CHAPTER 2 – OVERVIEW OF TREATMENT
Principle 1: CBT treatment plans are based on an ever-evolving cognitive
conceptualization
I base my conceptualization of clients on the data they provide at the evaluation,
informed by the cognitive formulation (key cognitions, behavioral strategies, and
maintaining factors
Principle 2: CBT requires a sound therapeutic relationship.
Clients vary in the degree to which they are initially able to develop a good
therapeutic alliance.
You use the relationship to provide evidence that clients’ negative beliefs, especially
beliefs about the self (and sometimes about others), are inaccurate and that more
positive beliefs are valid. If the alliance is sound, you can maximize the time you
spend helping clients resolve obstacles they will face in the coming week.
Principle 3: CBT continually monitors client progress.
Advice for weekly symptom checklists and to elicit both verbal and written feedback
from clients at the end of sessions. Client outcomes are enhanced when both clients
and therapists receive feedback on how clients are progressing.
Principle 4: CBT is culturally adapted and tailors treatment to the individual.
CBT has traditionally reflected the values of the dominant culture in the United
States. Clients with different ethnic and cultural backgrounds have better outcomes
when their therapists appreciate the significance of cultural and ethnic differences,
preferences, and practices.
Principle 5: CBT emphasizes the positive.
Recent research demonstrates the importance of emphasizing positive emotion and
cognition in treating depression. You help clients actively work toward cultivating
positive moods and thinking. It is also very important to inspire hope.
Principle 6: CBT stresses collaboration and active participation.
Both therapists and clients are active.
Principle 7: CBT is aspirational, values based, and goal oriented.
In your initial session with clients, you should ask them about their
- values what is really important to them in life
- aspirations how they want to be, how they want their life to be
- specific goals for treatment what they want to accomplish as a result of
therapy
-
Principle 8: CBT initially emphasizes the present.
The treatment of most clients involves a strong focus on the skills they need to
improve their mood (and their lives).
You can shift to the past and afterward discuss what your client now understands
about the past.
,Principle 9: CBT is educative.
A major goal of treatment is to make the process of therapy understandable.
Principle 10: CBT is time sensitive.
Try to make treatment as short term as possible while still fulfilling our objectives.
Some clients need considerably more treatment over a longer period of time. A year
or even two of therapy may be insufficient. Even after termination, they may need
periodic sessions or additional (usually shorter) courses of treatment.
Principle 11: CBT sessions are structured.
CBT therapists aim to conduct therapy as efficiently as possible to help clients feel
better as quickly as possible. Adhering to a standard format (as well as teaching the
therapeutic techniques to clients) facilitates these objectives. You will tend to use this
format in every session (unless your client objects, in which case you may need to
negotiate the structure initially).
Principle 12: CBT uses guided discovery and teaches clients to respond to
their dysfunctional cognitions.
Collaborative empiricism helping the client determine the accuracy and utility of
their ideas through a careful review of the evidence. Note that we refrain from
challenging cognitions (by stating or trying to convince clients that their thoughts or
beliefs aren’t valid); rather, we help clients through cognitive restructuring, a process
of assessing and responding to maladaptive thinking.
Principle 13: CBT includes Action Plans (therapy homework).
An important aim of treatment is to help clients feel better by the end of the session
and to set them up to have a better week.
Principle 14: CBT uses a variety of techniques to change thinking, mood, and
behavior.
In fact, we adapt strategies from many psychotherapeutic modalities within the
context of the cognitive framework
SUMMARY
The basic principles described in this chapter apply to most clients. Guided by your
cognitive conceptualization of each client, you will vary the techniques you use to
tailor treatment to the individual. CBT treatment takes into account individuals’
cultures, family history, and other important characteristics; the nature of their
difficulties; their goals and aspirations; their ability to form a strong therapeutic bond;
their motivation to change; their previous experience with therapy; and their
preferences. The foundation of treatment is always a solid therapeutic relationship.
, CHAPTER 3 – CASE CONCEPTUALIZATION
Cognitive conceptualization Summary of all the information, to understand
clients, how they developed a psychological disorder with dysfunctional thinking and
maladaptive behavior. To plan treatment.
You constantly modify the conceptualization and check it with your client.
Elicit feedback from the client, to more accurately conceptualize and to strengthen
the alliance.
Dysfunctional negative beliefs
- Helplessness Being ineffective
- Unlovability Having personal qualities resulting in an inability to get or
maintain love from others
- Worthlessness Being an immoral sinner or dangerous to others
Information processing diagram
This diagram demonstrates how negative data are immediately processed,
strengthening the core belief, while positive data are discounted (changed into
negative data) or unnoticed.
,Intermediate beliefs:
- Attitudes It’s terrible to fail
- Rules I should give up if a challenge seems to great
- Assumptions If I try to do something difficult, I’ll fail
Core beliefs influence the development of this intermediate class of beliefs, which
consists of attitudes, rules and assumptions.
Dysfunctional beliefs can be unlearned and more reality-based and functional new
beliefs can be developed and strengthened.
It’s important to develop both strengths-based and problem-based
conceptualizations.
Cognitive model People’s emotions, behaviors and physiology are influenced by
their perception of events (both external and internal)
Cognitive Conceptualization Diagrams (CCDs) help you organize the amount of data
you get from a client.
Strengths-Based Cognitive Conceptualization Diagram (SB-CDD) Helps you pay
attention to and organize the patterns of helpful cognitions and behavior.
,The Strengths-Based Cognitive Conceptualization (SB-CCD)
,The traditional (problem based) CCD
The CCD depicts the relationship among
- Important life events and core beliefs
- Core beliefs and the meaning of clients’ automatic thoughts
- Core beliefs, intermediate beliefs and dysfunctional coping strategies
- Trigger situations, automatic thoughts and reactions
Fill in the bottom half of the CCD, starting with three typical current situations related
to the presenting problems in which clients became upset or behaved in an unhelpful
way. If clients have one more theme in their automatic thoughts, make sure to choose
situations that reflect those themes.
,To complete the top box of the diagram, ask yourself (and the client):
• How did the core belief originate and become maintained?
• What life events (often including those in childhood and adolescence, if any are
relevant) did the client experience that might be related to developing and
maintaining the beliefs?
Next ask yourself, “What are the client’s most important intermediate beliefs: rules,
attitudes, and conditional assumptions?” Unhelpful rules often start with “I should” or
“I shouldn’t,” and unhelpful attitudes often start with “It’s bad to.” These rules and
attitudes are often connected to client’s values, or they may serve to protect the client
from the activation of the core belief. Clients’ broad assumptions often reflect their
rules and attitudes and link their maladaptive coping strategies to the core belief.
The completed diagram will mislead you if you choose situations in which the themes
of clients’ automatic thoughts are not part of an overall pattern.
The meaning of negative thoughts:
You usually ask for the meaning of their thoughts a little later in therapy.
At some point, usually in the middle part of treatment, you will share the information
from both the top and the bottom of the CCD, when your goal for a session is to help
the client understand the broader picture. Review the conceptualization verbally,
draw a simplified diagram for your client, and elicit feedback. Occasionally, clients
benefit from completing a blank CCD with you. (Don’t present a filled-out CCD to
clients because it won’t be as good a learning experience.)
, SUMMARY
Conceptualizing clients in cognitive terms is crucial to determine the most effective
and efficient course of treatment. It also aids in developing empathy, an ingredient
that is critical in establishing a good therapeutic relationship. Conceptualization
begins at the first contact and is an ongoing process, always subject to modification
as new data are uncovered and previous hypotheses are confirmed or rejected. You
base your hypotheses on the information you collect, using the most parsimonious
explanations and refraining from interpretations and inferences not clearly based on
actual data. You continually check out the conceptualization with clients for several
reasons: to ensure that it is accurate, to demonstrate your accurate understanding to
them, and to help them understand themselves, their experiences, and the meanings
they put to their experiences. The ongoing process of conceptualization is
emphasized throughout this book, as are techniques to present your
conceptualization to clients.
