One of the central features of cognitive-behavioral therapy for depression is its emphasis on the psychological significance of clients’ negatively biased beliefs about themselves, the world around them, and their future (Beck, Rush, Shaw, & Emery, 1979). Clinically depressed clients tend to believe that they lack the ability to cope with difficult circumstances (helplessness), that others are happier and more competent (inadequacy), and that the future is bleak (hopelessness). The clients’ depressotypic thinking is perpetuated by cognitive processes that maintain it. For example, depressed clients may selectively attend to instances in their lives when they had setbacks but fail to pay similar attention to evidence of their accomplishments and successes. Similarly, depressed clients who have suffered personal disappointments or rejections may conclude that they are all alone and nobody cares, when in fact there may be a number of important people in their lives who try to offer friendship and support. “Such biases in information processing often lead depressed individuals to neglect their interpersonal relationships and to give up prematurely in trying to achieve important goals. The result is a deepening of their pessimism, a worsening of their mood, and a vicious cycle of further withdrawal” (Newman & Beck, 2009, p. 2857).

CBT for depression also focuses on the clients’ actions, in that depressed clients often demonstrate problems with fatigue, low motivation, and withdrawal from activities that otherwise could give them a sense of mastery and pleasure. The inactivity of the depressed clients leads to low positive reinforcement, few opportunities for experiencing joy, and stagnation or regression in feeling a sense of personal growth and empowerment. This interacts negatively with the clients’ negative cognitive biases to produce even more self-reproach, helplessness, and hopelessness. In the most severe cases, depressed clients believe that life is so unremittingly painful and unrewarding that suicide may be the only “answer.”

A major aim of CBT is to teach depressed clients the skills of systematically identifying, evaluating, and modifying their thinking styles toward the goal of gaining a more objective and manageable view of their problems, along with constructive ways of addressing them. Session work often emphasizes modification of “hot cognitions”—automatic thoughts and images that are associated with a change or increase in emotion. Another overarching goal of CBT is to increase the clients’ involvement in activities that are enjoyable, prosocial, and lead to a sense of accomplishment. This system of therapy is comprised of a core set of cognitive and behavioral techniques used strategically in the context of a comprehensive case conceptualization (Kuyken, Padesky, & Dudley, 2009), facilitated by an understanding, accepting, empathic therapeutic relationship (Gilbert & Leahy, 2007). CBT is time-effective and well-structured, with special emphasis given to “empowering and educating [clients] in psychological skills such as rational responding, objective self-monitoring, formulating and testing personal hypotheses, behavioral self-management, problem-solving, and [other skills]” (Newman & Beck, 2009, p. 2858). CBT therapists collaborate with their clients to devise homework assignments that will reinforce these skills, leading the clients to experience better maintenance of therapeutic gains over the long term (Burns & Spangler, 2000; Rees, McEvoy, & Nathan, 2005), a hallmark of CBT (DeRubeis et al., 2005; Hollon et al., 2005).

To those who have not been formally trained in cognitive-behavioral therapy, it is easy to fall prey to some of the common myths about this psychotherapeutic approach. The following is a brief, nonexhaustive list of such inaccuracies, along with rejoinders that more aptly describe CBT as it is actually delivered in practice and taught to practitioners-in-training.

Myth #1: CBT Is Necessarily Short-Term

CBT is more accurately described as “time effective.” Depending on the scope of the client’s problems, different cases will require different frequencies of sessions and lengths of treatment. At times, CBT may go on for years (see Giesen-Bloo et al., 2006; Newman, Leahy, Beck, Reilly-Harrington, & Gyulai, 2001). Although practical concerns (e.g., limitations of insurance, grant protocol stipulations) may keep therapy contained within certain limits, cognitive-behavioral therapists recognize that some clients require a longer period of treatment than others. In any case, time is treated like the precious resource that it is—cognitive-behavioral therapists do their best to structure sessions, focus on high-priority topic areas, and assign homework so that clients acquire self-monitoring and self-management skills that facilitate prompt improvement and long-term maintenance. Therapy may not always be short-term, but time is used well.

Myth #2: CBT Pays Little Attention to the Expression of Emotions

The term cognitive-behavioral therapy denotes the important role that clients’ thought processes and behavioral patterns play in their difficulties and in their learning to function more effectively. However, this is not to say that emotions are not important. Cognitive-behavioral therapists endeavor to help their clients achieve a higher quality of life, including a wider range of emotionality, a greater capacity for hopefulness and joy, improved efficacy in recognizing negative emotions (e.g., anger, grief, fear) so that they may be processed in a healthy way, and (arguably) the ability to find humor in themselves and the occasional absurdities of life (see Newman, 1991). Nevertheless, cognitions and behaviors (by definition) play a central role in cognitive-behavioral therapy, as they provide particularly fruitful points of assessment and intervention.

Myth #3: The Therapeutic Relationship Is an Afterthought in CBT

From its early days, CBT concerned itself with the therapeutic relationship (Beck et al., 1979). Effective CBT is not a mechanistic imparting of techniques, nor is it a process of arid, intellectual debate. Good rapport and a sense of positive, trusting collaboration between therapist and client is essential if the treatment is to have its intended impact (Gilbert & Leahy, 2007). In cases where clients have marked difficulties in getting along with others, the therapeutic relationship in CBT serves as a valuable model for mutual understanding, respect, and good will.

Myth #4: CBT Is Synonymous With “the Power of Positive Thinking”

More accurately, CBT values constructive, objective thinking. This means that clients are encouraged and taught to evaluate themselves and their lives so that problems may be identified—not denied—in a way that promotes change without undue self-reproach. As depressive thinking is typified by negatively biased assumptions that promote helplessness and hopelessness (Abramson, Alloy, & Metalsky, 1995; Beck, Wenzel, Riskind, Brown, & Steer, 2006), it is important for CBT to present a relatively optimistic approach. However, cognitive-behavioral therapists do not teach their clients to indulge in idle positive thinking that trivializes their struggles.

Myth #5: CBT Encourages Clients to Avoid Pharmacotherapy

Cognitive-behavioral therapists strive to take an empirical approach to treatment. As such, they respect the data in the field of mental healthcare. There is ample evidence that medications can and do play an important role in the treatment of depression and particularly in such disorders as bipolar spectrum illnesses and schizophrenia. The use of medication per se is not incompatible with the concurrent delivery of CBT (Wright, 2004). However, cognitive-behavioral therapists address their clients’ dysfunctional beliefs about medications, such as when the clients maintain that their pills will substitute for the learning of psychological skills, or attribute all their gains to the medicine, thereby deriving little or no boost in self-efficacy, or erroneously hold that potentially helpful medications will rob them of their “true selves.”

Although it is customary for clinicians to begin the process of conceptualizing a client’s case at the outset of treatment—perhaps in the form of an official “intake” session—the task of understanding the internal and external factors that have led to and maintain the client’s present problems is one that is ongoing throughout therapy. As therapists, we may be able to glean a great deal of information about the client by conducting a formal diagnostic evaluation (e.g., the Structured Clinical Interview for the Diagnostic and Statistical Manual-IV; First, Spitzer, Gibbon, & Williams, 1996), at which point we may ascertain that the client suffers from a major depressive disorder (see APA, 2000). We will also want to garner a good deal of information about the client’s personal history, including his or her important experiences in school, work, family relationships, and important extra-familial relationships. Further, the client’s responses at intake may provide us with a reasonable glimpse into his or her cognitive style—how he or she perceives: (a) himself or herself, (b) other people (and the world at large), and (c) the future—the “cognitive triad” (Beck et al., 1979). We may also provide clients with self-report inventories (e.g., the Personality Beliefs Questionnaire: PBQ; Beck et al., 2001) that shed light on maladaptive beliefs that clients may hold. These data are valuable for hypothesizing the ways in which the clients’ thought patterns play a role in their psychological difficulties. Collectively, this information puts the therapist in a good position to collaborate with clients in establishing some preliminary goals for therapy that the clients will find relevant and on target.

As therapy progresses, the therapist will come to learn more about the client simply by observing the client’s cognitive, behavioral, and emotional reactions to current events in his or her life, as well as to the goings-on in the therapy sessions, including the therapeutic relationship. This information will be incorporated into the case conceptualization, which is a somewhat fluid entity. For example, the therapist may learn that a given depressed client is prone to mistrust what the therapist is saying, becoming wary and taking offense at otherwise benign therapist comments. This would be in contrast to another depressed client who is eager to learn what the therapist has to teach him or her and expresses enthusiasm about the usefulness of the therapeutic dialogue. Some clients seem to have great difficulty in arriving on time for sessions or in doing their therapy homework, whereas others are quite punctual and/or reliably give a good-faith effort to complete their between-sessions assignments. Similarly, there are important differences between depressed clients who are reticent in session, often saying “I don’t know” in response to the therapist’s questions about their thoughts, versus those clients who readily and willingly engage in spirited, collaborative dialogue with the therapist, offering hypotheses whenever they are asked to contribute their ideas. These sorts of differences between clients become quite germane to their respective case conceptualizations. As such, astute cognitive therapists will use this differential information in the service of understanding the clients better, communicating more accurate empathy, making adjustments in their interpersonal style so as to maximize collaboration, and devising goals that are most relevant for the individual clients in question. Therapists who formulate a good, data-driven case conceptualization will be in the best position to answer the following sorts of questions they may ask themselves during the course of therapy:

• What are the client’s personal strengths, and how can we use them in the service of maximizing the benefits of therapy?
  
• What are the signs that the client is struggling to understand what I am saying or to understand the purpose of the homework? How can I describe things more clearly or give better rationales so that my client and I can be on the same page?
  
• What are the risks and benefits of my introducing a given issue that I believe is important but that the client has not yet volunteered? How can I express my thoughts about this issue so that it is most acceptable to this particular client?
  
• What are the client’s most likely responses to a given intervention? If the client’s responses confound my hypotheses, what could be accounting for this? Are there missing data? How can we explore this further and yet maintain a sense of safety and collaboration in the therapeutic relationship?
  
• Which changes would be most therapeutic for this client to make? What procedures would make these changes most durable? How can I determine if the client is actually learning something useful in therapy or is merely being superficially agreeable?

These are but a handful of questions that therapists can entertain, pertinent to the case conceptualization and related treatment plan. The upshot is that a cognitive case conceptualization involves gathering and organizing data about the client’s beliefs systems, behavioral patterns, emotional experiences, and interpersonal functioning across situations and longitudinally over time. These data help therapists to construct individualized treatment plans and to make (and test) predictions about how the client will respond. As noted earlier, it is important to identify and utilize the client’s personal strengths in the service of therapy, as this strategy demonstrates respect for the client and boosts the client’s morale and sense of self-efficacy (see Kuyken et al., 2009).

The following are some brief, circumscribed examples of using the case conceptualization to craft the appropriate therapeutic intervention, using the fictitious depressed clients “Hal” and “Fay.” Hal (divorced, age 60) presents as a reserved, introspective man who is very pragmatic in his approach to life. He lives alone with his dog and has few friends. He makes quick judgments about people and situations, but rarely vocalizes them. His parents apparently were depressed as well, but never sought treatment, and expressed the attitude that “Life is tough, and doesn’t owe you anything.” Fay (single, age 32) is more vocal and gregarious and has a number of good friends, though she is quick to compare herself unfavorably to them. She wants to get more out of life, but finds that she inhibits herself from taking personal and vocational risks owing to her lack of confidence and her belief that she cannot deal with disappointment. Fay is aware that life has a lot to offer, but she is worried that she is letting life pass her by. In light of the above information, here are four ways in which the same cognitive therapist may choose to use different interventions with Hal and Fay.

These are but a few ways in which a conceptual understanding of the clients can lead the therapist to pursue interventions that are maximally relevant for and suited to the individual in question. The following section addresses some of the core interventions in CBT.

It is somewhat artificial to separate “techniques” from case conceptualization and the therapeutic relationship, as these three main elements of treatment are best construed as being intertwined and synergistic. CBT techniques that are presented as rote procedures, out of the context of the client’s life, and minus a sense of good-natured collaboration with the therapist, are rather “clunky” at best, and may even seem irrelevant and forgettable. As a metaphor, we may view CBT techniques as “products” (e.g., skills, words of wisdom) that we wish to impart to our clients. The case conceptualization is the map that will help us transport these products to the right place, in a reasonable time. The therapeutic relationship is the route itself, such as a road, a waterway, or a flight path. We want this route to be as smooth as possible, without undue bumps in the road, rapids in the water, or turbulence in flight. Taken together, this metaphor illustrates how the efficacy of therapeutic techniques is buttressed by an accurate case conceptualization and a safe, reasonably smooth therapeutic relationship. In light of this, the following subsections on techniques should be considered in this context. Thus, the order of presentation of the following techniques is not meant to imply priority or primacy, as that depends on the individual case at hand. Further, although the following techniques are presented one at a time, there is no reason that the skilled CBT therapist cannot use combinations of these (and other related) techniques, provided that there is a good rationale for doing so and assuming that the results support their use in this manner. With that in mind, let us proceed with a description of some of the core techniques in the CBT repertoire.

Behavioral Experiments

Although the term behavioral experiment seems to imply that this technique is purely in the behavioral realm, it is more completely viewed as an experiential experiment, as changing one’s behavior in a strategic way has the potential power to alter the client’s emotions and thought processes as well. What is a behavioral experiment? Simply put, it is an opportunity to act in a way that is hypothesized to bring about something healthy and positive, even if the client at first doubts that he or she can do it, or cannot fathom that the experiment will result in anything worthwhile. Behavioral experiments are most often enacted as part of a cognitive therapy homework assignment (see Bennett-Levy et al., 2004), but they may also be used in-vivo in the therapy session itself.

As an example of the latter, a depressed man revealed that he had been avoiding checking his work-related e-mail, as he was certain that there would be messages from colleagues questioning his progress on some projects he had been avoiding. Realizing that this sort of avoidance represented poor problem-solving skills and could result in a worsening of consequences for his client, the therapist asked the client what was stopping him from reading such e-mail. The client replied (reflecting his negative assumptions) that he “wouldn’t be able to cope with the criticisms” and that reading the e-mail “wouldn’t help the situation anyway.” At first, the therapist thought he might assign the client the task of opening up all of his work-related e-mail as a behavioral experiment between sessions, but then hypothesized that this client may simply avoid the assignment. Therefore, the therapist suggested an in-vivo behavioral experiment, in which the client was invited to use the therapist’s computer to read his e-mail on the spot, in session. The following dialogue illustrates how the therapist presented this idea to the client:

Not only did this client succeed in doing this behavioral experiment, he exceeded the expectations of the therapist, as the client actually went beyond the intended intervention to send reply e-mail to his colleagues to begin the process of solving the problem that he had heretofore avoided and dreaded. One of the significant benefits of behavioral experimentation is that it sometimes leads to a chain reaction of constructive actions that creates a positive feedback loop.

Activity Monitoring and Scheduling

When depressed clients suffer from anergia and anhedonia, they often scale back the degree to which they engage in potentially productive or rewarding activities, a condition that unfortunately reinforces the client’s helplessness and low mood. In response to this problem, CBT therapists often will encourage clients to self-monitor their activities (e.g., via the use of the Daily Activity Schedule, or DAS; see J. S. Beck, 1995), to rate each of their activities in terms of mastery and pleasure (e.g., scales of 0–10 for “Ms” and “Ps”), to study ways in which it might be advantageous to schedule new activities, and to implement gradually increased schedules of activities. This may be done as a freestanding method or in combination with techniques that target the clients’ thought processes (see below). Expectedly, when depressed clients feel sluggish and low in motivation, their therapists will need to be understanding and encouraging in making such behavioral prescriptions. The client’s collaboration with the behavioral plan is of paramount importance, as is the therapist’s ability to inspire their clients to extend themselves toward greater levels of activity, as well as to be patient when clients report at first that they “cannot” enact the planned exercises. Caring perseverance is the key.

The DAS (or other behavioral self-monitoring form) can be particularly valuable as an assessment of how the clients are using and/or structuring their time. A completed DAS (perhaps as an early homework assignment) will provide the therapist with potential hypotheses about the factors that may be maintaining the client’s depression. For example, one client’s DAS showed that her life was overbooked as she ran from one obligation to another in her efforts to work and go to school while raising a young child alone. She had no time for friends, a relationship, or recreational events, and she reported feeling constantly worn out. The therapist had the sense that this client was courageously coping with the demands of single-parenthood, but was struck by the client’s penchant for self-criticism. The therapist came to realize that this client was turning down offers of help from family and friends, fearing that if she accepted their assistance she would be a “burden” to them. By contrast, another depressed client’s DAS showed that he was always awake well after midnight and was never out of bed until early afternoon. Many of the items on his DAS were poorly described (e.g., “hanging” and “chilling”), leading the therapist to hypothesize that this client may be using alcohol and drugs on a regular basis, while doing little for a sense of accomplishment or healthy pleasure. The client denied that he was abusing substances, but eventually revealed that he was spending hours each day looking at Internet pornography and feeling helpless in looking for a job. Yet another client’s DAS indicated that his days were quite filled with work-related, social, and recreational activities, yet he had described his life as having “an emptiness about it.” This incongruity (and in-session discussion thereof) ultimately led to the client’s revealing that he was in an on-again, off-again extramarital relationship that left him questioning his morals and life direction. Once again, the potential value of data from the DAS went well beyond a simple accounting of the client’s activities to identify significant problems that were not so obvious at the initial self-reporting.

In terms of scheduling activities, the following behavioral assignment can be presented to the client in the form of the following instruction—“create more, consume less.” Although this behavioral prescription is modest in its concept, many clients find that it is difficult to enact, as it asks them to reduce the “consumptive” activities on which they have come to rely for mood regulation, such as overeating, drinking too much alcohol, using illicit drugs, spending too much money on material goods or gambling, having sex in excessive ways (e.g., multiple, casual partners), and other behaviors that ostensibly “feed their monster” of low impulse control and poor self-image. At the same time, the “create more, consume less” credo asks the clients to increase the degree to which they create something good in their lives. It may be useful to assign the clients the homework of generating a list of such creative activities in which to devote more of their time and energy in the service of improving their self-esteem and mood. An abbreviated example of such a list follows:

Following the “consume less, create more” theme can be naturally antidepressive, but therapists must be empathic and understanding about the difficulties their clients may encounter in trying to pursue their goals. Enacting this credo requires the client to delay gratification, tolerate discomfort, summon up energy, and think in a constructive manner—all difficult tasks for the depressed individual. Nonetheless, it offers a simple, understandable blueprint for counteracting helplessness and gaining some distance from habitual behaviors that otherwise worsen one’s mood and self-esteem.

Role-Playing

Acquiring an effective behavioral repertoire usually requires a process of trial and error. To the degree that someone can take the “error” part of the equation in stride, much learning can be accomplished over the years. Unfortunately, some of our clients are quite averse to making mistakes, owing to personal histories of being unduly punished by important others for not doing things “right,” and/or their own self-punitive or catastrophic mindsets regarding what will happen if they dare to try but “fail.” When this occurs, clients miss many opportunities to learn new, adaptive behaviors, particularly in the realms of appropriate emotional self-expression, assertiveness, public speaking, and general conversational skills. The resultant deficits in these skill sets aggravates a depressed client’s sense of low self-efficacy, leading them to engage in further avoidance of trial-and-error opportunities in life. Especially for such depressed clients (many of whom also evince comorbid anxiety disorders), role-playing represents a promising technique in CBT.

The best way to encourage clients to take part in role-play exercises is for the therapists themselves to show enthusiasm for this intervention. Far too many therapists sidestep this technique because they find it potentially awkward or embarrassing, just like their clients! However, it is possible to look at role-playing as a “no-lose” situation that makes the threat of feeling silly seem like part of the intervention rather than an impediment to its implementation. For the client, it is a win if the role-play succeeds in providing the client with an opportunity to practice a new behavior, and it is a win if it simply stirs up some hot cognitions that can be subject to modification via rational responding (see below). Similarly, for the therapist taking part in a therapeutic role-play, it is a win if he or she is able to model behaviors that are helpful for the clients to emulate; and it is a win if the therapist stumbles, stammers, and/or draws a blank, as this offers the therapist the chance to demonstrate some accurate empathy for the client’s difficulties. For example, in the case of a client who struggles to assert herself with her overbearing, hypercritical father, the therapist may elect to play the role of the client, while the client plays the role of the father. If, in the course of the role-play, the therapist is at a loss as to how to respond to the “father’s” harsh comments (as portrayed by the client), the therapist can say, “Wow, does he really say things like that to you? That’s outrageous! I had no idea what you were up against. Now I see why it’s so difficult for you to face him. I guess we really have our work cut out for us.” This sort of interaction bolsters the therapeutic relationship, while demonstrating that even a “failed” role-play contributes useful information.

