Cognitive Behavioral Therapy Simplified

Cognitive Behavioral Therapy

Simplified

Edited By

Stephen Jambunathan and Jesjeet Singh Gill

Co g n i t i v e B e h a v i o r a l Th e r a p y S i m p l i f i e d

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1

Introduction to the general principles of CBT Stephen Jambunathan & Jesjeet Singh Gill


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What Is Cognitive Behavioural Therapy (CBT)? CBT is a type of psychotherapy that helps a person change behaviour, thinking and

emotions by understanding and reorganizing their relationship. The basis behind

CBT is that cognition and emotions can be monitored and altered and desired

behavioural change can be achieved through these changes. Thoughts help us define

the mood we experience and also influence the way we behave. Thoughts and beliefs

also affect our physical reaction. Our environment and subjective experiences

influence attitudes, beliefs and thoughts. By understanding these connections one

will be able to modify the emotional responses to our thoughts and environment.

The main features of CBT are as follows: • Emphasis on the present

In CBT there is no need to explore the past, as the main issue is to clarify

and restructure current thinking processes and modify behaviour.

• Collaborative empirism

The patient and the therapist works together towards a common goal unlike the

psychodynamic therapies where the therapist may evoke uncomfortable emotional

reactions and transferences. In CBT, the atmosphere is one where resistance and

competitiveness between the therapist and patient is reduced by a collaborative

task-orientated alliance.

• Specific goals

One of the early steps in CBT is to identify areas to be addressed in therapy.

The core structure of therapy will be determined by the goals set. With the help

of the therapist the patient will be guided to target and achieve only realistic

goals. The goals can be changed during the process of therapy depending on the

needs of the patient.

• Outcome evaluation

In CBT the patient will be able to objectively evaluate the progress of therapy as

he experiences changes in behaviour and mood. This is an important process

that will help motivate the client to further develop his thinking skills.

Although CBT is a highly structured form of therapy, the structure of the

sessions can be modified depending on time constraints, the patients‟ needs

and the patient-therapist contract.


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The basic structure in CBT 1. Behavioural methods:

A. Relaxation- Imagery, Breathing exercises,

Progressive muscle relaxation

B. Distraction- object focusing

C. Distraction- sensory awareness

D. Monitoring activities

E. Scheduling activities

F. Graded Tasks

2. Cognitive Methods:

A. Explaining the mechanism and symptoms of the relevant disorder

B. Identifying and challenging negative thoughts

C. Cognitive restructuring

Who will benefit from CBT? CBT can be of benefit to patients with most psychiatric disorders. This form of

therapy is most commonly used in Depression, Anxiety disorders, Eating disorders,

Substance abuse, Personality Disorders and under special supervision, for

psychosis. The individual qualities of a client that would be beneficial when doing

CBT include:

1. A good understanding of the basic principles of CBT

2. The ability to identify emotional responses to given situations

3. The capacity to identify automatic thoughts

4. The ability to critically analyze the evidence supporting the automatic thoughts

5. The sense of responsibility for one‟s own outcome

6. The ability to stay focused on the agreed upon targets

7. The willingness to participate actively in the home-work


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Initial Interventions A detailed psycho-evaluation is the most important first step before any form of

therapy is to begin. This is to ensure a thorough understanding of the patient‟s

needs and skills.

Cognitive defusion will help the patient look at the problem objectively based on only

the facts without being influenced by the affective component. It is a therapeutic

technique to help a patient detect their thoughts and see them as a hypotheses

rather than objective facts about the world.

Stress reduction strategies such as relaxation therapies like breathing exercises and

muscle relaxation are important to be taught early in therapy in order to enable the

patient to experience relief when under acute discomfort. By being able to regulate

and deal with stressful situations one will also have a subjective sense of control

over particular difficult situations in their life. The patient is also encouraged to

postpone all major life changes to avoid more stress and possible conflict.


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2

Basic steps in CBT

Jesjeet Singh Gill & Stephen Jambunathan


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Behavioural Aspects Relaxation Techniques

There are several techniques designed to help people learn how to relax voluntarily.

Relaxation is a skill that can be learnt by anyone, applied in any situation and helps

improve the state of mind. “Practice makes perfect” but one must practice only

when calm. Once perfected it may be used in any tense or anxiety laden situation.

If a person tries to practice this technique when under stress and without adequate

mastery, the situation may become worse.

Preparation for practice

• A comfortable, conducive place.

• No shoes, loose clothing.

• Avoid eating, smoking or drinking. Preferably before meals.

• Comfortable posture.

• Do not force relaxation. Be patient; new skills take time to acquire.

