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4. COGNITIVE AND BEHAVIORAL TECHNIQUES IN CBT

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4. COGNITIVE AND BEHAVIORAL
TECHNIQUES IN CBT

If you are distressed by anything external, the pain is not due to the thing itself but
to your own estimate of it; and this you have the power to revoke at any moment
- Marcus Aurelius Antonius

OVERVIEW

In this module, we will cover the following topics:

 Cognitive Restructuring
 Thought Records
 Imagery Based Exposure
 Rational Alternatives and Cognitive Rehearsal
 Behavioral Activation
 Behavioral Experiments
 Situation Exposure Hierarchies

Cognitive Techniques in CBT Module 4 Page 1

COGNITIVE TECHNIQUES

As the name suggests, Cognitive Behavioral Therapy (CBT) is a blend

of cognitive and behavioral techniques designed to affect positive
change in emotions and behavior, which improves overall well-being.
Some of these techniques focus on the thinking aspect of the patient
by recognizing that most negative moods and behaviors can be
associated with distorted thinking patterns that have become habitual
and are activated by deep-seated problematic core beliefs.

Generally, these methods aim to identify, challenge, and modify the

patient’s distorted and illogical automatic negative thoughts that
generate distressing emotions and dysfunctional behavior. In the CBT
assessment phase the automatic negative thoughts and underlying
beliefs are highlighted. Becoming aware of these thoughts and how
they affect our daily lives is the first step to reconditioning the mind.

COGNITIVE RESTRUCTURING

This psychotherapeutic process of learning to identify and dispute

irrational or maladaptive thoughts is known as cognitive restricting. It
is a core part of the CBT process. It entails practicing to notice when
one is having an automatic negative thought and tracking the accuracy
of the thought. For example, one might be prone to think that “It I
think a lot about my problem, it’ll help me find a solution.” Each time
such a thought arises, write it down and note if the worrying actually
lead (or directly contributed) to solving the problem.

This is part of evaluating evidence for and against a negative thought.

By looking objectively at proof that the thinking is valid, and
comparing facts that it is not true—even partly or sometimes—
negative thoughts become more balanced and less emotional. It helps
one to think and develop more positive and functional alternatives.
For example, “I can never do anything right”, one might realize that “I
sometimes (more than I previously thought) do something right”
instead.

It should be apparent how such an attitude change will have positive

effects of mood and attitude. The main types of automatic thoughts
involve self-evaluations, evaluation of others, coping strategies, and
behavioral and avoidant plans. According to Hope et al. (2010),
cognitive restructuring in CBT involves four basic steps, namely:

Cognitive Techniques in CBT Module 4 Page 2

 1. Identification of Automatic Negative Thoughts, or ANT’s,
which are dysfunctional or negative views of the self, world, or
future based upon already existing beliefs about oneself, world,
or the future.
2. Classification of the type of distorted thinking pattern in the
negative thought
3. Disputing or challenging the distorted thoughts using Socratic
questioning and objective reasoning by uncovering the
assumptions and evidence that underpin people's thoughts in
respect of problems
4. Development of rational and functional alternative thoughts
The use of cognitive restructuring in CBT is based on two main
notions, namely that irrational or dysfunctional beliefs activate
negative thoughts, which affect emotions and behavior, and is
responsible for most psychological disorders and distress. Therefore,
the central objective of cognitive restructuring is to develop
alternative positive thoughts by challenging and objectively thinking
about the irrational and counterproductive nature of the negative
thoughts. Of the many methods commonly used in the cognitive
restructuring process, a few only are discussed here: using thought
records, imagery based exposure, rational alternative, and cognitive
rehearsal to modify automatic negative thoughts.

THOUGHT RECORDS

Another important technique in CBT to reframe a negative thought is

by keeping a daily thought record. Below is an example of a though
record, which is a one-page chart that allows the client to capture his
or her daily experiences and thoughts and analyze it reflectively and
objectively. Thereby it is possible to recognize that automatic
thoughts may not be completely true all the time and that there are
more positive options that account for all evidence.

