Session 6: cognitive restructuring

Cognitive Behavioral Therapy

Theory of Change

Change occurs by learning to modify dysfunctional thought patterns. Once a

patient understands the relationship between thoughts, feelings, and behaviors,

s/he is able to modify or change the patterns of thinking to cope with stressors in a

more positive manner.

Role of Therapist

 The therapist is a collaborative teacher who uses structured learning experiences

that teach patients to monitor and write down their negative thoughts and mental

images. The goal is to recognize how those ideas affect their mood, behavior, and

physical condition.

 Therapists also teach important coping skills, such as problem solving and

scheduling pleasurable experiences.

 The therapist creates structured sessions and provides homework for clients to

continue to work on problems in-between visits.

Treatment Goals

 Patients learn to recognize negative patterns of thought, evaluate their validity,

and replace them with healthier ways of thinking.

 Patients’ symptoms or problems are relieved.

 Patients develops positive coping skills and strategies

 Negative Cognitive Triad:

1. View of self(“I’m not worth anything.”)

2. View of the world(“Every body hates me.”)

3. View of prospects for the future(“There are no hopes for my future.”)

 Automatic Thoughts: Thoughts about ourselves or others that individuals are

often not aware of and thus are not assessed for accuracy or relevancy.

 Maladaptive Automatic Thoughts: These are automatic thoughts that are typically

centered on negative themes or distorted reflections that are accepted as true.

 Schemas: A network of rules or templates for information processing that are

shaped by developmental influences and other life experiences. These rules

dictate how individuals think about and interpret the world and play a role in

regulating self-worth and coping skills. Changing schemas is a major target of

CBT.

 Overgeneralization: Single negative event is seen as a never-ending pattern of

defeat. One mistake leads to “I never do anything right”

 Arbitrary Inference: Cognitive distortion that leads to drawing conclusions

without evidence or facts to support those conclusions

 Selective Abstraction: Attending to detail while ignoring total context. Taking

detail out of context and missing the totality of the situation

 Personalization: Seeing yourself as a cause of negative external event

Polarized Thinking: Thinking in extremes, viewing things as black or white.

Interventions
 Teach the client about negative triad

 Socratic Questioning: Questioning allows the therapist to stimulate the client’s

self-awareness, focus in on the problem definition, expose the client’s belief

system, and challenge irrational beliefs while revealing the client’s cognitive

processes.

 Reframing: Thinking differently by “reframing” negative or untrue assumptions

and thoughts into ones that promote adaptive behavior and lessen anxiety and

depression

 Cognitive Restructuring: Teaches client to identify irrational, distorted, or

maladaptive beliefs, question the evidence for the belief, and generate alternative

responses.

 Homework: To assist with cognitive restructuring, clients are often assigned

homework. Typical CBT homework assignments may include activities in

behavioral activation, monitoring automatic thoughts, reviewing the previous

therapy session, and preparing for the next therapy session.

 Self-Monitoring: Also called diary work, self-monitoring is used to record the

amount and degree of thoughts and behaviors. This provides the client and

therapist information regarding the degree of a client’s negative affirmations.

 Behavioral Experiments: The experiment process includes experiencing,

observing, reflecting, and planning. These steps are conducted through thought

testing, discovery, activity, and/or observation.

 Systematic Desensitization: Systematic Desensitization pairs relaxation with

exposure to something stressful. Clients are taught to relax in anxiety producing

situations.
 Anxiety Management Training: Teaches skills for specific situations using

imagery. The client practices relaxation until anxiety is reduced then continues

with imagery.

 Assertiveness Training: Teaches client to specify desires and needs using

minimally effective responses to assert their position. Used with unassertive or

overly aggressive clients.

 Behavioral Activation: Increases activity for depressed or passive clients by using

activity scheduling and incentives.

 Communication Skills Training: Used in couples therapy to help couples talk

about feelings and problems.

 Downward Arrow: Used to uncover underlying assumptions. “If this is true, what

does it mean about you and your life?

 Exposure: Client faces fear stimuli without resorting to escape or avoidance

maneuvers. Can be done in real life or with imagery

 Finding Alternatives: Clients review all possible options and alternatives for

either interpreting a situation or resolving a problem

 Labeling Distortions: Teaches client to recognize and label particular distortions

in thinking that can lead to problems with interpretations of events.

 Mastery/Pleasure Ratings: Clients use activity chart and rates mastery or pleasure

that they derive from activity

 Opposite Action: Client is encouraged to engage in behavior that is be

counterintuitive or opposite to what she or he may feel at time (e.g., when feeling

very angry say something kind or decent)

problem definition, generation of alternatives, decision making and solution

implementation and verification of results

 Relaxation Training: Teaches client to relax muscles to condition a relaxation

response to counter tension. Uses imagery, music, and other stimuli to assist in

acquiring response • Successive Approximation: Client and therapist collaborate

in developing a plan for the client to engage in steps that approximate an ultimate

goal, to allow the client to have success at each step along the way to the goal.

 Three Column Technique: client collects automatic thoughts and lists the

situation in which the thought occurred, the automatic thought, and the associated

feelings

 Thought Record: expands on the three column technique, with columns to record

alternative responses to the automatic thought and behavioral or emotional

outcomes of changing the thought

Phases of Treatment

Beginning: Establish safe and supportive therapeutic relationship; Complete a

functional analysis to assess and define the problem and negative thought patterns;

Educate and explain CBT; Set collaborative goals.

Middle: Identify negative thought patterns; Uncover negative schemas; Assign

homework to self- monitor thoughts and moods and behaviors; Label cognitive

distortions; Reframe thoughts; Learn and practice new skills and behaviors.

End: Review gains; Identify skills learned; Rehearse for new situations; anticipate

future struggles.