Cognitive Behavioral Therapy
Part 2 – Strategies and Methods
Research has established that cognitive-behavioral therapies (CBT) are valuable tools in assisting clients reach their treatment goals. Implementing CBT effectively, however, requires skills and preparation. Too often counselors do not take the time necessary to prepare to guide clients through a learning process that can enhance their recovery, their relationships and their sense of self-efficacy. In this article we will review briefly a number of strategies and change methods shared by a number of CBT programs. We will begin with some general strategic recommendations. Pucci (2009) suggests that counselors are more likely to be effective using CBT when they use these strategies:
Use a coherent systematic approach.
When a counselor uses a systematic approach to CBT s/he will have a therapeutic roadmap as
a guide. Using a systematic approach to CBT ensures there is a focus point to each session that builds on the client’s previous learning. Such approaches are typically published as manuals. Examples include Carroll (1998), Reilly & Shopshire (2002), and CSAEstablish accurate empathy.
Establish accurate empathy.
When a counselor establishes accurate empathy the client begins to feel understood. Accurate empathy creates a therapeutic bond with the client who begins to feel the therapist truly understands what s/he is experiencing. If a counselor offers an alternative unfamiliar way of thinking that is contrary to the client’s beliefs, the client may begin to feel misunderstood. Therefore, it is best to establish an empathic relationship prior to helping the client examine
and change self-defeating beliefs and assumptions.
Recognize irrational thoughts.
One aspect of CBT is helping the client see the relationship between thoughts or beliefs and behavior. For example, most CBT approaches encourage the client to replace irrational beliefs about a situation (“This is awful, terrible and horrible”) with a less severe, more rational statement (“This is unfortunate but it’s not the end of the world”). The counselors ability to distinguish rational from irrational beliefs in the context of the client’s life and culture is one key to conducting effective CBT.
Assist in creating rational replacement thoughts.
Focus on client assumptions.
The counselor needs to help the client develop new rational replacements for exaggerated or irrational thoughts. Old beliefs do not easily give way to new ones. It is important to be patient
at this stage of CBT.
CBT directs clients to focus on the assumptions underlying their thoughts or beliefs. For example, a client may state that her friends don’t really appreciate her. A good therapeutic response might be, “Are you sure that there is evidence that they don’t appreciate you? Remember that there are several other possible explanations to explore. Consider that your friends might have been distracted and forgot to thank you at that moment. It could be very helpful for you to explore other possibilities.” Alternatively, the counselor could focus on the underlying assumption which may be contributing to the client’s distress, encouraging the client to say something like, “It would be nice, but not essential, for my friends to acknowledge my efforts.” When the underlying assumption is corrected and made for rational, the client is not likely to feel quite so distressed.
Leahy (2003) notes that some clinicians view CBT as too technique-oriented, too mechanical,
too structured and too formula driven. But the purpose of the structured ingredients used in
CBT combine to actively intervene by using specific strategies to move the client forward into
self-efficacy. Counselors are encouraged to master CBT methods that have proven to be effective before modifying the methods to suit personal preferences.
Obtaining feedback from the client is also essential in CBT. It’s valuable for the counselor and client to periodically summarize the methods they have used to determine which were useful, which were not, and why. For example, it can be beneficial to explore why weighing the evidence for a client’s automatic thought does not work all the time. Such examination may uncover more fundamental client beliefs or rules that can be explored. Awareness of what works for the client will help the counselor understand which strategies are most likely to be successful as therapy proceeds.
Methods for drawing out the client’s thoughts and assumptions are often less about modifying a thought and feeling and more about beginning an inquiry that leads to a deeper understanding of underlying beliefs and assumptions. Leahy describes the following methods to illustrate how CBT can be used to open a window into the client’s core issues.
- Explain how thoughts can precipitate feelings.
The counselor focuses on how feelings are influenced by beliefs and assumptions. The client’s feelings are not disputed but rather the thoughts that elicit those feelings are called into question. Client homework or practice includes keeping track of feelings and how they are related to thoughts, beliefs or assumptions.
- Possible problems: Client may confuse thoughts with feelings and/or they may have difficulty identifying the thoughts associated with their feelings.
- Distinguish thoughts from facts
Thoughts can prove to be either true or false. First, clients learn how to identify their thoughts; second, they are guided to examine the facts. Practice focuses on keeping track of any preceding events that led to a particular feeling or belief.
- Possible problems: The client may respond to examining facts as invalidating and as critical of their feelings. It is important for the therapist to help the client recognize that examining situational facts does not automatically mean that they are incorrect.
- Rate the degree of emotion and the strength of the related belief
Identifying how strongly a client feels about a belief helps the client understand the intensity of their emotions. Through homework focused on tracking thoughts, beliefs and feelings over time the client explores how their emotional intensity might modify over time.
- Possible problems: Client motivation to track thoughts and feelings may dissipate
with time. It’s important to maintain consistent encouragement, coaching the client to continue following-through with their assignments. It is only through consistent practice that clients begin to alter their perceptions and their behavior.
- Look for variations in a specific belief
Understanding the client’s beliefs across time and in different situations provides valuable information for both the counselor and client. Changes and variations in beliefs can be linked to changes in the client’s feelings. Client homework, again, focuses on tracking.
- Possible problems: Clients may be less inclined to track their negative thoughts during times when they are feeling better. Counselor encouragement can let the client know that important information can also be gained through tracking even when they’re not feeling negative
- Categorize the distortion in thinking
Thoughts can be true, false or they can have some degree of validity. Clients can monitor their thoughts and then categorize them (see Cognitive Distortions chart in Part 1) to begin associating their negative feelings with irrational thoughts and cognitive distortions. Tracking homework will help reveal repetitive categories of thoughts for the client.
- Possible problems: Clients may feel their thoughts are invalidated through categorization. The counselor’s job is to illuminate any troublesome thought patterns that are prevalent and to develop interventions to help the client change that pattern.
- Explore thoughts through vertical descent
Exploring the beliefs underlying fear of a particular outcome can help to alter the thought. Vertical descent is a tool for uncovering the client’s bottom-most belief by writing the client’s thoughts at the top of a page and then documenting implied beliefs in a descending order. Homework involves identifying negative thoughts and the string of implied beliefs related to the thought that leads to an uncomfortable feeling.
- Possible problems: Clients may find it difficult to complete the sequence of implied beliefs and resulting feelings without counselor encouragement and guidance.
- Assign probabilities in the sequence
Using vertical descent the client estimates the probability of particular outcomes.
- Possible problems: Clients may end the sequence prematurely. The counselor can encourage the progression by emphasizing that sequencing--even if the client doesn’t totally believe in the next implied belief and resulting feeling--can uncover issues that may be important to examine.
- Guess the thought
For clients who have trouble identifying their negative thoughts, the counselor can suggest possible thoughts that may be consistent with what the client is experiencing. Homework or practice for the client could be listing their feelings and then attempting to identify or guess at what their thoughts might be that influenced the feeling.
- Possible problems: The client may have difficulty finding enough emotional distance from a feeling to identify their thoughts or the client may not be able to identify the feelings.
Leahy (2003) provides detailed information on more CBT techniques in Cognitive Therapy Techniques: A Practitioner’s Guide.
Cognitive Behavioral Therapy is a general term that refers to several therapeutic approaches which stress how thoughts affect both behavior and feelings. Some of the models are Rational Emotive Therapy, Cognitive Therapy, Rational Behavior Therapy, Rational Living Therapy, Schema Focused Therapy, and Dialectical Behavior Therapy with each having a set of practices that use CBT principals and methods.
NIDA’s Therapy Manuals for Drug Abuse: Manual 1 - A Cognitive-Behavioral Approach: Treating Cocaine Addiction
Download at http://archives.drugabuse.gov/txmanuals/CBT/CBT1.html
NIDA’s Therapy Manuals for Drug Abuse: Manual 2 - A Cognitive-Behavioral Approach: Treating Cocaine Addiction
Download at http://archives.drugabuse.gov/txmanuals/CBT/CBT20.html
SAMHSA’s Anger Management for Substance Abuse and Mental Health Clients.
Download at http://kap.samhsa.gov/products/manuals/pdfs/anger1.pdf
SAMHSA’s Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions
Download at http://kap.samhsa.gov/products/manuals/cyt/pdfs/cyt1.pdf
NIAAA’s Cognitive-Behavioral Coping Skills Manual
Download at http://pubs.niaaa.nih.gov/publications/MATCHSeries3/index.htm
Stress management: What is it? Lephuong Ong, Wolfgang Linden, and Sandra Young.
Department of Psychology, University of British Columbia,
Download at http://www.coedu.usf.edu/zalaquett/gua/Stress%20management%20what%20is%20it.doc
Cognitive-Behavior Therapy for Substance Dependence: Coping Skills Training. Ronald M. Kadden, Ph.D. University of Connecticut School of Medicine
Download at http://www.bhrm.org/guidelines/CBT-Kadden.pdf
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