INTRODUCTION TO CBT

CBT is an intensive, short-term (six to 20 sessions), problem-

oriented approach. It was designed to be quick, practical and goal-oriented and to
provide people with long-term skills to keep them healthy. The focus of cbt is on
the here-and-now—on the problems that come up in a person’s day-to-day life. cbt
helps people to look at how they interpret and evaluate what is happening around
them and the effects these perceptions have on their emotional experience.
Cognitive-behavioral therapy (CBT) emerged as a rational amalgam
of behavioral and cognitive theories of human behavior, causal and maintaining
forces in psychopathology, and targets for intervention. The numerous strategies
that comprise CBT reflect its complex and integrative history. Following from early
respondent conditioning theories, CBT incorporates concepts such as extinction
and habituation. CBT went on to integrate modeling and cognitive restructuring
strategies from social learning and cognitive theories. In addition, Meichenbaum
and Goodman’s focus on self-talk and D’Zurilla and Goldfried’s problem solving
are each evident in CBT’s general focus on fostering the development of personal
coping strategies and mastery of emotional and cognitive processes. Consistent
with a tripartite view (cognition, behavior, emotion) of psychopathology, CBT
targets these multiple areas of vulnerability and employs multiple avenues of
intervention.
In CBT, you learn to identify, question and change the thoughts,
attitudes, beliefs and assumptions related to your problematic emotional and
behavioural reactions to certain kinds of situations. By monitoring and recording
your thoughts during situations that lead to emotional upset, you learn that the way
you think can contribute to emotional problems such as depression and anxiety. In
CBT, you learn to reduce these emotional problems by:
• identifying distortions in your thinking
• seeing thoughts as ideas about what is going on rather than as facts
• “standing back” from your thinking to consider situations from different
viewpoints.
 Although CBT continues to evolve, most individuals see the
foundation of the approach in one of two domains. For some, CBT grew from its
allied field of behavior therapy. By the 1970s, behavior therapy had begun to
move beyond an explicit and limited focus on observable behavior to a broader
approach that included conceptions related to internal cognitions and emotions. For
example, social learning theory (Bandura, 1986) recognized that when children
learn a new behavior, they have to observe a model, internalize the actions of that
model, and then be able to replicate the observed behavior in themselves. This
complex series of acts related to observation, recognition, and planning are all
cognitive activities; thus, cognitive processes played a central role in the social
learning approach. Research that focused on the process of delay of gratification
similarly invoked the idea that children could maintain a cognitive representation
of the gratification (i.e., positive reinforcer) that they were going to obtain even as
they engaged in the behavior that would eventually lead to the reinforcement. On
the basis of these ideas, the field of cognitive behavior modification (Mahoney,
1974; Meichenbaum, 1977) began, which set the stage for cognitive behavioral
therapy. Applications to issues such as anxiety disorders quickly evolved, and it
appeared that cognitive behavior modification and social learning therapy would
become movements in their own right.
The other major innovation in the 1970s that led to the development
of CBT was more revolutionary than that seen in behavior therapy. Early theorists
in what would become the field of CBT, such as Albert Ellis and Aaron T. Beck,
were initially trained in psychoanalysis and in that training had an emphasis on
early experience, unconscious process, and personality dynamics. Both theorists,
however, recognized that many aspects of psychodynamic theory did not appear to
contribute to significant change in psychotherapy, and they both articulated a more
parsimonious and, some might argue, a more simplistic view of human dynamics
in behavior change. For example, both suggested that people’s beliefs affected the
manner in which they viewed the world and that it was their beliefs and construal
of events that was in fact more important in the ultimate response to life’s
circumstances than the circumstances themselves. Predicated on this assumption,
both theorists developed models in which cognitive assessment and cognitive
change became the pivotal point for later behavioral adaptation and emotional
success. Rational emotive therapy, as it was called (Ellis & Whiteley, 1979), and
cognitive therapy (A. T. Beck, 1970) eventually emerged as well developed
psychotherapies that became the focus of training, research, and practice. Since the
early evolution of cognitive behavioral therapies, many other approaches have
joined their ranks (K. S. Dobson & Dozois, 2009).
It is now recognized that the cognitive behavioral therapies rest on
several basic tenets, including the ideas that:
(a) cognition mediates the relation between activating events or stressors and the
reactions to those stressors.
(b) cognitions are not unconscious but can be monitored with training and the
proper technology.
(c) systematic changes to cognition can lead to planned therapeutic outcomes.

