Cognitive-behavioural therapy: an information guide

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Cognitive-behavioural

therapy

Aninformation

guideNeil A. Rector, PhD, CPsych


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i

Cii-baira

rapy

Airmai

idNeil A. Rector, PhD, CPsych


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ii Cognitive-behavioural therapy : An inormation guide

Library and Archives Canada Cataloguing in Publication

Rector, Neil A.

Cognitive-behavioural therapy : an inormation guide / Neil Rector.Issued also in French under title: Thrapie cognitivo-comportementale.Includes bibliographical reerences.Issued also in electronic ormats.ISBN 978-1-77052-294-7

1. Cognitive therapy. I. Centre or Addiction and Mental Health II. Title.RC489.C63R43 2010 616.89142 C2010-904213-1

isbn: 978-1-77052-294- 7(print)

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electronic or mechanical, including photocopying and recording, or by any inormationstorage and retrieval system without written permission rom the publisherexcept ora brie quotation (not to exceed 200 words) in a review or proessional work.

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Disponible en ranais sous le titre :Thrapie cognitivo-comportementale : Guide dInormation

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Cognitive-behavioural therapy : an inormation guide iii

Contents

Ab ar v

Ackwdm v

Irdci vi

1 What is cognitive-behavioural therapy? 1Introducing cbt

What happens in cbt?

What conditions can cbt treat?

Why is cbt an eective therapy?

2 The basics o cognitive-behavioural therapy 6

The nature o automatic thoughtsEvaluating automatic thoughts

Patterns in automatic thoughts

Identiying distortions in automatic thoughts

Rules and assumptions

Core belies

3 CBT approaches to cognitive change 14Identiying relations between thoughts, moods

and behaviours

Questioning and evaluating negative automatic thoughts

Identiying and correcting cognitive distortions

Recording your thoughts

Targeting assumptions and belies

Behavioural experiments

4 CBT approaches to behavioural change 24Sel-monitoringExposure therapy



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i Cognitive-behavioural therapy : An inormation guide

5 CBT in practice: Questions and answers 33How will I know icbt is or me?

How can I nd a qualied cbt therapist in my area?

What can I expect on my rst visit with a cbt therapist?

What happens in a cbt session?

How can I get the most out ocbt between sessions?

How long does cbt last?

How requent are the sessions?

Do I need to prepare or cbt sessions?

Will the cbt therapist be able to understand and appreciate

my own unique background?Is cbt an eective treatment or children and adolescents?

What are the common barriers that come up in cbt?

Should I start treatment with medications or cbt or both

in combination?

How can I stay well ater nishing cbt?

6 Alternative cognitive-behavioural approaches 41

Mindulness therapy and mindulness-basedcognitive therapy

Acceptance and commitment therapy

Dialectical behavioural therapy

Meta-cognitive therapy

Rrc 46

Rrc 47


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Cognitive-behavioural therapy : an inormation guide

Ab ar

Neil A. Rector, PhD, CPsych, is a clinical psychologist and research

scientist at Sunnybrook Health Sciences Centre in Toronto. He is a

ounding ellow o the Academy o Cognitive Therapy (USA) and is

an active clinician, educator and researcher in the area o cognitive-

behavioural therapy. Dr. Rector is also the author o two other

inormation guides in this series: Anxiety Disorders and Obsessive-

Compulsive Disorder.

Ackwdm

Thanks to the many people who reviewed and commented on

earlier drats o this guide. Reviewers included Diana Ballon,

Eva Dipoce, Lori Douglas, Alexander Roseneld and Krystyna

Walko. Proessional reviewers included Lance Hawley, PhD,

CPsych, Judith Laposa, PhD, CPsych, and Sandra L. Mendlowitz,

PhD, CPsych.


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i

Irdci

This inormation guide is or people who may be considering or

currently participating in cognitive-behavioural therapy (cbt) as

a treatment, either alone or with medications or another orm o

psychotherapy. The guide is also or people who want to better

understand cbt to help them support a amily member or riend.

The aim o this guide is to provide an easy-to-read introduction toa rich and complex therapy. The guide describes the nature and

process ocbtwhat it is and what it involves. It also outlines the

goals ocbt and the tasks used in therapy to help people reach

those goals. For a better understanding o the many aspects o this

orm o psychotherapy, the guide should be read rom cover to

cover; however, some readers may preer to dip into parts o the

book that are o particular interest.

Details in the examples in this guide have been altered to protect

client anonymity.


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Cognitive-behavioural therapy : an inormation guide 1

1 Wa i cii-baira rapy?

For much o the 20th century, the dominant orm o psychotherapy

was psychoanalysis. This approach involved seeing a therapist sev-

eral times a week, oten or years. Then, in the 1970s, an explosion

o dierent approaches to psychotherapy began to appear. Many o

these were short term, lasting only weeks or months.

In 1979, Time magazine reported that there were almost 200 di-

erent types o psychotherapy. As o 2010, there are thought to be

between 400 and 500 types. However, when directly compared,

only a handul o therapy approaches have been shown to be highly

eective or the kinds o problems people usually seek help or,

such as depression, anxiety, phobias and stress-related problems.O the many therapies available, cognitive-behavioural therapy(cbt)

is increasingly identied as the gold standardthat is, the best

type o therapy or these diculties. This conclusion is supported

by more than 375 clinical trial studies since 1977 and also by current

international treatment guidelines, which are based on the collective

knowledge o experts in the eld. For instance, the National Institute

o Mental Health (nimh

) in the United States and the NationalInstitute or Health and Clinical Excellence (nice) in the United

Kingdom have concluded that among the available psychological


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2 Cognitive-behavioural therapy : An inormation guide

treatments or anxiety and depression, cbt is recommended as the

rst-line psychological treatment.

CBT has been shown to be eective or people o all ages, rom early

childhood to older adults, and or people o dierent levels o educa-

tion and income and various cultural backgrounds. It has also been

shown to be eective when used in individual or group ormats.

Introducing CBT

CBT is an intensive, short-term (six to 20 sessions), problem-oriented

approach. It was designed to be quick, practical and goal-oriented

and to provide people with long-term skills to keep them healthy.

The ocus ocbt is on the here-and-nowon the problems that comeup in a persons day-to-day lie. cbt helps people to look at how they

interpret and evaluate what is happening around them and the

eects these perceptions have on their emotional experience.

Childhood experiences and events, while not the ocus ocbt, may

also be reviewed. This review can help people to understand and

address emotional upset that emerged early in lie, and to learnhow these experiences may infuence current responses to events.

According to cbt, the way people eel is linked to the way they

think about a situation and not simply to the nature o the situation

itsel. This idea is rooted in ancient Eastern and Western philoso-

phies and became part o a mainstream psychotherapy approach

in the early 1960s. Aaron T. Beck, the ather ocbt

, described thenegative thinking patterns associated with depression (i.e., critical

thoughts about onesel, the world and the uture) in his early writ-

ings. He also outlined ways to target and reduce negative thoughts


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3What is cognitive-behavioural therapy?

as a way to improve mood. In later work, Beck and his colleagues

ocused on the content and processes o thought related to anxi-

ety and ways to treat anxiety problems. Since its creation, cbt has

expanded into one o the most widely used therapeutic approaches.

What happens in CBT?

