Aaron Beck developed a form of psychotherapy in the 1960s and 1970s that he originally named “cognitive therapy,” a term that is often used synonymously with “cognitive behavior therapy” (CBT) by much of our field. Beck devised a structured, short-term, present-oriented psychotherapy for depression (Beck, 1964). Since that time, he and others around the world have successfully adapted this therapy to a surprisingly diverse set of populations with a wide range of disorders and problems, in many settings and formats. These adaptations have changed the focus, techniques, and length of treatment, but the theoretical assumptions themselves have remained constant.

In all forms of CBT that are derived from Beck’s model, clinicians base treatment on a cognitive formulation: the maladaptive beliefs, behavioral strategies, and maintaining factors that characterize a specific disorder (Alford & Beck, 1997). You will also base treatment on your conceptualization, or understanding, of individual clients and their specific underlying beliefs and patterns of behavior. One of Abe’s underlying negative beliefs was “I’m a failure,” and he engaged in extensive behavioral avoidance so his (perceived) incompetence, or failure, wouldn’t be apparent. But his avoidance ironically strengthened his belief of failure.

As of right now, start noticing when

• your mood has changed or intensified in a negative direction,
• you are having bodily sensations associated with negative emotion (such as your heart beating fast when you become anxious), and/or
• you are engaging in unhelpful behavior or avoiding engaging in helpful behavior.

Ask yourself what emotion you are experiencing, as well as the cardinal question of cognitive therapy:

“What was just going through my mind?”

This is how you’ll teach yourself to identify your own automatic thoughts. Pay particular attention to automatic thoughts that get in the way of achieving your goals, especially the ones that interfere with reading this book and trying techniques with clients. You may recognize thoughts such as these:
“This is too hard.”
“I may not be able to master this.”
“This doesn’t feel comfortable to me.”
“What if I try it and it doesn’t help my client?”

Principle 12: CBT uses guided discovery and teaches clients to respond to their dysfunctional cognitions. In the context of discussing a problem or goal, you ask clients questions to help them identify their dysfunctional thinking (by asking what was going through their mind), evaluate the validity and utility of their thoughts (using a number of techniques), and devise a plan of action. With Abe, I use gentle Socratic questioning, which helps foster his sense that I am truly interested in collaborative empiricism, that is, helping him determine the accuracy and utility of his ideas through a careful review of the evidence. Note that we refrain from challenging cognitions (by stating or trying to convince clients that their thoughts or beliefs aren’t valid); rather, we help clients through cognitive restructuring, a process of assessing and responding to maladaptive thinking.

CBT is based on the cognitive model, which hypothesizes that people’s emotions, behaviors, and physiology are influenced by their perception of events (both external, such as failing a test, and internal, such as distressing physical symptoms).

Situation/event
↓
Automatic thoughts
↓
Reaction (emotional, behavioral, physiological)

It’s not a situation in and of itself that determines what people feel and do but rather how individuals construe a situation (Beck, 1964; Ellis, 1962). Imagine, for example, a situation in which several people are reading a basic text on CBT. They have quite different emotional and behavioral responses to the same situation, based on what is going through their minds as they read.

Right from the beginning, I obtain a sample of important automatic thoughts. Abe reports that he often thinks, “There’s so much I should be doing but I’m so tired. If I even try [to do things like cleaning up the apartment], I’ll just do a bad job” and “I feel so down. Nothing will make me feel better.” He also reports an image, a mental picture that had flashed through his mind. He saw himself, sometime in the indeterminate future, sitting in the dark, feeling utterly hopeless and helpless.

I also look for factors that maintain Abe’s depression. Avoidance is a major problem. He avoids cleaning up his apartment, doing errands, socializing with friends, looking for a new job, and asking others for help. Therefore, he lacks experiences that could have given him a sense of mastery, pleasure, or connection. His negative thinking leads to his being inactive and passive. His inactivity and passivity reinforce his sense of being helpless and out of control.

As he developed stronger symptoms of depression, he started avoiding additional tasks he thought he wouldn’t do well, for example, paying bills and doing yard work. He had many automatic thoughts across situations about the likelihood that he would fail. These thoughts led him to feel sad, anxious, and hopeless. He viewed his difficulties as due to an innate flaw and not as the result of encroaching depression. He developed a generalized sense of incompetence and helplessness and curtailed his activities further. His relationship with his wife became quite strained, and they started having significant conflict. He interpreted the conflict as meaning he was failing in the marriage, that he was incompetent as a husband.

Over the course of several months, Abe’s problems at work became even worse. Joseph became quite critical of Abe and downgraded him at his yearly performance review. Abe’s depression intensified significantly when his wife filed for divorce. He became preoccupied with thoughts of how he had let her and his children and his boss down. He felt like (that is, he had a belief that he was) an incompetent failure. He felt (believed he was) at the mercy of his sad and hopeless feelings (“I’m out of control”) and thought there was nothing he could do to feel better (“I’m helpless”). And then he lost his job.

Then use CBT techniques on yourself if any client comes to mind. Identify your cognitions about this client and do one or more of the following:

• Evaluate and respond to your cognitions about the client; create a coping card to read.
• Check on your expectations for your clients. Work on accepting them and their values as they are.
• Check on your expectations for yourself. Make sure they’re realistic.
• Specify your concern and conceptualize: What might the client do or say (or not do or not say) in session (or between sessions) that could be a problem? Which beliefs might underlie this behavior?
• Cultivate nondefensiveness and curiosity.
• Problem-solve by yourself or with a colleague/supervisor.
• Set appropriate limits with clients.
• Work on accepting your own emotional discomfort.
• Do good self-care throughout the day (e.g., deep breathing, taking a walk, calling a friend, doing a short mindfulness practice, eating in a healthy way).

CLIENT 2: These forms are a waste of time. Half the questions are irrelevant.
THERAPIST: What’s the worst part about filling them out?
CLIENT 2: I’m busy. I have a lot to do. If my life fills up with meaningless tasks, I’ll never get anything done.
THERAPIST: I can see you feel pretty irritated. How long does it take you to fill them out?
CLIENT 2: … I don’t know. A few minutes, I guess.
THERAPIST: I know some of the items don’t apply, but actually they save us time in our session because I don’t have to ask you lots of questions myself. Could we try to problem-solve and see where you could fit in the time to do them?
CLIENT 2: (Sighs.) I guess it’s not that big a deal. I’ll do them.

Here I avoid directly evaluating the accuracy of the client’s automatic thoughts because he is annoyed and I sense that he will perceive such questioning in a negative way. Instead, I provide a rationale and help the client realize that the task is not as time consuming as he has perceived it to be. In a third case, I judge that further persuasion to fill out forms will negatively affect our tenuous therapeutic alliance.

Abe, for example, has to stay home to fix an active leak under the sink, so he can’t attend his grandson’s soccer game. He thinks, “Ethan will be so disappointed.” His thinking then becomes more extreme: “I’m always letting him down.” He accepts these thoughts as true and feels quite sad. After learning tools of CBT, however, he’s able to use his negative emotion as a cue to identify, evaluate, and respond adaptively to his thoughts. In another situation, Abe was able to respond to a similar automatic thought in this way: “Wait a minute, her parents are going to be at there [at her dance recital]. She may be a little disappointed that I’m not. And it’s not true that I’m always letting her down. I’ve gone to lots of her performances.”

You seek to identify automatic thoughts that are dysfunctional—that is, those that

• distort reality,
• are associated with an unhelpful emotional and/or physiological reaction,
• lead to unhelpful behavior, and/or
• interfere with clients’ sense of well-being and ability to take steps to reach their goals.

Like Maria, some clients believe that negative emotions are unsafe: “If I get upset, _____,” for example, “it will get worse and worse until I can’t stand it, I’ll lose control, it will never go away, or I’ll end up in the hospital.” These kinds of beliefs can interfere with working to achieve their goals. Clients may avoid situations in which they predict they will become upset. They may avoid talking about or even thinking about distressing problems. When clients have dysfunctional cognitions about experiencing negative emotion, they may not make much progress in treatment. You can use standard cognitive restructuring techniques to help clients evaluate their beliefs. Doing a behavioral experiment using mindfulness (pp. 278–279) is especially effective. When clients successfully disengage from a thought process such as worry, you can guide them in changing their cognitions from “Worry is uncontrollable” to “I can choose to disengage in worry when I notice it has started.”