BASIC CONCEPTS OF CBT

A primary focus of cognitive therapy is to assist clients in examining
and restructuring their core beliefs (or core schema) (Dozois & Beck, 2011). By
encouraging clients to gather and weigh the evidence in support of their beliefs,
therapists help clients bring about enduring changes in their mood and their
behavior.

Behavioral Concepts
CBT uses all the armamentarium developed by the rich tradition of
behavior therapy.

Exposure
The essence of exposure is bringing patients into contact with the
cues that evoke their negative emotions, in a deliberate, self-controlled manner.
They remain in contact with these cues until:
(1) their anxiety diminishes (habituation)
(2) they begin to realize that the consequences they expected do not occur
(disconfirmation).
The types of cues that become the target of the technique are decided
in terms of the case conceptualization.
Graded task assignment
This strategy may be used when a patient feels too depressed and
hopeless or too anxious to begin a complex or demanding task (A. T. Beck et al.,
1979). A complex action is broken into smaller components, and the client is asked
to attempt these steps in a sequence. This strategy is useful for tackling maladaptive
perfectionism and performance anxiety and for challenging hopelessness. It is
usually applied at the beginning of the session, and then the client is expected to
continue the sequence of tasks as part of his or her homework.
Modeling
Based on the principles of observational learning (Bandura, 1977a,
1977b), this strategy aims at helping clients find adequate models for the behavior
that they want to acquire. This can be performed by the therapist, if necessary, but
models are often found in films and in the client’s circle of friends, workmates, or
schoolmates. Modeling is commonly used for skills training and exposure
exercises. It must be faded out as soon as possible, so that the client increases his
or her sense of self-efficacy.
Problem-Solving
Lack of problem-solving skills is observable in patients with severe
mental disorders such as major depression or substance dependence, who resort to
dysfunctional behaviors when facing life challenges as a result of their lack of
ability to engage in more functional alternatives. Traditional behavior therapy
focused primarily on problem solving, but researchers (Linehan, 1993) have
indicated that this first-order change strategy can be problematic when applied
initially to clients with complex and severe mental disorders.
Behavioral Activation
 Traditionally used in the treatment of depression, the global goal of
behavioral activation (reward planning and activity scheduling) is to increase
behaviors that likely lead a patient to be rewarded in some way. Increasing
pleasurable activities helps lift a person’s mood and also helps decrease rumination
(A. T. Beck et al., 1979). It also is also helpful in dealing with procrastination and
behavioral avoidance.
Behavioral activation consists of four steps:
(1) monitoring current activities in terms of mastery and pleasure
(2) developing a list of rewarding activities
(3) planning the activities
(4) engaging in the activities

Cognitive Concepts
The main objective of cognitive strategies is to increase cognitive
flexibility. Clients must learn that we relate to the world by means of thoughts, but
that these thoughts are just mental events that do not necessarily reflect the exact
nature of reality.
Automatic thoughts and core beliefs
Beck, formerly a practicing psychoanalytic therapist for many years,
grew interested in his clients’ automatic thoughts (personalized notions that are
triggered by particular stimuli that lead to emotional responses). As a part of a
psychoanalytic research study, he was examining the dream content of depressed
clients for anger that they were turning back on themselves. He began to notice that
rather than retroflected anger, as Freud theorized with depression, clients exhibited
a negative bias in their interpretation or thinking. Beck asked clients to observe
their negative automatic thoughts that persisted even though they were contrary to
objective evidence, and from this beginning he developed one of the most
comprehensive theories of psychopathology in the world. Individuals tend to
maintain their core beliefs about themselves, their world, and their future.
A primary focus of cognitive therapy is to assist clients in examining
and restructuring their core beliefs (or core schema) (Dozois & Beck, 2011). By
encouraging clients to gather and weigh the evidence in support of their beliefs,
therapists help clients bring about enduring changes in their mood and their
behavior.
Identifying cognitive distortions
Aaron Beck (1967) posited that abnormal cognition is the result of
distorted thinking. Identifying and challenging these distortions is central to
cognitive therapy. There is a lot of debate as to whether it is correct to use the term
“distortion,” but in any case, it is clear that people with mental disorders have
specific biases in their perceptions of reality. Beck’s cognitive therapy of
depression involves identifying and challenging some common cognitive
distortions in depressed patients.
The following is a list of the distortions described by Beck et al. (1979):
(1) Arbitrary inference. The client reaches a conclusion in the absence of data or
against data.
(2) Selective abstraction: The client selects a negative aspect of a situation and uses
it as the only piece of data for a global negative conclusion.
(3) Overgeneralization: The client makes a general rule out of an isolated negative
event.
(4) Mind-reading: The client “reads” negative impressions about him- or herself in
the eyes of someone else.
(5) Fortune-telling: The client treats a negative prediction as fact.
(6) Minimization, maximization : The client minimizes positive data and
maximizes negative data in order to maintain his or her hypothesis.
(7) Personalization : The client attributes to him- or herself some negative outcome
without justification.
(8) Catastrophic thinking : The client believes the worst outcome is the only one
possible.
(9) All-or-none thinking : The client views a situation in extremes.

