Reading E

Having looked at the core principles of CBT, let us review some of the key therapeutic strategies, beginning with four fundamental ideas that provide an over-arching framework for most CBT: structure, collaboration, use of the Socratic method and the importance of homework.

Session Structure

“Standard” CBT has a clear structure to its sessions. A typical session might look like this:

1. Agenda-setting: both you and your client suggest topics for discussion in the session, and jointly agree on prioritizing topics if there are too many to cover them all. You only depart substantially from the agenda if both of you agree that is appropriate.
2. A (usually brief) review of the client’s week; of the last session (what was useful, what was learned etc.); and of homework (how did it go, what was learned, problem-solving any difficulties etc.).
3. Covering the main topics for the day, which might be any of a wide range of areas: a difficult event in the client’s life, a therapeutic strategy you want to introduce, a difficulty that arose during homework, developing the formulation, for example.
4. Collaboratively deciding what might be useful homework to take forward or further develop themes from the current session.
5. Asking your client for feedback on the session: what was helpful, what was not, was there anything difficult or upsetting, and so on.

This structure helps to keep sessions focused on what is most important to your client, and also open up channels to communicate about the general process of therapy, which may help to prevent it getting blown off course by misunderstanding or other relationship problems. There is some empirical support for the importance of session structure, for example, part of the famous Treatment of Depression Collaborative Research Program (which compared CBT for depression to interpersonal therapy and medication) assessed CBT therapists using the Cognitive Therapy Scale to see whether therapist competence predicted outcomes (Shaw et al., 1999). They found that the strongest association with outcome came from the “therapy structure” items (agenda setting, pacing of the session and the use of homework).

Collaborative Approach

One of the most important characteristics of CBT is the attention paid to developing and maintaining a collaborative therapeutic relationship between you and your client. (See Chapter 3 of this book for more substantial discussion of some of the issues involved in maintaining a good therapeutic relationship.)

CBT is not something you do to your client, and it does not see you as the all-wise guru who will enlighten clients about how to solve all their problems – still less tell them the meaning of life! CBT sees therapy as involving two people who are as far as possible equal partners, each with their own area of expertise. The client is the world authority on his or her own experience of the target problems, while you hopefully bring some expertise on how to understand and reduce such problems. There are always two heads in the room and we want to make use of both of them.

Of course, it would be naïve to imagine that the relationship can always be completely equal. At a very basic level, only one of the people in the room is getting paid to do this; and clients will often attribute a degree of authority to the therapist no matter how hard you strive to be collaborative. But this just means you need to try harder to encourage clients’ active participation, to take seriously their ideas and to respect their independence.

In general, we see the client as the ultimate authority. For example, if there is a difference of opinion about some aspect of the formulation, or about how to apply a therapeutic strategy, in most cases you will work with the client’s view – while retaining the option to revisit the question if it does not seem to be working out well. CBT’s empirical approach can be useful here, because you can test out such differences of opinion using behavioural experiments (see below): “Rather than have a lengthy debate, let’s try it out and see what happens …”.

A corollary of this collaborative approach is that CBT therapists tend to have an open attitude to sharing goals, hypotheses, and information about problems and therapeutic strategies. Our ultimate aim is to make ourselves redundant by helping clients to become their own therapists.

Socratic Method

Socratic method has been described as “the cornerstone of cognitive therapy” by Padesky in a pivotal conference speech on this approach (Padesky, 1993). Socratic method refers to therapists’ use of questions to help clients broaden their perspective and consider a wider range of alternatives to their original view of an event or situation. Instead of simply offering the client a different thought – or even worse, telling the client how to think – the CBT therapist usually tries to ask questions that will help clients to find their own alternatives. Common kinds of question involve helping clients shift their view in time (e.g., “Imagine that in a year’s time, I’m looking back at this situation – what advice would I be giving myself?”); in person (e.g., “What would I say to a friend who was in the same situation?”); or in emotion (e.g., “How would I see this if I was not depressed?”)

Again, we have to confess to an embarrassing lack of empirical evidence for the central role of the Socratic method in CBT. That role is based on informed opinion rather than any substantial research (and as always, such opinion might turn out to be wrong once we have more evidence). Nevertheless there are some plausible reasons for using Socratic method despite it being based on common sense or clinical intuition rather than solid evidence. These reasons include:

• Socratic method helps get clients actively involved in thinking about their problems and therefore promotes collaboration.
• It helps clients start to consider their thoughts as “just thoughts”, rather than necessary truths.
• It helps to avoid imposing therapist views on clients: we can make sure we explore and work with their thoughts, rather than assuming our own thoughts are relevant or useful.
• By working through their own thinking, clients are more likely to find new perspectives that make sense to them, and are also more likely to “own” those alternatives.
• It assists the goal of clients becoming their own therapists: instead of just giving them “answers”, Socratic method helps them learn how to find their own answers.

It is also clear that there are risks in Socratic questioning, especially if it is not done skillfully. Clients may feel interrogated, or as if they are being “caught out” by a clever cross-examination, or simply that they are being led around a very circuitous path towards what the therapist wants them to say. At its most obvious, Padesky (1993) pointed out that there is no point in asking anyone a Socratic question if they lack the information to answer. (I probably would not get far with most readers if I asked you Socratic questions about, say, quantum mechanics!)

Given these risks, as well as the lack of research evidence about its benefits, we need to be clear that Socratic method is not a fetish and there are no grounds for saying it is universally applicable. Sometimes a blind insistence on doing everything Socratically may just make therapy much more long-winded than it needs to be. There will be times when you need to give your clients information in a more straightforwardly didactic way, or give them direct advice about how to proceed in a therapeutic task. For example, you know – but many clients do not – that exposure needs to be reasonably prolonged to be effective. There is unlikely to be any great benefit in trying to arrive at that conclusion Socratically.

Use of Homework

Homework (clients’ doing tasks related to therapy in the time between therapy sessions) is generally considered another core feature of CBT (although of course other forms of therapy may also use homework tasks). Homework can consist of many different kinds of activity, such as:

• therapeutic reading (e.g., self-help or educational materials);
• self-monitoring (e.g., diaries, thought records or activity schedules);
• practising a therapeutic strategy (e.g., verbal testing of thoughts, or increasing rewarding activity); and
• carrying out behavioural experiments

In contrast to the above discussion about the relatively sparse empirical support for the use of formulations or Socratic method, there is reasonably good evidence that doing homework is indeed associated with improved outcomes in CBT. In a recently updated meta-analysis based on 46 original studies, Kazantzis, Whittington, and Dattilio (2010) concluded that homework has a significant positive effect on the outcome of CBT (d = 0.48 in the subgroup of controlled studies).

Perhaps the central goal of CBT is to help clients reconsider and re-evaluate the negative cognitions associated with their negative mood states. As the name of CBT suggests, there are two main ways we try to do that: cognitively (helping our clients through discussion and reasoning), and behaviourally (helping our clients through changing what they do in action in the world).

Verbal Testing of Thoughts

Looking for Evidence

The first main method for testing thoughts is to help clients think systematically about what evidence there is that either supports or contradicts their negative thoughts. Usually it is best to start by considering evidence in favour of the thoughts, since that will often be easier for the client. Then move on to looking for evidence that may not fit with the thought. This is one of the areas where Socratic questions may be useful, by helping clients to consider evidence that is currently outside their awareness, for example, questions like “What has actually happened in the past when I thought I was about to die?”, or “Have there been any times when you have successfully coped with this situation? If so, how?”

It is often important to remind clients that, in most cases, feelings are not good evidence. The kind of evidence we are looking for is more like the standard of objective evidence that a court of law would be looking for. The prosecution lawyer would not get very far if his only evidence against the accused was “Well, I just feel he’s guilty, your honour”! In the same way, if we are trying to evaluate the idea that “I’m a bad mother”, then “I just feel that I am” does not count as evidence.

Weighing Pros and Cons

Some thoughts or beliefs are not easily evaluated in terms of truth or accuracy. An obvious example is the old cliché that an optimist sees the glass as half full while a pessimist sees it as half empty. Neither of those two views is more truthful than the other, and there is no objective evidence that could support one of them rather than the other. But it might well be that different consequences follow from the two views. For example, perhaps the optimist’s view leads to different emotional states than the pessimist’s one.

Thus, an alternative to looking at truth or accuracy is to look in a more pragmatic way at consequences. Put aside for the moment whether this cognition is true; let’s just think about how it affects you (or others who are important to you). This approach involves looking in systematic way at both the pros and cons of holding the cognition. What advantages/benefits does it give you? But also what disadvantages or costs does it have?

As always, you as therapist have to be honest in exploring this, and accept that it is always possible that your client will conclude that it is more advantageous to continue believing what seems to you like an unhelpful cognition. Your job is to make sure that your client has thought it through as thoroughly as possible, not to dictate the conclusion.

Working with Imagery

Although CBT has always been aware that negative cognitions can take the form of images as well as verbal thoughts, interest in working with images has grown in the past few years. There are many variations on therapeutic work with images, but most involve:

• Identifying troublesome images and getting a detailed description of them.
• Developing alternative images. This can be done in different ways, including the use of fantasy (e.g., constructing an image of a rescuer intervening for someone troubled by images of abuse), realistic corrective information (e.g., using video feedback to construct a more realistic self-image for someone with social anxiety); or changing the structure of the image(s) (e.g., imagining the image on a TV screen and then making it smaller, or more distant).
• Practising use of the new image, first in sessions and then later in real-life situations.

See Hackmann, Bennett-Levy, and Holmes (2011) for a comprehensive exploration of imagery work.

Behavioural Methods

Both the original forms of behaviour therapy (BT), originating in the 1950s and 1960s, and the later developments of the “cognitive revolution” in the 1970s, gave a prominent role to treatment strategies that focus on making changes in the behavioural system. They agree that changing what you do is often a particularly powerful way of changing how you think and feel. The main difference in approach is the conceptual framework around behaviour change, which in turn influences some of the details of how behavioural work is carried out.

Within traditional BT, the main therapeutic strategy for anxiety disorders is exposure, that is, instead of trying to escape or avoid feared stimuli, approach them, either in reality (in vivo exposure) or in imagination. Exposure will generally be most effective when it is prolonged (e.g., long enough for anxiety to decline) and frequent (e.g., practised at least daily).

In more cognitively oriented therapy we have the concept of behavioural experiments, defined as:

These procedures may look very similar from the outside, for example, both might involve a client with OCD in leaving his house without checking, but they are distinguished by the underlying rationale, their hypothesized mode of operation and their applicability. Table 2.1 summarizes some of these differences in the treatment of anxiety.

Table 2.1 Behavioural strategies: Exposure compared to behavioural experiments
	Exposure	Behavioural experiments
Conceptual model	Behavioural	Cognitive
Fundamental idea	Works through repetition/ duration leading to habituation	Works through testing our predictions arising from thoughts/beliefs; may not need as much repetition
Illustration (for OCD)	Repeatedly walking out of the house without checking and the anxiety will gradually die away	Walk out of the house without checking and you can find out whether your feared disaster actually happens
Applicability	Mainly in anxiety (habituation is not supposed to work with depression, for example)	Any kind of problem (can work anywhere there is a negative thought tat generates testable predictions)

Both are well-established approaches, with good evidence for their effectiveness. There is currently not enough evidence to say whether one is more effective than the other, but a recent review suggested that, although conclusions are limited by the small number of studies and their methodological problems, the available data for anxiety disorders provides “some evidence that behavioral experiments were more effective than exposure alone” (McMillan & Lee, 2010, p. 467).

The other behavioural strategy commonly used in CBT is activity scheduling in depression. Like the above discussion of behavioural methods in anxiety, activity scheduling can be conceptualized as a straightforward behavioural procedure, in which reinforcing activities lead to improvements in mood, or as a series of behavioural experiments designed to test out the client’s negative cognitions about himself, about activities, etc. (Fennell, Bennett-Levy, & Westbrook, 2004).

Focusing on activity has in a sense come full circle in recent years. Following Jacobson et al.’s (1996) “dismantling” study of Beck’s cognitive therapy for depression, which showed that the purely behavioural, activity-based components of CT for depression seemed to be as effective as the full package, these behavioural components were developed into a new CBT treatment for depression that has come to be known as behavioural activation (Martell, Addis, & Jacobson, 2001).

Working with Assumptions/Beliefs

Finally, let us consider some of the strategies that have been developed specifically for working with DAs and/or CBs. As noted above, beware of assuming that all CBT must tackle such longer-term beliefs. However, there are times when progress seems to be blocked by such cognitions, and therefore they may need to be tackled directly. Of course all the methods already covered – weighing up the evidence, looking at the pros and cons, and behavioural experiments – will also be useful for DAs/CBs, but in this section we focus on some commonly used additional strategies.

Historical Review

As noted earlier, CBs and DAs typically develop early in life, and one strategy based on this is to do what is sometimes called a historical review. The aim here is to put the cognitions in perspective by helping your client review what experiences might have led to their learning these ideas, to understand their origins and also to understand how the context may be very different now, so that although the beliefs once made sense, they are less applicable now. The idea is that examining what led to these idenot as may help the client realize that they were learned (and are not simply absolute truths) and also that it is therefore possible that they could have learned, and still might learn, something different.

Continuum Work

The aim of this technique (Padesky, 1994) is to re-evaluate DAs and CBs that often take extreme, “black-and-white” forms: “Either I do everything perfectly or I am a complete failure”; “If I snap at my children once then I am a bad mother”; or “No-one cares about me”.

Continuum work is a way of trying to help clients think about such evaluations along a dimension, or continuum, rather than as one extreme or the other: not “I am terrible” versus “I am perfect”, more like “I am somewhere on a continuum between terrible and perfect”; somewhere in the shades of grey, rather than either black or white.

You help your client draw up a dimension along a line between the two extremes, and rate their starting belief (which is typically towards the extreme negative end of the dimension – e.g., “I am 100 per cent bad”). Then you collaboratively draw up criteria for both ends of the continuum as well as some of the “shades of grey” in between. This can be done either by constructing abstract criteria (e.g., 50 per cent on the scale of “good motherhood” includes “regularly feed and dress children”); or it can be done by using actual people your client knows or has heard of (e.g., 100 per cent on the scale of a “bad person” is Hitler). These procedures often help clients to re-evaluate their extreme beliefs and move towards a more moderate view (e.g., “I don’t like myself much but I’m not a mass murderer, so I guess I can’t be 100 per cent bad”).

Positive data log

This technique, also described by Padesky (1994), is essentially a specialized form of collecting evidence. Its focus is on negative beliefs about the self, and it can be used once your client has begun to develop a possible alternative, less negative, belief. The well-known biased perception and recall of negative versus positive information makes it hard for clients to notice or remember relevant evidence that might contradict their negative beliefs or support their new beliefs. The positive data log is therefore designed to help them focus more on such evidence. It is explicitly not designed to be balanced, on the grounds that your client will likely have spent years collecting evidence that appears to support their negative beliefs. What is needed to get a balanced view is to spend some time focusing on evidence that supports the new belief. Clients are therefore asked to keep a record focused only on such information, which they are to try to update daily, and bring along to every session for discussion. Although simple in conception, this is usually a very difficult task for clients, and needs a great deal of therapist support and encouragement as well as a long period of time – it may well need to continue after the end of therapy.

“Third Wave” Cognitive Behavioural Therapy

The outline above has focused on “classical, Beckian” CBT, but for the sake of completeness it should be noted that the past 10 years have also seen the growth of what have been called “third wave” CBT approaches (Hayes, 2004). There is not much agreement about which models should be classified under that label, but the candidates include Acceptance and Commitment Therapy (ACT: Hayes, Strosahl, & Wilson, 1999), Mindfulness-Based Cognitive Therapy (MBCT: Segal, Williams, & Teadale, 2002), Dialectical Behaviour Therapy (DBT: Linehan, 1993) and Rumination-Focused CBT for Depression (Watkins et al., 2011). These therapies are by no means all the same, but they have in common a shift away from the classical Beckian approach of examining and testing the content of cognitions, towards an increased interest in cognitive processing styles and in the relationship between people and their cognitions: less disputing of one’s thoughts and more disengaging from them, recognizing that they are “just thoughts” that can be calmly accepted rather than avoided or argued with.

There is some disagreement about the extent to which this shift is truly novel. For example, it has been argued that classical CBT has always contained an element of “distancing”, or separating oneself from one’s thoughts (Hofmann, Sawyer, & Fang, 2010), and indeed one might say that such an approach is suggested by the motto “Don’t believe everything you think” described earlier in this chapter. Nevertheless there is no doubt that these new models are producing some interesting alternatives to, and perhaps may lead to enhancements of, traditional CBT – even though at present much more research on their effectiveness is needed.