An Introduction to Cognitive Behaviour Therapy, 2 edition

2

Distinctive Characteristics of CBT

CBT has many features in common with other therapies, but it is also different in important respects. In this chapter we describe the fundamental characteristics of the CBT approach, and we also explore some of the myths about CBT. We hope this is helpful for you, but also for your clients: giving them accurate information about therapy allows them to make an informed choice about whether they want to proceed (Garfield, 1986) and may also improve outcome (Roth & Fonagy, 2005).

CBT is distinguished by a combination of characteristics which are described in this chapter. It is collaborative, structured and active, time-limited and brief, empirical and problem-oriented; it also frequently employs the techniques of guided discovery, behavioural methods, in vivo work, summaries and feedback.

Collaboration

CBT is fundamentally a collaborative project between therapist and client. Both are active participants, with their own areas of expertise: the therapist has knowledge about effective ways to solve problems, and the client has expertise in his own experience of his problems. This collaborative emphasis may be different from what the client expected of therapy, and so it is important to clarify what he is anticipating so that you can establish a shared view from the outset. Part of the initial introduction to therapy would include a statement about the client’s crucial role. For example, you might say:

 

We each have an important role in the treatment. I know quite a lot about CBT, and about how particular sorts of problem can present difficulties for people. However, you know very much more than I do about the details of how your problem affects you, and it is this knowledge that will allow us to understand and gradually change the situation for you. This really is a joint enterprise.

This also implies that you cannot be expected to know all of the answers all of the time. If you are unsure, you can always ask the client for clarification, more information, or their view of the situation.

 

A client described a vivid dream to a therapist and asked, ‘What am I supposed to make of that?’ Before immediately answering the question, the therapist asked, ‘What do you think was important about your having that dream?’ and ‘What did it leave you feeling?’

Remember that CBT encourages openness and honesty between therapist and client: be overt about what you are doing and why, and ask the client to give honest feedback about what he finds helpful and what he does not.

Collaboration should develop as treatment proceeds. Encourage your client gradually to take a more active role in setting agendas, devising homework and giving feedback. Enhance this by being genuinely respectful of the client and by fostering the sense that he is becoming his own therapist. The hope is that clients will leave therapy as skilled CBT practitioners, so they are encouraged to use the approach independently, and to be prepared should a relapse occur in the future (see Chapter 6).

Structure and active engagement

The problem-focused and structured nature of CBT requires the therapist to work with the client to maintain structure in the sessions. For example, at the beginning of each session, we set an explicit agenda with the client, and then largely stick to it (see Chapter 11, which elaborates on the process of agenda-setting).

CBT therapists are actively engaged with the client and may talk more than in some other therapies – perhaps as much as 50% of the time in the early stages. This can feel onerous to new therapists. However, much of your input is in the form of questions, and the way the session develops is the result of a joint effort. In the early stages of therapy, the content of sessions will be directed to a greater extent by the therapist, but responsibility is increasingly picked up by the client as sessions progress. For example, homework tasks are likely to be devised by you at first, but as treatment proceeds, your clients will have a greater role in setting up tasks for subsequent meetings.

For example, a woman had obsessional problems focused on sticking to the rules, not falling foul of authority, and complying absolutely with official requirements. She had more generalised beliefs about always needing to do the right thing, and the likelihood of rejection if she stepped out of line. She had had eight treatment sessions and was taking more responsibility for the content of sessions when the following discussion took place:

Therapist:

You say that doing something for yourself, particularly for pleasure, would be very difficult for you. How do you think you might take this forward, so that we could find out more about how you feel, and what beliefs are operating in situations like that? (i.e. therapist setting stage for experiment).

Client:

Well, my friend has twice invited me to go to a jewellery class with her, and I would love to go, but both times I said that I had too much on … and I did, but I would have found it difficult to say yes, even if I’d got nothing to do. So I suppose I could go with her, and see what happened.

T:

For our purposes, what do you think you could look out for?

Client:

Well, I would need to know what feelings I had, and what beliefs seemed to be relevant.

T:

Anything else that would be useful to look out for?

