A Therapist's Guide to Brief Cognitive Behavioral Therapy, Lecture notes of Psychotherapy

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A T H E R A P I S T ’ S G U I D E T O

BRIEF COGNITIVE

BEHAVIORAL THERAPY

JEFFREY A. CULLY, PH.D.

ANDRA L. TETEN, PH.D.

Published by the Department of Veterans Affairs, South Central Mental Illness Research,

Education, and Clinical Center (MIRECC), 2008.

Suggested citation: Cully, J.A., & Teten, A.L. 2008. A Therapist’s Guide to Brief Cognitive

Behavioral Therapy. Department of Veterans Affairs South Central MIRECC, Houston.

To request a copy of this manual, please contact Michael Kauth at michael.kauth@va.gov

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This manual is designed for mental health practitioners who want to establish

a solid foundation of cognitive behavioral therapy (CBT) skills. Concepts

contained in the manual detail the basic steps needed to provide CBT

(“Practicing CBT 101”) with the intent that users will feel increasingly

comfortable conducting CBT. The manual is not designed for advanced

CBT practitioners.

Instructional material in this program is designed to be used within the

context of a psychotherapy supervisory relationship to ensure appropriate

application of the training materials and timely feedback, which are viewed

as critical to the development of CBT skills.

The content of this manual is a compilation of foundational works on CBT,

such as Judith Beck’s (1995) Cognitive Therapy: Basics and Beyond, with the

addition of key skills needed for developing CBT therapists. The information

is condensed and packaged to be highly applicable for use in a brief

therapy model and to aid in rapid training.

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1 Introduction to Brief Cognitive Behavioral Therapy (CBT) .... 06

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4 Case Conceptualization and Treatment Planning .............. 18

ESSENTIAL CBT SKILLS

5 Orienting the Patient to Brief Cognitive Behavioral Therapy .. 28

6 Goal Setting ............................................................................. 32

7 Agenda Setting ........................................................................ 36

8 Homework .................................................................................. 40

9 Identifying Maladaptive Thoughts and Beliefs .................. 44

10 Challenging Maladaptive Thoughts and Beliefs .................. 54

11 Behavioral Activation ............................................................. 60

12 Problem Solving ....................................................................... 66

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14 Ending Treatment and Maintaining Changes ..................... 82

Module 1: Introduction to Brief Cognitive Behavioral Therapy (CBT)

Objectives

To understand CBT and the process of Brief CBT

To identify key treatment considerations and problems most suitable for Brief CBT

To learn how to assess the patient’s suitability for Brief CBT

What is Brief CBT, and why does it require specific treatment considerations?

CBT combines cognitive and behavioral therapies and has strong empirical support for

treating mood and anxiety disorders (Chambless & Ollendick, 2001; DeRubeis & Crits-

Christoph, 1998). The basic premise of CBT is that emotions are difficult to change directly,

so CBT targets emotions by changing thoughts and behaviors that are contributing to the

distressing emotions.

CBT builds a set of skills that enables an individual to be aware of thoughts and emotions;

identify how situations, thoughts, and behaviors influence emotions; and improve feelings

by changing dysfunctional thoughts and behaviors. The process of CBT skill acquisition is

collaborative. Skill acquisition and homework assignments are what set CBT apart from “talk

therapies.” You should use session time to teach skills to address the presenting problem and

not simply to discuss the issue with the patient or offer advice.

Brief CBT is the compression of CBT material and the reduction of the average 12-20 sessions

into four to eight sessions. In Brief CBT the concentration is on specific treatments for a

limited number of the patient’s problems. Specificity of the treatment is required because of

the limited number of sessions and because the patient is required to be diligent in using

extra reading materials and homework to assist in his or her therapeutic growth.

Brief CBT can range in duration from patient to patient and provider to provider. Although

variability exists, the following table shows an example session-by-session outline. You are

encouraged to think flexibly in determining length of treatment. Time-limited therapy may

offer additional incentive for patients and therapists to work efficiently and effectively.

However, the exact length of treatment will likely be determined by a host of factors

involving the therapist, patient, and treatment setting. As indicated in the following table,

you are not expected to rigidly adhere to a "set schedule" of progress or topics but rather

should be flexible and adaptive in approaching all brief CBT applications. For example, it is

often helpful to work within a "session-limited framework" where the patient receives four to

six sessions of "active" treatment, followed by one or more follow-up sessions that occur at

increasing intervals after the active-treatment phase (e.g., 2 weeks post treatment with an

additional booster 4 weeks after that).