Socratic dialogue
 This old dialectical skill became one the central techniques of
cognitive therapy at its inception in the 1960s. Socratic dialogue is very useful when
patients rigidly hold on to certain beliefs, enabling the therapist to generate
cognitive dissonance without causing too much tension in the therapeutic
relationship. The therapist, because of his or her knowledge of psychopathology,
knows in advance where the false premise or contradiction of the client’s argument
lies. He or she formulates questions aimed at detecting that contradiction, thus
generating dissonance in the client’s view of the matter. Perception of
argumentative incongruence is a powerful tool for psychological change.

THEORETICAL BASIS OF CBT

CBT can be viewed as a family of models that share fundamental
theoretical assumptions and usually are similar to the referral exemplar of CBT—
Beck’s standard cognitive therapy for depression. The relative emphasis on
cognition and behavior varies among cognitive-behavioral approaches; however,
Dobson and Dozois (2001) proposed that three main propositions are shared by all
forms of CBT:
(1) Cognitive processes affect behavior.
(2) Cognitive activity can be monitored and changed.
(3) Changes in people’s cognitions—thoughts, interpretations, and assumptions—
can lead to modification in their actions.

Behavioral Approach
Traditionally, three main approaches in contemporary behavior
therapy have been identified.
(1) Applied behavior analysis
(2) A neo-behavioristic mediational stimulus–response model
(3) Social–cognitive theory
These three approaches differ in the extent to which they use
cognitive concepts and procedures. At one end of this continuum is applied
behavior analysis, which focuses exclusively on observable behavior and rejects all
cognitive mediating processes. At the other end is social–cognitive theory, which
relies heavily on cognitive theories.
Applied Behavior Analysis:
This approach is a direct extension of Skinner’s (1953) radical
behaviorism. It relies on operant conditioning, the fundamental assumption being
that behavior is a function of its consequences. Accordingly, treatment procedures
are based on altering relationships between overt behaviors and their consequences.
Applied behavior analysis makes use of reinforcement, punishment, extinction,
stimulus control, and other procedures derived from laboratory research.
The Neo-behavioristic Mediational Stimulus–Response (S–R) Model:
This approach features the application of the principles of classical
conditioning, and it derives from the learning theories of Ivan Pavlov, E. R. Guthrie,
Clark Hull, O. H. Mowrer, and N. E. Miller. Unlike the operant approach, the S–R
model is mediational, with intervening variables and hypothetical constructs.

Social–Cognitive Theory:
The social–cognitive approach depends on the theory that behavior
is based on three separate but interacting regulatory systems

(1) External stimulus events

(2) External reinforcement
(3) Cognitive mediational processes.
In the social–cognitive approach, the influence of environmental
events on behavior is largely determined by cognitive processes governing how
environmental influences are perceived and how the individual interprets them
Psychological functioning, according to this view, involves a reciprocal interaction
among three interlocking sets of influences- behavior, cognitive processes, and
environmental factors.
In social–cognitive theory, the person is the agent of change. The
theory emphasizes the human capacity for self-directed behavior change. Strongly
influenced by the social–cognitive model, the clinical practice of behavior therapy
has increasingly included cognitive methods.

