INTRODUCTION TO COGNITIVE BEHAVIOR THERAPY
First, I conducted a diagnostic evaluation. In the next session, our first treatment session, I gave Abe information about his diagnosis, the theory of CBT, the process of therapy, and my proposed treatment plan. I asked about his aspirations (how he wanted his life to be) and values (what was really important to him) and then we set goals. (Page 1)
Maria saw herself as helpless, inferior, unlovable, and emotionally vulnerable. She viewed others as potentially critical, uncaring, and likely to hurt her. These beliefs were often triggered during our sessions. Initially she was quite suspicious of me, on guard lest I harm her in some way. It was much more difficult to establish a strong therapeutic relationship with Maria. Her intense hopelessness and anxiety about therapy and about me interfered with her fully engaging in treatment for quite a while. While Abe’s treatment exemplifies a standard approach, I had to adapt treatment considerably for Maria. (Page 2)
WHAT IS CBT? (Page 3)
Aaron Beck developed a form of psychotherapy in the 1960s and 1970s that he originally named “cognitive therapy,” a term that is often used synonymously with “cognitive behavior therapy” (CBT) by much of our field. Beck devised a structured, short-term, present-oriented psychotherapy for depression (Beck, 1964). (Page 3)
These adaptations have changed the focus, techniques, and length of treatment, but the theoretical assumptions themselves have remained constant. (Page 3)
In all forms of CBT that are derived from Beck’s model, clinicians base treatment on a cognitive formulation: the maladaptive beliefs, behavioral strategies, and maintaining factors that characterize a specific disorder (Page 3)
his avoidance ironically strengthened his belief of failure. (Page 3)
Originally trained as a psychoanalyst, Beck drew on multiple sources when he developed this form of psychotherapy, including early philosophers, such as Epictetus, and theorists, such as Karen Horney, Alfred Adler, George Kelly, Albert Ellis, Richard Lazarus, Albert Bandura, and many others. (Page 3)
THE CBT THEORETICAL MODEL (Page 4)
In a nutshell, the cognitive model proposes that dysfunctional thinking (which influences the client’s mood and behavior) is common to all psychological disturbances. When people learn to evaluate their thinking in a more realistic and adaptive way, they experience a decrease in negative emotion and maladaptive behavior. (Page 4)
In traditional CBT, your therapist would likely help you examine the validity of this thought, and you might conclude that you had overgeneralized and, in fact, you still do many things well, despite your depression. (Page 4)
Cognitions (both adaptive and maladaptive) occur at three levels. Automatic thoughts (e.g., “I’m too tired to do anything”) are at the most superficial level. You also have intermediate beliefs, such as underlying assumptions (e.g., “If I try to initiate relationships, I’ll get rejected”). At the deepest level are your core beliefs about yourself, others, and the world (e.g., “I’m helpless”; “Other people will hurt me”; “The world is dangerous”). For lasting improvement in clients’ mood and behavior, you will work at all three levels. Modifying both automatic thoughts and underlying dysfunctional beliefs produces enduring change.
CBT RESEARCH (Page 5)
CBT has been extensively tested since the first outcome study was published in 1977 (Rush et al., 1977). At this point, more than 2,000 outcome studies have demonstrated the efficacy of CBT for a wide range of psychiatric disorders, psychological problems, and medical problems with psychological components. (Page 5)
THE DEVELOPMENT OF BECK’S CBT
In the late 1950s, Dr. Beck was a certified psychoanalyst; his clients free-associated on a couch while he made interpretations. Beck recognized that the concepts of psychoanalysis needed to be experimentally validated if this school of psychotherapy were to be taken seriously by scientists. In the early 1960s, Beck decided to test the psychoanalytic concept that depression is the result of hostility turned inward toward the self. He investigated the dreams of depressed clients, which, he predicted, would manifest greater themes of hostility than the dreams of psychiatric clients without depression. To his surprise, he ultimately found that the dreams of depressed clients contained fewer themes of hostility and far greater themes of defectiveness, deprivation, and loss. He recognized that these themes paralleled his clients’ thinking when they were awake. The results of other studies Beck conducted led him to believe that a related psychoanalytic idea—that depressed clients have a need to suffer—might be inaccurate (Beck, 1967). At that point, it was almost as if a stacked row of dominoes began to fall. If these psychoanalytic concepts weren’t valid, how else could depression be understood? (Page 6)
Their randomized controlled study of depressed clients, published in 1977, established that cognitive therapy was as effective as imipramine, a common antidepressant. This was an astounding study. It was one of the first times that a talk therapy had been compared to a medication. In a follow-up study, cognitive therapy was shown to be much more effective than imipramine in preventing relapse. Beck and colleagues (1979) published the first cognitive therapy treatment manual 2 years later.
RECOVERY-ORIENTED COGNITIVE THERAPY (Page 7)
A TYPICAL COGNITIVE INTERVENTION
BECOMING AN EFFECTIVE CBT THERAPIST
If you feel anxious about starting to use CBT with clients, make yourself a “coping card,” a physical or virtual index card on which you have written statements that are important to remember. You’ll be using coping cards or their equivalents with your clients (because we make sure that anything we want clients to remember is written down). (Page 10)
To the untrained observer, CBT sometimes appears deceptively simple. The cognitive model, the proposition that one’s thoughts influence one’s emotions and behavior (and sometimes physiology), is quite straightforward. Experienced CBT therapists, however, seamlessly accomplish many tasks at once: building rapport, socializing and educating the client, collecting data, conceptualizing the case, working toward clients’ goals and overcoming obstacles, teaching skills, summarizing, and eliciting feedback. As they’re accomplishing these tasks, they sound almost conversational. (Page 11)
MAKING THE BEST USE OF THIS BOOK
OVERVIEW OF TREATMENT
I base my conceptualization of clients on the data they provide at the evaluation, informed by the cognitive formulation (key cognitions, behavioral strategies, and maintaining factors that characterize their disorder[ s]). From the beginning, I incorporate their strengths, positive qualities, and resources into my conceptualization too. I continue to refine this conceptualization throughout therapy as I collect additional data, and I use the conceptualization to plan treatment. (Page 17)
Third, I hypothesize about the key developmental events and his enduring patterns of interpreting these kinds of events that may have predisposed him to depression. As a preteen, Abe’s mother expected him to take on significant responsibilities at home, for which he was developmentally ill equipped. Rather than seeing that his overwhelmed mother was expecting too much of him, he interpreted her criticism as valid. (Page 17)
Using good Rogerian counseling skills, asking him for his reaction to the treatment plan, making collaborative decisions about treatment, providing rationales for interventions, using self-disclosure, eliciting feedback during and at the end of sessions, and working hard to achieve (and have him recognize) progress contributed to our alliance. (Page 18)
Some clients, particularly those with personality disorders, do require a far greater emphasis on the therapeutic relationship and advanced strategies to forge a good working alliance (Page 18)
Various studies have since demonstrated that routine monitoring improves outcomes (Page 18)
With an increased emphasis on a recovery orientation, many CBT therapists now also measure clients’ general functioning, progress toward their goals, and sense of satisfaction, connection, and well-being. (Page 18)
CBT tends to emphasize rationality, the scientific method, and individualism. (Page 18)
You help clients actively work toward cultivating positive moods and thinking. It is also very important to inspire hope. (Page 19)
He also misread neutral experiences as negative at times. In addition, he often discounted or failed to recognize more positive experiences. His difficulty in processing positive data in a straightforward manner led him to develop a distorted sense of himself. (Page 19)
Both therapists and clients are active. I encourage Abe to view therapy as teamwork; together we decide what to work on each session, how often we should meet, and what Abe can do between sessions. At first, I’m more active in suggesting a direction for therapy sessions and for some Action Plans (therapy homework). As Abe becomes less depressed and more socialized to treatment, I encourage him to become increasingly active in the session: deciding which steps to take toward his goals, problem solving potential obstacles, evaluating his dysfunctional cognitions, summarizing important points, and devising Action Plans. (Page 19)