Client:

I suppose what I felt like afterwards, because that is when the guilt is likely I suppose what I felt like afterwards, because that is when the guilt is likely to kick in.

T:

Let’s include that then. What sort of diary form shall we set up?

The extent to which the client determines the content of sessions is partly a function of his personality, beliefs and attitudes. An autonomous person might assume control from early in treatment, whereas a more dependent person will benefit from a slower handover of responsibility.

Time-limited and brief

Both clients and commissioners of services find CBT attractive, partly because it is often relatively brief. In this context, ‘brief’ means somewhere between six and 20 sessions. The number of sessions is guided by treatment trials concerning the target problem but is also influenced by the specifics of the problem and the client, as well as available resources. As resources are often scarce, it is important to help people efficiently, and the structure and focus of CBT contribute to achieving that. Table 2.1 gives some suggestions about possible lengths of treatment for different types of problem.

Table 2.1    Guidelines on length of treatment

Type of problem

Number of sessions

Mild

Up to 6

Mild to moderate

6–12

Moderate to severe or moderate problems with co-existing personality disorder

12–20

Severe problems with co-existing personality disorders

>20

 

 

Evidence does not suggest that long treatments necessarily do better than shorter ones (Baldwin, Berkerjon, Atkins, Olsen & Nielson, 2009), and neither do clients who have been on long waiting lists necessarily require an equally lengthy treatment. For therapists used to other treatment approaches, the rapid move from one or two sessions of assessment and formulation into a six- or eight-session therapy may feel uncomfortably rushed, but this is likely to become less difficult as you become more familiar with the approach.

It is helpful to give your clients an indication of how long treatment is likely to last and to build in regular progress reviews. If it appears that the therapy is not helpful, or if progress has reached a plateau, it is easier to bring treatment to a close if reviews have been pre-established. If the client is making progress but residual problems are still present, then it is probably worth continuing with treatment, although it may be worth considering the benefits of allowing your client to manage such difficulties independently. This is best done by gradually increasing the length of time between sessions, so that the client takes increasing responsibility for dealing with residual problems and setbacks, while there continue to be opportunities for review with the therapist.

There is no commitment within CBT to a standard ‘50-minute hour’, or any other standard session length. A session involving in vivo experiments, for example with a client with agoraphobia, may last 2 or 3 hours. On the other hand, a review session towards the end of treatment may last only 20 minutes. Bear in mind that if relevant and productive homework assignments have been set up, then the majority of treatment can be considered to be taking place outside the ‘therapy hour’.

Empirical in approach

There is a strong emphasis within CBT on using empirical psychological knowledge. For example, it is established that early loss of a parent predisposes one to depression in adult life (Brown, Harris & Bifulco, 1986); that people with generalised anxiety disorder (GAD) are intolerant of uncertainty (Ladouceur, Dugas, Freeston, Leger, Gagnon & Thibodeau, 2000); and people who are depressed have a reduced ability to access specific memories, especially of positive events, i.e. they have an ‘over-general memory’ (Williams, Teasdale, Segal & Soulsby, 2000). Therapy rests on this knowledge base. Furthermore, CBT has borrowed from behaviour therapy a commitment to establishing the efficacy of treatment in individual clinical cases (see Chapters 5 and 18).

As a therapist, you need to keep informed about the evidence from research trials and use this to guide interventions in individual cases. It is sometimes claimed that the samples studied by research teams are atypical of those found in clinical settings and therefore trial data are not relevant. However, unless you have good evidence to demonstrate why another approach would be likely to be more successful, then it is fairer to the client if the available empirical evidence is given appropriate weight. This is not to discount therapist intuition about what is likely to be helpful, merely to suggest that such insights should be built into a formulation that is consistent with evidence about psychological processes. None of us should be cavalier about discounting well-described and apparently relevant data, and we need to be aware that there is some indication that therapists tend to switch too early from treatment protocols, and that this is detrimental to therapeutic outcome (Schulte & Eifert, 2002), although the evidence is not conclusive (Ghaderi, 2006).