, CHAPTER 4 – THE THERAPEUTIC RELATIONSHIP
Rogerian skills:
- Empathy
- Genuineness
- Positive regard
Monitoring clients’ affect and eliciting feedback
Clients often express negative thoughts about themselves, the process of therapy, or
you. When they do, make sure to positively reinforce them. “It’s good you told me
that.”
Collaborating with clients
You’ll explain to clients in the first session that you and they will act as a team. You’ll
be transparent and ask for feedback about your goals, the process of therapy, the
structure of sessions, and your conceptualization and treatment plan.
Tailor the therapeutic relationship to the individual!
Using self-disclosure
Self-disclosure should have a definite purpose, for example, strengthening the
therapeutic relationship, normalizing the clients’ difficulties, demonstrating how CBT
techniques can help, modeling a skill, or serving as a role model.
Repairing ruptures
It’s important to use your conceptualization of the client to prevent or repair problems.
If you get negative feedback but you haven’t made a mistake:
- Express empathy
- Ask for additional information in the context of the cognitive model
- Seek agreement to test the validity of the thought
Helping clients generalize to other relationships
Help clients draw a conclusion about your relationship and test it in the context of
other relationships.
You and your clients have a reciprocal influence on each other.
It’s important to observe your negative reactions, accept your emotional reactions
nonjudgmentally, and then figure out what to do. Once clients feel safe with you, you
can address the maladaptive coping strategies they use with you - and likely with
others as well. Monitor your level of empathy, and be on the alert for your own
unhelpful reactions
SUMMARY
It’s essential to have a good working relationship with clients. You facilitate this
objective by adapting treatment to the individual, using good counseling skills,
working collaboratively, eliciting and responding appropriately to feedback, repairing
ruptures, and managing your own negative reactions. Clients who are in distress may
have strong negative core beliefs about themselves that they bring to the therapy
session.
Principle 1: CBT treatment plans are based on an ever-evolving cognitive
conceptualization
I base my conceptualization of clients on the data they provide at the evaluation,
informed by the cognitive formulation (key cognitions, behavioral strategies, and
maintaining factors
Principle 2: CBT requires a sound therapeutic relationship.
Clients vary in the degree to which they are initially able to develop a good
therapeutic alliance.
You use the relationship to provide evidence that clients’ negative beliefs, especially
beliefs about the self (and sometimes about others), are inaccurate and that more
positive beliefs are valid. If the alliance is sound, you can maximize the time you
spend helping clients resolve obstacles they will face in the coming week.
Principle 3: CBT continually monitors client progress.
Advice for weekly symptom checklists and to elicit both verbal and written feedback
from clients at the end of sessions. Client outcomes are enhanced when both clients
and therapists receive feedback on how clients are progressing.
Principle 4: CBT is culturally adapted and tailors treatment to the individual.
CBT has traditionally reflected the values of the dominant culture in the United
States. Clients with different ethnic and cultural backgrounds have better outcomes
when their therapists appreciate the significance of cultural and ethnic differences,
preferences, and practices.
Principle 5: CBT emphasizes the positive.
Recent research demonstrates the importance of emphasizing positive emotion and
cognition in treating depression. You help clients actively work toward cultivating
positive moods and thinking. It is also very important to inspire hope.
Principle 6: CBT stresses collaboration and active participation.
Both therapists and clients are active.
Principle 7: CBT is aspirational, values based, and goal oriented.
In your initial session with clients, you should ask them about their
- values what is really important to them in life
- aspirations how they want to be, how they want their life to be
- specific goals for treatment what they want to accomplish as a result of
therapy
-
Principle 8: CBT initially emphasizes the present.
The treatment of most clients involves a strong focus on the skills they need to
improve their mood (and their lives).
You can shift to the past and afterward discuss what your client now understands
about the past.
,Principle 9: CBT is educative.
A major goal of treatment is to make the process of therapy understandable.
Principle 10: CBT is time sensitive.
Try to make treatment as short term as possible while still fulfilling our objectives.
Some clients need considerably more treatment over a longer period of time. A year
or even two of therapy may be insufficient. Even after termination, they may need
periodic sessions or additional (usually shorter) courses of treatment.
Principle 11: CBT sessions are structured.
CBT therapists aim to conduct therapy as efficiently as possible to help clients feel
better as quickly as possible. Adhering to a standard format (as well as teaching the
therapeutic techniques to clients) facilitates these objectives. You will tend to use this
format in every session (unless your client objects, in which case you may need to
negotiate the structure initially).
Principle 12: CBT uses guided discovery and teaches clients to respond to
their dysfunctional cognitions.
Collaborative empiricism helping the client determine the accuracy and utility of
their ideas through a careful review of the evidence. Note that we refrain from
challenging cognitions (by stating or trying to convince clients that their thoughts or
beliefs aren’t valid); rather, we help clients through cognitive restructuring, a process
of assessing and responding to maladaptive thinking.
Principle 13: CBT includes Action Plans (therapy homework).
An important aim of treatment is to help clients feel better by the end of the session
and to set them up to have a better week.
Principle 14: CBT uses a variety of techniques to change thinking, mood, and
behavior.
In fact, we adapt strategies from many psychotherapeutic modalities within the
context of the cognitive framework
SUMMARY
The basic principles described in this chapter apply to most clients. Guided by your
cognitive conceptualization of each client, you will vary the techniques you use to
tailor treatment to the individual. CBT treatment takes into account individuals’
cultures, family history, and other important characteristics; the nature of their
difficulties; their goals and aspirations; their ability to form a strong therapeutic bond;
their motivation to change; their previous experience with therapy; and their
preferences. The foundation of treatment is always a solid therapeutic relationship.
, CHAPTER 3 – CASE CONCEPTUALIZATION
Cognitive conceptualization Summary of all the information, to understand
clients, how they developed a psychological disorder with dysfunctional thinking and
maladaptive behavior. To plan treatment.
You constantly modify the conceptualization and check it with your client.
Elicit feedback from the client, to more accurately conceptualize and to strengthen
the alliance.
Dysfunctional negative beliefs
- Helplessness Being ineffective
- Unlovability Having personal qualities resulting in an inability to get or
maintain love from others
- Worthlessness Being an immoral sinner or dangerous to others
Information processing diagram
This diagram demonstrates how negative data are immediately processed,
strengthening the core belief, while positive data are discounted (changed into
negative data) or unnoticed.
,Intermediate beliefs:
- Attitudes It’s terrible to fail
- Rules I should give up if a challenge seems to great
- Assumptions If I try to do something difficult, I’ll fail
Core beliefs influence the development of this intermediate class of beliefs, which
consists of attitudes, rules and assumptions.
Dysfunctional beliefs can be unlearned and more reality-based and functional new
beliefs can be developed and strengthened.
It’s important to develop both strengths-based and problem-based
conceptualizations.
Cognitive model People’s emotions, behaviors and physiology are influenced by
their perception of events (both external and internal)
Cognitive Conceptualization Diagrams (CCDs) help you organize the amount of data
you get from a client.
Strengths-Based Cognitive Conceptualization Diagram (SB-CDD) Helps you pay
attention to and organize the patterns of helpful cognitions and behavior.
,The Strengths-Based Cognitive Conceptualization (SB-CCD)
,The traditional (problem based) CCD
The CCD depicts the relationship among
- Important life events and core beliefs
- Core beliefs and the meaning of clients’ automatic thoughts
- Core beliefs, intermediate beliefs and dysfunctional coping strategies
- Trigger situations, automatic thoughts and reactions
Fill in the bottom half of the CCD, starting with three typical current situations related
to the presenting problems in which clients became upset or behaved in an unhelpful
way. If clients have one more theme in their automatic thoughts, make sure to choose
situations that reflect those themes.
