Summary of Cognitive Behavior Therapy: Basics and Beyond by Beck - 2nd edition

What are the fundamentals of Cognitive Behavioral Therapy? - Chapter 1

In the 1960s, Aaron T. Beck, MD, a practicing psychoanalyst, wanted to empirically demonstrate psychoanalytic theories so that they would receive more respect in the scientific community. He identified that distorted, negative cognition was a defining feature of depression and created Cognitive Behavioral Therapy as a short-term treatment that would target those negative cognitions.

What is CBT?

Cognitive Behavioral Therapy (CBT) is a structured, short-term, present-oriented psychotherapy used for depression. It targets dysfunctional thinking and behavior in order to solve current problems in the patient’s coping. The therapy has seen countless adaptations and use with a number of different psychological disorders beyond depression. In all forms of CBT, treatment is based on the understanding and conceptualization of individual patients as the therapist seeks different ways to encourage cognitive change and bring about enduring emotional and behavioral change.

What are the different types of CBT?

Variations on CBT tend to emphasize different elements of the treatment. These variations include:

• Rational emotional behavior therapy.

• Dialectical behavior therapy.

• Problem-solving therapy.

• Acceptance and commitment therapy.

• Exposure therapy.

• Cognitive processing therapy.

• Cognitive behavioral analysis system of psychotherapy.

• Behavioral activation.

• Cognitive behavior modification.

• And others.

CBT often uses techniques from these other therapies, so they are all interconnected. CBT has also been adapted for patients in all levels of socioeconomic status and many different cultures. It can be used in group, couple and family therapy, as well as in child therapy. It can be shortened for patients (like those with schizophrenia) who cannot tolerate a full session.

What is the Cognitive Model?

The Cognitive Model is the theory that underlies Cognitive Behavioral therapy. According to this model, dysfunctional thinking disrupts a patient’s mood and behavior and causes psychological disturbances. To recover from psychological disturbance, then, involves developing a more realistic and adaptive way of reflecting on one’s thought processes, and frequently questioning the validity of automatic negative thoughts. Such automatic negative thoughts can lead to damaging emotions like sadness and damaging behaviors like isolating oneself.

Does treatment have a lasting effect?

In order to treat patients in a meaningful and lasting way, CBT therapists will focus on a deeper level of cognition: a patient’s fundamental beliefs about themselves, the world, and other people. If a person has an underlying belief that they are incompetent, this may manifest in them frequently underestimating their abilities and feeling powerless. Combating this belief would involve focusing on specific situations in which it is proven false, and would allow one to see that having difficulty with certain tasks does not make one universally incompetent.

What sort of support is there for CBT?

There is overwhelming support (more than 500 outcome studies) for the efficacy of CBT as a therapy for depression and other psychological disorders. Several researchers have found that there are neurobiological changes associated with CBT.

How did CBT come into being?

One of the main concepts of psychoanalysis is that depression is hostility turned inwards. After some research, Beck found instead that depressed people have more feelings of defectiveness, deprivation, and loss. He observed patients having two streams of thoughts – automatic negative thoughts and evaluative thoughts closely tied to emotions. When Beck helped patients identify, evaluate, and respond to these unrealistic thoughts, they rapidly improved. Beck taught his residents to use the treatment, and eventually worked together with A. John Rush on an outcome trial in 1977. This trial established that CBT was at least as effective as a common antidepressant used at the time.

CBT helps patients identify and solve problems, activates their behaviors, and helps curb depressed thinking and beliefs. Patients with anxiety not only need to learn to better assess risks, they also need to decrease avoidance and confront scary situations.

What are the principles of CBT Treatment?

While CBT must be tailored to the individual patients, there are certain underlying principles that persist through all effective CBT treatments.

CBT is based on the constantly changing formulation of a patient’s problems and the conceptualization of that patient in cognitive terms

Current thinking is identified to see where feelings of sadness originate. Problematic behavior is identified, as well as any precipitating factors that may have influenced perceptions at the beginning of the depression. A hypothesis is made about how developmental events may have caused enduring patterns of interpretation to occur and to predispose the patient to depression. Once the patient is taught how to recognize destructive thoughts, they are taught to formulate more adaptive cognitions

CBT works on a firm therapeutic alliance

Therapists working with CBT must form an alliance with their patients, sharing a trusting relationship and regarding the patient with care and warmth.

CBT requires active participation and collaboration

CBT encourages the patient to see the therapy as teamwork – the therapist and patient decide together what sort of work needs to be done, and how to do it.

CBT is goal-oriented and problem-focused

CBT involves working towards specific goals that are decided upon in the initial sessions. Thoughts that interfere with that goal can be more easily identified and interrupted.

CBT begins by emphasizing the present

Whereas some therapies emphasize the origin of issues (the past), CBT is all about the present, regardless of the diagnosis. CBT only looks at the past in order to provide a context to explain the childhood roots of dysfunctional thinking, or because the patient expresses a strong desire to focus on the past.

CBT involves education and emphasizes relapse prevention

Educating the client is an essential element of CBT. Not only does the therapist explain how automatic negative thoughts impact behavior, but they also help the client set goals, identify and evaluate thoughts, and plan behavioral change. Therapy notes are taken home so that the client may benefit longer from their treatment.

CBT aims to be time-limited

Depression and anxiety disorders tend to receive a treatment of six to 14 sessions, with the goal of relieving symptoms, training positive coping methods, and helping patients solve their most pressing problems. Some patients are easily treated in a short amount of time, though others with more rigid beliefs may need a couple of years of attention.

CBT sessions are structured

A session of CBT follows a certain structure designed to maximize the efficiency and effectiveness of the treatment. This involves an introduction (a mood check, a weekly review, etc.), a middle (homework review, problem discussion, etc.), and a conclusion (homework assignment, feedback).

CBT teaches patients to identify, evaluate, and respond to dysfunctional thoughts

Therapists help patients identify the key cognitions that lead to their anxiety and to adopt more realistic, adaptive cognitions that will lead them to feel better and tackle issues more effectively.

CBT uses different techniques to change thinking, mood, and behavior

Strategies like Socratic questioning and guided discovery are only some among many techniques used in CBT. Problem-solving and behavioral techniques are also essential. Psychodynamic techniques can help as well. It is a case-by-case decision.

How does a CBT session generally play out?

It begins with reaffirming the client-therapist relationship. The therapists checks on the patient’s mood, symptoms, and experiences from the week. Together, they decide which problems will be dealt with. Homework and the action-plan are reviewed. As a specific problem is discussed, the cognitive processes involved in the problem are brought up and can be picked apart. A strategy for solving the problem is then collaborated upon. New homework is assigned.

How to become a CBT Therapist?

CBT seems, from an outsider’s perspective, to be very simple. However, the CBT therapist must be able to conceptualize the case while building up a relationship with their client, as well as socializing and educating them. They must be able to identify problems, collect data, test hypotheses, and summarize. An inexperienced CBT therapist often has trouble doing all of these things at once – this is where the highly-structured format comes into play.

Developing expertise in CBT is a three-stage process. Stage 1 involves learning the basic skills of conceptualizing a case in cognitive terms based on data collected in the initial evaluation and in the sessions that follow. Structure and common sense help the therapist then identify problems and dysfunctional thoughts during the sessions. Stage 2 involves becoming more proficient at integrating the conceptualization with the tools and techniques available to any CBT therapist. Once this becomes easier, the therapist becomes more skilled in identifying critical treatment goals and conceptualizations. In Stage 3, new data is able to be automatically integrated into the conceptualization of the case – hypotheses are easier to formulate, and tools are more easily accessible.

What does treatment look like? - Chapter 2

What is the Therapeutic Relationship?

From the initial introduction onward, the CBT therapist must work to build trust and rapport with their client. There are many skills and methods that can contribute to this, which will be detailed in the following sections.

What sort of counseling skills are needed?

Good counseling skills reinforce the client-therapist relationship. Empathic statements, word choice, tone of voice, facial expressions, and body language all influence how the client feels about the interaction. It is important to treat the patient with respect and kindness, and to reflect your accurate comprehension of their problems by asking thoughtful questions and reflecting things back when you do not completely understand. Confidence and caring are key. A positive client-therapist relationship will indirectly allow the client to feel likable, feel less alone, feel more optimistic, and gain more self-efficacy.

How do conceptualization and treatment relate to each other?

In order to maintain an accurate conceptualization of a client’s issues, it is important to continuously share your observations and understandings. When you are accurate, the client will confirm. Otherwise they will correct and give feedback, allowing you both to stay on the same page.

What is collaborative decision-making?

During the sessions, the therapist actively encourages the client to participate in prioritizing problems. When suggesting an intervention, approval is sought and both client and therapist act as a team to enact the intervention.

What is feedback-seeking?

While the sessions progress, the therapist remains alert to the client’s emotional reactions (from body language to word choice). This acts as data – when an emotional reaction is spotted, the client and therapist can delve further into the cognitive processes that caused the reaction. Failure to identify a patient’s negative feedback means that they will not focus well on solving their real-life issues. Even with a strong alliance, it is vital to elicit feedback at the end of the sessions.

Does it help to vary your style?

It can help to vary the style with which you approach the client – some people react best to unconditional positive regard, while others can be irked by touchy-feely treatment. Read emotional responses.

When does stress relief set in?

When a patient’s symptoms begin to decrease, the client-therapist relationship often strengthens. When the alliance is strong, sessions can be more efficient.

How does the planning of treatment work?

In order to conduct therapy efficiently and to keep the process of therapy understandable to both the therapist and the patient, a standard format should be followed. This does not mean that the treatment is impersonal or cold, simply that it occurs within an organized format. When patients know what to expect from a therapy session, they often feel more comfortable and are better able to understand what is asked of them.

Before a patient even enters the office, the therapist begins planning, reviewing their chart, their treatment goals, and their homework assignments from previous sessions. The session structure is generally decided, and the overarching therapeutic goal guides the creation of a plan. During the session itself, the patient’s symptoms and your conceptualization of their experiences guides the specific content of the session.

How can sessions be structured?

The session begins with a reaffirmation of the therapeutic alliance. Data is collected and priorities for the session are set. Then those prioritized issues are discussed, and cognitive coping mechanisms are taught. Appropriate homework assignments emerge from this discussion and usually involve the patient reminding themselves systematically to reevaluate their negative thoughts. At the end of the session, you will review the content of the session together and receive feedback.

What sort of responses are there to dysfunctional cognitions?

The CBT session is about helping patients respond to inaccurate and maladaptive thoughts. These can be identified in many ways, though usually a simple open question will begin the discussion, such as “What are you thinking about?” The patient’s thoughts will be evaluated using either guided discovery or behavioral experiments.

What is guided discovery?

When discussing a patient’s problem, you will be able to see which cognitions are upsetting to the patient, and can then as a series of questions that will help them gain distance from which they can evaluate the validity and utility of their cognitions and de-catastrophize their fears. For instance, you might ask “what is an alternative way to view this situation?”, or something similar.

What are behavioral experiments?

One way to examine and question maladaptive beliefs is to conduct a small behavioral experiment, either within the course of the session or during a homework assignment. For instance, if someone believes that bringing up a concern with their spouse will lead to their spouse hating them and yelling at them, one experiment would be to do just that and see if the belief is true. Behavioral experiments may be smaller, of course.

How can focusing on the positive be emphasized?

When a patient is depressed, they will have a tendency to focus on negative elements of any situation, automatically attending to negative thoughts and failing to notice the positive. Having trouble processing positive data is one of the reasons that their sense of reality is distorted. The therapeutic alliance reassures the patient that you see them as a valuable human being. Negative thinking may be bypassed using questions that specifically force the patient to consider the positive elements of a situation, comments that highlight the positive elements of a story and recognition of any positive coping strategies the patient may have used in dealing with their problems.

How can homework help facilitate change?

Homework is a way to set a patient up to have a better week by helping them notice and respond to automatic thoughts experienced between sessions, teaching them to devise solutions to these problems, and teaching them skills they can practice during the week. Patients will likely forget much of what is said in a session, so write things down for them. Homework naturally flows from the content of the discussion. It is vital to review homework the following week.

From the initial introduction onward, the CBT therapist must work to build trust and rapport with their client. There are many skills and methods that can contribute to this, which will be detailed in the following sections.

What is cognitive conceptualization?- Chapter 3

A cognitive conceptualization provides the framework for understanding patients. The therapist begins to construct the cognitive conceptualization during the first contact with the patient. He formulates hypotheses that may explain the underlying dynamics of the presenting problem in order to formulate an appropriate treatment plan. The conceptualization is fluid, and has to be reconsidered when the patient presents the therapist with new information. The therapist should always check out the conceptualization with patients, to assure that it is accurate and to help patients understand themselves and their difficulties.

What is the cognitive model?

Cognitive behavior therapy is based on the cognitive model. The cognitive model states that people’s emotions, behaviors, and physiology are influenced by their perception of events. The situation itself does not immediately determine how people feel or what they do. Their emotional response is mediated by their perception of the situation. Situation--> Automatic thoughts --> Reaction. One person may construe a situation differently than another person. The explanation lies in beliefs.

What different sort of beliefs are there and how do they influence people?

People develop certain ideas about themselves already at a young age. Their most central beliefs are called core beliefs. These core beliefs are deep and enduring understandings of the world that people see as absolute truths. People do often not articulate them, even to themselves. When a belief is activated, a person interprets situations through the lens of this belief, even though the interpretation may be invalid. People tend to focus on information that confirms their core belief. This may lead to a distorted way of processing information. If information doesn’t fit the schema of the core belief, people tend to change the shape of the data in order to fit the schema again, rather than that they change their core belief. Core beliefs are the most fundamental level of belief. Automatic thoughts are the most superficial level of cognition. Intermediate beliefs are the class of thoughts that intermediates the two.

Intermediate beliefs consist of attitudes, rules and assumptions. Intermediate beliefs are influenced by core beliefs. It is threatening for patients if their therapist questions their core beliefs. Therefore the usual course of therapy is to start with the modifying of automatic thoughts. The deeper modification of more fundamental beliefs will follow, and will make patients less likely to relapse.

What is the correlation between behavior and automatic thoughts?

The hierarchy of cognition can be illustrated as follows: Core beliefs --> Intermediate beliefs --> Situation --> Automatic thoughts --> Reaction. Thinking, mood, environment, behavior and physiology can all affect one another. It is important as a therapist to put your self in your patient’s shoes to understand how they perceive the world, given their history and beliefs.

A cognitive conceptualization provides the framework for understanding patients. The therapist begins to construct the cognitive conceptualization during the first contact with the patient. He formulates hypotheses that may explain the underlying dynamics of the presenting problem in order to formulate an appropriate treatment plan. The conceptualization is fluid, and has to be reconsidered when the patient presents the therapist with new information. The therapist should always check out the conceptualization with patients, to assure that it is accurate and to help patients understand themselves and their difficulties.

What is an evaluation session? - Chapter 4

The first meeting with a patient is the evaluation session. Effective cognitive behavioral therapy requires the therapist to evaluate patients thoroughly, so that the therapist can accurately formulate the case, conceptualize the individual patient, and plan treatment. Assessment is not limited to the first meeting, because with each session the patient will enclose new information. Even if another clinician has performed the evaluation, the current therapist will at least need to collect additional information before starting with the therapy. Before the first session takes place, the therapist needs to collect as much information as possible about the patient. In the first session it can be discussed if it could be helpful if the patient would bring a close friend or family member to one of the sessions. This could provide the therapist with more information and insight into the patient’s life. It is important that the therapist lets the patient know what to expect from the appointment. This is called: setting the agenda.

What are the goals of an assessment session?

A checklist of sorts can be applied when it comes to the assessment session:

• The therapist can create a case conceptualization of the patient.

• The therapist should consider if he/she is the right therapist for the patient. For example: Does the therapist have enough time for the patient?

• The therapist should consider whether additional services or treatment (such as medication) may be indicated.

• The therapist should initiate a therapeutic alliance with the patient.

• The therapist begins to socialize the patient into the structure and process of the therapy.

• The therapist identifies broad goals.

How would a therapist structure an assessment session?

Once again, a checklist could be applied to the session that would look roughly like this:

• Greet the patient.

• Collaboratively decide whether a family member should attend.

• Set the agenda.

• Conduct the assessment.

• Set initial broad goals.

• Elicit feedback from the patient.

In the assessment phase the therapist will ask about many areas of the patient’s current and past experience. Another important part of the evaluation is asking patients how they spend their time. Are there variations in their mood? How do they interact with other people? How are they functioning at school/work? Are they actively avoiding situations? These are questions that can be answered if a patient describes his/her typical day. A therapist needs to be alert for indications that the patient is unsure about committing to the treatment. For example: Depressed patients can express hopeless thinking as an automatic thought: ‘I don’t think anything can help.’

In the final part of the assessment, it is useful to ask patients whether there is anything else important to know. At the end the therapist needs to explain that he will need to review notes and form an eventual diagnosis. It depends on the patient whether it is a good idea to tell them their diagnosis, or if it is better to just summarize the problems and symptoms the patient is experiencing without labeling it in the form of a diagnosis.

Setting goals and relating to a treatment plan at the end of the session can provide patients with hope. The therapist also sets the expectations for treatment, including: how long patients should expect the treatment to take.

After the first session the therapist writes a cognitive conceptualization and comes up with a treatment plan. The therapist should check his/her findings with other health professionals to collect more information about the patient.

The first meeting with a patient is the evaluation session. Effective cognitive behavioral therapy requires the therapist to evaluate patients thoroughly, so that the therapist can accurately formulate the case, conceptualize the individual patient, and plan treatment. Assessment is not limited to the first meeting, because with each session the patient will enclose new information.

How is the first therapy session structured? - Chapter 5

What are the goals for the first therapy session?

The goals for a therapist for the first therapy session are:

• To establish rapport and trust with the patient, normalize their difficulties and instill hope.

• Socialize patients into treatment by educating them about their disorder, the cognitive model and the process of therapy.

• Collect additional data to help conceptualize the patient.

• Develop a goal list.

• Start solving a problem important to the patient.

How can these goals be accomplished?

To accomplish these goals, the following format is used:

1. Initial part of session 1

   • Set the agenda. By setting the agenda the patient knows what to expect. The therapist must make sure that the patient agrees with the topics he/she set on the agenda. The therapist must explain the rational for why the agenda is set at the beginning of the session. In this way the patient will collaborate more actively and the session will be more productive.

   • Do a mood check. The therapist asks the patient for a brief narrative report of their mood since the last time they saw each other. This can be in the form of a question during the session, but a patient could also fill out a form before the session starts.

   • Obtain an update. The therapist asks the patient if there are any important problems or issues that might not yet have been discovered. The therapist can decide which problems are urgent to discuss by asking how distressed a patient is by the problem. Long-term, or chronic issues can usually postponed to future sessions. After this, the therapist asks if anything positive happened last week, this will help patients see the reality more clearly.

   • Discuss the patient’s diagnosis and do psycho education. Most patients want to know their diagnosis, and to establish that the therapist should emphasize that they are not abnormal or strange. For personality disorders it is better not to label it, but describe it. It is also desirable to give patients some initial information about their condition, so they can start attributing some of their problems to their disorder, instead of to their character. The therapist will explain what their disorder is about and can eventually give homework to read a chapter about their diagnosis at home.

2. Middle part of session 1

   • Identify problems and set goals. The therapist helps the patient to turn their problems into therapy goals. The patient can write these goals down, so that he/she will remember them during therapy. It is also good to create one general goal for therapy in behavioral terms, for example: ‘I would like to be happier.’

   • Educate the patient about the cognitive model. The therapist will help patients understand how their thoughts have an influence on their behavior. The therapist can explain this model using the patients’ own examples.

   • Discuss a problem. The therapist will try to show the patient that there are different ways of viewing the problem and the therapist can provide the patient with concrete steps in solving problems. This will instill hope in the patient that the therapy might work.

3. End of session 1

   • Provide or elicit a summary.

   • Review homework assignment. The therapist makes sure the patent knows what to do. If the patient seems to doubt if he/she will be able to do all the exercises, the therapist should offer to change it. It is important that the patient will feel successful in making the homework; otherwise it can contribute to their low self-worth.

   • Elicit feedback. What did the patient think about the session and the therapist? This feedback can be given in verbal or written form by filling out a form. Shows that the therapist cares about what the patient thinks, this strengthens rapport.

The goals for a therapist for the first therapy session are:

• To establish rapport and trust with the patient, normalize their difficulties and instill hope.

• Socialize patients into treatment by educating them about their disorder, the cognitive model and the process of therapy.

• Collect additional data to help conceptualize the patient.

• Develop a goal list.

• Start solving a problem important to the patient.

What is behavioral activation? - Chapter 6

One of the most important goals for depressed patients is getting active and scheduling activities. Depressed patients have often stopped doing many activities and instead stay longer in their beds or watch television more often. By getting more active and to give themselves credits for it, they will strengthen their sense of self-efficacy and see that they can have more influence on their mood than they had previously thought. Even if patients still engage in activities, they won’t enjoy it, because of their self-critical automatic thoughts, e.g. “I can’t do it’ My friends won’t want to spend time with me’. Self-critical thoughts may arise before, during or after an activity. It is important that the patient will enjoy the activities he/she has to do for homework, because otherwise they won’t do it again. Therefore the therapist needs to anticipate automatic thoughts that could interfere with doing an activity. Patients can fill in a form where they write down the activities they do and how they feel doing it and afterwards. This gives an insight in whether becoming more active increases their mood.

A behavioral experiment can help patients to test their beliefs. For example: If a patients think their friends don’t want to meet up, the behavioral experiment could be to call one of their friends and see if they really don’t want to.

During a session the therapist and the patient can engage in making a schedule for the following days. It is important to take small steps, in order to not overwhelm the patient. The patient should give him or her self credit every time he/she does something active. At the next session they will discuss and review the homework assignment of following the schedule. If patients reported that getting more active had no impact on their mood it could be that they had interfering automatic thoughts or that they did experience mood changes, but the patient didn’t notice them or can’t remember them. A good exercise to see if the patient really didn’t experience any pleasure last week is to have the patient rate the sense of mastery and pleasure they have. The patient has to think of an activity high in pleasure and mastery, medium in pleasure and mastery and low in pleasure and mastery. For example: The patient rated ‘arguing with partner’ as the lowest in pleasure. If the patient sais he went to the bookstore and didn’t experience any pleasure, the therapist could ask if going to the bookstore was the same in pleasure level as arguing with their partner. This will make the patient realize that he did experience at east some pleasure in that bookstore. When patients are still skeptical that scheduling activities can help, the therapist can ask them to predict levels of mastery and pleasure or mood on one activity chart and then record actual ratings afterwards on another chart. These comparisons can be a useful source of data.

How are follow-up sessions structured? - Chapter 7

What's the start of the session like?

• Do a mood check. The therapist will ask the patient to compare how they are feeling now to how they did last week. The therapist compares the subjective description from patients (what they are telling the therapist) to the objective test scores (from a chart the patient filled in before the session started). The mood check is not just about this day, but also about the time between the two sessions. A mood check is usually quick. As a therapist you should be careful that patients don’t attribute mood changes to external factors. The patient should understand that their mood depends on their thinking patterns. Patients should feel that they have some control over how they feel. If patients state that nothing can improve their mood, it can be helpful write down ‘things that make me feel better’ and ‘things that make me feel worse’. This can give them insight in the fact that a more active lifestyle makes them feel less depressed. If patients are taking medication, the therapist should ask about any difficulties. As a psychologist you cannot change the medication, but you can help the patient respond to eventual cognition that interfere with them taking medication.

• Set the agenda. This also is a very brief part of the session in which the therapist asks patients what they want to discuss in the current session. If patients engage in a lengthy description of the problem the therapist should interrupt and direct the topic back to setting the agenda. Lengthy descriptions of the problem are part of a later part of the session. The patient can choose which topic on the agenda has priority. Sometimes the therapist can suggest the first agenda item himself if he thinks that a specific problem is the most important for now. The priority topics are the ones that are discussed first. If there is not enough time, less important issues can be moved to future sessions. It is important to note that you need not always adhere to the agenda. When deviating from the agenda, the change should be made explicit and the change can only take place with the patient’s agreement. If the patient drifts off to a topic that is not on the agenda, the therapist can interrupt the patient and ask if he or she wants to deviate from the agenda.

• Obtain an update of the week. The therapist tries to get a general idea of how the patient’s week went. This is a bridge between the previous session and the new one. The therapist should not only ask about problems, but should also emphasize positive experiences the patient might have had. This will make the patient realize that their week had some positive points and that they didn’t feel the same level of sadness the whole week.

• Review homework. If a therapist doesn’t engage in this part, the patient will eventually stop doing homework. Therefore it is an important part of the session. The previous homework is discussed and new homework is created for next week.

What's the middle of the session like?

• Work on a specific problem and teach cognitive behavior therapy skills in that context. The therapist continues to reinforce the cognitive model and continues teaching about automatic thoughts. The therapist can provide some symptom relief through helping patients respond to their anxious thoughts.

• Follow-up discussion with relevant, collaboratively set homework assignments.

• Work on the next problem, till the time is up.

What's the end of the session like?

• Summarize session. The therapist can summarize the discussed content in the patient’s words. If the therapist uses his/her own words it could seem to patients that the therapist didn’t understand them right. The therapist could also ask the patient to summarize what they discussed and eventually add things the patient forgot.

• Discuss new homework assignments.

• Elicit feedback. If patients didn’t fully express their reaction to the session, the therapist can ask them to complete a therapy report. If patients have negative feedback the therapist should positively reinforce them and try to solve the problem together with the patient. Negative feedback is usually because the therapeutic alliance isn’t optimal.

As in the assessment and first therapy session it is still important that the therapist and the patient have a good working relationship. If patients are starting to feel better, the therapist can begin to start working on relapse prevention.

What sort of changes may occur in proceeding sessions?

All sessions after session 2 have the same format. As the therapy progresses there is are some gradual shifts:

• The patient knows how the sessions go and will take more responsibility for it. For example: patients will summarize themselves, identify their own distorted thinking and devise their own homework assignments.

• There is a shift from an emphasis on automatic thoughts to a focus on both automatic thoughts and underlying beliefs.

• The last shift is from providing insights in patients’ thoughts to preparing the patient for termination and relapse prevention.

The therapist also has goals for therapy that he/she has to integrate with the goals and problems the patient sets on the agenda.

A therapist has to make notes to remember everything that is discussed and keep track of progress. While making notes, the therapist should maintain eye contact as much as possible. If the patient reveals something emotional it is better to not make notes and be more fully present for the patient.

The sessions starts with a mood check, setting the agenda, obtaining an update of the week, and reviewing homework.

What sort of problems may occur when structuring a therapy session? - Chapter 8

Problems can arise in structuring the session as a therapist. Some therapists fail to interrupt patients if they drift off of the agenda. This could be because the therapist has cognitions that interfere with interrupting a patient, such as: ‘’He’ll get mad if I am too directive’. A therapist can also interrupt a patient too much. The patient could find this annoying. It is important to be open to each other and solve this problem. A second common difficulty in maintaining structure in the sessions can be that the therapist didn’t socialize the patients adequately into therapy. The therapist should explain the therapy structure to the patient. Otherwise the patient doesn’t know what is expected of him/her. A third common difficulty arises when patients have dysfunctional beliefs that interfere with their ability to commit to working in treatment. They may not have clear goals or may have unrealistic hopes about therapy. The therapist must help patients to respond to these kinds of interfering cognitions so that the therapy will work better. A fourth common difficulty involves patients that are unwilling to conform to the structure of the therapy. A reason for this might be that the therapeutic alliance needs strengthening.

What sort of problems can mood checks run into?

Common problems involve patients’ failure to fill out forms, annoyance with forms, or difficulty in subjectively expressing their general mood during the week. This could be because of faulty socialization and remembering patients about the rationale behind this may be sufficient to solve the problem. They might also be annoyed by the request of filling out all the forms, a therapist can then relate to the automatic thoughts that might accompany the reluctance of filling out the forms.

What sort of problems occur when asking for updates?