If you practice in bed at night be prepared to fall asleep midway. These sessions

must be considered as additional to the basic practice sessions.

Imagery

Try to picture a relaxing scenic view that gives you pleasure like a beach or trees in

a park. By doing so one will be distracted from the stressful situation and be able

to calm down.

Breathing Technique

The correct technique of relaxing breathing is abdominal more than thoracic in

nature and slow, deep and regular.

During anxiety the pattern of breathing is fast, shallow and irregular. Self-monitoring

and regular practice of correct technique in a calm state will enable a person to

overcome the anxiety inducing rapid respiration.

Ideally the patient is advised to control the breathing by slow inspiration for about

5 to 7 seconds, holding the breath for 5 to 7 seconds and finally slow controlled

exhaling for 5 to 7 seconds.

The exercise can be done in sets of 3 to 5 around 3 times daily.


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Progressive Muscle Relaxation (PMR) - Jacobsen technique

The idea behind this technique is that by making muscles tense before relaxing one

is able to appreciate better the sense of relaxation. Distraction also plays a role here

as the person applying this technique becomes totally engrossed in the activity,

paying less attention to the stressful situation.

Each group of muscles must be tensed for 5 seconds before relaxing for 30 seconds.

Begin either from the head or toes and move on systematically towards the

other end.

• Raise both eye-brows; shut eyes tightly

• Clench teeth; open mouth wide.

• Force head back against raised shoulders;

• Flex the neck till chin meets chest.

• Clench right fist

• Flex right elbow

• Repeat on the left.

• Raise both shoulders; rotate both shoulders.

• Inhale deeply and hold the breath with shoulders pulled back;

exhale allowing shoulders to hang.

• Tighten abdominal wall; push it out.

• Push right foot forward into the floor

• Raise right heel

• Flex toes of right foot

• Repeat for left foot.

At the end of PMR keep eyes closed, maintain state of relaxation while breathing

deeply and slowly. Stretch. PMR and abdominal breathing may be practiced and

applied alternatively 3 to 5 times each and 3 times a day.

The following behavioural aspects of CBT will be discussed in detail in chapter 3.

1. Distraction - object focusing

2. Distraction - sensory awareness

3. Monitoring activities

4. Scheduling activities

5. Graded Tasks


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Cognitive Aspects A. Explaining the mechanism and symptoms of

the relevant disorder

Clients suffering from depression or anxiety very often do not understand the cause

of their symptoms. Fear of the unknown leads to perpetuation of the disorder,

often leading to further deterioration in health. An example of how this is applied

is discussed in chapter 3.

B. Identifying and challenging negative automatic thoughts

The basic idea is to help the patient elicit and test automatic thoughts and come

up with rational alternatives. This is to help the patient identify and modify

underlying dysfunctional assumptions and schema. The process where a patient is

guided to develop alternative cognitive responses to given situations is known as

cognitive restructuring. One has to identify thoughts following an event that leads

to uncomfortable emotions. These thoughts are usually cognitive distortions of a

real situation that causes strong emotional reactions. These thinking errors are then

challenged and substituted with a non-rigid appropriate rational thought that is not

anxiety provoking or self-defeating.

Practicing and self-monitoring of one‟s thinking patterns takes time and will need

feedback from the therapist. Once the patient has mastered the skill he will be able

to use this technique for all situations in the future. Realistic thoughts are usually

self-enhancing, logical, accurate and flexible. Unrealistic thoughts on the other hand

are self-defeating, illogical, inaccurate and rigid.

The following are examples of various realistic and unrealistic thoughts

Example 1

Unrealistic thoughts

• Everything is going to go wrong.

Realistic thoughts

• Things may not turn out the way I expected but I still can do something about it.

Example 2


• I cant cope.

Realistic thoughts

• I am in a difficult situation. I will try my best. I have done it before.


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Example 3


• I am not good enough.

Realistic thoughts

• I have my limitations but I can try my best. I will learn how to improve.

I have pulled through in the past.

Example 4


• I am sure I have a serious medical problem. I may be dying.

Realistic thoughts

• The doctors have said that my symptoms are that of an anxiety disorder.

I may have symptoms but all the medical tests were negative.

Example 5


• I am sure that something dreadful is going to happen.

Realistic thoughts

• There is no evidence that something bad is about to happen. Nothing has so far.

Example 6


• I don‟t think I will be able to finish the job.

Realistic thoughts

• I know I worry a lot but I will try my best.

Example 7


• Life is cruel.

Realistic thoughts

• Yes, I have bad times before but I also have many things in life to be grateful for.

Example 8


• My life is a very sad story.

Realistic thoughts

• I can do something about. I can make changes. I can seek treatment.

