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Chapter: Essentials of Psychiatry: Cognitive and Behavioral Therapies

Cognitive and Behavioral Treatment Strategies

The cognitive and behavioral therapies are well known for their use of specific treatment techniques.

Cognitive and Behavioral Treatment Strategies

The cognitive and behavioral therapies are well known for their use of specific treatment techniques. Commonly used CBT procedures are directly linked to the theoretical constructs and empirical research of this school of therapy. Although techniques are given somewhat more emphasis in CBT than in other forms of psychotherapy, there is still considerable room for therapists to be creative and flexible in developing a treatment plan. In fact, nov-ice therapists sometimes focus too much on applying techniques at the expense of nurturing the therapeutic alliance and case for-mulation. Development of a productive therapeutic relationship and an individualized case conceptualization should always take precedence over the implementation of specific cognitive or be-havioral techniques. A number of the more important CBT strat-egies are described briefly here. More detailed accounts of CBT interventions can be found elsewhere (Beck et al., 1979; Beck 1995; Barlow and Cerny, 1988; Freeman et al., 1989; Persons, 1989).


Collaborative Empiricism


The therapeutic relationship is as important in CBT as in any of the other effective psychotherapies. However, interchanges be-tween therapist and patient often differ from those observed in supportive or dynamically oriented treatment. One difference is that the therapist is responsible for managing the pace of the ses-sion and uses an agenda to help make each session as efficient as possible. Cognitive–behavioral therapists strive for a therapeutic relationship that emphasizes: 1) a high degree of collaboration and 2) a scientific attitude toward testing the validity or usefulness of particular cognitions and behavior. This therapeutic stance is re-ferred to as collaborative empiricism. The empirical nature of the relationship reflects that therapist and patient work together as an investigative team to develop hypotheses about cognitive or be-havioral patterns, examine data, and explore alternative ways of thinking or behaving. At first, therapists usually spend more time teaching and explaining in CBT than in other forms of therapy, yet in the course of therapy, patients are actively engaged to be-come increasingly involved in the work of treatment.


The collaborative empirical stance requires that the thera-pist and patient work together to make an honest appraisal of the validity of cognitions as well as of the adaptive or maladaptive nature of beliefs and behaviors. If a negative assessment proves to be accurate (e.g., the patient actually has made serious mistakes, the individual’s spouse is highly likely to leave, or the patient has engaged in a repetitive self-defeating behavior pattern), then the therapist and patient need to work together in a problem-solving mode to develop a plan to cope with the problems at hand or prac-tice more adaptive strategies for use in the future.


Wright and Beck (1994) and others (Clark et al. 1999) have recommended several strategies for enhancing collaborative empiricism. These include: 1) adjusting the therapist’s level of activity to match the patients’ symptom severity or the phase of treatment; 2) encouraging use of self-help procedures; 3) attend-ing to the “nonspecific” variables important in all therapeutic relationships (e.g., empathy, respect, equanimity, kindness and good listening skills); 4) promoting frequent two-way feedback; 5) devising coping strategies to help deal with real losses or im-plementing a plan of action to address maladaptive behavior; 6) recognizing transference phenomena; 7) customizing thera-peutic interventions; and 8) using humor judiciously. It is also important to recognize and account for the wide variety of indi-vidual differences in cultural backgrounds, social attitudes and expectations that each patient brings to the therapy encounter (Wright and Davis, 1994).




Most forms of CBT integrate explicit psychoeducational proce-dures as a core element of the treatment process. Psychoeduca-tional procedures are typically blended into treatment sessions in a manner that de-emphasizes formal teaching. There is a con-certed effort to teach the patient why it is important to challenge automatic thoughts, identify cognitive errors and practice imple-menting a more rational thinking style. Behavioral interventions are also preceded by psychoeducation to convey the background for principles such as extinction, reinforcement, self-monitoring, exposure and response prevention.


In the early phases of treatment, special attention is paid to socializing the patient to CBT. The basic cognitive–behavioral model is demonstrated, and expectations for both patient and ther-apist are conveyed. Some of the frequently used psychoeducational procedures in CBT include brief, impromptu explanations (often written on a chalkboard or a pad of paper to increase the chances of comprehension and retention) and reading assignments, such as Coping with Depression (Beck and Greenberg, 1974), Feel-ing Good (Burns, 1980), Mind Over Mood (Greenberger and Padesky, 1995) or Getting Your Life Back (Wright and Basco, 2001). Psychoeducational initiatives typically become more com-plex as therapy proceeds. For example, detailed explanations and repeated exercises may be needed before the patient fully grasps abstract concepts such as attributional style or schemas. As ther-apy progresses, homework assignments continue explicitly to re-inforce material covered during therapy sessions.


Modifying Automatic Thoughts


The first step in changing automatic thoughts is to help the patient recognize when she or he is having them. The therapist is oftenable to illustrate the presence of automatic negative thoughts dur-ing the initial session by gently calling attention to a change in the patient’s mood. Such “mood shifts” can be excellent learning experiences that give personally relevant illustrations of the link-age between cognitions and feelings.


One common misconception of CBT is that its practition-ers disregard the role of affect or feelings in the etiology and treatment of psychiatric disorders. Actually, one of the principal components of CBT is the stimulation and modulation of emotion (see Figure 69.3). In fact, Beck referred to emotion as “the royal road to cognition” (Beck, 1991). In contrast to experiential thera-pies, variations in emotion are used in CBT to establish links with cognition and identify errors in information processing. Getting in touch with feelings is thus not a goal in CBT but only a means by which therapy helps patients to gain greater control over the processes that influence their moods and behaviors.


Socratic Questioning


The most frequently used technique to uncover and modify au-tomatic negative thoughts is Socratic questioning (or guided discovery) (Beck et al., 1979; Overholser, 1993a, 1993b, 1993c). Socratic questioning teaches the use of rationality and inductive reasoning to challenge whether what is thought or felt is actu-ally true. The therapist models the use of Socratic questioning and encourages the patient to start raising questions about the validity of his or her thinking. There are few formal guidelines for Socratic questioning (Overholser, 1993a). Rather, therapists learn to use their experience and ingenuity to frame good ques-tions that engage the patient in a process aimed at recognizing and modifying a biased or distorted cognitive style. Typical ques-tions include: What ran through your mind at that time? What is the evidence that your impression is accurate? Could there be any alternative explanations? If this were true, what would be the worst thing that would happen? When guided discovery methods are not sufficient to draw out automatic thoughts, the therapist may turn to several alternative ways of eliciting dysfunctional cognitions, as described in the following.


Imagery Techniques and Role-playing


Imagery techniques and role-playing are used when direct ques-tioning does not fully reveal important underlying cognitions. When imagery is used, the therapist sets the scene by asking the patient to visualize the situation that caused distress. Although some patients can readily imagine themselves in a previous scene, many need prompts or imagery induction to encourage their ac-tive participation in the exercise. Several types of questions can be used to help frame the scene. These include inquiries about: 1) the physical details of the setting, 2) occurrences immediately before the interaction, and 3) descriptions of the other people in the scene (Wright and Beck, 1994). In role-playing exercises, the therapist and patient act out an interpersonal vignette to uncover automatic thoughts or to try out a revised pattern of thinking. This technique is used less frequently than imagery by most cog-nitive–behavioral therapists and may be reserved for situations in which transference distortions are unlikely (Wright and Beck, 1994).


Thought Recording


Thought recording is one of the most useful procedures for iden-tifying and changing automatic thoughts. This technique is first presented in relatively simple two- or three-column versions in the early stages of therapy. When the two-column procedure is used, patients are instructed to write down events in one column and thoughts in the other. Alternatively, they can record events, thoughts and emotions in the three columns. The purpose of this exercise is to encourage patients to begin to use self-monitoring to increase awareness of their thought patterns. Next, the strength of the emotion and the believability of the automatic negative thoughts are rated on a scale of 0 to 100. In subsequent sessions, a more complex five-column thought record, the Daily Record of Dysfunctional Thoughts (DRDT) is introduced (Figure 69.4). The fourth column of the DRDT encourages the patient to develop rational alternatives that rebut the automatic negative thoughts; the fifth column is used for a reevaluation of the mood and cog-nitive ratings. Work on identifying cognitive errors can also be included in this form of thought recording.


Examining the Evidence


The examining the evidence procedure is a collaborative exercise used to test the validity of automatic negative thoughts. Cogni-tions are set forth as hypotheses rather than established facts. The patient is encouraged to write down evidence that either supports or refutes the automatic thought using a two-column form (i.e., pros and cons). Cognitive errors such as magnification, person-alization and all-or-nothing thinking are frequently revealed in these situations.


Next, the therapist helps to guide revision of the auto-matic negative thought in light of the evidence (e.g., “I often feel inferior to others, even when there’s no good evidence that they feel that way” or “I have had a number of difficulties with my teachers and employers, but not all relationships have been bad”). The process thus moves from the patient’s general and globally negative interpretations to more specific, factually based statements.


When an honest appraisal uncovers evidence in support of negative cognitions, the therapist may choose to focus on the patient’s attributions of causality or internality. The patient who posits a negative attribution for poor work evaluation (e.g., “My performance was poor because I don’t have what it takes”) can usually be aided to consider a more neutral attribution (e.g., “My performance was poor because I was underprepared…my depression also prevented more energetic preparation”). The treatment plan may also be revised to develop better methods of coping in similar situations or to work on ways of remedi-ating skill deficits. Sometimes, particular difficulties cannot be changed (e.g., physical handicaps, markedly unattractive physi-cal looks, or severe financial limitations).


Generating Alternatives


If automatic thoughts prove to be largely dysfunctional, the pa-tient is encouraged to generate alternatives that are more accu-rate or factual. Many of the techniques discussed earlier can be used to help generate alternatives to automatic thoughts. Socratic questioning is used in therapy sessions to help the patient start to think more creatively. Also, psychoeducational procedures may be employed to teach brainstorming techniques. For exam-ple, the patient may be taught to use “expert testimony” or the opinions of someone who knows her or him well (i.e., a sibling, spouse, or best friend) to help develop more rational alterna-tives. Thought records are often used to record alternatives to automatic thoughts. We often encourage patients to collect their thought records in notebook form for ongoing use. Figure 69.4 illustrates the use of rational alternatives during CBT for a de-pressed patient.


Many patients with depression, anxiety and related conditions have relatively rigid cognitive styles that perpetuate dysfunctional thought and behavior patterns. These individu-als frequently experience “second-order” automatic negative thoughts, that is, negative thoughts that are triggered by rational alternatives (“that’s a cop-out…quit making excuses”). These thoughts about thoughts tend to undermine the credibility of the rational responses and may dampen the patient’s enthusiasm for using the procedure. The therapist may notice a particular facial expression or a change in the patient’s posture that suggests the existence of second-order thoughts. In such cases, more active therapeutic assistance may be needed. For example, the therapist may need to act as a teacher or coach in the area of adaptive cog-nitive functioning, rapidly rebutting automatic thoughts as they arise. Coping cards, which are index cards with helpful remind-ers on the use of CBT methods (in this case, rational responses to repetitive automatic negative thoughts), may be written during sessions and carried by the patient in his or her pocket, wallet, or purse for later use.


Cognitive–Behavioral Rehearsal


Cognitive–behavioral rehearsal is a treatment strategy that is par-ticularly useful for preparing patients to put their experiences in CBT to work in real-life circumstances. After automatic thoughts have been elicited and modified through procedures described before, the therapist guides the patient in a series of rehearsalexercises to try out alternative cognitions in a variety of situa-tions. By using imagery and role-playing scenarios to practice generating more adaptive cognitions, the patient may become aware of problems that could interfere with implementation of the new style of thinking. Further practice and targeted homework as-signments may then be needed before alternative cognitions can be fully used. For example, the effects of cognitive–behavioral rehearsal may be extended to real situations by assigning home-work to test use of the modified automatic thoughts.


Modifying Schemas


The emphasis in the early phases of therapy is usually on behavioral activation, identifying and changing automatic thoughts, and the reduction of symptoms. However, as the patient gains knowledge of cognitive–behavioral principles and acute symptoms begin to subside, the focus of the treatment sessions usually shifts toward work on the schema level. Because schemas serve as underlying templates for making sense of new information, they play a major role in the modulation of more superficial cognitions (automatic thoughts), regulation of affect, self-esteem and control of the behavioral repertoire. Thus, schema modification is an important component of cognitively oriented therapies.


With Axis I disorders such as major depressive disorder and panic disorder, schema revision efforts are directed at cor-recting dysfunctional attitudes that may predispose the patientto symptomatic recurrences. After several months of produc-tive therapy, schema modification may be placed in the context of reducing future vulnerability. CBT of personality disorders typically requires that a major portion of therapy be devoted to modifying schemas and related patterns of behavioral dysfunc-tion (Beck et al., 1990). When schematic work cannot be fully addressed in time-limited therapy, the model of ongoing change may be introduced. Thus, the patient may begin to change her or his “life course” by development of a long-term self-help plan. Jarrett and colleagues (2001) have proposed continuation and maintenance phases of CBT treatment of depression, and they argue for focusing on schema change in these phases of treatment if it is not accomplished in the acute phase of treatment.