A common difficulty arises when patients provide too detailed an account of or unfocused rambling about their week. After several such sentences, the therapist should gently jump in and interrupt the patient. A patient can find this annoying, so the therapist should explain why he did it. If the patient wants to continue to be too detailed, the therapist should explain to the patient that in that why there won’t be enough time to discuss all the problems. If the patient is fine with that, the therapist and the patient should collaboratively look for a solution. For example: the therapist won’t interrupt for the next 5 minutes and then summarize what has been said. It is important to get patients into a problem-solving mode. Most patients are passive and feel hopeless about discussing their problems.

What sort of problems can a therapist run into when reviewing and assigning homework?

A typical problem arises when therapists, in their haste to get to patients’ agenda issues, fail to ask patients about the homework they did over the past week. This may lead to the patient not doing their homework anymore or taking the wrong lessons from it. The opposite problem sometimes arises when the therapist reviews homework in too much detail before turning to the patient’s agenda topics. This costs too much time and they won’t get to the real problems the patient wants to solve.

Patients are less likely to do homework:

• When they have dysfunctional thoughts about homework.

• When the therapist suggests an assignment that is too difficult or unrelated to the patient’s concerns.

• When the therapist fails to provide a good rationale.

• When the therapist forgets to review the homework assigned.

• When the therapist does not stress the importance of daily homework.

• When the therapist does not explicitly teach the patient how to do the assignment.

• When the therapist does not have the patient write down the assignment.

• When the therapist non collaboratively sets the homework assignment that the patient does not want to do.

What sort of problems occur when discussing agenda items?

Typical problems here include hopelessness, unfocused discussion, inefficient pacing, and the failure to make a therapeutic intervention. Unfocused discussion takes place when the therapist doesn’t interrupt the patient when he/she drifts off the subject. Pacing is the overestimation of how many issues can be discussed in one therapy session. It is important to keep track of time and discuss with the patient what to do if time is running out. It is optional for the patient to also keep track of time. The therapist's failure to make a therapeutic intervention happens when the therapist fails to identify and respond to a patient’s dysfunctional thoughts.

Why are final summaries and feedback so important?

The therapist needs to summarize a lot during the session to make sure he understands everything the patient said. Problems arise when patients are distressed at the end of a session and you have not left sufficient time to resolve their distress, or when patients are upset but fail to relate their distress to you. A practical solution to avoid running out of time is to start closing down the session 5–10 minutes before the end.

Problems can arise in structuring the session as a therapist. Some therapists fail to interrupt patients if they drift off of the agenda. This could be because the therapist has cognitions that interfere with interrupting a patient, such as: ‘’He’ll get mad if I am too directive’. A therapist can also interrupt a patient too much. The patient could find this annoying. It is important to be open to each other and solve this problem.

How can one identify automatic thoughts? - Chapter 9

The cognitive model states that the interpretation of a situation (rather than the situation itself), often expressed in automatic thoughts, influences one’s subsequent emotion, behavior, and physiological response. Of course some events are upsetting for everyone, but people with psychological disorders often misconstrue positive or neutral events. This means that their automatic thoughts are biased. Automatic thoughts are a stream of thinking that coexists with a bigger stream of thoughts. Everyone has automatic thoughts. People often are more aware of the emotion they feel as a result of their thoughts than of the thoughts themselves, but with a little training these thoughts can be conscious. When they are conscious most of us will do a reality check of these thoughts, but people with psychological disorders don’t question these thoughts and just accept them. Automatic thoughts are often in short hand form. For example: a patient might think ‘damn’ and this means ‘ I was stupid to leave my cellphone at home’.

How can automatic thoughts be categorized?

Automatic thoughts can be evaluated according to their validity and their utility. The most common type of automatic thought is distorted in some way and occurs despite objective evidence to the contrary. A second type of automatic thought is accurate, but the conclusion the patient draws may be distorted. A third type of automatic thought is also valid, but decidedly dysfunctional. Identifying and responding to automatic thoughts is usually helpful to a patient and may produce a positive shift in affect. The automatic thoughts can be identified during a session while discussing a problem the patient is experiencing. It is important that the therapist checks again at the end of the session to ascertain how well the patient understands the cognitive model.

How can automatic thoughts be evaluated?

A homework assignment for patients in identifying these automatic thoughts is to simply ask oneself: ‘What was going through my mind?’ when patients mood starts getting worse. As a therapist you will ask this question when patients describe a problematic situation that arose or when you notice a shift to negative affect during a session. In this latter situation it is often important to be alert to both verbal and nonverbal cues from the patient, so as to be able to elicit their hot cognitions that is, important automatic thoughts and images that arise in the therapy session itself, and are associated with a change or increase in emotion. These hot cognitions can be about the patient him/herself, the therapist, or the subject under discussion. They may interfere with the patient’s concentration, motivation, feelings of worth, or the therapeutic relationship. If patients are unable to answer the question: ‘What was just going through your mind?’ the therapist can ask them how they are feeling and where in their body they experienced the emotion (this will heighten the emotional level during the session and the patient might remember what it felt like to be in the situation again), elicit a detailed description of the situation, request that the patient visualizes the distressing situation, suggest that the patient and the therapist engage in role play, elicit an image, supply thoughts opposite to the ones you hypothesize actually went through their minds, ask for the meaning of the situation for them, or phrase the question differently. These are all techniques that may help patients in identifying their automatic thoughts. If patients are still unable to identify their automatic thoughts, the therapist should move on to another subject in order to not let the patient feel as a failure.

What other problems may occur when treating automatic thoughts?

Patients may have other automatic thoughts about their (emotional or behavioral) reaction to the situation they had automatic thoughts about. Patients can have automatic thoughts before a situation, during a situation, or after a situation. Therapists should discover which thoughts were most distressing to a patient.

If a patient worries about many problems and can’t say which one is most important to him/her, the therapist might ask the patient to hypothetically eliminate one problem, and determine how much relief the patient feels if this problem wouldn’t be there. The problem the patient feels most relieved about when eliminated is likely to be the most troublesome to the patient. When the most troublesome problem is discovered the focus can be on identifying automatic thoughts and problem solving.

When you ask for patients’ automatic thoughts, you are seeking the actual words or images that have gone through their mind. Until they have learned to recognize these thoughts, many patients report interpretations, which may or may not reflect their actual thoughts. For example: The interpretation: ‘I couldn’t get myself to start reading’, actual automatic thought: ‘I can’t do this’. These interpretations should be changed into the real automatic thought to evaluate them effectively. Patients also sometimes report thoughts that are not fully spelled out, e.g. ‘Uh-oh”, the therapist guides the patient to express the thought more fully.

External and internal stimuli can give rise to automatic thoughts. Patients can have automatic thoughts about their cognitions, their emotions, their behavior, or their physiological or mental experiences. Identifying automatic thoughts is a skill that comes naturally to some patients and is more difficult for others. Therapists need to listen closely to ensure that patients report actual thoughts, and may need to vary their questioning if patients do not readily identify their thoughts. Techniques that can be used are discussed in this chapter.

The cognitive model states that the interpretation of a situation (rather than the situation itself), often expressed in automatic thoughts, influences one’s subsequent emotion, behavior, and physiological response. Of course some events are upsetting for everyone, but people with psychological disorders often misconstrue positive or neutral events. This means that their automatic thoughts are biased. Automatic thoughts are a stream of thinking that coexists with a bigger stream of thoughts.

How can a therapist identify emotions? - Chapter 10

How can emotions be classified?

Patients with a psychiatric disorder often experience an intensity of emotion that can seem excessive or inappropriate to the situation. The reactions of these patients will start to make sense when you recognize the power their automatic thoughts and beliefs have. Many patients do not clearly understand the difference between their thoughts and their emotions. It is the therapist’s task to organize the patient’s problems into categories of the cognitive model: situation--> automatic thought--> reaction. An emotion can be classified as a reaction. Some patients report an emotion that does not seem to match the content of their automatic thoughts. If the therapist fails to mention it, they will work with a peripheral thought. Working with central/key automatic thoughts will speed up the process of therapy.

What is an emotion chart?

Some patients experience difficulties in labeling emotions and display an impoverished vocabulary for emotions or understand the labels intellectually, but have difficulty labeling their own specific emotions. Devising an “Emotion Chart” can help patients learn to label their emotions more effectively. Patients can list current or previous situations in which they felt a particular emotion and refer back to it whenever they are having difficulty naming how they felt. It is sometimes important for patients not only to identify their emotions, but also to quantify the degree of emotion they are experiencing. Some have dysfunctional beliefs about experiencing emotion for example, believing that if they feel a small amount of distress, it will increase and become intolerable. Learning to rate the intensity of emotions aids patients in testing this belief. A patient can determine the influence an emotion has on a scale from 0-100 percent and if the patient is not good with numbers he can state if he was little, medium or very sad. If the patient is still not able to determine the amount of sadness, the therapist can draw a scale on paper to make it imaginable. If a situation is not that distressing anymore, it is usually not important enough to discuss it during the session. Therefore the therapist needs to have a clear picture of situations that are distressing to a patient and will help the patient differentiate between emotions and thoughts. In this way patients will learn more about how their dysfunctional thoughts influence their mood.

Patients with a psychiatric disorder often experience an intensity of emotion that can seem excessive or inappropriate to the situation. The reactions of these patients will start to make sense when you recognize the power their automatic thoughts and beliefs have.

How does the evaluation of automatic thoughts work? - Chapter 11

What are some ways to address the thoughts a patient has?

