A CBT therapist aims to help people suffering from emotional problems [...]]]> Cognitive Behavioural Therapy (CBT) is an effective psychotherapy
for a wide range of emotional and psychological problems. The basic tenet of CBT is that our emotions are affected by our cognitions. To put it another way – the way we think affects the way we feel.

A CBT therapist aims to help people suffering from emotional problems by helping them to identify the ways in which their thinking may be causing their problem. A first step in CBT is therefore the identification of “Negative Automatic Thoughts” (or “NATs” for short) – these are the thoughts that accompany unpleasant or unhelpful emotions such as depression or anxiety.

A closely related aim of the CBT therapist is the identification of so-called “Thinking Errors”. These are habitual (and unhelpful) ways a person has of thinking about themselves, others, and the world around them. These thinking errors will often twist or distort experiences, acting to make the person seem a failure, others as hostile, and the world as dangerous or unpleasant.

The identification of NATs and related Thinking Errors is half the battle in CBT – once a person is aware of their unhelpful thoughts and mental habits they can then choose to think in more rational, healthy ways. A CBT therapist can guide them through this (fairly straightforward) process.

As a Psychiatrist and therapist working in Edinburgh I use CBT techniques extensively. Some of my clients are quite happy with the results they get from simply challenging their NATs and Thinking Errors – they feel much better and have no desire to delve further. However, the majority of clients are keen to “get to the bottom” of why they had their emotional problems in the first place. I tend to encourage this further work as it helps to reinforce the progress made to date and, in my opinion, helps to prevent the client from relapsing at some future date.

This further work involves a search for “Negative Core Beliefs” (or “NCBs”). These are the unhelpful beliefs that a person has had throughout their later childhood and adult life. They are core components of the person’s personality and they are the root cause of the person’s Thinking Errors and ultimately their NATs. If a CBT therapist can help a person to change their Negative Core Beliefs (or, more realistically, find more rational and healthier alternatives), then the person’s Thinking Errors and NATs will diminish, and their emotional problems will lessen (usually!).

A difficulty with NCBs is that a person is rarely aware of them. Even when someone is competent at identifying NATs and Thinking Errors, the cause of these problems may be hidden. But we can use NATs and Thinking Errors as clues.

In my experience as a Psychiatrist in Edinburgh I have found two techniques of most benefit in the search for the NCBs of my clients.

Firstly, there is the method of “Repeated Questioning”. I ask the client what a particular NAT he has identified means to him – he will give an answer, and I then ask him what that answer means to him. He will give a second answer, and I then ask him what that second answer means to him, and so on. Within a short space of time, the client ends up with a global statement that can’t be taken any further. This is a Negative Core Belief. It’s probably best demonstrated with an example:

Client: “There’s loads of litter around Edinburgh” (He’s angry)
CBT Therapist: “What does that mean?”
Client: “That I’m the only one who cares about it”
CBT Therapist: “What does it mean if you’re the only one who cares about it?”
Client: “People don’t care about things that aren’t their personal property”
CBT Therapist: “And what does it mean if people only care about their own stuff?”
Client: “People are only out for themselves”

(“People are only out for themselves”. This is the client’s Negative Core Belief – a global statement that is uncompromising and will clearly influence the way he views and interacts with others in other areas of life, not simply littering!)

A second method of identifying Negative Core Beliefs is to look for the “themes” that run throughout a persons many NATs and Thinking Errors. Such themes may be “I’m a failure” or “There’s no point to life” (very common in depression), or perhaps “The world’s a dangerous place to live” (common in anxiety conditions).

Once a client’s Negative Core Beliefs have been identified, the CBT therapist will (along with the client) try and explore alternative and more rational ways of thinking about the self, others, and the world in general.

What can be done about Negative Core Beliefs? There are several options open to a CBT Therapist, but [...]]]> Please note that this is a “follow-on” article. It is best read after my articles “Cognitive Behavioural Therapy (CBT) and Negative Core Beliefs (NCBs) – Causes” and “Cognitive Behavioural Therapy (CBT) and Negative Core Beliefs (NCBs) – Identification”.

What can be done about Negative Core Beliefs? There are several options open to a CBT Therapist, but in my experience as a Psychiatrist and Therapist in Edinburgh I find that the following method is particularly effective.

Firstly, the method is to challenge these Negative Core Beliefs, in much the same way that a CBT Therapist would challenge a person’s Negative Automatic Thoughts. The CBT Therapist and the client can look for evidence that the Negative Core Belief is true, and then look for evidence that it is false. The client is then in a position to make a reasoned judgement as to whether it is rational and healthy to continue holding their Negative Core Belief. If they don’t think it’s rational, then they can begin to look for alternative beliefs that better explain the evidence.

An example of this method might be challenging a client’s Negative Core Belief that “People are dangerous”. Evidence in favour of this belief might be that they had unpleasant and frightening experiences growing up – perhaps their father was abusive, or they were severely bullied at school. Experiences as an adult may also play a role – the overbearing boss at work, or the “friend” who turns out to be rather two-faced etc. Evidence against the belief that “People are Dangerous” could include the fact that their mother and grandparents were kind and loving, and that she had a few friends at school who were supportive. Perhaps most of her work colleagues now are nice and trustworthy, and the boss is renowned for being unpleasant and cantankerous to everyone.

With evidence of this sort compiled both “for” and “against” the belief, the client can weigh it up and make a judgment. In this particular case, the evidence may seem roughly evenly balanced both “for” and “against”. In which case the client may decide not to totally reject their original belief, but modify it somewhat. They may decide that the statement: “Some people are dangerous, but some aren’t” is a better description of the evidence. Learning to live with this new modified belief will almost certainly lead to the client having less emotional problems.

However, this is easier said than done. After all, your Negative Core Beliefs have been with you a long time – they can seem like an integral part of who you are, and as such, you can’t just “turn them off” like that. They’re well-trodden paths that can feel very comfortable and familiar, even if (in the long run) they cause you a lot of problems.

What a CBT Therapist may suggest is that rather than trying to actively eliminate your Negative Core Belief, it can be more productive to focus your attention on actively cultivating your new, alternative Core Belief. In my experience as a therapist in Edinburgh, one of the most powerful ways that a client can employ in order to start thinking in newer, healthier ways is to start behaving as if they already truly believed the new Core Belief. That is, to make a conscious decision to act in accordance with their new belief. In the example given, the client will act as if they already believed the new core belief “Some people are dangerous but some aren’t”. They will (quite consciously and deliberately) assume that people are not always dangerous and act in accordance with this (e.g. smile, be friendly, trusting etc), and make a conscious note of the results of such behaviour. Ordinarily the results will be pleasant, positive, and re-inforcing of the new belief. By repeating this behaviour day-in and day-out it will become second-nature, and the client will, deep down, really start to believe their new Core Belief. No longer will they see all other people as inevitably dangerous, and their instinctive initial responses to others will reveal a mature and trusting attitude.

This CBT technique of acting “As-If” is a very powerful way of inculcating real sustainable changes in your Core Beliefs.

Thus it is important for me to help each client to become familiar with their [...]]]> The theory of Cognitive Behavioural Therapy, or CBT, is that emotions are closely linked to cognition. Put more simply, CBT says that “the way you think affects the way you feel”. People who think anxious thoughts will end up feeling anxious.

Thus it is important for me to help each client to become familiar with their own ways of thinking, and to help them to identify ways in which their thinking patterns may be contributing to their emotional problems.

A CBT therapist has a term for patterns of thinking that can lead to emotional problems – they are called “Thinking Errors”. Many different types of thinking error have been identified over the years, but what follows is a brief summary of those thinking errors commonly found when working with people suffering from anxiety.

“Catastrophising” is a thinking error frequently found in anxious people. In fact, I’m sure we’ve all done it ourselves at some point! When someone catastrophises they automatically “assume the worst”. A message to call back the boss is taken to mean that you’re going to be sacked, a clunking noise in your car means that the engine is about to fall to bits, and a pain in the chest is the beginnings of a heart attack. CBT hypothesises that habitually thinking like this will lead to long-term problems with anxiety.

Another common thinking error seen in people with anxiety is called “Mind-Reading”. As the name suggests, a person who’s exhibiting this thinking error will believe that they know (absolutely know) what people are thinking about them. This belief will often go contrary to what the other person says and does, and is almost always pessimistic in nature. For instance, if the CBT therapist yawns (heaven forbid!) during a session, the client will know that the CBT therapist is bored or fed up with them – even if the therapist apologises and explains that her young daughter is teething and kept her awake last night. Or if the person gets invited to a dinner party, they will know that they’re only invited along to make up the seating numbers. Thinking in this way can make life one long series of possible sleights and put-downs, leading to increased anxiety and excessive monitoring of those around you.

“Fortune Telling” is a third common thinking error in anxiety. People thinking in this way know what is going to happen in the future. And, lo and behold, it’s bad! The bus will definitely be running late, they will definitely fail the interview, and they will absolutely make a fool of themselves at the works party. Not a pleasant way to think. And certainly not a good way to prepare for an interview (or even a party!). CBT encourages people to “keep it real” – there’s enough strife out there without looking into the future for extra!

The term “rumination” relates to a repeated cycle of activity – in the case of cows (“ruminants”), this means chewing the cud! In CBT [...]]]> Cognitive Behavioural Therapy, or CBT, is an effective psychological treatment for a wide range of psychological and emotional problems. A prominent feature of their symptom profile is the presence of “Depressive Ruminations”.

The term “rumination” relates to a repeated cycle of activity – in the case of cows (“ruminants”), this means chewing the cud! In CBT circles, ruminations are the repeated, seemingly endless, “stuck” ways of thinking seen in certain psychological conditions. It is particularly common in depression.

There can be many “themes” to an individuals ruminations, but the most common is a search for some sort of answer to questions such as “Why am I feeling like this?” or “What could I have done to avoid this?”. Another common theme is one of remorse or regret – “If only I had done (whatever) differently I wouldn’t be in this position now” or “I’ve ruined my life”. Depressive ruminations about the future are also seen – “Everything’s going to go wrong”. Ruminations often incorporate what a CBT therapist would call “Thinking Errors”.

What does it feel like to ruminate? Well, I’m sure we’ve all done it at one time or another! It’s like trying to solve an unsolvable riddle – you just go round and round inside your head, examining the same old “clues”, time and time again. If only you’d done this, or said that, or had this, or not had that. You convince yourself that there’s an answer, and that when you find it then you’ll be fine. But of course there is no “answer”. People can ruminate for hours in severe cases, but up to an hour is more usual.

How do you know when you’re ruminating? Because you’ve stopped doing everything else! You haven’t turned the page of your book for the past 20 minutes, or you’re standing in the kitchen with a dishcloth in your hands, gazing off into space. If someone asks you what you’ve been thinking, you can bet it’s the same old depressive thoughts that you’ve been carrying around for ages.

Is there a problem with ruminating? Well, yes. It differs from other forms of thought such as problem-solving, or reflecting, or remembering, in two ways. Firstly, most people find it rather unpleasant. The same old worries getting churned up again and again are bound to make us feel sad or anxious. Secondly, rumination tends to worsen (or at least maintain) depression – if you focus on how bad you feel and how hopeless (you feel) your situation is, then you will ignore opportunities for change.

CBT theory sees depressive ruminations as a major obstacle to recovery from depression, and as such it is important for clients to learn how to deal with them. There are a range of techniques, but the ones I favour are both simple and effective (and almost common sense!).

If you realise you are ruminating, then now’s the time to do something energetic. It’s hard to ruminate when you’re out on a run, or swimming, or doing press-ups. The pain tends to get in the way! Or, if you’re not the exercise type, try refocusing your attention. Focus (really focus hard!) on some aspect of your surroundings – a picture on the wall, a tree, the cat – and examine it for detail, noting each and every irregularity and shade of colour. Pretend that you’re a famous artist and that you’re going to paint the most brilliant, detailed, lifelike picture ever! Really focusing on things outside of you (meaning “outside of your head”!) helps to dislodge your thinking from ruminative patterns. A final tactic – one that some clients swear by and others can’t get the hang of at all – is to “stand-back” (“in your head”, as it were!) and let your thoughts simply churn away to themselves, whilst acknowledging them as pointless symptoms of your depression. By letting them “get on with it”, and refusing to “play with them”, you disarm them of their depression-causing capability – eventually they’ll get bored and go away!

There are a number of other methods out there in the literature, and I don’t claim that these work for everybody. A good thing about the CBT ethos is that it shies away from doctrinal doings – there’s no “You have to do it this way or else!” in CBT. So the bottom line is, use whatever method you find helps you the most, and say “Goodbye!” to those unpleasant ruminations!

The theory behind this method was formed as a result of merging the works of [...]]]> Cognitive therapy is first and foremost a psychotherapeutic approach which attempts to influence human behaviours and dysfunctional emotions. The methodology behind cognitive therapy is to analyse negative emotions and identify inaccurate and dysfunctional behaviours. The method is both goal-oriented and well-organised.

The theory behind this method was formed as a result of merging the works of Aaron T. Beck and Albert Ellis. The two theories that were merged to create this method were behaviour theory and cognitive theory. It is therefore now known as Cognitive Behavioural Theory (CBT). Albert Ellis first originated rational therapy which was a main step in the development of CBT. Aaron T. Buck was inspired by Ellis’ work and this led him to develop cognitive therapy.

In the beginning both of these theories were compared and there was an attempt made to determine which one was the best approach. However they were merged instead into one to form CBT. The creation of this joint theory has led to the development of successful treatments for panic disorders. CBT is also very good for the treatment of issues including: personality complexes, anxiety, mood, and substance abuse. Other psychotic issues can also benefit from CBT and it has been used to reduce some criminal behaviour as well.

After analysing negative emotions and identifying inaccurate and dysfunctional behaviour, CBT seeks to replace these harmful influences with more realistic and positive ones. Some of the therapeutic systems which make up CBT are: cognitive therapy, rational emotive behaviour therapy and multi modal theory. Techniques included in these systems include keeping a record of negative feelings, thoughts, behaviour and beliefs and learning how to accurately identify them. These techniques are practiced by the patients themselves under the monitoring of a therapist. CBT can help stabilize mood and treat conditions like bipolar disorder.

If there is a phobia of social situations, the same theory and methods are used however they are modified slightly for use in a group setting.

Clients can also use software programs to practice CBT. These programs can serve as an alternative to a face-to-face meeting with a therapist. If a therapist is unavailable, this means that a patient can still get the guidance and the counselling that they need. Some people who suffer from depression and loss may feel too afraid or may hesitate in talking to a person about their problems. In these cases CBT software may be the best solution in these cases.

Some of the main conditions which are treated by CBT include insomnia, mental disorders, mood disorders and panic disorders. With the help of a therapist, a client may also do some behavioural experiments in order to see how and if this would help them improve their quality of life.

CBT is also used with children and adolescents. There has been some remarkable work done in this area by Mark Reinikie and his colleagues. The “Friends Program” that was started by Paula Barrette is also a part of the CBT approach. The World Health Organization has recognized that this program is the best for the treatment of anxiety in children.

CBT is very similar to the “Scientist Practitioner Model” where the clinical practice and research work is done from a scientific perspective. This method places an emphasis on measurement.

There are some non-CBT therapists who criticize its methodology. Some further information on CBT (including some of the criticisms) includes:
• The amount of research and published literature on CBT may give the impression that other, less documented forms of therapy are somehow inferior or sub-standard.
• People who undergo any form of therapy will, in theory, show some signs of improvement. Therefore, the number of people who are showing improvement may not be related to any extra level of effectiveness of CBT
• CBT is effective in the treatment of anxiety disorders. Studies do show that someone with one of these disorders may show much more improvement than someone with the same disorder who used a different method of therapy
• CBT provides a valuable level of relief from depression and other mood disorders
• Several analyses show that CBT is good at treating mental disorders. Recently, CBT has become well-known for its effectiveness in correctional settings. It can reduce criminal behaviour and CBT programs have been started in many different prisons and jails.
• Patients will show gradual improvement over the course of the therapy sessions. It is this continual level of improvement that has caused it to become well known in comparison with other therapy methods. Some disorders may show up again during the course of therapy but this is decreased by consistent and regular therapeutic sessions

It is important to realize that the effects of cognitive behavioural therapy will not be felt overnight. It can take considerable time and effort from the patient and the therapist in order to replace psychotic or negative behaviours.

To be sure, there are a great many antidepressants available, and many are very effective… but for those of us who prefer not to use such medications, or [...]]]> When most of us are faced with depression, whether it’s a friend, a family member, or ourselves, the first approach most professionals will take is the pharmaceutical route.

To be sure, there are a great many antidepressants available, and many are very effective… but for those of us who prefer not to use such medications, or have found them ineffective, cognitive therapy for depression can be an excellent substitute.

Even when medications are working well, we may also benefit greatly from some added cognitive therapy, for depression is a many-faceted issue that often needs to be addressed from several angles.

While the prevailing notion among many psychiatrists and mental health professionals is that depression is caused by faulty brain chemistry, the brain is not entirely out of our control. By understanding the thought processes that impact our happiness, we can learn – quite deliberately – how to avoid those processes and lead better lives.

Cognitive therapy for depression is not magic, nor is it an archaic approach; self-awareness, in all its forms, can only improve and enrich our lives. It can be likened to the old joke about the visit to a doctor: “Doctor, it hurts when I do this.”

“Well, don’t do that!”

Once you begin to achieve an awareness of the thoughts and beliefs that are leading you to feel depression, you can actively avoid those thoughts and beliefs. Cognitive therapy for depression is nothing more or less than an education in the way your own brain operates, and which thoughts and beliefs “hurt” – making you depressed.

An understanding of why we are depressed, and how we can overcome those impulses and instincts that lead us to unproductive behavior, often proves to be the missing factor that leads us to happier and more fulfilling lives.

2. Fortunetelling: You predict the future negatively: Things will get worse, or there is danger ahead. “I won’t get that job.”

3. [...]]]> A Guide for Patients
1. Catastrophizing: You believe that what has happened or will happen will be so awful and unbearable that you won’t be able to stand it. “It would be terrible if I failed.”

2. Fortunetelling: You predict the future negatively: Things will get worse, or there is danger ahead. “I won’t get that job.”

3. Mind reading: You assume that you know what people think without having sufficient evidence of their thoughts. “He thinks I’m an idiot.”

4. Labeling: You assign global negative traits to yourself and others. “I’m undesirable,” or “He’s a rotten person.”

5. Negative filtering: You focus almost exclusively on the negatives and seldom notice the positives. “Look at all of the people who don’t like me.”

6. Discounting positives: You claim that the positive things you or others do are trivial. “That’s what wives are supposed to do—so it doesn’t count when she’s nice to me,” or “Those successes were easy, so they don’t matter.”

7. Overgeneralizing: You perceive a global pattern of negatives on the basis of a single incident. “This generally happens to me. I seem to fail at a lot of things.”

8. Dichotomous thinking: You view events or people in all-or-nothing terms. “I get rejected by everyone,” or “It was a complete waste of time.”

9. Shoulds: You interpret events in terms of how things should be, rather than simply focusing on what is. “I should do well. If I don’t, then I’m a failure.”

10. Blaming: You focus on the other person as the source of your negative feelings, and you refuse to take responsibility for changing yourself. “She’s to blame for the way I feel now,” or “My parents
caused all my problems.”

11. Personalizing: You attribute a disproportionate amount of the blame to yourself for negative events, and you fail to see that certain events are also caused by others. “The marriage ended because I failed.”

12. Unfair comparisons: You interpret events in terms of standards that are unrealistic—for example, you focus primarily on others who do better than you and find yourself inferior in the comparison.
“She’s more successful than I am,” or “Others did better than I did on the test.”

13. Regret orientation: You focus on the idea that you could have done better in the past, rather on what you can do better now. “I could have had a better job if I had tried,” or “I shouldn’t have said that.”

14. What if?: You keep asking a series of questions about “what if” something happens, and you fail to be satisfied with any of the answers. “Yeah, but what if I get anxious?” or “What if I can’t catch my breath?”

15. Emotional reasoning: You let your feelings guide your interpretation of reality. “I feel depressed; therefore, my marriage is not working out.”

16. Inability to disconfirm: You reject any evidence or arguments that might contradict your negative thoughts. For example, when you have the thought “I’m unlovable,” you reject as irrelevant any evidence that people like you. Consequently, your thought cannot be refuted. “That’s not the real issue. There are deeper problems. There are other factors.”

17. Judgment focus: You view yourself, others, and events in terms of evaluations as good–bad or superior–inferior, rather than simply describing, accepting, or understanding. You are continually
measuring yourself and others according to arbitrary standards, and finding that you and others fall short. You are focused on the judgments of others as well as your own judgments of yourself. “I didn’t perform well in college,” or “If I take up tennis, I won’t do well,” or “Look how successful she is. I’m not successful.”

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