CBT Specialization Ic

CBT is a collaborative empirical approach looking for evidence. It is to be presented as one useful perspective and non-cognitive determinants of distress are not to be ignored. The focus is on trialling the new perspective in order to decrease the emotional commitment to the old. It is about asking ‘what’s useful?’ ‘what’s not useful?’

In order to develop a Cognitive Behavior Formulation, I have to assess client’s suitability for CBT in terms of accessibility of ATs, awareness of differentiation of emotions, acceptance of personal responsibility for change and compatible cognitive rationale of ‘beliefs may be given up if found to be invalid and self-defeating.’ Client must have the potential for alliance. Chronic issues may be harder to treat as compared with an acute issue.

Having considered the above, I will first create an all-inclusive problem list that includes major symptoms and problems in functioning. Then I will look for the underlying (or overaching) theme that might underlie all the problems (e.g. low self-esteem) and then hypothesize how the underlying theme might cause the problems. Explore the precipitants for the current problem. Look for the origin of the problem in the client’s early life. Predict obstacles in treatment based on the formulation.

The 3 stages of Cognitive Restructuring:

Stage 1 - Developing self-awareness

Help the client to identify their evaluative negative ATs, the associated processes of cognitive distortion and their underlying schemas. When client ‘floods’ the therapist with his story, one way to slow him down will be to write down key words to slow down the process. Client may do so in an attempt to reduce anxiety by not going in-depth.

Recounting specific episodes (the ABC model) by asking client to relate the most recent or most important event through free association, imagery or role-plays. Explore and interpret shifts in affect when discuss about the worst case scenario. Look for thoughts that might explain feelings. Distinguish thoughts from facts. Categorize the distorted thinking. Encourage the client to keep a Dysfunctional Thought Records as homework.





Using the Vertical Arrow technique to identify schemas:

What if I babble? (NAT)…. that will be distressing because..
People will notice…………… that will be distressing because..
They might laugh at me……. that will be distressing because..
They won’t take me seriously… that will be distressing because..
They will think I’m stupid.. that will be distressing because..
I’ll think I’m stupid and… that will be most devastating!
(Auto-pilot thinking)

Assumption: If I babble, or am incoherent, people will think I’m stupid (or it means I’m stupid).

Belief: I’m stupid.

Some ways to deal with problems of arousal (Symptom Induction):

1. Use of controlled breathing to reduce anxiety (client feels threatened and can’t cope)

2. Self-soothing (mindfulness)

> Appreciate positive things:

visually (nature; be in the pleasurable moment)
hearing (music)
smell (perfume)
taste (yummy food)
touch (spa; massage)
kinestic (rocking chair)

3. Distraction techniques: [Marshall Linehan – Alternative Process]

ACCEPTS

A – Activities (child throws tantrum at home, take child outdoor)
C - Contributing (talk to someone)
C - Comparisons (others are anxious too)
E - Emotions (alternative)
P - Push away (leave)
T - Thoughts (distracting thoughts)
S - Sensations (alternative eg when having thoughts of self-mutilation, put cold water on chest)


Stage 2 – Identifying CONTRASTS in thinking

Bring to client’s awareness that thoughts or evaluations CAN be different. Rate client’s emotions and beliefs. Help client to identify CONTRASTS in other people that people can behave differently in same situation. Ask client, ‘if you were to think this other way, what might you feel or behave?’ (Thought Insertion). Client experiences personal contrasts in thinking too as in they hold meaningful perspectives at different times/events.

Stage 3 – Evaluating and Challenging Thoughts

- Define terms such as ‘I am a failure.’ Objectively (useless good for nothing) and subjectively. (What does that mean to you? – ‘I didn’t get a HD for this paper.’)

- Cost-benefit analysis (Advantages and disadvantages)

‘I’ll get rejected if I go to the party.’

Costs: I won’t enjoy even if I go. I will the chance for being accepted.

Benefits: I avoid some anxieties of going. I don’t have to make any effort. (Avoidance)


- What is the evidence?

- Is there any other way of looking at this? (alternative explanations)

- So what if it happens? (evaluating actual consequences)

- Using behaviour to resolve the negative thought (eg using ‘shame attack’)

- Double standard technique (Others can do anyhow but I must give a flawless presentation.)

- Challenging the ‘should’ statement (absolute).

- Identify conditional rules (‘If I perform 100% at work, I’ll be ok.’

- Help client to distinguish PROGRESS from PERFECTION.
(Do not need the BEST outcome. Do not have to be perfect.)