Patients can have a thousand thoughts a day. In therapy there is no time to evaluate them all, and you will only address a few of them per session. Selecting key automatic thoughts is paramount to addressing them. To determine if an automatic thought is an important one the therapist needs to answer the following questions: Is the automatic thought (still currently) distressing to the patient? Is the patient likely to have this kind of thought again? There may also be situations in which an automatic thought seems to be important, but the therapist will decide not to discuss it. For example a reason could be that there is an even more important problem to discuss or that the patient’s level of distress is too high to evaluate his thinking.

Another method is to use Socratic questioning. When an important automatic thought is identified, the therapist should collaboratively decide with the patient to evaluate it. The automatic thought should not be directly challenged, because as a therapist you don’t know if an automatic thought is true, a direct challenge may lead patients to feel invalidated and challenging a cognition violates a fundamental principal of CBT, that of collaborative empiricism: the patient should get the chance to test the automatic thought’s validity. Socratic questions help patients evaluate their thinking and involve a dialectical discussion. In CBT this dialectical discussion needs to be structured in order to discuss the thoughts in depth. There a different kinds of questions that can be asked in evaluating an automatic thought:

• The ‘evidence’ questions. Because automatic thoughts usually contain a degree of truth, patients usually do have some evidence that supports their accuracy, but they often fail to recognize evidence to the contrary:

  • For example: "What is the evidence that supports this idea?"

• The ‘alternative explanation’ question:

  • For example: "Is there an alternative explanation or viewpoint?"

What other sorts of questions could be asked in order to address a patient's issues?

In addition to the aforementioned, there are specific categories of questions that could be used to help a patient assess their automatic thoughts. A few examples are:

• The ‘decatastrophizing’ questions:

  • Many patients predict a worst-case scenario, but that almost never happens. The therapist can lead them to realizing that and help them think of more realistic outcomes. The therapist can also let the patient see that even if the worst would happen; the patient would be able to cope. For example: "What is the worst that could happen?"

• The ‘impact of automatic thought’ questions:

  • The therapist helps the patient assess the consequences of responding and not responding to his/her distorted thinking. For example: "What could be the effect of changing my thinking?"

• The ‘distancing’ questions:

  • Patients often benefit from getting some distance from their thoughts by imagining what they would tell a close friend or family member in a similar situation. For example: "What would I tell a friend if he or she was in my situation?"

• The ‘problem solving’ questions:

  • The therapist and patient think of ways to solve the problem and come up with a behavioral plan. For example: "What should I do?" The therapist helps the patient devise an alternative explanation for what has happened.

Asking all of these questions takes too long and might make the process too burdensome for a patient. Therefore the therapist should choose one or two that they think are most relevant. The process will get shorter the longer the patient already is in therapy. The patient will eventually know what is expected of them and will only need minor encouragements from the therapist.

What are some follow-up steps a therapist should take?

Therapists need to assess the outcome of the evaluation process. In this phase the therapist checks how much the patient still believes the automatic thought. In addition, they also need to conceptualize when evaluation is ineffective. If the patient still believes the automatic thought, the therapist needs to conceptualize why the cognitive restructuring has not been sufficiently effective. Reasons why the restructuring might have been ineffective could be that: there are other more central automatic thoughts left unevaluated, the evaluation of the automatic thought is superficial or inadequate, the patient has not sufficiently expressed the evidence that he or she believes supports the automatic thought, the automatic thought itself is also a core belief or the patient understands intellectually that the automatic thought is distorted, but does not believe it on an emotional level.

Some other methods may be to use alternate methods of questioning and responding to automatic thoughts.

In addition to using Socratic questions you could also:

• Vary the questions.

• Identify the cognitive distortion. Patients tend to make consistent errors in their thinking. Often there is a systematic negative bias in the cognitive processing of patients who suffer from a psychiatric disorder. The most common errors are:

  • All or nothing thinking: Patients view a situation in only two categories instead of on a continuum.

  • Catastrophizing: Patients predict the future negatively without considering other, more likely outcomes.

  • Disqualifying or discounting the positive: Patients unreasonably tell themselves that positive experiences, deeds, or qualities do not count.

  • Emotional reasoning: Patients think something must be true, because they feel it so strongly.

  • Labeling: Patients put a fixed, global label on themself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion.

  • Magnification/minimization: When patients evaluate themselves, another person, or a situation, they unreasonably magnify the negative and minimize the positive.

  • Mental filter: Patients pay too much attention to one negative detail instead of seeing the whole picture.

  • Mind reading: Patients believe they know what others are thinking, failing to consider more likely possibilities.

  • Overgeneralization: Patients make a sweeping negative conclusion that goes far beyond the current situation.

  • Personalization: Patients believe others are behaving negatively, because of them, without considering more plausible explanations for their behavior.

  • ‘Should’ and ‘must’ statements: Patients have a fixed idea of how they or others should behave, and they overestimate how bad it is if these expectations are not met.

  • Tunnel vision: Patients only see the negative aspects of a situation.

• It often helps to label distortions and to teach patients to do the same. A therapist may also provide patients with a list of all the distortions.

• Use self-disclosure. The therapist tells the patient a relevant example of his/her own life to show the patient that the therapist also sometimes had those thoughts and was able to change them.

• Respond when automatic thoughts are true. When automatic thoughts are true the therapist should focus on problem solving, investigate whether the patient has drawn a valid conclusion, or work on acceptance of the problem.

• Teach patients to evaluate their automatic thoughts. This will take place at the end of therapy, when patients know what is expected of them.

Patients can have a thousand thoughts a day. In therapy there is no time to evaluate them all, and you will only address a few of them per session. Selecting key automatic thoughts is paramount to addressing them. To determine if an automatic thought is an important one the therapist needs to answer the following questions: Is the automatic thought (still currently) distressing to the patient? Is the patient likely to have this kind of thought again? There may also be situations in which an automatic thought seems to be important, but the therapist will decide not to discuss it. For example a reason could be that there is an even more important problem to discuss or that the patient’s level of distress is too high to evaluate his thinking

What are some ways to respond to automatic thoughts? - Chapter 12

How can patients be taught to deal with automatic thoughts?

Patients not only have automatic thoughts during sessions, but also when they are at home. Patients experience two kinds of automatic thoughts outside of session: ones they have already identified and evaluated in session, and novel cognitions.

For the first group of thoughts patients should know what to do because it was discussed in session and sometimes even written down. The notes made in therapy may contain adaptive responses to dysfunctional thinking, behavioral assignments or a combination of both. Reading these notes at home might help patients cope with their automatic thoughts. For patients that dislike writing and reading there are audio-recorded therapy notes.

To respond to novel automatic thoughts between sessions, the therapist will teach patients to use Socratic questions on themselves or to use a worksheet such as a thought record. But there are other ways to respond to automatic thoughts. Patients can engage in problem solving, use distraction or relaxation techniques, or label and accept their thoughts and emotions without evaluation.

What is a thought record?

The thought record is a working sheet that prompts patients to evaluate their automatic thoughts when they feel distressed. The thought record exists of five columns where patients need to: describe the situation, write down their automatic thoughts that accompanied the situation, write down their emotions, think of adaptive responses and summarize the outcome (‘How much do they now believe the automatic thought?’). Patients should also write down how much they believe in the responses they think are adaptive. An alternative for the Thought record is the ‘Testing your thoughts’ worksheet. This is a simplified version of the thought record.

Most patients, at some point, find that completing a particular worksheet did not provide much relief. If the therapist emphasizes its general usefulness and “stuck points” as an opportunity for learning, you help patients avoid automatic thoughts critical of themselves, the therapy, the worksheet, or you.

Sometimes the therapist uses other techniques such as the AWARE-technique. This technique contains: Accepting anxiety, Watching anxiety without judgment, Acting as if patients are not anxious, Repeating the first three steps, Expecting the best.

Patients not only have automatic thoughts during sessions, but also when they are at home. Patients experience two kinds of automatic thoughts outside of session: ones they have already identified and evaluated in session, and novel cognitions.

How can intermediate beliefs be identified and modified? - Chapter 13

What is cognitive conceptualization?

A cognitive conceptualization is made at the beginning of therapy by the therapist. In this conceptualization the deeper-level beliefs are already formulated. A therapist can use the cognitive conceptualization diagram to do this. It provides a cognitive map of the patient’s psychopathology and helps organize the multitude of data that the patient presents. In the beginning the therapist doesn’t have enough information to fill in the whole form and the diagram might change. The therapist needs to check his/her findings with the patient. The therapist starts of by filling in the bottom part of the diagram. The bottom of the diagram starts of with a patients’ behavior and the top finishes with relevant childhood data that may have contributed to core beliefs. Coping strategies are also in the diagram, why did a patent develop a certain coping style? The answer lies in the environment. Coping strategies are normal behaviors that everyone engages in at times; patients in distress might overuse these strategies at the expense of more functional strategies. Some patients are intellectually and emotionally ready to see the larger picture early on in therapy; you should wait to present it to others. Intermediate beliefs can be identified by:

• Recognizing when a belief is expressed as an automatic thought.

• Providing the first part of an assumption. If the patient has difficulty providing the second part of the assumption, the therapist rephrases the question.

• Directly eliciting a rule or attitude.

• Using the downward arrow technique. First a key automatic thought has to be identified. This automatic thought might stem directly from a dysfunctional belief. Then the therapist asks the patient for the meaning of this cognition, assuming the automatic thought is true. This is continued until the more important beliefs have been uncovered. Asking what a thought means to the patient often elicits an intermediate belief; asking what it means about the patient usually uncovers the core belief. Sometimes the conversation gets stuck when the patient answers with a ‘feeling’ instead of with cognition. The therapist should gently empathize and then try to get back on track.

• Examining the patient’s automatic thoughts and looking for common themes.

• Asking the patient directly.

• Reviewing a belief questionnaire completed by the patient. An example is the ‘Dysfunctional attitude scale’.

Deciding whether to modify a belief is the next step. Having identified a belief, the therapist needs to determine whether the intermediate belief is central or more peripheral. Generally, to conduct therapy as efficiently as possible, the focus should be on the most important intermediate beliefs. It is not worth the time or effort to work on dysfunctional beliefs that are tangential, or that patients believe only slightly. The therapist will begin belief modification as soon as possible. When patients no longer endorse their beliefs or do not believe them as strongly, they will be able to interpret their experiences in a more realistic way. But some beliefs are very deeply held, and it is advisable to teach patients to evaluate their more superficial cognitions (automatic thoughts) first, so they can learn that just because they think or believe something doesn’t necessarily mean it is true. Belief modification is relatively easy with some patients and much more difficult with others. Modifying intermediate beliefs is generally accomplished before modifying core beliefs, as the latter may be quite rigid. After the identification of the strongly held belief, the therapist can educate a patient about beliefs in general; that beliefs are learned and can be revised. For patients it is easier to recognize a distortion in an assumption than in their rule. An assumption can be tested. Often it is useful for patients to examine the advantages and disadvantages of their beliefs. Most of the time the disadvantages are greater than the advantages and the patient will see that it would be better to change the belief. The therapist and patient will then formulate a new belief together.

How can beliefs be modified?

Some beliefs may change easily and others take much effort over a long period of time. To check whether the belief is still strong or not the therapist may ask how much the patient currently believes the old belief and the new belief (0-100%). Some techniques to modify beliefs are listed below:

• Socratic questioning. The same questions used to identify patients automatic thoughts are used to examine intermediate beliefs.

• Behavioral experiments. As with automatic thoughts, you can help patients devise behavioral tests to evaluate the validity of a belief. Behavioral experiments, when properly designed and carried out, can modify a patient’s beliefs more powerfully than verbal techniques in the office.

• Cognitive continuum. The therapist draws a number line and asks the patient where on the continuum they stand and where others stand. The patient will get insight in the fact that he/she might do better than he/she thought. The cognitive continuum technique is useful when the patient is displaying dichotomous thinking.

• Intellectual-emotional role-plays are useful when patients say that intellectually they can see that a belief is dysfunctional, but that emotionally it still feels true. In the first part the patent plays the emotion and the therapist plays the role of the intellect. In the second part they switch roles. In both segments the intellect and the emotion both play the patient and use the word ‘I’.

• Using others as a reference point. Patients often are stricter to themselves as they are to others. When patients consider other people’s beliefs, they often obtain psycho- logical distance from their own dysfunctional beliefs. They begin to see an inconsistency between what they believe is true or right for them- selves and what they more objectively believe is true about other people.

• Acting ‘as if’. The patient should act as if he/she doesn’t believe in their intermediate belief at all. This is based on the theory that changes in behavior lead to changes in belief.

• Self-disclosure. The therapist tells something relevant of his/her own life.

A cognitive conceptualization is made at the beginning of therapy by the therapist. In this conceptualization the deeper-level beliefs are already formulated. A therapist can use the cognitive conceptualization diagram to do this. It provides a cognitive map of the patient’s psychopathology and helps organize the multitude of data that the patient presents.

How can core beliefs be identified and modified? - Chapter 14

What are some potential problems with core beliefs?

Core beliefs are one’s most central ideas about the self. There are two categories of core beliefs: 1.) Beliefs associated with helplessness and 2.) Beliefs associated with worthlessness. Core beliefs are developed at a young age. Most of the time people relatively positive and realistic core beliefs, but in times of distress negative core beliefs may come to the surface.

Core beliefs are unlike automatic beliefs not fully articulated and therefore more difficult to identify. It is important to start working on belief modification as early in treatment as possible. The belief modification won’t be successful if patients:

• Have core beliefs that are quite rigid and overgeneralized.

• Do not yet believe that cognitions are ideas and not necessarily truths.

• Experience very high levels of affect when beliefs are elicited or questioned.

• Do not have strong enough alliance with the therapist.

In these cases the therapist should start with identifying automatic thoughts and start with identifying core beliefs later. It varies from patient to patient how difficult it is t identify a core belief. For patients with Axis I disorders it is much easier than for patients with personality disorders. During the course of treatment the following is done to identify and modify core beliefs:

How can core beliefs be categorized?

Core beliefs can be categorized into helplessness, unlovability, or worthlessness (amongst others).

Examples of helpless core beliefs: ‘I am incompetent’, ‘I am a victim’. ‘I am out of control’, I can’t do anything right’, ‘I am not good enough’.

Examples of unlovable core beliefs: ‘I am unlovable’, ‘I am unattractive’, I am different’, ‘I am not good enough’, ‘I am bound to be rejected, ‘I am bad’, ‘I am unlikeable’.

Examples of worthlessness core beliefs: ‘I am worthless’, ‘I am bad’, ‘I am evil’, I don’t deserve to live’.

Some core beliefs seem to overlap; the therapist should then ask more questions to be able to categorize the belief. Some ways to do so are:

• Specifying the core beliefs. The same techniques as for identifying intermediate beliefs can be used, such as the downward arrow technique.

• Checking the therapist’s hypothesis. The therapist presents his/her hypothesis about the core belief to patients, asking for confirmation or disconfirmation.

• Educating patients about core beliefs. Patients should understand that their core belief is an idea, not necessarily the truth and that this idea can be tested. The therapist explains why the belief is so strong (rooted in childhood, information processing, feel it to be true). The therapist makes sure the patient understands everything that has been told.

• Helping patients create a new, more adaptive core belief. Some patients had a realistic belief before the onset of their Axis I disorder and can easily identify this belief again. When a patient can’t remember the former belief, a new belief has to be created. The new belief should be relatively positive and not too extreme. For example: Old belief-‘I am bad’, new belief-‘I am okay’.

• Modifying and evaluating the negative core belief. Decreasing the strength of the old belief and strengthening the new core belief.

What are some techniques to modify core beliefs?

Techniques to modify core beliefs are: Socratic questioning, examining advantages and disadvantages, intellectual-emotional role plays, acting ‘as if’, behavioral experiments, cognitive continuum, self disclosure, core belief worksheet, extreme contrasts, stories and metaphors, historical tests, restructuring early memories and coping cards. The first 7 were already discussed in previous chapters, the remaining are additional techniques and will be explained.

In the core belief worksheet patients monitor the operation of their beliefs and reframe evidence that seemed to support the old belief. Patients have to recognize positive data. Patients might find this difficult and the therapist might use some techniques to make it easier, such as making patients think about what they would say to another person or what another person would say about them.

Using extreme contrasts to modify core beliefs is another technique to modify core beliefs. It can be helpful for patients to compare themselves with someone, either real or imagined, who is at the negative extreme of the quality related to their core belief. Using stories, movies and metaphors can help patients develop a different idea about themselves by encouraging them to reflect on their view of characters or people who share the same negative core belief.

‘Historical tests of the core belief’ is another technique. With this technique patients try to discover where their belief started. Patients record memories that may have contributed to the establishment or maintenance of the core belief; this can be continued in homework assignments. A second step in this process is to search for evidence in memory that supports the new, positive belief. The third step is to reframe each piece of negative evidence.

In the fourth and last step patients summarize their memories. For many Axis I patients the intellectual techniques discussed above are sufficient to modify their core belief. For others, special emotional techniques, in which patients’ affect is aroused, are also indicated. One such technique is restructuring an earlier traumatic experience. The therapist and patient can engage in role-play to reenact and reinterpret an earlier experience. They stop when the patient reports that the younger-self is feeling less sad or anxious.

Core beliefs are one’s most central ideas about the self. There are two categories of core beliefs: 1.) Beliefs associated with helplessness and 2.) Beliefs associated with worthlessness. Core beliefs are developed at a young age. Most of the time people relatively positive and realistic core beliefs, but in times of distress negative core beliefs may come to the surface.

What are some additional cognitive and behavioral techniques? - Chapter 15

What does problem solving and skills training consist of?

Patients are encouraged to devise solutions to their problems. Some patients are deficient in problem-solving skills and need direct instruction in problem solving. Many patients also have skill deficits and require skill training from their therapist or an outside source. Patients that don’t have these skill deficits will be able to solve their problems after their inhibiting automatic thoughts are discussed and diminished. The therapist should increase patients’ self-efficacy, so that they will have more confidence that if problems arise, they will be able to handle them.

How can therapists help patients make decisions and allow them to refocus?

Many patients have difficulties making decisions. A simple solution is to compare disadvantages and advantages of each option and then decide on which option is best.

Refocusing is useful when concentration is needed for the task at hand, such as completing a work assignment, and when patients are having obsessive thoughts for which rational evaluation is ineffective. The therapist will teach patients to label and accept their experience and then refocus on the attention-seeking task at hand. Some times patients are too distressed by their thought to immediately refocus again, distraction is then a helpful short-term technique. This may only be used as a short-term solution and is harmful if used too much. Then the distracting will turn into avoiding. In this way patients will not learn that feeling upset may be painful, but is not harmful. If patients avoid their feelings, the AWARE-technique could be used.

What are some ways that can help improve a patient's mood and behavior?

For some patients, it is helpful to use the activity chart, not to schedule activities, but to monitor their moods while engaged in various activities, to look for patterns of occurrence.

Relaxation and mindfulness

Many patients benefit from learning relaxation techniques. These techniques should be learned during sessions, because for some patients relaxation exercises will lead to anxious thought that need to be discussed. Mindfulness techniques help patients non judgmentally observe and accept their internal experiences, without evaluating or trying to change them.

Graded task assignments

This technique approaches the process of reaching a goal in small steps. In this way the patient won’t get too overwhelmed.

Exposure

Many patients engage in avoidance as a coping strategy. Avoidances are called safety behaviors if they associate them with decreasing anxiety. Patients believe that if they engage in safety behaviors the threat will decrease. In exposure-therapy patients are faced with their fears and are not allowed to engage in safety behaviors. Repeating the exposure will eventually lead to diminished anxiety. It is important to provide a rationale for exposure; otherwise patients won’t like to do it.

Role-playing

Role-playing can be used to uncover automatic thoughts, to develop an adaptive response, to modify intermediate and core beliefs and to practice and learn social skills. Before teaching patients social skills, the level of skill they already possess has to be assessed. Many patients know exactly what to do and say, but have difficulty using this knowledge because of dysfunctional thoughts. In this case role playing to teach social skills is not necessary.

Using the ‘pie’ technique

It can be helpful for patients to see their thoughts in graphic form. A pie chart can be used for helping patients set goals or determining relative responsibility. In the pie chart they can see that there are alternative explanations for someone else’s behavior.

Self-comparisons and credit list

Patients have a negative bias in information processing. They compare themselves with the person they would like to be. This will not lead to improvement in their psychiatric disorder. The therapist should help the patient change the self-comparison into more functional comparisons. Patients should focus on how far they have progressed since their worst point, rather than on how far they are from their best point. Credit lists are daily lists of positive things the patient is doing and deserves credit for. By making these lists the patient will focus more on the positive things and feel better about themself.

Patients are encouraged to devise solutions to their problems. Some patients are deficient in problem-solving skills and need direct instruction in problem solving. Many patients also have skill deficits and require skill training from their therapist or an outside source. Patients that don’t have these skill deficits will be able to solve their problems after their inhibiting automatic thoughts are discussed and diminished. The therapist should increase patients’ self-efficacy, so that they will have more confidence that if problems arise, they will be able to handle them.

What does imagery do? - Chapter 16

What sort of techniques are there to explain and deal with mental imagery?

Many patients experience automatic thoughts not only as unspoken words, but also in the form of mental pictures or images. Failure to identify and respond to upsetting images may result in continued distress for the patient. The word image may not be clear to the patient. The therapist can then use synonyms, such as mental picture or daydream. Some patients may not report their mental images, because they find them too distressing and don’t want to re-experience it. The therapist can teach them about these images and normalize them.

The therapist may tell about an image he/she gets while the patient is telling him/her something. In this way the patient will be better able to understand what the therapist means by a mental image. There are several techniques to teach a patient to respond to their mental images:

• Following images to completion. The therapist will encourage patients to continue visualizing a spontaneous image until the patient imagines getting through a crisis and feels better, or the patient imagines a final catastrophe, such as death. In the first scenario the patient can be convinced of a realistic outcome quite easily and the therapist can help the patient with creating a new, more positive image. In the second case the patient cuts of the image at the worst point. The patient should imagine what would happen after the worst point. The therapist can also help the patient induce a coping image.

• Jumping ahead in time. For example: The patient is really struggling with a paper he has to make. When the therapist asks to complete the image the patient only gets more anxious and keeps imagining more obstacles. In this case it is a good technique to suggest that the patient imagines himself in the near future, while finishing his paper and sending it to his professor. This could make the patient feel relieved and feel better and more confident about the future.

• Coping in the image. In this technique the therapist guides patients so they can imagine they are coping with a difficult situation they have spontaneously envisioned.

• Changing the image. The therapist teaches patients to reimagine a spontaneous image, changing the ending to alleviate their distress.

• Reality testing the image, just as is done with verbal automatic thoughts. It is better though to use an imagery technique for dealing with images.

• Repeating the image. The therapist suggests that patients keep imagining the original image over and over again, paying attention to whether their level of distress change. Some patients seem to do an automatic reality check, and make their image more realistic.

• Substituting images

What sort of techniques are there to induce imagery?

Sometimes the therapist will induce an image to help a patient respond to a spontaneous image. Some techniques used to induce images:

• Covert rehearsal.

• Rehearsal of coping techniques. Patients continually imagine themselves realistically coping with the situation in detail. They practice using coping strategies in imagination.

• Distancing helps patients see their problems in greater perspective. The therapist shows patients that difficulties are likely to be time-limited. The therapist and patient will look into the future and see how bad things really are.

• Reduction of perceived threat. The patient views a situation with a more realistic assessment of actual threat. For example: imagining the encouraging faces of their friends when they have to do a presentation.

Many patients experience automatic thoughts not only as unspoken words, but also in the form of mental pictures or images. Failure to identify and respond to upsetting images may result in continued distress for the patient. The word image may not be clear to the patient. The therapist can then use synonyms, such as mental picture or daydream. Some patients may not report their mental images, because they find them too distressing and don’t want to re-experience it. The therapist can teach them about these images and normalize them.

What role does homework play? - Chapter 17

How can homework assignments be set up?

Patients who carry out homework assignments progress better in therapy than those who do not. Good homework assignments provide opportunities for patients to educate themselves further, to collect data, to test their thoughts and beliefs, to modify their thinking, to practice cognitive and behavioral tools, and to experiment with new behaviors. Homework assignments need to be tailored to the individual. For example: If a patient has dyslexia they shouldn’t have to do too many writing and reading exercises. Not only the type of assignment is important, but also the amount of it. It is therefore important to predict potential difficulties before assigning homework. The homework should err on the side of being too easy as opposed to too difficult, patients should not feel like a failure.

In the beginning the therapist will suggest homework assignments, but as soon as possible the patient should try to devise their own homework assignments. Typical homework assignments:

• Behavioral activation, getting active, and scheduling activities.

• Monitoring automatic thoughts: Patients should ask themselves: ‘What is going through my mind right now?’ when they notice their mood is changing and remind themselves that this thinking may or may not be true.

• Evaluating and responding to automatic thoughts. The therapist will help patients modify their inaccurate and dysfunctional thoughts and write down their new way of thinking. An essential homework assignment is to have them read these therapy notes on a regular basis. Patients will also learn to evaluate their own thinking and practice doing so between sessions.

• Problem solving: The therapist will help patients devise solutions to their problems, which they will implement between sessions.

• Behavioral skills. To effectively solve their problems some patients may need to learn new skills, which they will practice for homework, e.g. time management.

• Behavioral experiments: patients need to directly test the validity of automatic thoughts that seem distorted.

• Bibliotherapy: Important concepts you are discussing in session can be greatly reinforced when patients read about them in books or magazines.

Preparing for the next therapy session: Patients need to think about what was important last week before they come to the session.

How can homework adherence be increased?

Although some patients easily do the suggested assignments, home work is more problematic for others. Implementation of the following guidelines increases the likelihood that patients will be successful with homework and experience an elevation in mood:

• Tailor the assignment to the individual. (Be 90–100% sure the patient can and will do the assignment.)

• Provide a rationale as to how and why the assignment might help. Patients are more likely to comply with homework assignments if they understand the reason for doing them. This is called providing a rationale. The therapist will provide a brief rationale initially; later in treatment, the therapist will encourage patients to think about the purpose of an assignment.

• Set homework collaboratively. The therapist seeks the patient’s input and agreement.

• Make homework a no-lose proposition. Tell the patient that it would be good if he/she gets the homework done, but that it is okay if the patient has trouble finishing it. The patient should not feel like a failure.

• Begin the assignment in session. This motivates patients to complete the assignment.

• Help set up systems for remembering to do the assignment. What will help the patient remember to do the homework?

• Anticipate possible problems: The therapist should ask the patients how likely he/she is to carry out the assignment (0-100%). If the patient is less than 90% confident the therapist can engage in the following strategies:

  • Covert rehearsal uses induced imagery to uncover and solve potential homework-related problems. Which practical obstacles and dysfunctional cognitions may hinder the completion of homework?

  • Change the assignment.

  • Do an intellectual/emotional role-play.

• Prepare for a possible negative outcome (when applicable). When devising a behavioral experiment or testing an assumption, it is important to set up a scenario that is likely to succeed. It is a good idea, though, to have patients predict likely automatic thoughts or beliefs if the experiment does not turn out well, to prepare them how to react in case of a possible negative outcome.

How can difficulties be conceptualized?

The first question that should be asked is: Why did the problem arise, and what was it related to?

Types of problems that may occur:

• A practical problem. A practical problem can often be avoided if the assignment is carefully set. There are four common practical problems:

• A psychological problem. If patients don’t do an assignment that was set up properly and which they had the opportunity to do, their difficulty may stem from one of the psychological factors described next:

• A psychological problem masked as a practical problem. Some patients believe that a practical issue is preventing them from making the homework, but there may actually be a thought or belief that is inferring. This belief has to be discussed before moving on to solving the practical issue.

• A problem related to the therapist’s cognitions. Therapists can have dysfunctional thoughts about assigning homework or exploring why a patient has not done homework, such as: ‘ I’ll hurt his feelings if I try to find out why he didn’t do the homework’ or ‘ She’ll be angry if I question her’. The therapist should be aware that he is not doing his patients a favor by allowing them to skip homework.

Other problems that may occur are:

• Doing therapy homework at the last minute.

• Forgetting the rationale for an assignment.

• Disorganization or lack of accountability.

• Difficulty with an assignment.

• Overestimating the demands of an assignment. The patient may overestimate the effort, energy and time an assignment will cost.

• Perfectionism. Some patients feel that they need to be perfect. The therapist should tell them that these assignments do not have to be perfect. A good assignment for perfectionists could be to let patients make an imperfect assignment on purpose.

There is also a problem related to negative predictions. Patients may have negative predictions about doing homework such as: ‘I shouldn’t have to put forth so much effort to feel better’ or ‘I am incompetent. These predictions stand in the way of doing homework assignments. It can be helpful to have the patient test these predictions, for example by carrying out an assignment during the session. The therapist should prepare the patient for their reaction to a possible negative outcome through Socratic questioning. The therapist should make the usefulness of the assignment clear, but has to acknowledge that the outcome of an assignment is never sure to avoid disappointment.

Patients who carry out homework assignments progress better in therapy than those who do not. Good homework assignments provide opportunities for patients to educate themselves further, to collect data, to test their thoughts and beliefs, to modify their thinking, to practice cognitive and behavioral tools, and to experiment with new behaviors. Homework assignments need to be tailored to the individual. For example: If a patient has dyslexia they shouldn’t have to do too many writing and reading exercises. Not only the type of assignment is important, but also the amount of it. It is therefore important to predict potential difficulties before assigning homework. The homework should err on the side of being too easy as opposed to too difficult, patients should not feel like a failure.

When can termination begin and how can relapse be prevented? - Chapter 18

What are some techniques that help facilitate relapse prevention?

The goal in CBT is to facilitate remission of patients’ disorders and teach them skills they can use throughout their lifetime. A therapist cannot solve all the problems a patient has, but can teach the patient to be his/her own therapist. The therapist will tell the patient already in the first session that the goal is for them to become their own therapist. The course of recovery with its ups and down is discussed. Patients will also have some downs after therapy, but by then they will have the tools to help themselves

There are quite a few techniques designed to prevent relape, some of them are:

• Attributing progress to the patient: The therapist should reinforce patients for their progress. They should emphasize the fact that patients experienced mood improvements and why. It should be clear to the patient that the patient is responsible for the positive changes, not only to the therapist, medication or circumstance (self efficacy).

• Teaching and using tools learned in therapy. The patient should understand that the techniques used in therapy could be used in many other situations. The therapist should help patients understand how they can use these tools in other situations. For example: doing relaxation exercises or using thought records.

• Preparing for setbacks during therapy. As soon as patients begin to feel better, therapists will prepare patients for a potential setback by asking them to imagine what will go through their mind if they start to feel worse. The therapist and patient both discuss how the patient could respond to these negative thoughts in the future by using coping cards and look at a process of therapy graph (with ups and downs).

How is termination initiated?

Several weeks before therapy ends the frequency of therapy sessions will decrease to get used to the idea. Some patients might get anxious at the idea of termination. For these patients it can be helpful to write down advantages and disadvantages of leaving therapy. The disadvantages need to be reframed into disadvantages that can be coped with. Tapering can be viewed as an experiment. At each succeeding session, the therapist and the patient agree either to continue spacing sessions or to return to more frequent sessions. It is important that patients read and organize their therapy notes so they can easily refer to them in the future. The therapist will encourage the patient to use a self-therapy plan. In this way they are continuing therapy, but at their own convenience and without charge. It could be useful to start the self-therapy already during therapy so that the patients will see which difficulties with self-therapy they might encounter. These difficulties then can be discussed with the therapist.

After therapy a booster session can be planned after a couple of weeks or months. A booster session is to check on the patient’s well being and plan for continue maintenance or progress. If during a booster session in occurs that the patient is not feeling well, additional session can be planned again.

The goal in CBT is to facilitate remission of patients’ disorders and teach them skills they can use throughout their lifetime. A therapist cannot solve all the problems a patient has, but can teach the patient to be his/her own therapist. The therapist will tell the patient already in the first session that the goal is for them to become their own therapist. The course of recovery with its ups and down is discussed. Patients will also have some downs after therapy, but by then they will have the tools to help themselves

How does treatment planning work? - Chapter 19

What are some essentials that lead to effective treatment planning?

Treatment is tailored to the individual; the therapist develops an overall strategy as well as a specific plan for each session. The therapist develops and continually modifies a general plan for treatment across sessions and a more specific plan before each session and within each session. There are certain areas that can be considered essential to effectively plan treatment, some of which are:

• Accomplishing broad therapeutic goals. Therapeutic goals are not only to facilitate remission of patients’ disorders, but also to prevent relapse. The patients are taught to become their own therapist.

• Planning treatment across sessions. The therapist develops a specific plan for each individual session.

Broadly speaking, therapy has three phases:

1. Devising treatment plans. A treatment plan helps in remaining focused on the important things. For each problem situation or dysfunctional behavior there needs to be a therapeutic strategy.

2. Planning individual sessions. The therapist has to plan and prepare a session before it starts by formulating an overall plan. It can be helpful to review the notes of the former session. At each stage of the session the therapist should ask him/her self some questions to see if they can go to the next session-phase.

3. Deciding whether to focus on a problem. Is the problem important and distressing enough to devote time to this session?

A therapist should read about a patient’s disorder and educate themselves in their key cognitions and behavioral strategies for the psychiatric disorder at hand. This means a therapist should be prepared to modify exisiting treatment plans when (and if) needed. Other important factors are:

• To develop a therapeutic alliance, teach the cognitive model, get patients behaviorally activated, educate patients about their disorder, teach them to identify and respond to their automatic thoughts and instruct patient in coping strategies

• Emphasize identifying, evaluating, and modifying patients’ beliefs.

• Relapse prevention.

Treatment is tailored to the individual; the therapist develops an overall strategy as well as a specific plan for each session. The therapist develops and continually modifies a general plan for treatment across sessions and a more specific plan before each session and within each session.

What are some of the problems that exist in therapy? - Chapter 20

What are the key steps to identifying a problem?

Problems in therapy arise almost with every patient; they provide insight into problems the patient experiences outside the office. Problems can be uncovered in a number of ways: By listening to patients’ unsolicited feedback, by directly soliciting patients’ feedback, whether or not they have provided verbal or nonverbal signals of a problem, by reviewing recordings of therapy sessions alone or with a colleague or supervisor and rating the tape on the Cognitive Therapy Rating Scale or by tracking progress according to objective tests and the patient’s subjective report of symptom relief.

Having identified a problem, a therapist should be aware of automatic thoughts blaming the patient. The problem can have different causes and ideally the therapist can show recordings of the session to a colleague to evaluate the cause of the problem together. Problems can occur in one or more of the following categories: diagnosis, therapeutic alliance, structure of the session, socialization of the patient, dealing with automatic thoughts, accomplishing therapeutic goals across sessions and patients’ processing of the session content. At times, patients may feel better during individual sessions but fail to make progress over the course of several sessions. The experienced therapist, in lieu of the preceding questions, may first wish to rule in or rule out five key problem areas:

1. Do the patient and I have a solid therapeutic alliance?

2. Do we both have a clear idea of the patient’s goals for therapy? Is he committed to working toward his goals?

3. Does the patient truly believe the cognitive model—that his thinking influences his mood and behavior, that his thinking at times is dysfunctional, and that evaluating and responding to dysfunctional thinking positively affect how he feels emotionally and how he behaves?

4. Is the patient socialized to cognitive behavior therapy—does he contribute to the agenda, collaboratively work toward solving problems, do homework, provide feedback?

5. Is the patient’s biology (e.g., illness, medication side effects, or inadequate level of medication) or his external environment e.g., an abusive partner, an extremely demanding job, or an intolerable level of poverty or crime in his environment) interfering with your work together?

A therapist should monitor his/her own thoughts and mood when seeking to conceptualize and remediate problems in therapy because their cognitions may at times interfere with problem solving. It is likely that all therapists, at least occasionally, have negative thoughts about patients, the therapy, and/or themselves as therapists.

Problems in therapy arise almost with every patient; they provide insight into problems the patient experiences outside the office.

How can progress as a cognitive behavior therapist be made? - Chapter 21

What makes a good CBT therapist?

To become a good CBT therapist you should do the following:

• Monitor your moods and identify your automatic thoughts when you engage in maladaptive behavior. This way you can understand what the patient has to do in therapy.

• Write down your automatic thoughts. This way you might discover potential obstacles patients may have writing down their thoughts.

• Identify your automatic thoughts that interfere with carrying out the step above. Why do I think that I don’t have to write down my thoughts to become a good CBT therapist? Why should I do it anyway?

• Once you have become proficient at identifying your automatic thoughts, start doing one thought record a day when you notice your mood is changing.

• Fill out the bottom half of the cognitive conceptualization diagram using three typical situations in which you behaved in a maladaptive way.

• Fill out the top half of the cognitive conceptualization.

• Fill out a core belief worksheet

• Try other basic techniques, such as activity scheduling or acting ‘as if’.

• Having used some of the fundamental conceptual and treatment tools yourself, choose a straightforward, uncomplicated patient for your first attempt at cognitive behavior therapy. It is preferable to start with a new patient.

• Obtain written consent for recording therapy sessions. Review of therapy tapes with a colleague or supervisor is essential to progress.

• Keep broadening your knowledge about CBT by reading books, watching other therapists, seeking opportunities for training and supervision, and consider attending conferences.

To become a good CBT therapist you should do the following: