In this section you will learn to:
- Determine client suitability for cognitive behavioural therapy.
- Work with clients using a CBT approach.
- Explain the CBT approach and develop a case formulation.
- Document and monitor progress in CBT.
- Apply CBT to particular client issues.
Supplementary materials relevant to this section:
- Reading F – Cultural Considerations in Applying CBT
- Reading G – Who Benefits from CBT?
- Reading H – Monitoring and Evaluation in Low Intensity CBT Interventions
Now that you have some understanding of the key concepts and techniques of cognitive behavioural therapy, let’s take a closer look at some of the key considerations involved in applying CBT in counselling practice.
Before applying any specific counselling approach with a client, the counsellor must assess whether the approach is suitable for a client and the client’s issue. CBT has been a very popular type of counselling because it offers a relatively straightforward approach that has both face and empirical validity, as well as flexible and broad treatment modalities that encompass many useful interventions (Simmons & Griffiths, 2017). It emphasises goal setting, accountability, and results in a respectful and collaborative fashion and requires the client to take responsibility within the counselling relationship and learn skills and techniques that they will be able to apply themselves once the counselling relationship has come to an end.
CBT is considered to be a widely applicable approach that can be used with a wide range of clients and client issues, including: “anxiety, anxiety disorders (e.g., social phobia, obsessive-compulsive disorder or post-traumatic stress disorder), depression, low self-esteem, irrational fears, hypochondria, substance misuse, problem gambling, eating disorders, insomnia, marriage or relationship problems, and certain emotional or behavioural problems in children or teenagers” (Better Health Channel, 2022). CBT also has a potential to be adapted for use with clients from a wide range of cultural backgrounds.
Read
Reading F – Cultural Considerations in Applying CBT provides a brief practice article that outlines some key considerations when applying CBT to racial/ethnic minority groups.
Like all counselling approaches, CBT will not be suitable for all clients. To commit to participating in CBT, and for the counselling to be effective, the client must be able to locate their thoughts, be willing to explore their feelings, have the flexibility to modify their distortions, and be able to understand their interconnectedness in order to adjust their behaviours. Barriers to this may include limitations in the client’s ability to understand the concepts of CBT, the challenge of completing homework, the restrictive nature of their issue, or the distress that CBT strategies may cause. Before embarking on CBT with a client, a therapist may assess the following criteria (Simmons & Griffith, 2017):
- Client’s ability to access automatic thoughts about situations and events (with some prompting if required)
- Client’s awareness of different emotions and the differences between them.
- Whether client recognises their own responsibilities and prepared to put in work towards making changes to address difficulties.
- Whether client accepts the rationale that thoughts, feelings and behaviours are relevant, and one affects the others.
- Client’s ability to form positive relationships with the therapist and other people in general.
- Chronicity of client’s difficulties – long-standing problems is likely to require more sessions.
- The extent to which the client relies on ‘props’ such as alcohol as a short-term relief to their problems.
- Client’s ability to remain focused in session.
- General optimism about the potential of therapy.
Read
Reading G – Who Benefits from CBT? elaborates on the items listed as well as discusses referral criteria for CBT. This reading also provides questions that counsellors may consider asking to see if CBT is likely to be suitable and helpful for a client.
Clients who do not hold these characteristics may not be suitable for, or may not yet be ready to get the most out of, a CBT-style intervention. CBT also requires a strong commitment from the client to experiment, practise, and learn to apply the strategies long after counselling has concluded. In particular, CBT generally requires clients to participate in homework activities. This may not suit all clients. An alternative for some clients may be to combine aspects of CBT with techniques of another model. If the counsellor decides to do this, they need to take care to ensure that the techniques selected are complementary. Of course, there are a wide range of CBT techniques that can be used effectively within other counselling approaches. For example, the techniques of challenging thoughts/ ‘self-talk’, setting homework tasks, psychoeducation, and role-playing are widely used by counsellors from other theoretical orientations.
However, some organisations may not allow counsellors to use alternative counselling approaches or the counsellor themselves may not be skilled in the most appropriate approach for the client. In these cases, referral to another organisation/counsellor may be required. If a client does require referral, it is important for the counsellor to follow their organisation’s referral guidelines and ensure that the client understands that a referral is not a rejection (i.e., the counsellor should explain the reasons for the referral in an appropriate manner).
CBT 101 questions for clients
This video provides excellent insight on how to challenge and question a client to discover suitability and more.
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Check your understanding so far!
You have previously learned about the importance of contracting and ensuring that the client is aware of the counselling approach that will be used. Explaining the counselling approach is twice as important in CBT because an explanation of the underlying model actually forms the basis of the key technique of cognitive restructuring. Clients need to be made aware of the underlying premise and model, such as the connection between thoughts, feelings and behaviours, in order to identify problematic thoughts and take responsibility for making changes.
The following extract from Neenan and Dryden (2021, p. 291) provides a comprehensive overview of how a counsellor may go about explaining CBT to clients:
During the first session of CBT it is important for the therapist to orient her clients to the thought–feeling link; in other words, to teach the cognitive model. The therapist's clinical judgement can determine the best time or moment to introduce the model. For example, the client might attend the appointment in an anxious state and it may be productive for the therapist to elicit there and then her client's anxiety-provoking thinking: 'What thoughts are going through your mind right now to make you anxious about coming here?' The client might reply: 'I'm worried you're not going to be able to help me and I'll never get better.' The therapist can ask her client what thoughts would reduce his anxiety: 'I suppose if I thought you could help me and there was hope for me after all.'
During the session the client might fall silent, become tearful, react angrily to a question, or stare at the floor. Such moments can become opportunities for teaching the model by exploring the client's thinking with a 'What's going through your mind right now to make you tearful?' type question. Writing the thought–feeling link on a whiteboard or flipchart can help the client in two ways: to step back from his upsetting thoughts and feelings in order to examine them more objectively; and make the cognitive model more concrete, vivid and understandable. The above examples are meant to teach the model through the use of questions so that the client makes the thought–feeling connection himself rather than being told by the therapist.
However, the therapist can take a didactic stance in teaching the model if questioning is proving unproductive as some clients will want direct explanations. You feel the way you think (Burns, 1999) might be the starting point:
Let me explain what I mean by that statement with an example. Two men are very keen on the same woman. They ask her out and she rejects both of them. One man becomes depressed because he tells himself he’s not attractive to the women and never will be; the other man is disappointed with her ‘no’ but sees it as no big deal to be rejected and there are other women to ask out. So, it’s not the situation that makes each man feel the way that he does, but how each man interprets the situation that influences how he feels. This is the essence of the model: you feel the way you think.
The therapist can then show her client how the model can be used to understand his emotional reactions to life events, e.g. the client says he is anxious in social situations because he fears people will find him boring and avoid him. As Blackburn and Davidson (1995:56) point out:
The therapist would indicate how the interpretation was congruent with the feeling but not necessarily the only interpretation possible. Such examples from the patient's own experiences would lead the therapist to demonstrate how cognitive therapy is relevant for the individual and might help to overcome his dysphoric moods.
It’s important for the therapist to remember that the client might understand the model but not agree with it (the mistake is to assume understanding for agreement); therefore, any reservations about or objections to the model need to be elicited (e.g. 'The model doesn't make any sense if you're in a concentration camp or dying of a terminal illness, does it?') and addressed (see Point 1). The client does not need to have complete conviction in the model to benefit from it (therapists are not free of doubts about the approach they use). Teaching the cognitive model is not a 'one off' but is done frequently throughout the course of therapy, with the client taking increasing responsibility for making his thought—feelings links and demonstrating to himself that by changing his upsetting thinking he is able to ameliorate his unpleasant moods. For many clients, taking responsibility for their emotional reactions to events is a liberating rather than an unwelcome message because it shows them that they don’t have to rely on changing others or situations first before they can feel better which, if this was the case, would make personal change very much more difficult to achieve.
Cognitive Behavioural Therapy- Explanation of the Principles
This video demonstrates how to explain CBT to clients. Answer the questions that follow.
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In order to identify the most useful cognitive and behavioural strategies for a client, the counsellor should obtain a detailed formulation or assessment of the client’s issue. A case formulation provides an agreed framework in which both the counsellor and client can understand the presenting issue, using CBT theory and concepts:
The case formulation comprises a kind of mini-theory of the individual client and their problems. Within the formulation, the particular circumstances of the client’s life and problems are explained in terms of CBT theory and concepts… The collaborative stance of CBT is reinforced through a process in which the formulation is explained to the client, the response of the client is used to sharpen the formulation, and the client is provided with a written copy of the formulation that will serve as a guide for subsequent work. […] the formulation also opens up a space within therapy where the client can begin to learn about CBT concepts. This is a significant aspect of cognitive-behavioural work – ultimately, the aim is for the client to become their own therapist, and to become able to deal with future occurrences of problem areas by initiating CBT strategies on their own.
(McLeod, 2019, p. 127)
CBT Case Formulation--The Importance of Focus
In this video, Dr. Aaron Beck discusses how identifying patients' beliefs, behaviors, and points of focus is an integral part of cognitive behavioral case formulation. Dr. Beck then provides an example to illustrate how beliefs, behaviors, and points of focus are interrelated and can lead to the activation of core beliefs.
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According to Persons and Tompkins (2007, cited in McLeod, 2019, p. 127), a good formulation may include the following elements:
- A problem or symptom list itemising the client’s difficulties in terms of cognitive, behavioural, and emotional components.
- Explanatory accounts of both the current problem (what it is and how it is maintained) and the underlying personality predispositions or vulnerability that has created the conditions of the problem to emerge.
- Current precipitants – events or situations that are activating the client’s vulnerability at this time.
- Origins of the underlying vulnerability.
- Treatment plan.
- Obstacles to treatment and facilitators (e.g., sources of support, personal strengths).
In practical terms, developing a case formulation means identifying the interaction of the four components of the CBT model (i.e., thoughts, behaviour, emotions and physical) and how these maintain the client’s current difficulty. For example, a counsellor can identify behavioural components by undertaking a ‘functional analysis of behaviour’ and asking questions such as:
- “What did you do/say?”
- “Who was involved?”
- “How long did it go on for?”
- “How many times has it happened?”
- “Does it always happen the same way?”
Furthermore, by also exploring the thoughts and any physical consequences involved in the issue, counsellors can develop a comprehensive picture of the interaction of cognitive and behavioural components involved in the client’s difficulty. For example:
Thoughts
“What are you thinking about or dwelling on when this issue happens?”
“Please describe what kinds of thoughts or images go through your mind when this occurs.”
“What’s going through your mind when _________ occurs? Can you recall what you were thinking then?”
“Let’s set up a scene. You imagine that you’re starting to feel a bit upset with yourself. Now run through the scene and relate the images or pictures that come through your mind.”
Physical consequences
“What goes on inside of you when you do this when this happens?”
“What are you aware of when this occurs?”
“Notice any sensations you experience in your body when this happens.”
“When this happens, describe anything that feels bad or uncomfortable inside you – aches, pains, dizziness, and so on.”
(Adapted from Cormier et al., 2017, pp. 221-222)
It can be useful for the counsellor to chart these four components in collaboration with the client in a diagram, such as the following one:
Counsellors will use this case formulation as well as the client’s goals (goal setting is explored shortly) in order to select the most appropriate techniques and interventions to use with the client.
Check your understanding so far!
Case study clinical example CBT: a client with symptoms of depression (CBT model)
This role-play displays the counsellor working with the CBT model in a first session, after the intial contracting with the client. Answer the questions that follow.
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Once the counsellor has a good understanding of the client’s issue, the next step in the CBT process is to identify goals in collaboration with the client.
Goal setting is the process of collaboratively identifying specific therapeutic outcomes for treatment. Goals must be observable, measurable and achievable and relate to cognitive or behavioral changes relevant to the [client]’s presenting problem. Goals are tied to specific skills to be addressed in treatment. Goals increase the continuity of sessions; allow directed, focused treatment; and enable the [client] and [counsellor] to assess the progress of therapy and identify change in an objective manner.
(Cully et al., 2020, p. 57)
Goal setting is one of the first counselling activities to be completed in CBT. Although they can be changed at any point during counselling, a preliminary set of goals should be established and agreed upon by the end of the first session. This may not be the case for other counselling approaches – for instance, goal setting is not as necessary or emphasised in the person-centred approach to counselling which you have learned in the previous module. The goal-oriented feature of CBT supports the monitoring and evaluation of outcomes, which contributes to its ample empirical support.
The following extract has been included to help you better understand the different between SMART goals and ‘non-SMART’ goals:
Examples of SMART Goals:
- Whilst I am looking for a job, I would like to call 3 prospective employers each week and ask them about any vacancies. I would like to be able to do this within the next three weeks.
- I would like to meet a friend for a drink 2 times a week and spend 30 minutes talking with them. I would like to achieve this within the next 3 months.
- I would like to learn how to better control my worrying so that I do not always jump to negative conclusions. Instead of worrying about things all day, I would like to allocate 20 minutes a day to worry. Throughout the day I will write down all my worries then refocus and worry about them at the allocated time. I would like to achieve this by the end of the month.
Examples of goals which are NOT SMART goals:
- I would like to feel less anxious.
- I would like to stop avoiding things.
- I would like to do the things I used to do.
(Adapted from Hertfordshire Partnership University NHS Foundation Trust, 2016)
Check your understanding so far!
Counseling Treatment Planning - Goal and Objective Setting Related to Mild Depressive Symptoms
This video features a counseling role-play in which counseling treatment planning is demonstrated. The treatment planning includes setting a goal and the corresponding objectives related to mild depressive symptoms. After watching the video, answer the questions that follow.
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As with other forms of counselling, it is important that cognitive behavioural therapists keep records and document their work with clients. This includes appropriate contracting and writing case notes about each session that is conducted. Cognitive behavioural therapists should also specifically make notes about any homework assignments that have been agreed to in the session. This helps provide a memory aide for the counsellor to review the homework at the beginning of the next session and can also provide protection for the counsellor (e.g., this documents what was agreed to as proof in cases where a client may allege the counsellor recommended something illegal or immoral).
Keeping appropriate documentation can also help counsellors monitor client progress. Monitoring progress in important in CBT (just as it is important in all counselling). While CBT counsellors can use a range of ‘standard’ monitoring processes such as asking for client feedback and asking clients to complete feedback forms, the nature of CBT techniques and interventions often allow cognitive behavioural therapists to also monitor client progress via more objective measures as well.
For example, monitoring thoughts and behaviours is an important part of many CBT interventions. In cases in which the client has been instructed to keep a thought diary or to engage in experiments, the client or counsellor will usually need to record the occurrence/strength of negative thoughts or the client’s reported level of negative arousal. As counselling progresses over time, the counsellor and client can compare current records against old records in order to determine if the occurrence/strength of negative thoughts and arousal has reduced. If so, this provides evidence that the interventions being used are having the desired effect. Of course, if this monitoring were to show no change in symptom occurrence/strength then this would indicate that the counselling approach is not working as intended and the counsellor will need to consider what changes to make.
The CBT Mood Check
Weekly mood evaluation is key to assess the success of treatment. Talking about what went well, and what didn’t, can help you and your clients decide what needs to be adjusted so that they can feel better.
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Check your understanding so far!
Read
Reading H – Monitoring and Evaluation in Low Intensity CBT Interventions provides additional information on the process of monitoring and review in low intensity CBT. Low intensity CBT interventions are a type of CBT that is quite simple and brief; that is, they are shorter in length and use less intense intervention resources, with a focus on self-help materials.
CBT formulation in anorexia: Case study clinical example
This video demonstrates some of the triggers, thoughts, feelings and responses linked with anorexia. This section here represents a segment from a CBT therapy session, but in order to try and outline the vicious cycle, it moves faster than an average session might. The video features an actor playing the character of Jodie, but the dialogue is not scripted, and as such represents a natural therapeutic exchange.
After watching the video, answer the questions that follow.
Watch
Reading through the following case studies will help you better understand the processes and techniques of cognitive behavioural therapy. The first case study involves a counsellor using a CBT approach with a client who has stress issues. Stress is a very common issue that brings clients to counselling and CBT processes and techniques can be highly effective for assisting clients to better manage their stress.
Case Study 1 - Stress
Miranda has been referred by her doctor who feels her physical symptoms of fatigue, feelings of anxiety, headaches and irritability may be related to stress. In her initial counselling session, Miranda appears overwhelmed and tearful. She is working full-time in a stressful job, is a single mother to two children (aged 4 and 6), and her mother has recently been diagnosed with Alzheimer’s disease.
The counsellor agrees with the doctor’s assessment that Miranda could benefit from stress management training and determines that a cognitive behavioural approach would work effectively for Miranda.
After completing the standard contracting process, the counsellor begins the first CBT-style intervention by helping Miranda understand her stress in-line with the CBT model.
| Counsellor: | Stress is unavoidable and it can be helpful in short doses. It activates physical responses which result in increased alertness and responsiveness, which in turn, generally leads to enhanced performance. However, it becomes a problem when stressors are on-going or severe as the physical, emotional and psychological responses are unsustainable. |
The counsellor then goes on to explain more about the CBT model and the link between thoughts, emotions, behaviours, and physiology. The counsellor then works with Miranda to complete the diagram, so Miranda can develop an understanding of how her own cognitive, behavioural and physical components interact to increase her stress.
Case Study 1 – Stress (Cont’d)
This process helps Miranda understand that while the demands on her are very real, her ‘self-talk’ or the way she thinks about them may be making the situation worse.
The counsellor then considers a treatment plan in-line with the case conceptualisation and discusses this with Miranda. Essentially, the counsellor decides to use a combination of cognitive behavioural techniques:
- Help Miranda identify all of her stressors and determine which ones are in her control and may be tackled with a problem-solving process.
- Use cognitive strategies (e.g., the use of thought records to identify situations that are particularly stressful and the automatic thoughts that are triggered in these situations followed by a deeper exploration of core beliefs).
- Teach Miranda a number of behavioural strategies that she will be able to use (e.g., calming and relaxation techniques such as deep breathing techniques aimed at reducing the physical and behavioural symptoms of stress; the introduction of activities that Miranda enjoys to help reduce her levels of stress).
Another common issue that brings clients to counselling is self-esteem. The second case study explores how CBT can be used effectively in relation to this client issue:
Case Study 2 – Self-Esteem
Kevin, a 20-year-old unemployed male, attends counselling with persistent low mood and lack of motivation. It soon becomes clear that Kevin has very low self-esteem, possibly stemming from abuse and neglect experienced in his childhood. The counsellor explains to Kevin how these early life experiences have resulted in Kevin developing negative core beliefs leading to him avoid trying new things or socialising creating a vicious cycle of avoidance and low mood.
The counsellor explains: “When we strongly believe these negative core beliefs about ourselves, it is not surprising that we feel very bad about ourselves and experience strong negative emotions. To protect ourselves and ensure we keep on functioning, we begin to develop rules and assumptions for how we live our lives. They aim to guard and defend us from the truth of our negative core beliefs. For example, the person who thinks they are “worthless” may develop rules such as “I must please other people” or “I must not express my needs” and assumptions like “Only if I do things perfectly will people like me.””
The counsellor decides to use cognitive restructuring to help Kevin start to challenge his automatic thoughts, assumptions, and, ultimately, core beliefs. The counsellor begins this process in-session but to help continue to facilitate this process out-of-session, the counsellor asks Kevin to use the thought record shown below (Centre for Clinical Interventions, 2005a, p. 8).
| Identify my negative self-evaluations | |
|---|---|
| What is the at-risk situation? | How much do I believe these evaluations? (0 -100%) |
| What am I saying to myself? How am I evaluating myself? Putting myself down? Criticising myself? | What emotion(s) am I feeling? (Rate the intensity 0-100%) |
| What unhelpful behaviours did I engage in? | |
| Challenge my negative self-evaluations | |
| What is the evidence for my evaluations? | What is the evidence against my evaluations? |
| Are these opinions I have of myself or facts? | |
| How helpful is it for me to evaluate myself in this way? | |
| How else could I view the situation? What other perspectives are there? | |
| What advice would I give to a friend in the same situation? | |
| What would be more a more helpful behaviour I could carry out? | |
| Balanced self-evaluations | |
| A more balanced evaluation of myself is? | |
| How much do I believe my original negative self-evaluation now (0-100%)? | How intense are my emotions now (0-100%)? |
Case Study 2 – Self-Esteem (Cont’d)
The counsellor also decides that Kevin would benefit from behavioural activation techniques. The counsellor helps Kevin identify more helpful behaviours such as pleasant activities that help him develop confidence and a sense of achievement. For example, Kevin is a very good gamer. He and the counsellor decide that he will create his own YouTube channel to record and share his skills and knowledge with other players.
The counsellor noted that Kevin was particularly interested when the cognitive behavioural model was explained, so the counsellor also decided that Kevin would benefit from additional psychoeducation on it. As such, the counsellor provided Kevin with the handout adapted from Centre for Clinical Interventions, 2005b, p. 3) to help Kevin better understand the CBT process and start him on the road to employing CBT techniques on his own.
- At risk situations
- Situations where unhelpful rules and assumptions are tested. For example, trying a new activity
- Activation of old negative core beliefs
- Cognitive restructuring
- Use thought records to develop realistic expectations to self and situation
- Develop more balanced self-evaluation using thought records
- Behavioural activation
- Engage in helpful behaviours
- Approach challenges with an open mind
- Stop avoidance, escaping and safety behaviours
- Treat yourself well
- Engage in life
- No withdrawal, isolation or self-neglect
- Behavioural experiments
- Adjust negative core beliefs by looking at the evidence, developing new more balance core beliefs, and then behaving in ways that support this new core belief.
- Adjust and helpful rules and assumptions by questioning their helpfulness, looking at the pros and cons of these rules, and devising do you have full rules and assumptions, and putting them into practice.
- Cognitive restructuring
- Possible consequences
- Opportunities for new experiences and new learning
- The possibility of adjustments or more flexibility in your rules, assumptions and core beliefs
- Threshold for at-risk situations may increase
- Improved self-esteem
Case study clinical example: First session with a client with symptoms of borderline personality disorder (CBT model)
This role-play demonstrates some of the triggers, thoughts, feelings and responses linked with problematic low mood. This section here represents the first 13 minutes of an initial therapy session, but in order to try and outline the vicious cycle, it moves faster than an average session might. The video features an actor playing the character of Gabriella, but the dialogue is not scripted, and as such represents a natural therapeutic exchange. Answer the questions that follow.
Watch
In this section of the module you have learned about how cognitive behavioural therapy concepts and techniques can be applied in counselling practice. However, it is important to remember that cognitive behavioural therapy is a specialist approach. Students who have developed an interest in CBT are encouraged to seek out further training and skill development to broaden their understanding and enhance their practice capabilities.
- Better Health Channel. (2022). Cognitive behaviour therapy (CBT). https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/cognitive-behaviour-therapy
- Centre for Clinical Interventions. (2005a, updated 2019). Module 5: Negative self-evaluations. Improving self-esteem. https://www.cci.health.wa.gov.au/~/media/CCI/Consumer-Modules/Improving-Self-Esteem/Improving-Self-Esteem---09---Healthy-Self-Esteem.pdf
- Centre for Clinical Interventions. (2005b, updated 2019). Module 9: Healthy self-esteem. Improving self-esteem. https://www.cci.health.wa.gov.au/~/media/CCI/Consumer-Modules/Improving-Self-Esteem/Improving-Self-Esteem---09---Healthy-Self-Esteem.pdf
- Cormier, S., Nurius, P. S., & Osborn, C. J. (2017). Interviewing and change strategies for helpers (8th ed.). Cengage Learning.
- Cully, J. A., Dawson, D. B., Hamer, J., & Tharp, A. L. (2020). A provider’s guide to brief cognitive behavioral therapy. Department of Veterans Affairs South Central MIRECC. https://www.mirecc.va.gov/visn16/docs/therapists_guide_to_brief_cbtmanual.pdf
- Hertfordshire Partnership University NHS Foundation Trust. (2016). Cognitive behavioural therapy (CBT) skills training workbook. https://www.hpft.nhs.uk/media/1655/wellbeing-team-cbt-workshop-booklet-2016.pdf
- Kazantzis, N. (2021). Introduction to the special issue on homework in cognitive behavioral therapy: New clinical psychological science. Cognitive Therapy and Research, 45, 205-208. https://doi.org/ 10.1007/s10608-021-10213-9
- McLeod, J. (2019). An introduction to counselling and psychotherapy: Theory, research and practice. (6th ed.). McGraw Hill.
- Neenan, M. & Dryden, W. (2021). Cognitive behaviour therapy: 100 key points and techniques (3rd ed.). Routledge.
- Simmons, J., & Griffiths, R. (2017). CBT for beginners (3rd ed.). Sage.
