Core Beliefs

Overview

In this module, we will be examining the deepest part of the CBT Iceberg: Core Beliefs.  Core beliefs are the most deeply held and strongest beliefs that people have.  They form the foundation of who a person is and guide all of our goals, plans and behaviors.  We will begin by examining their characteristics and when to begin addressing them in therapy.  Afterwards, our focus will turn to how socialize and educate clients on core beliefs and then we will look at how to identify core beliefs in therapy.  After learning how to identify these beliefs, we will discuss how to challenge and change those core beliefs.  We will then put all levels of the iceberg together and look at schemas in general and the module will end with a brief discussion on termination and booster sessions.

Core Belief Characteristics

Core beliefs, as previously mentioned, are our most strongly held opinions, points of view and beliefs about ourselves, other people and the world within which we live.  At the core of many mental health disorders are distorted core beliefs that fuel and maintain the disorder. CBT therapists seek to identify maladaptive core beliefs and eliminate them by replacing them with more adaptive core beliefs.  There are certain Core beliefs have certain typical characteristics that include:

  • Rigid and Resistant to change: Core beliefs tend to be deeply held and are infused with strong emotional content. They tend to be very difficult to challenge and change and often require great effort to do so.
  • Tend to be polarized and over-simplified: Core beliefs often reflect all-or-nothing thinking and frequently contain words such as “all, every, none or nobody.” Negative core beliefs tend not to recognize nuance and tend to be over simplified.
  • Formed in Childhood: Core beliefs are often formed in childhood during really important events. For example, being bullied by another student in grade school may cause a core belief: “I don’t belong anywhere” to form and exist subconsciously into adulthood.  Core beliefs are often problematic because they are often unconscious and unexamined.  However, not all core beliefs are formed in childhood as they can be formed during any pivotal life event. For example, experiencing a trauma as an adult, such as being raped, can alter core beliefs about how safe the world is.
  • Maintained through distortions and biases: Core beliefs, once formed, are difficult to change because cognitive distortions, filters and confirmation bias tend to maintain them.  For example, if a client believes she is incompetent then she will ignore evidence that contradicts this and be hyper-focused on signals that might confirm this belief.  Other distortions such as overgeneralizing or disqualifying the positive will act to strengthen and maintain these beliefs.  Distortions need to be identified and corrected for in order to change core beliefs.
  • Are not necessarily true: People often hold their core beliefs as absolute truths and yet they are not necessarily true.  Core beliefs can be maintained despite overwhelming evidence that they are not true and thus can be irrational.  They are often based on partial truths but do not accurately capture the totality of a concept.
  • Can be tested and evaluated: Core beliefs are often taken for granted and are not subjected to rigorous testing or evaluation.  However, we can take a core belief and develop a test to determine its accuracy.  For example, if a person has a core belief: “Nobody can be trusted” then we can identify a series of tests to determine if this is true.  This may involve first defining trust and then having the client do something that requires trust in another person.  The core belief will either be supported or challenged based upon the results.

Core Belief Socializing

You can use the “all roads lead to Rome” analogy to help clients understand that all of their thoughts and rules flow from their core beliefs.  Their core beliefs are like the city Rome and the roads are comparable to their automatic thoughts and rules for living.

Another popular metaphor is of the blind men and the elephant.  A group of blind men each touch different parts of an elephant such as the tusks, trunk, leg, ears and body.  However, since each blind man only has experience with one aspect of the elephant it distorts his entire view of the creature.  In the same way, core beliefs can form based upon a distorted experience of reality.  The elephant is comparable to reality and the blind man is the client whose entire view has been distorted by a selective focus on only part of the whole.

Of course, you can also understand core beliefs using the metaphor of the partially submerged iceberg that we have already discussed and that you probably already know very well by now.

Another popular analogy is to compare the mind to a tree and each of the trees component parts to different levels of the mind.  The roots of the tree are the core beliefs, the trunk is the rules for living and the branches are the automatic thoughts that flow from the tree and yield a certain kind of fruit.  If the roots of the tree (core beliefs) are malnourished then the rest of the tree begins to die.  You can also use this analogy to help yourself understand the utility of your core beliefs.  Good core beliefs will yield good fruit from the branches of the tree while bad core beliefs can be known by the bitter fruit they produce.  You need to learn to care for your mind by nourishing its roots and pruning away rotten branches.

One final metaphor to consider is that of the magnet.  This metaphor is used to help you understand how core beliefs are maintained.  Core beliefs are like magnets because they attract any evidence that supports them while repelling any evidence that does not.

From a neurological perspective, Core Beliefs are neural pathways that have established themselves through connections and highways in the brain. They are stored bodies of knowledge or structures that interact with incoming information to influence selected attention and memory search.  Genetic predispositions can also contribute to the formation of Core Beliefs.  Genetics can provide a predisposition to negative emotions which can then combine with certain environmental triggers to cause the onset of negative core beliefs.”

Judith Beck also provides a useful list of common core beliefs that you can examine.  Recall that there are three major types of core beliefs:

  1. Beliefs about the Self: I am worthy/unworthy, good/bad, lovable/unlovable, success/failure, and competence/incompetence.
  2. Beliefs about Others: others are trustworthy/untrustworthy, others have certain group characteristics.
  3. Beliefs about the World: The world is safe/unsafe, beautiful/ugly, just/unjust.

Common Core Beliefs about the Self

i.) Helpless

  • I am inadequate, ineffective, incompetent, can’t cope.
  • I am powerless, out of control, trapped.
  • I am vulnerable, weak, needy, a victim, likely to be hurt.
  • I am inferior, a failure, a loser, defective, not good enough, don’t measure up.

ii.) Unlovable

  • I am unlikable, unwanted, will be rejected or abandoned, always be alone.
  • I am undesirable, ugly, unattractive, boring, have nothing to offer
  • I am different, flawed, defective, not good enough to be loved by others.

iii.) Worthless

  • I am worthless, unacceptable, bad, crazy, broken, nothing, a waste.
  • I am hurtful, dangerous, toxic, evil.
  • I don’t deserve to live.

The theme across all of these negative core beliefs about the self appears to be: “I am incapable of having intrinsic needs met.”  If a client believes she is helpless then she believes she does not have the capacity to handle life problems to meet important goals.  If she believes she is unlovable then she believes she lacks the capacity to be loved.  If she believes she is worthless, again she believes she lacks the capacity to contribute in any meaningful way.  The overall theme is about not having the capacity to have important needs met.

Identifying Core Beliefs

There are many sources of data that you can draw upon to identify key maladaptive core beliefs.  Some of the major sources include:

  1. Themes in Thought Records: Once you have done enough thought records, you can begin comparing them to identify common themes. While situations or surface thoughts might change, you will probably be able to identify common core beliefs that do not change across thought records.  If you see a belief continually popping up in thought records, this is a good indication that it is a core belief.
  2. List of Core Beliefs: A therapist can also give a client a list of core beliefs (like Judith Beck’s list) and have the client select which ones resonate. This is useful to use with clients who have a hard time articulating themselves or who may say they have no idea what their core beliefs are.
  3. Client reports: You can also simply ask yourself what you believe your core beliefs are.  Describe pivotal events in your life and then look for how those events changed your view of either yourself, the world or other people.
  4. Fears: Fears can also be a good source of core beliefs.  Negative core beliefs elicit a lot of fear and people are constantly on guard to protect against the core belief activating.  Ask  yourself what you fear is true about yourself, the world or other people.
  5. Judith Beck’s Case Conceptualization: Judith Beck provides a good worksheet for you to help fill in the blanks of the client’s cognitive map.  If you are struggling with core beliefs, fill out the rest of the form and you should be able to make an educated inference on what the core beliefs are.  It has been provided below for your convenience.

The Downward Arrow

The Downward arrow technique is an especially useful tool for identifying core beliefs.  It involves starting with a surface level thought and probing for implications of the thought.  Clients typically go no deeper than their surface thought but the downward arrow technique prompts them to examine the implications of their surface thoughts until we arrive at the true core belief being masked.

The general question for the downward arrow technique is: “And if that were true, what would that mean to you?”  This is an incredibly powerful question and is one that you may need to stick with until you can provide an answer.  It isn’t’ unusual that you  might think: “I don’t know” so you may need to stick with it until you can answer it.

Here are some examples of using the downward arrow technique to go from surface thought to core belief:

  1. “I can’t accept that my husband is gone for good.” (If that were true what would it mean?)
  • That would mean what I believe about marriage isn’t true.
  • If what I believe about marriage isn’t true, what else am I wrong about?
  • I am a foolish person.
  1. “It’s 11 pm and my wife isn’t home yet.” (If that were true what would it mean?)
  • She must not value spending time with me.
  • I am not worth of her time
  • I am unlovable.
  1. “The soup I made is terrible.” (If that were true what would it mean?)
  • I am a bad cook.
  • I cannot fulfill my role obligations.
  • I am a failure.
  1. “I didn’t get a call back from the job I applied to.” (If that were true what would it mean?)
  • I am never going to get a job.
  • I will not be able to provide for my family.
  • I am a failure.

Restructuring Core Beliefs

After educating yourself on core beliefs and identifying the key core beliefs that are maintaining the presenting issue it’s time to begin challenging and restructuring those core beliefs.  You can begin challenging core beliefs in the same way that you would challenge normal thoughts or rules for living, including generating evidence and identifying distortions.  You can begin by listing any evidence at all that might indicate this belief is not always true.   If this isn’t enough (it often isn’t) then you can turn to a few new techniques to help challenge these problematic beliefs including: cognitive continuum’s, behavioral experiments, a historical review of data and the positive data log.  We have already discussed continuum and experiments so we will turn our focus now to the historical data review and the positive data log.

Since core beliefs form during pivotal events that often occur in childhood, we may need to analyze those pivotal events to allow you to reprocess them and interpret them from what is usually a more mature perspective (adult self vs. child self).  A historical review of the data simply involves listing all of the key pivotal events that you believe are reasons why the core beliefs are true and then doing thought records around them and coming to balanced interpretations of those events.  This can be time consuming but also very powerful as it can defuse emotional memories that are holding you hostage.  You treat these memories just like you would situations that you analyze with thought records every week.  Identify what the situation meant , whether the interpretation was distorted and what evidence there is that this is the best interpretation possible.  Construct a new balanced interpretation of the memory for each of the memories you list.  A worksheet developed by Judith Beck has been provided below that illustrates this technique.

Another important tool for changing core beliefs is the positive data log.  This is a relatively simple intervention to understand but is often difficult to practice.  It simply involves taking the balanced core belief that you are trying to adopt and then listing evidence every day that supports the new belief.  It’s important to understand that you have had a lot of practice (sometimes decades) rehearsing your old core beliefs and that we need to create new connections in the brain by rehearsing new beliefs.  If you have trouble doing this as homework then do it in session until you become better at adopting alternative perspectives.

In summary, core belief work progresses in the following way:

Step 1: Educate yourself on core beliefs.

Step 2:  Identify key core beliefs.

Step 3: Develop balanced alterations of the core belief using CB techniques.

Step 4:  Implement new core belief in new situations.

Step 5: Pay attention to new evidence and reinforce new balanced belief.

Putting it all together: Schemas

One final term that you may come into contact with in the CBT literature is that of the schema.  Going back to the iceberg analogy, the schema can simply be thought of as encompassing the entire iceberg and includes all levels of mental life.  Thus a singular schema may consist of a core belief, the rules for living and then the automatic thoughts that flow out of that core belief.  In cognitive therapy, we seek to identify maladaptive schemas and replace them with adaptive schemas.  Below are some example of both adaptive and maladaptive schemas in certain situations.

  1. Situation: A friend doesn’t talk to the client at a party.

a.) Adaptive Schema

CB: I am a generally likable person

RFL: If I mingle, I might have a new friend at the end

AT: “Wow! My friend is busy tonight!”

Embedded memory: simply of last year’s party.

b.) Maladaptive Schema

CB: Others are more interesting than I am

RFL: If I am not interesting, I will be ignored

AT:
My friend doesn’t really like me

Embedded memory: Rejection

  1. Situation: Husband doesn’t remember what the wife told him earlier.

a.) Adaptive Schema

CB: Husband cares about me.

RFL: If my husband forgets what I told him, it doesn’t mean he doesn’t love me.

AT: “He has a lot on his mind.”

Embedded memory: conversation with husband.

b.) Maladaptive Schema

CB: Husband doesn’t care about me.

RFL: If my husband forgets what I told him its proof he doesn’t love me.

AT: I can’t believe my husband forgot this.

Embedded memory: Rejection and isolation.

  1. Situation: A man who was mugged 5 years ago won’t leave his house.

a.) Adaptive schema

CB: The world can be dangerous at certain places and times but where I live it is mostly safe.

RFL: If I take precautions and be reasonable, I will be safe.

AT: “It’s dark out so I should be safe.”

Embedded memory: feeling in control.

b.) Maladaptive schema

CB: The world is dangerous.

RFL: If I don’t leave my house I can’t get hurt.
AT: I can’t leave my house.

Embedded memory: Fear and powerlessness.

Resources

Core Belief Worksheets

Rules for Living & Behavioral Experiments

Overview

In this post, we are going to focus on an important part of the CBT Iceberg and look at the intermediate level of beliefs: Rules for Living.  As we go beneath the iceberg it will become more difficult but also more rewarding and life changing to restructure these aspects of your cognitive maps.  Remember that resistance will be natural and typical as this is a level of change that takes time and perseverance.  This level of change is “life work.” Rules for living are more difficult to challenge and change than automatic thoughts but less difficult than core beliefs.

After we examine the characteristics of rules for living we will turn to the next behavioral intervention designed to tackle these rules: Behavioral Experiments.  Behavioral experiments involve challenging rules by changing the “if” part of the rule to test whether new “then” conclusions can be made.

Rules for Living

Rules for living are sometimes referred to as “intermediate beliefs” or “compensatory strategies” in the CBT jargon.  They are “intermediate” between automatic thoughts and core beliefs and they often lead to ways of compensating for core beliefs.  For example, if someone has a core belief: “I am inadequate and will be rejected” then they may compensate for this belief by developing a rule: “If I stick to myself then I can’t be rejected.”  The rule is designed to protect against the core belief becoming activated.

We all have rules and we would not be able to function without them.  These rules exist implicitly even if a person cannot explicitly articulate what they are.  Rules are ever present, even if they are not immediately obvious.  For example, even the belief: “I do not believe in rules” is a rule!  Stated differently, this belief in rule form would look like: “Always reject rules and never stick to a consistent principle.”  There is, therefore, no way of getting around the fact that we all have rules that we follow whether we are aware of them or not.  These rules often exist on a subconscious level (below the water line on the CBT iceberg) and need to be brought to consciousness for evaluation.

Rules are learned and are not genetically hardwired, though genetics may predispose us to adopt certain rules easier than others.  Rules are thus heavily influenced by sociocultural factors and by our families of origin.  Rules tend to be transmitted from parents to children and form the rationale for many of the behaviors we adopt.  It is difficult to change behavior without understanding the rule that drives that behavior.  Rules therefore tend to be stubborn and resistant to change as we wouldn’t adopt rules that we didn’t think made us safe or functional in some way.

When starting to examine rules, it is easiest to translate them to an “If….then” framework.  For example, a couple may come to therapy to talk about their constant conflict with each other and an inability to repair their relationship.  They may simply report: “We fight a lot and drift apart afterwards” but a skilled CBT therapist may identify a maladaptive rule in the background such as: “If I say sorry then I’ll appear weak.”  As you can see, the rule is probably at the heart of the couples troubles but it is often not articulated immediately as: “If…then.”  With skillful probing, a therapist needs to be able to take vague statements and put them into the “if…then” rule framework so that clients can more easily understand their psychological world.

If…then rules also contain lots of unexamined implicit assumptions that need to be analyzed.  For example, “If I say sorry then I will appear weak” can also be understood as a set of assumptions.  This rule implies a certain definition of weakness, assumes that others share this view and assumes that denying weakness is desirable and valuable.  In many cases, the person will simply not have examined this rule in such depth and will probably not be aware of the assumptions that fall apart upon examination.  In some cases the rule may be more entrenched so the assumptions can become targets for standard CBT challenging techniques such as identifying distortions or the evidence technique.

Rules can also be thought of as contingency plans.  A contingency is something that occurs when a given condition is met.  For example: “If I am put in a new situation…then I remain quiet” can be thought of a contingency.  The condition of “new situation” triggers the contingent behavior of silence.  Contingencies are similar to the “compensatory strategies” we listed earlier.  They are planned ways of achieving goals when certain situations arise.

Rules for living are important because they organize and coordinate our daily existence.  They can also be viewed as “coping strategies” that help individuals deal with stress.  For example, if a person is terrified of rejection they may develop the rule: “If I’m nice to everyone then they’ll like me.”  Being nice becomes a coping strategy for preventing the feared outcome of rejection.  This rule is probably useful in many situations but there are others where this rule would lead to a person becoming unassertive and avoiding healthy conflict.  This leads us to the next skill therapists need to develop: how to tell helpful from unhelpful rules.

Helpful vs. Unhelpful Rules

Since we all have rules it’s important to be able to distinguish between maladaptive and adaptive aspects of rules.  There are certain typical characteristics of helpful rules that include:

  • Being Realistic: Helpful rules will reflect a realistic view of reality and will not be distorted too much in any one direction. These rules will be realistic to achieve and will not reflect impossible standards.  For example, the rule: “I must be perfect at everything” is clearly unrealistic because it is not achievable by anybody.  A healthy approximation of this might be: “I do my best when focusing on things important to me.”  This is a much more realistic rule that is capable of being achieved.
  • Flexible over time, experience and learning: Helpful rules are not too rigid and are able to be adapted when new learning or experience calls for change.  For example, the rule: “I shouldn’t trust new people” may be developed in high school and may be based upon experiences of being bullied.  However, this rule may cease to be useful later in life and would become maladaptive if it could not be changed to suit new circumstances.
  • Intelligent: Helpful rules make accurate distinctions between what we can and cannot control.  They focus on process rather than outcomes since outcomes are often out of our control.  For example, the rule: “If I study hard then I will always get 100%” is outside of the person’s control and is therefore unhelpful.  Changing this rule to: “If I have a test then I study until I know the material” is a much more helpful rule since it focuses on what the person can control (studying) rather than the outcome that depends upon another person’s judgment which is outside of the student’s control.
  • Meaningful: Helpful rules are necessary and meaningful to the individual and are not superfluous or not needed.  For example, a person may be taught the rule: “Always knock on wood when speaking of your own good fortune” but not really believe in it. Since this rule isn’t meaningful, it is probably unhelpful in the grand scheme of things.
  • Tend to lead to behaviour patterns that “work.” We can judge the efficacy of rules by judging the behaviors that they lead to. If a rule leads to dysfunctional or maladaptive behaviors then the rule itself is probably unhelpful.  Helpful rules will lead to behaviors that facilitate beneficial goal achievement and will not hinder those goals.

In contrast to helpful rules, unhelpful rules have the following inverse characteristics:

  • Unrealistic: These rules reflect a distorted view of reality and set impossible standards that cannot reasonably be maintained.
  • Rigid: These rules are inflexible and completely resistant to change even when new data reveals their inadequacy. For Example: “If I enroll my kids in many activities, then I am a good parent” may be rigid when new evidence (child exhaustion) fails to modify the rule.
  • Unreasonable: These rules focus on what is outside of a person’s control rather than what they can control. They focus on outcomes rather than processes.
  • Unnecessary: These rules are often safety behaviors that don’t really keep the person safe. For example, knocking on wood doesn’t really keep a person safe but the person may believe it does.
  • Lead to dysfunctional behaviors: A rule can be determined to be maladaptive simply because it leads to maladaptive behaviors.

Below are some examples of common rules for living that form the cognitive map for certain DSM diagnoses:

  • “If I say something dumb at a party then people will think I am stupid.” (Social Anxiety)
  • “If people hurt me, then they should never be trusted again.” (Attachment Disorder)
  • “If I think about something terrible, then it will happen.” (OCD)
  • “If this job doesn’t work out, then I am a failure.” (Depression)

Identifying Rules for Living

As has been previously mentioned, Rules for Living are not always explicitly articulated by people and need to be skillfully identified.  There are many different sources that you can look to when determining your rules for living that include:

  • Thought Records: Your rules are sometimes listed directly as automatic thoughts in a thought record. They can also emerge from multiple thought records after identifying general themes in them.
  • Socratic Dialogue: Sometimes rules are identified in conversation with the client. For example, if a therapist gives a suggestion and the client resists there may be an underlying rule you’ve identified.  A therapist may say: “I wonder if saying sorry would solve the problem” and a client may respond: “That’s out of the question.”  A little more probing may identify a general rule that the client has about apologies in general.
  • Client value judgments or anger: Another good source for identifying rules is when you notice yourself responding with judgment or anger to certain people or situations. Judgments and anger are both frequent responses to rule violations.  For example, if you are angry with your husband, ask him what rule he broke that is causing this response.
  • Shoulds, Oughts and Musts: People will also frequently frame rules with words like: “should” “ought” or “must.” Pay attention when these words are used as they are good hints that you are probably dealing with a rule for living that needs examination.
  • Society and Culture: Having knowledge of certain subcultures may provide good hints for a therapist trying to identify rules.  For example, a person who comes from a Christian background will probably have rules that reflect that worldview.  Similarly, a person with a Muslim background will probably have rules influenced by that religion.

Challenging Rules for Living

Rules for Living can be challenged using standard cognitive restructuring techniques or they can be challenged using behavioral experiments. We will first briefly discuss cognitive restructuring techniques and then look at behavioral experiments in more depth afterwards.

Just like automatic thoughts, Rules for Living can be taken through the process of identifying distortions, generating evidence and creating balanced rules.  For example, if you identify the rule: “If I am not the top in my class then I am nothing” then you can examine its validity and utility.  This rule clearly reflects all-or-nothing thinking, over-generalizing and a host of other distortions.  Examining the evidence a client has for this belief may reveal where this rule came from and whether it is realistic, reasonable and flexible.  This rule can also be examined for its utility: “What effects does this rule have on your life?” and for double standards: “What would you tell a best friend who was not the top in their class?”  After going through this process, you may be able to generate a balanced rule: “If I do my best in class then I can be satisfied with the results.”

Whenever a person reasons using rules, they are using certain patterns of inference to justify those rules.  Rules are claims that: “If x situation occurs then y response is necessary or forbidden.”  The rule mediates between what is claimed as fact and what the client claims needs to be done about that fact. Reasoning with rules also frequently involves reasoning with analogies as the person says: “X should be done in Y situation.”  “My rule is activated because this new situation is similar enough to situation x to justify this y response.”

However, this line of reasoning is subject to certain tests to ensure sound reasoning is occurring.

  • Do the facts of the situation justify activating the rule? This test ensures that the essential requirements of the rule are met before it’s activated.  For example, if a client has a rule: “If someone is rude to me then I must be rude back” we need to ensure the essential facts of the situation justify the rule activation.  We need to determine if the person really was being rude or whether there was some other explanation for the behavior.  Clients may be activating rules in situations that don’t meet the essential requirements of the rule.
  • Have all relevant aspects of the situation been considered? Ensure that a client considers all aspects of a situation before activating his rule. For example: “If my child misbehaves then he should be disciplined” should only be activated if all aspects of the situation have been considered.  Is the child really misbehaving or is there some other explanation that would cause this rule to be deactivated?
  • Is the rule itself based upon sound principles? Clients should reflect on why they believe a rule is useful and the evidence base needs to be examined. For example, the rule: “If my husband is upset then I must do everything to please him” may be based on examples from past relationships.  This general rule may have been formed based on inadequate data

A general process for challenging rules is listed below:

  1. Identify the unhelpful rule First identify the rule using the sources we have already discussed.
  2. Work out where it came from: Try and understand what role this rule has served in the clients life and whether it was once useful or not.
  3. Ask: Is the rule realistic, reasonable or achievable? Examine the rule according to the criteria discussed about helpful and unhelpful rules.
  4. “Name” the negative consequences of having and keeping this rule: Examine the rules utility and usefulness in the client’s life.
  5. Identify a more helpful rule, if there were one: Generate a balanced rule that can be experimented with.
  6. Plan how to adjust life with new rule: Troubleshoot and debrief rule changes with the client at subsequent sessions to solidify gains.

Behavioral Experiments

Cognitive Restructuring is sometimes not enough to challenge resistant rules for living. When these tools are not enough, behavioral experiments are powerful interventions for challenging rules for living.  As mentioned earlier, behavioral experiments challenge rules by manipulating the: “if…” part of a rule to challenge the “then” conclusions that clients have.  The rule is based upon the foundation that “if” will reliably lead to “then” and the behavioral experiment is designed to cast doubt on this assumption.

For example, the rule: “If I speak up in class then I will be ridiculed” can be tested through a behavioral experiment.  The client needs to speak up in class in order to test whether the rule is accurate or not.  Now, usually, the rule is based upon a few isolated experiences that the client has had so you will need to make sure the experiment is done with new situations that are likely to yield a difference outcome.  Ideally, testing this rule in a variety of circumstances will be more beneficial rather than just doing it once.

Behavioral experiments are a perfect bridge between cognitive and behavioral interventions.  They help us gather data/evidence against our most influencing negative assumptions.  They are designed like an experiment to test the predictions or validity of our conclusions by exposing us to new information.  They can be done in session, but they are also often designed in session and then done as homework between sessions.

Behavioral experiments are often confused with exposure work but they are different interventions.  While exposures are done to reduce fear/anxiety, behavioral experiments can be used for a variety of reasons, such as changing a rule or testing a new idea.  Also, behavioral experiments do not involve prolonged toleration of anxiety but instead simply involve a changed behavioral response and then reflecting upon the data generated.  While exposures usually need to be repeated over and over, behavioral experiments usually only need to be done a few times until the client shifts the initial conclusion.  Instead, behavioral experiments are uniquely designed events aimed at testing a hypothesis (or rule).  Behavioral experiments can include conducting surveys, introducing new behaviors/thoughts and monitoring the results of those changes.

A step-by-step guide for conducting behavioral experiments is included below for your convenience:

Steps to Doing Behavioral Experiments

Phase 1: Pre-Experiment Work

Step 1: Write down the assumption, rule or expectation that you want to test.  For example, the belief: “If I speak up in class I will be ridiculed” might be recorded here.

Step 2: Design an Experiment that will accurately test whether this prediction will come true or not.  Answer the following questions: how are you going to measure this? How many times? Determine specifics to your plan: what, when, where, who and how?  The experiment usually flows naturally from the rule.  For the above example, the series of experiments might include: “I will speak up in math class on Monday, science on Wednesday and Art on Friday.”

Step 3: Make your predictions about what the likely outcomes of the experiment are and rate how likely you think each outcome is to happen out of 100. Also, write down alternative predictions that you might not think are likely. For example, the client may predict: “When I speak up, I will be made fun of” or “When I speak up people will be surprised.”

Step 4: Problem solve barriers by anticipating what could go wrong and then creating a contingency plan to deal with it.  For example, the student about to speak up in class might anticipate that looking at everyone’s faces before doing so might scare her.  She may then resolve to purposely avoid doing so until she has spoken up.  She might also develop coping statements she can use in the moment when her fear becomes heightened.

Phase 2: Conduct the Experiment

Step 5: Conduct the Experiment that was planned, ensuring all of the details that were planned were followed through on.

Phase 3: Post-Experiment Work

Step 6: Review outcomes to determine if your predictions were confirmed.  Does the new data justify a new rule or hypothesis? Determine if you need to do a re-test or to gather more data.  If your hypothesis was confirmed brainstorm why it may have been.

Step 7: Revision and New Experiments.  If your hypothesis was not confirmed and you feel you have enough data to adapt a healthy rule, you don’t need to do any more experiments.  You may want to anyways, to solidify gains but that’s up to the therapist and client.  If your predictions were accurate, new behavioral experiments need to be designed that will be more likely to yield positive outcomes.  Determine what characteristics of the situation led to the negative outcome and then try and eliminate them on subsequent experiments.  The client will need to learn how to differentiate between contexts that suit the rule and contexts that do not.

You can also do behavioral experiments much more informally by reducing them to their core components. For example, you can design something relatively quickly for a client with social anxiety that might look like this:

  • Prediction: Thought, “I will do something dumb and everyone will laugh” (90% confidence)
  • Task: Go to mall, drop change on floor
  • Record: How many people stop and laugh, how that makes me feel
  • Bring back: What (actually) happened, how you felt, how “right” you were about prediction

Resources

Rules for Living and Behavioral Experiments

 

Behavioral Activation & Goal Setting

Behavioral Activation & Goal Setting

The next behavioral intervention that we will examine is called “behavioral activation.” This intervention simply involves planning and monitoring new behaviors that are designed to accomplish your therapeutic goals.  This intervention is one of the first things that you would do if you are struggling with depression.  Some research suggests that behavioral activation is all that is needed in many cases of depression, and that cognitive work is not even necessary.  However for others, a combination of both cognitive and behavioral interventions is required.

You can also use behavioral activation tools to accomplish general lifestyle and behavior modification changes.  Behavioral activation also serves to reinforce cognitive gains and can provide the experience necessary for shifting perspectives.  Behavior change also interrupts perpetuating cycles and introduces new cognitions (Ex. “I begin exercising daily and meeting my goals so I think “I am healthy”, which may in turn create new healthy core belief cycles).  Behavioral activation is also useful when cognitive work doesn’t appear to be working.  Changed behaviors will result in changed environments and thus provides new data for the client to interpret that may challenge old beliefs.

Behavioral Activation involves 4 major steps:

i.) Identifying Values: This is a step that is often overlooked but is very important to establish before goal setting. People are often unaware of their values or they set goals that are inconsistent with those values.  In order to ensure that you set the right goals for yourself, it is helpful to brainstorm what your top 10 values in life are. Consult a list of common values and select 10 of them and prioritize the most important ones.  For example, if your really value family but the goals you have set are all about improving your career then those goals are unlikely to be fulfilling in the long-term.  Identifying these values first will help ensure that the goals you set reflect those values and will lead to lasting fulfillment.

ii.) Vision casting:  After identifying values, it’s important to engage in vision casting.  This can involve asking some variation of the miracle question: “If a miracle occurred and you had the perfect life, what would it look like?”  Dream big and hold nothing back.  Too often, people dedicate themselves to pursuing lesser causes because they are afraid to commit themselves to their biggest dreams.  Write out and envision this future in detail and to be specific.  Be sure to include family, work, recreation, spirituality, health, environment, activities and hobbies, volunteering etc…Creating this vision will also serve as a strong motivating force and give purpose to the mundane planning and monitoring work that will need to occur for this to come true.  Remember that work without vision is drudgery so people need to vision cast to give their lives meaning.

iii.) Creating Goals:  After identifying values and vision casting comes goal creation.  Most people are familiar with the concept of SMART goals but a brief review here will be provided.  SMART goals are:

  • Specific: They are clear and concise and avoid vague statements like “I will feel better or be happy.” A specific version of this goal might be: “I will do 2 activities a week that make me happy.”
  • Measurable: Goals needs to be defined or operationalized in a way that they can be measured. For example, the goal: “I want to feel better” is not really measurable while: “I want to score 10 points lower on the BDI” is measurable.
  • Achievable: Goals must be realistic and within your scope of competence to accomplish.  For example, a man with no musical training should not set a goal: “I will get a record deal in 6 months.”  Instead, a more realistic goal might be: “I will practice every day for the next 6 months so that one day I can get a record deal.”
  • Relevant: Goals should also be focused on that which you value most.  Setting goals around things you don’t really care about but think you should care about will not be helpful.
  • Timed: All goals need to have a deadline.  If there is no deadline then it is unlikely that goal will be achieved.  For example, saying: “I will become a teacher sometime in my life” will not be as effective as: “I will enter teachers college in the next 2 years.”

Ensure that the goals you set  are calculated to achieve the grand vision set forth and that they are reflective of the values you have chosen.  Create a list of goals in at least the following categories: Family relationship, social and community relations, education and career, Hobbies and Recreation, Volunteer Work, Spirituality, environment and physical health.

iv.) Planning and Monitoring Goal Progress:  And finally, after identifying values, vision casting and setting long-term goals you need to plan out your week in advance, scheduling in activities that will help her meet those goals.  For example, if the client has a goal of “I will lose 10 pounds” then she should schedule exercise time on 4 days in the coming week.  The client similarly plans out activities for the coming week that will help her meet her goals in all of the categories listed above.  Attached below is a “behavior checkout” worksheet that you can give to your clients to help them schedule and monitor activities consistent with their goals.

Resources

Behavioral Activation Worksheet

Monitoring Tools – Activity Tracking

Monitoring Tools

This post is all about becoming familiar with the tools used to track moods, thoughts and behaviors.  There are two foundational tools that include the daily activity monitoring worksheet and the thought record.  The former is used to track activities, moods and behaviors and the latter is used to track thoughts and beliefs.   Before we can challenge, change or restructure behaviors and thoughts we must first become aware of them.  Monitoring tools are designed to help you become aware of how you are spending your time and how you are feeling.  Good monitoring sheets will ask you to measure the frequency, duration and intensity of moods and behaviors on a daily basis.

Activity Tracking 

Most CBT monitoring sheets are either in a daily or weekly format.  Which exact sheet you use is simply a matter of preference but one has been included below as an example for you to see.   The worksheet is fairly simple to follow and simply involves recording your activities throughout the day and your mood on a SUDS scale (Subjective units of distress).  With depression, you will also use the monitoring sheet to record pleasure and accomplishment activities. You either rate how much pleasure and accomplishment each activity gives you out of 10 or you pre-plan those activities and record whether they were done.  As you can see, there are going to be slight variations to monitoring tools and methods but all focus on gathering data on the frequency, intensity and duration of your moods, thoughts and behaviors.  Along with traditional paper worksheets, many apps now exist that make monitoring more discreet and convenient.  Some popular monitoring apps that exist right now include: Thought Diary Pro, Thought Buddy, Pacifica and Mood Kit.  Most of these apps will track everything for you including situations, moods and activities.  Check your favorite app store for the keywords “CBT” “Monitoring” and “Tracking” to stay up to date with new and improved apps.

Monitoring tools in themselves are a powerful intervention, as they allow you to become more self-aware and they may challenge distorted beliefs.  Many clients are unaware of how frequently they do or avoid doing things and they are also unaware of the actual frequency and intensity of their moods.  When clients collect this data, they are often surprised as it frequently does not match their preconceived notions.  This data can be extremely convincing in challenging distorted beliefs or the lack of understanding clients may have about their own life experience.  A few examples will illustrate how monitoring can challenge beliefs:

  • Client with anger management problems: Many clients begin therapy and are ambiguous towards change because they aren’t convinced their behaviors are problematic.  Frequently, with anger management clients, they will minimize or dismiss the frequency and intensity of their anger.  Having these clients fill out a monitoring sheet is objective data that many cannot ignore that may convince them if anger is a problem or not.  Also, the mere act of monitoring behavior tends to change it! It takes us off of auto-pilot mode and helps us be more deliberate in how we behave and spend our time.  Having a client commit to monitoring anger should reduce the frequency of anger outbursts in itself.
  • Client with depression: Many clients who are depressed are not really aware of the amount of time that they spend doing activities that do not make them feel a sense of accomplishment.  Filling out a weekly activity sheet can help them see that they are most likely doing very little to advance towards important goals in their life.  Again, many simply are not aware of how they are spending their time and tracking their time is the first step in them realizing that their current behavior is unhelpful.  Matching mood to activities also helps the clients make connections between what they are doing and what they are feeling.  Many are simply not aware that certain situations tend to trigger depression.  Monitoring is thus useful because it helps clients track patterns and identify triggers.
  • Client with addiction: Monitoring tools are extremely important to use with clients who present with addiction problems.  First, like anger, they can provide objective evidence that may challenge a client’s tendency to minimize how frequently they use.  They also provide a baseline measure for the client to compare future progress.  One of the major problems with addiction is the “abstinence violation effect” or the tendency for clients who lapse to give up and say “there is no point, I might as well go all the way now.”  Monitoring sheets can help challenge the abstinence violation effect by helping them see if they are on an upward trend or not.  If the client’s baseline measure shows 10 lapses a week and the next week shows only 8, that is progress that the client can be proud of but probably would not be aware of unless they were monitoring their behavior.
  • Client with anxiety: And one final example of a client with anxiety problems will illustrate the importance of monitoring tools.  One of the major maladaptive behaviors that maintains anxiety disorders is avoidance of what the person fears.  Monitoring tools can help the client see how often they are avoiding what they are anxious about compared to how often they are confronting those fears.  Monitoring their anxiety can also help them draw connections between avoidance and feeling worse.  Monitoring will also help them see that avoidance tends to generalize to other situations and the client can see if their anxiety is indeed generalizing or not.

In summary, monitoring tools are useful for a variety of reasons that include:

  • Baseline measures: Monitoring tools provide baseline measures by which we can measure further progress in therapy.
  • Belief Challenging: Monitoring tools provide the objective data that may convince a client that their belief is either true or not true.
  • Synthesizing and Analysis: Monitoring tools provide the data for clients to analyze their experience and to draw connections between what they are doing and how they are feeling.  They help identify triggers for problematic beliefs and moods.
  • Increased Self-Awareness: Monitoring tools promote self-awareness as they cause the client to become aware of how they are acting and feeling.  They take clients off “auto-pilot” mode and encourage a deliberate and purposeful approach to life.
  • Assessment Accuracy: Monitoring tools are an essential part of assessment as they provide the objective data on the frequency, intensity and duration of maladaptive behaviors.

Resources

Activity Diary

The Cognitive Model

The Human Matrix
A matrix is an environment within which something develops. The human being develops within a matrix of various components. Those components include:

i.) Biology
ii.) Psychology
ii.) Social World
iv.) Environment
v.) Spirituality

The “biopsychosocial” model is an example of a matrix model that suggests that each wing of the matrix can affect each other. The Components of the human matrix each intersect and are independent of one another. However, they are not neatly compartmentalized as each wing can have reciprocal effects on each other so that feedback loops are created where the output of one wing affects inputs of another. For example, physical exercise focuses primarily on the biological wing of the matrix but has spillover effects in each other area.

A spillover effect occurs when changes in one wing of the human matrix causes changes in another. For Example, Psychosocial dwarfism is a disorder that proves spillover effects in one wing can affect another. Children with psychosocial dwarfism all share one thing in common: they come from deprived home environments and are often physically or sexually abused. They are very short for their age but aren’t undernourished. Their pituitary gland simply refuses to secrete growth hormone (even though there is nothing wrong with their gland). If they are given growth hormone while still in their abusive home it has no effect. However, once removed from their abusive homes, these children begin to grow again! This is an incredible example of the effects that one wing (social) can have on another (biology). This was an example of a negative spillover effect but it also works in the opposite direction. Positive gains in one wing of the matrix can have positive spillover effects to facilitate growth in another.

The implications of this model are that it may not even matter whether the primary presenting problem was psychogenic or not. Cognitive therapy can intervene through the mind to have spillover effects on every other wing of the matrix including biology.

The Cognitive Model

This brings us to the core assumption of Cognitive Behavioral Therapy expressed through the “Cognitive Model.” Most people assume that emotions are caused by events or situations but the cognitive model suggests that there is another intervening variable that is responsible for how we feel. This intervening variable is “thoughts” or as I would prefer to name them “interpretations.” The gist of the cognitive model is that events don’t cause emotions, interpretations of them do. And unfortunately, our interpretations are not necessarily accurate or useful and we are often blind to the possibility of other interpretations.

Every moment of your life, data is being received from your environment. You are tasked with interpreting this data, which is a creative endeavor subject to bias and error. How you choose to interpret your experience determines your emotions, moods and behaviors. One of the best coping skills you can learn is to be flexible in your ability to interpret situations. You can control your emotions and behaviors by learning how to interpret situations in different ways.

Other terms we use to describe thoughts are: conclusions, beliefs, truths, self-talk, visual pictures or assumptions. Other terms we use for moods include: emotions, feelings, internal experiences and sensations. With moods we are usually referring to some kind of autonomic and neural activation that lead to physical sensations while thoughts are the interpretations that lead to those sensations. Emotions differ from moods in terms of duration and intensity. Emotions are short lived and intense while moods persist longer but are less intense than emotions. People commonly mistake thoughts with emotions so it’s important that you understand the difference.

The Cognitive Model is often expressed through a worksheet called the “Five Factor Model.” The Five Factors are simply:

1.) Situation
2.) Thoughts
3.) Moods
4.) Behaviors
5.) Sensations

You can use this worksheet to understand the cognitive model and can use some examples from your life to see the power of your interpretations. Keep the situation the same, but generate different interpretations to help yourself see that you have control over your emotional experience.

A couple of examples will illustrate the point.

1. Situation: A Husband asks his wife to talk but the wife rushes out the door to take kids to school saying “I don’t have time for this.”
2. Possible Interpretation: “She is deliberately ignoring me.”
3. Moods/Emotions: “She is deliberately ignoring me.” -Anger
4. Behaviors: Husband may text wife expressing frustration or call and yell at her.
5. Physical sensations: Sweaty palms, racing heart etc…

As you can see, the interpretation “She is deliberately ignoring me” led to the predictable emotion of anger and then to the maladaptive behavior of yelling or confrontation. Now, let’s keep the situation the same but just change the interpretation.

1. Situation: A Husband asks his wife to talk but the wife rushes out the door to take kids to school saying “I don’t have time for this.”
2. Possible Interpretation: “She must be rushed, I will talk to her later.”
3. Moods/Emotions: Calmness.
4. Behaviors: Husband continues with his day and accepts that he has to wait to talk
5. Physical sensations: Nothing remarkable.

With this interpretation, the husband was able to avoid a confrontation and continue with his day. Let’s try another interpretation:

1. Situation: A Husband asks his wife to talk but the wife rushes out the door to take kids to school saying “I don’t have time for this.”
2. Possible Interpretation: “She dismisses me because she doesn’t value me.”
3. Moods/Emotions: Sadness.
4. Behaviors: Husband withdraws and begins mourning lost love.
5. Physical sensations: tightness in the chest.

And finally, let’s take a look at one final interpretation:

1. Situation: A Husband asks his wife to talk but the wife rushes out the door to take kids to school saying “I don’t have time for this.”
2. Possible Interpretation: “Her dismissal means she is going to leave me.”
3. Moods/Emotions: Fear.
4. Behaviors: Husband frantically texts the wife, seeking reassurance that they are okay.
5. Physical sensations: racing heart, hyperventilation etc…

As you can see, it wasn’t the situation of the wife leaving the house abruptly that caused the husbands emotion but rather it was his interpretation of what those actions meant that resulted in his emotional experience. The point of this exercise was not to judge the legitimacy of each interpretation but simply to illustrate that different interpretations lead to different emotions. Many mental health problems and other life stressors are a result of biased or unhelpful interpretations. If we can become flexible in our range of interpretations and accurate in our selection of the most adaptive ones, we can control our emotional experience.

Resources

Five Factor Model Digital

The Cogitive Model

An Overview of Psychotherapy & CBT

Who are Psychotherapists and where does CBT FIT?
From a broad perspective, a Psychotherapist is a person who creates an interaction likely to initiate change, primarily through use of the self. This means that psychotherapists use interpersonal interactions as catalysts for change to help clients achieve desirable goals.

The APA gives a more detailed definition: “Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable.” If we break down this definition, we see that there are several elements.

i.) Informed and intentional: First, psychotherapy is performed by those who are properly trained and with the informed consent of those clients seeking treatment.
ii.) Deliberate: Interventions are deliberately planned.
iii.) Established Principles: interventions are based upon sound therapeutic principles that have been empirically validated through the broader scientific community.
iv.) Modifying Thoughts, Emotions & Behaviors: The purpose of the psycho-therapeutic relationship is to modify maladaptive behaviors, thoughts and emotions so that they cease interfering with the client’s stated objectives and to replace them with more adaptive behaviors that are conducive to accomplishing the client’s goals.

While the term “psychotherapy” is relatively modern, the function of facilitating change through an interpersonal relationship and through “talking” can be traced back to antiquity where ancient sages, elders, priests and seers would give guidance to those seeking help. Other roles throughout history that have approximated this function include: mentors and mentees, masters and apprentices and teachers and students.

Similarly, just as psychotherapy was approximated by different roles throughout history, psychotherapists are now tasked with fulfilling the functions of some of those roles that either
no longer exist or whose influence has eroded over time. For example, many people relied upon a relationship with and guidance from the priestly caste, but secularization has left a hole that is increasingly needing to be filled by psychotherapists.

Many others do not receive adequate training in the scientific method and need to rely upon those trained to help them identify causes and effects in their lives. This is partially what “established psychological principles” refers to as psychotherapists are experts on the causes of mental illness or maladaptive thoughts, emotions and behaviors.

Psychotherapists also find that they are tasked with fulfilling the role of a teacher or parent and must educate clients on basic coping mechanisms, social skills and in some cases basic life skills.
Finally, psychotherapists routinely help clients temporarily meet their spiritual needs of meaning and connection that used to be satisfied through strong families, communities and religion. Our secular materialist society has many benefits but some of the drawbacks include that loss of connection with others and with something greater than ourselves. Since meaning has often been reduced to the pursuit of wealth, in our society, it is no wonder many seek the aid of psychotherapists to find out why they are “empty” and “isolated.”

There are many different types of psychotherapy so one useful way of differentiating between them is on a continuum with 4 dimensions: Structure, Driver, Initiator and Measures.

i.) Structure refers to how protocol driven a therapy is or how much guidance the model provides the clinician. Highly structured therapies provide detailed models for clinicians to follow and they achieve more homogeneity among clinicians who practice. Less structured therapies provide less guidance but allow the clinician more leeway in deciding therapeutic directions.
ii.) Driver refers to who is taking the lead in setting the course for therapy and in determining the treatment plan. Therapist driven therapies emphasize the therapist’s role as an expert in knowing what to prescribe for common presenting issues. Client-driven therapies, in contrast, focus on the client as the expert of his/her life and has the therapist playing a supportive role in wherever the client chooses to go.
iii.) Initiator refers to the stance that the therapist takes in relation to the client. Therapists can be viewed either as initiators or responders. When therapists are initiators, they proactively provide a treatment plan for the client to follow, based upon previous work with people of similar presenting issues. When therapists are responders, they allow the client to determine what content to discuss in session and allow for the client to set the direction of therapy.
iv.) Finally, Measures refer to how the effectiveness of therapy is evaluated. With outcome driven therapies, success is defined by achieving some predetermined goal such as a decrease in the rate of behavior or a decreased score on objective measures such as the Beck Depression Inventory. In contrast, experience driven therapies define success by the subjective reports and experiences of the participants. If the client “feels” that therapy is working then success has been achieved.

Generally speaking, “right” leaning therapies tend to be therapist driven and initiated that are highly structured and use outcomes as measures of success. Electroconvulsive Therapy may be a prototype here as it involves nothing but the therapist imposing an intervention on a passive client and measuring whether symptoms of depression have been alleviated.

In contrast, “left” leaning therapies tend to be client driven where the therapist acts only as a responder and are less structured. These therapies tend to use the subjective experience of the participants to judge effectiveness. Rogerian therapy is a good prototype of a left-leaning therapy as it involves a therapist acting only as a responder to a client who determines the content and direction of therapy.

Based upon these criteria, we must conclude that CBT would be a “center right” or even “right” leaning therapy. CBT is a highly structured therapy that provides lots of guidance or “protocols” for clinicians to follow based upon presenting issues. The CBT therapist is an expert on the “cognitive model” of mental health disorders and brings this knowledge to initiate therapy. Finally, outcomes are usually used as the measure of success rather than experience of the participants.

Philosophical Basis of CBT
Cognitive Behavioral Therapy is grounded in a certain philosophical framework of Western Rationalism and Empiricism. It accepts that knowledge can be gained through experience (empiricism) and through mental processes (rationalism). CBT is also grounded in modernism more so than post-modernism and assumes an objective reality exists and that we can therefore learn consistent and reliable causes and effects. Since cause and effect is predictable, we can therefore determine common causes for mental health disorders and make reliable prescriptions for those we have not interacted with much yet based upon presenting symptoms.

In contrast, post-modern therapies tend to reject an objective reality and focus on how truth is constructed by the subject. Given this assumption of reality, it only follows that the client would be viewed as the expert and would initiate and set the course for therapy. This is why the therapist also does not act as an “expert” since the experience of the subject is emphasized over the objective knowledge of the therapist.

In order to practice CBT, one must be comfortable with the philosophical basis upon which it is founded. If you can accept that an objective reality exists and that we can determine cause and effect through the scientific method and therefore draw generalizable conclusions for larger populations than you will fit right in with this model.

The Tenets of CBT
Judith Beck outlines 10 Tenets of CBT that are useful to repeat.

Principle 1: Cognitive therapy is based on an ever-evolving formulation of the patient and her problems in cognitive terms.

  • This means that client’s problems are put into the “cognitive model” and the therapist remains open to revising that model as new information arises. CBT therapists identify current thinking and behavior that maintains the problem and attempt to change those problematic interpretations and behaviors.

Principle 2: Cognitive therapy requires a sound therapeutic alliance.

  •  Contrary to what some believe, CBT can only be done effectively if there is a sound therapeutic alliance. The therapeutic alliance is of paramount importance. CBT interventions are the icing on the cake of the therapeutic alliance.

Principle 3: Cognitive therapy emphasizes collaboration and active participation.

  • On the continuum of psychotherapies, CBT is a right-leaning therapy but it is not so far right that the client has no say in the direction of therapy. CBT is based upon mutual collaboration so that both the expertise of the therapist and the desires of the client are equally considered.

Principle 4: Cognitive therapy is goal oriented and problem focused.

  • Since the efficacy of CBT is based upon outcomes it’s important to set SMART goals (Specific, Measurable, Achievable, Realistic, Timed) that can be measured. CBT therapists focus on solving problems more than directionless talking.

Principle 5: Cognitive therapy initially emphasizes the present.

  • Cognitive therapists are concerned mostly with CURRENT thoughts and behaviors that are maintaining problems and are not as interested in past problems. However, CBT
    therapists shift to the past when core beliefs in the present are justified by past experiences that need to be re-examined.

Principle 6: cognitive therapy is educative and aims to teach the patient to be her own therapist.

  • The goal of the CBT therapist is to put themselves out of work! The CBT therapist wants to teach the client to be able to challenge and change beliefs and behaviors by themselves eventually. CBT also emphasizes education and skill development instead of simply supportive listening.

Principle 7: Cognitive therapy aims to be time limited.

  • Cognitive Therapists stick to goals and seek to put themselves out of work and thus CBT functions best in a time-limited format. However, CBT is best done within the context of 10-20 sessions as opposed to 4-6.

Principles 8: Cognitive therapy sessions are structured.

  •  Cognitive Behavioral Therapy follows a prescribed format from the beginning with a “session bridge” worksheet to ending with assigning homework. Cognitive Behavioral interventions are routinely prescribed for similar presenting issues.

Principle 9: Cognitive therapy teaches patients to identify, evaluate and respond to their dysfunctional thoughts and beliefs.

  • Dysfunctional beliefs are at the core of most mental health disorders. Thus, learning how to evaluate and change distorted beliefs to more balanced ones can alleviate mood disorders and other mental health problems.

Principles 10: Cognitive therapy uses a variety of techniques to change thinking, mood and behavior.

  • CBT interventions focus on changing thoughts and behaviors to manage mood.

The Empirical Status of CBT
Cognitive Behavioral Therapy is an empirically validated therapy, meaning that it has been proven to be more effective than placebo and comparable therapies in controlled experiments. For a list of CBT outcome studies please see this link from the Academy of Cognitive Therapy: http://c.ymcdn.com/sites/www.academyofct.org/resource/collection/A05F3041-8C5D-48C8-813E-A5E913CE4948/CBT_Outcome_Studies.pdf

A major meta-analysis of CBT outcome studies summarizes the efficacy of CBT with different disorders quite well. It concluded that large effect sizes were found for CBT with depression, generalized anxiety disorder, panic disorder, social phobia, PTSD and childhood depression and anxiety. It found moderate effect sizes for marital distress, anger, bulimia and chronic pain. It was equally effective as behavior therapy for OCD. Overall, CBT is a proven therapy for mood disorders and many other mental health disorders.

For more info see: (Butler, A.C., Chapman, J.E., Forman, E.M., & Beck, A.T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17-31.)

Resources

Overview of Psychotherapy & CBT

 

Overcoming Pornography – Talk Openly About Sexuality

Objective 16: Talk Openly About Sexuality

Review “Of Souls, Symbols, and Sacraments” by Elder Jeffrey R. Holland and then discuss it with your client.

Intervention 1: Recognizing That Your Body Is a Temple

Read 1 Corinthians 6:19. Ask your client the following questions:

  1. What is the significance of your body being a temple of God?
  2. What do you do with the knowledge that your body is a temple?
  3. What do you do with the knowledge that someone else’s body is also a temple?
  4. In what ways do you objectify your own body?
  5. In what ways do you objectify others’ bodies?
  6. How have you learned to humanize people?
  7. How do you see your body as the gift that it is?
  8. How do you treat your body as a gift?
  9. How do you thank Heavenly Father for this gift even when it is not perfect?
  10. How do you thank Heavenly Father for this gift when you are not happy with it?

Overcoming Pornography – Setting Healthy Expectations

Objective 15: Setting Healthy Expectations

Intervention 1: Creating a Relapse Plan

Introduce the idea that recovery can be like basketball. We focus on a strong offense, a powerful defense, and a quick rebound. A strong offense includes developing healthy habits and living them. Help the client remember the healthy habits he has created in the process of recovery. Talk together about how these habits have made him feel stronger and more stable. Have him list these habits on a piece of paper.

Explain that temptation is normal and that he will be tempted throughout his life. Discuss how developing a powerful defense includes planning what to do when temptations come. Over time the temptations may come less often, but he needs to be ready with a powerful plan for defense. As appropriate, include a discussion of the potential role of overconfidence in his move toward recovery and healthy living. Review with the client his plan for responding to temptation. Have him write this plan on his piece of paper.

Point out that there may be times when his offense lapses and his defense isn’t enough. This will give him an opportunity to rebound. In basketball, the most successful teams rebound more than other teams. The client can rebound quickly by engaging his support system, following his plan, and getting back on track. Have him write down a plan for recovering after a relapse.

Intervention 2: Counteracting Objectification

Discuss with the client how pornography leads us to objectify others. Consider asking:

  1. What do you know about the actors in pornographic films or pictures?
  2. What can you imagine about their family life?
  3. What can you imagine about their mother and father?
  4. What can you imagine about their spouse or children?
  5. What can you imagine about their hopes and dreams?
  6. What can you imagine about their stresses and challenges and how they have managed those?
  7. What can you imagine about their finances?
  8. What can you imagine about how they became involved in producing pornography?
  9. What can you imagine about their potential health challenges?

Discuss how the client might see these people as more than just objects. Talk about how we might occasionally see others as objects and how we must work to see others as real people. Consider asking:

  1. How might seeing people as objects have hindered your ability to connect with others?
  2. What are ways you can see people more deeply and fully?
  3. How does seeing people as people make a difference in your life?
  4. How does it aid you in maintaining healthy living?

Overcoming Pornography – Becoming Self-Reliant

Objective 14: Becoming Self-Reliant

Intervention 1: Reinforcing Effective Intrinsic and Extrinsic Motivators

Discuss what it means to be intrinsically and extrinsically motivated. Intrinsic motivations are influences that come from within, such as values and beliefs. Extrinsic motivations are influences that come from outside the individual, such as relationships, circumstances, consequences, and experiences. While extrinsic motivation can be useful, placing greater emphasis on intrinsic motivation tends to produce more lasting results.

Draw three columns on the board. Ask the client what motivates him to continue his healthy living, and write down these motivators in the left-hand column. In the middle column, write whether the motivation is intrinsic or extrinsic.  Discuss which motivators work and can be sustained. Make a plan to reinforce the three most effective motivators, and write this down in the right-hand column. See the example below: