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Verbal techniques are used to explore the logic behind and the basis for specific conclusions, while behavioural techniques may be used to change behaviour and also to elicit more thoughts.  For example, exposure therapy has value as a counter conditioning or desensitisation technique, but it can also elicit thoughts and images that may be at the base of the agoraphobic’s avoidance.  Like the behaviourist, his aim is to help the client get more satisfaction from life, but also, like the psychodynamic therapist he must be flexible and respond to his client’s needs rather than impose a fixed treatment pattern.

Cognitive Psychotherapy can be considered in four stages.

STAGE ONE – Eliciting Automatic Thoughts

The first task is to help the client become aware of his negative self-statements and to recognise the relationship between them and his change in mood.  It is the therapist’s role to facilitate but the client’s job to unearth the data.

Automatic Thoughts Experienced in Therapy

It is sometimes possible to detect a sudden change of mood during the session itself, perhaps after a casual comment by the client or therapist.  As soon as the change is observed the therapist should focus on the automatic thoughts which led from the event to the response, and question the client, e.g., “It seems to me you have become very withdrawn since I said we would have to change the time of next week’s appointment.  Why is that?

Instant Replay 

In the early stages of therapy, the patient will only have a hazy memory of the emotive episode and, therefore, will have difficulty in reporting the “automatic thoughts” associated with it.  The therapist should:

  1. Ask the client to describe the incident in precise detail.
  1. Summarise the whole episode, e.g., “Your boss asked to see you for a few minutes, and you               immediately thought he was dissatisfied with your work.  You felt downhearted as a result,                         and when you arrive you had nothing to say.  Because you were so unresponsive your boss                  asked if you were happy in your work and you took this to mean he wanted you to leave.                   Is that how it   went?”

Role Play

If the client is unable to report his automatic thoughts or recall the sequence of events, it is useful to stimulate the episode during the session itself so that the thoughts may become evident.

Establishing the Meaning of an Event

If the client is unable to furnish any details of a particular episode, and role play is not suitable then the therapist should endeavour to examine the significance of the event for the patient, e.g., “What do you think it was about the situation that led you to being so upset?”

STAGE TWO – Creating New Interpretations

The client should now be helped to discover the new ways of thinking to replace the unhelpful ones.  It is important that the therapist should not impose his or her views on the client, but suggest various tasks so that the client can discover these thoughts for himself.

The two techniques that are used are distancing and using a Daily Log:

  1. Distancing

This encourages the client to stand back from the problem situation in order to gain a more objective view.  There are two methods:

  1. Begin by looking at an event from the past which had more positive consequences than the                       patient expected at the time.
  1. To examine current problems, use role reversal technique.  Here the therapist plays the part                        of the client and the client plays the part of a well meaning friend.  This helps him to                                     see other possible explanations.

Since it is unlikely that the patient will immediately discard his old ways, it is useful to ask him to ‘rate’ his options by assigning a proportion of 100% to each hypothesis e.g:

He does not care for me.                     85%

Option 1                    He has a lot on his mind.                    10%

Option 2                    I rejected him.                                       3%

Option 3                    He cannot show his true feelings.         2%

The above is a tangible way of demonstrating to the patient that he is not totally committed to his negative belief.

  1. Daily Record of Dysfunctional Thoughts

It is very useful for the client to keep a daily record of his emotional changes and the automatic thoughts associated with them.  The client is also requested to evaluate the intensity of each emotional experience, and to rate alternative cognitions according to their credibility as he sees them.  This record gives the therapist much useful information to work with at the start of each session, it monitors progress, and acts as a reminder as well as a learning experience in itself for the client.

STAGE THREE – Reality Testing

This is where the client is encouraged to test out his various beliefs and attitudes in a systematic way, and is the cornerstone of the cognitive approach.

The client is helped to see that it is possible to discover the truth or otherwise of his beliefs. The therapist will set specific assignments which the client can carry out between sessions.  The therapist is not saying, “Your beliefs are wrong” but, “Let’s find out”.

The Steps in Setting up an Assignment

  1. Using the client’s daily record, a particular automatic thought and the alternatives associated                           with it are selected for testing.
  1. A task is decided upon which will enable the validity of the thought to be tested.
  1. Before attempting a task the client should be absolutely clear what is expected of him.                        Perhaps a preparatory role play may be enacted.
  1. Immediately after the event, the client should write a step by step account of what actually                             happened to discuss with the therapist.
  1. At the next session the evidence is related to the initial pessimistic hypothesis.

Reality testing forces the client to confront and contradict the initial unduly pessimistic view he had of the problem situation.  The philosophy underlying every stage of the cognitive therapy process is that the client should discover more constructive ways of interpreting events for himself.

STAGE FOUR – Modifying Underlying Assumptions

As the client improves, the focus of therapy can shift from the superficial automatic thoughts to the deeper assumptions that underlie them.

Beck has isolated some to the common assumptions which predispose people to depression:

  1. In order to be happy I have to be successful in whatever I undertake.
  1. To be happy I must be accepted by all people at all times.
  1. If I make a mistake, it means I am inept.
  1. I cannot live without you.
  1. If someone disagrees with me, it means he does not like me.
  1. My value as a person depends on what others think of me.

Since these beliefs have usually been instilled at a very early age, they are often quite resistant to change.

To gain clues to underlying assumptions therapists can ask the client to use his daily record to identify recurring themes or he can ask the client to describe friends of his whom he considers to be happy and to state why.

Many clients will recognise the absurdity of a belief once it has been verbalised, though getting them to take action to disprove it may not be so easy.


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