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All of the cognitive behavioral approaches share the same basic characteristics and
assumptions as traditional behavior therapy

Quite diverse, they do share these attributes:

• (1) a collaborative relationship between client and therapist
• (2) the premise that psychological distress is often maintained by cognitive processes
• (3) a focus on changing cognitions to produce desired changes in affect and behavior
• (4) a present-centered, time-limited focus
• (5) an active and directive stance by the therapist, and
• (6) an educational treatment focusing on specific and structured target problems

Based on a structured psychoeducational model, make use of homework, place

responsibility on the client to assume an active role both during and outside therapy sessions,
emphasize developing a strong therapeutic alliance, and draw from a variety of cognitive
and behavioral strategies to bring about change. Therapists help clients examine how they
understand themselves and their world and suggest ways clients can experiment with new
ways of behaving

To a large degree, both cognitive therapy and cognitive behavior therapy are based on the
assumption that beliefs, behaviors, emotions, and physical reactions are all reciprocally
linked. Changes in one area lead to changes in the other areas.

CBT therapists apply behavioral techniques such as operant conditioning, modeling, and
behavioral rehearsal to the more subjective processes of thinking and internal dialogue. In
addition, therapists help clients actively test their beliefs in therapy, on paper, and through
behavioral experiments.

Albert Ellis
• Realizing that he could counsel people skillfully and that he greatly enjoyed doing so, Ellis
decided to become a psychologist. Believing psychoanalysis to be the deepest form of
psychotherapy, Ellis was analyzed and supervised by a training analyst.

• Early in 1955 he developed an approach to psychotherapy he called rational therapy and

later rational emotive therapy, and which is now known as rational emotive behavior
therapy (REBT). Ellis has rightly been referred to as the grandfather of cognitive
behavior therapy.

• To some extent Ellis developed his approach as a method of dealing with his own problems
during his youth. By applying rational and behavioral methods, he managed to conquer some
of his strongest emotional blocks

• Rational emotive behavior therapy (REBT) was the first of the cognitive behavior therapies,
and today it continues to be a major cognitive behavioral approach.

• Its also emphasizes thinking, assessing, deciding, analyzing, and doing. A basic
assumption of REBT is that people contribute to their own psychological problems, as
well as to specific symptoms, by the rigid and extreme beliefs they hold about events
and situations.

• REBT is based on the assumption that cognitions, emotions, and behaviors interact
significantly and have a reciprocal cause-and-effect relationship. REBT has
consistently emphasized all three of these modalities and their interactions, thus
qualifying it as a holistic and integrative approach
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• Ellis gave credit to Alfred Adler as an influential precursor of REBT, and Karen
Horney’s (1950) ideas on the “tyranny of the shoulds” are apparent in the conceptual
framework of REBT

• Ellis’s reformulation of Epictetus’s dictum can be stated as, “People disturb themselves
as a result of the rigid and extreme beliefs they hold about events more than the
events themselves.”

• REBT’s basic hypothesis is that our emotions are mainly created from our beliefs,
which influence the evaluations and interpretations we make and fuel the reactions we
have to life situations. Through the therapeutic process, clients are taught skills that
give them the tools to identify and dispute irrational beliefs that have been acquired
and self-constructed and are now maintained by self-indoctrination, and replacing
them with more rational ones!

• They learn how to replace such detrimental ways of thinking with effective and
rational cognitions, and as a result they change their emotional experience and their
reactions to situations. The therapeutic process allows clients to apply REBT principles
for change not only to a particular presenting problem but also to many other problems in
life or future problems they might encounter.

View of Emotional Disturbance

• REBT is based on the premise that we learn irrational beliefs from significant others
during childhood and then re-create these irrational beliefs throughout our lifetime. We
actively reinforce our self- defeating beliefs through the processes of auto suggestion and self-
repetition, and we then behave in ways that are consistent with these beliefs. Hence, it is
largely our own repetition of early-indoctrinated irrational beliefs, rather than a parent’s
repetition, that keeps dysfunctional attitudes alive and operative within us.

• Ellis asserted that blame can be at the core of many emotional disturbances. If we want to
become psychologically healthy, we had better stop blaming ourselves and others and
learn to fully and unconditionally accept ourselves despite our imperfections.

• 3 Basic Musts (or irrational beliefs) we internalize that inevitably lead to self-defeat (A.
Ellis & Ellis, 2011):

• “I must do well and be loved and approved by others.”

• “Other people must treat me fairly, kindly, and well.”

• “The world and my living conditions must be comfortable, gratifying, and just,
providing me with all that I want in life.”

A-B-C-D-E Framework

• A is the existence of an activating event or adversity, or an inference about an event by an

individual.

• C is the emotional and behavioral consequence or reaction of the individual; the reaction
can be either healthy or unhealthy. A (the activating event) does not cause C (the emotional
consequence).

• Instead, B, which is the person’s belief about A, largely creates C, the emotional reaction.
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• Ellis maintains that the beliefs about the rejection and failure (at point B) are what mainly
cause the depression (at point C)—not the actual event of the divorce or the person’s inference
of failure (at point A). Believing that human beings are largely responsible for creating their
own emotional reactions and disturbances, and showing people how they can change their
irrational beliefs that directly “cause” their disturbed emotional consequences, is at the heart of
REBT
• D (disputing). Essentially, D encompasses methods that help clients challenge their
irrational beliefs. There are three components of this disputing process: detecting,
debating, and discriminating.

• Clients learn to discriminate irrational (self-defeating) beliefs from rational (self-

helping) beliefs (A. Ellis & Ellis, 2011). Once they can detect irrational beliefs,
particularly absolutistic “shoulds” and “musts,” “awfulizing,” and “self-downing,” clients
debate dysfunctional beliefs by logically, empirically, and pragmatically questioning
them.

