Assessing suitability for CBT:
Before starting Cognitive Behavioural Therapy (CBT), it is important to assess the client’s suitability for this type of therapy. This involves checking if they are able to identify their thoughts/emotions, want to change and have no cognitive impairments which would affect sessions.
If they struggle to differentiate between thoughts and emotions, then it can be useful to help them practice this using a Thoughts vs Feelings worksheet.
You can also give them a list of emotions to help them identify how they are feeling:
CBT is based on the assumption that how we think affects how we feel and behave: Stimuli/event > thoughts/judgements > emotions > behaviour. It is not the event itself that makes you feel anxious or depressed, but your interpretations of the event.
We can respond to the same event in very different ways depending on our thoughts. For example:
People sometimes have negative automatic thoughts/unhelpful thinking styles, which can lead to inaccurate judgements about events. Here are some examples of these ‘mind traps’:
One way to help change your unhelpful thinking styles can be to keep a record of your negative thoughts.
ABC thought Records:
Start by writing down what happened and what you thought, felt and did in response to it. Rate how much you believed in your thought:
You then note down evidence for or against your thought:
Once you have looked at all the evidence for and against, you can decide how accurate your original thought was. All events have multiple meanings and there are often more helpful interpretations.
You generally have to complete this process several times to get into the habit of questioning your unhelpful thoughts. You can find the worksheet here.
You can also then try behavioural experiments, where you test out if some of your assumptions are true.
Write down what you plan to do (be as specific as possible) and what you think will happen as a result. For example: I will say hello to my classmates when I arrive at class on Monday. I predict that they will ignore me or laugh at me, to the point where I am so embarrassed that I leave.
You can find the behavioural experiment worksheet here
Usually the therapist and client will complete a formulation following assessment; this is a summary the client’s history, current presentation and maintaining factors. It is collaborative and dynamic, which changes often being made throughout therapy.
CBT formulations generally include: relevant childhood information, the presenting problem, core beliefs, underlying assumptions, automatic thoughts, emotions and behaviour.
Automatic thoughts are usually ideas or phrases that pop into your head without conscious control. For example, doing something wrong and thinking ‘I can’t believe I did that’ or being mistreated and thinking ‘how dare you’.
Underlying assumptions are usually unspoken rules that we live by. For example, ‘if I don’t get 100 percent then I’m a failure’ or ‘If I get up after 9am then people will think I’m lazy’.
Core beliefs are fundamental concepts about ourselves, others and the world, which are usually all-or-nothing generalisations eg ‘I am a failure’, ‘people are dangerous’ and ‘the world is a cruel place’. They can also be positive eg ‘I am successful’ or ‘I am a strong person’.
An example case conceptualisation would be:
Event: Make a minor mistake or don’t meet my high standards
Thought: ‘Why did I do that?!’
Emotion: Depression, annoyance with self and guilt.
Behaviour: Working even harder or self harming.
Core belief: I’m a failure.
Underlying assumption: If I don’t do everything 100 percent right then I’m a failure.
Thre are various ways to organise a Formulation, such as the 5 P’s:
And longitudinal formulations:
CBT techniques and sessions:
CBT therapists use socratic dialogue (open informational questioning, active listening through reflection, analytical questioning and summarising) to help the client explore their current thoughts and identify new, more helpful ways of thinking.
At the start of each session, the therapist and the client set an agenda. In between sessions, the client may be asked to try some ‘homework’.