Potential Brief CBT Session Structure

Session Content Possible Modules Session 1 Orient the Patient to CBT. Assess Patient Concerns. Set Initial Treatment Plan/Goals.

Module Module Module

Orienting the Patient Case Conceptualization Goal Setting Session 2 Assess Patient Concerns (cont'd). Set Initial Goals (cont'd)

Module Module

Case Conceptualization Goal Setting

Or

Begin Intervention Techniques.

Technique Modules 9-13: Maladaptive Thoughts, Behavioral Activation, Problem Solving, Relaxation Session 3 Begin/Continue Intervention Techniques Technique Modules 9- Session 4 Continue Re-assess

Intervention Techniques. Goals/Treatment Plan.

Technique Modules 9- Module 4: Case Conceptualization Module 6: Goal Setting Session 5 Continue/ Refine Intervention Techniques. Technique Modules 9- Session 6 Continue Intervention Techniques. Technique Modules 9- Session 7 Continue Intervention Techniques. Discuss Ending Treatment and Prepare Maintaining Changes.

for

Technique Modules 9- Module 14: Ending Treatment Maintaining Changes

and

Session 8 End Treatment and Help Patient to Module 14: Ending Treatment and Maintain Changes. Maintaining Changes

When? (Indications/Contraindications)

Certain problems are more appropriate for Brief CBT than others. The following table

summarizes problems that may and may not be conducive to Brief CBT. Problems

amenable to Brief CBT include, but are not limited to, adjustment, anxiety, and depressive

disorders. Therapy also may be useful for problems that target specific symptoms (e.g.,

depressive thinking) or lifestyle changes (e.g., problem solving, relaxation), whether or not

these issues are part of a formal psychiatric diagnosis.

Brief CBT is particularly useful in a primary care setting for patients with anxiety and

depression associated with a medical condition. Because these individuals often face

acute rather than chronic mental health issues and have many coping strategies already in

place, Brief CBT can be used to enhance adjustment. Issues that may be addressed in

primary care with Brief CBT include, but are not limited to, diet, exercise, medication

compliance, mental health issues associated with a medical condition, and coping with a

chronic illness or new diagnosis.

Other problems may not be suitable for the use of Brief CBT or may complicate a

straightforward application of Brief CBT. Axis II disorders such as Borderline Personality

Disorder or Antisocial Personality Disorder typically are not appropriate for a shortened

therapeutic experience because of the pervasive social, psychological, and relational

problems individuals with these disorders experience. Patients exhibiting comorbid

conditions or problems also may not be appropriate because the presence of a second

issue may impede progress in therapy. For example, an individual with substance

dependence comorbid with major depression may not be appropriate because the

T hings to Consider in Evaluating Patients for Brief CBT

1. Strong Motivation to Change a. Increased distress is often associated with increased motivation to change. b. Positive treatment expectancies (e.g., knowledge of CBT and perceived benefits of treatment is associated with improved outcomes). Alternatively, the patient does not have negative self-thoughts that might impede progress or change (e.g., "Seeking care means I am crazy”; "Nothing I will do can change things"). c. Patients who have clear goals for treatment are good candidates.
2. Time Commitment a. Patient is willing to devote the time needed for weekly sessions. b. Patient is willing to devote energy to out-of-session work (e.g., homework).
3. Life Stressors a. Too many life stressors may lead to unfocused work and/or frequent "crisis- management" interventions. b. Patients who are supported by family and friends are more likely to benefit.
4. Cognitive Functioning and Educational Level a. Not being able to handle the extra independent reading material and/or homework expectations may be a poor prognostic indicator. b. Patients able to work independently are more likely to carry out between- session work. c. Patients who are psychologically minded are more likely to benefit from short- term therapy.
5. Severity of Psychopathology a. Patients with comorbid psychopathology may be more difficult to treat in short- term therapy. In addition, some conditions such as substance abuse or serious mental illness require focused and more intensive interventions. b. Patients with an Axis II diagnosis are also less likely to benefit from short-term CBT. Long-standing interpersonal issues often require longer treatment durations.

Supplemental Materials

Bond, F.W. & Dryden, W. (2002). Handbook of Brief Cognitive Behavioral Therapy. San

Francisco: Wiley.

