COGNITIVE BEHAVIOR THERAPY
A: Occasionally patients state a goal over which they do not have direct control: “I’d like my partner to be nicer to me”; “I want my
boss to stop putting so much pressure on me”; “I want my kids to listen to me.” In this case, it is important to help them phrase the goal so that it is something they do have control over:
TherapisT: I don’t want to promise you that we can directly get Joe to be nicer to you. What do you think of phrasing it this way:
“Learn new ways of talking to Joe.” Maybe if you take control and change what you’re doing, it will have some impact on Joe.
For a fuller discussion of what to do when patients set goals for others, see J. S. Beck (2005).
EDUCATING THE PATIENT ABOUT THE COGNITIVE mODEl
An important feature of the initial session is helping patients under- stand how their thinking affects their reactions, preferably using their own examples. You can take advantage of patients’ spontaneous utter- ances in session (e.g., “I can’t do anything right. Nothing can help. I’ll never feel better”). Or you can ask them, “What’s going through your mind right now?” when you notice a shift in affect. It is probably easier, though, for the novice therapist to devote a portion of the first session providing psychoeducation about the relationship among triggering situations, automatic thoughts or images, and reactions (emotional, behavioral, and physiological).
TherapisT: Can we talk for a few minutes about how your thinking affects your mood? Can you think of any time in the past few days when you noticed your mood change? When you were aware that you had become particularly upset?
paTienT: I think so.
Structure of the First Therapy Session 71 TherapisT: Can you tell me a little about it?
paTienT: I was having lunch with a couple of people from my Eng- lish class, and I started to feel really bad. They were talking about something the professor had said in class that I didn’t really under- stand.
TherapisT: Do you remember what you were thinking?
paTienT: Ummm, that they’re much smarter than I am. That I’ll prob- ably flunk the course.
TherapisT: (using Sally’s precise words) So you had the thoughts “They’re much smarter than I am. I’ll probably flunk the course,” and how did those thoughts make you feel emotionally? Happy, sad, wor- ried, angry. . . ?
paTienT: Oh, sad, really sad.
TherapisT: Okay, how about if we make a diagram? You just gave a good example of how, in a specific situation, your thoughts influ- ence your emotion. (Composes the diagram below and reviews it with Sally.) Is it clear to you? That how you viewed this situation led to automatic thoughts that then then influenced how you felt?
paTienT: I think so.
Situation: At lunch with classmates
Automatic thoughts: “They’re much smarter than I am.
I’ll probably flunk the course.”
Reaction (emotional): Sad
TherapisT: Let’s see if we can gather a couple more examples from the past few days. Is there another time when you were feeling particu- larly upset?
paTienT: Well, just a few minutes ago, when I was waiting in the waiting room. I was feeling really down.
TherapisT: And what was going through your mind at the time?
paTienT: I don’t remember exactly.
TherapisT: [trying to make the experience more vivid in Sally’s mind]
Can you imagine yourself back in the waiting room right now? Can you imagine sitting there? Describe the scene for me as if it’s hap- pening right now.
paTienT: Well, I’m sitting in the chair near the door, away from the
receptionist. A woman comes in, she’s smiling and talking to the receptionist. She looks kind of happy and . . . normal.
TherapisT: And how are you feeling as you look at her?
paTienT: Kind of sad.
TherapisT: What’s going through your mind?
paTienT: She’s not like me. She’s happy. I’ll never be like that again.
TherapisT: [reinforcing the cognitive model] Okay. That’s another good example. The situation was that you saw a happy-looking woman in the reception area and you thought, “I’ll never be like that again”—and that thought made you feel sad. Is this clear to you?
paTienT: Yeah. I think so.
TherapisT: [making sure Sally can verbalize her understanding of the cognitive model] Can you tell me in your own words about the con- nection between thoughts and feelings?
paTienT: Well, it seems that my thoughts affect how I feel.
TherapisT: Yes, that’s right. [facilitating Sally’s carrying through the work of the therapy session throughout the week] What I’d like you to do, if you agree, is to keep track this coming week of what’s going through your mind when you notice your mood changing or getting worse. Okay?
paTienT: Uh-huh.
TherapisT: In fact, how about if I write it down on the Homework List: When I notice my mood getting worse, ask, “What’s going through my mind?” and jot down the thoughts. When you come in next week, we can evaluate your thoughts to see whether they’re 100% true, or 0% true, or someplace in the middle. Okay?
paTienT: Yes.
TherapisT: Lots of times, because you’re depressed, I think you’ll find that these thoughts aren’t completely accurate. I’ll write something down about that, too: Just because I think something doesn’t necessarily mean it’s true. When we find out your thoughts aren’t true, or not completely true, I’ll teach you how to look at the situation in a more realistic way. When you do that, I think you’ll find that you feel bet- ter. For example, we might find that your classmates aren’t much smarter than you, and that the reason you’re struggling has noth- ing to do with your intelligence, but has everything to do with the fact that you’re depressed. And we might then do some problem solving to help you with the course. For example, you might ask for help from a friend or a teaching assistant or a tutor.
Structure of the First Therapy Session 73 paTienT: That sounds hard.
TherapisT: That’s another good example of an automatic thought:
“That sounds hard.” Well, that’s what I’m here for. We’ll be working as a team, together, to help you solve your problems, and we’ll go step by step. (pause) Can you see how changing your thinking and doing some problem solving might help improve your mood?
paTienT: Yes.
TherapisT: (Using an encouraging tone of voice.) And I think you’ll find that you’ll get good at it pretty soon. Meanwhile, can you try to write down other depressed thoughts like that so we can look at them next session?
paTienT: Okay.
TherapisT: [checking to see whether Sally anticipates difficulties that might require advance problem solving] Do you think you’ll have any trouble doing that?
paTienT: No. I think I’ll be able to.
TherapisT: Good. But even if you can’t, that’s okay. You’ll come back next week and we’ll work on it together.
paTienT: Okay.
In this section, I explain, illustrate, and record the cognitive model with the patient’s own examples. I try to limit my explanations to just a couple of sentences at a time; depressed patients, in particular, have difficulty concentrating. I also ask Sally to put what I’ve said in her own words so I can check on her understanding. Had Sally’s cognitive abilities been impaired or limited, I might have used more concrete learning aids such as faces with various expressions to illustrate emotions, and car- toon characters with empty “thought bubbles” above their heads.
Q: What if . . . patients have difficulty grasping the cognitive model in the first session?
A: You will decide whether to try other techniques (see Chapter 9), or