• REBT emphasizes the process of vigorously disputing (D) such beliefs both during
therapy sessions and in everyday life. Following that, clients are encouraged to develop
E, a new effective philosophy, which also has a practical side. A new and effective belief
system consists of replacing unhealthy irrational thoughts with healthy rational ones.

Therapeutic Goals
• Collaborative effort between therapist and client to choose realistic and life-enhancing
therapeutic goals.

• The therapist’s task is to help clients differentiate between realistic and unrealistic goals
and also between self-defeating and life-enhancing goals.

• Another goal of REBT is to assist clients in the process of achieving unconditional self-
acceptance (USA), unconditional other-acceptance (UOA), and unconditional life-acceptance
(ULA).

Therapist
1. The therapist disputes clients’ irrational beliefs and encourages clients to engage in
activities that will counter their self-defeating beliefs by replacing their rigid “musts” with
preferences.
2. Demonstrate how clients are keeping their emotional disturbances active by continuing to
think illogically and unrealistically. In other words, when clients keep reindoctrinating
themselves, they create their own psychological problems.

3. Helping clients change their thinking and minimize their irrational ideas. Although it
may be unlikely that we can entirely eliminate the tendency to think irrationally, we can
make ongoing efforts to reduce the frequency of such thinking. The therapist encourages
clients to identify the irrational beliefs they have unquestioningly accepted, demonstrates
how they are continuing to indoctrinate themselves with these beliefs, and reminds them that
change is possible with persistent effort.

4. Strongly encourage clients to develop a rational philosophy of life so that in the future
they can avoid hurting themselves again by believing other irrational beliefs. Tackling only
specific problems or symptoms can give no assurance that new disabling fears will not
emerge. It is desirable, then, for the therapist to dispute the core irrational thinking and to
teach clients how to substitute rational beliefs and healthy behaviors for irrational beliefs and
self-defeating behaviors.
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Client

• REBT emphasizes here-and-now experiences and clients’ present ability to change the
patterns ofthinking and emoting that they constructed earlier.

• Therapist may not devote much time to exploring clients’ early history and making
connections between their past and present behavior unless doing so will aid the
therapeutic process.
• Transference is not encouraged, and when it does occur, the therapist is likely to confront
it because it is generally based on the client’s dire need to be liked and approved of by
the therapist. Any unhealthy neediness clients display can be counterproductive and
foster dependence on approval from the therapist.

• By carrying out behavioral homework assignments, clients become increasingly proficient at

minimizing irrational thinking and disturbances in feeling and behaving. Homework is
carefully designed and agreed upon and is aimed at getting clients to carry out productive
actions that contribute to emotional and attitudinal change. These assignments are checked in
later sessions, and clients continue to focus on learning effective ways to dispute self-
defeating thinking.

Therapist & Client Relationship

• Because REBT is a cognitive and directive behavioral process, a warm relationship

between therapist and client is not required, but it may enhance the process for some

• REBT practitioners strive to unconditionally accept all clients and to teach them to
unconditionally accept others and themselves. The therapist takes the mystery out of the
therapeutic process, teaching clients about the cognitive hypothesis of disturbance and
helping clients understand how they are continuing to sabotage themselves and what they
can do to change.

• REBT practitioners accept their clients (and themselves!) as imperfect beings who can
be helped through a variety of techniques including teaching, bibliotherapy, and
behavior modification

The Practice of Rational & Emotive Behaviour Therapy

• REBT practitioners use a number of different modalities (cognitive, emotive, behavioral, and
interpersonal) to dispel self-defeating cognitions and to teach people how to acquire a rational
approach to living.

• Cognitive Methods: demonstrate to clients, often in a quick and direct manner, what it is that
they are continuing to tell themselves. Then they teach clients how to challenge these self-
statements so that they no longer believe them, encouraging them to acquire a philosophy
based on facts. REBT relies heavily on thinking, disputing, debating, challenging,
interpreting, explaining, and teaching. The most efficient way to bring about lasting emotional
and behavioral change is for clients to change their way of thinking
• Disputing Irrational Beliefs—therapist actively disputing clients’ irrational beliefs and
teaching them how to do this challenging on their own. Clients dispute a particular
“must,” absolute “should,” or “ought” until they no longer hold that irrational belief, or
at least until it is diminished in strength.
• Cognitive Homework—clients are expected to make lists of their problems, look for
their absolutist beliefs, and dispute these beliefs. Homework assignments are a way of
tracking down and attending to the “shoulds” and “musts” that are part of their
internalized self-messages. In this way, clients gradually learn to lessen anxiety and to
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challenge basic irrational thinking. Clients may be encouraged to put themselves in

risk-taking situations that will allow them to challenge self-limiting beliefs.

• Bibliotherapy—advantages of bibliotherapy, such as cost-effectiveness, widespread

availability, and the potential of reaching a broad spectrum of populations.
Bibliotherapeutic approaches have empirical support for a range of clinical problems,
including the treatment of depression and many anxiety disorders

• Changing One’s Language— imprecise language is one of the causes of distorted

thinking processes. Clients learn that “musts,” “oughts,” and absolute “shoulds” can be
replaced by preferences. “It would be absolutely awful if …” they learn to say “It would
be inconvenient if …” Clients who use language patterns that reflect helplessness and
self-condemnation can learn to employ new self-statements, which help them think
and behave differently.

• Psychoeducational Methods—various educational materials such as books, DVDs,

and articles. Therapists educate clients about the nature of their problems and how
treatment is likely to proceed. They ask clients how particular concepts apply to them.
Clients are more likely to cooperate with a treatment program if they understand how
the therapy process works and if they understand why particular techniques are being
used

• Emotive Techniques: including unconditional acceptance, rational emotive role playing,

modeling, rational emotive imagery, and shame-attacking exercises. These emotive techniques
tend to be vivid andevocative in nature, and their purpose is to dispute clients’ irrational beliefs.
These strategies are used both during the therapy sessions and as homework assignments in
daily life. Their purpose is not simply to provide a cathartic experience but to help clients
change some of their thoughts, emotions, and behaviors

• Rational Emotional Therapy (REI)—form of intense mental practice designed to

establish new emotional patterns in place of disruptive ones by thinking in healthy
ways. Clients are asked to vividly imagine one of the worst things that might
happen to them and to describe their disturbing feelings. Clients are shown how to
train themselves to develop healthy emotions, and as their feelings about
adversities change, they stand a better chance of changing their behavior in the
situation.

• Humour—Humor has both cognitive and emotional benefits in bringing about

change. Humor shows the absurdity of certain ideas that clients steadfastly
maintain, and it teaches clients to laugh—not at themselves but at their self-
defeating ways of thinking.

• Role Playing—emotive, cognitive, and behavioral components. The therapist may

interrupt to show clients what they are telling themselves to create their disturbances
and what they can do to change unhealthy feelings to healthy ones. Clients can
rehearse certain roles to bring out what they feel in a situation.

• Shame Attacking Exercises—exercises to help people reduce shame and anxiety

over behaving in certain ways. He asserts that we can stubbornly refuse to feel
ashamed by telling ourselves that it is not catastrophic if someone thinks we are
foolish. Exercises can reduce, minimize, and prevent feelings of shame, guilt,
anxiety, and depression. Aimed at increasing self-acceptance and mature
responsibility, as well as helping clients see that much of what they think of as
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being shameful has to do with the way they define reality for themselves. Clients
may take the risk of doing something that they are ordinarily afraid to do
because of what others might think. Through homework practice, clients eventually
learn that they can choose not to let others’ reactions or possible disapproval stop
them from doing the things they would like to do.
Behavioural Techniques: use most of the standard behavior therapy procedures, especially
operant conditioning, self-management principles, systematic desensitization, relaxation
techniques, and modeling. Behavioral homework assignments carried out in real-life situations
are particularly important. These assignments are done systematically and are recorded and
analyzed. Homework gives clients opportunities to practice new skills outside of the therapy
session, which may be even more valuable for clients than work done during the therapy hour

Applications to Group Counseling

• One of the most common CBT group approaches is based on REBT principles and techniques.
REBT practitioners employ an active role in encouraging members to commit themselves to
practicing what they are learning in the group sessions in everyday life. The group context
provides members with tools they can use to become self-reliant and to accept themselves, and
others, unconditionally as they encounter new problems in daily living.

• Members are taught how to apply REBT principles to one another. Ellis recommends that
some clients experience group therapy as well as individual therapy. Group members (1) learn
how their beliefs influence what they feel and what they do, (2) explore ways to change self-
defeating thoughts in various concrete situations, and (3) learn to minimize symptoms
through a profound change in their philosophy

• Group REBT is frequently the treatment of choice because it affords many opportunities to
practice assertiveness skills, to take risks by practicing different behaviors, to challenge self-
defeating thinking, to learn from the experiences of others, and to interact therapeutically and
socially with each other in after-group sessions.

Aaron Temkin Beck

• Health issues growing up as a child which then he experienced blood & injury fears, fear of
suffocation, and anxiety about his health. Beck used his personal problems as a basis for
understanding others and for developing his cognitive theory.

• Through his research, Beck developed a cognitive theory of depression, which represented a
new and comprehensive conceptualization. He found the cognitions of depressed
individuals were characterized by errors in interpretation that he called “cognitive
distortions.” For Beck, negative thoughts reflect underlying dysfunctional beliefs and
assumptions. When these beliefs are triggered by situational events, a depressive pattern
is put in motion.

• Beck is the founder of cognitive therapy (CT), one of the most influential and empirically
validated approaches to psychotherapy. He has won nearly every national and international
prize for his scientific contributions to psychotherapy and suicide research and was even short-
listed for the Nobel Prize in medicine.

• Beck has successfully applied cognitive therapy to depression, generalized anxiety and panic
disorders, suicide, alcoholism and drug abuse, eating disorders, marital and relationship
problems, psychotic disorders, and personality disorders. He has developed assessment scales
for depression, suicide risk, anxiety, self-concept, and personality.
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Judith S. Beck
• Daughter of Aaron Beck, completed a postdoctoral fellowship at the Center for Cognitive
Behavior Therapy at the University of Pennsylvania. In 1994 she and her father opened the
nonprofit Beck Institute for Cognitive Therapy in suburban Philadelphia, and she is currently
president of the institute.

• A premier training organization, the institute is devoted to national and international training
in cognitive therapy through workshop and supervision programs for students and faculty,
deployed and returning military families, and health and mental health professionals at all
levels.

Aaron Beck’s Cognitive Therapy

• Aaron Beck developed cognitive therapy (CT) about the same time that Albert Ellis was
developing REBT. Albert Ellis developed REBT based on philosophical tenets, whereas
Beck’s CT was based on empirical research

• CT emphasizes education and prevention but uses specific methods tailored to particular
issues. The specificity of CT allows therapists to link assessment, conceptualization, and
treatment strategies

• Beck’s careful empirical approach was eventually adopted by colleagues around the world.
Evidence- supported CT approaches were developed for many disorders including
depression, panic disorder, social anxiety, phobias, posttraumatic stress disorder,
schizophrenia and other psychotic disorders, hypochondriasis, body dysmorphic disorder,
eating disorders, insomnia, anger issues, stress, chronic pain and fatigue, and distress due to
general medical problems such as cancer

• Research revealed that depressed clients had a negative bias in their interpretation of
certain life events, which resulted from active processes of cognitive distortion. This led
Beck to believe that a therapy that helped depressed clients become aware of and change
their negative thinking could be helpful.

• Beck’s research indicated that depression could result from negative thinking, but it could
also be precipitated by genetic, neurobiological, or environmental changes. One of
Beck’s early contributions was to recognize that regardless of the cause of depression,
once people became depressed, their thinking reflected what Beck referred to as the
negative cognitive triad: negative views of the self (self-criticism), the world
(pessimism), and the future (hopelessness).

