COGNITIVE BEHAVIOUR THERAPY

Traditional behaviour therapy focuses mainly on changing observable behaviours by means

of providing different or rewarding consequences. The cognitive behaviour school broadens
behaviour therapy to incorporate the contribution of how people think to creating,
sustaining and changing their problems. In cognitive behaviour approaches, therapists
assess clients and then intervene to help them to change specific ways of thinking and
behaving that sustain their problems.

Cognitive behaviour therapy is a psychotherapy of the re-educative kind. The term

cognitive comes from the Latin term "cognoscere", meaning "to recognize." It is a
combination of two therapeutic approaches, namely, cognitive therapy and behavioural
therapy, thus, comprising of cognitive (pertaining to memory, perception, judgement,
reasoning) and behavioural factors. Characteristically it is problem-focused, goal directed,
future oriented, time limited and empirically based. It believes that the acquisition and
maintenance of psychopathology is mediated by the cognitive and emotional process. In
the 1960s, Aaron Beck developed cognitive behaviour therapy (CBT) or cognitive therapy
that has been found to be effective in a large number of outcome studies for some
psychiatric disorders, including depression, anxiety disorders, eating disorders, substance
abuse, and personality disorders.

The aim of this kind of therapy is to form a clear idea of one’s own thoughts, attitudes and
expectations. The goal is to reveal and change false and distressing beliefs, because it is
often not only the things and situations themselves that cause problems, but the
importance that we attach to them too. For example, a dangerous thought pattern might be
when somebody immediately draws negative conclusions from an occurrence, generalizes
them and applies them to similar situations. This generalized way of thinking is called “over-
generalizing.”

You see somebody you know on the street and say hello, but they do not say hello back.
Your own reaction to that very much depends on how you assess the situation: A harmful
thought pattern would be “He doesn’t like me anymore”, arising feelings would be of
sadness and rejection, and the consequence of such a thought would be to avoid this person
in the future (behaviour).

Cognitive processing is understood to play a crucial role in this model because humans
continuously appraise the significance of any event in their environment and within them,
and cognitions are closely related to emotional reactions. When the maladaptive cognitions
stimulate the emotional and physiological responses the resulting behavioural response
tends to be problematic (Wright et al., 2006). Cognitive Behaviour therapists identify this
interaction of biological, environmental, interpersonal and cognitive behavioural elements
to treat psychiatric disorders (Wright, 2004).
 1. Levels of processing: The primary levels of cognitive processing were identified by
Beck and his colleagues (Beck et al., 1979). A highest level of cognition is considered
to be consciousness, a state of awareness in which decisions can be made rationally.
It allows
a) To monitor and assess interactions with the environment
b) Link pas with the present experiences
c) Control and plan future actions (Sternberg, 1996).

CBT therapists encourage building up one’s adaptive conscious thought processes,

like rational thinking and problem solving. The patients are made to recognize and
change pathological thought pattern at levels of relatively autonomous information
processing: Negative Automatic thoughts and Schemas (Beck et al., 1979; Wright et
al., 2003; Clark et al., 1999).

NEGATIVE AUTOMATIC DYSFUNCTIONAL

INTERMEDIATE BELIEFS
THOUGHTS ASSUMPTIONS

Levels of Cognition by Westbrook et al., 2007

Schemas: These are basic rules for information processing that underlie the most superficial
layer of automatic thoughts (D.A. Clark et al., 1999; Wright, 2003), that assist in explaining
experiences, mediating perception, and guiding responses. They are enduring, stable belief
systems that start to shape in early childhood and assume three forms according to Clark
and colleagues:

a) Simple Schemas - These have little effect on psychopathology as they deal with the
rules about the physical nature of the environment, management of everyday
activities, or the laws of nature. Example, take a shelter during a thunderstorm.
b) Intermediate Schemas – These are the if-then statement conditional rules, that have
an implication on emotional regulation and self-esteem. “If I don’t please others all
the time, they will reject me.”
c) Core beliefs about the self- These are the fundamental beliefs about one’s self, other
people and the world, thus, being the global absolute rules for interpreting the
environmental information related to self-esteem. Example, “I am dumb”, “I am a
failure”. Characteristically, they are immediately accessible to consciousness, and are
inferred from one’s characteristic thoughts and behaviour in different situations.
Dysfunctional Assumptions: General beliefs about the world and themselves, making
one prone to interpreting specific situations in an extremely negative and dysfunctional
manner (Hawton et al., 1989). It connects the core beliefs to the negative automatic
thoughts and is believed to be the ‘rules of living’. Example “If people get to know me,
they will find out how useless I am, and reject me; I must be good at everything I do,
otherwise my uselessness will be revealed”. Characteristically, they consist of
conditional statements, may not be easily verbalised, can be culturally reinforced, they
are rigid and often over-generalised.

Negative Automatic Thoughts: These are self-critical or exaggerated negative self-

statements that are automatically generated in a person’s mind, about specific events or
situations, that become easily conscious, and are taken as true without testing their
accuracy especially when emotions are strong. Example, I am being boring, I don’t know
what to say; they think I am stupid; I am a failure, she does not like me.

Cognitive Errors: Beck, 1963, 1964 and Beck et al., 1979 theorized that there are
characteristic errors in logic in the automatic thoughts and cognitions. Some of them
are: -

 Overgeneralization- Conclusions made about an isolated event and then extended

illogically to broad areas of functioning.
 Magnification and minimization- Significance of an event, attribute or sensation is
exaggerated or minimized.
 Personalization- External events are actively related to oneself when there is little or
no basis for doing so. Blame taking or excessive responsibility is taken for negative
events.
 All or none thinking- Judgements about oneself, personal experiences, are thought
of as all good or all bad, or total success or total failure.
 Selective abstraction- Only one small portion of an information is viewed to draw
conclusions.
 Arbitrary inference- reaching to a negative inference when there is no evidence for it
or it is vague, unclear, and circumstantial. There are two types of arbitrary
inferences- Mind reading- “she thinks I am weak, I just know it”, “the boss doesn’t
like me, I am certain”.
Negative prediction – imagining or anticipating negative/ unpleasant consequences-
“I just know there will be a problem in this vacation”.

Techniques in CBT

1. Socratic Method- It involves a series of logical questions that leads the person to
challenge their beliefs or thoughts. These are used to obtain information about the
person along with raising issues and to offer suggestions. It may evoke responses like
“I don’t know”. ‘What?’ and ‘why?’ are often used by the clinician as a probe. It
involves questions addressing the emotional significance of a specific event, and to
 take the interpretation of it in a deeper level guiding the client to understand the
beliefs and assumptions that led them to the event the way they did. It has 4 stages
given by Padesky (1996): -
a) Concrete questioning
b) Empathic listening
c) Summarizing
d) Synthesizing or analysing questions
2. Cognitive Method- This method involves bringing a change at the level of one’s
cognitions through identification of the cognitions, diary keeping, cognitive
restructuring, re-attribution, evaluation of negative automatic thoughts and
beliefs and reality testing.
In identifying cognition, words used to describe emotions are identified. Clients are
helped to recognize and label their emotions, differentiate between different
emotions, their feelings and thoughts and recognize links between their feelings and
the events so that feelings become a cue for cognitive exploration (Wright, 2006). In
diary keeping, records of cognitions, most accurate at the time that it occurs, are
kept. Clients are asked to tune into the relevant thoughts, stand back and evaluate
them (Westbrook, 2007). In cognitive restructuring, the negative thinking is
challenged and people are taught more adaptive thought patterns. Identification of
the negative impact of the thought pattern is assessed and taught to replace the
dysfunctional cognitions with more adaptive ones. Some of the targets for
restructuring are automatic thoughts, negative self-statements, interpretations,
beliefs and cognitive distortions. In re-attribution, the unrealistic blame taking by the
client for adverse events to oneself is re-attributed. In evaluation of negative
automatic thoughts and beliefs, a clinician encourages cognitive change through
exploration and evaluation of the negative thoughts and appraise events and
feelings realistically (Wright, 2006) and in reality testing, the objective evaluation of
emotions or thought are done against the real life.
3. Behavioural Method- It involves working at the behavioural level to bring a change
in the cognitions as behaviours are assumed to affect one’s cognitions and how one
feels. In involves methods like activity scheduling, graded task assignment,
behavioural rehearsal, thought stopping, distraction, breathing retraining,
imaginal exposure, in-vivo exposure, relaxation training, applied tension and
problem solving. In activity scheduling the client’s symptoms are directly addressed,
involving procuring information about the client’s activities, through diary keeping
on an hourly basis until they go to sleep. In graded task assignment, overwhelming
tasks are broken down into smaller and easily accomplishable pieces. In behavioural
rehearsal, a behavioural plan is proposed to the client to be completed outside
therapy, that is rehearsed in treatment session. The therapist gives client feedback,
checking the ability of the client to carry out the activity, practice behavioural skills,
spot the potential roadblocks, and to reassure the patient that the plan will have a
 positive outcome. In thought stopping, the process of negative thinking is stopped
by replacing it with adaptive thought, through recognizing the thought, giving
command to stop the thought (“Stop!” or “Quit thinking that way”) evoking visual
image to reinforce the command (a stop sign visualized) and then switching the
image from the command to a relaxing scene (a vacation memory, a photograph, a
pleasant person’s face). In distraction, client may be encouraged to read, go for a
walk, a movie, work on a hobby, socialize with friends, spending time on the interest.
In breathing retraining, client is instructed to breathe rapidly and deeply for a short
time followed by breathing slowly again until regaining a normal control over his
breathing. It aims to eliminate the catastrophic fears about possible outcomes by
explaining the physiological aspect during hyperventilation. In imaginal exposure,
the therapist asks the patient to immerse oneself in a scene and imagine how they
react. In in-vivo exposure, client is directly confronted with the feared stimulus. In
relaxation training, client is made aware of the benefits of applying the relaxation
techniques, as physical tension might be a maintenance factor for many problems. In
problem solving, client’s problems are actively identified and are brainstormed for
solutions, listing the pros and cons of solutions, putting the solutions into action
through role play first. It is useful for interpersonal skills, helps the client to deal with
their everyday difficulties in getting on with others.

STRENGTHS

 CBT has been adapted to a wide range of disorders including depression and anxiety.
 CBT is a well-researched, evidence based therapy that has proven effective for
clients from multiple backgrounds.
 It has also led to development of a number of useful and important clinical
instruments such as Beck’s Anxiety Inventory, Beck’s Hopelessness Scale and Beck’s
Depression scale.
 CBT has number of training centres around the US and Europe.

LIMITATIONS

 It is structured and requires client’s to be active such as completing assignments.

 It is not appropriate for those seeking more unstructured, insight oriented approach
that does not require strong participation.
 It is primarily cognitive in nature and not effective for intellectually limited or those
who are unmotivated to change. CBT is demanding. Clinicians as well as clients must
be active and innovative
Conclusion
Presently CBT is widely accepted in a variety of clinical and clinical-health setting.
Cognitive structures are relatively amenable to empirical assessment and enough
attempts have been made to assess the ways in which the structures are altered as a
result of psychotherapy.
 RATIONAL EMOTIVE BEHAVIOUR THERAPY:

What Is Rational Emotive Behavior Therapy?

Rational emotive behavior therapy (REBT) is a type of cognitive behavioral therapy (CBT)
developed by psychologist Albert Ellis. It emphasizes clients re-indoctrinating themselves
with irrational beliefs that contribute to unwanted feelings and self-defeating actions.
Psychotherapy involves disputing clients’ irrational beliefs and replacing them with more
rational beliefs. Elegant or profound psychotherapy entails changing clients’ philosophies of
life.

REBT is an action-oriented approach that’s focused on helping people deal with irrational
beliefs and learn how to manage their emotions, thoughts, and behaviors in a healthier,
more realistic way. When people hold irrational beliefs about themselves or the world,
problems can result. The goal of REBT is to help people recognize and alter those beliefs and
negative thinking patterns in order to overcome psychological problems and mental
distress.

According to REBT, our cognition, emotions, and behavior are connected.2 In order to
understand the impact of events and situations that people encounter throughout life, it’s
essential to look at the beliefs people hold about these experiences and the emotions that
arise as a result of those beliefs.

Techniques:

A core concept of REBT is the ABC model. This model explains how, while we may blame
external events for our unhappiness, it is our interpretation of these events that truly lies at
the heart of our psychological distress. "ABC" is an acronym for:

A: Activating event, which is when something happens in the environment around you

B: Belief, which describes your thoughts about the event or situation

C: Consequence, which is your emotional response to your belief

Identifying Beliefs and Applying the ABC Model:

During REBT, your therapist will help you learn how to apply the ABC model to your daily
life. If you’re feeling depressed due to a conflict in your relationship, for example, your
therapist may help you identify the activating event for your problem before encouraging
you to figure out which beliefs led to your negative feelings. They would then work with you
to change those beliefs and, ultimately, your emotional response to the conflict.

An important step in this process is recognizing the underlying beliefs that lead to
psychological distress. In many cases, these are reflected as absolutes, as in "I must," "I
should," or "I can’t." Some of the most common irrational beliefs include:

 Feeling excessively upset over other people’s mistakes or misconduct

 Believing that you must be perfectly competent and successful in everything to be
valued and worthwhile
 Believing that you will be happier if you avoid life’s difficulties or challenges
 Feeling that you have no control over your own happiness; that your contentment
and joy are dependent upon external forces

Holding unyielding beliefs like these makes it almost impossible to respond to activating
situations in a psychologically healthy way. Possessing rigid expectations of ourselves and
others only leads to disappointment, recrimination, regret, and anxiety.

Disputation:

One step toward changing your beliefs is undergoing a process called disputation. During
disputation, your therapist will challenge your irrational beliefs using direct methods. They
may question your beliefs head-on, causing you to rethink them, or they could ask you to
imagine another point of view that you haven’t considered before.

Disputation is meant to teach you life-long skills to help you manage your emotional
response and overall mental health.

While each therapist may approach disputation differently, challenging your beliefs is part
of the process. Ellis suggested that rather than simply being warm and supportive,
therapists need to be blunt, honest, and logical in order to push people toward changing
their thoughts and behaviors.

Gaining Insight and Changing Behavior:

An important part of the REBT process is learning how to replace your irrational beliefs with
healthier ones. This process can be daunting and upsetting, and it’s normal to feel some
discomfort or to worry that you’ve made a mistake.

However, the goal of REBT is to help people respond rationally to situations that would
typically cause stress, depression, or other negative feelings. When faced with this type of
situation in the future, the emotionally healthy response would be to realize that it is not
realistic to expect success in every endeavor. All you can do is learn from the situation and
move on.
Three key insights that REBT teaches are:

 You are worthy of self-acceptance no matter what even when you struggle or make
mistakes; there is no need for shame or guilt.
 Others are also worthy of acceptance, even when their behavior involves something
that you don’t like.
 Negative things will sometimes happen in life, and that doesn’t mean that things are
happening in a way they shouldn’t be. Life is not positive all of the time, and there’s
no rational reason to expect it to be.

While REBT uses cognitive strategies, it focuses on emotions and behaviors as well. In
addition to identifying and disputing irrational beliefs, therapists and clients also work
together to target the emotional responses that accompany problematic thoughts.
Techniques that might be encouraged include:

 Meditation
 Journaling
 Guided imagery

What REBT Can Help With:

REBT has some data to support its benefit in a variety of conditions, including:

 Anxiety and distress

 Depression
 Disruptive behavior in children
 Obsessive-compulsive disorder (OCD)
 Social anxiety disorder
 Psychotic symptoms

REBT has also shown promise in sports psychology, where it can be used to help athletes
overcome irrational beliefs that may be negatively impacting their mental health and
performance.

Benefits of REBT

When developing REBT, Ellis’s goal was to create an action-oriented approach to

psychotherapy that produced results by helping people manage their emotions, cognitions,
and behaviors. Indeed, research suggests that REBT is effective at reducing irrational beliefs
and changing behavior.4

Overall, REBT offers several behavioral benefits, like:

 Reduced feelings of anger, anxiety, depression, and distress

  Improved health and quality of life
 Better school performance and social skills
 Effectiveness

REBT has a wide range of potential applications. Because it’s focused on education and
taking action, it may be effective for a variety of situations and mental health conditions. It
may even lead to lasting change in those who undergo this form of therapy.

CONCLUSION:

REBT can be a daunting process. For some, disputation may feel aggressive or
confrontational, and facing irrational thought patterns can be difficult, as it’s not easy to
accept these beliefs as unhealthy. The process of changing these thoughts can be even more
challenging, as it may involve learning to let go of long-held beliefs. REBT is meant to teach
life-long skills and, as such, it’s not a passive process. The sessions may involve reading
assignments and homework, and you’ll likely have to step out of your comfort zone to get
the benefits of this form of therapy.