In your initial session with clients, you should ask them about their values (what is really important to them in life), their aspirations (how they want to be, how they want their life to be), and their specific goals for treatment (what they want to accomplish as a result of therapy). (Page 20)
CBT initially emphasizes the present. (Page 20)
If he had had a personality disorder, I may have spent proportionally more time discussing his developmental history and childhood origin of beliefs and coping behaviors. (Page 21)
A major goal of treatment is to make the process of therapy understandable. Abe felt more comfortable once he knew what to expect from treatment, when he clearly understood what I wanted him to do, when he felt as if he and I were a team, and when he had a concrete idea of how therapy would proceed, both within a session and over the course of treatment. In our first session, I educated Abe about the nature and course of his disorder, the process of CBT, the structure of sessions, and the cognitive model. I provided him with additional psychoeducation in future sessions, presenting my ongoing and refined conceptualization and asking him for feedback. I used diagrams throughout treatment to help Abe understand why he sometimes had distorted thoughts and maladaptive reactions. (Page 21)
We try to make treatment as short term as possible while still fulfilling our objectives: to help clients recover from their disorder( s); work toward fulfilling their aspirations, values, and goals; resolve their most pressing issues; promote satisfaction and enjoyment in life; and learn skills to promote resilience and avoid relapse. (Page 21)
Some clients need considerably more treatment over a longer period of time. Sometimes these clients have chaotic lives or face ongoing severe challenges such as poverty or violence. Some have chronic or treatment-resistant disorders. Others have personality disorders, entrenched substance use, bipolar disorder, eating disorders, or schizophrenia. A year or even two of therapy may be insufficient. Even after termination, they may need periodic sessions or additional (usually shorter) courses of treatment. (Page 22)
I start planning Abe’s treatment before he enters my office. I quickly review his chart, especially his goals for treatment and Action Plans (including therapy notes) from the previous session( s). My overarching therapeutic goal is to improve Abe’s mood during the session and to create an Action Plan so he can feel better and behave more functionally during the week. What I do in any given session is influenced by Abe’s goals and issues, my conceptualization, the strength of our therapeutic relationship, Abe’s preferences, and the stage of treatment. (Page 22)
Your goal in the first part of a therapy session is to reestablish the therapeutic alliance, review the Action Plan, and collect data so you and the client can collaboratively set and prioritize the agenda. In the second part of the session, you and the client discuss the issues or goals on the agenda. These kinds of discussions and interventions naturally lead to Action Plans. In the final part of the session, you or the client summarizes the session. You make sure the Action Plan is reasonable and then elicit and respond to clients’ feedback. While experienced CBT therapists may deviate from this format at times, novice therapists are usually more effective when they follow the specified structure. (Page 22)
Podría publicar como un ejemplo de cómo yo NO hago terapia.
In the context of discussing a problem or goal, you ask clients questions to help them identify their dysfunctional thinking (by asking what was going through their mind), evaluate the validity and utility of their thoughts (using a number of techniques), and devise a plan of action. (Page 22)
We refrain from challenging cognitions (by stating or trying to convince clients that their thoughts or beliefs aren’t valid); rather, we help clients through cognitive restructuring, a process of assessing and responding to maladaptive thinking. (Page 23)
Máxima en CBT.
psicoterapia cbt principio creencia adaptación
Through questioning, I also guide him in evaluating the validity and functionality of his beliefs. (Page 23)
When automatic thoughts are part of a dysfunctional thought process such as rumination, obsession, or continual self-criticism, you might help clients accept their thoughts nonjudgmentally and allow them to come and go on their own. (Page 23)
To change cognitions at the emotional or gut level, you might use imagery, tell a story, offer analogies and metaphors, employ experiential techniques, do role-playing, or suggest behavioral experiments. (Page 23)
Anything we want clients to remember is recorded. (Page 23)
You or your client should write down therapy notes and Action Plans, either on paper or in the client’s phone or tablet. Or you can record therapy notes on a cell phone by using an app. Here’s an example of a therapy note that Abe and I collaboratively composed: (Page 23)
A frequent mistake of therapists is suggesting Action Plans that are much too difficult. (Page 24)
CBT uses a variety of techniques to change thinking, mood, and behavior. In fact, we adapt strategies from many psychotherapeutic modalities within the context of the cognitive framework. (Page 24)
COGNITIVE CONCEPTUALIZATION
INTRODUCTION TO COGNITIVE CONCEPTUALIZATION (Page 26)
You begin to construct the conceptualization during your first contact with a client and refine it at every subsequent contact. It’s important to understand the cognitive formulation for the client’s diagnosis( es), the typical cognitions, behavioral strategies, and maintaining factors. (Page 27)
You share your conceptualization and ask the client whether it “rings true” or “seems right.” (Page 27)
INITIATING THE PROCESS OF CONCEPTUALIZATION (Page 28)
CBT is based on the cognitive model, which hypothesizes that people’s emotions, behaviors, and physiology are influenced by their perception of events (both external, such as failing a test, and internal, such as distressing physical symptoms). (Page 28)
The way people feel emotionally and the way they behave are associated with how they interpret and think about a situation. The situation itself does not directly determine how they feel or what they do. (Page 29)
These cognitions are called automatic thoughts and are not the result of deliberation or reasoning. Rather, these thoughts seem to spring up spontaneously; they are often quite rapid and brief. You may barely be aware of these thoughts; you are far more likely to be aware of the emotion or behavior that follows. Even if you are aware of your thoughts, you most likely accept them uncritically, believing they are true. You don’t even think of questioning them. You can learn, however, to identify your automatic thoughts by attending to your shifts in affect, behavior, and/ or physiology. (Page 29)
For example, when I have a lot do, I sometimes have the automatic thought “I’ll never get it all finished.” But I do an automatic reality check, recalling past experiences and reminding myself, “It’s okay. You know you always get done what you need to.” (Page 30)
BELIEFS (Page 30)
Beginning in childhood, people develop certain ideas about themselves, other people, and their world. Their most central or core beliefs are enduring understandings so fundamental and deep that they often do not articulate them, even to themselves. (Page 30)
Esto es, en términos generales, completamente consistente con lo que plantea el psicoanálisis y con cómo lo entiendo yo, en términos de paisaje adaptativo. Sin embargo, parece tener una elaboración muy simplista.
cbt causas personalidad creencias desarrollo cita
Note that some clients hold overly positive beliefs, especially if they’re manic or hypomanic. They may see themselves, others, the world, and/ or the future in an unrealistically positive light. When these beliefs are dysfunctional, they may need help in viewing their experiences more realistically, which is in a negative direction. (Page 32)
Reader E tends to selectively focus on information that confirms her core belief, disregarding or discounting information to the contrary. (Page 33)
In Piagetian terms, the schema is a hypothesized mental structure that organizes information. Within this schema is Reader E’s core belief: “I’m incompetent.” When Reader E is exposed to a relevant experience, this schema becomes active, and the data, contained in negative rectangles, are immediately processed as confirming her core belief—which makes the belief stronger. (Page 34)
INTERMEDIATE BELIEFS: ATTITUDES, RULES, AND ASSUMPTIONS
Core beliefs are the most fundamental level of belief; when clients are depressed, these beliefs tend to be negative, extreme, global, rigid, and overgeneralized. Automatic thoughts, the actual words or images that go through a person’s mind, are situation specific and may be considered the most superficial level of cognition. Intermediate beliefs exist between the two. Core beliefs influence the development of this intermediate class of beliefs, which consists of (often unarticulated) attitudes, rules, and assumptions. (Page 35)
cbt psicoterapia disposición creencia concepto pensamiento
I ask him how he felt the previous evening. When Abe confirms that he was as depressed as usual, I ask, “What was going through your mind?” Right from the beginning, I obtain a sample of important automatic thoughts. Abe reports that he often thinks, “There’s so much I should be doing but I’m so tired. If I even try [to do things like cleaning up the apartment], I’ll just do a bad job” and “I feel so down. Nothing will make me feel better.” (Page 38)
I also look for factors that maintain Abe’s depression. Avoidance is a major problem. He avoids cleaning up his apartment, doing errands, socializing with friends, looking for a new job, and asking others for help. Therefore, he lacks experiences that could have given him a sense of mastery, pleasure, or connection. His negative thinking leads to his being inactive and passive. His inactivity and passivity reinforce his sense of being helpless and out of control. (Page 38)
CBT tiene esta dimensión interesante de integrar la variable conductual que refuerza las creencias nucleares desadaptativas, haciéndolo incluso a través de incitaciones directas a la acción (tareas).