The Structure of Cognitive Therapy Behavioural Techniques Cognitive Techniques and Homework

Cognitive therapy is made up of a range of therapeutic approaches (Figure 2.3).

The first class of therapeutic approaches focus on the client's behaviour. The rationale is that for some people behaviour monitoring, behavioural activation and behavioural change can lead to substantive gains. For example, people with more severe depression often become withdrawn and inactive, which can feed into and exacerbate depression. They withdraw and then label themselves as 'ineffectual', fuelling the depression. By focussing on this relationship and gradually increasing the person's sense of daily structure and participation in masterful and pleasurable activities the person can take the first steps in combating depression (Beck et al., 1979). Other behavioural strategies include scheduling pleasurable activities, breaking down large tasks (such as finding employment) into more manageable graded tasks (buying a newspaper with job advertisements, preparing a resume...), teaching relaxation skills, desensitising a person regarding feared situations, role playing and assertiveness training. Recent adaptations to cognitive therapy for depression suggest that the changes in behavioural contingencies may be particularly important in treating severe and recurrent depression (McCullough, 2000).

The second class of therapeutic approaches focus on the client's automatic thoughts and beliefs. Automatic thoughts intervene between situations and emotional reactions and have an automatic, repetitive and uncontrolled quality. Cognitive techniques are designed to increase clients' awareness of these thoughts, challenge them by evaluating their basis in reality, and providing more adaptive and realistic alternative thoughts. The Dysfunctional Thought Record is used as a primary tool for developing this skill (Table 2.3). In enabling clients to learn this skill, the therapist acts as a teacher, adapting his or her style depending on the client's response. Some clients find this process easy to learn and make significant gains very quickly, whereas for others it is more difficult.

In cognitive theory dysfunctional assumptions ('If I put my needs first, others will dislike me') and core beliefs (e.g. 'I am unlikeable') underlie automatic thoughts and are the next focus of cognitive interventions. Careful questioning about and exploration of the client's unrealistic and maladaptive beliefs is carried out to examine if beliefs are based in reality and to correct the distortions and maladaptive beliefs that perpetuate emotional distress. The joint exploration of the person's beliefs engenders a spirit of guided discovery, in which maladaptive constructions of reality are gradually uncovered. By discovering maladaptive meanings ascribed to experiences, life can take on a 'new meaning', more geared to reality and the person's satisfactions and goals in life. This process opens the relationship between the person's maladaptive beliefs, feelings and behaviour. For example, the man who believed 'I must always put others needs above mine' found that he often felt guilty and resentful. As a consequence he would try even harder to meet the needs of his co-workers, family and friends, to the point that he became exhausted, lost sight of his own goals and needs, and became depressed. A broad range of cognitive techniques has evolved to facilitate this cognitive work (J. Beck, 1995; Greenberger & Padesky, 1995). For example, core beliefs like 'I am unlikeable' can be evaluated and replaced with more adaptive core beliefs ('I am basically OK and likeable') through Socratic questioning, examining advantages and disadvantages of the old and new core beliefs, acting 'as if' the new core beliefs were true, using coping cards, developing metaphors, subjecting the beliefs to tests across the

Table Disfunctional Thoughts Record
Figure 2.3 The cognitive therapist's toolkit. Adapted from Stallard (2002). Reprinted with permission.

person's life history and reconstructing associated memories and images (see J. Beck, 1995).

For many clients, automatic images or picture, rather than thoughts, are powerfully associated with emotions and behaviours. Images are central to many anxiety disorders,

Table 2.3 Dysfunctional thought record. Beck et al (1979). Reprinted with permission

Daily record of thoughts and feelings

Week ending---

Daily record of thoughts and feelings

Week ending---

What were you doing or thinking about?

Emotion

What did you feel? How bad was it (0-1 00)?

Automatic thoughts

What exactly were your thoughts? How far did you believe each of them (0-100%) ?

Rational response

What are your rational answers to the automatic thoughts? How far do you believe each of your rational responses right not?

What was the outcome?

How do you feel (0-100)? What can you do now?

such as post-traumatic stress disorder (PTSD), social phobia and panic disorder. Images are handled in similar ways but instead of verbally evaluating and challenging images, more visual techniques are used (J. Beck, 1995).

The third range of approaches takes place between therapy sessions as homework assignments. Homework is an essential element of cognitive therapy, aimed at building understanding and coping skills throughout the week, increasing self-reliance and rehearsing adaptive cognitive and behavioural skills. Homework moves the discussions in session from abstract, subjective discussion of issues to real day-to-day experiences. The therapist acts as coach, guiding and debriefing the client from week to week. Homework assignments are designed collaboratively, are tailored to the individual, are set up as no-lose propositions and may range from the therapist suggesting a relevant book to the person agreeing to undertake a long procrastinated assignment (such as telephoning a friend to resolve an area of unspoken conflict), while monitoring the thoughts and images that come to mind in preparing for the assignment (for example, 'the friend will be angry towards me'). As therapy progresses, the client takes on more responsibility for setting and reviewing the homework. Several therapy process-outcome studies suggest that homework is perceived as helpful and contributes significantly to change in cognitive therapy (Burns & Nolen-Hoeksema, 1991; Burns & Spangler, 2000; Detweiler & Whisman, 1999).

We have described the practice of cognitive therapy by outlining the components that together distinguish it, by describing a typical cognitive therapy session, by detailing the main phases of therapy and briefly outlining some of the most common cognitive and behavioural techniques. A case example follows to illustrate cognitive therapy.

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