Chapter 6 Cognitive-Behavioral Therapy

This chapter provides an overview of cognitive-behavioral therapy (CBT), beginning with the guiding principles and evidence-based research for CBT. Basic cognitive and behavioral techniques are presented that the advanced practice psychiatric nurse (APPN) can integrate into practice. Various modifications, which include schema focused and dialectical behavioral therapies, are discussed, as well as the application of models of CBT treatment for specific populations. The chapter concludes with a case study illustrating the use of CBT and with how to obtain certification requirements for postmaster’s training.

CBT is the most widely researched psychotherapeutic model, which has demonstrated effectiveness in the treatment of a wide range of emotional and behavioral problems (Hollon et al., 2005, 2006; Leichsenring & Leibing, 2003; McLean et al., 2001; Mohr et al., 2001; Paunovic & Ost, 2001). CBT is the first order of business and treatment of choice for most patients who need internal resources and coping skills enhanced. The therapist, together with the patient, structures each session and sets reasonable, measurable, specific goals so that both participants know when progress has been made. Goals include problems to overcome and positive changes that need to be made. Each session ends with homework assigned, which is reviewed at the beginning of the next session. CBT is based on treatment plans that are clearly conceptualized and on tested theories that guide the clinician through each action, session, and overall plan of care.

Guiding Principles

Cognitive therapy “is a collaborative process of empirical investigation, reality testing, and problem solving between the therapist and the client” (Beck & Weishaar, 1986, p. 43). The basic premise is that depression is the result of cognitive distortions and that these distortions are learned errors in thinking. CBT evolved primarily from the work of Aaron T. Beck. Beck, originally trained in psychoanalysis, departed from psychoanalytic concepts as he studied Adler, Horney, and Sullivan. Beck concentrated on a person’s distortions in self-image, thereby creating a more systematic cognitive-behavioral conceptualization of psychiatric disorders and personality structure (Clark et al., 1999). Through a series of studies on depression and suicidal thinking, Beck developed a systematic structuring of cognitive therapy with a blueprint of guiding principles and specific procedures to follow (Beck, 1976, p. 15).

During the 1970s, researchers began to apply behavioral theory to cognitive theories and strategies. Traditional behavior theory focused on guided experiments to shape measurable behaviors, such as avoidance and suicidal ideation, with little attention paid to the cognitive processes involved in the behavioral changes. For example, fearful responses were extinguished with exposure protocols. Meichenbaum and Lewinsohn began to incorporate these behavioral interventions within the cognitive theoretical structures, and they observed that this added depth, context, and deeper understanding to outcomes (Lewinsohn et al., 1985; Meichenbaum, 1977). Since then, extensive research has demonstrated significant efficacy in the combined approach using cognitive techniques (i.e., cognitive restructuring) along with behavioral techniques (i.e., exposure therapy and relaxation training).

Cognitive behavioral therapy or CBT is a “system of psychotherapy based on a theory which maintains that how an individual structures his or her experiences largely determines how he or she feels and behaves” (Beck & Weishaar, 1986). The model posits that dysfunctional (or maladaptive) thoughts relating to self, the world, or others are rooted in irrational or illogical assumptions. The individual’s view of self and the world are central to the determination of emotions and behaviors, and by changing one’s thoughts, emotions and behaviors can also be changed. CBT is structured hierarchically, with cognitive processes understood in terms of primary and secondary thinking. Secondary thinking views the social and cultural world in determinate, positive, rational terms, whereas primary thinking recognizes the indeterminate, negative, and irrational as forever part of human action. CBT places significant importance on cognitive information processing and behavioral change. The resultant theoretical model combines features of traditional psychotherapy within a unique conceptual framework.

Clinical strategies are used to help the individual recognize the dysfunctional nature of their thinking patterns and to help the person change their conclusions. Theoretical refinement of the model and empirical testing have resulted in a consensus that it is the interplay among thoughts, feelings, and behaviors within a person’s environment that results in psychopathology. Interventions must target all three foci to affect sustainable changes, but cognition is the pivotal point.

Evidence-Based Research

Many research studies have validated the efficacy of CBT for medical and psychiatric disorders, as well as for many mental health problems (Table 6-1).

Table 6-1 Evidence-Base Research for Cognitive-Behavioral Therapy

Type of Disorder	References
Medical Disorder
Tinnitus	Andersson et al., 2005
Chronic pain	Bogduk, 2004; Thomas, 2005; Thorn, 2004
Premenstrual dysphoric disorder (PMDD)	Hunter et al., 2002
Sexual dysfunction	Nofzinger et al., 1993
Chronic insomnia	Espie et al., 2001
Chronic fatigue syndrome	Price & Couper, 1998
Psychiatric Disorder or Mental Health Problem
Depression	DeRubeis et al., 2005; Hollon et al., 2006
Anxiety and panic disorders	Heldt et al., 2005; James et al., 2005; Klinger et al., 2005; Ost et al., 2004; Persons et al., 2005; Stanley et al., 2004
Eating disorder	Leung et al., 2000; Pike et al., 2003
Personality disorders	Leichsenring & Leibing, 2003
Substance misuse disorders	Tyrer et al., 2003, 2004
Marriage and couple problems	Dattilio & Epstein, 2005
Posttraumatic stress disorders (PTSD)	Bisson & Andrew, 2005; Hinton et al., 2005; Otto et al., 2003; Paunovic & Ost, 2001; Taylor et al., 2001
Self-injurious behaviors	Tyrer et al., 2003
Obsessive-compulsive disorder	Benazon et al., 2002; McLean et al., 2001; Piacentini et al., 2002; Rufer et al., 2006; Whittal et al., 2005
Schizophrenia and schizophrenic symptom reduction	Jones et al., 2004; Rector & Beck, 2001, 2002; Turkington et al., 2004
Hypochondriasis	Bouman & Visser, 1998
Antisocial behaviors	Kazdin, Marciano, & Whitley, 2005
Sexual offenders	Yates, 2003
Borderline personality disorder (using a dialectical behavior therapy approach)	Binks et al., 2006

Cognitive Techniques

Specific techniques integrated by the APPN psychotherapist assist in changing or modifying the patient’s thinking and behaviors. Cognitive therapy advocates guided discovery rather than directly challenging the patient’s views. It is sometimes necessary to be direct or even confrontational, such as in cases when the therapist must intervene quickly. However, it is always best to be as collaborative as possible and to allow the patient to find the answers to the problems or dilemmas as much as possible. This approach minimizes debate and increases the sense of mastery and participation.

Socratic Dialogue

The Socratic dialogue (SD) is a technique described as “mutual discovery in which the therapist guides the client through a series of questions and answers to elicit automatic thoughts and assumptions and examine the logic and evidence that relates to them” (Leahy, 2001). Socratic methods are radically different from the techniques of psychodynamic schools and nondirective styles of therapy (Freeman, 2005). These approaches synthesize the patient’s information, and the therapist interprets to the individual, intentions, motivations, and conflicts (Freeman, 2005). The therapist’s interpretations are thought to lead the patient to insight, integration, and eventual change. In the SD method, the therapist asks specific questions derived primarily from restatement of the individual’s own words, and this is the major technique used to encourage the patient to self-discover insight that leads to subsequent changes (Freeman, 2005).

Seven types of questions are involved in the SD method: memory, translation, interpretation, application, analysis, synthesis, and evaluation. SD is a series of well-placed questions that guide the patient to the expected response, rather than pointing out the answer to the individual. It is a much more powerful technique to have the individual find the answer than to direct the individual. Box 6-1 describes the types of questions used in the SD method of therapeutic interaction (Freeman, 2005). Box 6-2 illustrates the basic rules for SD, which are adapted from Freeman (2005) and used in conjunction with the types of questions described earlier.

Box 6-1 Socratic Dialogue

History questions (non–Socratic dialogue type): “How many children did you have in your first marriage?”

Memory questions (remembering that the individual’s recall is influenced temporally, interference and “facts” being considered inconsequential): “When did you first notice that your sleep patterns had changed?”

Translation questions (asks the patient how the data refer to the individual): “When you say you become anxious, explain to me what it feels like for you to feel anxious.”

Interpretation (helps the patient identify relationships between facts and experiences): “How does your sensitivity to criticism play out with your husband?”

Application (asks the individual to apply previously mastered skills to a new situation): “How can you use what you learned with your boss in your discussion with your son?”

Analysis (requires breaking a problem into a number of parts): “What evidence do you have to support this conclusion?”

Evaluation (asks the individual to make decisions or judgments based on data): “On a scale of 0 to 10, where would you rate your level of anxiety today?” “How does that compare with 4 months ago?”

From Freeman, A. (2005). Socratic dialogue. In A. Freeman, S. H., Felgoise, A. M., Nezu, C. M. Nezu, & M. A. Reinecke (Eds.), Encyclopedia of cognitive behavior therapy (pp. 380–384). New York: Springer Publishing.

Box 6-2 Socratic Dialogue Basic Rules

1. The techniques are embedded in the collaborative dialogue and are goal directed and specific.

2. The therapist has a problem list that generates the plan of direction that begins the Socratic dialogue (SD) process. SD is not a series of drifting questions that “follow the patient.” Each question must be strategically placed to reach the predefined goal. This is where the concept of guided discovery comes from for the therapeutic interaction.

3. The questions must be short, focused, and targeted, as in the following examples. “Do you experience difficulty agreeing with your husband?” “Is this similar to interactions with others?” “How does this play itself out in this situation?” “Can you think of another way to respond that may result in a less defensive response from him?”

4. The questions must progress in a manner that keeps anxiety at a minimum for the patient.

5. The SD questions should be framed in a way to elicit an affirmative response. For example, the following question may be used for a reluctant individual: “There are probably a lot of places you would rather be than here, right?”

6. Negative responses to questions mean that the therapist must reframe the question to gain an affirmative response. “Is it your idea to come to therapy today?” “No! I don’t want to be here!” “There are probably a lot of things you would rather be doing today than sitting here.” “Yeah! That’s for sure!”

7. The therapist must monitor the patient’s reactions and moods on an ongoing basis. If a question increases a reaction, the therapist needs to address it immediately. “What just happened? I noticed a reaction—what was that?”

8. The therapist must pace the questions to suit the patient’s mood and style and the content of information.

9. The questions must be planned and asked in a logical sequence. The therapist must have an internal map for the session and move the session in a planned direction toward the desired goal.

10. The therapist must be careful to self-monitor and not “jump in” to offer interpretations or solve the patient’s problems. This reserve is more respectful to the patient, and it allows for greater clarity.

11. Self-disclosure should be extremely limited and used only with extreme caution and great care about the motive for the disclosure. Comparing what the therapist did or does with what the patient did or does moves away from an SD approach into discussion and possibly constitutes misjudgment.

12. The therapist may use everyday experiences as therapeutic metaphors. For example, a therapist may use Aesop’s Fables and other well-known stories and characters to make a point such as “sour grapes” that can elicit content and affect.

From Freeman A. (2005). Socratic dialogue. In A. Freeman, S. H., Felgoise, A. M., Nezu, C. M. Nezu, & M. A. Reinecke (Eds.), Encyclopedia of cognitive behavior therapy (pp. 380–384). New York: Springer Publishing.

Downward Arrow

The downward arrow technique was first used by Beck in 1979 to refer to the method of logical sequencing of reasoning. The individual is helped to uncover underlying assumptions in logic and sequence through careful questioning by the therapist asking, “If this is true, then what happens?” For example, Mrs. Jones, a successful attorney, was concerned that a staff member Jane was having problems with would undermine her practice if she terminated her, even though Mrs. Jones and the woman had not been able to work out their differences for months. The APPN asked her what specifically would happen if she fired Jane.

Mrs. Jones: She would bad mouth me to her friends at the courthouse, and that would give me a bad name!

Therapist: And how would that affect your practice?

Mrs. Jones: Everyone would believe her, and I have a lot of clients who work at the courthouse!

Therapist: And how many of those clients do you have at the courthouse?

Mrs. Jones: I guess about 15.

Therapist: And how many clients do you have in your practice?

Mrs. Jones: About 250.

Therapist: And how many of the 15 at the courthouse would believe Jane and drop you?

Mrs. Jones (laughing): Okay, 2 or 3 maybe.

Therapist: So, if you fired Jane, 2 or 3 of 250 clients would possibly drop you.

Mrs. Jones: Yes, I guess I do this all the time! I’ve been making myself nuts over nothing!

Idiosyncratic Meaning

The therapist assists the patient to clarify statements and terms used so that both have a clear understanding of perceived reality. For example, Mr. Smith says, “When she makes those little faces, it just puts me out! You know what I mean.” The therapist responds, “No, I don’t what you mean. Please explain what you mean by ‘puts you out.’”

Labeling of Distortions

Individuals are helped to identify automatic thoughts that are “dysfunctional or irrational” as a type of self-monitoring for more accurate descriptions. Table 6-2 provides examples of cognitive distortions. In the first session, patients are asked to choose four or five of their favorite cognitive distortions and to bring this information to the next session. This information is then integrated into future sessions as educational material as it is noticed in a patient’s verbalizations or written information. The patient is stopped and asked to notice what has been said (thought) and encouraged to reframe the information. Other examples of distorted, automatic thoughts are also caught and restructured as needed.

Table 6-2 Cognitive Distortions

Type of Distortion	Sample Statement
All-or-nothing	“I’m either a success or a failure.”
Mind reading	“They probably think that I am incompetent.”
Emotional reasoning	“Because I feel inadequate, I am inadequate.”
Personalization	“That comment must have been directed at me.”
Global labeling	“Everything I do turns out wrong.”
Catastrophizing	“If I go to the party, there will be terrible consequences.”
Should statements	“I should visit my family every time they want me to.”
Overgeneralization	“Everything always goes wrong for me.”
Control fallacies	“If I’m not in complete control all the time, I will go out of control.”
Comparing	“I am not as competent as my coworkers or supervisors.”
Heaven’s reward	“If I do everything perfectly here, I will be rewarded later.”
Disqualifying the positive	“This success experience was only a fluke. The compliment was false.”
Perfectionism	“I must do this perfectly, or I will be criticized and be a failure.”
Time tripping	“I screwed up my past, and now I must be vigilant to secure my future.”
Objectifying the subjective	“I have this belief that I must be funny to be liked, so it is fact.”
Selective abstraction	“All of the good men are taken or gay.”
Externalization of self-worth	“My worth depends on what others think of me.”
Fallacy of the change of others	“You should change your behavior because I want you to, and it will immediately make me happier/feel better.”
Fallacy of worrying	“If I worry about it enough, it will be resolved.”
Ostrich technique	“If I ignore it, maybe it will go away.”
Unrealistic expectations	“I must be the best absolutely all of the time.”
Filtering	“I must focus on the negative details while I ignore and filter out all the positive aspects of a situation.”
Being right	“I must prove that I am right, because being wrong is unthinkable.”
Fallacy of attachment	“I can’t live without a partner.” “If I was in a relationship, all of my problems would be solved.”
Fallacy of perfect effect	“If I do things perfectly, the results will be perfect.”

Questioning the Evidence

The technique of questioning the evidence assists patients in questioning the facts related to their cognitions and conclusions. This procedure investigates whether their information is based on facts or assumptions. For example, Mr. Hanson has been struggling with intimacy issues with his wife and reported that they had “finally” had sexual intercourse after 2 years of abstinence. He was very happy that this had occurred but was upset because he was sure she was not satisfied with the experience. The therapist stopped him at this point and asked him for his evidence to support this fact. He said he “just knew.” The therapist did not let this statement stand as evidence and helped Mr. Hanson review the basis for his conclusion. After the review, Mr. Hanson reported that his wife had said that she was happy and “felt good.” The therapist said, “So you think she lied to you?” Mr. Hanson said, “No.” The therapist said, “Well, either she lied to you, or she felt happy. Which do you think was true?” Mr. Hanson replied, “I guess she was happy.” He then smiled.

Examining Options and Alternatives

The technique of examining options and alternatives involves the development of all possible explanations to learn the skills in generating options rather than using one-way thinking. For example, Mrs. Umber was going to visit her son and daughter-in-law, with whom she did not get along.

Mrs. Umber: I just can’t stand the idea of spending a whole week with them!

Therapist: How did you choose to spend an entire week?

Mrs. Umber: Well, it is clear out on the coast, so if we are going clear out there, it doesn’t make sense to only go for a weekend.

Therapist: What are your options?

Mrs. Umber: I am not sure what you mean.

Therapist: You are going to the coast for a week. Do you have to spend the entire week with your son?

Mrs. Umber: I hadn’t thought about that. I guess I don’t, do I!

With that revelation, she began to explore the possibilities of shortening her visit with her son and instead having a brief vacation with her husband in addition with the visit with her son.

Reattribution

For patients with the habit of accepting all or most of the blame for outcomes, reattribution is an excellent technique for redistribution of responsibility. It is also helpful for individuals with personality disorders who place the blame squarely on the shoulders of others for most outcomes.

Mrs. White: I can’t believe he left me! I am such a loser!

Therapist: You were married to him for 22 years, and he had five affairs that you knew of. You said that you were there for him more than any other woman would have been. How is that being a loser?

Mrs. White: I know. I just feel like a loser!

Therapist: What was his part in this break up?

Mrs. White: I guess he had some of it, but maybe if I wasn’t such a loser, he wouldn’t have had all of those affairs.

Mrs. White has a way to go, but she has opened the door to the possibility that her husband played a part in ending their marriage. The therapist can work with her in identifying the component parts of her husband’s responsibility and her own.

Decatastrophizing

Catastrophic thinking is one of the hallmarks of anxious individuals. They tend to focus on the most negative possible outcome of any given situation. Decatastrophizing allows balance and realistic focusing by examining the “worst possible outcome” and developing a plan of action. For example, a young woman complained that she could not sleep.

Woman: I haven’t been able to sleep for 2 months! If I can’t get some sleep, I won’t be able to stand it! I can’t live like this!

Therapist: Take a deep breath, and tell me the worst thing that would happen if you could not sleep.

Woman: I can’t live like this!

Therapist: But what would happen if you continue to not sleep?

Woman: I would walk around like a zombie!

Therapist: Have you been to your doctor for sleeping medication?

Woman: No. I am worried I would get addicted!

Therapist: What would be worse: not sleeping or getting addicted?

Woman: Not sleeping.

Therapist: Do you think your doctor would let you get addicted?

Woman: No, she has known me for years. She is really careful.

Therapist: Would you let me call from here and get you an appointment today for an evaluation of your medication?

Woman: Yes. I guess I am really overreacting because I am so tired!

Advantages and Disadvantages

For individuals who appear to be stuck between two options, examination of the advantages and disadvantages of certain situations helps them to develop alternative perspectives. This breaks the all-or-nothing mindset and permits a more balanced view of the situation. For example, Mr. Black is wondering whether to accept a promotion at work, which means more money but more travel and time away from his family. The therapist can help him outline a list of advantages and disadvantages in a cost-benefit analysis similar to what he may do at his job and that looks familiar to him so he can weigh his choices by placing points next to each choice and then totaling the categories.

Paradox or Exaggeration

The technique of paradox or exaggeration should be used only by the very skilled therapist; otherwise, the patient may view this technique as sarcasm or belittling. When it is used appropriately, the therapist takes an issue to the extreme to help the patient see the absurdity of his/her sometimes overinflated viewpoints. One therapist had been working with a couple for several months. The couple had originally come in with issues related to his obsessive-compulsive tendencies for neatness and her tendency to be a free spirit. They had reached a number of compromises and were very happy. At one point in the session, they were talking about putting in a garden area and were having difficulty deciding how to organize it. The therapist said to the couple, “Oh my goodness! He wants the plants in rows and to be neat and orderly! Where on earth would he get an idea like that?” The couple, realizing that this exactly matched his style, immediately started laughing.

Turning Adversity to Advantage

The technique of turning adversity to advantage is similar to making lemonade out of lemons. Patients are helped to identify how they can use what appears to be a negative situation to their advantage. For example, being turned down for a job may open up more attractive possibilities that had not been investigated previously.

Cognitive Rehearsal

Before making a behavioral change, it is sometimes less threatening to practice the new behavior through visualization and discussion. The cognitive rehearsal could include practicing assertiveness in a mirror or “talking through” a confrontation out loud before engaging in the actual conversation.

Automatic Thought Records

The automatic thought record is a key component of CBT. The record was first introduced by Beck in 1979 to capture and analyze automatic thoughts during and between sessions (Beck et al., 1979). The automatic thought record is used as homework after introducing the process within the therapy session. The individual completes the columns identifying a troubling situation and resulting emotion and the thoughts associated with both. The therapist and patient work on clarification and development of rational responses in order to debate or challenge the original reaction. When practiced and repeated, the process of clarification and debate becomes internalized in the individual. Appendix II-1 (p. 273) provides the form for an automatic thought record.

Thought Stopping

Thought stopping is one of the simpler techniques in CBT. The patient interrupts her/his stream of thoughts with a sudden stimulus, such as snapping a rubber band on the wrist and saying, “Stop it!” out loud, or the patient uses some other real or imagined stimulus and then changes the stream of thoughts. The technique is most credible when demonstrated to the patient in session and then is assigned as homework. After patients are given a loud stimulus in a session (e.g., “Stop it!”) and then allowed to regain their composure and report what the thought pattern is after the stimulus, they realize that this simple technique is very effective.

Cognitive Restructuring

The process of cognitive restructuring refers to the use of an automatic thought record combined with other cognitive techniques to effect changes in negative thinking patterns. The patient is asked to check in with themselves a few times each day at random times and write down what s/he is thinking. After keeping the automatic thought record for a week, the therapist and patient review the log, underline thoughts that are negative, and identify the cognitive distortions used by the patient (see Table 6-2). The patient then is asked to say the negative thoughts aloud to enhance awareness and to slow them down and to say out loud the targeted negative messages whenever they occur during the next week. The therapist and patient generate a list that counters those distortions. For example, one patient who was anxious about going to an upcoming social event became aware that her negative thoughts reflected her poor self-esteem: “I will have a terrible time because nobody likes me.” A positive comment was developed to counter this: “People usually like me.” The patient was asked to practice thought stopping and substitute the positive statement from the list of positive statements that she carried with her whenever she found herself thinking the negative thought during the next week. The steps in cognitive restructuring are provided in Box 6-3.

Box 6-3 Steps in Cognitive Restructuring