,To complete the top box of the diagram, ask yourself (and the client):
• How did the core belief originate and become maintained?
• What life events (often including those in childhood and adolescence, if any are
relevant) did the client experience that might be related to developing and
maintaining the beliefs?
Next ask yourself, “What are the client’s most important intermediate beliefs: rules,
attitudes, and conditional assumptions?” Unhelpful rules often start with “I should” or
“I shouldn’t,” and unhelpful attitudes often start with “It’s bad to.” These rules and
attitudes are often connected to client’s values, or they may serve to protect the client
from the activation of the core belief. Clients’ broad assumptions often reflect their
rules and attitudes and link their maladaptive coping strategies to the core belief.
The completed diagram will mislead you if you choose situations in which the themes
of clients’ automatic thoughts are not part of an overall pattern.
The meaning of negative thoughts:
You usually ask for the meaning of their thoughts a little later in therapy.
At some point, usually in the middle part of treatment, you will share the information
from both the top and the bottom of the CCD, when your goal for a session is to help
the client understand the broader picture. Review the conceptualization verbally,
draw a simplified diagram for your client, and elicit feedback. Occasionally, clients
benefit from completing a blank CCD with you. (Don’t present a filled-out CCD to
clients because it won’t be as good a learning experience.)
, SUMMARY
Conceptualizing clients in cognitive terms is crucial to determine the most effective
and efficient course of treatment. It also aids in developing empathy, an ingredient
that is critical in establishing a good therapeutic relationship. Conceptualization
begins at the first contact and is an ongoing process, always subject to modification
as new data are uncovered and previous hypotheses are confirmed or rejected. You
base your hypotheses on the information you collect, using the most parsimonious
explanations and refraining from interpretations and inferences not clearly based on
actual data. You continually check out the conceptualization with clients for several
reasons: to ensure that it is accurate, to demonstrate your accurate understanding to
them, and to help them understand themselves, their experiences, and the meanings
they put to their experiences. The ongoing process of conceptualization is
emphasized throughout this book, as are techniques to present your
conceptualization to clients.
, CHAPTER 4 – THE THERAPEUTIC RELATIONSHIP
Rogerian skills:
- Empathy
- Genuineness
- Positive regard
Monitoring clients’ affect and eliciting feedback
Clients often express negative thoughts about themselves, the process of therapy, or
you. When they do, make sure to positively reinforce them. “It’s good you told me
that.”
Collaborating with clients
You’ll explain to clients in the first session that you and they will act as a team. You’ll
be transparent and ask for feedback about your goals, the process of therapy, the
structure of sessions, and your conceptualization and treatment plan.
Tailor the therapeutic relationship to the individual!
Using self-disclosure
Self-disclosure should have a definite purpose, for example, strengthening the
therapeutic relationship, normalizing the clients’ difficulties, demonstrating how CBT
techniques can help, modeling a skill, or serving as a role model.
Repairing ruptures
It’s important to use your conceptualization of the client to prevent or repair problems.
If you get negative feedback but you haven’t made a mistake:
- Express empathy
- Ask for additional information in the context of the cognitive model
- Seek agreement to test the validity of the thought
Helping clients generalize to other relationships
Help clients draw a conclusion about your relationship and test it in the context of
other relationships.
You and your clients have a reciprocal influence on each other.
It’s important to observe your negative reactions, accept your emotional reactions
nonjudgmentally, and then figure out what to do. Once clients feel safe with you, you
can address the maladaptive coping strategies they use with you - and likely with
others as well. Monitor your level of empathy, and be on the alert for your own
unhelpful reactions
SUMMARY
It’s essential to have a good working relationship with clients. You facilitate this
objective by adapting treatment to the individual, using good counseling skills,
working collaboratively, eliciting and responding appropriately to feedback, repairing
ruptures, and managing your own negative reactions. Clients who are in distress may
have strong negative core beliefs about themselves that they bring to the therapy
session.
