An excerpt from the first chapter of Cognitive Behavior Therapy: Basics & Beyond (2nd Edition, 2011):
The basic principles of cognitive behavior therapy are as follows:
Principle No. 1. Cognitive behavior therapy is based on an ever-evolving formulation of patients’ problems and an individual conceptualization of each patient in cognitive terms.
I consider Sally’s difficulties in three time frames. From the beginning, I identify her current thinking that contributes to her feelings of sadness ("I’m a failure, I can’t do anything right, I’ll never be happy"), and her problematic behaviors (isolating herself, spending a great deal of unproductive time in her room, avoiding asking for help). These problematic behaviors both flow from and in turn reinforce Sally’s dysfunctional thinking. Second, I identify precipitating factors that influenced Sally’s perceptions at the onset of her depression (e.g., being away from home for the first time and struggling in her studies contributed to her belief that she was incompetent). Third, I hypothesize about key developmental events and her enduring patterns of interpreting these events that may have predisposed her to depression (e.g., Sally has had a lifelong tendency to attribute personal strengths and achievement to luck, but views her weaknesses as a reflection of her "true" self)...
Principle No. 2. Cognitive behavior therapy requires a sound therapeutic alliance.
Sally, like many patients with uncomplicated depression and anxiety disorders, has little difficulty trusting and working with me. I strive to demonstrate all the basic ingredients necessary in a counseling situation: warmth, empathy, caring, genuine regard, and competence. I show my regard for Sally by making empathic statements, listening closely and carefully, and accurately summarizing her thoughts and feelings. I point out her small and larger successes and maintain a realistically optimistic and upbeat outlook. I also ask Sally for feedback at the end of each session to ensure that she feels understood and positive about the session...
Principle No. 3. Cognitive behavior therapy emphasizes collaboration and active participation.
I encourage Sally to view therapy as teamwork; together we decide what to work on each session, how often we should meet, and what Sally can do between sessions for therapy homework. At first, I am more active in suggesting a direction for therapy sessions and in summarizing what we’ve discussed during a session. As Sally becomes less depressed and more socialized into treatment, I encourage her to become increasingly active in the therapy session: deciding which problems to talk about, identifying the distortions in her thinking, summarizing important points, and devising homework assignments.
Principle No. 4. Cognitive behavior therapy is goal oriented and problem focused.
I ask Sally in our first session to enumerate her problems and set specific goals so both she and I have a shared understanding of what she is working toward. For example, Sally mentions in the evaluation session that she feels isolated. With my guidance, Sally states a goal in behavioral terms: to initiate new friendships and spend more time with current friends. Later, when discussing how to improve her day-to-day routine, I help her evaluate and respond to thoughts that interfere with her goal, such as: My friends won’t want to hang out with me. I’m too tired to go out with them. First, I help Sally evaluate the validity of her thoughts through an examination of the evidence. Then Sally is willing to test the thoughts more directly through behavioral experiments in which she initiates plans with friends. Once she recognizes and corrects the distortion in her thinking, Sally is able to benefit from straightforward problem solving to decrease her isolation.
Principle No. 5. Cognitive behavior therapy initially emphasizes the present.
The treatment of most patients involves a strong focus on current problems and on specific situations that are distressing to them...Therapy starts with an examination of here-and-now problems, regardless of diagnosis. Attention shifts to the past in two circumstances. One, when patients express a strong preference to do so, and a failure to do so could endanger the therapeutic alliance. Two, when patients get "stuck" in their dysfunctional thinking, and an understanding of the childhood roots of their beliefs can potentially help them modify their rigid ideas. ("Well, no wonder you still believe you’re incompetent. Can you see how almost any child— who had the same experiences as you—would grow up believing she was incompetent, and yet it might not be true, or certainly not completely true?")
Principle No. 6. Cognitive behavior therapy is educative, aims to teach the patient to be her own therapist, and emphasizes relapse prevention.
In our first session I educate Sally about the nature and course of her disorder, about the process of cognitive behavior therapy, and about the cognitive model (i.e., how her thoughts influence her emotions and behavior). I not only help Sally set goals, identify and evaluate thoughts and beliefs, and plan behavioral change, but I also teach her how to do so. At each session I ensure that Sally takes home therapy notes— important ideas she has learned—so she can benefit from her new understanding in the ensuing weeks and after treatment ends.
Principle No. 7. Cognitive behavior therapy aims to be time limited.
Many straightforward patients with depression and anxiety disorders are treated for six to 14 sessions. Therapists’ goals are to provide symptom relief, facilitate a remission of the disorder, help patients resolve their most pressing problems, and teach them skills to avoid relapse. Sally initially has weekly therapy sessions. (Had her depression been more severe or had she been suicidal, I may have arranged more frequent sessions.) After 2 months, we collaboratively decide to experiment with biweekly sessions, then with monthly sessions. Even after termination, we plan periodic "booster" sessions every 3 months for a year.
Not all patients make enough progress in just a few months, however. Some patients require 1 or 2 years of therapy (or possibly longer) to modify very rigid dysfunctional beliefs and patterns of behavior that contribute to their chronic distress. Other patients with severe mental illness may need periodic treatment for a very long time to maintain stabilization.
Principle No. 8. Cognitive behavior therapy sessions are structured.
No matter what the diagnosis or stage of treatment, following a certain structure in each session maximizes efficiency and effectiveness. This structure includes an introductory part (doing a mood check, briefly reviewing the week, collaboratively setting an agenda for the session), a middle part (reviewing homework, discussing problems on the agenda, setting new homework, summarizing), and a final part (eliciting feedback). Following this format makes the process of therapy more understandable to patients and increases the likelihood that they will be able to do self-therapy after termination.
Principle No. 9. Cognitive behavior therapy teaches patients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs.
Patients can have many dozens or even hundreds of automatic thoughts a day that affect their mood, behavior, and/or physiology (the last is especially pertinent to anxiety). Therapists help patients identify key cognitions and adopt more realistic, adaptive perspectives, which leads patients to feel better emotionally, behave more functionally, and/or decrease their physiological arousal. They do so through the process of guided discovery, using questioning (often labeled or mislabeled as "Socratic questioning") to evaluate their thinking (rather than persuasion, debate, or lecturing). Therapists also create experiences, called behavioral experiments, for patients to directly test their thinking (e.g., "If I even look at a picture of a spider, I’ll get so anxious I won’t be able to think"). In these ways, therapists engage in collaborative empiricism. Therapists do not generally know in advance to what degree a patient’s automatic thought is valid or invalid, but together they test the patient’s thinking to develop more helpful and accurate responses...
Principle No. 10. Cognitive behavior therapy uses a variety of techniques to change thinking, mood, and behavior.
Although cognitive strategies such as Socratic questioning and guided discovery are central to cognitive behavior therapy, behavioral and problem-solving techniques are essential, as are techniques from other orientations that are implemented within a cognitive framework. For example, I used Gestalt-inspired techniques to help Sally understand how experiences with her family contributed to the development of her belief that she was incompetent. I use psychodynamically inspired techniques with some Axis II patients who apply their distorted ideas about people to the therapeutic relationship...
The emphasis in treatment also depends on the patient’s particular disorder(s). Cognitive behavior therapy for panic disorder involves testing the patient’s catastrophic misinterpretations (usually life- or sanity-threatening erroneous predictions) of bodily or mental sensations. Anorexia requires a modification of beliefs about personal worth and control. Substance abuse treatment focuses on negative beliefs about the self and facilitating or permission-granting beliefs about substance use.