Many of the techniques used to test and modify auto-matic thoughts are also used to identify and revise schemas. Psychoeducational interventions are usually required as a first step. Most patients are not aware of their “guiding principles”, so the therapist may need to begin by introducing and illustrat-ing this concept. It is often useful to use synonyms for the term schema (such as basic assumptions or core beliefs) and to dem-onstrate how schemas are linked to automatic negative thoughts using material from the patient’s own experience (Wright and Beck, 1994). Socratic questioning is the core procedure used for schema modification (Beck et al., 1979; Overholser, 1993c).


The downward arrow technique (Figure 69.5) is a particu-larly powerful way to move from surface cognitions to deeper cognitive structures (Thase and Beck, 1993). This technique de-scribes asking the patient a question such as: “If this automatic thought were true, what would it mean about you as a person?” Another useful approach is to examine patterns of automatic thoughts from thought records to sort out common themes. The therapist may suggest a thematic collation based on her or his knowledge of the patient’s automatic negative thoughts. In some



situations, it may be helpful to have patients review a description of common pathological schemas to recognize some of their core beliefs (see Table 69.2). On occasion, it may be useful to have the patient write a brief autobiography to help elucidate the historical antecedents of the schema. Computerized learning programs can also be employed to help patients uncover their schemas (Wright et al., 1995, 2002a).


Because schemas are so strongly held (in essence, they have helped define reality and mold behavior for years), they may require intensive work in a number of therapy sessions to undergo significant change. Sometimes long-term continuation and maintenance CBT is required to accomplish schematic re-structuring. Therapists can select from a number of CBT tech-niques, including examining the evidence, listing advantages and disadvantages, generating alternatives, cognitive response prevention and cognitive–behavioral rehearsal, as they attempt to modify schemas (Wright and Beck, 1994). Examining the evidence, generating alternatives and cognitive–behavioral re-hearsal were described earlier as methods of changing automatic thoughts.


Cognitive Response Prevention


In cognitive response prevention, the patient agrees to complete a homework assignment in which she or he must behave in a way that is inconsistent with the pathological schema. For example, a person with perfectionistic attitudes may be engaged in an assign-ment in which she or he must perform in a “so-so” manner. This is intended to activate the schema which is triggering automatic negative thoughts (e.g., “They’ll think I’m a sloth” or “I’ll never be trusted with an important assignment again”). By not respond-ing to the perfectionistic demands dictated by the schema, the individual thus has the opportunity to cope with the automatic negative thoughts consequent to this “rule violation”.


Listing Advantages and Disadvantages


The listing advantages and disadvantages procedure is particu-larly useful when a schema appears to have both adaptive and maladaptive features. Schemas that have damaging effects are often maintained because they also have a positive side. For ex-ample, the schema “I must be perfect to be accepted” can have significant benefits (e.g., hard work and attention to detail often lead to success in work or school). Nevertheless, because perfec-tion is seldom possible, the individual may remain vulnerable to setbacks. Other schemas, such as “I’m a complete loser”, may not seem to have any advantages at first glance. However, even such a markedly negative basic assumption can have certain behavioral reinforcers associated with it. For example, a person who believes that he or she is a loser may avoid making commitments, with-draw from challenging assignments, or refuse to exert a sustained effort to solve a difficult problem. This strategy may thus protect the person from painful setbacks. The advantages and disadvan-tages analysis provides the patient and therapist with essential in-formation for planning modifications. Revised schemas are most likely to be used when they take into account both the maladap-tive and the adaptive features of the old basic assumption.


In general, it is recommended that patients keep a list of the schemas as they have been identified. The schema list helps to focus the patient’s attention on the overarching nature of these maladaptive principles. Because schemas often become manifest only during periods of increased stress or symptom expression, they may appear to fade in significance as the patient begins to improve. For example, behavioral treatment programs that nei-ther endorse nor aim to modify schemas are generally as effective as CBT in the short run. However, there may be a false security engendered by symptom relief. The cognitive model posits that the individual will remain vulnerable to the depressogenic im-pact of “matching” life events unless schema revision is accom-plished (Thase and Beck, 1993).


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