Unrealistic thoughts are a result of cognitive distortions, a way of coming to

conclusions that are not accurate or without reason or evidence. As a result

of persistent distortions of thinking one may develope negative automatic

thoughts (NATs).


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Cognitive Distortions These are misinterpretations of reality that reinforce negative conclusions.

Examples of cognitive distortions are as follows:

1. Arbitrary Inferences

This occurs when one comes to conclusions about themselves or environment

without suggestive evidence.

Examples

A person begins to think that he is the sole cause of his football team‟s defeat

because his coach said that a few players played very badly.

A secretary feels she is going to be sacked because the manager said that he will be

sacking some staff.

2. Over-generalizing

A single instance is taken as an example of a wide range of situations.

Examples

A child is scolded by her mother for not helping with the house cleaning.

She concludes that she is not a good daughter.

A person who has experienced a break-up in a relationship jumps to the conclusion

that he is a failure in all relationships.

3. Dichotomous Thinking

Also called Polarized or All or none thinking.

This occurs when a person feels that the failure to achieve complete success

indicates total failure.

Examples

“If I don‟t get first position in class examinations I am a total failure.” In this case

even 2nd position is as good as complete failure.

A person who feels everything must be perfect for them without considering the

fact that it would be nice if everything was perfect and that not everything comes

out the way they expect.


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4. Selective Abstractions

Drawing conclusions from only particular aspects of an event or situation without

looking at the whole picture.

Examples

Feeling that one is responsible for a mishap when actually many other contributing

factors were involved.

A student who has failed in one subject at school feels as if he is a total failure

and will never make it to university. He however fails to realize that he also scored

straight A‟s in all other subjects.

5. Personalizing

Feeling responsible for everything around or relating any external event to themselves.

Examples

Feeling solely responsible for the mistakes made by a team of people.

Feeling that the class teacher does like him because she did not chose him when he

raised his hand up as a volunteer for a project.

6. Minimizing and Magnification

Down playing positive situations or exaggerating negative events respectively.

Examples

A person is given a complement by the boss but feels that his achievement was not

all that special and did not deserve the complement.

A high achiever is given some constructive criticism but feels that the criticism

indicates that everything is not appreciated or recognized.

Negative Automatic Thoughts (NATs)

These are thoughts that automatically come to mind when in certain situations.

These thoughts evoke emotions that often lead to a disorder. NATs can be

challenged by rational questioning and examination of the evidence supporting

this thought.


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Simple questions like those listed below can be used to check the accuracy of

the NATs.

• Is it true?

• I am over reacting?

• Can it be explained in any other way?

• What is the evidence?

• Am I experiencing an emotion without thinking about things first?

• Am I jumping to conclusion?

• Is it as bad as I think it is?

Assumptions and Core Beliefs

Assumptions and core beliefs are deeply ingrained patterns of thinking with

regards to more general themes such as opinions about the world, life in general,

past experiences and about people around us. These ways of thinking are beliefs

that are formed through repeated past experiences. They are not easily assessed or

accessed as they are deduced from recurrent cognitive distortions and automatic

thoughts, mainly from childhood early experiences.

Examples

1.Everyone is selfish

2.Life is full of failures

3.This world is unkind

4.You can never depend on anyone

Cognitive Restructuring The process of cognitive restructuring basically helps the client to alter the

cognitive appraisal by self questioning.The therapist can best help the client actively

come up with alternative solutions and responses to a given situation by using the

technique of socratic questioning. This is a style of questioning that encourages the

client to exercise the skill of problem solving.

Examples of Socratic questioning are as follows.

• why do I feel like this

• what are alternative explanations

• what is the evidence


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• what does this mean to me

• how is it effecting people around me

• can I do things a different way

This form of questioning will help the client explore the relationship between

conscious cognitions and dysfunctional assumptions. The key factor here is to help

the client think rationally before reacting with emotions. Often emotions are evoked

given a specific situation without a rational trigger. This dysfunctional process leads

to exaggerated and uncomfortable emotions.

The dysfunctional thought chart or thought record is used to monitor thoughts and

emotions. This chart helps us develop the skills of writing down and analyzing our

thoughts and not just automatically reacting emotionally to the negative automatic

thoughts (NATs). By using the chart, one will come to realize that the NATs affects

their emotions in certain situations without adequate reason. The severity of the

mood disturbance is almost always out of proportion. Listing down the points in

favour of the NATs and points against the NATs the client will come to realize how

the cognitive distortions makes us jump to unhealthy and self-defeating conclusions.

This chart can be modified depending on the suitability to the patient.

The following two charts are examples of how the dysfunctional thoughts chart

can be modified. The main outcome is for the patient to be able to realize that the

Automatic Thoughts or NATs, if challenged will lead to a reduction in the severity

of the emotions experienced.


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Dysfunctional Thought Chart 1

Situation Emotion (rate )

NATs Evidence in favour of NATs

Evidence contradicting

NATs

Emotion (re-rate)

This chart uses the columns to evaluate the pros and cons of the NATS and

re-rate the intensity of mood.

Dysfunctional Thought Chart 2

Emotion (rate )

Situation Automatic thoughts

(rate)

Alternative responses

Outcome (Automatic

thought re-rated)

Outcome (Emotion re-rated)

This chart uses the columns to evaluate, rate and re-rate conviction of NATs and

the resulting intensity of emotions.


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3

CBT in Anxiety and Depression

Jesjeet Singh Gill & Stephen Jambunathan


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This chapter covers various aspects of CBT with examples from case studies.

1. Behavioural aspects of CBT

2. Cognitive aspects of CBT

1.Behavioural Aspects of CBT A. Relaxation - Breathing exercises (refer to previous chapter).

B. Distraction - Object Focusing

This can be used to distract the mind when the person is constantly thinking of matters

that makes the person depressed or anxious. Teach the person to focus attention on

an object, (using paper clips that are lying on the therapists table as example), and

describe it or them in detail, and try to answer questions such as „where exactly

are they?‟, „what exactly are they used for?‟, „what are they made of?‟, „what‟s their

sizes?‟ etc. Remember, only with repeated practice will this be beneficial.

C. Distraction - Sensory Awareness

A distraction technique that can be used to distract the mind in someone who

is depressed or anxious. Teach the person to focus on the surroundings, using all

senses (sight, smell, touch, hearing, taste), and ask oneself questions such as:

~ what can I see around me?

~ what can I hear?

~ what can I feel on my body, head etc?

Again remember, only with repeated practice will this be beneficial.

D. Monitoring Activities

Used when a depressed or anxious patient complains that she spends her time doing

nothing useful or enjoyable. Activity monitoring provides information regarding the

patients overall level of activity. This allows us to test the patients notion that she

is not doing anything. If this so happens to be true, this self monitoring method

helps identify how and where difficulties arise, and allows the planning of a more

satisfying pattern of activities (refer to “Scheduling Activities” on page 20).

Example:

The patient was told to record what she does on an hourly basis in a “Weekly

Activity Schedule” record sheet. She was told to rate each activity out of 10 for

“Mastery”(M), where it was explained that a score of 10 indicates that she fully


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achieved carrying out the particular activity and a score of 0 indicates she was not

able to carry out the activity at all. She was also instructed to rate the “Pleasure”(P)

that she experienced in carrying out the activity, where a score of 10 meant she

fully enjoyed the activity and a score of 0 indicates there was no pleasure at all

associated with the activity. An example of a completed “Weekly Activity Schedule”

is illustrated on page 21.

Going through the recorded activities, the therapist pointed out that it was not

exactly true that the patient did not do anything the whole day. It was probably

only during the afternoons and evenings that the patient was inactive. The therapist

together with the patient also detected the activities that gives some degree of

pleasure to the patient, particularly cooking (M = 6, P = 6-7) and chatting with her

sister (M = 9, P = 8). Activities such as watching television, listening to radio and

reading newspapers were also rated low in both the Mastery and Pleasure scales.

E. Scheduling Activities

Explain to the patient that people generally function better when they have a

schedule and it allows them to avoid inactivity and engage in activities that are

mainly pleasurable.

Using the same example in “Monitoring Activities”, it was decided that the patient

will take sole responsibility for carrying out the cooking chores at home for every

meal (including breakfast). This would enable her to spend longer periods cooking.

The patient decided to try to start doing some gardening, an activity she felt she

could enjoy in the afternoon.

F. Graded Task Assignments

A depressed person can become unmotivated and lose the ability to carry out routine

tasks which they could do before. By using a graded or „step by step‟ method, they

may be capable of completing these tasks. When they do so, they usually experience

satisfaction and an improvement in their mood, which motivates them to tackle

more difficult tasks.

Example:

A patient who was previously good at knitting, is unable to do so now (M = 1,

P = 1). The therapist and the patient came up with a „graded‟ method of carrying

it out. It was decided that the patient would target 3 lines of stitching a day only.

By achieving this limited target the patient began to enjoy the activity more and

experienced a sense of achievement.


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Thursday (12/4/01)

Time (M) (P)

6-7 am Woke up, prayers 2 2

7-8 am Took shower 9 2

8-9 am Breakfast 8 3

9-10 am Do washing 5 3

10-11 am Helped sister cook 6 7

11-12 pm Listen to radio 1 2

12-1 pm Read newspaper 5 3

1-2 pm Lunch 1 3

2-3 pm Talking to sister 9 8

3-4 pm Slept 5 5

4-5 pm Watch TV 3 3

5-6 pm Watch TV 3 3

6-7 pm Watch TV 3 3

7-8 pm Helped sister cook 6 6

8-9 pm Watch TV 3 4

9-10 pm Went to bed 2 2

Weekly Activity Schedule


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Cognitive Aspects of CBT A. Explaining Mechanism of Depression and Anxiety

Simple explanations on how depressive and anxiety disorders occur and how they

cause physical symptoms will reduce the level of worry or anxiety and as a result

help reduce the severity of the disorder. Explain that depression gives rise to negative

thoughts, which may frequently be illogical, and which would in turn worsen the

depression. Similarly, inaccurate beliefs about bodily sensations may lead to panic

attacks. These beliefs along with the subsequent beliefs about the origin of the

panic attacks may worsen the situation. The aim of CBT is help the patient identify,

understand and challenge these beliefs or thoughts in order for him to feel better.

B. Identifying and Challenging Negative Thoughts

Explain that depressed persons frequently have negative views about themselves,

their current experiences and the future, and these beliefs are formed as a result

of negative or dysfunctional thoughts. These thoughts occur automatically, are

usually illogical or irrational, and worsen their depression. In anxiety disorders

negative thoughts such as misinterpretation of bodily sensations may result in

a catastrophic reaction. In order to improve, one should be able to identify and

challenge these thoughts.

Give examples to the patient to help him understand.

Examples

A depressed clerk felt sad and useless as she thought her boss hated her as he did not acknowledge her as she passed his desk.

It was explained that here, the negative thought was “my boss hates me” and it

was deemed irrational as there are many possible reasons to why her boss did not

acknowledge her; for example, he was to engrossed in his work.

A 40 year old man had a panic attack and felt he was going to die of a heart attack.

A relative had passed away due to a heart ailment one month earlier.

The therapist help the patient identify the dysfunctional thought by a series of

Socratic questions. The NAT the patient eventually uncovered was “ I am having a

heart attack. I am going to die”.


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Below are a few points that proved this thought to be irrational and self-defeating.

1. I have just completed a heart examination and the doctor said I was well.

2. I know that I have panic attacks and it does go away when I do

breathing exercises.

3. I am still upset and preoccupied with the death of my relative.

Teach the patient to recognize negative thoughts in three steps by using a “Daily

Record of Dysfunctional Thoughts” form. (refer to pages 17 and 27 )

Step 1

Identify adverse emotions when they occur (ie: sad, angry, anxious) and rate the

intensity or severity in percentage. Using the same example, „sad - 80%‟ would

be filled in the adverse emotion column in the “Daily Record of Dysfunctional

Thoughts” form.

Step 2

Identify the situation this emotion occurs in. Here, „boss did not acknowledge me

as I passed his desk‟ would be filled in the adverse situation column.

Step 3

Identify „Negative automatic thoughts‟ or „dysfunctional thoughts‟. These thoughts

are identified by recollecting their thoughts at that time that could have led to the

emotion. The patient believed that her boss hated her and this made her feel sad.

Ask the patient to then rate in percentage how much she believed in this thought.

She said 75%. Therefore “my boss hates me - 75%” and this was filled in the Negative

automatic thoughts column.

Give as many examples as possible to help the patient understand better. Once she

has grasped the concept, encourage her to fill in the “Daily Record of Dysfunctional

Thoughts” form each time she experiences an unpleasant emotion and rate the

emotion and accompanying dysfunctional thoughts. Only the first three columns

are used initially so as to enable the patient to master this skill in steps. Remember,

only with practice can the patient be adequately skilled in identifying negative

thoughts. You may have to go through this several times with the patient. Only

when the patient is able to do this task smoothly, should you proceed to step 4,

Challenging Negative Thoughts and the subsequent steps.


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More examples of the first 3 steps of “Daily Record of Dysfunctional Thoughts” are

as follows:

Emotion - Felt depressed (rated 60%)

Situation - Sat in front of the television the whole evening doing nothing

Automatic thoughts - I will never get a job as I can‟t even do anything

(belief rated 80%)

Emotion - Felt anxious (rated 10%)

Situation - Walked to a nearby stall to by some cakes for the house

Automatic thoughts - I might get a panic attack (belief rated 10%)


Situation - A friend called on the phone. Later wondered why my boss has not

called me up in a long time.