In cbt, you learn to identiy, question and change the thoughts,attitudes, belies and assumptions related to your problematic

emotional and behavioural reactions to certain kinds o situations.

By monitoring and recording your thoughts during situations that

lead to emotional upset, you learn that the way you think can con-

tribute to emotional problems such as depression and anxiety. In

cbt, you learn to reduce these emotional problems by:

identifying distortions in your thinking

seeing thoughts as ideas about what is going on rather than as

acts

standing back from your thinking to consider situations from

dierent viewpoints.

For cbt to be eective, you must be open and willing to discuss

your thoughts, belies and behaviours and to participate in exer-

cises during sessions. For best results, you must also be willing to

do homework between sessions.


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What conditions can CBT treat?

CBT is an eective treatment or many psychological conditions.

These include:

mood disorders, such as depression and bipolar disorder

anxiety disorders, including specic phobias (e.g., fear of animals,

heights, enclosed spaces), panic disorder, social phobia (social

anxiety disorder), generalized anxiety disorder, obsessive-compul-sive disorder and posttraumatic stress disorder

bulimia nervosa and binge eating disorder

body dysmorphic disorder (i.e., body image)

substance use disorders (i.e., smoking, alcohol and other drugs).

CBT can also be used to help people with:

psychosis

habits such as hair pulling, skin picking and tics

sexual and relationship problems

insomnia

chronic fatigue syndrome

chronic (persistent) pain

long-standing interpersonal problems.

A similar ramework is used to treat dierent emotional problems

in cbt; however, the approach and strategies vary and are tailored

to address each specic problem.


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5What is cognitive-behavioural therapy?

Why is CBT an eective therapy?

CBT is an eective therapeutic approach because it:

is structured

is problem-focused and goal-oriented

teaches proven strategies and skills

emphasizes the importance of a good, collaborative therapeutic

relationship between the therapist and client.

In describing how cbt works, the ocus o this guide will be on

how it applies to treating people experiencing emotional distress.


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2 t baic cii-baira rapy

Most oten, people think o their distress as emerging directly

rom events and situations in their lives: I had an argument with

my partner this morning and I am still angry, My boss criticized

my work and I eel so deeated or I read the business section o

the paper this morning, saw that my stock was down, and elt veryanxious. In each example, the person highlights how the situation

has causedhis or her emotional upset.

situation emotional reaction

However, what you eel in response to a situation is determined

not only by the situation, but also by the way youperceive the situ-ation or make meaning o it. This way o seeing your emotional

reaction as determined by what you think about a situation is a

basic assumption o the cognitive-behavioural approach.

For example, i you are ast asleep at 3:00 a.m. and you are woken

by a crashing sound at your bedroom window, the way you respond

to the situation will dier, depending on what you think is happen-ing. I you think it is an intruder, you are likely to eel ear and ter-

ror and respond by rushing out o the room to saety. I you think

that it must be your roommate (assuming you have one) coming


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7The basics o cognitive-behavioural therapy

in through the window because he or she has orgotten the key

(again!), you will likely eel rustration and annoyance and respond

by arguing with your roommate. Finally, i you think it may be your

romantic partner coming over or a late night rendezvous, you will

likely eel and act with excitement.

The nature o automatic thoughts

In each previous example, the event is the same: a loud noise at the

window at 3:00 a.m. However, you could have a dierent, quick

thought to evaluate the situation, or what is reerred to in cbt as

an automatic thoughta thought that pops into your mind and

shapes the particular emotion experienced (e.g., ear, annoyance,

excitement) and the resulting behaviour (e.g., escape, conronta-

tion, warm greeting).

More than the situation itsel, it is these pop-up, automatic

thoughts that lead to your emotional and behavioural reactions.

situation automatic emotional/behavioural

thoughts reactions

Evaluating automatic thoughts

Automatic thoughts are usually so brie and quickly overridden by

your awareness o the emotions that ollow rom them that you

may not even notice them.

The ability to notice and evaluate your automatic thoughts when

you are in the midst o upsetting situations is one o the core skills

learned and practiced in cbt. In cbt, you learn to ask yoursel,


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What was going through my mind when I noticed eeling emo-

tionally upset?

Try this cbt exercise now: Think o a time earlier in the day or in

the past couple o days when you elt some kind o emotional up-

set, such as anxiety, sadness or anger. Now, try to remember what

you were thinking about at the time. As you recall your thoughts

during this event, you may become more aware o automatic

thoughts that were going through your mind that you had not

noticed at the time.

Identiying your automatic thoughts helps you to clariy the nature

o the resulting emotion and understand why the situation was so

upsetting.

Patterns in automatic thoughts

When people begin to monitor and record their automatic

thoughts, they oten recognize apattern. In his earliest writings on

cbt in the 1960s, Aaron T. Beck ound that patients who were de-

pressed oten reported having automatic thoughts characterized by

negative perceptions o themselves (Im worthless), o the worldaround them (Nobody likes me), and o the uture (Im hopeless

and cant change). This pattern o thinking was termed the cogni-

tive triad o depression.

Becks later writings rom the 1980s described a pattern o auto-

matic thoughts that seemed to be more uniquely related to anxiety,

with clients reporting more thoughts related to threat and danger(What i something terrible happens?) and the inability to cope

(Im overwhelmed, I cant go on like this).


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While everyone has their own way o seeing situations and events

in their lives, when people experience depression or anxiety the

content o their automatic thoughts begins to take on a predictable

and characteristic orm.

A goal ocbt is to help you become aware o your automatic

thoughts and to learn to stand back and question, evaluate and

correct inaccurate, negative automatic thoughts. However, cbt is

nottrying to teach positive thinking as a solution to lies problems.

Rather, the goal is or you to learn to evaluate your experiences

and problems rom dierent perspectivespositive, negative and

neutralto arrive at accurate conclusions and creative solutions to

your diculties.

Identiying distortions in automaticthoughts

A second eature o negative automatic thoughts in people with

emotional distress is that they tend to refect distortions or errors

in thinking. For example, the person who thinks that I will never

nd a partner because o one unsuccessul date is catastrophizing

the outcome o this date and is more likely to experience excessive

emotional upset than the person who thinks This date didnt go

well but hopeully things will go better next time. In another ex-

ample, a student who concludes that a low mark on a recent exam

means that he is stupid and a ailure is labellinghimsel and

thinking in all-or-nothingterms, and is more likely to be distressed

than a student who thinks, I didnt do as well as I would have liked

but Ill seek out extra help and study harder next time.

Distortions in thinking exaggerate the emotional signicance o

common, everyday events. One aim ocbt is to help you become


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more aware o distortions in your perception o day-to-day experi-

ences, especially when you are very upset.

Everyone has negative automatic thoughts that pop up in the fow

o consciousness, and most o us have cognitive distortions rom

time to time. However, some people are more likely to have auto-

matic thoughts related to depression and anxiety, and to have more

cognitive distortions. The cbt approach suggests that automatic

thoughts are infuenced by two deeper levels o thinking, which

can make people more vulnerable to having recurrent negative and

distorted thinking patterns. These deeper levels are known as rules

and assumptions and core belies.