Module 2: Using Supervision

Objectives

To discuss the importance of supervision / consultation in CBT training

To provide information on how to use clinical supervision and consultation in CBT

training

To outline various models of supervision / consultation in CBT training

To provide tips on selecting a supervisor / consultant

Introduction

Knowledge about psychotherapy can be broken down into two broad domains – 1)

knowledge of concepts and 2) knowledge of how to apply concepts. Information

contained in this manual will provide you with a basic knowledge of CBT concepts and will

attempt to provide you with practical tips on how to use these concepts. However,

because the provision of CBT is highly variable, depending on the therapist, patient, and

treatment setting, applications of CBT will need to be customized and practiced in real-

world settings. This manual is therefore only the first step toward obtaining information and

knowledge about how best to apply CBT principles to actual clinical patients. Supervision

and consultation are two methods to advance CBT practice skills through routine feedback

and interaction with a CBT trainer.

What is Supervision, and why Is It Important to CBT?

Supervision is designed to a) foster the supervisee's development and b) ensure patient

welfare and safety by monitoring patient care – see following table:

Goals and Focus of Supervision

For the Supervisee □ □ □ □

Provides therapist performance feedback Provides guidance and acquisition of alternative viewpoints Contributes to the process of forming a therapist's identity Serves as a secure base to explore applications and t herapeutic principles For the Patient □ To ensure that patients receive acceptable care

• Therapists do no harm
• Therapists possesses sufficient skills
• Those who lack skills are provided with remediation Supervision is NOT Therapy … although supervision may involve an t herapist's personal experiences, such a focus is t hat influence the therapist's professional work.

exploration restricted to

of a issues

Supervision versus Consultation

There is a difference between supervision and consultation. Whereas supervision involves

the direct oversight of clinical cases over a period of time (often involving evaluation of the

clinician), consultation refers to a relationship that is designed to assist in professional

development but does not involve formal oversight of clinical cases and may or may not

continue over time. In essence, consultation involves a growth-oriented discussion of cases

or issues without oversight or evaluation.

Selecting a Supervisor/Consultant

The following are characteristics to seek out in selecting a CBT supervisor or consultant:

1) CBT knowledge and practice experience

o Ideally, CBT supervisors and consultants have received formal training in CBT

and use CBT in their daily practice settings.

2) Availability

o For those first learning how to apply CBT, it is highly recommended that you

identify supervisors/consultants who are available for weekly or bi-weekly

meetings that involve anywhere from 30 to 60 minutes per meeting. The

actual length of meetings can be determined by the number of cases being

reviewed.

o Consider logistical issues in scheduling. Would the supervisor/consultant be

available for in-person or telephone sessions (in-person is more effective)?

Consider proximity, travel, and availability of resources (e.g., audio/video

taping).

3) Experience with a patient population similar to those you will be serving.

Supplemental Readings

Bernard, J. M. & Goodyear, R.K. (2004). Fundamentals of Clinical Supervision – 3rd

Edition. New York: Pearson.

Liese, B.S. & Beck, J.S. (1997). Cognitive Therapy Supervision. In Watkins, C.E. (Ed). In

Handbook of Psychotherapy Supervision. New York: Wiley; pp114-133.

Module 3: Nonspecific Factors in Brief CBT

Objectives

To better understand the need for a strong therapeutic relationship in Brief CBT

To understand the factors associated with a strong therapeutic relationship

To learn strategies for developing rapport and maximizing non-specific factors

What are Nonspecific Factors, and why are they important to CBT?

CBT is structured and goal-directed. The context is supportive, and the techniques are

paired with a collaborative therapeutic stance. Nonspecific factors refer to the relationship

components of therapy (e.g., rapport, installation of hope, trust, collaboration) and can be

compared with specific factors that refer to the technical aspects of psychotherapy (e.g.,

the actual techniques such as guided imagery, thought challenging, etc.) Nonspecific

factors are common within all psychotherapies and serve as the foundation for patient

improvement. Specific factors refer to intervention techniques unique to the type of therapy

being provided (e.g., CBT, psychodynamic, interpersonal). Studies show that nonspecific

factors are responsible for a large percentage of the change associated with

psychotherapy treatments.

When? (Indications/Contraindications)

Nonspecific factors are critical during the early stages, but important at all phases, of

treatment. Strong nonspecific factors aid in engaging and retaining patients in

psychotherapy and also strengthen the technical components of treatment. Patients who

perceive the therapeutic relationship to be collaborative, safe, and trusting are in a better

position to obtain benefit from the treatment, will likely be less resistant and will be more

open to exploration and change. As treatment progresses, the therapeutic relationship

should become stronger, allowing the therapist and patient to gradually move into more

complex and meaningful therapeutic issues.

How? (Instructions/Handouts)

Borrowing from person-centered therapy, this module focuses on three factors important to

the development of a strong therapeutic relationship. These factors are empathy,

genuineness, and positive regard. These concepts are defined and discussed but represent

general characteristics that all therapists should seek to attain in working with patients.

Following a discussion of these principles, the concept of active listening is introduced as a

technique to better attain a solid therapeutic relationship.

Empathy (Validating the Patient's Experience)

Empathy is the ability to understand experiences from another person’s point of view.

Empathy is an important part of building rapport and facilitates feelings of trust and mutual

respect between the patient and therapist. It is necessary for the therapist to consider the

concept of “multicultural empathy,” which relates to understanding persons from other life

backgrounds (ethnicity, socioeconomic status, age cohort, gender, etc.). It is impossible for

a therapist to be knowledgeable about every patient's unique background. Empathy,

which at its core consists of asking questions in a respectfully curious manner and expressing

emotional understanding of the answers received, is a solid first step towards understanding

patients' unique life background. Additional reading about cultural differences may

can cause a patient to feel inferior or intimidated. It is important to remember that

the therapeutic relationship is one of partnership and that the therapist and patient

work together to alleviate concerns, fears, and problems in the patient’s life.

Congruence: Making sure that your words, nonverbal behavior, and feelings match

each other is referred to as congruence. Not demonstrating congruence of your

feelings and thoughts can become confusing or misleading to a patient.

Spontaneity: This concept deals with the way the therapist speaks and the timeliness

of responses. Responses and feedback provided "in the moment" are more valuable

than feedback provided at a later time. Patients are more likely to receive

spontaneous messages as genuine.

Positive Regard

Positive regard simply means showing all patients the respect they deserve. It’s essential to

show the patient that he/she is valued and that what he/she has to say is important.

Patients who feel that their thoughts and feelings are acknowledged and understood often

share more and feel more connected to the therapist and the therapeutic process.

Communicating positive regard may be harder than it seems, especially if you hold some

negative beliefs about the person you are trying to help, which can be a common

experience for therapists. Sharing any negative feelings or beliefs about your patients with

your supervisor or consultant can be an excellent method to ensure that you develop and

demonstrate genuine positive regard toward your patients.

Commitment to the patient means that you are dedicated to working with the

patient on whatever issues he or she is bringing to therapy. This includes being on

time, avoiding cancelling the patient’s appointments, and using all efforts to help

the patient work through those issues.

Having a nonjudgmental attitude towards the thoughts, feelings, and actions of the

patient is essential. It is possible to accept and understand a perspective without

necessarily agreeing with it.

Displaying warmth towards patients is a vital part of building rapport. Warmth can be

displayed through tone of voice, facial expressions and body postures, or the

thoughtfulness of your responses.

The following section addresses the concept of active listening. Active listening is a useful

technique to communicate the nonspecific factors of empathy, genuineness, and positive

regard.

Active Listening

Listening to your patients is the foundation of all therapeutic approaches. Listening is made

up of three steps: receiving a message, processing it, and sending it back. Therapists should

attempt to remain open to all messages from their patients (both verbal and nonverbal),

and attempt to process as many messages as possible.

Clarification: Since we all speak from our own frame of reference, messages we send

to others may not be received in the way we intended. Clarification is a useful and

necessary tool for all therapists. Clarification can be used to help simplify a message

that is being sent by the patient or to help confirm the accuracy of what the

therapist thinks he or she understood.

Patient: I just do not feel like trying any more. Therapist: Tell me more about what you mean. Patient: I just feel like giving up. Therapist: Do you mean giving up on your goal to complete college; or are you referring to something different, like giving up on life and possibly harming yourself? Patient: I am not referring to suicide, if that is what you mean, but I am feeling really depressed. Each day seems like such a struggle, and I often just feel like staying in bed. When I said “give up,” I guess I was referring to not wanting to face all the struggles I face in life … my school work, financial problems, relationship problems, etc.

Notice that the clarifying statement and question helped the therapist and patient

to more fully explore her feelings and thoughts. Given this new information, the

therapist is in a better position to explore in more detail the patient's concerns and to

set up targeted efforts and strategies for treatment.

Paraphrasing and Reflection: These techniques involve restating the patient’s main

thoughts in a different way or reflecting back the emotions the patient is currently

experiencing to gain depth or clarification.

Patient: Since my fiancé's death, I feel like every day is a struggle, and I often question whether my life will ever get better. I just miss him so much that I think about him constantly. I don't know what to do, but the pain is getting to be too much. Therapist: You are really struggling to feel better, and much of your pain comes from the grief and loss you feel from losing your fiancé. You may even be questioning whether or not this pain will subside because it is getting unmanageable. Patient: Yes, that is correct. I do not want you to think that I think only about the pain of losing him. The pain I feel comes from my intense feelings of loss, but this pain is also because I miss all the things he meant to me, and the joy he brought to my life. I am really struggling because I do not want to let go of him, but holding on hurts so much.

In this example of paraphrasing, the therapist gives back to the patient what he or

she heard, which allows the patient to hear her own words and react with a more

detailed response. The use of paraphrasing in this example facilitated a deeper

understanding of the issue but also conveyed to the patient a feeling of being heard

and understood.

Listening for Themes and Summary Statements: Often, patients express thoughts,

feelings, and behaviors that become thematic across situations. Although novice

therapists may initially have difficulties identifying this thematic content, repetition

Module 4: Case Conceptualization and Treatment Planning

Objectives

• To better understand the role of case conceptualization in cognitive-behavioral

therapy.

• To develop specific case conceptualization skills, including:

a) Assessing patient concerns/difficulties

b) Establishing a treatment plan (goal setting)

c) Identifying treatment obstacles

What are case conceptualization and treatment planning, and why are they important in

Brief CBT?

Case conceptualization is a framework used to 1) understand the patient and his/her

current problems, 2) inform treatment and intervention techniques and 3) serve as a

foundation to assess patient change/progress. Case conceptualization also aids in

establishing rapport and a sense of hope for patients.

Case conceptualization is vital to effective treatment and represents a defining

characteristic of expert clinicians. Using these skills, clinicians are better able to define a

treatment plan using intervention techniques that provide the best opportunities for

change. This focused and informed approach provides the roadmap for both patients and

therapists and should include a foundation for assessing change/progress. Case

conceptualization is particularly important for short-term therapy, as it serves to focus both

the patient and clinician on the salient issues so as to avoid ancillary problems that often

serve as distractions to core goals.

When? (Indications/Contraindications)

Conceptualization should begin during the first session and become increasingly

refined as treatment progresses.

An assessment of current difficulties and the creation of a problem list should occur

during the first session.

A treatment plan (including treatment goals) should be addressed early in treatment

(sessions 1, 2). Early conceptualization and treatment planning may require

modification as additional information becomes available.

Treatment plans and goals should be routinely revisited to ensure that the patient is

improving and agrees with the flow of the therapeutic work.

How? (Instructions/Handouts)

Case Conceptualization Step 1: Assessing Patient Concerns/Difficulties

The patient's presenting concerns and current functioning can be assessed in a number of

different ways. The following section outlines several possible avenues for identification of

problems/concerns.

A) Using established self-report symptom inventories. A common practice in CBT involves

the use of self-report symptom measures to assess baseline functioning as well as

therapeutic progress. Frequently used measures for depression and anxiety include Beck

Depression Inventory – Second Edition, Patient Health Questionnaire (depression), Geriatric

Depression Scale, Beck Anxiety Inventory, and the State-Trait Anxiety Inventory.

Self-report measures are often completed by patients while in the waiting room and

evaluated by the clinician during the session. Often self-report measures can serve as a

routine agenda item during CBT sessions and can highlight important improvements and/or

continuing symptoms. Information obtained from these self-report inventories can also

provide insight into the way the patient thinks and behaves and factors that might be

important areas of need.

B) Problem lists. These are a common and useful strategy for identifying the psychological,

social, occupational, and financial difficulties faced by patients. Therapists who used

problem lists typically elicit a list of five to 10 difficulties from the patient during the first part

of session 1. Problems are best identified using open-ended questions (e.g., “What brings

you to this clinic?” “What issues would you like to focus on in our work together?”). Problems

are best described in terms of symptom frequency (How often does the symptom occur?),

intensity (How mild or severe is it?) and functional impact (What influence does the

symptom have on daily functioning or general distress?).

Some patients may describe their difficulties or goals in vague or abstract ways, such as, “I

want to improve my life, or I want to be happy again.” Problems and subsequent goals are

best described in specific terms to maintain clinical focus. For example, specific problems

are listed in the following table.

P roblem Frequency Severity I mpact Socially I solated

Stay at home out of 7 days

6 Limited social contacts; m oderate-to-severe isolation

H ighly distressing; socially d ebilitating; estranged fa mily/friends P ain E xperience p ain each hour

P ain intensity is w hen present

high, 7 of 10, P ain leading to decreased a ctivity level, inability to work Feelings of W orthlessness

Occur d ays

3 out of 7 V ery intense when present; sometimes involves suicidal t houghts

H ighly distressing; w ork, social, and r elationships

influences intimate

Fatigue Occurs almost c onstantly

Fatigue not intense t roublesome

but D ecreased activity level, fr equent naps, inability to c omplete daily tasks