• Cognitive therapy (CT) has a number of similarities to both rational emotive behavior
therapy and behavior therapy. All of these therapies are active, directive, time-limited,
present-centered, problem- oriented, collaborative, structured, and empirical. They include
homework assignments and require clients to explicitly identify problems and the situations
in which they occur

• Similar to REBT and unlike behavior therapy, CT is based on the theoretical rationale that
the way people feel and behave is influenced by how they perceive and place meaning on
their experience.
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• Three theoretical assumptions of CT are

(1) that people’s thought processes are accessible to introspection,

(2) that people’s beliefs have highly personal meanings, and
(3) that people can discover these meanings themselves rather than being taught or having
them interpreted by the therapist

A Generic Cognitive Model

• Beck has proposed a generic cognitive model to describe principles that pertain to all CT
applications from depression and anxiety treatments to therapies for a wide variety of other
problems including psychosis and substance use

• Generic cognitive model provides a comprehensive framework for understanding

psychological distress, and some of its major principles are described here. Beck encouraged
others to design research to investigate the components of his model in an effort to reach the
best understanding possible of human cognition, behavior, and emotion.

• Psychological distress can be thought of as an exaggeration of normal adaptive

human functioning. When people are functioning well, they experience many
different emotions in response to life events and behave in ways that help them solve
problems, achieve goals, and protect themselves from harm

• Faulty information processing is a prime cause of exaggerations in adaptive

emotional and behavioral reactions. Our thinking is directly connected to our
emotional reactions, behaviors, and motivations. When we think about things in
erroneous or distorted ways, we experience exaggerated or distorted emotional and
behavioral reactions as well

• Arbitrary Influences— conclusions drawn without supporting evidence. This

includes “catastrophizing,” or thinking of the absolute worst scenario and outcomes
for most situations. You might begin your first job as a counselor with the conviction
that you will not be liked or valued. You are convinced that you fooled your professors
and somehow just managed to get your degree, but now people will certainly see through
you!

• Selective Abstraction— forming conclusions based on an isolated detail of an

event while ignoring other information. The significance of the total context is
missed. As a counselor, you might measure your worth by your errors and weaknesses
rather than by your successes.

• Overgeneralization— process of holding extreme beliefs on the basis of a single

incident and applying them inappropriately to dissimilar events or settings. If you
have difficulty working with one adolescent, for example, you might conclude that you
will not be effective counseling any adolescents. You might also conclude that you will
not be effective working with any clients!

• Magnification and Minimization— consist of perceiving a case or situation in a

greater or lesser light than it truly deserves. You might make this cognitive error by
assuming that even minor mistakes in counseling a client could easily create a crisis for
the individual and might result in psychological damage.

• Personalization— tendency for individuals to relate external events to themselves,

even when there is no basis for making this connection. If a client does not return for a
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second counseling session, you might be absolutely convinced that this absence is due to
your terrible performance during the initial session. You might tell yourself, “This
situation proves that I really let that client down, and now she may never seek help
again.”

• Labeling and Mislabelling— portraying one’s identity on the basis of imperfections

and mistakes made in the past and allowing them to define one’s true identity. If you
are not able to live up to all of a client’s expectations, you might say to yourself, “I’m
totally worthless and should turn my professional license in right away.”

• Dichotomus Thinking— categorizing experiences in either-or extremes. With such

polarized thinking, you might view yourself as either being the perfectly competent
counselor (you always succeed with all clients) or as a total flop if you are not fully
competent (there is no room for any mistakes).

• Our beliefs play a major role in determining what type of psychological distress we will
experience. Each emotional and behavioral disorder is accompanied by beliefs specific to
that problem. Consider two students who apply to college and are not accepted to their first
choice of school. One of the students becomes depressed, the other becomes anxious.
Depression is accompanied by negative thoughts about oneself (“I’ve failed,” “Nothing
will work out for me,” “I’ll never get into medical school”). Anxious thoughts reflect
overestimations of threat or danger (“Everyone will think less of me when they find out I
wasn’t admitted to that college”) and underestimations of one’s coping (“I won’t know
what to say to people about it”) and underestimation of resources (“These other colleges
won’t prepare me well enough for medical school”).

• Central to cognitive therapy is the empirically supported observation that “changes in

beliefs lead to changes in behaviors and emotions” If the students in the previous
example can change the way they think about not being accepted to their first choice
school, their depression and anxiety are likely to be lessened. The first student will
undoubtedly feel less depressed once a more balanced view of the rejection letter is
adopted (“More good students apply than can be admitted. My rejection does not mean I
failed. I’m sure many students from my second choice school go on to attend medical
school.”). Similarly, the anxious student would benefit from new beliefs as well (“I can tell
others that I am disappointed that I did not get into my first choice college. Some people
might think less of me, but those who really care about me will understand that not
everyone gets their first choice and they will be supportive.”).

• If beliefs are not modified, clinical conditions are likely to reoccur. Even without
counseling or a change in beliefs, people often recover from feelings of depression or
anxiety and return to their usual healthy functioning. However, these feelings may return
in times of future stress or disappointment if their basic beliefs have not changed. In
studies of the long-term effects of treatments for depression and anxiety disorders,
cognitive therapy and other types of CBT therapies have the lowest rates of relapse. Many
believe this is because these therapies lead to enduring changes in beliefs.

Basic Principles of Cognitive Therapy

• Cognitive therapy (CT) perceives psychological problems as an exaggeration of adaptive

responses resulting from commonplace cognitive distortions. Like REBT, CT is an insight-
focused therapy with a strong psychoeducational component that emphasizes recognizing and
changing unrealistic thoughts and maladaptive beliefs. Cognitive therapy is highly
collaborative and involves designing specific learning experiences to help clients understand
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the links between their thoughts, behaviors, emotions, physical responses, and situations

• Once clients identify cognitive distortions, they are taught to examine and weigh the
evidence for and against them. This process of critically examining thoughts involves
empirically testing them by looking for evidence, actively engaging in a Socratic dialogue
with the therapist, carrying out homework assignments, doing behavioral experiments,
gathering data on assumptions made, and forming alternative interpretations

• Cognitive therapy is focused on present problems, regardless of a client’s diagnosis. The past
may be brought into therapy when the therapist considers it essential to understand how and
when certain core dysfunctional beliefs originated and how these ideas have a current impact
on the client’s difficulties

Some Differences Between CT & REBT

• Both CT and REBT, reality testing is highly organized. Clients come to realize on an
experiential level that they have misconstrued situations

• REBT is often highly directive, persuasive, and confrontational, and the teaching role of the
therapist is emphasized. The therapist models rational thinking and helps clients to identify
and dispute irrational beliefs. In contrast, CT uses Socratic dialogue, posing open-ended
questions to clients with the aim of getting clients to reflect on personal issues and arrive at
their own conclusions.
• CT places more emphasis on helping clients identify misconceptions for themselves
rather than being taught. Through this reflective questioning process, the cognitive
therapist collaborates with clients in testing the validity of their cognitions (a process
called collaborative empiricism)

• There are also differences in how Ellis and Beck view faulty thinking. Through a process of
rational disputation, Ellis works to persuade clients that certain of their beliefs are irrational
and nonfunctional. Beck views his clients’ distorted beliefs as being the result of cognitive
errors rather than being driven solely by irrational beliefs. Beck asks his clients to conduct
behavioral experiments to test the accuracy of their beliefs

• For Beck, people live by rules (underlying assumptions); they get into trouble when
they label, interpret, and evaluate by a set of rules that are unrealistic or when they use
the rules inappropriately or excessively. If clients decide they are living by rules that
are likely to lead to misery, the therapist asks clients to consider and test out alternative
rules.

Client-Therapist Relationship
• A therapeutic alliance is a necessary first step in cognitive therapy, especially in counseling
difficult-to- reach clients. Therapists must have a cognitive conceptualization of cases, be
creative and active, be able to engage clients through a process of Socratic questioning, and be
knowledgeable and skilled in the use of cognitive and behavioral strategies aimed at guiding
clients in significant self-discoveries that will lead to change

• Cognitive therapists are continuously active and deliberately interactive with clients, helping
clients frame their conclusions in the form of testable hypotheses. The cognitive therapist
functions as a catalyst and a guide who helps clients understand how their beliefs and
attitudes influence the way they feel and act.

• Clients are expected to identify the distortions in their thinking, summarize

important points in the session, and collaboratively devise homework assignments
that they agree to carry out. Client’s thinking and behavior will be most likely to occur
with the client’s initiative, understanding, awareness, and effort
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• Cognitive therapists identify specific, measurable goals and move directly into the areas
that are causing the most difficulty for clients
• One way of educating clients is through bibliotherapy, in which clients complete
readings that support and expand their understanding of cognitive therapy principles and
skills. These readings are assigned as an adjunct to therapy and are designed to enhance the
therapeutic process by providing an educational focus

• The purpose of homework is not merely to teach clients new skills but also to enable them
to test their beliefs and to try out different behaviors in daily-life situations. Homework is
generally presented to clients as an experiment that serves to continue work on issues
addressed in a therapy session

• Cognitive therapists realize that clients are more likely to complete homework if it is tailored
to their needs, if they participate in designing the homework, if they begin the homework in the
therapy session, and if they talk about potential problems in implementing the homework

Applications
• Cognitive therapy initially gained recognition as an approach to treating depression, but
extensive research has been devoted to the study and treatment of many other psychiatric
disorders. Hundreds of research studies have confirmed the theoretical underpinnings of CT,
and hundreds of outcome trials have established its efficacy for a wide range of psychiatric
disorders, psychological problems, and medical conditions with psychological components

• Cognitive therapy has been successfully used to treat depression, each of the anxiety disorders,
cannabis dependence, hypochondriasis, body dysmorphic disorder, eating disorders, anger,
schizophrenia, insomnia, and chronic pain, suicidal behavior, borderline personality disorders,
narcissistic personality disorders, and schizophrenic disorders, personality disorders, substance
abuse, medical illness, crisis intervention, couples and families therapy, and child abusers,
divorce counseling, skills training, and stress management

• Moreover, the effects of CT for depression and anxiety disorders seem to be more
enduring that the effects of other treatments, with the exception of behavior therapy, which
sometimes matches CT induration of positive outcome.

• Cognitive methods focus on identifying and examining a client’s beliefs, exploring the origins
of these beliefs, and modifying them if the evidence does not support these beliefs. Examples
of behavioral techniques typically used by cognitive therapists include activity scheduling,
behavioral experiments, skills training, role playing, behavioral rehearsal, and exposure
therapy.

• The length and course of cognitive therapy varies greatly and is determined by the therapy
protocols used for specific diagnoses. Activity has an antidepressant effect, especially when
the client engages in a mix of pleasurable, accomplished, and anti-avoidance activities.

• As depression begins to lift, the therapist introduces additional skills such as thought
records, which help clients identify negative automatic thoughts and test them. When
evidence does support the problematic thought, clients are helped to create an action plan to
solve the problem rather than ruminating on it

• Cognitive therapy for panic disorder generally lasts only 6 to 12 sessions and targets
catastrophic beliefs about internal physical and mental sensations. Clients are helped to identify
the sensations that trigger a panic attack and the catastrophic beliefs about these sensations.
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• The therapist helps the client generate an alternative hypothesis to explain these feared
sensations.

• The cognitive behavioral approach focuses on cognitions, emotions, and behavior as they exert
a mutual influence on one another within family relationships to cause dysfunction

• Cognitive Theory emphasizes schema, elsewhere defined as core beliefs, as key aspect of the
therapeutic process. Therapists help families restructure distorted beliefs (or schema) in order
to change dysfunctional behaviors.

• These jointly held beliefs about the family have formed as a result of years of interaction
among family members. These schemata are influenced by the parents’ family of origin and
have a major impact on how each individual thinks, feels, and behaves in the family system

Strengths-Based Cognitive Behavioral Therapy

• Strengths-based cognitive behavior therapy (SB-CBT) is a variant of Aaron Beck’s

cognitive therapy developed by Christine Padesky and Kathleen Mooney’s

• One central addition of SB-CBT is an emphasis on identification and integration of client

strengths at each phase of therapy. The main idea of SB-CBT is that active incorporation of
client strengths encourages clients to engage more fully in therapy and often provides
avenues for change that otherwise would be missed.

• Chrisitine Padesky:

• Beck and Padesky met and became friends, and he was her mentor throughout her
career

• Opened one of the first Centers for Cognitive Therapy in the western United States (now
located in Huntington Beach, California). She partnered in this venture with Kathleen
Mooney, a creative CBT therapist dedicated to innovation and therapist education.

• Padesky and Mooney developed many innovations in the practice of cognitive therapy
including the use of constructive questions, the importance of identifying client imagery
and metaphors for change, and an emphasis on client strengths.

• SB-CBT expands previous models of CBT to include methods that help people develop
positive qualities. Their ideas developed in parallel with positive psychology, a research
field that investigates happiness, resilience, altruism, and a host of positive emotions
and behaviors

• Like cognitive therapy, SB-CBT is empirically based. This means that

• (1) therapists should be knowledgeable about evidence-based approaches pertaining
to client issues discussed in therapy
• (2) clients are asked to make observations and describe the details of their life
experiences so what is developed in therapy is based in the real data of clients’ lives
• (3) therapists and clients collaborate in testing beliefs and experimenting with new
behaviors tosee if they help achieve desired goals.
• Strengths are integrated into each phase of treatment in SB-CBT beginning with the intake
interview. After reasons for seeking therapy are described and explored, the SB-CBT
therapist expresses an interest in positive aspects of the client’s life. Positive interests and
strengths identified in early therapy sessions can provide a wealth of information to help
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therapist and client collaboratively integrate strengths into case conceptualization and
treatment.
• SB-CBT therapists help clients develop and construct new positive ways of interacting in
the world. The SB-CBT model for building and strengthening personal resilience can be
used on its own or integrated with another evidenced-based CBT treatment for a diagnostic
disorder

Client- Therapist Relationship

• SB-CBT therapists are collaborative, active, here-and-now focused, and client-centered. SB-
CBT therapists are encouraging allies of their clients and need to be genuine, caring, and
willing to engage with clients as full human beings in both struggles and successes. SB-
CBT therapists do not take an “expert” stance but instead serve as curious assistants or
guides to their clients’ own discovery and growth.

• SB-CBT practitioners ask clients for imagery and metaphors to describe their experiences, both
positive and negative. More than words, imagery and metaphors capture and integrate the
emotional, cognitive, physiological, and behavioral aspects of experience. In addition to
deconstructing beliefs and problems, SB-CBT emphasizes the constructive use of Socratic
questioning.
Applications
• 3 current applications for SB-CBT are as
• (1) an add-on for classic CBT
• (2) a four-step model to build resilience and other positive qualities
• (3) the NEW Paradigm for chronic difficulties and personality disorders. SB-CBT
operates as an add-on to classic CBT when clients come to therapy with goals to reduce
problematic moods (depression, anxiety, anger), behaviors (eating disorders, substance
misuse) or other difficulties (psychoses, hypochondriasis) for which there are well-
established and effective CBT protocols.

• 4 steps are (1) search, (2) construct, (3) apply, and (4) practice. Padesky and Mooney point
out that there are usually just a few common pathways to a psychological disorder, but
there are thousands of pathways to resilience.

1. Rather than teach clients particular ways to be resilient, Padesky and Mooney
suggest that therapists inquire about activities in clients’ lives that are going well
and that clients do on a regular basis.

2. Discover what obstacles clients encounter while doing these activities and how they
manage these obstacles. A central idea is that everybody encounters obstacles in any
frequently practiced activity but we manage obstacles without even realizing that is
what we are doing when we enjoy the activity. Strategies can be written down in
Personal Model of Resilience (PMR).

3. The third step involves the therapist helping the client creatively consider how
he/she can apply his/her PMR to remain resilient in a more problematic area of
his/her life. For example- dating.

4. The fourth stage involves conducting a series of dating experiments while she/he
practices maintaining a focus on resilience. A key to this stage of the therapy is that
the client sets a goal to “be resilient in the face of challenges,” not to succeed at
dating. Because his goal is to “stay resilient” he has a better chance of experiencing
his dates in a positive way. Even if he and his date don’t get along, he can feel good
about staying resilient.
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• The final application of SB-CBT is the NEW Paradigm for chronic issues and personality
disorders. This approach is more comprehensive and requires clients to vividly construct new
ways to feel, think, and behave in their life. The four steps of this model are-
• (1) Conceptualize the OLD System of operating and help clients understand they do
things “forgood reasons,”

• (2) construct NEW systems of how clients would like to be

• (3) strengthen the NEW using behavioral experiments to try on NEW ways of being and
edit themas needed

• (4) relapse management.

Donald Michenbaum

• Conducted research on the development of cognitive behavior therapy (CBT). He is one of the
founders of cognitive behavior therapy, and in a survey of clinicians he was voted one of the
most influential therapists in the 20th century.

• Meichenbaum attributes the origin of CBT to his mother, who had a knack for telling stories
about her daily activities that were peppered with her thoughts, feelings, and a running
commentary. This childhood experience contributed to Meichenbaum’s psychotherapeutic
approach of constructivist narrative therapy, in which clients tell their stories and describe
what they did to “survive and cope.”

• Donald Meichenbaum’s cognitive behavior modification (CBM) focuses on changing the

client’s self-talk.

• A basic premise of CBM is that clients, as a prerequisite to behavior change, must notice how
they think, feel, and behave and the impact they have on others. For change to occur, clients
need to interrupt the scripted nature of their behavior so that they can evaluate their behavior in
various situations

• This approach shares with REBT and Beck’s cognitive therapy the assumption that distressing
emotions are often the result of maladaptive thoughts. REBT is more direct and
confrontational in uncovering and disputing irrational thoughts, whereas Meichenbaum’s
self-instructional training focuses more on helping clients become aware of their self-talk
and the stories they tell about themselves. Both REBT and CT focus on changing thinking
processes, but Meichenbaum suggests that it may be easier and more effective to change our
behavior rather than our thinking.

• Therapeutic process consists of teaching clients to make self-statements and training clients to
modify the instructions they give to themselves so that they can cope more effectively
with the problems they encounter.

• Cognitive restructuring plays a central role in Meichenbaum’s (1977, 1993) self-instructional

training. He describes cognitive structure as the organizing aspect of thinking, which
monitors and directs the choice of thoughts through an “executive processor” that “holds the
blueprints of thinking” that determines when to continue, interrupt, or change thinking.

• Meichenbaum (1977) proposes that “behavior change occurs through a sequence of

mediating processes involving the interaction of inner speech, cognitive structures, and
behaviors and theirresultant outcomes”.
• Phase 1: Self-observation. Clients learning how to observe their own behavior. When
clients begin therapy, their internal dialogue is characterized by negative self-statements
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and imagery. A critical factor is their willingness and ability to listen to themselves. This
process involves an increased sensitivity to their thoughts, feelings, actions, physiological
reactions, and ways of reacting to others. If depressed clients hope to make constructive
changes, for example, they must first realize that they are not “victims” of negative
thoughts and feelings.

• Phase 2: Starting a new internal dialogue. As a result of the early client–therapist

contacts, clients learn to notice their maladaptive behaviors, and they begin to see
opportunities for adaptive behavioral alternatives. If clients hope to change what they are
telling themselves, they must initiate a new behavioral chain, one that is incompatible with
their maladaptive behaviors. Clients learn that psychological distress is a function of the
interdependence of cognitions, emotions, behaviors, and resultant consequences. In
therapy, clients learn to change their internal dialogue, which serves as a guide to new
behavior.

• Phase 3: Learning new skills. Clients learn to interrupt the downward spiral of
thinking, feeling, and behaving, and the therapist teaches clients more adaptive ways of
coping using the resources they bring to therapy. Clients learn more effective coping
skills, which are practiced in real-life situations. As they behave differently in situations,
they typically get different reactions from others. The stability of what they learn is
greatly influenced by what they say to themselves about their newly acquired behavior
and its consequences.

Stress Inoculation Training

• A particular application of a coping skills program is teaching clients stress management
techniques by way of a strategy known as stress inoculation training (SIT). Individuals are
given opportunities to deal with relatively mild stress stimuli in successful ways, and they
gradually develop a tolerance for stronger stimuli. This training is based on the assumption
that we can affect our ability to cope with stress by modifying our beliefs and self-statements
about our performance in stressful situations. Meichenbaum’s stress inoculation training is
concerned with more than merely teaching people specific coping skills. His program is
designed to prepare clients for intervention and motivate them to change, and it deals with
issues such as resistance and relapse.

• SIT—combination of information giving, Socratic discovery-oriented inquiry, cognitive

restructuring, problem solving, relaxation training, behavioral rehearsals, self-monitoring,
self-instruction, self- reinforcement, and modifying environmental situations. These coping
skills are designed to be applied to both present problems and future difficulties. Clients
are assisted in generalizing what they have learned so they can use these skills in daily living,
and relapse prevention strategies are taught

The following procedures are designed to teach these coping skills:

• Expose clients to anxiety-provoking situations by means of role playing and imagery
• Require clients to evaluate their anxiety level
• Teach clients to become aware of the anxiety-provoking cognitions they experience
in stressful situations
• Help clients examine these thoughts by re-evaluating their self-statements
• Have clients note the level of anxiety following this reevaluation

Phases of SIT / three-stage model for stress inoculation training:

(1) the conceptual-educational phase

- primary focus is on creating a therapeutic alliance with clients. This is done by helping clients
gain a better understanding of the nature of stress and reconceptualizing it in social-interactive
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terms. Initially, clients are provided with a conceptual framework in simple terms designed to
educate them about ways of responding to a variety of stressful situations.

- They learn about the role cognitions and emotions play in creating and maintaining stress
through didactic presentations, by curious questioning, and by a process of guided self-
discovery. A collaborative relationship is created during this early phase, and together
they rethink the stress concerns clients bring to understand the nature of the problem.

- As a way to understand the subjective world of clients, the therapist generally elicits stories
that clients tell themselves. Training includes teaching clients to become aware of their own
role in creating their stress and their life stories. They acquire this awareness by
systematically observing the statements they make internally as well as by monitoring the
maladaptive behaviors that flow from this inner dialogue. Such self-monitoring continues
throughout all the phases.

(2) the skills acquisition and consolidation phase

- focus is on giving clients a variety of behavioral and cognitive coping skills to apply to
stressful situations. This phase involves direct actions, such as gathering information about
their fears, learning specifically what situations bring about stress, arranging for ways to
lessen the stress by doing something different, and learning methods of physical and
psychological relaxation.

- The training involves cognitive coping; clients are taught that adaptive and maladaptive
behaviors are linked to their inner dialogue. Through this training, clients acquire and
rehearse a new set of self- statements (Ex: “How can I prepare for a stressor?” “How can I
cope feeling overwhelmed?”)

- Clients also are exposed to various behavioral interventions, such as relaxation training,
social skills training, time-management instruction, and self-instructional training. They are
helped to make lifestyle changes by reevaluating priorities, developing support systems, and
taking direct action to alter stressful situations. Through teaching, demonstration, and guided
practice, clients learn the skills of progressive relaxation and practice them regularly to
decrease arousal due to stress.

(3) the application and follow-through phase.

- focus is on carefully arranging for transfer and maintenance of change from the therapeutic
situation to everyday life. Clients practice their new self-statements and apply their new skills
to everyday life. To consolidate the lessons learned in the training sessions, clients participate
in a variety of activities, including imagery and behavior rehearsal, role playing, modeling,
and graded in-vivo exposure.

- Once clients have become proficient in cognitive and behavioral coping skills, they practice
behavioral assignments, which become increasingly demanding. They are asked to write down
the homework assignments they are willing to complete.

- The outcomes of these assignments are carefully checked at subsequent meetings, and if
clients do not follow through with them, the therapist and the client collaboratively consider
the reasons for the failure.

- Relapse Prevention—consists of procedures for dealing with the inevitable setbacks clients
are likely to experience as they apply what they are learning to daily life, is taught at this
stage. Clients learn to view any lapses that occur as “learning opportunities” rather than as
“catastrophic failures.” Clients explore a variety of possible high-risk, stressful situations
that they may reexperience.
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- Clinical applications of SIT are individually tailored to specific target populations and
include anger control, pain control, anxiety management, assertion training, improving
creative thinking, treating depression, dealing with health problems, and preparing for
surgery. Stress inoculation training has been employed with medical patients and with
psychiatric patients. SIT has been successfully used with children, adolescents, and adults
who have anger problems, anxiety disorders, phobias, social incompetence, addictions,
alcoholism, sexual dysfunctions, social withdrawal, or posttraumatic stress disorder (PTSD),
including use with veterans who experience combat-related PTSD

A Cognitive Narrative Approach to CBT

• Meichenbaum (2015) has embraced a cognitive narrative perspective, which focuses on
the plots, characters, and themes in the stories people tell about themselves and others
regarding significant events in their lives
• This approach begins with the assumption that there are multiple realities. One of the
therapeutic tasks is to help clients appreciate how they construct their realities and how they
author their own stories
(see Chapter 13). Meichenbaum claims that we are all “story tellers” and that we should
be aware of the stories we tell ourselves and others.
• Therapists help clients appreciate how they construct reality and examine the implications and
conclusions clients draw from their stories. Telling the “rest of the story”—what they did to
survive and cope—bolsters clients’ strengths and helps them develop resilient-engendering
behaviors. In this way, clients can move from being “stubborn victims” to becoming
“tenacious survivors” and perhaps “impressive thrivers.”
• He uses a Socratic discovery-oriented approach and the art of questioning to assist clients
in reaching their goals. Meichenbaum (1997) uses these questions to evaluate the outcomes
of therapy:
• Are clients now able to tell a new story about themselves and the world?
• Do clients now use more positive metaphors to describe themselves?
• Are clients able to predict high-risk situations and employ coping skills in dealing with
emerging problems?
• Are clients able to take credit for the changes they have been able to bring about?

Strengths
• Cognitive behavioral approaches have several strength in working with individuals from
diverse cultural, ethnic, and racial backgrounds. Cognitive behavior therapy tends to be
culturally sensitive because it uses the individual’s belief system, or worldview, as part of
the method of self-exploration

• Clients tend to appreciate the emphasis on cognition and action, as well as the stress on
relationship issues.

• Some of the factors that Spiegler identifies that makes CBT diversity effective include
individualized treatment, focus on the external environment, active nature, emphasis on
learning, reliance on empirical evidence, concern with present behavior, and brevity. A strength
of CBT is integrating assessment of client beliefs, emotional responses, and behavioral choices
throughout therapy, which communicates respect for clients’ viewpoints regarding their
progress.

• Aspects that contribute to an integrative framework include the following:

• Interventions are tailored to the unique needs and strengths of the individual.
• Clients are empowered by learning specific skills they can apply in daily life (CBT)
and by the emphasis on cultural influences that contribute to clients’ uniqueness
(multicultural therapy).
• Inner resources and strengths of clients are activated to bring about change.
• Clients make changes that minimize stressors, increase personal strengths and supports,
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and establish skills for dealing more effectively with their physical and social (cultural)
environments.

Shortcomings
• REBT therapists would do well to use caution in their choice of language and expression
when confronting clients about their beliefs and behaviors. REBT suggests that the
therapist’s job is to help clients critically examine long-standing cultural values that result in
dysfunctional emotions or behaviors, but a potential limitation of REBT is its negative view
of dependency.

• Clients with long-cherished cultural values pertaining to interdependence may not respond
favorably to forceful methods of persuasion toward independence. Skillful REBT practitioners
carefully monitor their manner, style, and choice of words and communicate whenever
possible in language that is congruent with the client’s culture. By emphasizing collaboration
over confrontation, as the cognitive behavioral approaches do, the therapist can avoid seeming
to be disrespectful

• The emphasis of CBT on assertiveness, independence, verbal ability, rationality, cognition,

and behavioral change may limit its use in cultures that value subtle communication over
assertiveness, interdependence over personal independence, listening and observing over
talking, and acceptance overbehavior change

• In CBT the focus is on the present, which can result in the therapist failing to recognize
the role of the past in a client’s development. Cognitive behavioral assessments involve the
investigation of a client’s personal history. If the therapist is unaware of a client’s cultural
beliefs, which are rooted in the past, the therapist may have difficulty interpreting the client’s
personal experiences accurately.

• Another limitation of CBT from a multicultural perspective involves its individualistic

orientation. An inexperienced therapist may overemphasize cognitive restructuring to the
neglect of environmental interventions. Hays (2009) points out that these potential limitations
do not preclude the integration of CBT and multicultural counseling. Instead, being aware of
these limitations “presents opportunities for rethinking, refining, adapting and increasing the
relevance and effectiveness of psychotherapy”.