Table 4.1: Daily Thought Record

Negative Evidence Evidence Alternative Rerate

Situation Emotion
Thought For Against Thought Emotion
Are there
What How do you
Describe What facts indications Think of a
Where, thoughts, feel about
in one support the that this new thought
what, memories, the situation
word & validity of thought is not that take all
who, or images now? Rate
rate 0- the completely evidence
when? did you again 0-
100% thought? true all of the into account
have? 100%
time?

Cognitive Techniques in CBT Module 4 Page 3

It is common for client to express doubt that this exercise will have
any notable positive effect, and although it may be difficult at first and
require patience, but it has been proven to work effectively. As clients
become adept in completing the sheet, most find that it becomes
increasingly possible to reframe a negative thought instantly without
even having to write everything down any more. The thought record
helps create awareness of negative thoughts and their impact on our
emotions, which is a helpful start to change distorted thinking
patterns. As a result, thoughts become more realistic and balanced. It
allows a more functional response to challenging and distressful
situations.

IMAGERY BASED EXPOSURE

Prolonged exposure (PE) techniques are commonly used for PTSD,

but also have a significant risk and failure rate. PE is characterized by
re-experiencing the traumatic event through remembering it and
engaging with, rather than avoiding, as facilitated by the therapist
through images or in vivo exposure. However, because of the
relatively high risk it is recommended that imagery-based cognitive
restructuring component is added in the context of cognitive
modification.

In this case imagery-based exposure, more formally known as

Imagery Rescripting and Reprocessing Therapy (IRRT), is used to
activate the trauma memory so that the distressing cognitions (i.e. the
trauma-related images and beliefs) can be identified, challenged,
modified, and processed using other cognitive techniques Grunnert,
Smucker, Weis, & Rusch, 2007).

There are different versions of imagery exposure techniques, but one

version involves bringing to mind a recent memory that provoked
strong negative emotions. The therapist prompts the client to recall
and describe such a memory in high sensory detail, trying to
accurately label their emotions, thoughts, and behavioral urges.
Imagery based exposure is useful to reduce the level of distress,
counteract rumination, and reduce avoidance coping. As a result, the
client is able to choose more positive coping actions.

RATIONAL ALTERNATIVES AND COGNITIVE REHEARSAL

We have already seen how thought records enable clients to

objectively review their thoughts for evidence in support and against
its accuracy and usefulness. Thereby the client is able to develop and

Cognitive Techniques in CBT Module 4 Page 4

implement functional alternatives for distorted thoughts and
dysfunctional beliefs and behaviors. In conjunction with finding
rational alternatives and balancing thoughts the therapist assists the
client to rehearse these new improved ways of dealing with a
challenging or distressing situation. As a result, the client learns to
recognize cues and anticipate potentially problematic events, which
makes him or her better equipped to respond more effectively
whenever it actually arises.

The technique of cognitive rehearsal also facilitate better utilization of

learning and socialization by moderating instinctive negative
reactions. It affords the client the opportunity to work out in advance
what the most appropriate way is to respond in a difficult situation as
it helps them to take the lessons of therapy into their real-world
situations. According to Wright (2006), cognitive rehearsal is “usually
introduced in a therapy session after the ptient has already done some
groundwork with other methods to change automatic thoughts” (p.
118).

“One way of doing cognitive rehearsal is to ask the patient to take

these steps: (1) think through a situation in advance, (2) identify
possible automatic thoughts and behavior, (3) modify the automatic
thoughts by writing out a TCR [thought change record] or doing
another CBT intervention, (4) rehearse the more adaptive way of
thinking and behaving in your mind, and then (5) implementing the
new strategy.” (p. 118).

Skills and other CBT techniques are practiced with the client to help
them increase the potential for achieving their goals and objectives
and be able to follow through with the new alternative strategies.
Rehearsing in a therapy session is very useful before the client is
again confronted with the situation in real life. The principle of
cognitive rehearsal can be applied to almost any situation viewed with
trepidation, from social anxiety, traumatic re-experiencing, anger
outbursts, to loss, loneliness, and failure.

Cognitive Techniques in CBT Module 4 Page 5

Exercise 4.1

Give a brief example of how a thought record and cognitive rehearsal

may be used in conjunction to modify thoughts and behavior.

Answers can be found at the end of the module

Now watch this video

Dr. Pucci Explains the ABCs of Emotions in CBT: How our Emotions
Actually Work

https://www.youtube.com/watch?v=1AYAJcOcXFE [21:52]

BEHAVIORAL TECHNIQUES

Another set of techniques that is an important part of Cognitive

Behavioral Therapy (CBT) behavioral techniques. These are used in
conjunction with cognitive techniques, but are directly focused on
changing behavior, primarily with the use of conditioning methods.
Different from cognitive methods, behavioral techniques do not
intentionally involve thoughts and feelings as primary subject of

Cognitive Techniques in CBT Module 4 Page 6

exploration and reflection, but simply prime the client to engage in
more positive behavior by repetition and positive (or negative)
association.

BEHAVIORAL ACTIVATION

The technique of behavioral activation emerged as an important

change element in CBT from component analyses. The principles of
behavioral activation is most commonly applied in the treatment of
depressive disorders. Typically, the client is asked to complete a daily
activity schedule for the period until the following session, ensuring
that they include pleasant activities among their other responsibilities.
Their adherence to this schedule is monitored, including what effect it
had on emotions and behavior. Below is a simplified example of a
monitoring sheet, which can be used by the client at home to plan and
track their pleasant activities. By focusing on those that seem to have
a higher impact on negative thoughts, feelings, and behaviors, positive
experiences are activated and reinforced.

Table 4.2: Daily Activity Tracking

Pleasant Impact
Mon Tue Wed Thu Fri Sat Sun
Activities 0-4
Thought/behavior
diary
      
Pleasant events
      
Relaxation
exercise
      

Therefore, although behavioral activation is not directly targeted for

thought change, the cognitive aspects of depression are presumed to
become more adaptive following behavioral activation procedures and
are important secondary gains of the technique (Lejuez, Hopko, &
Hopko, 2001). Finally, selecting small personal rewards for achieving
weekly behavioral goals further reinforces sustained positive
behavior.

Cognitive Techniques in CBT Module 4 Page 7

BEHAVIORAL EXPERIMENTS

Another form of behavioral technique is by experimentation with pre-

selected behavior in a specific situation. The client is guided to select
a real or perceived situation that is particularly unpleasant or
challenging causes (or is expected to cause) distressing thoughts and
dysfunctional behavior. An example of such a prediction is that
speaking in public will cause them to freeze or shake so much that
people will laugh at them. As the next step the client is asked when
such a situation may occur and describe the detail. For instance, the
client may have a meeting the next week where they have the
opportunity to present their work (see Table 4.3 below). Now, think
about behaviors that can replace others to alleviate the fear and
distress. In this case it may be not to grasp the table or papers, but to
keep the hands loosely folded instead. Observe the other participants
or ask trusted friends afterwards how he or she did, i.e. if they noticed
shaking or other discomfort.

Table 4.3: Behavioral Experiment

Prediction
What is your prediction?
What do you expect will happen?
How would you know if it came true?

Rate how strongly you believe

this will happen (0-100%)

Experiment
What experiment could test this prediction? (where and when)
What safety behaviors will need to be dropped?
How would you know if your prediction came true?

Outcome
What happened?
Was your prediction accurate?

Cognitive Techniques in CBT Module 4 Page 8

Learning
What did you learn?
How likely is it that your prediction will happen in the
future?

Rate how strongly you agree

with your original prediction
now (0-100%)

After the event occurred, inquire what happened and whether the
client’s prediction was accurate. Maybe they were very nervous and
aware of their hands, but received feedback that they did well and
nobody noticed shaking. Next, ask the client to describe what they
learnt and how likely the prediction will come true in the future. The
client will likely feel more confident to face the same situation in
future, which in turn enables them to perform even better, more
naturally, and with less distress. In such a behavioral experiment the
key aspect is identifying the anticipated problem behavior and exactly
what it is that precedes or triggers it; then formulating strategies to
deal with or prevent the activation from occurring. In this experiment
it may be to ask a colleague to explain or confirm something while
getting one’s thoughts in order again.

Behavioral activation is well supplemented by cognitive rehearsal as

the situation and behaviors can be rehearsed ahead of time to practice
the experimental behaviors. The therapist must also remind the client
that patience may be required as experiments may not be 100%
successful the first time around, and may require developing other
options or refining the applied behaviors. The process works equally
well when a measure of unpredictability is expected in the situation
that the client expects to face.

SITUATION EXPOSURE HIERARCHIES

Exposure hierarchies are another basic CBT tool commonly used for
the treatment of anxiety. The hierarchy is used to gradually introduce
clients to feared stimuli. From discussions with the client and
psychological tests, such as the fear assessment, fear survey schedule,
social phobia inventory, and Beck Anxiety Inventory, a list of anxiety-
producing situations is identified. Together with the therapist, the
client rates each in terms of a subjective units of distress scale, or
SUDS, ranging from zero (completely relaxed) to 100 (the worst
anxiety he/she can imagine feeling). The items are arranged in a list
from high to low.

Cognitive Techniques in CBT Module 4 Page 9

The idea of an exposure hierarchy is to start with lower ranked items
(around 60). The client is exposed to a selected object or situation
during a session or in vivo. Once they have managed to master an
item on the hierarchy, they move on to a more difficult one,
continuing the process until they have achieved their goals. This often
(but not always) means feeling comfortable with the highest item on
their hierarchy.

As with all other exposure-based behavioral approaches, graded

exposure hierarchies involve clients confronting previously avoided
objects or situations, while resisting the tendency to avoid or escape
from them (Richard & Lauterbach, 2006). It focuses on direct
symptom relief and behavior change without delving into underlying
thoughts and beliefs, which are addressed with cognitive techniques.
As most fears and anxieties are learned or acquired via a process of
classical conditioning, behaviorists argue that behavioral interventions
are more directly effective and can even be applied as standalone
treatment (without accompanying cognitive methods). As fears and
anxieties are sustained through negative reinforcement and escape and
avoidant behaviors, directly confronting those instead of furthering
avoidant strategies are proposed as the most appropriate approach.
Nevertheless, CBT has proven successful in combining cognitive and
behavioral techniques in a relatively short treatment program.

Exercise 4.2

Briefly describe the difference between behavioral activation and

graded exposure.

Answers can be found at the end of the module

This list of Cognitive Behavioral Therapy (CBT) techniques is far

from exhaustive but will give you a good idea of the variety of

Cognitive Techniques in CBT Module 4 Page 10

techniques that are used. In the next module we discuss the origins
and underlying principles of mindfulness, including its use as a
relatively new adjunct technique in CBT.

EMPHASIS BOX

It is widely accepted that many forms of psychopathology can be

conceptualized as unhealthy efforts to escape and avoid emotions,
thoughts, memories, and other private experiences.

The behavioral techniques in CBT are directly focused on activating

positive behavior and deactivating avoidant behavior by reinforcement
and exposure.

The cognitive techniques in CBT focus on understanding and

modifying unpleasant and distressing thoughts and feelings, which has
a secondary positive effect on behavioral outcomes. As such,
cognitive and behavioral interventions in CBT are combined to
complement each other in producing improved well-being that is
sustainable.

Cognitive Techniques in CBT Module 4 Page 11

REMINDER

Have you completed the following exercises?

 Exercise 4.1
 Exercise 4.2

Tick each box when you have completed the exercises. Then you can
move on to the next module.

SUMMARY

1. CBT applies a combination of cognitive and behavioral techniques

to activate positive behavior, prevent avoidant behavior, and
modify distorted thinking.
2. Commonly used techniques in CBT are cognitive restructuring,
thought records, imagery based exposure, rational alternatives and
cognitive rehearsal, behavioral activation and experiments, and
situation exposure hierarchies.
3. The process of cognitive restructuring aims to identify, challenge,
and modify distorted cognitions.
4. Thought records are used to develop and implement functional
alternatives.
5. In imagery based exposure a client’s traumatic experience is
activated in order to explore the underlying thoughts and feelings.
6. Cognitive rehearsal involves the client repeating and practicing
predicted problematic situations and their solutions.
7. Behavioral activation implies that the client schedules and engages
in pleasant activities, which improve their mood, attitude, and
willingness to engage.
8. In a behavioral experiment the client predicts a distressing event
and formulates behavior that may prevent or alleviate the problem,
which he or she evaluates after the event.
9. Graded exposure hierarchies are used to incrementally confront
the client with increasing stressors as they learn to manage lesser
ones.

NEXT STEPS

Well done! You have completed Module 4.

Cognitive Techniques in CBT Module 4 Page 12

REFERENCES

Grunnert, B. K., Smucker, M. R., Weis, J. M., & Rusch, M. D. (2007).

When prolonged exposure fails: Adding an imagery-based cognitive
restructuring component in the treatment of industrial accident victims
suffering from PTSD. Cognitive and Behavioral Practice, 10(4), 333-
346. DOI: 10.1016/S1077-7229(03)80051-2

Hope, D. A., Burns, J. A., Hyes, S. A., Herbert, J. D. & Warner, M. D.

(2010). Automatic thoughts and cognitive restructuring in cognitive
behavioral group therapy for social anxiety disorder. Cognitive
Therapy Research, 34(1), 1-12. DOI: 10.1007/s10608-007-9147-9

Huppert, J. D. (2009). The building blocks of treatment in Cognitive-

Behavioral Therapy. The Israel Journal of Psychiatry and Related
Sciences, 46(4), 245-250.

Lejuez, C. W., Hopko, D. R., & Hopko, S. D. (2001). A brief

behavioral activation treatment for depression. Behavior Modification,
25(2), 255-286.

Richard, D. C. S., & Lauterbach, D. (2006). Handbook of exposure

therapies. San Diego, CA: Academic Press.

Wright, J. H. (2006). Learning cognitive-behavior therapy: An

illustrated guide. Washington, DC: American Psychiatric Publishing.

Cognitive Techniques in CBT Module 4 Page 13

 EXERCISE ANSWERS

EXERCISE 4.1. ANSWERS

Give a brief example of how a thought record and cognitive rehearsal

may be used in conjunction to modify thoughts and behavior.

In a thought record the client lists daily situations that causes him or
her distress or problems in terms of unpleasant thoughts, emotions,
and negative behavior. The client weighs evidence that supports and
contradicts their thoughts/beliefs about the situation, which is utilized
to formulate a more positive attitude and response to the situation. It is
likely that such a more positive and functional balancing of thoughts
and beliefs will generate improved emotions and result in more
adaptive behavior.

Now, the thought records can be used to predict similar future

situations and rehearse the balanced and positive new thoughts and
behaviors attached to it. Thereby an instinctive and natural approach
that is also positive becomes more possible.

EXERCISE 4.2. ANSWERS

Briefly describe the difference between behavioral activation and

graded exposure.

Behavioral activation utilizes positive reinforcement in terms of

pleasant activities to induce a positive mood and attitude. It may
involve small rewards to increase the reinforcement further. It is most
commonly utilized to decrease depressive symptoms.

Graded exposure involves creating a list of the client’s fears and

anxieties, ranking it from the highest to lowest severity. The client is
exposed to lower ranked items first, working his or her way up the list
when each is properly managed. Hereby they are able to confront their
fears instead of avoiding them, which is often associated with
psychological distress.

Cognitive Techniques in CBT Module 4 Page 14

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