Rules and assumptions

From early childhood, you learn certain rules and assumptions

through your interactions with amily members and the world

around you. For instance, you may learn rules about:

how to relate with others (e.g., If you dont have anything nice to

say, then dont say anything at all)

the acceptability of expressing emotions (e.g., Dont ever let themsee you sweat)

your performance (e.g., If you cant do something perfectly, then

its not even worth trying or I should be great at everything I do).

These rules and assumptions may not be obvious to you and re-

main out o your awareness. However, when you begin to monitor

your automatic thoughts in upsetting situations, you become awareo patterns in your automatic thoughts that are linked to your un-

derlying rules and assumptions.


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For example, i you hold an underlying assumption that you must

be the best at everything you do, you are more likely to be distressed

by a less than optimal outcome (e.g., ailed test, lost promotion,

unsuccessul job interview) than someone who does not hold

this assumption.

Automatic thoughts can arise from underlying rules and assumptions.


thoughts reactions

assumptions/rules

CBT aims to help you become more aware o your own rules and

assumptions and how these contribute to a pattern o negative

automatic thoughts in emotionally upsetting situations.

Core belies

At the deepest level o cognition, even deeper than your rules and

assumptions, are your core belies. Core belies usually develop

early in lie. They refect rigid and absolute notions about yoursel,

others and the world. Examples o positive core belies are Im

attractive, Im smart and Im loveable. Examples o negative

core belies are Im worthless or Im weak; others are danger-

ous and not to be trusted; and the world is a scary place and

overwhelming.

Aaron T. Beck suggested that people with negative core belies are

more at risk o developing depression or anxiety than people with

positive core belies. Negative core belies may be inactive and not

aect a persons lie until a stressul lie event, such as a death in

the amily, a break-up or job loss activates these belies. For example,


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a woman who has a core belie that she is unlovable may also

believe that i she works hard to please her partner, he may love her

anyway. However, i her partner breaks up with her, her core belie

o being unlovable may be reactivated, and increase her vulner-

ability to depression or anxiety.


thoughts reactions

assumptions/rules

core beliefs

A basic assumption ocbt is that people can learn to identiy,

evaluate and change their assumptions and core belies, just

as they are able to identiy and change their negative automatic

thoughts. When you begin to reduce negative assumptions andbelies, you also begin to have ewer negative and distorted auto-

matic thoughts. Reducing the negative underlying assumptions

and core belies that give rise to your emotional problems lessens

your emotional upset and also oers you some protection rom

becoming depressed and anxious again.

In summary, cbt is dierent rom many other therapeutic approach-es because it ocuses on helping you learn to identiy the relation-

ship between your thoughts, eelings and behaviours. While each

o these are interdependent (they all serve to infuence each other),

cbt gives special attention to the role o cognition (automatic

thoughts, rules and assumptions and core belies) in creating and

maintaining emotional diculties such as depression and anxiety.

CBT aims to help you identiy, evaluate and change your habitual

thinking patterns at each o these levels o cognition. Working with

the therapist, you learn that assigning less extreme, more helpul


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and more accurate meanings to negative events leads to less

extreme and less disturbing emotional and behavioural responses.

Once you have learned these skills in therapy, you will become

your own therapist, with the ability to manage dicult experiences

and emotional upset on your own.


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14

3 CBt apprac cii ca

Automatic thoughts pop up all the time in everyones minds. Some

o these thoughts are positive, some are neutral and some are neg-

ative. The ones that are o particular interest in cbt are the negative

automatic thoughts that relate to periods o intense moods. An

early aim ocbt is to help you learn to identiy negative automaticthoughts and cognitive distortions in problematic situations. This

skill can be learned relatively quickly by some people, while or oth-

ers it will take practice and require patience.

Identiying relations between thoughts,moods and behaviours

The rst step toward identiying automatic thoughts and cognitive

distortions in problematic situations is or you to discuss recent

upsetting situations with your cbt therapist. This discussion helps

you to learn about the relationship between your thoughts, moods

and behaviours, as in the ollowing example:

Therapist: Can you think o a situation in the past week when

you elt upset?


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15CBT approaches to cognitive change

Peter: I was sitting on the subway and noticing all o the couples

together.

Therapist: And what eelings came up or you as you were notic-

ing the couples?

Peter: I was eeling sad and angry.

Therapist: And what were you thinking about as you were eeling

sad and angry?

Peter: I was thinking everyone seems to have someone in their lie

but me, and its just not air.

Therapist: And i its true that everyone seems to have someone

but you, do you think this says something about you?

Peter: Yah, that Im a loser and will always be alone.

Therapist: And what did you do when you were thinking and

eeling this way?

Peter: Ater a while I couldnt take it anymore so I got o the

subway even though I hadnt reached my stop yet. I went home

and just sat on my bed thinking about all o this.

In this example, the ollowing elements are identied:

Situation: On the subway, noticing couples

Moods: Sad and angry

Thoughts: Everyone has someone but me, it isnt air, Im a loser, Iwill be alone orever.

Behaviours: Escape rom subway, return home to ruminate


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This example shows that to understand why Peter was eeling sad

and angry, we need to understand what he was thinking:

that he does not have a relationship and really wants to be in one

that it does not seem fair to him that everyone else seems to get

what he desires so much in his lie

that because he does not have someone now, he will never nd

someone and will always be alone.

As an exercise, try to think o a situation in the past week that was up-

setting. Please take a moment to see i you can identiy the ollowing:

Situation: _________________________________________________

(Where were you? Were you with anyone?)

Moods: ___________________________________________________

(What were you eeling?)

Thoughts: ______________________________________________

(What was going through your mind?)

Behaviours: ______________________________________________

(What did you do? How did you cope?)

Questioning and evaluating negativeautomatic thoughts

As you learn to identiy your negative automatic thoughts, you will

also learn to question and evaluate these thoughts. A main goalocbt is to help you learn to see your thoughts as ideas that do not

necessarily refect reality. In other words, just because you think

something does not always mean it is true.


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To help you move toward this goal, the therapist will direct you

through cognitive restructuring exercises. In these exercises,

you will learn to stand back and question your negative automatic

thoughts and to evaluate the evidence that either supports or does

not support the thoughts. You will then be able to draw conclu-

sions about the accuracy o your thoughts.

A cbt therapist working with Peter in the previous example might

ask him the ollowing questions:

Do you know anyone that you like and respect who is not cur-

rently in a relationship?

Do you have any past experiences in romantic relationships?

If you had a good friend that had the same thoughts about him-

sel or hersel, what would you say to that riend?

Are you possibly discounting any life experiences to suggest that

you will not be completely alone?

Are you potentially blaming yourself for something that you do

not have complete control o?

The goal here is not to challenge Peters thinking but rather to

move him to a questioning mode and to consider the accuracy o

his automatic thoughts based on evidence rom his lie.

Identiying and correcting cognitivedistortions

Identiying and changing negative automatic thoughts related to

strong eelings also involves learning to identiy distortions orerrors in thinking as you experience or recall upsetting situations.


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Distortions in thinking are more likely to occur when you eel dis-

tressed. This is because emotional distress can wear you down, and

eeling worn down tends to make people more reliant on shortcuts

or more simplistic ways o thinking. Everyone has distortions in

thinking at times. Below are some types o distortions in thinking

(Burns, 1999), with examples to illustrate what they look like:

All-or-nothing (black-and-white) thinking: When you see things as

either black or white with no grey area in between (e.g., Amina

nished the term with three A+s, two As and one B+ and is think-

ing that because she did not ace all her courses she is a ailure).

Disqualiying the positive: When you discount positive experiences

and continue to ocus only on the negative (e.g., Josh is a devoted

ather who helps his son with homework every night and spends

as much time with him as possible on the weekends. Recent

business travel has kept him away rom home more than usual,

leading him to conclude that he is a lousy ather).

Overgeneralization: When you see a single event as something

that will never end (e.g., Ingrid elt anxious in the meeting at

work and now concludes that she will never be able to interact

with her colleagues comortably).

Mental flter: When you pay attention to a small negative detail in

an experience so that it takes on great importance (e.g., Dwight

is speaking to a group o 10 youth at his church and continually

ocuses his attention on one person who seems disinterested in

what he has to say rather than the other nine who seem quite

engaged).

Catastrophizing: When you think o the worst case scenariothat

is, you assume that a situation will be more awul or horrible than

it is likely to be (e.g., Susan awakes one morning and notices a

rash on the back o her leg. Rather than thinking o all the actorsthat could have contributed to the rash, she quickly concludes

that she has skin cancer and rushes to the doctor).


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Mind reading: When you jump to conclusions thinking that some-

one is thinking o you negatively beore you have all o the acts

(e.g., Guy walks into a movie theatre and as he goes to sit down,

he trips and stumbles and spills his popcorn and drink. He thinks

that everyone must be thinking that hes a total loser).

Personalization: When you see events not going well as a result o

something about you (e.g., Charmaine is hosting a party and sees

that two guests are sitting quietly on their own. She begins to

think it must be her ault that they are not having a good time).

Recording your thoughts

Early in treatment, the cbt therapist will question you in ways that

help you to identiy and question your negative automatic thoughts

and cognitive distortions. As you progress, the therapist will askyou to use the thought recordbetween sessions as homework. With

practice, you will become skilled at using the thought record to re-

cord, question and evaluate your automatic thoughts and to reduce

emotional distress in your day-to-day lie.

The best time to do the thought record is soon ater the situation or

event that causes distress. This is when you are most aware o thethoughts related to your experience. However, sometimes this is

dicult; or instance, i the problem comes up at work or at other

times where it would be inconvenient or where your privacy would

be compromised. When this is the case, try to nd a time later the

same day to record the details, beore they ade, and to help you

eel better about the situation sooner, rather than later.

The rst three columns o the thought record (shown in Table 1) are

used to record the situation that you were in when you began to

experience a strong emotion, the automatic thoughts related to the

event or experience, and the strength o your emotional reaction.


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The example in Table 1 shows how a client named Nancy reported

on the experience o anxiety when thinking about an upcoming

event:

tab 1. t rcrd: eamp

situation automaticthoughts

emotions

tiki abdrii p r ca

I am i aa paic aack widrii

ery wi b arywi m

I w b ab cpwi iai

Far (80%)

Once Nancy listed her automatic thoughts, the next step was or

her to consider the evidence that supported and did not support

her thoughts and to evaluate their accuracy, as shown in Table 2.

tab 2. eaai idc

evidence for: evidence against:

F r dri p ra im.

e I r, I did a a -dd paic aack.

Pp did m mwa p by ac a I p my i

ri i my rm ar dria im.

e I wa cmrab,I wa i ab dri ad I

r ay.


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evidence for: evidence against:

My byrid wi b drii wim ad i ry dradiad ppri ad w arywi m.

I a rad f r im iyar wi ay aiy a a.

e i I d ry ai ada a paic aack, I kw a i

i dar m. I wi cpby ryi caarpi aiy.

By evaluating the evidence supporting or not supporting the negative

automatic thoughts, both through discussion with her therapist

and through the use o the thought record, Nancy was able to arrive

at a more balanced alternative appraisal o the situation. As is otenthe case or everyone, just a little bit o new inormation led Nancy

to a dierent and less upsetting interpretation o the situation.

Targeting assumptions and belies

As therapy progresses, the cbt therapist will introduce other cogni-tive strategies and homework worksheets to target your underlying

assumptions and core belies.

One way to identiy your core belies and assumptions is to use your

thought records to identiy specic situations that lead to emotional

distress, and to look or themes that recur. The cbt therapist can

then help you to question and evaluate these assumptions andbelies and to generate less distressing, alternative viewpoints as

they occur in upsetting situations.


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Another way assumptions and belies are targeted or change in

cbt is to write down a negative core belie on one side o the page,

or example, unlikeable and an alternative, less distressing

belie that you would preer to hold about yoursel, or example,

likeable on the other side o the page. You would then be asked

to keep track o your experiences over the week, noting instances

where the negative or positive belie seemed to be supported. In

situations where you collected evidence to support the negative

belie, you would also be asked to review the situation careully

or supporting and contrary evidence to arrive at a more balanced

perspective.

BehAvIouRAl exPeRIMents

A powerul tool or questioning and evaluating underlying

assumptions and core belies is to test their validity with behav-ioural experiments. For instance, i you had an underlying

assumption that I I make a mistake everyone will laugh and

ridicule me, you might be asked to perorm an experiment to

determine what actually happens when mistakes are made. O

course, you will only conduct experiments that you think you

are ready or, and ater you have developed strategies to cope

with the ull range o possible outcomes rom these types oexperiments.

When you are ready, you may, or example, be asked to make a mis-

take on purpose, such as to go into a store and drop change while

in line, or to spill a drink in a caeteria. This will allow you to see

the extent to which: a) people notice, b) people respond (e.g., do

others laugh and ridicule you as eared or alternatively, do peoplenot seem to notice or criticize you), and c) how well you can cope

with the situation.


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In summary, the initial ocus ocbt is to help you identiy and

change negative automatic thoughts that lead to emotional distress

in problematic situations. You learn skills to identiy and correct

negative automatic thoughts and the cognitive distortions that uel

strong moods. The main tool or cognitive change is the thought

record. Other cognitive strategies are used to consolidate progress

with changing negative automatic thoughts and the deeper assump-

tions and belies. These include:

examining the advantages and disadvantages of holding such

belies

examining the evidence that supports and does not support the

assumptions and belies

trying to nd less extreme, more middle-ground views of oneself,

others and the world

performing behavioural experiments.


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24

4 CBt apprac baira ca

So ar, we have ocused on the C ocbt, which reers to changing

the cognitive aspects, or thinking, that can lead to emotional dis-

tress. We now move on to the B in cbt, which reers to changing

the behaviours that can worsen and prolong negative moods.

Changes in thinking and behaviours go hand in hand: When you

change the way you think about a situation or problem, your behav-

iours may also change. The reverse is also true: When you change

how you approach a situation or problem, you may come to think

dierently about it. For instance, i you smoke, and some new

inormation leads you to believe that smoking is more dangerous

to your health than you once thought, this may lead you to quitsmoking (i.e., cognitive change leads to behavioural change). Or, to

turn it around, i you go or a week without smoking because you

are sick or unable to smoke, it could lead you to think, I I can go

a week without smoking, maybe I could go a month. This think-

ing could lead to a new behavioural goal o trying to quit smoking

or a month (i.e., behavioural change leads to cognitive change).

CBT uses a variety o behavioural methods and strategies to reduce

your distress, which are introduced on the ollowing pages.


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25CBT approaches to behavioural change

Sel-monitoring

Chapter 3 outlined the use o thought records to identiy and evalu-

ate negative thoughts and cognitive distortions. Thought records

are one type o sel-monitoring strategy that you will be asked to do

in cbt. You may also be asked to do other orms o sel monitoring,

such as:

monitoring your moods or feelings of pleasure or mastery day byday, perhaps rating them on a scale rom zero to 10 or zero to 100

monitoring symptoms of your problem in specic situations

scheduling activities or monitoring your progress with a behav-

ioural goal; or instance, planning or recording how many times

you exercised at the gym in the past week.

selF-MonItoRIng DAY BY DAY

By keeping track o problems as they occur day by day, people

become more aware o the specic situations that tend to activate

their distress. The monitoring orms used in cbt help people be-

come more tuned in to the particular type o reactions they have to

dicult situations. For instance, do certain events tend to activate

eelings such as sadness, anxiety, anger, hurt or disappointment?

Monitoring orms are also used to help people become more aware

o the intensity o their moods. For instance, does one situation

oten lead to low levels o anxiety, while another situation always

leads to extremely high levels o anxiety?

Finally, monitoring orms are not just used to track problems;they are also used to help people become more aware o how well

they are doing. For instance, monitoring orms can be used to

rate the degree o success people have achieved toward reaching


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a behavioural goal, or to track their experience o pleasure or mastery

(i.e., achievement and skill) during certain events and tasks.

People with depression and other emotional problems that aect

motivation tend to become less involved or engaged in activities.

When they do engage in an activity, they tend to report less enjoy-

ment than they actually elt at the time they were doing the activity.

One way or people to get a better idea o how they spend their

days and how much pleasure and sense o mastery they derive

rom each activity is to keep track o what they do and how they elt

at the time. I you have problems with motivation, keeping track o

your activities can help you recognize that you can get more pleasure

and mastery rom doing things than rom not doing them. In simple

terms, doing things, even small things, can help you to eel better.

An activity schedule lists the days o the week across the top and

the hours o the day down the let side. Your therapist may ask you

to record your activities hour to hour and to make pleasure and

mastery ratings on a scale rom zero to 10, as seen in the example

o a partially completed schedule in Table 3 below.

tab 3. Wky aciiy cd wi par rai

monday tuesday wednesday

78 a.m. g p, ad c

P (par) 2;M (mary) 0

g p, rad papr ad madbraka

P 4; M 4

g p, akd rid ra

P 6; M 0

89 a.m. tk d r

a wak

P 3; M 3

tk d r

a wak

P 2; M 3

tk d r a

qick wak, rd ca

P 1; M 5


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910 a.m. tk b ca

P 0; M 4

M dy rp wrk

prai

P 2; M 8

Add ca

P 5; M 6

1011a.m.

Add ca

P 2; M 7

sam Add 2d ca

P 7; M 8

11 sam Add 3rd ca

P 6; M 4

1p.m.

M rid rc

P 6; M 1

Rrd m,mad ayc

P 4; M 7

12 p.m. Add ca

P 5; M 7

Ca p

adry

P 0; M 7

selF-MonItoRIng sYMPtoMs

Specialized orms to help you monitor and track your symptoms

throughout treatment are available or virtually all clinical problemsin cbt. The process o closely monitoring and recording your

experiences can in itsel improve your mood and well-being, and

so this is usually encouraged ollowing the rst cbt session.

I you are seeking help or anxiety, you may be asked to complete

monitoring orms to record the precise symptoms o anxiety

depending on the particular anxiety problem you are experiencing.For example, i you are seeking help or social anxiety, you will be

asked to complete a monitoring orm that will ask you to record

social or perormance situations in the past where you elt anxious.


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I you are seeking help or obsessive-compulsive disorder, you will

record the nature and distress associated with obsessive thoughts

throughout the week as well as the requency and duration o com-

pulsive rituals.

Table 4 provides an example o a symptom monitoring orm that

is tailored or panic attacks. This orm allows you to record all o

the symptoms experienced during a panic attack over the week

between sessions.

tab 4. Paic aack miri rm

situation:

Ra aiy riy:

sympm (tick a pricd):

q Accrad ar ra

q C pai r dicmr

q Dii

q Paria (mb)

q trmbi r akiq sai r bra

q Bi

q swai

qnaa / rwi mac

qMc i

qDry m

q Iabiiy ra

q R

q Fai

qDicmrq sp difci

q Irriabiiy r ar br

qDifcy ccrai

qhypriiac r dar

q earad ar rp

n Mdra I

0 5 10


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sCheDulIng ACtIvItIes

The same schedule used in Table 3 to monitor activities and makepleasure and mastery ratings may also be used to help you sched-

ule. One use is to schedule activities that you may have been avoid-

ing. This can help to remove indecisiveness around whether or not

you should do an activity. For instance, i you decide in advance

that you will go to the gym between 5:00 p.m. and 6:00 pm on

Tuesday, you are more likely to go than i you wait to decide based

on how you eel that day.

The therapist may also ask you to schedule both pleasurable activities

(e.g., lunch with a riend) and mastery tasks (e.g., organizing and

paying bills) or the upcoming week. You will likely also be asked to

keep track o your automatic thoughts during your weekly activities

to help you identiy distortions or other appraisals that minimize

or undermine your pleasure or sense o mastery in the activity.

A urther use o the activity schedule is to help you recognize the

barriers to completing tasks and to break down these tasks into

smaller units to make the tasks less distressing and more likely

to be accomplished. Graded tasks can then be constructed where

you schedule the easier steps o the task beore getting to more

complicated and challenging parts o the task. Simply changing thestructure and the approach to tasks in this way can create remark-

able changes in the likelihood that you will accomplish tasks.

Exposure therapy

A standard component ocbt treatment or anxiety is exposure

therapy. Exposure therapy works to reduce your ear o certain

things (e.g., insects, snakes) or situations (e.g., closed spaces,

heights) by gradually increasing your exposure to the eared thing


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or situation. To begin, you may be asked to imagine or look at pic-

tures o that eared thing or situation (indirect exposure) and then

gradually increase your exposure until you are able to touch the

thing or experience the situation (direct exposure).

With gradual exposure to your ears, your anxiety decreases and

you learn that your ears are excessive and irrational. This process

is called habituation. Figure 1 shows that as the number o expo-

sures to the eared thing or situation increases, the level o anxiety

produced by exposure decreases.

Fir 1. habiai cr i pr rapy

Exposure therapy usually starts with exposure to situations that

create only mild-to-moderate ear and gradually progress to situa-

tions that create higher levels o anxiety. Beore starting exposure

therapy, you will complete a hierarchy o your ears, listing all othe situations that trigger your anxiety and the dierent levels o

anxiety associated with each trigger. In the example o a completed

hierarchy o ear in Table 5, a person who ears coming into contact

Exposure 5-8

Exposure 3-5

Exposure 1-2

Anxiety

Time


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with beetles rates situations involving beetlesrom mildly dis-

tressing to most distressing.

tab 5. hirarcy ard iai: eamp

FEARED SITUATION

(midy diri m diri)

DISTRESS

(10100)

viw car drawi b, c i 10

viw p ra b, c i 20

sad i rm wi ma b, wak wii f

b

30

Wak wii ma b 40

sad i rm wi ar b, wak wii f

b

50

Wak wii ar b 60tc ma b wi fr 70

Aw ma b craw arm 80

tc ar b wi fr 90

Aw ar b craw arm 100

At rst you will complete exposure tasks with the help o the

therapist. Later, as you progress, you will be asked to do them on

your own as homework between sessions. The rate at which you

progress in treatment will depend on the severity o your ear and

on your ability to tolerate the discomort associated with arousing

your anxiety. Exposure tasks need to be repeated and last long

enough (usually not less than 30 minutes) to result in optimalimprovements. You learn that anxiety comes down naturally when

you remain in the ear-provoking situation long enough.


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Behavioural experiments were described on page 22 as a way o

testing your underlying assumptions and belies. Behavioural

experiments ask you to act out a eared situation to see i what you

ear might happen does happen. Should the eared outcome occur,

the experiments will also enable you to see how well you cope with

the situation.

These tasks are behavioural because they require that you test out

new ways o thinking by doing something dierently, oten by go-

ing into situations and choosing a dierent behavioural strategy.


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33

5 CBt i pracic:Qi ad awr

Answers to requently asked questions about cbt, such as how to

nd a therapist and what to expect in treatment, are outlined below.

How will I know i CBT is or me?

Most people know within the rst ew sessions i they are comort-

able with cbt and whether it is meeting their treatment needs.

The therapist will also check to see that cbt is the right t or

you. When the t is not quite right, the therapist may adjust the

treatment or suggest other treatment options. However, in general,

cbt may be a good therapy option or you i:

you are interested in learning practical skills to manage your

present, day-to-day lie and associated emotional diculties

you are willing and interested in practising change strategies

(homework) between sessions to consolidate improvement.

CBT may not be or you i you want to ocus exclusively on past is-

sues, i you want supportive counselling, or i you are not willing to

do homework between sessions.


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How can I fnd a qualifed CBT

therapist in my area?

To nd the contact inormation or certied cbt therapists in

Canada and the United States, consult the ollowing resources:

Academy of Cognitive Therapies

www.academyoct.org

Association for Behaviour and Cognitive Therapies

www.abct.org

What can I expect on my frst visit witha CBT therapist?

At your rst visit, you and the cbt therapist will discuss:

the nature and causes of your difculties and factors that could be

maintaining them

how the therapist will apply the cbtmodel to your specic problems

how the tasks that you will do in therapy can work to change dif-

erent aspects o the problems what you want to get out of treatment

whether cbt is a suitable treatment approach or you

whether other treatment approaches might be called for, either

instead o or in addition to cbt.

By the end o this rst visit, you and the therapist will have devel-

oped a goal-oriented treatment plan to address your diculties.


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35CBT in practice: Questions and answers

What happens in a CBT session?

CBT sessions can be given to clients individually or in groups. Both

ormats ollow the same predictable structure, as ollows:

Mood check: The therapist asks about your mood since the

previous session. This may include the use o scales to assess

depression, anxiety or other emotional problems. The purpose

o the mood check is to see i your mood improves rom sessionto session.

Bridge: The focus of the previous session is reviewed to create a

bridge to the current session.

Agenda: The therapist and client identify issues to address in the

current session that will act as the agenda.

Homework review: Homework from the previous session is re-

viewed to note progress and troubleshoot any diculties that mayhave emerged.

Agenda items: Agenda issues are addressed using cognitive and

behavioural strategies.

New homework: Exercises and tasks for the upcoming week are

assigned.

Summary and client feedback: Wrap up of the session.

How can I get the most out o CBTbetween sessions?

CBT is a treatment approach that teaches you skills to become your

own therapist over time. You learn new skills in the therapy ses-sions, but ultimately much o the change occurs between therapy

sessions when practising the skills in your own environment as

part o homework. Early in treatment, the cbt therapist will suggest


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homework, such as monitoring thoughts and behaviours, taking

steps to reduce avoidance behaviour, conducting experiments to

test out predictions and completing worksheets to challenge nega-

tive thoughts or belies. As treatment progresses, you will learn to

set your own homework between sessions to help you accomplish

your treatment goals. Research demonstrates that the more you

successully practise the skills ocbt in your homework, the better

the treatment outcome.

How long does CBT last?

CBT is a time-limited, ocused treatment approach. For problems

such as anxiety and depression, cbt usually involves 12 to 20 ses-

sions. However, the length o treatment can vary, depending on the

severity and complexity o your problemssome clients improvesignicantly in our to six sessions, while others may need more

than 20 sessions. Hospital-based programs targeting specic prob-

lems are usually 12 to 15 sessions.

How requent are the sessions?

CBT usually starts out with weekly sessions. As treatment pro-

gresses, sessions may be spaced urther apart, such as every two

weeks or month. Once people have nished a course ocbt, it is

common or them to return or occasional booster sessions to

keep up their progress, deal with any setbacks and prevent relapse

o problems. Again, hospital-based programs are typically pre-set

(e.g., a group meeting weekly at the same time or 12 weeks) andare less fexible in terms o scheduling and spacing sessions than

community-based cbt therapists.


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Do I need to prepare or CBT sessions?

Preparing to discuss a specic problem at each session helps you

to get the most out ocbt. Coming prepared helps to keep you o-

cused on your goals or therapy. It also helps to build a therapeutic

relationship between you and your therapist and to communicate

well throughout the session.

Will the CBT therapist be able tounderstand and appreciate my ownunique background?

Research on cbt demonstrates that it is an eective treatment

regardless o gender, race, ethnicity, culture, sexual orientation or

social economic status. cbt therapists are trained to recognize the

importance o cultural values and to adapt their treatments to meet

culturally unique needs. They are trained, or example, to:

be aware of their own personal values and biases and how these

may infuence their relationship with the client

use skills and intervention strategies that are culturally appropri-ate or the person being seen

be aware of how certain cultural processes may inuence the

relationship between the therapist and client.

As a client in cbt you should eel that you can openly discuss

aspects o your culture or sexual orientation, or example, and that

your treatment will be delivered in a manner that is consistentwith these values.


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Is CBT an eective treatment or

children and adolescents?

CBT has been adapted or use with children and has been shown

in research to be an eective intervention or a variety o clinical

problems that can emerge in childhood, including anxiety and

depression. The content and pacing o the therapy is adjusted to

be appropriate or the childs level o development. Oten, the cbt

therapist will work with the parent and childthe younger the

child, the more involved the parent will be in learning and deliver-

ing cbt strategies or their childs problem.

What are the common barriers that

come up in CBT?Barriers to treatment can include:

perceived stigma associated with mental health treatment

difculty identifying and distinguishing emotions and their

intensity

difculty in reecting on thoughts difculty tolerating heightened emotions

not completing homework

nancial constraints

chronic conditions and multiple difculties

low optimism toward improving

avoiding treatment sessions.

The therapist will work with you to reduce these barriers and will

also oer strategies that you can use to overcome barriers.


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Should I start treatment with

medications or CBT or both incombination?

Many people who seek treatment or emotional diculties in

Canada are rst treated by their amily doctor with one or more

medications (e.g., antidepressants) beore cbt is considered. Not

much research has been done to show whether it is best to starttreatment with medication or cbt or both. However, research has

shown that cbt, with or without certain types o medications, is

equally eective or the treatment o anxiety problems, and that

cbt and medications together are best or treating severe depres-

sion and psychosis. Importantly, taking these kinds o medications

has not been shown to interere with cbt, and in some instances

may help people to get more out o the therapy.

There is, however, one class o medication commonly prescribed

to people with anxiety problems, known as benzodiazepines, which

can potentially limit the benets ocbt. Medications in this class

include clonazepam (Rivotril), alprazolam (Xanax) and lorazepam

(Ativan). While these medications can rapidly relieve and control

anxiety in the short term, they can also make it harder to learn newthings, which is essential to benet rom cbt and reduce anxiety in

the long run. I you are taking these medications and are about to

start cbt, your cbt therapist will want to review the advantages and

disadvantages o continuing with these medications during cbt

treatment.

When considering or startingcbt

, discuss all o your questionsor concerns about your medications with your cbt therapist and/

or your prescribing medical doctor. Medications can be monitored

and discussed throughout treatment and adjusted depending on


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your progress in cbt. Note that recommendations or changes to

your medication can only be made by your prescribing doctor. I

your cbt therapist is not a doctor, he or she canwith your per-

missioncommunicate with your doctor to help ensure that you

receive the optimal combination o treatments.

How can I stay well ater fnishing

CBT?

A major goal ocbt is or you to become your own therapist and to

continue to practise cbt skills even ater you are eeling better. You

may also wish to return or ollow-up or booster sessions rom

time to time. A key component ocbt treatment is teaching relapse

prevention strategies. This includes helping you learn to identiy

the triggers and early signs o relapse and to develop an action plan

to prevent downward spirals o negative emotions.


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6 Arai cii-baira apprac

O the hundreds o psychological treatments available, several are

closely related to cbt, but have distinct approaches. Although the

eectiveness o these alternative cbt approaches is not as well

proven as the mainstream approach described so ar in this guide,

the our introduced on the ollowing pages have been ound to beeective in helping people with certain types o problems. Overall,

they all share a common goal o helping people learn how to let

go o ocusing on and reacting to their thoughts.

Mindulness therapy and mindulness-based cognitive therapy

Mindulness techniques can be used to help people distance them-

selves rom their negative thinking and recognize that thoughts do

not have to determine behaviours. Mindulness is a state o aware-

ness, openness and receptiveness that allows people to engage ully

in what they are doing at any given moment. Mindulness skillsare mainly taught through meditation; however, other experiential

exercises (e.g., walking or eating with awareness) can also be used

to teach these skills.


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Mindulness skills can be broken down into three categories:

Deusion: distancing onesel rom and letting go o unhelpul

thoughts, belies and memories.

Acceptance: accepting thoughts and eelings without judgment,

simply allowing them to come and go rather than trying to push

them out o awareness or make sense o them.

Contact in the present moment: engaging ully in the here-and-now

with an attitude o openness and curiosity.

Mindulness skills promote reedom rom the tendency to get

drawn into automatic negative reactions to thoughts and eelings.

Mindulness techniques have been used in the treatment o

chronic pain, hypertension, heart disease, cancer, gastrointestinal

disorders, eating disorders, anxiety disorders and substance use

disorders. Mindulness-based cognitive therapy has been ound to

be eective in reducing relapse to depression.

Acceptance and commitment therapy

While some therapies attempt to change upsetting thoughts andeelings, acceptance and commitment therapy (act) helps people

to simply notice and accept thoughts and eelings in the present

moment.

ACT views psychological suering as being caused by avoiding or

evaluating thoughts and eelings, which in turn can lead to ways

o thinking that interere with our ability to act consistently withimportant personal values. The ocus oact is on helping people

accept what is out o their personal control while committing to

doing what is within their control to improve their quality o lie.


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43Alternative cognitive-behavioural approaches

ACT aims to help people handle the pain and stress that lie inevi-

tably brings and to create a rich, ull and meaningul lie. People

learn how to deal with painul thoughts and eelings in ways that

have less impact and infuence over their lives. For example, they

learn to:

distance themselves from upsetting thoughts (cognitive defusion)

accept experiences in the present moment

discover important and meaningful personal values

set goals consistent with these values

commit to take action.

ACT has been ound to be eective in treating depression, anxiety,

stress, chronic pain and substance use disorders.

Dialectical behavioural therapy

Dialectical behavioural therapy (dbt) is an eective treatment or

people with excessive mood swings, sel-harming behaviour and

other interpersonal problems related to the expression o anger.

DBT has an individual and a group component. In individual therapy,the therapist and client ollow a treatment target hierarchy to guide

their discussion o issues that come up between weekly sessions.

First priority is given to sel-harming and suicidal behaviours, then

to behaviours that interere with therapy, and next to improving

the clients quality o lie. The quality-o-lie improvement part o

the therapy involves identiying skills that the person has but is not

using to ull advantage, to teaching new skills, and to discussingobstacles or using those skills. Weekly group therapy ocuses on

acquiring new skills.


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Clients keep diary cards to help monitor their use o the skills and

have access to 24-hour phone consultation with their therapist.

The our modules odbt are core mindulness, emotion regulation

(e.g., identiying and labelling emotions and reducing vulnerability

to negative emotions), interpersonal eectiveness (e.g., assertive-

ness skills) and distress tolerance skills (e.g., crisis survival skills

such as distracting, sel-soothing and improving the moment).

Meta-cognitive therapy

Meta-cognitive therapy (mct) was rst developed to treat general-

ized anxiety disorder and is now also used to treat other anxiety

disorders and depression.

Metacognition is the aspect o cognition that controls mental

processes and thinking. Most people have some direct conscious

experience o metacognition. For example, when a name is on the

tip o your tongue, metacognition is working to inorm you that

the inormation is somewhere in memory, even though you are

unable to remember it.

People with depression or anxiety oten eel as though they have

lost control over their thoughts and behaviours. Their thinking and

attention become xed in patterns o brooding and dwelling on

themselves and on threatening inormation. They develop cop-

ing behaviours that they believe are helpul, but that can actually

worsen and prolong emotional distress. This pattern o thinking is

called cognitive-attentional syndrome (cas

).


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45Alternative cognitive-behavioural approaches

In mct, people learn to reduce the cas by developing new ways o

controlling their thinking and attention and o relating to depressive

or anxious thoughts and belies. They also learn to modiy the

belies that give rise to the cas.


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Rrc

Burns, D.D. (1999). The Feeling Good Handbook: The New Mood

Therapy. New York: HarperCollins.


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Rrc

Hundreds o sel-help and proessional books on cbt are available.

Listed below are a ew examples. Many o the web links listed later

in this section provide an even broader list o reading and work-

book options.

CBT sel-help books or anxiety anddepression

AnxIetY DIsoRDeRs (ADults)

Antony, M.M. & Norton, P.J. (2009). The Anti-Anxiety Workbook:

Proven Strategies to Overcome Worry, Panic, Phobias, and Obsessions.

New York: Guilord Press.

Bourne, E.J. (2003). Coping with Anxiety: 10 Simple Ways to Relieve

Anxiety, Fear & Worry. Oakland, CA: New Harbinger.

AnxIetY DIsoRDeRs (ChIlDRen)

Rapee, R.M., Spence, S.H., Cobham, V., Wignall, A. & Lyneham,

H. (2008). Helping your Anxious Child: A Step-by-Step Guide or

Parents, 2nd ed. Oakland, CA: New Harbinger.

DePRessIonGreenberger, D. & Padesky, C.A. (1995). Mind Over Mood: Change

How You Feel by Changing the Way You Think. New York: Guilord

Press.


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Knaus, B.J. (2006). The Cognitive Behavioral Workbook or Depres-

sion: A Step-by-Step Program. Oakland, CA: New Harbinger.

geneRAl AnxIetY DIsoRDeR

Craske, M.G. & Barlow, D.H. (2006). Mastery o Your Anxiety and

Worry (2nd ed.). New York: Oxord. (See also accompanying thera-

pist manual.)

Meares, K. & Freeston, M. (2008). Overcoming Worry: A Sel-Help

Guide Using Cognitive Behavioral Techniques. New York: Basic Books.

oBsessIve-CoMPulsIve DIsoRDeR

Abramowitz, J.S. (2009). Getting overocd: A 10-Step Workbook or

Taking Back Your Lie. New York: Guilord Press.

Hyman, B.M. & Pedrick, C. (2005). The ocd Workbook: Your Guide

to Breaking Free rom Obsessive-Compulsive Disorder (2nd ed.). Oak-

land, CA: New Harbinger.

PAnIC DIsoRDeR

Antony, M.M. & McCabe, R.E. (2004). 10 Simple Solutions to Panic:

How to Overcome Panic Attacks, Calm Physical Symptoms, and Reclaim

Your Lie. Oakland, CA: New Harbinger.

Wilson, R. (2009). Dont Panic: Taking Control o Anxiety Attacks

(3rd ed.). New York: HarperCollins.


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49Resources

PosttRAuMAtIC stRess DIsoRDeR

Rothbaum, B.O., Foa, E.B. & Hembree, E.A. (2007). ReclaimingYour Lie rom a Traumatic Experience (Workbook). New York:

Oxord. (See also accompanying therapist manual.)

soCIAl AnxIetY DIsoRDeR

Markway, B.G., Pollard, C.A., Flynn, T. & Carmin, C.N. (1992).

Dying o Embarrassment: Help or Social Anxiety and Phobia. New

York: New Harbinger.

Stein, M.B. & Walker, J.R. (2009). Triumph over Shyness: Conquer-

ing Social Anxiety Disorder (2nd ed.). Silver Spring, MD: Anxiety

Disorders Association o America.

CBT sel-help books or other disorders

AttentIon DeFICIt DIsoRDeR

Saren, S.A., Sprich, S., Perlman, C.A. & Otto, M.W. (2005). Mas-

tering Your Adultadhd: Client Workbook. A Cognitive-Behavioral

Treatment Program. New York: Oxord University Press. (See also

accompanying therapist manual.)

BoDY DYsMoRPhIC DIsoRDeR

Claiborn, J. & Pedrick, C. (2002). The bdd Workbook: OvercomeBody Dysmorphic Disorder and End Body Image Obsessions. Oakland,

CA: New Harbinger.


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BoDY-FoCuseD IMPulsIve DIsoRDeRs

Franklin, M.E. & Tolin, D.F. (2007). Treating Trichotillomania:Cognitive-Behavioral Therapy or Hair Pulling and Related Problems.

New York: Springer.

eAtIng DIsoRDeRs

McCabe, R.E., McFarlane, T.L. & Olmstead, M.P. (2004). Overcom-

ing Bulimia: Your Comprehensive, Step-By-Step Guide to Recovery.

Oakland, CA: New Harbinger.

hYPoChonDRIAsIs AnD heAlth AnxIetY

Asmundson, G.J.G. & Taylor, S. (2005). Its Not All In Your Head:

How Worrying About Your Health Could Be Making You Sick andWhat You Can Do About It. New York: Guilord.

sChIzoPhRenIA

Beck, A.T., Rector, N.A., Stolar, N. & Grant, P. (2008). Schizophre-

nia: Cognitive Theory, Research, and Therapy. New York: Guilord

Press.

sleeP DIsoRDeRs

Edinger, J.D. & Carney, C.E. (2008). Overcoming Insomnia: A

Cognitive-Behavioral Therapy Approach Workbook. New York: Oxord

University Press. (See also accompanying therapist manual).


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51Resources

suBstAnCe use DIsoRDeR

Daley, D.C. & Marlatt, D.C. (2006). Overcoming Your Alcohol orDrug Problem: Eective Recovery Strategies (2nd ed.). New York:

Oxord University Press. (See also accompanying therapist manual.)

CBt WIth DIveRse PoPulAtIons

Hays, P. & Iwamasa, G. (Eds.). (2006). Culturally Responsive

Cognitive-Behavioral Therapy: Assessment, Practice, and Supervision.

Washington, DC: American Psychological Association Press.


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Internet resources

Academy o Cognitive Therapy

www.academyoct.org

American Psychiatric Association

www.psych.org

American Psychological Associationwww.apa.org

(Click Psychology Topics, then A-Z Topics, then Therapy.)

Association or Behavioral and Cognitive Therapies

www.abct.org

Canadian Mental Health Associationwww.cmha.ca

Centre or Addiction and Mental Health

www.camh.net

Counselling Resource

http://counsellingresource.com

Royal College o Psychiatrists

www.rcpsych.ac.uk/deault.aspx

(Click Mental Health Ino, then Treatments, then cbt.)


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or id i i ri

Addiction

Anxiety Disorders

Bipolar Disorder

Borderline Personality Disorder

Concurrent Substance Use and Mental Health Disorders

Couple Therapy

Depressive Illness

First Episode Psychosis

The Forensic Mental Health System in Ontario

Obsessive-Compulsive Disorder

Schizophrenia

Women, Abuse and Trauma Therapy

Women and Psychosis

To order these and other camh publications, contact:

camh Publications

Tel: 1 800 661-1111 or 416 595-6059 in Toronto

E-mail: [email protected]


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cognitive-behavioural therapy (cbt) is a widely

recommended treatment for depression, anxiety and other

emotional problems. cbt works on the assumption that the

way you think can contribute to your emotional problems.

In cbt, you learn to identify, question and change distorted

and negative thinkingto see thoughts as ideas rather

than as facts, and to stand back from your thoughts and

consider situations from different points of view. You

also learn to change behaviours related to negative moods.

Ultimately, cbt teaches you to become your own therapist.

This guide provides a brief, easy-to-read introduction to

the principles, process and strategies ofcbt. The book is

written for people who are considering or starting out in

cbt, for family members and friends who would like to

know more about the treatment, and for anyone else with

an interest in cbt.

This publication may be available in other formats.For information about alternate formats or otherCAMH publications, or to place an order, pleasecontact Sales and Distribution:Toll-free: 1 800 661-1111

Toronto: 416 595-6059E-mail: [email protected] store: http://store.camh.net

Website: www.camh.net

Disponible en franais.

Documents

Cognitive-behavioural therapy: an information guide