Cognitive Model
The cognitive model describes how people’s thoughts and
perceptions influence their lives. Often, distress can distort people’s perceptions,
and that, in turn, can lead to unhealthy emotions and behaviors. CBT helps
individuals learn to identify and evaluate their “automatic thoughts” and shift their
thinking to be healthier. The cognitive model is at the core of CBT, and it plays a
critical role in helping therapists use gentle Socratic questioning to develop
treatments. Cognitive behavior therapy is based on a cognitive theory of
psychopathology. The cognitive model describes how people’s perceptions of, or
spontaneous thoughts about, situations influence their emotional, behavioral (and
often physiological) reactions. Individuals’ perceptions are often distorted and
dysfunctional when they are distressed. They can learn to identify and evaluate their
“automatic thoughts” (spontaneously occurring verbal or imaginal cognitions), and
to correct their thinking so that it more closely resembles reality. When they do so,
their distress usually decreases, they are able to behave more functionally, and
(especially in anxiety cases), their physiological arousal abates.

TECHNIQUES USED CONTEXT, BENEFITS AND

CONTRAINDICATIONS

• Disputing Irrational Beliefs.

The most common cognitive method of REBT consists of the
therapist actively disputing clients’ irrational beliefs and teaching them how to do
this challenging on their own. Clients go over a particular “must,” absolute
“should,” or “ought” until they no longer hold that irrational belief, or at least until
it is diminished in strength.
• Doing Cognitive Homework
 REBT clients are expected to make lists of their problems, look for
their absolutist beliefs, and dispute these beliefs. They often fill out the REBT Self-
Help Form, which is reproduced in Corey’s (2013b) Student Manual for Theory
and Practice of Counseling and Psychotherapy. They can bring this form to their
therapy sessions and critically evaluate the disputation of some of their beliefs.
• Bibliotherapy
REBT, and other CBT approaches, can be delivered to some degree
in a bibliotherapeutic format. It is probably best to utilize bibliotherapy as an
adjunctive form of treatment. There are 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
the treatment of depression, for a variety of anxiety disorders, and for a range of
clinical problems (Jacobs, 2008).
• Changing one’s Language: REBT rests on the premise that imprecise language
is one of the causes of distorted thinking processes. Clients learn that “musts,”
“oughts,” and absolute “shoulds” can be replaced by preferences. 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. As a
consequence, they also begin to feel differently.
• Psycho educational Methods: REBT programs introduce clients to various
educational materials. 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 (Ledley, Marx, & Heimberg, 2010).

Emotive Techniques
• Rational Emotive Imagery: This technique is a form of intense mental practice
designed to establish new emotional patterns (see Ellis, 2001a, 2001b). Using the
technique of rational emotive imagery (REI), clients are asked to vividly imagine
one of the worst things that might happen to them. They imagine themselves in
specific situations where they experience disturbing feelings. Then they are shown
how to train themselves to develop healthy emotions in place of disruptive ones.
As clients change their feelings about adversities, they stand a better chance of
changing their behavior in the situation.
• Using Humor: REBT contends that emotional disturbances often result from
taking oneself too seriously, thus, this approach employs a good deal of humor. One
appealing aspect of REBT is that it fosters the development of a better sense of
humor and helps put life into perspective (Wolfe, 2007). Humor has both cognitive
and emotional benefits in bringing about change. Humor shows the absurdity of
certain ideas that clients steadfastly maintain, and it can be of value in helping
clients take themselves much less seriously. It teaches clients to laugh—not at
themselves, but at their self-defeating ways of thinking.
• Role Playing: Role playing has emotive, cognitive, and behavioral components,
and the therapist often interrupts to show clients what they are telling themselves
to create their disturbances and what they can do to change their unhealthy feelings
to healthy ones. Clients can rehearse certain behaviors to bring out what they feel
in a situation. The focus is on working through the underlying irrational beliefs that
are related to unpleasant feelings.
• Shame-Attacking Exercises: The rationale underlying shame-attacking
exercises is that emotional disturbance related to the self is often characterized by
feelings of shame, guilt, anxiety, and depression. Ellis (1999, 2000, 2001a, 2001b)
developed exercises to help people reduce shame and anxiety over behaving in
certain ways. Ellis asserts that we can stubbornly refuse to feel ashamed by telling
ourselves that it is not catastrophic if someone thinks we are foolish. The exercises
are aimed at increasing self-acceptance and mature responsibility, as well as
helping clients see that much of what they think of as being shameful has to do with
the way they define reality for themselves. Clients may accept a homework
assignment to take the risk of doing something that they are ordinarily afraid to do
because of what others might think.
Behavioral Techniques
 REBT practitioners use most of the standard behavior therapy
procedures, especially operant conditioning, self-management principles,
systematic desensitization, relaxation techniques, and modeling. Behavioral
homework assignments to be carried out in real-life situations are particularly
important.
Applying Cognitive Techniques
Beck and Weishaar (2011) describe both cognitive and behavioral
techniques that are part of the overall strategies used by cognitive therapists.
Cognitive techniques focus on identifying and examining a client’s beliefs,
exploring the origins of these beliefs, and modifying them if the client cannot
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 therapist
would have made the client become aware of the distortions in your thinking
patterns by examining their automatic thoughts. The therapist would ask the client
to look at your inferences, which may be faulty, and may investigate whether these
inferences can be traced back to earlier experiences in their life. Then the therapist
would help to see how clients sometimes come to a conclusion when evidence for
such a conclusion is either lacking or based on distorted information from the past.
A client in cognitive therapy, will also learn about the process of magnification or
minimization of thinking, which involves either exaggerating the meaning of or
minimizing it.
Donald Meichenbaum’s Cognitive Behavior Modification
Stress Inoculation Training
Stress inoculation training consists of a 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
(Meichenbaum, 2008). SIT involves collaborative goal setting that nurtures hope,
direct-action skills, and acceptance-based coping skills. These coping skills are
designed to be applied to both present problems and future difficulties. Clients are
assisted in generalizing what they learn in the training to daily living, and relapse
prevention strategies are taught.
Meichenbaum (2008) describes stress inoculation training as
a complex, multifaceted cognitive behavioral intervention that is both a preventive
and a treatment approach. Clients can acquire more effective strategies in dealing
with stressful situations by learning how to modify their cognitive “set,” or core
beliefs.
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 reevaluating their self-statements
● Have clients note the level of anxiety following this reevaluation.

BENEFITS, DRAWBACKS AND CONTRAINDICATIONS OF CBT

Benefits of CBT
● Can be as effective as medication in treating some mental health disorders
and may be helpful in cases where medication alone has not worked.
● Can be completed in a relatively short period of time compared to other
talking therapies.
● Focuses on re-training your thoughts and altering your behaviours, in order
to make changes to how you feel.
● The highly structured nature of CBT means it can be provided in different
formats, including in groups, self-help books and computer programmes.
● Skills you learn in CBT are useful, practical and helpful strategies that can
be incorporated into everyday life to help you cope better with future
stresses and difficulties, even after the treatment has finished.
● The combination of mindfulness and CBT used within MBCT is thought to
help individuals recognize the automatic activation of dysfunctional
 cognitive processes, such as ruminative and negative thoughts, and to
disengage from these dysfunctional processes with the goal of reducing
depressive symptoms and future risk of depressive relapse.
Drawbacks of CBT
● To benefit from CBT, the client needs to commit oneself to the process. A
therapist can help and advise them, but cannot make their problems go away
without their cooperation.
● Attending regular CBT sessions and carrying out any extra work between
sessions can take up a lot of time.
● Due to the structured nature of CBT, it may not be suitable for people with
more complex mental health needs or learning difficulties.
● As CBT can involve confronting the client’s emotions and anxieties, he/she
may experience initial periods where they are more anxious or emotionally
uncomfortable.
● Some critics argue that because CBT only addresses current problems and
focuses on specific issues, it does not address the possible underlying causes
of mental health conditions, such as an unhappy childhood.
● CBT focuses on the individual’s capacity to change themselves (their
thoughts, feelings and behaviours), and does not address wider problems in
systems or families that often have a significant impact on an individual’s
health and wellbeing.

Contraindications of CBT
● CBT relies heavily on verbal interventions. If an individual is not verbally
communicative, it will be difficult to use CBT effectively. If the client is
non-communicative due to severe depression or psychosis, appropriate
medication may be needed to get the client to the point where they are
communicative enough for CBT to be effective.
● CBT relies on abstract thought a fair amount. If an individual's capability
for abstract thought is limited by neurological impairments, a more
behavioural approach may be needed.
 ● For some problems, such as schizophrenia and bipolar disorder, the client
needs to take appropriate medication in order for CBT to be effective. If the
individual cannot be persuaded to take their medication consistently, CBT
may be contraindicated. However, CBT often can be quite useful in
improving compliance with medication.
● CBT is a collaborative approach where therapist and client work together
towards mutually agreeable goals. If a client initially is not motivated to
change or cannot identify goals towards which he or she is willing to work,
therapy needs to begin with the therapist working to establish a
collaborative relationship, to elicit motivation for change, and helping the
client to identify goals towards which he or she is willing to work. Usually
it is possible to elicit motivation for change and identify mutually agreeable
goals. However, if this cannot be done, it is difficult to do CBT effectively.
● Sometimes an individual enters with strong preconceptions about what type
of treatment they need. If they are convinced that they have another
approach (for example, exploring childhood conflicts) and are not willing
to give CBT a good try, it probably is pointless to try to force CBT upon
them. If they are skeptical but are willing to give CBT a try, they often are
pleasantly surprised.

CASE FORMULATION
The case formulation approach to cognitive-behaviour therapy is a
framework for providing cognitive-behaviour therapy (CBT) that flexibly meets the
unique needs of the patient at hand, guides the therapist’s decision making, and is
evidence based. Case formulation-driven CBT is not a new therapy. It is a method
for applying empirically supported CBTs and theories in routine clinical practice.
The therapist begins by collecting assessment data to obtain a diagnosis and
develop an individualized formulation of the case. The therapist uses the
formulation to aid the work of developing a treatment plan and obtaining the
patient’s consent to it. As treatment proceeds, the therapist uses the formulation to
guide decision making and works with the patient to collect data to monitor the
progress of therapy and make adjustments as needed. All this happens in the context
of a collaborative therapeutic relationship.

Elements of a Case Formulation

A complete case formulation ties all of the following parts together
into a logically coherent whole:
1. It describes all of the patient’s symptoms, disorders, and problems.
2. It proposes hypotheses about the mechanisms causing the disorders and
problems.
3. It proposes the recent precipitants of the current disorders and problems
4. The origins of the mechanisms.
So, for example, a case formulation for Jon, a patient with
depression, based on Beck’s theory, reads as follows. The elements of the
formulation are identified with CAPITAL LETTERS.
In childhood and adolescence, Jon was brutally teased and
humiliated by his father (ORIGINS). As a result, Jon learned the schemas “I’m
inadequate, a loser,” and “Others are critical, attacking, and unsupportive of me”
(MECHANISMS). These schemas were activated recently by a poor performance
evaluation at work (PRECIPITANT). As a result, Jon began having many automatic
thoughts (MECHANISMS), including, “I can’t handle this job,” and experienced
anxiety and depression (SYMPTOMS, PROBLEMS), with which he coped by
avoiding (MECHANISM) important work projects and withdrawing from collegial
interactions with both peers and superiors (PROBLEMS). The avoidance caused
Jon to miss some deadlines (PROBLEM), which resulted in criticism from his
colleagues and boss (PROBLEM) and led to increased sadness, feelings of
worthlessness, self-criticism and self-blame, low energy, and loss of interest in
others (SYMPTOMS, PROBLEMS). Jon’s low energy and hopelessness
(PROBLEM) caused him to stop his regular program of exercise, which
exacerbated his prediabetic medical condition (PROBLEM).
 As this example illustrates, a good cognitive-behaviour formulation
is internally coherent. Its elements cohere to tell a compelling story that pulls
together many aspects of the patient’s history and functioning (Persons, 1989). The
formulation of Jon’s case ties together all of his problems, including his depression,
alcohol use, and medical condition. A case formulation helps the therapist
understand how apparently diverse problems are related and develop an efficient
treatment plan to address them.
A simple example is the case of Jane, who sought help for what she
described as “compulsive shopping.” A comprehensive assessment revealed that
she also had panic and some agoraphobic symptoms. Careful monitoring of all these
symptoms revealed that Jane’s urges to shop were triggered by anxiety and panic
symptoms that, in turn, were triggered by catastrophic cognitions about unpleasant
somatic sensations. Shopping was negatively reinforced by its anxiolytic effects.
Based on this formulation, Jane’s therapist developed a plan that treated all of
Jane’s problems simultaneously by teaching Jane to monitor her somatic
experiences, catastrophic cognitions, and urges to shop, and to use strategies other
than shopping (e.g., cognitive restructuring, present-moment mindfulness) to
manage uncomfortable somatic sensations and the anxiety they provoked.
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