Centre of Excellence Online – Cognitive Behavioural Therapy (CBT)

10. Basic Cognitive Behaviour Techniques

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 Centre of Excellence Online – Cognitive Behavioural Therapy (CBT)

10.1 Introduction
Now that you have a clear background understanding of the counselling process, how to
structure a CBT session and the core principles of CBT, you are well on your way to becoming
a CBT therapist. The next step is to familiarise yourself with the techniques used in CBT.

We will begin by exploring the most basic techniques in CBT, including identifying and
challenging automatic thoughts and altering cognitive distortions. Throughout the rest of
the course we will build on these basic techniques and work toward interventions for
specific presentations that are of a more complex nature.

These are the common CBT techniques that we will examine as the course progresses:

- Behavioural experiments

- Thought records

- Activity scheduling

- Situation exposure hierarchies

- Imagery based exposure

Each technique in this module will cover psychoeducation (knowledge to be shared with
your client), tasks of the counsellor and details of the intervention.

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10.2 Automatic Thoughts

Psychoeducation

The most important message to convey to your client is: thoughts cause feelings. The
emotions that they feel are preceded and caused by their thoughts. Thoughts may be
fleeting, unnoticed or prevailing.

Automatic thoughts are a brief stream of thought about oneself or others. They tend to
apply to specific situations or events and can occur quite quickly. While we can be unaware
of the presence of an automatic thought, we are familiar with the feelings which they create
within us.

Maladaptive automatic thoughts are the beliefs about oneself, the world and the future that
are dysfunctional and distressing. These can be triggered by situations or exacerbated by
psychological states such as anxiety or depression. It is these maladaptive automatic
thoughts that we will focus on, as this is what clients typically want to address.

The second important message is that events do not contain emotional content. It is the
perception of the event that causes the emotions.

Event Thought Feeling

When an event occurs that is important to us, then we react with emotions and tend to not
notice the automatic thoughts that stimulate the emotions.

Automatic thoughts often have the following characteristics:

 They appear as just one word or short phrase and function as a label for a group of
memories, fears or guilt. They don't always appear as words thoughts – they can be
a visual image, an imagined sound or smell or any form of physical sensation
 They are almost always believed, no matter how illogical they seem
 They are experienced as spontaneous
 They are often embedded with rules of “should”, “oughts” or “musts”
 Automatic thoughts tend to make a situation catastrophic
 They are self-perpetuating and hard to turn-off
 They may differ to how the person presents themselves in public
 They can create a tunnel vision approach to situations
 They are learnt (and therefore can be unlearnt)

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It is also important to inform your clients that we all automatically make interpretations of
everything we experience through our senses – what we see, hear, touch and feel. We judge
events as good or bad, enjoyable or upsetting, safe or risky. Our thoughts are rarely noticed,
but they can be powerful enough to create the most intense emotions. Sharing this
information with your client will help them see themselves as similar to other people and
reassure them that other people experience automatic thoughts, too. It is the impact of
these automatic thoughts that will set apart those who can continue to function in daily life
and those that seek professional help.

Intervention

Step one: identify automatic thoughts

As explored in the ABC model, this interplay is where careful questioning about thought
processes to identify what fuels negative feelings comes into play.

Here is an example:

A. Event: your client arrives to work late and then can't find their swipe card to access the
meeting room.

B. Thought: your client perceives the event by telling themselves "Oh no, I'm going to be
stuck out here and I'll be really late”.

C. Feeling: your client experiences anxiety about being late.

In exploring this example with your client, it becomes clear that the thought about the event
instigated negative feelings such as anxiety. The philosophy behind CBT asserts that if you
change the thought, then you change the feeling.

For example, if the client in the example above had thought, "That's okay, I will phone the
receptionist and ask them to let me in”, then the emotions they experience would likely
have been different, even if they still might have felt slightly anxious about being late.
Instead, they might have felt hopeful or relieved.

Sometimes using examples can be helpful in explaining these patterns; however, real-life
examples that your client brings to a session will be more powerful in uncovering and
perceiving automatic thoughts.

