Cognitive Therapy Michael Neenan Windy Dryden

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2 Cognitive Therapy In the last two decades cognitive therapy has been applied to an ever-increasing number of disorders including anxiety, post traumatic stress disorder and psychosis and used with children, adolescents and older people. Cognitive Therapy: 100 Key Points and Techniques is a crisp, concise elaboration of the 100 main features of this most popular approach within the field of cognitive behaviour therapy. The 100 key points and techniques cover cognitive therapy theory and practice, and examine misconceptions about the approach. Divided into helpful sections, topics covered include: Undertaking, structuring and teaching cognitive therapy Assessment Homework Ways of detecting NATS Developing new core beliefs and strengthening existing ones Resistance and relapse prevention This neat, usable book is an essential guide for psychotherapists and counsellors, both in training and in practice, who need to ensure they are entirely familiar with the key features of cognitive therapy as part of a general introduction to the current major psychotherapies. Michael Neenan is Associate Director of the Centre for Stress Management, London. Windy Dryden is Professor of Psychotherapeutic Studies at Goldsmiths College, London.

3 Cognitive Therapy 100 key points and techniques Michael Neenan and Windy Dryden

4 First published 2004 by Brunner-Routledge 27 Church Road, Hove, East Sussex BN3 2FA Simultaneously published in the USA and Canada by Brunner-Routledge 29 West 35th Street, New York, NY This edition published in the Taylor & Francis e-library, Brunner-Routledge is an imprint of the Taylor & Francis Group 2004 Michael Neenan and Windy Dryden All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. This publication has been produced with paper manufactured to strict environmental standards and with pulp derived from sustainable forests. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Neenan, Michael. Cognitive therapy : 100 key points / Michael Neenan and Windy Dryden. 1st ed. p. cm. Includes bibliographical references. ISBN (hardcover : alk. paper) ISBN (pbk. : alk. paper) 1. Cognitive therapy. I. Dryden, Windy. II. Title. RC489.C63N dc ISBN Master e-book ISBN ISBN (Adobe ereader Format) ISBN (hbk) ISBN (pbk)

5 Contents Preface xi Part 1 CT THEORY 1 1 It is not events per se which determine our feelings but the meanings that we attach to these events 3 2 Information processing becomes distorted when we experience emotional distress 5 3 An emotional disorder is usually understood by examining three levels of thinking 7 4 Thoughts, feelings, behaviour, physiology and environment are interconnected 9 5 Emotional reactions to events are viewed along a continuum 11 6 Emotional disorders have a specific cognitive content 13 7Cognitive vulnerability to psychological disturbance 15 8 Our thoughts and beliefs are both knowable and accessible 17 9 Acquisition of emotional disturbance Maintenance of emotional disturbance The client as personal scientist 23 v

6 CONTENTS Part 2 MISCONCEPTIONS ABOUT CT Only articulate and intelligent clients can really benefit from CT CT does not focus on feelings CT is basically positive thinking CT seems too simple CT is little more than symptom relief 35 17CT is not interested in the client s past or childhood experiences CT does not make use of the relationship as a means of client change CT is not interested in the social and environmental factors that contribute to clients problems CT is just the application of common sense to clients problems CT teaches clients to think rationally in tackling their problems 45 Part 3 CT PRACTICE 47 Getting started Setting the scene Undertaking an assessment Assessing client suitability for CT Structuring the therapy session Setting the agenda 61 27Drawing up a problem list Agreeing on goals Teaching the cognitive model Developing a case conceptualization Developing treatment plans 73 Ways of detecting NATS Detecting NATS Guided discovery Using imagery Making suggestions In-session emotional changes 85 vi

7 CONTENTS 37Finding the thoughts by ascertaining the client s idiosyncratic meaning of the event Focusing on feelings Assuming the worst In vivo exposure Role play Analysing a specific situation NATS in shorthand Symptom induction Behavioural assignments Eliciting NATS from less important cognitive data Separating situations, thoughts and feelings Distinguishing between thoughts and feelings 109 Examining and responding to NATS Answering back Weighing the evidence Constructing alternative explanations Identifying cognitive distortions Looking at the advantages and disadvantages Defining terms Reattribution Decatastrophizing Exploring double standards Modifying imagery Behavioural experiments Socratic questioning (guided discovery) Exaggeration and humour Writing down alternative responses to NATS 143 Homework Rationale for homework Types of homework assignment Negotiating homework assignments Reviewing homework assignments 155 Ways of identifying underlying assumptions and rules Revealing if... then statements Spotting musts and shoulds 163 vii

