Cognitive Behavioural Therapy

🧠 1. Historical Foundations and Theoretical Models

Beck’s Cognitive Therapy

Aaron Beck developed Cognitive Therapy based on the idea that how we think affects how we feel and behave. He noticed that people with depression had negative automatic thoughts about themselves (“I’m a failure”), the world (“People are cruel”), and the future (“Nothing will ever change”) — this is known as the cognitive triad.

Ellis’s Rational Emotive Behaviour Therapy (REBT)

Albert Ellis proposed that it’s not the events in our lives that cause distress, but our beliefs about those events. His ABC model includes:

• A – Activating event (e.g. failing an exam)

• B – Beliefs (e.g. “I must succeed at everything”)

• C – Consequences (e.g. shame, anxiety)

The Five-Part CBT Model

This model helps explain how our:

• Situations trigger

• Thoughts, which influence

• Emotions, Physical sensations, and

• Behaviours

Example: A client avoids a job interview.

• Situation: Interview scheduled

• Thoughts: “I’ll embarrass myself.”

• Emotion: Anxiety

• Physical: Sweaty palms, racing heart

• Behaviour: Cancels interview

In the exam, you can use this model to break down a client’s issue in a case study and then explain how you would intervene at the thought or behavioural level.

Core Assumptions of CBT

CBT assumes that:

• People have automatic thoughts (quick, often unconscious thoughts) that affect feelings and actions.

• These thoughts are shaped by core beliefs (deep, central ideas about self, others, world) and intermediate beliefs (rules/assumptions like “I must always be liked”).

Cognitive distortions are typical thinking errors, like:

• All-or-nothing thinking: “If I fail once, I’m a total failure.”

• Catastrophizing: “If I have a panic attack, I’ll die.”

Understanding these helps you choose what to target in therapy.

Four Stages of CBT Therapy

1. Assessment and case formulation

2. Intervention and skill building (cognitive & behavioural)

3. Consolidation and relapse prevention

4. Termination/closure

In the exam, use these stages to structure how you’d approach therapy with a client across time (e.g., “In the early sessions, I would…”).

📝 2. Assessment and Case Formulation

Structured Assessment

This means collecting comprehensive info about:

• Presenting problem (e.g. “I can’t leave the house”)

• History (When did it start? How has it changed?)

• Precipitating factors (What triggered it?)

• Maintaining factors (What keeps it going?)

This is where you build trust, gather information, and start to understand the person’s experience.

SMART Goals

These are Specific, Measurable, Achievable, Relevant, Time-bound goals that help guide therapy.

Example:

In the exam, you might be asked to set a therapeutic goal. You can say:

Case Formulation Frameworks

The 5 Ps model is common in CBT:

🛠 3. Cognitive Techniques

These focus on helping clients become aware of and change unhelpful thoughts.

Automatic Thoughts

These are spontaneous, often unexamined thoughts like “I’m a loser” or “They’re laughing at me.” They can be accurate, exaggerated, or completely false. In therapy, you help clients identify and evaluate these thoughts.

Socratic Questioning

Rather than telling the client they’re wrong, you ask thoughtful questions that help them see things differently:

• “What’s the evidence for that thought?”

• “Is there another explanation?”

• “What would you say to a friend who thought that?”

This encourages clients to rethink their assumptions.

Beliefs Hierarchy

• Core beliefs: deeply held views (“I’m unworthy”)

• Intermediate beliefs: rules (“If I’m not successful, I’m a failure”)

• Automatic thoughts: surface-level reactions (“I’ll mess this up”)

In therapy, you often start by identifying automatic thoughts and then work down to the deeper beliefs.

Common Distortions

• Mental filter: focusing only on the negative

• Labeling: calling yourself names (“I’m an idiot”)

• Should statements: “I should always be perfect”

You teach clients to recognize these patterns and replace them with more balanced thoughts.

🧩 4. Behavioural Techniques

These work by changing actions to affect thoughts and emotions.

Behavioural Activation

Used for depression, where people withdraw from pleasurable activities. The idea is: mood improves when you increase meaningful engagement.

You might:

• Make an activity list with the client

• Use a rating scale for pleasure and mastery

• Schedule and review each week

Graded Exposure

Used for phobias, panic, and social anxiety. You:

• Build a hierarchy of feared situations (easy → hard)

• Gradually expose the client without safety behaviours (e.g. no phone use)

• Reduce avoidance over time

ERP (Exposure and Response Prevention)

Used in OCD. You:

• Expose the client to the obsession trigger (e.g. touching a bin)

• Prevent the compulsion (e.g. hand washing)

• Teach that anxiety goes down on its own (habituation)

Behavioural Experiments

Used to test beliefs. For social anxiety:

• Belief: “If I speak up, I’ll be laughed at.”

• Experiment: Speak in class and notice reactions

• Outcome: Usually disproves the belief

Homework and Self-Monitoring

Clients may:

• Fill in mood/activity diaries

• Track situations that trigger anxiety

• Practice thought records

In exams, you can say:

🧬 5. Integration and Cultural Adaptations

Adaptation for Populations

Older adults might need:

• Slower pacing

• Memory aids (handouts, summaries)

• Adjusted goals

Neurodiverse clients might benefit from:

• More visual materials

• Concrete, literal language

• Predictable session structure

Cultural & Contextual Adaptation

Cultural competence in CBT involves:

• Exploring the client’s cultural view of distress

• Avoiding assumptions (e.g., that all clients value independence)

• Using culturally relevant metaphors and examples

• Collaborating with family or community leaders if appropriate

In your exam, if the client is from a different cultural background, you might say:

📈 6. Evidence Base & Limitations

CBT is highly evidence-based for:

• Depression

• Anxiety disorders (GAD, panic, social anxiety)

• OCD

• PTSD

Criticisms include:

• Overly focused on symptoms, not underlying trauma

• Assumes clients can reflect and do homework (may not suit all)

• Less suitable for personality disorders or comorbid cases

In exams, balance praise with critique: