order to create the opportunity to treat and handle any misconceptions and misunderstandings that might arise over the course of therapy.

Cognitive techniques used in CBT

Treatment may start by identifying and questioning automatic thoughts. This can be done in different ways:

  • The therapist guides clients to assess their automatic thoughts, especially when they seems to be emotional during the session, by simply asking: 'What is going through your mind at the moment?'

  • Cognitive distortions may be highlighted by asking empirical questions such as 'What are the evidences for your conclusion?', 'Are you omitting contradictory evidence?', 'Are there alternative explanations that may be more accurate in explaining this particular experience?'

  • A Dysfunctional Thought Record (DTR) may be used to help track the thoughts that were activated by a certain situation and that generated problematic emotions

  • However, for long term changes to occur, the therapist and client must go deeper than negative automatic thoughts triggered by a certain event, to uncover underlying, ingrained schema, assumptions and rules that are at the root of them

  • Cognitive rehearsal is a technique where clients experience feared situations by imagining that it is occurring right at that moment. Clients can then rehearse problem solving and assertiveness strategies

Behavioural techniques used in CBT

The therapist and client collaborate to assign experiments collaboratively to test the client’s negative expectations. For example, a depressed woman may believe she is no longer capable of preparing the Sunday dessert that her grandchildren liked so much, largely because she believes she is unable to stay out of bed long enough to do almost anything. To gather evidence she rates her mastery and pleasure expectations before performing the task on Sunday morning and compares these ratings to her thoughts and feelings after she completed the assigned task. She will probably receive many positive experiences, which will help her correct inaccurate mastery and pleasure predictions in the future.

Frequently depressed patients have dysfunctional expectations about their capabilities when feeling depressed, and are surprised at a much better outcome than they expected. As the patient puts them to test, the outcome brings a different perspective.

Social skills training may be a necessary tool as part of the treatment plan. A patient that

fears social situations and has poor social performance will benefit from role-playing the feared situation with the therapist to build up inhibited social skills and overcome the problem.

Adapted from:

Knapp, P & Beck, AT (2008) Cognitive therapy: foundations, conceptual models, applications and research. Brazilian Journal of Psychiatry Oct;30 Suppl 2:s54-64