Within individual therapy, the client is also encouraged to tackle his problems in an empirical way. For example,

 

  • Thoughts and beliefs are considered as hypotheses to be investigated– for example, a woman who thought, ‘I am a useless mother’ was encouraged to see this as one possible view among other possibilities and to look at the evidence supporting each view.
  • Data can be collected to test out ideas– for example, a man who feared spiders because he believed that they would run towards him was encouraged to collect data about how often a spider on a tray ran towards a (therapist’s!) hand, rather than away from it (see Chapter 9 for a discussion of Behavioural Experiments like this).
  • New beliefs can be formulated in the light of evidence and subsequently tested out– there is an emphasis on ‘discovering how it is’ by trying out new behaviours, new ways of thinking, new ways of interacting, and not simply relying on verbal discussion or new insights for changes in feelings and beliefs. It is always important to be guided by the client about what new evidence would be helpful (again, look at Chapter 9 for more detail about such interventions):

Following discussions with her therapist, a woman who was chronically depressed held a belief that ‘You must always try to make the most of your potential’. As part of therapy, she was working on a new belief that ‘Things can be done for their own sake, and still feel satisfying and enjoyable. You do not need to be making the most of your potential.’

To test this out, she chose to join a non-auditioned choir for the fun of it, and she began to learn French so that she could ‘get by’, with no intention of becoming fluent.

Problem-oriented in approach

Your client’s problem may be a dysphoric mood, a relationship difficulty, an unhelpful behaviour (for example, a repetitive habit like hair-pulling), or an occupational problem (for example, frequent loss of jobs). CBT identifies what problems are pertinent for the client, and then focuses on resolving or reducing them. Problems are described in specific terms, not at the general level of diagnosis. For example, if a client was suffering from depression, you would want to know how this was actually affecting him and what specific aspects of the problem he wanted help with: e.g. for one person, this may be self-critical thoughts, low mood, social withdrawal, reduced interests, while for another it may be impaired concentration, poor sleep, tearfulness, and irritability.

Once you have agreed what problems will be tackled, goals are set for each problem and these goals provide the focus for treatment. The process of goal-setting explicitly focuses the client on where he hopes to be at the end of treatment, and in what ways he wants to be different from how he is now (see Chapter 11).

In choosing strategies to address your clients’ difficulties, you might well find that you draw on other strategies in addition to those laid out in this text. For example, interventions such as skills training (assertiveness, time management, etc.), or grief work, or couple therapy, may also be relevant. Whatever interventions are used, they should be evaluated so that you can review the efficacy of our treatment.

Guided discovery

The therapist uses a form of questioning often described as ‘Socratic’ in a process of guided discovery, helping the client to clarify his thoughts and beliefs (see Chapter 7). This involves carefully constructed questioning, to help clients understand the idiosyncratic meanings of situations, to work out for themselves alternative ways of looking at things and to test out the usefulness of new perspectives.

Behavioural methods

Behavioural interventions are a necessary element of CBT, and many assignments include behavioural tasks and experiments. These are used to test out new perspectives derived in treatment sessions, to enhance learning and also to encourage generalisation from treatment sessions to everyday life – where the changes really need to be made. There is a wide variety of possible behavioural interventions (seeChapter 9 for a thorough review of behavioural strategies), and some of the principles of behaviour therapy have been directly adopted by CBT: for example, taking a graded approach to new tasks and breaking them down into manageable chunks.

In vivo work

CBT therapists often take therapy out of the office and into the real world, in order to help with assessment or to carry out a behavioural experiment. Such real-life ‘in vivo’ work can be invaluable. For example, a client with long-standing obsessional-compulsive disorder (OCD) may have become unaware of the detail of his obsessional rituals, and you may underestimate his problems unless you directly observe them. Similarly, it is important to check out that changes in belief in a clinic setting are translated into real-life settings, so it may be helpful to do experiments in vivo, possibly with the therapist accompanying the client.

A man with health anxiety believed that if he became short of breath, he could pass out and die; he therefore made sure that he always stayed within reach of a doctor’s surgery. During therapy in the clinic, he had challenged this belief. With his agreement, the therapist then drove him into the countryside where neither of them knew the whereabouts of doctors’ surgeries, and they ran up and down the road to make him breathless (an activity he had been avoiding), so that he could test out his new belief that he would not pass out.

If the client is trying out a difficult new behaviour, it may be helpful for you to be there to offer encouragement and support. In some instances, therapist modelling of behaviours may be useful, although you should withdraw as soon as possible, and allow the client to continue alone in such experiments.

A woman with agoraphobia had catastrophic concerns about the consequences of becoming anxious, particularly that she would be publicly ridiculed if she were to soil herself. The client accompanied the therapist to a local shopping centre and observed from a distance the responses of members of the public to an obvious brown stain on the back of the therapist’s skirt – responses best described as studied indifference.

It is often possible to draw on the assistance of relatives or friends for in vivo work, but this must be planned carefully, with an eye to detail, and it may be necessary to help the aide identify and challenge unhelpful thoughts of their own. For example, a spouse may believe that exposing their loved one to panic may be harmful; such a belief would be counterproductive in a behavioural experiment about the consequences of panic.

Summaries and feedback

CBT makes frequent use of summaries and feedback during sessions, which is one way of keeping the agenda in focus. You might pause to summarise the main points under discussion approximately every 10 minutes, and more frequently than that in the early stages of therapy. Summaries should include the emotions that the client has described, and the meaning of the event or situation for him. This is not supposed to be an interpretation of what the client has said. Indeed, it is better to use the client’s own words as far as possible, rather than substitute your own. The latter may significantly change the meaning for the client, especially if he has used a metaphor or some idiosyncratic phrasing.

It can be equally helpful to ask your client to summarise the discussion, by saying, for example: ‘Can you feed back to me what you think the main points of our discussion are so far? I would just like to check out that I am on the same track as you.’

This provision of summaries helps to ensure a shared understanding of key points. It is sometimes startling to learn how misunderstood the client or the therapist has been.

After discussing why it is helpful to write down NATs, the therapist mentioned that it was really helpful that the client was readily able to identify his thoughts. When asked for feedback, the client said that he now understood that, as he was aware of his NATs but still felt bad, it was unlikely that he would benefit from CBT.

Summaries can also be enlightening for the client. For example,

Therapist:

It sounds as if the qualities that attracted you to your partner are now the things that you find most upsetting. Is that right?

Client:

Yes, but I had not thought about it like that before.

It is particularly useful to summarise the key points at the end of the session and to ask the client what is the ‘take-home’ message for him – again, this will reduce misunderstandings. It is also important to gather feedback on the session, for example what has been helpful, unhelpful or upsetting.

Therapist:

It would be helpful if you would let me know if I say anything which is difficult to understand, or indicates that I am barking up the wrong tree, or is upsetting in any way. It is sometimes difficult for people to mention things that they do not like, or that imply that there is a mis-understanding. It can be very helpful if you let me know if there are things that are unhelpful, because we can then sort it out, or clarify what we meant. Have I said anything today which will play on your mind, or was upsetting?

 

I will ask you a similar question at the end of each session. Do not hes-itate to let me know if there is any comment you would like to make.

 

What are the main points that you will take away from today?

Clients are more likely to give genuine feedback if you take time early in treatment to explain why feedback is valuable and give honest encouragement when you receive it.

Each session can also begin with a request for feedback on the previous one – what had been helpful or whether the client had any new ideas about the previous discussion. Again, it is more likely that your client will review the session and give feedback, if you have discussed the advantages of thinking about the therapy between sessions, and taken seriously the client’s feedback on this.

For example, a client said that he did not like to think about sessions when he was not with the therapist. Exploration revealed that he struggled with negative thoughts about being overwhelmed, thoughts that could then be dealt with.

Myths about CBT

In this section, we will identify and explore some of the common myths surrounding CBT.

The therapeutic relationship is not important in CBT

The therapist qualities that are valued in other therapies are equally important within CBT. Warmth, empathy and unconditional regard, which were identified by Rogers (1951) as important for successful psychotherapeutic work, have been found to be typical of CBT therapists (for example, Wright & Davis, 1994) and to be valued by clients (Ackerman & Hilsenruth, 2005). This contrasts with the mistaken view that CBT is impersonal and not concerned about the therapeutic relationship. At the most basic level, if a client is to be willing to reveal personally significant material, to carry out frightening and difficult new behaviours and to feel safe, then he has to be able to trust the therapist. Therefore, although CBT does not see the relationship as the major therapeutic tool, it is nevertheless seen as an essential foundation for effective therapy. It is recognised that the therapist must pay attention to any emerging difficulties in the therapeutic relationship and must attempt to understand what client beliefs may have been triggered to produce them (see Chapter 3).

It is sometimes believed that CBT therapists have no interest in the client’s feelings about the therapist. However, there has been an increasing recognition over the past 20 years of the importance of relationship factors – but construed in cognitive rather than psychodynamic terms (see Orlinsky, Grawe & Parks, 1994).

CBT is mechanistic – just apply technique X to problem Y

CBT is based on an explicit model that links emotion, behaviour, cognition and physiology, and this model underpins the therapeutic strategies that have been shown to work effectively. At a clinical level, there is often a specific model for the problems presented by a client. For example, there is a model for panic disorder which highlights the role of catastrophic misinterpretation of benign physical or mental symptoms; there is a different model for depression which focuses on the client’s negative view of the self, other people and the world. There may also be a fairly detailed protocol derived from such a model for treating clients with a specific kind of problem. In that case, a formulation based on the model would be developed for the individual client, but the treatment would not be technique-driven (e.g. ‘I think he needs some anxiety management training’), but would instead be based on an understanding of what psychological processes are maintaining his problem and what the specific relationships between emotions, thoughts, behaviours and physiological features are important in his case. This is discussed further in Chapter 4.

CBT is about positive thinking

It is sometimes suggested that CBT is not concerned with the client’s circumstances or interpersonal situation but is only interested in getting the client to see things positively. This is a misunderstanding: CBT aims to help clients realistically evaluate their thoughts, not to show that they are always wrong or that things are always positive. When people have problems, their thinking may be excessively negative, but sometimes it is accurate – your client may think his partner is not interested in him because his partner is not interested in him! The formulation should take account of interpersonal and socio-economic circumstances and not assume that the client’s thoughts are distorted.

A woman presented with low mood following redundancy from her job in a hotel. This was the third job that she had lost, the first two through redundancy, and the last after interpersonal difficulties with her boss. She was feeling low because however hard she tried, it seemed that luck was against her, and things went wrong. She felt hopeless about being able to improve things. Rather than assuming that her view was distorted, the therapist helped the client to review the evidence, to see what had contributed to each of the job losses and what responsibility she seemed to have for the outcomes. Therapy might have needed to focus on her interpersonal skills, or her occupational standards, or possibly a tendency to attribute blame to others. In the event, it appeared to be much as she had initially thought: luck had been against her, and treatment therefore focused on helping her to tolerate the intrinsic unfairness of events.

CBT also acknowledges that some unhelpful thoughts may have been accurate in the past but are no longer accurate. For example, a child growing up in an emotionally deprived home may accurately have believed that ‘No one is there for me’, but this may no longer be true in her adult world. The aim of treatment is to understand and resolve problems, not to fix thinking!

CBT does not deal with the past

Most CBT sessions focus on the ‘here and now’, because most therapy is concerned with tackling current problems and hence what is currently maintaining them. This is not to say that CBT cannot work with past history when necessary, nor that it discounts the importance of past experiences in accounting for problem development (see Chapter 4). The main reason for focusing on the ‘here-and-now’ is that the factors that account for the development of a problem are often different from the ones that are maintaining it, and so relatively greater attention is paid to the present situation than to the past.

A 16-year-old girl with anxiety about wetting herself had had an experience as a young child when she felt humiliated after wetting herself in front of her friends on a school trip. She had not been able to ‘hold on’ when instructed to do so by her teacher and had been teased by her friends. Now she was older, she knew she was capable of holding on for many hours and no longer had friends who would tease her. The problem now was largely maintained by avoidance of situations where she would not have easy access to a lavatory, by not drinking before going out, and by a range of ‘safety behaviours’ like wearing long thick socks under her trousers so that urine would be absorbed if she did have an accident. For this girl, the problem had been precipitated by one set of factors, but was being maintained by different ones.

