Cognitive Behavioural

Therapy

Lesson 10

Mindfulness CBT
The CBT therapist and the CBT clinic
Case Study
Conclusion
Reading List
Useful Addresses and contacts

Mindfulness CBT

CBT has been constantly developing by incorporating various aspects of other

therapeutic traditions that have been shown to be effective in helping
individuals reduce or manage their symptoms.

One of the latest developments in CBT is mindfulness-based cognitive therapy

which combines a form of meditation with elements of cognitive therapy.

Clinical research indicates that MBCT is effective in enabling people who have
experienced depression repeatedly, to stay well (Teasdale 2000).

Mindfulness CBT is partially based upon Eastern Buddhist meditation which

has been in existence for many centuries.

Recent studies on CBT with mindfulness (Hayes, Follette and Linehan,

Mindfulness and Acceptance Guilford, 2004) have shown marked effectiveness
for a wide range of clinical psychological problems and these include anxiety,
depression, stress management, OCD, social anxiety and personality disorders.

What is Mindfulness?

Mindfulness is a process of observing thoughts, images and feelings in an

accepting way without

Engaging with them

Or
Stepping back to interpret them in the normal way

NEETA TRAINING & CONSULTANCY SERVICES WWW.NEETATCS.COM

The various processes used within CBT will allow the individual to step back
into an impartial observer position which allows them to test their concept or
perception of their current reality or situation.

Or using distraction techniques to try to suppress and escape from them.

How does it work?

When a client comes for CBT their natural behaviour is to analyse and interpret
their negative thoughts.
Their aim is to find a solution to issues and distorted thought patterns in a more
empowering and balanced way. As in the same way they would look for a
practical solution to the average problems faced in every day life e.g.
employment, physical health, financial and social external conditions in their
environment around them.

The normal thinking process reacts to a negative thought, image or feeling

which presents itself to the mind, by engaging with that thought.

In CBT the term ‘Magnification’ is used to term an error in logic which means
that as one thought comes into the mind the client associates and chains it with
another thought until it gets bigger and bigger.

E.g. If the client thinks that they are going to fail a test of interview, or will
themselves look stupid whilst performing, or be rejected by someone they ask
out on a date, their thought process will act like a computer in a negative
feedback loop and give the client all of the similar situations in their life when
similar things have happened.
This causes the original thought process to grow out of all proportion and then
becomes all encompassing and a self-fulfilling prophecy.

Mindfulness CBT works as a different way of dealing with a thought process or

issue. Therefore instead of engaging with negative thoughts, images and
emotions or attempting to remove themselves from them, the Mindfulness
option actually allows the client to be there and to accept them but then to
ignore them.

The mind works by the fact that if the client can accept the negative images and
feelings and allow them to be there without becoming too focused upon them
then the mind will then move on to the next thing.
The CBT therapist and the CBT clinic

So what actually happens at a consultation?

Firstly, within the CBT process an initial assessment appointment is offered in

order to identify:

If CBT is likely to be of any help to the client

The factors maintaining the presenting issue

Specific treatment goals

A treatment plan

The amount of sessions likely to be required to treat the problem

In CBT the therapist and the client work together to modify the patterns of
thinking and behaviour, which are maintaining the problem.

The client will agree to play an active and participatory role in therapy and will
systematically practice the skills learned during the therapy sessions.

The client will agree upon sessions taking place on a weekly basis and last for
50 minutes to 1 hour for a specific period of time.

What will happen during a treatment session?

The success of CBT depends on the client’s active participation in the whole

At the early treatment sessions, the client and the therapist will work together to
identify patterns of thought and behaviour which are causing the presenting
issues.

CBT differs from other therapies because sessions have a structure, rather than
the person talking freely about whatever comes to mind.

At the beginning of the therapy, the client meets the therapist to describe
specific problems and to set goals they want to work towards.
They will also allow time for discussing the conclusions from the previous
session. And they will look at the progress made with the homework or
assignment that the therapist or the client set at the previous session.

As a way of determining how the client has been feeling over the last
week, compared to other weeks, at the beginning of each session the client
will be asked to rate their mood, normally on a numerical sliding scale.

The therapist will ask them about their previous week and together, based on
what has happened in the preceding 7 days, they will draw up an agenda for the
session. In this will feature any significant difficulties or issues that the client
would like to discuss as well as looking at ways that the client has changed or
reflected on their thought processes or behaviours following their previous
session.

As the client and therapist follow the agenda they will be able to incorporate a
combination of problem-solving techniques that enable the client to distance
themselves from the problematic situation in order to assess the accuracy of
their thoughts and beliefs.

The client will also learn new skills and think about ways to implement these
into their coming week, especially focusing upon any challenging situations or
triggers they are aware of in the following week.

The client and therapist will then plan a structured way forward with
agreed practical objectives for future work within the sessions.

This ongoing information helps decide upon and plan future sessions, including
the treatment aims and tasks.

Further sessions involve discussing agreed topics in a practical way, focusing on

the difficulties that the client is currently tackling and looking at new and
different ways how to solve them.

CBT focuses upon a more equal relationship that is more business-like, being
problem-focused and practical.
The therapist will frequently ask the client for feedback and for their views
about what is going on in therapy.
Beck actually used the term 'collaborative empiricism', which emphasises the
importance of client and therapist working together to test out how the ideas
behind CBT might apply to the client's individual situation and problems.

The therapist takes an ongoing and active role in structuring the sessions to
begin with but as therapeutic progress is made the client will take more
and more responsibility for the content of sessions.

By the end of the sessions the client will feel empowered enough to continue
working independently.

At the end of the session, they will plan another assignment to do outside
the sessions.

A key part of all CBT treatment is the homework and assignments the therapist
will give to the client or be decided upon by the client and these frequently may
include reading material, research, written assignments, keeping a journal or
workbook or specific practical or goal orientated tasks.

For example, at the start of the therapy, the therapist might ask the client to keep
a diary of any incidents that provoke feelings of anxiety or depression, so that
they can examine thoughts surrounding the incident. Then as the therapy
progresses, another assignment may consist of exercises to cope with problem
situations of a particular kind relating to the client’s anxiety levels or depression
triggers.

The assignments give the client the opportunity to test out and practice
techniques they have learned during the sessions, or to expose themselves
gradually to situations that they have concerns about.

Common CBT techniques that may be experienced during standard treatment

include challenging irrational beliefs, replacing them with alternative ones,
stopping unhelpful thoughts, gradual exposure to situations, assertiveness,
relaxation, guided imagery, visualisation and social skills training.

How many sessions will be required?

CBT is a short-term treatment which typically lasts for 10 to 15 individual,

weekly sessions but this is dependant upon the individual client need.
The number of sessions will depend on the type of presenting issue and the
client’s overall commitment and drive to succeed.
CBT sessions typically last between 50 and 60 minutes, dependant on the
therapist and follow a specific structure that helps ensure that session time is
used to maximum efficacy throughout.

Group sessions

CBT is usually a one-to-one therapy.

But so saying, it can also suit working in groups, organisations or families,

especially at the beginning of therapy.

Many people find much benefit from sharing their difficulties with others who
may have similar problems, even though this may seem concerning or
challenging at first.

The group can also be a source of especially valuable support and advice,
because it comes from people with personal experience of a problem.

Also, by treating several people at once, service-providers can offer help to

more people at the same time, so people get help sooner and waiting lists are
reduced.

What type of clients would most benefit from CBT?

Clients who have specific presenting issues are often the most suitable for CBT
work because it works through having a specific focus and goals.

It tends to be far less suitable for someone who feels vaguely unhappy or
unfulfilled, but who does not present with specific recognisable symptoms, a
presenting issue or a highlighted part of their life they want to work on and
improve.

It is also more helpful for a client who can relate and understand the CBT
process with its problem-solving approach and the need for practical self
regulated self-assignments.

Individuals often seem to prefer CBT if they want a more practical treatment
where gaining insight is not the major focus of the treatment criteria.
CBT can be an effective therapy for a number of problems as we have
previously discussed but CBT does not claim to be able to alleviate all issues.

E.g. It is unable to cure chronic pain or disorders such as chronic fatigue

syndrome but it may be able to help people with arthritis or chronic fatigue
syndrome by finding new ways of coping while living with the disorders by
focusing on their level of pain differently and in a more balanced way.

There is an emerging interest in using CBT alongside medication with people

who suffer from hallucinations and delusions and also for those with long-term
problems in relating to others and sociopathic issues but this is currently in the
early stages of research and trial treatment.

One fact is also clear, though. CBT is rapidly developing and growing in its
uses and success levels.

All the time, new ideas are being researched to deal with the more difficult
aspects of individual’s presenting issues.

It is now possible to get CBT on the NHS in some parts of the UK, and the NHS
Mental Health Service is developing CBT clinics and practitioners currently.

Some counsellors and psychologists offer CBT under the NHS and also some
nurses, doctors, occupational therapists and clinical psychologists working in
community mental health teams can also provide CBT in specific
circumstances.

However, waiting lists tend to be long and there are not many private
practitioners currently, although many private hospitals employ CBT therapists.

There is currently no legal requirement for therapists to register and be

approved, but the British Association of Behavioural and Cognitive Therapy has
a register of its members and advises that any practitioner who has undergone
appropriate training and qualification to join a relevant organisation or
governing body.

Therapists registered with the British Association of Behavioural and Cognitive

Therapy has to present detailed information on their training and experience,
supported by a qualified practitioner.
They have to agree to conditions of ethical practice, to include supervision and
continuing professional education (CPD).
Case Study

Beth is a 44-year-old gay woman who had suffered frequent bouts of

depression, throughout several periods in her life. This has caused her to make
several career changes as she never felt happy or accepted within the workplace
because of her sexuality and personality.

She tried to commit suicide on several occasions and she also had suffered from
a great deal of anxiety and stress, had some alcohol and drug problems and
found it difficult to control her anger and rage especially when drinking and
using substances.

Beth was referred for CBT after a typical episode was triggered by anger and
underlying stress at work.

At her first meeting with her therapist, Beth already knew what she wanted to
focus upon and deal with.

She felt a great sense of frustration and failure over her history of depression
and anger and what she felt was her lack of career success.

She was also very worried about her career prospects generally because of her
history of not staying with any one employer for any length of time and her very
long and varied CV.

She also felt ugly and undesirable and was worried about ageing and about
further losing her sexual appeal to other woman and her partner leaving her for
someone younger.

She was also very worried that her anger and anxiety impulses were in danger
of getting out of control and that she was beginning to feel that she could not
trust herself in many situations.

In CBT therapy, Beth learned to monitor her actions and her emotional
responses to situations and thoughts.

Beth began to plan activities that gave her confidence a lift and to deal with
situations that she had previously avoided through worry.
She began to learn to identify when she was being unfair or irrational in her
thinking or behaviours and she became focused on examining her emotion-
driven thoughts and reasoning them out in order that she was able to place
situations and thoughts into a proper perspective.

She noticed that her mood improved and she began to look at dealing with more
intense presenting issues that she had.

After this, she began looking at her career prospects and began by planning a
more realistic choice of career and from this started to send in applications to
more appropriate and relevant employment establishments.

She then looked to establishing a more loving and equal relationship with her
partner, one based more on positive communication and supporting her partner
as opposed to the previous drunken and drugged fuelled relationship that she
had been operating under.

She worked really hard on her issues around certain social situations, without
demanding attention and special treatment from friends and becoming stressed,
argumentative and raging at everyone.

As the therapy continued, Beth had to face up to problems that were difficult to
admit to e.g. her need for perfectionism and the unreasonable demands she had
always made on other people throughout her life.

No matter how difficult it was for Beth, she was always highly motivated by
the unpleasantness of her current life to find alternative ways of living and
thinking that would make her life firstly more bearable and then gradually
more enjoyable.

Beth continued to work hard, always kept her focus and completed her
assignments religiously and applied herself constantly to bring about the
changes she so needed to improve her life.

By the end of the sessions a year ago she had an interview for a position in an
employment field she had always been interested in but had only ever seen as a
hobby.

She embarked upon a substance user’s course and counselling project and
undertook some couples counselling with her partner.
Today, Beth is alcohol and drug free and has been so for a period of time. She
is now a recognised article writer for several publications and recently was
married to her partner in a civil ceremony but still using the strategies she
learnt within the sessions to ensure her life continues to remain on track and
always improving.

Conclusion

CBT is quite complex. There are several possible theories about how it works,
and clients often have their own views and as we have seen there is no one
explanation.

CBT works in a number of ways at the same time, some ways are shared with
other therapies but then some are specific to CBT.

Through the connection of meaning and insight and understanding of core

beliefs and how they affect the individual, it is possible for powerful and
positive changes in the way individuals see themselves, their environment, and
the future to be made and successfully.

Not only does CBT focus upon current presenting issues but CBT facilitates the
development of new skills, and teaches a way of focused current and future
problem solving. In this way, clients can become, in effect, their own therapist
with a variety of proven and understood strategies that will allow them to better
cope with future problems as they arise. They are no longer completely
dependant on Mental Health Services and therapist input as before to make the
changes they need to live happy, successful and empowered lives.
 Further Reading

Change Your Thinking: Overcome Stress, Combat Anxiety and Improve Your
Life with CBT
by Sarah Edelman
ISBN-10:
0091906954

Mind Over Mood: Change How You Feel By Changing the Way You Think
by Christine A Padesky, Dennis Greenberger
ISBN-10: 0898621283

Cognitive Therapy: Basics and Beyond

by Aaron T. Beck, Judith S. Beck
ISBN-10: 0898628474

An Introduction to Cognitive Behaviour Therapy: Skills and Applications

by David Westbrook, Helen Kennerley, Joan Kirk
ISBN-10: 141290840X

Cognitive Therapy of Anxiety Disorders: A Practical Guide

by Adrian, Dr. Wells
ISBN-10: 047196476X

Cognitive Therapy of Depression

by Aaron T. Beck, A. John Rush, Brian F. Shaw, Gary Emery
ISBN-10: 0898629195

Case Formulation in Cognitive Behaviour Therapy

by Nicholas Tarrier
ISBN-10: 1583918418

Learning Cognitive-Behavioural Therapy: An Illustrated Guide (Core

Competencies in Psychotherapy)
by Jesse H. Wright, Monica Ramirez Basco , Michael E. Thase
ISBN-10: 1585621536
 Useful Addresses and Contacts

Useful Organisations

Association for Cognitive Analytic Therapy

tel. 0844 800 9496
web: www.acat.me.uk

Association for Rational Emotive Behaviour Therapy

tel. 01376 572 777
web: www.rebt.bizland.com

British Association for Behavioural and Cognitive Psychotherapies

(BABCP)
tel. 0161 797 4484
web: www.babcp.com

British Association for Counselling and Psychotherapy (BACP)

tel. 0870 443 5252
web: www.bacp.co.uk

The British Psychological Society

tel. 0116 254 9568
web: www.bps.org.uk

Depression Alliance
tel. 0845 123 2320
web: www.depressionalliance.org

National Phobic Society

helpline: 0870 122 2325
web: www.phobics-society.org.uk

OCD Action
tel. 0845 390 6232
web: www.ocdaction.org.uk

Oxford Cognitive Therapy Centre

tel. 01865 223 986
web: www.octc.co.uk
Triumph over Phobia (TOPUK)
tel. 0845 600 9601
web: www.triumphoverphobia.com

United Kingdom Council for Psychotherapy (UKCP)

tel. 020 7014 9955
web: www.psychotherapy.org.uk

Useful Websites

www.abct.org
Association for Behavioural and Cognitive Therapies

www.beckinstitute.org
The Beck Institute for cognitive therapy and research

www.calipso.co.uk
Calipso produces mental health training materials for healthcare professionals,
and self-help materials, including CDs

www.cognitivetherapyassociation.org
The International Association for Cognitive Psychotherapy

www.eabct.com
European Association for Behaviour and Cognitive Therapies

www.nice.org.uk
National Institute for Health and Clinical Excellence, provides reports and
guidelines on various mental disorders and treatments.

© Sue Etherden 2008

The right of Sue Etherden to be identified as the author of this work has
been asserted by her in accordance with the Copyright, Designs and
Patents Act 1988.
 QUESTIONS ON LESSON TEN

Q1. What is your understanding of MBCT?

Q2. An initial CBT assessment appointment is offered in order to identify

what?

Q3. What term did Beck use to emphasise the importance of client and
therapist working together to test out how the ideas behind CBT
might apply to the client's individual situation and problems?

Q4. How many sessions will be required?

Q5. Give 2 examples of problems that CBT cannot cure?

Q6. How can CBT group work be useful?

Q7. Within the NHS, who is currently offering CBT?

Q8. What type of client would most benefit from CBT?

Q9. Briefly, how does CBT vary from other therapies?

Q10. How will the therapist check how the client’s preceding week has
been?
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