A Brief Introduction to Cognitive Behavioural Therapy (CBT)

Counselling Theory and Practice:- Cognitive Behavioural Therapy

THINKING

C B T

FEELING

BEHAVING

AN INTRODUCTION To C B T Heartsease Training, Shifnal Shropshire

email : - [email protected]

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© 2010 - Peter Creagh, Trainer, Supervisor and BACP Registered Counsellor UKRC CBT


COGNITIVE BEHAVIOURAL THERAPY (CBT) A Brief Introduction INTRODUCTION There are many ideas, theories and strategies strategies in counselling. There are those who contend that it is a skilled process, those who feel it has a mainly theoretical base, those who consider it is all about relationship and being and those who feel it combines all or elements of the first three. However, there is considerable agreement that broadly speaking therapeutic approaches can be divided into four main schools. These are:• Psychodynamic Approaches Approaches - concerned with the mind , psyche ,instincts and drives. This is often referred to as ‘working with the presenting past’ . • Cognitive –Behavioral Approaches Approaches — concerned with the mind ,its thoughts thoughts feelings and behaviors and mainly how to assist clients to live in the present and look for a preferred future. • Humanistic and Existential Approaches Approaches - concerned with relationship and being. being. • There is the development of the 4th wave. This includes approaches such as Solution Focused Brief Therapy and a variety of eclectic (e.g. (e.g. Egan’s Skilled Helper Model) and integrative integrative approaches approaches (e.g. Culley’s Integrative Helping Model) . The Eclectic and integrative models combine aspects of some or all of the first three. This development in integration and eclecticism is particularly relevant to models of helping for those who use counseling skills and for those who wish to combine several theoretical approaches e.g. CBT with aspects of Humanistic Therapy ( see Nelson-Jones 2002). McLeod (1998) suggests suggests that ‘eclecticism’ ‘eclecticism’ is a model where where the counsellor selects selects or chooses the best or appropriate concepts and techniques from a broad range of theories. Whereas integration usually uses no more than 3 models He further suggests that some of the t he main differences between an eclectic and integrative approach are: ECLECTIC

INTEGRATIVE

Technical

Theoretical

Focus on differences

Focus on commonalities

Choosing from many theories

Combining many (normally 3 max)

Applying what is

Creating new approaches

Table 1 : Adapted & Summarised Summarised from McLeod(1998) McLeod(1998)

Heartsease Training, Shifnal Shropshire


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These notes are designed mainly to provide a backdrop to a presentation and experiential exercises on CBT. They will look at its background, roots and some of the main concepts which underpin this approach to helping and outline several exercises designed to facilitate a greater understanding of this popular and effective approach to therapy.

Cognitive Behavior Therapy (CBT) Cognitive Behavioural Therapy (CBT) is a combination of cognitive therapy, (whose major exponent was Aaron Beck) -, behaviour modification therapy (of which Joseph Wolpe was a well known expert) and Rational Emotive Behaviour Therapy (REBT) (whose main exponent and founder was Arthur Ellis). Ellis, in particular, formed his theory as a direct alternative to psychoanalysis, the then dominant force in therapy. This seemed to emphasise the irrational aspect of people, caught in a struggle between the irrational ID and the over-moralising, controlling, parental super-ego. Like many others, he felt that an approach that acknowledged the connection between thinking and feeling, and the ability of people to change patterns in the present, was important. Thus the cognitive and behavioural approach to therapy was born and this eventually led to CBT. Each of these terms is now briefly defined. Cognitive is a process such such as mental thinking. thinking. It refers to everything in the mind, such as thoughts, dreams, memories, images etc. Behaviour is everything we do. What we say, say, do, act or avoid and do not say, do, act or avoid. Therapy, Therapy, comes from the Greek word ‘to heal’ and it is how the concepts and strategies of CBT are used in a helping relationship. This (very short history) is important because it describes the antecedents and basic premise of this important and widely accepted form of therapy. It is a therapy that can be readily ‘adapted’ or ‘integrated’ within other approaches More About CBT. CBT. CBT is based on the assumption that most unwanted thinking thinking patterns and emotional and behavioural reactions are learned over a long period of time. The aim is to identify the thinking that is causing unwanted feelings and behaviours behaviours and to learn to replace this thinking with positive thoughts. This can result in behaviours that are more positive. The therapy does not not focus on the events from the past (such as childhood) but focuses on current difficulties in the here and now. CBT aims to teach new skills and new ways of reacting. Strategies. It uses cognitive techniques (such as challenging negative thoughts) allied with behavioural techniques techniques (such as exposure exposure therapy that gradually gradually desensitises a person to ,say, phobia and also techniques such as relaxation, breath awareness etc. This combination is designed to help challenge negative thoughts, beliefs and behaviour. Heartsease Training, Shifnal Shropshire