Automatic thoughts - I must be useless that even my boss doesn‟t bother to call me

(belief rated 60%).

Challenging Negative Thoughts

(refer to chart on page 27)

Once the patient is adequately skilled in identifying negative thoughts, the next

step is to teach her how to challenge them. This is done by using the skills of

Socratic questioning.

Examples:

~ what is the evidence?

~ what alternate rational explanations are there?

~ what are the advantages / disadvantages of this way of thinking?

Once the alternate rational explanations are elicited, the patient‟s belief in these new

thoughts should be rated in percentages and filled in the “Alternative Thoughts Column”

in the Daily Record of Dysfunctional Thoughts form.Teach the patient to compare these

thoughts and beliefs with the initial negative thoughts. Now, the patient should re-rate

both the initial unpleasant emotion (sad, angry, and anxious) and negative thoughts

in the “Outcome” column. Below are several examples that can be used to teach the

patient. Another way of using the chart is by rating only the emotions and NATs and

re-rating the NATs and Emotions after challenging the dysfunctional thoughts.

In the example discussed above, the alternative thoughts were also rated. The

columns that are rated and rerated may vary depending on the patient‟s skills and

ability to analyze their own thoughts.


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Example 1:


Situation - Sat in front of the television the whole evening doing nothing

Automatic thoughts - I will never get a job as I can‟t even do anything

(belief rated 80%)

Alternative responses - There is no evidence as I‟ve not even tried to look for a job

(belief rated 90%)

I‟m ill at the moment but my illness is improving and soon

will be able to go back to work (belief rated 80%)

Outcome - Automatic thought re-rated 40%

Emotion re-rated 20%

Example 2:

Emotion - Felt anxious (rated 20%)

Situation - Walked to a nearby stall to by some cakes for the house

Automatic thoughts - I might get a panic attack (belief rated 40%)

Alternative responses - Even if I get an attack, I know now that it is not

life threatening (belief rated 70%) Even if I start to experience an attack, I know counter

measures to make it stop. (belief rated 80%)



Example 3:


Situation - Wondered why my boss has not called me in a long time.

Automatic thoughts - I must be useless. Even my boss doesn‟t bother to call me

(belief rated 60%)

Alternative responses - He knows I‟m emotionally unwell and doesn‟t want to

bother me (belief rated 75%)

My boss is ungrateful (belief rated 80%)




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Example 4:


Situation - Called up a old friend at her workplace but was informed that

she doesn‟t work there anymore.

Automatic thoughts - She never bothered to inform me. I must be insignificant.

(belief rated 80%)

Alternative responses - She forgot to inform me as we haven‟t been in contact for

such a long time (rated 90%)



Example 5:

Emotion - Felt depressed and angry (rated 70%)

Situation - Woke up late on the morning of my appointment with the doctor.

My sister didn‟t wake me up.

Automatic thoughts - My sister must not like or bother about me as she did not

wake me up even though she knows I have a doctor‟s

appointment. (belief rated 60%)

Alternative responses - She forgot (belief rated 80%)

She didn‟t want to disturb me as I don‟t always manage

to sleep late (belief rated 70%)



Co g

n i t i v e B

e h

a v i o r a l T

h e

r a p

y S i m p

l i f i e d

27

Daily Record of Dysfunctional Thoughts

Emotion (Rate)

Situation

Automatic thoughts

(Rate)

Alternative responses (Rate)

Outcome (Automatic

thought re-rated)

Outcome (Emotion re-rated)

Sad

80%

Sat in front of

television the

whole evening

doing nothing

I will never

get a job as

I can‟t even

do anything

- 80%

There is no evidence as

I‟ve not even tried to

look for a job - 90%

I‟m ill at the moment but

my illness is improving

and soon will be able to

go back to work - 80%

Automatic

thought

re-rated 40%

Emotion

re-rated

20%

Anxious

20%

Walked to a

nearby stall to

buy some cakes

for the house

I might get a

panic attack

- 40%

Even if I get an attack,

I know now that it is not

life threatening - 70%

Even if I start to

experience an attack,

I know counter measures

to take stop it - 80%

Automatic

thought

re-rated 10%

Emotion

re-rated

10%

Depressed

70%

A friend called

on the phone.

Later wondered

why my boss has

not called me up

in a long time.

I must be

useless that

even my boss

doesn‟t bother

to call me

- 60%

He knows I‟m emotionally

unwell and doesn‟t want

to bother me - 75%

My boss is ungrateful -

80%

Automatic

thought

re-rated 10%

Emotion

re-rated

10%

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C. Cognitive Restructuring

In the process of identifying and challenging dysfunctional automatic thoughts the

process of cognitive restructuring has begun.

Further emphasis on the alternative responses to NATs and how these responses

prevent self defeating thinking patterns will help the client re-structure the way he

thinks in response to any given situation.

Socratic questioning such as questions like “What does this mean to me?”,

“Are there any alternative solutions?”, “What would I advise a friend in the

same position?” will help the client replace the rigid, illogical and self defeating

thoughts with flexible, logical and self-enhancing thoughts. Practice and revision

will eventually help the client restructure his way of thinking when in difficult and

uncomfortable situations.

With regards to the case scenarios discussed in this chapter, restructuring of

cognition was evident when the client was able to come up with the following:

Example 1

There is no evidence as I‟ve not even tried to look for a job. I‟m ill at the moment but

my illness is improving and soon will be able to go back to work.

Reinforcement by Socratic questioning to ensure cognitive restructuring.

I should not jump to the conclusion that everything will always turn out bad for me.

If I try, I may succeed.

Illness will always get people down.

I always work well when I am well.

Example 2

Even if I get an attack, I know now that it is not life threatening. Even if I start to

experience an attack, I know counter measures to take stop it.


Now that I am aware of the physical manifestations of stress, I will be able to

cope with it.

Not all symptoms suggest a near death experience.

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Example 3

He knows I‟m emotionally unwell and doesn‟t want to bother me.

My boss is ungrateful.


In future I will not let my worries make me come to wrong conclusions.

There is always a different side to every story. I just have to think about it first.

Example 4

She forgot to inform me as we haven‟t been in contact for such a long time.


I should not let isolated incidents make me derive at irrational conclusions without

looking at things from other points of view.

She may be having her own personal issues to tend to and she may be very busy.

She has always been there for me and perhaps I may be taking her for granted.

Example 5

She forgot. She didn‟t want to disturb me as I don‟t always manage to sleep late.


Perhaps I worry too much about the negative things that people might think when

there are always other possibilities.

Looking at my pattern of thinking, it looks to me that I tend to jump to negative

conclusions without looking at other possible explanations.

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4

CBT in Adolescence

Subash Kumar Pillai & Ahmad Hatim Sulaiman

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Introduction The general public is quite unaware of the occurrence of mood and anxiety disorders

in children and adolescents. It is customary to believe that depression can only occur

in adults. Children do experience depression but it is mostly overlooked because

the symptoms are unclear or tend to be more behavioural in nature. Whether it

occurs in adults or in children, it still remains one of the most disabling conditions

that a person can experience. According to some studies as high as 20-25% of

adolescents would have at least one depressive episode by the time they reach the

age of 18. It is also shown that at least 8% of high school students make serious

suicidal attempts each year and there are at least 13/100,000 completed suicides

each year among adolescents. It is also seen that the prevalence of depression

among this group is increasing while the age of onset seems to be decreasing.

There are many factors that are considered to be risk factors for depression in this group

of patients. One risk factor is gender. As in adults, the female sex are more at risk of

developing depression. It is also more common if there are parents with depression.

Environmental stressors also play a role in causing depression. These common

stressors include parental conflict, loss of parent, school failure, peer rejection,

trauma or physical illness and also poor social adjustment. The other factors that

may also play a role include being in a disadvantaged position (economic, ethnic,

social). A chronic sense of low self esteem as well as substance abuse are additional

risk factors that can contribute to the development of depression in this group.

The Many Faces of Depression

The diagnosis of depression in adults and children is similar. However, symptoms

are very often unclear and may manifest only in behavioural changes. The common

symptoms of depressin are as follows:

• Persistent depressed/irritable mood

• Change in sleep

• Change in appetite/weight

• Fatigue

• Decreased concentration

• Psychomotor change

• Anhedonia

• Worthlessness

• Thoughts of death / suicide

• Guilt

• Hopelessness

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Although the core symptoms of depression are similar in adults and in children or

adolescents, there are symptoms that are peculiar to certain age groups. There is a

greater presence of somatic symptoms and behavioural problems in children who

are in pre-school and in primary school. In the pre-school children typical symptoms

are often missed as they may be misunderstood as attention seeking behaviour or

simply misbehaviour. Other symptoms include behavior that is regressive, a loss

of interest in playing or curiousness, irritability as well as crying spells. One key

symptom that needs to be assessed is the change in the level of interaction that the

child has with its caregivers. Primary school children pose another challenge as again

the predominating symptoms are mostly behavioural. These children often complain

that they are bored and often show a gradual deterioration in their performance in

school. Adolescence can be a difficult and stressful period for youngsters. It is a time

when teenagers go through a phase where they experience hormonal changes and

also begin to take on responsibilities as a young adult in order to achieve an identity

of their own. Teenagers who are depressed tend to complain of feeling bored or even

stupid. Their mood, however does not usually remain persistently low but tends to be

rather reactive; where the mood does brighten up with welcomed events. This again

may give the impression that the teenager is not depressed but just having a normal

emotional reaction. The behavioural changes seen in depression in boys include

temper tantrums and conduct problems. This may be misdiagnosed as conduct

disorder. Girls on the other hand have been known to show disinhibited behaviour,

sometimes misdiagnosed as a bipolar mania. Teenagers who are depressed also tend

to be very sensitive to rejection and may also be intensely self-consciousness about

their bodies and appearance.

Cognitive Behavioral Therapy in Adolescents

Cognitive behavior therapy in adolescents is generally based on adult models,

including skill deficits or deviant cognitive structure present in adult repertoires.

However it is only the method or manner in which the therapy is carried out that

differs from adults. All emotions, thoughts and behaviors are connected and interact

with environment. Adolescents seem to be more influenced by environment

(modeling, prompting, rewarding, punishing) than adults. CBT seeks to identify and

modify maladaptive beliefs, attitudes and behaviors and teach coping skills.

The key factor in successfully implementing CBT in adolescents lies in the first few

visits. These visits, if successful will allow the child to form a healthy therapeutic

relationship with the therapist. It is important that the therapist see the child first

instead of the parents on the first visit. If the parents insist on seeing the therapist

first, then it would be advisable to spend a short time with the parents ( just to allay

their fears) and spend more time with the child. The sessions should, if possible take

place in a comfortable room that does not resemble a clinic. An arrangement that

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resembles a living room may be more appropriate. There are numerous obstacles

that must be dealt with while working with adolescents. Firstly, unlike adults who

mostly come on their own to seek help, most teenagers would have been forced by

their parents to see the therapist. The second issue is of course the stigma that is

attached to seeing a psychiatrist. This often causes the child to be rather guarded or

difficult in the initial sessions. These two issues may cause the initial ice breaking

session to take longer, sometimes as long as a few weeks before the teenager is

comfortable enough to trust the therapist. It is of utmost importance that the

therapist remains patient until this happens. Most clinicians agree that humour is

a good tool for ice breaking and it may be also helpful to delay talking about the

stressors on the first session. It may be necessary to talk about neutral subjects

until the adolescent is comfortable or ready to talk about his problems. Do not feel

pressured to get results quickly.

Teenagers must be reassured about the confidentiality of the sessions as many feel

that the therapist is always on the side of the parents. Most sessions will often

take about 45 minutes. Sometimes it may be necessary to use drawings or other

tools to help the teenager express himself better. Combined or joint sessions with

parents can be done at a later stage when the child is ready. If there is a need for

corroborative history or clarification, a separate appointment for the parents without

the child should be made at a later date. Sessions should be more flexible than the

adult sessions, giving room for the adolescent to speak and express themselves

freely without too much emphasis on the goals of therapy. The introduction of

mood charts and relaxation/breathing exercises can be done once the sessions are

on the way. The general principles remain similar to adult CBT except that it may be

necessary to simplify it to some extent.

The use of the activity monitoring and dysfunctional thought monitoring charts

should be made more simple to ensure better comprehension and participation

for the younger age group. For the very young age group who do not have

the adequate writing and reading skills the emphasis should be more on the

behavioural component where the effective and desired change is reinforced by

positive reinforcement.

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Conclusions

This book is not designed to make the reader an expert therapist

in CBT, but rather teach a few simple principles of CBT that can be

applied to clients. The reader does not have to apply all the principles

presented here, but rather choose the ones that might benefit clients

the most, taking into account what their predominant symptoms are.

Someone who complains of many anxiety symptoms would mainly

benefit from the behavioural methods such as relaxation, breathing

exercises and the distraction methods. Someone who complains of

inactivity and low motivation can benefit from the „Monitoring and

Scheduling‟ activities. Those who predominantly complain of negative

automatic thoughts should be trained in the cognitive methods of

identifying and challenging negative thoughts. Always remind your

clients that only with practice can he or she master these methods.

You may have to go through the methods several times with the client

before they start to benefit from them. The principles discussed here

are the simpler methods of CBT. There are of course other principles

that are more specialized such as identifying Basic Schema / Silent

Assumptions and Core Beliefs. Proper training should be obtained if

one is to treat patients with severe disorders.

Cognitive Behavioral Therapy

Simplified

Health & Medicine

Cognitive Behavioral Therapy Simplified