Once you have explained the role of automatic thoughts in emotional experiences, then you
help the client identify their automatic thoughts. However, this in itself is not the entire
intervention, although you may find that your client will experience some relief in their
symptoms of anxiety or depression and this is a good sign that CBT is likely to help your
client quickly.

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Step two: thought journaling

This is not an essential step in CBT, but most clients will make progress during the first week
or two by consistently keeping a thought journal. The more practice they have of tuning into
their automatic thought process, the better they will get at identifying these patterns.
Automatic thought identification is a skill that requires practice.

Here is an example of a thought journal template you could administer for homework.

Where were What were Event Automatic Feeling Rate the

you? you feeling? thought feeling

Have your client rate the intensity of the feeling they experienced following the automatic
thought.

Step three: negative feedback loop

Human thoughts and feelings can be complex and sometimes confusing. The ABC series may
not occur in isolation and can form a feedback loop. This means that the end feeling of one
ABC sequence then becomes the starting event for another sequence.

If the last feeling of a sequence is an uncomfortable one, then this can become the 'event'
of the next sequence. This feeling can be the subject of further thoughts and create more
negative feelings. The loop continues until the person becomes overwhelmed with feelings
consistent experiencing anxiety, depression or anger problems.

In this case, the physiological component associated with the feelings also needs to be
identified. Sometimes clients find it difficult to identify their feelings, but they can tell you
that they 'felt sick in the stomach' or 'had a headache' or 'trembling hands'. All these
physiological sensations provide an indicator of what your client was feeling in that
moment.

Remember that as you work through this process with your client, you are explaining the
language and concepts so that they understand what is happening. This will empower your
client to identify their automatic thoughts, feelings and physiological reactions without
heavy reliance on you to do the work for them.

Your client will need help to understand and begin to identify the negative loops in their
thinking and how these loops impact their daily functioning and quality of life.

Let's expand on the ABC example provided above to demonstrate a negative feedback loop.

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A. Event: client arrives to work late and then can't find their swipe card to access the
meeting room.

B. Thought: client perceives the event by telling themselves, "Oh no, I'm going to be stuck
out here and I'll be really late”.

C. Feeling: your client experiences the following physiological symptoms associated with
anxiety: heart beating fast, feeling hot and sweaty, panicky.

B. Thought: "This is so bad! My boss will be really angry!"

C. Feeling: tension in the stomach, difficulties breathing, dizziness

B. Thought: "I'm freaking out! How am I going to do my presentation at the meeting when
I'm this stressed”?

C. Feelings: adrenaline rush as stress hormone activates.

D. Behaviour: the client may then struggle to make that presentation at the meeting or
perhaps they avoid the meeting altogether and call in sick!

To help your client identify a negative feedback loop, it will be most effective if you choose
one situation that has concerned them and together break it down into the thoughts,
feelings and physiological sensations experienced on a moment-by-moment basis.

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10.3 Altering Cognitive Distortions

Psychoeducation

One of the main roles you have as a CBT counsellor is to share your knowledge about
cognitions, feelings and behaviour with your clients. You teach them what you know,
enabling them to learn to analyse their automatic thoughts and limited thinking patterns.

The list of cognitive distortions you looked at in an earlier module will be helpful in helping
your client identify their cognitive distortions. This document from PsychologyTools.org is an
example of a great hand-out you can utilise in CBT with your clients. There's an abundance
of worksheets, hand-outs and homework assignments available on the internet or you may
wish to devise your own.

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Challenging automatic thoughts and cognitive distortions is a powerful way to counteract

perfectionism, procrastination and symptoms of depression and anxiety. It will likely take
one to four weeks of analysing thought patterns to observe some success.

Intervention

Step one: teach the concepts of cognitive distortions

You won't need to teach your client about every distortion, especially if you have already
identified a few that they tend to use so you can focus on these. Hand-outs such as those
shown above will help your client identify the cognitive distortions they use.

Step two: thought journal

The thought journal was introduced earlier as a way of recording automatic thought
patterns. For cognitive distortions, the thought journal can also be utilised with an
additional three columns:

Cognitive distortion Alternative thought Re-rate your feeling

When your client has identified the cognitive distortion in their ABC sequence, then they
can rewrite their automatic thoughts in a more balanced way by composing an alternative
thought that refutes the automatic thought. In the final column, have your client re-rate
their unpleasant feelings once they've countered their automatic thought. Ideally, the
feeling will be less intense after this.

Step three: compiling alternative thoughts

Alternative responses to each of the cognitive distortions is listed in the table below. These
concepts will be taught to the client and they should have a copy of them to use as
reference while they are completing their thought journals as homework.

Cognitive distortion Alternative thought

1. Filtering Deliberately shift the focus:

 Focusing on the negative
 Filtering out the positive
 Focus on coping strategies for
dealing with the problem
 Focus on the opposite of the theme
that characterises their problem.
For example, if the theme is loss due
to a job redundancy, focus instead

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2. Polarised thinking
 Seeing everything as fantastic or
horrible (nothing in between)
3. Overgeneralisation
 Making broad statements based on
little evidence
4. Mind reading
 Assuming you know what other
people are feeling or thinking
5. Catastrophising
 Assuming the worst case scenario
6. Magnifying
 Making difficulties bigger than they
are
 Minimising positives
7. Personalisation
 Assuming the way other people
behave always relates to you
 Comparing yourself to others
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on what the client currently has that
is of value to them
Challenge black-or-white judgements:
 Think in percentages. For example:
"About 20% of me is really stressed
about my upcoming exam, but the
other 80% is coping okay”
What's the evidence?
 Quantify
 There are no absolutes
 No negative labels
 Avoid words such as: always, n--ever,
massive, etc. For example, instead of
"I have a huge pile of debts to pay"
to "I have two bills I need to pay”
Identify conclusive evidence:
 What is the evidence for the
conclusions you've made?
 Are there alternative explanations?
 Reframing interpretations
 You can't really know how another
is thinking or feeling unless they
communicate this to you
Assess the odds:
 How likely is it that the worst will
happen?
 How likely is it that the situation will
work out okay?
Get things in proportion:
 There's no need to magnify or
minimise
 Change your language for describing
situations. For example, instead of
'awful', you could say "I can cope”
Everyone has strengths and weaknesses:
 Comparison is very unhelpful
 Challenge whether others’
behaviour really is because of you
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8. Shoulds Create flexible rules:

 Holding illogical rules for your own
or others' behaviour
9. Predictions
 Self-fulfilling prophecies
 Values are personal
 Flexible expectations
 Think of at least three exceptions to
the 'rule'
Performance is related to effort and
persistence:
 For example, a client who says "I am
going to fail this test" may use the
alternative thought "I may not be as
good as other students, but I can do
better in my test if I study hard”

When automatic thoughts and cognitive distortions are challenged with alternative, rational
explanations, it may result in a list of actions that need to be carried out by the client,
including (but not limited to):

 Checking out assumptions

 Gathering more information
 Being assertive
 Clearing up a misunderstanding
 Making plans
 Changing their schedule
 Making commitments

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Assessment 10
Review of Key Ideas

Write a half-page response to each of the questions below.

Q1. How would you explain an automatic thought to a client?

Q.2 In your own words, define 'cognitive distortions'.

Q3. What is the purpose of a thought journal?

Mini Quiz

Q1. The statement "He'll lose his job and we'll be homeless" is an example of what
cognitive distortion?

a) Prediction
b) Mind reading
c) Catastrophising

Q2. The statement "He should know better" is an example of what cognitive distortion?

a) Shoulds
b) Filtering
c) Magnifying

Q3. The statement "I know he thinks I'm just stupid" is an example of what cognitive
distortion?

a) Catastrophising
b) Prediction
c) Mind reading

Q4. The statement "She quit her job because of me" is an example of what cognitive
distortion?

a) Magnifying
b) Shoulds
c) Personalisation

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