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Research Research indicates that CBT is particularly useful in the treatment of a wide variety of presenting problems and particularly, anxiety, panic attacks, depression, OCDs and phobias. It is designed to combine combine elements of cognitive therapy that assist clients to modify or eliminate unwanted unwanted thoughts and beliefs-, and behavioural therapy, which which can help to change behaviour in response to those thoughts. So in short CBT could be said to rest on the following seemingly simplistic saying; ‘You feel the way you think and/or you think the way you feel’ It offers an approach that is designed to work with unhelpful thoughts and thus change how we feel. In this way it sets out to assist people; to avoid and/or eliminate unhelpful behaviours. Like other approaches it proposes that we are ultimately responsible for our choices and our ABC’s

Learning Your ABCs A major aid in cognitive therapy is what Albert Ellis called the ABC Technique or system of Irrational Beliefs. This ‘system’ attempts to bring together the feeling-thinking feeling-thinking link and the meaning you attach to this with the resulting consequences and behaviours. These behaviours are normally normally acted out and this ‘acting out’ comes in three main main forms:

Self- Destructive Behaviours - addictions & self harm

Isolating and moody Behaviours - depression

Avoidance Behaviours – leading to phobias and Obsessive Compulsive Disorders (OCDs)

Before examining the thinking-feeling link in greater detail, each of the components of the ABC concept will be outlined.



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A - Activating Event or objective situation. situation . We live live in an ‘environment’ or world world is eventful. An outline of this, including some typical events is shown below.:

A = Activating Event The Activating Event – often ‘Trigger’ is referred to as a ‘Trigger’ is caused by one of these : • •

Our Eventful World

•

A real external event An anticipated event An internal event in the mind – thoughts, image , memory dream

EVENTS The World Other people- relationships Personal Experiences Personal History Future ( thoughts & feelings) Self

Note ‘ situation that ultimately leads either to some sort This activating event is an ‘objective ‘ situation of emotional response and/or possible irrational thinking.

B – BELIEFS. BELIEFS. We live in this eventful world world with a set of beliefs . These include rules, demands and thoughts that we connect to events. In problematic and negative issues these can be irrational and lead to negative consequences.

B = BELIEFS Beliefs

**** THOUGHTS lead to

These include the :

Attitudes Rules Demands Beliefs Images Meanings

thoughts, rules, demands , meanings that we attach to events & the world :



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Note These beliefs, which lead to negative thoughts and feelings and behaviours, are the link or bridge between the Activating Event and the Consequences. *** Very often people find it difficult diffi cult to identify the thoughts linked to the belief ( More on this later when we explore how to complete an ABC Table)

C – The CONSEQUENCES So we live in this eventful world with a set of beliefs which effect our thoughts and lead to consequences for us, others and our ‘world’

C = the CONSEQUENCES Consequences include

EMOTIONS

emotions, behaviours and physical sensations

Healthy feelings Unhealthy feelings Physical Sensations

caused by A and B

BEHAVIOURS Constructive Action Destructive Action

Note The thoughts caused by the ‘belief’ leads to the emotions and resulting behaviour. These emotions could be anger, anxiety, distress etc . These are often referred to as the Mad, Sad, Bad, Glad range of emotions. Before moving on, it can be useful to look at the ‘volcano of felt experiences’



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THE VOLCANO OF FELT EXPERIENCES We are all aware of the term t erm ‘emotion’ but it is important to understand where these ‘rise up’ from. The following diagram shows the Volcano of Felt Experiences Rise of Emotions. Note the Intensity increases as the ‘Cone’ width decreases

Emotions

Feelings

Felt Senses

Raw or Basic Life Energy

FOUR LEVELS OF FELT EXPERIENCE All feelings and emotions (of which we are more aware) rise up through us like lava in a volcano. They rise up from a Raw or Primitive Basic Life Energy. This ‘courses up’ through the Felt Senses (see Gendlin and Existential Therapy) and up to the Feelings & Emotions levels. Feelings are more easily recognised than the t he Felt Sense. Emotions are more intense than feelings . e.g. irritation and rage. Emotions totally DOMINATE our attention, whereas feelings are more subtle and fluid than emotions Understanding the levels of felt experience experience helps us to decide how we can use the therapeutic relationship to assist clients to control , explore and manage these experiences.



