Cognitive therapy is an active, directed, time-limited, structured approach, used to treat a variety of psychiatric disorders (depression, anxiety, phobias, chronic pain and others)

1. Silvina Galperin, D. Psych., C. Psych
CBT workshop
For Internationally trained
Health Professionals
CAMH

2. Cognitive Therapy
Definition
Cognitive therapy is an active, directed,
time-limited, structured approach, used
to treat a variety of psychiatric disorders
(depression, anxiety, phobias, chronic
pain and others)
It is based on an underlying theoretical
rationale that an individual’s affect and
behaviour are largely determined by the
way in which he structures the word
Aaron Beck (1979)

3. Cognitive Therapy:
Characterisitcs
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Present oriented
Based on an ongoing case
conceptualization
Educative: teaches patient to be selftherapist
Time-limited
Collaborative
Structured
Goal oriented: problem focused
Variety of techniques to change
thoughts, feelings and behaviour
Relapse prevention

4. Principles of Cognitive Therapy
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Strong therapeutic alliance
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Goal oriented and problem focused
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Emphasizes skill acquisition
 Homework
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Uses cognitive and behavioural techniques to
change thinking, mood and behaviour.
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Thought records, Socratic questioning, action
plans, behavioral experiments, cognitive
continuum, exposure and other techniques to
evaluate and modify dysfunctional thoughts
and beliefs (cognitive restructuring).

5. Suitability for Brief Cognitive
Therapy
Dimensions:
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Accessibility of Automatic Thoughts
Awareness and differentiation of emotions
Acceptance of personal responsibility with
treatment
Compatibility with cognitive rationale
Alliance potential (in-session)
Alliance potential (out- of-session)
Focality
Security operations
Chronicity vs. Acuteness
Optimism vs. Pessimism
Safran, J., Segal, Z. (1990) Interpersonal process in
Cognitive Therapy. Basic Books. New York

6. Structure of the CBT Session
Six components
1. Mood check up
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How was your mood during the past week?
What did you work on during the last week?
2. Bridge from previous session
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What did you learn in the last session?
Was there anything that bothered you our last session?
3. Agenda Setting
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What problems do you want to put on the agenda?
Which ones have priority for today’s session?
4. Review of Homework
5. Discussion of the Agenda, new
homework assignment
6. Final summary and feedback
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What do you think about today’s session?
What will be important for you to remember?

7. The Cognitive Model
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The cognitive model states that the
behaviour is reciprocally
determined by the individual’s
thoughts, feelings and physiological
reactions.
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None of these elements is
necessarily more important.
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The therapist can intervene by
focusing on each of these areas at
different times of the treatment.

8. Cognitive Model
Thoughts
Environment
Moods
Physiological reactions
Behaviour

9. How to use the Cognitive Model
with the clients: Examples
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1. Pierre is a VP of multinational company. Three months ago
he was diagnosed with rosacea. He thinks that to have his face
red is a sign of weakness and that people will think he is afraid
or nervous and this makes him feel extremely uncomfortable,
irritable and anxious.
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2. Chris is a 21 year old student that is afraid of meeting people.
He has friends but when there are new people around he just
can’t talk.
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3. Greta is a 67 year old married, retired woman who has been
avoiding to get out of her home for 2 months. She had several
episodes of diarrhea at home and now she is afraid of having
an “accident” anytime.
Other examples:
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Typical cases of depression
Typical cases of separation anxiety

10. Role Playing
Introducing the Cognitive Model
to a client
-Groups of Three1. Patient: Describes situation, answers therapist’s questions
2. Therapist: Asks questions to the client to clarify
3. Observer: Assists therapist and/or client, gives feedback
Task:
1.
Ask about a specific situation (where, when, with who, what
happened) in which the change of mood occurred (started to feel
afraid, embarrassed, anxious, etc.)
2.
Ask about all the emotions that this situation triggered in the client
and write it down
3.
What was going through your mind just before you started to feel
this way? What other thoughts did you have at that moment?
4.
Ask about specific physical sensations associated
5.
What was the resulting behaviour at that time

11. Goal Setting
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Why set goals for therapy?: CBT is a time-limited.
Setting some specific goals ensures that we work with a
focus and clients get the most out of therapy. It also
allows to track the progress in therapy.
Goals are based on the client’s expectations for
therapy
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What would you like to accomplish in therapy?
What woul ou like to be different in your life?
General
Overall areas that need improvement
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I want to be healthier
I want to take better care of myself
I want to have friends
Specific
Observable and reasonable changes that can be
measured
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What can do to start?
List small steps towards the goal
Are the steps observable?

12. Goal Setting
Specific
Measurable
Achievable
Realistic
Time-limited
Questions to answer:
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Where are you now?
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Where you would like to get?
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What small steps can you take to
get from where you are now to
where you want to be?

13. Practice setting up goals
Define general goals
 Prioritize 3 (the ones that would give most
immediate relief)
For each goal :
 Where are you now?
 Where would you like to be?
 Define small, reasonable, achievable,
measurable steps to take.
 Rate level of difficulty of each step
 Arrange according to the level of difficulty
starting from the easiest.
 Ask: What would be the first sign that you are
making progress?
 Practice setting up 8 small steps towards a
specific goal.
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14. Automatic Thoughts
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Are thoughts that pop into our heads
automatically throughout the day
We don’t have the intention of having
them
Usually, we are not even aware of them
One of the goals of cognitive therapy is
to bring automatic thoughts into
awareness
I.E.: If you are late for an appointment,
what would you think as you are
traveling to get there?

