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One of the fundamental principles of CBT is that there needs to be a collaborative relationship between the client and therapist. This collaboration takes the form of a therapeutic alliance in which the therapist and client work together to fight a common enemy: the client's distress.
To establish a collaborative relationship, the therapist needs to strike a balance between being directive and imposing structure on the one hand, and allowing the client to make choices and take responsibility on the other. This balance involves deciding when to talk and when to listen; when to confront and when to back off; when to offer suggestions and when to wait for the client to make their own suggestions.
Beck Institute for Cognitive Behavior Therapy: Cognitive Therapy and the Emotional Disorders, pp. 220-221; Cognitive Therapy of Depression, pp. 50-54
BEHAVIOURAL TECHNIQUES FOR MODIFYING UNDERLYING ASSUMPTIONS In contrast to strictly cognitive techniques, behavioural techniques focus more on how to act or cope than on how to view or interpret events. One of the principle goals of behavioural techniques is to modify dysfunctional cognitions. For example, the client who believes "I can't enjoy anything anymore" often modifies this automatic thought after completing a series of behavioural assignments designed to increase the number and variety of pleasurable activities they engage in. Thus behavioural change is often used as evidence to bring about cognitive change (Beck Institute of Cognitive Behavior Therapy, 2016).
MINDFULNESS
Emphasis on not forcing change to take place, but on promoting awareness and acceptance.
BEHAVIOUR EXPERIMENTS
Behaviour experiments may be enacting sequences of behaviour in the therapy room or out.
These may be opportunities for the client to practice new skills and ways of coping (e.g. in a
group setting); or involve confronting (rather than avoiding) feared situations and stimuli.
ASSERTIVENESS AND SOCIAL SKILLS TRAINING
People can develop psychological problems because they are not very good at engaging in
micro-level social interaction sequences.
EXPOSURE TECHNIQUES
Graded hierarchy of fear-eliciting situations that have been planned and discussed in advance.
IMAGERY RESCRIPTING
Following a phase of reflection on the event, client is asked to ‘rescript’ the event by imagining
what would need to happen to have made the original event less distressing.
HOMEWORK
Practice new behaviours and cognitive strategies, engagement in behavioural experiments and
collection of self-monitoring data between therapy sessions.
Kazantzis et al. (2005) suggest the following principles for successful use of homework
assignments in therapy:
Rationale for homework assignments provided in first session
Relevant to the client’s goals and aligned with existing coping strategies
Specific rather than vague
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Check the client has understood what is expected
Written instructions provided
Assignment not discussed if client is highly distressed
Outcome discussed at following session
Kazantzis, N., McEwan, J., & Dattilio, F.M. (2005). A guiding model for practice. In N. Kazantzis,
F.P. Deane, K.R. Ronan, & L. L’Abate (eds). Using homework assignments in Cognitive Behavior
Therapy. London: Routledge.
SELF-HELP LEARNING MATERIALS
Information sheets and worksheets that enable client to learn how to apply CBT ideas and use
CBT methods to make changes in their lives.
GRADED TASK ASSIGNMENT
The therapist may break down an activity into subtasks, ranging from the simplest part of the task to the most complex and taxing. These graded tasks provide the immediate and unambiguous feedback that they can succeed.
COGNITIVE REHEARSAL
Technique of asking the client to imagine each step leading to the completion of the task. This rehearsal imagery helps focus attention on the task, and also permits the therapist to identify potential obstacles that may make the assignment more difficult for a particular patient.
ROLE PLAYING
Role-playing may be used to elicit automatic thoughts in specific interpersonal situations; to practice new cognitive responses in social encounters that had previously been problematic for the client; and to rehearse new behaviours in order to function more effectively with other people. Role-reversal is often effective in guiding clients to "reality test" how other people would probably view their behaviour, and thus allow clients to view themselves more sympathetically. Role-playing can also be used as part of assertiveness training. Role-playing frequently is accompanied by modelling and coaching procedures.
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e. Monitoring
Measuring client improvement is an important part of an evidence-based modality like CBT.
Monitoring is also reassuring to remind the client of progress when they may be feeling
insecure due to loss of their usual coping strategies.
This can be done using SUDS – subjective units of distress scale – where the client rates their
level of anxiety or panic on a scale of 0-10 or 100; or the use of standardised measurement
instruments for specific diagnoses.
McLeod, J. (2013). An introduction to counselling (5th ed.). Maidenhead, Berkshire: Open
University Press.
f. Relapse prevention
Relapse may happen when the client is faced with a crisis; therefore it is necessary in CBT to
prepare for this and provide the client with skills and strategies for dealing with relapse events.
Three common types of experience:
Downers (feeling depressed)
Rows (interpersonal conflict)
Joining the club (pressure from others to resume behaviour)
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TROUBLE SHOOTING
Some of the most common mistakes for new cognitive therapists include:
1. Failure to agree on specific problems to focus on;
2. Selection of peripheral problem to attack rather than a central concern;
3. Tendency to skip from problem to problem across sessions rather than persistently seek a
satisfactory solution to one or two problems at a time.
Other common sources of lack of progress include:
Problems in the working alliance/Poor therapeutic bond
Therapeutic bond is too good
Therapist lacks general therapeutic skills
Therapist lacks CBT-specific skills
Client believes change isn’t possible
Client has doubts about therapy but doesn’t disclose this
Client thinks intellectual insight is sufficient (doesn’t work on behaviour)
Client is not prepared to work for change
Client is intolerant of discomfort and unfamiliarity of change
Dryden, W. (2015). How to help your clients get the most out of CBT: A therapist’s guide. New York, NY: Routledge.
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7. GROUP THERAPY
Once clients have the basic cognitive model down, they are often placed in group therapy to
further refine and practice the philosophy that they are applying to their problems.