8 CONTENTS 69 Discerning themes in clients automatic thoughts Investigating marked mood variations The downward arrow Memories, family sayings, mottoes 171 Revising assumptions and rules Behavioural experiments Disobeying the shoulds and musts Redrawing personal contracts Examining the short- and long-term usefulness of assumptions and rules Developing an alternative assumption that retains the advantages of the maladaptive assumption and jettisons its disadvantages Listing the advantages and disadvantages of a rule or assumption Exploring the historical development of assumptions and rules Using imagery to modify assumptions 189 Uncovering core beliefs The downward arrow Conjunctive phrasing Sentence completion Core beliefs appearing as automatic thoughts 199 Developing and strengthening new/existing core beliefs Educating clients about core beliefs Developing alternative core beliefs Use of a continuum Positive data logs Acting as if Historical test of the new core belief Challenging each thought in the downward arrow procedure Rational emotional role play Learning self-acceptance 219 viii

9 CONTENTS Resistance Client resistance Therapist resistance 229 Towards termination and beyond Relapse prevention Termination Maintaining gains from therapy Follow-up 245 Cognitive therapy: is it just for clients? Practising what you preach 249 Appendices 253 References 259 ix

10 Preface Cognitive therapy (CT) was developed by Aaron T. Beck (b. 1921), an American psychiatrist, at the University of Pennsylvania in the early 1960s (J. S. Beck, 1995). CT seeks to ameliorate clients emotional distress by helping them to identify, examine and modify the distorted and maladaptive thinking underlying their distress. Beck s approach initially focused on research into and the treatment of depression (Beck et al., 1979), but in the last two decades CT has been applied to an ever-increasing number of disorders, including anxiety and phobias (Beck et al., 1985), substance abuse (Beck et al., 1993), personality disorder (Sperry, 1999), obsessive-compulsive disorder (Salkovskis, 1999), post-traumatic stress disorder (Ehlers and Clark, 2000), psychosis (Morrison, 2001), bipolar disorder (Newman et al., 2002), and populations such as psychiatric inpatients (Wright et al., 1993), patients with chronic medical problems (White, 2001), children and adolescents (Friedberg and McClure, 2002), and older people (Laidlaw et al., 2003). CT has become the most popular and best-validated approach within the field of cognitive behaviour therapy (CBT); seventeen different approaches in this field have been listed (Mahoney and Gabriel, 1987). In this book we will elaborate on 100 key points and techniques of cognitive therapy. Each elaboration will be of varying length. The 100 points and techniques will cover CT theory and practice, and examine misconceptions about this approach. The book is aimed primarily at xi

11 PREFACE CT/ CBT trainees and other counsellors interested in this approach who need to be familiar with it as part of a general introduction to the current major psychotherapies. We hope that this will cover a wide readership. Michael Neenan and Windy Dryden xii

12 CT THEORY 1 It is not events per se which determine our feelings but the meanings that we attach to these events At the very heart of the CT [cognitive therapy] model is the view that the human mind is not a passive receptacle of environmental and biological influences and sensations, but rather that individuals are actively involved in constructing their reality (Clark, 1995: 156). In order to understand a person s emotional response to a particular event it is important to discover the meaning he attaches to events in his life: his subjective construction of reality. For example, a person whose partner has left him believes he cannot be happy or cope on his own and becomes depressed; another person whose partner has departed feels relieved as he believes he has been freed from a stifling relationship ; a third person feels guilty as he views his bad behaviour as the reason for his partner s departure the same event for each person, but not the same emotional reaction to it as each reaction is mediated by the person s view of the event. Therefore in order to change the way we feel about events we need to change the way we think about them. This is not to argue that a person s emotional problems are simply created in her head but that the impact of adverse events (e.g. job loss) can be greatly exacerbated by the person s unhelpful thoughts and beliefs that interfere with her ability to cope constructively with such events (e.g. I shouldn t have lost my job. I m worthless without one ). CT helps clients to develop alternative viewpoints in order to tackle their problems (e.g. I ve lost my job, not my self-worth as this is not dependent on having a job ). Developing alternative viewpoints underscores the CT principle that there is always more than one way of seeing things and therefore a person chooses her viewpoint (Butler and Hope, 1996). Even in the unspeakable horrors of Auschwitz, Viktor Frankl, a famous psychiatrist, observed that everything can be taken from a man but one thing: the last of the human freedoms to choose one s attitude in any given set of circumstances, to choose one s own way (1985: 86). 3