15. Identifying
Automatic Thoughts
Basic question:
What was going through your mind when you had that
strong feeling (or reaction to something)?
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Ask this question when you notice a shift in affect during a
session.
Have the client describe a problematic situation or a time
during which he/she experienced a shift in affect
If needed, use imagery to describe the situation in detail
"as if it's happening now«
If needed have the client roleplay a specific interaction
Other questions to elicit automatic thoughts:
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What do you guess you were thinking about?
What did this situation mean to you?
What images or memories did you have in this situation?
What were you afraid might happen?
Were you thinking____________? (Therapist supplies an
automatic thought opposite to the expected one.)
What does this say about you, your life, your future?

16. What are the cognitions we
evaluate in therapy?
Interpretations
Meanings
Predictions
Judgments
Labels
Memories
(selective)
Images
Self-talk
Perceptions
Attributions of
cause as to
why things
happen

17. Hot Thought
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Is the thought that is more emotionally
charged -- strongly connected with the
emotional shift.
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Is the thought that triggers the mood
change.
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Appear spontaneously during the day.
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It can be words, images or memories.
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We circle the Hot Thought in the
Thought Record and focus on this
thought.

18. THOUGHT RECORD
Situation Mood Automatic Evidence Evidence Balanced/ Re-rate
1- 100 Thought For AT Against Alternative Mood
AT
Viewpoint

19. Thought Record
First 3 columns
Situation
1.
2.
3.
4.
What
When
Where
With who
Mood
(Rate 0-100%)
Automatic
Thoughts
(Circle Hot Thought)

20. Evidence that supports
the Hot Thought
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We ask for facts, things that actually happened
in the past.
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This includes situations, experiences, reactions,
consequences, etc.
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We don’t write down ideas, interpretations of
facts or thoughts in this column

21. Evidence Against the
Hot Thought
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Have I had any experiences that don’t support the H.T.
or that would indicate that it is not 100% true?
If my best friend would have this thought, what would I
tell him/her?
When I am not feeling this way, do I think differently in
the same situations? How?
When I felt this way in the past, what helped me feel
better?
In five years from now, would I look at this situation
differently? Would I focus on a different part of my
experience?
Are there any positives in me or the situation that I am
ignoring?
Am I blaming myself for something over which I do not
have complete control?
Adaptation from Mind over Mood, Greenberger, Padesky 1995 Guildford Press

22. THOUGHT RECORD
Situation Mood Automatic Evidence Evidence Balanced/ Re-rate
1- 100 Thought For AT Against Alternative Mood
AT
Viewpoint

23. How to create a Balanced or
Alternative Thought
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Considering the information listed for and against the
hot thought, is there an alternative way of understanding
or thinking about this situation?
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Write one sentence summarizing or combining the
information of both columns (using “even though”,
“and”, etc.)
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Can other people think of other way of understanding
this situation?
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If a friend of mine would be in this situation, how would
I suggest to understand it?
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If my hot thought is true, what is the worst, the best and
the most realistic outcome?
Adaptation from Mind over Mood, Greenberger, Padesky 1995 Guildford Press

24. Cognitive Distortions
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Are patterns of dysfunctional thinking
Instead of reacting to the reality of an
event, an individual reacts with a
personal interpretation that is partial.
For example, a person may conclude
that is worthless just because he was not
invited to a party or did not pass an
exam.
Cognitive therapists make patients aware
of these distorted thinking patterns.

25. COGNITIVE DISTORTIONS
-Patterns of negative thinking1. All or nothing thinking: You view a situation in only two
categories instead of on a continuum.
"If I'm not a total success, I'm a failure."
2. Castastrophizing: You predict the future negatively without
considering other, more likely outcomes.
" I’ll be so upset, I won't be able to function at all."
3. Disqualifying or discounting the positive: You
unreasonably tell yourself that positive experiences or qualities do
not count. I did that project well, but that doesn't mean I'm competent; I
just got lucky."
4. Emotional reasoning: You think something must be true because
you "feel" (actually believe) it so strongly, ignoring or discounting
evidence to the contrary.
"I know I do a lot of things okay at work, but I still feel like a failure.»
5. Labeling: You put a fixed, global label on yourself or others
without considering that the evidence might more reasonably lead
to a less disastrous conclusion.
"I'm a loser." " He's no good. »
6. Magnification/minimization: When you evaluate yourself,
another person, or a situation, you unreasonably magnify the
negative and/or minimize the positive.
"Getting a mediocre evaluation proves how inadequate I am. Getting high
marks doesn't mean I'm smart."

26. David Burns
3 columns exercise to identify cognitive
distortions
Automatic
Thought
Identify
Cognitive
Distortions
If I don’t present Mental Filter
an excellent report Catastrophizing
to my boss, he
might fire me and
I won’t have
money to support
my family.
(Anxious 90%
Afraid 80% )
Alternative
Thought
Even if this report
is not presented in
an excellent way, I
am an efficient,
reliable and
experienced
employee and
would not be so
easy to replace me.
(Anxious 50%,
Afraid 40%)

27. Examples of Non-Socratic
Questions/Comments
(note how much less useful they are. )
1. Why are you being so hard on yourself?
2. What's the big deal about yelling at
your kids? Almost everyone does it.
3. Didn't your parents ever yell at you?
4. I'm sure your kids will get over it. It doesn't
seem so bad to me .
5. You're basically a great mother; don't you
remember what you told me you did for your
kids the other day?

28. Read more about Cognitive
Behavioural Therapy here:
http://www.cbtpsychology.com/
Thank you!