Groups serve as a microcosm of the larger world in which clients can practice reacting to
criticism, rejection, or pleasure in more rational ways. They can also practice new behaviours
such as assertiveness. The focus is on the application of cognitive therapy methods.
Prochaska, J.O., & Norcross, J.C. (2014). Systems of Psychotherapy: A transtheoretical analysis
(8th ed.). Stamford, CT: Cengage Learning.
Benefits of CBT group therapy:
Cost effective
Members profit by hearing other members talk about their problems
Members are able to identify cognitive distortions
Sense of belonging and a safe environment
Conditional beliefs rise to surface and allow identification, testing and revising in safe
environment
Learn problem solving techniques from other members, especially adaptive responses
Social modelling and learning
Practice in a real life approximation of society
NOTE: Knowledge and ability to conduct individual CBT sessions is important before
conducting groups, due to the complex demands involved in tracking and facilitating group
process issues.
Corey, G. (2013). Theory and practice of counselling and psychotherapy (10th ed.). Boston, MA:
Cengage Learning.
Steps in CBT group work:
Step 1:
Therapeutic alliance - Group leader combines empathy and sensitivity with technical
competence in establishing their relationship with members.
Step 2:
Cognitive conceptualisation of cases – Group leader needs to be creative and active, and able
to engage clients through Socratic questioning and other cognitive and behavioural strategies.
Step 3:
Group leader must remain continuously active, deliberately interactive with members, helping
them frame their conclusions in the form of testable hypotheses.
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GROUP FEATURES:
Agenda
Feedback
Goal setting (both from therapist and group members)
Homework (behavioural experimentation)
Socratic questioning (clients begin to learn how to use this in their interactions with each
other)
CBT GROUP WORK DOES NOT INCLUDE:
Random self-disclosure
Emotional confrontation among group members
Straying into deeply affective expressions in the absence of a CBT strategy or technique
Client actively
working and benefiting
from group
Task (i.e. CBT and therapeutic activities)
Clients' involvement
Process (how members react and interact; dynamics tracked by
leader)
Group leader
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SOME EXAMPLES OF CBT GROUP THERAPY:
Mosman Private Hospital
There is a clinical assessment, including providing information about group treatment, assessing whether suitable for the client, and determining client’s motivation.
Group-work includes: psycho-education about depression; self-assertion, interpersonal relationships, and social network; resources and pleasurable activities; the cognitive model of depression and cognitive restructuring; and relapse prevention and evaluation of treatment. A patient workbook is used during treatment.
Sessions have the following structure: 1) review of homework; 2) presentation of topic A; 3) exercise related to topic A - conducted individually, in pairs, or in groups; 4) break; 5) presentation of topic B; 6) exercise related to topic B - conducted individually, in pairs, or in groups; and 7) presentation of homework.
The Sydney Clinic - Anxiety Group Some topics covered include:
Managing physical sensations associated with anxiety
Increasing awareness of unhelpful thinking patterns with techniques to challenge and
change them
Exposure to situations associated with social anxiety
Building resilience
Mood and addictive disorders
Managing physical symptoms of stress and anxiety
Enhancing life management skills
Learning skills to improve sleep
Learning ways to combat worry
Increasing awareness of unhelpful thinking patterns, and learning techniques to challenge
them
Adopting assertive communication skills
Learning ways to address perfectionism
Identifying strengths
Relapse prevention
Dialectical Behaviour Therapy (DBT)
Skills training in: core mindfulness, interpersonal effectiveness, emotional regulation
Acceptance and Commitment Therapy (ACT)
Develop acceptance of unwanted experiences
Develop skills of mindfulness
Identify and align values
Work toward a valued and meaningful life using a committed approach
Learn to implement cognitive diffusion techniques – separating yourself from your
thoughts
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The Hills Clinic - Mood and anxiety day programme
CBT based treatment designed to follow on from the inpatient programme.
Focuses on the here and now and teaches skills for thinking, feeling and acting in ways that
promote better mental health. Some topics covered during the mood and anxiety day patient
groups include:
Balanced life style
Goal setting
Problem solving
Core beliefs
Healthy thinking
Dealing with relapse
Mindfulness and acceptance
Relapse prevention
New Farm Clinic CBT approach to assist with skill development and facilitating behaviour change. Some topics covered include:
Understanding anxiety and depression
Relaxation techniques
Effective communication, active listening, assertiveness
Managing unhelpful thoughts
Managing stress
Self esteem
Toowong Private Hospital
CBT programme , with the following topics:
Understanding how thinking and behaviours affect feelings
Identifying negative and harmful thinking
Coping skills
Stress management
Relapse prevention
Perth Clinic
CBT programme, with the following topics:
Recognising and challenging unhelpful thinking
Identifying and exploring core beliefs which underpin unhelpful thinking
Goal setting/planning
Managing anxiety and panic attacks
Managing depression
Communication/assertion skills
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Support networks
Self esteem
Stress management
Relaxation techniques
Healthy lifestyles
Medication information
*Programme is flexible and responsive to the needs of each group member. Most effective
when individuals work to apply skills to their own personal circumstances. Participants are
assigned active practice and homework tasks individually, taking into account their
circumstances and personal goals.
Belmont Private Hospital
CBT programme content:
Schemas
Lifestyle balancing
Goal setting
Mindfulness
Nutrition and medication
Mastering your worries
Emotional intelligence
Perfectionism
Improving self esteem
Healthy relationships
Cognitive distortions
Putting off procrastinating
Community support
Stress management
Managing anxiety
Understanding anger
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8. APPENDIX – Sample worksheets
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(CBT worksheets are available at http://www.therapistaid.com/therapy-worksheet/simple-