13 CT THEORY 2 Information processing becomes distorted when we experience emotional distress CT is based on an information-processing model which posits that during psychological distress a person s thinking becomes more rigid and distorted, judgements become overgeneralized and absolute, and the person s basic beliefs about the self and the world become fixed (Weisharr, 1996: 188). In an undisturbed frame of mind, a person is likely to check her impressions and appraisals of events in order to obtain clear and accurate information. When emotionally upset, the person will usually distort incoming information by introducing a consistently negative bias into her thinking so that it becomes rigid and overgeneralized, e.g. she becomes upset when she is not invited to a friend s party because she interprets the lack of an invitation as meaning that she is an unlikeable person. Instead of ascertaining the reasons for not being invited, or keeping an open mind about it, the person dwells on her supposed unlikeability. Common information processing errors found in emotional distress include: All or nothing thinking: situations are viewed in either/or terms, e.g. You re either a success or failure in life. I m a failure. Jumping to conclusions: judgements are rushed, e.g. a client says after the first session: Therapy isn t helping me. Mind reading: discerning the thoughts of others without any accompanying evidence, e.g. My boss didn t smile at me this morning, so that means she is unhappy with my work. Labelling: attaching labels to oneself instead of to one s behaviour, e.g. Because I failed my exam, this means I m a failure. Emotional reasoning: assuming that feelings are facts, e.g. I feel incompetent, so it must be true. Teaching clients how to identify and correct these errors in their thinking facilitates the return of information processing that is more evidence-based, flexible and relative (non-absolute). In the example 5

14 COGNITIVE THERAPY: 100 KEY POINTS in the opening paragraph, the person discovers that her friend had invited her but my mother forgot to pass on the message. If I hadn t got upset, then I wouldn t have jumped to conclusions. 6

15 CT THEORY 3 An emotional disorder is usually understood by examining three levels of thinking These three levels of thinking are: negative automatic thoughts (NATS), underlying assumptions/rules and core beliefs. NATS are situation-specific and involuntarily pop into a person s mind when he is experiencing emotional distress such as depression or anxiety. They appear plausible to the person and are difficult to turn off. NATS often lie outside immediate awareness but can be quickly brought to the client s attention by asking standard CT questions like: What was going through your mind at that moment when you got to the meeting late? (Client s reply: I m always late. I m undisciplined, sloppy. My colleagues will look down on me. ) Underlying assumptions (e.g. If I impress others, then I should get ahead in life ) and rules (e.g. I should not let people down ) guide behaviour, set standards and provide rules to follow. These assumptions and rules are often unarticulated. Underlying assumptions are usually identified by their if... then construction, and rules are usually expressed in must and should statements. These assumptions and rules are the means by which individuals hope to avoid coming face to face with their negative core beliefs (e.g. I m incompetent ). The truth of these beliefs is not questioned and, therefore, assumptions and rules serve to maintain and reinforce them. Trouble looms for the person when behaviour is not what it should be, standards are not met or rules are violated; trouble is the activation of the bottom line (core belief). Beck et al. (1985) suggest that maladaptive assumptions often focus on three major issues: acceptance (e.g. I m nothing unless I m loved ), competence (e.g. I am what I accomplish ) and control (e.g. I can t ask for help ). Assumptions and rules are cross-situational and are also known as intermediate beliefs because they lie between NATS and core beliefs (Beck, 1995). 7