As we can see, role-playing has multiple uses. It offers the opportunity for the client to practice new interpersonal repertoire, in the safety of the therapist’s office, with multiple chances to repeat the exercise, thus gaining practice without any of the objective trial-and-error drawbacks that may occur in everyday life outside the office. Role-playing stimulates hot cognitions, in that the clients will likely be emotionally activated in the process, thus helping to identify new, relevant cognitions. It can also be used in the service of reenacting important past situations that clients wish to process, as well as rehearsing upcoming interactions (e.g., a job interview) for which the clients want to prepare. Role-playing can be used in a hypothetical manner, such as when a painfully shy client is asked to read a script (written by the therapist) depicting a highly confident person so as to provide the client with an almost visceral experience in functioning at a higher level. Role playing can depict metaphorical arguments between different parts of the client’s experiences, such as when the therapist plays the role of the client’s “cynical, pessimistic” self, while the client has to play the role of his or her “aspiring, optimistic” self, providing hopeful rebuttals against the therapist’s comments, in the form of a friendly debate. Novel or otherwise useful responses that the client generates in the process of doing such role-plays should be written down as examples of more functional ways of thinking.

Of course, therapists wish to be collaborative with their clients and therefore should not be too forceful in insisting that clients do the role-plays if they flat out refuse. Nonetheless, therapists can assess the clients’ catastrophic expectations that inhibit them from taking part in this technique and can nicely ask if they may revisit the option of doing role-plays in future sessions. There is no safer place to practice new behaviors and new ways of thinking than in the privacy of the therapist’s office. If clients do not role-play there, it is highly unlikely that they will enact the target behaviors in their lives during the week, where risks may be real and where the clients may only get one chance to speak their minds. In sum, role-playing is a valuable, multipurpose intervention that is probably underutilized, given its therapeutic attributes.

Rational Responding (and Automatic Thought Records)

Rational responding is perhaps the quintessential CBT technique. Therapists teach clients to view their negative emotions (sadness, guilt, anger, shame, etc.) as cues to ask themselves the question, “What is going through my mind right now that could be contributing to my feeling this way?” The goal is to teach the clients the skill of spotting their automatic thoughts in given situations, to evaluate these thoughts, to test their validity, and to modify them to a more constructive form. Patterns in automatic thoughts may lead therapists and clients to ascertain certain beliefs or deeper schemas that clients may maintain that adversely affect their emotional lives (see Beck, Davis, & Freeman, 2004; Young, Klosko, & Weishaar, 2003). With training and practice, clients can learn to spot and counteract the thoughts that otherwise would maintain and/or exacerbate their depressive symptoms. Clients use a series of questions (adapted from the ATR; see J. S. Beck, 1995) to help themselves reconsider the validity and/or utility of their thoughts. Such questions include (see Newman & Beck, 2009):

• What are some other plausible ways I can look at this situation?
  
• What concrete, factual evidence supports or refutes my automatic thoughts?
  
• What constructive action can I take to deal with this situation?
  
• What sincere, helpful, realistic advice would I give to a good friend in the same situation?
  
• What is the worst-case scenario in this situation? What is the best-case scenario? Now that I have considered both extremes, neither of which is statistically likely to occur, what is the most likely outcome?
  
• What are the pros and cons of continuing to believe my automatic thoughts? What are the pros and cons of trying to change my automatic thoughts to make them more constructive and hopeful?

Although all of the earlier questions can be used in the service of testing and modifying depressive thinking, it is not necessary to use all of these questions for all maladaptive thoughts and/or in all cases. This is where it is useful for the therapist to have a good conceptualization of the case, including a firm grasp of the important events of the client’s life. For example, if a depressed client has made many unwise decisions in her life and therefore has suffered many losses (e.g., her addiction problems have led her to leave school, lose jobs, and get divorced), there is a basis in fact for her thought, “I’ve made so many mistakes, and now that my life is damaged and hard to manage, I have nobody to blame but myself.” Therefore, the therapist would not be so be quick to utilize a question such as, “What concrete, factual evidence supports or refutes my automatic thoughts?” Clearly, there is plenty of hard evidence that supports the client’s depressive thinking! However, it may be quite constructive to ask some of the other questions from the earlier list. Let us consider how the therapist and the client, working collaboratively in session, might answer the following three questions: