Cognitive Behavior Therapy

Chapter 2 reviewed the cognitive model of depression, which states that depression is often maintained and exacerbated by exaggerated or biased ways of thinking. Cognitive behavior therapy (CBT) is utilized to help depressed patients recognize and modify their idiosyncratic style of thinking through the application of evidence and logic. CBT uses some very well-known and tested reason-based models such as the Socratic logic-based dialogues and Aristotle’s method of collecting and categorizing information about the world (Leahy, 2003). CBT therapists engage their patients in scientific and rational thinking by guiding them to examine the presupposition, validity, and meaning of their beliefs that lead to their depressive affect. Because CBT techniques are fully described in several excellent books (e.g., Beck, 1995), they are not described in detail here. Within the cognitive-hypnosis (CH) framework, I adopt (Alladin, 2006, 2006a) the following sequential progression of CBT, which can be extended over four to six sessions. However, the number of CBT sessions is determined by the needs of the patient and the severity of the presenting symptoms:

Explanation of the cognitive model of depression
Reading assignment (to read first three chapters from Feeling Good: The New Mood Therapy [Burns, 1999])
Patient identification of cognitive distortions ruminated on
Patient logging of dysfunctional thoughts on the CAB Form
Introduction of disputation or restructuring of cognitive distortions
Introduction of the ABCDE Form
Identification and restructuring of core beliefs
Development of the habit of monitoring and restructuring negative beliefs

The progression of CBT is illustrated by describing the first two CBT sessions carried out with Patty, whose case was formulated in Chapter 7.

First Session

Explanation of Cognitive Model of Depression

In the first CBT session, the patient is provided a detailed but practical explanation of the cognitive model of depression. This psychoeducational session usually lasts about an hour. Some beginning therapists may think it is a waste of time to spend so much time in psychoeducation. However, Ledley, Marx, and Heimberg (2005) have listed several advantages for spending one or two sessions in explaining the CBT model to the patient:

It provides a nonthreatening means of interaction.
It helps to establish and strengthen rapport.
It is a learning process for patient and therapist.
It actively involves both patient and therapist.
It facilitates ongoing case conceptualization.
It provides open discussion and collaboration between patient and therapist.
It provides a context within which the therapist may normalize patient experiences.
It allows opportunity to discuss how problems are interfering with patient’s functioning.
The whole process helps the patient gain confidence in the treatment.

It is important for the therapist not to deliver the psychoeducational material in a lecture format. Such an approach will damage therapeutic rapport. It is important for the therapist to strike a balance between sharing information and keeping the patient involved. The excerpt from Patty’s first CBT session illustrates this balance in the presentation of the psychoeducational material covered.

ABC Model of Psychopathology

The patient is given a practical explanation for understanding the cognitive model of psychopathology, specifically the cognitive model of depression. While explaining the model, the therapist writes the salient points on a piece of paper or on a board. Writing provides a visual representation of the model, and both the patient and therapist can refer to the notes to check on a point.

Redefining Depression

Therapist: At the end of our last session, we concluded that you have a major depressive disorder. Although this term is a useful description, it’s not very meaningful to you in terms of your experience. I am going to redefine your condition. Your condition can be described as an emotional problem or an emotional disorder, and we refer to it as an emotional disorder when it gets severe. An emotional disorder has two main characteristics. First, a person with an emotional disorder has excessive negative feelings. This means the person has lots of negative feelings that the person does not want, but can’t get rid of, even when the person is in a situation where the person should be having a good time. Do you feel this way?

Patty: Yes, most of the time.

Therapist: Secondly, a person with an emotional disorder tends to overreact to situations. That is, the feeling is out of proportion to the situation. Do you feel this way?

Patty: Yes.

Therapist: In this session, I am going to explain to you why you have excessive negative feeling and why you overreact to situations. If you know the reasons why, then you may be able to do something about it.

Patty: I would really be interested to know why.

Explanations about Emotions

Therapist: Since we are focusing on emotions, let’s talk about emotions for a while. The English language is very rich in describing emotions. There are over 300 adjectives used to describe emotions or feelings. But they can be categorized either as positive or negative emotions. In our discussion, we are going to use words like emotions, feelings, and reactions interchangeably. That is, they mean the same thing. We say we are emotional when we are reacting or expressing a feeling. Can you give me some examples of positive feelings?

Patty: Happy, confident, feeling good.

Therapist: That’s right. And also sense of success, sense of achievement, joy, and so on. Now can you give me some examples of negative feelings?

Patty: Sad, angry, anxious.

Therapist: That’s right. Other negative feelings are guilt, fear, feeling depressed, and so on. OK, we have both negative and positive feelings, but from where do they come? Are we born with feelings, or do we learn them?

Patty: We are born with feelings.

Therapist: It seems this way, but we are not really born with feelings and emotions. We learn them.

Patty: But how come a baby cries?

Therapist: When a baby is born, it experiences distress and gratification. If the baby is hungry or wet, it is distressed and cries. But if the baby is warm and fed, it is gratified and usually goes to sleep. In other words, the baby has the ability to feel feelings and emotions, but a newborn baby does not know when or where to express feelings. The baby has to learn how, when, and where to express feelings, because most feelings are related to people or situations.

Patty: I did not realize this. I did not know that feelings are learned. Now that you mentioned it, it makes sense.

Therapist: There are three lines of evidence to prove that emotions are learned. First, as we discovered, a newborn baby does know what feelings to express in different situations. Second, different people feel different feelings in the same situations. Third, different cultures express different feelings in the same situation. For example, in some cultures, people are grieved at a funeral. In other cultures, they celebrate at a funnel. For example, in certain parts of Ireland and Scotland, they have a wake when someone dies.

Patty: I find this very interesting.

Therapist: The reason why we are attaching so much importance to learning is because, if emotions are learned, then we can change them or modify them.

The Link between Emotion and Cognition

In this part of the psychoeducation, the therapist helps the patient understand the link between emotion and cognition.

Therapist: Now, we know that emotions and feelings are learned, but what triggers them? We don’t laugh or cry for no apparent reasons. What triggers feelings?

Patty: People. Something happens.

Therapist: That’s right. When something happens. This is what we call an event or a situation. There is a relationship here. When a positive event or situation occurs, we have a positive feeling. But when a negative event or situation occurs, we have a negative feeling. For example, suppose a person close to you wins a million dollars. How would you feel?

Patty: I would feel happy for the person.

Therapist: But let’s suppose your close friend is involved in a serious accident and is in the hospital. How would you feel?

Patty: I would feel sad and distressed.

Therapist: But these are current situations, things happening now. Events can also be past or future. For example, if you think of a good event that occurred many years ago, you will feel good about it because it was a happy event.

Patty: I understand this, but what do you mean by an event being in the future?

Therapist: Let’s suppose you are having this therapy with me, and you believe that in 6 months you will improve, as the literature predicts. You will feel happy, although you are not there yet. So the past, the present, or the future can influence us now.

Patty: Is that why some people get upset when you mention something about the past or about the future?

Therapist: That’s right. You seem to be very perceptive, Patty!

Patty: I find this interesting. I have always enjoyed psychology.

Therapist: I am glad you find this meaningful. Let’s summarize what we have covered so far. We discovered that events or situations trigger our feelings, that is, events or situations, depending on whether they are negative or positive, determine our feelings. In other words, we are saying that events cause us to feel happy or sad. In other words, events are responsible for how we feel. We are not responsible for how we feel. Events are responsible.

Patty: That’s right.

Therapist: Let’s examine whether events and situations are responsible for how we feel, and that we are not responsible for how we feel.

Patty: OK.

Therapist: Let’s take divorce as an example. Imagine 100 people got divorced this morning. These 100 people represent a representative sample of our society. They are from all walks of life. How do you think they felt after they got their divorces?

Patty: I suppose some felt relieved and some felt distressed.

Therapist: Would you like to speculate on what percent felt relieved or happy and what percent felt unhappy or distressed?

Patty: I would say 70% felt depressed and 30% felt relieved.

Therapist: Now, if there were 100 people in this room and we ask them the same question, people would give different answers. Some may say, like you, 70% will feel depressed while 30% will feel happy. Others may say 50-50 or 60-40 or 80-20. But I bet you no one will say 100% will feel happy or sad.

Patty: I agree with you.

Therapist: If this is true, then we are contradicting ourselves. Earlier on we agreed that (pointing to the notes) events or situations are responsible for how we feel, and we are not responsible for how we feel. If this were true, then everyone will feel either happy or depressed since it’s the same situation for everyone–that is, everyone got divorced.

Patty: Well, different people have different reactions.

Therapist: True. Reactions are feelings or emotions. If the event was responsible for how we feel then everyone will feel the same, since it’s the same situation.

Patty: I see what you mean. You mean it’s not the event that causes the feeling.

Therapist: You’re right. The event can’t be causing the feeling, otherwise everyone who got divorced would have felt either sad or happy. We agreed that some were feeling sad and others were feeling happy. This would prove that the event is not responsible for how we feel. Patty, if the event is not responsible, what do you think is responsible for how we feel?

Patty: Our brain.

Therapist: It may be coming from our brain, but can you be more specific?

Patty: Our experience.

Therapist: You are moving in the right direction. Can you be a bit more specific?

Patty: What we remember from our experience.

Therapist: You’re right. It’s not the event that causes us to feel sad or happy, but it’s our perception of the event. The way we evaluate or appraise the event, based on our experience and learning, determines how we feel. The event simply acts as a trigger. I am sure you already knew that but never thought about it systematically the way we are analyzing it.

Patty: You’re right. I always knew that my thinking is too negative.

Therapist: The mental process that’s involved in thinking, evaluation, self-talk, and inner dialogue is called cognition. So it’s our cognition that determines how we feel and not the situation on its own. Let’s examine the example about divorce a bit further. What types of cognition do you think went into the person’s head who felt happy after divorce?

Patty: I am free. I can marry the person I really love.

Therapist: And what kind of cognition in the person who felt sad after the divorce was granted?

Patty: I am a failure, I failed again. I will be lonely.

Therapist: Because cognitions determine how we feel, cognitions can be tragic. I am sure you have come across a person who is doing the wrong things, but the person believes he or she is doing the right thing. And the person will tell you “I know I’m right because I believe it.” Believing in something does not make you right, because we are not born with beliefs. We learn them, and it’s possible for us to learn the wrong beliefs based on our experience. Or the person may say “I’m right because I feel it.” Feeling does not make you right, because feelings are created by our thinking. The thinking may be wrong. Have you come across such people?

Patty: Sure. My friend Jennifer is just like that.

Therapist: It’s tragic for two reasons. First, the person continues to believe in something that’s not helpful, although it continues to cause lots of difficulties in the person’s life. And second, the person is not even aware that the belief is creating the problems.

Patty: I always knew that my thinking was causing my depression, but how do I change it?

Therapist: The main purpose of cognitive behavior therapy or CBT is to show you how to restructure your thinking.

Patty: But how can you change it when I have been thinking this way all my life?

Therapist: It’s not easy, but it can be changed. That’s why we were attaching so much importance to learning. Since your thinking is learned, it can be changed or modified. CBT shows you how to do this.

Patty: I am impatient. I want to know more about this.

Therapist: I am glad you find this interesting. Let’s talk a bit more about cognitions, and then we will address how you start working with your thinking. We mentioned that cognitions can be tragic. Let’s examine this a bit further. In other words, cognitions can be accurate, helpful, adaptive, and rational or they can be inaccurate, unhelpful, unadaptive, and irrational, and we don’t know about it. We simply believe what we believe in, and our thinking becomes automatic, never questioning or paying attention to our beliefs. Our beliefs are learned and shaped by our experience. David Burns in his book, Feeling Good: The New Mood Therapy

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