CBT deals with superficial symptoms, not the roots of problems, so alternative ‘substitute’ symptoms are likely to occur

As noted in Chapter 1, there used to be concern that simply ‘removing symptoms’ would result in the emergence of other manifestations of an underlying problem. However, a number of studies show that CBT clients are, if anything, protected against relapse, rather than developing further problems (e.g. Durham & Turvey, 1987; Williams, 1997; Hollon et al., 2005).

The strategies taught in CBT are often readily generalised to other problems. In addition, the CBT formulation of a client’s problems aims to throw light on the psychological processes maintaining them, and to intervene in ways that impact on these processes. In doing so it addresses fundamental maintaining patterns. This is discussed in more detail in Chapter 4.

A woman with agoraphobic symptoms had a number of other difficulties, including obsessive-compulsive problems about harm coming to her relatives, depression, worries about being rejected and abandoned by loved ones, and lack of assertiveness. The agoraphobic problem was successfully dealt with at the beginning of treatment, as the client identified this as a priority because it prevented her from functioning effectively as a wife and mother. She was able to travel around independently, even though the issues concerning being abandoned were at that stage intact. The obsessional symptoms were subsequently dealt with, before attention was paid to the more generalised concerns about self-worth.

CBT is adversarial

It is sometimes suggested that the CBT therapist tells the client what is wrong with his thinking and how he ought to think. As one mental-health information centre leaflet put it, ‘Cognitive therapy takes the form of an argument between client and therapist. As such, it is only suitable for the robust.’ In reality, only bad CBT looks like an argument! You should aim to approach your client open-mindedly so that you can get a sense of what it is to be him, to experience the problem as he does and to help him learn to question his beliefs for himself. There are good psychological reasons for encouraging him, via questioning, to work out new perspectives for himself. If he reviews the evidence for a belief for himself, and then draws his own conclusions, he is more likely to be convinced (see Chapter 7).

CBT is for simple problems: you need something else for complex problems

CBT is a wide-ranging and flexible approach to therapy, which skilful practitioners can apply to many psychological problems, provided the client is at least minimally engaged in the process. Within Axis I disorders (as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM-IV-TR; APA, 2000), clients with very severe and chronic difficulties have been helped by this approach (Haddock, Barrowclough, Shaw, Dunn, Novaco & Tarrier, 2009), and there is now increasing evidence of its efficacy for those with personality disorders (see Chapter 17).

CBT is interested in thoughts and not emotions

CBT is indeed interested in helping people modify thoughts, but usually as a means to an end, not an end in itself. Most clients want help with mood, feelings or behaviour rather than with dysfunctional thinking. Cognitive change is a means of helping people change in those other systems, but therapy is rarely fruitful if it is a purely intellectual discussion of abstract thoughts. If the client is experiencing no emotion during the process, it is very unlikely that he will achieve a shift in emotion or behaviour (Safran, 1998).

A depressed client who was socially isolated described a situation when she met some friends but perceived herself to be on the edge of the group, and insignificant as far as other people were concerned. She described the scene and her negative thoughts in a calm and measured way, and although she could identify evidence that she was valued by the others (they included her in plans for the evening, they chatted as though they assumed she would join them on a weekend trip), this had no impact on her view that she was peripheral. She was asked to talk about the scene again, but while describing her negative thoughts this time, she was asked to bring to mind and engage with how she was feeling during the distressing situation. Only then did the strength of her negative thoughts begin to weaken.

CBT is only for clients who are psychologically minded

Typically, CBT needs clients to be able to recognise and talk about thoughts and emotions, and to distinguish between them. It is also advantageous if a client can relate to psychological models – a vicious cycle or a preliminary formulation, for example. However, if a client has difficulty in reflecting in this way, the therapist can help him to increase his capacity to do that (see Butler & Surawy, 2004), and it is worth offering a trial of a few sessions to see if the client can take to the approach.

CBT is quick to learn and easy to practice

CBT has some powerful strategies that are relatively easy to learn and apply, and this book introduces you to the basic skills. However, using the approach in a creative and flexible way is as difficult as any other therapy, and you are reminded that you will need to receive regular supervision (see Chapter 19) and keep yourself updated on developments in CBT.

CBT is not interested in the unconscious

CBT does not use the concept of the unconscious in the Freudian sense but certainly recognises that cognitive processes may not be conscious. In many instances, you and your client are attempting to clarify the meanings of experiences that may initially be out of awareness. This is not generally interpreted as repressed material but is taken to be at a pre-conscious level, available on reflection to consciousness. Many clients need training to increase their awareness of, for example, NATs or assumptions. Socratic enquiry is used to help the client identify such cognitions and subsequently to establish the meaning of them. However, the therapist does not offer an interpretation of her own; the client is by and large considered to be the expert. This is discussed in Chapter 7.

There are instances when thoughts or images may be actively blocked by the client. For example, someone who has been sexually abused as a child might dissociate from any experience or memory which is too distressing to deal with; in OCD, many clients never confront the disturbing thoughts that motivate their ritualistic behaviour, by avoiding situations that would trigger the thoughts. Generally, the CBT techniques described in Chapters 8 and 9 are used to identify the nature of these unconscious thoughts or beliefs.

CBT demands high intelligence

CBT makes no greater demands on intelligence than any other therapy and, indeed, has been adapted for use with people with learning difficulty. Similarly, CBT has been adapted for use with children and young people (Graham, 1998), and with very elderly adults (Wilkinson, 2002).

 

Summary

The basic characteristics of CBT make this a fascinating and satisfying way of working with clients, as you help them develop strategies for managing problems, and guide them as they work out new, more adaptive perspectives on their world.

Some of the key characteristics include:

 

  • Collaboration, where client and therapist each bring their expertise to bear on the problem.
  • A structured and active format, with agenda-setting and goals for treatment contributing to a structured therapy, in which therapist and client actively engage in the therapeutic process.
  • Time limits,with most therapy lasting between 6 and 20 sessions.
  • An empirical basisrelying on psychological evidence, and emphasising measurement of problems, and empirical estimates of outcome.
  • Problem-orientation, with treatment addressed via a detailed formulation of the problems.
  • Guided discoveryas the cardinal mode of questioning.
  • Behavioural awareness, with many behavioural tasks and assignments.
  • Summaries and feedbackfrequently used, to make sure that therapist and client are on track.

Learning exercises

Review and reflection:

 

  • If you are currently working in psychological therapy, are the assessment or treatment sessions described here more structured than you are used to? If so, how could you check with your client whether he is feeling able to say what he wants to get across? Do you have any other misgivings about the structure?
  • If you have read things about CBT that have surprised you, what were they? Did you buy into the myths about CBT? If so, how strongly did you believe each of them?
  • Are there any aspects that you anticipate would make you feel uncomfortable? How could you tackle this in a graded way?

Taking it forward:

 

  • If you look back at the last five clients you have seen, in how many sessions did you agree homework that involved a behavioural task of some kind? Could you identify any sessions where it would have been helpful to include behavioural tasks? What could they have been?
  • If there were any myths that you bought into (for example, that CBT is adversarial), check out whether this was borne out in practice in your sessions with clients. If so, think about how you could make the sessions more typical of CBT, and try this out.
  • Work out how you could explain to your client that feedback is helpful and welcome, and practise this with two clients. How could you ask them whether your request made them feel uncomfortable in any way?

Further reading

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy for depression. New York: Guilford Press.

A classic text which gives a very good description setting out characteristics of the approach.

Westbrook, D., Mueller, M., Kennerley, H., & McManus, F. (2010). Common problems in therapy. In M. Mueller, H. Kennerley, F. McManus & D. Westbrook (Eds.), Oxford guide to surviving as a CBT therapist. Oxford: Oxford University Press.

An interesting chapter where the authors discuss common problems in therapy associated with many of the distinctive features of CBT.