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In general the deeper the level of felt experience the more existential is the t he issue . Therefore CBT can help at the feelings/emotions level, but if these are rooted in existential questions, then approaches that are more humanistic/existential , and candeal with the ‘spiritual’ are more appropriate. This can assist in deciding how and when to integrate aspects of CBT into our practice. As feelings are thoughts can be linked, we now move on to errors in thinking t hinking that can give rise to inappropriate and often unhealthy feelings

Errors in Thinking Before exploring both how the ABC ‘model’ could could be applied and at some examples of its use, it is useful to look at how ‘beliefs’ can lead to faulty thinking. Now, CBT is based on the proposition that feelings and emotions are directly linked to thinking. Therefore, we can develop ‘thinking errors’ and these lead to unhealthy emotions with subsequent destructive action. Consequently, Consequently, it is important to begin to recognise and then challenge faulty or irrational thinking. These irrational thoughts are are Witches’ or the ‘3 Dunnerby often rooted in what can be termed the ‘Three Bad Witches’ or Sisters!

I SHOULDA Done or Be

I AUGHTA Done or Be

I MUSTA Done or Be

These ‘witches’ are often at the root of many of the following typical irrational/faulty thinking errors.

‘With ME It’s ALL or NOTHING Very often our beliefs lead to extremes of ‘either : or’ i.e. love: hate: ; right: wrong etc. This ‘all or nothing’ type of thinking t hinking can then lead to extremes in emotions. In short we either take full responsibility or blame for an event or else take none. Very often it is better to t o have a more balanced view and to be open to ‘both: and’ type of thinking. ‘ Gonna Build a Mountain’ Awfulising This form of thinking error turns a relatively minor event into a major catastrophe . Everything Everything is ‘awfulised’ and a minor ‘crisis’ is turned into a major drama. An example could be that somebody turns down your invitation to have a coffee and you assume ‘ They hate me’ or ‘ I’ll never speak to them again’ !



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‘It can never be or it always will be ’ Thinking Very often we can over-predict the future. We can in a sense be ‘prophets of of doom’ and decide that bad experiences experiences from the past will. certainly happen in the future. In this way we can often cause unhealthy emotions and actions. Another form of this thinking is that we ‘guess’ the future f uture and predict that all our guesses must be right. This nearly always extends into ‘mind reading’ others and deciding you know what they are thinking t hinking and feeling. These ‘guesses are virtually always negative and very often incorrect. We can so easily ignore the facts, get in touch with the negative be’ forms of thinking.’! feelings and their link with our ‘it can never be or always will be’ forms ‘Feelings are facts’ Thinking Being totally ruled by your feelings and subsequent thoughts; in other words, words, taking your feelings at their face value. value. Whilst feelings are authentic and deserve to be ‘heard’ they are also part of a complex emotional system, with deepening layers that often reach back into our past. This is often referred to t o as the ‘Volcano of Emotions’ with at least 4 layers of of consciousness. Thus feelings are not only complex but they form only one part of the true t rue meaning of incidents and events. Other Possible Errors Some other possible ways of faulty thinking are based on the following : The ‘Perfect’ World

Remember, seeking perfectionism is a lost cause.

There is difference and diversity and not ‘perfection’ ‘perfection’ Attempting to find the ‘perfect’ ‘perfect’ in life leads to disappointment and mental stress. Over-generalising – Remember, one swallow does not necessarily make a Summer. Beware Beware of any tendency to form general ‘rules’ ‘rules’ for particular events events Over-Personalising whilst taking responsibility and personalising events can be helpful, we need to remember that we are not the centre of the world and thus everything does not ‘rotate’ or ‘relate’ to myself. Labelling Needlessly labelling yourself yourself or others, This is often connected with all or nothing thinking Only seeing the negative Failing to see ,or filtering out , positives, this is often Connected with ‘awfulising ’ There are many other possible faults in in thinking that can lead to unhealthy emotions and destructive actions. Individuals can benefit from identifying their faulty thoughts and then developing strategies to challenge and change these. these .



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PAUSE FOR EXERCISE Exploring irrational / faulty thinking

Putting the ABC’s Together Returning to the simple ABC model . It can be seen that an Activating event can trigger a Belief with consequential thoughts and these can give Consequences. This can this can lead either to Unhealthy/Destructive or Healthy rise to Consequences. /Constructive Action. An example of each of these is shown in the following two ABC Tables.

EXAMPLE 1 – Unhealthy / Destructive Action A – The Event B : - The Beliefs You get a C Grade in your You expect an A. You Assignment on a course think “ I’m useless, I should have done better” ‘ This means I’m going to fail the Course ’

‘ Vicious Cycle’

C : - The Consequences You experience feeling of panic and anxiety (emotions (emotions)) feel sick ( physical sensation) and stay in bed next day and don’t attend the School/ behaviour) University ( behaviour)

EXAMPLE 2:- Healthy/Constructive Healthy/Constructive Action ‘ Virtuous Cycle’ A – The Event Peter ( 17) fails his driving test

B : - The Beliefs Peter thinks ‘Too bad I failed the test. Practice makes perfect. I’ll have to take more lessons’

C : - The Consequences Peter feels regret and emotion) irritation.( emotion) A slight ‘sinking feeling’ physical) ( physical) Decides to take more lessons and re-take the test as soon behaviour) as possible.( behaviour)



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Initially, therapists often use a simple ABC Table to assist clients to ‘map ‘m ap out’ the whole of their ABC process. Once this has been done, a more complex Table is used to further the process. The latter will be looked at in greater detail later on in this note. If we were to look at the simple examples of the ABC Table shown above, it is reasonable to suppose that clients are often readily aware of the Consequences and then can move on to identify the Activating event. The bridge or or link between these (the A and the C ) is the Belief that lead to Unhealthy/Destructive or Healthy /Constructive Action. However, many clients find it difficult to readily identify these and the ensuing faulty thoughts. Therefore, when working to explore and identify an ABC ‘pattern’ it is important im portant to reach a point where the ‘thinking’ rooted in the Belief is identified. Then, if it leads to Unhealthy/Destructive Action ( C ) strategies can be devised devised to counter-act the faulty/irrational thoughts thus leading to a more healthy/constructive cycle. Most people can more readily access the Consequences and this is probably the best starting point in identifying an ABC pattern. Some points on this are to be found in the next section.



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Format for a simple ABC Table Table There are many formats for an ABC table. But a simplified version is shown shown below. The five steps are an indication of the order that can be used to complete the Table for a given event. A – The Event The ‘Trigger’

B : - The Beliefs

C : - The Consequences

3.

4

1.

Record ‘trigger’- what started emotions

Record thoughts & beliefs that occurred

Record Emotions

5.

2.

Try to identify ‘fault or error in thinking

Record Behaviour/Action

Step 1.

Record the emotions that have arisen (concerning the event)’

Step 2

Record the resulting behaviour and action (also any physical sensations)

Step 3

Record and explore the ‘trigger’ event that gave rise to Steps 1 and 2.

Step 4. Record the thoughts and beliefs (and explore) that occurred with Steps 1 to 3. These are the link or bridge between the t he Consequences and the Activating event. The Helper/Therapist can either do this during the session with the client and/or encourage the client to maintain their own ABC log or set of tables.

Before moving on to explore how to adapt the simple ABC Table and begin to challenge and change the faulty or irrational thinking, we need to pause for an experiential exercise that uses the simple ABC Table.

PAUSE FOR EXERCISE Establishing the ABC link Part 1



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Taking it Forward – Challenge and Change Once the simplified ABC Table has been explored and the irrational thought(s) identified, then it is possible to begin to deepen the exploration, understanding and action towards challenging and changing unhealthy/destructive patterns. This requires two extra components to be added to the basic ABC scheme. These are often referred to as Disputing irrational thoughts and the Effect of alternative action/changes. This leads to an A B C D E Table, Both of these extra components ( D and E ) will be briefly explored, sub-steps sub-steps for each proposed and then the complete ABCDE Table will be outlined

Disputing Irrational Thoughts The obvious first step is to begin to challenge the irrational thoughts which are based on a ‘faulty’ understanding that is fed by unhealthy beliefs. This requires two new steps, steps 6 and 7 , that follow Steps 1 to 5.. Step 6 Identify and Challenge Identify the ‘thinking error’ and also record a challenge to this. This can best be achieved by a much closer examination of the negative thought(s). Some ways of doing this are to explore the following areas and questions. a.

Is the thinking ‘rigid’ or ‘flexible’? Very often, ‘rigid’ ‘rigid’ thinking leads to negativity.

b.

Are these these thoughts thoughts logical, logical, sensible sensible and can can they be checked checked out with with friends and others?

c.

Are emotions ‘flooding’ and swamping the thoughts?.

Step 7 Generate Alternatives Once errors have been identified, it is important to begin to generate alternative thoughts for the Beliefs. This can be helped by asking the following questions; a.

What do do I do differently when when I’m either not feeling so bad or feeling OK?

b.

What ‘coping ‘coping strategies’ have I adopted in the past either for this or similar situations ?

c.

How can I think in a more flexible and balanced way?

d.

If I were to advice my best friend about this situation, what what one thing might I recommend that could improve the situation?



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These are many other strategies and questions that could be asked in order to assist in Steps 6 and and 7. Now to move move on the E where alternative thoughts, beliefs, emotions and behaviours are explored and implemented as an Experiment and Evaluated. Effects on Emotions and Behaviour Behaviour of Alternative Alternative Thoughts and proposed Action Once Steps 1 to 5 ( initial ABC Table) and Steps 6 and 7 ( challenging negative thoughts and proposing alternatives) has been achieved, it is now time to reflect on this and to try something different. This will require a further step which has two main parts Step 8 : - Effect of Alternative behave differently :

Having decided how you ( wish or think) will feel and

a.

Assess any (predicted) healthy emotions on a scale of either 0 to 10 or 0 to 100, with the higher number being the best

b.

Outline your ‘new’ or ‘modified’ behaviour or action

The final stage is to to implement and act on Step 8b and assess its effects. effects.



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Format for a Complete ABC Table

The final Table is outlined below with all 8 Steps

Steps 1 to 5 A – The Event The ‘Trigger’

B : - The Beliefs

C : - The Consequences

3.

4

1

Record ‘trigger’- what started emotions

Record thoughts & beliefs that occurred

Record Emotions

5.

2

Try to identify ‘fault or error in thinking

Record Behaviour/Action

Steps 6 to 8 D = Dispute / Challenge

E = Effect of Alternative Thought

6.

8

Identify and challenge faulty thoughts and beliefs

Rate the effects of 7 on your emotions Outline your new or modified behaviour / action

7 Find alternatives to those that are challenged

The Helper/Therapist can initially do the simple ABC Table with clients. Once that has been done done , then the ABCDE Table can be explored explored and completed completed either during the session with the client and/or the client can be encouraged and and asked to maintain their own ABC/ ABCDE log or set of of tables. This may take more than one session. session.

PAUSE FOR EXERCISE Establishing the ABC link Part 2



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The aim of the CBT therapy is to assist clients to create more Healthy/ Constructive Consequences, like example 2. of the ABC Model shown earlier. Conclusions This short introduction to CBT outlined the background and some of the t he main concepts of this approach. It defined the terms of CBT and the underlying concept of the link between thoughts, feelings and behaviours. It looked at the ABC Table of activating event or trigger, the consequences for feelings and behaviours of this trigger and the underlying beliefs that underpin the thoughts that generate these emotions and behaviours. IT outlined how this ABC link could result in either healthy/Constructive or Unhealthy/ Destructive emotions or actions. The latter were fuelled by irrational or faulty thinking. t hinking. Some of the more common types of thinking errors were outlined. Finally, it looked at how these thinking errors could be challenged and alternatives found and put into action. All of the above were brought together in a complete ABCDE Table and three exercises facilitated an experiential understanding of these important but introductory concepts of CBT. There is much more to this approach to therapy and change. It is highly effective in treating the triad of neurosis (depression, aggression and addiction) and has a range of advanced concepts and strategies. These are not the subject of this brief note. However, the basics of CBT have been covered. These involve exploring and understanding the Thinking – Feeling – Behaviour cycle. Only when understanding is gained can people decide to and plan goals and actions that change vicious negative cycles into virtuous positive cycles.



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SAGE London Constable, London Constable, London

PCCS Ross on Wye


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A Brief Introduction to Cognitive Behavioural Therapy (CBT)

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